Contents

6. Access to Care. 6-1

Coverage by Health Insurance. 6-1

No Health Insurance Coverage. 6-2

Medicaid Coverage and Eligibility. 6-4

Medicaid and Hoosier Healthwise Coverage and Access Issues. 6-6

Usual Source of Health Care. 6-7

Primary Health Care Providers. 6-9

Dentists. 6-11

Hospital Resources. 6-12

Population Changes and the Marion County Health Advantage Program.. 6-13

Primary Care and Medically Underserved Areas in Marion County. 6-14

Available Primary Care Services for Vulnerable Populations. 6-14

Payer Sources for Acute Care Hospitalizations. 6-18

Tables and Figures

Table 6‑1: Access to Care Summary Table. 6-1

Figure 6‑1: Indiana Residents Without Health Insurance by Race 2005 (N =716)6-3

Figure 6‑2: Marion County Households Without Health Insurance, 2001-05. 6-4

Table 6‑2: Marion County Adults Without Health Insurance, 2001, by Age. 6-4

Table 6‑3: Percent of Total Population with Medicaid or Self-Pay Status, 2006. 6-4

Table 6‑4: Marion County June 2006 Medicaid Enrollment6-5

Table 6‑5: Indiana Adults Over 18 Without a Personal Health Care Provider, 2005. 6-8

Table 6‑6: HP 2010 Objectives for Usual Source of Care by Age Group. 6-9

Table 6‑7:  Primary Care Physicians, OB/GYN Physicians, and Dentists, Marion County, Indiana, and U.S., 2001, 2005  6-10

Figure 6‑3: Marion County Dental Professional Shortage Areas; HRSA 2005. 6-12

Table 6‑8: Marion County State Licensed Hospitals, by Type and Beds, 2006. 6-12

Table 6‑9: Health Advantage Participants: 2000-2005. 6-13

Figure 6‑4: 2005 Marion County HRSA-Designated Medically Underserved Area and Professional Shortage Area Census Tracts. 6-16

Figure 6‑5: Federally Qualified Health Centers (FQHCs) and Medically Underserved Populations/Professional Shortage Areas in Marion County: 2005. 6-17

Table 6‑10: Self Pay as a Percent of All Discharges from Marion County Hospitals: Marion County Residents  Coded as Self-pay Patients, by Age, Race, and Gender, 2005. 6-19

Table 6‑11: Medicaid as a Percent of All Discharges from Marion County Hospitals: Marion County Residents  Coded as Medicaid Insured, by Age, Race, and Gender, 2005. 6-19

6. Access to Care

Table 6‑1: Access to Care Summary Table

Measure

County Data

Recent Change

U.S. Comparison

IN Comparison

HP 2010

Yrs

% Change

DC

U.S. Data

DC

IN Data

DC

Positive Indicators for Marion County

% Uninsured (Self-pay) Hospitalizations

6.4%

(2005)

6

-18%

(1999-2005)

C

5%

(2002)

DC

NA

 

NA

Neutral Indicators for Marion County

% Hospital stays

paid by Medicaid

19%

(2005)

6

+23%

(1999-2005)

16.1%

(2004)

NA

 

NA

% of Population Enrolled in Medicaid

18.6%

1

+40%

(2005-2006)

12.0%

(2006)

16.0%

(2006)

NA

% <18 year old Population in Hoosier Healthwise

39.3%

(2005)

NA

 

 

25.1%

(2005)

20.9%

(2005)

NA

Negative Indicators for Marion County

% Adults without Health Insurance

17.5%

(2005)

3

+16.7%

(2002-2005)

D

14.5%

(2005)

15.5%

(2005)

1.1

0%

% of Population in Medically Underserved Areas

37%

(2000)

NA

 

 

20%

(2007)

D

NA

 

NA

Table notes: County data: Is for most recent year available. Recent Change: Percent change of most recent measurement from a measurement the noted number of years prior.  Changes of more than 5 percent in either direction are denoted by thumbs up or thumbs down symbolsthumps up and thumbs down.  Neutral thumbs indicate no change, even though no change may be a negative outcome; U.S. or IN population data: Is for most recent year available; U.S. (or IN) Comparison: Comparison of most recent data using thumbs up or thumbs down symbols to denote differences that are statistically significant or deemed to be noteworthy from the analysts’ professional perspective. Note: When there is no public health implication associated with a measure, directional arrows replace thumb icons to indicate the direction of change or the relationship of the Marion County measure (higher/lower/not different) to the U.S./IN measure.  

Coverage by Health Insurance

Nationally, the proportion of persons aged 18 and older who reported not having health insurance increased from 11.9 percent in 2000 to approximately 14.5 percent in 2005.[122]  In 2005, over 644,473[123] (15.5%, 95% CI=14.2-16.8)of Indiana adults over age 18 reported that they ”had no current health insurance”[124], up from 12 percent in 1995.  This does not include the 8 to 12 percent who may have lost health insurance for only a portion of the year.[125],[126] The numbers of uninsured in the nation’s under 65 year old population have risen from 16.1 percent in 2000 to approximately 17.9 percent in 2005.[127] Contributing factors include that only half of employers offered health care benefits, and less than 75 percent of eligible workers took up coverage. Only 59 percent of working Americans were covered by employer-based health insurance in 2005, while the percentage covered by Medicaid remained unchanged (13% nationwide).[128]Lack of insurance was especially common among those with part-time jobs, the self-employed, and those employed in the service industry and agriculture. The Healthy People 2010 objective 1-1 indicates 100 percent of the population should have health insurance coverage[129].

