West Philadelphia has a large number of quality institutional health providers that serve publicly and privately insured individuals. However, there is a dearth of quality private primary care providers for low income residents. This results in an excessive and costly over-reliance on hospitals, and particularly hospital emergency rooms.

Health Status of West Philadelphians
West Philadelphians exceed the City-wide death rates for diseases of the heart; malignant neoplasms (cancers); and cerebral vascular disease -- the three leading causes of death among Philadelphians. City-wide infant mortality rates generally exceed national norms, and the rates for 1990 in West Philadelphia were almost 24% above City-wide rates and more than double national rates, which are among the worst in the Western Hemisphere. The glimmer of hope in these shocking statistics is that the infant mortality rate in Philadelphia has shown a steady, if slowing, decline from 1960 through 1990.

Table 20

There are various ways to measure morbidity (the incidence and prevalence of disease). Diseases reported to the Pennsylvania Department of Health (specifically lead poisoning, tuberculosis, syphilis and gonorrhea) are one measure: and for each of these, West Philadelphia exceeded the City-wide average. HIV and AIDS are serious problems in West Philadelphia, as in the rest of the City. To date, over 900 West Philadelphians have developed full-blown AIDS. The number of infections in West Philadelphia is 41 per 10,000 residents, higher than the 35 per 10,000 residents City-wide. Another approach is to ask residents about their subjective sense of well-being. In 1983, the Philadelphia Health Management Corporation (PHMC) conducted a survey, and 41% of the elderly in West Philadelphia, and 20% of West Philadelphians at large, believed themselves to be in poor or fair health. Among West Philadelphia adolescents whom PHMC surveyed in 1987, 64% reported at least one primary health problem, about average for the City.

The pattern of poor health applies to infants and children in West Philadelphia. In 1990, all of Philadelphia's neighborhoods were ranked by the Philadelphia Department of Public Health according to their rates of infant deaths; low birth weight babies; and pregnant women who received inadequate pre-natal care. There were three West Philadelphia communities included among the 10 highest ranking neighborhoods. Mantua ranked first (census tracts 92 and 105 to 110); West Park/Market ranked fifth (tracts 93 to 96, 102 to 104, 111 to 113); and West Market/Cobbs Creek was eighth (tracts 80 to 85; see map on page 18).

Table 21

Health Facilities
West Philadelphia has an extensive array of in-patient services, with 6 hospitals that accept acute care patients and four specialty hospitals (Children's Hospital, Philadelphia Psychiatric Center, Children's Seashore House and the Institute of Pennsylvania Hospital). These facilities serve patients at all income levels and have outpatient clinics as well as private physicians' offices. Many West Philadelphians use these resources and other facilities located throughout the City.

Also, primarily serving residents with limited incomes, are two City operated health centers and one federally supported community health center. Health Center Three, located on South 43rd Street between Baltimore and Chester Avenues, serves the communities south of Market Street, and District Health Center Four, on Haverford Avenue near 44th Street, provides services to those who live on the north side of Market Street. However, West Philadelphia residents are not restricted in their choice of site and can opt to go to any City center. District Health Centers are funded through a variety of sources, including Medical Assistance reimbursements, other third party payers and the City General Fund. Because the City's Health Centers were recently certified as "federally approved community health centers," they are now eligible for increased reimbursement from the federal government.

West Philadelphia also has its share of private physicians and group practices, but only some of these serve publicly insured patients. Thus, West Philadelphians with adequate income and/or private resources or health insurance can obtain high quality health care from institutional and private providers. Low income patients continue to rely heavily on clinics and hospitals for care and, unfortunately, continue to use hospital emergency rooms for primary as well as emergency health needs.

Focus on Neediest Communities
West Philadelphia contains both well-to-do and very poor neighborhoods with diverse health characteristics and needs. University City is largely populated by University employees and students who are comparatively healthy. In contrast, nearby Mantua is one of the poorest communities in the City and its inhabitants have a much higher incidence of health problems. It is important that the City direct its resources to the areas of greatest need.

Special Populations have Discrete Health Needs
At least in part because of their poverty, several West Philadelphia neighborhoods have discrete populations that are especially at risk for health problems. Teenage pregnancy, coupled with inadequate health care, leads to poor health for mothers and their babies. Other social problems, such as drugs and AIDS, increasingly affect adolescents of both sexes as well as adults. In addition to targeting the neediest communities, the City must develop programs that focus on those groups most at risk.

Barriers to Care
Despite the extensive array of quality health care facilities and providers in West Philadelphia, all West Philadelphians do not have equal or adequate access to care. Health care is expensive. Many low income working families have no or inadequate health insurance and thus have no regular source of care.

There are also language and cultural barriers. West Philadelphia has a very diverse population, with a number of recent Southeast Asian and African refugees and immigrants. These communities frequently are unable to find health care providers with whom they can communicate or who understand their cultures and concerns.

