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Clinics Prepare for Onslaught of Patients

Published: June 6, 2012 | No Comments

Dr. Rekha Reddy discusses health care reform in an exam room at MayView Community Health Center in Palo Alto.

Numbers are expected to skyrocket when more are insured

By Genevieve Bookwalter
California Health Report

As federal health care reform promises insurance for tens of thousands of Santa Clara County residents, local health clinics are scrambling to prepare for the expected onslaught in demand.

For the soon-to-be-insured poor, health care reform is an opportunity to take care of aches and pains many have ignored for years, doctors said. As a result, demand for primary care doctors is expected to surge around Santa Clara County. These family physicians are the first stop for most patients, to help them identify the roots of their problems.

However, the pool of these doctors is shrinking as medical students pursue more lucrative or prestigious careers as specialists, clinic officials say. In addition, the ongoing economic downturn leaves them little extra money to hire the few primary care doctors left in high demand.

As a result, the county’s medical clinics — especially those that serve the poor — are looking for ways to streamline their services without spending more money.

“All of this stuff is going to require more than the traditional methods of care,” said Kent Imai, medical director of Community Health Partnership. The partnership is a nonprofit that advocates for affordable medical care in Santa Clara and San Mateo counties, and represents health clinics in the South Bay and on the San Francisco Peninsula.

How clinics respond to this demand, Imai said, will “represent a sea change in the way we see patients.”

More than 250,000 Santa Clara County adults lack health care insurance, according to the county’s health department. Between 2000 and 2009—the most recent numbers available—the percentage of uninsured residents jumped from 8 to 18 percent.

Of those, not all will be covered when federal health care reform mandates insurance coverage for U.S. citizens and legal residents in 2014. Coverage does not include those who are in the United States illegally, although clinic doctors say they will continue to treat those patients — with or without insurance. County officials said they do not have an estimate of how many will not be covered.

To accommodate the increased demand, some medical clinics are expanding facilities, while others are lengthening hours. Some are hiring more doctors, while others are looking to nurses and assistants to fill in the gaps.

“It will be a challenge,” said Reymundo Espinoza, CEO of Gardner Family Health Network, a group of seven Santa Clara County clinics that serve about 50,000 low-income residents.

His clinics are offering internships and considering student-loan repayment, “so people get an idea of what it’s like and are committed to the type of service we provide,” Espinoza said.

At MayView Community Health Center, with clinics in Palo Alto, Mountain View and Sunnyvale, physician Rekha Reddy and CEO Shamima Hasan said they are adding more hours, doctors and a mental health team in preparation for 2014. They’re also digitizing health records and working through partnerships with Stanford University and Quest Diagnostics labs, among others, to get patients the care they need.

Of the clinic’s nearly 6,300 patients, 93 percent earn less than 200 percent of the federal poverty level, or $46,402 each year for a family of four, according to clinic statistics.

Right now, about 40 percent of MayView’s patients have some sort of insurance coverage, according to clinic statistics. About 1,500 patients have no insurance at all.

“Half the time (patients) feel bad to go to community clinics,” Reddy said. She anticipates seeing those patients more often, she said, once they have insurance and finally pursue treatment for bothersome symptoms.

“They do wait, because they waited for years,” Reddy said.

To deal with the onslaught, Imai predicts clinics will adopt a team approach.

Instead of patients calling a doctor in response to a mysterious or painful symptom, Imai said, a team of doctors, nurses and others would reach out to those with diabetes, asthma and other chronic diseases. These teams would teach patients how best to handle their illnesses and prevent major problems before they start.

This team strategy — which Imai referred to as a “medical home” — should keep patients healthier and save both patients and clinics time and money, he said. Not everyone on the team would earn a physician’s salary, and patients would avoid costly procedures often necessary without preventative care.

“It replaces the episodic, symptom-driven way of taking care of patients,” Imai said.

However, Imai said, most clinics are “just barely getting started” in preparing for the increased demand.

Fortunately for local health clinics, health care reform is not all happening at once.

Valley Care is Santa Clara County’s effort to launch federal health care reform early. It now covers those who make less than $699 per month for a single person, or 75 percent of the federal poverty line.

Those signing up for Valley Care will move into Medicaid in 2014, when that program expands as part of federal health care reform. Medicaid, known as Medi-Cal in California, is a federal program run by the states to provide medical insurance for low-income U.S. citizens and legal permanent residents.

