Eliminating the Safety Net

Back Article Jan 21, 2016 By Dr. Jonathan Porteus

The concept of a safety net sets off alarm bells for many administrators and public health professionals. It connotes duplication, inefficiency, incoherence and a 2-tiered health delivery system. It misses the very real business opportunities and positive health impacts that have emerged for the entire population.

A safety net is a last resort, often dangerous to jump into, but perhaps not as dangerous as not jumping. It’s also a rather small patch of safety, moved around with the hope of catching people and implying there may be another net here and there,  or wide open areas without any net at all. And how do people transition from one net to another? This seems like an awful way to describe a health delivery system that, just in 2014, saw the conversion of 122,000 people into MediCal in Sacramento County alone, bringing the overall number of those enrolled to well over 400,000.

Without health coverage, many in our region’s low-income population have historically used costly urgent or emergency care settings to get treatment, often waiting until conditions have become dangerous. The stellar episodic care afforded in those settings is then often squandered when people return to the community but have to manage their own care and can only access a patchwork of primary care and prevention services. It’s for this reason that in my organization, we have historically referred to leaving the safety of treatment in a hospital system as “walking the plank.”

The last few years have seen the landscape of safety nets in the Sacramento region transform into what I like to call a “blanket of care” — a true integrated health care continuum. Coordinating care services requires, and breeds, health and fiscal efficiency. This efficiency has engendered a cascade of business opportunities in construction, the health professions and the service sector. Furthermore, a healthier population means a more engaged population of adults in the workforce, children more readily able to focus on their academics, and families focused on wellness instead of illness.  

A blanket of care means that the full health care continuum (spanning from prevention and  primary care to specialty care and acute/inpatient care) is well-defined. Care is driven down to its least restrictive, least expensive and most preventive level. Transition mechanisms ensure seamless continuity from one level of care to another. This new treatment system re-engineers investments in and around the care continuum and its ancillary businesses, moving the population towards increasingly better health. Higher costs at one level of care are managed, and the returns yielded enable new and smaller investments in lower levels of care — to stop the higher costs from re-occurring. Improved health for the population, particularly those previously without access to health care, leads to less resource burden on the overall system, as well as potential economies of scale for providers who may not have worked with the MediCal population in the past.

In Sacramento County, about 7 to 8 cents of every MediCal dollar is spent on primary care services, while the remainder is spent on specialty and acute/inpatient care.  This makes a lot of sense as much of the MediCal population is relatively sick, new to health coverage and has traditionally received sporadic, episodic or no treatment. Now, a greater proportion of persons have coverage (since 2014, our uninsured rate has dropped from around 28 percent to 20 percent of all primary care visits) and are enrolled through health plans such as Anthem, HealthNet, Molina, Kaiser, and California Health and Wellness –— who either directly contract for primary care services or contract with a third-party independent physician association. Primary care is delivered through federally qualified health centers, clinics and some of the treatment affiliates of the plans themselves (e.g. Molina and Kaiser). Individuals and medical groups provide specialist care, and acute care is offered through contracts with the region’s health systems.  

Obviously, some of the initial efforts have focused on increasing primary care accessibility. This includes both a brick-and-mortar approach (building new exam rooms) as well as care management efficiency (using existing exam rooms more efficiently). Other outreach and enrollment initiatives have supported access to insurance and entitlements, getting people enrolled in the coverage that drives this new economy. The adoption of electronic health records helps providers coordinate between one another to reduce the cost and relative inaccessibility of some specialty care — so that treating MediCal patients becomes a value option. Still other efforts have focused on providing people with the right care in the right place, exemplified by programs like T3 (triage, transport, treat). This program engages people who have been using emergency departments for non-urgent care, brings them out to local community health centers and establishes them as long-term recipients of preventive and primary care.

The Sacramento region is in the midst of a major transition, with the abandonment of safety nets and the adoption of a far more integrated care delivery system that demands and pays for services for the MediCal population. This new system will rely on innovation, and will ultimately be driven by quality and care delivery at the right level in the continuum. The creation of a basic foundation of preventive and primary care access has been the weakest link, but it is strengthening. Interestingly, this was the case with the adoption of RomneyCare in Massachusetts, which caused a temporary run on higher levels of care as people became covered by insurance, but drove statewide emergency department utilization down permanently below pre-RomneyCare levels once community-level access had been strengthened.