Recent Trends in the Use of and Capacity for Primary Health Care Services Among Travis County Safety Net Providers The Indigent Care Collaboration

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1 Recent Trends in the Use of and Capacity for Primary Health Care Services Among Travis County Safety Net Providers The Indigent Care Collaboration Sandy Coe Simmons, Director of Research and Evaluation Paul Gionfriddo, Executive Director October 2003

2 Executive Summary In calendar year 2002, key Travis County safety net providers increased the number of medical slots and appointments available to the public daily by 8 and 14% respectively, by increasing provider staff at several locations. In addition, while the total dollars dedicated to the safety net provider clinic budgets increased by 11%, the average cost per visit increased by 7% from 2001 to 2002, and the average cost per patient rose by over $50 in this time period. While the overall number of uninsured patients seen by all providers decreased slightly from 2001, the average number of visits per person increased slightly. These are highlights of the second annual survey of Travis County safety net providers conducted by the Indigent Care Collaboration (ICC). The survey reveals that these providers are predominantly serving pediatric and adult patients under age 65, a majority of whom are non-english speaking patients. Data from these providers indicate: Over 83,000 patients were seen in CY 2002; Over one-third (34%) of patients were age 0 thru 18, and two-thirds (63%) were adults age 19-64; and Two-thirds of all patients (67%) have either no third party payment source, or are MAP or Seton Care Plus recipients, or are funded through other sources, such as Title V or Title X, which are not considered insurance. Furthermore, ICC survey data indicate that member agencies experienced an average of 3.1 visits per patient, which is the same as the average number of visits per person indicated in the 2001 national ambulatory survey data. The median no-show rate for appointments among providers was 24%. In 2002, Travis County safety net providers had the following capacity: 25 clinic facilities with 192 exam rooms; 52.3 FTE physician and mid-level providers; 951 clinical hours of operation each week; 954 medical slots available daily; and 1,151 medical appointments booked daily. 1

3 Introduction Recent reports by the U.S. Census Bureau revealed that not only did the number of people living in poverty in the U.S. rise in 2002 to nearly 34.6 million people, but the number of people without health insurance also rose to over 43 million. The main reason cited for the increase in numbers of uninsured was the continued decline of employersponsored coverage. Public programs such as Medicaid and the Children s Health Insurance Program (CHIP) covered more people, but not enough to offset the decrease in people covered through employer-sponsored programs. In addition, the Census Bureau report indicated that of those individuals living in poverty, 49% of those who worked full-time were uninsured. Texas had the highest percentage of uninsured in the nation in 2002 with 24.1 percent. The three-year average ( ) of percent of people in poverty for Texas was 15.3, compared to 11.7 for the nation as a whole. None of these figures are news for the Travis County safety net providers who are members of the Indigent Care Collaboration, or ICC. The ICC is a coalition of safety net providers in Travis, Hays, and Williamson counties. Many of these providers within Travis County also accept patients from Williamson and Hays counties, as well as the outlying counties of Bastrop, Burnet and Caldwell. In this report, we set out to describe the current use and capacity of major safety net primary care providers in Travis County, based on actual visit data as reported to us by these providers in a survey completed in September Collectively, these data continue to paint a compelling picture of the safety net stress that has not improved significantly from A map of the ICC member agencies is provided below. 2

4 Map of ICC Consortia Member Service Area Locations Jonestown Jonestown Lago Vista Lago Vista Anderson Anderson Mill Mill Pflugerville Pflugerville Travis Travis Travis rcliff rcliff Travis Travis Northeast Northeast 35 Hudson Bend Hudson Bend Hurst Hurst Hurst Hurst Hurst Creek Creek Creek Arm Arm Arm way way Manor Manor Colorado Colorado Colorado River River River TR RA AV V II S S T Austin Austin Austin Austin 183 Walter Walter Walter EE E Walter Walter Walter E Long Long Long Long Long Long Town Town Town Town Town Town 290 Sunset Sunset Valley Valley Bear Bear Creek Creek Garfield Garfield 71 M II LL A AM M M AN NO O LL LL A W II LL LL II A AM M SS O ON N W BU UR RN NEETT B BU UR R LL EESS O O B EESS PP II EE RA A VV II SS TT R LL EEEE B LL A AN NC CO O B W WA A BA A SS TT R RO O PP B H HA A YY SS K EEN ND DA A LL LL K A YY EETT TT EE FF A CA A LL D DW W EELL LL C CO OM MA A LL C UA G GU AD DA A LL U U PP EE C CO O LL O OR ICC Aff iliated Public Clinic Williamson County Public Clinic Planned Parenthood Clinic Source: ICC Member Agency Data People's Community Clinic ICC Aff iliated Rural Hospital ICC Aff iliated Hospital 3

