Re-visioning the Delivery of Health Care Services to Uninsured Patients in Harris County

1. Re-visioning the Delivery of Health Care Services to Uninsured Patients in Harris County Final Report Prepared for Save Our ERs July 20, 2004

2. Table of Contents • Introduction • Study Approach • Drivers of Inappropriate Harris County ED Use • Key Findings • Conclusions • Models of Care in Other Communities • Components of a Care Re-visioning Framework • Strategic Options for Harris County • Study Conclusion and Recommendation

3. Introduction • In recent years, Harris Counties emergency care system has become increasingly overburdened by growing emergency department (ED) volume, particularly among uninsured non-emergent patients to whom ED’s are substitutes for more appropriate, yet frequently unavailable, community-based primary care. • Since 2001, conditions have worsened to the point that a study commissioned by the “Save our ER’s” coalition (the Coalition) concluded that the already overburdened emergency system is likely to continue to decay to the point of collapse without corrective action in the near term.1 • This conclusion has helped create support among Harris Counties health care and business communities that a substantive restructuring of health care services is needed to reduce inappropriate ED use and fragmentation of care. 1. Houston Trauma Economic Assessment and System Survey, Bishop+ Associates, prepared for Save our ERs, 2002.

4. Introduction (cont.) • The Lewin Group, Inc. (Lewin) was commissioned by the Coalition to assist them in creating a framework for re-visioning the organization and delivery of health care services in Harris County by developing and examining three conceptually distinct and credible options for reconfiguring care to safety-net populations in Harris County. • Each option is arrayed by the degree of system re-organization and resources required to undertake. • Expanding appropriate ambulatory care capacity. • Improving coordination of care. • Exploring options for restructuring city and county public health functions. • Building effective governance.

5. Study Approach • Key study questions and issues are complex, requiring input from many data sources and informants. • Lewin’s methodology was multi-tiered. • Key elements included: • Collecting and analyzing survey data from Harris County providers and secondary quantitative data sources. • Conducting 20 on-site key informant interviews. • Conducting over 40 telephone interviews. • Conducting an environmental scan of promising practices in five other communities that have reorganized care for safety net populations. • Interacting with key Harris Co. and other state stakeholders on important study issues. • Findings were synthesized to develop three credible options for reducing inappropriate ED use.

6. Study Approach (cont.) • Our approach to support development of three system reconfiguration options is organized around an assessment of several key study questions, including: • What are the magnitude and drivers of ED overcrowding in Harris County and what are the implications of continuing the status quo? • What approaches for reducing in-appropriate ED use, building capacity and better coordinating care have been successfully implemented in other communities? What are the potential benefits and challenges of these models for Harris County? • What are the objectives, major components and expected outcomes of three alternative options for reducing inappropriate ED use and improving access to care for the uninsured in Harris County? • The remainder of this study presents: • Our findings regarding the questions outlined above; and • The key features, benefits and challenges of three distinct and progressively more comprehensive options to reduce in-appropriate ED use and improve access to care for safety-net populations in Harris County.

7. Magnitude and Drivers of Inappropriate ED Use in Harris County

8. Magnitude of ED Use in Harris County • If current trends continue, Harris County ED use is projected to grow 38% between 2002 and 2015, after increasing 48% between 1991 and 2002. Trends in Total Harris County ED Visits 1991-2015 Sources: AHA and the Draft HCHD Strategic Plan

9. Magnitude of ED Use in Harris County:ED Use Is Concentrated Among Houston Safety Net Hospitals Source: Begley, Charles, et al. Houston Safety Net Hospitals Emergency Department Use Study: January 1, 2002 through December 31, 2002 Final Report November 18, 2003.

10. Magnitude of ED Use in Harris County: Age Distribution of Harris County ED Users • Overall, most Harris County ED users are adults somewhat older than the general population. Overall Harris Co. Population n=17 hospitals Sources: Lewin Survey of Harris County Providers, 2000 Census data

11. Magnitude of ED Use in Harris County: Income and Status of Harris County Hospital District ED Users • The income of most HCHD ED users is above 250% of poverty and most are US citizens. n=2 hospitals Source: Lewin Survey of Harris County Providers

12. Magnitude of ED Use in Harris County: Payer Mix of Harris County ED Users • While HCHD’s share of county-wide ED visits is only 14%, two-thirds are uninsured. Others have a more balanced payer mix. HCHD (n=2) Other Hospitals Reporting ED Data. (n=15) Source: Lewin 2003 Survey of Harris County Providers

13. Magnitude of Inappropriate ED Use in Harris County • Over half of all ED visits are inappropriate. • By 2015, if current trends continue and no action is taken: • Inappropriate ED use will likely grow 38%, to about 950,000 visits. • Medicaid and the uninsured will comprise half of all inappropriate use.

