Road to Recovery
Travis County's Clinics Are in Better Health Than Ever. But a Cut in Medicaid Funding Could Put Them Back on the Critical List.
Dr. Lisa Glenn sees more patients in a typical workday now than she ever has before as a family practice physician at the Rosewood-Zaragosa health clinic. She's happy about that -- kind of. Three years ago, her schedule was less demanding because her employer, the Austin/ Travis County Primary Care Department, was a lot sicker. Clinic operations were so inefficient that Glenn, a family practice physician, could treat patients faster than they could be admitted. Today, a streamlined scheduling system keeps Glenn hopping. Gone are the days when clinic physicians wrote their own schedules in paper binders. Now, intake clerks use computers to fill appointments, and doctors are expected to see at least 20 patients a day. That means Glenn leaves work later in the day and sometimes loses her lunch hour. The payoff, she says, is knowing that health care for the county's poor won't be turned over to a private provider any time soon. "In two years," she says, "we've gone from worrying about whether the clinics were going to be here to feeling pretty good about [their survival]."
Local government officials never seriously talked about abandoning the network of public clinics that deliver health care to around 40,000 Travis County patients -- most on Medicaid or lacking health insurance -- each year. But both the city and county, which jointly fund the clinic system, once made noises about cutting the clinic system loose from the city's administrative responsibility. Management of the clinics proved too inefficient to adjust as health care costs escalated in the Nineties; the clinics hemorrhaged money and patients waited weeks to get appointments. A 1997 consultant's study concluded that while the clinics' quality of care was good, the system suffered from "high service costs, excessive staffing levels, low provider productivity, and an overall lack of management and financial controls."
Soon after that report, the Travis County Commissioners Court decided that the problem couldn't be fixed from within and solicited bids from health care providers to run the five clinics in Austin's outlying areas. The Seton Healthcare Network offered to tackle the job, but with the caveat that some of the clinics would have to be closed to make the system run less expensively. Not wanting to be responsible for forcing wheelchair-bound senior citizens from Manor to trek into Austin for insulin shots, the commissioners wisely said no thanks.
Meanwhile, the Austin City Council hired a consulting group to manage the clinics, hoping to stabilize costs by identifying staff cuts, putting the Medicaid billing process in order, and flat-out getting patients through the doors more quickly. Those consultants, Goggio and Associates (now called JKM Consultants), finished their two-year contract in July. They've left behind a Primary Care Department that looks a lot different from the old one, the foremost change being its new status as an an independent department, no longer a division lost in the hapless bureaucracy of the Health and Human Services Department, which is responsible for everything from dispensing welfare checks to running the animal shelter. Now, Primary Care administrators are eager to show off their leaner, more responsive health care machine, which just finished its third year in the black and for the first time in years didn't take a budget hit from the city manager.
Administrators say the face of public primary care has changed to better serve its customers. This year, the 11 health clinics in the Austin/Travis County system logged about 9,300 patient visits per month, way more than the 6,000 to 7,000 visits the clinics were seeing in 1997, and they've done it with fewer staff. Patients who call in for appointments can now expect to receive treatment within two weeks, instead of two months, and within 24 hours if they're acutely ill.
While meeting with a reporter at the Rosewood-Zaragosa clinic, recently hired external programs manager John Gilvar produces a one-page summary sheet listing all city/county clinic locations, the services offered, eligibility information, and a phone number to call for an appointment. It's a simple handout, available on the city Web site. But it's also an extraordinary piece of work. Never before has a resource like it been offered by the clinics, as far as Gilvar knows. "It's one of the first things I put together when I started," he says. "When I asked if this information was available, people brought in books for me to look through." For that matter, Gilvar's position -- which is essentially a single, accessible connection point between the community and the clinics -- is brand-new, too.
JKM consultants report that such transgressions against the basic rules of customer service were all too typical of the primary care system when the consultant came onto the scene. In a summary report handed to City Council members in August, JKM principals Kathleen Music and John Kuenning wrote that "the system was set up to be convenient for the staff and providers, not the patients." JKM was particularly critical of the physicians, saying they saw far too few patients, showed up late in the mornings, and canceled appointments when they didn't feel like keeping them. Staff absenteeism was rampant, they added, and workplace behavior was unprofessional. Physicians and nurses respond that they were unfairly blamed for the shortcomings of an inherently flawed organization that offered no pay or recognition for performance and too little office time.
As noted in the 1997 consultant's report, the Primary Care administration was hopelessly labyrinthine and circular before it was split off from Health and Human Services -- headed by both city and county staff, and reporting to a board of directors as well as to the City Council and Travis County Commissioners Court. "Now we're much more nimble," says Gilvar. "We just call Betty" (as in Dunkerley, the assistant city manager overseeing Primary Care).
