Clinics and the Weight of the Wait

In a post yesterday from Professor John V. Jacobi, he pointed out that “Uninsurance kills people, and extending coverage to all is critical.” A recent AP article, “Free Clinics Hit with More Patients, Less Funding ” is worth a quick read:

Like countless others stripped of health insurance because of the recession, Anderson and his family were forced to turn to a free health clinic. In all, about 4 million Americans are expected to visit the nation’s 1,200 free health clinics this year - a surge that comes as clinics face a drop-off in financial support.

“Over the last year, free clinics have seen patient load increase by 40 to 50 percent,” said Nicole D. Lamoureux, executive director of the National Association of Free Clinics. “People who just last year had health coverage are now out of work and need to have their health care needs met.”

And there is perhaps one aspect of the situation which the article does not address that is worth noting. With increase in volume and decrease in resources, wait times must mount. Wait time for the working poor can be onerous. Obviously, a long wait is a long wait for anyone, but if one is out of work the time element is not as pressing as it would be for one who is employed.

I had occasion recently to accompany someone to what will remain an unnamed sliding scale clinic in Elizabeth, N.J. She lacked transportation. The place was mobbed and although we had a 12 noon appointment, it took a full 3 and a half hours and then some to make it out of the waiting room,  and then another 45 minutes to an hour to be seen, examined and treated by a doctor. After paying the bill, I was lucky to get my companion to her  poorly paid no benefits job on time at 5pm. That job, difficult as it was to find in this economy, is pretty much all that stands between her and destitution. It is not a good job, but it is better than nothing. In speaking with the office manager/nurse, I was told that the wait time was, unfortunately, give or take “normal.” That funding was scarce and volume as high as it has ever been.

When it’s truly difficult to make ends meet, to find 4 or 5 hours to commit to a doctor  visit, as opposed to hustling the dollars one needs to squeak by, can be  hard. Arduous as the wait can be, it makes it that much easier to postpone the visit. And lest we forget for whom the bell tolls, if she postponed that visit to her ultimate detriment and wound up uninsured in an emergency room–the cost of care (falling, ultimately as it would, upon the public) would have been extreme by comparison: in health care, the old adage “a stitch in time saves nine” can sometimes seem modest. In addition, there is a national cost in lost productivity to consider. Earlier this year I wrote the following in regard to lost productivity through illness:

Having just returned from my family physician (who stayed open past hours to see me), perhaps you will forgive me if, not feeling well myself, I dwell for a moment upon the cost of illness and inefficiency. Not as a matter of out of pocket cost, per se, but as a matter of macroeconomic cost–a roughshod (I am sick) calculus based upon diminished productivity and national opportunity cost: simply put, if I am busy being sick, I may well have to forego the productivity of work–or I may perform that work at a lesser level ( I suppose this post will tell).

For the working poor, with very little buffer to sustain them, sickness can easily amount to a calculus of ruin.

Seton Hall Regent Donna M. O’Brien Honored with NIH Director’s Award

[Ed. note: Today's post was culled from Seton Hall University News and was written by Jill Mathews]

Seton Hall University Board of Regent member Donna M. O’Brien, President of Community Healthcare Strategies, LLC, has been selected to receive the National Institutes of Health (NIH) Director’s Award. This award is being presented in recognition of Ms. O’Brien’s work in developing The National Cancer Institute’s (NCI) Community Cancer Centers Program (NCCCP). She will receive her award during a presentation on July 29th in Bethesda, Maryland.

The National Cancer Institute (NCI), the largest institute of the National Institutes of Health, leads the nation’s research efforts to discover better ways to prevent, diagnose and treat cancer. In 2007, NCI launched NCCCP as a three-year pilot program to extend the reach of NCI’s cancer research into more U.S. states, cities and towns, including rural areas and inner cities. The NCCCP program has 16 community hospital cancer centers in 14 states representing a cross-section of this country’s population and its health care organizations — with a special focus on reaching minority and underserved patients. The NCCCP program sites serve 27,000 cancer patients each year. Plans are underway to expand the program.

The NCCCP program is creating a platform in the healthcare delivery system for personalized medicine and developing a national electronically-linked network which will collect high quality biospecimens and patient data to support molecular medicine and the work of the Cancer Genome Atlas. The overarching goal is to bring science, early-phase clinical research, and evidence-based therapies to people in their home communities.

Ms. O’Brien currently coordinates healthcare projects in several locations across the U.S. Her prior experience includes serving as Executive Vice President of Catholic Health Services of Long Island, Associate Director of the Alliance for Catholic Health and Human Services in New York City, and as Assistant Administrator for Hospital Administration at the University of Texas M.D. Anderson Cancer Center. She was a Member of the New York State Governor’s Commission to Restructure Healthcare Facilities for the Twenty-first Century and currently serves on the Board of Regents for Seton Hall University and on the Board of Directors of the Flushing Savings Bank.

