srhcp_market_analysis_final_103012

S A C R A M E N T O R E G I O NH E A L T H C A R E P A R T N E R S H I P / 2 0 1 2

A Market Analysis of the Sacramento Region Primary Care Safety Net

A Sierra Health Foundation initiative

Preparing for Transformation: Rethinking, Revitalizing and Reforming the Sacramento Regions Health Care System

S A C R A M E N T O R E G I O NH E A L T H C A R E P A R T N E R S H I P / 2 0 1 2

A Strategic Plan for the Sacramento Region

A Sierra Health Foundation initiative

Preparing for Transformation: Rethinking, Revitalizing and Reforming the Sacramento Regions Health Care System

S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P

This market analysis of the Sacramento Region primary care safety net system was commissioned and funded by Sierra Health Foundation with additional funding from

The California Endowment and Sacramento Region Community Foundation. The analysis was conducted by The Abaris Group, Public Health Institute and Hatches Consulting.

Consultant Team

The Abaris Group

Mike Williams, MPA/HSA, Project Lead

Marsha Regenstein, PhD

Alaina Dall

Juliana Boyle, MBA

Mark Zocchi

Chuck Baucom

Public Health Institute

Carmen Nevarez, MD, MPH

Marisel Brown, MPH, MSBA

Art Chen, MD

Elaine Zahnd, PhD

Nancy Shemick, MPP

Amy Neuwelt, MPH

Heather Bonser-Bishop

Hatches Consulting

Barrett Hatches, PhD

The Abaris Group, Public Health Institute, Hatches Consulting, Mighty Pen Writing & Editing and Sierra Health Foundation contributed to the writing and editing of this market analysis.

S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P

Table of ContentsAcknowledgements 1

LetterfromtheFunders 4

LetterfromCongresswomanDorisMatsui 5

ExecutiveSummary 6

ProjectOverview 9

HowThisReportWasDeveloped 11

TheSacramentoRegionsSafetyNetPopulation 13

HealthReformBackgroundandImplications 15

SafetyNetSnapshot 19

CurrentSafetyNetProviders 20

EmergencyDepartmentsOverusedforPrimaryCare 23

DetailedDataAnalysisFindings 23

SafetyNetDemand 23

Preventable/AvoidableEmergencyDepartmentVisits 25

SafetyNetCapacity 26

HealthProfessionalShortageAreas 29

SafetyNetProjections 31

SafetyNetFunding 34

StakeholderFeedback 36

ConclusionsandNextSteps 38

Appendices 1.GlossaryofTerms 41

2.SacramentoRegionCommunityHealthIndicators 44

Available Online at www.sierrahealth.org/healthcarepartnershipCommunityHealthCenterSiteVisitsandInterviews

CommunityPhysicianDiscussionGroupInterviews

HealthCenterConsumerFocusGroupInterviews

SACOGTransitStudyHighlights

CountyProgramsfortheUnderserved

SacramentoRegionHealthCarePartnershipMarketAnalysisChartbook

S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P | P a g e 1

AcknowledgementsThank you to the many stakeholders who contributed their time, expertise and involvement with the development of this market analysis. Sincere apologies to anyone who may have been inadvertently left off this list.

JonathanLehrman,MDAccessElDorado

ChristineSisonAccessElDorado

SandiSnelgroveAnotherChoiceAnotherChance

SeanAthaAnthemBlueCross

KerryBrownAnthemBlueCross

KimWilliamsBuildingHealthyCommunities

JosephHafkenschielCaliforniaAssociationforHealthServicesatHome

ChristineSmithCaliforniaConsortiumforUrbanIndianHealth

RosanaJacksonCaliforniaDepartmentofPublicHealth

LeticiaAlejandrezCaliforniaFamilyResourceAssociation

DorethaWilliams-FlournoyCaliforniaInstituteforMentalHealth

CarolLeeCaliforniaMedicalAssociationFoundation

ElissaMaasCaliforniaMedicalAssociationFoundation

EdMendozaCaliforniaOfficeofStatewideHealthPlanningandDevelopment

RonaldSpingarn CaliforniaOfficeofStatewideHealthPlanningandDevelopment

JonathanTeague CaliforniaOfficeofStatewideHealthPlanningandDevelopment

SandraPerezCaliforniaOfficeofthePatientAdvocate

MarthaTorres-MontoyaCaliforniaOfficeofthePatientAdvocate

KiranGrewalCaliforniaPharmacistAssociation

DeborahOrtizCaliforniaPrimaryCareAssociation

DavidQuackenbushCaliforniaPrimaryCareAssociation

SteveBarrowCaliforniaStateRuralHealthAssociation

AlHernandez-SantanaCalifoniaStateRuralHealthAssociation

MartyKealeCapitolCommunityHealthNetwork

AshelyTolleCapitolCommunityHealthNetwork

JohnAdamsCASAElDorado

DebbieBrussard CenterforAIDSResearch,Education&Services

RobertKamrath CenterforAIDSResearch,Education&Services

JanetParkerCenterforAIDSResearch,Education&Services

WendyPetkoCenterforCommunityHealthandWell-Being,Inc.

KarenShoreCenterforHealthImprovement

TaraDavisCenterForInnovativeCommunitySolutions

SheliaDuruisseau-SidqeCenterForInnovativeCommunitySolutions

AutumnValerioCenterforMulticulturalDevelopment

CathyFreyCentralValleyHealthNetwork

LisaDaviesChapa-DeIndianHealthProgram,Inc.

RobinAffrimeCommuniCareHealthCenters

LeonSchimmel,MDCommuniCareHealthCenters

AlanLangeCommunityLinkCapitalRegion

ArielLovettCommunityRecoveryResources

BrianGraafCommunityResourceProject

KellyBennett-WoffordCovertheKids

JoilXiongCovertheKids

MichaelNegrete,PharmD CPhAandCaliforniaNorthstateUniversity

KaciBaldiDignityHealth

RosemaryYountsDignityHealth

LizDowellDivideReadyby5

JohnBachman,PhDElDoradoCommunityHealthCenter

JamesEllsworth ElDoradoCommunityHealthCenter

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DeborahPalmer ElDoradoCounty

OliviaByron-Cooper,MPH ElDoradoCountyHealth&HumanServicesAgency

JoanMeisWilsonElDoradoCountyHealth&HumanServicesAgency

MichaelUngeheuer,RN,MN,PHNElDoradoCountyHealth&HumanServicesAgency

ChristyWhiteElDoradoCountyHealth&HumanServicesAgency

ChristineHoyt ElDoradoCountyPublicHealth

AlexBolteElHogarMentalHealthandCommunityServices

EileenSnickerFeministWomensHealthCenter

RickAlfordFirst5ElDorado

KathleenWalker First5ElDorado

DebraPayneFirst5Sacramento

JulieGallelo First5Yolo

DebraOto-Kent HealthEducationCouncil

RichardIkeda,MDHealthforAll

EffieRugglesHealthNetofCalifornia

MarthaGeraty HealthNetStateHealthPrograms

ScottSeamonsHospitalCouncilofNorthernandCentralCalifornia

JenniferAblogKaiserPermanente

EllenBrownKaiserPermanente

StephanieLandrum KaiserPermanente

MyrnaRivas KaiserPermanente

PatriciaRodriguez,RN,MPHKaiserPermanente

CarolSerreKaiserPermanente

ChaosarnChao LaoFamilyCommunityDevelopment,Inc.

ElisaHerrera LatinoLeadershipCouncil

BobLong,MD LatinoLeadershipCouncil

BillKennedy LegalServicesofNorthernCalifornia

FrankLemus,PhDLemusConsultingGroup

JenniferDwight-FrostMarshallMedicalCenter

SherryGeurinMarshallMedicalCenter

VernSaharaMarshallMedicalCenter

DennyPowellMercyGeneral

MarciaWells MercyNorwoodFamilyClinic

TonyBrowneMidtownMedicalCenterforChildren&Families

ElizabethCassin MidtownMedicalCenterforChildren&Families

RobertReichMidtownMedicalCenterforChildren&Families

RichardDanaMutualAssistanceNetwork

LeonardRanasinghe,PhD,MDNatomasCrossroadsClinic

BarbaraSayre-Thompson NCADDSacramento

GailCatlinNonprofitResourceCenter

RichardBurton,MD,MPHPlacerCountyHealth&HumanServices

JamesGandley,DDS,MPHPlacerCountyHealth&HumanServices

ElizabethFraley PlannedParenthoodMarMonte

RaquelSimentalPlannedParenthoodMarMonte

JenniferStorkPlannedParenthoodMarMonte

LindaWilliams PlannedParenthoodMarMonte

LorraineRinkerRinkerandAssociates

AliciaRossSacramentoAreaCongregationsTogether

AllisonSwanSacramentoAreaCongregationsTogether

NenickVuSacramentoAreaCongregationsTogether

JoeConcannonSacramentoAreaCouncilofGovernments

GordonGarrySacramentoAreaCouncilofGovernments

MonicaHernndezSacramentoAreaCouncilofGovernments

RebeccaThorntonSloan SacramentoAreaCouncilofGovernments

SharonSprowlsSacramentoAreaCouncilofGovernments

DiAnneBrownSacramentoCityUnifiedSchoolDistrict

JerryBliatoutSacramentoCommunityClinic/HALO

MiguelSuarezSacramentoCommunityClinic/HALO

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BradHudsonSacramentoCounty

PaulLakeSacramentoCountyDepartmentofHumanAssistance

SandyDamiano,PhDSacramentoCountyHealthServices

MarciaJo,PhD SacramentoCountyHealthServices

AnnEdwardsSacramentoCounty,CountywideServices

BruceWagstaffSacramentoCountyCountywideServices

KathyHarwellSacramentoCountyHealth&HumanServices

OliviaKasirye,MD,MS SacramentoCountyHealth&HumanServices

GlennahTrochett,MDSacramentoCountyHealth&HumanServices

DyannWolfeSacramentoFamilyMedicalCenter

KendraBridges SacramentoHousingAlliance

LisaBatesSacramentoHousingRedevelopmentAgency

EricEnriquezSacramentoNativeAmericanHealthCenter,Inc.

