Transcript Proposal for Re-visioning the Delivery of Health Care

Re-visioning the Delivery of Health Care
Services to Uninsured Patients in Harris
County
Final Report
Prepared for
Save Our ERs
July 20, 2004
Table of Contents



Introduction
Study Approach
Drivers of Inappropriate Harris County ED Use






Key Findings
Conclusions
Models of Care in Other Communities
Components of a Care Re-visioning Framework
Strategic Options for Harris County
Study Conclusion and Recommendation
2
Introduction



In recent years, Harris Counties emergency care system has become
increasingly overburdened by growing emergency department (ED)
volume, particularly among uninsured non-emergent patients to
whom ED’s are substitutes for more appropriate, yet frequently
unavailable, community-based primary care.
Since 2001, conditions have worsened to the point that a study
commissioned by the “Save our ER’s” coalition (the Coalition)
concluded that the already overburdened emergency system is likely
to continue to decay to the point of collapse without corrective
action in the near term.1
This conclusion has helped create support among Harris Counties
health care and business communities that a substantive restructuring
of health care services is needed to reduce inappropriate ED use and
fragmentation of care.
1. Houston Trauma Economic Assessment and System Survey, Bishop+ Associates, prepared for Save our ERs, 2002.
3
Introduction (cont.)


The Lewin Group, Inc. (Lewin) was commissioned by the Coalition
to assist them in creating a framework for re-visioning the
organization and delivery of health care services in Harris County
by developing and examining three conceptually distinct and
credible options for reconfiguring care to safety-net populations
in Harris County.
Each option is arrayed by the degree of system re-organization
and resources required to undertake.


Expanding appropriate ambulatory care capacity.
Improving coordination of care.
Exploring options for restructuring city and county public health
functions.
 Building effective governance.

4
Study Approach




Key study questions and issues are complex, requiring
input from many data sources and informants.
Lewin’s methodology was multi-tiered.
Key elements included:
 Collecting and analyzing survey data from Harris
County providers and secondary quantitative data
sources.
 Conducting 20 on-site key informant interviews.
 Conducting over 40 telephone interviews.
 Conducting an environmental scan of promising
practices in five other communities that have
reorganized care for safety net populations.
 Interacting with key Harris Co. and other state
stakeholders on important study issues.
Findings were synthesized to develop three credible
options for reducing inappropriate ED use.
Qualitative
Quantitative
Observational
5
Study Approach (cont.)

Our approach to support development of three system reconfiguration
options is organized around an assessment of several key study
questions, including:




What are the magnitude and drivers of ED overcrowding in Harris County
and what are the implications of continuing the status quo?
What approaches for reducing in-appropriate ED use, building capacity and
better coordinating care have been successfully implemented in other
communities? What are the potential benefits and challenges of these
models for Harris County?
What are the objectives, major components and expected outcomes of
three alternative options for reducing inappropriate ED use and improving
access to care for the uninsured in Harris County?
The remainder of this study presents:
Our findings regarding the questions outlined above; and
 The key features, benefits and challenges of three distinct and
progressively more comprehensive options to reduce in-appropriate ED use
and improve access to care for safety-net populations in Harris County.

6
Magnitude and Drivers of Inappropriate
ED Use in Harris County
Magnitude of ED Use in Harris County

If current trends continue, Harris County ED use is projected to grow 38%
between 2002 and 2015, after increasing 48% between 1991 and 2002.
Total
ED Visits
in Harris
County
1991-2015
Trends
in Total
Harris
County
ED Visits 1991-2015
2,000,000
1,742,000
1,800,000
1,600,000
Total Visits
1,400,000
1,261,317
1,200,000
1,000,000
853,968
800,000
600,000
400,000
200,000
FY 1991
FY 2002
FY 2015 (Projected)
Sources: AHA and the Draft HCHD Strategic Plan
8
Magnitude of ED Use in Harris County:
ED Use Is Concentrated Among Houston Safety Net Hospitals
Source: Begley, Charles, et al. Houston Safety Net Hospitals Emergency Department Use Study: January 1, 2002 through December 31,
2002 Final Report November 18, 2003.
9
Magnitude of ED Use in Harris County:
Age Distribution of Harris County ED Users

Overall, most Harris County ED users are adults somewhat older than
Age distribution of ED visits in Harris County Hospitals
the general
population.
Age distribution of in Harris County
65+ Years
26%
0-18 Years
27%
65+ Years
7%
0-18 Years
29%
0-18 Years
19-64 Years
65+ Years
19-64 Years
19-64 Years
47%
n=17 hospitals
64%
Overall Harris Co.
Population
Sources: Lewin Survey of Harris County Providers, 2000 Census data
10
Magnitude of ED Use in Harris County:
Income and Status of Harris County Hospital District ED Users

The income of most HCHD ED users is above 250% of poverty and
most are US citizens.
HCHD ED visits by income distrbution
HCHD ED visits by Documentation Status
201%-250% of FPL
1%
Other
1%
Undocumented
Immigrants
16%
101%-200% of FPL
9%
Documented
Immigrants
9%
0%-100% of FPL
14%
Other
21%
250%+ of FPL
55%
U.S. Citizens
74%
n=2 hospitals
Source: Lewin Survey of Harris County Providers
11
Magnitude of ED Use in Harris County:
Payer Mix of Harris County ED Users
 While HCHD’s share of county-wide ED visits is only 14%, two-
thirds are uninsured. Others have a more balanced payer mix.
Harris County Hospital District Total # of ED Visits, by Payer Mix
HCHD
(n=2)
OTHER
3%
Other All
Hospitals
Reporting
EDVisits,
Data.
Other Hospitals
Total # of ED
by Payer Mix
(n=15)
CHIP
0%
CHIP
2%
COMMERCIAL
11%
OTHER
15%
COMMERCIAL
26%
MEDICAID
14%
SELF-PAY
65%
SELF-PAY
24%
MEDICARE
7%
MEDICAID
20%
MEDICARE
13%
Source: Lewin 2003 Survey of Harris County Providers
12
Magnitude of Inappropriate ED Use in Harris County


Over half of all ED visits are
inappropriate.
By 2015, if current trends
continue and no action is
taken:

Inappropriate ED use will
likely grow 38%, to about
950,000 visits.
 Medicaid and the uninsured
will comprise half of all
inappropriate use.
Estimate of County-Wide Inappropriate
Uninsured and Medicaid Emergency Department
Visits, FY 2002 Compared to FY 2015 Estimate
Assuming No System Change
FY 2002
FY 2015
(Projected)
1,261,317
1,742,000
54.5%
54.50%
Estimated Number of
Inappropriate ED Visits
687,418
949,390
Uninsured and Medicaid
Share of Inappropriate ED
Visits
51.70%
51.70%
Uninsured/Medicaid
Inappropriate ED Visits
355,395
490,835
Total County-Wide ED
Visits1
Percent of Inappropriate
ED Visits
Sources:
1.
Total County-Wide ED Visits from the AHA 2002 Annual Hospital Survey
2.
Percent of Inappropriate ED Visits from the "Houston Safety Net Hospitals Emergency Department Use Study" Final Report
3.
Uninsured/Medicaid share of Inappropriate ED Visits from 17 hospitals responding to the Save Our ER's data request, representing
68% of county-wide ED use
4.
Source for FY 2015 estimated ED visits is the HCHD strategic plan.
13
Drivers of Inappropriate ED Use in Harris County

Drivers of growth in Harris County inappropriate
ED use include the downstream impacts of:






