VOLUNTEERS IN MEDICINE-SD

FEASIBILITY ANALYSIS

February, 2002

Purpose:

The purpose of this document is to provide the reader with an analysis of San Diego demographics, which defines the relevant need and site selection options for a primary care clinic for the uninsured.

At the time of this analysis, the San Diego County Medical Society has indicated its support and identified at least 60 physicians seeking a quality place at which to donate their services. Some 17 VIM sites are operating in the United States under the auspices of the Volunteers in Medicine Institute (www.vimi.org) with over 20 others in various stages of development.VIMI has identified San Diego as a potential site and provided us with complete Start Up and Operations Manuals. A small Steering Committee has been formed to develop the concept of creating a free clinic where credentialed, volunteer physicians can provide free care to the uninsured of San Diego.

Philosophy:

Volunteers in Medicine is neither an upscale competitor to private physician offices and clinics, nor a government-sponsored program for the indigent. Instead, a VIM clinic in San Diego represents the purest philosophy of the healing arts: a place in which compassionate, qualified clinicians can share their expertise with the less fortunate unfettered by concerns for insurance status, government funding, equipment or staffing shortages. As one of our Founding Fathers, Thomas Jefferson, said "Without health there is no happiness. The most uninformed mind, with a healthy body, is happier than the wisest valetudinarian [person of weak or sickly constitution]." If Thomas Jefferson was right, and we believe he was, our patients have the inalienable right to access quality primary care on a continuing basis, and they were all created equal in our eyes. It is, quite simply, a manifestation of the Hippocratic Oath taken by most physicians:

“Into whatever houses I enter, I will go into them for the benefit of the sick…..and I shall see the man, just the man.”

An Overview of San Diego Healthcare:

According to the United Way Healthy Communities Index (www.unitedway-sd.org), only 56.5% of a statistically valid sample of 3,700+ San Diegans had all their health needs met in 2000, virtually unchanged from 1999. In the six HHSA regions of San Diego Country, only the Central region varied in the 42 parameters studied, showing unmet needs, which correlated to ethnicity, education, and income levels. From 1999 to 2000, only two of the parameters showed a statistically significant change in the percentage of respondents indicated “all needs met”: social service support (down 7.1%) and public help (down 10%), although caution is suggested in analyses of one year trends(1).

In 1997, a report from the Hospitals of San Diego County, “Health Care in San Diego: A Fragile Balance,” identified characteristics of healthcare which are more problematic, if not unique, to San Diego. Managed Care penetration in San Diego is double that of the national average; commercial insurance premiums continue to increase steadily; hospitals and large medical groups have become particularly skillful in managing patients on a capitated basis despite declining provider payments; most seniors do not have complete pharmacy coverage for their medications.

San Diego lies adjacent to Tijuana, a third world city of 2 million, and is connected by the busiest border crossing in the world. Almost 300,000 illegal immigrants were intercepted as well in 1996. It is not unusual for a San Diego emergency room to receive a woman in labor dropped off without any attendant, legal immigrant status, or pre-natal care.  To complicate matters, San Diego has no public hospital .  Whereas 37% of uncompensated care in the U.S. comes from public hospitals, 100% in San Diego comes from non-government, private-sector hospitals.

San Diego has a history of collaboration to meet its unique problems of fast population growth, border proximity, and the absence of a public hospital system.  Programs such as the integrated Trauma System (for severe injuries), Project Heartbeat (for emotionally disturbed children), Community Health Advocates (to promote access), and CHIP, the Community Health Improvement Partnership program (to improve the health for all), were all operational by the late nineties.  Due to the dominance of the Navy hospital and clinic system for active duty personnel, and the presence of essentially four major private systems (Sharp HealthCare, ScrippsHealth, UCSD, and Kaiser, collaboration has been taken to a much higher degree than is customary in most American cities.  This collaboration has led to an annual hospital contribution to care for the uninsured that has continued to rise from 145 million dollars in 1995(2).

Who are the Uninsured?

