CALIFORNIA Health Care Almanac REGIONAL MARKETS SERIES OCTOBER 2020 Humboldt and Del Norte Counties: Community Collaboration in the Face of Health Adversity Summary of Findings statewide, and almost 60% of people get health cover- The rural north coast California counties of Humboldt and age through Medi-Cal or Medicare, compared with 45% Del Norte face multiple health and health care challenges, statewide. including high death rates from stroke, accidents, suicide, ▶ Erosion of independent physician practice. The and alcohol or drug use; severe shortages of health care retirement of a generation of local doctors, higher costs professionals in primary care and behavioral health; and associated with running a practice, such as the expense limited access to care in remote areas. To work on solving of electronic health records, and increased complexity of these and other challenges, the region comes together as billing and regulatory requirements have contributed to a community, including collaborations to keep clinicians in an exodus of independent physicians in private practice, the area and expand treatment for mental health and sub- who have largely disappeared from the region. stance use disorder (SUD). Passage of the Affordable Care Act (ACA), particularly expansion of Medi-Cal, has helped expand ▶ A severe shortage of health care professionals, espe- access to care and stabilize health care providers’ finances as cially in primary care and behavioral health. Driven the share of people without health insurance declined mark- by the retirement of local doctors and difficulty recruiting edly. However, the cost of private health insurance is high physicians and other clinicians, the workforce shortage and rising rapidly. Like other California communities and the makes providing access to care in remote areas extremely nation as a whole, the region faces significant disruptions challenging. The community has come together to create from the COVID-19 pandemic but avoided an initial surge in a wide-ranging plan to fill the gap, from creating a family cases by quickly mobilizing to stem the virus’s spread. residency program for new physicians to offering training opportunities for locals interested in health care careers. Key factors affecting the local health care market include: ▶ Leadership from a local nonprofit on data exchange ▶ A stagnant economy, high poverty rates, and the to improve care and community health outcomes. health consequences of long-term alcohol, tobacco, Launched as an effort to connect health care providers and drug use. Since its logging heyday, the region has in the area, the region’s health information exchange in struggled to diversify economically. The all-cause death recent years has moved to cross-sector data exchange rate in Humboldt County is about one-third higher than with human services agencies in support of community This paper is one of seven included in CHCF’s 2020 Regional Markets Study. Visit our website for the entire Almanac Regional Markets Series. health outcomes. The resulting community care coordi- page 21, for more information). Within Humboldt and nation platform serves approximately 1,400 clients with Del Norte Counties, 72% of people identify as White, 13% complex needs across Humboldt County, linking hospi- as Latinx, 10% as other (including Native Americans), 3% tals and emergency departments (EDs) with local social as Asian, and 2% as Black (see Table 1). Native Americans service and criminal justice agencies. compose 6% of the region’s population, with 11 tribes in the two counties, including the state’s largest reservation, Hoopa ▶ Strong community collaboration — anchored by Valley. Native Americans historically have been poorly served the region’s Medi-Cal health plan, largest Federally Qualified Health Center, and dominant hospital — to address provider shortages and expand access TABLE 1. D emographic Characteristics Humboldt and Del Norte Counties vs. California, 2018 to mental health and SUD treatment. In response to Humboldt/ Del Norte California ongoing shortages and recruitment challenges, the com- POPULATION STATISTICS munity has adopted a “grow your own” health workforce Total population 164,201 39,557,045 strategy that has broad engagement from the health Five-year population growth 1.2% 3.2% sector, educational institutions, and local government. AGE OF POPULATION, IN YEARS Similarly, the community has collaborated on multiple Under 18 19.5% 22.7% initiatives to improve access to mental health services 18 to 64 62.6% 62.9% 65 and older 17.9% 14.3% and SUD treatment, especially in light of the opioid epi- RACE/ETHNICITY demic’s devastating impact on the area. Latinx 13.2% 39.3% White, non-Latinx 72.1% 36.8% Market Background Black, non-Latinx 1.6% 5.6% Asian, non-Latinx 2.7% 14.7% Humboldt and Del Norte Counties are home to about Other, non-Latinx 10.3% 3.6% 164,000 people spread over 5,282 square miles, an area the BIRTHPLACE size of Connecticut. Many residents live in small communi- Foreign-born* 8.4% 25.5% (0%–17.6%) ties along the coast, but a significant number of people are EDUCATION scattered across more remote areas connected by rough High school diploma or higher 89.1% 83.7% roads that frequently close in winter.1 About one-third of College degree or higher 36.1% 42.2% Humboldt’s 136,000 residents live in Eureka, the region’s ECONOMIC INDICATORS health care hub and largest city, and in nearby Arcata. A 2 Below 100% federal poverty level (FPL) 20.3% 12.8% quarter of Del Norte’s 28,000 residents live in Crescent City, 100% to 199% FPL 20.3% 17.1% Household income $100,000+ 19.0% 38.0% the county seat.3 Densely forested and mountainous, the Median household income $51,409 $75,277 region borders the Pacific to the west, Oregon to the north, Unemployment rate 3.8% 4.2% Siskiyou and Trinity Counties to the east, and Mendocino Able to afford median-priced home* (2019) 37.0% 31.0% County to the south (see map on page 21). *Humboldt data only. The area has the least diverse population — racially and Sources: “County Population by Characteristics: 2010–2019,” Education by County, FPL by County, Income by County, US Census Bureau; “AskCHIS,” UCLA Center for Health Policy Research (confidence ethnically — of the seven regions in the ongoing Regional intervals are large for Humboldt County and are included in the table); “Employment by Industry Data: Historical Annual Average Data” (as of August 2020), Employment Development Dept., n.d.; and “Housing Affordability Index - Traditional,” California Association of Realtors. All sources accessed Market Study (see Background on Regional Markets Study, June 1, 2020. California Health Care Foundation www.chcf.org 2 by the health care system and social systems broadly and so A “culture of secrecy” in the area — a legacy of the are more likely to have lower incomes and higher poverty underground cannabis trade, according to a respondent rates and to be uninsured than the White population. Native interviewed for the study — compounds the difficulty of Americans also tend to have higher rates of infant mortality, both assessing the need for health and social services and diabetes, heart disease, and obesity, as well as higher rates of providing treatment in remote areas. While the region faces alcohol, drug, and tobacco use. 4 grave socioeconomic and health challenges, a tight-knit Population growth in Humboldt and Del Norte hovers group of community leaders regularly collaborates on ini- near 1% annually, much lower than the statewide average of tiatives to improve access to care and community health 3.2%. While timber remains an important industry, the region outcomes. “There’s hope and innovation in our commu- has struggled to diversify economically since its logging nity,” one respondent said. Another mirrored that sentiment, heyday. Humboldt County’s largest employers include local saying, “There’s no one else, so we need to figure it out — government and school districts, Humboldt State University, working together.” and St. Joseph Hospital.5 Many Del Norte residents work for local government and school districts as well as the tribes, TABLE 2. Age-Adjusted Death Rates (per 100,000 population) Humboldt County vs. California, 2014–2016 Average including United Indian Health Services (UIHS).6 Cannabis   Humboldt California cultivation also plays a notable role in the local economy, All causes 815.8 608.5 historically as an illicit industry. But state legalization for recre- All cancers 164.9 140.2 ational use in 2016 has brought cannabis cultivation into the Coronary heart disease 106.9 89.1 mainstream economy. Nonetheless, many residents subsist Accidents 69.2 30.3 in generational poverty. Four in 10 residents in the region live Stroke 65.6 35.3 in households that earn less than 200% of the federal poverty Chronic lower respiratory disease 45.4 32.1 Drug-induced deaths 37.4 12.2 level, or $52,400 for a family of four in 2020.7 Suicide 25.6 10.4 The all-cause death rate in Humboldt County is about Chronic liver disease and cirrhosis 20.3 12.2 one-third higher than statewide. For example, the death rate Firearm-related deaths 20.5 7.6 from stroke is almost twice the state average: 65.6 deaths Motor vehicle traffic crashes 18.7 8.8 per 100,000 people in Humboldt, compared with the state Note: Del Norte County’s rates are similar but statistically unreliable and are not shown here. average of 35.3 deaths. Humboldt County residents die from Source: ”Table 1,” in County Health Status Profiles 2018 (PDF), California Department of Public Health, 2018. suicide, drug use, and firearms at about 2.5 to 3 times the state average (see Table 2). This differential is consistent with the higher rates of mortality observed among rural residents nationwide, across all races and ethnicities, a result of what some experts call “structural urbanism,” a systematic bias toward large population centers that disadvantages rural communities.8 California Health Care Foundation www.chcf.org 3 Health Coverage Sources and Trends PHC is the only health plan in the region with a local pres- A much smaller share of the population of Humboldt and Del ence, including