Projected population growth
Employment and healthcare coverage trends
Lack of effective physician capacity
Inadequate ambulatory care capacity
Gaps in coordination of non-emergent care
Cultural predisposition towards use of EDs
14
Drivers of Inappropriate ED Use:
Projected Population Growth in Harris County
Harris County’s population is
expected to grow 26% between
2000 and 2015.
Near-term growth will be concentrated
among Hispanic and Asian populations.
Projected CMSA Population Grow th Trends in
Harris County, 2000-20015
Projected CMSA Population Growth Trends in
Harris County, by Race and Ethnicity
70.00%
4
Change in Population Mix
Population (millions)
4.5
3.5
3
60.00%
50.00%
White
40.00%
Black
30.00%
Hispanic
20.00%
Asian/Pacific Is.
10.00%
0.00%
1997
2.5
2000
Census
2003
2006
2008
2000
2003
2006
2015
Source: 2000 U.S. Census, ESRI/CACI Demographics
15
Drivers of Inappropriate ED Use:
Employer Health Care Coverage Trends

Between 1990 and 2000, Harris County enjoyed
employment growth averaging 2.1 percent annually.2



The Houston-Galveston Area Council projects similar
employment gains through 2025.
Much of the future growth is expected to be among
small businesses, many of whom historically have
provided limited or no health care coverage.
These trends threaten to increase the number of
uninsured and place additional pressure on Harris
Counties already strained emergency care system.
2. Houston-Galveston Area Council 2025 Regional Growth Forecast, May, 2003.
16
Drivers of Inappropriate ED Use:
Lack Of Effective Primary Care Physician Capacity


Harris County has enough
primary care physicians to
meet population need.
However, inadequate
reimbursement is a serious
barrier to care for the
uninsured and many
Medicaid recipients.
Ratio of Persons/Primary Care Physicans in Harris and
Surrounding Counties
2003
Ft. Bend Co.
Montgomery Co.
Harris Co.
2001
-
1,000
2,000
3,000
Persons/Primary Care Physicians
Source: TX State Board of Medical Examiners, ESRI/CACI Demographics
Note: The shorter bars represent more physicians per person.
17
Inadequate Ambulatory Care Capacity: Current HC Clinic
Locations Are Appropriate, But More Capacity is Needed


Harris County clinics
appear well sited to
meet the needs of
safety-net
populations.
But more capacity is
needed to meet
demand and care is
fragmented.
Source: HCHD “Service Delivery Throughout Harris County” Presentation prepared by Gateway to Care 2003.
18
Inadequate Ambulatory Care Capacity:
Primary Care Demand Exceeds Supply
Unm et Need vs Current ED Capacity


Available capacity
addresses less than
half of primary care
demand among Harris
County’s low income
uninsured.
Therefore, there are
no alternative access
points to redirect
inappropriate ED use.
Total Demand =
1.45 million visits
1600000
1400000
1200000
1000000
Estim ated
Unm et
Need,
47%
800000
600000
400000
200000
Total
Estim ated
Capacity,
53%
0
19
Inadequate Ambulatory Care Capacity: Demand For
Primary Care By Low Income Uninsured Is High

A current estimate of primary care demand by
uninsured Harris County residents under 200% poverty
is over 1.4 million visits annually.
Estimated Number of Uninsured
830,000
Number of Uninsured Under 200%
Poverty1
413,423
Average Primary Care Visits per
Year Nationally
Estimated Primary Care Demand
by Uninsured Under 200% Poverty
3.5
1,446,981
visits
Note: Uninsured under 200% FPL defined as Safety Net populations per AHRQ.
Sources: HCHD Strategic Plan, AHRQ
20
Inadequate Ambulatory Care Capacity:
Primary Care Demand Exceeds Capacity

Available data suggests that demand among the
uninsured for primary care exceeds current capacity .
Clinic Type
Number of
Sites
Total Primary Care
Visits
Estimated
Uninsured Visits
HCHD: Current and
Approved
11
882,713
496,085
City/County DOH
12
184,460
99,846
Major non-profit
7+TCPA sites
1,015,983
84,682
13
50,000
28,100
Teen
6
16,614
9,337
FQHC
2
19,513
10,942
27
66,169
35,489
2,235,452
764,481
School-Based
Other (planned parenthood,
mobile vans, etc.)
Total Estimated Capacity
Estimated Need
Estimated Unmet Need
1,446,981
682,500
Sources: HCHD Office of Strategic Planning, Gateway to Care Health Home survey, Lewin Survey of Harris County providers, Dr.
Chuck Begley and Lewin Group analysis
21
Inadequate Ambulatory Care Capacity:
Demand for Behavioral Health is Also High


Demand for behavioral health services also exceeds
available capacity in Harris County.
According to the Harris County Mental Health Needs
Council, an estimated 120-130,000 people in Harris
County have severe mental illness.



About 60% are reportedly uninsured.
In 2003, the public sector, including HCHD (7,305) and MHMRA
(186,567) together reported seeing about 194,000 visits.
Private sector capacity in Harris County was
unavailable for this study.
22
Conclusions Regarding Inappropriate ED Use in
Harris County





Analysis of available data led to a number of conclusions regarding
inappropriate ED use in Harris County. These include:
Inappropriate ED use is significant and, absent effective intervention,
will continue to grow due in part to factors outside the health
sector’s control.
Continuing the status quo is risky, as future trends are likely to
exacerbate stresses on the local health care delivery system and
further compromise the ability of many Harris County residents to
access needed care on a timely basis.
Strategies focused solely on re-directing inappropriate ED use are
likely to fail due to lack of adequate alternative capacity.
Any adopted strategy must seek to better balance the local health
care system through building new capacity and improving
coordination of care.
23
Environmental Scan of Models of Care
Adopted in Other Communities
Approaches Adopted In Other Communities May
Be Useful


Lewin conducted an environmental scan to identify
promising practices and administrative and governance
models successfully tested elsewhere to reduce
inappropriate ED use and system fragmentation.
Following are examples of models to:
 Build effective organization and governance.
 Expand healthcare coverage for small businesses.
 Increase physician capacity.
 Expand ambulatory care capacity.
 Improve coordination of ambulatory care.
 Consolidate public health services.
25
Organization and Governance
27
Denver Health - History




Prior to the creation of Denver Health, the City of Denver operated the Health and
Hospital Department. The Department was in charge of all public health services, the city
public hospital and clinics, as well as the Rocky Mountain Poison Control Center. The
manager of the Department and all of the members of the board were appointed by the
Mayor. The Department’s board acted mainly in an advisory capacity.
In the 1990s, Denver was subject to aggressive movement by managed care into the
market. Many of the new HMOs began cherry-picking patients from the Department (e.g.,
patients with private insurance), threatening the department’s financial base. To combat
this problem, the Department tried different strategies such as creating an HMO for city
employees, among other activities.
In the mid-1990s, Denver’s mayor appointed a blue-ribbon task force to look at the
organization of the department and develop recommendations for change and looked at
several different options. However, the Mayor stipulated that the department could not
become a private, free-standing non-profit entity.
The final recommendation was to develop an authority structure. While the authority
remains public (a subdivision of the State of Colorado), it is able to operate independently
as its own authority. In order to transition the Department into an authority, it was
necessary to obtain authorization from the Colorado State Legislature.
28
Denver Health: Governance

Denver Health has a contractual relationship with the City of
Denver to provide health care and public health services. When
Denver Health became an authority, the contract included three
agreements:



