1. Bridging the Healthcare Gap: A Five Year Reassessment of Greenvilles Health; Profiling the Impact of the Uninsured and Underserved in Greenville County Presentation to the Community September 2003 Copyright © 2003 Community Health Alliance. All rights reserved. Unless otherwise indicated, all materials in this document are copyrighted by the Greenville Community Health Alliance. Materials may be used and distributed, but must be cited. Photo of the Main Street Bridge by Russell H. Stall

2. 2 Todays Agenda Welcome Doug Brown, Chairman, Community Health Alliance Revisiting Our Past Margaret Clark, Bon Secours St. Francis Health System The Journey of the Community Health Alliance Eleanor Dunlap, Community Health Alliance Reassessment Study Summary Russell Stall, ResearchWorks Call to Action Michelle Shain, Greenville City Council and Furman University John Moore, Interim President, Greater Greenville Chamber of Commerce

3. 3 In 1998, the Community Planning Council and partners studied the medically under-served… Greenville Hospital System Bon Secours St. Francis Health System Local Government City of Greenville Greenville County Greenville County Health Department Others Chamber of Commerce Community Volunteers Piedmont Healthcare Foundation Advisors HealthCare Concepts ResearchWorks Project Overview

4. 4 …and created valuable community dialogue. the most comprehensive health assessment in Greenville Countys history… The Greenville News

5. 5 The Community Health Alliance was charged with developing programs to improve the health of Greenvillians. As a result of the 1998 study, task forces were created and many initiatives were addressed to focus on: Health Status Indicators Heart disease Sexually transmitted diseases Prenatal care Spousal and child abuse Healthcare Coverage Increase coverage for uninsured, under-insured, and under-served Access for Medically Under-Served Increase availability and awareness of services for the medically under-served Transportation Public transportation to medical services Public transportation for medically under-served and low income Community Planning Council

6. 6 CHA Vision and Mission CHA Vision The Community Health Alliance strives to achieve community wellness and improved health care through knowledge and greater access to effective, county-wide medical resources. CHA Mission The Community Health Alliance aims to reduce the number of medically underserved persons in Greenville County.

7. 7 Seven Point Plan 1.Facilitate the development of an integrated network of neighborhood-based medical care centers in identified areas of need. 2.Ensure adequate local medical transportation. 3.Create a local health care coverage plan for individuals who are not eligible for Medicaid coverage, yet cannot afford health care coverage on their own. 4.Promote community health education through neighborhood outreach that generates well educated health care consumers and informs residents of available health care resources. 5.Increase availability and affordability of pharmaceuticals for the underserved. 6.Promote opportunities for exercise and healthy lifestyle changes. 7.Support health care advocacy on issues involving the medically underserved and on issues related to Medicaid coverage for low income families. Project Overview The role of the CHA is not to provide services, but to facilitate programs through our partners.

8. 8 The Reassessment Study Team Pete Bailey, SC Office of Research and Statistics Doug Brown, Chairman, Community Health Alliance Stephanie Brundage, Chairman, Greenville County Health Department Dawn Blackhurst, Greenville Hospital System Anne Culberson, Greater Greenville Chamber of Commerce Nicole Fitzpatrick, Greenville County Health Department Maya Herren, Bon Secours St. Francis Health System Hank Hyatt, Greater Greenville Chamber of Commerce Kristy Maher, Furman University Kelly McCormick, United Way of Greenville County Weldon Mikulik, United Way of Greenville County Shannon Owen, United Way of Greenville County Michelle Shain, Furman University Windsor Sherrill, Clemson University Chris Sullivan, Greenville Hospital System Tarraz Woodruff, United Parcel Service

9. The Journey of the Community Health Alliance Presentation to the Community September 2003 Copyright © 2003 Community Health Alliance. All rights reserved. Unless otherwise indicated, all materials in this document are copyrighted by the Greenville Community Health Alliance. Materials may be used and distributed, but must be cited.

