SRHCP_Market_Analysis_Final_103012

S A C R A M E N T O R E G I O N
H E A L T H C A R E P A R T N E R S H I P / 2 0 1 2
A Market Analysis of the Sacramento Region Primary Care Safety Net
A Sierra Health Foundation initiative
Preparing forTransformation:
Rethinking, Revitalizing and Reforming
the Sacramento Region’s Health Care System

S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P
This market analysis of the Sacramento Region primary care safety net system was
commissioned and funded by Sierra Health Foundation with additional funding from
The California Endowment and Sacramento Region Community Foundation. The analysis
was conducted by The Abaris Group, Public Health Institute and Hatches Consulting.
Consultant Team
The Abaris Group
Mike Williams, MPA/HSA, Project Lead
Marsha Regenstein, PhD
Alaina Dall
Juliana Boyle, MBA
Mark Zocchi
Chuck Baucom
Public Health Institute
Carmen Nevarez, MD, MPH
Marisel Brown, MPH, MSBA
Art Chen, MD
Elaine Zahnd, PhD
Nancy Shemick, MPP
Amy Neuwelt, MPH
Heather Bonser-Bishop
Hatches Consulting
Barrett Hatches, PhD
The Abaris Group, Public Health Institute, Hatches Consulting,
Mighty Pen Writing & Editing and Sierra Health Foundation
contributed to the writing and editing of this market analysis.

S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P
Table of Contents
Acknowledgements 1
Letter from the Funders 4
Letter from Congresswoman Doris Matsui 5
Executive Summary 6
Project Overview 9
How This Report Was Developed 11
The Sacramento Region’s Safety Net Population 13
Health Reform Background and Implications 15
Safety Net Snapshot 19
Current Safety Net Providers 20
Emergency Departments Overused for Primary Care 23
Detailed Data Analysis Findings 23
Safety Net Demand 23
Preventable/Avoidable Emergency Department Visits 25
Safety Net Capacity 26
Health Professional Shortage Areas 29
Safety Net Projections 31
Safety Net Funding 34
Stakeholder Feedback 36
Conclusions and Next Steps 38
Appendices
1. Glossary of Terms 41
2. Sacramento Region Community Health Indicators 44
Available Online at www.sierrahealth.org/healthcarepartnership
Community Health Center Site Visits and Interviews
Community Physician Discussion Group Interviews
Health Center Consumer Focus Group Interviews
SACOG Transit Study Highlights
County Programs for the Underserved
Sacramento Region Health Care Partnership Market Analysis Chartbook

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Acknowledgements
Thank you to the many stakeholders who contributed their time, expertise and involvement with the development of this market
analysis. Sincere apologies to anyone who may have been inadvertently left off this list.
Jonathan Lehrman, MD
Access El Dorado
Christine Sison
Access El Dorado
Sandi Snelgrove
Another Choice Another Chance
Sean Atha
Anthem Blue Cross
Kerry Brown
Anthem Blue Cross
Kim Williams
Building Healthy Communities
Joseph Hafkenschiel
California Association for
Health Services at Home
Christine Smith
California Consortium for
Urban Indian Health
Rosana Jackson
California Department of Public Health
Leticia Alejandrez
California Family Resource Association
Doretha Williams-Flournoy
California Institute for Mental Health
Carol Lee
California Medical Association Foundation
Elissa Maas
California Medical Association Foundation
Ed Mendoza
California Office of Statewide Health
Planning and Development
Ronald Spingarn
Jonathan Teague
Sandra Perez
California Office of the Patient Advocate
Martha Torres-Montoya
California Office of the Patient Advocate
Kiran Grewal
California Pharmacist Association
Deborah Ortiz
California Primary Care Association
David Quackenbush
California Primary Care Association
Steve Barrow
California State Rural Health Association
Al Hernandez-Santana
Califonia State Rural Health Association
Marty Keale
Capitol Community Health Network
Ashely Tolle
Capitol Community Health Network
John Adams
CASA El Dorado
Debbie Brussard
Center for AIDS Research,
Education & Services
Robert Kamrath
Janet Parker
Wendy Petko
Center for Community Health and
Well-Being, Inc.
Karen Shore
Center for Health Improvement
Tara Davis
Center For Innovative
Community Solutions
Shelia Duruisseau-Sidqe
Center For Innovative
Community Solutions
Autumn Valerio
Center for Multicultural Development
Cathy Frey
Central Valley Health Network
Lisa Davies
Chapa-De Indian Health Program, Inc.
Robin Affrime
CommuniCare Health Centers
Leon Schimmel, MD
CommuniCare Health Centers
Alan Lange
Community Link Capital Region
Ariel Lovett
Community Recovery Resources
Brian Graaf
Community Resource Project
Kelly Bennett-Wofford
Cover the Kids
Joil Xiong
Cover the Kids
Michael Negrete, PharmD
CPhA and California Northstate University
Kaci Baldi
Dignity Health
Rosemary Younts
Dignity Health
Liz Dowell
Divide Ready by 5
John Bachman, PhD
El Dorado Community Health Center
James Ellsworth
El Dorado Community Health Center

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Deborah Palmer
El Dorado County
Olivia Byron-Cooper, MPH
El Dorado County Health &
Human Services Agency
Joan Meis Wilson
El Dorado County Health
& Human Services Agency
Michael Ungeheuer, RN, MN, PHN
Christy White
Christine Hoyt
El Dorado County Public Health
Alex Bolte
El Hogar Mental Health
and Community Services
Eileen Snicker
Feminist Women’s Health Center
Rick Alford
First 5 El Dorado
Kathleen Walker
First 5 El Dorado
Debra Payne
First 5 Sacramento
Julie Gallelo
First 5 Yolo
Debra Oto-Kent
Health Education Council
Richard Ikeda, MD
Health for All
Effie Ruggles
Health Net of California
Martha Geraty
Health Net State Health Programs
Scott Seamons
Hospital Council of Northern
and Central California
Jennifer Ablog
Kaiser Permanente
Ellen Brown
Kaiser Permanente
Stephanie Landrum
Kaiser Permanente
Myrna Rivas
Kaiser Permanente
Patricia Rodriguez, RN, MPH
Kaiser Permanente
Carol Serre
Kaiser Permanente
Chaosarn Chao
Lao Family Community
Development, Inc.
Elisa Herrera
Latino Leadership Council
Bob Long, MD
Latino Leadership Council
Bill Kennedy
Legal Services of Northern California
Frank Lemus, PhD
Lemus Consulting Group
Jennifer Dwight-Frost
Marshall Medical Center
Sherry Geurin
Vern Sahara
Denny Powell
Mercy General
Marcia Wells
Mercy Norwood Family Clinic
Tony Browne
Midtown Medical Center
for Children & Families
Elizabeth Cassin
Robert Reich
Richard Dana
Mutual Assistance Network
Leonard Ranasinghe, PhD, MD
Natomas Crossroads Clinic
Barbara Sayre-Thompson
NCADD Sacramento
Gail Catlin
Nonprofit Resource Center
Richard Burton, MD, MPH
Placer County Health & Human Services
James Gandley, DDS, MPH
Placer County Health & Human Services
Elizabeth Fraley
Planned Parenthood Mar Monte
Raquel Simental
Jennifer Stork
Linda Williams
Lorraine Rinker
Rinker and Associates
Alicia Ross
Sacramento Area Congregations Together
Allison Swan
Nenick Vu
Joe Concannon
Sacramento Area Council of Governments
Gordon Garry
Monica Hernández
Rebecca Thornton Sloan
Sharon Sprowls
DiAnne Brown
Sacramento City Unified School District
Jerry Bliatout
Sacramento Community Clinic/HALO
Miguel Suarez
Sacramento Community Clinic/HALO

Brad Hudson
Sacramento County
Paul Lake
Sacramento County Department
of Human Assistance
Sandy Damiano, PhD
Sacramento County Health Services
Marcia Jo, PhD
Sacramento County Health Services
Ann Edwards
Sacramento County, Countywide Services
Bruce Wagstaff
Sacramento County Countywide Services
Kathy Harwell
Sacramento County Health & Human Services
Olivia Kasirye, MD, MS
Glennah Trochett, MD
Dyann Wolfe
Sacramento Family Medical Center
Kendra Bridges
Sacramento Housing Alliance
Lisa Bates
Sacramento Housing Redevelopment Agency
Eric Enriquez
Sacramento Native American
Health Center, Inc.
Britta Guerrero
Health Center, Inc.
Allie Shilin
Health Center, Inc.
Priscilla Enriquez
Sacramento Region Community Foundation
John Chuck, MD
Serotonin Surge Charities
William Sandberg
Sierra Sacramento Valley Medical Society
Kristine Wallach
Aileen Wetzel
Kelly Brenk
Sutter Health
Tom Gagen
Sutter Health
Holly Harper
Sutter Health
Keri Thomas
Sutter Health
Jose Alberto Arevalo, MD
Sutter Independent Physicians
Marlon Cuellar
The California Endowment
Christine Tien
The California Endowment
Eric Fimbres
The Effort, Inc.
J. Rodney Kennedy
The Effort, Inc.
Bunry Pin
The Effort, Inc.
Jonathan Porteus, PhD
The Effort, Inc.
Tom Stanko, MD
The Gathering Inn Clinic
Grace Rubenstein
The Sacramento Bee
Warren Barnes
UC Berkeley SoPH/Right Care Initiative
Shelton Duruisseau, PhD
UC Davis Health System
Laura Niznik
Claire Pomeroy, MD, MBA
Carolyn Ramirez
Robert Waste, PhD
Congresswoman Doris Matsui
U.S. House of Representatives
Nathan Dietrich
Office of Congresswoman Doris Matsui
Kari Lacosta
Office of Congresswoman Doris Matsui
Dale Ainsworth, PhD
Valley Vision
Carl Heard
Western Clinicians Network
Charla Parker
Casie Parrish
Alexander Giloff
Western Sierra Medical Center
Sher Barber
Wind Youth Services
Kim Suderman
Yolo County Alcohol, Drug
and Mental Health
Jill Cook, MS, RN, PHN
Yolo County Public Health
Traci Lucchesi
Yolo County Public Health
Trisha Stanionis
Yolo Family Service Agency
Greg Bergner, MD
Dawn Dunlap
Consultant
Grantland Johnson
Former Secretary of California Health and
Human Services Agency
Sierra Health Foundation:
Chet Hewitt
Diane Littlefield
Robert Phillips
Abraham Daniels
Susan King
Katy Pasini