Transfer Agreement: All assets were transferred from the City
to Denver Health.
Operating Agreement: Denver Health will serve the City of
Denver in perpetuity. This insures that the city will not bid out
for services.
Personnel Agreement: Employees from DHH are allowed to
remain city employees or become employees of Denver
Health. In the former case, they are leased to Denver Health.
29
Denver Health: Governance – Board
Structure




Denver Health is governed by a nine-member board, appointed by the Mayor and
confirmed by the City Council for a five-year term. Individual board members
terms may be renewed for one additional term.
There are no stipulations regarding who may serve on the board of directors.
When seats on the board are vacant, the CEO and remaining board members
provide the Mayor with a list of possible replacements. Denver Health’s CEO
serves as an invited member of the Mayor’s cabinet.
The City of Denver contracts with Denver Health for services. As a result, the
Mayor and City Council have no direct authority over Denver Health beyond board
appointments. The Board has complete authority over Denver Health.
Denver Health operates eight FQHCs. Each FQHC in the system has its own board
to remain compliant with Section 330 requirements. Two members of the Denver
Health Board are members of each FQHC board.
30
Denver Health: Organization and Structure


Denver Health is directed by a Chief Executive Officer, who also acts as Medical
Director for the hospital.
Denver Health is divided into a number of Divisions, including:
 Hospital Division: The division runs the city hospital, as well as the city 911
system.
 Public Health Division: The division provides the majority of public health
services in the city, including infectious disease clinic, communicable disease
control, TB clinic, STD clinic, immunization clinic, public health laboratories,
and vital records.
 Community Health Center Division: The division operates Denver Health’s 8
FQHCs and 13 school-based clinics.
 General Council and Risk Management Division
 Human Resources
 Finance
 Quality Review and Office of the Assistant Medical Director
 Director of Managed Care
 Rocky Mountain Poison Control Center
31
Denver Health – Organizational Chart
Denver Health Board of Directors
(Nine Members)
CEO & Medical Director
Director of Quality Review
and Associate Medical Director
Chief Operating Officer
•
•
Hospital
911
Director of Public Health
Director of
Community Health Centers
Public Health
8 FQHCs
Infectious
Disease
11 School-based
Clinics
Director - Rocky Mountain
Poison Control Center
General Counsel
Risk Management
Chief Financial Officer
Director of Managed Care
Director of Human Resources
PH Labs
Vital Records
TB Clinic
32
Marion County, IN – Health and Hospital
Corporation (HHC): Overview



Program Description: Beginning in 1954, Marion County, Indiana consolidated
public health and health care functions into a single authority, the Health and
Hospital Corporation (HHC).
Program Purpose: HHC provides medical health care, environmental health, and
population health services to Marion County and the City of Indianapolis, Indiana.
Key Features:
 HHC operates both the Wishard Memorial Hospital System and the County
Health Department
 Physicians who work for HHC clinics all come from the Indiana University
Medical Group Primary Care (IUMGPC)
 HHC established a program called “Advantage,” a managed care-like program
for low-income, uninsured residents of Marion County, Indiana. The program
is jointly owned by Wishard Hospital and Indiana University School of
Medicine.
33
Marion County, IN – Health and Hospital
Corporation (HHC): Governance




HHC is governed by a seven-member Board of Trustees, three appointed by the
Mayor, two by the City-County Council, and two by the Board of County
Commissioners. Historically, the board has included representation from the
community, as well as legal and financial expertise.
HHC has few limitations on its own authority. While the Mayor may make
requests, the board is free to turn them down. HHC’s annual budget must be
approved by the county council. However, modifications made by the council can
be appealed to the state.
As a consolidated taxing authority, HHC must work with the State Board of
Accounts, which must approve all levies made by HHC. The State Board of
Accounts must verify that levies do not exceed the state-mandated annual limits.
HHC also works closely with the State Board of Health and State Medicaid agency.
34
HHC: Organization and Structure


HHC operations are overseen by an Executive Division, including the
President/Executive Director. The Executive Division is able to move assets,
leverage funding from various sources, and coordinate activities to maximize
efficiency.
The Marion County Health Department is divided into two bureaus:
Bureau of Environmental Health: Services include Food Safety, Housing and
Neighborhood Health, Childhood Lead Poisoning Prevention, Indoor Air Quality,
and Occupational Health.
 Bureau of Population Health: Services include Communicable Disease Control,
Chronic Disease Control, Dental Health, Immunizations, Maternal and Child
Health, Nutrition Services, Public Health Laboratory Services, and Vital
Records.

35
HHC: Organization and Structure

HHC’s Hospital Division operates Wishard Memorial Hospital and its health
services. In the late 1990s, authority for all seven clinics within HHC was given
over to the Hospital Division (previously the Hospital Division was in charge of only
2 of the clinics). This has brought about increased reimbursement and better
integration with the Wishard Memorial Hospital for specialty care.
The seven clinics affiliated with HHC are currently under review for FQHC
look-alike status. This will be a co-applicant arrangement between HHC and a
single community board (51% community/49% other – of which 2 seats are for
HHC). HHC will maintain budgetary control, while other issues will be
handled jointly. This will likely provide greater oversight of the clinics and
the benefits of look-alike status. HRSA is expected to approve this
arrangement.
 The Indiana University Medical Group – Primary Care (IUMGPC) provides staff
for all of the clinics directly under HHC (i.e., Wishard clinics). IUMGPC also
selects the medical director for the clinics.

36
Health and Hospital Corporation – Marion
County
Health and Hospital Corporation
Executive Division
Hospital Division
Wishard Memorial
Hospital
Health Department
Clinics
Bureau of
Environmental Health
Bureau of
Population Health
37
Cook County, Illinois - Bureau of Health
Services



Program Description: In 1991, Cook County, Illinois formerly established
the Bureau of Health Services (CCBHS) to provide health, hospital, public
health, and health education services to throughout Chicago and its
suburbs.
Program Purpose: CCBHS was designed to create a better-coordinated
and more integrated system of health care delivery within Cook County.
Key Features:
 CCBHS includes a referral network that allows integration of specialty
care, in both affiliate and non-affiliate clinic, with the County
Hospital.
 CCBHS operates over 30 community-based clinics.
 Provides care to specific patient populations, including HIV/AIDS,
chronic care, and detainees in the correction system.
38
Cook County, Illinois
Bureau of Health Services - Governance



Cook County Bureau of Health Services (CCBHS) is an executive agency of
Cook County, under the President of the County. The Cook County Board
of Commissioners acts as the governing board for the Bureau’s operating
entities.
CCBHS is run by a the Bureau Chief. The chief operating officer of each
operating division reports to the Bureau Chief. CCBHS includes seven
separate divisions.
The Bureau Chief is appointed by the President of the County with the
consent of the Board of Commissioners.
39
Cook County, Illinois
Bureau of Health Services - Structure

CCBHS includes seven separate divisions:







Ambulatory & Community Health Network: The Network coordinates primary
and specialty outpatient care in community, school-based and hospital
outpatient settings.
Cermak Health Services: Cermak provides health services to roughly 10,000
detainees at the Cook County Department of Corrections and the Department
of Community Supervision and Intervention
Department of Public Health (DPH): DPH provides public health services in all
of Cook County, except for Chicago and four other cities/towns in the County.
Ruth H. Rohnstein CORE Center: The CORE Center provides outpatient care to
those with HIV/AIDS and other infectious diseases.
John H. Stroger, Jr. Hospital: Cook County’s main hospital has 464 beds and a
Level 1 Trauma Center.
Oak Forest Hospital: Oak Forest provides long-term, chronic disease, and
rehabilitation services, and includes over 600 staffed beds.
Provident Hospital: Provident is a full-service hospital serving more than
50,000 patients annually.
40
Cook County, Illinois
Bureau of Health Services - Org. Chart
Cook County
Board of Commissioners
Bureau of
Health Services
Ambulatory and Community
Health Network
Cermak Health Services
Department of
Public Health
Ruth H. Rohnstein CORE Center
John H. Stroger, Jr. Hospital
Oak Forest Hospital
Provident Hospital
41
Models for Expanding Insurance Coverage
Health Access – Muskegon County, Michigan