14. Drivers of Inappropriate ED Use in Harris County • Drivers of growth in Harris County inappropriate ED use include the downstream impacts of: • Projected population growth • Employment and healthcare coverage trends • Lack of effective physician capacity • Inadequate ambulatory care capacity • Gaps in coordination of non-emergent care • Cultural predisposition towards use of EDs

15. Drivers of Inappropriate ED Use: Projected Population Growth in Harris County Harris County’s population is expected to grow 26% between 2000 and 2015. Near-term growth will be concentrated among Hispanic and Asian populations. Source: 2000 U.S. Census, ESRI/CACI Demographics

16. Drivers of Inappropriate ED Use: Employer Health Care Coverage Trends • Between 1990 and 2000, Harris County enjoyed employment growth averaging 2.1 percent annually.2 • The Houston-Galveston Area Council projects similar employment gains through 2025. • Much of the future growth is expected to be among small businesses, many of whom historically have provided limited or no health care coverage. • These trends threaten to increase the number of uninsured and place additional pressure on Harris Counties already strained emergency care system. 2.Houston-Galveston Area Council 2025 Regional Growth Forecast, May, 2003.

17. Drivers of Inappropriate ED Use:Lack Of Effective Primary Care Physician Capacity • Harris County has enough primary care physicians to meet population need. • However, inadequate reimbursement is a serious barrier to care for the uninsured and many Medicaid recipients. Source: TX State Board of Medical Examiners, ESRI/CACI Demographics Note: The shorter bars represent more physicians per person.

18. Inadequate Ambulatory Care Capacity: Current HC Clinic Locations Are Appropriate, But More Capacity is Needed • Harris County clinics appear well sited to meet the needs of safety-net populations. • But more capacity is needed to meet demand and care is fragmented. Source: HCHD “Service Delivery Throughout Harris County” Presentation prepared by Gateway to Care 2003.

19. Inadequate Ambulatory Care Capacity: Primary Care Demand Exceeds Supply • Available capacity addresses less than half of primary care demand among Harris County’s low income uninsured. • Therefore, there are no alternative access points to redirect inappropriate ED use. Total Demand = 1.45 million visits

20. Inadequate Ambulatory Care Capacity: Demand For Primary Care By Low Income Uninsured Is High • A current estimate of primary care demand by uninsured Harris County residents under 200% poverty is over 1.4 million visits annually. Note: Uninsured under 200% FPL defined as Safety Net populations per AHRQ. Sources: HCHD Strategic Plan, AHRQ

21. Inadequate Ambulatory Care Capacity: Primary Care Demand Exceeds Capacity • Available data suggests that demand among the uninsured for primary care exceeds current capacity . Sources: HCHD Office of Strategic Planning, Gateway to Care Health Home survey, Lewin Survey of Harris County providers, Dr. Chuck Begley and Lewin Group analysis

22. Inadequate Ambulatory Care Capacity: Demand for Behavioral Health is Also High • Demand for behavioral health services also exceeds available capacity in Harris County. • According to the Harris County Mental Health Needs Council, an estimated 120-130,000 people in Harris County have severe mental illness. • About 60% are reportedly uninsured. • In 2003, the public sector, including HCHD (7,305) and MHMRA (186,567) together reported seeing about 194,000 visits. • Private sector capacity in Harris County was unavailable for this study.

23. Conclusions Regarding Inappropriate ED Use in Harris County • Analysis of available data led to a number of conclusions regarding inappropriate ED use in Harris County. These include: • Inappropriate ED use is significant and, absent effective intervention, will continue to grow due in part to factors outside the health sector’s control. • Continuing the status quo is risky, as future trends are likely to exacerbate stresses on the local health care delivery system and further compromise the ability of many Harris County residents to access needed care on a timely basis. • Strategies focused solely on re-directing inappropriate ED use are likely to fail due to lack of adequate alternative capacity. • Any adopted strategy must seek to better balance the local health care system through building new capacity and improving coordination of care.