No Health Insurance Coverage

Lack of health insurance for Indiana and Marion County exceeded national rates.[130] In a 2005 survey in Indiana, 15.5 percent (95% CI=14.2-16.8) replied “no” to the question “Do you have any kind of health care coverage?”  This included 12.9 percent of White respondents, one in four Blacks (25.6%) and nearly half of Hispanics (46.8%) (Figure 6‑1).  Two-thirds (64.8%) of respondents reported annual household incomes under $25,000: over 30 percent of this group reported no current insurance.[131]

Figure 6‑1: Indiana Residents Without Health Insurance by Race 2005 (N =716)

Source: CDC BRFSS 2005 ( Whites: 541, Black: 65, Hispanic 71, Other 22) ( http://apps.nccd.cdc.gov/brfss/display.asp?cat=HC&yr=2005&qkey=868&state=IN, DR0460.

 

Over seventeen percent (17.5%) of Marion County adults 18 and older reported lack of current health insurance coverage in 2005.[132] The highest rate over the past 5 years was 19 percent in 2004 (Figure 6‑2).  Marion County’s percentage of uninsured in 2005 was slightly higher than for the state (15.5%).[133]

Approximately 40 percent of all uninsured in Indiana reside in the Indianapolis metropolitan statistical area.[134]  A 2001 survey in Marion County indicated that insurance coverage among adults increased with age from 78 percent among 18 to 24 year olds to 94 percent among those 65 years old or older (Table 6‑2).[135]

Figure 6‑2: Marion County Households Without Health Insurance, 2001-05

 .

Source: 2001-2005 Marion County BRFSS _SMART data.

 

Table 6‑2: Marion County Adults Without Health Insurance, 2001, by Age

 

Age (years)

 

 

18-24

25-44

45-64

65+

Total

% Currently Not Having Insurance

21.8

13.9

7.9

5.8

12.3

Sources: 2001 Marion County Community Health Assessment Telephone Survey; 2005 CDC BRFSS

 

Medicaid Coverage and Eligibility

Marion County had 157,420 Medicaid recipients in 2006, a 40 percent increase from 2005 (112,369 recipients). County residents receiving Medicaid represented 18.6 percent of the total population, and roughly one in five of all Indiana Medicaid enrollees in 2006.[136]  In comparison, 16 percent of the total Indiana population and 12 percent of the U.S. population[137] are covered by Medicaid (Table 6‑3).

Table 6‑3: Percent of Total Population with Medicaid or Self-Pay Status, 2006

% of Population

Medicaid Enrollees

Self-Pay (uninsured)

Marion County

18.6%

19%

Indiana

16%

15.5%

U.S.

12%

14.5%

Source: Marion County: Indiana FACT/ FSSA/June 2006; Kaiser Foundation Indiana Medicaid Factsheet, 2006

 

Over half of Marion County enrollees (58.9 percent) are children in one of the following groups:

·        Members of Temporary Assistance for Needy Families (TANF) recipient families

·        Under 1 year of age with family’s income under 150 percent of federal poverty guidelines (FPG)

·        Aged 1 to 5 years and in a family with an income under 133 percent FPG

·        Over 1 year of age with family income between 133 and 150 percent of FPG (CHIP Phase I)

·        Children with special medical needs

 

Another 7.9 percent are participants in the state defined (non-entitlement portion of) State Children’s Health Insurance Program (SCHIP) with family incomes between 150 and 200 percent of FPG (also known as SCHIP Phase II/Package C) (Table 6‑4). In other categories, 3 percent of Marion County’s Medicaid enrollees are pregnant uninsured women, and 16.5 percent are persons meeting Aged or Disabled/Blind categories of eligibility. Some 3079 of Marion County’s Medicaid population (2 percent) are persons in long term nursing care.

Table 6‑4: Marion County June 2006 Medicaid Enrollment

Category of Eligibility

Number of enrollees

% of enrollees

Child

92,650

58.9

CHIP

12,430

7.9

Pregnant Women

4,723

3.0

Aged

9,737

6.2

Blind/Disabled

16,220

10.3

Adult

21,660

13.8

Total Enrolled

157,420

100.0

Source: December 2006 Indiana FSSA Demographic Trends Report, Division of Family Resources, State Fiscal Year  2005 Marion County: Indiana FACT/ FSSA/June 2006 Totals may not equal the sum of categories due to rounding.

 

Hoosier Healthwise (HHW) provides full medical services for entitlement Medicaid enrollees and primary and preventive services for children to age 19, pregnant women and low income families not meeting entitlement criteria whose incomes are at or below 200 percent of FPG. Indiana’s HHW enrollment increased by 28.6 percent between 2000 and 2006.[138]  In 2006, 65.7 percent of Medicaid enrollees were in HHW. The remaining adult enrollees were in the “Medicaid Select” or medically needy portion of the Medicaid program or temporarily in a private, fee-for-service setting until a Medicaid primary care provider could be assigned.[139]

In Marion County, over 92,000 children or 39.3 percent of the population under age 18 (235,712 in 2004) were enrolled in the Hoosier Healthwise entitlement portion of the Medicaid program.[140] In comparison, 20.9 percent of Indiana children and 25.1 percent of U.S. children under 18 are covered by Medicaid (2005). Even with the HHW program, 16.6 percent of Indiana children meeting this income requirement and 19 percent of such children nationally are not enrolled, and have no health insurance.[141]

Medicaid and Hoosier Healthwise Coverage and Access Issues

All Medicaid and SCHIP enrollees are required to participate in Risk Based Managed Care through an approved Managed Care Organization (MCO).  However, in the first 30 days of eligibility, some remain with a fee-for-service with a provider until a primary medical care provider in one of the 5 approved MCO can be arranged.[142] As Medicaid provider panels become full, timely first visits of newly enrolled patients into a “primary medical care home” may be delayed.