Program Description: “Health Access,” a subsidized health care program
for uninsured employees of small businesses and their dependents in
Muskegon County, Michigan, established by the county with an initial grant
from the Kellogg Foundation.
Program Purpose: To provide a basic health insurance-like product for low
income workers who do not have access to health insurance, either on
their own or through their employer.
Funding Source: Employers and employees each pay for 30 percent of
product’s costs, while the community picks-up the rest utilizing DHS
funds.
Key Features: Businesses that have not offered insurance for the past 12
months and have a median employee salary of no more than $11.50 are
able to enroll in the program. Employees receive a basic benefits package
and have their care managed by a primary care physician. The program
only covers care given by providers located in Muskegon County and pays
them on a fee-for-service basis. High-cost specialty care is covered by
Medicaid by employing spend-down strategies.
43
Muskegon County, Michigan
Pros for Harris County
 The program could provide access to health care for many working
uninsured in Harris County.
 The product is not insurance, so reserve requirements do not take effect.
Cons for Harris County
 Because DSH funds are being maximized by Harris County, an alternative
source of funding would have to be found.
 Dedicated providers would have to be found to act as primary care
physicians for program beneficiaries.
 A current or new entity would have to take responsibility for managing
claims and administration.
Recommendations
 SOER should consider this option if a dedicated funding source can be
found to subsidize the program. Business and provider buy-in is also
critical for such a program.
44
Advantage – Marion County, Indiana




Program Description: “Advantage,” a managed care-like program for lowincome, uninsured residents of Marion County, Indiana, established in 1997
by the Marion County Health and Hospitals Corporation and jointly owned
by Wishard Hospital and Indiana University School of Medicine.
Program Purpose: To reduce inappropriate Emergency Department use
and unnecessary hospital admissions, and to better track and monitor
quality care.
Funding Source: Local taxes and redirected hospital federal
disproportionate share funding.
Key Features: Uninsured residents are enrolled and assigned to a primary
care provider who coordinates their care. The program includes an urgent
visit center to complement Wishard’s Level I trauma center, a 24-hour call
center that can redirect emergency calls to primary care providers and a
focus on referring patients back from specialist to the primary care
provider of record.
45
Advantage – Marion County, Indiana

History: When Advantage began, only clinics under the purview of HHC
were utilized. Clinics outside the network were not integrated. As a
result, a number of problems developed.
 The outside clinics wanted to offload their non-paying patients to the
HHC system. However, they could not make referrals to specialty care
at Wishard Hospital. So, the clinic physicians would make a diagnosis
and then refer their patients to the Wishard ED where they would be
re-diagnosed and admitted for specialty care.
 Outside clinics did not have access to the integrated data network of
HHC. As a result, they could not maintain continuity of care for
patients who were using both systems.
46
Advantage – Marion County, Indiana

History (cont’): As a result of these problems, HHC decided to expand the
network for Advantage to include a number of outside clinics. As a result:
 the outside clinics have referral privileges to Wishard Hospital;
 the Advantage system can make sure that these clinics adhere to
protocols for referring specialty care (e.g., certain tests must be
conducted before a referral can be made);
 an electronic medical record can now be used for all Advantage
patients throughout the entire system. This helps to maintain
continuity of care. EDs also have access to this integrated data
network; and
 Advantage members, in some cases, may also access specialty care
from hospitals outside of HHC through the outside clinics.
47
Advantage – Marion County, Indiana
Pros for Harris County
 Physicians are under a capitated arrangement, so they are encouraged to
have patients using the most appropriate care.
 This type of program utilizes the current health care system and does not
necessitate major functional changes.
Cons for Harris County
 This type of a program requires total subsidization. The population served
does not qualify for other programs like Medicaid.
Recommendations
 Although the capitated arrangement with participating physicians is
attractive, SOER should be cautioned from replicating this model without
first finding multiple sources of funding.
48
Increased Ambulatory Care Capacity and
Coordination
Federal New Access Point Initiative




Program Description: The “New Access Point Initiative” was developed
by the Bush Administration in August 2001 to expand current FQHCs and
add new FQHCs around the country.
Program Purpose: To expand health coverage to the uninsured.
Funding Source: Federal appropriations distributed by the Bureau of
Primary Health Care within the Health Resources and Services
Administration (HRSA)
Key Features: The five-year program calls for $1.2 billion to fund 1,200
new or expanded FQHCs. Of the 1,200 sites, 570 will be expansions of
current FQHCs. Of the 630 remaining sites, 420 will be expansions of
existing health centers and 210 will be new start community health
centers. New sites will receive a maximum grant of $650,000 per year
and expansion sites will receive a maximum grant of $550,000.
50
Federal New Access Point Initiative
Pros for Harris County
 This program makes available funds for additional sites and expansions of
current sites.
 The Texas Legislature created an FQHC Incubator Program to facilitate existing
clinics in their attempt to obtain FQHC status.
 Obtaining FQHC “look-alike” status would still be beneficial in the interim.
Cons for Harris County
 The process for obtaining FQHC status is very competitive and a great deal of
effort can be expended without receiving approval.
 The governance requirements for FQHCs are strict, with 51 percent of the
board coming from the community.
Recommendations
 FQHC expansion should be continued as part of a broader capacity building
strategy.
51
Chicago’s Access Community Health Network




Program Description: “Access Community Health Network,” a large FQHC
system serving residents located on the South and West sides of Chicago.
Program Purpose: To provide underserved areas with high-quality health
care in a clinic setting.
Funding Source: The program receives Section 330 funds for the clinics
with FQHC status. The program also receives federal grant money for
infant mortality, state grants for breast and cervical cancer, and
foundation and individual philanthropic support. The most significant
amount of funding comes from Medicaid, Medicaid HMO wrap-around, and
Medicare.
Key Features: The Network operates 42 clinics under single corporate
structure. Federal funds for FQHCs are passed through the Network to
those clinics. The Network itself enjoys some of the benefits of the FQHC
status, including medical malpractice coverage. The Network has
relationships with a number of hospitals, allowing patients to be seen in a
number of different places for specialty care.
52
Chicago’s Access Community Health Network
Pros for Harris County
 Having FQHCs and other clinics in an integrated network helps to reduce
administrative costs and provides economies of scale.
 The network structure allows funding and contracting to be leveraged
throughout the system.
 An integrated Network can more easily facilitate continual growth,
particularly with regard to adding additional FQHCs.
Cons for Harris County
 An integrated Network approach requires substantial upfront coordination
and a willingness of various entities to work together.
 The board for such a Network would have to have diversity so as to
prevent overrepresentation by a single entity.
Recommendations
 If SOER proceeds with efforts to bring additional FQHCs to Harris County,
this model should be considered as a method to coordinate the effort.
However, buy-in among all participants is critical for it to work.
53
FQHC Look-Alike Initiative – Marion County, IN



