Jondi Gumz, Reporter at Large: How’s your health? Taking our temperature
Santa Cruz Sentinel, October 22, 2006
By Jondi Gumz
If you're sick, who will take care of you? How much will it cost? Will you be able to afford it?
More businesses are reducing health-care coverage for employees or asking them to pay more. A growing portion of the population cannot afford health care, and that is raising the cost of health care for everyone. Meanwhile, physicians are increasingly unwilling to work in Santa Cruz due to the high cost of living combined with low federal reimbursement rates for people covered by Medicare.
Here in Santa Cruz County, a rare public-private partnership is working to make our health-care system better. The group brings together physicians in private practice and doctors at nonprofit community clinics, hospital administrators, county health officials and the local Medical Society. Partnership leaders set four goals for measurably better health in Santa Cruz by 2010.
Sentinel reporter Jondi Gumz spoke with four key members in the Health Improvement Partnership:
• Dr. Larry deGhetaldi, CEO of Sutter Santa Cruz.
• Rama Khalsa, director of Santa Cruz County Health Services Agency.
• Alan McKay, executive director of Central Coast Alliance for Health the Medi-Cal health plan for Santa Cruz and Monterey Counties.
• Dr. Poki Namkung, Santa Cruz County health officer.
The discussion was facilitated by Leslie Conner, program director for the partnership.
Q When was the Health Improvement Partnership founded, and why did you get involved?
KHALSA: Our funding came in 2003 with a federal grant intended to support the Safety Net Clinic Coalition, which became the HIP Council. We had been meeting for well over a year when we applied for the grant. We felt we needed a broader partnership, with hospitals, doctors, the Medical Society and all ancillary treatment resources.
We received more than $1 million the first year, which funded computer enhancement at clinics, outreach and other programs, one of which was the Healthy Kids insurance plan for children up to age 18.
Every health director dreams of having a policy board where we can talk about policy issues and improvements spanning the system of care.
MCKAY: We're a regional health plan serving Medi-Cal clients so the benefit of getting involved was immediate for me. It's a one-stop shop for folks concerned with the quality of local health care.
NAMKUNG: I'm relatively new to the county, overseeing public health. Public Health is so lucky to be at the table; we are thinking about prevention and population health, lessening the burden on the clinical treatment side.
DEGHETALDI: We have two of the big three providers in our county: Sutter and Catholic Healthcare West parent of Dominican Hospital. We're seeing "silos" around their delivery systems, isolating patients who go to those systems for care. I wanted to find a way to break down those silos and improve care delivered to patients.
Q Do other communities have similar collaborations? How can this partnership make a difference for people in the community who need health care?
KHALSA: It's pretty rare. Solano County and to a limited extent Sonoma County has something, but this is a pretty rare structure to deal with children's health, Medicare and doctor reimbursement rates.
MCKAY: There's a group in Monterey County that's modeled similarly, the Monterey Health Development Group. I bring ideas to them and vice versa, across the county line.
Q Why is this kind of collaboration unusual?
KHALSA: A lot of times, people do what they are required to do, and no one requires these entities to work together. A lot of health care is structured to make people competitors and build up mistrust between providers. We do have competition, but we find common ground.
DEGHETALDI: There's a 100-year history of ineffective dialogue between hospital managers and the physician work force. Anti-trust issues prevent hospitals from working together, and there are huge barriers between physician organization. Then you throw in health plans, and it's difficult.
MCKAY: Health care is so complicated that it kind of invites those in health care to become specialists in our own areas. That breeds silos, and it's hard to interact on a systems level.
NAMKUNG: I work at the national and state level, and this partnership is absolutely unique. It brings people to the table you never see coming to the table. This exists because of pure leadership in the health care community. Rama anchors it.
Q Tell me about the health care goals and why they are important. Let's start with access to medical care. This is about reducing the percentage of people who don't have health insurance. How do you measure that?
MCKAY: In Santa Cruz County, the survey for the Heathy Kids program showed about 12.6 percent of the non-elderly population do not have health insurance. At first blush, we look good, because statewide it's 24 percent and nationwide is 15 percent. This is 28,000 people, a significant number. It's enough of a challenge to not just talk about it, but to do something about it.
