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Health Care

Health care plays an important role in the economy of the Alamo region, particularly in the San Antonio metropolitan area. The greater San Antonio area is home to 24 of the region’s 47 hospitals, the University of Texas Health Science Center at San Antonio and two U.S. military medical centers. A 2007 study found that about one out of every seven San Antonio employees works in the health care and biosciences industries, with 80 percent of those jobs in the health services sector (which includes hospitals, medical personnel, nursing homes and other specialty providers). Health services accounted for about $9.9 billion of economic activity in 2007.¹

Health care challenges in the Alamo region include a lack of insurance and a shortage of health care providers in some areas. In addition, the region’s obesity and diabetes rates are higher than the state average – which is higher than the national average.

Health Care Infrastructure

Major medical facilities play a substantial economic role in the Alamo region. In San Antonio, the sprawling South Texas Medical Center covers 900 acres and employs some 25,000 people. Fourteen percent of all employees in San Antonio work in the medical field.²

The Alamo region has 26 for-profit hospitals, six nonprofit hospitals and 15 public hospitals (Exhibit 37). San Antonio accounts for 24 of these, including three public hospitals –University Hospital (part of the University Health System), the Texas Center for Infectious Disease and San Antonio State Hospital – two nonprofit and 19 for-profit hospitals. Victoria has the next highest number of hospitals at four.³

San Antonio has the region’s largest number of acute-care beds – 6,384 beds for patients receiving short-term medical care at a hospital or other facility. Baptist Medical Center in San Antonio is the region’s largest, with 1,742 beds. Methodist Hospital is the next largest, with 1,733 acute-care beds, followed by CHRISTUS Santa Rosa Hospital with 978 acute-care beds. Victoria has the next-largest number of acute beds at 701. In 2008, the region’s hospitals had a total of 8,696 staffed beds (7,980 acute-care beds and 716 psychiatric beds).⁴

The Alamo region also has 11 hospital districts (Exhibit 38). Hospital districts are authorized to levy taxes within their jurisdictions for the support of health care and hospital services. Once approved by the voters, a hospital district can levy property and sales taxes.⁵

In June 2009, Medina County voters voted to create the Medina County Hospital District in Hondo. The district’s property tax rate is expected to be capped at 5 percent for its first year, according to its authority board.⁶

Three of the region’s 19 counties, Bandera, Goliad and Kendall counties, do not have a hospital (Exhibit 39).⁷ Bandera County does have an emergency medical services unit, which provides ambulatory services for the county.⁸ Kendall County also has an emergency medical services unit, the Methodist Boerne Medical Center, which provides pre-hospital patient care, including basic trauma care and life support.⁹ San Antonio’s Methodist Healthcare opened the Methodist Boerne Medical Center in 2008. It is the area’s first freestanding emergency department, giving residents of Kendall County immediate and direct access to emergency room services.¹⁰

These two counties also provide indigent health care services. The state, through its Department of State Health Services, supports a County Indigent Health Care Program. The Program provides services to indigent residents through local entities like hospital districts and public hospitals.¹¹ Bandera County’s program provides services to individuals who are not currently eligible for state or federal assistance and who meet an income limit of 21 percent of the federal poverty income level for a family of one. The program covers general medical services such as physician exams, physicals and immunizations as well as prescriptions and x-rays.¹² Kendall County also provides indigent health care services designed solely to assist in the payment of medical services.¹³

Upcoming Projects

A number of major health care projects are under way in the Alamo region. San Antonio’s University Hospital recently received approval from the Bexar County Commissioners Court to expand its Level 1 trauma center. Level 1 centers are designed to handle patients with serious and complex injuries; at present, Texas has only 13 of them.

The University Hospital Level 1 trauma center was last expanded 25 years ago and is too small to meet the current needs of the city’s population or to treat all of those involved in any major emergency. University Hospital also anticipates ongoing updates of its other facilities including an expansion of its emergency center; a redesign of inpatient and adult rooms last updated in 1968; and additional parking spaces.¹⁴

The recent federal stimulus legislation provides funding for 30 research projects at the University of Texas Health Science Center at San Antonio (UTHSCSA). The largest fund award will support a study examining interventions to reduce sexually risky behavior among Mexican-American adolescent women in rural areas.¹⁵ The project’s funding exceeds $500,000. Other UTHSCSA projects funded under the stimulus bill include a clinical trial of treatments for advanced solid tumors in cancer patients and an investigation into treatments of inflammation.