Contrary to popular belief, the uninsured are people like you and me.  According to one UCLA study (3) 25% of San Diego’s population has no form of health insurance, of which 83% are members of working families.  An estimated 110,000 children from low-income families in San Diego County are uninsured(4).  CHIP reported in 1998 that 476,000 San Diego adults are uninsured, with 2/3rds at or near 200% of the poverty level ($26,500).  According to this survey, fully 91% of the uninsured are in working families with a disproportionately high percentage of women and people of color, especially Hispanic.  Nearly one-third of women under the age of 65 depend on some sort of free healthcare service(5).

For reasons of access to public facilities, language barriers, or education, as  many as 30%, or 50,000, of uninsured children in San Diego would qualify for MediCal, yet have not entered the system.  That said, many physicians believe MediCal rates are too low to sustain a practice.

Since 88.3% of all employers (58,665 San Diego companies) had fewer than 20 employees, with 98% fewer than 100, the rising insurance rates have a disproportionate effect, since smaller companies often cannot bear the cost of premium increases without downsizing.  Hence, when small companies are forced to downsize, their employees lose health insurance for pre-existing conditions or often for anything beyond the 18 month COBRA benefit.

One-half of uninsured working adults report that they cannot afford to buy health insurance.  This group, plus those between jobs, have a unique, double jeopardy effect of sudden health needs.  Whereas they are too poor to afford insurance premiums, they cannot benefit from the insurance payor adjudicating a lower “reasonable and customary” payment from providers; hence, they become responsible for the entire billed amount for healthcare.  Since everyone knows how high such bills are, providers often refuse to accept “cash pay” patients and this population avoids care until an emergency is perceived.

They are then  forced to visit the emergency room, with even higher charges.  National studies have consistently reported that 80-90% of emergency room patients do not need immediate physician attention; the San Diego EMS system has consistently reported that 80% of 911 transports are not suffering an immediately life-threatening condition.  The culmination of numerous trends has led to consistent gridlock in the EMS system, with paramedics often forced to “shop” for an emergency room which is not saturated, thus threatening the health of the patients with true emergencies.

Result?  The uninsured is forced to seek care from a facility which does not want them, in which they do not have medical records, with which they do not have a privileged physician, and in a department (the ER) where the costs are clearly the highest to bear.

How is San Diego Different?

A report published by the Urban Clinic Associations in the six largest California cities detailed the differences San Diego has from both the nation and other large cities in the State(6).  The report analyzed the different systems developed by the six cities to provide access to care for the uninsured, while emphasizing their concern about solutions based upon government funding.  Specific to San Diego, the impact of MediCal managed care, the decline in Medicaid provisions mandated by the 1997 Balanced Budget Act, the decline in funding for the Federally Qualified Health Centers (FQHCs), and further restrictions expected on funding for disproportionate share hospitals (DSHs).  The results of this report and concerns expressed were published well before the impact of September 11, 2001 had been contemplated.

San Diego differs from all other large California cities, except the affluent Orange County, in that it has no public hospital and provides care to the indigent through public payor systems.  Funds for this system come from FQHC monies (steadily declining) and five main State of California sources. 

1.  Proposition 99 is restricted to the uninsured.  A portion of Proposition 99 (the Early Access to Primary Care program) is guaranteed to community clinics.  

2.  Realignment of State allocated funds between cities  is based upon percentage of uninsured (San Diego is the fastest growing).

3.  County funding from local assets, which is startlingly lower than in the cities with a public  provider system, such as Los Angeles.

4.  Medi-Cal SB 855 revenues are provided to pay for county care to the uninsured, but not available to areas with a public payor systems, such as San Diego.

5.  Medi-Cal 1255 revenues are limited to DSH hospitals with emergency rooms and are discretionary with the California Medical Assistance Commission (CMAC), which negotiates rates.  The paucity of DSH’s in San Diego is problematic.