Program Description: The Health and Hospital Corporation (HHC) of
Marion County is currently seeking FQHC Look-alike status for each of its
seven clinics.
Program Purpose: To obtain the benefits of FQHC look-alike status for
clinics serving the HHC.
Key Features:
 The seven clinics affiliated with HHC are currently under review for
FQHC look-alike status. This will be a co-applicant arrangement
between HHC and a single community board (51% community/49%
other – of which 2 seats are for HHC). HHC will maintain budgetary
control, while other issues will be handled jointly. This will likely
provide greater oversight of the clinics and the benefits of look-alike
status. HRSA is expected to approve this arrangement.
54
FQHC Look-Alike Initiative – Marion County, IN
Pros for Harris County
 FQHC Look-alike status is not competitive, yet still provides a number of
FQHC benefits, including enhanced revenue due to Prospective Payment
System reimbursement, PHS Drug Pricing Discounts, access to DHHS
outstationed eligibility workers, and “first dollar” Medicare
reimbursement.
Cons for Harris County
 While the FQHC Look-alike status is not competitive, all of the Section 330
requirements must be met, including board requirements.
 HHC has a co-applicant arrangement with the FQHC Look-alike boards. It
may be difficult to isolate a single entity in Harris County to assume this
responsibility.
Recommendations
 SOER may want consider finding CHCs that are near FCHC Look-alike
status to sponsor. Various entities could take on the responsibility of
incubator.
55
Referral Network: Cook County, Illinois



Program Description: Since 1985, Cook County has maintained a referral system
for non-affiliate clinics, allowing patients to receive specialty care through the
County Hospital.
Program Purpose: To allow uninsured and indigent patients access to specialty
care through referrals from primary care physicians.
Key Features:
 This network allows both clinics in Cook County’s Ambulatory & Community
Health Network (~30) and non-affiliated clinics (~60) to refer patients to Cook
County Hospital for specialty care, as well as allowing Cook County’s ED the
ability to re-direct patients to clinics for more appropriate care.
 Clinics also have access to the hospitals labs and pharmacy (although
pharmacy is now being scaled back to some degree).
 Clinics in the network now use a Web-based referral system for their patients.
 Primary Care Physicians must abide by referral rules detailed in the Webbased system. Approximately 10,000 patients per month are being referred
through this system. The hospital uses the Web-based system as well to help
patients locate clinics near their homes for primary care.
56
Referral Network: Cook County, Illinois
Pros for Harris County
 This system would allow clinics not affiliated with Ben Taub or LBJ
Hospitals to utilize a systematized method of referral.
 A Web-based system would provide efficiencies to the referral process.
 Hospitals would have a means to find primary care homes for nonemergent patients.
Cons for Harris County
 While Cook County has one dominant health body, Harris County has
many. It may be difficult to coordinate among the different
stakeholders in Harris County.
 A Web-based system might require infrastructure improvements from
already cash-strapped clinics.
Recommendations
 SOER should consider an integrated system for referrals. At the same
time, careful planning should occur to make insure that no one hospital
system or clinic is overrun.
57
Project Access – Buncombe County, North
Carolina




Program Description: “Project Access,” a volunteer physicians program
for uninsured and indigent residents in Buncombe County, North Carolina,
established in late 1995 in collaboration with the Buncombe County
Medical Society.
Program Purpose: To match uninsured and indigent patients in need of
specialty care with physicians willing to provide care for free
Funding Source: All services are donated by physicians and hospitals to
which they are affiliated
Key Features: Physicians who participate in the program agree to see
approximately 20 patients for free each year. Participating physicians are
then put on a list available at local clinics and at the health department.
Those who are in need of specialty care and do not have a means to pay
for such care are referred to the appropriate and available doctor on the
list. The physician is responsible for the needed care for that patient for
three months, when the patient is re-evaluated to assess whether further
specialty care is needed. The program currently has an average
enrollment of 900-1,000 patients.
58
Issues to Consider Project Access – Buncombe
County, North Carolina
Pros for Harris County
 The program could reduce the number of indigent patients who receive
specialty care from Ben Taub and LBJ Hospitals.
 Costs are limited to program administration and physician recruitment.
 Physicians are able to limit the number of patients they see under this
arrangement to prevent being overrun.
Cons for Harris County
 This type of program involves significant buy-in from the physician
community, as well as hospitals for testing and labs.
 An administrative system would have to be established that could be used
in the many clinics and hospitals around the county.
Recommendations
 SOER should consider this option in order to include private physicians as
part of the solution. To maintain continuity of care, physicians should be
required to commit to at least one-year of service for each patient.
59
Health Services Consolidation
Health Services Consolidation – Marion County, IN




Program Description: Beginning in 1954, Marion County consolidated public health
and health care functions into a single authority, the Health and Hospital
Corporation (HHC)
Program Purpose: To improve coordination of care and gain operating
efficiencies.
Funding Source: Local tax levies approved by the State Board of Accounts.
Key Features:
 HHC is a consolidated taxing authority. HHC’s Executive Division oversees the
corporation, with the heads of the Hospital Division and Department of Health
Division reporting to the Executive Director of HHC. HHC also acts as the
board of health for the county.
 HHC maintains a seven-member board (3 appointed by the Mayor, 2 appointed
by the City-County Council, and 2 appointed by the Board of Commissioners).
 Eight years ago, the hospital division assumed control over all seven clinics
under the jurisdiction of HHC in order to maximize reimbursement from
patients and other payers, and better integrate care with the Hospital.
61
Health Services Consolidation – Marion County, IN

Key Features (cont’):
 The Indiana University Medical Group – Primary Care (IUMGPC)
provides staff for all of the clinics directly under HHC (i.e., Wishard
clinics). IUMGPC also selects the medical director for the clinics.
 The medical director of Wishard Hospital (i.e., public hospital for
Marion County) is a faculty member from Indiana University.
However, the University’s contract with Wishard is up soon and
changes are likely to occur, including finding a new medical director.
The change is due to the current and other recent medical directors’
difficulties with hospital management.
62
Health Services Consolidation – Marion County, IN
Pros for Harris County

Consolidating clinics and hospitals into an integrated delivery model would allow
for better patient management (e.g., specialty care) and data collection. This
could help alleviate fragmentation in Harris County.

As a consolidated entity, public medical care and public health activities could be
coordinated to maximize their benefit and eliminate duplicity.
Cons for Harris County

HHC’s role as a consolidated taxing authority would be difficult to replicate in
Harris County due to the multiple jurisdictions involved.