Veterans’ Health Care

The South Texas Veterans Health Care System (STVHCS) is one of six veteran health care systems in Texas. A veteran’s health care system is defined as a full service health care provider, which includes hospitals, outpatient clinics, mental health services and rehabilitative services. The STVHCS is geographically the largest veteran’s health care system in Texas, covering veterans in San Antonio and South Texas, which extends all the way to the border. STVHCS has a 268-bed facility in San Antonio providing primary, secondary and tertiary health care, surgery, psychiatry and rehabilitation medicine. It also includes a 90-bed Extended Care Therapy Center, a 30-bed Spinal Cord Injury Center, an eight-bed Bone Marrow Transplant Unit and a Geriatric Research, Education and Clinical Center also located in San Antonio.

In affiliation with the University of Texas Health Science Center at San Antonio, STVHCS offers an active ambulatory care (outpatient) program with satellite clinics in Corpus Christi, McAllen, San Antonio, Laredo, Harlingen and Victoria. STVHCS also contracts with local community health care providers to run clinics in Alice, Beeville, Eagle Pass, Kingsville, New Braunfels, San Marcos and Seguin that provide primary care to veterans close to their homes or work. STVHCS also operates veteran outreach centers in Corpus Christi, Laredo, McAllen and San Antonio that address the special needs of older veterans.²⁶

The STVHCS Kerrville Division (KD), located 65 miles northwest of San Antonio, began operations in 1947. It provides medical and long-term care services for an estimated 16,000 veterans residing in the Texas Hill Country. KD comprises 226 hospital beds and a 154-bed Nursing Home Care Unit. KD has developed an extensive primary-care delivery system and enjoys successful affiliations with Schreiner University and Howard College.²⁷

Psychiatric Care

Like many other areas of the state, the Alamo area is experiencing a health professional shortage in its mental health workforce. Fortunately, San Antonio is designated as an Area Health Education Center (AHEC). AHECs were established by the U.S. Congress in 1971 to recruit and train health professionals in underserved communities. For example, students are provided information about mental health careers and provided community-based educational placements in mental health settings. The AHECs also help communities recruit and retain mental health professionals and mental health programs.²⁸

The region’s psychiatric care is coordinated by a number of community mental health and mental retardation (MHMR) centers affiliated with the Texas Department of State Health Services (DSHS). In addition, the area has two state-administered inpatient crisis stabilization centers and long-term care facilities housed at the Kerrville and San Antonio state hospitals (Exhibit 40).

Community MHMR centers serve as the usual entry point for mental health treatment. These centers provide a number of services that can be divided into two general categories: mental health assessment and referral and outpatient treatment and counseling. Each community MHMR center provides assessment and treatment services to both children and adults through interdisciplinary treatment teams that either refer clients to specialized service providers or develop treatment plans to serve their individual needs.

DSHS administers the Alamo region’s two inpatient public psychiatric state hospitals, Kerrville State Hospital and San Antonio State Hospital. Both provide crisis stabilization and long-term psychiatric care but serve very different populations.

Kerrville State Hospital cares for persons with major mental illnesses who need the safety, structure and resources of an in-patient setting. Lengths of stays vary with the needs of each patient. The facility has 184 beds for patients hospitalized on a “forensic commitment,” which results when an individual charged with a crime appears to be mentally ill and the court questions whether they are competent to stand trial for the offense.²⁹

San Antonio State Hospital provides intensive inpatient diagnostic treatment, rehabilitative and referral services for seriously mentally ill persons from South Texas, with a focus on low-income and indigent clients. Admission may be voluntary or involuntary depending on whether a court has determined that the patient is seriously mentally ill, dangerous to his or her self or others or dangerous if left untreated. The facility has 302 beds and 912 staff members.³⁰

In addition to these facilities, the region is home to the University Health System (UHS) psychiatric services program, which serves clients with a wide array of mental health disorders including bipolar spectrum disorder, schizophrenia and psychotic disorders, substance abuse behavior, anxiety and post-traumatic stress disorders (PTSD), childhood and adult attention deficit hyperactivity disorder (ADHD), personality disorders and suicidal or violent behaviors.

