| Appendix A:
Qualitative Findings
Overview of Health
in San Mateo County
barriers to access
difficulty
getting medical care
Many barriers related
to low income or immigrant status were identified in accessing health care services. These
are described in the following comments.
"I work primarily with an
immigrant, low income population and the issues that I see a lot of the time are a lack of
knowledge, a lack of access to services. They’re on Medi-Cal and they’re very
diligent about seeking health care for their children. When it comes to seeking health
care for themselves, it’s a whole other issue. It’s something that I’ve
been working very hard with the mothers just ensuring that they’re healthy, which
definitely is a direct link to the health of their child…"
— Social Services Representative
"Though the resources are
there, even for the English community that are low literacy and limited in resources, I
think they’re still not as accessible. Transportation, procedures, systems… I
think we many times develop things that are comfortable to us, but really for somebody who
needs to know, it’s not easy."
— Social Services Representative
"Sometimes the low-income
are better off than the people that have just a little bit too much money that they
don’t qualify for any of these programs."
— Social Services Representative
"They can’t go during
the day if they’re working, so I know that I often see them at the RotaCare Clinics.
And they’re often the young adults. In Daly City I see more working poor."
— Social Services Representative
Physicians believe the county
system can be difficult to access.
"To have access to the
county system, you have to be registered, and that requires a social service screening. I
don’t know what the parameters are, but it’s very limiting. Unless you have a
county card, you can’t get into the county system."
— Physician
"There was separate funding
from the state to the county for MIA [medically indigent adult] care, but it’s my
understanding that that amount has been progressively diminishing. I don’t know what
exactly happens to those people. My guess is that they get bills for their medical care.
And they get crisis care."
— Physician
A few participants did mention
some clinics in the area that serve these populations, though the clinics may not be
well-known.
"We started a medical
clinic only because we had so many people among our client base who had no access to
health care. We will take only people who have no access to health care, which means the
bulk of our practice is undocumented people… I’m told that our clients are
getting the best care in San Mateo County. That’s because the doctors get to come in
and do what they want to do and not have to mess around with all of the other stuff that
gets in the way of practicing medicine, so it has turned out to be a very fascinating
experience."
— Social Services Representative
"There’s also a Well
Clinic which virtually nobody knows about it. There’s a fair amount of patients in
the county who aren’t even aware that they’re eligible for Medi-Cal.
There’s just a lot of holes in the system."
— Physician
location of services
Another problem in
accessing health care is location of services. These social services providers believe
school clinics are good ways to bring health care services to this population.
"I would really reinforce
that you need to look at providing health care in locations where it is comfortable for
people to get to. It’s expensive beyond measure, but when it’s on a school site,
it should be open to all members of the community, which is the ultimate goal –
people with gray hair like me as well as the little ones – then you will really have
effective programs."
— Social Services Representative
"I’m very involved
with the Taft School Clinic and I’d like to mention that we are going to provide
school-based or linked services to two more elementary schools in the North Fair Oaks
area, so that within a radius of Fair Oaks Family Health Clinic, we will be providing
health services to four elementary schools. It is very cost effective, by the way, this is
not frivolous money being spent."
— Social Services Representative
language/cultural differences
Furthermore, community
panel members identified language and cultural barriers to accessing health care,
particularly with the great ethnic diversity in San Mateo County.
"In Redwood City, while
people respect the hospitals because they’re reaching out into the community,
particularly the Latino/Hispanic community feels they do not have adequate access to
health care."
— Community Leader
"As it relates to Latinos,
we need to learn to develop protocol models of working non-traditionally with some of
these populations."
— Social Services Representative
"I work with monolingual
Spanish-speaking [families], that is the biggest barrier to services that I see in this
community."
— Social Services Representative
"There’s not adequate
access as it relates to certain communities, particularly communities of color,
particularly the non-English speaking, the pre-literate, etc. Access for them is not just
transportation, it’s cultural appropriateness and linguistic appropriateness."
— Social Services Representative
"I think the barrier is
understanding, as it relates to the low-income, recent immigrant population. Also the
changes within that population. We’ve had migrations of immigrants for a long time,
but there’s various differences in the immigrants now… Now you’re finding
poor people, pre-literate people, no understanding, a lot of them are coming down
essentially from the mountains and those are the immigrants that are migrating. We have to
understand that when we design programs… I think that the barriers are in many
instances self-imposed, but I think that the challenge for us is to be able to get through
them and work with them."
— Social Services Representative
These social service
representatives recommend, to include all, bilingual, bicultural health care workers and
materials need to be developed for these populations.
"At the same time, we have
found there is a big gap of bilingual, bicultural workers in San Mateo County in the
health industry for example, so we’re beginning to penetrate that industry.
