Wednesday, April 1, 2009

Community Health Centers & County Clinics

I have posted before about Community Health Clinics, and my serious reservations about them. Yesterday I interviewed an applicant for our currently-vacant Administrator post and was sardonically amused to hear what he had to say.

This very nice man had been CEO of two clinics that were Federally Qualified Health Centers. He told me about their financing. I was especially interested to hear about one of them, a network of seven clinics located around Fresno, with headquarters in Parlier. I asked him if one of the clinics was in Orange Cove. He said yes, as a matter of fact, that was the original clinic, set up in 1970. I said yes, I know about that - because I was the one who started it!

Actually, at that time I was a Medical Officer in the US Public Health Service, and was acting as head of the Migrant Health Program nationwide. We had received surprise extra funding from the Nixon Adminstration - no one precisely knew why, but we guessed it was some sort of idea to woo the Hispanic population, but that was just a guess. So with just a few months to go we had to program the extra money quickly. We had determined that instead of using the old style of grants, we would program the new money in the style of the then-new Neighborhood Health Centers, but in rural areas. These were the forerunners of the current CHC's.

Anyway, we had to act fast to program the money, so we identified people to go to known areas of migrant concentration that had the possibility of administering a freestanding clinic. And we demanded that the governing board of the clinic be composed o a majority of users of the clinic - maximum feasible participation of the population to be served. We didn't know who to go to in the Central Valley, so I made one trip there with a consultant, Wendy Brooks, and determined that Orange Cove had possibilities. Then I took a week and wrote the grant with Wendy, consulting with a community organizer there named Bobby Russell. Then I took the grant back to headquarters and I approved the grant I had written. Voila! Money flowed to Orange Cove.

Part of the reasoning about doing a clinic this way was that on top of providing services, it would promote community organization, leaders would emerge, and the whole community would be lifted up. That was the theory. Some of it probably worked.

Now at this interview I was hearing about what had happened in a snapshot taken 39 years later. My interviewee observed that what we have observed about CHC's locally in Oakland holds true both down in Fresno, and in his second CHC in Half Moon Bay. He said that the government funding resulted in his clinics receiving about $140 per visit (exclusive of vaccines, etc.) He said that the FQHC's in a neighboring county were getting over $400 per visit. He said that money was really plentiful - construction, etc., was no problem. We get about $50 per visit in private practice.

The problems the clinics faced? One, the requirement that the clinics have community/recipient majority on the Board. This former CEO said that after a while his clinics became essentially ungovernable. I was not surprised but very saddened to hear this, since years ago I was an enthusiastic proponent of this sort of governance. As I say, there might well have been many positive results of community involvement; many leaders may have been produced, etc. But from a strictly medical point of view, it is discouraging. I know about these dysfunctional boards where everyone is out for himself, looking to move up, etc. Representing the good of the people - that's what made Cesar Chavez great. And unusual, unfortunately.

Another problem - the doctors. By another coincidence, the Half Moon Bay clinic happened to employ a family practitioner who had to leave our group because he couldn't relate to patients, and wound up seeing only patients of other clinicians who wanted urgent visits and so got him for that visit. But they were not attracted and thus never came back to him as their regular doctor. At least not much. The ex-CEO said that this doctor appeared competent (he is), punctual, and his records were good. The fact that he has great difficulties relating to patients had escaped notice. Not a big issue at the clinics. What a shame.

Another problem doctor was a surfer. When the surf was up, he would simply cancel his patients for that day and go surfing. He has since resurfaced (!) as an urgent care physician.

Unfortunately, the Half Moon Bay CHC has just gone bankrupt. The ex-CEO warned them, even consulting a bankruptcy attorney in November. But now here in March bankruptcy came as an apparent surprise to the Board. Perhaps another symptom of Other People's Money.

[By the way, I posted previously about OPM. But I forgot to mention that I heard the great economist Milton Friedman on the radio being asked, after a lifetime of work, if he could sum up his economic philosophy simply, what would he say? He responded: People don't treat Other People's Money the way they treat their own. Talk about pregnant observations!]

And here's more of the story. The Half Moon Bay clinic, before bankruptcy, became part of the county health clinic network o San Mateo County. So in the process of joining the two sides compared productivity. The CHC's goal was to have its docs see 20-22 patients per day. The county was horrified. How many patients per day did its docs see? About 8 patients per day. And these docs were well paid, more than competitive with the starting salaries of private docs in the area.

Let's now tie this to the national situation. I support Obama and I support the stimulus package as necessary. I agree with Keynes - in tough times when each individual acts rationally to save money, the government must provide demand. And in our current situation, much of the stimulus money will go to state and local governments. We hear that the effect will be that teachers and police will not have to be laid off. But what about the clinics? Think there is a chance that the county will look at the clinics and say, we need to boost productivity? I'd say there is no chance in hell that this will happen. In tough times, companies are supposed to get lean and mean. To stay competitive they need to become more efficient, more productive, produce goods and services for less. In tough times, however, governments get mean but not lean. I remember the passage of Prop 13. Governments, pissed off, said they would have to decrease the number of fire stations, lengthen response times, and do all they could to -- avoid layoffs!

It's enough to make a strong man weep.

Budd Shenkin

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