UHS psychiatric facilities include a psychiatric emergency services (PES) facility that provides around-the-clock emergency psychiatric services. The PES facility is South Texas’ only dedicated psychiatric emergency room. Because UHS serves as the main teaching hospital for UTHSCSA’s medical professionals, the PES is staffed with experienced UTHSCSA faculty as well as psychiatry resident physicians, UTHSCSA students who have completed their course work and licensure but are completing their residency training. With about 400 visits monthly, many consider PES to be the “safety net” for psychiatric services in the San Antonio area.

All UHS outpatient psychiatric services are provided in collaboration with UTHSCSA’s Department of Psychiatry. UHS provides a full spectrum of psychiatric care for children and adolescents, adults and geriatric and substance-abuse patients. It has clinics around the San Antonio metro area, each equipped to serve patients with an array of mental health conditions including anxiety and depression, bipolar disorder, dementia and cognitive disorders, ADHD, learning problems and developmental delays.³¹

Veterans’ Psychiatric Care

The South Texas Veterans Health Care System offers veterans psychiatric assistance for conditions including PTSD, mood disorders, schizophrenia and substance abuse, through both inpatient and outpatient services. STVHCS’ Audie L. Murphy Veterans Affairs (VA) Hospital provides inpatient crisis stabilization and short-term care through two 25-bed inpatient acute-care psychiatric units. It also has a 26-bed substance abuse rehabilitation program that provides an intensive detoxification program as well as a relapse prevention program. For veterans needing longer inpatient care, the Audie L. Murphy VA Hospital operates a 40 bed-domiciliary (a residential program) that provides coordinated clinical care for veterans to help them achieve and maintain the highest level of independence possible.³²

STVHCS’s Kerrville Division provides veteran mental health services including a mental health clinic with a psychiatrist, psychologist, nurse practitioner and social work therapists. KD can treat a full range of psychiatric disorders on an outpatient basis and often consults with clients’ primary-care doctors during any hospitalizations. A psychologist is co-located in the KD’s primary-care clinic areas to act as a liaison between primary-care providers and the mental health clinic. Similarly, KD has assigned a geropsychologist to its geriatric clinic to perform neuropsychology evaluations and to serve geriatric and demented patients, both in the hospital and as outpatients.³³

Children’s Psychiatric Care

The Alamo region has several entities that serve children with mental health issues.

The Behavioral Health Clinic in the Goldsberry Children’s Center of CHRISTUS Santa Rosa Children’s Hospital is a joint venture of the hospital, UTHSCSA’s Division of Child and Adolescent Psychiatry and the Child Guidance Center of San Antonio. It provides services to children suffering from mental health issues, specializing in ADHD, bipolar disorder, depression, anxiety and adjustment disorders. The clinic is run and staffed by child psychiatry faculty, child and adolescent psychiatry residents from UTHSCSA, psychologists and therapists from the Child Guidance Center and psychologists from the community.³⁴

The Child Guidance Center (CGC) of San Antonio is a nonprofit agency that provides outpatient mental health care to Bexar County children and adolescents regardless of family income. In 2008, CGC provided services to 2,178 children at locations throughout the county. CGC offers a full range of services including individual and family psychosocial assessments, psychiatric evaluations and medication management.³⁷

Laurel Ridge Treatment Center, a 196-bed facility located in San Antonio, is a psychiatric hospital that serves children, adolescents and adults. It offers crisis intervention, assessment and referral services 24 hours a day for all clients regardless of age. These services are often short in duration, lasting from three days to a month. Once patients are stabilized, they are moved to community-based outpatient services in their home areas. For children and adolescents requiring more lengthy stays, Laurel Ridge also offers residential treatment. Residential treatment usually lasts from three to 18 months, with the goal of ultimately moving clients to less-restrictive environments or to outpatient services in their home communities.³⁸

The Cindi Taylor Krier Juvenile Correctional Treatment Center (CTKJCTC) provides services to youth who have been convicted of juvenile crimes in Bexar County. CTKJCTC houses up to 96 residents with average lengths of stay of approximately nine months. UTHSCSA’s Division of Child and Adolescent Psychiatry provides psychiatric services to CTKJCTC. The program, part of the Bexar County Juvenile Probation Department, is structured to provide behavioral and educational services in a structured environment. It offers a self-paced educational program run by the East Central Independent School District, as well as around-the-clock nursing staff.³⁹