5 Community Needs and Utilization of Services The U.S. Census Bureau 2001 estimates the population for Travis County to be over 833,000 individuals, up from 812,000 in The population for the tri-county area is over 1.2 million, with an average uninsured rate of approximately 24%, or over 280,000 individuals. Census data also reflect a significant percentage of individuals at or below 200% of the federal poverty level by county, namely 29% in Hays, 28% in Travis, and 14% of the population in Williamson. Many of these individuals are employed but uninsured and are the clientele of the ICC member agencies. Among the most urgent health needs of this project s target population, especially those with chronic conditions, is the access to primary and specialty care services and the prescription medications that accompany those services. As of August 2003, there was a four-month waiting list for appointments at the local Cardiology specialty clinic and a seven-month waiting list for the Diabetes specialty clinic. Data from the ICC s Master Patient Index/Clinical Data Repository reflect almost 300,000 visits by uninsured and other low-income patients to a combination of thirteen primary care clinics, five Planned Parenthood clinics, and seven hospitals during the first nine months of Hospitals continue to see a large number of spill over patients from primary care providers. Data from the MPI/CDR through August 2003 also reveal that patients from cities within Bastrop, Burnet and Caldwell counties travel up to 40 miles to ICC safety net providers located in and around Travis, Hays and Williamson counties, because very few independent providers exist in these outlying counties. Several of the Travis county ICC members who do not have restricted service areas reported in their surveys that a range of anywhere between 5% and 14% of their clients were from outside of Travis County. While the providers surveyed for this report are physically located within Travis County, many of them nonetheless provide services to a population from outside of the county limits. See map of patient locations below. 4

6 Count of ICC Patient Encounters by Zipcode A S O N L L A N O B U R N E T W I L L I A M S O N M I L A M B U R L E G I L L E S P I E B L A N C O T R A V I S L E E W A H A Y S B A S T R O P E R A K E N D A L L C O M A L C A L D W E L L F A Y E T T E GUADALUPE CO O M C C U L L O C H C O R Y E L L L A M P A S A S S A N S A B A F A L L S L E O N H O U R D B E L L R O B E R T S O N M A D I S O N M A S O N L L A N O B U R N E T W I L L I A M S O N M I L A M B R A Z O S W A L K E R B L E B U R L E S O N G R I M E S S A G I L L E S P I E T R A V I S L E E B L A N C O W A S H I N G T O N K E R R B A S T R O P H A Y S A U S T I N K E N D A L L F A Y E T T E C A L D W E L L C O M A L B A N D E R A M O N T G O H A R R M MEDINA B E X A R G U A D A L U P E G O N Z A L E S C O L O R A D O F O R T B E N D Source: ICC MPI/CDR August 2003 Count of ICC Patient Encounters by Zip Code 0 to 100 (2574) 100 to 300 (19) 300 to 2,500 (42) 2,500 to 4,500 (2) 4,500 to 6,030 (7) 5

7 The updated demographic profiles for Travis County from the 2001 census estimates are summarized in Table 1. Table 1 Demographic Profile of Travis County Compared to the State of Texas 1 Category Travis County State of Texas Population, 2001 estimate 833,797 21,325,018 Percent of persons under 5 years 7.2% 7.8% Percent of persons under 18 years 23.8% 28.2% Percent of persons age 65 or over 6.7% 9.9% Percent White persons, not of Hispanic/Latino 56.4% 52.4% origin Percent Black or African American 9.3% 11.5% Percent persons of Hispanic or Latino origin 28.2% 32.0% Percent of Asian persons 4.5% 2.7% Percent of American Indian, Alaska Native, Native Hawaiian and Other Pacific Islander.7%.7% Language other than English spoken at home, percent age 5 and above, % 31.2% Per capita money income, 1999 $25,883 $19,617 The recent ICC Use & Capacity survey reveals that Travis County safety net providers are serving patients that are primarily adults (63%) and children age 0 12 (24%). In addition, nearly one-third (27%) of all safety-net provider patients are Medicaid, a few (5%) are Medicare, but the majority of patients have no form of public or private insurance (44%). A summary of the Travis County safety net provider population is provided in Table 2. In 2002, patients averaged 3.1 visits per person to the safety net providers, which right in line with the 2001 average number of office visits per person reported by the National Ambulatory Medical Care Survey 2. 6