County officials hope to enroll 12,000 residents in Valley Care by June 30. By county estimates, about 23,500 residents qualify.

With the U.S. Supreme Court considering the legality of health care reform,
Valley Care probably would not be immediately affected, officials said. But the 2014 Medicaid expansion could be. That decision is expected in June.

Meanwhile, Reddy said she often sees sick parents without health insurance bring their children — who are covered by public programs — in for doctors’ visits. She looks forward to treating the entire family.

“The mom’s health affects the kids,” Reddy said. “The whole family goes down with one sick person.”

 

Little Clinic, Huge Heart

Published: May 10, 2012 | No Comments

By Jessica Portner
California Health Report

Dr. Dimitri Sirakoff, the founder and medical director of Serve the People Health Center, rushed around his small, bright clinic tucked into an office complex in Santa Ana one recent afternoon. In one of the nine exam rooms, a man was suffering from back pain. In another, a woman was diagnosed with high blood pressure, and in another, a patient complained of dizziness. Dr. Sirakoff, a board certified general medicine doctor, opened the clinic in 2009*. He offers the gamut of clinic services from pap smears to diabetes screening to mammograms — all for about $15.

Whipping around in his white-coat and clutching charts in hand, the doctor has the demeanor of a man on a mission. Sirakoff started this clinic with a skeleton staff because he saw in his own private practice a great need to serve the community of poor, low-income, and primarily Latino patients in Santa Ana who could not afford health care. He set up the clinic in the modest building he owns and where he also maintains his regular practice.

He works for free, relying on grants to pay for his small clinic staff.

On one recent Saturday more than 40 women came in to get mammograms. In the cheery waiting room, an educational video broadcast a health message about the importance of regular screenings. There were refreshments and educational materials, and the staff gave each patient a pink polka dot makeup bag as a goodbye gift. Women of Mexican descent have higher incidence of late stage breast cancer, according to the Susan G. Komen Foundation, which gave Serve the People Health Center a small grant for the screening program.

As an evangelical Christian, Dr. Sirakoff sees serving this most vulnerable community as his moral obligation. “Most doctors don’t want to treat them because it’s not a moneymaker,” said Sirakoff, who serves 6, 000 patients annually. “We are pretty much trying to do what we can in the community.”

The clinic isn’t all that Serve the People does. The center also has a food pantry that serves 1,600 families a month, a legal aid service for those who can’t afford representation, and even parenting classes.

Serve the People Health Center is gearing up to do a lot more. The Orange County Community Clinic Coalition recently chose the center as one of five clinics in Orange County to receive support under a pilot program to help clinics become Patient Centered Medical Homes — a term for doctor’s offices that track all of a patient’s health issues and needs.

Under the Affordable Care Act, which seeks to improve the standard of care for patients, clinics who win certification as Patient Centered Medical Homes would be in line to receive more patients once health care reform is implemented. California supports setting up models for more comprehensive and coordinated care for some of state’s most vulnerable residents in order to prep for the higher numbers of people who will have access to expanded services once health care reform is fully implemented.

“Once we are certified, we are going to see how feasible it is to get up to speed,” Dr. Sirakoff said. “It’s a whole different ballgame.”

Certification will put the clinic ahead of the curve, but the requirements are substantial. The clinic, for example, has to invest in electronic medical records because every medical treatment, lab test, and procedure has to be measured and tracked to ensure efficiency and quality.

With such a large caseload and limited time with patients, Dr. Sirakoff has to glean information and diagnose ailments quickly. On a recent day, one woman, an assembly line worker at an electronics company that serves the local aerospace industry, had come in complaining of back pain. Her work involves repetitive motion and Dr. Sirakoff had given her non-steroidal medication. Now, she says she is feeling better. But, Dr. Sirakoff doesn’t let her leave without giving her a little nutritional take-away. More fruit, more fish, and continue on those Omega 3 supplements, too, he told her.

Sometimes, his patient’s ailments can’t be gleaned from tests, though, because the cause of the discomfort is hidden.

Magdelena Ortuno sits hunched over on a table in another exam room. The 44-year-old had complained of dizziness and bronchitis and was at the clinic as a follow up to get her lab results back. Dr. Sirakoff told the woman in Spanish that the labs were normal. He has ruled out lupus, an autoimmune disorder, which he’d suspected. But, now he thinks her symptoms are stress-related.

