Health Professional Shortages in the San Joaquin Valley: The Impact on Federally Qualified Health Clinics

1. Health Professional Shortages in the San Joaquin Valley: The Impact on Federally Qualified Health Clinics

2. The Central Valley Health Policy Institute is funded through a grant from The California Endowment.

3. CVHPI History and Overview Established in 2002 and funded in 2003 by The California Endowment to solve the region�s health issues and educate decision makers and community leaders Focuses on health policy issues in 8 San Joaquin Valley Counties Regional Advisory Council of community and health leaders provides input and feedback to the Institute San Joaquin, Stanislaus, Merced, Madera, Fresno, Kings, Tulare and KernSan Joaquin, Stanislaus, Merced, Madera, Fresno, Kings, Tulare and Kern

4. Institute Objectives Based on community feedback on needed research and education Conduct Valley- focused research and policy analysis Train emerging leaders Provide master�s level training in health policy Connect evidence-based research with policy makers Promote collaboration to solve health system problems

5. Research Focus (current and future) Uninsured adults in the San Joaquin Valley Environmental influences on health Chronic diseases, mental health and substance abuse Health Professional Shortages

6. Acknowlegements Dr. John Capitman, Executive Director Cheryl Paul, Administrative Analyst Laurie Primavera, Associate Director Dr. Marlene Benjiamin, Research Associate Dr. Mathilda Ruwe, Research Associate Cheryl: Editing and DesignCheryl: Editing and Design

7. Introduction Developed and conducted a survey in an effort to respond to regional concerns regarding health professional shortages (HPS) and their effect on the health of Valley residents Three primary objectives: Describe impact of HPS on access to primary care in the SJV Describe current patterns of health resources coming into the valley Identify new approaches to addressing the consequences of HPS

8. Background All 8 counties have medically underserved areas/populations designations with Madera listed as a county-wide MUA/P All counties have shortage designations for primary care, dental and mental health Six of the eight counties have county-wide mental health shortage area designations MUA/MUPs qualify for PHS Section 330 Grant (FQHC and LookAlike), new start/ expansion program, and RHCs certification HPSA eligible for National Health Scholarship Corps Personnel, Education loan repayments for providers, RHC certification, and 10% Medicare incentive payment for physician servicesMUA/MUPs qualify for PHS Section 330 Grant (FQHC and LookAlike), new start/ expansion program, and RHCs certification HPSA eligible for National Health Scholarship Corps Personnel, Education loan repayments for providers, RHC certification, and 10% Medicare incentive payment for physician services

9. Background A recent report from the California Institute for Nursing and Health Care2 calculated a national average number of filled registered nursing (RN) positions (both full-time and part-time) at 787 per 100,000 persons and compared that average to California and 24 metropolitan statistical areas (MSAs) in California. MSA is a geographic entity defined by the US Office of Management and Budget A metro area contains a core urban area of 50,000 or more population, and Each metro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. A recent report from the California Institute for Nursing and Health Care2 calculated a national average number of filled registered nursing (RN) positions (both full-time and part-time) at 787 per 100,000 persons and compared that average to California and 24 metropolitan statistical areas (MSAs) in California. MSA is a geographic entity defined by the US Office of Management and Budget A metro area contains a core urban area of 50,000 or more population, and Each metro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core.