8 Table 2 Summary of Travis County Safety Net Provider Population Data Category Number/Percent of Population Pediatric Patients (age 0 12) 24% Adolescent Patients (13 18) 10% Adult Patients (19-64) 63% Geriatric Patients (65 +) 3% Patients with Medicaid 27% Patients with CHIP 1% Patients with City/County Medical Assistance Program (MAP) 11% Patients with Seton Care Plus 5% Patients with No Insurance 44% Patients with Medicare 5% Other (Title V, X, XX) 7% Estimate of non-english speakers 40% Average number of visits per patient in Average number of visits per patient in Average number of visits per patient in Average cost per patient in 2002 $ Average cost per patient in 2001 $ Average cost per visit in 2002 $ Average cost per visit in 2001 $95.02 The increasing average number of visits per patient over the three-year period holds a combination of good news and bad news for providers and the health care delivery system. On the one hand, as visits creep up toward national averages, this reflects a patient population obtaining increasing amounts of their primary health care in true primary care centers, as opposed to hospital emergency departments. This reduces overall cost to the delivery system, and stress on emergency departments and specialty care providers. On the other hand, the additional visits are likely to be visits of sicker patients, adding to costs. As costs per patient and visit increase, this puts additional strain on the primary care providers examination time, pharmacy and other resources, and bottom lines. In addition, more visits per patient translates into the capacity to serve fewer patients overall, meaning that wait times for appointments also increase, and/or that more patients are turned away. Finally, even if these problems were to be overcome, the creep up is 7

9 still slow, and the region has a long way to go before it meets the national standards. See Figures 1 and 2 below. Average Number of Visits Per Patient Average Number of Visits Year Figure 1 Travis County safety net providers saw over 83,000 patients in calendar year For those providers other than People s Community Clinic, this represents an increase of nearly 1% compared to Because People s changed its methodology for reporting patients between 2002 and 2003 to conform to the approach used by the other safety net provider, People s data cannot be compared to the previous year s data. However, nearly all providers reported, on an anecdotal level, either needing to delay significantly appointments for substantial numbers of patients, or just turn them away because they were unable to schedule appointments. 8

10 Average Cost per Visit and Average Cost per Patient $ $ $ $ $- $50.00 $ $ $ $ $ $ Avg Cost per Person Avg Cost per Visit Figure 2 Capacity Data The capacity for services in an area can be determined by a number of factors including the number of providers, number of exam rooms, hours of operation and scheduling policies. A summary of capacity data for Travis County safety net providers is listed below in Table 3. Several ICC member agencies added provider staff from 2001 to 2002 in order to address capacity issues 9

11 Table 3 Summary of Capacity Data for Travis County Safety Net Providers Category Number/Percent Number of Clinic facilities 25 Number of Exam rooms 192 Total Hours of Operation (week) Number of Direct care providers FTEs 52 Clinical Hours (week) 497 Number of medical appointments (daily) 954 Number of medical appointments booked (daily) 1,151 No show rate (average) 24% Annual Clinic budgets Total all clinics $26,228,222 The Medical Group Management Association (MGMA) completes an annual survey of Physician Compensation and Production. The MGMA 2001 report based on 2000 data surveyed 2216 family practice physicians in 281 practices and found that in a typical Family Practice environment (without OB services) a provider will manage an average of 4,584 patient encounters per year. The 52 FTE providers managed over 258,000 patient encounters in 2002, which is 8.5% over capacity. ICC Responses One of the goals of the ICC is to help improve the efficiency of the local area safety net providers, thereby having an impact on the providers capacity to serve the uninsured in Travis County and Central Texas. One way to increase efficiency is to reduce preparation time by providers and clinic staff by ensuring that the appropriate information is readily available and easily accessible to providers. Another way of increasing efficiency of providers is to reduce duplication of effort that exists between the multiple agencies within the regional healthcare system. The establishment of the Internet based Master Patient Index/Clinical Database Repository (MPI/CDR) is seen as the foundation of increased efficiency for regional safety net providers. As it implements this tool, the ICC is able to provide the regional safety net providers with realistic unduplicated counts of uninsured patients, and with more complete health records that include individual patient encounter histories drawn from the medical records of multiple safety net providers. The MPI data include demographics on who these patients are (age, race/ethnicity, etc.), and from where they come (county level data based on zip code). The MPI/CDR also allows providers to have electronic access to clinical information, including patient visits to other providers and diagnoses, that was previously unavailable to them. 10