“She is out of job, has pain, and no insurance,” Dr. Sirakoff. “She is stressing herself out and that is manifesting in physical symptoms.” He has seen cases of rashes, swelling, and itching — all from stress.

Ortuno, after Dr. Sirakoff leaves the exam room, said she likes her doctor’s demeanor.

“The doctor is amiable and fast and answers you quickly,” Ortuno said. “He really does care about his patients and asks them how they are doing, and make the person feel comfortable.”

A few minutes later, Dr. Sirakoff went into an adjacent exam room to see Arturo Galindo, 52. The man said he is still losing his hair even though Dr. Sirakoff gave him a gel to apply to his scalp. It might take a while, Dr. Sirakoff said, and Galindo promised to be patient. “And no more hats,” said the doctor, “because you don’t want your scalp to sweat so much.”

Then, Dr. Sirakoff pivots to another of Galindo’s problem: blood sugar that’s a little too high. For that, the man is told to reduce his intake of starches and go easy on the pastas, and breads. “Oh, I eat a lot of rice. Oh, my goodness and breads,” said Galindo. “Just a little bit less,” Dr. Sirakoff gently, “because you are right on the border line of diabetes so we want to make sure you don’t develop that.”

Melissa Marchand, a 21-year-old college student who wants to become a doctor, volunteers at the clinic Thursdays and Saturdays. She takes patients’ vital signs (weight, height, blood pressure, blood sugar, and urine tests) and says the hours fly by.

“We see tons of patients, we’re always packed, and so many patients are so grateful,” she said, noting that the legal assistance and twice-a-month food drives are another reason for that. “This is the most profound organization I have ever seen.”

*This story has been updated. An earlier version of the story said the clinic opened in 2010.

 

Low-income health program will insure only a fraction of eligible residents in Monterey County

Published: August 9, 2011 | Comments (2)
Pamela Norton, who runs Monterey County's only free clinic, consults with a volunteer

Pamela Norton, who runs Monterey County's only free clinic, consults with a volunteer

By Robin Urevich

Carmen Martinez, a cafeteria worker who helps support her family in El Salvador on minimum wage, was among dozens who lined up outside the Rotacare Clinic -– Monterey County’s only free clinic –- on a recent Wednesday. Martinez needed a prescription to ease her asthma symptoms.

In Monterey County, an estimated 68,000 people lack health insurance, according to researchers at the UCLA School of Public Health, and many can’t afford the medical care they need. The Rotacare Clinic, staffed by volunteers and funded by local Rotary Clubs, opens just one evening a week in Seaside, about 15 miles west of Salinas. It’s housed in a county-run health center, which also cares for the poor. But some in the queue said they can’t even afford the county’s reduced rates.

A 50-year old man, who didn’t want his name used, is on his feet constantly as a part-time bellman at a pricey Carmel hotel. But now he’s limping because of a sore knee, and he’s at the clinic to find out what’s wrong.

“I haven’t seen a doctor in 20 years,” he said.

The need for healthcare is overwhelming and it’s been growing recently, said Pamela Norton, who has directed the once-weekly clinic for 17 years.

“We are their only means of care,” Norton said of the men, women and kids who fill the clinic waiting room.

Relief will come for some when the Patient Protection and Affordable Health Act, or federal heath reform goes into full effect in 2014. County officials predict that 23,000 uninsured residents will join the Medi-Cal rolls, and the federal government will foot the bill.

Some people will get help as early as this September from the state’s Low Income Health Program, which will use federal dollars to expand care to people previously excluded from Medi-Cal benefits. Adults ages 19 – 64 who earn less than the federal poverty level of $10,890 annually, and who’d previously been disqualified from Medi-Cal because they have no children at home, can now apply for benefits. The federal funds, called the Bridge to Reform program, will help counties get a head start on Medi-Cal expansion and the coming federal healthcare reform.

Eleven thousand Monterey County residents are expected to be eligible, according to an estimate by the UCLA Center for Public Health Research.

But the county can only afford to insure 1,000 to 1,500 of them this year, even though the federal government will match its spending dollar for dollar.

“We don’t have the resources to meet the need,” said Elsa Jimenez, a management analyst for the Monterey County Health Department.

Most of the state’s counties have set similar enrollment limits and restricted the program to their poorest residents. But seven counties, including Alameda, Riverside and Yolo, will extend benefits to those who earn as much $21,180 a year for a single individual.