Ms. O’Brien is a graduate of the College of the Holy Cross and she has her Masters of Health Administration from St Louis University. She is a Fellow in the American College of Healthcare Executives.

Nurse Practitioners and the Allocation of Resources

In my last post, I made a rather conclusory (and parenthetical) statement regarding the utilization of nurse practitioners in retail health clinics. I wrote:

Retail health clinics have sprouted up across America as of late. They can be found in grocery stores and pharmacies, are open nights and weekends, often (wisely) utilize the services of nurse practitioners for minor ailments and feature a clearly listed schedule of fees.

Today I’ll clarify. The view espoused is largely based upon simple resource allocation theory: that one utilizes resources effectively by matching the need with the skill; that to underutilize is to engage in waste, and, given demand and a shortage of doctors, when a physician is attending to minor ailments, and charging physician rates to do so, society has experienced a net loss.

The trick of course is in a) making sure that there is a sufficient supply of well trained nurses (you may wish to take a look at this interesting RWJF blog from Susan Hasmiller, “projected shortage of 500,000 nurses by 2020,” despite the present difficulty of some nurses to find work ); and b) assuring that the need of the client is matched with the appropriate level of skill: that the service provider is capable.

According to the Mayo Clinic, “NPs are registered nurses (RNs) who are prepared, through advanced education and clinical training, to provide preventive and acute health-care services to individuals of all ages. Today, most NPs complete graduate-level education that leads to a master’s degree. They work independently and collaboratively on the health-care team.”

As to the capability of nurse practitioners, this quote (n. 14) from William M. Sage, Out of the Box: The Future of Retail Medical Clinics, Harvard Law And Policy Review Online (2009), is worth noting:

Debate over the relative merits of primary care from nurse practitioners and from physicians is purely rhetorical. A review of 11 trials and 23 observational studies in primary care settings concluded that “[q]uality of care was in some ways better for nurse practitioner consultations.” Sue Horrocks et al., Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors, 324 BRIT. MED. J. 819, 819 (2002). See also Linda H. Aiken, Achieving an Interdisciplinary Workforce in Health Care, 348 NEW ENG. J. MED. 164 (2003) (editorial describing the quality of non-physician professionals); Mary O. Mundiger et al., Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial, 283 JAMA 59 (2000) (demonstrating equivalent outcomes).

Location. Location. Location. 13% of Much Heralded Retail Health Clinics are in Medically Underserved Neighborhoods

Retail health clinics have sprouted up across America as of late. They can be found in grocery stores and pharmacies, are open nights and weekends, often (wisely) utilize the services of nurse practitioners for minor ailments and feature a clearly listed schedule of fees. According to the Washington Times, “visits typically cost $40 to $75,” and “people pay cash or use insurance.”

CVS Caremark Corp. and Walgreens Co. are the leading purveyors of retail clinics. At present, there are said to be more than 1200 of these clinics spread out across the nation; at issue here is how they are spread.

A new study authored by Dr. Craig Pollack of the University of Pennsylvania which was published in the Archives of Internal Medicine shows that a little more than 13% (123) of the 930 retail clinics operating last year were found to be “in areas defined by the federal government as medically underserved.”

The Washington Times states:

The researchers mapped 930 retail clinics operating last year, then used U.S. census data to describe the income and racial makeup of the neighborhoods. In counties with at least one retail clinic, the researchers compared census tracts with and without retail clinics.

Only 123 clinics were in areas defined by the federal government as medically underserved. Tracts with clinics had lower percentages of black and Hispanic residents, lower rates of poverty, higher rates of homeownership and higher median incomes.

The Washington Times reported that Dr. Pollack said that “The study’s results suggest financial incentives may be needed to lure the clinics to low-income neighborhoods.”

There are, I think, a few points to be derived form this article. First things first: the Washington Times article headline to the Associated Press story, “Few retail clinics found serving poor,” is an inference not necessarily substantiated by the underlying research. The research goes to the location of the clinics, not the economic status of the clientele. Importantly, other news outlets which ran the story, such as the Seattle Times, the Times Leader, and the A.P itself,  were careful to run the story under the title of “Study: Few retail clinics in poor neighborhoods.” It may well be that poor people do not frequent the retail clinics outside the neighborhoods in which they live, but the study does not purport to answer that question. It merely tells us where the centers are. The article states:

The poor and uninsured do make their way to retail clinics, said Margaret Laws, director of the California Healthcare Foundation’s Innovations for the Underserved program.