Our first priority is uninsured children. We brought in funding from the county, the First 5 Commission, private donors, Sutter Health, Dominican Hospital and the California Endowment, and we started enrolling children in the Healthy Kids insurance plan in July 2004. Today, we have almost 2,000 enrolled and receiving health, dental and mental health care. We're very close to our target of enrolling 2,300 children. Our outreach also increased local enrollment in Medi-Cal and Healthy Families programs.
DEGHETALDI: Santa Cruz and Santa Clara counties stepped up to the plate. Two adjoining counties, Monterey and San Benito, neither one has this program.
We also face challenges.
The federal government measures relative costs of health care and this year, Santa Cruz moved from second-highest costs to the highest hospital labor costs of 3,200 counties in the country. When we try to deliver affordable care, it's very expensive to hire health-care workers, and hospitals are 40 percent of the health-care dollar.
Doctors here are paid at a very low rate of reimbursement for Medicare patients and that exacerbates the physician shortage in the community.
KHALSA: Employers are struggling to keep their work force insured because of the cost of health-care insurance. So we have a very large group of uninsured adults that impact that system. We are working on a grant to expand the county's MediCruz indigent care program, which would include preventive care. It wouldn't reach everybody, but it would be a start.
MCKAY: It's not just a feel-good effort. The uninsured don't go away. They wait for care and seek it in the emergency room. Uninsured kids tend to use emergency room more than insured children, which is very expensive and not very effective because they could be better served in a doctor's office or urgent care center. People need to remember that those who are insured are paying expensive premiums to cover the unpaid bills of the uninsured. Someone has to pay. By covering the uninsured, everybody wins.
DEGHETALDI: Just because you have Medicare doesn't mean you have access to medical care. In Santa Cruz, some physicians do not accept Medicare patients. The reimbursement from Medicare to hospitals has increased by 4-5 percent a year; doctors have seen zero net increase.
KHALSA: So we are very worried. Baby boomers are aging. We're expecting a surge of folks over 60, and the current system can't handle the capacity.
Q What's important about increasing use of electronic health records?
DEGHETALDI: My organization has a 10-year-old electronic health record that's very useful. I can review very quickly a synopsis of a patient's history. If you prescribe medication, you're told if a patient is allergic. No more 3 inches of hand-scribbled notes, which would take two to three hours to review appropriately.
This could save lives. In 1999, a book reported 100,000 people a year die due to medical errors. In Santa Cruz, it's probably 100 patients a year. President Bush said he wants every American to have a portable electronic health record. It's probably easier to get to the moon.
Making this change is expensive and it requires retraining of the delivery system and organizational change. It's not just installing a computer. There are a dozen emerging versions and it's a "Tower of Babel" problem — they don't talk to each other. Even a simple summary is not available to another medical group.
The Veterans Administration emerged early in the decade with a high-functioning electronic medical record system. Then Kaiser and Sutter selected EPIC, another vendor, but the VA system doesn't talk to EPIC.
It will take Sutter five years to implement this system, and the same for Kaiser. Sutter and Kaiser never envisioned the public sector would beat them, but the Santa Cruz County clinics adopted EPIC before us and other community clinics plan to follow suit.
In a perfect world, your entire medical record could follow you at the click of a button. We're struggling to make that happen here in Santa Cruz County.
We're focusing on diabetes, with a three-year federal grant to develop a shared clinical registry for every diabetic. That's just one disease of hundreds.
KHALSA: The payoff in terms of continuity of care is huge, so even with these challenges we're not going to give up.
DEGHETALDI: Some people are concerned about privacy but actually electronic records are more private than paper records. With a paper chart, I have no idea how many people have read it. With an electronic health record, you can track and audit everyone who ever logged on to see that record.
Q Another goal is to increase the percentage of people who know about end-of-life choices and health care. How many people have that information now?
CONNER: It's about 30 percent nationally, and the local figure is probably similar. We'll start asking that question in the United Way Community Assessment Project survey.
KHALSA: A huge percentage of health-care funding is spent in the last year of life, and many times people feel a lot of those interventions aren't necessary. You can decide if you want additional surgery, or if you want every measure taken to resuscitate you. Unless we have that legal document, we are forced to take every measure to keep a person alive, and that may not be what the person wants.
MCKAY: It's not just an issue for older people. Younger people can be in traffic accidents. A robust 18-year-old surfer guy can make his wishes known to his loved ones.
KHALSA: The Health Improvement Partnership, along with Hospice Caring Project and the End-of-Life Coalition have launched a local project to raise awareness. There's a Web site, www.makeyourwishesknown.org, which has free forms in English and Spanish, and a list of free presentations open to the public. This was triggered by Terri Schiavo's situation. She was brain dead yet kept alive year after year, despite her husband's belief that was not what she wanted.