Letter from the Funders
Dear Colleagues,
In 2011, Sierra Health Foundation launched the Sacramento Region Health Care Partnership with the goal of
finding ways to improve access, care coordination and the quality of the region’s primary care system, with a
specific focus on community health centers. Partners in this initiative included leaders from community clinics,
health systems, health plans, associations and counties, as well as physicians, policymakers and others. The
timing was right, as the implementation of the Affordable Care Act in 2014 offers an unprecedented
opportunity to extend health insurance coverage to those currently uninsured.
In order to fully realize the opportunities of the ACA, we need to understand both the strengths and the
weaknesses of the current regional system that serves residents of El Dorado, Placer, Sacramento and Yolo
counties. Accordingly, the Partnership commissioned two studies: a market analysis that identifies the current
service capacity within the primary care safety net, and a strategic plan to develop an integrated health care
delivery system model that efficiently links community health clinics to regional providers, thus expanding
access to high quality and culturally sensitive services for low-income adults and children in our region. The
California Endowment and Sacramento Region Community Foundation were funding partners for the market
analysis and strategic planning process.
We are pleased to share with you the market analysis and the strategic plan, which illuminate what we can do
as a region to prepare for the transformative impacts of health care reform. The stresses on our regional safety net
are substantial; at the same time, we are galvanized by the vision of a collaborative, accessible, high quality and
culturally competent primary care health system that is outcome-based and sustainable. That is a vision we can
and must support, individually and collectively.
We offer these reports to inspire conversation and action about the ways to create a high quality patient care
system that will be ready, willing and able to serve our newly insured residents. This is a time of tremendous
challenge and opportunity, and we must take wise steps together as we create a stronger and wider safety net
to effectively serve all of our residents.
Sincerely,

Chet P. Hewitt Dr. Robert K. Ross Ruth Blank
President and CEO President and CEO CEO
Sierra Health Foundation The California Endowment Sacramento Region Community Foundation

Executive Summary
Preparing the Sacramento Region for the
transformative impacts of health care reform
Is the Sacramento Region ready for health care reform?
Can the Sacramento Region primary care safety net absorb
a dramatic influx of newly insured patients in 2014? How
can the Sacramento Region maximize the benefits afforded
by the Patient Protection and Affordable Care Act (ACA)
to improve access and quality for the Sacramento Region’s
most vulnerable residents? What resources (ACA and other)
can the Sacramento Region apply to bolster safety net
functioning to better meet current and looming demands?
ACA offers an unprecedented opportunity to rethink,
revitalize and reform Sacramento’s regional health care
system. But even without this law, the four counties that
make up the region — El Dorado, Placer, Sacramento
and Yolo — would be wise to consider addressing weakness
in their primary care system. Why? Because the capacity
of the institutions that represent the medical safety net is
directly linked to its ability to meet the health care needs of
the region’s most vulnerable residents. As this report makes
clear, all of the health care stakeholders in the Sacramento
Region must work together to close the gaps between
residents’ health care needs and the system’s ability to
efficiently meet them.
This market analysis and a companion regional strategic
plan conclude the initial work of the Sacramento Region
Health Care Partnership. Our goals for this work were
straightforward: to better understand the dynamic affecting
the safety net system and develop a regional strategic plan to
foster the development of an integrated health care delivery
system that efficiently links community health centers to
regional providers. It was the collective hope of the many
groups and individuals who participated in this work that it
would result in expanded access to high quality services for
low-income adults and children in the Sacramento Region.
The market analysis identifies the Sacramento Region safety
net’s strengths, weaknesses, opportunities and stressors.
Armed with these insights, the Sacramento Region can
better meet its communities’ health care needs today to
improve health, while preparing itself for vastly increased
demand under ACA.
Health Care Reform Background and Context
The passage of the Patient Protection and Afforable
Care Act (ACA)
1
, as amended by the Reconciliation Act
of 2012 (P.L. 111-152) — collectively referred to as the
health reform law — transforms the delivery and financing
of the health care system. The intent of ACA is to expand
health insurance coverage while also reforming the health
care delivery system to improve quality and value. ACA also
includes provisions to eliminate disparities in health care,
strengthen public health care access, invest in the expansion
and improvement of the health care workforce, and encourage
consumer and patient wellness in both the community
and the workplace. ACA is investing $11 billion in new
mandatory federal spending through 2015 to support the
expansion of health center capacity for the millions of
uninsured Americans who will be eligible for Medicaid or
private coverage beginning in 2014.
The vehicle for this funding is the Community Health
Centers and National Health Service Corps Trust Fund,
which was created by the passage of ACA. This new trust fund
changes the way new health center funding is appropriated.
Instead of Congress making the determination of funding
levels each year, the Department of Health and Human
Services will be able to directly appropriate the health center
funds once the federal budget is passed and signed into law.
The thrust of the Health Center Trust Fund is to expand
health centers’ capacity and to invest in health centers as a
strategy for building health care capacity in the U.S.
2
According to the Congressional Budget Office, the law will
increase coverage to about 94 percent of Americans, while
slowing the rate of growth in federal health expenditures by
$124 billion over the next decade.
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1 ^ Pub.L. 111-148, 124 Stat. 119, to be codified as amended at scattered sections of the
Internal Revenue Code and in 42 U.S.C.

2 Kaiser Commission on Medicaid and Uninsured: Community Health Centers:
The Challenge of Growing to meet the need for primary care medically underserved
communities. http://www.kff.org/uninsured/upload/8098-02.pdf

227,500 newly insured patients will overwhelm
our region’s safety net.
Table 1.
In the Sacramento Region (El Dorado, Placer, Sacramento
and Yolo counties), a projected 227,500 non-elderly adults
and children will be eligible for health coverage through
expanded Medi-Cal benefits or subsidized private insurance
(health care exchanges).
Significant Opportunities for Improvement
The health reform law permanently authorizes and expands
community health centers and the National Health Services
Corps. The health reform law provides a total of $1.5
billion in new funding through 2015 to train more
primary care providers via scholarships and loan repayment
assistance. ACA investments will double community health
center capacity. Through federal programs and grants to
states, the health reform law will help expand the nation’s
health workforce — from physicians and nurses to public
health professionals — through scholarships and local
repayment assistance. The law also aims to improve the
diversity of the health care workforce to deliver care that is
appropriate for the entire population.
In short, the law provides many opportunities to strengthen
the safety net, but also poses real challenges. Meeting the
vastly increased demand for health care services is no small
task. Throughout the nation, communities are at different
points in preparing for the increased number of residents
covered through Medicaid expansion mandated by ACA.
The Role of Sacramento Region
Health Care Partnership
At the request of several community stakeholders, in
2011 Sierra Health Foundation launched the Sacramento
Region Health Care Partnership. The initiative grew out
of conversations with policymakers, health systems and
community health centers, who approached Sierra Health
Foundation to serve as intermediary in preparing the
Sacramento Region, which includes El Dorado, Placer,
Sacramento and Yolo counties, to implement health reform.
The Health Care Partnership creates the region’s first
coordinated philanthropic, county agency, nonprofit
provider and community health center effort focused
solely on regional health care reform preparedness
and implementation.
The Sacramento Region Health Care Partnership includes a
broad range of health care partners and leaders throughout
the Sacramento Region, including community health
centers, health systems, health plans, associations and
counties, as well as physicians, policymakers and other
nonprofits that work within the safety net. Sierra Health
Foundation, The California Endowment and Sacramento
Region Community Foundation are funding partners
of the market analysis and regional strategic plan.
The Health Care Partnership’s Goal
The Sacramento Region Health Care Partnership’s goal is to
find ways to improve access, care coordination and quality
of the region’s safety net primary care system through input
from health care and civic leaders and other stakeholders.
The Health Care Partnership’s ultimate vision is to increase
and improve primary care access and quality for individuals
and families in low-income communities and communities
of color in El Dorado, Placer, Sacramento and Yolo counties.
Better access to primary care will lower the cost of health
care overall, better allocate health care resources (e.g., reduce
expensive, unnecessary acute care responses to preventable
chronic disease) and improve public health in the
Sacramento Region.
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SacramentoRegionInsuranceCoverage2009and2014
Source: MCIC Chicago, 2012
Insurance 2009 Percent Movement 2014 Percent
Individual 103,973 4.9% 109,610 213,583 10.0%
Medicare 248,432 11.6% - 248,432 11.6%
Medi-Cal 369,057 17.3% 117,947 487,004 22.8%
Uninsured 303,306 14.2% (227,557) 75,749 3.6%
Total 2,132,796 - - 2,132,796 -
Employer 1,108,028 52.0% - 1,108,028 52.0%
2014
SacramentoRegionMedianHouseholdIncome&FederalPovertyLevels,2010
Note: For purposes of comparison the 2010 FPL is shown. 2012 FPL is $11,170
for individuals and $23,050 for families of four.
Sources: 2010 American Community Survey (ACS); Health and Human Services Poverty Guidelines
El Dorado County $66,129
Placer County $67,884
Sacramento County $52,709
Yolo County $55,798
California $57,708
100 Percent $10,830 $22,050
200 Percent $21,660 $44,100
Median Household
Income 2010 Federal
Poverty Levels
Individual Four-person
Family
SelectedCharacteristicsofIndividuals<138percent
ofFPLandUninsuredforallorpartof2009
Source: 2009 CHIS
Percent Male 62.6
Percent White 35.4
Percent Latino 38.3
Percent Unemployed 47.6
Percent “no usual source of care” 55.8
Percent “delayed or did not 24.2
get needed medical care”
Percent “fair or poor health” 26.9
Percent “current smoker” 29.9
Percent “obese” 28.2