a regional office in Eureka. The PHC Board Norte Counties is covered by private insurance compared of Commissioners includes several representatives from with the state as a whole (35.3% versus 47.7%), a difference Humboldt and Del Norte. PHC invested $25 million in afford- that has grown in recent years; a larger share is covered by able housing in its 14-county service area in 2018, including Medicare (21.6% versus 15.9%) (see Table 3).9 The percent- $2.8 million in Humboldt and Del Norte.11 Compared with age of uninsured residents fell sharply, and the share of the other Medi-Cal managed care plans serving rural areas, PHC’s population with Medi-Cal coverage increased between 2014 enrollees generally travel shorter distances for care, con- and 2015 as the ACA took effect (not shown). Since then, the tributing to better access.12 In July 2020, PHC launched the percentage of uninsured residents dropped slightly (from Wellness and Recovery Program in seven counties, including 7.8% to 7.2%) and the percentage enrolled in Medi-Cal has Humboldt, substantially expanding SUD treatment services increased gradually from 33.1% of the population to 36.0%. available to enrollees through the Drug Medi-Cal Organized Delivery System pilots.13 PHC also has a robust portfolio of TABLE 3. Trends in Health Insurance, by Coverage Source quality improvement programs, including initiatives target- Humboldt and Del Norte Counties vs. California, 2015 and 2019 ing primary care, hospital, long-term care, palliative care, and HUMBOLDT/DEL NORTE CALIFORNIA perinatal care quality.14 The plan earned interim accredita- 2015 2019 2015 2019 Medicare* 19.7% 21.6% 14.4% 15.9% tion from the National Committee for Quality Assurance in Medi-Cal 33.1% 36.0% 29.1% 28.7% August 2019. Private insurance† 39.4% 35.3% 47.8% 47.7% Only two commercial health plans — Blue Shield of Uninsured  7.8% 7.2% 8.6% 7.7% California and Anthem Blue Cross — offer private coverage *Includes those dually eligible for Medicare and Medi-Cal. in Humboldt and Del Norte. In both the employer-sponsored † Includes any other insurance coverage (excluding Medicare and Medi-Cal). Source: Calculations made by Blue Sky Consulting Group using data from the US Census Bureau, the and individual markets, available products typically are pre- Centers for Medicare & Medicaid Services, and the California Department of Health Care Services. ferred provider organizations (PPOs). Covered California, the state’s ACA exchange, enrolled about 6,000 people in Medi-Cal Plan Exerts Strong Market Influence Humboldt and 600 in Del Norte in 2019, with a fairly even Partnership HealthPlan of California (PHC), a nonprofit plan distribution of membership between the two Blue plans; that administers Medi-Cal benefits, is the region’s largest enrollment has held steady over the last several years.15 health plan. PHC serves Humboldt and Del Norte Counties Covered California premiums have increased dramatically in as part of the 2013 eight-county expansion in the rural recent years for the rural north rating region, which includes north of the state’s county-organized health system model, 22 counties. The weighted average cost of the silver plan under which a single plan administers Medi-Cal coverage for doubled from $327 to $644 a month between 2015 and managed care members.10 PHC had about 56,000 members 2019; by comparison, the statewide average for a silver plan in Humboldt in 2018, an increase of 28% since 2014; in Del increased from $312 to $454 during the same period (see Norte, PHC had 12,000 members in 2018, up 13% from 2014. Table 4 on page 5). By comparison, the statewide increase in Medi-Cal enroll- ment between 2014 and 2018 was 15%. Local health care providers advocated for PHC to serve as the Medi-Cal health plan, and they view PHC as a strong partner. California Health Care Foundation www.chcf.org 4 TABLE 4. Covered California Premiums and Enrollment understanding of the novel virus and also personal protective Humboldt and Del Norte Counties (Region 1) vs. California, 2015 and 2019 equipment as the two hospitals prepared for the pandemic. REGION 1 CALIFORNIA The region also has two critical access hospitals (CAHs): 2015 2019 2015 2019 Redwood Memorial and Jerold Phelps Community Hospital. Monthly premium* (Silver Plan on the $327 $644 $312 $454 exchange for a 40-year-old individual) This Medicare designation is intended to ensure essential Percentage of population enrolled 3.8% 3.6% 3.0% 3.1% services remain available in rural communities and enables *The price for Rating Region 1 is weighted by enrollees in Humboldt and Del Norte Counties. CAHs to receive cost-based reimbursement for Medicare ser- Source: Blue Sky Consulting Group analysis of data files from “Active Member Profiles: March 2019 Profile” (as of May 31, 2020) and “2019 Covered California Data: 2019 Individual Product Prices for All vices. To be designated as a CAH, a hospital must be in a rural Health Insurance Companies,” Covered California. area, have 25 or fewer inpatient beds, and be located more than 35 miles from another hospital or more than 15 miles In January 2020, about 28,000 Humboldt and 6,100 from another hospital in areas with mountainous terrain or Del Norte residents where enrolled in original fee-for-service only secondary roads. The fifth hospital in the region is the Medicare, and three-quarters of these residents also had investor-owned Mad River Community Hospital in Arcata, a prescription drug plan (Medicare Part D).16 There are no about 20 minutes north of St. Joseph’s Hospital in Eureka (see Medicare Advantage plans in Humboldt or Del Norte, but Table 5 on page 6 for hospital details). the first rural Program of All-Inclusive Care for the Elderly St. Joseph Health is the dominant hospital presence (PACE) in California, Redwood Coast PACE, opened in 2014. in the region, with 138-bed St. Joseph Hospital in Eureka PACE provides all services covered by Medicare and Medicaid and 25-bed Redwood Memorial Hospital in Fortuna, about to eligible individuals, and providers receive a capitated 20 miles to the south. St. Joseph Hospital opened in 1920, payment — a fixed amount per member, per month. As of founded by Catholic nuns who were initially focused on August 2020, the program had 202 enrollees.17 opening schools but shifted their mission to health care when the 1918 flu epidemic hit the community. St. Joseph St. Joseph Health Dominates Hospital Sector Health, headquartered in Irvine, merged with Washington One notable characteristic of this rural region’s hospital market State–based Providence Health & Services in 2016; the result- is the presence of multiple hospitals affiliated with large health ing nonprofit Providence system operates 51 hospitals and systems: Providence St. Joseph Health, one of the nation’s more than 1,000 clinics in seven western states. largest Catholic health systems, owns St. Joseph Hospital and The merged system created Well Being Trust, a national Redwood Memorial in Humboldt, while Sacramento-based foundation with a $100 million endowment focused on Sutter Health owns Sutter Coast Hospital in Del Norte. System mental, social, and spiritual health. In addition, as a condi- affiliation has the potential to improve financial performance tion for the merger, California’s attorney general required that through economies of scale in administrative functions, $30 million be spent on mental health initiatives in California increase leverage for higher payment rates from health service areas. To date, St. Joseph has invested $2 million in the plans, and generate more favorable credit terms in the bond region, most notably to develop and initially subsidize operat- market.18 For St. Joseph Hospital and Redwood Memorial, ing costs for Waterfront Recovery Services, a 56-bed medically the Providence system’s size and role as the site of care in managed detox and residential treatment facility opened in Washington State for the first COVID-19 patient in the United 2017 for people with SUDs. In 2019, the site received certi- States proved valuable in acquiring both fast-moving clinical fication from the state Department of Health Care Services California Health Care Foundation www.chcf.org 5 TABLE 5. Hospital Overview: Humboldt and Del Norte Counties, 2018 HUMBOLDT DEL NORTE St. Joseph Redwood Memorial Mad River Community Jerold Phelps Community Sutter Coast Ownership Providence St. Joseph Health Investor-owned District Sutter Health (nonprofit) (nonprofit) Critical access 4 4 Medi-Cal DSH* 4 4 City Eureka Fortuna Arcata Garberville Crescent City Licensed beds (acute) 138 25 78 9 39 Occupancy (acute) 68% 61% 27% 36% 51% Discharges (acute) 6,610 1,413 1,752 59 2,156 Emergency department visits 31,460 11,995 17,301 3,102 19,540 Share of revenue from: Medicare 30% 34% 24% 52% 34% Medi-Cal 25% 27% 65% 20% 30% *DSH is disproportionate share hospital. The DSH program, operated by the California Department of Health Care Services, provides a supplemental payment to hospitals serving a “disproportionate share” of Medi-Cal members and uninsured individuals. Sources: “Hospital Annual Financial Data - Selected Data & Pivot Tables,” California Office of Statewide Health Planning and Development, accessed June 1, 2020. Critical access hospital designation is available from the California Hospital Association. Share of revenue based on total revenue, not restricted to revenue from acute care. (DHCS) for inclusion in the Drug Medi-Cal Organized Delivery emergency care. Mad River is known for maternity care; in System, which will provide ongoing funding for the facility. 