Prevention
Prevention will, in the long run, provide the greatest payoff for the City and the residents of West Philadelphia. There are many levels of prevention, all of which are needed in West Philadelphia. First, citizens in general need a safe and healthy environment, e.g., clean air and water; crime-free neighborhoods; and safe and sanitary housing. Second, individuals must be helped to improve their health through healthy life styles, e.g., adequate nutrition; moderating their intake of alcohol; and avoiding harmful drugs, including cigarettes. Finally, government must provide programs that prevent disease or identify problems early, such as pre-natal care; regular health screening; and immunizations.

There are a number of important new prevention and treatment programs with the potential to improve the health of West Philadelphia residents and for low income citizens City-wide. Most focus on the health needs of poor women and children. West Philadelphia is a recent recipient of one of 15 federal "Healthy Start Initiative" grants. These grants go to areas with particularly serious infant mortality problems and will permit West Philadelphians to receive intensive and innovative maternal and infant health care.

The Healthy Start Initiative was planned and is being monitored by a consortium of provider and professional organizations, advocates, State health and welfare officials, the School District, foundations and others, under the leadership of the Philadelphia Department of Public Health. The project will provide comprehensive outreach to the target population using community based staff who will provide home visits. Other goals are to educate pregnant women and mothers of new babies about the need for adequate medical care, and to connect women with quality health care providers, such as the two City District Health Centers in West Philadelphia, Children's Hospital and the Hospital of the University of Pennsylvania.

"Healthy Beginnings Plus," an innovative Medical Assistance program, provides expanded maternity care to poor pregnant women and women with children up to the age of one. The Healthy Beginnings Plus program is a joint effort between the Pennsylvania Departments of Public Welfare and Health to provide basic medical care; high risk medical care; special services such as obstetric care, social services, homemaker and home nursing care; and substance abuse identification and counseling.

Another crucial program is "Early and Periodic Screening, Diagnosis and Treatment Program" (EPSDT), the federal program that requires and funds screening and treatment services for poor children up to age 21. Basically, EPSDT is the children's component of the federal-state Medical Assistance Program which reimburses physicians, hospitals and other health care providers that provide health care to low income persons.

EPSDT has been operating for many years, and has long mandated periodic medical screening for poor children. Recent Congressional amendments to this program have expanded the number of children who are eligible and the range of services to which they are entitled. Even more importantly, the new amendments have expanded the "T," or treatment part of EPSDT. Now, Pennsylvania is required to provide-and the federal government is required to reimburse-53% of the cost of all medical services necessary to treat all mental or physical problems identified in poor children. Since the federal government pays for much of the costs of EPSDT services (and the Commonwealth pays the rest), encouraging the use of this program is cost free to the City and may release treatment dollars for other needs.

In a departure from the traditional Medical Assistance service delivery model, the Pennsylvania Department of Public Welfare has undertaken a demonstration project to provide and evaluate "managed care" for the Medicaid populations in West and South Philadelphia. All Medicaid recipients in West Philadelphia are required to select a provider who will provide directly or arrange for all necessary health care services. Medicaid pays the provider a fixed amount for each person, no matter how few or how many services the patient uses. The program is designed to provide the patient with a single point of contact with the health care delivery system, a reliable on-going source of quality preventive and curative care. It is also hoped that managed care will be a more cost-effective way of delivering medical care to low income families. The City's District Health Centers also participate in this program.

Goal
Improve the health status of West Philadelphians, particularly the most vulnerable segments of the population.

Objectives
Emphasize prevention programs, including illness prevention, prenatal and child care, injury prevention and immunization services.

• Continue to attract state and federal grants such as the Healthy Start Initiative.
• Ensure full participation of West Philadelphia children in the panoply of screening and diagnostic services available under EPSDT and funded by the state and federal governments.
• The City's Health Department should collaborate with community leaders, major institutions and non-profit groups such as Philadelphia Citizens for Children and Youth to better organize and deliver immunization and preventive health services.
• City Health Centers should educate citizens about how to achieve healthy lifestyles and avoid diseases such as AIDS, alcoholism and addictive drug use.

• Reinforce the on-going programs of the District Health Centers that address the needs of these populations;
• Support the efforts of the Healthy Start Initiative and Healthy Beginnings Plus to reduce infant mortality by eliminating impediments to adequate maternal and infant health care, increasing community awareness of available services, and expanding service delivery sites;
• Empower families to take increased control over their health care needs;
• Make special efforts to identify the very old and ensure that they receive adequate health care;
• Maintain the District Health Centers in West Philadelphia so that they can continue to deliver quality health care services.

Objectives

• District Health Centers Three and Four should continue to function as provider sites in the Medicaid Managed Care demonstration project.
• The District Health Centers should make maximum use of their newly granted status as federally approved health centers to generate increased revenues to support the Centers.
• The City Health Department should monitor the mandated use of health insuring organizations by Medicaid eligible West Philadelphians to ensure that the services provided are of sufficient quality, scope and duration to prevent and treat illness.
• The City Health Department should expand the use of EPSDT at the District Health Centers and throughout the health care system to increase the quantity of needed health care services provided and to maximize state and federal revenues.
• The City Health Department should conduct and support outreach efforts, such as those under the Healthy Start Initiative and through the District Health Centers, to link residents with primary health care providers and to reduce the use of hospital emergency rooms for non-emergency conditions.