Medicaid coverage for parents may be terminated as their children reach age 19, or if the parent becomes employed under the welfare-to-work programs like the Indiana Manpower and Comprehensive Training (IMPACT) program.[143] In 2005, an average of 5,924 TANF recipients per month, and another 4,143 adults per month receiving Food Stamps enrolled in the IMPACT program.[144] Of these, approximately 600 per month left for regular employment.  Such individuals could lose health insurance coverage when they become ineligible for Medicaid unless they were eligible under Hoosier Healthwise (HHW).[145]

The availability of federally subsidized health care for adults has been decreasing.  Hoosier Healthwise does not cover childless low-income adults (an additional 575,000 Indiana adults). The federal 1996 Welfare Reform Act[146] and subsequent legislation implemented limitations on the total years an adult may receive income assistance (TANF) in their lifetime as an unemployed parent or head of household. Those adult Medicaid enrollees that did not qualify for Medicaid under disability, indigent aged, or long-term care, were beginning to be terminated from TANF/ Medicaid coverage starting about 2001.  In 2005, 39.3 percent of the Marion County children under 18 years old were enrolled in the Hoosier Healthwise portion of the Medicaid program[147]. That same year, 20.9 percent of Indiana children and 25.1 percent of U.S. children under 18 were covered by Medicaid[148].

The Federal Deficit Reduction Act of 2005 allows states to apply for Medicaid waivers to cover some portion of their uninsured population. Waivers to increase coverage of the uninsured have been recently debated in the 2006-2007 session of the Indiana General Assembly.

Usual Source of Health Care

Along with health insurance coverage, having a usual source or location for health care, especially primary care, is a major indicator of access to timely and appropriate care.[149]

Table 6‑5 shows the percent of Indiana adults who reported having no personal health care provider. Marion County results are not available, but may be somewhat worse, given that the prevalence of no health insurance among Marion County’s adults is 13 percent greater than that of the state (see the “No Health Insurance Coverage” section on page 6-2).

In 2005, 17.5 percent of Marion County adults reported having no usual source of medical care.  In Indiana, 16.1 percent of adults reported not having a personal health care provider, similar to 15.1 percent nationally[150].   The proportion declines with age from one in three young adults (aged 18 to 24 years) to less than 6 percent of persons over 75 years old.  Men are twice as likely as women to not have a usual source of care (20.8 versus 11.8 percent, respectively).

While all minority populations have a higher prevalence of adults without a usual source of healthcare, the greatest disparity occurs among Indiana Hispanics.  Half of the adults in that group have no usual source of care, not due to unemployment, but due to employment which often does not offer insurance coverage[151].

Table 6‑5: Indiana Adults Over 18 Without a Personal Health Care Provider, 2005

 

% with no personal healthcare provider

 

 

% with no personal healthcare provider

Age Group:

 

 

Income Group:

 

  18-24

34.1

 

  < $15,000

31.9

  25-34

24.7

 

  $15-$24,999

23.3

  35-44

17.2

 

  $25-$49,999

15.6

  45-54

11.1

 

  $50-$74,999

10.2

  55-64

7.2

 

  >=$75,000

8.8

  65-74

3.8

 

  Unknown

16.7

  75 +

5.4

 

Employment Status:

18.1

Gender

 

 

  Employed

 

  Male

20.8

 

  Not employed

37.3

  Female

11.8

 

  Student/Homemaker

15.0

Race/Ethnicity:

 

 

  Retired/Unable to work

6.0

  White, Non-Hispanic

13.2

 

Indiana Overall

16.1

  Black, Non-Hispanic

25.3

 

 

 

  Hispanic

52.2

 

 

 

  Other/Multiracial

23.4

 

 

 

Source: CDC Behavioral Risk Factor Surveillance System (BRFSS) http://www.cdc.gov/brfss/

 

Lack of a usual source of healthcare among low-income urban adults is more frequent among men than women (19.6 versus 10.6 per 100,000), similar to Indiana overall (20.8 and 11.8 percent, by gender, respectively). Nationally, urban uninsured (48.6 percent) and Hispanic segments (26.1 per 100,000) of the low-income population are most likely to lack a regular care source.[152] In Indiana the situation may be more serious, as over half (52.2 percent) of all Hispanics reported  having no regular provider (Table 6‑5).

The Healthy People 2010 objective 1-4a. for a usual source of healthcare for all adults, regardless of income, is 96 percent by 2010.[153]  The state’s prevalence of adults without a usual care source (16.1%) is 4 times the HP 2010 objective of 4 percent (Table 6‑6.)

 

Table 6‑6: HP 2010 Objectives for Usual Source of Care by Age Group

HP 2010

Objective

Persons With Specific Source of Ongoing Care

HP 2010

Target

1-4a.

All ages

96%

1-4b.

Children and youth aged 17 years and under

97%

1-4c.

Adults aged 18 years and older

96%

 

Primary Health Care Providers

In 2005, Marion County had a total of 3,382 licensed physicians and 647 licensed dentists in Marion County.[154] Breakdowns by subspecialty can be inferred from a 2001 survey which detailed the number of active, practicing physicians whose work setting was located within Marion County boundaries, conducted by the ISDH and the Health Care Professionals Development and Health Care Professions Bureaus.[155]

In 2001 the State Licensure Agency included general and family practitioners, general pediatricians and general internal medicine practitioners in the category of “Primary Care Physicians[156]” (PCPs). In some instances obstetrics-gynecologists (OB-GYN) are also included in this category.  The state Health Professional Licensing Agency and ISDH published[157] the following figures for primary care and OB-GYN practitioners in Marion County (Table 6‑7).