We’re developing people who are now moving up the ladder."
— Social Services Representative
"For some communities, the
pre-literate, non-English speaking, for these we are going to have to develop some very
user-friendly types of materials that they can look through, maybe based on
pictures…"
— Social Services Representative
health insurance coverage
Even though San Mateo
is a wealthy community, this individual indicated there is a large segment of uninsured in
the area.
"Many child care workers,
people who work in doctors’ offices often don’t have health insurance. There are
many, many temporary and part-time people that are working three jobs and they’re the
ones in need."
— Social Services Representative
Part of the difficulty with the
uninsured is that they frequently require more medical care than those with insurance, and
physicians shared that it is difficult to find consulting or referral doctors for them.
"Part of the dilemma is
that the patients who have the least access to insurance, or the worst types of insurance,
require the most care, not only direct medical care, but behavioral medicine. They’re
the most difficult to deal with."
— Physician
"Even when we do accept
those patients, trying to get them services outside our group, for example psychiatric
services, is so much trouble. You don’t want those patients basically because they
are problematic."
— Physician
"If you are caring for a
patient like that and they need a particular kind of consultant, the amount of effort that
you have to put in to finding someone to provide that care is just enormous."
— Physician
Moreover they said even those
with Medi-Cal have difficulty finding medical care because physician reimbursements are so
poor.
"Even the county Medi-Cal
system has limited access. The Health Plan of San Mateo has a system, but we don’t
all participate in that system equally. For example, our medical group has limited numbers
of patients we will accept from the Health Plan of San Mateo. So even though they want
access to physicians, they cannot necessarily get it. It’s not open because of
reimbursement. Because the needs those people have for the most part are crisis medicine.
That’s part of public education."
— Physician
"I think that physicians in
the past were more willing to squeeze people like that into their schedule when there was
a cushion in their income and they could afford to see people for nothing. Now they
can’t even afford to see the people they’re seeing because of the reimbursement
levels. It’s clear that the willingness – or the ability shall we say – to
do that sort of pro bono activity is colossally diminished."
— Physician
"Adequate reimbursements
for the work that is being done, with agreements about taking care of those patients…
I think all the private areas should have some percentage of that."
— Physician
Participants also indicated even
those with managed care plans have difficulties accessing medical services. First, they
said managed care plans are too complicated to understand.
"The managed care
environment is too complicated for most people in the community, regardless of
socio-economic level."
— Social Services Representative
"We’re all very used
to just having the doctor tell us what to do and doing it. I think just the whole concept
of managed care is very different. And if I don’t understand it and I can’t
manage it… I can understand how my mother who doesn’t speak English or read
English tries to deal with it, some of my relatives who are very poor, who are just trying
to meet their daily needs of housing and food… I think we are going to have to
address how we are going to get people, inform them and then empower them to manage their
health."
— Social Services Representative
In addition, community members
believe managed care has destroyed physician-patient relationships with the limited amount
of time being spent with patients and restrictions on care given.
"HMOs I think have
destroyed doctor-patient relationships… and we have a pretty good health care plan,
so if it’s that way for us, what’s it like for small businesses with just a
small number of employees? It must be dreadful."
— Community Leader
"I think the real negative
about managed care is the one thing that does get compromised is time – time being
spent with physician groups, time being spent with patients. In order to properly diagnose
depression or what have you, they need time. I don’t think it’s going to change,
it’s going to continue to get worse. We need to try to educate the consumers, get
them all aware, get them able to plug into what’s available in the community, and
actually educate the physician groups so that they have a much better understanding of
what’s available."
— Social Services Representative
"I think doctors are
becoming more and more distant from their patients. Where I work I see that people just
are not comfortable with their doctors. Their health care system is really failing them,
their insurance, they just throw up their hands. It’s completely
incomprehensible."
— Social Services Representative
"What’s been in the
papers recently is the issue of paying for treatment and medications that have nothing to
do with health in the way it’s generally considered, but have to do with improving
quality of life. Of course, we’re talking about things like Viagra, and how
that’s going to be paid for. There certainly have been situations where things which
are much more important to the general health aren’t paid for. Health plans that
might pay for Viagra, but won’t pay for immunizations, for example."
— Physician
"My experience is with my
mom, she was in Secured Horizons. They gave me a book of physicians and I called everybody
in the book and nobody would take her as a client. ‘How old is your mom? What’s
her problem? Oh, we don’t take those kinds of people.’"
— Community Leader
In order to address managed care
problems, some physicians believe the government should put restrictions on insurance
companies; that in order to insure residents, insurance companies must meet certain
guidelines and provide the community with certain resources.
