Researching, interviewing, reporting, and writing our series on the San Diego healthcare market has been a pleasure and a privilege. So many leaders in San Diego healthcare are moving that market forward, at a pace that is outstripping the pace of change in so many U.S. healthcare markets.
What makes for that pace of change in the San Diego healthcare market? Geography actually is a significant factor: though San Diego is at the southwestern end of California, the largest state in terms of population in the United States (with nearly 40 million people), and our third-largest in area (after Alaska and Texas), it is also significantly isolated, with the Pacific Ocean on the west, the Sonoran Desert on the east, the Laguna Mountains on the north, and the Mexican border on the south. Healthcare leaders emphasized to me that this gives the San Diego market an “island-like” quality, even as it is of course part of the North American continent. But that isolation has helped to stimulate the push into risk-based contracting, which is considerably further advanced in the San Diego metro area than to the north in the vast Los Angeles basin.
As San Diego healthcare leaders have told me, semi-isolation has bred both a more rapid ramping up of partially and fully capitated contracting, as well as a greater sense of cooperation among stakeholder group leaders in the region. As Dan Chavez, executive director of San Diego Health Connect, the metro area’s highly advanced health information exchange (HIE), put it to me, “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 said, “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.” And he cited Blue Shield of California and Anthem Blue Cross as being particularly willing to work closely with providers.
What’s more, Joseph Garcia, COO of Community Health Plan, a locally based health plan, 95 percent of whose members are MediCal (California’s version of Medicaid) recipients, agreed with Chavez, noting of his plan that “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.
Meanwhile, 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.
What’s more, maturation breeds the fruits of maturation. As Dan Gross, vice president, hospital operations, at the seven-hospital Sharp HealthCare, said, “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 to the 1980s.” And, he added, “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.”
Population health management, care management—in context
With strategy, with alignment, with collaboration, come some of the fruits of the labors of leaders in the San Diego healthcare market, most notably successful population health management and care management programs. On the one hand, there remain some core challenges to establishing and advancing those programs as elsewhere, Vicki DeBaca, R.N., confirmed to me. DeBaca is 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. Looking at the issues, DeBaca says, those facing the leaders of Sharp Rees-Stealy and San Diego healthcare leaders are essentially the same as those across the U.S. healthcare system. “What I find when I participate in conferences,” she says, “is that the issues are all pretty similar. I don’t know that our market has giant differences in this area. You have the uninsured, you have the complex population, the patients who aren’t really actively engaged in their care. It’s really similar everywhere.”
What is different, DeBaca told me, is that “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 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. “And 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.”
Given all these factors, it’s no surprise that provider leaders at patient care organizations from across the U.S. have been looking to the advances being made in the most sophisticated markets like San Diego’s, for insights on how (and in which areas) to move forward.
In the end, while every healthcare market has its unique characteristics, what is clear is that San Diego’s healthcare market is a pacesetter one for U.S. healthcare. The levels of cooperation and alignment of stakeholders, the advancement of risk-based contracting, the consolidation of the market, and the advanced development of health information exchange, all set it apart from other markets, including from other California markets.
It will be excellent to hear from San Diego and California healthcare leaders, when Healthcare Informatics convenes its Health IT Summit in San Diego. Industry leaders from San Diego, from across California, and from around the U.S., will be gathering February 1 and 2 at the Omni San Diego Hotel, to discuss issues of tremendous importance to healthcare leaders everywhere. I look forward to those presentations and discussions.
In the meantime, I look forward to keeping abreast of developments in the San Diego healthcare market. There’s no question that a lot of pioneering developments will emerge there earlier than elsewhere.