Dis­trict Lack­ing In Ac­cess To Care

1 in 5 Have No Med­i­cal Provider, Rand Re­port Says

The Washington Post - - Metro - By Susan Levine

One in five Dis­trict res­i­dents have no reg­u­lar source of health care, and ris­ing rates of hospi­tal vis­its sug­gest de­clin­ing ac­cess to physi­cians and com­mu­nity clin­ics, ac­cord­ing to the most com­pre­hen­sive re­port ever of D.C. health is­sues.

The re­port, re­leased yes­ter­day, looked at data on chronic dis­ease, in­sur­ance, hospi­tal ca­pac­ity and emer­gency ser­vices and found much want­ing. “There ap­pears to be con­sid­er­able room for im­prove­ment in qual­ity of care and its mea­sure­ment,” con­cluded the Rand Corp., the non­profit re­search or­ga­ni­za­tion that the D.C. Coun­cil com­mis­sioned to help the city move for­ward.

The prob­lem is not a lack of health in­sur­ance for most res­i­dents. Thanks to private plans, Medi­care and Med­i­caid and the Dis­trict’s D.C. Al­liance for many of its work­ing poor, less than 10 per­cent of Dis­trict res­i­dents are unin­sured, com­pared with 19 per­cent or more in Philadel­phia and Detroit, the re­port said.

Yet for rea­sons that of­fi­cials do not un­der­stand fully, cov­er­age does not al­ways lead to reg­u­lar pri­mary care. Pa­tients with con­di­tions that could have been pre­vented, or

treated ad­e­quately, in a qual­ity com­mu­nity set­ting are show­ing up at hos­pi­tals.

The rates are “star­tlingly high,” Ni­cole Lurie, a se­nior sci­en­tist at Rand, said yes­ter­day at a news con­fer­ence with city lead­ers. And since 2004, the rates have been get­ting worse.

Young chil­dren and adults who are cov­ered by Med­i­caid visit hospi­tal emer­gency rooms rou­tinely, the re­port found; at least 40 per­cent make one or more trips a year. Among adults with a chronic con­di­tion such as heart dis­ease, the pro­por­tion is even greater. Fewer than 20 per­cent see a car­di­ol­o­gist an­nu­ally, but more than 70 per­cent are in the emer­gency room at least once.

Like oth­ers, Lurie ac­knowl­edged that re­vers­ing those trends and fun­da­men­tally chang­ing the sys­tem re­mains an im­mense chal­lenge. “It’s go­ing to take ev­ery­body work­ing to­gether to do it,” she said.

The Rand study was re­quested by the D.C. Coun­cil in late 2006 as it voted to spend $245 mil­lion in to­bacco set­tle­ment funds to con­struct ma­jor clin­i­cal fa­cil­i­ties, strengthen emer­gency care and de­velop pro­grams that re­duce the toll of such dis­eases as di­a­betes and can­cer. Rand’s rec­om­men­da­tions were to help al­lo­cate nearly $200 mil­lion set aside for the cap­i­tal projects, di­rected mainly to­ward com­mu­ni­ties on the city’s east side, where health prob­lems are great­est but ser­vices scarce.

The coun­cil has spent $79 mil­lion of that to help close the sale of Greater South­east Com­mu­nity Hospi­tal. Lurie, the lead au­thor on the 134-page as­sess­ment, said she does not ex­pect Rand’s pro­pos­als for the rest of the to­bacco money to be com­pleted un­til early sum­mer.

The re­port, how­ever, hints of the so­lu­tions un­der con­sid­er­a­tion. In un­der­scor­ing the con­cern that many Dis­trict res­i­dents end up at a hospi­tal un­nec­es­sar­ily, it broaches in­cen­tives to en­cour­age physi­cians to serve in com­mu­ni­ties with the great­est need and to per­suade pa­tients to “use care ap­pro­pri­ately.” Rand could not de­ter­mine how many providers are ac­cept­ing new pa­tients, es­pe­cially those cov­ered by Med­i­caid or the Al­liance.

Its con­clu­sions make clear that the an­swer is not more or big­ger hos­pi­tals, a sig­nif­i­cant point for the coun­cil, which sev­eral years ago was ready to com­mit hun­dreds of mil­lions of dol­lars to­ward a new med­i­cal cen­ter. The re­searchers at Rand, work­ing with pol­icy ex­perts from Ge­orge Wash­ing­ton Univer- sity’s school of pub­lic health, said the hospi­tal sys­tem “does not ap­pear to be op­er­at­ing on the brink of sat­u­ra­tion,” with only one of the eight D.C. fa­cil­i­ties near full oc­cu­pancy and over­all ad­mis­sions rel­a­tively flat.

City lead­ers promised yes­ter­day to fol­low the re­port’s lead. “It’s the most im­por­tant doc­u­ment we’ve seen with re­spect to the fu­ture of health care,” said coun­cil mem­ber David A. Cata­nia (I-At Large). And, he added, it should guide not only the re­main­ing to­bacco funds but the $2.2 bil­lion spent ev­ery year on health care in the Dis­trict. “We will not let this be a one-hit won­der.”

Among the key find­ings and is­sues high­lighted in the study’s first phase:

There are big gaps in data needed to im­prove ser­vices. Health-care of­fi­cials know lit­tle about the sta­tus of chil­dren’s health and their ac­cess to care. Re­li­able es­ti­mates on the preva­lence of men­tal health prob­lems are “ex­tremely lim­ited.” More­over, even when data are col­lected, anal­y­sis lags, so de­ci­sions are based on out­dated in­for­ma­tion.

The Dis­trict’s health is com­pa­ra­ble to that of cities with sim­i­lar de­mo­graph­ics, though with many trou­bling health indicators. More than 25 per­cent of D.C. adults have high blood pres­sure and 10 per­cent have asthma; nearly 25 per­cent are obese. More than one in three chil­dren ages 6 to 12 are over­weight, one in two in Ward 6. Twelve per­cent of chil­dren through age 17 have asthma, a num­ber that spikes to al­most one in five in Ward 7.

Eight per­cent of city res­i­dents have not vis­ited a den­tist in five years or longer.

Com­pared with an over­all ra­tio of 54 adult pri­mary-care providers per 100,000 Dis­trict res­i­dents, Ward 7 has the small­est ra­tio in the city, with six health-care providers per 100,000 res­i­dents. More than 23 per­cent of adults there ranked their health as fair or poor, the worst self-ap­praisal in the city.

“We will not let this be a one-hit won­der,” D.C. Coun­cil mem­ber David A. Cata­nia said of the Rand re­port.

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