Southwest Mental Health Center is a private, nonprofit children’s hospital specializing in the treatment of mental, emotional and behavioral disorders. It serves children aged three through 17, offering acute inpatient care, residential care, day treatment care and outpatient care. The acute-care program is a short-term psychiatric hospital that focuses on stabilizing children or adolescents in crisis. The residential treatment program is also provided in a hospital setting, and provides 24-hour treatment for children and adolescents with chronic psychiatric disorders.⁴⁰

Professional Shortages and Rural Health Care

Health Professional Shortage Areas are designated by the U.S. Department of Health and Human Services as geographic areas or certain populations that have a significant shortage of available health care personnel. Seven counties in the Alamo region (Atascosa, Bandera, Goliad, Jackson, Karnes, Medina and Wilson) have health professional shortages. Atascosa, DeWitt, Frio, Goliad, and Medina are also considered to be dental health professional shortage areas.⁴¹ Bandera County has five direct primary-care physicians (physicians who have direct patient contacts and who cannot also be categorized as administrative staff or researchers) for a population of 21,032 residents; Karnes County has four direct primary-care physicians for 15,969 residents; and Goliad County has two for a population of 7,488.⁴²

In 2008, largely rural Frio and Medina counties expanded their mental health and primary-care service offerings with a grant from the U.S. Department of Health and Human Services. The $150,000 grant went to South Texas Rural Health Services, Inc., a pilot program started in 2006 to provide mental health, substance abuse and primary-care services to the medically underserved in these two counties. The funds are targeted for area residents who may be uninsured, underinsured or otherwise members of a vulnerable population.

To help further expand health care services to undeserved areas in San Antonio, the pharmaceutical company Pfizer recently started a Promotores initiative. Promotores are community health workers who provide a vital link between community health resources and patients in underserved areas. They also provide culturally sensitive information on health care to the Hispanic community. Through the Pfizer initiative, the drug company will train individuals to reach out to uninsured Hispanics and educate them on a Pfizer program that saves money on prescription drugs.⁴³

The Uninsured

Texas has the nation’s highest share of residents who are uninsured. In the years 2006 and 2007, an average of 24.8 percent of all Texans lacked health insurance.⁴⁴ In 2005, the uninsured rate in the Alamo region was 25.9 percent.

In the region, the lowest rate was in Victoria County, with an estimated 21.3 percent of its residents uninsured, while the highest rate was in Bandera, with a 32.9 percent uninsured rate. The uninsured rate in Bexar County, the region’s most populous county, was 24.6 percent in 2005.⁴⁵ The San Antonio MSA had a slightly lower uninsured rate of 23.6 percent, but the rate was considerably higher among Hispanics (30.6 percent) and African Americans (27.0 percent).⁴⁶

Uninsured residents of the Alamo region typically receive care from a number of “safety-net” providers including hospital districts, public hospitals, other area hospitals, University of Texas Health Science Center facilities in San Antonio and community health clinics that provide low-cost or free medical care.

In Bexar County, the public hospital (the University Health System) cares for the uninsured through its hospital, neighborhood health centers and clinics. In 2008, the hospital collected about $220 million in property taxes, but provided more than $261 million in charity care. About 44 percent of UHS patients were uninsured in 2008.⁴⁷

In 1996, the growth in the uninsured population spurred UHS to establish CareLink, a financial assistance program for low-income Bexar county residents. Uninsured Bexar County residents who do not qualify for Medicaid, Medicare, veteran’s benefits or the Children’s Health Insurance Program (CHIP), and who meet income eligibility requirements, can become members of CareLink and obtain health care through UHS. While it is not an insurance program, CareLink members are offered a monthly payment plan based on their family size and income.⁴⁸ In 2008, 19 percent of UHS’ paying clients were CareLink members.⁴⁹ One study of San Antonio’s safety net noted that CareLink is one of the few ways the uninsured can access health care services at a lower cost.⁵⁰

Faculty, residents and students at UTHSCSA also care for the uninsured through their School of Medicine’s medical practice, UTHSCSA’s Cancer Therapy and Research Center, CHRISTUS Santa Rosa Health Care, the South Texas Veterans Health Care System and other facilities. UTHSCSA provides more than $100 million annually in uncompensated care to the uninsured and underinsured.⁵¹

