(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Performance and efficiency review : Department of Public Health : Controller's Office analysis 2005-2008"

SAN FRANCISCO PUBLIC LIBRARY, 



3 1223 06836 2889 



PERFORMANCE AND 
EFFICIENCY REVIEW: 
DEPARTMENT OF 
PUBLIC HEALTH 

Controller's Office 
Analysis 2005-2008 



D 

REF 

353.6097 

Sa577p 



DOCUMENTS DEPT. 

JUN 2 4 2008 

SAN FRANCISCO 
PUBLIC LIBRARY ' 




June 20, 2008 



Controller's Office - City Services Auditor 

In November of 2003, voters passed a charter amendment which created the City Services Auditor 
within the Controller's Office. Under Appendix F to the City Charter, the City Services Auditor: 

• Reports on the level and effectiveness of San Francisco's public services and benchmarks 
the City to other public agencies and jurisdictions. 



• 



Conducts financial and performance audits of City departments, contractors, and functions 
to assess efficiency and effectiveness of processes and services. 

• Operates a whistleblower hotline and website and investigates reports of waste, fraud, and 
abuse of City resources. 

• Ensures the financial integrity and improves the overall performance and efficiency of City 
government. 




City and County of San Francisco 

Office of the Controller - City Services Auditor 



Performance And Efficiency Review: Department of Public Health 
Controller's Office Analysis 2005-2008 



June 20, 2008 



Purpose of the Report 

This report analyzes the San Francisco Department of Public Health's provision of services, efficiency of operations, and 
patients and payer mix. It draws on multiple analyses planned and coordinated by the San Francisco Controller's Office 
from 2005-2008. In 2005, Mayor Newsom and the Board of Supervisors requested the Controller's Office to evaluate the 
Department of Public Health under the Controller's mandate to measure, audit, and report on government performance. 
Critical analysis is increasingly needed as the City implements Healthy San Francisco and rebuilds Laguna Honda 
Hospital and San Francisco General Hospital and Trauma Center. 



MHHBHHHHHB^HM 






Highlights 

The Department of Public Health is the City's primary provider of health 
services to the Door and uninsured. 

e needed to promote prevention, free up 
and resulting from Healthy San Francisco. 

>, the rebuilt Laguna Honda Hospital will be 
kind, which is inconsistent with nationwide 



hospital beds in the City, San Francisco 
percent of the psychiatric, HIV, and 

) General Hospital's patients are uninsured 
percent citywide. 

ovides the only trauma facility in the City 
sed by violence, falls, car crashes, and 




\an Francisco Public Library 

Government Information Center 
San Francisco Public Library 
WOtarkin Street, 5th Floor 
San Ftan&isco, Cm 941G2 

IEFERENCE BOOK 

ot to be taken from the Library 



Dccupancy rate is 97 percent, well above 
id rate of 80 percent, and well above any 

San Francisco General Hospital is at or near the top of a benchmark range in 
overall clinical quality for treatment for heart attacks, heart failure, pneumonia, 
and the prevention of surgical infections. 

• San Francisco General Hospital is productive and is financially well run when 
compared to similar hospitals across the country. For example, General 
Hospital uses 26 percent less overtime and 61 fewer full time equivalents, 
saving $5.7 million annually, and its revenue cycle processes are complete 
and effective. 

• There are no providers able and willing to fill critical gaps in services should 
San Francisco General Hospital not be rebuilt to meet state seismic 
standards. 



Recommendations 

• Continue to focus on 
primary care clinic 
redesign to reduce wait 
times for appointments 
and increase patient 
throughput 

• Develop more out- 
patient, community- 
based health services, 
including smaller 
facilities and in-home 
services for long-term 
and skilled nursing 
care 

• Expand care delivery 
alternatives for lower 
acuity and medical and 
psychiatric services to 
allow expansion of 
hospital trauma volume 
and acute inpatient 
capacity 

• Increase investments 
in information 
technology 

• Maintain area hospital 
capacity, including 
rebuilding San 
Francisco General 
Hospital 



Copies of the full report may be obtained at: 
Controller's Office • City Hall, Room 31 6 • 1 Dr. Carlton B. Goodlett Place • San Francisco, CA 94102 • 415.554.7500 

or on the Internet at http://www. sfpov. org/controller 




City and County of San Francisco 

Office of the Controller - City Services Auditor 



Performance And Efficiency Review: Department of Public Health 
Controller's Office Analysis 2005-2008 



June 20, 2008 



Purpose of the Report 

This report analyzes the San Francisco Department of Public Health's provision of services, efficiency of operations, and 
patients and payer mix. It draws on multiple analyses planned and coordinated by the San Francisco Controller's Office 
from 2005-2008. In 2005, Mayor Newsom and the Board of Supervisors requested the Controller's Office to evaluate the 
Department of Public Health under the Controller's mandate to measure, audit, and report on government performance. 
Critical analysis is increasingly needed as the City implements Healthy San Francisco and rebuilds Laguna Honda 
Hospital and San Francisco General Hospital and Trauma Center. 






Highlights 

• The Department of Public Health is the City's primary provider of health 
services to the poor and uninsured. 

• Increased primary care services are needed to promote prevention, free up 
hospital capacity, and absorb demand resulting from Healthy San Francisco. 

• Even at a reduced size of 780 beds, the rebuilt Laguna Honda Hospital will be 
among the largest institutions of its kind, which is inconsistent with nationwide 
best practices. 

• With only 17 percent of the staffed hospital beds in the City, San Francisco 
General Hospital provides over 50 percent of the psychiatric, HIV, and 
substance abuse care citywide. 

• Sixty-four percent of San Francisco General Hospital's patients are uninsured 
or covered by Medi-Cal versus 23 percent citywide. 

• San Francisco General Hospital provides the only trauma facility in the City 
for response to critical injuries caused by violence, falls, car crashes, and 
other accidents. 

• San Francisco General Hospital's occupancy rate is 97 percent, well above 
the industry standard recommended rate of 80 percent, and well above any 
other San Francisco hospital. 

• San Francisco General Hospital is at or near the top of a benchmark range in 
overall clinical quality for treatment for heart attacks, heart failure, pneumonia, 
and the prevention of surgical infections. 

• San Francisco General Hospital is productive and is financially well run when 
compared to similar hospitals across the country. For example, General 
Hospital uses 26 percent less overtime and 61 fewer full time equivalents, 
saving $5.7 million annually, and its revenue cycle processes are complete 
and effective. 

• There are no providers able and willing to fill critical gaps in services should 
San Francisco General Hospital not be rebuilt to meet state seismic 
standards. 



Recommendations 

• Continue to focus on 
primary care clinic 
redesign to reduce wait 
times for appointments 
and increase patient 
throughput 

• Develop more out- 
patient, community- 
based health services, 
including smaller 
facilities and in-home 
services for long-term 
and skilled nursing 
care 

• Expand care delivery 
alternatives for lower 
acuity and medical and 
psychiatric services to 
allow expansion of 
hospital trauma volume 
and acute inpatient 
capacity 

• Increase investments 
in information 
technology 

• Maintain area hospital 
capacity, including 
rebuilding San 
Francisco General 
Hospital 



Copies of the full report may be obtained at: 
Controller's Office • City Hall, Room 316 • 1 Dr. Carlton B. Goodlett Place • San Francisco, CA 94102 • 415.554.7500 

or on the Internet at http:/Avww. sfpov. org/controller 



Page intentionally left blank. 




CITY AND COUNTY OF SAN FRANCISCO 



OFFICE OF THE CONTROLLER Ben Rosenfield 

Controller 

Monique Zmuda 

Deputy Controller 

June 20, 2008 

The Honorable Gavin Newsom 

Mayor, City and County of San Francisco 

Room 200, City Hall 

The Honorable Members, Board of Supervisors 
Room 244, City Hall 

The Honorable Members, San Francisco Health Commission 
101 Grove Street, Room 31 1 

Dear Mayor Newsom, Ladies and Gentleman: 

The Controller's Office, City Services Auditor, presents a summary of its performance and 
efficiency reviews of the Department of Public Health (DPH). This report analyzes and makes 
recommendations on DPH's provision of services, efficiency of operations, and patients and 
payer mix. 

The Controller's Office has issued this report in response to requests from City leadership and 
community advocates to audit DPH. To accurately evaluate an entity of the scope and scale of 
DPH, the Controller's Office has performed a series of evaluations, technical assistance 
projects, and audits addressing different aspects of its functioning. This has included review of 
DPH's revenue and financial management, the efficiency and effectiveness of acute and long- 
term hospital care, DPH's role in San Francisco's healthcare market, and financial controls of 
nonprofit contractors providing services funded by the Department. This report summarizes and 
provides conclusions based on these multiple analyses coordinated by the Controller's Office 
from 2005-2008. 

Key recommendations in the report include: 

• Maintain area hospital acute care, trauma, and safety net capacity: The services that 
San Francisco General Hospital and Trauma Center provides are critical to the City's 
emergency and trauma response ability and healthcare safety net. No providers are able 
and willing to fill all of the gaps in services if General Hospital is not rebuilt to meet state 
seismic standards. General Hospital provides the only trauma center and over half of the 
hospital-based psychiatric, HIV, and substance abuse care in the City. Sixty-four percent of 
its patients are uninsured or covered by Medi-Cal, and it supplies the majority of charity- or 
uncompensated- care worth $76 million in fiscal year 2005 compared with $18 million 
provided by all other hospitals. General Hospital has strong clinical outcomes, high 
productivity, and is financially well run and effective when compared with similar hospitals 
across the country. It is at or near the top of a benchmark range in overall clinical quality for 
treatment for heart attacks, heart failure, pneumonia, and the prevention of surgical 
infections. By using 26% less overtime and 61 fewer full time equivalents, General Hospital 
saves approximately $5.7 million annually. 



415-554-7500 City Hall • 1 Dr. Carlton B. Goodlett Place • Room 316 • San Francisco CA 94102-4694 FAX 415-554-7466 



• Develop smaller and assisted living facilities as well as in-home services to provide 
long-term and skilled nursing care: Currently, approximately one out of every 700 people 
in San Francisco lives in Laguna Honda Hospital - the City has institutionalized more of its 
population, across a wider spectrum of needs, than anywhere in the country. Although the 
rebuilt facility will contain fewer beds, Laguna Honda will still be a large institution by 
nationwide standards, which is inconsistent with best practices in patient care. Alternative 
models to delivering long-term and skilled nursing healthcare are critical given that the City's 
residents aged 65 and over are projected to increase by 79% by 2030. Such models would 
better serve patients as well as benefit the City financially. 