10. 10 Health initiatives have inspired change. Project Overview Opened Three Neighborhood Based Medical Centers. Opened centers in Greer, Golden Strip, and West Greenville through a partnership with the Greenville Free Medical Clinic, New Horizon, and the Greenville County Health Department. The centers have had over 31,000 patient visits in the last three years. Created MedWell Access and Linked with Commun-I-Care. Operating out of the Greenville County Medical Society, MedWell Access provides free health care services to uninsured, working individuals through a coordinated system of volunteer physician services, donated hospital services, and donated pharmaceuticals. Over 250 physicians are now participating and over $650,000 worth of services have been provided to date. Linked New Horizon with Medical Centers. New Horizon, with grantsmanship help from CHA, was awarded a $1.2 million technology grant from the U.S. Health Resources and Services Administration (HRSA) to link the computer systems of the neighborhood-based medical centers with those of key medical institutions.

11. 11 Health initiatives have inspired change. Project Overview Distributed Health at Home Self Help Books. Created outreach and education programs, including distribution of 1,200 Health at Home self help books. These books are distributed in targeted neighborhoods with large numbers of medically under-served families to help people make good health decisions. Distribution is accompanied by training on the value and proper use of the books. In a survey of book readers, 61% saved an unnecessary visit to the doctor and 47% saved an unnecessary visit to the ER as a result of the book. One-third of those who work say they saved an unnecessary sick day from work. Created Healthy Connections. HRSA awarded $250,000 to develop Healthy Connections, a program aimed to help students get the medical care needed to succeed. The program has started at Hollis Elementary and will also target Tanglewood, Lakeview, and Parker Middle schools. Improved Medical Transportation. The CHA approved the release of $12,000 from its local match funds to assist Greenville Transit Authority (GTA) in developing the GAP (Greenville Area Paratransit) program which provides curb- to-curb medical transportation service as well as service for residents with disabilities.

12. 12 Through grants and community collaborations, we have brought over $2.7 million into Greenville to address the health of our residents. Greenville Community Health Network$826,000 CHA Operations$281,000 Healthy Connections$263,000* Outreach and Education (Healthy You)$90,000 Health Assessment$70,000 GTA Medical Transportation match$12,000 New Horizon CAP technology grant$1,162,000 Total Measurable Grants$2,704,000 Project Overview Based on expenses of about $228,000 since 2000, the return for every dollar spent by the CHA is $12.10. 90% of all monies go directly toward resident services. * $200,000 expected in the next four years Community Health Alliance Grants and Income

13. 13 Greenville Hospital System Bon Secours St. Francis Healthcare Piedmont Health Care Foundation Greenville County Health Department United Way of Greenville County New Horizon Family Health Services Greenville Free Medical Clinic Greenville County Medical Society Greenville Technical College Greater Greenville Chamber of Commerce Furman University Greenville Transit Authority Greenville County School District Communities in Schools First Steps for School Readiness County of Greenville Greenville County Commission on Alcohol and Drug Abuse Department of Social Services Faith Community Local Health Care Professionals Local Businesses Community Volunteers While many agencies are involved in the CHA, several funding agencies provide critical financial support. CHA Funding Partners Bon Secours St. Francis Health System Bon Secours St. Francis Health System Foundation Community Foundation of Greater Greenville Greenville Hospital System Greenville County Medical Society Greenville County Medical Society Alliance Health Resources and Services Administration New Horizon Family Health Services Piedmont Health Care Foundation SC DHEC The Duke Endowment United Way of America/Bureau of Primary Care United Way of Greenville County

14. 14 Now is the time to measure our progress in the last five years. Reevaluate and redefine the status of the medically underserved in Greenville County. Document the progress of the Community Health Alliance and community agencies in closing the underserved gap since 1998. Document and describe the gaps that still exist and prioritize where key resources should be focused. Develop an economic case study of the impact of the underserved on the community. CHA Study Sponsors New Horizon Family Health Services Greenville County Medical Society Greenville County Health Department Piedmont Health Care Foundation South Carolina Department of Health and Environmental Control Greenville Hospital System Bon Secours St. Francis Health System Foundation

15. Reassessment Study Summary Presentation to the Community September 2003 Copyright © 2003 Community Health Alliance. All rights reserved. Unless otherwise indicated, all materials in this document are copyrighted by the Greenville Community Health Alliance. Materials may be used and distributed, but must be cited.