BrittaGuerrero SacramentoNativeAmericanHealthCenter,Inc.

AllieShilinSacramentoNativeAmericanHealthCenter,Inc.

PriscillaEnriquezSacramentoRegionCommunityFoundation

JohnChuck,MDSerotoninSurgeCharities

WilliamSandbergSierraSacramentoValleyMedicalSociety

KristineWallachSierraSacramentoValleyMedicalSociety

AileenWetzelSierraSacramentoValleyMedicalSociety

KellyBrenkSutterHealth

TomGagenSutterHealth

HollyHarperSutterHealth

KeriThomasSutterHealth

JoseAlbertoArevalo,MDSutterIndependentPhysicians

MarlonCuellar TheCaliforniaEndowment

ChristineTienTheCaliforniaEndowment

EricFimbresTheEffort,Inc.

J.RodneyKennedyTheEffort,Inc.

BunryPinTheEffort,Inc.

JonathanPorteus,PhDTheEffort,Inc.

TomStanko,MDTheGatheringInnClinic

GraceRubensteinTheSacramentoBee

WarrenBarnesUCBerkeleySoPH/RightCareInitiative

SheltonDuruisseau,PhDUCDavisHealthSystem

LauraNiznikUCDavisHealthSystem

ClairePomeroy,MD,MBAUCDavisHealthSystem

CarolynRamirezUCDavisHealthSystem

RobertWaste,PhDUCDavisHealthSystem

CongresswomanDorisMatsuiU.S.HouseofRepresentatives

NathanDietrich OfficeofCongresswomanDorisMatsui

KariLacostaOfficeofCongresswomanDorisMatsui

DaleAinsworth,PhDValleyVision

CarlHeardWesternCliniciansNetwork

CharlaParkerWesternCliniciansNetwork

CasieParrishWesternCliniciansNetwork

AlexanderGiloffWesternSierraMedicalCenter

SherBarberWindYouthServices

KimSudermanYoloCountyAlcohol,DrugandMentalHealth

JillCook,MS,RN,PHNYoloCountyPublicHealth

TraciLucchesiYoloCountyPublicHealth

TrishaStanionisYoloFamilyServiceAgency

GregBergner,MD

DawnDunlapConsultant

GrantlandJohnsonFormerSecretaryofCaliforniaHealthandHumanServicesAgency

SierraHealthFoundation:

ChetHewitt

DianeLittlefield

RobertPhillips

AbrahamDaniels

SusanKing

KatyPasini

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Letter from the Funders

DearColleagues,

In2011,SierraHealthFoundationlaunchedtheSacramentoRegionHealthCarePartnershipwiththegoalof

findingwaystoimproveaccess,carecoordinationandthequalityoftheregionsprimarycaresystem,witha

specificfocusoncommunityhealthcenters.Partnersinthisinitiativeincludedleadersfromcommunityclinics,

healthsystems,healthplans,associationsandcounties,aswellasphysicians,policymakersandothers.The

timingwasright,astheimplementationoftheAffordableCareActin2014offersanunprecedented

opportunitytoextendhealthinsurancecoveragetothosecurrentlyuninsured.

InordertofullyrealizetheopportunitiesoftheACA,weneedtounderstandboththestrengthsandthe

weaknessesofthecurrentregionalsystemthatservesresidentsofElDorado,Placer,SacramentoandYolo

counties.Accordingly,thePartnershipcommissionedtwostudies:amarketanalysisthatidentifiesthecurrent

servicecapacitywithintheprimarycaresafetynet,andastrategicplantodevelopanintegratedhealthcare

deliverysystemmodelthatefficientlylinkscommunityhealthclinicstoregionalproviders,thusexpanding

accesstohighqualityandculturallysensitiveservicesforlow-incomeadultsandchildreninourregion.The

CaliforniaEndowmentandSacramentoRegionCommunityFoundationwerefundingpartnersforthemarket

analysisandstrategicplanningprocess.

Wearepleasedtosharewithyouthemarketanalysisandthestrategicplan,whichilluminatewhatwecando

asaregiontoprepareforthetransformativeimpactsofhealthcarereform.Thestressesonourregionalsafetynet

aresubstantial;atthesametime,wearegalvanizedbythevisionofacollaborative,accessible,highqualityand

culturallycompetentprimarycarehealthsystemthatisoutcome-basedandsustainable.Thatisavisionwecan

andmustsupport,individuallyandcollectively.

Weofferthesereportstoinspireconversationandactionaboutthewaystocreateahighqualitypatientcare

systemthatwillbeready,willingandabletoserveournewlyinsuredresidents.Thisisatimeoftremendous

challengeandopportunity,andwemusttakewisestepstogetheraswecreateastrongerandwidersafetynet

toeffectivelyserveallofourresidents.

Sincerely,

ChetP.HewittDr.RobertK.Ross RuthBlank

President and CEO President and CEO CEO

Sierra Health Foundation The California Endowment Sacramento Region Community Foundation

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Executive SummaryPreparing the Sacramento Region for the transformative impacts of health care reform

Is the Sacramento Region ready for health care reform? Can the Sacramento Region primary care safety net absorb a dramatic influx of newly insured patients in 2014? How can the Sacramento Region maximize the benefits afforded by the Patient Protection and Affordable Care Act (ACA) to improve access and quality for the Sacramento Regions most vulnerable residents? What resources (ACA and other) can the Sacramento Region apply to bolster safety net functioning to better meet current and looming demands?

ACA offers an unprecedented opportunity to rethink, revitalize and reform Sacramentos regional health care system. But even without this law, the four counties that make up the region El Dorado, Placer, Sacramento and Yolo would be wise to consider addressing weakness in their primary care system. Why? Because the capacity of the institutions that represent the medical safety net is directly linked to its ability to meet the health care needs of the regions most vulnerable residents. As this report makes clear, all of the health care stakeholders in the Sacramento Region must work together to close the gaps between residents health care needs and the systems ability to efficiently meet them.

This market analysis and a companion regional strategic plan conclude the initial work of the Sacramento Region Health Care Partnership. Our goals for this work were straightforward: to better understand the dynamic affecting the safety net system and develop a regional strategic plan to foster the development of an integrated health care delivery system that efficiently links community health centers to regional providers. It was the collective hope of the many groups and individuals who participated in this work that it would result in expanded access to high quality services for low-income adults and children in the Sacramento Region. The market analysis identifies the Sacramento Region safety nets strengths, weaknesses, opportunities and stressors. Armed with these insights, the Sacramento Region can

better meet its communities health care needs today to improve health, while preparing itself for vastly increased demand under ACA.

Health Care Reform Background and Context

The passage of the Patient ProtectionandAfforable CareAct(ACA)

1, as amended by the Reconciliation Act

of 2012 (P.L. 111-152) collectively referred to as the health reform law transforms the delivery and financing of the health care system. The intent of ACA is to expand health insurance coverage while also reforming the health care delivery system to improve quality and value. ACA also includes provisions to eliminate disparities in health care, strengthen public health care access, invest in the expansion and improvement of the health care workforce, and encourage consumer and patient wellness in both the community and the workplace. ACA is investing $11 billion in new mandatory federal spending through 2015 to support the expansion of health center capacity for the millions of uninsured Americans who will be eligible for Medicaid or private coverage beginning in 2014.

The vehicle for this funding is the Community Health Centers and National Health Service Corps Trust Fund, which was created by the passage of ACA. This new trust fund changes the way new health center funding is appropriated. Instead of Congress making the determination of funding levels each year, the Department of Health and Human Services will be able to directly appropriate the health center funds once the federal budget is passed and signed into law. The thrust of the Health Center Trust Fund is to expand health centers capacity and to invest in health centers as a strategy for building health care capacity in the U.S.

2

According to the Congressional Budget Office, the law will increase coverage to about 94 percent of Americans, while slowing the rate of growth in federal health expenditures by $124 billion over the next decade.


1^Pub.L.111-148,124Stat.119,tobecodifiedasamendedatscatteredsectionsoftheInternalRevenueCodeandin42U.S.C.2KaiserCommissiononMedicaidandUninsured:CommunityHealthCenters:TheChallengeofGrowingtomeettheneedforprimarycaremedicallyunderservedcommunities.http://www.kff.org/uninsured/upload/8098-02.pdf

227,500 newly insured patients will overwhelm our regions safety net.

Table 1.

IntheSacramentoRegion(ElDorado,Placer,Sacramento

andYolocounties),aprojected227,500non-elderlyadults

andchildrenwillbeeligibleforhealthcoveragethrough

expandedMedi-Calbenefitsorsubsidizedprivateinsurance

(healthcareexchanges).

