Snapshot of San Joaquin Valley Captures Pivotal Role of FQHCs

March 8, 2021
Federally qualified health centers now provide care to more than half the region’s Medi-Cal enrollees

The number of federally qualified health center (FQHC) sites in California’s San Joaquin Valley increased from 63 to 85 between 2014 and 2018, and they now provide care to more than half the region’s Medi-Cal enrollees. A recent report and panel discussion described their increasing importance to the region’s healthcare ecosystem.

The nonprofit California Health Care Foundation has commissioned studies of seven regional markets that identify common themes and emerging issues that influence how Californians receive care. The San Joaquin Valley spans the counties of Fresno, Kings, Madera, Mariposa, and Tulare. Among other topics, the March 2 webinar looked at the increasing role of FQHCs, how access to mental health and substance use disorder services is improving for Medi-Cal enrollees, and new efforts to recruit both primary care clinicians and specialists.

Leonard Finocchio, Dr.P.H., principal at Blue Sky Consulting Group and one of the report’s authors, set the stage for the conversation. He noted that compared to California overall, the San Joaquin Valley is much poorer and younger, and the residents are almost twice as likely to be unemployed. The LatinX community is almost 57 percent of the entire region. From California Health Interview Survey data, which are self-reported responses to questions about general health, Valley residents have much poorer health status than Californians more broadly, he said. The obesity rate and infant mortality rate are about 50 percent higher than rates statewide. There are higher rates of asthma, higher rates of diabetes, and more residents are more likely to report that they are  in fair to poor health than Californians more broadly. He also noted that the San Joaquin Valley has been hit quite hard by COVID-19, both the cases per 100,000 and deaths per 100,000 —much higher than other regions of the state.

There are several large FQHC networks, which together accounted for nearly 2 million encounters or patient encounters in 2018, Finocchio said, and the number of encounters in FQHCs grew by 50 percent. (Federally designated rural health centers also have a very large presence in the valley.) The FQHCs have partnerships with hospitals. Camarena Health, which is in Madeira County and Family Health Care Network, which is in Fresno, Kings and Tulare counties, have partnerships with hospitals to provide outpatient care upon discharge, and also to refer patients for inpatient services.

In 2018, nearly half of the residents in the San Joaquin Valley were covered by Medi-Cal (44 percent), and 8 percent were uninsured. Concerning the MediCal managed care model, four of the five counties participate in a two-plan model where you have one publicly run plan that competes with a commercial plan. CalViva, which is the local initiative for Fresno, Kings and Madeira counties, covers 70 percent of the more than 500,000 Medicaid enrollees in those three counties. Anthem Blue Cross serves as the commercial plan to serve the remainder of the of the MediCal enrollees in those three counties.

While the additional FQHCs and rural health centers have contributed tremendously to access to services both for primary care, specialty care and behavioral health services, this is in the context of provider shortages, which continue to pose access challenges, Finocchio said. In the San Joaquin Valley 92 percent of residents live in a health professional shortage area, and the physician-to-population ratios are well below the statewide averages, and are among the lowest in the state.

During the response panel to Finocchio’s presentation, Paulo Saurus, CEO of Camarena Health, which runs a network of FQHCs, said that over the last five to 10 years, they have seen more than just the physical growth in the number of sites or patients being seen, but the FQHCs have really developed into more complex organizations than they were a decade ago.

 “Some of the growing partnerships in the region are really going to pay dividends when we're trying to provide access and services to some of the populations that have those challenges. Ten years ago, a lot of the health centers were just these small family practice clinics that didn't get a lot of attention,” Saurus said. “But as the MediCal population grows tremendously in this region, and federally qualified health centers become, in some areas, the largest primary care providers, those partnerships with the hospitals are very important as they help minimize ER utilization and lower readmission rates.”

“Beyond the hospitals, we're also seeing some really strong partnerships between federally qualified health centers and health plans, especially some of the, MediCal managed care plans,” Saurus added. “It creates a great opportunity for some of these performance improvement and quality improvement plans to take place between the providers and the plans and the hospitals, and to really improve the overall health of these communities.”

 Speaking to the provider shortages mentioned in the report, Saurus added that community health centers and FQHCs are playing a larger role in supporting some local residency programs, allowing some of these physicians in training to step into the health centers and provide care to the region’s large MediCal population. “Hopefully, we're going to start seeing that pay some dividends and getting them to stay,” he said. “We're also training a lot of physician assistants and nurse practitioners, working with local schools and even schools outside of the area, to help train them and attract them here and keep them here.”

Tom Hamilton, regional health plan officer of insurer Health Net of California, said care coordination was one area the region could improve on. “The managed care industry has evolved a lot in the last 10 to 20 years, but one of the areas we still have a ways to go is just the coordination of care. It's still somewhat of a fragmented system,” he explained. “Treating things like diabetes, obesity, congestive heart failure, hypertension, and making sure that the people who have these conditions are being managed appropriately, so that we can prevent repeat usage of the ER. And when they get into the hospital, making sure that we have proper transitions of care — whether it's going into a home health setting, or a skilled nursing facility setting, you need to have all the components of care available to you and have the people that can help transition those members from one setting to another to make sure they get appropriate care at the right place at the right time.”

Dawan Utecht, director of the Fresno County Behavioral Health Department, noted that the report highlighted the high degree of poverty as well as the incredible diversity in the Valley. “We certainly saw great benefit from Medicaid expansion. But we've really been rushing to keep up in terms of growing our delivery system,” she said. “The way that behavioral health fits into the healthcare delivery system is very siloed and fragmented. Across the state we're looking at the structure of the system, and how we can improve the outcomes for the people that we serve by designing a better system.”

Utecht said she wanted to highlight a need to increase capacity throughout the system of care. “We have a 16-bed adult inpatient facility, a psychiatric health facility here in Fresno, and it's full all the time. But some of the people who are in there are in that setting because the downstream beds are not available as well. So we get these bottlenecks in emergency departments and crisis stabilization units, as well as inpatient units.” She mentioned that there are funds in the governor's most recent budget for increasing capacity.

She also spoke about the rapid switch to telehealth as a great success story during the pandemic but added that “we do know there are pockets of vulnerability — individuals who either don't have the proper equipment to do telehealth or some of our youngest clients who really need that in-person services or they don't have access to the Internet. We definitely see telehealth as an integral part of our services and an adjunct to some of our in-person services. But we'll have to overcome some of those barriers and/or really tailor those in-person services for people who can't get their needs met through telehealth.”

Finocchio described how at the end of each of these market reports, they look forward and ask questions about what should be tracked over the next four years. Here are the main areas he said they thought it be important to study and to continue to track:

• How will expected state budget shortfalls driven by the pandemic effect MediCal which covers almost half of the region's residents?

• Will larger hospitals and health systems continue to perform well financially as they have over the past few years? (Of course, COVID is impacting them now.)

• Will the financial struggles of district hospitals spur more consolidation between hospitals?

• Will pressure for providers to take risk-based payment increase? And how will providers develop the infrastructure and data analytics to manage risk successfully?

• Will emerging partnerships among county mental health plans, managed care plans and other county agencies be sustained?

• Will telehealth be integrated into the delivery of routine care after the pandemic and improve access to care for some services?

• What will be the long-term impacts of the pandemic on the health and socioeconomic disparities in the San Joaquin Valley region?

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