About the Market Analysis
This market analysis is the largest and most comprehensive bench-
mark of the primary care safety net in the Sacramento Region to
date, assessing both current and forecasted demand and capacity.
Rather than relying solely on data analysis, a systems view
was taken to understand the current and forecasted capacity
of the primary care safety net. The focus was on community
health centers, health systems, health care providers and
nonprofits that are part of the entire engine that drives the
Sacramento Region’s safety net. Conversations with people
on the front lines of health care delivery in the region and
low-income residents were also included in this analysis.
This market assessment incorporates input from stakeholder
interviews, community health center site visits, data analysis
from a variety of sources, and focus group interviews with a
cross-section of leaders, physicians and consumers of
community health center services.
Key Findings: 10 Stressors and Strengths Driving
Regional Safety Net Performance
The Sacramento Region Health Care Partnership has
identified 10 critical issues impacting safety net performance
and sustainability. Some are challenges to be mitigated, and some
are strengths to be capitalized on. All present opportunities to
improve our region’s primary care and specialty care delivery
for the underserved population in the Sacramento Region.
1. Rethink Primary Care. While the current safety net in
the region has many challenges, the advent of ACA allows
the community the opportunity to rethink its approach to
primary care as currently provided by the safety net.
2. Growing Demand. 227,500 non-elderly adults and
children will be eligible for health care coverage under
ACA. The safety net population is growing and will
continue to grow naturally. Demand will accelerate with
the advent of ACA.
3. Sicker Citizens. Community health indicators predict
the newly insured population will be sicker than the
existing publicly insured patient population and have
significantly higher levels of chronic diseases and risk
factors, such as asthma, diabetes, high blood pressure,
obesity, smoking and previously unmet needs for health
care and/or mental health/alcohol or drug help.
4. Maxed Out Capacity. The primary care capacity of
community health centers and emergency departments
to treat the safety net population has grown, but without
further efforts it will likely reach capacity prior to 2016.
5. Regional Capacity Below Average. The number of
community health centers in the Sacramento Region
has grown, but falls significantly short of many other
similar-sized regions in California.
6. More Medi-Cal Payments. Approximately 60 percent
of the newly insured patients will be insured by
Medi-Cal, making it the second largest payer source in
the Sacramento Region.
7. Overuse of High Cost Hospital and Emergency
Department Services. Currently, the safety net is
overly dependent on expensive hospitals, and emergency
departments, in particular, to provide outpatient care.
8. Financially Challenged Community Health Centers.
Roughly half of the region’s community health centers
are financially challenged, with expenses consistently
exceeding revenues.
9. Limited Federally Qualified Health Centers.
The number and location of federally qualified health
centers (FQHCs) in the region is lower than the state
average and other regions. Many community health
centers are not able to take advantage of financial
incentives afforded to FQHCs.
10. Lack of Coordinated Leadership. The current health care
safety net lacks a lead agency, coordination and integration.
Next Steps
Based on the findings in this market analysis, the Sacramento
Region Health Care Partnership has developed a regional
shared vision and strategic plan to address the most critical
factors in order to improve the primary care safety net in the
region. This plan is presented in a companion report: Preparing
for Transformation: Rethinking, Revitalizing and Reforming the
Sacramento Region’s Health Care System, a Strategic Plan for
the Sacramento Region. These reports are available online at
www.sierrahealth.org/healthcarepartnership.

Project Overview
Identifying needs and opportunities to optimize
the Sacramento Region’s safety net system
Project Objective:
To fully understand and transform the Sacramento Region’s
health care system (primary care, specialty care, acute
care and health plan management) in preparation for full
implementation of health reform; ensure care capacity and
resident access; and identify opportunities for various
stakeholders to contribute to these changes.

Market Analysis Background and Context:
Building on Previous Research
In 2009, the California HealthCare Foundation issued a
market report of the Sacramento Region. A key finding
underscores a longstanding challenge: “The safety net is
characterized by a fragmented group of small and
financially fragile health centers that together offer limited
outpatient capacity.”
3
A separate report
4
identified these
specific challenges facing the Sacramento Region’s safety net:
• underdeveloped administrative and service delivery
capacity,
• limited access to medical specialists and dental care,
• insufficient linguistic and cultural resources, and
• transportation barriers.
In addition, over the last four years, many of the region’s
county health agencies have seen their general fund
support dwindle. A case in point is the Sacramento County
Department of Health and Human Services. Consistent
cuts to Sacramento County’s Department of Health and
Human Services beginning in 2008 have resulted in a 50%
reduction in its total budget and the closure of five of its
six primary care clinics.
In 2010, the four local health systems — Dignity Health
(Catholic Healthcare West), Kaiser Permanente, Sutter
Health Sacramento Sierra Region and the University of
California Davis Health System — partnered with Valley
Vision to conduct a Community Needs Assessment in the
Greater Sacramento Region. The assessment highlighted
challenges and needs within underserved populations and
identified key sources for hospital admissions and emergency
department visits. Zip code data provided insight in
defining the needs of the underserved population. These
were the predominant obstacles that hindered or prevented
access to health care within the underserved population:
5
• affordability of health care services, especially
health insurance,
• locating physicians, specialists, dentists, mental/
behavioral health and other providers who accept
Medi-Cal and/or work at reduced rates,
• navigating a complex and inefficient safety net and
related social services system, and
• cultural barriers, including language and social customs.
Anticipating the Regional Impact of ACA
Implementation of the federal Patient Protection and
Affordable Care Act (ACA) in 2014 represents an
unprecedented opportunity to expand health insurance
coverage to those currently uninsured and support new and
innovative payment models. The ACA also brings renewed
attention to enrollment in a “patient-centered medical
home” to improve efficiency and coordination of care,
which will be studied as demonstrations by the Center for
Medicare and Medicaid Innovation, the new research and
development arm of the Center for Medicare and
Medicaid Services
6
.
3 California HealthCare Foundation, Sacramento Powerful Health Systems Dominate a Stable
Market. http://www.chcf.org/publications/2009/07/sacramento-powerful-hospital-systems-
dominate-a-stable-market#ixzz1t5kNz6tN (Last access 4-25-12)

4 July 2008 report, “Toward an Improved Health Care System for Sacramento County’s
Underserved Residents,” authored by the Sacramento Health Improvement Project.

5 Ainsworth D., Diaz H., Schmidtlein M. 2010 Community Needs Assessment For the Greater
Sacramento Region. http://www.healthylivingmap.com/CNA%20Report%202010.pdf.

6 Analysis of ACA Title II Subtitle I Sec. 2303 – Payment; Sec. 2703—State option to provide
health homes for enrollees with chronic conditions; Sec. 2706—Pediatric Accountable Care
Organization demonstration project; Title III Sec. 3021—Establishment of Center for
Medicare and Medicaid Innovation within CMS; Title V Sec. 5301—Training in family
medicine, general internal medicine, general pediatrics, and physician assistantship; Sec.
5501—Expanding access to primary care services and general surgery services; Health Care
and Education Reconciliation Act Sec. 1202—Payments to primary care physicians.

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Current estimates project 227,500 non-elderly adults and
children in the region will be eligible for coverage through
expanded Medi-Cal benefits or subsidized private insurance.
Hospital emergency departments currently play a large role
in the care of uninsured and Medi-Cal patients.
7
In most
instances, these newly eligible insured will now be accessing
health care services from safety net providers, clinics
and community health centers. In order to realize the
opportunity of the ACA, leaders in the region’s health care
community must work together to expand and stabilize
the primary care safety net.
Sierra Health Foundation’s Role and the
Sacramento Region Health Care Partnership
Sierra Health Foundation has a long history of partnership
and support for the health care safety net in the Sacramento
Region, with a particular emphasis on the underserved. This
focus area underscores the foundation’s mission to invest in
and serve as a catalyst for ideas, partnerships and programs
that improve health and quality of life in Northern California.
At the request of several community stakeholders, in 2011
Sierra Health Foundation launched the Sacramento Region
Health Care Partnership, a coordinated philanthropic,
county agency, nonprofit provider and community health
center effort to strengthen the health care safety net in the
four-county Sacramento Region. The initiative grew out
of conversations with health care leaders, including policy-
makers, health systems and community health centers, who
approached the foundation to play a key intermediary role in
the building of a 21st-century patient care and coordination
system for the region’s medically underserved.
The Sacramento Region Health Care Partnership’s goal is to
find ways to improve access, care coordination and quality of
the region’s primary care safety net system. The Sacramento
Region Health Care Partnership began by conducting
this updated market analysis to obtain a baseline of the
current service capacity within the primary care safety net
and forecast of clinic capacity needs. The findings informed
the development of a regional strategic plan to develop an
integrated health care delivery system model that efficiently
links community health centers to regional providers.
The ultimate vision is to increase and improve primary
care access and quality for individuals and families in
low-income communities and communities of color in
El Dorado, Placer, Sacramento and Yolo counties.
Partners
Sierra Health Foundation is developing partnerships with
health and civic leaders and building on the series of
Health Care Working Group convenings held in 2011 by
Congresswoman Doris Matsui. Initiative partners include
a broad range of leaders from community health centers,
health systems, health plans, community-based
organizations, associations and counties, as well as
physicians, policymakers and nonprofits that work within
the safety net. Sierra Health Foundation, The California
Endowment and Sacramento Region Community
Foundation are funding partners for this market analysis
and subsequent strategic plan.

Expected Outcomes
• Establish a more sustainable and financially viable
primary care safety net system.
• Improve administrative and service delivery capacity of
primary care providers to accommodate the vast increase
of insured residents under the Affordable Care Act.
• Facilitate the development of an integrated health
care delivery system model that links primary care to
specialty care and hospital systems.
• Expand access to high-quality and culturally sensitive
services for residents across the Sacramento Region.
7 JAMA 2010;304(6):679-680 Katz, Mitchell. Future of the Safety Net Under Health Reform:
http://jama.ama-assn.org/cgi/content/full/304/6/679

How This Report Was Developed
A systems approach offers multiple
perspectives on safety net performance.
The consultant team used a combination of sources and
qualitative and quantitative methodologies to gather
input about the current and future demand for care and
the health care safety net’s current and future capacity to
provide it.
Qualitative Input: Stakeholder Site Visits,
Surveys and Interviews
To capture a 360-degree view of the region’s safety net, the
consultant team did more than analyze data. They went out
and talked to health care providers and stakeholders who
are on the front lines of the region’s safety net. Site visits,
surveys, interviews, discussion groups and focus groups
provide feedback and insights.
The consultant team interviewed community health center
leaders and administered a survey on the state of the safety
net. These site visits also assessed current and anticipated
capacity needs. The team also held a discussion group with
primary care physicians practicing in various care settings
throughout the region.
In addition, the team conducted interviews with the
major health systems (Dignity Health, Kaiser Permanente,
Sutter Health, University of California Davis Health
System and Marshall Medical Center) and with key health
plans (Health Net of California and Anthem Blue Cross).
For a complete list of site visits and individual interviews,
visit www.sierrahealth.org/healthcarepartnership.
Once the data was collected, the consultant team made
presentations in each of the four Sacramento Region
counties to gather input, feedback and suggestions for the
final market analysis instruments.
The team also conducted three focus groups with residents
who are safety net consumers of health care services. See
www.sierrahealth.org/healthcarepartnership for background
and details.
Quantitative Data Sources
The market analysis tapped a variety of data sources. The
primary data source used for health center and hospital
demand and capacity was the California Office of Statewide
Planning and Development (OSHPD). OSHPD collects
data and disseminates information about California’s health
care infrastructure, promoting an equitably distributed
health care workforce and publishing information about
health care outcomes.
8
Emergency department utilization estimates of preventable/
avoidable visits used the New York University ED
Algorithm. More information about the development and
methodology of this algorithm can be found at the NYU
Center for Health and Public Service Research.
9
Data for Federally Qualified Health Centers (FQHC) was
obtained and mapped using the federal Uniform Data
System’s (UDS) mapper system, an online data source at
www.udsmapper.org, to evaluate data sent from federally
funded community health centers. The project team used
this data to create region-level and county-level maps and
other analyses.
Demographic and Population Health Data
For historical and current population estimates, this report
uses data from the U.S. Census Bureau and California
Department of Finance. Sacramento Area Council of
Governments (SACOG) population data was used for the
county-level population projections through 2016.
Population health data was obtained from the California
Health Interview Survey (CHIS). This survey is conducted
continuously, released biannually, and contains survey data
on a variety of health access, insurance status, health
outcome and behavior indicators.
8 http://www.oshpd.ca.gov/aboutus

