Children’s Hospital of Central California (CHCC), Madera, Calif., cuts a wide swath through its 45,000-square-mile catchment area, which overflows with 1 million children. Eight miles northwest of Fresno, it nestles in a wheat field, part of the San Joaquin Valley’s 1.88 million acres of rich farmland that contributes $4 billion annually to California’s economy. Fresno is home to a population that is 60% minority; the city is a multicultural mélange of Hispanics, blacks, and Asians with dozens of languages and homelands.
CHCC’s challenge is to continue to attract privately insured patients, who account for 30% of its clients and choose the hospital for its clinical excellence, while serving a 70% majority of publicly insured and uninsured migrant and poor urban families. Even with public payers, national statistics starkly highlight CHCC’s reimbursement quandary: Healthcare expenditures for uninsured and publicly insured immigrants are approximately half those of their U.S.-born counterparts, while immigrant children account for 74% lower per capita expenditures than U.S.-born children.1
CHCC’s patients are treated in an architecturally dramatic hospital organized around an “Our Universe” theme. Bright colors splash everywhere, its low-profile buildings don’t scare children, and cozy lounges and other homey touches are welcoming.
CHCC is organized into four 32-bed “starships.” Starship Discovery covers gastroenterology and infectious diseases, while Starship Apollo’s passengers get 24-hour supervision of cystic fibrosis, bronchitis, syncytial virus, and sleep apnea. In Starship Explorer, hospitalists tend to about 10,000 postoperative patients annually, with cardiovascular, neuro, and orthopedic procedures predominating. Starship Craycroft is dedicated to hematology, oncology, diabetes, and nephrology, as well as clinical trials for cancer, sickle cell anemia, and hemophilia. Hospitalists move readily from one starship to another, rather than being assigned to a service.
The hospitalists, members of Children’s Hospital Medical Group (an 80-doctor multi-specialty group) are now integral to CCHC, but the program started shakily. According to Don Fields, DO, and chairman of the hospital medicine group, administrators approached him and another physician in 1998, asking them to establish a hospitalist service in anticipation of relocating from Fresno to the new hospital. Moving from a busy downtown location convenient to doctors’ offices to a hospital in rural Madera required more driving for office-based physicians making hospital rounds. Geography and huge practice loads in a medically underserved area created the need for a hospital medicine group.
The physicians, naïve to the challenges, agreed to start a service. “When the program started it wasn’t busy because the attending physicians didn’t have a concept of who hospitalists were and what we did,” recalls Dr. Fields. “We had few patients and were worried we’d be fired because of lack of interest.”
After the hospital’s chief medical officer spread the word to community physicians, doctors started referring in droves. “The community [doctors] realized they didn’t have to take night calls or leave their busy offices to make hospital rounds,” adds Dr. Fields.
A recent feather in CHCC’s cap is Kaiser-Permanente of Fresno’s decision to contract for the hospital medicine group’s services. Alice Calhoun, MD, and CHCC’s hospital medicine group’s co-director, says that “the Kaiser staffers, administrators and clinicians, are total sticklers about outcomes and efficiency, and this recent decision speaks to our reputation and competence.”