Fueled by new demand created by the Affordable Care Act, Inland Empire Health Plan, a not-for-profit insurer designed for low-income residents, announced this month that it now covers more than one million people.
Roughly the size of Maine, the Inland Empire spans Riverside and San Bernardino Counties and has more than four million residents. That means one in four residents now obtain medical services through IEHP providers.
Enrollment has more than doubled since 2011, when the health plan had 500,000 enrollees. In 2014, 350,000 patients were added, said Bradley Gilbert, IEHP’s CEO. Two-thirds of enrollees were newly eligible for insurance as a result of the ACA.
“We did not predict 350,000 members. Not even close,” Gilbert said. “We quickly outgrew everyone’s projections.”
While many of the county Medi-Cal health plans in the state have gained members, Gilbert believes IEHP is the fastest growing large Medi-Cal health plan in California. Medi-Cal is California’s Medicaid program. The health plan is now the second-largest community-developed low-income health plan in the state, after L.A. Care. IEHP annual revenue totals approximately $3.6 billion.
Region in Need
While IEHP’s growth has been dramatic, its expansion was not unforeseen. Because the Inland Empire is relatively poor compared to the rest of the state and has a high number of uninsured as a result of high unemployment from the recession, it was anticipated that a large number of people would qualify for expanded Medi-Cal or turn to Covered California for insurance, said G. Richard Olds, dean of UC-Riverside’s School of Medicine.
“It’s not surprising that we have the highest percentage of newly insured,” he said. “We predicted we would add 500,000 newly insured people with the implementation of the Affordable Care Act.”
Matthew Keane, CEO of the Community Clinic Association of San Bernardino County, said that in addition to unemployment from the recession, the Inland Empire’s rising poverty levels have been a driver for IEHP’s growth.
“I think it really speaks to the economics of the region,” he said.
Gilbert said local officials estimate the region had about 750,000 uninsured residents before health care reform. In 2010, a similar number was estimated by the UCLA Center for Health Policy Research in a study that found the uninsured made up 20% and 23% of the populations in San Bernardino and Riverside counties, respectively. With people now enrolling through Covered California and those newly eligible for Medi-Cal, Gilbert estimates there may now be approximately 250,000 uninsured in the Inland Empire.
Uncommon Two-County Structure
IEHP’s structure was unique within the state and the nation until a few years ago. The low-income health plan was formed through a joint powers agreement between Riverside and San Bernardino counties in 1994. Its first members enrolled in 1996.
“It was very unusual for two counties to do anything of this caliber,” Gilbert said. “In the long run, it has made a huge difference in how we approach health care, and it’s more efficient.”
IEHP was the only health plan shared between two California counties until a similar one, CalViva, was formed between several counties in the Central Valley three years ago, Gilbert said.
Olds said the formation of a shared entity was insightful because the two counties have much in common and the structure makes it easier to spread costs.
“I think others should take a look at it because I think it’s an excellent model for improving health care,” he said.
Gilbert said IEHP’s structure has enabled the health plan to grow and take on a larger number of enrollees.
“We’re a public entity, but because we are separate from the county, we have a lot more flexibility as to how we operate,” he said.
One of the greatest challenges faced by the health plan has been to ensure adequate access to care for its high number of new enrollees. The Inland Empire has the most severe doctor shortage in California and has relatively few federally qualified health centers compared to the rest of the state.
“All of these things make the situation worse,” Olds said. “It’s not just doctors … we just don’t have the infrastructure or the professionals to care for this many people.”
Community clinics that belong to the Community Clinic Association of San Bernardino County have seen about a 20% increase in the number of IEHP patients, Keane said.
“It’s clearly going to place some stress and test the system,” he said of the high number of newly insured.
Keane said the region’s doctor shortage is exacerbated by an aging physician population.
“A challenge is replacing and replenishing the workforce of primary care providers,” he said. “Most people agree that manpower is the No. 1 issue.”
An effective strategy has been to incentivize health centers to recruit physicians to create more robust networks, he said. In addition to recruiting doctors, Olds stressed that facility expansions are needed, as well as new training programs and more residencies.
To keep up with demand, IEHP has worked to expand network size and sign up new primary care doctors and specialists, Gilbert said. And the health plan has added new medical groups that accept Medi-Cal and Medicare.
The health plan has implemented several programs to manage its high volume of new patients. It has contracted with two companies that perform home visits for patients and has a pay-for-performance program for pharmacies.
Another program was launched to recruit new physicians and specialists to the region. IEHP set aside $8 million for the program and expects to hire approximately 85 new doctors. The health plan will pay half of a physician’s or specialist’s salary for the first year.
“It’s guaranteeing the physician’s salary,” Gilbert said. “Once you get them in, you start getting patients to them, and then they have an income.”
The program is expected to have a significant impact since each doctor can enroll up to 2,000 patients, he said.
Keane, who contends that solving the physician shortage requires out-of-the-box thinking, said IEHP seems to be leading the pack in addressing access-to-care issues for Medi-Cal patients.
“They are out recruiting, and they are creating partnerships and discussing the problem with local officials and universities,” Keane said.