16. 16 Residents have a sense that many of the access issues have improved over the last five years. However, insurance related issues have become increasingly worse. Tell me how health care has changed in Greenville over the last five years? % Improved % Gotten Worse Resident Survey Escalating Costs Improved Access

17. 17 The Face The Data Findings are based on reliable, comprehensive tools. 1,507 completed telephone interviews with over-sampling of ZIP codes with higher levels poverty. 13 minute survey focusing on the uninsured with 90% response rate. Precision of +/-2.5% at 95% confidence interval. Citizen Telephone Survey Web-based survey sent to 1,700 Greater Greenville Chamber of Commerce members. Completed by 292 Chamber of Commerce members for a response rate of 17%. Focus on providing insurance to employees and the barriers to providing coverage. Business Insurance Survey Revisited issues explored in 1998 with more emphasis of changes over time. Deeper analysis including census tract level reporting. Benchmarks against other similar communities. Health Indicators Data Scan One on one and telephone interviews with community leaders and health care providers. Expert Interviews 15 focus groups wrapped around health care issues. Participants included a wide representation of health care and community leaders. Community Focus Groups Two focus groups with uninsured and underserved residents. Participants recruited from telephone survey respondents. Underserved Focus Groups Project Overview

18. 18 We have a solid base of knowledge and there are advantages in building on the previous effort. Comparable base of knowledge and consistency of collection modalities insuring data comparability. Understanding from past effort on the geographic areas with the greatest needs, and thus the ability to focus even deeper into geographies. Understanding that the data represents individuals, and the face of individuals is what differentiates and inspires change.

19. 19 Since 1998, the demographic profile of Greenville has changed. Demographic Overview Then (1998) Now (2002) We are… Population Total population living in the county 353,845389,466 Growing rapidly Population Growth 10.5% (1990-1998) 9.2% (1998-2001) … and faster than SC Income Average household income $58,829$62,900 … incomes are rising slightly Unemployment % Unemployed 2.0%5.8% Unemployment has more than doubled DJIA Dow Jones Industrial Average 9,500 11,500 in early 2000 8,000 9,500 today More difficult economic environment Growing Population Challenging Economy

20. 20 Population Growth 1990 to 2000 The population is growing to the southeast. 75% of the countys population now live outside the traditional downtown geographies. Source: Claritas and US Census Bureau Secondary Data ZIP Code % Growth 1990 to 2006 29681 Simpsonville 29680 Simpsonville 29652 Greer 29644 Fountain Inn 29635 Cleveland 29650 Greer 29651 Greer 29688 Tigerville 29615 Greenville 29690 Travelers Rest 29697 Williamston 29662 Mauldin 29669 Pelzer 29673 Piedmont 29636 Conestee 29356 Landrum 29687 Taylors 29607 Greenville 29627 Belton 29661 Marietta 29617 Greenville 29609 Greenville 29611 Greenville 29683 Slater 29605 Greenville 29601 Greenville 99.8% 98.9% 84.6% 72.2% 49.3% 46.8% 41.6% 38.6% 37.9% 32.6% 32.2% 30.1% 27.5% 26.3% 26.0% 24.5% 22.3% 21.9% 19.5% 19.2% 14.9% 5.3% -2.5% -3.5% -4.9% -20.2%

21. 21 We should continue to focus on areas of high poverty, taking services to the places of greatest need. Secondary Data 14% of our children live in poverty. Among subgroups, 28% of Hispanic children and 29% of African American children live in poverty.

22. 22 The Clinics are positioned in areas of the greatest financial and health care access need. Secondary Data Average Household Income

23. 23 Patient visits to satellites have replaced the more expensive emergency room visits. As the number of visits to the satellites climbed from 5,148 in 2001 to over 15,000 through June in 2003, the number of visits to the emergency room at GHS declined. *2003 number are through June.

24. 24 Half of the households in Greenville that live in poverty are headed by single mothers with children under the age of 18. Source: Claritas, 2002 Secondary Data

25. 25 The Hispanic population in 1990 was relatively non-existent. Source: Claritas, 2001 Secondary Data Only one census tract had more than 2% of its population with Hispanic origin. 1990 % Hispanic Population

26. 26 The Hispanic population in the county has grown over 400% in the last ten years. Hispanics are at a double disadvantage with respect to health insurance because they are more likely than non-Hispanic counterparts to work in industries where insurance coverage is traditionally not offered and less likely to be offered insurance even when coverage is provided. Hispanics are the most uninsured ethnic group in America. - Project HOPE Center for Health Affairs Source: Claritas, 2001 Secondary Data Now, several census tracts have in excess of 15% Hispanic populations. 1990 % Hispanic Population Since 1990, the reported Hispanic population has grown from less than 3,000 to over 16,300.