Gilvar is himself a notably expeditious addition to the Primary Care offices. A former City Council aide known for being at times more outspoken than his boss, Beverly Griffith, Gilvar is also a graduate of the UT Center for Public Policy Dispute Resolution, where students learn negotiating models called "Getting Past No" and "Getting to Yes." Lately, he's been presiding over staff problem-solving teams focused on further mitigating bottlenecks in the clinics' patient flow -- the kind of in-house review process that was simply unknown in the old days. Other new faces comprising the Primary Care superstructure include chief operating officer Neli Cavazos, a former longtime clinic director; Bob Brown, recently hired as CFO; and, just announced last week, Seton Healthcare exec Patricia Young is expected to take over as chief executive officer.
The relationship between the JKM consultants and clinic staff was decidedly tense during the past two years as the consultants, acting as the Primary Care directors, enforced their new policies and procedures. As doctors will point out, much of the clinics' improved financial performance was gained by squeezing more work out of employees. But the clinic staff tends to agree that patients are better off under the new system, and much of that improvement, though not all, is the consultants' handiwork.
Waiting time for appointments has been cut, principally through a centralized call center. In the past, patients who tried to get in at busy clinics had to simply wait or call around to other locations, but now scheduling clerks can direct them to where slots are available. A triage nurse, stationed at the center 24 hours per day, helps determine the priority for appointments. Patient files are now accessible on computer, which helps prevent patients from getting shuffled between clinics. Even the design of the clinics has been overhauled to cluster physicians with different specialties together so that patients needing treatment for more than one condition don't have to schedule multiple appointments.
To help plug the financial leaks that plagued the clinics in the past, Gilvar says, the staff has placed new emphasis on helping patients sign up for insurance programs and other financial assistance, collecting co-pays, and submitting accurate Medicaid records. Once, more than half of the clinics' claims for Medicaid reimbursement were being rejected because they were faulty or incomplete. Now only one in five are, and the system goal is to resubmit no more than one in 10. "We've made significant inroads on all those issues we were cited for three years ago," says Gilvar, referring to the 1997 study. Longtime clinic patient Julia Mitchell, who serves on the clinics' citizen oversight board, agrees that the changes are noticeable. "It doesn't take as long for you to see the doctor," says Mitchell. "All the people, they're concerned ... and the customer service is better."
But the Primary Care Department has done more than just repair the clinic's nagging problems. Clinics are now expanding the scope of their care into prevention and social service. Dr. Nana Lopez, for example, the new director of dental services, has pushed to expand care to Austin Independent School District students. She now manages two portable dental hygiene labs that set up on campuses and apply durable plastic sealants to kids' teeth, which helps prevent tooth decay -- the number-one chronic childhood disease. The dental clinics had provided sealant treatments for only a few hundred patients a year, but this year Lopez, with an assist from the St. David's Foundation, plans to reach nearly 4,000 students.
Four clinics have also established Reach Out and Read programs, a national initiative that has gained recognition from pediatric journals for increasing many times over young children's proclivity to read. Volunteers trained by the nonprofit VISTA program read to children while they sit in waiting rooms. And at the end of the child's appointment, doctors hand parents "reading prescriptions" -- a pile of books to share with their children. Doctors involved with the program say that on return visits, the children -- many who come from the 25% of Texas households that own fewer than 10 books -- request another reading prescription.
But while patient services and staff morale have generally improved at the health clinics, the long-term viability of the system is still at risk, besieged by health care realities that aren't all within the control of the Primary Care Dept. Greater efficiency will help sustain the clinics, but the pressure to serve larger and larger populations that can't pay for their health care is bound to grow. The clinics will have to tread carefully to prevent getting buried under a mountain of disease on one hand and drowning in a lake of cynicism on the other. So far, they've mostly been criticized for not treating enough patients, but would public officials really be wiling to pay for all the health care needs a more aggressive outreach could draw in? Last year, the Primary Care Dept. had to pull an advertisement off a cable access channel because the volume of phone calls that resulted made the staff fear it could be swamped. "What we're going to discover is more disease if we go looking for it," Gilvar says.
JKM's Kathleen Music says the clinics are still only operating at about 75% capacity and could handle many more patients than they do, even though during the past two years the hired consultants trimmed about 25 unfilled staff positions from the Primary Care budget. But Glenn, who in addition to making her doctor's rounds serves as the system's chief medical director, says clinic staffing levels are more stretched than they appear on paper. Glenn is one of the few clinic doctors meeting national standards for the numbers of patients seen in a month, but she says that's only because her support team is well-trained and reliable. Other doctors are hampered by bare-bones staff support that breaks down because of frequent absenteeism.
"I can do 17 patients in a four-hour period, but sometimes when it's just me and [the nurse practitioner] here, we struggle to do 10," says Glenn. "When everybody's at work, things work just great. If somebody's out on vacation or sick, it makes it a tougher day. Whereas before, if one person was out, it really didn't affect us that much."