Significant Opportunities for Improvement

Thehealthreformlawpermanentlyauthorizesandexpands

communityhealthcentersandtheNationalHealthServices

Corps.Thehealthreformlawprovidesatotalof$1.5

billioninnewfundingthrough2015totrainmore

primarycareprovidersviascholarshipsandloanrepayment

assistance.ACAinvestmentswilldoublecommunityhealth

centercapacity.Throughfederalprogramsandgrantsto

states,thehealthreformlawwillhelpexpandthenations

healthworkforcefromphysiciansandnursestopublic

healthprofessionalsthroughscholarshipsandlocal

repaymentassistance.Thelawalsoaimstoimprovethe

diversityofthehealthcareworkforcetodelivercarethatis

appropriatefortheentirepopulation.

Inshort,thelawprovidesmanyopportunitiestostrengthen

thesafetynet,butalsoposesrealchallenges.Meetingthe

vastlyincreaseddemandforhealthcareservicesisnosmall

task.Throughoutthenation,communitiesareatdifferent

pointsinpreparingfortheincreasednumberofresidents

coveredthroughMedicaidexpansionmandatedbyACA.

The Role of Sacramento Region Health Care Partnership

Attherequestofseveralcommunitystakeholders,in

2011SierraHealthFoundationlaunchedtheSacramento

RegionHealthCarePartnership.Theinitiativegrewout

ofconversationswithpolicymakers,healthsystemsand

communityhealthcenters,whoapproachedSierraHealth

Foundationtoserveasintermediaryinpreparingthe

SacramentoRegion,whichincludesElDorado,Placer,

SacramentoandYolocounties,toimplementhealthreform.

TheHealthCarePartnershipcreatestheregionsfirst

coordinatedphilanthropic,countyagency,nonprofit

providerandcommunityhealthcentereffortfocused

solelyonregionalhealthcarereformpreparedness

andimplementation.

TheSacramentoRegionHealthCarePartnershipincludesa

broadrangeofhealthcarepartnersandleadersthroughout

theSacramentoRegion,includingcommunityhealth

centers,healthsystems,healthplans,associationsand

counties,aswellasphysicians,policymakersandother

nonprofitsthatworkwithinthesafetynet.SierraHealth

Foundation,TheCaliforniaEndowmentandSacramento

RegionCommunityFoundationarefundingpartners

ofthemarketanalysisandregionalstrategicplan.

The Health Care Partnerships Goal

TheSacramentoRegionHealthCarePartnershipsgoalisto

findwaystoimproveaccess,carecoordinationandquality

oftheregionssafetynetprimarycaresystemthroughinput

fromhealthcareandcivicleadersandotherstakeholders.

TheHealthCarePartnershipsultimatevisionistoincrease

andimproveprimarycareaccessandqualityforindividuals

andfamiliesinlow-incomecommunitiesandcommunities

ofcolorinElDorado,Placer,SacramentoandYolocounties.

Betteraccesstoprimarycarewilllowerthecostofhealth

careoverall,betterallocatehealthcareresources(e.g.,reduce

expensive,unnecessaryacutecareresponsestopreventable

chronicdisease)andimprovepublichealthinthe

SacramentoRegion.


Sacramento Region Insurance Coverage 2009 and 2014

Source: MCIC Chicago, 2012

Insurance 2009 Percent Movement 2014 Percent

Individual 103,973 4.9% 109,610 213,583 10.0%

Medicare 248,432 11.6% - 248,432 11.6%

Medi-Cal 369,057 17.3% 117,947 487,004 22.8%

Uninsured 303,306 14.2% (227,557) 75,749 3.6%

Total 2,132,796 - - 2,132,796 -

Employer 1,108,028 52.0% - 1,108,028 52.0%

2014 Focus Group Demographic Data

Sacramento Region Median Household Income & Federal Poverty Levels, 2010

Note: For purposes of comparison the 2010 FPL is shown. 2012 FPL is $11,170 for individuals and $23,050 for families of four.

Sources: 2010 American Community Survey (ACS); Health and Human Services Poverty Guidelines

El Dorado County $66,129

Placer County $67,884

Sacramento County $52,709

Yolo County $55,798

California $57,708

100 Percent $10,830 $22,050

200 Percent $21,660 $44,100

Median HouseholdIncome 2010 Federal

Poverty Levels

Individual Four-personFamily

2524

-Total Number of Returned Demographic Forms -

Age71muminiM -86mumixaM -

Average 24egA -

Gender%238elaM%4661elameF

Highest Level of Educaon Completed8th grade or %213sselSome high school, but didn't graduate 3 12%High school graduate or %426DEGSome college or 2-year degree 9 36%4-year college %41eergedMore than 4-year college degree 2 8%

Combined Household IncomeLess than %0401000,01$More than $10,000 but less than $13,000 5 20%More than $13,000 but less than $15,000 3 12%More than $15,000 but less than $20,000 2 8%More than $20,000 but less than $30,000 2 8%More than $30,000 but less than $40,000 1 4%More than $40,000 but less than $50,000 1 4%More than $50,000 0 0%Don't %00wonk

Race/Ethnicity%238etihW

Black or African- %827naciremA%41naisA%238cinapsiH

Insurance StatusDo not have %827ecnarusniHave %8671ecnarusnI

Insurance TypeEmployer- %00desab

%413eracideMMedi- %7641laC

%012ISSOther %012)PIHCY(

Total Number of Parcipants

Diabetes, Adults, Sacramento Region, 2009Asthma, Ages 1 Year and Older, Sacramento Region, CHIS 2009

Selected Characteristics of Individuals = 300 percent FPL 16.7 196,000 Insurance Status Insured 16.4 306,000 Uninsured 14.3 30,000

Total Reporng Asthma

16.2

336,000

Source: 2009 California Health Interview SurveySource: 2009 California Health Interview Survey

Italics are signicantly dierent rates.

Populaon Group Percent Pop. EsmateAge Group (Years)

18-24

25-64 5.5* 60,000

65 or older 23.8* 58,000

Gender

Male 8.3 62,000

Female 6.8 56,000

Race/Ethnicity

White 5.7* 56,000

Lano 15.2* 40,000

African American

AI/AN

Asian/Nave Hawaiian/PI

Two or More Races(Non-Lano) Immigrant Status

U.S. Born 7.4 96,000

Foreign Born

Federal Poverty Level

0-99 percent FPL

100-199 percent FPL 10.8 25,000

200-299 percent FPL 8.1 20,000

>= 300 percent FPL 5.8 54,000

Insurance Status

Insured

Uninsured

Total Diagnosed with Diabetes

7.5 118,000

Obese (BMI>30), Adults, Sacramento Region, 2009

Source: 2009 California Health Interview Survey


High Blood Pressure, Adults, Sacramento Region, 2009


Populaon Group Percent Pop. Esmate

Age Group (Years)

18-24

25-64 22.1* 241,000

65 or older 57.6* 140,000

Gender

Male 25.5 193,000

Female 24.7 200,000

Race/Ethnicity

White 26.9 265,000

Lano 22.6 60,000

African American 37.6 36,000

AI/AN

Asian 13.2 21,000

Two or More Races (Non-Lano)

24.3 10,000

Immigrant Status

U.S. Born 26.3 339,000

Foreign Born 19.4 54,000


0-99 percent FPL 24.1 41,000

100-199 percent FPL 28.5 66,000

200-299 percent FPL 23.5 57,000

>= 300 percent FPL 24.8 228,000

Insurance Status

Insured 26.6* 367,000

Uninsured 13.9* 27,000

Total Diagnosed with HBP

25.1 393,000

18-24 16.2 38,000 25-64 26.3 287,000 65 or older 25.9 63,000 Gender Male 25.9 196,000 Female 23.6 192,000Race/Ethnicity White 22.5* 221,000 Lano 36.4* 96,000 African American 48.1* 46,000 AI/AN

El Dorado County Community Health Center El Dorado FQHC

Placerville Health and Wellness Center El Dorado FQHC

Birth and Family Health Center Sacramento FQHC

The Effort Medical Clinic Sacramento FQHC

The Effort Oak Park Community Health Center Sacramento FQHC

The Effort South Valley Center Sacramento FQHC

Sacramento Nave American Health Center, Inc. Sacramento FQHC

Suer Seniorcare Sacramento FQHC

Suer Seniorcare Site II Sacramento FQHC

Davis Community Clinic Yolo FQHC

Peterson Clinic Yolo FQHC

Salud Clinic Yolo FQHC

Winters Healthcare Clinic Yolo FQHC

Health for All, Inc. Sacramento FQHC Look-Alike

Health for All Freeport Clinic Sacramento FQHC Look-Alike

Health for All Las Palmas Clinic Sacramento FQHC Look-Alike

Sacramento Community Clinic Del Paso Sacramento FQHC Look-Alike

Sacramento Community Clinic Southgate Sacramento FQHC Look-Alike

Barton Memorial Hospital Family Clinic El Dorado Neither

Shingle Springs Tribal Health Program El Dorado Neither

Chapa-De Indian Health Program, Inc. Placer Neither

Planned Parenthood Roseville Placer Neither

Alternaves Pregnancy Resource Center Sacramento Neither

The Birthing Project Clinic Sacramento Neither

Center for Aids Research, Educaon & Services Sacramento Neither

Feminist Womens Health Center Sacramento Sacramento Neither

MMC for Children and Families * Sacramento Neither

Planned Parenthood Capitol Plaza Sacramento Neither

Planned Parenthood Fruitridge Sacramento Neither

Planned Parenthood Mar Monte B Street Health Ctr. Sacramento Neither

Planned Parenthood North Highlands Sacramento Neither

Rancho Cordova Community Clinic Sacramento Neither

Sacramento Life Center Sacramento Neither

Society for the Blind, Inc. Sacramento Neither

Chapa-De Indian Health Program, Inc. Yolo Neither

MMC for Children and Families Yolo Neither

Planned Parenthood Woodland Yolo Neither

Asian Two or More Races(Non-Lano)