• Increase access to primary and community-based care: DPH needs to redesign and 
renovate many of its community-based clinics in order to increase access to primary care. 
Such redesign, already underway, reduces wait times for appointments, increases patient 
throughput, and leads to better health outcomes such as reduced hospitalizations. Healthy 
San Francisco, launched in July 2007, is expected to increase aggregate demand and 
access to quality primary care services. DPH should also continue to expand community- 
based approaches to providing non-hospital alternatives for psychiatric patients. 

• Increase investments in information technology: Expert healthcare consultants 
examining DPH's revenue cycle and acute hospital care noted that investments in 
information technology could reduce costs and inefficiencies as well as improve patient 
outcomes. For example, an updated revenue accounting system for DPH could provide 
more real-time revenue data and facilitate revenue monitoring, scenario planning, and 
budget decision-making. Better systems in General Hospital's Emergency Department 
could improve patient flow and overall operational efficiency. A productivity information 
management system could improve management's ability to monitor and utilize labor and 
human resources. Best practices of other public hospitals in information technology 
systems include integrated electronic medical records, automated physician referral, and 
computerized physician order entry, and computer access in all patient rooms. 

The Controller's Office provides ongoing analysis and support to DPH. We are currently 
assisting Laguna Honda in its transition planning to new hospital facilities as well as preparing 
in-depth evaluation and technical assistance on substance abuse treatment services. Building 
upon the extensive oversight of DPH exercised by state and federal agencies, our office 
continues to work closely with DPH to identify areas of need and ensure efficient operations and 
high quality healthcare services for all San Franciscans. 

We appreciate the assistance and cooperation that DPH staff consistently provides and has 
provided to us for this report. 

Respectfully submitted, 
T 



Ben Rosenfield 
Controller 

cc: Mayor, Board of Supervisors, Civil Grand Jury, Budget Analyst, Public Library 



Table of Contents 



I. Introduction 6 

II. About the Department of Public Health 10 

III. Department of Public Health Services 14 

1. Primary Care 14 

2. Acute Hospital Care 18 

3. Emergency and Trauma 22 

4. Long-term Care 25 

5. Behavioral Healthcare 27 

6. Recommendations 27 

IV. Department of Public Health Operations 28 

1. Workforce Efficiency 28 

2. Revenue Maximization 31 

3. Cost Efficiency and Productivity 33 

4. Nonprofit Contracting 36 

5. Recommendations 37 

V. Patients and Payer Mix 38 

1. Demographic Changes 38 

2. Citywide Payer Mix 40 

3. Department of Public Health Payer Mix 41 

4. Recommendations 46 

VI. List of Analytical Projects 2005-2008 47 



I. Introduction 




Patient receives primary care services at a Department of Public Health Clinic 

In 2005, Mayor Newsom and the Board of Supervisors requested that the 
Controller's Office evaluate the Department of Public Health under the 
Controller's mandate to measure, audit, and report on government 
performance. There has been no comparable evaluation of the 
Department of Public Health in recent years. Critical analysis is 
increasingly needed as the City implements Healthy San Francisco 1 and 
rebuilds San Francisco General Hospital and Laguna Honda Hospital. 

To accurately evaluate an entity as large as the Department of Public 
Health, the Controller's Office has performed a series of evaluations, 
technical assistance projects, and audits addressing different aspects of its 
functioning. This has included review of the Department of Public Health's 
revenue and financial management, the efficiency and effectiveness of 
acute and long-term hospital care, the Department's role in San 
Francisco's healthcare market, and financial controls of nonprofit 
contractors providing services funded by the Department. The Controller's 
Office has also taken into account the extensive oversight and quality 
assurance by state and federal entities to which all local public health 
agencies, hospitals, and clinics are subject, such as licensing, inspections, 
audits, reporting, and other compliance requirements. 



Photo. Molly Duggan Associates, LLC 

The Controller's Office 
has performed a serie? 
of evaluations, 
technical assistance 
projects, and audits to 
evaluate the Health 
Department 



Healthy San Francisco is expanding services and restructuring the City's safety net system from a crisis delivery approach to an 
emphasis on primary care. More information can be found at: http://www.healthysanfrancisco.org. 



This summary report analyzes the Department of Public Health's provision 
of services, efficiency of operations, and patients and payer mix, drawing 
on multiple analyses planned and coordinated by the Controller's Office 
from 2005-2008. Such analyses include evaluation and benchmarking 
studies from expert consultants like the Lewin Group, Phase 2 Consulting, 
Brady and Associates, and Health Management Associates. Please see 
section six of this report or the "Healthcare Analysis" section of the 
Controller's website (www.sfgov.org/controller) for more details. Please 
also note that some analysis is not yet complete, such as transition 
support for the rebuilt Laguna Honda Hospital as well as an evaluation of 
substance abuse services. 

The San Francisco Department of Public Health is among the nation's 
leading public health departments. 2 San Francisco spends more per 
person per year on public health than other cities by a huge margin. In 
2005, the City spent approximately $400 per person compared with the 
nationwide average of approximately $64 per person. Due to great support 
for our public health system, San Francisco is able to deliver a broad 
range of primary, acute, emergency, long-term, and behavioral health 
programs that are not available in other public health systems. Overall, the 
standards of care are very high. The delivery system uses both hospital 
and community-based providers in partnership and provides culturally 
sensitive services to the City's diverse population. 

Of particular note is the strong performance of San Francisco General 
Hospital. When compared to similar hospitals nationwide, San Francisco 
General Hospital is at or near the top in overall clinical quality in areas 
such as treatment for heart attacks, heart failure, and pneumonia, as well 
as the prevention of surgical infections. Despite factors that tend to 
decrease efficiency, such as a high number of patients and an aging 
infrastructure, San Francisco General Hospital has high productivity and is 
financially well run and effective. Hospital hours per patient discharged 
have been reduced since 2005, and General Hospital employs fewer 
people and uses less overtime than comparable hospital departments. 
San Francisco General Hospital also maintains a low number of days that 
bills are in accounts receivable and outperforms some peer hospitals in 
delivering cost-efficient inpatient care. 

The Department of Public Health is the City's primary provider of health 
services to the poor and uninsured. For example, 64 percent of San 
Francisco General Hospital's patients are uninsured or covered by Medi- 
Cal versus 23 percent citywide. Over three quarters of the patients at the 
Department of Public Health's primary care clinics are below the federal 
poverty level and less than one percent has private insurance. San 
Francisco General Hospital provided charity (uncompensated) care worth 
$76.4 million in fiscal year 2005 compared to $17.9 million provided by all 



San Francisco delivers 
a broad range of health 
programs not available 
in other public health 
systems 



General Hospital has 
high productivity and is 
financially well run 



The Department is the 
City's primary provider 
of health services to 
the poor and uninsured 



Market Assessment and Benchmarking Report, the Lewin Group, 2007, page 1 . 




Patient receives services at San Francisco General Hospital 



Photo: Molly Duggan Associates, LLC 



other hospitals. The majority of the Department of Public Health's clients 
come from areas where there is greater poverty and greater ethnic and 
racial diversity as compared with the rest of the City. 

San Francisco voters will likely consider the bond to rebuild San Francisco 
General Hospital to meet state seismic requirements in November of 2008. 
No providers appear able and willing to fill all of the critical gaps in 
services if General Hospital is not rebuilt. With only 17 percent of the 
staffed hospital beds in the City, San Francisco General Hospital provides 
more than 50 percent of the psychiatric, HIV, and substance abuse care. 
Without General Hospital, there would likely be inadequate healthcare 
access for tens of thousands of San Franciscans, particularly those living 
in the southern and eastern sectors of the City, who are covered by Medi- 
Cal or who are uninsured or underinsured. Such patients face difficulty 
securing needed healthcare services because they bring less revenue to 
hospitals as compared with those covered by commercial insurance. 
Without San Francisco General Hospital, there is no other hospital in San 
Francisco that would qualify for state and federal funds earmarked for the 
healthcare safety net population - that is, the poor, uninsured, and 
underinsured - and thus the City would forgo over a hundred million 
healthcare dollars annually. 

San Francisco General Hospital is critically important to every San 
Francisco resident, regardless of their zip code or insurance coverage. 
General Hospital provides the only trauma facility in the City for response 
to critical injuries caused by violence, falls, car crashes, and other 
accidents, with the next closest trauma center for adults located 35 miles 



General Hospital is 
important to every San 
Francisco resident, 
regardless of their zip 
code or insurance 
coverage 



away in Stanford. The Lewin Group's San Francisco healthcare market 
assessment concluded that area hospital capacity should be maintained or 
expanded, and recommended that San Francisco General Hospital be 
rebuilt. 

Other recommendations highlighted in the following report include San 
Francisco's need to develop more primary, out-patient, and community- 
based health services. The Department of Public Health should continue 
to expand community and home-based options for long-term and skilled 
nursing care, as well as primary care clinic redesign to reduce wait times 
for appointments and increase patient throughput. 3 The Department of 
Public Health will also need to continue to explore care delivery 
alternatives for lower severity, medical, and psychiatric services to expand 
emergency inpatient capacity in San Francisco General Hospital and other 
City hospitals. To increase operational efficiency, the Department of Public 
Health should consider increased investments in information technology. 
Despite current budget shortfalls, technology investments in areas such as 
a productivity information management system would significantly facilitate 
management's ability to better monitor and utilize labor and human 
resources, thus reducing future costs. 

The Controller's Office would like to acknowledge the work of the Lewin 
Group, Phase 2 Consulting, Brady and Associates, and Health 
Management Associates, which informed the analysis in this report. We 
also thank the Department of Public Health and other healthcare 
professionals in San Francisco and across the country who contributed 
significant data and expertise. 



More primary, out- 
patient and community- 
based health services 
are needed 



"Patient throughput" refers to the time and processes required to successfully move a patient through the continuum of care in a 
hospital or in an outpatient setting such as a clinic. The faster, or more efficiently a patient is moved through the process, the 
lower the length of stay, the better the cost management, and the quicker services can be provided to another patient, which is 
new revenue to a hospital or clinic and prompter services to clients. 



II. About the Department of Public Health 




The San Francisco Department of Public 
Health is the largest City Department and 
has a $1.3 billion budget and 6,000 full time 
employees. The Department provides 
healthcare at two 24/7 hospitals - San 
Francisco General Hospital and Laguna 
Honda Hospital - community health centers, 
and the County's jails. The Department also 
provides services for health promotion and 
prevention, maternal and child health, 
HIV/AIDS, infectious disease control, 
behavioral health, environmental health and 
housing, and homeless assistance. 