9 http://wagner.nyu.edu/chpsr/. See ED Algorithm. (last accessed 4-24-12)

S A C R A M E N T O R E G I O N H E A L T H C A R E P A R T N E R S H I P | P a g e 1 2
Health Reform Data
Data on health reform was obtained from the Metro
Chicago Information Center (MCIC). MCIC used 2009
American Community Survey (ACS) data to calculate
estimates of insurance coverage status and estimates from
the Department of Homeland Security to adjust for the
ACS undercount of non-citizens and to calculate the
number of undocumented residents.
These estimates were incorporated into the projection
models to project community health center and emergency
department demand under ACA. The market analysis also
uses projections of “uptake” rates of those currently
uninsured to insured, which used zip code-level analysis
to produce data specific to the Sacramento Region.
Projection Methodology
Projections of community health center and emergency
department demand were developed using a simple linear
projection model. The model uses 2006-2010 data to
establish a baseline projection for 2012, 2014 and 2016.
The model then adds or subtracts from the baseline to
reflect estimated impact of health reform changes on payer
mix and utilization patterns.
The emergency department projection model assumes
that the growth trend seen in the region’s emergency
department demand will continue into 2012, 2014 and
2016. This assumption is based on findings of Chen et
al,
10
who concluded that the Massachusetts health reform
of 2006 did not impact emergency department utilization.
However, this may not be the case for health reform
implementation in California. Some have argued that the
decline in emergency department use in Massachusetts is a
result of better access to primary care.
11
Others have argued
that emergency department use will increase under ACA
due to lack of access in other settings.
12
Ultimately, whether
emergency department use is impacted is also a matter of
how access to primary care is granted. The current system
may cause overutilization by denying patients the ability to
select their own health home or changing it if dissatisfied,
whereas the emergency department must see the patient
whenever the patient wants. This study shows the changes
needed if emergency departments are to absorb demand
with no migration of care to other settings.
Transportation Issues Data
To expand on previous studies, SACOG sought and
obtained a Caltrans Environmental Justice Planning Grant
to examine the transportation needs of low-income,
transit-dependent residents of the SACOG region, and
analyze gaps in public transit service to reach essential or
“lifeline” destinations. Highlights of findings from the
SACOG study are detailed at www.sierrahealth.org/
healthcarepartnership.
Study Limitations
This market analysis was conducted between November
2011 and April 2012 using the latest data sources available.
As in many large regional studies, public data sources (e.g.,
OSHPD, UDS, etc.) were deemed the most useful. These
sources are readily accessible and comparable due to their
defined data definitions set. However, missing from these
public reports are non-reporting entities, which include
county-run primary care health centers, “free clinics” and
independent primary care physicians and other service
delivery entities — all of which play important roles in
meeting the health care needs of the region’s safety
net population. While efforts were made to obtain
quantitative data from these sources, the study’s scope
did not allow their inclusion in this report. Instead, the
consultant team captured input from these providers via
qualitative research methods.
10 Chen C., Scheffler G., Chandra A. Massachusetts’ Health Care Reform and Emergency
Department Utilization. New England Journal of Medicine. 2011:110907140018030.

11 Smulowitz P.B., Lipton R., Wharam J.F., et al. Emergency Department Utilization After
the Implementation of Massachusetts Health Reform. Annals of Emergency Medicine.
2011;58(3):225–234.e1.

12 Goodman J. What Will Happen To Emergency Room Traffic? Health Affairs Blog.
July 12, 2010. Available at: http://healthaffairs.org/blog/2010/07/12/what-will-happen-to-
emergency-room-traffic/. Accessed April 23, 2012.
Sacramento
Source: U.S. Census Bureau, American Community Survey 2005-2009 5-yr est; Health Resources
and Services Administration (HRSA); Uniform Data System, (UDS); www.udsmapper.org
50-100% loss Other Hospital
10-50% loss Short Term Hospital
<10% change Rural Health Clinic
10-50% gain FQHC Look-Alike
>50% gain CHC (*FQHC)
Change in CHC* Utilization,
2008 - 2010
Yolo
Sacramento
El Dorado
Placer
Medically Underserved Areas and General Acute Care Hospitals, 2010
Source: Health Resources and Services Administration (HRSA)
Hospital (General Acute Care)
Medically Underserved Area
Regional Map of CHCs and County Run Clinics
Source: OSHPD, 2011

The Sacramento Region’s
Safety Net Population
Who is served by the Sacramento Region’s
safety net?
The consultant team began its analysis with an overview of
the Sacramento Region’s population in El Dorado, Placer,
Sacramento and Yolo counties in Northern California. Who
does the region’s primary care safety net serve now? How are
residents accessing primary care?
The Sacramento Region is home to approximately 2.15
million residents. The area’s population has grown rapidly in
the past decade. While Sacramento residents have higher
income, education, private insurance coverage and better
overall health than average for California, there exist wide
health disparities within the region by race, ethnicity and
income. However, almost one-third of Sacramento Region
residents have incomes below 200 percent of the Federal
Poverty Level (FPL) and 15.1 percent live below
100 percent of the FPL.
Table 1. Sacramento Region Population Estimates
Table 2. Median Household Income and FPL
Sacramento
Placer
ElDoradoYolo
Sacramento
Placer
ElDoradoYolo
El Dorado, Placer, Sacramento and Yolo counties.
Sacramento
Placer
ElDoradoYolo
Sacramento
Placer
ElDoradoYolo
nue Margins, 2010
HPD Primary Care Clinic Utilization Data Files, 2010
Source: California Department of Finance, 2006-2010
edical Care HPSA-Facilities
D licensed clinic; † FQHC; ‡ FQHC Look-Alike
Name County
Memorial Hospital Community Clinic* El Dorado
o Community Health Center*† El Dorado
prings Tribal Health Program* El Dorado
e Indian Health Program, Inc.* Placer
a Rural Indian Health Board, Inc. Placer
a State Prison Sacramento Sacramento
tate Prison Sacramento
or All, Inc.*‡ Sacramento
nto Community Clinic*‡ Sacramento
nto County Department of Health Sacramento
nto NaƟve American Health Center, Inc. Sacramento
rt*† Sacramento
nicare Health Center*† Yolo
n Medical Center for Children
ilies*
Yolo
Healthcare Founda on*† Yolo
Sacramento Region California
s -4.8% 1.9%
-3.3% 2.2%
ok-Alike 13.6% -5.4%
HC -8.4% 2.3%
SafetyNetTrendsataGlance,between2006and2010
Increasing Steady Decreasing
Region’s PopulaƟon
Chronically Ill Residents
Insured Residents (Medi-Cal, Private)
Uninsured Residents
Community Health Center Use
Emergency Department Use
for Primary Care
Community Health Center Staﬃng
Community Health Center Capacity
Emergency Department to
Hospital Admissions
Hospital InpaƟent Capacity
Hospital Bed Occupancy
Community Health Center
OperaƟng Expenses
SacramentoRegionPopulationEstimates,2006to2010
Avg. Annual
Percent
Change
El Dorado 175,258 177,195 178,599 179,701 181,183 0.8%
Placer 322,270 329,719 337,914 344,088 350,609 2.1%
Sacramento 1,372,275 1,388,086 1,400,939 1,411,403 1,420,447 0.9%
Yolo 190,809 194,854 197,589 199,697 200,995 1.3%
2006County 2007 2008 2009 2010
Individual 103,973 4.9% 109,610 213,583 10.0%
Medicare 248,432 11.6% - 248,432 11.6%
Medi-Cal 369,057 17.3% 117,947 487,004 22.8%
Uninsured 303,306 14.2% (227,557) 75,749 3.6%
Total 2,132,796 - - 2,132,796 -
Employer 1,108,028 52.0% - 1,108,028 52.0%
2014
Yolo County $55,798
California $57,708
100 Percent $10,830 $22,050
200 Percent $21,660 $44,100
Median Household
Income 2010 Federal
Poverty Levels
Family
Percent Male 62.6
Percent White 35.4
Percent Latino 38.3