The data herein represents data from the late nineties, a period of budget surplus or neutrality, and do not reflect necessary changes anticipated by the $12B budget shortfall anticipated in 2002.  As compared to averages of pooled data from Alameda, Los Angeles, San Franciso, Santa Clara, and Orange counties, San Diego County is:

1.  lowest in annual county spending per uninsured ($73 vs. $283)

2.  lowest in annual county match funds per uninsured ($26 vs. $154)

3.  second highest in percent of population uninsured (27% vs. 20%)

4.  lowest in percent uninsured served by the county (14% vs. 23%)

From 1991-1996, San Diego spent 11% of its funding ($5.4M) on emergency room care, 33% ($16M) on inpatient care, and 47% ($17M) on outpatient care for the uninsured.  San Diego had the lowest rate of outpatient or clinic visits for the uninsured (.4 per year per uninsured) of the six urban areas studied.  The County paid for about 50,000 outpatient community clinic visits per year during this period.

In San Diego, community clinics are paid for on a fee for service basis, collecting some $5M annually from the County Medical Servcies program.  Along with other contracts and grants, these funds were used to reimburse community clinics an average of $45 per fisit with add-ons for pharmacy, dental, optometry, and supplementary services to a total of $69 per visit.  For comparison, total per visit payment was $74 in Orange County, $122 in Alameda, and $62 in Los Angeles.  San Diego County paid 11% of the total expenses of the community clinics in 1995.

Another way to compare San Diego’s uninsured outpatient system is to compare the payments above for clinic services to the total per visit cost in 1996.  The total cost per outpatient visit of $66 in San Diego contrasts with Santa Clara ($178), San Francisco ($131), Orange ($104), Los Angeles ($200), and Alameda ($166).  Thus, San Diego appears to have the most efficient delivery system of government-funded primary care clinics in the State.

While it appears that San Diego, with perhaps the lowest cost and most efficient delivery system for primary care to the uninsured, is meeting at best a small proportion of the total patients, and doing it with a system of government funding which is sure to drastically decrease in the future.

What Forms of Transportation are Available?

In January of 2001, the San Diego Metropolitan Development Transit Board (MTDB) published a  market analysis of current public transportation needs, attitudes and predictions for the next 20 years.  It identified six types of residents in San Diego and their attitudes toward transportation.  Although lack of health insurance is a characteristic of all groups, it is probably penetrates the group known as “Flexible Flyers” the most.  These are residents, generally with low incomes, who do not have alternatives to public transportation.  In San Diego, a fast-growing city with no subway, the light rail trolley and public buses represent the most likely modes of transportation.

The MTDE report analysis leads the reader to assume that, for the next twenty years, there will be increasing highway gridlock in most corridors, and little in the way of new options to the existing bus routes and trolley stops.  It would appear, a free clinic for the uninsured should be located near either or both of these conveniences.

What Alternatives Exist for the Uninsured?

In an analysis of the uninsured provided by the County EMS department using data from the Fall, 2001, 55,792 adults between ages 19-64 and 55,958 children were eligible for MediCal, with 33,556 adults and 45,320 children eligible for the Healthy Families Programs.  The United Way analysis in 2000 using a statistically valid 23-minute telephone survey of 3,711 randomly selected households between January 15 and April 11, 2000, more than 360,100 citizens did not have medical insurance coverage with the highest concentration in the central district.  Predictors of non-insured status were income below 20,000 dollars, low education status, and being Hispanic.  Of the insured, 21.8% of the adults were dissatisfied due to limited coverage, and 23.4% were dissatisfied because their insurance was too difficult to use.  Percentages of dissatisfaction and the reasons were slightly higher for children in the surveyed households.

The reason San Diegans cited for adults not being insured in the United Way survey in 2000 were “couldn’t afford coverage” (48.4%), “not offered by employer” (13.8%), and “don’t feel the need for coverage” (11.1%).   Only 8% of adults said that unemployment was the reason they were uninsured.  Thus, the uninsured in San Diego mimic national and State trends to involve a broad swath of society of mostly employed, all ethnic categories, and geographically mixed in all areas.  Where can they go  for medical care?