While HHC oversees one hospital system and one department of health,
consolidation in Harris County would include numerous entities in both medical
care and public health.
Recommendations

Harris County should examine the legal feasibility of any consolidation efforts
before proceeding. Harris County may want to consider a step approach, with
consolidation happening in stages over time.
63
Summary Of Lessons Learned
From Examining Other Communities
After examining other communities, several common success factors
emerged that are relevant for Harris County as it considers
options for strengthening service delivery and coordination of
care. These include:
 Strong leadership is essential for success.
 Consensus may be difficult to achieve but it is important to keep
stakeholders engaged in the process.
 It is important to anticipate and flexibly plan for potential future
policy, economic and other environmental developments.
 Sound financial analysis and planning are critical to ensure the
long term financial viability of alternative models and to make the
“business case” for investment.
 The need to establish transition planning, including leadership
succession planning, as implementing meaningful change takes
time.
64
Components of a Framework for
Re-visioning Care in Harris County
Framework for Re-visioning Care

Lewin created a framework around which to develop,
compare and assess three actionable strategic options
for Harris County. The framework evolved from:





Analysis of the magnitude and drivers of in-appropriate ED use.
Feedback from Harris County stakeholders.
Approaches adopted by other communities.
The framework is grounded in a conclusion that the
problem calls for a multi-faceted and well coordinated
approach.
This chapter describes the framework’s components
and summarizes stakeholder feedback regarding
current status and future opportunities.
66
Options to Address the Problem in Harris
County Feature Five Coordinated Components
Expand Ambulatory
Care Capacity
Restructure
Public
Health Functions
Establish
Effective
Governance
Improve
Coordination
of Care
Assure Adequate
Financing
67
Expanding Ambulatory Care Capacity:
Harris County Stakeholder Feedback


Most stakeholders believe new capacity is needed to
relieve pressure on EDs, but approaches differ.
Many agree that a public/private solution includes a
mix of:






New specialty clinics.
Expanded hours at HCHD and City and County public health
clinics.
Development of new public and private FQHC and FQHC lookalike capacity.
Additional urgent care centers adjacent to private hospitals.
More school-based health services.
More physician capacity. Potential sources include volunteers,
medical schools, and National Health Service Corps.
68
Expanding Ambulatory Care Capacity (Cont.)
Progress is being made in many areas.
 Specialty Care: Two new HCHD clinics providing 106,000
annual visits received conceptual County approval.
 Expanded Hours: HCHD clinics will expand hours in 2004,
growing capacity by 160,000 visits annually.
 FQHCs: HCA converted a clinic to an FQHC in 2003 and
several other clinics are planning to apply in 2004.
 Urgent Care Centers: Several private providers are
exploring opening urgent care centers to redirect
inappropriate ED use.
 School-Based Care: Houston school district is working to
expand the number of clinics.
69
Improving Coordination of Care:
Stakeholder Feedback


Many Harris County stakeholders believe any growth in capacity must
be accompanied by improved care coordination.
Components of a public-private solution cited include.






Establish contractually-based patient referral guidelines a la the Chicago
model to reduce fragmentation.
Hire additional full time community “Navigators”* to assist in overcoming
barriers to care.
More effectively advertise and expand the number and hours of telephone
nurse triage services to help persons find alternatives to ED use.
Integrate patient medical records to follow patients across sites of care.
Expand educational tools and outreach strategies to promote appropriate
use of health care services and improve access to insurance.
Develop a coordinated patient transportation strategy.
* Defined as individuals who can help direct care towards appropriate sites within the community.
70
Assuring Adequate Financing:
Opportunities and Challenges


Funding will be needed to develop and operate new
ambulatory care capacity.
Stakeholders noted opportunities, including:






Support for change by the Mayor, Commissioners Court and the
business community.
Conceptual county approval of funding for new ambulatory
care capacity called for by the HCHD strategic plan.
Active efforts by coalitions such as Gateway to Care to plan
and coordinate FQHC expansion and other capacity building.
Interest by private providers in new FQHCs and urgent care
centers to redirect inappropriate ED use.
Foundation support.
Efforts by The Houston Independent School District’s to expand
school-based health programs.
71
Assuring Adequate Financing:
Opportunities and Challenges (cont.)

Challenges to overcome are significant, including:





Limited potential for additional federal DSH funding due
to cutbacks and stricter oversight.
Limited availability of federal funding for FQHC
expansion. HRSA received about 1,280 applications in FY
2002-2003, but only 418 were funded.
State cutbacks in Medicaid and CHIP eligibility.
Little likelihood that the Texas legislature will increase
Medicaid outpatient and physician payment rates.
Passage of the Governor’s tax cap proposal would limit
property tax revenue growth and county funding
available for healthcare.
72
Restructuring Public Health Functions

Most Harris County stakeholders favor consolidation of
City and County public health departments. Reasons
cited include:





Opportunities for improved integration of services.
Opportunities for cost efficiencies by eliminating and
consolidating redundant services and functions.
Opportunities to maximize use of underutilized capacity.
Opportunity to establish a centralized point of
accountability.
Opportunity to provide a county-wide unified response to
public health emergencies.
73
Restructuring Public Health Functions

Those opposed cite:





Concern that public health priorities and funding would be
diminished if merged with larger HCHD.
Little real potential for cost efficiencies, as both departments
have independently achieved economies of scale.
Cost of standardizing information and other systems and
potential for disrupting implementation of the HCHD IS
strategic plan if merged with HCHD.
Cost of upgrading public health sites providing primary care
services to JCAHO standards if merged with HCHD.
The strongest opposition centers around merging with
HCHD.
74
Strategic Options for Harris County
Overview

We created a framework around which to develop
and compare three actionable strategic options after
assessing:
The extent of inappropriate ED use and other stresses on
Harris County’s delivery system.
 Feedback from key Harris County and other
stakeholders.
 Models developed in other communities.


The framework for each option includes five key
components.
76
Overview

Each option features a different mix of five key
components:
Expand Ambulatory
Care Capacity
Establish
Restructure
Effective
Public
Health Functions Governance
Improve
Coordination
of Care
Assure Adequate
Financing
77
Overview

In developing three conceptually distinct strategic
options, two categories emerged:
A minimalist or reactive option, which seeks to improve
system efficiency while minimizing new funding
commitments.
 Two more proactive responses, which seek to expand
health system capacity through multiple access points
and improve system efficiency and coordination.


The following slide illustrates our framework for
revisioning the delivery of health care services in
Harris County.
78
Framework for Revisioning
Health Care in Harris County
Range of Configuration Options
Most
Comprehensive
Coordinated
Community
Health System
Option
3
Strategic
Realignment
Option
2
Reactive
Option
1
Current
System
Least
Comprehensive
Current
Capacity/
Coordination
Heightened
System
Efficiency
New Capacity
and
Coordination
Fully
Rebalanced
System
79
Framework for Revisioning
Health Care in Harris County




The following describes key features and projected outcomes
of three options for re-visioning organization and delivery of
health care services in Harris County.
These options are arrayed by the magnitude of system change
required.
Options are designed to be additive, with each more complex
option building upon the components of less ambitious options.
This approach acknowledges variation in the scope of change
required and provides stakeholders flexibility to move up or
down the continuum of change.
80
Strategic Options for Harris County:
A Reactive Option
Range of Configuration Options
Most
Comprehensive
3
2
Reactive
Option
1
Current
System
Least
Comprehensive
Current
Capacity/
Coordination
Heightened
System
Efficiency
81
Reactive Reconfiguration Option:
Objectives and Key Features



Under this option, Harris County would move incrementally and
opportunistically toward its revisioning goals.
The focus of this “small fix” approach would center around
maximizing the efficiency of the current system.
County providers would minimize new investment and maximize
reimbursement through the selective conversion of existing
community-based ambulatory care capacity to better reimbursed
FQHCs and FQHC look-alikes and modest expansion of urgent
care centers.
82
Reactive Reconfiguration Option:
Objectives and Key Features

Major components of this “closed system” reactive option
include:





Several new urgent care centers built by private hospitals near EDs to
redirect nonemergent care and reduce financial losses.
Opportunistically converting selected community clinics to FQHCs or
FQHC look-alikes to maximize reimbursement, but little investment in
new capacity or referral linkages to other providers.
Maximizing revenue and reducing inappropriate ED use through
improved billing and collections, along the lines of HCHD’s “Everyone
Pays” initiative.
No change in the organization of city and county public health
departments.
No new organizing or governance structure.
83
Reactive Reconfiguration Option:
Summary Assessment


We examined the dimensions of such a system, including
benefits and risks for Harris County, and compared its
outcomes with the status quo.
We concluded that, despite some improved system
efficiencies and financial performance, this option will
not:


Infuse enough new capacity to meaningfully improve access to
care reduce inappropriate ED use.
Will not build needed coordination linkages across provider
sites and levels of care to reduce system fragmentation.
84
Framework for Revisioning Health Care
in Harris County: Proactive Options


In contrast to the reactive option, proactive options seek to build
a system with greater capacity and coordination that is maximally
efficient and effective.
Both proactive options developed present more ambitious
scenarios to improve access and reduce fragmentation of care, but
differ with respect to such factors as:

Community orientation.