DEPARTMENT OF PUBLIC HEALTH'S 
ORGANIZATION AND STRUCTURE 

The San Francisco Department of Public 
Health is structured in two major divisions, 
the Community Health Network and 
Population Health and Prevention. The 
Community Health Network provides an 
array of personal healthcare services and 
includes San Francisco General Hospital, 

Laguna Honda Hospital, Community Oriented Primary Care, Health at Home, and Jail Health 

Services. Major service 

components include primary care 

(provided at 18 sites throughout 

the City), specialty care, acute 

care, home healthcare, long-term 

care, and emergency care. The 

Population Health and Prevention 

Division includes traditional public 

health functions, such as 

environmental health, sexually 

transmitted diseases, disease 

control, tuberculosis, substance 

abuse, as well as mental health. 

The following chart illustrates the 

organization of the Department on 

Public Health: 



San Francisco Department of Public Health Offices 



Department of Public Health's Strategic Plan: 
A Vision for Health for All 

In the Department of Public Health's continuing effort to 
protect and promote the health of all San Franciscans, it 
has created a strategic plan that will be effective through 
2009. The Strategic Plan Goals are: 

Goal 1 : To ensure San Franciscans have access 
to the health services they need. 

Goal 2: To ensure disease and injury are prevented. 

Goal 3: To ensure services, programs, and facilities are 
cost-effective and resources are maximized. 

Goal 4: To create and sustain partnerships with 
communities to assess, develop, implement, and 
advocate for health funding, policies, programs, 
and services. 



10 



Health Commission 



Director of Hearth 

MithaiH Katz. MD 



Long Term Care 
Coordlraior 

EleabethGray 



Chief Financial Oflcer 
Contracts MS 
Gregg Sass 



Planning «. 
Ad ml nlstratlon 
Arme Kronenberg 



-CHN*- 



Laguna Honda Hospital 
John kanaley 



San FlDdm General 
HospNat, CHN 

Gene O'Comell 



Executive Secretary 
Pamela Tyson 



Compl lance 

Yvonne Lowe 
Josephine McCrean/ 



Human Resources 
Elizabeth Jacobi 



Healthy San Francisco 
Tangerine Brigham 



Community Health 

Programs 

Barbara Oaraa 



Health at Home 
KathyEng 



San Francisco 

BriHMd Heath 

Center 

Sharon Wlcher 



Primary Care 

Michael Drennan.MD 



Maternal Chid Health 

Tw(a Brown 



Behavioral Health 

Bob Cabal, MD 



Housing & Urban Health 
Marc Trotz 



Community Heal ti 
Promotion & Prevention 

Dinger Smyly 



HIV Health Services 

Michelle Long 



HiV Prevention 

Grant Colfax, MD 





Community Health A 
Safely Services 
















C ommunl cable D tseese 
Control A Prevention 
Susan FemyaK MD 






Public Health Laboratory 
Sally Uska, Dt PH 










Environmental Health A 
OSH 

RalltBhalta, MD 


STD Prevention & Control 

Jerrwausnet, MO 










Emergency Medical 

Services 
John Brown, MD 


IB Control 
Masae kawamura. MD 










HTV Research 
Susan Buchbinder, MD 


WVSurveHlance 

Susan Scheer 
UngChhlsu 










Commurmy Health 
Epidemiokigy 

Tomas Aragon. MD, DrPH 


Hrvseroepidemiology 






Will McFarland, MD 



"CHN = Community Health Netvsork. the integrated health service delivery system of the Health Department 
"PHP = Populabon Health and Prevention 

The Department of Public Health runs the following major programs: 

San Francisco General Hospital Medical Center 

San Francisco General Hospital provides comprehensive emergency, urgent, primary, and 
specialty care to 98,244 adults and children annually. General Hospital is a leader in its field 
and is the only Level 1 Trauma Center for 1.5 million residents of San Francisco and northern 
San Mateo County. San Francisco General Hospital is also the only acute inpatient and 
rehabilitation hospital for psychiatric patients in the City and provides 24 hour psychiatric 
emergency care. 

Laguna Honda Hospital and Rehabilitation Center 

Laguna Honda Hospital and Rehabilitation Center is the largest skilled nursing facility in the 
country, with approximately 1,030 disabled or chronically ill adult San Franciscans as 
residents (daily average in fiscal year 2006-2007). Laguna Honda Hospital provides a full 
range of skilled nursing services to those with wounds, head trauma, stroke, spinal cord 
injuries, orthopedic injuries, AIDS, and dementia. The Hospital provides respite and hospice 
care, outpatient services through the Adult Day Health Care Center, as well as neighborhood 
nutrition services. 



11 



Community Behavioral Health Services 

Community Behavioral Health Services provides mental health and substance abuse 
services. The division makes up about 24 percent of the Department of Public Health's total 
budget and serves approximately 35,000 patients annually through a comprehensive array of 
culturally sensitive programs. The majority of funds are spent on community-based programs, 
and most mental health and substance abuse services are provided through contractors. 

Health At Home 

Health At Home is the Department of Public Health's Medicare-certified home health agency 
helping more than 1,200 low income clients stay in their homes annually. Health At Home 
provides symptom management, restorative care, respite, personal care, HIV management, 
wound and ostomy care, medical escort services, diabetic and respiratory care, and nutrition 
and palliative care. Health at Home's staff includes nurses, social workers, home health 
aides, volunteers, as well as physical, occupational and speech therapists. 

Jail Health Services 

Jail Health Services provides a comprehensive integrated system of medical, psychiatric, and 
substance abuse care to approximately 32,425 inmates in San Francisco jails (fiscal year 
2006-2007). 

Community-Oriented Primary Care 

Community-Oriented Primary Care brings primary care, community medicine, and public 
health together. The Department's 18 primary care clinics are an essential part of the local 
healthcare safety net, since patients are seen regardless of insurance status or ability to pay. 
In fiscal year 2006-2007, the Department of Public Health's Primary Care Division (including 
San Francisco General Hospital clinics and community health centers) provided 321,850 
primary care visits and 141,722 specialty visits. 

Environmental Health 

The Environmental Health section ensures safe and healthy living and working environments 
for San Franciscans through a variety of programs including those addressing children's lead 
poisoning, asthma prevention, food safety, water quality, and chemical hazards. 

Housing And Urban Health 

Housing and Urban Health creates housing options for homeless and disabled residents. The 
Department of Public Health's goal is to provide community-based supportive housing along 
with innovative healthcare services for those living on the streets, in shelters, and/or rotating 
through institutional settings. 



12 



Community Health Promotion and Prevention 

Community Health Promotion and Prevention's mission is to promote health and prevent 
disease and injury in San Francisco. Programs depend on the active involvement of the 
community and include: African-American Health Initiative, Injury Prevention, Newcomers 
Program (Refugee Health), SF Violent Injury Reporting Center, Intimate Partner Violence 
Strategic Plan, Tobacco Free Project, YouthPower, and Telehealth. 

AIDS 

San Francisco County has the highest incidence of HIV/AIDS in California with an estimated 
15,129 people living with HIV/AIDS (as of the end of calendar year 2006). The Department of 
Public Health has made HIV/AIDS research, prevention, and services a top priority. The AIDS 
Office develops prevention strategies, provides direct services (through community partners) 
to those living with HIV or at risk, contributes to scientific and special service communities 
through research and studies, and formulates HIV policies for the Department. 

Maternal and Child Health 

The Department of Public Health promotes the health and well being of women of 
childbearing age, infants, children and adolescents who are at increased risk of adverse 
health outcomes by virtue of financial, language or cultural barriers, or mental or physical 
disabilities. The Department provides health promotion and clinical healthcare services such 
as nutrition, reproductive health, dental health, and primary care for children and youth. 

For additional information, please visit the Department of Public Health's website at 
www.sfdph.org. 



13 



III. Department of Public Health Services 



1. PRIMARY CARE 




Patient receives services at a Department of Public Health primary care clinic 



CLINIC NETWORK 

The Department of Public Health operates a network of 18 community- 
based primary care clinics throughout San Francisco. These clinics offer a 
broad array of primary care and mental health services including youth 
health, senior health, infectious disease, and family planning. The 
Department of Public Health's clinic network provides culturally sensitive 
care to the underserved, uninsured, and at-risk populations who otherwise 
may not have access to any healthcare services. The Department of 
Public Health served over 60,000 unique patients in fiscal year 2006 and 
operated a total of 214 exams rooms. In addition, the Department of Public 
Health provides funding to, and works in partnership with, many of the ten 
nonprofit clinics in the San Francisco Community Clinic Consortium. 4 This 
Consortium provides primary care services to similar populations 
throughout the City. 



Health Department's 
18 community-based 
clinics served more 
than 60,000 people 
in 2006 



Curry Senior Center is both a member of the Clinic Consortium as well as a Department of Public Health clinic. 



14 



Figure 1: Community-based Primary Care Clinic Network in San Francisco 



Madiuliy Undtrurvtd Ar*» 

Medical Centers 

A Coalman ly Clirvc 

Consortium 
• Oept of Pubic Health 

Primary Care CI niC) 




The Department of Public Health and Community Consortium clinics are 
strategically situated in high poverty, Medically Underserved Areas 
(MUAs) 5 (Figure 1) in which residents have a shortage of personal health 
services. The Department of Public Health clinics of Ocean Park, 
Southeast, Silver Avenue, Potrero Hill, and Chinatown are all located in 
MUAs. Castro-Mission, Curry, and Tom Waddell are located adjacent to 
these areas as well. However, it should be noted that there are service 
gaps in the far western part of the City. 

AMBULATORY CARE SENSITIVE HOSPITALIZATIONS 

Early intervention and access to primary care can prevent later 
hospitalization. An Ambulatory Care Sensitive hospitalization is a condition 



Potentially preventable 
hospitalizations are 
highest in the City's 
most impoverished 
neighborhoods 



A Medically Underserved Area may be a whole county or a group of counties, civil divisions, or urban census tracts that score 
below a 62 on the Health Resources and Service Administration (US Department of Health and Human Services) Index of Medical 
Underservice. This index is based on the ratio of primary medical care physicians per 1,000 population, infant mortality rate, 
percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. 



15 



for which outpatient care can potentially prevent the need for hospitalization or for which early 
intervention can prevent complication or more severe disease. Ambulatory Care Sensitive 
hospitalizations can occur when there is insufficient access to primary care, thereby forcing 
individuals to seek care either through the emergency room at a hospital or to wait until the 
condition progresses in severity before seeking treatment. 

San Francisco's average rate of Ambulatory Care Sensitive hospitalizations for certain conditions 
is consistently lower than statewide averages. However, San Francisco's Ambulatory Care 
Sensitive hospitalization rates by condition have been mixed since 1997 (Figure 2). In addition, 
similar to the national experience, Ambulatory Care Sensitive hospitalizations are highest in the 
City's most impoverished neighborhoods. 

