Health Summit Struggles With
Funding Options
Eight New Docs Could Help

Tulare County - Health care providers - representatives of agencies, hospitals and physicians themselves have been meeting in recent months looking for a local approach to Tulare County’s mounting health care crisis. That crisis presents itself every night at Kaweah Delta’s emergency room where there is a shortage of specialist physicians, surgeons and orthopedic surgeons for example, to care for a flood of injured and sick people who have no place else to go.

The burden of caring for that flood of people - many who either have no insurance at all, perhaps 20% of the residents out there, and those with health plans that pay physicians cents on the dollar - falls on a dwindling number of doctors forced by policy to cover emergency care at the ER night after night despite working long hours all day.

Something More Than Zero

“What would I like?,” Visalia orthopedic surgeon Jim Guadagni asked. “I’d like a 12 hour day to be a long day and not a short day. Then I’d ask for at least some compensation for the work I do instead of zero.”

Guadagni quipped he had to hurry his comments at the November meeting at the Visalia Convention Center because he needed to be at the ER in ten minutes since he was on call. The issue was critical to surgeon Victoria Gerken - a physician that has been outspoken over the need for reform and more resources. She couldn’t attend the late November meeting because she was on floor at Kaweah Delta.

Health care research says Tulare County should have 24 orthopedic surgeons for the population size but we have only 15. In general surgery there should be 37 to cover the county’s population, but we have just 13, says county health administrator Brooke Frost.

While 5 surgeons covered call duty at Kaweah Delta’s ER in the early 90s when visits were just 15,000 annually, only 6 take call today when visits have skyrocketed to over 60,000 annually.

The focus of this Health Care Summit is - how to get more physicians to come to Tulare County and how to ease the financial and work overload burdening the physicians already here?

Physician recruitment appears to be the tangible goal this group can agree upon and a partnership on this effort appears to be gaining strength between KDDH, Visalia Medical Clinic, Family HealthCare Network and Tulare County.

Tulare County’s top health care official Ron Probasco told the group that included some 20 physicians that it is possible over the next year together they could bring in four new orthopedists and four new general surgeons - eight in total to help shoulder the load.

While the County continues to rule out using the tobacco settlement Millennium Fund to help with physician recruitment despite continued pressure - Probasco threw out the probability that the County would support use of Proposition 10 funds - also tobacco related, aimed at children - to boost funding to insure access to Tulare County’s children. Some $10 million annually comes into the county under this funding divided up by an appointed commission. Probasco sits on the commission board.

Rousing Success

Tulare County Medical Society head Steve Beargeon told the group that “if we get eight new physicians it would be a rousing success.” Beargeon is drafting a letter to the commission requesting support.

A week after the meeting Probasco told the Voice that he was hopeful the county could be instrumental in bringing in 8 new specialists - four general surgeons and four orthopedic surgeons by tapping “a substantial amount” for the Prop 10 funds. Probasco says he could support using perhaps 50% of the more than $7 million that come in for this purpose. Probasco said the county was already working with Sierra View on bringing in two specialists and he would propose the same arrangement with Tulare District and Kaweah Delta. The Prop 10 monies could provide a base of funds “to insure access” to the children of Tulare County that a doc would be there in the case of an accident or sickness. “Hospitals are spending over $1 million a year to pay for call services from physicians,” says Probasco and some of this Prop 10 monies could free some of that money up allowing incoming physicians a guaranteed salary base.

Probasco says Mr. Beargeon will make the proposal at the January Prop 10 committee meeting and if well received the county could work with the hospitals to insure the recruitment moves forward.

Kaweah Delta has already signed up new physicians that will begin this spring and Probasco says the two new docs funded with the Prop 10 monies are in addition to the two KDDH has signed up by offering a guaranteed salary. Besides the hospital, Family HealthCare Network has said they would significantly support bringing in more specialists as well.

“I think we can make the case to the commission that we really are in a health care crisis in Tulare County,” says Probasco.