The health clinics currently provide about 3.5 support positions -- nurses, aides, and clerks -- for every physician. That's little more than half the staff that doctors were accustomed to in the past. East Austin clinic director Beth Abreu says no one expects to ever return to those levels, but the consultants' decision to eliminate staff positions permanently could make it harder for the clinics to meet future demand. "I don't know that that was in the best interests of the department overall," says Abreu. Ultimately, she says, the City Council may have to restore some of those positions. Staffing is particularly critical because clinics are located in parts of the city and county where the ratio of patients to private physicians is dangerously high (see chart). So the loss of support staff that allows the physicians to see more patients is always a critical issue.
Caught in the midst of a nationwide nursing shortage, the clinics struggle to fill even the positions they do offer. Nurse practitioner Mirella Mays, who works alongside Glenn at Rosewood-Zaragosa, says the city needs to raise its salaries for nurses and recruit a pool of freelance nurses who could be called upon when clinic personnel are out. Recruiting is difficult because physicians and nurses at public clinics handle a much needier population than private providers, Mays points out; it takes more time and energy to diagnose, educate, and medicate patients with untreated and sometimes multiple chronic conditions such as diabetes and hypertension. Abreu says clinic managers are trying to retain and motivate employees through increased recognition and events, but invoking the necessary commitment is hard. "Some just can't show up for work every day," she says.
Public health clinics across the country are typically in financial trouble these days, with about one in 10 systems struggling just to stay afloat, according to a report from the General Accounting Office. The primary culprits are the dramatic rise in the numbers of uninsured patients (up 50% since 1980) and the cuts in federal grants for indigent health care (down 10% in the same period). Here in Travis County, where about 20% of the population lacks health insurance, clinics have escaped the deluge of the uninsured because the city/county Medical Assistance Program (MAP) enrolls many low-income residents who don't qualify for Medicaid. (MAP coverage, however, is also an expense to local taxpayers, and the rolls are growing.) Still, uninsured patients -- who are euphemistically dubbed "self-pay" customers in the health care field, but who typically pay little or nothing for care -- account for about four out of 10 visits to Travis County clinics.
But the biggest threat to the clinics are the looming cuts to Medicaid payments required by the Balanced Budget Act of 1997. Medicaid receipts, currently paid out to health care providers according to the average costs of patient visits, are the clinics' largest source of income, and make it possible for them to treat the lower-income residents who don't qualify for federal assistance. But beginning next year, the amount the Medicaid program will pay for the average clinic visit could begin to drop, quickly plunging below the actual costs that clinics incur. It's doubtful that many public health centers nationwide, including those in Travis County, will ever be able to cover the cost of services to patients at the lower funding levels. Various legislation has been proposed to counteract the potentially devastating effects of the Medicaid cuts, but the future is uncertain, and for the clinics, very frightening. They already suffer from the managed-care Medicaid grind in Texas, a state notorious for delaying reimbursements to providers, not to mention keeping eligible recipients off the Medicaid rolls.
Meanwhile, additional strains on the clinic system press in from other directions.
Market assessments compiled by JKM predict that poor residents won't comprise a greater percentage of the Travis County population in the near future, but the fact remains that low-paid workers are a big part of the labor force moving into the county. Pockets of low-income households are springing up in places far from the clinics' traditional service areas, which Gilvar estimates already contain many more eligible residents than the clinics presently serve. Private doctors are virtually nonexistent in those East Austin census tracts, and, as Travis County Commissioners learned last year, physicians aren't exactly flocking to the new low-income boroughs to the north.
The only way publicly financed primary care can cope with the rising tide of the uninsured, Music says, is to stay vigilant at tightening efficiencies and never lose an opportunity to maximize revenues; for instance, by competing harder for commercially insured patients. Clinic staff already roam maternity wards at hospitals reminding mothers on Medicaid about the clinics' excellent well-child programs, says Music (the clinics compete with several area providers for those Medicaid dollars), and the same strategy can be applied to those with private insurance. Renovations at the Northeast Clinic are already proceeding with that thought in mind, says Music. Abreu says, however, that she's not convinced that privately insured patients could ever form a big-enough customer base to have a financial impact. The state's new Children's Health Insurance Program (CHIP) could bring 4,000-5,000 new teen patients through the clinic doors, but no one knows what the real effect of that program will be, either.
Longtime health advocate and clinic governing board member Rose Lancaster says she hopes that public officials won't wait too long when it becomes obvious that clinic system expansion, not just efficiencies, are needed to serve the poor. Lancaster still regrets that the city cut several nutritionists from the clinic staff last year -- positions she considers crucial for preventing chronic illness. The Health and Human Services and Primary Care departments need to better coordinate preventative public health initiatives to combat the social behavior that leads to expensive health care down the road. The JKM consultants have recommended converting the current Montopolis clinic into a specialty center for just that kind of mission. Meanwhile, Lancaster says she's grateful that for the time being, public health has a new lease on life in Travis County.
"It's kind of a wait and see, but we've got a chance now," says Lancaster.