2018, the hospital reported 539 deliveries, making up more After delays, the program — called Wellness and Recovery by than 30% of discharges. However, the hospital has struggled PHC — took effect in summer 2020. financially in recent years. Mad River recently transferred its St. Joseph Hospital is the strongest hospital financially in obstetrics clinic to Open Door Community Health Centers the region and offers the broadest range of services, includ- (Open Door), though deliveries continue to be a core hos- ing a Level III trauma unit and a Level II neonatal intensive pital service. About 90% of Mad River’s revenue comes from care unit. In 2018, more than half of the hospital’s discharges government programs, primarily Medi-Cal. (55%) were Medicare patients, but those discharges gener- Jerold Phelps Community Hospital, a CAH operated by ated only 30% of revenue. A shortage of skilled nursing beds the Southern Humboldt Community Healthcare District, in the area means discharges are often delayed, resulting serves the southern part of the county bordering Mendocino in longer lengths of stay and financial losses on Medicare with nine acute care beds, eight skilled nursing beds, and patients. Medi-Cal patients account for about one-quarter 24-hour emergency services. While the 2018 occupancy of both discharges and revenue. Reportedly, private insur- rate for acute care beds was 36%, the occupancy rate for the ance is an important but relatively small slice of the hospital’s long-term care beds was 100%. Almost all of the hospital’s 59 business. The affiliated St. Joseph Health Medical Group, with acute care discharges in 2018 (93%) were covered by govern- about 150 physicians, provides most of the specialty services ment payers, primarily Medi-Cal. in the area. Built in 1992, Sutter Coast Hospital in Del Norte operates Mad River Community Hospital, built in 1972, is the 39 inpatient beds; about two-thirds of revenue is from gov- second-largest hospital in the region — with 78 licensed ernment payers, split fairly evenly between Medicare and beds, only 46 of which are staffed — and provides 24-hour Medi-Cal. In addition, Sutter Coast operates a 10-bed acute California Health Care Foundation www.chcf.org 6 rehabilitation center. The hospital provides the only emer- Primary and Specialty Care Landscape gency services in the local area and reported almost 20,000 In recent years, the erosion of physicians in independent prac- emergency department (ED) visits in 2018. tice has characterized the market for primary and specialty Compared with the state as a whole, Humboldt and care in Humboldt and Del Norte. According to respondents, Del Norte have a similar number of beds per capita. Staffing many factors have contributed: the retirement of a genera- (measured as full-time equivalents, or FTEs, per 1,000 adjusted tion of local doctors; higher costs of running a practice, such patient days) is lower, likely because of health workforce as the expense of electronic health records (EHRs); increased shortages in the area. Lower levels of staffing, on average, complexity of coding, billing, and regulatory requirements; may be driving lower operating costs and higher margins and low payment rates. While the transition in the Medi- (see Table 6). Cal program from fee-for-service payment to mandatory managed care in 2013 and the expansion of Medi-Cal TABLE 6. Hospitals (Acute Care) enrollment through the ACA in 2014 went smoothly for the Humboldt and Del Norte Counties vs. California, 2018 most part, some rural health clinics struggled with the new Humboldt/ Del Norte California financial model and closed. The upshot is that independent Beds per 100,000 population 176 178 private practice has largely disappeared in the area. Open Operating margin 9.1% 4.4% Door, the largest Federally Qualified Health Center (FQHC) Paid FTEs per 1,000 adjusted patient days 10.6 14.8 in the region, has absorbed some primary care practices, Total operating expenses per adjusted patient day $2,832 $4,488 while many specialty practices have joined St. Joseph Health Note: FTE is full-time equivalent. Source: “Hospital Annual Financial Data - Selected Data & Pivot Tables,” California Office of Statewide Medical Group. Table 7 highlights the importance of FQHCs Health Planning and Development, accessed June 1, 2020. in Humboldt and Del Norte, with more than three times as many patients and encounters, or patient visits, per capita Scarce Inpatient Psychiatric Beds than in the state as a whole. Operated by Humboldt County, the 16-bed Sempervirens TABLE 7. Federally Qualified Health Centers Psychiatric Health Facility in Eureka is the only inpatient psy- Humboldt and Del Norte Counties vs. California, 2018 chiatric hospital within a 300-mile radius. Maintaining clinical Humboldt/ Del Norte California staffing for the facility has been challenging and is now pro- Patients per capita 0.52 0.15 vided through a contract with Traditions Behavioral Health, Encounters per capita 1.76 0.51 the largest provider of psychiatric services in California. Operating margin 6.8% 2.1% Patients requiring inpatient mental health services, including Notes: Includes FQHC Look-Alikes, community health centers that meet the requirements of the those held involuntarily because they are a threat to them- Health Resources and Services Administration Health Center Program but do not receive Health Center Program funding. Patients may be double counted if the same person visits more than one health center. selves or others, sometimes must wait in a hospital ED until a Source: “Primary Care Clinic Annual Utilization Data,” California Office of Statewide Health Planning and Development, accessed June 1, 2020. bed opens at Sempervirens or they can be discharged safely. California Health Care Foundation www.chcf.org 7 Open Door: program requires pharmaceutical manufacturers partici- Primary Care Provider to the Community pating in Medicaid to make outpatient prescription drugs Having started as a single clinic in 1971, Open Door now available at a discounted price to FQHCs and other orga- has 12 sites across Humboldt and Del Norte Counties, offer- nizations that care for uninsured and low-income patients. ing primary care, dental care, and behavioral health care. An However, respondents noted that the state’s new pharma- FQHC since 1999, Open Door also operates three mobile ceutical purchasing program is projected to result in a $3.5 clinics (two providing dental care). As the number of phy- million loss of 340B funds for Open Door. Some of the loss sicians in independent practice continues to decline, Open may be offset through state supplemental payments; the Door has become the main provider of primary care services state budget agreement reached in July 2020 included $52.6 in the area. “[Open Door’s] population has been redefined million statewide for this purpose. from the core disenfranchised population to almost every- Open Door has actively embraced telehealth, starting one in our area,” according to a respondent. with grant-funded efforts to connect local patients with spe- Open Door has grown from 200 employees and a $14 cialists in remote locations on a small scale and expanding million budget in 2004 to more than 700 employees and an to additional providers and specialties over time. Specialty $80 million budget in 2020. A new clinic opened in Fortuna services available through telehealth include dermatology, in 2018 with capacity to see 200 patients daily. Open Door gastroenterology, pulmonology, and psychiatry. About 40% serves 55,000 patients annually, about a third of the area’s of specialist referrals take place through eConsult, provided total population. with the support of PHC, with a report back to the primary As local rural health clinics and private physician prac- care physician. Open Door’s extensive experience with tele- tices closed, Open Door has absorbed many clinicians who health enabled its health centers to quickly ramp up remote were struggling to survive financially in private practice. care during the pandemic. Integrating providers into its FQHC network has reportedly been costly and challenging, but Open Door sees the move St. Joseph Health Medical Group: as essential to maintaining access to care. In 2020, Open Grows by Acquiring Region’s Specialty Groups Door worked to integrate two practices, one obstetrics and Formed in 2006, St. Joseph Health Medical Group in Humboldt one obstetrics/gynecology; keeping these clinicians in the has grown from four physicians to 150 — primarily special- community was viewed as essential to maintaining on-call ists, though two primary care practices and a pediatrician capacity for obstetrics. joined the group in recent years. St. Joseph Health Medical Following ACA coverage expansions, the proportion of Group Humboldt is one of eight medical groups aligned with Open Door’s uninsured patients dropped significantly, con- St. Joseph Heritage Healthcare and now part of the broader tributing to a positive bottom line. Open Door’s payer mix Providence St. Joseph Health system; other affiliated medical varies substantially by site and has shifted in recent years groups include those in Napa, Petaluma, and Santa Rosa, as as the health center gained more privately insured patients well as several in Southern California. — a mixed blessing because commercial reimbursement St. Joseph Health Medical Group is the primary provider reportedly does not cover operational costs. Another essen- of specialty services in the Humboldt area and is expanding tial funding source is the 340B Drug Pricing Program, which its focus on primary care. The group’s payer mix is report- accounts for about a quarter of Open Door’s revenue. The edly split fairly evenly among commercial, Medicare, and California Health Care Foundation www.chcf.org 8 Medi-Cal/uninsured. Reimbursement is predominantly fee- Humboldt Community Health Trust, focused on cross-sector for-service. The medical group’s members also belong to the collaboration to improve community-wide health. Humboldt Independent Practice Association (IPA). United Indian Health Services: “Tribally Owned and Humboldt IPA: Governed” Care for the Native American Community Reinvented Business Model as Independent Practice Declined UIHS, incorporated in 1970, serves nine of the 11 tribes in Humboldt IPA’s role in the community has shifted as the local Humboldt and Del Norte at seven clinic sites ranging from health care landscape changed over the past decade. In the Fortuna in south Humboldt County to Crescent City in Del late 1990s, the IPA managed about 20,000 health mainte- Norte; an eighth site is expected to open in 2021.19 The nance organization (HMO) lives on behalf of local