FRESNO — One of the poorest and most underinsured regions in the state trails other areas of California when it comes to health care reform readiness, according to a study examined in a public forum last week.

The Fresno region, which includes Fresno, Madera, Mariposa, Kings and Tulare counties, needs to do more to prepare for the large increase in patients who will have health care coverage under the Affordable Care Act, according to the report.

A team of researchers from the Center for Studying Health System Change conducted the study on behalf of the California HealthCare Foundation. CHCF publishes California Healthline.

Researchers interviewed health care leaders in the Fresno region, some of whom met at a forum in Fresno last week to discuss the results of the study and to make recommendations for change. 

Fresno Faces its Own Distinct Challenges

The Fresno area has challenges specific to the region, said Peter Cunningham, director of Quantitative Research at HSC.

For one, it encompasses a large geographic region –16,000 square miles — that is rural and remote in some areas. It’s also impoverished and has a seasonal agricultural economy. “This is a tough population to deal with because of high poverty and the uninsured,” Cunningham said. There also are many undocumented residents who need health care but will not be eligible for insurance coverage under the Affordable Care Act.

Other challenges include a shortage of physicians, a lack of alignment between hospitals and physicians who are used to operating independently and an exclusive agreement between one hospital and Fresno County for indigent care. Cunningham said the exclusive agreement “has prevented creative alternatives,” such as setting up a Low Income Health Program or LIHP. HMOs also have a weak presence in this region. PPOs are dominant.

While hospitals have expanded patient capacity, they lag behind in health reform preparation, the study said.

Region Has Severe Physician Shortages

Health care providers on the Fresno panel all agreed that the region does not have enough physicians.

“One of the biggest challenges we all face is none of us have enough providers,” said Stephen Schilling, CEO of Clinica Sierra Vista, an organization that provides primary and preventive health care to underserved populations in the Valley.  

Fresno has a huge access problem, said Stacy Vaillancourt, chief administrator at St. Agnes Medical Center. “People turn to the [emergency department]. They don’t have primary care.” She said the region needs to “recruit [providers] in the triple digits.”

The region has 118 doctors per 100,000 residents, far below the state average of 174 doctors per 100,000 residents.   

Vaillancourt said her hospital is launching an independent practice association model to help manage costs. “There’s a culture of a very independent physician community. That said, we need to work more closely together,” she said.   

According to the study, Fresno hospitals also compete with federally qualified health centers and hospital-operated rural health clinics for physicians, who typically have shown little interest in alignment.

Efforts To Train, Recruit, Retain Physicians

The region has benefitted from efforts such as the UC-San Francisco Sunnyside Doctors Academy, which prepares local high school students interested in medical careers.

“Kids that train here, they tend to stay in the valley. We’ve got to grow what we need,” Schilling said.

A new program to recruit physicians will begin this summer. Fresno Health Community Access Partners has federal approval to start an ACA Teaching Health Center for family medicine residents, said Norma Forbes, CEO. The center will be one of three pilot projects in the state. The other two are in Modesto and Redding. The ACA provides funds for creating new residency slots in community health centers.

“We’re getting tremendous interest from family medicine residents who want a medical home,” Forbes said. The program is initially approved for four new doctors each year for the next three years, but Fresno has to demonstrate a sustainable model.

The program is vital, said Forbes, because the region has even fewer family physicians than other types of doctors. Currently, there are only 47 family medical doctors for every 100,000 people in the Valley. Statewide, there are 80 family medical doctors for every 100,000 people. “So we are severely below,” Forbes said.

County Agreement With Hospital Prevents Access to Funds      

Fresno is one of only three of California’s 58 counties to not accept federal funds to set up a Low Income Health Program.

LIHPs are part of California’s “Bridge to Reform” Medi-Cal waiver, which combines state and federal funding to expand health coverage to help the state prepare for coming changes under the federal health reform law. Medi-Cal is California’s Medicaid program. 

Fresno County opted out of the funds because it has a 30-year-agreement with Community Medical Centers to treat the indigent population. The contract, which has 14 years remaining, has hurt LIHP development, according to the study.

“Each side has a position on the 30-year contract,” Schilling said. “It’s just unfortunate that the parties that needed to … couldn’t come up with an agreement” to alter the contract.

That lack of collaboration has stymied efforts to prepare for health reform, the study found.

The issue is “there’s no health care policy,” said Forbes. “We’re in the position of haphazardly approaching this … and we’re going to be behind.”

Information Exchanges Called Vital

The panel agreed on the importance of electronic health information exchange. An exchange would allow medical practitioners to gain access to health records on the computer for their patients and would prevent the need for redundant testing.

The region has been reluctant to look at collaborative approaches to invest in an exchange, resulting in expensive, duplicative efforts in treating patients, said Forbes.

“It’s not a technology issue, it’s a collaboration issue,” she added. “Who should own it, how to handle transfer of information?”

Vaillancourt agreed that the medical community needs to have a more coordinated network when it comes to medical records.

“The word of the day for us is sustainability,” said Vaillancourt. “There’s less money coming in and higher demand.”

The region offers excellent medical care and has top-notch doctors, but competition has gotten in the way of a more efficient system, Cunningham said.

Forbes agreed. “Competition is good but there are big issues where working together can actually be good for the whole community,” she said. “We each slay the dragon every day, individually.”

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