CONNER: It's also a benefit to families because it relieves a lot of the anguish and burden of guilt if you know what kind of care the person wants.
Q The fourth goal is to reduce childhood obesity by 5 percent. I've seen national statistics that a third of kids today are obese. Is that true locally?
NAMKUNG: About a fourth of kids of our kids are overweight. For Latino children, the percentage is higher, 36 percent, which is one in three kids. Being obese is the biggest risk factor for developing diabetes, so it's a compelling problem.
But it isn't just medical care, it's how families eat, it's our whole way of life — land-use planning, the way we do agriculture, the ability of kids to walk to school.
Q Has anybody been successful at reducing rates of overweight children?
NAMKUNG: In other places, people are more physically active and eat better. Communities are more livable.
MCKAY: Doctors say they would like programs to refer overweight children to because this is a condition that can't be treated in a doctor's office. We live in a culture of video games and fast food. Our strategy is find a pressure point.
DEGHETALDI: Sometimes you feel overwhelmed — you wonder "can you affect the average weight of kids in the community?"
KHALSA: It's a great opportunity to connect with land use — the importance of sidewalks, bike lanes and farmers' markets.
Q What programs do you have to reach these goals?
KHALSA: More than half of emergency room visits are for conditions that could be treated at a doctor's office or urgent care center; if they aren't, the emergency room is less effective. So we identified highest users of the emergency room and we're working to connect them to doctors. This initiative is called Project Connect.
Over two and a half years, the project reduced emergency room use by up to 54 percent. For example, someone who is homeless, exposed to weather and eats poorly, gets sick a lot. This is preventable if you get that person in the right housing situation.
MCKAY: It's an opportunity to intervene to find a solution that yields benefits on the economic side. It's very positive for folks who need a hand up, and positive for the community at large.
KHALSA: The California Endowment considers this program a model. The question is how do you sustain that program? We got a year extension on the funding and we're looking for other funding sources.
NAMKUNG: It's cost-effective and we have data to demonstrate that. With electronic health records, we have the capability to analyze data make good decisions. For example, after Hurricane Katrina, we had kids from Louisiana, which has an immunization registry. We had the information so kids didn't get inappropriate vaccinations.
Q How can the public get involved?
MCKAY: The Healthy Kids insurance plan is supported by contributions, so donations are welcome by going online to www.cfscc.org. If you know a family that needs insurance for kids, ask them to call 454-2515 or 763-8568 and get an application started.
We also support Proposition 86 a tax on cigarettes as a way to sustain the Healthy Kids program on a statewide basis for all California children will be insured.
KHALSA: For information on end-of-life care, the public can look at the Make Your Wishes Known Web site or call the project hotline at 469-6222. You can go a class that will walk you through filling out the form; I just did it with my whole family. It was a great opportunity for dialogue.
CONNER: We want to reassure the public on the privacy of electronic health records.
DEGHETALDI: Patients can sign up, access their own records, review their health goals and communicate with their doctor with the Web. It's a wonderful tool that is coming.
Q It sounds like online banking.
DEGHETALDI: Look at the airline industry — they addressed safety and now you can pick your seat on your next flight. Why is the health care industry behind the airlines industry and the banking industry? Silos.
Contact Jondi Gumz at jgumz@santacruzsentinel.com.
Goals for 2010
• Improve access to medical care.
• Electronic records available at 80 percent of health-care providers.
• 75 percent of people over 60 have information on end-of-life health-care planning
• Reduce childhood obesity by 5 percent.
Source: Health Improvement Partnership of Santa Cruz County.
By the numbers
• 226,000 people under 65 live in Santa Cruz County.
• 42,000 people under 65 lack health insurance for all or part of the year.
Source: 2003 California Health Interview Survey, www.healthpolicy.ucla.edu.
Resources on the Web
• Healthy Kids insurance plan: www.scchealthykids.org.
To enroll, call 454-2515. To contribute, mail a check to:
The Community Foundation of Santa Cruz County c/o Healthy Kids Fund 2425 Porter St., Suite 17, Soquel, CA 95073
• End of life care: www.makeyourwishesknown.com or call Hospice, 469-6222.
• Overweight children: www.unitedwaysc.org/goforhealthplan.pdf.