24. Environmental Scan of Models of Care Adopted in Other Communities

25. Approaches Adopted In Other Communities May Be Useful • Lewin conducted an environmental scan to identify promising practices and administrative and governance models successfully tested elsewhere to reduce inappropriate ED use and system fragmentation. • Following are examples of models to: • Build effective organization and governance. • Expand healthcare coverage for small businesses. • Increase physician capacity. • Expand ambulatory care capacity. • Improve coordination of ambulatory care. • Consolidate public health services.

26. Organization and Governance

28. Denver Health - History • Prior to the creation of Denver Health, the City of Denver operated the Health and Hospital Department. The Department was in charge of all public health services, the city public hospital and clinics, as well as the Rocky Mountain Poison Control Center. The manager of the Department and all of the members of the board were appointed by the Mayor. The Department’s board acted mainly in an advisory capacity. • In the 1990s, Denver was subject to aggressive movement by managed care into the market. Many of the new HMOs began cherry-picking patients from the Department (e.g., patients with private insurance), threatening the department’s financial base. To combat this problem, the Department tried different strategies such as creating an HMO for city employees, among other activities. • In the mid-1990s, Denver’s mayor appointed a blue-ribbon task force to look at the organization of the department and develop recommendations for change and looked at several different options. However, the Mayor stipulated that the department could not become a private, free-standing non-profit entity. • The final recommendation was to develop an authority structure. While the authority remains public (a subdivision of the State of Colorado), it is able to operate independently as its own authority. In order to transition the Department into an authority, it was necessary to obtain authorization from the Colorado State Legislature.

29. Denver Health: Governance • Denver Health has a contractual relationship with the City of Denver to provide health care and public health services. When Denver Health became an authority, the contract included three agreements: • Transfer Agreement: All assets were transferred from the City to Denver Health. • Operating Agreement: Denver Health will serve the City of Denver in perpetuity. This insures that the city will not bid out for services. • Personnel Agreement: Employees from DHH are allowed to remain city employees or become employees of Denver Health. In the former case, they are leased to Denver Health.

30. Denver Health: Governance – Board Structure • Denver Health is governed by a nine-member board, appointed by the Mayor and confirmed by the City Council for a five-year term. Individual board members terms may be renewed for one additional term. • There are no stipulations regarding who may serve on the board of directors. When seats on the board are vacant, the CEO and remaining board members provide the Mayor with a list of possible replacements. Denver Health’s CEO serves as an invited member of the Mayor’s cabinet. • The City of Denver contracts with Denver Health for services. As a result, the Mayor and City Council have no direct authority over Denver Health beyond board appointments. The Board has complete authority over Denver Health. • Denver Health operates eight FQHCs. Each FQHC in the system has its own board to remain compliant with Section 330 requirements. Two members of the Denver Health Board are members of each FQHC board.

31. Denver Health: Organization and Structure • Denver Health is directed by a Chief Executive Officer, who also acts as Medical Director for the hospital. • Denver Health is divided into a number of Divisions, including: • Hospital Division: The division runs the city hospital, as well as the city 911 system. • Public Health Division: The division provides the majority of public health services in the city, including infectious disease clinic, communicable disease control, TB clinic, STD clinic, immunization clinic, public health laboratories, and vital records. • Community Health Center Division: The division operates Denver Health’s 8 FQHCs and 13 school-based clinics. • General Council and Risk Management Division • Human Resources • Finance • Quality Review and Office of the Assistant Medical Director • Director of Managed Care • Rocky Mountain Poison Control Center

32. Denver Health – Organizational Chart

33. Marion County, IN – Health and Hospital Corporation (HHC): Overview • Program Description: Beginning in 1954, Marion County, Indiana consolidated public health and health care functions into a single authority, the Health and Hospital Corporation (HHC). • Program Purpose: HHC provides medical health care, environmental health, and population health services to Marion County and the City of Indianapolis, Indiana. • Key Features: • HHC operates both the Wishard Memorial Hospital System and the County Health Department • Physicians who work for HHC clinics all come from the Indiana University Medical Group Primary Care (IUMGPC) • HHC established a program called “Advantage,” a managed care-like program for low-income, uninsured residents of Marion County, Indiana. The program is jointly owned by Wishard Hospital and Indiana University School of Medicine.