One out of three people living under 138 percent FPL
are currently uninsured in the Sacramento Region,
but will be eligible for Medi-Cal under ACA
Figure 1. Trends in Adults Living in Poverty
Health Outcome Rankings
When looking at the region’s health in terms of overall
longevity and quality of life, Placer, Yolo and El Dorado
counties rank in the top quartile of all California counties,
while Sacramento County is significantly less healthy,
ranking in the third quartile.
Maps 1 and 2. County Health Outcomes Rankings
Community Health Indicators
Community health indicators predict health care usage.
The indicators were derived using the California Health
Interview Survey (CHIS), the largest state population-based
survey in the nation.
From the CHIS data, these community health indicators
were selected:
• Asthma
• Heart Disease
• Diabetes
• High Blood Pressure (HBP)
• Obesity
• Overweight
4
1
5%
Sacramento Placer YoloEl Dorado
2009 289,312 16,286 31,303 32,156
2014 379,533 23,375 42,453 41,643
+31%
+44%
+36% +30%
0
50,000
100,000
150,000
200,000
250,000
20.0%
%Poverty
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0%
2006 2007 2008 2009 2010
Yolo County
18.3%
15.7%
10.0%
8.8%
300,000
350,000
400,000
71%
Percentage of Adults 18-64 Living Below the Federal
PovertyLevel(100% FPL)*, 2006-2010
* For reference, the 2010 FPL was an annual income of $10,830 or less for an individual
Source: U.S. Census Bureau, 2006-2010 ACS 1-year estimates
Note: The FPL for eligibility for ACA is 133% but there is an income disregard of 5%
that could raise the level to 138%
El Dorado County Sacramento CountyPlacer County
6,000
000
800,000
Males
Females
Sacramento Region Estimates of Age & Race, 2009
Source: 2009 California Health Interview Survey
0 200,000 400,000 600,000 800,000 1,000,000
Children +
Adolescents (0-17)
Adults (18-64)
Seniors (65+)
Estimated Number
145,000
240,000
24,000
260,000
806,000
179,000
53,000
79,000
17,000
51,000
146,000
16,000
Asian (non-LaƟno)
African American (non-LaƟno)
White (non-LaƟno)
LaƟno
Yolo
Sacramento
El Dorado
Placer
112th Congressional Districts
>45% Percent of Population Living below
30-45% 200% Federal Poverty Level,
15-30% American Community Survey
<15% (2006-2010), by Census Tract
El Dorado
Placer
4th
f life) Health Factors (health behaviors, clinical care, social and economic factors,
physical environment) California County Ranking, 2012
, 2012
El Dorado
Placer
1st Quartile (Top 25%)
2nd Quartile
3rd Quartile
4th Quartile (Bottom 25%)
ongressional Districts and
ation Data Files
Patient Visits,
2010
<1,000
1,000 - 5,000
5,000 - 10,000
10,000 - 15,000
Total Population,
2010
1,730 or more
1,240 - 1,730
910 - 1,240
<910
FQHC Look-
alike
Other
CHC
Population Density, Highways and Utilization of
Community Health Centers (CHC), 2010
Source: U.S. Census, OSPHD Primary Care Clinic Utilization Data Files
Source: University of Wisconsin County Health Rankings, 2012
Yolo
Sacramento
El Dorado
Placer
2nd Quartile
3rd Quartile
Interstate
Highway
Health Outcomes RankingHealth Outcomes Ranking
112th Congressional Districts
>45% Percent of Population Living below
30-45% 200% Federal Poverty Level,
15-30% American Community Survey
<15% (2006-2010), by Census Tract
FQHC
FQHC look-alike
Other CHC
Yolo
Sacramento
El Dorado
Placer
5th
10 th
1st
2nd
4th
3rd
4th
Health Outcomes (premature death and quality of life)
California County Ranking, 2012
Source: University of Wisconsin County Health Rankings, 2012
Yolo
Sacramento
El Dorado
Placer
2nd Quartile
3rd Quartile
Low-Income Population by CensusTract, Congressional Districts and
Community Health Centers (CHC), 2010
Source: U.S. Census, OSPHD Primary Care Clinic Utilization Data Files
Yolo
El Dorado
Placer
Low-Income Population not using a Federally Funded
Community Health Center (CHC), 2010
Health Outcomes Ranking
Note: The Federal Poverty Level for ACA eligibility
is 133% ($30,675 for a family of four in 2012), but
there is an income disregard of 5% that could raise the
level to 138% ($31,809 for a family of four in 2012.
• Smoking
• Unmet medical needs
• Services received for
perceived need for Mental
Health/Alcohol and Other
Drugs (MH/AOD)

The region’s safety net population for the most part mirrors
California’s in terms of illnesses that predict health care
utilization rates. Regionally, 12.4 percent of the population,
or one in every eight residents, is likely to delay getting care,
but the majority of residents (59.1 percent) are able to
access specialty behavioral health services. Across the
adult population, the most prevalent health concerns are
overweight, closely followed by high blood pressure and
obesity. Among those who need services for mental health/
alcohol and other drug abuse, high rates of not receiving help
were also reported. Seniors (65+) with mental health needs were
more likely to receive help than those aged 18-64, and females
were more likely than males to report that they received needed
mental health help. The trends for asthma and high blood
pressure indicate that rates decreased from 2007 to 2009;
however, rates for obesity increased slightly over the same period.
For detailed analysis by health indicator, see Appendix 2.
Figure 2. Community Health Indicators
Health Reform Background
and Implications
ACA will transform the safety net, requiring a
coordinated regional effort to succeed.
The passage of the Patient Protection and Affordable
Care Act (ACA)
13
, as amended by the Reconciliation Act of
2012 (P.L. 111-152) — collectively referred to as the health
reform law — transforms the nation’s health care system. The
intent of ACA is to expand health insurance coverage while also
reforming the health care delivery system to improve quality
and value.
ACA includes provisions to eliminate disparities in health care,
strengthen public health care access, invest in the expansion
and improvement of the health care workforce, and encourage
consumer and patient wellness in both the community and
the workplace.
ACA Transformation: More Insured = More Demand
ACA Opportunities:
Increase Capacity
Expand and Improve Workforce
Improve Access
Eliminate Disparities
Encourage Wellness
The health reform law permanently authorizes and expands
community health centers and the National Health Services
Corps. ACA investments will double community health center
capacity. Through federal programs and grants to states,
the health reform law will help expand the nation’s health
workforce — from physicians and nurses to public health
professionals — through scholarships and local repayment
assistance. The law also aims to improve the diversity of the
health care workforce in order to assure care that is appropriate
for the entire population.
Sacramento Region Community Health Indicators, CHIS 2009
Got Needed MH/AOD Services is based on a smaller sample - it is asked only
of those who said they needed MH/AOD services - 15.2% of the regional population
60%
50%
40%
30%
20%
10%
0%
Source: California Health Interview Survey, 2001-2009
16.2
13.7
6.5 5.9
7.5 8.5
25.1
26.2
33.7
59.1
55.5
33.6
24.7
22.7
14.413.6 12.4
15.1
Asthma-AllAges
HeartDisease-Adults
Diabetes-Adults
HBP-Adults
Overweight(BMI25-29.9)-Adults
Obese(BMI>
or=
to30)-AdultsCurrentSmoker-Adults
Delayed/Didn’tGetCare-AllAges
GotNeededMH/AODServices-Adults
Sacramento Region State of California
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
2001 2003 2005 2007 2009
14.7% 16.2%
17.4% 18.5%
16.2%
Asthma Rate, Ages 1 Year and Older, Sacramento Region,
CHIS 2001-2009
Source: California Health Interview Survey, 2001-2009
30.0%
35.0%
25.0%
20.0%
15.0%
10.0%
2001 2003 2005 2007 2009
23.4%
21.9%
25.8%
28.8%
25.1%
High Blood Pressure Rate, Adults 18 and Older,
Sacramento Region, CHIS 2001-2009
Obese (BMI> or = to 30) Rate, Adults 18 and Older,
Sacramento Region, CHIS 2009
13 ^ Pub.L. 111-148, 124 Stat. 119, to be codified as amended at scattered sections of
the Internal Revenue Code and in 42 U.S.C.
Findings:
16 percent Asthma 8 percent Diabetes
25 percent HBP 25 percent Obese
14 percent Smokers
12 percent Delayed or did not get needed care
Among those who needed MH/AOD help,
59 percent got needed services

National Impact
At the national level, health reform is expected to insure 32
million currently uninsured individuals through health benefits
exchanges and expanded eligibility for Medicaid.
14
According to
the Congressional Budget Office, the law will increase
coverage to about 94 percent of Americans, while slowing the
rate of growth in federal health expenditures by $124 billion
over the next decade.

State Impact
The UCLA Center for Health Policy Research estimates that
about 2.13 million non-elderly uninsured Californians will
be eligible for Medi-Cal under ACA.
15
To streamline the
Medicaid enrollment of all these newly eligible individuals,
the ACA includes new requirements for states to simplify this
process. For the private sector, the ACA creates state-based
American Health Benefit Exchanges and Small Business Health
Option (SHOP) Exchanges administered by governmental or
nonprofit entities, through which individuals and small
businesses with up to 100 employees can purchase
qualified coverage.
16

Regional Impact
Implementation of the health reform law has already begun to
have an impact in the Sacramento Region. Patients, providers
and purchasers are aware of and preparing for the opportunities
and challenges that lie ahead.
See www.sierrahealth.org/healthcarepartnership for county
programs for the underserved under way in the region’s
rural counties.
More than one in four people in the Sacramento
Region are uninsured or underinsured.
Table 3. Current Safety Net User Insurance Coverage
How ACA Expands Health Coverage
to More Residents
Newly Insured: Health Benefits Exchange
Under ACA, almost half (48 percent) of uninsured residents
in California are expected to get health insurance through
the state’s health benefit exchange. An estimated 109,610
uninsured Sacramento Region residents will obtain coverage
through this statewide health insurance exchange by 2014.
Newly Insured: Medi-Cal Expansion
Under ACA, an estimated 117,947 uninsured residents in the
region will obtain health coverage through Medi-Cal. This
represents just over half (52 percent) of all residents in the
region who are currently uninsured. Most of the new
Medi-Cal recipients will be low-income childless adults
who previously did not qualify for Medi-Cal.
Sacramento Region Uninsured
303,306 > 75,749
52% of newly insured will get
Medi-Cal coverage
48% will get coverage from statewide
health care exchanges
14 Kaiser Commission on Medicaid and the Uninsured. Focus on Health Reform –
Summary of Coverage Provisions in the Patient Protection and Affordable Care Act. April
14, 2011. Available at: http://www.kff.org/healthreform/upload/8023-R.pdf. Accessed
April 22, 2012.

15 UCLA Center for Health Policy Research. Health Policy Brief - Californians Newly
Eligible for Medi-Cal under Health Care Reform. May 2011. Available at:
www.healthpolicy.ucla.edu/pubs/files/medicalpb-may2011.pdf. Accessed April 23, 2012.

16 The Abaris Group. The Impact of Health Care Reform from a Federal Perspective.
CHC Staffing and Encounters (Visits) per FTE, 2010
Safety Net No or Underinsured Health
Insurance Coverage, 2010
Source: U.S. Census Bureau, 2010 American Community
Survey 1-Year Estimates
Insurance Type Region California
No Health Insurance 12.7 percent 18.5 percent
Medicare & Medicaid 1.1 percent 1.0 percent
Medicaid (ages 18-64) 6.1 percent 5.7 percent
Medicaid (ages <18) 7.9 percent 8.8 percent
Total 27.7 percent 34.0 percent
Ratio of Population to Primary Care Physicians
Source: 2011 County Health Rankings, Health Resources and Services
Administration’s Area Resource File, 2009
*90th percentile among all U.S. counties
CHC Visits and ED Discharges, 2006-2010
Source: OSHPD Primary Care Clinic Utilization Data; OSHPD
Hospital Annual Utilization Data; California Department of
Finance, 2006-2010
2006 2010
Average Annual
Percent Change
CHC Visits 350,418 472,662 9.4 percent
ED Discharges 445,918 580,184 6.8 percent
PopulaƟon 2,060,612 2,153,234 1.1 percent
CHC Capacity, 2006-2010
*Providers = physicians, physicians assistants & nurse family practitioners.
Visits represent CHC encounters specifically with those provider types.
Source: OSHPD Primary Care Clinic Utilization Data Files, 2006-2010
ource: OSHPD Primary Care Clinic Utilization Data Files, 2010
2006 2010 % Change
Primary Care Clinics 31 37 19.4%
Providers (FTE) 72.5 110.2 52.0%
Visits 259,673 342,864 32.0%
CHC
Sourc
Provider
Full-Time
Equivalents(FTE) Encounters
Encounter
per FTE
512,23146.64snaicisyhP 2,835
Physician Assistants 22.69 77,067 3,397
Nurse Family PracƟƟoners 40.88 133,582 3,268
526,2286.8seviwdiM 2,607
VisiƟng 0essruN - -
628,749.12stsitneD 2,184
Dental 572,475.1stsineigyH 2,723
471,1170.11stsirtaihcysP 1,009
Clinical Psychologists 3.75 4,081 1,088
221,741.8WSCL 875
Other Medi- 251,634.04laC 895
Other 494,789.31PSPC 536
El Dorado County 868:1
Placer County 643:1
Sacramento County 814:1
Yolo County 519:1
California 847:1
NaƟonal Benchmark* 631:1
Prima
*OS
Fac
Bar
El D
Shin
Cha
Cali
Cali
Fols
Hea
Sac
Sac
Sac
The
Com
Mid
and
Win
Al
FQ
FQ
No

