District Lacking In Access To Care
1 in 5 Has No Medical Provider, Rand Report Says

By Susan Levine
Washington Post Staff Writer
Thursday, January 31, 2008; B01

One in five District residents has no regular source of health care, and rising rates of hospital visits suggest declining access to doctors and community clinics, according to the most comprehensive report ever of D.C. health issues.

The report, released yesterday, looked at data on chronic disease, insurance, hospital capacity and emergency services and found much wanting. "There appears to be considerable room for improvement in quality of care and its measurement," concluded the Rand Corp., the nonprofit research organization that the D.C. Council commissioned to help the city move forward.

The problem is not a lack of health insurance for most residents. Thanks to private plans, Medicare and Medicaid and the District's D.C. Alliance for many of its working poor, less than 10 percent of District residents are uninsured, compared with 19 percent or more in Philadelphia and Detroit, the report said.

Yet for reasons that officials do not understand fully, coverage does not always lead to regular primary care. Patients with conditions that could have been prevented, or treated adequately, in a quality community setting are showing up at hospitals.

The rates are "startlingly high," Nicole Lurie, a senior scientist at Rand, said yesterday at a news conference with city leaders. And since 2004, the rates have been getting worse.

Young children and adults who are covered by Medicaid visit hospital emergency rooms routinely, the report found; at least 40 percent make one or more trips a year. Among adults with a chronic condition such as heart disease, the proportion is even greater. Fewer than 20 percent see a cardiologist annually, but more than 70 percent are in the emergency room at least once.

Like others, Lurie acknowledged that reversing those trends and fundamentally changing the system remains an immense challenge. "It's going to take everybody working together to do it," she said.

The Rand study was requested by the D.C. Council in late 2006 as it voted to spend $245 million in tobacco settlement funds to construct major clinical facilities, strengthen emergency care and develop programs that reduce the toll of such diseases as diabetes and cancer. Rand's recommendations were to help allocate nearly $200 million set aside for the capital projects, directed mainly toward communities on the city's east side, where health problems are greatest but services scarce.

The council has spent $79 million of that to help close the sale of Greater Southeast Community Hospital. Lurie, the lead author on the 134-page assessment, said she does not expect Rand's proposals for the rest of the tobacco money to be completed until early summer.

The report, however, hints of the solutions under consideration. In underscoring the concern that many District residents end up at a hospital unnecessarily, it broaches incentives to encourage doctors to serve in communities with the greatest need and to persuade patients to "use care appropriately." Rand could not determine how many providers are accepting new patients, especially those covered by Medicaid or the Alliance.

Its conclusions make clear that the answer is not more or bigger hospitals, a significant point for the council, which several years ago was ready to commit hundreds of millions of dollars toward a new medical center. The researchers at Rand, working with policy experts from George Washington University's school of public health, said the hospital system "does not appear to be operating on the brink of saturation," with only one of the eight D.C. facilities near full occupancy and overall admissions relatively flat.

City leaders promised yesterday to follow the report's lead. "It's the most important document we've seen with respect to the future of health care," said council member David A. Catania (I-At Large). And, he added, it should guide not only the remaining tobacco funds but the $2.2 billion spent every year on health care in the District. "We will not let this be a one-hit wonder."

Among the key findings and issues highlighted in the study's first phase:

¿ There are big gaps in data needed to improve services. Health-care officials know little about the status of children's health and their access to care. Reliable estimates on the prevalence of mental health problems are "extremely limited." Moreover, even when data are collected, analysis lags, so decisions are based on outdated information.

¿ The District's health is comparable to that of cities with similar demographics, though with many troubling health indicators. More than 25 percent of D.C. adults have high blood pressure and 10 percent have asthma; nearly 25 percent are obese. More than one in three children ages 6 to 12 are overweight, one in two in Ward 6. Twelve percent of children through age 17 have asthma, a number that spikes to almost one in five in Ward 7.

Eight percent of city residents have not visited a dentist in five years or longer.

¿ Compared with an overall ratio of 54 adult primary-care providers per 100,000 District residents, Ward 7 has the smallest ratio in the city, with six health-care providers per 100,000 residents. More than 23 percent of adults there ranked their health as fair or poor, the worst self-appraisal in the city.