The most obvious alternative is the use of the emergency room, where emergency care is mandated by federal law.  The problem is that, with the closure of seven (out of 32) emergency rooms in San Diego, and escalating uninsurance rates, gridlock is common, and costs are high.  The impact of saturating the EMS system with non-emergent but unmet medical problems has been well-studied and leads to risks for both the acutely-ill patients and the EMS system itself.

As discussed above, San Diego is unusual in large urban sites in California, in that it has a mature and efficiently managed series of some 17 Family Clinics, funded through a combination of federal, State and County funds.  These clinics serve the public on a needs-basis and offer primary care for payment on a sliding scale.  Those using the clinics are screened for their financial status, and are asked to make appropriate payments.  These clinics differ in several remarkable ways to the Volunteers in Medicine concept.

First, they are government sponsored and run; hence, they are subject to government funding cycles and the requirement under the California State Constitution for a balanced budget.  Currently, newspaper reports indicate that  budget restrictions are preventing expansion and limiting the system of clinics in San Diego.  A VIM clinic provides a sustainable additional resource for future planning.

Second, the need is so great, only a small minority (14%) of the uninsured population is being served at present.  VIM clinics provide additional resources to fill the gap in areas not served by a government-sponsored clinic.

Third, since we expect many of the San Diego Volunteers in Medicine to be physicians with a specialty designation, a VIM clinic acts as a source of free specialty consultation to other community primary care resources.

Finally, the philosophy of Volunteers in Medicine is to provide a personalized, continual ongoing relationship between a physician and her patients.  This is not, of itself, different from any public or private clinic, but the use of retired physicians presupposes that they will not change their habits or their residence for many years.  The emphasis is on quality and not quantity of the visits, which has proven to be stabilizing for both the patients and  clinics in  past years.

Where in San Diego is a Clinic Needed?

Data for specific local areas is surprisingly hard to come by, but State Assembly and Senate Districts, as well as Congressional Districts, provide a snapshot of the need.

In California Assembly District 78 and Senate District 39, comprising similar central, coastal areas of a population 394,000 and 817,000 respectively, 22% of residents age 0-64 are uninsured, and 23% of residents age 19-64 are uninsured.  With several hospital/emergency room closures in this area (Mission Bay, Harborview, Paradise Valley) in recent years, the availability of care for the uninsured is restricted to the remaining hospital emergency rooms and government clinics with their precarious funding sources (discussed above).  In these areas, fully one-third of residents earn below 200% of the federal poverty level.

Currently, the Steering Committee is investigating appropriate sites and demographic needs.  We encourage the readers of this feasibility analysis to contact us with their suggestions and comments.  We believe the correct placement requires a VIM Clinic be seen as a community resource and not interfere with overlapping charitable or subsidized health clinics.

Criteria to take into Account for Site Selection

+ location, location, location to be accessible to the target population (e.g. near a bus stop)

+ adequate parking, allowing for expansion, (e.g. near another public facility with parking)

+ near another magnet service used by target population (e.g. a discount food store)

+ provides a clean, safe, well-lighted area for pedestrians

+ possibly near a hospital or closed hospital to take advantage of prior behaviors

+ will consider the community in which it is places, involving them in the decision

+ not to compete with similar services (e.g. Presbyterian Crisis Center, St. Vincent de Paul)

+ room for expansion allowed by City code

+ easy commute for retired clinicians, preferably against traffic patterns

+ potential for near-by church association using shared space for education in preventive health

+ must “stand alone” visually to promote specific community buy-in for the concept

+ allowance for handicap ramping on near-by streets

+ must have an appearance of professionalism, quality, comfort, community  (e.g. avoids risk of “inner city” blight, but able to serve the same residents

+ has 10,000 potential patients within a five mile radius

Summary:

The uninsured person is San Diego is more likely to be employed earning less than 200% of the poverty level, have no more than a high school education, be Hispanic, between the ages of 20 and 35, commuting to work on public transportation, have limited access to any form of medical care outside of the emergency room or government funded clinics with a sliding scale payment, and live anywhere in the city, but more likely in central San Diego.  Given the large and growing number of uninsured, they may, in fact, be living next door to you and me.