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San Francisco’s Health Plan for Uninsured Offers Clues for National Reform Effort

New America Media, News Feature, Justine Drennan Posted: Aug 14, 2009

SAN FRANCISCO – Until this summer, Edgardo Gonzalez, 49, a pastor at Victory Outreach Church in San Francisco, hadn’t seen a doctor in 15 years. He had no health insurance, but no serious health problems. But in March, he began suffering from severe back pain. Though he could not afford a hospital visit, unbearable pain eventually forced him to San Francisco General Hospital.

Gonzalez feared an enormous bill for the X-ray and pain medications he received until he learned about Healthy San Francisco (HSF), the city’s plan that offers health care for uninsured residents. Patients pay a fee based on their income, and Gonzalez was eligible for free care that included his hospital costs.

As the nation debates health care reform, HSF offers a model of one approach to providing health care for those without insurance. HSF is one of 10 county plans chosen by the Health Care Coverage Initiative (HCCI), a federally funded program launched in 2007 to extend coverage to the the city’s 60,000 uninsured residents. HSF has made great strides in reducing those numbers and creating continuity of care at participating clinics. Early assessments of the program, which is not insurance but direct subsidized care, show it may reduce hospital visits and that it is a cost-effective program. But there are some problems, such as the lack of dental care, and waits for appointments can be long.

Of participating counties, San Francisco offers the widest coverage, due to its strong pre-existing system of clinics and the large size of its federal grant – $73.1 million for three years.

HSF has enrolled 43,000 uninsured San Franciscans, according to a July report from the Department of Public Health. Of those, 70 percent are at or below the federal poverty line ($22,O50 for a family of four and $10,830 for a single person) but are not eligible for Medicaid because they have no disability, dependents, or other qualifying factors. The rest of HSF participants are individuals who make two to five times the poverty level.

Enrollment is “pretty representative of the uninsured population in San Francisco,” said Tangerine Brigham, HSF’s director. Asians lead enrollment numbers, followed by Latinos, Caucasians, and African Americans.

HSF includes services from San Francisco General Hospital, the city’s 13 non-profit Community Consortium clinics and 14 public clinics. Certain private providers, such as Kaiser Permanente, also participate.

A month after his hospital visit, Edgardo Gonzalez made his first visit to one of the participating clinics, the Potrero Hill Health Center. If not for HSF, Gonzalez would not have sought care after his hospital visit.

“Or if I did,” he said, “it would probably be an emergency. Then I’d get a bill, and I couldn’t afford it.”

A medical home

To encourage patients like Gonzalez to seek care before minor health issues become more serious and expensive, HSF requires each patient to select a “medical home,” a primary care clinic like Potrero Hill, to which the patient can return regularly.

“I wouldn’t have known about my high cholesterol if not for Healthy San Francisco,” said Mack Taylor, 51, a patient at Silver Avenue Family Health Center.

The medical home-approach also aims to reduce costs by centralizing the non-medical side of patient care. Clinics are now responsible for managing records, coordinating specialty services, and offering case management.

In-language services enable clinics to accommodate people like Iok Leong, 64, a monolingual Cantonese speaker who visits the Chinatown Public Health Center. In 2007, she lost her job as an in-home caregiver when her client’s family took over care and also lost her health insurance from Healthy Workers, a government program especially for such caregivers. Leong was previously uninsured and feared becoming so again.

“I feel I’m getting older now, and I’m more concerned about health,” Leong said through an interpreter. “When I had no insurance, I had to pay in full for a visit to a clinic – $100, worth three days’ income. I would not buy as many groceries to save up in case I had to go to the doctor. I would always wait to see a doctor until I couldn’t wait anymore.”

Thanks to HSF, Leong can continue seeing a Cantonese-speaking doctor at Chinatown.

While it is early to draw conclusions about the efficacy of HSF’s medical home strategy, a June report from the Department of Public Health projects that hospital admissions for this fiscal year have decreased 34.8 percent compared to last year. The report also shows a moderate reduction in average hospital stay length since last year, from 3.6 to 3.3 days.

Striving for efficiency

Along with government money, HSF’s funding comes from patient premiums, the co-pays of higher-income participants and from San Francisco businesses that employ over 19 people. The law that created HSF mandates that these businesses must buy into HSF or provide each employee with health insurance or comparable contributions to a health savings account. The mandate has been just as controversial in San Francisco as it has been in the national health care reform debates, with small business interests opposing it as a financial burden.

HSF funding has so far been high enough that providers have seen relatively few cuts since the economic downturn. In fact, they have served mental health patients and others who had been using services that have been cut.

For this fiscal year, while HSF’s projected revenue exceeds new costs by $3.3 million, the city’s general fund will subsidize the extra $80.5 million by which the program’s total expenses exceed its revenue. Total expenses include the costs of services that the city has always subsidized but which now come under HSF. Over 70 percent of HSF patients used their clinics before HSF began, paying on a less formal sliding-scale system. Because there is no data on the amount of government subsidies for these patients before HSF, it is difficult to assess HSF’s cost efficiency. But current costs per patient are well below market rates, according to HSF director Brigham.

“What we know is that Healthy San Francisco costs $280 per participant per month, less than what it would cost if we tried to purchase health insurance for the uninsured, which would cost $388 to $618 a month,” Brigham said.

HSF may be more affordable, but is it good care when people need it? Opponents of universal health coverage often argue that expanding coverage would reduce the quality of care and increase wait times for appointments.