10. Background Northern/Sierra counties: Sacramento: Sacramento, Placer, Yolo, El Dorado Greater Bay Area: Santa Clara, Alameda, Contra Costa, San Francisco, San Mateo, Sonoma, Solano, Marin, Napa Southern California: Los Angeles, Orange, San Diego, San Bernardino, Riverside, Imperial Central Coast: Ventura, Santa Barbara, Santa Cruz, San Luis Obispo, Monterey, San Benito State of California, Department of Finance, (2005). "E-1 City / County Population Estimates with Annual Percent Change�January 1, 2004 and 2005 2 American Medical Association, (Dec. 16, 2005). �Physician- Related Data Resources� 3 Includes family medicine, family practice, general practice, general preventative medicine and public health, internal medicine, obstetrics and gynecology, pediatrics 4 Selected specialists based on those with the most problematic access for uninsured as reported by the California Healthcare Foundation . Specialties included are Specialists include: Allergy/immunology; dermatology; endocrinology, diabetes & metabolism; gastroenterology; nephrology; neurology; occupational medicine; orthopedics and sports medicine; otolaryngology; neurological surgery; physical medicine and rehabilitation; psychiatry; pulmonary conditions; surgery (other than vascular surgery); urology; vascular surgeryNorthern/Sierra counties: Sacramento: Sacramento, Placer, Yolo, El Dorado Greater Bay Area: Santa Clara, Alameda, Contra Costa, San Francisco, San Mateo, Sonoma, Solano, Marin, Napa Southern California: Los Angeles, Orange, San Diego, San Bernardino, Riverside, Imperial Central Coast: Ventura, Santa Barbara, Santa Cruz, San Luis Obispo, Monterey, San Benito State of California, Department of Finance, (2005). "E-1 City / County Population Estimates with Annual Percent Change�January 1, 2004 and 2005 2 American Medical Association, (Dec. 16, 2005). �Physician- Related Data Resources� 3 Includes family medicine, family practice, general practice, general preventative medicine and public health, internal medicine, obstetrics and gynecology, pediatrics 4 Selected specialists based on those with the most problematic access for uninsured as reported by the California Healthcare Foundation . Specialties included are Specialists include: Allergy/immunology; dermatology; endocrinology, diabetes & metabolism; gastroenterology; nephrology; neurology; occupational medicine; orthopedics and sports medicine; otolaryngology; neurological surgery; physical medicine and rehabilitation; psychiatry; pulmonary conditions; surgery (other than vascular surgery); urology; vascular surgery

11. Methodology Surveyed 8 Federally Qualified Health Clinics (FQHC) with 60 clinic sites in the San Joaquin Valley Clinics serve almost 300,000 patients, providing over one million visits/year Conducted by telephone (5), in person (2), by email (1)

12. Methodology

13. Methodology Quantitative: The survey asked participants to rate how important or how often various clinic, patient, access dynamics were a factor in providing health care (17 questions) Qualitative: 15 open ended questions allowed clinics to express their unique experiences and strategies in addressing those factors

14. Quantitative Analysis Results All sites rated access to specialists and site limitations as very or extremely important in limiting their clinic�s ability to provide health care The majority of clinics rated other medical services, substance abuse, mental health and case management referrals as difficult most of the time or almost always

15. Quantitative Analysis Results When comparing referral difficulty by insurance status, the majority of clinics noted that uninsured had difficulty accessing specialists half or more than half of the time (exception was nephrology) For Medi-Cal patients access was difficult half or more than half of the time for 7 out of 20 specialties Paradoxically, for some specialties clinics reported difficult access more often for their Medi-Cal patients than their uninsured patients

16. Quantitative Analysis Results Factors rated extremely important in limiting access to specialists by all sites were Medi-Cal and county indigent program reimbursement rates All clinics ranked low numbers of providers accepting Medi-Cal or uninsured patients and excess demand for specialty care as extremely or very important The low number of regional specialists was ranked as extremely important by � of the clinics and important or very important by the other �.

17. Results of Qualitative Analysis Four recurring themes Inadequacy of Funding Recruiting Issues Capacity Specialty Access

18. Strategies to Reduce the Impact of Professional Shortages Taking advantage of multiple federal, state and foundation funding opportunities Participation in Health Disparities Collaboration Programs Develop informal and formal relationships for providing non-physician services Increased use of technology to increase clinic efficiency

19. Recommendations Modify and increase reimbursement rates Health Policy Changes Workforce Development �Demand that community providers accept Medi-Cal and uninsured patients�

20. Recommendations Educate the public as to the breadth and benefits of services FQHCs provide to the community Policy changes to remove 5 yr practice restrictions for Dentists coming to CA Continue the vision of developing �an integrated and collaborative model of patient care for FQHCs as advocated but not funded by federal, state and private funders�

21. Next Steps Survey expansion to document experiences from other community clinics in the SJV and state Explore the feasibility and barriers to implementing policy recommendations Clarify what statute or regulatory changes are needed to allow clinics to hire specialists as staff with appropriate reimbursement. Also determine their impact on health outcomes and clinic solvency

22. Next Steps Another area for further study is to evaluate the effect of advancing the use of community health workers or �promotoras� in the community clinic model for use as practice extenders including: Best practices in training and scope of practice Sustainable funding/reimbursement

23. Conclusion These findings can be used to: Compare differences between primary care settings To evaluate regional differences in the impact of HPS To provide direction to policy makers in resource allocation decisions

24. Conclusion Efforts such as these are critical to developing healthcare reforms that effectively address the needs of providers and their patients.

25. Report is available on the web at : http://www.csufresno.edu/ccchhs/HPI/images/HPSA%20Full%20Report.pdf Or you may go to publications at the CVHPI website: www.cvhpi.org