Table 4. Impact of the ACA on Insurance Coverage
Characteristics of the Medi-Cal
Eligible Population
Of particular interest to the Sacramento Region Health Care
Partnership is the large segment of the region’s population
that is under 138 percent of the FPL and also does not have
health insurance. This population group is most likely to be
eligible for Medi-Cal under ACA.
Table 5. Characteristics of newly eligible
Medi-Cal under the ACA
Impact of ACA at the County Level
Using zip code-level health insurance data, the number
of individuals in each county that will move from being
uninsured to obtaining coverage either under Medi-Cal
or through the health benefits exchange in 2014 were
estimated. Note that due to the reliance on 2009 zip code
versus the reporting of 2010 regional (county-level) data, these
coverage estimates are slightly different than presented elsewhere
in this report.
Health Coverage in Each County in 2014
Each county will gain Medi-Cal and individually insured
residents and see a drop in the number of uninsured residents.
Figure 3. Movement in Individual Insurance
Figure 4. Movement in Medi-Cal
The data shows movement, meaning
increases are due to ACA changes, not
natural population growth.
Individual 103,973 4.9% 109,610 213,583 10.0%
Medicare 248,432 11.6% - 248,432 11.6%
Medi-Cal 369,057 17.3% 117,947 487,004 22.8%
Uninsured 303,306 14.2% (227,557) 75,749 3.6%
Total 2,132,796 - - 2,132,796 -
Employer 1,108,028 52.0% - 1,108,028 52.0%
2014
Yolo County $55,798
California $57,708
100 Percent $10,830 $22,050
200 Percent $21,660 $44,100
Median Household
Income 2010 Federal
Poverty Levels
Family
Source: 2009 CHIS
Percent Male 62.6
Percent White 35.4
Percent Latino 38.3
Individual 103,973 4.9% 109,610 213,583 10.0%
Medicare 248,432 11.6% - 248,432 11.6%
Medi-Cal 369,057 17.3% 117,947 487,004 22.8%
Uninsured 303,306 14.2% (227,557) 75,749 3.6%
Total 2,132,796 - - 2,132,796 -
Employer 1,108,028 52.0% - 1,108,028 52.0%
2014
Yolo County $55,798
California $57,708
100 Percent $10,830 $22,050
200 Percent $21,660 $44,100
Median Household
Income 2010 Federal
Poverty Levels
Family
Source: 2009 CHIS
Percent Male 62.6
Percent White 35.4
Percent Latino 38.3
HighBloodPressure,Adults,SacramentoRegion,2009
PopulaƟon Group Percent Pop. EsƟmate
Delayed/Did Not Get Needed Medical Care, All Ages,
Sacramento Region, CHIS 2009
Sacramento Placer Yolo
2009 52,998 12,494 24,607 13,874
2014 130,034 21,015 38,193 24,341
+145%
+68%
+55%
+75%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Movement in Individual Insurance, 2009 - 2014
El Dorado
Movement in Uninsured, 2009 - 2014
Mov
Source
1
1
2
2
2
%Poverty
1
1
1
1
1
3
3
4
2009 222,518 19,579 33,149 28,060
2014 55,261 3,969 8,413 8,106
-75%
-80% -75% -71%
0
50,000
100,000
150,000
200,000
250,000
Sacramento Region Estimates of Age & Gender, 2009
Perc
Pove
* For r
Source
Note:
that c
97,000
676,000
136,000
97,000
650,000
107,000
Adolescents (12-17)
Adults (18-64)
Seniors (65+) Males
Females
Sacr
Adu
Sen
2009 52,998 12,494 24,607 13,874
2014 130,034 21,015 38,193 24,341
+145%
+68%
+55%
+75%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Movement in Individual Insurance, 2009 - 2014
El Dorado
Movement in Medi-Cal, 2009 - 2014
2009 289,312 16,286 31,303 32,156
2014 379,533 23,375 42,453 41,643
+31%
+44%
+36% +30%
0
50,000
100,000
150,000
200,000
250,000
20.0%
%Poverty
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
18.3%
15.7%
10.0%
8.8%
300,000
350,000
400,000
-75%
50,000
100,000
150,000
200,000
250,000

Figure 5. Movement in the Uninsured
Change in Percentage of Uninsured
Maps at the zip code level visually depict the change in the
percentage of uninsured residents pre- and post-ACA.
Map 3. Uninsured as a Percentage of the
Population within Zip Codes - 2009
2009 52,998 12,494 24,607 13,874
2014 130,034 21,015 38,193 24,341
+68%
0
20,000
El Dorado
2009 289,312 16,286 31,303 32,156
2014 379,533 23,375 42,453 41,643
+44%
+36% +30%
0
50,000
20.0%
%Poverty
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0%
2006 2007 2008 2009 2010
Yolo County
18.3%
15.7%
10.0%
8.8%
2009 222,518 19,579 33,149 28,060
2014 55,261 3,969 8,413 8,106
-75%
-80% -75% -71%
0
50,000
100,000
150,000
200,000
250,000
Sacramento Region Estimates of Age & Gender, 2009
* For reference, the 2010 FPL was an annual income of $10,830 or less for an individual
Source: U.S. Census Bureau, 2006-2010 ACS 1-year estimates
Note: The FPL for eligibility for ACA is 133% but there is an income disregard of 5%
that could raise the level to 138%
El Dorado County Sacramento CountyPlacer County
170,000
97,000
676,000
136,000
180,000
97,000
650,000
107,000
0 200,000 400,000 600,000 800,000
Children (0-11)
Adolescents (12-17)
Adults (18-64)
Seniors (65+)
Estimated Number
Males
Females
Sacramento Region Estimates of Age & Race, 2009
0 200,000 400,000 600,000 800,000 1,000,000
Children +
Adolescents (0-17)
Adults (18-64)
Seniors (65+)
Estimated Number
145,000
240,000
24,000
260,000
806,000
179,000
53,000
79,000
17,000
51,000
146,000
16,000
Asian (non-LaƟno)
African American (non-LaƟno)
White (non-LaƟno)
LaƟno
Total Uninsured All Ages Before Health Insurance Reform, 2009
Remaining Uninsured All Ages 85% Uptake for Exchange and Medicaid, 2014
96161
96143
95728 95728
96148
95724
Source: IPUMS ACS Sample. Steven Ruggles, MaƩhew Sobek,
Trent Alexander, Catherine A Fitch, Ronald Goeken, Patricia
Kelly Hall, Miriam King and Chad Ronnander. Integrated
bl d [ h d bl
95631
95713
96145
95602
95701
96142
96146
95715
95681
9572695722
96141
95717
96143
96140
95717
95714
9570395703
96141
96148
95604
95736
Public Use Micodata Series: Version 4.0 [Machine-readable
database]. Minneapolis, MN: Minnesota PopulaƟon Center
[producer and distributor], 2010
95667
95648
95695
95607
96150
95720
95776
95634
95726
95627
95645
95937
95747
95679
95698
95664
95633
95603
96155
95606
95614
95658
95650
95672
95709
95735
95637
95626
95635
95668
95746
9567395837
95721
1565956759
95662
95678
95661
95677
95663
95610
95843
95653 95621
95660 95619
95726
95842
95697
95684
95636
95694
95683
95682
95620
9569395612
95623
95742
95624
95691
95762
95630
95616
95618
95829
95629
95608
95628
95758
95830
95670
95828
95823
95826
95834
95655
95838
95835
95832
95822
95815
95833
95831
95821
95864
95820
95827
95660
95639
95825
95841
95605
95824
95818
95842
95652
95819
95811
95817
95816
95814
Percentage of Uninsured
95638
95632
95757
95612
95690
95641
95615
95639
95680
95615
95680
by Zip Code - 2009
Suppressed Zips
0.01% - 11%
11.01% - 14%
14.01% - 16%
94571
County Boundaries
16.01% - 19%
There will be an 85 percent uptake
of uninsured to insured residents
due to ACA.

Map 4. Uninsured as a Percentage of the Population within
Zip Codes - Projected for 2014
Transportation Access Issues
The issue of transportation access to health care, already
an issue for the Sacramento Region, will likely become
even more important in light of federal health care reform
legislation. Under ACA, both health care services and
public transportation demand by the region’s residents to
reach services will increase significantly. The location of
new services will also have implications for future public
transportation planning.
To expand on previous studies, the Sacramento Area Council
of Governments (SACOG) sought and obtained a Caltrans
Environmental Justice Planning Grant to begin to examine
more specifically the transportation needs of low-income,
transit-dependent residents of the SACOG region, and analyze
gaps in public transit service to reach essential or “lifeline”
destinations. Highlights of findings from the SACOG study
are at www.sierrahealth.org/healthcarepartnership. As more
residents become Medi-Cal eligible under ACA, their
transportation needs must be addressed.

