L.A. County expands no-cost healthcare

CAL/AAEM News Service calaaem.news.service1 at gmail.com
Mon Oct 24 19:20:18 PDT 2011

Description: Description: Description: Description: CAL/AAEM: California
Chapter of the American Academy of Emergency Medicine

October 9, 2011


L.A. County expands no-cost healthcare 




By Anna Gorman



Hoping to establish new programs before Medi-Cal takes over in 2014, it
plans to register as many as 550,000 patients and assign them to medical
clinics for free services.


In one of the largest expansions of health coverage to the uninsured, Los
Angeles County is enrolling hundreds of thousands of residents in a publicly
funded treatment program and setting the stage for the national healthcare


The county hopes to register as many as 550,000 patients and is assigning
them to medical clinics for services at no cost to them. At the same time,
the county is transforming its healthcare system to be less focused on acute
care and more on primary care. The changes are expected to reduce costs,
streamline care and attract patients.


Under President Obama's controversial healthcare overhaul, millions more
uninsured Californians will be eligible for Medicaid - the healthcare
program for the poor - beginning in 2014. Even as the debate over the law
continues in Washington, California is starting that expansion now and using
federal dollars to do so. Altogether, the state expects to receive $2.3
billion to expand and modernize its Medicaid program, known as Medi-Cal, now
available only to certain low-income residents.


In L.A. County, the stakes are high. In 2014, the newly insured county
residents will be able to seek treatment wherever they want. To keep them
with the county, health leaders recognize that they must make the system one
of choice rather than of last resort. Otherwise, the only patients left will
be illegal immigrants and others still ineligible for public coverage.


"Our survival depends on it," said Mitchell Katz, director of the county
Department of Health Services. Unless the healthcare system improves, he
said, "if people have choice, they won't choose us and the system will


Health departments across the nation are watching L.A. County, where nearly
one-quarter of the 9.8-million population is uninsured. If the county is
successful in expanding coverage and revamping its healthcare system,
observers say, it could become a model for others.


But that won't be easy.


"The scale here is just mind-boggling," said Andy Schneider, a consultant to
the Kaiser Family Foundation. "And there are so many changes that have to
occur simultaneously.... It's like trying to reorganize the health system of


Health workers began signing patients up for a program called Healthy Way
L.A. in July and so far have enrolled 24,000, many of whom are receiving
services. County residents are eligible if they are between the ages of 19
and 64, citizens or permanent residents of five years and earn less than
133% of the federal poverty level (about $14,500 for an individual and
$29,700 for a family of four).


The coverage is not insurance and cannot be used outside of L.A. County, but
it does give patients the ability to receive free primary and specialty
care, mental health services, chronic disease management, medication and
emergency treatment. Most of the enrollment is being done when patients go
to the county's network of hospitals and clinics. 


Advocates are closely tracking the expansion and said they have found
several problems, including lack of translated documents, delays in setting
up appointments and extensive patient paperwork, said Barbara Siegel,
managing attorney at Neighborhood Legal Services of Los Angeles.


"We have to get it right so that in 2014, the county continues to play that
critical role in providing healthcare to our indigent population," she said.


Over the next two years, the county will pay half the cost for Healthy Way
L.A. - or about $300 million - and the federal government will pay the other
half. By 2014, when the patients become eligible for Medi-Cal, the federal
government will pick up the entire tab, which will help bolster the
financially strapped county's health system. The county also expects to
receive about $300 million more for other changes.


"It's the county's job to provide care for the uninsured," Katz said. "If I
have an opportunity to get half of that paid for by the federal government,
I'd be a fool not to take it."


Healthy Way L.A. and other programs throughout the state will ensure that
there isn't a flood of new patients or any delay in receiving federal
dollars for their care in 2014, said Anthony Wright, executive director of
the California advocacy group Health Access.


"We are taking this two years to get fully ramped up so we are ready on Day
One," Wright said. "The more Los Angeles [County] enrolls people in the next
two years, the more folks will be on the federal rather than the county


Just three months in, county health officials are already encountering
obstacles. Outdated technology and a lack of electronic records are causing
delays and making it difficult for doctors to effectively manage care. And
moving people away from urgent care has required a massive culture shift.


"Old habits are hard to break," said Ernest Espinoza, administrator of the
El Monte Comprehensive Health Center. "Everyone was entrenched - both staff
and patients."


One of those habits was using specialists as primary-care doctors. The
county recently moved 4,000 patients - who were getting all their medical
care from neurologists, cardiologists and other specialists - back to
primary-care doctors. That makes more room for people who need specialists
and decreases wait times for appointments, Katz said.


Perhaps the biggest change has been the creation of medical homes, clinics
where patients receive consistent, comprehensive primary care by the same
team of providers. The El Monte center, which has enrolled about 1,200 new
patients in Healthy Way L.A., is one of the first in the county.


Administrators at the El Monte center are assigning patients to specific
doctors, expanding clinic hours and allowing more same-day appointments.
They are also urging patients to call the 24-hour nurse advice line, rather
than go to a hospital emergency room, and they are offering health education
classes and mental health services on site. The goal, Espinoza said, is to
build a relationship with patients so they keep coming back.


Evan Ramirez, 50, is an uninsured cancer survivor who said she typically
goes to the emergency room when she gets sick. But if she has to buy
medicine, she said, "there isn't enough for food." Ramirez learned last week
that she could enroll in Healthy Way L.A. and planned to return to the El
Monte clinic with the remaining paperwork. "For me, it's a great benefit,"
said Ramirez, whose only income is from baby-sitting her grandchild.


Chee To, 60, who works as a caregiver and recently became covered under the
new program, went to the clinic last week to follow up on her diabetes and
high blood pressure. To said she liked seeing the same doctor twice. "If I
see other doctors, they don't understand my medical condition as well," she


The clinic's adult medicine chief, Dennis Wong, said he is able to develop
relationships with his patients and follow their progress. "That continuity
is very important, not only for the patients but for us," he said.


The UCLA Center for Health Policy Research is evaluating Healthy Way L.A.
Its associate director, Gerald Kominski, said it is too early to tell how it
will turn out, noting that changing behavior is difficult.


"You are talking about a population that is accustomed to being uninsured,"
he said. "So they have had a lifetime of only seeking care when it is
absolutely necessary and going to the emergency room."

Emergency departments are increasingly serving as the safety net for
medically underserved patients, especially adults with Medicaid, a study
published in the Journal of the American Medical Association concluded. As
evidence of this trend, the co-authors point to the rise in rates of visits
to EDs in the U.S. among adults on Medicaid.


The rate at which adults with Medicaid visited emergency departments climbed
from 694 to 947 visits per 1,000 enrollees between 1999 and 2007.


The researchers also looked at the change in the number of emergency
departments classified as safety-net facilities--which they defined as those
that provide more than 30 percent of total ED visits to persons with
Medicaid, more than 30 percent of total ED visits to uninsured individuals,
or a combined Medicaid and uninsured patient population that exceeds 40
percent. Those facilities rose 41 percent to 2,489 from 1,770 between 2000
and 2007. The data comes from the 2007 National Hospital Ambulatory Medical
Care Survey.


Rising Medicaid enrollments could lead to more crowding in emergency
departments, co-author Ning Tang, assistant clinical professor of medicine
at University of California, San Francisco, told DOTmed.


"Since enrollment in Medicaid continues to rise in this recession and with
the new healthcare reform law, we are concerned that this rising enrollment
will lead to more ED crowding," Tang said.





Marcus Williams &
Brian Potts MD, MBA
Managing Editors, CAL/AAEM News Service



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