Community Regional Medical Center, located in downtown Fresno, is where the poorest of Fresno County residents go for medical care.
“The county was providing the services at the old Valley Medical Center and Community Medical Centers took it over in 1996 for about $18 million a year and providing basically Medi-Cal level services,” says Kevin Hamilton, an administrator with Clinica Sierra Vista.
For the past 15 years, Community has operated what is called the Medically Indigent Services Program (MISP). It is the most basic of treatment, no preventative or wellness care, with most patients seeing emergency room doctors.
Those with chronic illnesses like diabetes can got to one of Community’s specialty clinics, but Stephen Walter, Chief Financial Officer at Community says those facilities are so crowded and impacted that many patients wait until they get sick. Those patients then end up in the emergency department along with everyone else.
“We triage patients as they come in. Someone with a heart attack, a stroke, a compound fractures from an auto accident, they’re going to get triaged and they get seen quicker. The people that come in with a cough, ‘I don’t feel well,’ that sort of thing, they are going to have to wait until the more critical patients are seen first,” says Walter.
Community and other health professionals all agree that this is not the best way to operate a medical program. “The program is cumbersome, and it’s expensive to run, as it’s entirely hospital based,” says Hamilton.
His employer, Clinica Sierra Vista, is one of the largest primary care community health centers in the region. At its clinic in downtown Fresno, low-income medical patients can get a wide range of services. “We provide family health care, we provide pediatrics, we provide OB/GYN care and same day appointments,” says one Clinica Sierra Vista nurse.
Hamilton says as primary care providers, their job is to offer the preventative care that will keep patients well, at home and out of emergency rooms. Walter agrees that moving the county’s poor into a managed care system would save the hospital money.
“That would be the way to reduce cost, reduce those emergency room admissions. The problem is that it takes a change from what we are doing currently to going in that direction,” says Walter. The current contract that Community has with Fresno County doesn’t provide for primary care for the poor. But for more than a year, both parties have been examining ways to improve the current system.
“Around November of 2010, the [Fresno County] Department of Public Health really got involved in looking at what that meant for Fresno County in terms of opportunity to expand on indigent health care and also to expand on managed care and Medi-Cal into the future,” says Dr. Edward Moreno, who heads the Fresno County Department of Public Health.
What prompted this re-evaluation of the county’s system is health care reform. In 2014 the Patient Protection and Affordable Care Act, sometimes called “Obama Care” goes into effect. It will make many more of the nation’s poor eligible for Medicaid, or in California, Medi-Cal.
In an effort to help with the transition, the federal government is offering the state matching funds to set up a bridge program called the Low Income Health Program. It would change the way the county treats its indigent population of about 18,000 people.
“It really wants people to go into that managed care environment, focused on the primary care, medical home. There’s lots of words for it, but really getting those patients to get that one-on-one connection with the doctors, as opposed to going to the ED [emergency department],” says Walter.
Under the Low Income Health Program, Fresno County would receive matching funds from the $20 million it already pays Community to provide the care. Some estimates show the county could end up with more than $50 million in funding.
“This Low Income Health Program would have provided assistance to, additional health care enhancements to the poorest of Fresno County, the poorest and most vulnerable in Fresno County and that’s why they’re interested in doing this,” says Moreno.
After hiring consultants and meeting with stakeholders for more than a year, the county concluded there were too many risks involved in adopting the Low Income Health Plan. During what was a heated County Board of Supervisors meeting on September 20, Supervisors Debbie Poochigian, Phil Larson, and Judy Case voted to withdraw the county’s application.
“I’m not in favor of the federal program or health care expansion because I don’t see basic personal responsibility as a part of it,” said Supervisor Case at the meeting. “But the risk element of this is really the biggest problem.”
Supervisors Susan Anderson and Henry Perea didn’t support that decision to withdraw the county’s application . “The point is to me the hospital is willing to negotiate. And I think as long as we have an opportunity with funds on the table, to provide that flexibility, we should take it,” said Perea at the meeting. Anderson agreed. “Why would we vote on this idea that we’re not going to discuss this anymore, we’re not even going to look at the options?”
Despite the opposition, Fresno became the only county in the state to turn down federal dollars to set up a Low Income Health Plan for the county’s poor, and the estimated 500 jobs that would come with it.
“We were dumbfounded because here is a potential $56 million coming into the community that not only would be able to provide medical services for people who really need it in the community at a much more cost effective rate than we are currently doing it, but also with the high unemployment that we have in the valley, that fact this money is in the community could have created up to 500 new jobs, and they say we are not interested. It is just almost beyond explanation,” says Chris Schneider of Central California Legal Services (CCLS).
He says that has CCLS considering legal action. Among other concerns, Schneider believes one of the Supervisors had a conflict of interest and should have stepped away from the vote because she works at Saint Agnes Hospital.
“At the meeting where the Supervisors took this vote, Supervisor Case admitted that what the county does would have an impact on other hospitals in the community including Saint Agnes. At that point we believe she should have declared a conflict of interest,” says Schneider.
So what went wrong? What caused Supervisors to withdraw their support for a program nearly all say would benefit the county? First, to get the federal dollars, Fresno County would have to end, or amend its contract with Community Regional Medical Center. Under the contract the County pays Community $20 million to provide medical care to the county’s poor. County officials admit it’s a sweet deal for them. Fresno County has paid about the same amount of money for more than a decade while Community has seen its costs go up.
“Now we are experiencing costs of $80 million a year,” says Walter, Community’s CFO.
Another sticking point is what to do about the undocumented aliens now receiving care as part of the county’s contract with Community. Federal money can’t be used to provide medical services to those here illegally. “It’s about one third of the medically indigent adult population that we are serving. And those people would not be, and they aren’t eligible for Medicare, Medi-Cal or the LIHP program,” says Walter.
If Fresno County adopted the Low Income Health Plan and still wanted to provide medical services to the undocumented, the county would have to foot the bill itself. “That’s a big piece of the problem, and I am not sure how we solve that, but that needs to be a part of the conversation,” says Supervisor Anderson.
She also believes there was a lot of confusion surrounding the entire process. She says those studying the proposal believed they had been given direction to look at setting up a Low Income Health Plan without changing its contact with Community. “The contract is such a critical piece, that you can’t do this without looking at the contract.”
With so much confusion, Community, and a majority of the Board of Supervisors just couldn’t move forward, saying there was too much risk involved. But many health advocates say that was no reason to withdraw the county’s application. “This isn’t something that’s foreign to the valley. Other valley counties are doing it, they’re being successful with it,” says Hamilton.
The fallout from the supervisors vote may give the plan a second chance. In a recent letter to Board of Supervisors Chair Phil Larson, Community Regional Medical Center’s CEO, Tim Joslin offered up a solution.
Joslin’s proposal would scrap the hospital’s current contract with the county, and return control of the Medically Indigent Services Program back to the Board of Supervisors. The county could then use the federal money to set up the Low Income Health Plan, a primary care based program administered by provider Cal Viva Health Systems.
Supervisor Perea warned his colleagues on September 20 that if they don’t look for solutions, their inaction could force the hospital to ask to renegotiate its current contract. “I think what we basically are doing is setting the stage for a very weak hand from the county’s perspective when Community Hospital knocks on our door, probably in the very near future, to either renegotiate the current agreement or to eliminate it. That’s coming. We all know that’s coming.”
Special funding for this program comes from the California HealthCare Foundation