Still, Jimenez argued that the Monterey program will make a real difference despite its modest size.

Reducing ER visits

County officials will test the idea, laid out in the Affordable Care Act, that more consistent medical attention can improve patients’ overall health, and save the county money on costly ER visits.

The county plans a full range of health services for the newly insured, whose only previous options had been the emergency room, the free clinic, or the county’s medically indigent adult program, which offers limited acute care.

Dr. Craig Walls, who heads the emergency department at Monterey’s county hospital, Natividad Medical Center, said his ER census has almost doubled from five years ago, from 70 patients a day to 128.

“We have some patients who come every day. Some patients come in on an ambulance every day. We have patients who are here more than I am,” Walls said.

To steer the new Medi-cal enrollees away from the ER, they’ll be assigned to county health centers where social workers and case managers will help them navigate regular appointments, lab tests, preventive and specialty care.

“We want to show that by offering more services we can reduce costs,” Jimenez said.

Improving mental healthcare

The county has also aligned itself with federal health reform in moving mental health practitioners into its clinics, and allowing patients to get mental and physical health care under one roof.

“Taking care of mental health is huge,” Walls noted. “If you’re talking to God, chances are you’re not going to be checking your blood sugar.”

A 2006 report by the National Association of State Mental Health Directors found that people with serious mental illness die 25 years younger on average than those in the general population, mostly of diseases related to smoking, alcohol and drug abuse and lack of medical care.

Likewise, people with serious medical conditions are more inclined to also suffer from mental illness.

“These things track really tightly,” Walls said. “Depression and adjustment disorder are tied right in with diabetes.”

Dr. Gerard Fernandez, a psychiatrist who made the move from a behavioral health center to the county’s Seaside Clinic several months ago, said he’s already seen results. A man recently came in complaining of panic attacks and heart palpitations. He worried he was having a heart attack.

“Since I’m here, I was able to do an EKG and talk to the primary care doctor,” Fernandez said.

Within an hour, the two doctors determined the patient’s heart was fine.

“He might have ended up in the ER,” Fernandez said, if he’d had to wait days for a medical referral.

“We were able to shorten his suffering.”

Preparing for the flood

In addition to mental health care, Jimenez said, Monterey County’s program will focus on treating and preventing some of the most common serious medical problems: COPD (chronic obstructive pulmonary disorder), asthma, chronic pain, diabetes and heart failure.

Shoring up the health of the county’s neediest residents now will reduce at least some pent-up demand when a flood of people are newly insured in three years, Jimenez said.

But, many in Monterey County will remain outside the healthcare system because they’re undocumented and ineligible for benefits under federal health reform. Jimenez said she doesn’t know how many because reliable data aren’t available.

Among them are the Carmel hotel bellman, who got a diagnosis of arthritis and high cholesterol, and Martinez, the cafeteria worker with asthma.

Norton said 80 percent of her clients, many of whom work in the local tourism industry, are in the same situation, and she doesn’t expect either their needs or long lines at her clinic to dwindle, even when federal health reform kicks in.

 

Recent budget crisis has federally funded clinics asking – how much will health care reform help them?

Published: July 6, 2011 | No Comments

By Helen Afrasiabi

The Hurtt Family Health Clinic in Tustin had a close call recently. The Federally Qualified Health Center feared the loss of a $667,000 federal grant expected in March. Instead of getting their federal Healthcare for the Homeless grant this spring, they got a notice telling them that the budget impasse in Washington D.C. had locked their funds, along with bit of money to cover operating costs through May.

The federal gridlock didn’t result in disaster for the clinic–- this time. Hurtt and all other Federally Qualified Health Center expecting continuation funding got their funding continued in early June, said the Health Resources and Services Administration’s Director of Communications, Martin Kramer.

But clinics may continue to struggle. The budget cuts resulted in the denial of millions of dollars in new grant requests and saw cuts of over $600 million to the Health Center Appropriations for 2011, said Kramer.

Hurtt and other Community Health Clinics across the state need every dollar they can get, and they are not optimistic that they will have sufficient funds to expand clinics to keep pace with increasing demand.

Their experiences lead them to doubt, too, that increased funds from the coming health care reform will be a balm for their budget troubles.