25.0 10,000

Immigrant Status U.S. Born 26.5* 341,000 Foreign Born 16.8* 47,000 Federal Poverty Level 0-99 percent FPL 28.8 49,000 100-199 percent FPL 30.4 71,000 200-299 percent FPL 30.7 75,000 >= 300 percent FPL 21.0 193,000Insurance Status Insured 24.4 336,000 Uninsured 26.9 51,000 Total Obese 24.7 388,000

Delayed/Did Not Get Needed Medical Care, All Ages, Sacramento Region, CHIS 2009



1-1112-1718-24 11.3 26,00025-39 18.7* 71,00040-64 18.3* 130,00065 or older 4.1* 10,000

Gender Male 12.2 127,000 Female 12.5 134,000Race/EthnicityWhite 14.0 174,000Lano 9.7 40,000African AmericanAI/ANAsian

Two or More Races (Non-Lano) Immigrant StatusU.S. Born 12.6 228,000Foreign Born 10.8 33,000Federal Poverty Level0-99 percent FPL 17.6 49,000100-199 percent FPL 14.0 44,000200-299 percent FPL 14.1 47,000

>= 300 percent FPL 10.2 121,000Insurance Status Insured 11.1* 211,000 Uninsured 23.8* 50,000Total Delayed/Didn't Get Med. Care

12.4 261,000

Community Health Centers, 2010

Source: OSHPD Primary Care Clinic Utilization data les, 2010

Community Health Centers County FQHC or Look-Alikes

Received Past Year Mental Health/Alcohol or Other Drug Help, Adults 18 and Older with Need,Sacramento Region, CHIS 2009



18-24 52.9 22,000

25-64 59.9 111,000

65 or older 70.9 7,000

Gender

Male 52.5 43,000

Female 62.5 97,000

Race/Ethnicity

White 63.9 103,000

Lano 28.8 8,000


AI/AN

Asian


76.7 5,000

Immigrant Status

U.S. Born 58.6 145,000



0-99 percent FPL 55.0 27,000

100-199 percent FPL 46.4 18,000

200-299 percent FPL 63.9 27,000

>= 300 percent FPL 59.8 82,000

Insurance Status

Insured 59.0 143,000

Uninsured 44.9 12,000

Total Receiving Help 59.1 140,000

CHC Staffing and Encounters (Visits) per FTE, 2010

Safety Net No or Underinsured Health Insurance Coverage, 2010

Source: U.S. Census Bureau, 2010 American Community Survey 1-Year Estimates

Insurance Type Region CaliforniaNo Health Insurance 12.7 percent 18.5 percentMedicare & Medicaid 1.1 percent 1.0 percentMedicaid (ages 18-64) 6.1 percent 5.7 percentMedicaid (ages

About the Market Analysis

Thismarketanalysisisthelargestandmostcomprehensivebench-

markoftheprimarycaresafetynetintheSacramentoRegionto

date,assessingbothcurrentandforecasteddemandandcapacity.

Ratherthanrelyingsolelyondataanalysis,asystemsview

wastakentounderstandthecurrentandforecastedcapacity

oftheprimarycaresafetynet.Thefocuswasoncommunity

healthcenters,healthsystems,healthcareprovidersand

nonprofitsthatarepartoftheentireenginethatdrivesthe

SacramentoRegionssafetynet.Conversationswithpeople

onthefrontlinesofhealthcaredeliveryintheregionand

low-incomeresidentswerealsoincludedinthisanalysis.

Thismarketassessmentincorporatesinputfromstakeholder

interviews,communityhealthcentersitevisits,dataanalysis

fromavarietyofsources,andfocusgroupinterviewswitha

cross-sectionofleaders,physiciansandconsumersof

communityhealthcenterservices.

Key Findings: 10 Stressors and Strengths Driving Regional Safety Net Performance

TheSacramentoRegionHealthCarePartnershiphas

identified10criticalissuesimpactingsafetynetperformance

andsustainability.Somearechallengestobemitigated,andsome

arestrengthstobecapitalizedon.Allpresentopportunitiesto

improveourregionsprimarycareandspecialtycaredelivery

fortheunderservedpopulationintheSacramentoRegion.

1. RethinkPrimaryCare.Whilethecurrentsafetynetintheregionhasmanychallenges,theadventofACAallows

thecommunitytheopportunitytorethinkitsapproachto

primarycareascurrentlyprovidedbythesafetynet.

2. GrowingDemand.227,500non-elderlyadultsandchildrenwillbeeligibleforhealthcarecoverageunder

ACA.Thesafetynetpopulationisgrowingandwill

continuetogrownaturally.Demandwillacceleratewith

theadventofACA.

3. SickerCitizens.Communityhealthindicatorspredictthenewlyinsuredpopulationwillbesickerthanthe

existingpubliclyinsuredpatientpopulationandhave

significantlyhigherlevelsofchronicdiseasesandrisk

factors,suchasasthma,diabetes,highbloodpressure,

obesity,smokingandpreviouslyunmetneedsforhealth


careand/ormentalhealth/alcoholordrughelp.

4. MaxedOutCapacity.Theprimarycarecapacityofcommunityhealthcentersandemergencydepartments

totreatthesafetynetpopulationhasgrown,butwithout

furthereffortsitwilllikelyreachcapacitypriorto2016.

5. RegionalCapacityBelowAverage.ThenumberofcommunityhealthcentersintheSacramentoRegion

hasgrown,butfallssignificantlyshortofmanyother

similar-sizedregionsinCalifornia.

6. MoreMedi-CalPayments.Approximately60percentofthenewlyinsuredpatientswillbeinsuredby

Medi-Cal,makingitthesecondlargestpayersourcein

theSacramentoRegion.

7. OveruseofHighCostHospitalandEmergencyDepartmentServices.Currently,thesafetynetisoverlydependentonexpensivehospitals,andemergency

departments,inparticular,toprovideoutpatientcare.

8. FinanciallyChallengedCommunityHealthCenters.Roughlyhalfoftheregionscommunityhealthcenters

arefinanciallychallenged,withexpensesconsistently

exceedingrevenues.

9. LimitedFederallyQualifiedHealthCenters.Thenumberandlocationoffederallyqualifiedhealth

centers(FQHCs)intheregionislowerthanthestate

averageandotherregions.Manycommunityhealth

centersarenotabletotakeadvantageoffinancial

incentivesaffordedtoFQHCs.

10.LackofCoordinatedLeadership.Thecurrenthealthcaresafetynetlacksaleadagency,coordinationandintegration.

Next Steps

Basedonthefindingsinthismarketanalysis,theSacramento

RegionHealthCarePartnershiphasdevelopedaregional

sharedvisionandstrategicplantoaddressthemostcritical

factorsinordertoimprovetheprimarycaresafetynetinthe

region.Thisplanispresentedinacompanionreport:Preparing

for Transformation: Rethinking, Revitalizing and Reforming the

Sacramento Regions Health Care System, a Strategic Plan for

the Sacramento Region. Thesereportsareavailableonlineat

www.sierrahealth.org/healthcarepartnership.

Project OverviewIdentifying needs and opportunities to optimize the Sacramento Regions safety net system

Project Objective:

TofullyunderstandandtransformtheSacramentoRegions

healthcaresystem(primarycare,specialtycare,acute

careandhealthplanmanagement)inpreparationforfull

implementationofhealthreform;ensurecarecapacityand

residentaccess;andidentifyopportunitiesforvarious

stakeholderstocontributetothesechanges.

Market Analysis Background and Context: Building on Previous Research

In2009,theCaliforniaHealthCareFoundationissueda

marketreportoftheSacramentoRegion.Akeyfinding

underscoresalongstandingchallenge:Thesafetynetis

characterizedbyafragmentedgroupofsmalland

financiallyfragilehealthcentersthattogetherofferlimited

outpatientcapacity.3Aseparatereport

4identifiedthese

specificchallengesfacingtheSacramentoRegionssafetynet:

underdevelopedadministrativeandservicedelivery

capacity,

limitedaccesstomedicalspecialistsanddentalcare,

insufficientlinguisticandculturalresources,and

transportationbarriers.

Inaddition,overthelastfouryears,manyoftheregions

countyhealthagencieshaveseentheirgeneralfund

supportdwindle.AcaseinpointistheSacramentoCounty

DepartmentofHealthandHumanServices.Consistent

cutstoSacramentoCountysDepartmentofHealthand

HumanServicesbeginningin2008haveresultedina50%

reductioninitstotalbudgetandtheclosureoffiveofits

sixprimarycareclinics.