Safety Net Snapshot
What health care providers serve the region’s
safety net population, and how well?
In this market analysis, the health care safety net includes
the region’s community health center providers and
programs that serve the region’s low-income, uninsured or
underinsured population.
The region’s health care safety net has previously been
characterized by a fragmented group of small and financially
fragile health centers that together offer limited
outpatient capacity.
This is not to say the region’s safety net is broken, but it is
weak and vulnerable. It is underdeveloped. It is disorganized
Remaining Uninsured All Ages 85% Uptake for Exchange and Medicaid, 2014
95632
95690
95641
95680
95680
Suppressed Zips
0.01% - 11%
11.01% - 14%
14.01% - 16%
94571
County Boundaries
County Boundaries
16.01% - 19%
96161
95701
96146
95715
96143
95728
96140
95714
95728
96148
95724
95604
Trent Alexander, Catherine A Fitch, Ronald Goeken, Patricia
Kelly Hall, Miriam King and Chad Ronnander. Integrated
Public Use Micodata Series: Version 4.0 [Machine-readable
database] Minneapolis MN: Minnesota PopulaƟon Center
95631
95648
95634
95713
9593795679
96145
95603
95602
95614
95658
96142
95635
95681
9572695722
96141
95717
95717
9570395703
96141
95736
database]. Minneapolis, MN: Minnesota PopulaƟon Center
[producer and distributor], 2010
95667
9 684
95695
95607
96150
95720
95636
95776
95682
95726
9 623
95627
95645
95937
95747
95679
95691
95762
95698
95664
95633
96155
95606
95614
95630
95658
95650
95672
95709
95735
95637
95626
95668
95746
9567395837
95608
95721
95628
95670
1565956759
95662
95678
95834 95838
95661
95835
95677
95815
95833
95663
95610
95821
95843
95653 95621
95660 95619
95726
95841
95842
95652
95697
95684
95694
95683
95638
95620
95693
95757
95612
95623
95742
95624
95616
95618
95615
95829
95629
95758
95830
95670
95828
95823
95826 95655
95832
95822
95815
95831
95864
95820
95827
95639
9582595605
95824
95818
95819
95811
95817
95816
95814
95615 Percentage of Uninsured by Zip Code
Projected for 201495632
95690
95641
94571
95615
95680
95680
0.01% - 2.00%
2.01% - 3.00%
3.01% - 4.00%
4.01% - 5.00%

and thus inefficient. There are pockets of productivity and
some positive actions already being taken to improve health
care delivery. However, as a system, the safety net lacks
cohesion. Feedback from surveys with stakeholders indicates
that there is no lead agency or entity providing strategic
direction. These are key points the Sacramento Region
Health Care Partnership initiative seeks to address.
This section discusses the relative strengths and weaknesses
of the various health care providers within the Sacramento
Region’s safety net. We start with a chart showing an overview
of factors impacting the safety net.
Table 6. Safety Net Trends at a Glance,
between 2006 and 2010
Current Safety Net Providers
Silos of individual health care providers range
from strong to struggling.
Safety net health care market in each county
The rural county of El Dorado provides a unique
collaborative environment for Marshall Medical Center
and Barton Memorial Hospital. The expertise and resources
shared between these two providers extends into the
community. Additional providers of the safety net in
El Dorado County include El Dorado Community Health
Center, Shingle Springs Tribal Health, Western Sierra Health
and Placerville Health and Wellness Center. El Dorado
County’s safety net is challenged by geographical
differences, recruitment of specialty care providers, unified
health information technology and transportation.
17
Public
and private providers, community health centers and
hospitals participate in a county-wide collaborative called
Access El Dorado (ACCEL) on a county-wide telehealth
pilot project. This collaborative effort provides rural
community members with access to service providers
and training.
Placer County is served by two health systems — Kaiser
Foundation Hospital Roseville, Sutter Roseville Medical
Center and Sutter Auburn Faith Hospital).
18
Placer County
Health and Human Services operates four outpatient
clinics that serve adults and children. The safety net
providers are Northern Valley Indian Health (previously
known as Chapa-De Indian Health Program), Planned
Parenthood and The Effort, Inc. The challenges to the
Placer County safety net include access to mental health
and specialty care, county designation of a medically
underserved area and transportation.
19
Through the
Placer Collaborative Network, a project of the Placer
Community Foundation, a diverse group of more than 40
public and private providers, health systems, community
health centers, funders and nonprofit organizations come
together to develop creative solutions for change.
20
Sacramento County’s health care market is comprised of
four major health systems — Sutter Health Sacramento
Sierra Region, Dignity Health, Kaiser Permanente and
University of California Davis Health System. All are
nonprofit and financially strong. Most physicians practice
in large groups that are exclusively aligned with one of the
health systems. Sacramento County Health and Human
Services operates one health center, which provides primary
care, dental and mental health care services to the medically
indigent. The community health centers include Health
hapa-De Indian Health Program, Inc. Yolo Neither
MMC for Children and Families Yolo Neither
lanned Parenthood – Woodland Yolo Neither
Source: OSHPD Primary Care Clinic Utilization data files, 2010
Source: California Department of Finance, 2006-2010
SafetyNetTrendsataGlance,between2006and2010
Increasing Steady Decreasing
Region’s PopulaƟon
Chronically Ill Residents
Insured Residents (Medi-Cal, Private)
Uninsured Residents
Community Health Center Use
Emergency Department Use
for Primary Care
Community Health Center Staﬃng
Community Health Center Capacity
Emergency Department to
Hospital Admissions
Hospital InpaƟent Capacity
Hospital Bed Occupancy
OperaƟng Expenses
MMC for Children and Families became an FQHC in 2012
SacramentoRegionPopulationEstimates,2006to2010
Avg. Annual
Percent
Change
El Dorado 175,258 177,195 178,599 179,701 181,183 0.8%
Placer 322,270 329,719 337,914 344,088 350,609 2.1%
Sacramento 1,372,275 1,388,086 1,400,939 1,411,403 1,420,447 0.9%
Yolo 190,809 194,854 197,589 199,697 200,995 1.3%
2006County 2007 2008 2009 2010
17 April 3, 2012, Sacramento Region Health Care Partnership El Dorado County
Stakeholder Notes.

18 Center for Strategic Economic Research. Placer County Economic and Demographic
Profile 2012.

19 April 2, 2012, Sacramento Region Health Care Partnership Placer County
Stakeholder Notes.

20 Placer Collaborative Network. http://www.placercollaborativenetwork.org

for All, Inc., Midtown Medical Center for Children and
Families, Sacramento Native American Health Center, Inc.,
Sacramento Community Clinic and The Effort, Inc. The
not-for-profit health centers typically are small and many are
focused on a particular ethnic or immigrant group. Some of
these small health centers offer specialized services (e.g., family
planning), rather than comprehensive primary care.
The challenge in Sacramento County is the underdevelopment
of a key component of the health system – the primary
health care safety net. This includes assuring culturally and
linguistically sensitive access, education on mental health
services, transportation and formalized relationships among
health care stakeholders.
21
While some counties in
California have established networks of health centers and
strong collaborative partnerships among health centers to
serve as an empowered, unified voice in the community,
this infrastructure is woefully underdeveloped in
Sacramento County.
The health care providers in the Yolo County market —
Dignity Health, Kaiser Permanente, Sutter Health
Sacramento Sierra Region and University of California
Davis Health System — work in partnership with the
county health department, local community health centers
and social services to serve the community. The community
health centers are CommuniCare, Midtown Medical Center
for Children and Families, Northern Valley Indian Health
(previously known as Chapa-De Indian Health Program)
and Winters Health Care Clinic. The challenges in Yolo
County’s safety net are recruitment of primary care and
specialty providers, outreach about enrollment and coverage
options, health information exchange across health plans
and service providers locally and regionally, mental health,
dental and transportation.
22
A group called the Future of
the Safety Net Yolo County, originally started by former
Assemblywoman Helen Thomson and now led by County
Supervisor Don Saylor, convenes public and private health
service providers, county health/mental departments,
consortia and funders in a strategic dialogue about
improving the safety net in Yolo County.
Although all four counties are unique in terms of their care
providers, county operations and perspectives, they all share
similarities in challenges and opportunities. All four
counties have difficulty with recruitment, information
technology, mental health, dental and transportation.
The opportunity to overcome these county challenges is to
address the solutions from a regional perspective. Accessing
mental health and dental services for consumers were major
challenges within all four counties. Given the shared
regional transportation challenges, the recent update of the
Sacramento Region’s Metropolitan Transportation Plan/
Sustainable Communities Strategy (MTP/SCS) identified
stakeholder interests in more closely connecting health
with SACOG’s regional planning efforts through expanded
health performance metrics for transit access to health care,
active transportation, bicycle and pedestrian safety, air
quality and more.
23
Expanding Coverage
California was a leader in embracing health reform as a
state and has created pathways to ease the Medi-Cal
enrollees into health reform coverage. The federal
government granted California a waiver to Section 1115
of the Social Security Act to expand coverage to eligible
low-income adults through the Low Income Health
Program (LIHP).
24
This creates an optional program at the
county level. Adults are eligible for LIHP if they are between
the ages of 19 and 64 and are not eligible for Medi-Cal or
the Children’s Health Insurance Program, not pregnant
and meet county and federal requirements. Counties that
participate will have additional resources to pay for
uncompensated services and increase access.
25
There
are two parts: the Medicaid Coverage Expansion and the
Health Care Coverage Initiative.
26
21 April 2, 2012, Sacramento Region Health Care Partnership Sacramento County
Stakeholder Notes.

22 February 24, 2012, Sacramento Region Health Care Partnership Yolo County
Stakeholder Notes.

23 Abstracted from SACOG 2011 Lifeline Transit Study, with permission.

24 March 2011 California Dept of Health Care Services-California’s Bridge to Reform
Demonstration-Low Income Health Program.

25 Insure the Uninsured Project-County LIHP Proposals: Summary & Analysis April 1, 2011.

26 March 2011 California Dept of Health Care Services-California’s Bridge to Reform
Demonstration-Low Income Health Program.