In comparison to the state and nation, Marion County had a relatively smaller proportion of PCPs in the total practitioner pool in 2001 (24.7 percent versus 33 to 34 percent).  This may be explained by the higher concentration of specialty medical practices and secondary and tertiary care facilities in this county than in the remainder of the state.

Table 6‑7:  Primary Care Physicians, OB/GYN Physicians, and Dentists, Marion County, Indiana, and U.S., 2001, 2005

Region

Marion County

Indiana

U.S.

Year

2001

2005

2001

2001

2004b

Measure

# of MD/ DOs

PCP %

Persons per provi-der

# of MD/ DOs

Persons per provi-der

PCP %

Persons per provider

PCP % of Total

Persons per provi-der

Total

2640

 

 

3382

 

 

 

 

 

Primary Care Physician (PCP)

654

24.7

1315

853a

990a

34.3

1807

32.8

1321

PCP plus OB/GYNs

781

29.6

1101

NA

843a

39.1

1571

NA

NA

Dentists

NA

NA

NA

647

1304

NA

NA

NA

NA

aProjected 2005 PCPs based on previous state average growth in PCPs of 30.4 percent in the previous 5 year reporting period.

PCP = Primary Care Physician

OB/GYN = Obstetrician or Gynecologist

NA =Not Available

Source: Indiana Professional Licensing Agency; bGreen LA, Phillips RL. The family physician workforce: quality, not quantity. Am Fam Physician 2005;71(12):2248, 2253.

 

Marion County physicians make up roughly one in four of all Indiana physicians.  In 2001, Marion County had one primary care provider per 1,315 residents, roughly equivalent to the national ratio[158] and 37 percent more providers per resident than in the state overall.  Between 2001 and 2005, the number of licensed providers in Marion County increased by 28 percent, resulting in more than one primary care provider per 1000 residents.  About three quarters of physicians licensed in Marion County are specialists, compared to about two thirds of physicians in the state and the country overall.[159]  This high prevalence of specialists relative to primary care physicians is probably attributable to the concentration of hospitals and medical facilities in Marion County, and the presence of the second largest medical school in the country, the Indiana University School of Medicine.

According to the ISDH, the number of PCPs grew 30.4 percent in the 5 years after the 1997 Indiana Physician Survey.[160] The total licensed MD/DOs for the county and state in 2005 indicate a continuation of that growth rate since 2001.

Given Marion County’s relatively slow population growth, the more rapid growth in the number of physicians, and assuming that primary care physicians continue to comprise 24.7 percent of the physician pool, we estimate that Marion County had approximately 853 PCPs in 2005,.or one PCP for every 990 residents.

A more sobering aspect of the pool of providers is that nearly 1 in 4 (23.4%) Indiana physicians were 55 or older in 2001.[161]  The estimated population to PCP ratio for 2005 may be overstated as the retirement and reduced practice availability in these older practitioners has not been accounted for in this estimate.

Dentists

In 2005, Marion County had a total of 647 licensed dentists[162], resulting in a population- to-dentist ratio of 1304:1 for Marion County overall (Table 6‑7).  However, there are areas within Marion County defined as Dental Health Professional Shortage Areas (DHPSAs) by HRSA due to a shortage of dentists.  HRSA has designated areas to the east and south of the I-65 and I 70 interchange areas as DHPSA areas[163], as indicated on the map in Figure 6‑3.  In 2000, eight percent of Marion County residents lived in dental Dental Health Professional Shortage Areas.[164]

Figure 6‑3: Marion County Dental Professional Shortage Areas; HRSA 2005

Source: HRSA Health Professions Bureau:  http://datawarehouse.hrsa.gov/DWOnlineMap/MainInterface.aspx 

 

Hospital Resources

The ISDH licenses short term (acute care), long term, psychiatric and rehabilitation hospitals in the state.  As of 2006, the 21 hospitals in Marion County provided 4,287 state licensed set/staffed beds within Marion County [165] (Table 6‑8).  This represents 5.1 beds per 100,000 persons.  Most beds in short term care hospitals are acute care beds, so there are approximately 4.35 acute care hospital beds per 100,000 persons in Marion County.

Table 6‑8: Marion County State Licensed Hospitals, by Type and Beds, 2006

License Category

Total Hospitals in This Category

Total Beds in These Hospitals

Beds per 100,000 persons

Short Term

14

3670

4.35

Long Term

2

232

--

Psychiatric

4

295

--

Rehabilitation

1

90

--

Total

21

4287

5.1

State figures include Larue Carter State Hospital; Does not include Roudebush VA Hospital capacity.

Source: ISDH http://www.in.gov/isdh/20111.htm Posted 6/6/2007 Totals may not equal the sum of categories due to rounding.

 

For the Indiana Family and Social Services Administration Division of Mental Health and Addiction’s listing of Marion County’s providers of inpatient psychiatric care, please see Section 10 of this report, Social and Mental Health.

Population Changes and the Marion County Health Advantage Program

In 2005, 17.1 percent of Marion County residents had household incomes below 100 percent of the federal poverty guidelines (FPG).[166]  This includes one in ten Whites (10.3%), and one-quarter of Blacks (25.4%) and Hispanics (28.3%). Nearly 290,000 individuals lived in households at or below 200 percent of Federal Poverty Guidelines.