34. Marion County, IN – Health and Hospital Corporation (HHC): Governance • HHC is governed by a seven-member Board of Trustees, three appointed by the Mayor, two by the City-County Council, and two by the Board of County Commissioners. Historically, the board has included representation from the community, as well as legal and financial expertise. • HHC has few limitations on its own authority. While the Mayor may make requests, the board is free to turn them down. HHC’s annual budget must be approved by the county council. However, modifications made by the council can be appealed to the state. • As a consolidated taxing authority, HHC must work with the State Board of Accounts, which must approve all levies made by HHC. The State Board of Accounts must verify that levies do not exceed the state-mandated annual limits. • HHC also works closely with the State Board of Health and State Medicaid agency.

35. HHC: Organization and Structure • HHC operations are overseen by an Executive Division, including the President/Executive Director. The Executive Division is able to move assets, leverage funding from various sources, and coordinate activities to maximize efficiency. • The Marion County Health Department is divided into two bureaus: • Bureau of Environmental Health: Services include Food Safety, Housing and Neighborhood Health, Childhood Lead Poisoning Prevention, Indoor Air Quality, and Occupational Health. • Bureau of Population Health: Services include Communicable Disease Control, Chronic Disease Control, Dental Health, Immunizations, Maternal and Child Health, Nutrition Services, Public Health Laboratory Services, and Vital Records.

36. HHC: Organization and Structure • HHC’s Hospital Division operates Wishard Memorial Hospital and its health services. In the late 1990s, authority for all seven clinics within HHC was given over to the Hospital Division (previously the Hospital Division was in charge of only 2 of the clinics). This has brought about increased reimbursement and better integration with the Wishard Memorial Hospital for specialty care. • The seven clinics affiliated with HHC are currently under review for FQHC look-alike status. This will be a co-applicant arrangement between HHC and a single community board (51% community/49% other – of which 2 seats are for HHC). HHC will maintain budgetary control, while other issues will be handled jointly. This will likely provide greater oversight of the clinics and the benefits of look-alike status. HRSA is expected to approve this arrangement. • The Indiana University Medical Group – Primary Care (IUMGPC) provides staff for all of the clinics directly under HHC (i.e., Wishard clinics). IUMGPC also selects the medical director for the clinics.

37. Health and Hospital Corporation – Marion County

38. Cook County, Illinois - Bureau of Health Services • Program Description: In 1991, Cook County, Illinois formerly established the Bureau of Health Services (CCBHS) to provide health, hospital, public health, and health education services to throughout Chicago and its suburbs. • Program Purpose: CCBHS was designed to create a better-coordinated and more integrated system of health care delivery within Cook County. • Key Features: • CCBHS includes a referral network that allows integration of specialty care, in both affiliate and non-affiliate clinic, with the County Hospital. • CCBHS operates over 30 community-based clinics. • Provides care to specific patient populations, including HIV/AIDS, chronic care, and detainees in the correction system.

39. Cook County, IllinoisBureau of Health Services - Governance • Cook County Bureau of Health Services (CCBHS) is an executive agency of Cook County, under the President of the County. The Cook County Board of Commissioners acts as the governing board for the Bureau’s operating entities. • CCBHS is run by a the Bureau Chief. The chief operating officer of each operating division reports to the Bureau Chief. CCBHS includes seven separate divisions. • The Bureau Chief is appointed by the President of the County with the consent of the Board of Commissioners.

40. Cook County, IllinoisBureau of Health Services - Structure • CCBHS includes seven separate divisions: • Ambulatory & Community Health Network: The Network coordinates primary and specialty outpatient care in community, school-based and hospital outpatient settings. • Cermak Health Services: Cermak provides health services to roughly 10,000 detainees at the Cook County Department of Corrections and the Department of Community Supervision and Intervention • Department of Public Health (DPH): DPH provides public health services in all of Cook County, except for Chicago and four other cities/towns in the County. • Ruth H. Rohnstein CORE Center: The CORE Center provides outpatient care to those with HIV/AIDS and other infectious diseases. • John H. Stroger, Jr. Hospital: Cook County’s main hospital has 464 beds and a Level 1 Trauma Center. • Oak Forest Hospital: Oak Forest provides long-term, chronic disease, and rehabilitation services, and includes over 600 staffed beds. • Provident Hospital: Provident is a full-service hospital serving more than 50,000 patients annually.