affiliated California Rural Indian Health Board (CRIHB) holds the con- physicians; that number has fallen to fewer than 4,000 as tract with the federal government, and UIHS contracts with HMO coverage has declined. The IPA still handles contract- CRIHB to operate the clinic sites on behalf of the nine tribes. ing with Anthem Blue Cross and Blue Shield of California for The other two tribes, the Hoopa Valley Tribe and the Karuk 12,000 PPO members. Rather than operating as indepen- Tribe, operate their own clinics. dent physician practices, IPA-affiliated physicians now largely UIHS employs primary care clinicians directly and con- work for St. Joseph Health Medical Group or Open Door. The tracts with St. Joseph Health Medical Group for specialty care, IPA also runs the Priority Care Center, a clinic that provides sometimes bringing specialists into UIHS clinics to improve intensive care coordination for patients with complex needs, patient access to care. There is a gap in pediatrics, and available by referral to Anthem HMO and PPO and Blue UIHS is working to provide pediatric services via telehealth. Shield HMO enrollees as well as members of the Blue Lake Behavioral health needs are significant in the community, Rancheria tribe. Health plan contracts for Priority Care Center with high prevalence of adverse childhood experiences, and members feature risk-based payment (capitation for HMO UIHS is focused on embedding behavioral health services in members and shared savings for PPO members). the physical health care delivery model. The IPA has embraced several quality improvement According to UIHS, 12,000 patients visited a UIHS clinic efforts, playing a leadership role in Humboldt County’s between 2017 and 2019. UIHS has focused in recent years Aligning Forces for Quality alliance from 2008 to 2015, as well on shifting away from paper-based processes and increasing as the Surgical Rate Project. The Surgical Rate Project was a productivity. UIHS adopted the NextGen EHR software as part community-wide effort focused on variation reduction for of CRIHB’s rollout to participating clinics in 2013 and took over preference-sensitive care, such as for prostate cancer, for information technology infrastructure management from which more than one valid treatment approach is available CRIHB in 2019. The predominant source of coverage for UIHS and the best choice depends on how an individual patient patients is Medi-Cal. More than 10% of patients are uninsured; views the risks and benefits of different treatments. The IPA many of these patients are likely eligible for Medi-Cal but shares staffing with the North Coast Health Improvement distrust government institutions and decline participation, and Information Network (NCHIIN), a sister organiza- according to respondents. Revenue for Medi-Cal members tion that leads the area’s health information exchange. is based on a relatively high per-visit rate established by the Together, the two organizations have a leadership role in federal Indian Health Service Memorandum of Agreement, Rx Safe Humboldt, the county’s opioid safety coalition, and analogous to prospective payment system rate determina- tion for FQHCs. California Health Care Foundation www.chcf.org 9 Supporting Health Center Quality Improvement As shown in Table 8, the two counties have far fewer The regional clinic consortium for the rural northwest, North physicians, both primary care and specialist, than California’s Coast Clinics Network (NCCN), serves Open Door, Redwoods statewide average: 49.0 versus 59.7 primary care physicians Rural Health Center in Humboldt, and Southern Trinity per 100,000 residents, and 93.0 versus 130.8 specialists. The Health Services in neighboring Trinity County. When PHC ratio is similar for psychiatrists: on a population basis, the became the Medi-Cal managed care plan for the rural north region has approximately two-thirds the number available in 2013, the plan brought its robust performance incentive statewide (7.3 versus 11.8 per 100,000 residents). Based on program to the region. NCCN joined forces with the Health the two counties’ population of 164,200, that equates to 12 Alliance of Northern California (HANC) — the regional clinic psychiatrists in an area the size of Connecticut. The entire consortium for many other rural northern counties, includ- area qualifies as a federally designated primary care Health ing Siskiyou, Modoc, Shasta, Lassen, Shasta, Mendocino, and Professional Shortage Area (HPSA). Plumas — on an initiative to support health centers in identi- TABLE 8. Physicians: Humboldt and Del Norte Counties vs. California, 2020 fying and addressing quality gaps through data analysis and Humboldt/ Recommended quality improvement (QI) activities. PHC, NCCN, and HANC Del Norte California Supply* have collaborated on a toolkit to help build FQHC capacity Physicians per 100,000 population† 142.0 191.0 — for data analysis and QI and to support a population health ▶ Primary care 49.0 59.7 60–80 ▶ Specialists 93.0 130.8 85–105 approach. PHC’s provider network in Humboldt and Del ▶ Psychiatrists 7.3 11.8 — Norte scored below the minimum performance level on 10 % of population in HPSA (2018) 100% 28.4% — quality measures, including diabetes care, cancer screenings, *The Council on Graduate Medical Education (COGME), part of the US Department of Health and and childhood immunization and well-child visits in report- Human Services, studies physician workforce trends and needs. COGME ratios include doctors of osteopathic medicine (DOs) and are shown as ranges above. ing year 2019.20 The QI collaboration helps close gaps in Physicians with active California licenses who practice in California and provide 20 or more hours of † patient care per week. Psychiatrists are a subset of specialists. patient care, generates health center revenue in the form of Sources: Healthforce Center at UCSF analysis of Survey of Licensees (private tabulation), Medical Board of California, January 2020; and Health Professional Shortage Area (HPSA) data from Shortchanged: performance incentives, and focuses attention on improving Health Workforce Gaps in California, California Health Care Foundation, July 15, 2020. quality scores. Transportation and technology challenges exacerbate Severe Workforce Shortages Met with Coordinated workforce shortages in the rural region, where people may Community Response live hours from the nearest site of care, roads are poor and Humboldt and Del Norte face a severe shortage of physicians vulnerable to closure, and lack of internet connectivity and other health workers, driven in part by the retirement of can limit telehealth. Some residents cross the border into a generation of local doctors and difficulty recruiting physi- Oregon, where robust specialty networks are available in cians to the rural area. In response, the community has come nearby Grants Pass and Medford. But for Medi-Cal members, together to create a wide-ranging plan to fill the gap, includ- cross-border care creates a major challenge for PHC. Oregon ing a career ladder for local residents interested in becoming providers typically do not want to become Medi-Cal certi- health professionals and school-based opportunities for local fied by DHCS, so PHC is not allowed to include them in the students to develop skills related to health care and remain provider network and instead must handle each patient-pro- in the community. vider interaction separately. California Health Care Foundation www.chcf.org 10 The result is what one respondent called an “extreme severe provider shortage. While loan repayment has helped, challenge with access.” Primary care providers, especially the shortage persists. In recent years, locum tenens — health pediatricians, are in short supply, which can lead to overreli- professionals who sign temporary contracts — have helped ance on hospital EDs. Shortages in areas other than primary fill the gap. However, a temporary workforce of physicians care create access problems as well. For example, a shortage and nurses is expensive and variable in quality, and makes it of skilled nursing beds, in part from lack of staffing, in turn difficult for health care providers to create a strong organiza- can create a bottleneck for hospital discharges. tional culture. In response to ongoing shortages and recruitment chal- Access to Mental Health and SUD Treatment lenges, the community has adopted a “grow your own” Especially Difficult health workforce strategy that has broad engagement from Insufficient capacity for mental health treatment, both inpa- the health sector, educational institutions, and local gov- tient and outpatient, is a significant challenge. The annual ernment. The initiative was first tackled by the Humboldt report to the Behavioral Health Board for Humboldt County CEO Roundtable, which meets regularly, includes both notes: “The ability to recruit and retain qualified profession- representatives from the health care sector and other local als in most job classes is an ongoing challenge within the leaders, and is led by the California Center for Rural Policy at [Behavioral Health] Branch resulting in impacts to quality of Humboldt State University. The leadership group settled on care, caseloads, coverage for essential services and job satis- the dual objectives of addressing health workforce short- faction.” The county provides outpatient psychiatric services age issues and creating career and training opportunities for through a contract, which allows for flexibility but is costly, local youth and residents. and “even with contract providers, psychiatric services are Since 2019, St. Joseph Hospital and Open Door have col- overwhelmed.”21 Sempervirens, the county’s 16-bed secure laborated on a family medicine residency program, which psychiatric facility, uses a third-party agency for clinical staff. will ramp up to full capacity at 18 residents. Both institutions have invested significantly in this initiative, hoping that phy- Region Uses Stopgap Measures While Working on Longer- sicians will stay after completing their residencies and bolster Term Solutions to Shortages the supply of local primary