The county-funded Health Advantage program provides health care to uninsured Marion County residents who have household incomes under 200 percent of the federal poverty guidelines, and who have no other source of health insurance.  In 2006, 56,000 individuals were enrolled in the Health Advantage program.  As of 2006, roughly 19 percent of the poor and near-poor population in Marion County is covered by Health Advantage. 

Enrollment in the program has grown by 137 percent between 2000 and 2005. Enrollment by Hispanic residents has increased even more rapidly.  Hispanics represented 10.7 percent of enrollees in 2000 and 27 percent in 2005.[167]  The 2005 U.S. Census Bureau estimated that 6 percent of Marion County’s population was Hispanic in 2005.[168]  This Hispanic group’s four-fold over-representation in the Advantage population indicates its greater likelihood of having low-income jobs and being uninsured, similar to patterns elsewhere in the country.

Table 6‑9: Health Advantage Participants: 2000-2005

Race/Ethnicity

2000

2001

2002

2003

2004

2005

Black

10015

10789

12589

16282

19241

19265

White

9735

10868

12474

15030

17900

18434

Hispanic

2497

3844

6369

8721

12255

15081

Asian

298

342

395

662

469

474

Pacific Islander

4

4

49

337

325

312

Unknown

796

956

3418

4914

1468

1729

Total

23345

26803

35294

45946

51658

55295

 

Primary Care and Medically Underserved Areas in Marion County

Available Primary Care Services for Vulnerable Populations

Timely and appropriate access to primary care services may be helpful in improving a community’s health status and in reducing costly inpatient treatment of conditions, which might have been avoided.[169]

Primary Care Medically Underserved Areas (MUAs) are geographic areas or specific populations for which there is a deficit of, and/or high need for, primary care, dental, or mental health services.  Primary Care MUAs are, in part, defined by a high prevalence of families with incomes below the federal poverty guidelines, higher infant mortality rates, or where the proportion of residents are over age 65, or living with HIV/AIDS exceed certain Health Resource Services Administration (HRSA) thresholds.

HRSA has designated 103 of Marion County’s 212 census tracts as primary care Medically Underserved Areas (MUAs).[170]  In 2000, 37 percent of Marion County’s population, or roughly 320,000 persons, lived in medically underserved areas.[171]  Nationally, HRSA estimates about 20 percent of the 2007 U.S. population lives in MUAs.[172]  HRSA also designates geographic areas as Health Professional Shortage Areas (HPSAs) if the population to provider ratio is deficient to meet usual service needs of the population.  There were 61 census tracts designated as Primary Care Health Professional Shortage areas [173](HPSAs) in 2005, all of which are simultaneously contained within MUA designated tracts (Figure 6‑4).[174]  In 2000, 17 percent of Marion County residents lived in Health Professional Shortage Areas.[175]

Figure 6‑4: 2005 Marion County HRSA-Designated Medically Underserved Area and Professional Shortage Area Census Tracts

Source: HRSA Bureau of Health Professions website: Marion County Primary Care PSA-qualifying and MUA-qualifying census tracts http://hpsafind.hrsa.gov/HPSASearch.aspx

 

The Indiana Primary Health Care Association estimates that Wishard Health Services (WHS), clinical services division of the Health & Hospital Corporation of Marion County, is a major provider of primary and acute care to both Health Advantage-covered and other low income and uninsured Marion County residents. WHS clinics handled about half (48% or 190,650) of all 2005 primary care visits for Marion County’s underserved/vulnerable populations.  Federally Qualified Health Centers (FQHCs), including HealthNet, Citizen’s, Raphael Health Center, Shalom Health Care Center, and other freestanding clinics provided most of the remaining 52 percent of visits.[176]

Approximately 93,000 persons (Marion County residents and non-residents) were served by publicly funded local or state clinic programs.  Approximately 46,000 Marion County residents were served in 2004 by Marion County’s nine federally qualified health centers (FQHCs) shown on the map below (Figure 6‑5.).

Figure 6‑5: Federally Qualified Health Centers (FQHCs) and Medically Underserved Populations/Professional Shortage Areas in Marion County: 2005

Source: HRSA Geospatial Data Warehouse http://datawarehouse.hrsa.gov/

 

Community health centers (CHCs) are non-profit organizations providing comprehensive primary and preventive health services to residents of federally designated medically under-served areas. They are governed by consumer boards. Patients are charged on a sliding fee scale, regardless of insurance status, to reduce income and insurance barriers to timely primary care.[177] 

In Marion County for 2006, 20 primary care sites qualify as CHCs for federal or state funds[178] and serve some segment of Marion County’s medically underserved or designated high-risk, vulnerable populations. These are federally and/or state funded, and meet some or all CHC criteria.  Eight clinic sites are administered by Wishard Health Services, seven by HealthNet, three are single-center FQHCs, and two are administered by not-for-profit hospitals.

Primary care delay in meeting patients’ primary care needs is a national problem. Causes include patients’ out-of-pocket costs or other barriers to care.[179] For example, 40 percent of emergency department (ED) visits in one community study were not urgent, but occurred because patients couldn’t see their primary care physician. From 1997 to 2001 inability to get a timely appointment rose from 23 percent to 33 percent, and 43 percent of adults reporting an urgent condition were unable to receive care when needed.[180] 

Payer Sources for Acute Care Hospitalizations

Hospitals in Marion County categorize their inpatient discharges (persons admitted and staying at least one night) by insurance source. These sources include Medicare, Medicaid, commercial or private source, and Managed Care Organizations (usually employer-insurance sources).  Individuals without health insurance are categorized as “self-pay” in hospital discharge summaries.