41. Cook County, IllinoisBureau of Health Services - Org. Chart

42. Models for Expanding Insurance Coverage

43. Health Access – Muskegon County, Michigan • Program Description: “Health Access,” a subsidized health care program for uninsured employees of small businesses and their dependents in Muskegon County, Michigan, established by the county with an initial grant from the Kellogg Foundation. • Program Purpose: To provide a basic health insurance-like product for low income workers who do not have access to health insurance, either on their own or through their employer. • Funding Source: Employers and employees each pay for 30 percent of product’s costs, while the community picks-up the rest utilizing DHS funds. • Key Features: Businesses that have not offered insurance for the past 12 months and have a median employee salary of no more than $11.50 are able to enroll in the program. Employees receive a basic benefits package and have their care managed by a primary care physician. The program only covers care given by providers located in Muskegon County and pays them on a fee-for-service basis. High-cost specialty care is covered by Medicaid by employing spend-down strategies.

44. Muskegon County, Michigan Pros for Harris County • The program could provide access to health care formany working uninsured in Harris County. • The product is not insurance, so reserve requirements do not take effect. Cons for Harris County • Because DSH funds are being maximized by Harris County, an alternative source of funding would have to be found. • Dedicated providers would have to be found to act as primary care physicians for program beneficiaries. • A current or new entity would have to take responsibility for managing claims and administration. Recommendations • SOER should consider this option if a dedicated funding source can be found to subsidize the program. Business and provider buy-in is also critical for such a program.

45. Advantage – Marion County, Indiana • Program Description: “Advantage,” a managed care-like program for low-income, uninsured residents of Marion County, Indiana, established in 1997 by the Marion County Health and Hospitals Corporation and jointly owned by Wishard Hospital and Indiana University School of Medicine. • Program Purpose: To reduce inappropriate Emergency Department use and unnecessary hospital admissions, and to better track and monitor quality care. • Funding Source: Local taxes and redirected hospital federal disproportionate share funding. • Key Features: Uninsured residents are enrolled and assigned to a primary care provider who coordinates their care. The program includes an urgent visit center to complement Wishard’s Level I trauma center, a 24-hour call center that can redirect emergency calls to primary care providers and a focus on referring patients back from specialist to the primary care provider of record.

46. Advantage – Marion County, Indiana • History: When Advantage began, only clinics under the purview of HHC were utilized. Clinics outside the network were not integrated. As a result, a number of problems developed. • The outside clinics wanted to offload their non-paying patients to the HHC system. However, they could not make referrals to specialty care at Wishard Hospital. So, the clinic physicians would make a diagnosis and then refer their patients to the Wishard ED where they would be re-diagnosed and admitted for specialty care. • Outside clinics did not have access to the integrated data network of HHC. As a result, they could not maintain continuity of care for patients who were using both systems.

47. Advantage – Marion County, Indiana • History (cont’): As a result of these problems, HHC decided to expand the network for Advantage to include a number of outside clinics. As a result: • the outside clinics have referral privileges to Wishard Hospital; • the Advantage system can make sure that these clinics adhere to protocols for referring specialty care (e.g., certain tests must be conducted before a referral can be made); • an electronic medical record can now be used for all Advantage patients throughout the entire system. This helps to maintain continuity of care. EDs also have access to this integrated data network; and • Advantage members, in some cases, may also access specialty care from hospitals outside of HHC through the outside clinics.

48. Advantage – Marion County, Indiana Pros for Harris County • Physicians are under a capitated arrangement, so they are encouraged to have patients using the most appropriate care. • This type of program utilizes the current health care system and does not necessitate major functional changes. Cons for Harris County • This type of a program requires total subsidization. The population served does not qualify for other programs like Medicaid. Recommendations • Although the capitated arrangement with participating physicians is attractive, SOER should be cautioned from replicating this model without first finding multiple sources of funding.

49. Increased Ambulatory Care Capacity and Coordination

50. Federal New Access Point Initiative • Program Description: The“New Access Point Initiative” was developed by the Bush Administration in August 2001 to expand current FQHCs and add new FQHCs around the country. • Program Purpose: To expand health coverage to the uninsured. • Funding Source: Federal appropriations distributed by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA) • Key Features: The five-year program calls for $1.2 billion to fund 1,200 new or expanded FQHCs. Of the 1,200 sites, 570 will be expansions of current FQHCs. Of the 630 remaining sites, 420 will be expansions of existing health centers and 210 will be new start community health centers. New sites will receive a maximum grant of $650,000 per year and expansion sites will receive a maximum grant of $550,000.