Kaweah Delta has vowed to bring in two physicians and Visalia Medical Clinic another. Family HealthCare Network head Harry Foster says the nonprofit too “wants to participate financially in recruitment and retention” as long as they participate in “on call.”

Foster says the goal is to avoid “two tier health care delivery system” one for the well to do and one for the poor - needs to be avoided.

Probasco says the county is strategizing on some long term goals - to get federal approval for a Medical Enterprise Zone in Tulare County that gives physicians a tax break - one idea to get physicians to take MediCal despite low reimbursement - have the income be tax free.

Poorest County

“We are the poorest county in the state,” Supervisor Steve Worthley told the group “making use eligible for pilot programs even in these times of budget shortfalls.”

Other ideas - pass a parcel tax assessment in Tulare County like they did recently in LA County to help pay for on call physicians. Complaints by physicians that the county administered TCMS program for the indigent is hard to tap even when a person appears to be eligible. The problem, Tulare County has an eligibility worker stationed at the hospital but they aren’t there at night when most of the ER visits happen. “After sunset everyone goes to the emergency room,” says one doc. Another physician says “Fresno hates us” because we send them (UMC) all the patients we can’t handle here.

Meanwhile, some aren’t giving up using the Millennium Fund for help stemming the tide. Steve Beargeon argued at the meeting that it appears clear that the funds provided by the cigarette tax should go to health care instead of a new roof for county buildings and roads.

But Worthley pointed out that this year the $2.5 million funding from the fund will go to fixing the windows at the courthouse implicating the mold cases the county has been suffering under “is directly related to the health of our employees.”

Still, opponents aren’t taking no for an answer. Healthcare For All - a group affiliated with physician Victoria Gerken has hired a consultant to put together a plan for citizen referendum in Tulare County that would mandate use of the funds the county gets annually to be used for health care.

Initiative Plan

Dr. Victoria Gerken says she personally hired Michelle Revelle, a campaign consultant from Orange County who worked to pass an initiative on the Tobacco Settlement Funds in that County forcing them there to spend the windfall on health care. “We just have a disagreement with the County” of Tulare over how to use the monies.

She says lawyers who have looked at the Tulare County Millennium Fund agreement say “it’s easy to unwind” in contradiction to an argument used by county officials to suggest whey they can’t - a least for a number of years - change the way the fund is distributed to pay out. Gerken says after some more polling there will be a push for a voter initiative to sign up 21,000 votes on a petition to force a special election, likely next fall.

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Visalia - Visalia city council members surprised staff and a consultant hired to explore multiple choices to be studied for a new civic center in Downtown. They said they didn’t need to wait and instead unanimously choose one site.

“I’d like to fast track this” said council member Phil Cox suggesting first that the City Hall location be narrowed to the large open site at Burke St. north of Center. “We don’t want to do this in 5 to 7 years,” says Don Landers suggesting maybe 3 or 4 years and agreeing with all that the Burke St. site - Visalia’s Hobo Jungle area - much of it vacant railroad owned property has the highest potential to meet the city’s needs long term.

The city recently completed purchase of the corner of Burke and Murray, some 11.65 acres and is in serious negotiations with Union Pacific for another 24 acres combining much of the area north of Center, west of Ben Maddox and both east and west of Burke St.

The decision sets in motion a city policy to extend and encourage the city’s Downtown to move to the east from Santa Fe to Ben Maddox - the older service commercial part of town. Much of the investment in this area happened generations ago including the railroad yard area - that never has been built on. In the past few years the city has bought land and parceled it off to encourage development along Oak St. east of the Depot restaurant in a start of what could be a new “town center” corridor that heads east over the next decade.

Matter of Perception

Since the decision Tuesday, city manager Steve Salomon said he has been approached by some folks asking why “city hall was moving out of Downtown?” Salomon says that if a building was constructed on Oak and Burke St., its address would be 700 east block of Oak St., that compared to the current city hall address which is 707 W. Acequia. “It’s a matter of perception,” suggests the city manager.