Marion County hospitals cared for approximately 113,700 uninsured persons in 2005.[181]  Self-pay patients represented 6.4 percent of all Marion County hospital discharges in 2005 (Table 6‑10). This is an 18 percent decrease since 1999 in the proportion of all discharges that were self-pay. Eleven percent of hospitalizations of working age adults 25 to 44 years were uninsured. Nationally, about 5 percent of all discharges in 2002 were of self-pay patients.[182]

Black patients were nearly twice as likely as their white counterparts to be “self-pay” patients (9.3 versus 4.9 percent, respectively). Men were 40 percent more likely to be coded as self-pay than women. The greatest differences were seen in the ages 15 to 44 years, where Black and White males were three times as likely to be self-pay inpatients than their female counterparts. Over one in four Black males aged 15 to 44 years (28 percent) were coded as self-pay. The proportion of “self pay” visits among persons aged 65 and older was substantially lower because 85 percent of seniors have Medicare coverage for hospital care.

Table 6‑10: Self Pay as a Percent of All Discharges from Marion County Hospitals: Marion County Residents  Coded as Self-pay Patients, by Age, Race, and Gender, 2005

Age

Whites

White Males

White Females

Blacks

Black Males

Black Females

Total

<15

2.5%

2.8%

2.2%

4.7%

4.7%

4.7%

4.4%

15-24

7.2%

16.3%

5.3%

9.3%

28.0%

5.5%

9.7%

25-44

9.3%

20.1%

5.5%

14.4%

28.3%

9.0%

11.1%

45-64

8.3%

9.4%

7.4%

13.7%

13.8%

13.6%

9.1%

65+

0.3%

0.2%

0.3%

0.8%

0.6%

0.9%

0.4%

Total

4.9%

6.9%

3.7%

9.3%

12.6%

7.3%

6.4%

Source: Marion County Hospital Discharge Data, 2005 (DR0490 T7-8) Totals may not equal the sum of categories due to rounding.

 

The percentage of Marion County residents’ hospitalizations paid by Medicaid is seen in Table 6‑11.  Overall, Medicaid covered one in five of all Marion County hospital visits (19%), including over half of stays for young adults age 15 to 24 years (56.2%) and for children younger than 15 (58.1%).  The total percentage of discharges for which Medicaid was the primary payer increased 23 percent since 1999.  The group with the highest percentage of Medicaid covered patients were Black children under 15, and young Black and White women age 15 to 24 years.  Information specific to Hispanics was not available.[183]

Table 6‑11: Medicaid as a Percent of All Discharges from Marion County Hospitals: Marion County Residents  Coded as Medicaid Insured, by Age, Race, and Gender, 2005

Age

Whites

White Males

White Females

Blacks

Black Males

Black Females

Total

<15

48.8%

49.2%

48.3%

73.3%

74.2%

72.0%

58.1%

15-24

53.0%

25.2%

59.1%

67.8%

35.4%

74.4%

56.2%

25-44

21.0%

18.7%

21.8%

34.9%

19.1%

41.1%

26.6%

45-64

12.6%

12.4%

12.6%

17.3%

14.6%

19.8%

13.2%

65+

0.4%

0.3%

0.4%

2.1%

1.4%

2.5%

0.8%

Total

14.3%

11.2%

16.2%

28.0%

18.8%

33.8%

19.0%

Source: Marion County Hospital Discharge Data (DR0 490; T7-8) Totals may not equal the sum of categories due to rounding.

 



[122]The BRFSS and SMART question is:  Do you have any kind of health care coverage?  Median responses for all reporting states are reported for BRFSS national figures.

[123] U.S. Census Bureau, 2005 American Community Survey http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=Search&geo_id=&_geoContext=&_street=&_county=&_cityTown=&_state=04000US18&_zip=&_lang=en&_sse=on&pctxt=fph&pgsl=010

[124]Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2005] http://apps.nccd.cdc.gov/brfss/display.asp?cat=HC&yr=2005&qkey=868&state=IN

Respondents answered the query:  Do you have any kind of health care coverage? http://apps.nccd.cdc.gov/brfss-smart/MMSACtyRiskChart.asp?MMSA=39&yr2=2005&qkey=868&CtyCode=38&cat=HC#HC

[125]Comparing Federal Government Surveys That Count Uninsured People In America, Robert Wood Johnson Foundation, August 2006 http://www.rwjf.org/

[126] Rates of uninsured should be compared with caution. The BRFSS routinely asks for the respondents’ current coverage status. On the other hand the U.S. Census Annual Social and Economic Supplement (ASEC) to the Current Population Survey, a nationally representative survey of 100,000 households and their economic status, asks about lack of coverage at any time in the previous 12 months. Follow-up questions then probe for difference sources of insurance to verify lack of coverage. A three year moving average of those without insurance any time in the past year is presented by state at this link http://www.census.gov/hhes/www/hlthins/hlthin05/hlth05asc.html

[127]U.S. Census Bureau, Housing and Household Economic Statistics Division http://www.census.gov/hhes/www/hlthins/historic/hihistt6.html

[128]DeNavas-Walt C, Proctor, BD, Lee CH. Income, Poverty, and Health Insurance Coverage in the United States: 2005. U.S. Census Bureau, Current Population Reports, P60-231, U.S. Government Printing Office, Washington, DC, 2006. http://www.census.gov/prod/2006pubs/p60-231.pdf (DR0459)

[129] U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed  Objective 1-1 http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm#_Toc489432815