In February 2005, UTHSCSA opened a student-run free clinic program at Alpha Home, a center for indigent women in need of medical care, and staffed it with medical students, residents and faculty volunteers.⁵² In 2007, medical students and faculty donated 1,800 hours of free medical care to serve about 750 women at Alpha Home. The center has established another student-run free clinic at San Antonio Metropolitan Ministries, which provides shelter and care for the homeless.⁵³

Moreover, each of the region’s 19 counties operates a County Indigent Health Care Program (CIHCP) that provides medical services for eligible low-income individuals who do not qualify for other government programs such as CHIP, Medicaid or Medicare. Eligibility is based on income, the number of people in a household, financial resources and residence. In the Alamo region, some counties administer the CIHCP program while in others it is administered through a hospital district or public hospitals.⁵⁴

Another source of health care for low-income and uninsured people is the community health center (CHC), usually a private, nonprofit entity supported by faith-based organizations, civic leaders and local business owners. A recent federal government study called CHCs America’s primary-care safety net and noted that almost 40 percent of CHC patients are uninsured.⁵⁵

These health centers rely on funding from a variety of sources including federal grants and programs, state and local governments, patient payments and private donations. They are generally located in underserved areas, both urban and rural. In addition to primary care and laboratory services, CHC patients also receive preventive care. CHCs also may provide outreach, health education and screening programs as well as other social services tailored to meet the needs of their communities.

The National Association of Community Health Centers reports that every year, billions are spent on unnecessary and costly emergency room visits that could have been redirected to CHCs, which are more effective in providing primary care to the uninsured.⁵⁶ The federal government recently provided more funding for community health centers in its economic stimulus package. All five CHCs serving the Alamo region will receive stimulus funds.

Bexar County has two of the region’s CHCs – El Centro del Barrio dba CentroMed and Barrio Comprehensive Family Health Care Center dba CommuniCare Health Centers – both established in the early 1970s. CommuniCare has two full-service health clinics providing medical care to 76 medically underserved census tracts in San Antonio. In 2008, these two clinics provided medical care to about 35,000 patients.⁵⁷ Over the next two years, CommuniCare expects to receive $1.3 million in federal stimulus funding to expand its health services.⁵⁸

CentroMed provides primary health care, behavioral health services, nutritional and other support services through 20 sites in San Antonio and Bexar County. Six of its primary-care health clinics are located in or near seven homeless shelters. CentroMed also operates the Lanier Student Health Clinic, which provides medical, dental and psychiatric care to students enrolled in one of 14 public schools as well as their families.⁵⁹

Several other counties in the Alamo region also have CHCs. The Community Health Centers of South Central Texas provides primary health services to residents of Gonzales County and has service sites in the cities of Gonzales, Seguin and elsewhere. South Texas Rural Health Services serves Frio County residents with clinics in Pearsall and Dilley among others. The Atascosa Health Center has a primary health care clinic in Pleasanton that also provides services to residents of Atascosa County.

Diabetes and Obesity

The Alamo region has higher rates of adult obesity and diabetes than Texas as a whole. UHS System in San Antonio notes that diabetes is a major concern in Bexar County.⁶⁰ The prevalence of adult diabetes in Texas is rising rapidly, from 7.7 percent in 2004 to 9.7 percent in 2008.⁶¹ In the Alamo region, the prevalence of diabetes also rose, from 9.9 percent in 2005 to 11.4 percent in 2008.⁶² During the same period, the prevalence of overweight and obesity in Texas grew from 62.9 percent in 2004 to 66.2 percent in 2008.⁶³

Obesity is a major risk factor for diabetes, a serious public health problem.⁶⁴ In 2008, 68 percent of San Antonio MSA adults were overweight and obese, compared to 66.2 percent in the rest of Texas.⁶⁵ Hispanics, which make up 50.5 percent of the Alamo region population, have higher rates of obesity and diabetes than Anglos.⁶⁶ A 2005 study noted that by the 1990s, three out of four Mexican-American adults were either overweight or obese.⁶⁷