Landers said that because of city needs and the current low interest rates for financing right now, waiting to move forward on this wasn’t a good idea. “Lets look at it right now,” Landers pressed consultant Harry Tow if a project could be built in that time line. City manager Steve Salomon rescued Tow by suggesting that “these things take time” but that a project could easily be underway by then. “I see this happening in as much as 10 phases,” says Salomon citing discussions of a joint venture possibly with other government entities. They have had some discussions of a joint campus with the county who might want a new social services building while Bob Link held out hope that “the school district might come back downtown.”

Council members unanimously said the Burke St. site purchased last year offered a chance to plan a multi care campus without building any kind of urban tower structure with a parking garage on a smaller footprint of land. “This will be the catalyst for business to expand in this direction,” said Wendy Rudy.

Mayor Jesus Gamboa said staff should not be surprised that council didn’t want to wait anymore to study alternative sites sine the issue of a new City Hall has been on the radar screen “since I’ve been on council.” Gamboa noted that “deep in my heart I always knew we would pick this site.” The location had been suggested back in the 1980s by a number of former officials including former mayor Greg Collins.

A 1999 study by Quad Consultants - Tow’s firm - suggested that the cost of a new civic center could range from $15.3 to 27 million depending on its construction. Potential funding for the new center includes a reserve fund that has collected more than $7 million right now, funding from the public safety impact fee over the next 25 years of some $6 million and $6 million from the potential sale of the two block existing City Hall. Also on the list is a possible sales tax increase to benefit police and fire that voters would have to approve. Quad will now gear up design ideas and a rendering of how the place might lay out over the next few months.

Hanford Civic Square?

As to the design element, mayor Gamboa suggested they look at other town civic centers and consider the way Hanford’s historic architectural public square looked. Gamboa had a hand in designing the new transit center modeled after the look of the Depot restaurant in the mission style.

There had been some concern in the past that putting a new city hall so far to the east away from the rest of downtown, might not be wise. But council members agreed this was the best site offering room to grow over the years till the city reaches 200,000 population. The current site dates to the 1950s and many departments “are bursting out at the seams,” says assistant city manager Carol Cairns.

The new City Hall would allow all administration, finance and planning be housed in one location as well as office space for police and fire administration. It would also allow expansion of the Convention Center.

Wendy Rudy remarked that the new site has the potential to be designed with both Mill Creek, the oaks, a possible land/pond and trail system coming back into town - perhaps a “linear park” says city manager Steve Salomon, heading back into the downtown area clear to Court St.

The old county court house showed up this week as a possible City Hall location but was rejected by council members as too small. The county has told the city they want to sell the block and city despite the fact it won’t build the City Hall there - it remains the likely buyer to use for a downtown park and water feature.

Besides the Burke St. option and the old county court house option the council heard that the current City Hall site should not be considered since Kaweah Delta expansion in the Downtown made this a possible medical use office for the future. In addition the council looked at an East Main St. near Liberty site that would have required a smaller, taller City Hall. The council heard a recommendation to throw out a proposed site on Bridge just east of the Convention Center because the owners there were not wanting to sell and because of a possible contamination problem.

Short Term Plans

Even though council moved up plans for a new City Hall, city manager Steve Salomon hopes they consider plans to move the city council chamber to the Convention Center in the short term if they can find a room that has the same cozy feel, much of the equipment and even the furniture and dias is relocated. That would free up more office space at the current City Hall site. Salomon said he preferred not to rent property but utilize existing city owned land and property to expand on. “Six years ago we were paying $200,000 a year on rented space. Since then it’s been zero,” Salomon told the council. Mr. Landers reminded Salomon that this month is the six year anniversary of city manager Steve Salomon’s arrival. “Congratulations, you doubled the average time most city managers stay in one place,” joked Landers.

Both the police and fire are crammed into their current office space downtown, says Salomon. The building dates from 1974 when the city population was just 30,000. Today it is 100,000.

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