27. 27 Births to Hispanic mothers in local hospitals has more the doubled since the 1998 studyfrom 4% of births to over 10%. Source: Greenville County Health Department Secondary Data Of the 554 births to Hispanic mothers in local hospitals, less than 10% of those mothers had health insurance.

28. 28 Death rates have changed dramatically over the last few years. Secondary Data Standard Death Rates per 100,000 Then 1998 Now 2001 Healthy People 2010 Target Heart Disease165202166 Cancer188190160 Lung Cancer525545 Stroke555948 Chronic Obstructive Pulmonary Disease 504460 Diabetes2425NA Breast Cancer (female)292422 Prostate Cancer2319NA Colorectal Cancer2022NA All death statistics are age adjusted and standardized to the 2000 population. Source: Impact of Chronic Conditions, Greenvile County, 2001

29. 29 Health behaviors are still a concern, especially obesity. Then 1998 Now 2001 South Carolina Current Smoking25%22% 25% Sedentary lifestyle65%40% 62% Overweight*53%58% 53% High Cholesterol29%31% 24% South Carolina Behavioral Risk Factor Surveillance System, 1998, 1999, 2001 Poor nutritional habits not only make otherwise healthy young adults vulnerable to heart disease, cancer and other chronic conditions in subsequent decades of life, but also impair the development of babies and children in the care of young adults. - SC Young Adults Count, 2001

30. 30 THE UNDER SERVED ARE… Uninsured Have no health insurance excluding Medicare and Medicaid Under Insured Have health insurance, but delayed or avoided care because of the cost Access Barriers Insured, but delayed or avoided care because of access issues 41,000 Greenvillians are currently uninsured. 10.2%14.4%5.7% 1998 Health Assessment Said… 10.6%16.9%4.1% Todays Health Assessment Says… 36,000 lives51,000 lives20,000 lives 41,000 lives66,000 lives16,000 lives 30.3% 31.6% 107,000 lives 123,000 lives Amount of Insurance, Coverage, or Access Resident Survey Note: Number of lives are estimated based on current population projections. 2002 population estimated at 390,000. +5,000+15,000-4,000 +16,000 Change While the percentages are remaining relatively stable, the numbers are increasing.

31. 62,000 of those under age 65 (20%) do not currently or did not have insurance at some point during the year. Resident Survey Baseline 1997 = 17% Goal 2010 = 0%

32. 32 Even in a downturned economy, the uninsurance rate for the nation, including Greenville, have remained relatively stable. Then 1998 Now 2002* % Change Greenville County10.2%10.6%+.4% South Carolina16.3%15.7%-.05% United States13.0%14.1%+1.1% Source: Behavioral Risk Factor Surveillance System

33. 33 However, this is not as simple as the story of two people. It is the story of a wide range of people with very different stories. I used to think that all uninsured people were all homeless and destitute… until I became one. It could happen to anyone. Focus group participant

34. 34 Who are the uninsured? The uninsured have lower incomes. 44% of the uninsured in Greenville have incomes under $25,000. Only 3% of those making over $55,000 a year are currently uninsured. Yet, the uninsured tend to be employed. 64% of the uninsured currently work or have someone in the household who works. Almost 45% of the uninsured who work are employed by companies with less than 25 employees. 58% of the uninsured work for companies who offer insurance. The uninsured are younger. One in four (24%) of the uninsured are between ages 18 and 35, and half (51%) of those between the ages of 18 to 24 have been uninsured in the last year. One-third (31%) are currently uninsured. The uninsured are more likely to be members of minority groups. Almost one in four (23%) of the uninsured are minorities, and 21% of the African American population was not insured at some point during the year, and although the sample size was small, 32% of the Hispanic population was not insured. Single mothers are not as likely to have insurance. 30% of single mothers did not have insurance at some point during the year. 22% of single male households are uninsured. Many uninsured people have not had insurance in a long time. Over half (57%) of the currently uninsured have not had insurance for over a year. Over one in four (28%) have not had insurance in the last five years.