“People go out of their neighborhoods to work and shop,” she said. “I don’t think we should make the assumption that they won’t go out of neighborhoods to seek health care if it offers customer service, better hours and transparent prices.”

Ms. Laws makes a point worth noting, and although the Washington Times included this point in the article, it is unfortunate from a journalistic standpoint that the article’s title failed to reflect it.

In addition, it should be noted that another impetus for travel outside of one’s neighborhood is free health care. Which is exactly what Walgreens has offered to many this year. As we posted last month

Walgreens is offering free health care at its in-store Take Care clinics to patients (and their uninsured children and spouses) who have lost their jobs.  This program, called the Take Care Clinic Take Care Recovery Plan, is designed to assist current and future patients who lose their jobs and health coverage on or after March 31, 2009.

Limited as the program self-admittedly is, it is free. It is also worth mentioning that as a for profit enterprise, Walgreens is under no obligation besides their sense of good will to offer it. But as a for profit enterprise, they (and other retail clinics) can hardly be faulted for placing the majority of their clinics in areas they deem will be profitable. At the risk of beating a dead horse (primarily because I am met constantly by those who insist the horse is not dead and that we will soon be riding it to health reform and universal coverage ) a reliance upon for profit corporate America to undertake the unprofitable without government regulation and/or sponsorship is a misguided one. The primary duty of a corporation is to its shareholders; the primary duty of the government is to its people.

“Many people have promoted retail clinics as a cure for access to care for the underserved,” said Dr. Ateev Mehrotra of the University of Pittsburgh, who studies retail clinics but wasn’t involved in the new research. “These findings show that’s unlikely to happen.”

Dr. Pollock and his co-author, Dr. Katrina Armstrong, suggest that to further expand the reach of retail clinics “municipalities should consider offering incentives to store operators to open clinics in underserved areas where they already operate retail outlets. Currently, nearly a third of all chain stores are located in medically underserved areas.”

“There may be a real opportunity to put up clinics in underserved areas where there’s already supermarkets and drug stores” Armstrong says.

New Mammography Van Unveiled in Newark, NJ

The City of Newark, NJ, the University of Medicine and Dentistry of New Jersey (UMDNJ), and the Susan G. Komen for the Cure North Jersey recently unveiled a new and expanded Mobile Mammography Van, aptly called “Mammography in Motion.”  According to UMDNJ, “The Mammography in Motion mobile van provides access to screening mammograms, clinical breast exams and educational information for uninsured and underinsured residents in Newark and other northern New Jersey communities.”

As I reported earlier, studies have indicated that uninsured women are diagnosed with larger tumors and at later stages than otherwise similar, but insured women. The cause of this later and larger diagnosis may be attributable, in part, to a lack of mammography providers — an indication of just how critical the van is to the Newark community.

The new van was funded through the North Jersey Affiliate of Susan G. Komen for the Cure and is markedly more advanced and comfortable than its predecessor, which was a retro-fitted recreational vehicle that provide analog, as opposed to digital, mammography.  The van is a part of the New Jersey CEED (Cancer Education and Early Detection) S.A.V.E. (Screening Access of Value to Essex) Women and Men Project.  According to Catherine Marcial, Project Coordinator for S.A.V.E. Women, the new van is bigger and more pleasant.  It now has an exam room, changing room, reception area and all updated equipment.   She also pointed out that providers on the van — a physician or physician assistant and a mammography technician from UMDNJ — offer pelvic exams, PAP Smears (cervical cancer screenings) and recommend colorectal cancer screenings when warranted.  Deborah Q. Belfatto, Komen North Jersey Affiliate co-founder and executive director, commented that, “The Mammography in Motion program will provide state-of-the-art breast health screening services for women right in their own neighborhoods.  This is a giant step in addressing access to care for all women, especially those with no readily available resources.”  This is especially true given the prediction that the demand for mammography, and other outpatient diagnostic imaging, is expected to increase by double digits over the next three years.  Further, there is strong evidence that the provision of cancer education and screening programs serves to significantly reduce cancer rates in Newark, as was evidenced by a study on cervical cancer in the city.  This study found that “the ratio of in situ to invasive cervical cancer increased and decreased in a striking parallel with the provision and subsequent cessation of funding.”

Finally, it should be noted that cancer screenings are only the beginning of the battle for improving cancer outcomes for the un- and underinsured, Read more

Quality of Care Differences by Insurance Status at Community Health Centers

On the heels of President Obama’s announcement designating $155 million to establish 126 new community health centers across the country, a study recently published in the American Journal of Public Health found that these centers do not provide the same quality of care to all their patients.  These centers, also known as Federally Qualified Health Centers or safety net providers, are intended to “enhance the provision of primary care services in underserved urban and rural communities.”  Unfortunately, studies appear to indicate that even within the confines of the same community health centers, quality of care received by patients varies depending on insurance status — those with private insurance receiving the best quality of care and those without insurance at the opposite end of the spectrum.

