All U.S. healthcare markets have localized features, and the San Diego healthcare market is no different. In fact, as some have noted, there is an odd, almost “island-like” quality to the geography of the San Diego metropolitan area, in that it is bordered by the Mexican border on the south, the Mojave Desert on the east, the Pacific Ocean on the west, and Camp Pendleton on the north. At the same time, it’s also true that some of its nearly 3 million residents do seek patient care to the north, on the edges of the sprawling Los Angeles/Riverside/San Bernardino metro market. So in that sense, perhaps the metro San Diego market is most like a geographic/demographic peninsula of sorts.
Meanwhile, though it shares much in common with the large metro markets of San Francisco and Los Angeles to the north, the San Diego healthcare market also has differences, particularly with the L.A. healthcare market, particularly in two areas: the levels of inter-healthcare-organization collaboration present, and the levels of risk achieved in risk-based contracting.
Daniel Chavez, executive director of San Diego Health Connect, the metro area’s highly advanced health information exchange (HIE), attributes the level of collaboration to the fact that “We have no dominant players, we have all dominant players. We have a very active public health agency—our health and human services agency is the largest in the United States,” he says. And when it comes to payers and providers cooperating, Chavez says, “They get along as well here as anywhere I’ve worked, and I’ve worked on both the provider and health plan sides. I’ve lived up and down the state, and in Austin, Texas, and Tampa and Jacksonville, Florida, and this is the most collaborative community I’ve ever had the opportunity to work in. In balance, this is the most collaborative place.” He cites Blue Shield of California and Anthem Blue Cross as being particularly willing to work closely with providers. And of course, Health plan and provider leaders work very closely together inside the organizational structure of the local Kaiser Permanente organization, which also has a strong presence.
Speaking from the health plan perspective, Joseph Garcia agrees strongly with Chavez. Garcia is COO of Community Health Group (CHG), a local health plan with 290,000 members, 280,000 of whom are MediCal (California’s version of Medicaid) members. Community Health Plan actually started out as a federally qualified health center (FQHC) decades ago, and its leaders remain committed to sticking close to their community. Garcia’s perspective is also enriched by the fact that “We work with practically every primary care physician in San Diego County” outside the Kaiser and Sharp HealthCare organizations, as he notes.
“This is the only county we’re in; and every provider knows our corporate headquarters is right here, and they can meet with the CEO, COO, CMO—they can come over or call,” Garcia emphasizes, about CHG. “We have 30-year relationships. We were born out of a community health center, San Isidro Health Center. We were a provider, then a provider and health plan together, and then 20 years ago, we separated. And I and others have worked at both.” And that core attitude of cooperation, he says, extends to all of the plan’s interactions with providers.
Both CHG and SHC have been participating in a county-wide effort, led by the county’s health department, to control and end an outbreak of hepatitis A that has caused many problems and been difficult to control, especially given a very large homeless and transient problem in the county.
As an Oct. 31 report in the San Diego Union-Tribune noted, “The county Health and Human Services Agency published new weekly totals Tuesday, which add one to the number of deaths recorded since the health crisis started in November 2016. The running tally of confirmed cases also continues to increase, reaching 536 from a previous total of 516.”
As Chavez notes, “We’re going through a hepatitis A outbreak, and we’re coming together to solve that. We have the fourth-largest homeless population in the U.S.—about 10,000 people—and this is largely a result of that. We’re working hard on homelessness, and this involves the entire community.”
Indeed, Chavez notes, the broad reach of his HIE is turning out to be extremely helpful during this public health crisis. With 23 hospitals, 18 federally qualified health centers, and hundreds of physician practices connected, Chavez is able to boast that 99 percent of the patients living in San Diego and next-door Imperial Counties have their patient records entered into San Diego Health Connect’s core data repository, which is facilitating 20 million messages a month, encompassing everything from ADT alerts to full C-CDA (consolidated clinical documentation architecture) transfer. As a result, he reports, “With regard to hep A, we’ve done a wonderful job with public health reporting. I venture to say that in every one of those cases, that information was passed back and forth through the HIE, all automated, with no human intervention. As soon as we had any information through a diagnosis, we registered the case with public health, with no human intervention whatsoever. And people have no idea how important the HIE is, in that. What would that outbreak be, without HIE?” The response to the outbreak among providers, health plans, and public health, he says, has been terrific.