care practitioners. St. Joseph Recruitment of health professionals to Humboldt and Health Medical Group is a partner on specialty care, and Del Norte has been challenging. Respondents noted that residents travel to the University of California, Davis, for train- housing is costly, particularly in the Eureka-Arcata area of ing in inpatient and emergency pediatrics. For the inpatient Humboldt. One interviewee said: “Docs decide not to come portion of the residency, the hospital pays for the director, because they can’t afford to live here; people pay 70% of their program coordinator, and faculty; Open Door funds the out- salary to live in Arcata.” PHC has helped providers take advan- patient portion, including faculty and a dedicated site. tage of education loan repayment funds available through Nursing programs are another area of focus. Open Door CalHealthCares, funded by voter-approved state tobacco tax started a family nurse practitioner (NP) residency in 2016 in revenues (Proposition 56). Up to $300,000 is available to phy- collaboration with Community Health Centers, Inc., an FQHC sicians and dentists less than five years out of residency who system in Connecticut. The program, which has trained will commit to serve largely Medi-Cal patients for at least five three to four NPs in each of the most recent cohorts of the years.22 PHC is also advocating for greater consideration for 12-month program, is an outgrowth of Open Door’s participa- rural areas in allocation of CalHealthCares funds, given the tion in a nationwide best practices collaborative. Humboldt California Health Care Foundation www.chcf.org 11 State University is reopening a program to enable registered Health Information Exchange Lays Groundwork for nurses (RNs) to obtain a bachelor of science degree in nursing Community Health Initiative (BSN) — known as an RN-to-BSN program — with the first Launched as an effort to connect area health care providers, cohort of 25 students slated to begin the two-year program NCHIIN in recent years moved to cross-sector data exchange in fall 2020. College of the Redwoods, the local commu- with human services agencies in support of community nity college, offers a program for paramedics and licensed health outcomes. Humboldt’s health information exchange vocational nurses to become registered nurses, with sites was described by one respondent as “lean, innovative, and in Eureka (Humboldt) and Crescent City (Del Norte). Sutter scrappy.” NCHIIN shares staffing with Humboldt IPA, and Coast Hospital in Crescent City has emerged as a partner in many initiatives involve both organizations. this program, as well as in the RN-to-BSN program; St. Joseph NCHIIN was chartered in 2010, the year after the federal Hospital contributed $2 million to Humboldt State University Health Information Technology for Economic and Clinical to help launch the RN-to-BSN program. Health (HITECH) Act was enacted to support health care The workforce initiative also includes local schools, which providers across the county in adopting EHR systems and are creating pathways to prepare students for health-related to build the infrastructure for information exchange. NCHIIN study in college or entry-level health care jobs. In Del Norte established interfaces with local practices’ EHR systems, and adjacent tribal lands, the Building Healthy Communities St. Joseph Health Medical Group, and Open Door. Hospitals, initiative includes investments in health workforce initiatives, including EDs, provide real-time admit/discharge/transfer beginning in kindergarten. data and share information on lab results, radiology, and Multiple respondents expressed optimism that the ancillary services. NCHIIN also sends data to the California efforts and investment will help meet two pressing com- Immunization Registry and the California Reportable Disease munity needs: improved access to care and enhanced Information Exchange. NCHIIN is widely used by Humboldt economic opportunities for residents. More recently, the County providers, including all hospitals and an estimated CEO Roundtable has turned its attention to behavioral 90% of primary care physicians.23 The only provider entity of health, exploring an educational certification program for significant size not participating in the health information trauma-informed care and community health workers. exchange is UIHS, which to date has not agreed to join. The roundtable also is exploring opportunities to integrate behavioral health training into the new Humboldt State Care Coordination Platform Leverages Cross-Sector Data to University BSN program, as well as creating a career ladder Support Clients with Complex Needs for students interested in pursuing jobs related to SUD treat- Building on the success of routine data exchange, NCHIIN ment to enhance recruitment and retention for residential expanded functionality to encompass cross-sector data and outpatient services. exchange with social service agencies and the criminal justice system. The resulting community care coordination platform, managed by vendor Activate Care, serves approxi- mately 1,400 clients with complex needs across Humboldt. Interfaces were built to the Humboldt County Department of Health and Human Services (DHHS), the Homeless Management Information System, and the probation depart- ment; public data from the local jail are also pulled into the California Health Care Foundation www.chcf.org 12 system. Care coordinators receive alerts from the system when their clients experience an array of trigger events, Getting to the Finish Line Sharing Mental Health Data including registration at the ED, admission to a facility (acute The Humboldt County Department of Health and Human Services, together with NCHIIN and local health care care hospital, psychiatric hospital, or crisis stabilization unit), providers, has accomplished a notable implementation of assignment of a probation officer, and admission to jail. In all, patient data sharing in its outpatient mental health case approximately 40 alerts a day are sent through the platform management program through collaborative use of a care in support of the 1,400 clients with complex needs, provid- coordination platform. ing care coordinators with important information to help Many individuals receiving specialty mental health services manage their clients’ care. from the county also receive primary care from Open ED visits provide an example of how the care coordination Door. In addition, they may be seen in local hospitals, platform adds value to routine health information exchange either through the ED or as an inpatient. There are many entrenched barriers to sharing patient mental health data functionality. At all four Humboldt County hospitals, a new across multiple systems and facilities. The care coordination patient registration at the ED triggers real-time delivery of a platform has allowed Humboldt leaders to reach the summary of medical information (e.g., diagnoses) available finish line. in the NCHIIN repository. Moreover, if the ED patient is one Today, clinicians caring for the patient at Open Door and of the 1,400 clients with complex needs, the system provides at hospitals receive a “mental health summary” that alerts additional information on social services available from the the clinician that the patient is receiving specialty mental care coordination platform, such as involvement with county health services from the county and includes current mental health diagnoses and a medication list. programs that support people who are homeless and information on the care team, including care coordinators Respondents credited guidance from leaders of the San Diego effort to build a community information exchange,24 working with the individual; this occurs approximately 100 enlightened county attorneys, and patience (“it took quite times monthly. The care coordination platform is also being a long time”) with getting to the finish line on sharing successfully implemented in outpatient settings (see box). mental health data, a rare accomplishment among health Humboldt County works to provide housing for Medi- information exchanges. Data sharing does not yet extend Cal enrollees with serious mental illness, a major focus since to substance use disorder (SUD) services; legal restrictions (often referred to as “42 CFR Part 2,” the section of federal the Board of Supervisors adopted a “Housing First” model a regulations relating to the confidentiality of SUD patient couple of years ago. The care coordination platform plays a records) have long prevented sharing of SUD treatment key role in supporting these efforts. PHC has collaborated information through the platform. However, updated with the county on multiple housing developments, contrib- federal regulations announced in July 2020 will enable uting millions of dollars. County programs focused on street providers to share more patient information for the purpose of care coordination and could facilitate exchange outreach and ambulatory mental health were added to the of SUD treatment information in Humboldt County.25 platform in 2017 and 2018; the county’s program to assist families needing housing support is adopting the care coor- dination platform in 2020. Community benefit programs at St. Joseph Hospital also use the care coordination platform. CARE Network assists patients being discharged with transi- tion needs, including a medical respite service that connects homeless individuals with housing while they recover. Paso a California Health Care Foundation www.chcf.org 13 Paso provides childbirth and parenting support to the Latinx local community-based organizations, was publicly released community. In all cases, the care coordination platform in 2020. Finding funding for this ambitious initiative will be enables data exchange so that clinicians providing mental challenging, but leaders are optimistic. health services and social service providers have access to information relevant to the clients’ status and needs. Progress on Addressing SUDs — The community care platform is viewed positively by but a Steep Climb Remains leaders on the ground. One respondent