"The government contributes
to dealing with some of these problems and to a certain extent, a managed care
organization like Kaiser has programs that deal with some of these other problems…
but all of the virtual managed care organizations, all of the virtual HMOs that are
nothing more than administrative structures, shifting the risk and overhead to the
caregivers, they don’t provide any resources to dealing with those issues. Is there
any way that the county government can force HMOs, managed care organizations in the
county to contribute to dealing with those issues? Is there a coercive power in county
government in that regard?"
— Physician
dental care
Several community
members identified dental care for low-income children as an area need.
"If you don’t have
resources, it’s going to impact all the services you get. Pediatric dentistry is
probably one of the largest. It’s hard to prioritize these things, but the need is
just huge. A kid may get seen for a fever and scrounge up money for antibiotics, but
dentistry just gets put off."
— Community Leader
"Basics, like dental and
vision care. Somebody in the poorer section can’t even go to the dentist."
— Social Services Representative
"There really is no
orthodontia for example in the county, or anything that is more of a palliative kind of
thing."
— Social Services Representative
On a positive note, one program
working to meet these needs was mentioned.
"There’s one grant
program you should all know that fills some of those needs. It will give $4,000 dollars to
any child with a congenital dental problem."
— Social Services Representative
occupational health
The physician panel
spent some time discussing occupational health. One physician first indicated most people
injured on the job have insurance, but many individuals being examined before employment
do not and consequently have many general health problems, such as behavioral health
risks, high blood pressure, and poor dental health, and only seek crisis medical care.
"I have a limited amount of
people that I have worked with in industrial medicine in the last 11 years. Almost all of
the people who I see and who are injured on the job are regular employees and have
insurance. But I see anywhere from 4 to 8 new employees a day who are doing pre-employment
exams for a new job. Almost all of those don’t have insurance. It’s a very wide
range of ages. There are a lot of young people just coming out of school and so forth, but
there’s also people in their 50s and even early 60s who have been out of a job, have
lost their insurance. So, on that limited basis, there are a fair number of people I come
across every day."
— Physician
"Many of them are the
general kinds of health problems, terrible teeth, not good care of their own bodies, and
so forth. Occasionally there are [major health problems]. We do see some hypertensives who
don’t have any care and we say, ‘Where do you get your care?’ ‘I get
my care at the County when I need to.’ But it’s on a crisis basis."
— Physician
"I also do the exams for
people who are getting rehabilitation services from the state, and many of those people do
not have regular care except crisis care."
— Physician
This physician indicated most
occupational health problems he sees are back injuries or repetitive motion injuries. He
indicated the problems he has with these injuries are not the health problem itself, but
rather coordinating care for these patients that frequently commute great distances to
work.
"Most of it is relatively
light industry, backs are the bulk of what I see, knees, repetitive motion injuries, wrist
and arm and shoulder, things of that kind."
— Physician
"I see many patients in a
day’s time who live in Modesto, an hour to two hours away, because that’s the
only place they can live. So trying to coordinate their care here, for example, if
somebody gets injured on the job and is off, he’s home – two hours away from
here. My having to work out some kind of arrangement for him to get physical therapy or
whatever over there is terribly difficult if he can’t come back here. If he’s
partially disabled I can see him some during the day hours, but…"
— Physician
preventive
medicine
preventive care
Social service
providers indicated that preventive care is not done routinely in the county and that
physicians are not aware of prevention, wellness, and education programs in the community
and, consequently, are not referring their patients to those programs.
"The community-based
prevention activities, there’s a lot of lip service to it, but part of the
expectation in the whole managed care thing is that the private docs will in fact do all
this prevention work as part of their managed care contracts. They don’t have a clue
what that means and they won’t really work with the community-based organizations or
with the health department, and so there’s a huge gap there between what managed care
can provide and what we really mean by community-based prevention."
— Social Services Representative
"I find that [doctors]
don’t even understand the whole concept of prevention and community wellness and
community education. There’s such a disconnect and the reality because those groups
don’t talk to each other. Doctors don’t even refer very much to what is out
there now. Insurance is requiring that classes be offered by the various IPAs, various
physician groups and what they require is so inadequate. They say, ‘Let’s see, a
two-hour diabetes class and you will have diabetes management and you will be able to do
an evaluation and have the results at the end of two hours.’ I don’t think
so."
— Social Services Representative
"People are not even
diagnosed because they’re not even getting in for the preventive services."
— Social Services Representative
hospital emergency room utilization
Participants
said there is a county clinic system, but residents still utilize local emergency rooms
for primary care, saying the county system is difficult to access, crowded, and has long
waits.
