Provision of Indigent Health Care in San Mateo County
Findings:
Staff is in general agreement with the Grand Jury’s findings.
Recommendations:
The Grand Jury recommends that the San Mateo County Board of Supervisors:
1. Decide prior to May 2008 what level of indigent health care San Mateo County can provide given the available funds and demands of other San Mateo County programs.
Response: Concur. The County has been in the process of determining the cost of indigent healthcare services, and has hired the consulting firm of Health Management Associates (HMA) to review a financial analysis prepared by the Medical Center for its major service lines and payers. The County will use this information to develop the FY 2008-09 recommended budget for General Fund contributions related to (1) the County’s financial obligation under Section 17000 and (2) contributions in excess of the County’s Section 17000 mandate. The County will need to decide, as part of addressing its structural budget deficit, whether it will pay for a portion or all costs that exceed its Section 17000 obligation. The County is using HMA to help guide the decision making process by developing various options for the County to consider in determining the mix of services and payers that would create a financially viable system of care for indigent and uninsured residents. This work should be done in early 2008. It is anticipated that any decisions involving changes in the configuration of services or funding mix will be implemented over the course of several years.
2. Work with the County Manager to communicate a shared vision and message to the public concerning San Mateo County’s policy on subsidized health care.
Response: Concur. Before a vision on subsidized health care can be shared, the County must first have a clear understanding of what is currently being subsidized and at what cost. The County is mandated to provide health care for indigent residents under Section 17000 of the Welfare and Institutions Code. The cost to fund this mandate represents the “subsidy”, and any excess amount should be allocated at the Board’s discretion, either toward more health care services or toward other County programs and services. The County should not subsidize costs that can be funded by other payers, such as the state and federal government, and commercial payers. A shared vision on subsidized health care will be communicated as part of the January 2008 final recommendations from the Blue Ribbon Task Force on adult healthcare coverage, which will take into consideration the financial implications on existing County programs and General Fund contributions.
3. Commission a formal legal opinion as to San Mateo County’s minimum legal requirements under California’s Welfare and Institutions Code Section 17000 to provide medical care to the indigent. Once such minimum legal requirements are ascertained, the Board of Supervisors can knowingly decide whether San Mateo County should satisfy only the legal minimum or whether and to what extent it should exceed it.
Response: Agree. The County is currently in the process of revising its financial assistance policies for services provided by the San Mateo Medical Center. The Board approved the policies in December 2005. Subsequent changes in legislation, as well as identified improvements from the screening and verification pilot, need to be incorporated into the policies, which will be brought to the Board in December 2007. County Counsel will be requested to provide a formal legal opinion on minimum legal requirements under Section 17000 of the Welfare and Institutions Code, which will be included in the policy revision process and presented to the Board in December.
4. Withhold implementation of any Blue Ribbon Task Force recommendation until the full financial implications, including impacts on other County programs, are well developed and understood. If any such recommendation is adopted, consideration should be given to its implementation initially as a pilot program so that no long-term commitment is made before its financial feasibility is established.
Response: Agree. Prior to the completion of Blue Ribbon Task Force final recommendations, County staff will incorporate information regarding the financial implications of proposed recommendations for County programs such as our current indigent care program and other health care programs that address the needs of residents with incomes below 400% of the Federal Poverty Level. The Blue Ribbon Task Force preliminary recommendations incorporate consideration of phased enrollment in accordance with available resources, as well as learning from local experiences, such as pilot projects aimed at improving access to healthcare and improving population health. The Blue Ribbon Task Force final recommendations will be completed in January 2008.
5. Issue a request for proposal (RFP) by October 1, 2007, to review public health care services provided by San Mateo County with particular emphasis on indigent care. Qualified proposals should demonstrate a high level of experience and active involvement with indigent care models in California. The RFP should include but not be limited to the following tasks:
(a) Ascertain the financial strengths and weaknesses of the San Mateo Medical Center, including identifying all cost efficiencies, sources of revenue and consideration of the impact that any proposed change would have on such revenue sources.
(b) Identify the advantages and disadvantages of different payer or hybrid models as compared to San Mateo County’s provider health care system, including the fiscal, medical, and social effects of each.
(c) Consider the impact of shortages of primary care physicians, nurses, dentists and specialist physicians amid increasing demand for medical services.
(d) Estimate the number of uninsured and under-insured patients and plan for future increases in the cost of health care services for an aging population.
(e) Review how other public agencies are delivering service and where true efficiencies can be obtained.
(f) Determine how other communities have reduced costs and improved services, or at the very least, maintained a level of service.
(g) Consider how current and evolving state health care initiatives may impact any San Mateo County proposal.
(h) Consider the impact of health care issues that affect the whole San Mateo County community, such as the obesity epidemic, disparities in access to prenatal care, and a lack of access to preventative dental care.
Response: Concur. On June 11, 2007, the County entered into Phase 1 of an agreement with Health Management Associates (HMA) for the purpose of reviewing the internal financial analysis conducted by the Medical Center on its major service lines and payers, and preparing five-year financial projections, assuming no changes to the configuration of services at SMMC. The County Manager and executive management of SMMC, Health Department, and Health Plan of San Mateo selected HMA after proposals were solicited and interviews were conducted with HMA and another consulting firm with healthcare expertise. HMA specializes in public hospitals and the uninsured population, and has recent experiences in San Francisco and Los Angeles counties that were more relevant to the complex issues facing the County.
On September 25, 2007, the Board approved a contract amendment with Health Management Associates (HMA) for Phase 2 of the project. The firm will be interviewing and gathering information from County leadership, members of the Blue Ribbon Task Force on Adult Healthcare Coverage, County departments, other local hospitals and health care providers, community groups, physician groups, and others, and will develop various options for the County to consider in determining the mix of services and payers that would create a financially viable system of care for indigent and uninsured residents. Phase 2 should be completed in January 2008.
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