Figure 2: Ambulatory Care Sensitive Discharges per 100,000 Persons, 
San Francisco v. California, 1997 - 2003 



Prevention Quality Indicator 


San 

Francisco 

1997 


San 

Francisco 

2003 


Statewide 
2003 


Variance 

from 
Statewide 
Average 


Change in 

San 
Francisco 
Rate from 
1997-2003 


Adult Asthma 


139.3 


92.3 


97.7 


-5.4 


11 


Pediatric Asthma 


238.0 


115.3 


134.2 


-18.9 


11 


Chronic Obs. Pulmonary Disease (COPD) 


110.4 


119.1 


185.3 


-66.2 


t 


Congestive Heart Failure (CHF) 


373.3 


332.2 


408.0 


-75.8 


11 


Adult Diabetes - Short Term/Uncontrolled 


54.9 


45.4 


60.6 


-15.2 


11 


Adult Diabetes - Long Term 


74.8 


85.3 


112.4 


-27.1 


ft 


Low Birth Weight* 


54.2 


65.0 


49.2 


15.8 


tf 



* Per 1000 births 



"f^f 1 Increase > 10% ^ Increase - 10% 
■ Decrease > 10% 1 Decrease - 10% 



Source: Preventable Hospitalizations in California: Statewide and County Trends (1997-2003). 
OSHPD, November 2005. Lewin Analysis 



Citywide, the average wait time for a primary care appointment in a 
Department of Public Health clinic is 35 days for new patients, a wait time 
which is typical for safety net providers 6 located in urban settings. However, 
this wait time taken together with elevated levels of Ambulatory Care 
Sensitive hospitalizations may indicate insufficient primary care and 
outpatient capacity in certain San Francisco neighborhoods. 



A new patient must 
wait approximately 35 
days for a primary car 
clinic appointment 



A "safety net provider" provides healthcare services to the poor, underinsured, and uninsured. 



16 




Patient enrolls in Healthy San Francisco 



EXPANSION OF PRIMARY CARE SERVICES 

The Department of Public Health needs to renovate and redesign many of 
its community-based clinics in order to increase access to primary care. 
Such updates will reduce wait times for appointments, increase patient 
throughput, 7 and lead to better health outcomes such as reduced 
Ambulatory Care Sensitive hospitalizations. The Department of Public 
Health has programmed approximately 20 million dollars of renovations, 
and has currently completed 60 percent of the projects at ten community 
clinics. The Department plans to complete all needed renovations within the 
next three years. 

Healthy San Francisco, launched in July 2007, is expected to significantly 
increase aggregate demand and access to quality primary care services. As 
of May 2008, Healthy San Francisco is serving over 22,000 people in 22 
centers throughout the City - both in the Department of Public Health 
primary care clinics and in the private nonprofit clinics of the Community 
Clinic Consortium. Monthly enrollments have been steadily increasing and 
have averaged about 3,000 per month in recent months. The Lewin Group 
projected that 42,000 San Francisco residents, many of whom are already 
users of the public health system, will participate in Healthy San Francisco 
at full-scale implementation. The Department of Public Health is currently 



Reduce 

hospitalizations by 
increasing primary care 
capacity and early 
intervention 

Healthy San Francisco 
is currently serving 
20,000 people in 
22 centers throughout 
the City 



"Patient throughput" refers to the time and processes required to successfully move a patient through the continuum of care in a 
hospital or in an outpatient setting such as a clinic. The faster, or more efficiently a patient is moved through the process, the 
lower the length of stay, the better the cost management, and the quicker services can be provided to another patient, which is 
new revenue to a hospital or clinic and prompter services to clients. 



17 



planning for up to 66,000 enrollees in Healthy San Francisco. As a result, the Department is 
adding staff positions and budget to meet this demand. However it is important to note that a 
significant portion of the demand will be met by other Healthy San Francisco providers such as 
the Community Clinic Consortium. 

2. ACUTE HOSPITAL CARE 




San Francisco General Hospital 



CLINICAL QUALITY 

San Francisco General Hospital is staffed by physicians affiliated with the 
University of California, San Francisco, thus providing its patients with 
services from some of the best physicians in the country. San Francisco 
General Hospital is at the top of the range in overall clinical quality in areas 
such as treatment for heart attacks, heart failure, and pneumonia, as well as 
the prevention of surgical infections when compared with similar hospitals 8 
(Figure 3). 



General Hospital 
ranked near the top in 
clinical outcomes 



Benchmarks are all hospitals with over 300 beds, staffed by county employees, home to trauma centers and graduate medical 
education residency training programs, and serve a disproportionate share of Medicaid patients (greater than 31 percent of total 
discharges). Please see the Lewin's Group's Market Assessment and Benchmarking Report for more information on the 
benchmark hospitals and clinical quality measures. 

18 



Figure 3: Summary Clinical Quality of Care Indicator Results (Rank), 2005-2006 



Ranked 1 or 2 
Ranked 3 or 4 
Ranked 5 or 6 



^a** i Congestive _ . Surgical Infection All 4 

Heart Attack _f_ ., Pneumonia „ ... 

Heart Failure Prevention Clinical Areas 



Denver Health 


92.7% (3) 


82.5% (2) 


85.5% (1) 


77.1% (3) 


84.4% (1) 


SF General 


93.2% (2) 


81.6% (3) 


71.3% (2) 


81.9% (2) 


82.0% (2) 


Santa Clara 


89.5% (4) 


70.5% (5) 


61.4% (6) 


85.6% (1) 


76.7% (3) 


UMC- Southern NV 


96.1% (1) 


88.0% (1) 


61.7% (5) 


56.0% (6) 


75.4% (4) 


Riverside County 


84.5% (6) 


74.8% (4) 


69.3% (3) 


58.3% (5) 


71.7% (5) 



Alameda County 89.2% (5) 62.2% (6) 62.4% (4) 60.5% (4) 68.6% (6) 

Source: Lewin analysis of Center for Medicare and Medicaid Services; www.hospitalcompare.hhs.qov 



OCCUPANCY AND CAPACITY 

Half of the hospitals in San Francisco 
currently exceed the desired occupancy level 
of 80 percent, an industry standard, or 85 
percent, which is typically considered full 
(Figure 4). The industry standard is that a 
hospital can be at maximum 80 percent 
occupied capacity before losing operational 
efficiencies. 

San Francisco General Hospital's occupancy 
rate is 97 percent, well above the 80 percent 
capacity utilization level. San Francisco 
General Hospital has such a high occupancy 
rate because it is the City's primary safety 
net provider and does not turn away patients 
in need. Chinese Hospital, Kaiser, and the 
Medical Center at University of California 
San Francisco also have high occupancy 
rates of 83 percent, 84 percent, and 80 
percent respectively. 

These statistics are 
reflective of average 

utilization. Should a significant emergency occur, key hospital facilities may 

lack adequate capacity to treat a surge in demand for inpatient care. 9 




Patient receives services at San Francisco General Hospital 

Photo Molly Duggan Associates. LLC 



The other four San Francisco hospitals: California Pacific Medical Center, 
St. Francis, St. Luke's, and St. Mary's, fall below the 80 percent threshold, 
and thus have available capacity. 



General Hospital 
serves all, especially 
those most in need 



It should be noted that Veteran's Hospital, a federally-funded institution, and Laguna Honda Hospital, a long-term care facility, 
could also provide capacity in an emergency in San Francisco. However, these institutions were not included in the Lewin Group's 
analysis, which focused exclusively on non federal acute care hospital systems. 



19 



Figure 4: Average Daily Census and Unoccupied San Francisco Staffed Hospital Beds, 

March 2007 



100% 




SF CPMC Chinese Kaiser St. St. St. UCSF 

General Francis Luke's Mary's 



n Average Daily Census □ Unoccupied Staffed Beds 



Source: Self reported data from Lewin survey March 2007 

The Lewin Group estimates that there will be a 24 percent shortage in hospital 
acute care beds in San Francisco by 2030 (Figure 5). This projection assumes 
that San Francisco General Hospital, which currently provides 15 percent of 
the City's acute beds, will be rebuilt to meet state seismic requirements. 
However, it should be noted that this projection is only based on current 
utilization and practice patterns, and assumes that the total number of current 
acute care beds available - 1,622 - will remain constant. The projection does 
not consider advances in technology, increased community-based service 
providers, increased staffing levels, or conversion of existing hospital space 
which could provide extra hospital capacity in the coming decades. 



Figure 5: Comparison of Supply and Demand for San Francisco 
Staffed Acute Hospital Beds 



Staffed Beds 


2006 


2010 


2020 


2030 


Projected Bed Demand 


1,738 


1,943 


2,195 


Current Supply 


Availability (Shortage) of Beds 


Total Acute Care Beds at 
San Francisco Hospitals 


1,622 


(76) 


(281) 


(533) 



Source: Department of Public Health Bed Capacity Survey Administered March 2007, 
OSHPD 2005, Lewin Analysis 



Maximum 
Optimal 
Capacity 



There could be as 
much as a 24% 
shortage in San 
Francisco's hospita 
beds by 2030 

Source: The Lewin Group 



20 



SERVICE LINE MARKET SHARE 



San Francisco General Hospital has a greater mix of psychiatry and medicine 
services relative to the other hospitals in San Francisco, while other hospitals 
have a greater mix of surgical specialty services, such as heart and transplant. 
With only 17 percent of the staffed hospital beds in the City, San Francisco 
General Hospital provides over 50 percent of the psychiatric, HIV, and 
substance abuse care. Given that San Francisco General has the City's only 
trauma center, it provides nearly half of the City's trauma services. Although 
other San Francsico hospitals do not have trauma centers, they have the ability 
to provide limited trauma care for less severe accidents. 

San Francisco General Hospital's role as the core citywide psychiatry provider 
has increased dramatically in the last seven years. In 2005, San Francisco 
General Hospital discharged 59 percent of the psychiatric patients citywide, up 
from 40 percent in 1999. Other types of services provided by San Francisco 
General Hospital (i.e. medicine, general surgery, and obstetrics) have 
decreased (Figure 6). 



With only 17% of 
San Francisco's 
hospital beds, 
General Hospital 
provides over 50% 
of psychiatric, HIV, 
and substance 
abuse care 



FIGURE 6: San Francisco General's Market Share for Key Services, 1999-2005 



ou /o - 








^^* — 


K 


50% - 












40% • 






30% - 












20% • 


r 










10% . 


^"^^™ 


• ■* 








0%. 