In2010,thefourlocalhealthsystemsDignityHealth

(CatholicHealthcareWest),KaiserPermanente,Sutter

HealthSacramentoSierraRegionandtheUniversityof

CaliforniaDavisHealthSystempartneredwithValley


VisiontoconductaCommunityNeedsAssessmentinthe

GreaterSacramentoRegion.Theassessmenthighlighted

challengesandneedswithinunderservedpopulationsand

identifiedkeysourcesforhospitaladmissionsandemergency

departmentvisits.Zipcodedataprovidedinsightin

definingtheneedsoftheunderservedpopulation.These

werethepredominantobstaclesthathinderedorprevented

accesstohealthcarewithintheunderservedpopulation:5

affordabilityofhealthcareservices,especially

healthinsurance,

locatingphysicians,specialists,dentists,mental/

behavioralhealthandotherproviderswhoaccept

Medi-Caland/orworkatreducedrates,

navigatingacomplexandinefficientsafetynetand

relatedsocialservicessystem,and

culturalbarriers,includinglanguageandsocialcustoms.

Anticipating the Regional Impact of ACA

ImplementationofthefederalPatientProtectionand

AffordableCareAct(ACA)in2014representsan

unprecedentedopportunitytoexpandhealthinsurance

coveragetothosecurrentlyuninsuredandsupportnewand

innovativepaymentmodels.TheACAalsobringsrenewed

attentiontoenrollmentinapatient-centeredmedical

hometoimproveefficiencyandcoordinationofcare,

whichwillbestudiedasdemonstrationsbytheCenterfor

MedicareandMedicaidInnovation,thenewresearchand

developmentarmoftheCenterforMedicareand

MedicaidServices6.

3CaliforniaHealthCareFoundation,SacramentoPowerfulHealthSystemsDominateaStableMarket.http://www.chcf.org/publications/2009/07/sacramento-powerful-hospital-systems-dominate-a-stable-market#ixzz1t5kNz6tN(Lastaccess4-25-12)4July2008report,TowardanImprovedHealthCareSystemforSacramentoCountysUnderservedResidents,authoredbytheSacramentoHealthImprovementProject.5AinsworthD.,DiazH.,SchmidtleinM.2010CommunityNeedsAssessmentFortheGreaterSacramentoRegion.http://www.healthylivingmap.com/CNA%20Report%202010.pdf.6AnalysisofACATitleIISubtitleISec.2303Payment;Sec.2703Stateoptiontoprovidehealthhomesforenrolleeswithchronicconditions;Sec.2706PediatricAccountableCareOrganizationdemonstrationproject;TitleIIISec.3021EstablishmentofCenterforMedicareandMedicaidInnovationwithinCMS;TitleVSec.5301Traininginfamilymedicine,generalinternalmedicine,generalpediatrics,andphysicianassistantship;Sec.5501Expandingaccesstoprimarycareservicesandgeneralsurgeryservices;HealthCareandEducationReconciliationActSec.1202Paymentstoprimarycarephysicians.

Respi te Par tnership Col laborat ive | P a g e 6S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P | P a g e 1 0

Currentestimatesproject227,500non-elderlyadultsand

childrenintheregionwillbeeligibleforcoveragethrough

expandedMedi-Calbenefitsorsubsidizedprivateinsurance.

Hospitalemergencydepartmentscurrentlyplayalargerole

inthecareofuninsuredandMedi-Calpatients.7Inmost

instances,thesenewlyeligibleinsuredwillnowbeaccessing

healthcareservicesfromsafetynetproviders,clinics

andcommunityhealthcenters.Inordertorealizethe

opportunityoftheACA,leadersintheregionshealthcare

communitymustworktogethertoexpandandstabilize

theprimarycaresafetynet.

Sierra Health Foundations Role and the Sacramento Region Health Care Partnership

SierraHealthFoundationhasalonghistoryofpartnership

andsupportforthehealthcaresafetynetintheSacramento

Region,withaparticularemphasisontheunderserved.This

focusareaunderscoresthefoundationsmissiontoinvestin

andserveasacatalystforideas,partnershipsandprograms

thatimprovehealthandqualityoflifeinNorthernCalifornia.

Attherequestofseveralcommunitystakeholders,in2011

SierraHealthFoundationlaunchedtheSacramentoRegion

HealthCarePartnership,acoordinatedphilanthropic,

countyagency,nonprofitproviderandcommunityhealth

centerefforttostrengthenthehealthcaresafetynetinthe

four-countySacramentoRegion.Theinitiativegrewout

ofconversationswithhealthcareleaders,includingpolicy-

makers,healthsystemsandcommunityhealthcenters,who

approachedthefoundationtoplayakeyintermediaryrolein

thebuildingofa21st-centurypatientcareandcoordination

systemfortheregionsmedicallyunderserved.

TheSacramentoRegionHealthCarePartnershipsgoalisto

findwaystoimproveaccess,carecoordinationandqualityof

theregionsprimarycaresafetynetsystem.TheSacramento

RegionHealthCarePartnershipbeganbyconducting

thisupdatedmarketanalysistoobtainabaselineofthe

currentservicecapacitywithintheprimarycaresafetynet

andforecastofcliniccapacityneeds.Thefindingsinformed

thedevelopmentofaregionalstrategicplantodevelopan

integratedhealthcaredeliverysystemmodelthatefficiently

linkscommunityhealthcenterstoregionalproviders.

Theultimatevisionistoincreaseandimproveprimary

careaccessandqualityforindividualsandfamiliesin

low-incomecommunitiesandcommunitiesofcolorin

ElDorado,Placer,SacramentoandYolocounties.

Partners

SierraHealthFoundationisdevelopingpartnershipswith

healthandcivicleadersandbuildingontheseriesof

HealthCareWorkingGroupconveningsheldin2011by

CongresswomanDorisMatsui.Initiativepartnersinclude

abroadrangeofleadersfromcommunityhealthcenters,

healthsystems,healthplans,community-based

organizations,associationsandcounties,aswellas

physicians,policymakersandnonprofitsthatworkwithin

thesafetynet.SierraHealthFoundation,TheCalifornia

EndowmentandSacramentoRegionCommunity

Foundationarefundingpartnersforthismarketanalysis

andsubsequentstrategicplan.

Expected Outcomes

Establishamoresustainableandfinanciallyviable

primarycaresafetynetsystem.

Improveadministrativeandservicedeliverycapacityof

primarycareproviderstoaccommodatethevastincrease

ofinsuredresidentsundertheAffordableCareAct.

Facilitatethedevelopmentofanintegratedhealth

caredeliverysystemmodelthatlinksprimarycareto

specialtycareandhospitalsystems.

Expandaccesstohigh-qualityandculturallysensitive

servicesforresidentsacrosstheSacramentoRegion.

7JAMA2010;304(6):679-680Katz,Mitchell.FutureoftheSafetyNetUnderHealthReform:http://jama.ama-assn.org/cgi/content/full/304/6/679

Respi te Par tnership Col laborat ive | P a g e 7S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P | P a g e 1 0 S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P | P a g e 1 1

How This Report Was DevelopedA systems approach offers multiple perspectives on safety net performance.

Theconsultantteamusedacombinationofsourcesand

qualitativeandquantitativemethodologiestogather

inputaboutthecurrentandfuturedemandforcareand

thehealthcaresafetynetscurrentandfuturecapacityto

provideit.

Qualitative Input: Stakeholder Site Visits, Surveys and Interviews

Tocapturea360-degreeviewoftheregionssafetynet,the

consultantteamdidmorethananalyzedata.Theywentout

andtalkedtohealthcareprovidersandstakeholderswho

areonthefrontlinesoftheregionssafetynet.Sitevisits,

surveys,interviews,discussiongroupsandfocusgroups

providefeedbackandinsights.

Theconsultantteaminterviewedcommunityhealthcenter

leadersandadministeredasurveyonthestateofthesafety

net.Thesesitevisitsalsoassessedcurrentandanticipated

capacityneeds.Theteamalsoheldadiscussiongroupwith

primarycarephysicianspracticinginvariouscaresettings

throughouttheregion.

Inaddition,theteamconductedinterviewswiththe

majorhealthsystems(DignityHealth,KaiserPermanente,

SutterHealth,UniversityofCaliforniaDavisHealth

SystemandMarshallMedicalCenter)andwithkeyhealth

plans(HealthNetofCaliforniaandAnthemBlueCross).

Foracompletelistofsitevisitsandindividualinterviews,

visitwww.sierrahealth.org/healthcarepartnership.

Oncethedatawascollected,theconsultantteammade

presentationsineachofthefourSacramentoRegion

countiestogatherinput,feedbackandsuggestionsforthe

finalmarketanalysisinstruments.

Theteamalsoconductedthreefocusgroupswithresidents

whoaresafetynetconsumersofhealthcareservices.See

www.sierrahealth.org/healthcarepartnershipforbackground

anddetails.

Quantitative Data Sources

Themarketanalysistappedavarietyofdatasources.The

primarydatasourceusedforhealthcenterandhospital

demandandcapacitywastheCaliforniaOfficeofStatewide

PlanningandDevelopment(OSHPD).OSHPDcollects

dataanddisseminatesinformationaboutCaliforniashealth

careinfrastructure,promotinganequitablydistributed

healthcareworkforceandpublishinginformationabout

healthcareoutcomes.8

Emergencydepartmentutilizationestimatesofpreventable/

avoidablevisitsusedtheNewYorkUniversityED

Algorithm.Moreinformationaboutthedevelopmentand

methodologyofthisalgorithmcanbefoundattheNYU

CenterforHealthandPublicServiceResearch.9

DataforFederallyQualifiedHealthCenters(FQHC)was

obtainedandmappedusingthefederalUniformData

Systems(UDS)mappersystem,anonlinedatasourceat

www.udsmapper.org,toevaluatedatasentfromfederally

fundedcommunityhealthcenters.Theprojectteamused

thisdatatocreateregion-levelandcounty-levelmapsand

otheranalyses.

