CALIFORNIA’S OPEN DOOR PROVIDERS: Ten Case Studies of the Health Care Workforce JULY 2002 Catherine Dower, JD Tina McRee, MA Bram Briggance, MA Jenny Vance Edward H. O’Neil, PhD Acknowledgments This report was made possible through the support of the California HealthCare Foundation, which, in partnership with The California Endowment, funds the California Workforce Initiative. The authors thank Nadine Burke, M.D. for research support in the project’s preliminary stages. Additional support for research activities contributing to this report came from the California Association of Public Hospitals and Health Systems, the Calfornia Health Care Safety Net Institute, and the California Primary Care Association. The authors gratefully acknowledge the numerous individuals, institutions and organizations who provided information for this report. The findings and views contained in this report do not necessarily reflect the views of the California HealthCare Foundation, The California Endowment, the University of California, the reviewers, or contributors of the project. Design: John Malmquist Design / Berkeley, California © 2002 Center for the Health Professions, University of California, San Francisco. All materials subject to this copyright may be photocopied for the non-commercial purpose of scientific or educational advancement. Suggested citation style: Dower C, McRee T, Briggance B, Vance J, O’Neil E. California’s Open Door Providers: Ten Case Studies of the Health Care Workforce. San Francisco CA: California Workforce Initiative at the UCSF Center for the Health Professions. July 2002. California Workforce Initiative The California Workforce Initiative, housed at the UCSF Center for the Health Professions and funded by the California HealthCare Foundation and The California Endowment, is designed to explore, promote and advance reform within the California health care workforce. This multi-year initiative targets supply and distribution, diversity, skill base and regulation of health workers, utilization of health care workforce and health care workers in transition. The Center for the Health Professions The mission of the Center for the Health Professions is to assist health care professionals, health professions schools, care delivery organizations and public policy makers respond to the challenges of educating and managing a health care workforce capable of improving the health and well being of people and their communities. The Center is committed to the idea that the nation’s health will be improved if the public is better informed about the work of health professionals. California HealthCare Foundation CHCF, based in Oakland, is an independent philanthropy committed to improving California's health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information, visit us online at www.chcf.org. The California Endowment The California Endowment, the state's largest health foundation, was established to expand access to affordable, quality health care for underserved individuals and communities. The Endowment provides grants to organizations and institutions that directly benefit the health and well-being of the people of California. TABLE of FIGURES Figure 1. Percent of care to California Medi-Cal and indigent patients provided by open door provider hospitals, 2000 ................................................................ 5 Figure 2. Selected hospital services, California, 2000 ...................................................................... 6 Figure 3. California free and community clinics, patient demographics, 1990–2000 ................................ 7 Figure 4. Percent of total patient revenue, Medicare and Medi-Cal by hospital type, California, 2000 ......... 12 Figure 5. Number of patient visits per payer type, California free and community clinics, 1990–2000 ......... 16 Figure 6. Net revenue growth, California free and community clinics, 1995 –1999 ................................ 17 Figure 7. Proportion of grant and contract revenues, California free and community clinics, 2000 .............. 17 Figure 8. California population by race and ethnicity, 2000 ............................................................. 24 Figure 9. Percent change California youth population, by race and ethnicity, 1990 –2010 ........................ 24 Figure 10. California direct patient-care physicians, by race and ethnicity, 2000 ..................................... 25 Figure 11. California dentists by race and ethnicity, 1998 ................................................................ 25 Figure 12. California nurses by race and ethnicity, 1997 .................................................................. 25 Figure 13. Map of sites visited ................................................................................................. 34 TABLE of CONTENTS EXECUTIVE SUMMARY ............................................................................................... i Findings and Recommendations ..................................................................................... iii SECTION ONE Introduction ..................................................................................................................... 1 Characteristics of open door providers SECTION TWO Overview of health care workforce issues Issues that cross professions .......................................................................................... 21 Profession-specific issues .............................................................................................. 28 SECTION THREE Case studies .................................................................................................................... 35 Arrowhead Regional Medical Center, Colton .................................................................... 37 San Francisco General Hospital ..................................................................................... 43 Martin Luther King/Drew Medical Center, Los Angeles ..................................................... 49 Contra Costa Regional Medical Center, Martinez .............................................................. 55 Community Medical Center — Fresno ............................................................................ 61 Sacramento County Primary Care Clinic ......................................................................... 69 North County Health Services, San Marcos Health Center .................................................. 75 Venice Family Clinic .................................................................................................. 81 Humboldt Open Door Clinic, Arcata ............................................................................. 87 Salud Para La Gente, Watsonville .................................................................................. 93 CONCLUSION ............................................................................................................ 99 APPENDICES A. List and map of open door provider hospitals in California ............................................. 100 B. Mission Statements of Case Study Sites and Selected CAPH Members ............................. 102 C. Outpatient Services ............................................................................................... 108 D. Financing California’s Public Hospitals and Health Systems ........................................... 109 E. California HealthCare Foundation (CHCF) Analysis of California Hospital Financing ......... 113 F. Rising Staffing Costs, Declining Revenues .................................................................. 115 G. Emergency Departments ........................................................................................ 118 H. California’s Proposed Nurse-to-Patient Staffing Ratios .................................................. 121 REFERENCES ........................................................................................................... 122 CALIFORNIA’S OPEN DOOR PROVIDERS:TEN CASE STUDIES OF THE HEALTH CARE WORKFORCE EXECUTIVE SUMMARY Critical health care issues related to the available supply of professional workers have emerged across the nation as hospitals and clinics struggle to provide needed services. Despite this increased awareness, little attention has been paid to these issues as they play out in health care “safety net” or “open door provider” institutions. These insti- tutions provide: • The majority of care for 1 in 5 Californians 3 1 • Fully ⁄4 of Level I trauma centers and ⁄2 of the burn beds in California • Often the only access to health care for rural, low-income or uninsured Californians • Disproportionately high percentage of care to Medi-Cal patients • Vital training facilities for physicians and other health workers Open Door Provider — a hospital, academic medical center, community-based health center or other entity dedicated to assure the accessibility of cost-effective, high quality and culturally appropriate health care services for low-income and uninsured populations, beyond those emergency and stabilization services required by law. Open door providers also ensure the availability of critical public goods, such as trauma and burn care, essential to the health and well-being of the public-at-large (California Association of Public Hospitals and Health Systems (CAPH), 1999). Sustaining, through recruitment and retention, the right number of