35. 35 The uninsured are significantly unhealthier than the insured. One third (33%) of those without insurance say they are in Poor or Fair health compared to 19% of those who were insured for the whole year. Resident Survey

36. 36 Hurdles to Medical Care 22% of respondents were unable to pay all of their medical bills in the past year. 10% say someone in their household needed medical care, but did not get it in the past 12 months. 20% postponed getting medical care they thought they needed, and of those, 85% mentioned the lack of insurance or cost as the reason they postponed care. Resident Survey Q7.01.In the past year, were you unable to pay or did not pay all of your medical bills, including doctor or hospital, prescription drugs, nursing home, or home care bills? Q7.02.Was there any time in the past 12 months when you or someone in your family needed medical care, but did not get it? Q7.03.And was there any time during the past 12 months when you postponed getting medical care you thought you needed? Of ALL respondents…

37. 37 The number of respondents without a personal physician has dropped very slightly. Q8.01. Do you have someone you would consider to be your personal doctor? 40% of those currently without insurance do not have someone they would consider their personal physician. 27% of the under-served do not have a physician Resident Survey

38. 38 Of those who postponed getting medical care in the last year, 49% said their condition got worse as a result of postponing care. The uninsured are twice as likely to say their condition got worse. Did your condition get worse because you postponed getting health care? Resident Survey

39. 39 The uninsured are three to four times less likely to access services because of the cost. Resident Survey These individuals have made an attempt to see a doctor, but were not able to follow through.

40. 40 The uninsured are three to four times less likely to access services because of the cost. Resident Survey Childrens Health Adult Doctor Visits Preventive Care Gender Health All items are statistically significant at the 95% confidence level (p<.05).

41. The spillover costs of uninsurance experienced within communities result from both the poorer health of uninsured populations and the demands made on local public budgets and on providers to support care for those without coverage. Hidden Costs, Value Lost National Institute of Medicine

42. 42 For households making between $20,000 and $30,000 a year, the equivalent of $15.00 an hour, there is no disposable income left after buying essentials, to pay for health insurance. Secondary Data Apparel 4% Among those making $20K to $30K a year, 14% of US households, $24,587 is spent each year on essentials, $93 more than their median income. *Estimated health insurance premium costs for a family of four, 35 year old head of household. Analysis tailored from an analysis by the Colorado Coalition for the Medically Underserved. Health Insurance 27%* $6,000 Healthcare 4% Food 12% Housing 39% Transportation 23% Education 12% $9,446$5,639$4,494

43. 43 Half of all personal bankruptcies filed in 1999 involved a medical problem. - Into the Red to Stay in the Pink National Institute of Medicine, 2003

44. 44 The cost of health insurance for employers is going up dramatically, with no relief in sight. Q12. About how much does your company pay each month for health insurance per covered employee? Q13, About how much did your company pay each month fore health insurance per covered employee two years ago? Q14. About how much, at current coverage levels, do you believe you will be paying for health insurance per covered employee two years from now? Increase of 31% Increase of 32% Business Survey

45. 45 One in four companies surveyed do not offer health insurance to their employees… and are not likely to in the near future. Q3. Does your company currently offer health insurance coverage to its employees? Q4. Has your company offered health insurance to its employees within the last five years? Q5. How likely is it that your company will offer health insurance to its employees in the next two years? Of those who do not currently offer insurance to their employees, only 13% have offered health insurance in the last five years. 74% who currently do not offer insurance say they are not likely to offer health insurance in the next two years. Business Survey

46. 46 Many small businesses cannot afford to offer insurance to their employees. Q3. Does your company currently offer health insurance coverage to its employees? Q2, How many employees does your company employ? Business Survey 44% of companies with 10 or less employees offer insurance. All companies surveyed with more than 25 employees offer health insurance to employees, while less than half of those with five or fewer employees offer insurance. Half of the companies in Greenville (47%) have 10 or less employees.

47. 47 Companies are taking relatively drastic measures to manage the costs of health care insurance. Companies are taking relatively drastic measures to manage the costs of health care insurance. Almost half of companies say they have switched companies in the last two years. No one says they dropped coverage completely. Q11. In the last two years, has your company changed any of the following items related to its health insurance benefits offered to employees? Base: Offer health insurance Business Survey While 88% would reduce coverage if costs increased 50%, only 4% say they would drop coverage for employees completely. Q12. How would your business change its insurance coverage if costs increase in the next two years?

