Nearly half of District residents, many with chronic diseases, live in neighborhoods with a critical shortage of doctors to provide even basic care, a public health failure that a new report links to significant health consequences and costs.
Despite the abundance of major medical centers and specialist physicians in the nation's capital, the analysis released yesterday by the District of Columbia Primary Care Association found that entire communities lack adequate access to routine medical services, much less to the ongoing treatment needed for problems such as asthma, diabetes and hypertension.
"The result is poor general health among low-income residents, high rates of avoidable hospitalizations in parts of the city, overcrowded hospital emergency rooms, and, ultimately, higher health care costs for the District," the report concluded.
"Where We Are, Where We Need to Go" wastes little time on hand-wringing. It is, according to the association, the most comprehensive examination of the system that serves the city's most vulnerable populations, and it is intended to provoke discussion and action within a broader context -- a multi-year, multibillion-dollar reform effort that the city's health leaders call Medical Homes DC.
That initiative aims to construct a strong, cohesive community network that would give every resident an individual place for care. It would build health centers in areas with few programs or providers, while expanding, renovating and greatly improving what already exists elsewhere.
Many sites are small, are struggling with aging facilities and "have substantial capital needs," the report noted.
"This complex and long-standing situation requires an ambitious solution," it said.
The detailed review used data collected and analyzed by District officials and independent researchers. It focused on disparities not by ward but by Zip code.
In five Zip codes, extending from the edge of downtown to the District's eastern boundary and anchoring its southern corner, more than one in five adults have no regular source of preventive or primary care. No doctor's office, no clinic, not even a hospital outpatient program. Often the best residents can hope for is a mobile health van on their street.
Yet in several of those areas, almost half the adults suffer from a multiplicity of chronic diseases -- with more than half diagnosed with heart disease in some neighborhoods.
"That is stunning," declared Nicole Lurie, a physician and RAND Corp. health policy scientist who helped present the report yesterday before a crowded room of officials and providers at the Kaiser Family Foundation Conference Center.
If there were a one-on-one correlation between the acute zones and the sectors with the greatest percentage of adults lacking health insurance, the solution might come easier. But the report makes clear with map after map: Problems cut through much of the city.
The good news lies within the decreasing number of "avoidable hospitalizations," admissions for conditions that rarely should require inpatient treatment. Rates fell sharply for children in medium- and high-poverty Zip codes and declined for adults of all ages between 2000 and 2003. That was the same period in which the city liberalized Medicaid eligibility for residents and, with the closing of D.C. General Hospital, began the D.C. Health Care Alliance to offer insurance coverage to those still cut out of the other program.
The data suggest that more participants took advantage of their coverage and sought medical help within the community during those years. "And we continue to see these really promising trends," Lurie said. "If Medical Homes is successful, we ought to see huge declines."
Other numbers discussed yesterday -- numbers quantified by real dollars -- bolstered that hope. In fiscal 2004, hospital emergency departments across the city logged nearly 30 percent fewer patient visits compared with the previous year. At the same time, the number of patient visits to alliance programs and clinics increased by an even greater percentage. The savings to the District budget: more than $3 million.
"This is care closer to the people," said city Health Director Gregg A. Pane, a strong proponent of the Medical Homes DC project.
The District government has pledged $15 million toward the initiative over the next three years, adding to a $2.5 million federal grant the primary care association obtained in 2003. Sharon Baskerville, the association's executive director, said the money is being used to leverage private dollars. The ultimate goal is $145 million.
"We're beginning to connect the dots, and that's the power," she said.
By the end of the summer, the first capital projects should be identified and funded. Any facility that signs on will have to promise to remain open for 30 years and to accept patients regardless of their ability to pay.
In the meantime, the association's report urges city officials to address reimbursement rates that underpay providers by $70 or more per patient visit and to continue expanding health care coverage through Medicaid and the alliance.