In their article, Insurance Status and Quality of Diabetes Care in Community Health Centers, Zhang et al. found that uninsured patients were the least likely to satisfy specified diabetes quality of care measures and Medicaid patients’ quality of care closely resembled that of the uninsured.  It might be tempting to explain away this phenomenon by pointing out that this study is limited only to diabetes care and may not be representative of quality of care overall.  This assertion, however, may be at least somewhat quelled by a study published last year in Inquiry, where Bradley et al. found a similar pattern in breast cancer patients treated in a safety net setting.  In that study, Differences in Breast Cancer Diagnosis and Treatment:  Experiences of Insured and Uninsured Women in a Safety-Net Setting, researchers found that within the same safety net setting, “insured women with breast cancer were diagnosed with smaller tumors and at earlier disease stages, and received surgery and initiated chemotherapy considerably faster than otherwise similar uninsured women.”

So, how could quality of care disparities exist in a safety-net setting whose very goal is to “enhance” care to the underserved?  Read more

Clinic Expansion Under Bush Thought Likely to Continue Under Obama

The NY Times reports that “President Bush leaves office with a health care legacy in bricks and mortar: he has doubled federal financing for community health centers, enabling the creation or expansion of 1,297 clinics in medically underserved areas.”
The article notes that:

“As a crucial component of the health safety net, they [community health centers] are lauded as a cost-effective alternative to hospital emergency rooms, where the uninsured and underinsured often seek care,”

and that

“Studies have generally shown that the health centers — which must be governed by patient-dominated boards — are effective at reducing racial and ethnic disparities in medical treatment and save substantial sums by keeping patients out of hospitals. Their trade association estimates that they save the health care system $17.6 billion a year, and that an equivalent amount could be saved if avoidable emergency room visits were diverted to clinics.”

As an example, the Times article cited Nashville’s United Neighborhood Health Services, a recipient of increased funding which has expanded more than two-fold in the last 8 years. The Times notes that “One of the group’s recent grants helped open the Southside Family Clinic, which moved last year from a pair of public housing apartments to a gleaming new building on a once derelict corner.” A 68 year old patient of that clinic who had just received breathing treatments, “said she would have sought care for her bronchitis in a hospital emergency room were it not for the new clinic. Instead, she took a short drive, waited 15 minutes without an appointment and left without paying a dime; the clinic would bill her later for her Medicare co-payment of $18.88.”

The article also states that “Despite the clinics’ unprecedented growth, wide swaths of the country remain without access to affordable primary care. The recession has only magnified the need as hundreds of thousands of Americans have lost their employer-sponsored health insurance along with their jobs.”

Widespread Support for Community Health Centers
The Times notes that “In response, Democrats on Capitol Hill are proposing even more significant increases, making the centers a likely feature of any health care deal struck by Congress and the Obama administration.”

In August, President-elect Obama sponsored a bill in the Senate “that would quadruple federal spending on the program - to $8 billion from $2.1 billion — and increase incentives for medical students to choose primary care. His wife, Michelle, worked closely with health centers in Chicago as vice president for community and external relations at the University of Chicago Medical Center.”

In his recent book on health care reform, HHS secretary Tom Daschle referred to the health centers as “godsends.” The Times article also notes that the federal program “was first championed by Senator Edward M. Kennedy” and “has earned considerable bipartisan support.”

Physician Compensation, Subsidies and Service Requirements
The article notes that with United Neighborhood Health Services starting pay for doctors is $120,000. “Because of a nationwide shortage of primary care physicians, the clinics rely on federal programs like the National Health Service Corps that entice medical students with grants and loan write-offs in exchange for agreements to practice as generalists in underserved areas. Of the 16 doctors working for United Neighborhood, seven are current or former participants.”

Follow-up Care Lacking
Although widely lauded as a viable solution to Primary Care medical delivery, the article notes that follow-up for more serious conditions can be problematic.

“A deeper frustration for health centers concerns their difficulty in securing follow-up appointments with specialists for patients who are uninsured or have Medicaid. All too often, said Ms. Bufwack [Chief Executive, United Neighborhood Health Services], medical care ends at the clinic door, reinforcing the need to expand both primary care and health insurance coverage. ‘That’s when our doctors feel they’re practicing third world medicine,’ she said. ‘You will die if you have cancer or a heart condition or bad asthma or horrible diabetes. If you need a specialist and specialty tests and specialty meds and specialty surgery, those things are totally out of your reach.’”
Read full NYT article here. Read WSJ Health Blog report here.