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his case study describes the Dade County area, which has a highly diverse and changing population of approximately two million people.1 The North Dade area is primarily urban and includes the city of Miami, which makes up approximately 20 percent of the countys population and is home to many of the areas hospitals and physicians. The South Dade area, which is more rural, includes agricultural areas with a large migrant population and significantly fewer health resources. Much of the county consists of unincorporated areas that depend on Dade County for municipal services. The massive destruction caused by Hurricane Andrew, which occurred in 1992, continues to affect the area in the form of population and employment shifts, including the closing of a major military base.
The dominant population (approximately 50 percent) is Hispanic, followed by the African American community at 20 percent. As the major entry point from Central and South America, immigration into the region is constant, and includes both legal and undocumented individuals. Almost 15 percent of the population is over the age of 65, a lower proportion than the rest of the state, but 12 percent above the national average.2 The annual per capita income in the county is $19,266, below the national average for larger metropolitan areas; however, there is considerable variation in income cutting across ethnic and racial lines.3 An estimated 20 percent of the population is uninsured.4
The picture of health status in the market is mixed. Overall age-adjusted mortality is considerably higher than U.S. averages,5 and there are significant disparities between white (non-Hispanic) and non-white residents. Poor access to health care for at-risk populations, unemployment, lack of insurance and high rates of poverty reportedly contribute to high rates of premature morbidity and mortality.6 Despite these rates, however, infant mortality rates fall well below the national average, a situation widely attributed to concerted state and local efforts to increase access to prenatal care.7 Other major health problems remain, including high rates of HIV infection, AIDS, tuberculosis and problems of substance abuse and deaths related to violence, incidents that disproportionately affect different ethnic and racial groups. In addition, the constant influx of immigrants has resulted in the presence of a variety of infectious and communicable diseases that are not normally seen in other parts of the United States.
THE HEALTH CARE MARKET
The Miami health care market is characterized by an oversupply of health resources and fragmented, rapidly changing business relationships in what may be called an "every-health-care-organization-for-itself" environment. The market has over 31 percent more hospital beds per capita than the national average8 and 42 percent more physicians.9 At the same time, major areas of the city of Miami and South Dade County are designated as medically underserved areas, where the large indigent population has limited access to care.
Hospitals and health plans attempts to pursue a mix of regional and neighborhood/ethnic-based strategies have not succeeded in coordinating service delivery or creating accountability at the county level. Moreover, frequent ownership changes interfere with the formation and maturation of alliances among providers and plans that might lead to better coordination of service delivery, care management and attention to demonstrating quality. These issues, together with the constant deal making and lack of dominant players, make Miamis market dynamics difficult to predict.
Abundant health care resources are located throughout the county with physician offices located near hospitals and office buildings and in many strip malls. Specialty services and tertiary care facilities are heavily concentrated in the city of Miami and the surrounding area. Tertiary services and clusters of physicians tend to be located in and around the joint campus of the University of Miami Medical School and Jackson Memorial Hospital, the countys public hospital. Some of the community hospitals are located farther north toward Broward County and in ethnic enclaves in the northern part of the county. Baptist Health System is the dominant provider in South Dade, which is also served by a large, multipurpose, federally supported community health center.
Residents of Dade County primarily seek their health care from providers in the county, but the major hospital systems and health plans in the area view their market more broadly. The major tertiary hospitals in Miami proper draw patients from surrounding counties, including Broward and Palm Beach to the north and Monroe to the south. Jackson Memorials service area includes the rest of Florida, as well as Central and South America, and the Caribbean. The University of Miami Medical School maintains referral relationships with the physicians it trains from other countries, particularly for specialized services not available in those countries.
Historically, the Dade County tertiary hospitals, specialists and some of the North Dade community hospitals have attracted in-migration, that is, persons coming into the county for care, especially from adjacent Broward County. Two changes have occurred that are limiting some of this in-migration.
LEADERSHIP AND DECISION MAKING
Leadership and decision making generally reside at a very local level, with limited county-wide activity and little accountability at the county level. The dominance of national and regional ownership in the health care industry, however, generally means that most decisions about local hospitals and health plans are made outside the area. Leadership at the local level is also often bounded by racial, ethnic or geographic divisions. In fact, neighborhoods and broader ethnic communities do not come together in any way that provides either collaborative or political leadership to the entire Dade County area on health care or any other issues. Efforts to solve broad community problems are limited, though at times such efforts may be more concentrated and effective within a specific neighborhood.
In many cases, the legitimacy local leaders do have comes from these communities of concern. Some healthcare providers, particularly community hospitals and long-standing community health centers, have taken on the responsibility for organizing and implementing programs within their own neighborhoods. The boards of these providers are made up of community representatives, including members of the business community, civic and religious leaders. For example, the Pan American Hospital, which considers itself accountable primarily to the Cuban community it serves, works directly with many community leaders and area businesses to assess and address the health needs of its community.
On a broader, county-wide level, task forces and committees established to address health and other human services issues generally focus on assessment of health problems and identification of potential solutions. However, none of these organizations -- local or county-wide -- has the legitimacy, authority or resources to influence or initiate action. A number of advocacy groups serve the interests of vulnerable populations, such as children, immigrants, refugees and persons with HIV/AIDS, but they also have limited influence. The business community, through the local chambers of commerce and individual efforts of area businesses, is involved in working with various community-wide initiatives such as school health, prevention and health promotion efforts sponsored by community groups and hospitals.
Many respondents feel that no one is accountable for the effective expenditure of county health funds, though several organizations are either designated or have the potential to improve accountability. These organizations include the Dade County Health Department, the Jackson Memorial Public Health Trust and the relatively newly authorized Public Health Authority. The County Public Health Department recently divested itself of its clinical sites to concentrate on community and public health issues such as teen pregnancy and sexually transmitted diseases. The state-funded Health Department serves as a convenor around an issue, but cannot ensure that local action occurs because of limited local legitimacy and influence.
The Public Health Trust is the governing board for Jackson Memorial Hospital and its related enterprises and is charged with accountability to the "community." Made up of community representatives, the Trust is responsible for ensuring that efforts by Jackson Memorial and its clinics, especially in the use of county indigent care dollars, reflect the needs of the community. However, the Trust has been a source of some controversy and concern about whether it truly represents the community and is accountable. In response to these concerns, the Dade County Commissioners established the Public Health Authority, which began operating in November 1996. The Authority was set up to assess the extent to which the Trust was meeting community needs and to report its findings to the County Commissioners. Originally intended to act as an independent group, the Public Health Authority established a close working relationship with the Public Health Trust, leading respondents to question its ability to render independent judgment.
Miamis recent bankruptcy and accusations of corruption also raise questions about the future of the county governance in general and financing of indigent care in particular. Jackson Memorial receives a portion of its support from dedicated property tax millage. However, as unincorporated areas become incorporated, they must vote to retain millage. To the extent that newly incorporated areas do not do this, funding for Jackson Memorial could be affected. Many respondents hope that the new mayor of Dade County will address this issue, but his approach to health care financing is not yet clear.