Expansion of linkages between public and private not-for-profit health
systems.

Scale of commitment to investment in new ambulatory care access
points.

Creating new coordinating entities that consolidate currently
fragmented efforts.
85
Framework for Revisioning Health Care
in Harris County: Proactive Options


We developed two proactive options:

Strategic Realignment; and

The Coordinated Community Health System
We then assessed their expected outcomes and recommended a
preferred option for Harris County
86
Strategic Realignment Reconfiguration Option
Range of Configuration Options
Most
Comprehensive
3
Strategic
Realignment
Option
2
Reactive
Option
1
Current
System
Least
Comprehensive
Current
Capacity/
Coordination
Heightened
System
Efficiency
New Capacity
and
Coordination
Fully
Rebalanced
System
87
Strategic Realignment Reconfiguration Option:
Objectives and Key Features


This proactive option assumes that investment in new capacity
and coordination is imperative to offer appropriate lower cost
alternatives to non-emergent ED use and reduce system
fragmentation.
The proposed new capacity, scheduled to phase-in by 2015, is
diverse, featuring a variety of access points to care. It is
grounded, however, on a pragmatic assumption that funding
and commitment may not be available to support the full
complement of new capacity needed to address current unmet
need among safety net populations in Harris County.
88
Strategic Realignment Reconfiguration Option:
Objectives and Key Features

This option also calls for establishing a limited referral network
for redirecting inappropriate ED visits to clinics, FQHCs, FQHC
look-alikes and urgent and specialty care centers and
transferring selected patient care services from the city and
county public health departments to the Harris County Hospital
District (HCHD).
89
Strategic Realignment Reconfiguration Option:
New Capacity

System components include new capacity and
ambulatory care access points, including:
A network of seven new FQHC and FQHC look-alikes
sufficient to treat 175,000 annual visits, or about 25% of
current unmet need for primary care by the uninsured in
Harris County.
 New outpatient specialty clinics and urgent care centers
to accommodate referrals from new ambulatory care
access points and other community providers.

90
Strategic Realignment Reconfiguration Option:
Financing New Capacity

The new FQHC/FQHC look-alike network will require
support of annual operating deficits.
Financing of about $31 million will be required to meet
operating deficits that are projected to occur between
2005-2014 as new capacity is phased in.
 Annual operating losses are projected to peak at about
$4.6 million between 2007-2010 and then fall.


Caveat: Converting HCHD clinics to FQHCs requires
careful legal assessment, due to possible adverse
impacts on federal disproportionate share payments
to HCHD.
91
Strategic Realignment Reconfiguration Option
Estimated Annual Operating Losses
of Seven New FQHCs and FQHC Look-alikes
Phase in of 7 sites with 25,000 visists each
2005-2014
$5
$4.55
$4.60
$4.60
$4.57
$5
$4.07
Annual Dollar Losses (millions)
$4
$3.44
$4
$3
$3
$2.33
$2.25
$2
$2
$1
$0.61
$1
$0.02
$2005
2006
2007
2008
2010
2009
2011
2012
2013
2014
Year
Notes: Assumes each site has 25,000 visit capacity and a $4.5 million annual operating budget;
analysis excludes capital costs; assumes initial annual operating deficits of $1.5 million
for FQHCs and $2.0 million for look-alikes; assumes sites are phased-in between 2005-2011;
assumes deficits are eliminated in 3 years for FQHCs and 4 years for look-alikes through
revenue diversification.
92
Strategic Realignment Reconfiguration Option:
Coordination of Care

Selective new initiatives for better coordinating care
include:
Establishing a limited referral network between hospitals
and ambulatory care centers to refer non-emergent
patients from EDs to appropriate ambulatory care sites
and refer patients from those sites to hospitals for
specialty and diagnostic services.
 Expanding the current county telephone nurse triage
system and current community health education efforts.

–
Potential funding sources might include Greater Houston provider
organizations and grants.
93
Strategic Realignment Reconfiguration Option:
Coordination of Care

Formation of a coordinating board to provide
oversight and a unified planning structure for the
FQHC and FQHC look-alike network.


Board representation should reflect the diversity of
Harris County and include community, government and
private and public health sector representation.
The Board would be authorized and funded to plan
and begin implementing network expansion.
94
Strategic Realignment Reconfiguration Option:
Continued City/County Public Health Autonomy

Maintain each agency’s autonomy, but transfer
selected women’s and children’s primary health care
services to HCHC and explore greater collaboration
between city and county health departments.
City
Collaborate
County
Patient Care
Services
HCHD
95
Strategic Realignment Reconfiguration Option:
Summary Assessment

The pragmatic approach of meeting a pre-defined scope of need
limits the risks of implementation failure, and:

This option carefully phases-in meaningful capacity in a manner that
limits annual deficit funding and other financial risk.

This option builds some coordination between hospitals and ambulatory
care sites to improve coordination of care and reduce inappropriate ED
use.

This option may lower system-wide costs to the extent non-emergent
care can be appropriately redirected to lower cost alternatives.

Transfer of selected patient care services to HCHD improves care
coordination and facilitates “one stop shopping” for consumers.

This option may prove a useful fallback if the implementation risks of
the option described below prove too daunting.
96
Strategic Realignment Reconfiguration Option:
Summary Assessment Conclusion


After examining the dimensions of the Strategic Realignment
option in the context of its likely effectiveness in addressing
issues of concern, we concluded that this approach is superior to
the Reactive option.
In return for some investment, it partially rebalances the system
by adding valuable primary care and other capacity, builds some
system coordination infrastructure and creates a foundation for
future expansion.
However, we believe implementing this option will,
at best, buy time, as significant unmet need and
fragmentation of care will remain and ED overcrowding,
and its effects, will likely continue.
97
The Coordinated Community
Health System (CCHS) Option
Range of Configuration Options
Most
Comprehensive
Coordinated
Community
Health System
Option
3
Strategic
Realignment
Option
2
Reactive
Option
1
Current
System
Least
Comprehensive
Current
Capacity/
Coordination
Heightened
System
Efficiency
New Capacity
and
Coordination
Fully
Rebalanced
System
98
The CCHS Option: Overview




Efficient and effective health care requires a balanced and
integrated system of services designed to move patients
rapidly to the most appropriate treatment setting.
The framework of this second proactive option is designed to
help put in place the infrastructure to help achieve this in
Harris County.
It encompasses the elements of both previous options, but is
bolder and more far-reaching and is the strategy of choice.
The cornerstone of such a system for meeting the needs of
Harris County residents is a strong, well coordinated
ambulatory care network.
99
The CCHS Option: Summary

By 2015, CCHS calls for:





Substantial investment in new capacity sufficient to meet
current demand for primary care by the uninsured.
Significant improvements in system-wide coordination through
a county-wide patient referral network similar to Chicago’s.
Expanded and coordinated medical and behavioral health
patient call center and community health education center
capacity.
Consolidation of city and county public health functions.
Establishing a high level public/private governance structure
to maintain the oversight and coordination required for
effective system functioning.
100
The Recommended Option:
Coordinated Community Health System
Public
Health
EDs
Health
Education
Specialty
Clinics
Hospitals
Harris
County
CCHC
Urgent
Care
Centers
Call
Center
FQHCs
Behavioral
Health
FQHC
LookAlikes
101
The CCHS Option:
Investment in New Capacity

CCHS calls for a county-wide coordinated network of
new ambulatory care access points, including:
Five new FQHCs and nine FQHC look-alikes, each able to
see 50,000 visits annually, to address unmet need for
primary care by the uninsured.
 Additional outpatient specialty clinics and urgent care
centers as called for by the HCHD strategic plan to
accommodate referrals from new ambulatory care access
points and other community providers.
 Additional school-based health services and education.