called it “a major cat- Humboldt has struggled with high rates of opioid use, alyst” for data integration and hailed it as a success because and data show both significant progress and continuing “having access to data improves quality of care [clinicians] challenges. The rate of opioid-related overdose deaths in can provide in their clinic office.” Humboldt County in 2018 was 11.2 per 100,000 population, the seventh-highest county rate in the state and twice the Setting Sights on a Community Information Exchange statewide rate of 5.8 per 100,000 (see Table 9). While high, the While the care coordination platform continues to add overdose death rate has fallen dramatically in recent years: value in supporting team-based care for high-risk, high- in 2014, it was 20 per 100,000, quadruple the state’s rate of need patients, licensing fees make it prohibitively expensive 4.9 per 100,000. Prescriptions for buprenorphine, a medica- for use more broadly. Humboldt leaders hope to build a tion proven to be effective in treating opioid use disorder, community information exchange (CIE) that supports infor- have increased more than 300% in Humboldt, compared mation sharing with community-based organizations across with an increase of 19% statewide. In Del Norte, opioid over- the county. The CIE would facilitate screening for social dose deaths have ranged from zero to three annually for the service needs and provide closed-loop referrals, in which county’s population of 28,000 over the past several years, and referring providers receive follow-up information on patients buprenorphine prescribing has increased by a factor of 3.5. after services are received. While such reports are routinely The improvements in Humboldt reflect a commu- provided within the medical care system — for example, nity-wide mobilization around the challenge. The Rx Safe when primary care physicians refer patients to specialists Humboldt Coalition was among the first to join the California — it is less common and more challenging to close the refer- Opioid Safety Coalition Network, launched in 2015. The coali- ral loop between the medical and social service sectors. A tion is led by the Humboldt IPA, and participants include the CIE would allow Humboldt medical and social service pro- county, local hospitals, Open Door, the regional clinic con- viders to track patients over time, enabling identification of sortium North Coast Clinics Network, PHC, NCHIIN, the local gaps in care and enhancing care coordination. An initial step medical society, and the Humboldt Area Center for Harm toward a CIE, the North Coast Resource Hub, a database of Reduction. More recently, Del Norte has launched its own TABLE 9. Opioid-Related Deaths, ED Visits, and Prescribing (per 100,000 population): Humboldt and Del Norte Counties vs. California, 2014 and 2018 2014 2018 Humboldt Del Norte California Humboldt Del Norte California Opioid deaths 19.8 7.3 4.9 11.2 0 5.8 Opioid ED visits 54.0 18.5 18.3 43.7 49.2 21.4 Buprenorphine* Rx 36.9 23.8 12.2 116.5 84.2 14.5 *Buprenorphine is a medication used for treating opioid use disorder. Source: “California Opioid Overdose Surveillance Dashboard,” California Department of Public Health, accessed June 1, 2020. California Health Care Foundation www.chcf.org 14 coalition, Rx Safe Del Norte, which meets at Open Door’s (ACEs), which are a risk factor for SUD.28 Adults in the region Del Norte site. have higher than average ACE scores: on average, adults have Much of the SUD treatment in Humboldt and Del Norte is experienced four or more ACEs, nearly twice the statewide provided through Open Door, a leader in treating addiction average (this finding is based on data for Mendocino as well in primary care settings and in adopting medication-assisted as Humboldt).29 First 5 Humboldt, the county agency focused treatment — which combines behavioral therapy and medi- on children from birth to age five, has generated community cations to treat SUDs — as part of routine care.26 PHC began awareness of the prevalence and connection between ACEs advocating for safe opioid-prescribing practices years ago, and substance use in recent years. A town hall on ACEs in creating a Managing Pain Safely program for its provider November 2019 featuring California’s surgeon general gen- network and strengthening opioid-prescribing guidelines to erated so much community interest that people had to be reduce misuse. PHC reported a decrease of 89% across plan turned away (the event was livestreamed to accommodate members on very high levels of opioids between 2014 and more attendees). One respondent noted a “shift in commu- 2018.27 The state’s planned pharmacy carve-out, which will nity ownership, more belief that everyone in the community shift pharmacy benefits from Medi-Cal managed care to fee- can do something to turn the tide.” St. Joseph Hospital has for-service, has raised concerns that unless the state adopts partnered with several organizations in Humboldt to create similar formulary restrictions and other tools to support safe the Humboldt County ACEs Connection and provides prescribing, the region could backslide on opioid use. grant money to First 5 Humboldt for an ACEs and resilience Regionally, St. Joseph Hospital is the only participant in coordinator.30 California Bridge, a statewide program supporting imple- In 2017, the Humboldt Community Health Trust (HCHT) mentation of medication-assisted treatment in EDs and became one of 13 sites participating in the California hospital inpatient settings. The model emphasizes changing Accountable Communities for Health Initiative. HCHT is hospital and clinician culture to destigmatize substance use focused on addressing substance use in the community and instead treat addiction as a chronic illness. An impetus and brings together leaders from county government, law for the hospital to participate was concern from Open Door enforcement, education, children and family services, health providers that their patients receiving medication-assisted care, behavioral health, and community members; NCHIIN treatment could be hospitalized and discharged on high- serves as the “backbone” organization. Goals are to reduce dose opioids, disrupting SUD treatment. Through California injury and overdose, increase prevention and early interven- Bridge funding, St. Joseph deployed a full-time substance tion, address social determinants of health, and enhance use navigator in the ED starting in 2019. The hospital faces an treatment access and coordination. ongoing challenge with addressing stigma associated with Reflected in the HCHT’s portfolio of interventions are a addiction. Nurses have proved to be the best way to shift the variety of community projects related to SUD treatment culture in the hospital, particularly given that St. Joseph often and prevention. Responding to a perinatal SUD rate nearly relies on emergency physicians and hospitalists with tempo- three times the state average, a major undertaking for rary contracts to close the workforce gap. Nurses also have Humboldt RISE (Resilience and Inclusion through Support led the way in establishing a culture of trauma-informed care and Empowerment) is a project to support new mothers.31 and training physicians who rotate through the hospital. The project aims to screen all women for SUDs during pre- Across the community, there is increasing acknowledg- natal care and refer those who need support to a navigator ment of the importance of adverse childhood experiences who can connect them to treatment and other resources. A California Health Care Foundation www.chcf.org 15 perinatal care navigator is available at St. Joseph Hospital. The Early Experience with COVID-19 project also works to support providers in obtaining training Interviews for this report took place between March and and a federal waiver required to prescribe buprenorphine for May 2020, just as the COVID-19 pandemic was spreading in opioid use disorder and to foster community norms to dis- California. Accordingly, information about how health care courage cannabis use during pregnancy. organizations were responding relates to early planning A key aspect of the perinatal SUD project is a plan to and preparation. As one respondent put it, the Humboldt use the care coordination platform developed by NCHIIN and Del  Norte region has a “thin health system over large to share data across organizations providing services to geography with bad roads. Cases could quickly overwhelm enrolled women. As noted earlier, the regulatory barriers to infrastructure.” However, at least in the early phase of the sharing SUD treatment data are substantial. HCHT is trying to pandemic, the community fared relatively well; telehealth craft an approach that enables sharing information for care services rapidly replaced in-person primary care, and St. coordination while complying with federal requirements, an Joseph led preparation for a surge of acute cases. While effort that should be supported by the July 2020 regulatory worst-case concerns about the outbreak had not material- updates that ease the flow of data to support patient care. ized as this report was written, concerns about the economic Efforts to support pregnant women at risk of SUDs are implications of the pandemic were growing. also ramping up in the tribal community, with funding from Fewer COVID-19 cases and deaths than statewide. California’s Department of Social Services. The program, a Total cases of COVID-19 per 100,000 people in Humboldt and collaboration among tribal clinics (UIHS, Hoopa Valley Tribe’s Del Norte Counties remained low in the spring and through K’ima:w Medical Center, and Karuk Tribe’s Orleans Health the summer compared with California statewide and the Clinic) and First 5 Humboldt, will train and deploy health nav- other regions included in this study, as shown in Table 10.33 igators in tribal clinics. The program launched with UIHS in July 2020; COVID-19 delayed the launch at other clinics, but TABLE 10. COVID-19 Impacts: Humboldt and Del Norte Counties vs. California work is underway. Humboldt Del Norte H/DN (H) (DN) Region California While tangible progress