Demographic and Population Health Data

Forhistoricalandcurrentpopulationestimates,thisreport

usesdatafromtheU.S.CensusBureauandCalifornia

DepartmentofFinance.SacramentoAreaCouncilof

Governments(SACOG)populationdatawasusedforthe

county-levelpopulationprojectionsthrough2016.

PopulationhealthdatawasobtainedfromtheCalifornia

HealthInterviewSurvey(CHIS).Thissurveyisconducted

continuously,releasedbiannually,andcontainssurveydata

onavarietyofhealthaccess,insurancestatus,health

outcomeandbehaviorindicators.

8http://www.oshpd.ca.gov/aboutus9http://wagner.nyu.edu/chpsr/.SeeEDAlgorithm.(lastaccessed4-24-12)


Health Reform Data

DataonhealthreformwasobtainedfromtheMetro

ChicagoInformationCenter(MCIC).MCICused2009

AmericanCommunitySurvey(ACS)datatocalculate

estimatesofinsurancecoveragestatusandestimatesfrom

theDepartmentofHomelandSecuritytoadjustforthe

ACSundercountofnon-citizensandtocalculatethe

numberofundocumentedresidents.

Theseestimateswereincorporatedintotheprojection

modelstoprojectcommunityhealthcenterandemergency

departmentdemandunderACA.Themarketanalysisalso

usesprojectionsofuptakeratesofthosecurrently

uninsuredtoinsured,whichusedzipcode-levelanalysis

toproducedataspecifictotheSacramentoRegion.

Projection Methodology

Projectionsofcommunityhealthcenterandemergency

departmentdemandweredevelopedusingasimplelinear

projectionmodel.Themodeluses2006-2010datato

establishabaselineprojectionfor2012,2014and2016.

Themodelthenaddsorsubtractsfromthebaselineto

reflectestimatedimpactofhealthreformchangesonpayer

mixandutilizationpatterns.

Theemergencydepartmentprojectionmodelassumes

thatthegrowthtrendseenintheregionsemergency

departmentdemandwillcontinueinto2012,2014and

2016.ThisassumptionisbasedonfindingsofChenet

al,10whoconcludedthattheMassachusettshealthreform

of2006didnotimpactemergencydepartmentutilization.

However,thismaynotbethecaseforhealthreform

implementationinCalifornia.Somehavearguedthatthe

declineinemergencydepartmentuseinMassachusettsisa

resultofbetteraccesstoprimarycare.11Othershaveargued

thatemergencydepartmentusewillincreaseunderACA

duetolackofaccessinothersettings.12Ultimately,whether

emergencydepartmentuseisimpactedisalsoamatterof

howaccesstoprimarycareisgranted.Thecurrentsystem

maycauseoverutilizationbydenyingpatientstheabilityto

selecttheirownhealthhomeorchangingitifdissatisfied,

whereastheemergencydepartmentmustseethepatient

wheneverthepatientwants.Thisstudyshowsthechanges

neededifemergencydepartmentsaretoabsorbdemand

withnomigrationofcaretoothersettings.

Transportation Issues Data

Toexpandonpreviousstudies,SACOGsoughtand

obtainedaCaltransEnvironmentalJusticePlanningGrant

toexaminethetransportationneedsoflow-income,

transit-dependentresidentsoftheSACOGregion,and

analyzegapsinpublictransitservicetoreachessentialor

lifelinedestinations.Highlightsoffindingsfromthe

SACOGstudyaredetailedatwww.sierrahealth.org/

healthcarepartnership.

Study Limitations

ThismarketanalysiswasconductedbetweenNovember

2011andApril2012usingthelatestdatasourcesavailable.

Asinmanylargeregionalstudies,publicdatasources(e.g.,

OSHPD,UDS,etc.)weredeemedthemostuseful.These

sourcesarereadilyaccessibleandcomparableduetotheir

defineddatadefinitionsset.However,missingfromthese

publicreportsarenon-reportingentities,whichinclude

county-runprimarycarehealthcenters,freeclinicsand

independentprimarycarephysiciansandotherservice

deliveryentitiesallofwhichplayimportantrolesin

meetingthehealthcareneedsoftheregionssafety

netpopulation.Whileeffortsweremadetoobtain

quantitativedatafromthesesources,thestudysscope

didnotallowtheirinclusioninthisreport.Instead,the

consultantteamcapturedinputfromtheseprovidersvia

qualitativeresearchmethods.

10ChenC.,SchefflerG.,ChandraA.MassachusettsHealthCareReformandEmergencyDepartmentUtilization.NewEnglandJournalofMedicine.2011:110907140018030.11SmulowitzP.B.,LiptonR.,WharamJ.F.,etal.EmergencyDepartmentUtilizationAftertheImplementationofMassachusettsHealthReform.AnnalsofEmergencyMedicine.2011;58(3):225234.e1.12GoodmanJ.WhatWillHappenToEmergencyRoomTraffic?HealthAffairsBlog.July12,2010.Availableat:http://healthaffairs.org/blog/2010/07/12/what-will-happen-to-emergency-room-traffic/.AccessedApril23,2012.

10

1.5

2.6

1

.7

2.7

2.2

0

Yolo

Sacramento

El Dorado

Placer

Yolo

Sacramento

El Dorado

Placer

112th Congressional Districts

>45% Percent of Population Living below

30-45% 200% Federal Poverty Level,

15-30% American Community Survey


The Sacramento Regions Safety Net Population Who is served by the Sacramento Regions safety net?

Theconsultantteambeganitsanalysiswithanoverviewof

theSacramentoRegionspopulationinElDorado,Placer,

SacramentoandYolocountiesinNorthernCalifornia.Who

doestheregionsprimarycaresafetynetservenow?Howare

residentsaccessingprimarycare?

TheSacramentoRegionishometoapproximately2.15

millionresidents.Theareaspopulationhasgrownrapidlyin

thepastdecade.WhileSacramentoresidentshavehigher

income,education,privateinsurancecoverageandbetter

overallhealththanaverageforCalifornia,thereexistwide

healthdisparitieswithintheregionbyrace,ethnicityand

income.However,almostone-thirdofSacramentoRegion

residentshaveincomesbelow200percentoftheFederal

PovertyLevel(FPL)and15.1percentlivebelow

100percentoftheFPL.

Table 1. Sacramento Region Population Estimates

Table 2. Median Household Income and FPL

10

1.5

2.6

1

.7

2.7

2.2

0

Yolo

Sacramento

El Dorado

Placer

Yolo

Sacramento

El Dorado

Placer





= 300 percent FPL 5.8 54,000

Insurance Status

Insured

Uninsured


7.5 118,000







Age Group (Years)

18-24

25-64 22.1* 241,000

65 or older 57.6* 140,000

Gender

Male 25.5 193,000

Female 24.7 200,000

Race/Ethnicity

White 26.9 265,000

Lano 22.6 60,000


AI/AN

Asian 13.2 21,000


24.3 10,000

Immigrant Status

U.S. Born 26.3 339,000



0-99 percent FPL 24.1 41,000

100-199 percent FPL 28.5 66,000

200-299 percent FPL 23.5 57,000

>= 300 percent FPL 24.8 228,000

Insurance Status

Insured 26.6* 367,000



25.1 393,000








































25.0 10,000





1-1112-1718-24 11.3 26,00025-39 18.7* 71,00040-64 18.3* 130,00065 or older 4.1* 10,000




12.4 261,000







18-24 52.9 22,000

25-64 59.9 111,000

65 or older 70.9 7,000

Gender

Male 52.5 43,000

Female 62.5 97,000

Race/Ethnicity

White 63.9 103,000

Lano 28.8 8,000


AI/AN

Asian


76.7 5,000

Immigrant Status

U.S. Born 58.6 145,000



0-99 percent FPL 55.0 27,000

100-199 percent FPL 46.4 18,000

200-299 percent FPL 63.9 27,000

>= 300 percent FPL 59.8 82,000

Insurance Status

Insured 59.0 143,000






Insurance Type Region CaliforniaNo Health Insurance 12.7 percent 18.5 percentMedicare & Medicaid 1.1 percent 1.0 percentMedicaid (ages 18-64) 6.1 percent 5.7 percentMedicaid (ages = 300 percent FPL 5.8 54,000

Insurance Status

Insured

Uninsured


7.5 118,000







Age Group (Years)

18-24

25-64 22.1* 241,000

65 or older 57.6* 140,000

Gender

Male 25.5 193,000

Female 24.7 200,000

Race/Ethnicity

White 26.9 265,000

Lano 22.6 60,000


AI/AN

Asian 13.2 21,000


24.3 10,000

Immigrant Status

U.S. Born 26.3 339,000



0-99 percent FPL 24.1 41,000

100-199 percent FPL 28.5 66,000

200-299 percent FPL 23.5 57,000

>= 300 percent FPL 24.8 228,000

Insurance Status

Insured 26.6* 367,000



25.1 393,000








































25.0 10,000





1-1112-1718-24 11.3 26,00025-39 18.7* 71,00040-64 18.3* 130,00065 or older 4.1* 10,000