In the Sacramento Region, all four counties are at different
stages of implementing the LIHP program.
See www.sierrahealth.org/healthcarepartnership for examples of
county programs for the underserved.
Medi-Cal’s Role in the Safety Net
The Medi-Cal program in Sacramento County operates under
the geographic managed care (GMC) model, with the state
contracting with multiple managed care plans and paying
each plan on a capitated basis. Enrollment in managed care is
mandatory for all but low-income seniors and people who have
qualified on the basis of disability. Currently, four health plans
participate in the GMC market in Sacramento: Anthem Blue
Cross, Health Net, Kaiser and Molina.
Anthem Blue Cross has about half of the market of
approximately 170,000 Medi-Cal managed care enrollees.
Health Net, Kaiser and Molina cover the rest of the Medi-Cal
HMO population.
The GMC model will eventually be expanding to nearby
counties previously operating under fee for service. Placer
County is shifting to Medi-Cal Managed Care. The
California Primary Care Association is developing an alternative
for the non-managed Medi-Cal counties by creating a private-
labeled health plan with Centene Corp. Many of the residents
in El Dorado and Yolo counties who fall below 100% of FPL
populations are served by the County Medical Services
Program (CMSP). Implementation of the ACA will transfer
many CMSP insured patients to Medi-Cal in 2014.
Underutilized Community Health Centers
The Sacramento Region of El Dorado, Placer, Sacramento and
Yolo counties has 37 licensed individual primary care health
centers and nine county-run clinics. However, these health
centers are not the first choice for primary care services for
many residents. This is especially so in counties that have
assigned providers via the GMC model of Managed Medi-Cal.
Non-GMC counties have far higher primary care clinic usage.
Map 5. Low-Income Population Using a Federally Funded
Figure 6. Community Health Center Utilization
Yolo
Sacramento
El Dorado
Placer
El Dorado
Placer
l care, social and economic factors,
y Ranking, 2012
Percentage of Low-Income Population using a FederallyFunded
Community Health Center (CHC), 2010
Patient Visits,
2010
<1,000
1,000 - 5,000
5,000 - 10,000
10,000 - 15,000
Total Population,
2010
1,730 or more
1,240 - 1,730
910 - 1,240
<910
QHC Look-
alike
Other
CHC
ilization of
010
nic Utilization Data Files
Rankings, 2012
El Dorado
Placer
2nd Quartile
3rd Quartile
<20% Other Hospital
20 - 40% Short Term Hospital
40 - 60% Rural Health Clinic
60 - 80% FQHC Look-Alike
>80% CHC (*FQHC)
% of Low-Income Using a
Federally Funded CHC*
Yolo
Sacramento
El Dorado
Placer
Change in Utilization of Federally Funded
Community Health Centers (CHC), 2008-2010
50-100% loss Other Hospital
10-50% loss Short Term Hospital
<10% change Rural Health Clinic
10-50% gain FQHC Look-Alike
>50% gain CHC (*FQHC)
Change in CHC* Utilization,
2008 - 2010
Yolo
Placer
Medically Underserved Areas and General Acute Care Hospitals, 2010
Placer
ental Health)
Total
population
Health Outcomes Ranking
San Diego County
Alameda County
California
Santa Clara County
Sacramento region
Contra Costa/Solano Counties
Orange County
Visits
EDvisitsper1,000population
Sacramento Region
California
CHC Visits per 1,000 Population, 2010
Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; 2010 U.S. Census
Source: OSHPD Emergency Department Visits: Frequencies by County & EMS
utilization trends, 2006-2010, CA Department of Finance, Dec 2011
Note: ED utilization rates do not include ED visits that resulted in hospital admission.
e: California Health Interview Survey, 2001-2009
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
2001 2003 2005 2007 2009
14.7% 16.2%
17.4% 18.5%
16.2%
hma Rate, Ages 1 Year and Older, Sacramento Region,
S 2001-2009
300
250
200
150
100
50
0
2006 2007 2008 2009 2010
235
216
269
266
ED Utilization Rates per 1,000 population
e: California Health Interview Survey, 2001-2009
30.0%
35.0%
25.0%
20.0%
15.0%
10.0%
2001 2003 2005 2007 2009
23.4%
21.9%
25.8%
28.8%
25.1%
h Blood Pressure Rate, Adults 18 and Older,
ramento Region, CHIS 2001-2009
50.0%
ese (BMI> or = to 30) Rate, Adults 18 and Older,
ramento Region, CHIS 2009
209
211
220
222
411
567
616
0 100 200 300 400 500 600 700
ED
Sou
Pe
So
Co

Emergency Departments
Overused for Primary Care
Emergency Department use is growing almost
twice as fast in the region as in the state.
There are 16 emergency departments in the Sacramento
Region. Emergency department use has been rising, due
largely to the economic downturn and the increasing
difficulty finding private practitioners willing to take low-
income patients either as charity care or at Medi-Cal rates.
Unlike the region’s community health center utilization,
which is low (only 50 percent of the state average), the
region’s emergency department utilization has been close
to the state average over the last five years and is growing
almost twice as fast as emergency department utilization
statewide. Sacramento Region emergency department
utilization has grown 24.5 percent, while utilization in the
state increased only 13.3 percent.
Figure 7. Emergency Department Utilization, 2006-2010
Detailed Data Analysis Findings
Quantitative data analysis is a major component of this
market analysis. It is particularly useful for projecting future
demands on the safety net system based on historical trends.
The following sections describe the issues studied and
the findings.
Note that data analysis was also used to assess demographic
and other information presented in other parts of
this report.
Safety Net Demand
Use of community health centers for care is
below the state average, while emergency
department use is increasing rapidly.
The best available data to assess demand for safety net
services comes from California Office of Statewide Health
Planning and Development (OSHPD). OSHPD collects
detailed administrative data from hospitals and health
centers throughout the state and makes the data available
for public use. OSHPD does not collect data from private
medical offices or health centers operated by health
care systems.
The data used in this market assessment is focused on
hospitals and primary care health centers that submit data
to the state. County-run clinics are exempt from reporting
requirements and therefore are not included in this analysis.

Key Findings
• The safety net population uses a variety of health care
services throughout the region.
• Increasing demand for community health center and
emergency department services is outpacing the region’s
population growth.
• Growth in demand from Medi-Cal recipients and
self-payers is outpacing growth from commercial/
private payers.
San Diego County
Alameda County
California
Santa Clara County
Sacramento region
Orange County
Visits
PercentAdmitted
Sacramento Region
California
CHC Visits per 1,000 Population, 2010
Source: OSHPD Primary Care Clinic Utilization Data Files, 2010; 2010 U.S. Census
300
250
200
150
100
50
0
2006 2007 2008 2009 2010
235
216
216
170 170
186
197
220
232 238
265 269
269
266
209
211
220
222
411
567
616
0 100 200 300 400 500 600 700
ED Discharges
CHC Visits
300
250
200
150
100
50
0
2006 2007 2008 2009 2010
ED Discharges and CHC Visits per 1,000 Population, 2006-2010
ED Discharges and Admissions, 2006-2010
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
4.0%
2.0%
0.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Source: OSHPD Hospital Annual Utilization Database, 2006-2010
2006 2007 2008 2009 2010
Medi-Cal
Self-Pay
Private
Medicare
Other Non-Federal
Other
2010
2009
2008
2007
2006
0% 20% 40% 60% 80% 100%
Percentage of ED Discharges by Payer Source, 2006-2010
Source: OSHPD Emergency Department Encounters, County Frequencies by Patient
County of Residence 2006-2010
Percent AdmittedTotal AdmittedTotal Discharged
Percentage of ED Discharges Classified as ED Care Not Needed
All
Discharges
Self-Pay Medi-Cal Commercial Medicare
Emergent/Primary Care TreatableNon-emergent
40.4%
41.9%
46.1%
37.5% 36.3%
50%
45%
40%
35%
25%
15%
5%
30%
20%
10%
0%

• Medi-Cal grew from 27.1 percent of all visits in 2006
to 40.4 percent of all visits in 2010.
• Other safety net program utilization fell dramatically
from 42.6 percent to 26.3 percent.
• The percentage of self-payers and private payers
remained steady.
Figure 8. Trends in Community Health Center and
Emergency Department Utilization Rates
Figure 9. Trends in Community Health Center Visits
Figure 10. Trends in Community Health Center Payer Mix
Emergency Department Utilization
• Among the region’s residents utilizing an emergency
department, Medi-Cal payers increased from 24.1 to
28.0 percent and self-payers increased from 12.3 to
16.2 percent.
• Meanwhile, the percentage of private payers fell from
42.2 percent of all emergency department discharges to
35.8 percent.
• The number of emergency department visits has
increased, while the number of emergency department
visitors being admitted to the hospital has remained
relatively stable.
• In summary, the percentage of emergency department
hospital admissions has declined, which indicates
that people are using emergency departments for
non-life-threatening illness or injury that could better
be handled in a non-emergency setting.

CHC Visits, 2006 to 2010
0
50,000
100,000
150,000
200,000
250,000
300,000
Medi-Cal
Sliding Scale,
Self-Pay & Free
Indigent
“All Other”
Medicare
Private
350,000
400,000
450,000
500,000
Alameda County
San Diego County
California
Santa Clara County
Orange County
Sacramento region
CHCs per 100,000 Population, 2010
2006 2007 2008 2009 2010
2010
2009
2008
2007
2006
Percentage of CHC Encounters by Payer Source, 2006 to 2010
330,312 323,200
372,867
421,135
472,662
Total Number of ED Discharges Classified as ED Care Not Needed
90,000
80,000
70,000
60,000
40,000
20,000
0
50,000
30,000
10,000
41,245
75,366
79,452
37,560
1.72
1.73
1.80
1.91
2.75
3.39
4.50
CHCs
PercentAdmitted
0
50,000
100,000
Medi-Cal
Sliding Scale,
Self-Pay & Free
Indigent
“All Other”
Medicare
Private
Contra
CHC
Source
Note: “All Other” includes breast cancer, Child Health and Disability Prevention
Program, Expanded Access to Primary Care, and Family PACT encounters.
Indigent includes County CDSP and Healthy Families
2006 2007 2008 2009 2010
2010
2009
2008
2007
2006
0% 20% 40% 60% 80% 100%
Percentage of CHC Encounters by Payer Source, 2006 to 2010
Discharges and Admissions, 2006-2010
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
4.0%
2.0%
0.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
ce: OSHPD Hospital Annual Utilization Database, 2006-2010
2006 2007 2008 2009 2010
ED Discharges, 2006-2010
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Source: OSHPD Emergency Department Encounters, County Frequencies by Patient
County of Residence 2006-2010
2006 2007 2008 2009 2010
2006
0% 20% 40% 60% 80% 100%
445,919
484,584 504,083
565,568 580,184
urce: OSHPD Emergency Department Encounters, County Frequencies by Patient
unty of Residence 2006-2010
rcentage of ED Discharges Classified as ED Care Not Needed
All
Discharges
40.4%
41.9%
46.1%
37.5% 36.3%
50%
45%
40%
35%
25%
15%
5%
30%
20%
10%
0%
Contra
FQH
Source
Visits
PercentAdmitted
Sacramento Region
California
300
250
200
150
100
50
0
2006 2007 2008 2009 2010
235
216
216
170 170
186
197
220
232 238
265 269
269
266
ED Discharges
CHC Visits
Source: OSHPD Primary Care Clinic Annual Utilization Data Files & Emergency
Department Visits: Frequencies by County & EMS utilization trends, 2006-2010
300
250
200
150
100
50
0
2006 2007 2008 2009 2010
ED Discharges and CHC Visits per 1,000 Population, 2006-2010
ED Discharges and Admissions, 2006-2010
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
4.0%
2.0%
0.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Source: OSHPD Hospital Annual Utilization Database, 2006-2010
2006 2007 2008 2009 2010
Percentage of ED Discharges Classified as ED Care Not Needed
All
Discharges
40.4%
41.9%
46.1%
37.5% 36.3%
50%
45%
40%
35%
25%
15%
5%
30%
20%
10%
0%

SRHCP_Market_Analysis_Final_103012

SRHCP_Market_Analysis_Final_103012

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