How Obamacare Has Changed My Hospital

So far in 2014, we have brought almost 7,500 new patients into primary care facilitating better preventative health and chronic disease management

The holidays are a convenient time to take stock of our blessings and opportunities, and to consider the challenges we have overcome in the previous year. As I reflect back, I have many things to be thankful for: good health, a supportive, healthy family, colleagues I enjoy and respect, and a job that I love.

This year, the Affordable Care Act (ACA) had a profound and rapid change on my professional life as a physician who works in an institution that forms part of California’s safety net for those in need. I’m the chief medical officer for San Mateo Medical Center, the county hospital and affiliated clinics in San Mateo County. I also provide primary care in one of our outpatient clinics.

As a result of the ACA, many patients we serve in our county became newly eligible for Medi-Cal, California’s Medicaid program. With this transition, they were offered far more choices: They had access to services that were previously unavailable, such as dental services and expanded mental health services. And, instead of having to travel to our specialty clinic in the middle of the county, they could be referred to “private” specialists in their own communities. Far from luxuries, these new choices will help promote preventative care and early disease intervention; patients who in the past might have delayed a gallbladder or hernia surgery (and ended up in the emergency department with pain) can get prompt treatment with their new Medi-Cal coverage.

Before the ACA, most of our patients were either uninsured or were enrolled in a county program that only covered services at our institution; they could not seek care elsewhere. So more choice for patients means more pressure on us; as patients become eligible for Medi-Cal, they may now choose to leave our organization to seek care elsewhere. I will try to avoid clichés as I write this, but there is one that is especially appropriate here: “pressure makes diamonds.” I am seeing a spectacular gem being built around me here in San Mateo, far from flawless but beautiful nonetheless.

Competition has forced us to confront some difficult questions, such as: What is the role of the safety net in this new era when many more people are insured? Why should we, as an institution, continue to exist? Thankfully the answers to these questions came fairly easily.

As an integrated health system, we offer a range of services from outpatient to emergency services to inpatient to long-term care; we offer a distinct advantage over the traditional fragmented health care system. Embedded in the San Mateo County Health System, we can work with our colleagues in Adult and Aging Services, Family Health Services, and Public Health to better meet all the psychosocial needs of our patients. For example, our partnership with the county’s Behavioral Health and Recovery Services has allowed us to embed behavioral health experts in our primary care clinics so that they can better address the mental health needs of our patients; this partnership also expands our ability to refer patients with drug and alcohol problems.

As our patients have moved to Medi-Cal, the ACA has brought our institution some new funding. But we realize that this will be short-lived; many of the new programs of the ACA are funded by reductions to other parts of the safety net. Such pressure is not new; safety net programs are often short of resources, forcing adjustments and redesigns. But the ACA ramps up this pressure on us to innovate, to find ways to do things cheaper and more efficiently.