[130]U.S. Census Bureau, 2005 American Community Survey http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=Search&geo_id=&_geoContext=&_street=&_county=&_cityTown=&_state=04000US18&_zip=&_lang=en&_sse=on&pctxt=fph&pgsl=010

[131]2005 Indiana BRFSS Statewide Survey Data http://www.in.gov/isdh/dataandstats/brfss/2005/q005.htm

[132]Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2005] http://apps.nccd.cdc.gov/brfss-smart/MMSACtyRiskChart.asp?MMSA=39&yr2=2005&qkey=868&CtyCode=38&cat=HC#HC

[133] Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2005] http://apps.nccd.cdc.gov/brfss/display.asp?cat=HC&yr=2005&qkey=868&state=IN

[134]2003 Indiana Family and Social Services Administration Household Survey, commissioned by the Health Insurance for Indiana Families Committee http://www.statecoverage.net/statereports/in14.pdf

[135] 2001 Marion County Community Health Assessment Telephone Survey

[136] Indiana Family and Social Services Administration Office Of Medicaid Policy & Planning, June 2006 Indiana Fact Marion County: A Comparative Review Of Selected Programs. A “recipient” is a person for whom the state has paid a monthly capitation fee for Medicaid coverage regardless of whether the individual has received Medicaid services

[137] Merrill CT, Elixhauser A. Hospitalization in the United States, 2002: HCUP Fact Book No. 6. AHRQ Publication No. 05-0056, June 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/data/hcup/factbk6/

[138]EP&P Consulting Inc. Indiana’s Children’s Health Insurance Annual evaluation Report http://www.eppconsulting.com/pub_files/2005%20Indiana%20CHIP%20Report.pdf

[139] Medicaid Select is the name given to Indiana’s Medicaid program for adults who qualify as income and medically needy. See FSSA Indiana FACT/ FSSA/June 2006

[140] Medicaid Select is the name given to Indiana’s Medicaid program for adults who qualify as income and medically needy. See FSSA Indiana FACT/ FSSA/June 2006

[141] EP&P Consulting Inc. Indiana’s Children’s Health Insurance Annual evaluation Report http://www.eppconsulting.com/service_detail.asp?id=11

[142]EP&P Consulting Inc. Indiana’s Children’s Health Insurance Annual evaluation Report http://www.eppconsulting.com/service_detail.asp?id=11

[143]Department of Health and Human Services, Centers for Medicare and Medicaid Services http://www.cms.hhs.gov/MedicaidGenInfo/

[144]Indiana Family and Social Services Administration. Demographic Trends Report 2005 http://www.in.gov/fssa/family/pdf/DFR%20DTR%202005.pdf

[145]Roob M. Health Care Affordability and Quality, 2006 http://www.in.gov/fssa/pdf/fssauninsuredvision041206update.pdf

[146]1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWOR) (PL 104-193.  The 1996 welfare reform law was reauthorized in the Deficit Reduction Act of 2005 and required Secretary of the U.S. DHHS, by June 30, 2006, to promulgate regulations designed to address eligible work activities. The reauthorization maintains the requirement that 50 percent of states’ welfare caseloads fulfill statutory work requirements. http://www.acf.hhs.gov/programs/ofa/regfact.htm

[147]  FSSA Indiana FACT/ FSSA/June 2006

[148] EP&P Consulting Inc. Indiana’s Children’s Health Insurance Annual evaluation Report 2005 http://www.eppconsulting.com/pub_files/2005%20Indiana%20CHIP%20Report.pdf

[149] Fryer GE, Dovey SM, Green LA. The importance of having a usual source of health care. Am Fam Physician2000;62:477. Xu, KT. Usual source of care in preventive service use: a regular doctor versus a regular site. Health Services Research 2002;37(6):1509–1529.

[150] Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults: National health interview survey, 2005. National Center for Health Statistics. Vital Health Stat 10(232). 2006. http://www.cdc.gov/nchs/data/series/sr_10/sr10_232.pdf

[151] DeNavas-Walt C, Proctor, BD, Lee CH. Income, Poverty, and Health Insurance Coverage in the United States: 2005. U.S. Census Bureau, Current Population Reports, P60-231, U.S. Government Printing Office, Washington, DC, 2006. http://www.census.gov/prod/2006pubs/p60-231.pdf

[152]Pleis JR, Lethbridge-Çejku M. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2005. National Center for Health Statistics. Vital Health Stat, 2006; 10:232 http://www.cdc.gov/nchs/data/series/sr_10/sr10_232.pdf

[153]U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000. Objective 1-4. http://www.healthypeople.gov/document/html/uih/uih_4.htm#accesshealth

 

[154] Indiana State Department of Health http://www.in.gov/isdh/publications/2001report/appendix_f.htm

[155]2001 Indiana Physician Survey Data Book http://www.in.gov/isdh/publications/physiciansdata/2001/databook.pdf

[156] This includes practitioners with either M.D. or D.O. licensure.

[157]Indiana Professional Licensing Agency (http://www.in.gov/pla). Data as of August 2005 for Indiana residents only

[158] Green LA, Phillips RL. The family physician workforce: quality, not quantity. Am Fam Physician 2005;71(12):2248, 2253.

