Sunday, January 11, 2009

Health Care for the Underserved

I've always been a well-meaning kind of guy. Hey, Jewish doctor, son of 30's Commies, from Philadelphia by way of Harvard, what would you expect? My father always targeted me to public health, motivated by a concoction of intentions. His own history mainly, I think. As an ambitious Jew in America he craved acceptance and prestige. It wasn't enough for him to be a successful neurosurgeon, because he wasn't a professor at Penn. He worked hard as a private practitioner in a working class hospital. His friends from med school had gone into public health and he envied their status, even if he made more money. He resented academics because he thought they "had it easy." He also competed with his younger friend Paul Korshin, a professor of English at Penn, because to be a cultured person, my dad said he had to know not only science and his profession, but everything a professor knew culturally as well. It must have been tough to compete all the time.

Anyway, his own complexity and that of my mother must have led to a lot of complexity of my own, as I sought to fulfill their own ambitions and to compete with them in the fields of unexpressed but well indicated ambition. "That's Phil Klein's house. It's beautiful, and he got it for a song." So now I have a beautiful beach house that we made money on the moment it was done. That's just the way we are.

So, health care for the underserved, as we euphemistically call them. When I was a younger doctor avoiding the draft in the Public Health Service, and doing what I wanted to do anyway, which was to work in government and run programs, I followed my mentors and believed in community health clinics. Not the old-fashioned clinics which didn't have any class or pizzazz to them. My Dad worked for a short time at the clinic run by a labor union in Philadelphia and then quit, saiying, I remember, they treat me like shit. Fuck them. OTD (out the door). Not that, but the new clinics with "community participation" or "community direction," figuring that this "redistribution of power" would unleash the power of the people and stop oppression. Lotsa luck, but this is what we were thinking about. The advanced text was Saul Alinsky. I would ask as we were urged to construct some funded by the PHS, in imitation of the Office of Economic Opportunity, I would say, Where is an example of one that is working. There were vague responses. But this was the late 60's.

So, I learned about these clinics and I learned about administration in the PHS and how things get done in organizations and how right people are when they point to the many many jobs that are taken by people in the bureaucracy that are worth nothing at all. And I came to be charged at the age of 28 with administration of the Migrant Health Program, with 8 million dollars of grants that then swelled unexpectedly under the Nixon administration to $14 million, I think, and there I was in charge, especially when John Frankel, DDS, who was supposed to mentor me had a heart attack. We wound up programming all the new money into health centers, not just giving it out to county health departments in rural areas, the way that they had done before.

So, that's background. (I can indulge myself in going on like this, I figure, since I'm sure there will be so few readers of this - a weak excuse perhaps, but why not?) Now, I've had nearly 30 years of experience building a private practice in the East Bay, where we have about 25% Medi-cal patients. We have lots of clinics in the East Bay around us. These Federally Qualified Health Centers get about 3 times what we get for each visit, because they get extra funds from the government who make up the Medi-cal payments to "cover the costs" of the clinics. Talk about an uneven playing field. So here I am, a veteran of the clinic movement who now operates on the other side.

So I see the government acting under the assumption that care for the underserved comes from clinics - which in our area it doesn't. It's a true statistic -- 2/3 of the kids on Medi-cal in Alameda County are served by our private practices. The patients get to choose, and this is where they go. Yet the government figures, let's make sure we give care to the poor - that means poverty clinics, right? So Bush gives more money for community clinics, and what will Obama do?

Here's what I say on our American Academy of Pediatrics listserve for SOAPM (Section on Administration and Practice Management):

In reading the sketchy information available about what Obama will do for health, I'm wondering how the eventual balance will come out between paying for the underserved to see us in our office, and paying more for community health centers.

In my past I was an advocate for community health centers, and I still think they often fill a vital role in areas that private practitioners will not easily go. Some inner cities, for instance, and rural areas such as the Rio Grande Valley where I personally was responsible for initiating several health centers in a former life.

On the other hand, Medicaid sought to guarantee equal access to quality health care for the underserved, and in areas such as where I practice at present, as I have mentioned before, 2/3 of poor patients choose to be served by private practitioners. So, while it would make sense I would think to set up and fully fund more clinics where they were needed, in areas such as ours, it would not make as much sense. (Obviously, these are competitors of me and my private practice colleagues - full disclosure.) In fact, what happens in our area is simply that the clinics are paid 2-3 times as much per visit as we are.

[Also, there is an interesting article in last month's Pediatrics, which asks the question, why are so many "community" referrals not completed by the patients? The not surprising answer - the "community services" are degrading, the patients are treated in a patronizing fashion, etc. So they don't go. So much for socialism, Russell.]

So what comes to mind is the same one that everyone is asking about the rush to inject funds into the economy by the government (which I fully support) -- how smart will the injection of funds be? How much will go to make Medicaid a real option for the poor, by making "coverage" equal "access," by bringing rates of pay up? Or how much will "coverage" not equal "access," but instead go wasted on bureaucracy, and in this case, be flung ideologically to stick on health centers that really should concentrate on being more competitive, rather than bureaucratically successful at garnering funds?

So, that's today's post.

Budd Shenkin
(written from Makena, Hawaii)

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