12 As of October 2003, the MPI/CDR contained over 225,000 names and over 365,000 clinical and pharmacy encounters. Eight ICC members were contributing data since December 2002, with the others scheduled to begin in late 2003 and early 2004, seven member agencies were collecting authorization forms from patients and, over 20 clinical users had access to over 24,000 patient records that were authorized for exchange. All of these numbers were increasingly rapidly. The Project Access initiative, developed as a collaborative venture between the ICC and one of its members, the Travis County Medical Society (TCMS), is another response both to building safety net system capacity and to meeting increasing service demands. With Project Access, the ICC and TCMS are staying true to the original Project Access model, developed in Buncombe County, North Carolina, in which both primary and specialty care physician commit to treating a set number of uninsured patients each year, in return for improved access to referral settings, pharmaceutical assistance programs, and case management services. Project Access had over 600 total providers enlisted and 100 patients enrolled as of October 2003, with plans to expand patient enrollment to 300 to 500 by the spring of TCMS was in the process of seeking additional resources to cover expected or unexpected demands for pharmaceuticals, considered to be the greatest limiting factor on patient enrollment. Like safety net providers around the country, the ICC members regard increasing pharmaceutical costs to be the greatest barrier to accessing quality health care for patients with no financial resources. As a result, in response to increasing demand, ICC members have undertaken two strategies to make pharmaceuticals more available at lower cost to the uninsured population. Members are attempting to reduce their costs by (1) expanding participation in the 340B program through a series of creative new arrangements among traditional 340B eligible providers and non-340b eligible providers, and (2) working to centralize Pharmacy Assistance Program functions to make free pharmaceuticals available to more patients. Finally, ICC members are working collaboratively to reduce the number of uninsured patients in the area, as well. Using a common program eligibility tool, called Medicaider, ICC members and other community partners had completed over 20,000 eligibility screenings of uninsured patients as of October Of those screened, approximately 15% were eligible for a medical assistance program, typically Medicaid or CHIP, that would take them off of the rolls of the uninsured. The ICC partners have expanded the use of the Medicaider too to more than 100 eligibility screeners in 29 different locations. In addition, the ICC has committed to following up with eligible patients to ensure that they completed the application process. By October, nearly 500 patients had been moved from uninsured status to 3 rd party-funded programs through this effort, yielding nearly a million dollars of actual revenue. 11

13 Conclusions In 2001, ICC member agencies were operating above their own capacity for primary care services in order to meet the demand for such services in the community. In spite of member agency reaction to this demand by increasing the number of provider staff and appointment slots in 2002, the demand for primary care services continues to outpace the ability of these agencies to provide the services to everyone in need. Patients at community based provider facilities are being turned away due to lack of availability of appointments on a more regular basis than ever before, leaving them with no other option than to access care in a facility where they cannot be turned away. Increasingly, safety net providers report that these patients are no longer just the lowincome working poor, but include laid off workers who have lost (or are no longer able to afford) their continued health insurance option through the federal COBRA option. The ICC and the Central Texas safety net providers believe that the implementation of the MPI/CDR will result in cost savings for the providers, in terms of reduced duplication of effort, especially in the area of procedures and diagnostic tests ordered and/or performed. In addition, the availability of diagnostic information on patients, including any hospital visits, prior to a safety net clinic visit, can improve provider efficiency during the office visit and as well as improve the health outcomes of those patients who receive services from these providers. By improving the health of the community as well as the health of the community safety net system, the ICC and its partners strive to address both the demand and the capacity for primary care services in Central Texas. 12

14 References: 1. U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, 2000 Census of Population and Housing, 1990 Census of Population and Housing, Small Area Income and Poverty Estimates, County Business Patterns, 1997 Economic Census, Minority- and Women-Owned Business, Building Permits, Consolidated Federal Funds Report, 1997 Census of Government. 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics: National Ambulatory Medical Care Survey: 2001 Summary. 13