has been made, a steep hill PER 100,000 RESIDENTS (AUGUST 2020) remains to be climbed. The rate of ED visits for opioid over- ▶ COVID-19 cases 276 388 295 1,791 dose in Humboldt in 2018 was twice the statewide rate, falling ▶ COVID-19 deaths 3.0 3.6 3.1 33 only slightly since 2015. Several respondents were optimis- UNEMPLOYMENT RATE tic about the rollout in summer 2020 of the new Wellness ▶ Pre-pandemic (FEBRUARY 2020) 3.9% 6.2% 4.2% 4.3% ▶ Mid-pandemic (AUGUST 2020) 8.4% 9.4% 8.4% 11.4% and Recovery Program, PHC’s name for the Drug Medi-Cal MEDI-CAL ENROLLMENT Organized Delivery System implementation in Humboldt ▶ Percentage change –0.1% –0.8% –0.2% 1.0% and six other counties (not Del Norte). Statewide, the goal (FEBRUARY TO AUGUST 2020) CARES ACT, PER CAPITA (AUGUST 2020) of the program is to provide a more effective approach to ▶ Provider Relief Funds $466 $19 $390 $148 treating SUD, reframing addiction as a chronic disease.32 ▶ High Impact Funds $0 $0 $0 $16 Services provided through PHC’s Wellness and Recovery Sources: “COVID-19 Cases,” California Open Data Portal; “Employment by Industry Data,” State of Program include intensive outpatient treatment, detoxifica- California Employment Development Department; “Month of Eligibility, Dual Status, by County, Medi-Cal Certified Eligibility,” California Health and Human Services, Open Data; and “HHS Provider tion services, residential treatment, and medication-assisted Relief Fund,” Centers for Disease Control and Prevention. CARES Act data accessed August 31, 2020; all other data accessed September 30, 2020. treatment. California Health Care Foundation www.chcf.org 16 Providers receive some CARES Act funding to offset St. Joseph Health Hospital prepared for surge that losses. Providers in Del Norte have received significantly did not materialize. As noted previously, St. Joseph is part less CARES (Coronavirus Aid, Relief, and Economic Security) of the Providence system, which includes the hospital in Act Provider Relief Fund money per capita ($19) than pro- Washington State where the first US case of COVID-19 was viders in Humboldt ($466 per capita) and statewide ($148 diagnosed. Support from Providence included early clini- per capita). Providers in Humboldt County received $63.2 cal guidance, rapidly developed policies and protocols, and million and providers in Del Norte received half a million access to personal protective equipment via the large sys- dollars through the CARES Act and the Paycheck Protection tem’s supply chain. Along with many hospitals in California, Program and Health Care Enhancement Act. The largest hos- St. Joseph Hospital moved quickly to prepare for a surge pital, St. Joseph Health, received by far the largest amount of in cases by postponing imaging, elective procedures, and CARES Act funds ($36.5 million), followed by the Southern cancer care, as well as through operational measures, includ- Humboldt Community Healthcare District ($3.8 million). ing temperature takers in the lobby and a moratorium on The largest clinic providers, Open Door and UIHS, received visitors and staff training. In May, when a surge did not mate- the largest sums for clinics, $2.6 million and $2.1 million, rialize, the hospital began to reopen for routine care. For St. respectively.34 Joseph, as for hospitals across the state and country, the Rapid pivot to telehealth. As California’s shelter-in- reduction in utilization during the lockdown highlighted place order took effect in March, clinics and physician offices providers’ reliance on elective procedures and associated bill- began to close their doors and turn to telehealth to support ings and their financial vulnerability. nonurgent health care needs. Open Door was in an advan- Data exchange to support COVID-19 care. Humboldt’s tageous position as a result of extensive experience with vendor and partner for the care coordination platform, telehealth, including its use for a broad array of specialty ser- Activate Care, provided a free implementation of the plat- vices. That experience created a solid foundation for broader form for the County COVID-19 Response Team to support use of telemedicine, particularly for primary care. Tribal active management of COVID-19-positive individuals. The care also saw a rapid shift to telehealth, with rapid uptake platform, implemented in less than a week, was used for by patients. Respondents reported new uses of telehealth, rapidly housing at-risk homeless individuals in motels; it pro- including SUD and child welfare services, but raised concerns vided the care coordination framework for the newly housed about services less amenable to remote provision, such as and was described as a “major success.” dental care and well-child visits. Lack of connectivity in some Recession and emerging funding crisis compound areas of the rural north, particularly for low-income families pandemic challenges. Unemployment in Humboldt County without access to internet and phone service, also limits the jumped from 3.9% in February 2020 to 8.4% in August 2020 reach of telehealth. Several respondents noted that wider and from 6.2% to 9.4% in Del Norte County (see Table 10).35 use of telehealth could potentially spark long-term shifts in As of August 2020, Medi-Cal enrollment had not increased patterns of care and reconsideration of investment in new from February 2020, though most observers expected to see facilities. During this March–May timeline, reimbursement for an increase in the coming months as a result of employment telehealth services was a key concern for all respondents as losses.36 payers and regulators worked through how to ensure contin- County budgets across California were hit hard by uation of care and financial sustainability for providers during increased public health costs associated with COVID-19, such the crisis. as testing, acquiring personal protective equipment, and California Health Care Foundation www.chcf.org 17 contact tracing. Community needs for food and housing also Issues to Track increased as the economic shutdown led to job losses. And ▶ What results will the workforce initiatives yield for just as costs increased, revenue decreased. Counties rely on Humboldt and Del Norte? Will the family medicine resi- realignment funds from vehicle license fees and sales taxes dency program help shrink the primary care access gap? to fund social services, such as child welfare and behavioral What will long-term retention look like for the NP resi- health, and on Mental Health Services Act funding from high dency at Open Door? Can efforts to train local residents earners (1% income tax on personal income over $1 million) for health care jobs ease the shortage and improve the for case management of homeless individuals. region’s economic outlook? Yet, counties and cities with populations under 500,000, ▶ What steps will Mad River Community Hospital take to including Humboldt and Del Norte, were excluded from gain financial stability? How will service reductions affect receiving direct funding through the federal CARES Act in late access to care? March. Counties across the state banded together to advo- cate for state and federal funding to support local services ▶ How will Humboldt’s efforts to manage SUDs fare? Will in early May; officers from both Humboldt and Del  Norte Humboldt be able to sustain — and even accelerate — Counties signed a letter to Governor Gavin Newsom request- improvements? Will the programs to support perinatal ing help on behalf of the 42 (of 58) county governments women with SUD be effective? ineligible for CARES Act funding. ▶ Will Humboldt expand community information A May 4, 2020, letter from the Humboldt County adminis- exchange that allows for data sharing among commu- trative officer to state legislators requesting funding outlines nity-based organizations and across sectors? How will a the costs Humboldt incurred through April 2020, including CIE contribute to addressing social service needs in the $2 million for the Emergency Operations Center and Joint community and coordination across medical and social Information Center, which established a centralized hub at a service sectors? Eureka conference center staffed largely by DHHS personnel. Additional costs were incurred by the county for overtime ▶ What will happen with utilization of telehealth services staffing in the correctional facility, public health field nurses as the pandemic continues to unfold? Will more flexible and administration, child welfare, and social services. reimbursement for such services, provided temporarily, The state budget agreement reached in June 2020 pro- become permanent? Will telehealth become the norm vided some funding for counties that did not receive federal for routine primary care, behavioral health, and other ser- support, and both counties and the state were banking on vices previously provided mainly face-to-face? How will substantial additional federal funding. the community improve internet connectivity? ▶ How will the economic consequences of COVID-19, including big revenue losses for the county government and providers, play out in Humboldt and Del Norte? How severe will job loss — and loss of employment-based health coverage — be for local residents? How will safety net services and community initiatives fare in an era of budget cuts? California Health Care Foundation www.chcf.org 18 ENDNOTES 1.Humboldt County Maternal Child and Adolescent Health Community region. Similarly, the estimated share of the population enrolled Profile (2017–18), California Dept. of Public Health (CDPH); and in Medicare is based on Medicare enrollment figures for 2015 and Del Norte County Maternal Child and Adolescent Health Community 2019 published by the Centers for Medicare & Medicaid Services Profile (2017–18), CDPH, accessed July 21, 2020. and US Census Bureau population estimates. The “private insurance and all other insurance types” category was calculated as the 2.“QuickFacts: Population Estimates, July 1, 2019,” US Census Bureau, residual — after accounting for those who were uninsured, enrolled accessed July 24, 2020. The population of Humboldt County in 2019 in Medi-Cal, or enrolled in Medicare. See US Census, American was 135,558, Eureka 26,710, and Arcata 18,431. Community Survey 1-Year Estimates, Table DP03, accessed June 3.