“We have more demand on new patient appointments, and we keep running out,” said Cheryl Denson, Potrero Hill’s principal clerk.

While clinics try to see new patients within a month of enrollment, the wait for a regular visit at the Silver Avenue clinic, one of the busiest, has increased from three to five months, said Pat Green, the clinic’s nurse manager.

“We’re seeing more primary care patients,” said Roland Pickens, San Francisco General Hospital’s senior associate administrator. “We have not seen an increase yet on the specialty side.”

To accommodate increasing numbers of patients, clinics have found ways to improve efficiency, such as increasing use of disease registries and more group visits at certain clinics. Clinics are also cutting unnecessary follow-up visits and encouraging patients to use the phone rather than come in for prescriptions and minor concerns. Pickens said that due to the hospital’s expansion of its primary care hours, its staff has not had problems accommodating more patients.

Paul Levine, 54, who uses Chinatown’s mental health services, said he was impressed by the quality of care.

“We weren’t rushed, and the doctor was very involved,” Levine said.

However, some logistical problems continue. Levine said he found it inconvenient that medications are available only at pharmacies linked with each medical home.

Not insurance

Another problem are the bills that HSF clinics receive from providers outside the HSF network.

“Many clients are under the impression that [HSF] is insurance,” said Mila Ramos, Silver Avenue’s principal clerk.

Most patients, Ramos guessed, don’t bother to read the 12-page pamphlet that they receive when they enroll, and they show their HSF cards to other providers in place of insurance.

HSF does not cover patients outside the city limits, nor offer certain services, including dental work, transplants, and long-term care.

Due to HSF’s limited scope, “we try to make it clear that if someone has health insurance, they shouldn’t drop it to be in Healthy San Francisco,” Brigham said.

Many apply for HSF not knowing that they are eligible for government insurance programs, like Healthy Workers, Healthy Kids, Healthy Families, Medicare, and Medicaid. HSF staff helps them enroll in these programs.

Because of bills and patient calls from outside San Francisco, there is doubt that all HSF participants actually live in the city, Ramos said.

“Maybe they live in Oakland, and they make it seem like they live in San Francisco, just like when some people enroll their kids in school, they use someone else’s address,” Ramos said.

Administrators also suspect hat some patients lie about income and employment status, said Lucy Urbina, and eligibility worker at Silver Avenue.

“I hear them from the front office say, ‘Hey man, how’s your business going?’” Urbina said.

Still, such misuses of the system are not common, Ramos said. About 20 patients were cut from HSF in the past year because they were non-city residents.

Changing demographics

In February, HSF expanded to accept people who earn five times the federal poverty level. Clinics that served predominately low-income patients are now seeing more moderate-income patients.

Some health workers do not like this change, said Dr. Sushma Magnuson, medical director at Potrero Hill.

“They fear that people with more resources will obstruct care for the poorest,” said Magnuson.

However, Magnuson said higher-income patients make higher co-payments, which can subsidize poorer patients. They also expect better services.

“It’s good to see people who ask for more,” Magnuson said. “It makes everyone increase the quality of service.”

HSF has also begun to attract more young people, who unlike most initial HSF enrollees have no serious health concerns.

“Now we’re getting younger ones who want to establish a base,” said Green of the Silver Avenue clinic. “Hopefully, they will be the “healthy” ones in our Healthy San Francisco.”

Edith Urrutia, 23, who has thyroid problems, heard about HSF from her mother. As a patient at the Silver Avenue clinic, Urrutia hopes to prevent her thyroid problems from worsening and affecting her cognitive function, as has happened with her mother.

“I’m so blessed with this program,” Urrutia said. “I have coverage for so many things without paying anything.”

This year, HSF has also recently seen many people like Domingo Barcenas, 34, who this year lost his health insurance along with his construction job.

Barcenas heard about HSF from television and friends, he said.

“It seemed great to me because I have no job and no money for health care,” Barcenas said.

So far, the economic recession has not increased the HSF enrollment rate, Brigham said, maybe because federal stimulus funds have allowed more people to afford COBRA, the program that helps workers keep their insurance after job loss or reduction. However, rising unemployment has perhaps kept HSF’s enrollment rate from flattening out. Magnuson has seen many new HSF patients who used to go to private hospitals they can no longer afford.

City health workers continue to bring more people into the program.

“The staff now have a system of trying to identify patients for Healthy San Francisco,” said George Ward, South of Market Health Center’s billing supervisor. “Once you’re eligible, if you don’t try to enroll, someone will talk to you about it in each step of the process.”

Evaluating the model

In just two years, Healthy San Francisco has achieved many of its stated goals as well as revealing challenges to providing care to the uninsured, a key aim of the national reform effort underway in Washington, says Nadereh Pourat, of UCLA’s Center for Health Policy Research.

“I can think of a lot of lessons that could be learned, whatever happens,” said Pourat.

For example, the medical-home model can help “change the delivery of care under any system.”

Pourat and her colleagues are evaluating HSF and the statewide HCCI through surveys and statistics on enrollment, access and care. The evaluation may help determine the future of HSF in 2010, when federal funding expires with the possibility of renewal.

Although San Francisco Mayor Gavin Newsom promotes HSF as a model for the nation, Brigham pointed out that HSF significantly differs from current national proposals in that it is not an insurance plan. However, Brigham said, there are “a lot of similar principles.” These include shared responsibility for financing care and emphasis on prevention.

HSF already has company in another program of affordable care for the uninsured: Healthy Howard of Howard County, Md., started in January 2009.

Related Articles:

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