Northern California Addresses Safety-Net Challenges

Under the Affordable Care Act, as many as four million previously uninsured Californians will gain coverage, but providers and time to care for them will be scarce at the state’s already-busy community clinics and health centers.

Although the ACA will provide opportunities for more Californians to obtain coverage, it also will put pressure on community providers to care for the influx of newly insured.

The California Health Policy Forum predicts that once the ACA is fully implemented, about four million previously uninsured Californians could obtain coverage.

But it won’t be everybody. The Public Policy Institute of California estimates that four million Californians still will be uninsured after 2014, and many of them will rely on safety-net providers for care.

A report by the institute underscores the new role of safety-net providers — treating both those not eligible for coverage under reform and low-income, newly insured Californians.

Suddenly, these providers could wear two hats — providers of last resort and providers of choice.

Clinics Have ‘Open-Door Policy’

“With California home to fewer than 900 community health centers and clinics serving five million people annually — half covered by Medi-Cal (California’s Medicaid program) and the rest uninsured — our providers must have an open-door policy,” said Carmela Castellano-Garcia, executive director of the California Primary Care Association, a statewide trade association representing not-for-profit community clinics and health centers and their patients.

Late next year, in alignment with enrollment plans for the Health Benefit Exchange, the association will launch a branding campaign touting California Health+, the “plus” representing the holistic approach adopted by California’s community clinics and health centers.

Castellano-Garcia said the campaign will aim at educating newly insured Californians — up to 2.2 million — about provider options, improved access to care and reduced health disparities.

“The pressure is on to ensure that the clinics can recruit enough primary care physicians to meet the needs of the newly insured in 2014, especially up against larger health care systems that offer higher reimbursement to their providers,” said Marty Lynch, CEO of LifeLong Medical Care, which provides safety-net care through 12 clinics in Northern California.

In 2010, 39 states cut or froze Medicaid provider payment rates, contributing to the shortage of primary care physicians, according to the Kaiser Commission on Medicaid and the Uninsured.

Lynch said clinics often turn to mid-level providers to pick up the slack. 

Mid-Level Practitioners Might Be the Answer

Like LifeLong Medical in the East Bay, West County Health Centers in Sonoma County rely on mid-level providers who are carefully supervised and practicing at the top of their licenses, according to Mary Szecsey, executive director at West County Health Centers.

“The majority of patients can be effectively treated by them,” she said.

The clinics, which serve 14,000 patients in Sonoma County through three clinics at six sites, operate as quasi-patient-centered medical homes, Szecsey said, a model they have been following for years.

In addition, clinics are able to take advantage of electronic health records to ensure that patients receive routine testing and shots, appropriate medications and scheduled office visits.

Szecsey said she is not too concerned about finding enough primary care physicians to staff her clinics. Instead, she is spending more time recruiting access coordinators to ensure patients can navigate the new system, enroll and participate in their selected plans.

Stephen Shortell, dean of UC-Berkeley’s School of Public Health, concurred with Lynch and Szecsey about the value of mid-level practitioners whose current limited scope of practice could prevent them from assuming some of the responsibilities of physicians.

Sen. Ed Hernandez (D-West Covina), chair of the California Senate Committee on Health, plans to introduce legislation in 2013 that would expand the health care decision-making powers of nurse practitioners, pharmacists and other health care workers in an effort to address the shortage of primary care physicians in the state. Hernandez said that without changes, the state’s health care work force will be unable to meet the increased demand for health care services once the Affordable Care Act is fully implemented in 2014.

Shortell said an expansion in mid-level practitioners’ scope of practice could lead to fewer office, hospital and emergency department visits. He anticipates that there might not be enough primary care physicians available for four to five years.

A strong supporter of accountable care organizations, Shortell believes ACOs might serve as an appropriate vehicle for cost-effective care to Medicaid and uninsured populations.

However, he sees a challenging road ahead for safety-net providers, who face more barriers than other organizations trying to provide accountable care — less healthy beneficiaries, insufficient investment in information technology, lower skills in managing co-morbidities, lack of access to specialists, shortage of primary care providers, unleveraged partnerships with provider organizations and fragmented care.

Although Lynch at LifeLong also knows there are challenges ahead, he sees Medicaid expansion as an opportunity to develop more coordinated care and to take advantage of 100% federal funding.

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