[159]Indiana Professional Licensing Agency (http://www.in.gov/pla). Data as of August 2005 for Indiana residents only

[160] 2001 Indiana Physician Survey Data Book http://www.in.gov/isdh/publications/physiciansdata/2001/databook.pdf

[161] 2001 Indiana Physician Survey Data Book http://www.in.gov/isdh/publications/physiciansdata/2001/databook.pdf

[162] Indiana State Department of Health http://www.in.gov/isdh/publications/2001report/appendix_f.htm

[163] Among criteria used in designating Dental PSAs are: 1) a service population ratio greater than 5000:1, 2) the population: FTE dentist ratio is between 4,000 to 5,000:1, and the local population has high needs for dental services, or insufficient capacity among existing dental providers, 3) more than 20 percent of the civilian population meets 100% FPG, and 4) an area's existing providers have insufficient capacity due to at least one of the following: (a) More than 5,000 visits per year per FTE dentist serving the area, (b) Unusually long waits (over 6 weeks) for appointments for routine care, or (c) 2/3 or more of the area's dentists do not accept new patients.  See the following link for a detailed listing of census tracts designated as Dental- Underserved Areas by HRSA http://datawarehouse.hrsa.gov/DWOnlineMap/MainInterface.aspx

[164] U.S. Census Bureau 2000 Census (Marion County Health Department DR0616)

[165] These hospital counts/bed counts do not include other facilities, which may be run by a common owner or organization, but located outside the county boundaries; for example, Clarian West  (Avon Indiana), is a member of Clarian Health Partners, headquartered in Indianapolis.

[166] U.S. Census Bureau, 2005 American Community Survey http://factfinder.census.gov/servlet/STTable?_bm=y&-context=st&-qr_name=ACS_2005_EST_G00_S1702&-ds_name=ACS_2005_EST_G00_&-CONTEXT=st&-tree_id=305&-redoLog=false&-geo_id=05000US18097&-format=&-_lang=en

[167]Indiana University Medical Group Operating Report 2006: Ethnicity by Race

[168]U.S. Census Bureau, 2005 American Community Survey http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=Search&geo_id=&_geoContext=&_street=&_county=marion&_cityTown=marion&_state=04000US18&_zip=&_lang=en&_sse=on&pctxt=fph&pgsl=010

[169] Ambulatory Care Sensitive Conditions http://www.ahcpr.gov/data/safetynet/billappb.htm

[170]Medically underserved designations are based upon the ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage population under 100% FPG, and percentage of the population age 65 or over. The value of each of these variables is converted to a weighted value, according to established criteria. MUA Designation involves application of the Index of Medical Underservice (IMU) to data on a service area to obtain the area’s score on an IMU scale from 0 to 100, ( 0 represents completely underserved; 100 represents least underserved). Each service area with an IMU of 62.0 or less qualifies for designation as an MUA. The four criteria are weighted and summed for an area's IMU score.  The MUA designation may be defined for: a whole non-metropolitan county; groups of non-metropolitan contiguous counties, minor civil divisions (MCDs), or census county divisions (CCDs), with population centers within 30 minutes travel time of each other; or a metropolitan group of census tracts which represent a neighborhood due to homogeneous socioeconomic and demographic characteristics.

[171] U.S. Census Bureau 2000 Census (DR0616)

[172] HRSA Bureau of Health Professionals. Shortage Designation. http://bhpr.hrsa.gov/shortage/ (accessed 14Oct2007).

[173] To meet Federal Primary Care Health Professional Shortage Area (HPSA) designation requirements, an area must be a rational service area for the provision of primary care services, AND

Have a population to primary care physician ratio greater than 3,500:1, AND

Show that neighboring area primary care physicians are over-utilized, excessively distant, or inaccessible (e.g. population to physician ratio is already high; travel time to neighboring areas exceeds 30 minutes; the neighboring area significantly differs in demographic or socio-economic characteristics; or neighboring-area resources exhibit economic barriers such as physicians do not accept Medicaid) OR

Have a population to primary care physician ratio of 3,000:1 to 3,499:1, AND

Have a high birth rate, or high infant mortality rate, or more than 20% of the population below 100% FPL   OR

Show evidence of insufficient capacity of existing primary care physicians, as indicated by any 2 of the following: excessive office visits / year per physician, long wait times for routine appointments, excessive waiting room time, excessive emergency room use, physicians not accepting new patients, or low utilization of health services)

[174]See HRSA Bureau of Health Professions website for a complete listing of Marion County Primary Care PSA-qualifying and MUA-qualifying census tracts http://hpsafind.hrsa.gov/HPSASearch.aspx

[175] U.S. Census Bureau 2000 Census (DR0616)

[176] Market demand estimates by IPHCA provided to Kurt, Solomon Associates for September 29, 2006 Task Force Document, Primary Care, pg 11.

[177] Community Health Centers (CHCs) are local non-profit organizations that are strongly linked to the community, and are governed by consumer boards.  They serve medically undeserved rural and urban areas with few or no primary care providers and populations in poor health status. CHCs provide care for those whom other providers do not serve because of complex and costly health needs, including uninsured, vulnerable and high-risk populations. Most health centers offer health education, community outreach and translation services, and patients are charged according to a sliding fee scale http://www.indianapca.org/htm/CommHealthCentre.html

[178]The full list includes other providers designated by the Bureau of Primary Care as part of the county’s “safety-net” providers (personal communication, Rita Hope, Director, Office of Primary Care, Indiana State Department of Health, January 05, 2006)  

[179]Delayed care due to cost, United States 2005, National Health Interview Survey

[180] Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA 2003;289(8):1035-40.

[181] 2004/2005 U.S. Census Bureau CPS Survey

[182] Merrill CT, Elixhauser A. Hospitalization in the United States, 2002: HCUP Fact Book No. 6. AHRQ Publication No. 05-0056, June 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/data/hcup/factbk6/

[183] Marion County Hospital Discharge Data, 2005 (DR0 490; T7-8)