1 




1 


-I 1 



1999 



2000 



2001 



2002 



2003 



2004 



2005 



•Cardiology ♦ General Surgery a Medicine n Obstetrics » Psych — ■ — Trauma 



Source: OSHPD 1999-2005 



21 



3. EMERGENCY AND TRAUMA 




Patient receives emergency services at San Francisco General Hospital 



Photo. Molly Duggan Associates. LLC 



EMERGENCY 

More than one-half of all emergency department visits were concentrated at 
three area hospitals in 2005: San Francisco General Hospital, California 
Pacific Medical Center, and the Medical Center at University of California 
San Francisco. San Francisco General Hospital had nearly 45,000 visits in 
its emergency department, more than any other hospital (Figure 7). At 
current demand of 1,866 visits per station, San Francisco General Hospital 
is approaching the industry threshold level (2,000) for the average number 
of visits per emergency department station. Anything above 2,000 visits per 
emergency department station indicates the hospital's emergency 
department is operating above capacity and is in danger of decreasing 
efficiency and outcomes. 



General Hospital has 
San Francisco's 
busiest emergency 



room 






Figure 7: San Francisco Emergency Department Capacity and Utilization 



Hospital 


Emergency 
Dept. Visits 


Emergency 
Dept. Stations 


Visits/Station 


SF General 


44,779 


24 


1,866 


CPMC 


34,422 


24 


1,434 


Chinese 


5,719 


5 


1,144 


Kaiser 


25,821 


24 


1,076 


St. Francis 


19,292 


11 


1,754 


St. Luke's 


28,738 


13 


2,211 


St. Mary's 


18,056 


13 


1,389 


UCSF 


34,464 


29 


1,188 


Total 


211,291 


143 


1,478 



Source: OSHPD 2005 



22 



MINOR EMERGENCY DEPARTMENT VISITS 

Generally speaking, less severely ill patients presenting at emergency 
departments are more appropriately and efficiently treated in less costly 
settings such as physician offices, community health centers, and urgent 
care centers. Redirecting non-emergent patients to more appropriate levels 
of care also reduces emergency department overcrowding and frees up 
space to treat more severely ill patients. 

San Francisco General Hospital has been successful at reducing its 
proportion of minor emergency department visits to a low of five percent of 
all visits in fiscal year 2006. San Francisco General Hospital opened the 
Integrated Soft Tissue Infection Service (ISIS) clinic in 2000 and expanded 
the urgent care center hours in 2004 in order to minimize emergency room 
volume and provide non-emergency care in a lower cost setting. San 
Francisco General anticipates further reductions in minor emergency 
department visits as community care is expanded through the Healthy San 
Francisco initiative and due to recent efforts to increase referral to urgent 
and primary care services. When compared to similar hospitals, 10 San 
Francisco General Hospital occupies the middle of the range in regards to 
minor emergency department visits (Figure 8). 

Figure 8: Percent Minor Emergency Department Visits Fiscal Year 2004-2006 



General Hospital is 
reducing its proportion 
of inappropriate 
emergency department 
visits 



20% n 



1 5% ■ 



10% ■ 



5% 



0% 




2004 



2005 



2006 



-♦ — UMC- Southern NV Denver Health —A — SF General 

-■ — Alameda County Riverside County — I — Santa Clara 



Source: Lewin County Health System Benchmark Survey 5/07 



10 



Benchmarks are all hospitals with over 300 beds, staffed by county employees, home to trauma centers and graduate medical 
education residency training programs, and serve a disproportionate share of Medicaid patients (greater than 31 percent of total 
discharges). Please see the Lewin's Group's Market Assessment and Benchmarking Report for more information. 



23 




Patient receives trauma services at San Francisco General Hospital 



Photo: Molly Duggan Associates, LLC 



TRAUMA SERVICES 

San Francisco General Hospital has the only trauma center 11 in the City and 
has treated over 3,000 trauma cases every year since 2001. The trauma 
center treats critical injuries related to violence, falls, car crashes, and other 
accidents. The next closest trauma centers are Children's Hospital Oakland 
(20 - 28 minutes away) and, for adult patients, Stanford University Hospital 
(35 - 48 minutes away). San Francisco General also provides Level 1 
trauma services, a higher level of trauma services, 12 and the next closest 
Level 1 center is Santa Clara County Medical Center, approximately a one 
hour drive from San Francisco. 



The trauma center 
at General Hospital 
is the only one in 
San Francisco 



A Trauma Center is a designated, inpatient facility designed to provide specialized treatment for people who have experienced 
a physically damaging catastrophic event. The main focus of such centers is prompt, often emergency, treatment in order to 
prevent further damage and increase chances for recovery. 

12 

A Level I Trauma Center has a full range of specialists and equipment available 24 hours a day and admits a minimum required 
annual volume of severely injured patients. Additionally, a Level I center has a program of research, is a leader in trauma 
education and injury prevention, and is a referral resource for neighboring regions. 



24 



4. LONG-TERM CARE 




Laguna Honda Hospital resident and nurse 



TREATMENT SETTINGS 



Alternative models for delivering long-term and skilled nursing healthcare 
would benefit the City financially and better serve the citizens who most 
depend on public health. Currently, San Francisco's approach to long-term 
care and skilled nursing differs in both scale and delivery method from that 
of other public health systems, but not in progressive ways. Los Angeles 
County, with a population of over 16 million, does not have any publicly 
owned skilled nursing facilities, whereas San Francisco, with a population of 
approximately 775,000, as of 2005 had 1,200 public skilled nursing beds 
and is replacing Laguna Honda Hospital with a minimum of 780 beds. As a 
result, approximately one out of every 700 people in the City is living in 
Laguna Honda Hospital. The City has institutionalized more of its 
population, across a wider spectrum of needs, than anywhere in the 
country. By the Department of Public Health's own assessments, a 
significant portion of the Laguna Honda population does not need hospital- 
based long-term care and could be effectively treated in another setting - at 
home or in the community. 



Alternative models for 
delivering long-term 
and skilled nursing 
healthcare would 
benefit the City 



25 



Best practices nationwide demonstrate that public health systems should develop smaller 
facilities (200 beds or less), assisted living facilities, and in-home services to meet the need for 
long-term and skilled nursing care. These solutions offer advantages in terms of communication, 
problem-solving, medical management, and quality of life for patients. Implementing these 
changes will allow the City to keep the system affordable, meet more of the need for healthcare 
services, and treat patients in the way that best fits their medical needs. 



LAGUNA HONDA TRANSITION PLANNING 







Laguna Honda Hospital Construction 

Laguna Honda Hospital is constructing a new facility to create a better 
quality of life and more home-like environment for its residents. The new 
Laguna Honda building is expected to open in fiscal year 2010 and has 
approximately 780 beds. Although the planned facility is smaller than the 
current one, it is still considered a large institution by nationwide standards. 

Since August 2006, the Controller's Office has been working with Laguna 
Honda Hospital to ensure an effective and well-organized transition to the 
new facility, including staffing and budget plans to support the hospital 
before, during, and after the move. Experts are providing consulting 
services in hospital transition planning and workflow analysis. A detailed 
plan has been developed of how the facility will maintain consistent delivery 
of patient care during each step of the transition process, including workflow 
design, staffing levels, operational budgets, maintenance of operational 
integrity safety, and enhanced staff productivity and accountability. 



26 



The new Laguna 
Honda Hospital will stil 
be large by nationwide 
standards 



5. BEHAVIORAL HEALTHCARE 

The Department of Public Health's total mental health and substance abuse 
budget is $321 million in fiscal year 2008 and comprises about a quarter of 
its annual budget. San Francisco General Hospital has the City's only 
emergency psychiatric ward and serves 59 percent of the City's psychiatric 
patients requiring hospital-based care. Mental health services are also 
provided in the Department of Public Health's community-based clinics. 
However, most mental health and substance abuse services are provided 
through the Department of Public Health's community-based contractors. In 
fiscal year 2008, the Department provided private and nonprofit contractors 
$58 million for substance abuse treatment and $155 million for mental 
health services. 

The Controller's Office is planning evaluation and technical assistance for 
the Department of Public Health's substance abuse treatment services to 
commence in late 2008. 



Mental health and 
substance abuse 
comprises one quarter 
of the Health 
Department's total 
budget 



6. RECOMMENDATIONS FOR THE 

DEPARTMENT OF PUBLIC HEALTH 

□ Ensure sufficient citywide hospital capacity by rebuilding San Francisco 
General Hospital to comply with the state's seismic laws and by developing 
referral arrangements and collaborations with private providers. 

□ Continue to develop outpatient, community-based primary care services 
and maximize current medical provider and physical capacity through clinic 
re-design, renovation, and partnering with private providers as needed. 

□ Continue exploring care delivery alternatives for lower acuity medical and 
psychiatric services to allow expansion of trauma volume, higher acuity 
services, and emergency surge capacity at San Francisco General 
Hospital. 

□ Further reduce inappropriate emergency department utilization at San 
Francisco General Hospital through measures such as expanding 
ambulatory care service capacity and utilization of urgent and primary care. 

□ Develop smaller facilities, assisted living facilities, and in-home services to 
meet the need for assistance, long-term care, and skilled nursing care. 



27 



IV. Department of Public Health Operations 



1. WORKFORCE EFFICIENCY 




Staff at San Francisco General Hospital 



Photo: Molly Duggan Associates, LLC 



The Controller's Office, with expert consultants, has conducted an in-depth 
analysis of San Francisco General Hospital's workforce efficiency 
compared with similar hospitals throughout the country. 

San Francisco General Hospital exhibits strong workforce efficiency in 
areas such as full time equivalent count, overtime usage, and person hours 
per discharge. The favorable comparison is more notable considering that 
San Francisco General Hospital's staff productivity is constrained by the 
age and design of its buildings. Many departments operate in multiple 
locations that create duplicative overhead functions, add to staffing require- 
ments, and impede effective operations. San Francisco General Hospital's 
strong performance is also notable given the lack of information systems 
technology which could significantly support management's efforts to 
effectively monitor labor and activity data on a more real-time, regular basis. 

FULLTIME EQUIVALENT COUNT 

San Francisco General Hospital employed 61 fewer full time equivalents, 
saving approximately $3.2 million in salaries and other labor expenses, 



General Hospital 
exhibits strong 
workforce efficiency 
despite old buildings 
and information 
systems 



General Hospital save 
$3.2 million in salaries 
and labor expenses 
annually compared to 
similar hospitals 



28 



when compared to over 450 urban teaching hospital departments with similar functions and 
workloads. 13 



OVERTIME 

San Francisco General Hospital's departments used almost 26% less overtime 
compared to departments in over 450 peer hospitals nationwide, resulting in 
annual savings of about $2.5 million (Figure 9). 