102
The CCHS Option:
Investment in New Capacity

The FQHC/FQHC look-alike network meets primary
care demand with less financial risk than other
clinic models:
FQHCs/FQHC look-alikes are eligible for enhanced
Medicare and Medicaid funding and discounted drug
pricing.
 FQHCs also may receive malpractice coverage and
federal Section 330 grant funding up to $650,000
annually.
 Sites are required to provide primary, preventive and
behavioral health services directly or by arrangement.

103
The CCHS Option:
Investment in New Capacity

The new FQHC/FQHC look-alike network will
require financing substantial operating deficits
during the network phase-in period.

Total estimated operating losses of about $158 million
are projected between 2005-2017 as new capacity is
phased in.
104
Harris County CCHS Option
Estimated Annual Operating Losses
for 14 New FQHCs and FQHC Look-alikes
Phase-in of 14 Sites with 50,000 visits each
2005-2017
$18
$16.56
$15.56
Annual Dollar Losses (millions)
$16
$14.28
$13.28
$14
$12.28
$12
$10.56
$10
$9.28
$8.56
$8.28
$7.40
$8
$5.16
$6
$4
$2.00
$1.00
$2
$2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Year
Notes: Assumes each site has 50,000 visit capacity and $9 million operating budget; excludes capital
costs; assumes initial annual operating deficits of $3.4 million for 5 FQHCs and $4.0 million
for 9 look-alikes; assumes sites are phased-in between 2005-2015; assumes deficits are
eliminated in 3 years for FQHCs and 4 years for look-alikes through revenue diversification.
105
The CCHS Option:
Improving Care Coordination


Improving care coordination will require community-wide
involvement and linkages.
At the provider level, these include:
Establishing county-wide, contractually-based patient referral
linkages between hospital EDs, clinics and urgent care centers a la
the Chicago model, to reduce fragmentation of care.
 Use of a Web-based system to coordinate patient referrals.
 Use of common IT and data reporting systems and integrating patient
medical records to follow patients across sites of care.
 Integrating behavioral health and primary care services in
FQHC/FQHC look-alikes.

106
The CCHS Option:
Improving Care Coordination

At the community level, these include:
Expanding the telephone nurse triage system to add a 24/7 mental
health and substance abuse call center to provide counseling and
referral services county-wide.
 Developing a health education center and establishing linkages
to the telephone nurse triage system.

– The health education center would teach consumers how and when to access
both providers and insurers.
– The education and telephone triage and counseling centers coordinate in
sharing information to better target educational strategies, message
development and consumer outreach.
Goal:
To improve coordination of behavioral and physical health services
and reduce inappropriate ED use.
107
The CCHS Option:
Improving Care Coordination

Proposed call center and health education linkages.
Call Center
Liaison/Collaborate
Analyze call volume to
identify issues and trends.
Health Education
Tailor health education topics
and outreach strategies to address
major issues and trends.
108
The CCHS Option:
Restructuring Public Health Functions

Under CCHS, City and County population health functions
are consolidated and selected women and children’s
patient care services are transferred to HCHD.
City and County
Patient Care
Services
HCHD
109
The CCHS Option:
Restructuring Public Health Functions

Consolidating public health departments, as
proposed in the past, would provide county-wide
centralized administration of public health functions
and provide a consistent level of services across city
and county.
110
The CCHS Option:
Restructuring Public Health Functions

This reorganization would also establish a focal point for
public health accountability and allow for a county-wide
unified response to public health emergencies. Other
expected benefits of consolidating public health
departments include:
Flexibility to deploy resources county-wide where needed.
 Maintains autonomy of the local public health sector, while
streamlining and rationalizing services.
 Improves care coordination through “one stop shopping ” for
consumers.
 Serves as a useful transition for possible future consolidation with
HCHD and possibly MHMRA.

111
The CCHS Option:
Restructuring Public Health Functions

Consolidation of public health departments could be
conducted under the guidance of a transition plan
that describes:
The transfer of selected patient services to HCHD.
 The merger of city and county health departments.
 The establishment of county-wide administrative and
governance structures.
 The development of a sustainable funding mechanism.

112
The CCHS Option:
Create a High Level Governance Structure


An independent governance structure with
representation and strong leadership by senior
community leaders is an important element of the CCHS
option.
The Board would provide oversight and coordination.
113
The CCHS Option:
High Level Governance Structure

Board membership should reflect the diversity of Harris
County and should have sufficient credibility to enjoy the
strong support of elected officials. To help achieve these
goals, board membership might include:
Senior city and county political leadership.
 Senior leaders with acknowledged credentials from the
medical community.
 Representation from business community leaders.
 Representation from not-for-profit sector leaders.

114
The CCHS Option:
High Level Governance Structure

Essential principles of a framework to guide effective
board operation should include:
Sufficient independence from day-to-day political
pressure to operate effectively, but remain accountable
for results.
 An independent and reliable funding base.
 A leadership succession strategy to ensure continuity of
commitment.
 Ongoing Board training and education.

115
The CCHS Option:
Assessment of Benefits

Implementing CCHS offers Harris County residents many
benefits, including:







A much better balanced network of health care providers and services.
Significantly reduced inappropriate ED use.
Greatly strengthened system coordination and linkages across levels of care.
Improved public health efficiency and effectiveness.
Expanded community access to appropriate care, emphasizing lower cost
primary and preventive services.
Better integration of behavioral health with community-based primary care.
More appropriate and cost efficient use of health care by consumers through
expanded and coordinated health education and call center capacity.
116
The CCHS Option:
Assessment of Challenges

The relative boldness of this option also carries with it a
number of implementation challenges. These include:

The need for significant investment in new capacity in the face of
possible funding constraints, including:
– Stiff nation-wide competition for and limited availability of federal
funding for future FQHC expansion.
– State cutbacks in Medicaid and CHIP eligibility.
– Little likelihood that the Texas legislature will increase Medicaid
outpatient and physician payment rates.
Maintaining continuity of strong and committed leadership over time.
 Clinical staff recruitment for the expanded network may be
challenging in the face of nation-wide work force shortages.

117
The CCHS Option:
Conclusion and Recommendation

On balance, CCHS appears to be the best strategic option for
Harris County. While challenging to implement, we believe
CCHS will, more than the other two options examined:
Reduce inappropriate ED use and fragmentation of care in the most
efficient and effective manner.
 Assure optimal use of public and private financial resources.
 Proactively position Harris County for the future.


Implementing this approach may also heighten Harris County’s
health care leadership profile nationally and enhance its ability
to attract new businesses to spur continued regional economic
growth.
118