12.4 261,000







18-24 52.9 22,000

25-64 59.9 111,000

65 or older 70.9 7,000

Gender

Male 52.5 43,000

Female 62.5 97,000

Race/Ethnicity

White 63.9 103,000

Lano 28.8 8,000


AI/AN

Asian


76.7 5,000

Immigrant Status

U.S. Born 58.6 145,000



0-99 percent FPL 55.0 27,000

100-199 percent FPL 46.4 18,000

200-299 percent FPL 63.9 27,000

>= 300 percent FPL 59.8 82,000

Insurance Status

Insured 59.0 143,000






Insurance Type Region CaliforniaNo Health Insurance 12.7 percent 18.5 percentMedicare & Medicaid 1.1 percent 1.0 percentMedicaid (ages 18-64) 6.1 percent 5.7 percentMedicaid (ages


One out of three people living under 138 percent FPL are currently uninsured in the Sacramento Region,

but will be eligible for Medi-Cal under ACA

Figure 1. Trends in Adults Living in Poverty

Health Outcome Rankings

Whenlookingattheregionshealthintermsofoverall

longevityandqualityoflife,Placer,YoloandElDorado

countiesrankinthetopquartileofallCaliforniacounties,

whileSacramentoCountyissignificantlylesshealthy,

rankinginthethirdquartile.

Maps 1 and 2. County Health Outcomes Rankings

Community Health Indicators

Communityhealthindicatorspredicthealthcareusage.

TheindicatorswerederivedusingtheCaliforniaHealth

InterviewSurvey(CHIS),thelargeststatepopulation-based

surveyinthenation.

FromtheCHISdata,thesecommunityhealthindicators

wereselected: Asthma HeartDisease Diabetes HighBloodPressure(HBP) Obesity Overweight

Sacramento Placer Yolo

2009 52,998 12,494 24,607 13,874

2014 130,034 21,015 38,193 24,341

+145%

+68%

+55%+75%

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Movement in Individual Insurance, 2009 - 2014


El Dorado

Movement in Uninsured, 2009 - 2014


Sacramento Placer YoloEl Dorado

Movement in Medi-Cal, 2009 - 2014


Sacramento

San Diego County

Alameda County

California

Santa Clara County

Sacramento region

Contra Costa/Solano Counties

Orange County

Placer YoloEl Dorado

Sacramento RegionAverage

California Average


2009 289,312 16,286 31,303 32,156

2014 379,533 23,375 42,453 41,643

+31%

+44% +36% +30%

0

50,000

100,000

150,000

200,000

250,000

20.0%

% Pov

erty

Visits

ED visits

per 1,000

pop

ulation

Perce

nt Admitted

Total F

TE

Visits

per FTE

18.0%

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0%2006 2007 2008 2009 2010

Yolo County

18.3%

15.7%

10.0%8.8%

300,000

350,000

400,000

2009 222,518 19,579 33,149 28,060

2014 55,261 3,969 8,413 8,106

-75%

-80% -75% -71%0

50,000

100,000

150,000

200,000

250,000

Sacramento Region Estimates of Age & Gender, 2009


Percentage of Adults 18-64 Living Below the Federal Poverty Level (100% FPL)*, 2006-2010

* For reference, the 2010 FPL was an annual income of $10,830 or less for an individual

Source: U.S. Census Bureau, 2006-2010 ACS 1-year estimates

Note: e FPL for eligibility for ACA is 133% but there is an income disregard of 5%that could raise the level to 138%

El Dorado County Sacramento CountyPlacer County

Sacramento Region

California

170,000

97,000

676,000

136,000

180,000

97,000

650,000

107,000

0 200,000 400,000 600,000 800,000

Children (0-11)

Adolescents (12-17)

Adults (18-64)

Seniors (65+)

Estimated Number

MalesFemales

CHC Visits per 1,000 Population, 2010

Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; 2010 U.S. Census

Source: OSHPD Emergency Department Visits: Frequencies by County & EMS utilization trends, 2006-2010, CA Department of Finance, Dec 2011

Note: ED utilization rates do not include ED visits that resulted in hospital admission.

Sacramento Region Community Health Indicators, CHIS 2009


Got Needed MH/AOD Services is based on a smaller sample - it is asked onlyof those who said they needed MH/AOD services - 15.2% of the regional population

60%

50%

40%

30%

20%

10%

0%

Sacramento Region Estimates of Age & Race, 2009


Source: California Health Interview Survey, 2001-2009

0 200,000 400,000 600,000 800,000 1,000,000

Children +Adolescents (0-17)

Adults (18-64)

Seniors (65+)

Estimated Number

CHC Visits, 2006 to 2010

0

50,000

100,000

150,000

200,000

250,000

300,000

Medi-Cal

Sliding Scale,Self-Pay & Free

Indigent

All Other

Medicare

Private

350,000

400,000

450,000

500,000

145,000

240,000

24,000

260,000

806,000

179,000

53,000

79,000

17,000

51,000

146,000

16,000

Asian (non-Lano)African American (non-Lano)White (non-Lano)Lano

16.213.7

6.5 5.97.5 8.5

25.126.2

33.7

59.155.5

33.6

24.722.7

14.413.6 12.415.1

Asthma-All Ages

Heart Disease - Adults

Diabetes - Adults

HBP - Adults

Overweight (BMI 25-29.9) - Adults

Obese (BMI > or = to 30) - Adults

Current Smoker - Adults

Delayed/Didnt Get Care - All Ages

Got Needed M

H/AOD Services - Adults

Sacramento Region State of California

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

2001 2003 2005 2007 2009

14.7% 16.2%17.4% 18.5%

16.2%

Asthma Rate, Ages 1 Year and Older, Sacramento Region, CHIS 2001-2009

300

250

200

150

100

50

0

2006 2007 2008 2009 2010

235216

216

170 170186

197220

232 238

265 269

269266

ED Utilization Rates per 1,000 population


30.0%

35.0%

25.0%

20.0%

15.0%

10.0%

2001 2003 2005 2007 2009

23.4%21.9%

25.8%

28.8%

25.1%

High Blood Pressure Rate, Adults 18 and Older, Sacramento Region, CHIS 2001-2009


20.0%

25.0%

15.0%

10.0%

40.0%

45.0%

50.0%

35.0%

30.0%

5.0%

0.0%

2001 2003 2005 2007 2009

20.4% 19.5%20.8%

24.3% 24.7%

Obese (BMI> or = to 30) Rate, Adults 18 and Older, Sacramento Region, CHIS 2009

209

211

220

222

411

567

616

0 100 200 300 400 500 600 700

Alameda County

San Diego County

California


Santa Clara County

Orange County

Sacramento region

CHCs per 100,000 Population, 2010


ED Discharges

CHC Visits

Source: OSHPD Primary Care Clinic Annual Utilization Data Files & Emergency Department Visits: Frequencies by County & EMS utilization trends, 2006-2010

Source: OSHPD Primary Care Clinic Utilization Data Files, 2006-2010


Note: All Other includes breast cancer, Child Health and Disability Prevention Program, Expanded Access to Primary Care, and Family PACT encounters. Indigent includes County CDSP and Healthy Families

300

250

200

150

100

50

0

2006 2007 2008 2009 2010

2006 2007 2008 2009 2010

ED Discharges and CHC Visits per 1,000 Population, 2006-2010

Visits per FTE

Total FTE


250

200

150

100

50

0

3,000

2,500

2,000

1,500

1,000

500

3,000

3,500

4,000

2,500

2,000

1,500

1,000

500

800

900

1,000

700

600

500

400

300

200

100

02006 2007 2008 2009 2010

CHC Visits per FTE, 2006-2010

2010

2009

2008

2007

2006

0% 20% 40% 60% 80% 100%

Percentage of CHC Encounters by Payer Source, 2006 to 2010

330,312 323,200

372,867421,135

472,662

ED Discharges and Admissions, 2006-2010

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

4.0%

2.0%

0.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

Source: OSHPD Hospital Annual Utilization Database, 2006-2010

2006 2007 2008 2009 2010

ED Discharges, 2006-2010

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Source: OSHPD Emergency Department Encounters, County Frequencies by PatientCounty of Residence 2006-2010

2006 2007 2008 2009 2010

Medi-Cal

Sliding Scale,Self-Pay & Free

Indigent

Other

Medicare

Private

2016

2014

2012

2010

0% 20% 40% 60% 80% 100%

County Projected CHC Payer Mix, 2012 to 2016

% Patient Revenue

% Non-patient Revenue

% Federal

% State

% County/Local

% Private Donations & Grants

% Other Revenues

Medi-Cal

Self-Pay

Private

Medicare

Other Non-Federal

Other

2010

2009

2008

2007

2006

0% 20% 40% 60% 80% 100%

Percentage of ED Discharges by Payer Source, 2006-2010

445,919484,584 504,083

565,568 580,184

Source: OSHPD Emergency Department Encounters, County Frequencies by PatientCounty of Residence 2006-2010

Percent AdmittedTotal AdmittedTotal Discharged

Clinical Encounters per CHC FTE, 2010

Source: OSHPD Primary Care Clinic Utilization Data Files

Note: Clinical encounters includes visits to physicians, nurse family practitioners, physicians assistants, and midwives