General Hospital 
uses 26% less 
overtime than similar 
hospitals 



Figure 9: Overtime Hours and Expense in Peer Group vs. San Francisco General Hospital 



Overtime Hours Comparison 
Peer Group v. SF General 



145,205 




Peer Group Average 



San Francisco General 
Hospital 



Overtime Expense Comparison 
Peer Group v. SF General 

$8,229,468 



$5,727,020 




Peer Group Average 



San Francisco General 
Hospital 



Source: San Francisco General department fiscal year 2006 data. Brady and Associates 
benchmarking database of 450+ hospitals 



PERSON HOURS PER DISCHARGE 

"Person hours per discharge" refers to the total number of hospital staff hours devoted to a 
patient prior to discharge. San Francisco General Hospital reports a 20 percent drop in person 
hours per discharge between fiscal year 2005 and fiscal year 2006 (Figure 10). This is notable 
given San Francisco General Hospital's high number of mental health patients who cannot be 
discharged unless they have a home or other available housing or residential care options 
available. The decline in labor hours per discharge indicates San Francisco General Hospital's 
ability to minimize labor costs in inpatient settings and is a measure of efficient deployment of 
resources. 14 In recent years the four California benchmark hospital systems 15 have incurred a 
greater number of labor hours per discharge compared to their national counterparts. This finding 
may be influenced by California's mandated nurse staffing ratios, 16 differences in the average 
length of patient hospital stays, or other factors. 



Source: an Francisco General Hospital department fiscal year 2006 data; Brady and Associates benchmarking database of 
over 450 hospitals 

14 

Such data trends can also indicate staffing shortages, but this is unlikely in the case of San Francisco General Hospital: San 
Francisco General Hospital's staffing levels remain within the mid-point of the benchmark range, and it demonstrates strong 
performance on clinical quality measures which typically suffer in the presence of staffing shortages. 

Benchmarks are all hospitals with over 300 beds, staffed by county employees, home to trauma centers and graduate medical 
education residency training programs, and serve a disproportionate share of Medicaid patients (greater than 31 percent of total 
discharges). Please see the Lewin's Group's Market Assessment and Benchmarking Report for more information. 

The California Department of Health Services mandates that general acute care hospitals maintain a nurse-patient staffing ratio 
of 1:5. California is the only state with a nurse-patient ratio mandate. 



29 



FIGURE 10: Trends in Hospital Person Hours per Discharge, Fiscal Year 2004- 2006 



300 , 



250 ■ 



200 




150 




100 



2004 



2005 



2006 



-UMC — ■ 

■Alameda County — 



Denver Health 
Riverside County 



-SFGH 
-Santa Clara 



Note: California hospitals are subject to mandated nurse staffing levels. 
Source: Ingenix Financial Benchmarks. 2006 data unavailable for Santa Clara 



30 



2. REVENUE MAXIMIZATION 

The Department of Public Health revenue cycle processes are complete and 
effective as compared with other large public health systems. Key revenue 
cycle leaders have effectively implemented structural and procedural changes 
throughout the City healthcare system to greatly enhance revenue cycle 
functions. Overall organizational structure, policies and procedures, and 
workflow processes are in line with industry best practices. 

Although much of the information technology and systems used within the 
revenue cycle are progressive and up-to-date as compared with other public 
systems, the current revenue accounting system used by the Department limits 
the amount of real-time financial information available to departmental 
managers. Updating this system would facilitate revenue monitoring and 
efficient budget decision-making and scenario planning. 

COMMUNITY CLINIC REVENUE ENHANCEMENTS 

In early 2006, the Controller's Office contracted with Moss Adams, a healthcare 
consulting firm, to conduct a revenue maximization analysis of six Department 
of Public Health community clinics. Moss Adams identified two million dollars in 
revenue enhancing opportunities, including increasing physician productivity, 
revising billing codes and practices, and scheduling orientation and provider 
visits simultaneously. Since the report was issued, the Department of Public 
Health has enhanced the Patient Finance Services Department and 
registration process and is now meeting or exceeding the national standard in 
the accounts receivable area. In addition, the Department started an open 
access program in certain clinics, which allows patients to see a physician on a 
walk-in basis, reducing unfilled patient slots and increasing physician 
productivity. 

GENERAL HOSPITAL REVENUE MANAGEMENT EFFICIENCY 

Both Phase 2 Consulting and the Lewin Group reviewed revenue management 
efficiency in San Francisco General Hospital on the behalf of the Controller's 
Office in 2007 and 2008. Both sets of experts found such management to be 
highly efficient and exemplary among public hospital systems. 

Days in patient accounts receivable constitutes a useful way of comparing the 
efficiency of revenue cycle management across hospitals. It measures how 
many days, on average, hospitals take to collect third-party and other patient 
revenue for which the hospital has billed. This metric also represents the 
amount of hospital revenue tied up by outstanding bills. Therefore, increases in 
this measure can create cash flow problems for hospitals, and it is important 
that hospitals collect money from payers as quickly as possible. 



Departmental 
managers need 
more real-time data 
in the revenue 
accounting system 



Experts agree that 
General Hospital's 
revenue 
management is 
efficient and 
exemplary 



31 



As depicted in Figure 1 1 below, San Francisco General Hospital exhibits the second lowest days 
in accounts receivable compared to all other benchmark hospitals and the lowest among its 
California peers. 17 This suggests that San Francisco General Hospital collects its bills more 
rapidly than nearly all of the benchmarks and is relatively efficient in its patient revenue cycle 
management. However, none of the benchmark hospitals in this report meet the national 
benchmark among non-federal public hospitals of 60 days in accounts receivable. 

figure 11: Days in Accounts Receivable, Fiscal Year 2006 



National 

Benchmark 

= 60 




I UMC D Denver Health ■ SFGH ■ Alameda County D Riverside County ■ Santa Clara 



Note: National Benchmark = 50th percentile (median) among 250-399 bed, government owned (non-federal), urban facilities 

Source: Lewin County Health System Benchmark Survey 5/07; Alameda and Riverside Medicare Cost Reports 12/31/04; and the 

Comparative Performance of U.S. Hospitals: The Sourcebook 2005. 



DEPARTMENT-WIDE REVENUE ENHANCEMENTS 

In 2007, the Controller's Office engaged Phase 2 Consulting to analyze how 
the entire San Francisco Department of Health, including San Francisco 
General Hospital, Laguna Honda Hospital, Community Clinics, and 
Behavioral Health Services, could better maximize revenue. In the first half 
of 2008, the Department of Public Health implemented Phase 2's revenue 
maximization recommendations in the area of point-of-service collections, 
account follow-up, strategic pricing, and Medi-Cal process management. As 
a result, the Department of Public Health will receive an annual revenue 
enhancement of $10 million and produce a one-time revenue gain of $11 
million. 



The Department will 
save $21 million next 
year by implementing 
revenue enhancement 
recommendations 



Benchmarks are all hospitals with over 300 beds, staffed by county employees, home to trauma centers and graduate medical 
education residency training programs, and serve a disproportionate share of Medicaid patients (greater than 31 percent of total 
discharges). Please see the Lewin's Group's Market Assessment and Benchmarking Report for more information. 

32 



3. COST EFFICIENCY AND PRODUCTIVITY 




Worker at San Francisco General Hospital 



Photo Molly Duggan Associates, LLC 



The Controller's Office, with the Lewin consultants, conducted an in-depth 
analysis of San Francisco General Hospital's cost efficiency and 
productivity compared to similar hospitals. San Francisco General Hospital 
performs well on standard efficiency and productivity metrics, such as costs 
per discharge and inpatient length of stay. General Hospital performs well in 
this regard despite factors that tend to decrease hospital efficiency and 
drive up costs, including a large number of daily patients, aging buildings, a 
robust residency training program, and a lack of investment in information 
systems technology. 

The Lewin Group recommended that San Francisco General Hospital be 
rebuilt in order to achieve operating efficiencies and also identified best 
practices regarding information systems technology of high-performing 
public hospitals that could be adopted by General Hospital. Such best 
practices include integrated electronic medical records, automated 
physician referral, computerized physician order entry, and computer 
access in all patient rooms with disease-specific treatment 
recommendations for staff and physicians. In addition, better information 
systems technology in the Emergency Department could improve patient 
flow and overall operational efficiency. 



Experts recommend 
that General Hospital 
be rebuilt and its 
technology upgraded 



33 



COST EFFICIENCY 

As shown in Figure 12 below, San Francisco General Hospital performs 
moderately well in comparison to similar public healthcare systems 18 when 
costs are adjusted for factors outside of hospitals' control, such as 
variations in patient populations and regional wage levels. 



FIGURE 12: Comparison of Costs per Discharge Case Mix and Wage Adjusted, 

Fiscal Year 2006 



$20,000 



$10,000 



$18,052 

$16,570 Wm/t 



UMC- Southern NV □ Denver Health* ■ SF General ■ Alameda County B Riverside County 



= Cost per Discharge Unadjusted 



Source: Ingenix Financial Benchmarks as of 12/31/04; Santa Clara unavailable 



INPATIENT LENGTH OF STAY 

As depicted in Figure 13 below, San Francisco General Hospital's average 
length of stay of 3.5 days compares favorably to similar California hospital 
systems. 19 San Francisco General Hospital has improved patient 
throughput 20 by utilizing process redesign and enhancing coordination of 
care across access points into the system. For example, General Hospital 
has developed e-Referral to refer patients more efficiently to appropriate 
clinics and reduce wait times for patients requiring admission. 



General Hospital 
delivers cost-efficient 
inpatient care 




General Hospital's low 
average length of stay 
saves money and 
improves health 



Benchmarks are all hospitals with over 300 beds, staffed by county employees, home to trauma centers and graduate medical 
education residency training programs, and serve a disproportionate share of Medicaid patients (greater than 31 percent of total 
discharges). Please see the Lewin's Group's Market Assessment and Benchmarking Report for more information. 

19 

Case mix adjustment data was not available for the non-California benchmark hospitals. Benchmarks are all hospitals with over 
300 beds, staffed by county employees, home to trauma centers and graduate medical education residency training programs, 
and serve a disproportionate share of Medicaid patients (greater than 31 percent of total discharges). Please see the Lewin's 
Group's Market Assessment and Benchmarking Report for more information. 

20 

"Patient throughput" refers to the time and processes required to successfully move a patient through the continuum of care in a 
hospital or in an outpatient setting such as a clinic. The faster, or more efficiently a patient is moved through the process, the 
lower the length of stay, the better the cost management, and the quicker services can be provided to another patient, which is 
new revenue to a hospital or clinic and prompter services to clients. 