48. 48 Economic Impact of Uninsurance The Uninsured Increased financial risks and burdens Inability to fully access care Increased health problems from delayed care Decreased longevity of individual Disproportionate health care costs Childrens lost developmental costs Business Community Increase in employee insurance costs Increase in insurance costs for employers Reduced and lost employee coverage Lost productivity and absenteeism Greenville Residents Higher insurance premiums Increased taxes to pay for care for the uninsured Costs for charitable organizations who provide care Increased health care costs Governments Opportunity costs of Medicaid (If did not have, who would not be covered) Unreimbursed EMS charges Cost shifting to pay for care for the uninsured (e.g., Education funding going to Medicaid) Healthcare Providers Uncompensated and indigent care costs Rising costs of providing care Increased financial pressures on physicians and hospitals Decreased access to private practitioners Potential inability to offer full range of services to patients Cost of uninsurance in Greenville goes beyond just the uninsured. After an extensive search for a model created by another area or agency that demonstrates hard dollar costs to the medically underserved, none was found. We could uncover no other model of economic costs…. So we created our own.

49. 49 One way of looking at the impact of rising health care costs is by looking at the influences on job and wages. Source: American Association of Health Plans, 2003. The model estimates the total impact of a per annum increase in health care costs on employers, families and employees, beyond inflation as projected by the Centers for Medicare and Medicaid Services. Greenville computed as 9.5% of South Carolina. Toll of Rising Health Care Costs in Greenville

50. 50 For example… Between 2000 and 2001, self-pay and indigent charges at Greenville County hospitals increased 14% to $85 million at $230 per resident. For every dollar invested in prenatal care, $9 is saved in future care costs of the individual. Substance abuse and associated costs cost Greenvillians over $500 million a year. In recent years, the EMS services of Greenville County has written off between $2 and $4 million in uncollectable debt due to expired accounts, residents with no insurance and transient, non-resident and deceased individuals. $214 million was paid in Medicaid expenditures for residents of Greenville County in 2002. Based on figures from the National Institute of Health, uninsurance costs uninsured Greenvillians between $67 million and $135 million a year.

51. 51 Those who lack coverage have worse health outcomes than do similar individuals with insurance, because dollars alone do not confer the health benefits that continuous coverage does. If all members of society bear certain risks and costs from spillover effects of uninsurance, all should realize some benefit, at least indirectly, from a public policy ensuring that everyone has coverage. –Hidden Costs, Value Lost National Institute of Medicine

52. 52 Significant Findings The CHA has had a significant impact on the health of Greenvillians through the creation of programs that have improved access, education, and quality of health care in the county. However, we still have challenges including: –The 41,000 who remain uninsured. –Pharmaceutical and drug costs. –Coordination of and access to health care services. –Prevention and lifestyle change. The costs of uninsurance affects everyone in the community, perpetuating a cycle that results in higher health care costs, loss of jobs, a burdening on health and safety net providers, and negative implications on economic development.

53. 53 So, what can I do? The people who can least afford healthcare pay the most… It is my fervent prayer and hope that we see a level playing field where everybody gets treated the same. - Uninsured resident

54. Our Call to Action Copyright © 2003 Community Health Alliance. All rights reserved. Unless otherwise indicated, all materials in this document are copyrighted by the Greenville Community Health Alliance. Materials may be used and distributed, but must be cited.

55. 55 Residents Hospitals and Health Care Providers City, County and State Governments Schools and Universities Agencies CHA Change Agents Businesses Non Profit Agencies Faith Community Neighborhood Associations Local Foundations YOU

56. 56 This study is one of several initiatives conducted in the last few months that address the health of Greenville. Project Overview

57. For More Information and Reports: For More Information and Reports: www.researchwrks.com/communityhealthalliance.htm or www.unitedwaygc.org Copyright © 2003 Community Health Alliance. All rights reserved. Unless otherwise indicated, all materials in this document are copyrighted by the Greenville Community Health Alliance. Materials may be used and distributed, but must be cited. Operational September 15