Healthy Outlook? Doctors, officials seek new solutions

The national health care crisis has hit hard in Stanislaus County.

About 90,000 residents are uninsured, including a quarter of all adults ages 18 to 64. Poor and, increasingly, middle-class residents are struggling to access care. They are filling county clinics, crowding emergency rooms and, as they fall through holes in a fraying safety net, forgoing treatment.

The county now faces a pressing question: What can be done to relieve their misery?

"To me, this is the best thing about the crisis we are in," said Dr. Eric Ramos, chief medical officer of Doctors Medical Center in Modesto. "It gives us the opportunity to choose the way we are delivering care."

Ramos, 55, has worked in the community since he began his medical residency training at the former county hospital in 1989. It concerns him that the county has one of the highest heart-disease death rates in California and is above the state average for deaths from cancer and diabetes.

In recent months, he — along with county officials and other prominent members of the medical community — have begun a conversation about the future of health care in Stanislaus County. They point to a range of solutions, from applying for federal funding to overhauling the way care is delivered to training ordinary community members to help each other.

"We have very dedicated, very prominent physicians here," Ramos said. "We have very good medicine here. Our statistics just don't show that. So obviously we are doing something wrong. We are not doing it right."

Solution 1: Pursuinga federal waiver

Nationally, federal health care reform has begun expanding coverage — providing new insurance options for young adults and people with existing conditions and offering grants to community health centers. If the legislation withstands political and legal challenges, it promises coverage to virtually all legal residents. But not until 2014.

What can be done before then?

Many health care advocates point to applying for a federal waiver as the obvious first step for counties hoping to expand coverage of the uninsured.

The initiative, also known as the "Bridge to Reform," provides extra federal funding to counties who agree to cover more uninsured patients while reining in the costs of providing that care.

The "Bridge to Reform" would give counties a significant boost in funding to spend on clinics or care centers for the uninsured. The idea is to smooth the transition to 2014, when millions of new patients will join the state Medi-Cal rolls.

"The biggest thing for expanding coverage right now is absolutely the waiver," said Elizabeth Landsberg, director of legislative advocacy for the Western Center on Law & Poverty.

Stanislaus County officials say they want to study the costs of the Bridge to Reform before jumping in. Mary Ann Lee, director of the county's Health Services Agency, said the county would assume financial risks in creating an interim program to serve thousands more uninsured residents. A county-hired consultant will determine by August if the extra federal funding would cover these costs.

"You have to look at it like an insurer," Lee said. "Are there enough dollars to cover the scope of benefits for that population?"

Denny Litos, the chief executive officer of Doctors Medical Center, has championed the Bridge to Reform in talks with the county Health Services Agency, Golden Valley Health Centers and other groups.

"If your county has $5 million in Medi-Cal expenditures, you can get $5 million in federal dollars," Litos said. "You end up with double the funding to cover the uninsured."

To make it work, Litos said the county will need to contract with insurers that provide a large enough network of doctors to serve the larger population. Even then, he said, there likely won't be enough doctors to cover all eligible new patients, so the county would need to look for other ways to provide care.

One way to expand the pool of doctors may be through safety net providers such as Golden Valley Health Centers, which also stand to secure funding from health reform.

Carmela Castellano-Garcia, president of the California Primary Care Association, said county collaborations with community health centers are key to ensuring that all eligible patients can be seen. Golden Valley has received millions of dollars in stimulus money to expand its clinics.

Solution 2: Changing the way care is delivered

That shortage of primary care doctors likely will become even more pronounced once 2014 hits and most people become insured.

The solution, many believe, lies in systemic changes to the way care is delivered. That could mean using more physician assistants and nurse practitioners — not just doctors — as primary care providers. Some doctors are experimenting with group visits. Others are relying on phone and e-mail to do basic consultations.

"A person doesn't need to come into my office for me to tell them your blood work looks great," Ramos said. "It's a waste of my time, it's a waste of their time, it's a waste of resources. We need to make sure that we save room for those people that really need to be seen."

One of the best ways to keep people out of the doctor's office — and the emergency room — is to keep them healthy.

Sharon Rapport, of the Corporation for Supportive Housing, a national nonprofit that works on issues of homelessness, said several counties in California — including Alameda, Santa Cruz and Santa Clara — have created "frequent user" programs for just this purpose.

The programs provide intensive case management for chronically ill, uninsured people who land in the emergency room on a regular basis. By making sure these patients have access to regular treatment and medications, hospitals end up saving a great deal, Rapport said.

For the broader population, especially those with chronic illnesses such as diabetes, Ramos and many others are enthusiastic about the concept of the

"patient-centered medical home."

In this model, teams of providers, including physicians, nurses, physician assistants and nutritionists, coordinate care for patients. Patients have ready access to care on the day they need it, and may be monitored remotely via technology to ensure they stay healthy.

In Modesto, the patient-centered medical home model is alive and well at CareMore on McHenry Avenue. The Medicare managed care plan also operates facilities for seniors in a handful of other counties throughout California, Arizona and Nevada.

Because they assume the financial risk of caring for their elderly patients, said Dr. Wendy Tong, CareMore's regional medical officer, they have added incentive to keep people from getting sick.

"It's not denying people care," she said. "It's taking better care of them before they reach crisis."

CareMore has come up with some simple strategies to accomplish this.

About six months ago, 66-year-old Bill Simms went into CareMore for an appointment and learned his blood pressure was high. Staff there gave him a blood pressure cuff to wear at home. He was instructed to put it on twice a day, and it would send electronic readings to the providers. Once a month, he had a phone appointment to discuss his progress. Recently, his blood pressure dropped to normal levels.

"I'm in pretty good shape and I know that I'm in pretty good shape because they're watching out for me," he said.

Solution 3: The community steps up

In the very short run, before large systems can change, helping the uninsured simply may boil down to local innovation and acts of good will. Across Stanislaus County, creative local efforts are providing rays of hope in desperate times.

Some of this comes from the generosity of individual dentists and doctors, who continue to treat patients after they lose their insurance, providing them with free sample medications or calling in favors with colleagues. In lieu of payment, Ramos' low-income patients sometimes thank him with homemade cookies or baskets of fruit.

Churches, too, have stepped up to help. In 2009, Calvary Temple Worship Center's Nineveh Outreach started a volunteer-staffed Hope Medivan to provide free basic medical care to the uninsured. The church works with two Modesto dentists to create a free mobile dental clinic for the homeless and others in need.

Ruben Imperial, manager of prevention and early intervention services at county Behavioral Health and Recovery Services, said deep cuts to its mental health budget in recent years have meant the county no longer can provide care for many people who need it.

The department is considering devoting $380,000 over the next three years to work with churches, schools and other community groups to train members to intervene when someone is having a mental health crisis, or to reach out to friends or neighbors with depression.

Ramos, too, believes improving the county's health outcomes may require proactively teaching members of the community to help one another. He'd like to see more doctors get out of their offices and give lectures on health at schools and other community gathering spots. He'd like to see more community health "promoters," trusted community members who can help their neighbors with breast feeding, prenatal care and diabetes control.

"No, they're not physicians," he said, "but I think they can tell sick from not sick."

For Ramos, the good news is that discussions about the future of health care in the county finally seem to have begun in earnest.

"We realize this is a vital, important time for us to come together and coalesce into solving this problem," he said.

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