34 



FIGURE 13: Average Length of Stay, Case Mix Adjusted, California Benchmark Hospitals, Fiscal Year 2006 



Santa Clara 



Riverside County 



Alameda County 



SF General 




i Case Mix Adjusted a Not Adjusted 



Source: Lewin County Health System Benchmark Survey 5/07, Ingenix Financial Benchmarks 

From a financial perspective, the benefits of minimizing hospital stays 
include decreased total costs per patient. More rapid patient turnover may 
also enhance hospital operating revenue under per-case payment systems. 
Clinically, shorter hospital stays often signify improved ability of hospitals to 
stabilize patients more quickly or discharge them earlier to more appropriate 
outpatient, home, and other non-hospital settings. Such earlier discharges 
reflect advances in medical practice patterns and technology as well as 
better health outcomes for patients. 



CASE MIX INDEX 

San Francisco General Hospital's Medicare case mix index is in the middle 
of the benchmark range (Figure 14). 22 This index indicates the relative 
severity of a patient population, with a higher number associated with higher 
severity, costs, and revenues. San Francisco General Hospital's patient mix 
is generally typical of similar safety net providers. As the City's primary 
provider to the poor, uninsured, and underinsured, San Francisco General 
Hospital must meet the needs of many patients with less severe illnesses or 
who require less tertiary 23 capability. In particular, a large number of mental 
health patients in San Francisco are referred to and served by San 
Francisco General Hospital. Taking care of many patients who need lower 
level care or behavioral health services limits the number of higher acuity 
patients the hospital can admit, and thus keeps San Francisco General 
Hospital's Medicare case mix index modest. 



General Hospital 
meets the needs of 
many patients with 
mental health and 
lower acuity illnesses, 
preventing it from 
admitting more 
severely ill patients 



21 

Lewin adjusted each California benchmark hospital for the impact of differences in case severity, thus correcting for differences 
in patient populations. This produced more robust findings about regional hospital efficiency by removing a key factor influencing 
average length of stay that is outside the control of hospitals. 

22 Benchmarks are all hospitals with over 300 beds, staffed by county employees, home to trauma centers and graduate medical 
education residency training programs, and serve a disproportionate share of Medicaid patients (greater than 31 percent of total 
discharges). Please see the Lewin's Group's Market Assessment and Benchmarking Report for more information. 

23 Specialized consultative care, usually on referral from primary or secondary medical care personnel, by specialists working in a 
center that has personnel and facilities for special investigation and treatment. 



35 



Figure 14: Medicare Case Mix Index, Fiscal Year 2006 




0.5 



UMC- Southern NV □ Denver Health ■ SF General 

Alameda County □ Riverside County ■ Santa Clara 



Source: Lewin County Health System Benchmark Survey 5/07, Ingenix Financial Benchmarks 



4. NONPROFIT CONTRACT ADMINISTRATION 




An HIV rapid test administered by Larkin Street Youth Services in a program funded by 
the Department of Public Health 



Photo John Benson 



The Controller's Office regularly conducts financial reviews and audits of Department of Public 
Health nonprofit contractors. The Department of Public Health relies on contracts with local 
community-based health and human services organizations to provide care for the most 
vulnerable populations in the City. The Department contracted for such services worth more than 
$162 million in fiscal year 2006 and more than $174 million in fiscal year 2007. Services include 






36 



assisting the elderly, poor, youth, displaced and unemployed, as well as 
those at risk from drugs, violence, mental illness, criminal justice 
involvement, and HIV/AIDS. 

In the last three years, the Controller's Office has conducted about 150 
financial reviews of nonprofits that provide services funded by the 
Department of Public Health. These reviews have analyzed tens of millions 
of dollars in contracted services. Findings have largely been in the areas of 
invoicing, cost allocation, and financial record keeping. Nonprofit 
organizations followed up and addressed findings identified in these 
reviews. In a recent audit, the Controller's Office recommended that the 
Department of Public Health simplify its invoicing procedures and clarify its 
policy concerning budget revisions. An audit of a nonprofit contractor to be 
released by the end of 2008 will also address the Department's contract 
management practices. 

Since 2005, the Controller's Office has provided on-going support to the 
Department of Public Health through its administration of the Citywide 
Nonprofit Monitoring and Capacity Building Program. This program 
streamlines, coordinates, and improves the City's efforts to effectively 
monitor and ensure adequate capacity of nonprofit organizations providing 
health and human services funded by the City. The Controller's Office also 
participates in the Nonprofit Review Appellate Panel, which is overseeing 
improvements to the way the City does business with the nonprofit sector in 
response to the 2003 Nonprofit Task Force Report. 24 



The Health Department 
should simplify its 
invoicing procedures 
and clarify its policy on 
budget revisions for 
nonprofit contractors 



5. RECOMMENDATIONS FOR THE 

DEPARTMENT OF PUBLIC HEALTH 

□ Rebuild San Francisco General Hospital's aging infrastructure to meet state 
seismic laws, enhance operating efficiencies, and provide critical trauma 
and healthcare safety net services. 

□ Continue efforts to expand care delivery alternatives for lower severity and 
psychiatric services, as well as collaborate with other City providers to 
ensure a more equitable distribution of the psychiatric patient population. 

□ Invest in information systems upgrades to allow managers to make more 
informed, real-time decisions concerning efficient labor and financial 
allocations, as well as improve San Francisco General Hospital's operating 
efficiency. 

□ Simplify invoice procedures and clarify policy concerning budget revisions 
for nonprofit service providers. 



24 



Please see the "Resources for Nonprofits" section of the Controller's website under "Frequently Requested" for more 
information (www.sfgov.org/controller). 



37 



V. Patients and Payer Mix 



1. DEMOGRAPHIC CHANGES 




\ 





r 






Mother and baby receive services at San Francisco General Hospital 



^ 






iJ 






Photo- Molly Duggan Associates, LLC 



San Francisco's population is aging and the racial and ethnic profile is 
changing, which will affect future demand for healthcare services as well as 
require providers to update their provision of culturally sensitive care. 
Today, residents age 65 and over comprise 14 percent of the City's total 
population, but are expected to comprise 26 percent by 2030 - an increase 
of 79 percent. The City's younger population between the ages of 0-34 is 
projected to drop by 24 percent between 2006 and 2030 (Figure 15). 



San Francisco's age, 
racial and ethnic 
changes will change 
future demand for 
health services 



38 



Figure 15: San Francisco Population Estimates by Age Cohort (in thousands), 1997-2030 

% Change 
2006-2030 



99 



285 



244 



121 



1997 



114 



369 




124 



392 






205 



349 



135 



2006 



2010 



2030 



79% 



(5%) 




□ 0to17 



18 to 34 



□ 35 to 64 



□ 65 + 



Source: California Department of Finance 



The racial and ethnic make-up of San Francisco will also change significantly by 2030. The 
Hispanic and Asian/Pacific Islander populations are projected to grow modestly, six and four 
percent respectively, while the African-American population is projected to decline substantially 
by 21 percent (Figure 16). 

FIGURE 16: San Francisco Population Estimates by Race (in thousands), 1997-2030 



65 



236 



338 



54 



252 



356 



52 



257 



367 





% Change 
2006-2030 


43 


(21%) 
4% 


261 



345 



6% 



(3%) 



1997 



2006 



2010 



2030 



d White a Hispanic □ Asian/Pacific Islander □ Black 



Source: California Department of Finance 

DEPARTMENT OF PUBLIC HEALTH RESPONSE TO DEMOGRAPHIC CHANGES 

The Department of Public Health and the City and County of San Francisco are continuing to 
assess readiness to provide services to the City's changing safety net population in a culturally 
sensitive manner. The Department of Public Health is planning to serve an increasingly aging 
population with needed healthcare services through initiatives such as the rebuild of Laguna 
Honda Hospital. The City is also focusing on reducing demand for inpatient hospital services 
through enhancing community placements. In response to a 2005 Controller's Office report on 



39 



long-term care, the Department of Public Health created a new position to better coordinate long- 
term care across its continuum of services. In 2007, the City established the Community Living 
Fund Program, which targets individuals who are currently or at risk of being institutionalized. The 
program funds home and community-based long-term care, goods, and/or services, including 
housing and homecare. San Francisco's Department of Aging and Adult Services in the Human 
Services Agency administers this $3 million (annual) fund in cooperation with other City 
departments and community partners. 



2. CITYWIDE PAYER MIX 



25 



Over half of San Francisco's population receives health coverage from an 
employer, and nine percent of the population is uninsured. 26 Many more 
San Franciscans are underinsured or are challenged to obtain health 
services - for example, individuals covered by Medi-Cal face difficulty 
finding providers who will accept them due to low reimbursement rates 
offered through Medi-Cal. Some demographic groups disproportionately 
lack adequate insurance coverage. For example, while only accounting for 
seven percent of the total San Francisco population, African-Americans 
account for 17 percent of the City's Medi-Cal or uninsured patients. As 
shown in Figure 17 below, 43 percent of African American acute care 
hospital discharges in San Francisco were either covered by Medi-Cal or 
uninsured, a much higher rate than other ethnic groups. 

Figure 17: Payer Mix by Race for San Francisco Hospital Discharges In 2005 27 



43% of African 
Americans discharged 
from hospitals in San 
Francisco were either 
uninsured or covered 
by Medi-Cal, a much 
higher rate than other 
ethnic groups 



100% - 
90% 
80% 
70% 
60% ^ 
50% 
40% 

30% -i 

20% 
10% -| 
0% 



13,638 



12,043 



4,827 

rra r 1 



White 



5,745 



5,953 



1,119 



2,595 



7,625 



5,406 





Asian/Pacific 
Islander 



Black 



Native 
American/Unknown 



I Uninsured ■ Medi-Cal □ Medicare □ Commercial 
Source: OSHPD 2005 



25 

Payer Mix is defined as the ratio of various persons or payers providing funding for services rendered to patients. Payers can 
include the patient and/or third parties such as Medicare, Medi-Cal, managed care organizations, or other private insurance plans. 

Lewin Group analysis of the 2005 California Health Interview Survey (CHIS) inflated to 2007. Total San Francisco residents in 
2007 acquired from the California Department of Finance, July 2006 projection. Insurance coverage presented as a point in time 
estimate, which is equivalent to an average monthly count. 

27 

The uninsured category includes self pay patients which encompasses those without insurance at all income levels. 



40 



3. DEPARTMENT OF PUBLIC HEALTH PAYER MIX 




Family receives services at San Francisco General Hospital 



Photo Molly Duggan Associates, LLC 



The Department of Public Health, through San Francisco General Hospital, 
plays the primary role in caring for the underinsured and uninsured 
population of the City. Figure 18 shows the Department's role in serving 
uninsured residents across levels of care as compared to all other City 
providers. Healthy San Francisco 28 will increase healthcare for the 
uninsured in San Francisco and also restructure how the Department of 
Public Health provides care to those already in its network through offering 
services through a primary medical home. 