"I work in the emergency
room and we’re very often put in the situation of being kind of the pathway for
access for many of these people. We have no problem treating episodic, crisis care,
it’s the follow-up – to actually get somebody an office appointment is very
difficult. The county system, there doesn’t really seem to be a safety net…
There is a clinic system with the County Hospital, but it’s hard to access, patients
still get bills for it, it’s not widely publicized, their hours are not very good for
patients."
— Physician
"As to why they came to the
emergency room even though it’s not particularly an emergency problem —we have a
Fair Oaks Clinic, and a County Hospital Clinic System — they’ll tell you that
they’ve been to those and they’re just not satisfied with the care or they wait
too long. Patients will wait three hours at the Fair Oaks Clinic to be seen by a
pediatrician, and the waiting room is apparently small, claustrophobic, full, crowded, so
they choose to go the emergency room."
— Physician
"Many of these people are
employed, but they’re self-employed, or they’re employed with small firms that
do not include health benefits, and they’re just living so close to the edge that the
only treatment that they can get is in an emergency room."
— Community Leader
health
education
Another identified
aspect of prevention was health education. Not surprisingly, when discussing health
education, participants first mentioned health education through schools, saying though
required, the curriculum is not consistent throughout schools and many adolescents appear
to know little about health.
"I was involved with a
health education project with Sequoia High School in Redwood City. The school nurse there
tried to have an education class and it lasted a year or so, I don’t know what’s
happened to it. What struck me was these were… young people between the ages 14 to
17, and they have almost no concept of health or physiology of the body. None. It was
appalling. Some of them were on drugs, sexually active, the whole bit, and yet knew
nothing about what they were dealing with. That led me to think that there is a great need
for more education."
— Physician
"There is no comprehensive,
consistent curriculum for health education even though health education is a required
course [in the State of California]. There are coaches teaching health education and they
don’t even want to approach the area of pregnancy prevention, STD’s and HIV
prevention. We have outreach workers that we’ve trained to go in and we’ve
developed a pregnancy prevention curriculum and the kids are very responsive to it. We
also involved peers, high school students need to be more involved in this area because
the teachers are going to have limitations in presenting this kind of information to kids.
Teens do listen to their peers, so we have a group of peers organized in each high school
to come in and reinforce the information about pregnancy and AIDS prevention. I do think
we are just scratching the surface."
— Social Services Representative
"It depends on the school
district, it depends on the resources of that school. It depends on the teacher, Like at
Alta Loma there used to be a really wonderful health teacher, he had people from all over
the community coming into the classroom and really exposing the kids to a lot of
information, basic information that these eighth graders need to know. Do our eighth
graders get health education? Maybe they get a little sex education at the end of the
year. And the school nurse, we have her maybe one day a week to do ear and eye
tests."
— Social Services Representative
"The Heart Association has
a fairly active program for education regarding cardiovascular disease and particularly
the risk factors and so forth for school. They’ve involved many of the teachers. The
teachers are really eager to have this kind of material because they don’t get it
through their other programs. I think it’s been effective, but it’s just a drop
in the bucket."
— Physician
These individuals said the youth
themselves have identified issues they feel need to be covered in health education
including stress and academics, sex and sexuality, and self-esteem in elementary schools.
"I run our youth advisory
council for our city. Some of the things that our kids have been working on is finding out
exactly what young people are thinking about. They went out and they did a huge survey for
our city. It was a 19-page survey discussing with all the kids in our community issues
such as sexuality and sex, diversity, family issues, medical issues, alcoholism, drugs,
the whole gamut. The issues they came back with were very astounding to us in regard to
stress and academics and sex and sexuality and what was not in place in the schools. And
so the kids were able to approach the school district, the school board and ask them to
reevaluate their curriculum on what’s going on in the schools and what the kids are
being taught. The kids need to be asked. They need to be involved in what is going on in
the community and they need to be involved in the process of making decisions and
choices."
— Social Services Representative
"We have found that the
middle school and elementary school level is where the decisions are starting to be made,
and so by the time they get to high school, they’ve already made up their minds what
it is that they’re going to do and not do. Something that we really want to emphasize
in our community is that the younger the age group that you get, the better the chances
are for them. By the time they get to high school it’s already too late."
— Social Services Representative
Finally, these social service
providers indicated that health education needs to be culturally competent and involve the
entire community, and that positive outcomes should be marketed to physicians to show the
benefits of health education.
"[We need] culturally
competent health education…"
— Social Services Representative
"There are resources out
there and there are people who would be happy to come in and help with something like
that, but it just takes some coordination and somebody to really do some planning.
Everybody’s too busy, everybody’s stretched beyond what they can already
do."
— Social Services Representative
"As we collect data as a
community-based health project, in collecting the data and seeing the outcomes of
community health education, we’ll see some differences there [and] we have to market
that to the physicians."
— Social Services Representative
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