Responding to increased demands with decreased federal funds

East San Diego County-based Mountain Health operates fives clinics in the rural San Diego communities of Alpine, Escondido and Campo. Mountain Health was hoping for $220,000 under the new Expanded Medical Access grant. They were denied because of budget cuts, said CEO Judith Shaplin. They’d slated the money for everything from hiring additional physicians and case managers to getting a badly needed pharmacy at their Campo facility.

An increasing number of patients have filed into the clinics. The percent of uninsured patients coming to Mountain’s facilities, for instance, went from 20 percent in 2009-10 to 34 percent in 2010-11. The clinic, however, hasn’t seen the needed resources to support the increase.

Instead, Mountain Health has to hold off on planned expansions to ancillary services, and multitasking is a given for the staff. “This amounts to longer waiting times for patients, and our staff wearing multiple hats,” Shaplin said.

Their inability to hire more staff to cope with increasing numbers of uninsured patients base is a daily challenge, Shaplin said.

Like Mountain Health, Hurtt also treats patients regardless of their ability to pay, which is why it largely depends on federal assistance to sustain it. Federal funding, including the Healthcare for the Homeless grant, is one of Hurtt’s vital sources of support.

As director, Amavizca said it is part of her job to continually be on the lookout for other sources of funding. She has tried to be proactive, including a major restructuring of the clinic in 2004. That’s when Hurtt, which until then was operating as the Casa de Salud clinic in Santa Ana, was taken over by the Orange County Rescue Mission where Amavizca is Director of Health Care Clinics & Services.

Together with Amavizca and her staff, OCRM gave Hurtt a strategic makeover, repositioning the clinic to provide for a high volume patient base with minimal resources. OCRM moved the clinic three miles from Santa Ana to Tustin, where it is housed along with the Hurtt Mobile Clinic.

Both administer a full range of primary health care services (including dental) to the community’s homeless, poverty-stricken and uninsured population. Cities covered by Hurtt Mobile clinic include Tustin, Santa Ana, Orange and Garden Grove.

The most significant measure taken in Hurtt’s redesign, however, was obtaining status as a Federally Qualified Health Center. With federal grants as well as support from other donors since the takeover, patient services were expanded to a level that now accommodates a 140 percent patient volume increase since 2004.

“This is the hard part…you get a grant like this, which allows us to provide more all around, and now with more than double the patients, we’re left without it?” Amavizca said.

Will health care reform help?

The Affordable Care Act could provide clinics with a more stable line of funding. However, Shaplin describes herself as “cautiously optimistic” at best about the benefits of health care reform.

The ACA provides increased access to healthcare for patients who are currently uninsured, Shaplin said. But these reforms are very costly, and there are many gray areas in the law about how people qualify, and whether the new structure of the insurance market will be one that can support provider payment, she added.

Simply put, the biggest flaw is that the legislation doesn’t outline the exact mechanism for moving the ever-growing patient population into the program. California is trying to address this problem with their Bridge to Reform program, which will allow patients eligible for insurance under health care reform to begin receiving benefits before the Affordable Care Act begins.

One of Shaplin’s counterparts, Stephen Schilling, CEO of the Central Valley-based Clinica Sierra Vista, doesn’t believe it’s realistic to look toward the act as a source of increased funding. Sierra Vista recently agreed to participate in California’s Bridge to Reform program.

Schilling’s assessment is based on the dismal state of the economy and resulting budget cuts in Washington. Considering the cuts made to the regular budget, provisions under the Affordable Care Act don’t amount to “increased” funds, Schilling said. If anything, they just serve to compensate for the funding that clinics have recently lost.

Sierra Vista is comprised of 16 ambulatory facilities and a mobile health provider, and serves homeless and indigent patient populations across Inyo, Kern and Fresno counties. Increased funds from health care reform will only serve to keep community health centers funded at the same level as other sources of federal money are slashed, Schilling said.

The biggest problem, Schilling said, is that there is nothing being added to the existing budget to facilitate the clinic expansions that there will be a desperate need for after health care reform begins.

“This doesn’t yield the advantages we were hoping for…to get community clinics prepared for the new wave of insured patients under the PPACA with additional health centers,” Schilling said.

The bottom line amounts to continued uncertainty for clinics, directors said. Amavizca, Melgar, Shaplin and Schilling all agreed that there are a number of blind curves on the road ahead. They will operate, they said, with the knowledge that planning ahead is just not an option until there is more economic stability.

“We’re bracing for a lot of different scenarios,” Schilling said.

 
 
 

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