“QuickFacts: Population Estimates, July 1, 2019,” US Census Bureau, 2020 (for Census Bureau estimates of total county populations and accessed July 24, 2020. The population of Del Norte County was uninsured rates); Department of Health Care Services, “Month of 27,812 in 2019. Eligibility, Medicare Status, and Age Group, by County, Medi-Cal Certified Eligibility,” accessed June 2020 (for monthly Medi-Cal 4.United Indian Health Services, Inc. (UIHS) Community Health Profile enrollment totals); and CMS, “Medicare Enrollment Dashboard,” (PDF), California Rural Indian Health Board, December 2015; and accessed June 2020 (for Medicare enrollment data). Humboldt County Maternal Child and Adolescent Health Community Profile (2017–18) (PDF), CDPH, accessed July 24, 2020. 10. PHC’s service area includes Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano, Sonoma, Trinity, 5.2018 Humboldt County Community Health Assessment: Data for and Yolo Counties. Planning and Policy Making (PDF), Humboldt County Dept. of Health & Human Services, accessed July 21, 2020; Humboldt Maternal Child, 11. Linda Stansberry, “Partnership Health Awards Humboldt County CDPH; and “Major Employers in California: Humboldt County,” $1.05 Million for Affordable Housing,” North Coast Journal of Politics, California Employment Development Dept. (EDD), accessed July 21, People & Art, April 11, 2018. 2020. 12. Department of Health Care Services: It Has Not Ensured That Medi- 6.“Major Employers in California: Del Norte County,” EDD, accessed Cal Beneficiaries in Some Rural Counties Have Reasonable Access to July 21, 2020. Care (PDF), Auditor of the State of California, August 2019, 16–17. 7.“Poverty Guidelines,” US Dept. of Health and Human Services (HHS), 13. “Wellness & Recovery Program,” Partnership HealthPlan of last modified January 8, 2020. California, July 2020; and Medi-Cal Moves Addiction Treatment into the Mainstream: Early Lessons from the Drug Medi-Cal Organized 8.Janice Probst, Jan Marie Eberth, and Elizabeth Crouch, “Structural Delivery System Pilots (PDF), California Health Care Foundation (CHCF), Urbanism Contributes to Poorer Health Outcomes for Rural America,” August 2018. Health Affairs 38, no. 12 (December 2019), doi:10.1377/hlthaff.2019. 00914. 14. “Quality and Performance Improvement,” Partnership HealthPlan of California, accessed July 21, 2020. 9.“2019: ACS 1-Year Estimates Data Profiles — Selected Economic Characteristics,” US Census Bureau, accessed June 2020 (for Census 15. Katherine Wilson, “Covered California Dashboards,” CHCF, Bureau estimates of total county populations and uninsured rates); November 13, 2019. “Month of Eligibility, Medicare Status, and Age Group, by County, 16. “Medicare Enrollment Dashboard,” CMS, last updated May 2020. Medi-Cal Certified Eligibility,” Dept. of Health Care Services, accessed June 2020 (for monthly Medi-Cal enrollment totals); and “Medicare 17. PACE in the States (PDF), National PACE Assn., August 2020. Enrollment Dashboard,” Centers for Medicare & Medicaid Services 18.Glenn Melnick and Katya Fonkych, Is Bigger Better? Exploring the (CMS), accessed June 2020 (for Medicare enrollment data). Estimates of Impact of System Membership on Rural Hospitals, CHCF, May 2018. the uninsured rate for each region are based on the US Census Bureau’s 2015 and 2019 estimates of the uninsured rate in each county. The 19. According to the UIHS website, accessed July 21, 2020, the nine estimated share of the population enrolled in Medi-Cal is calculated tribes served are Bear River Band of the Rohnerville Rancheria, as total Medi-Cal enrollment from the California Department of Big Lagoon Rancheria, Cher-Ae Heights Indian Community of the Health Care Services’ data as of June 2015 and June 2019 (excluding Trinidad Rancheria, Elk Valley Rancheria, Resighini Rancheria, Table those dually eligible for both Medi-Cal and Medicare) divided by Bluff Reservation — Wiyot Tribe, Tolowa Dee-Ni’ Nation, and Yurok US Census Bureau’s 2018 population estimates aggregated for each Tribe of the Yurok Reservation. California Health Care Foundation www.chcf.org 19 20. Healthcare Effectiveness Data and Information Set (HEDIS): Report 34. “HHS Provider Relief Fund” (as of Aug. 31, 2020), Centers for Disease Year 2019; Measurement Year 2018; Summary of Performance (PDF), Control and Prevention, accessed August 19, 2020. Partnership HealthPlan of California, accessed July 21, 2020. 35. “Labor Force and Unemployment Rate for California Counties,” 21. Annual Reports 2016/17, 2017/18 (PDF), Humboldt County Behavioral EDD, accessed August 19, 2020. Health Board, April 1, 2019. 36. “Medi-Cal Certified Eligibles Tables, by County from 2010 to Most 22. “CalHealthCares,” Physicians for a Healthy California, accessed July Recent Reportable Month” (as of June 2020), CHHS Open Data, 21, 2020. accessed August 19, 2020. 23. Walter Sujansky, Promise and Pitfalls: A Look at California’s Regional Health Information Organizations, CHCF, January 2019. 24. “Community Information Exchange,” 2-1-1 San Diego, n.d. 25. “Health Privacy Rule 42 CFR Part 2 Is Revised, Modernizing Care Coordination for Americans Seeking Treatment for Substance Use Disorders,” press release, HHS, July 13, 2020. 26. Kelly Pfeifer, “In Humboldt County, Efforts to Fight Opioid Epidemic Bring Progress,” The CHCF Blog, May 11, 2018. 27. “Managing Pain Safely (MPS),” Partnership HealthPlan of California, accessed July 21, 2020. 28. Kara R. Douglas et al., “Adverse Childhood Events as Risk Factors for Substance Dependence: Partial Mediation by Mood and Anxiety Disorders,” Addictive Behaviors 35, no. 1 (Jan. 2010): 7–13, doi:10.1016/ j.addbeh.2009.07.004. 29. A Hidden Crisis: Findings on Adverse Childhood Experiences in California (PDF), Center for Youth Wellness, n.d. Among adults in Humboldt and Mendocino, 30.8% (versus 16.7% of adults statewide) experienced four or more ACEs. Survey data from the California Behavioral Risk Factor Surveillance System (CA BRFSS) 2008–2013. 30. 2018 Humboldt County Assessment, Humboldt County. 31. “Humboldt Rise Project: Resilience and Inclusion Through Support and Empowerment,” North Coast Health Improvement and Information Network, accessed July 21, 2020. 32. Molly Brassil, Carol Backstrom, and Erynne Jones, Medi-Cal Moves Addiction Treatment into the Mainstream: Early Lessons from the Drug Medi-Cal Organized Delivery System Pilots, CHCF, August 3, 2018. 33. “COVID-19” (as of Aug. 31, 2020), California Open Data Portal, accessed September 7, 2020. California Health Care Foundation www.chcf.org 20 Background on Regional Markets Study: Humboldt/Del Norte Between March and May 2020, researchers from Blue Sky Consulting Del Norte Group conducted interviews with health care leaders in Humboldt and Del Norte Counties in the north coast region of California to study Humboldt the market’s local health care system. The market encompasses the Eureka-Arcata-Fortuna Micropolitan Statistical Area and the Crescent City Micropolitan Statistical Area. Sacramento Area Humboldt/Del Norte is one of seven markets included in the Regional Bay Markets Study funded by the California Health Care Foundation. The purpose Area of the study is to gain key insights into the organization, financing, and delivery of care in communities across California and over time. This is the fourth round San Joaquin Valley of the study; the first set of regional reports was released in 2009. This is the first time the Humboldt/Del Norte region was included in the study. The seven markets Los Inland Empire included in the project — Humboldt/Del Norte, Inland Empire, Los Angeles, Sacramento Angeles Area, San Diego, San Francisco Bay Area, and the San Joaquin Valley — reflect a range of Orange economic, demographic, care delivery, and financing conditions in California. San Diego Blue Sky Consulting Group interviewed nearly 200 respondents for this study with 18 specific to the Humboldt/Del Norte market. Respondents included executives from hospitals, physician organizations, community health centers, Medi-Cal managed care plans, and other local health care leaders. Interviews with commercial health plan executives and other respondents at the state level also informed this report. The onset of the COVID-19 pandemic occurred as the research and data collection for the regional market study reports were already underway. While the authors sought to incorporate information about the early stages of the pandemic into the findings, the focus of the reports remains the structure and characteristics of the health care landscape in each of the studied regions. ▶ V ISIT OUR WEBSITE FOR THE ENTIRE ALMANAC REGIONAL MARKETS SERIES. ABOUT THE AUTHORS ABOUT THE FOUNDATION Jill Yegian, PhD, is principal of Yegian Health Insights, LLC, and a Blue Sky The California Health Care Foundation is dedicated to advancing Consulting Group affiliate; and Katrina Connolly, PhD, Senior Consultant meaningful, measurable improvements in the way the health care of Blue Sky Consulting Group. Blue Sky Consulting Group helps delivery system provides care to the people of California, particularly government agencies, nonprofit organizations, foundations, and private- those with low incomes and those whose needs are not well served by sector clients tackle complex policy issues with nonpartisan analytical the status quo. We work to ensure that people have access to the care tools and methods. they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, ACKNOWLEDGMENTS and connects with changemakers to create a more responsive, patient- The authors thank all of the respondents who graciously shared their centered health care system. time and expertise to help us understand key aspects of the health care California Health Care Almanac is an online clearinghouse for key data market in the north coast region. We also thank Alwyn Cassil of Policy and analysis examining the state’s health care system. Translation, LLC, for her editing expertise, and members of the Blue Sky Consulting Group project team.