Diabetes was the sixth most common cause of death in Texas from 2002 through 2005.⁶⁸ The statewide diabetes mortality rate in 2005 was 30 deaths per 100,000 persons. In the Alamo region, the diabetes mortality rate for 2001 through 2005 was 36.9 deaths per persons, and considerably higher for Hispanics and African Americans – 62.2 per 100,000 and 51.9 per 100,000, respectively. Mortality from diabetes, furthermore, is probably higher than indicated in statistics, since it is often listed as a contributing factor rather than a cause of death.⁶⁹

Untreated or poorly controlled diabetes can lead to long-term health complications including heart disease, stroke, vascular disease, blindness, kidney disease, nerve damage and amputation. Texas hospital data indicate that five – Frio, Atascosa, Victoria, Jackson, and Bexar – of the Alamo region’s 19 counties have a higher-than-average number of admissions per 100,000 residents for long-term diabetes complications (Exhibit 41). In 2005, the state average for such admissions was 122 per 100,000 residents.⁷⁰

The region is home to the Texas Diabetes Institute (TDI) in west San Antonio. In 1993, the University Health System, Bexar County’s public hospital, worked with the UT Health Science Center and the Texas Diabetes Council, a division of DSHS, to establish TDI, which provides diabetes-related services to communities in South Texas and throughout the state. Housed in UHS’s University Center for Community Health, TDI is committed to diabetes prevention through patient education, treatment and research.

In May 2008, San Antonio became the second city in the country (after New York City) to establish a diabetes registry to monitor cases in the city. The San Antonio Metropolitan Health District (SAMHD) initiated the effort, which was included in the city’s legislative agenda and approved by the 2007 Texas Legislature. A diabetes registry pilot program began in May 2008 and will last for 18 months. Information from about 50,000 active diabetic patients and four major testing labs will be collected to produce summary reports at the regional, community, provider and practice levels. SAMHD will use these data to monitor the diabetes epidemic and to aid efforts to improve the health of diabetes patients.⁷¹

Local organizations in the region are joining the fight against obesity and diabetes. The Bexar County Health Collaborative, whose members include Baptist Health System, Steve Blanchard, the Bexar County Department of Community Investment, CHRISTUS Santa Rosa Health Care, Methodist Health Care System, Community First Health Plans, UHS, Methodist Healthcare Ministries of South Texas, SAMHD, WellMed and the YMCA of Greater San Antonio, are working together to improve the health status of the community. Among their priority issues is obesity prevention, especially among youth.⁷²

In 1999, the Health Collaborative created Fit City, a program covering several initiatives to improve the health and wellness of residents of San Antonio and the surrounding community. The YMCA of Greater San Antonio now manages and operates the program, which encourages individuals to eat properly and exercise. Some of the initiatives are designed for all ages – Walk San Antonio, Healthy Vending, Body Mass Index and a newsletter.⁷³

Another program of the Health Collaborative is Project Measure Up, designed to decrease the prevalence of childhood obesity that can lead to Type 2 diabetes. Program volunteers have assisted Bexar County’s school districts in implementing Senate Bill 530 passed in 2007, which requires daily exercise for children through grade six and annual fitness assessments for children in grades three through 12. Studies have found that children who are overweight at age 12 are 75 percent more likely than others to be overweight as an adult.⁷⁴ Diabetes rates are substantially higher among sedentary people than those who are active.⁷⁵

The U.S. Agency for Health Care Research and Quality has lauded San Antonio’s Bienestar Health Program, a school-based program designed to teach students in elementary and middle school to eat properly and exercise, as innovative and effective. A San Antonio physician, Dr. Roberto Trevino, Executive Director of the Social and Health Research Center (SHRC), a non-profit diabetes and obesity prevention program, provided the impetus for the Bienestar program that is a collaborative effort between SHRC, the University of Texas at San Antonio and Texas State University. Private companies and foundations also provide funding and support for the program.

Bienestar was implemented in 1995 and by 2007 was in place in more than 300 schools within various South Texas school districts, mostly in low-income San Antonio and Laredo neighborhoods.⁷⁶ Preliminary results of a study evaluating the program’s success in 10 elementary and four middle schools in South San Antonio ISD found that both diabetes and obesity rates declined among participating students.⁷⁷

UT Health Science Center, San Antonio

PHOTO: UT Health Science Center, San Antonio

Endnotes

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