Percentage of ED Discharges Classified as ED Care Not Needed

AllDischarges

Self-Pay Medi-Cal Commercial Medicare

Emergent/Primary Care TreatableNon-emergent

40.4%41.9%

46.1%

37.5% 36.3%

50%

45%

40%

35%

25%

15%

5%

30%

20%

10%

0%

Total Number of ED Discharges Classified as ED Care Not Needed

Self-Pay Medi-Cal Commercial Medicare

Emergent/Primary Care TreatableNon-emergent

90,000

80,000

70,000

60,000

40,000

20,000

0

50,000

30,000

10,000

41,245

75,36679,452

37,560

Additional FTEs Needed to Meet State and Regional Benchmarks, 2014, 2016

2014 2016

180

160

140

Addl FTEs = regional avg

Addl FTEs = state avg

Current FTEs

120

80

40

0

100

60

20

1.72

1.73

1.80

1.91

2.75

3.39

4.50

0.00 1.00 2.00 3.00 4.00 5.00

CHCs

Alameda County

San Diego County

California


Santa Clara County

Orange County

Sacramento region

CaliforniaSacramento regionEl Dorado

FQHCs and FQHC Look-Alikes per 100,000 Population, 2010


0.00 0.50 1.00 1.50 2.00 2.50

FQHCs

FQHC Look-Alikes

0.60

0.47

0.73

0.75

1.39

2.33

2.32

0.23

0.03

0.28

0.00

0.17

0.13

0.07

ED Visits

/Statio

n

ED Statio

ns

ED Stations

ED Visits/Station

Source: OSHPD Annual Utilization Data Files, 2006-2010

2006 2007 2008 2009 2010

2010 2012 2014 2016

Emergency Department Capacity, 2006-2010


California Average


3,000

3,500

4,000

2,500

2,000

1,500

1,000

500

2,000

2,250

2,500

1,750

1,500

1,250

1,000

750

500

250

0

Mental Health Encounters per CHC FTE, 2010

Source: OSHPD Primary Care Clinic Utilization Data Files, 2010

Note: Mental health encounters includes visits to psychiatrists and clinical psychologists

Proj Visits/FTE

5,000

6,000

4,000

3,000

2,000

1,000

Projected CHC Visits per FTE, 2010-2016

Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; MCIC Chicago;e Abaris Group 2012

Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; MCIC Chicago;e Abaris Group 2012

Note: Additional FTEs represent additional beyond 2010 levels reported to OSHPDby the 37 licensed primary care clinic CHCs in the region.

CA 5-year avg Clinics with Loss

Clinics with Positive MarginsSac region 5-year avg


California Average


3,000

3,500

4,000

2,500

2,000

1,500

1,000

500

Dental Encounters per CHC FTE, 2010


Note: Dental encounters includes visits to dentists and dental hygienists

SacramentoSacramentoRegion

Geographic Area

Rate per 100

,000

PlacerCalifornia YoloEl Dorado

Primary Care Physician Categories per 100,000 Population by License Location

Source: California Healthcare Foundation, Fewer & More Specialized: An Assessment ofPhysician Supply in California, 2009. Data from California Medical Board Physician License Renewal Survery, 2008.

30.0

35.0

25.0

20.0

15.0

10.0

5.0

0.0

Family MedicineGeneral PracticeInternal MedicineGeriatricsPediatricsOB/GYN

Rate per 100

,000

Specialty

Selected Specialty Care Physician Categories per 100,000 Population by Licenses Location

Source: California Healthcare Foundation, Fewer & More Specialized: An Assessment ofPhysician Supply in California, 2009. Data from California Medical Board Physician License Renewal Survery, 2008.

10.0

12.0

8.0

6.0

4.0

2.0

0.0

PlacerSacramentoYolo

Card

iolog

y

Derm

atolo

gy

Endo

crino

logy

Gastr

oent

erolo

gy

Neph

rolog

y

Onco

logy

Neur

ology

Opht

halm

ology

Psyc

hiatry

Pulm

onolo

gy

1,5811,679

1,5761,671 1,657

352 354399 422

444

3,700

3,900

4,100

3,500

3,300

3,100

Occ

upan

cy Rate

Bed

s

Staffed Beds

Staffed Bed Occupancy Rate

Source: OSHPD Hospital Annual Financial Data, 2006-2010

2006 2007 2008 2009 2010

Hospital Staffed Bed Occupancy Rates, 2006-2010

80%

90%

100%

70%

60%

50%

40%

30%

20%

10%

0

76.6% 75.3% 74.5% 74.1% 72.2%

3,4573,522 3,553

3,600 3,631

Average Revenues/Encounter

Average Expenses/Encounter

2006 2007 2008 2009 2010

Average Expenses and Revenues Per Encounter, 2006-2010

$200

$150

$100

$50

$0

Projected CHC Visits, 2012-2016

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

Source: OSHPD Primary Care Clinic Utilization Data Files, 2006-2010; MCIC Chicago;e Abaris Group 2012

Source: OSHPD Primary Care Clinic Utilization Data Files, 2006-2010; MCIC Chicago;e Abaris Group 2012

2010 2012 2014 2016

2010 ReferenceLinear IncreaseChange due to ACA

725,227

690,143

472,662

Medi-Cal

Self-Pay

Private

Medicare

Other

Other non-Federal

2016

2014

2012

2010

0% 20% 40% 60% 80% 100%

Projected ED Payer Mix, 2012 to 2016

Projected ED Discharges, 2012-2016

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Note: e ED discharge projections includes residents of the Sacramento region discharged from an ED (does not include ED admissions).

Source: OSHPD ED Encounters, Frequencies by Patient County of Residence, 2006-2010; MCIC Chicago; e Abaris Group 2012

Source: OSHPD ED Encounters, Frequencies by Patient County of Residence, 2006-2010; MCIC Chicago; e Abaris Group 2012

2010 2012 2014 2016

Linear trendLinear+5%Linear+10% 2010 Reference

835,463795,679

580,184

875,247

CHC Total Net Revenues, 2010


110.2

110.213.1

28.115.7

17.6

800

900

1,000

700

600

500

400

300

200

100

0

ED Visits

/Statio

n

ED Statio

ns

Rev

enue

Sou

rce

ED Stations

ED Visits/Station


Note: Projections made using simple linear regression.

2010 2012 2014 2016

Emergency Department Capacity - No Stations Added, 2012-2016

National Benchmark

2,000

2,250

2,500

1,750

1,500

1,250

1,000

750

500

250

0

800

900

1,000

700

600

500

400

300

200

100

0

ED Visits

/Statio

n

Perce

ntag

e of Diabetes

Amon

g Adults

ED Statio

ns

ED Stations

ED Visits/Station


Note: 1,550 patients per treatment station is a national benchmark for full ED capacity

2010 2012 2014 2016

Emergency Department Capacity - With Stations Added, 2012-2016

2,000

2,250

2,500

1,750

1,500

1,250

1,000

750

500

250

0

1,657 1,657 1,657 1,657

444

502559

615


CHC Revenue Sources, 2010

70.3%

14.1%

1.3%4.9%

7.0%

2.3%

29.7%

- $20,333,464

$10,401,134

$25,000,000

$20,000,000

$15,000,000

$10,000,000

$5,000,000

$0

$5,000,000

$10,000,000

$15,000,000

N=16

Total Net Revenues = $(9,932,000)

Total N

et Rev

enue

Net Revenues

N=20

Clinics with Negative Margins

Clinics with Positive Margins

CHC Total Net Revenues, 2006-2010


2006 2007 2008 2009 2010Total CHC Margin -3.4% 0.0% -2.9% -0.9% -4.8%No. of clinics sites w/ + Margins 18 19 19 23 18No. of clinics sites w/ - Margins 13 8 13 10 19

$3,598,061

$3,044,701

$4,034,838

$6,549,394

$4,404,139

$5,840,320

$3,046,152

$6,150,357

$7,267,579

$9,130,472

2006

2007

2008

2009

2010

Percent of Total Revenues

Clinics with Negative Margins

Clinics with Positive Margins

Percent of CHC Total Revenues by Revenue Source, 2010

Source: OSHPD Primary Care Clinic Utilization Data Files, 2006-2010 Source: OSHPD Primary Care Clinic Utilization Data Files, 2006-2010

Notes: Sutter Senior Care not included. Barton Memorial Hospital Family Clinic did not report any nancial data in 2007.

Federal

Patient Revenues

State

County/Local

Donations & Grants

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

$152$149

$164 $161

$175

$155

$146

$167 $165

$185

2003 2005 2007 2009

Diabetes, Adults 18 and Older, Sacramento Region, 2003-2009

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

Source: California Health Interview Survey, 2001-2009. No data for 2001.

7.3%5.7%

6.5%7.5%

444 444 444 444

1,657

1,874

2,085

2,297

10

1.5

2.6

1

.7

2.7

2.2

0

Yolo

Sacramento

El Dorado

Placer

Yolo

Sacramento

El Dorado

Placer






Theregionssafetynetpopulationforthemostpartmirrors

Californiasintermsofillnessesthatpredicthealthcare

utilizationrates.Regionally,12.4percentofthepopulation,

oroneineveryeightresidents,islikelytodelaygettingcare,

butthemajorityofresidents(59.1percent)areableto

accessspecialtybehavioralhealthservices.Acrossthe

adultpopulation,the

srhcp_market_analysis_final_103012

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