From the health system perspective, a mature market—with alignment
Some of what makes collaboration possible, say those in the trenches, is the very maturity of the San Diego metro healthcare market. One executive who shares that viewpoint is Dan Gross, executive vice president, hospital operations, for the seven-hospital (four acute-care hospitals, three specialty hospitals), 1,836-bed Sharp HealthCare, one of the largest and most market-moving of the area’s large integrated health systems. Gross, who has witness a lot of health system change in the 38 years he’s been with Sharp (11 years in his current position), says that “I would describe San Diego as being a very mature, consolidated healthcare market. It is a market that embraced integrated healthcare delivery system design and risk-based reimbursement, very early on, going back the 1980s.”
Meanwhile, Gross says, “When I look at where we’re at and where we came from, it is that one truly has to have an integrated healthcare delivery model, and a very close affiliation and alignment with physicians, to be able to address risk-based reimbursement and capitated managed care, so that there’s an alignment between physicians and having common beliefs around care coordination, commitment to being a high-quality, low-cost provider with a very keen sense of service orientation, to a population served. The ‘magic,’ if you will, or the key to success, is that provider alignment; because without having physicians committed to the same outcomes, it doesn’t work. And you have to create an economic model so that everyone is incentivized to work towards the same outcomes and goals. It really requires that one think through how to ensure that everyone is winning, how you define winning. And also embedded, you have to have some great flexibility and knowledge around, how do you work with different patient populations, as it relates to the economic model behind them?”
The physician group perspective, even within the integrated Sharp system, can be different, even as it is consonant with the hospital executive perspective. Collaboration has flourished among physicians and physician groups, for a number of reasons, says Vicki DeBaca, R.N., vice president of health and provider services, at Sharp Rees-Stealy Medical Centers, the 500-physician employed medical group that is a component of the integrated Sharp health system. “Working at the medical group level, I find that most of the medical groups are dealing with the same issues, the same populations,” DeBaca says. “I think the groups try to be collaborative, per medication shortages” and similar issues. For example, she notes, “We’ve just recently worked on a hypertension collaborative with all the major medical groups. So we’re collaborative overall as a community. We pull together.”
Indeed, DeBaca says, perhaps one element in the collaborative element of the market has been the very isolation of San Diego from the rest of the state, and its relatively advanced work in risk-based contracting over a period of years. “We’ve been a highly capitated market for some time, unlike the case in Los Angeles,” she says. “So I think over time, the organizations in San Diego, because they’ve had a bit more flexibility with the dollars, have been able to focus and decide on how best to spend those dollars. So we might fund special diabetes programs, or special end-of-life programs, we have flexibility in terms of how we utilize resources.”
And, with regard to the physician culture, DeBaca says, “I feel that the physicians here are very engaged. There’s that the collaborative spirit here is about. They’re coming together to address the health of the population. We started the community health information exchange, which was highly advocated for by physicians. So they’re very caring and concerned, because they want to help patients.
And health information exchange, as facilitated by San Diego Health Connect, has clearly been a part of that equation, DeBaca says. “Many of my staff use it,” she says, referring to the HIE’s capability. “Ad our providers have a link within the EHR [electronic health record], and are able to go right into the EHR to find that information. And members of my staff, who are largely case managers, can access that information as well. It’s been excellent in terms of getting patients connected back to their primary care physicians after ED visits and hospitalizations. And the goal of our care managers is really to support the patients, in whatever they need.” So, she says, the continuous loop of information and data has proven to be very important in advancing case and care management.
In the next article in this series: where are population health management and care management headed in the San Diego market?