The Health Department 
plays the primary role 
in caring for the 
underinsured and 
uninsured population of 
San Francisco 



Healthy San Francisco is expanding services and restructuring the City's safety net system from a crisis delivery approach to 
an emphasis on primary care. More information can be found at: http://www.healthysanfrancisco.org. 



41 



FIGURE 18: Department of Public Health 2005 Market Share of San Francisco Resident 



Uninsured Population by Level of Care 



29 




84% 



63% 



Inpatient Discharges 



Emergency 
Department 
Encounters 




Ambulatory Surgery 
Visits 



Clinic Visits 



Department of Public Health 



Source: OSHPD Clinic Data 



SAN FRANCISCO GENERAL HOSPITAL PAYER MIX 

San Francisco General Hospital serves a higher proportion of the City's 
uninsured and Medi-Cal patients compared to other San Francisco 
hospitals (Figure 19): 64 percent of San Francisco General Hospital's 
patients are uninsured or covered by Medi-Cal versus 23 percent citywide. 
Private hospitals in San Francisco have a higher share of patients who 
typically provide greater revenues to hospitals, that is, patients over 65 and 
those covered by commercial insurance and Medicare. 



64% of General 
Hospital's patients are 
uninsured or covered 
by Medi-Cal versus 
23% citywide 



The uninsured category includes self pay patients, which encompasses those without insurance at all income levels. Without 
self pay patients the Department of Public Health's uninsured market share would be: Inpatient Discharges = 69 percent; 
Emergency Department Encounters = 44 percent; Ambulatory Surgery Visits = 10 percent; and Clinic Visits = 43 percent. 



42 



Figure 19: Payer Mix for San Francisco General Hospital v. Payer Mix for San Francisco 



Discharge Market, 2005 



30 31 



1 00% 



80% 



60% 



40% 



20% 



0% 



- 




— 4% 






39% 


— 2% 


12% 




12% 




52% 
















19% 





SF General 



San Francisco Market Total 



o Medi-Cal 



Medicare □ Uninsured □Commercial n Other 



Source: OSHPD 2005 

As a result of its disproportionate share of the uninsured market, San General Hospital 

Francisco General Hospital also absorbs a disproportionate level of 

uncompensated care, such as payment shortfalls and charity care 32 (Figure provides the vast 

'■ majority of charity 

(uncompensated) care 
in San Francisco 



30 San Francisco market is defined as San Francisco resident discharges from all San Francisco hospitals. 

31 The uninsured category includes self pay patients, which encompasses those without insurance at all income levels. "Other" 
includes patients covered by a variety of third-party contractual purchasers of healthcare (e.g. Short-Doyle, TRICARE (formerly 
CHAMPUS) and California Children's Services). 

32 Charity Care is defined by the City and County of San Francisco as emergency, inpatient, or outpatient medical services 
provided without expectation of reimbursement. 



43 



Figure 20: Charity Care Expenditures of San Francisco General Hospital v. Other Hospitals, 

Fiscal Year 2005 

100% 



75% 



50% 



25% 



0% 



$76.4 million 



$17.9 million 




SF General 



Other San Francisco Hospitals 



a SF General □ CPMC □ UCSF o St. Mary's □ St. Luke's ■ St. Francis ■ Kaiser □ Chinese 



Note: Charity Care Expenditures = Charity Care Charges * Cost to Charge Ratio 
Source: Fiscal Year 2005 San Francisco Hospital Charity Care Report Summary 

COMMUNITY CLINIC PAYER MIX 

The Department of Public Health operates 18 community-based primary 
care clinics throughout the City and at San Francisco General Hospital, 
serving over 60,000 patients annually. The clinic network provides culturally 
sensitive care to the uninsured and at-risk populations who might not 
otherwise have access to care. Over 77 percent of the Department of Public 
Health's primary care clinic patients are below the federal poverty level, and 
less than one percent has private insurance. The population is 50 percent 
Asian/Pacific Islander or African-American, with many non-English speaking 
monolingual patients. 

In addition to the Department of Public Health, the San Francisco 
Community Clinic Consortium and other nonprofit community-based clinics 
are an important component of the primary care safety net in San 
Francisco. As such, the Clinic Consortium is a critical partner in the 
implementation of the Healthy San Francisco initiative. The Clinic 
Consortium has a similar patient mix as the Department of Public Health 
clinic system, and meets nearly all of the remaining outpatient service 
demand from patients who lack private or public insurance (such as 
Medicare or Medi-Cal). The Brown & Toland and Kaiser networks also 
provide primary care. However, they are clustered in the northern and less 
impoverished areas of the City and primarily serve higher income 
populations with commercial insurance. 



Over 77% of the 
Health Department's 
primary care clinic 
patients are below the 
federal poverty level 

Nonprofit community- 
based clinics are also 
a crucial component of 
the primary care safety 
net 






44 









LOCATIONS OF PUBLIC AND PRIVATE HEALTHCARE FACILITIES IN 
SAN FRANCISCO 

Figure 21 shows the distribution of public and many private healthcare facilities in San Francisco, 
including acute care hospitals, community-based clinics, and skilled nursing facilities. 

Figure 21: Distribution of Public and Private Healthcare Facilities in San Francisco 



Medical Center* 

♦ Acjte Care Hosprta' 
A Community Clin c 

Consortium 

• Dept of Public Health 
Pnmary Care Clinks 

■ Skilled Nurs r .q r acii nes 




45 



4. RECOMMENDATIONS FOR THE 

DEPARTMENT OF PUBLIC HEALTH 

□ Continue to assess the Department of Public Health's readiness to provide 
services to the City's changing safety net population and the City's aging 
population. 

□ Continue to explore formal and informal collaboration with other safety net 
providers to identify the most resource efficient ways to deliver and 
coordinate care - this may be advanced through further analysis and 
collaboration with partners to better understand the drivers behind local 
hospital referral patterns by payer type. 






46 



VI. List of Analytical Projects 2005-2008 



I. CONSULTANT REPORTS 

The Controller's Office contracts with internationally-recognized healthcare consulting firms to 
bring best practices and expert analysis to San Francisco public health. All of these reports are 
available in the "Healthcare Analysis" section of the Controller's website 
( www.sfgov.org/controller ) listed under "Frequently Requested." 

REVENUE MANAGEMENT 
PHASE 2 CONSULTING, 2008 

This revenue maximization analysis reviews the Department of Public Health's revenue cycle 
at San Francisco General Hospital, Laguna Honda Hospital, Community Health Centers, and 
Behavioral Health Services. The report concludes that revenue cycle processes and 
procedures are among the most complete and effective as compared with other large public 
health systems in the nation. It also identifies $10 million in annual revenues and $11 million 
in one-time gains. 

MARKET ASSESSMENT AND BENCHMARKING 
THE LEWIN GROUP, 2007 

The market analysis summarizes the current healthcare environment in the City, makes 
projections of demand for healthcare services, and examines the Department of Public 
Health's role in providing direct healthcare to San Franciscans. The benchmarking analysis 
compares San Francisco General Hospital with comparable Bay Area, California, and 
national public healthcare delivery systems using industry measures of efficiency and 
effectiveness. 

HEALTHY SAN FRANCISCO IMPLEMENTATION SUPPORT 
THE LEWIN GROUP, 2007 

The Lewin Group provided expert analysis, modeling, and recommendations to assist with 
the Department of Public Health's planning and launch of Healthy San Francisco. This 
presentation projects demand for health services, analyzes the Department's capacity to take 
new patients and meet service demands, models the impact of changes in fees for the safety 
net population, and analyzes a 'one-stop' web-based eligibility and enrollment system. 

COMMUNITY CLINIC REVENUE MAXIMIZATION 
MOSS ADAMS, 2006 

This report reviews revenue cycle efficiency in Department of Public Health clinics and 
identifies two million dollars of revenue opportunity. Following the release of the report, the 
Department enhanced patient finance services and registration processes and is now 
exceeding the national standard in the accounts receivable area. In addition, clinic patients 
are now allowed to see a physician on a walk-in basis, reducing unfilled patient slots and 
increasing physician productivity. 



47 



CONTINUUM OF ACUTE AND LONG-TERM HEALTHCARE 
HEALTH MANAGEMENT ASSOCIATES, 2005 

This report focuses on the effectiveness of the Department of Public Health in providing a 
continuum of acute and long-term healthcare services. It finds that the City needs to 
substantially improve the integration of its hospitals and community-based services. San 
Francisco can better meet the needs of its citizens and gain significant financial benefits by 
providing a mix of long-term, skilled nursing, in-home, and community-based services. 

CURRENT ANALYSES 

The Controller's Office is currently working with the Department of Public Health and expert 
consultants to assist with the transition to the rebuilt Laguna Honda Hospital as well as 
develop technical assistance and evaluation for substance abuse treatment services. 



II. NONPROFIT FINANCIAL MONITORING AND AUDITS 

The Controller's Office regularly conducts financial reviews and audits of Department of Public 
Health nonprofit contractors to ensure adequate internal controls and efficiencies. In the last three 
years, the Controller's Office has conducted about 150 financial reviews of nonprofits that provide 
services funded by the Department of Public Health. These reviews have analyzed tens of 
millions of dollars in contracted services. 

RECENT FINANCIAL REVIEWS AND AUDITS 

Department of Public Health: Fiscal and Compliance Monitoring of Selected Community- 
based Organizations for Fiscal Years 2005-06 and 2006-07 

Department of Public Health: Monitoring of A-133 Single Audit Reports for Agencies Awarded 
Federal Funds by the Department in Fiscal Year 2005-06 

Department of Public Health: Monitoring of A-133 Single Audit Reports for Agencies Awarded 
Federal Funds by the Department in Fiscal Year 2004-05 

Department of Public Health: Fiscal & Compliance Monitoring of Selected Community-based 
Organizations for Fiscal Year 2004-05 

All of these reports are available in the "Healthcare Analysis" section of the Controller's website 
(www.sfgov.org/controller) listed under "Frequently Requested." 

NONPROFIT CONTRACTING 

The Controller's Office provides on-going support to the Department of Public Health through its 
administration of the Citywide Nonprofit Monitoring and Capacity Building Program. This program 
streamlines, coordinates, and improves the City's efforts to effectively monitor and ensure 
adequate capacity of nonprofit organizations providing health and human services to San 
Francisco residents. The Controller's Office also participates in the City's Nonprofit Review 
Appellate Panel, which is overseeing improvements to the way the City does business with the 
nonprofit sector. Please see the "Resources for Nonprofits" section of the Controller's website 
(www.sfgov.org/controller) for more information. 



48