The TAP-IN Blog

The Subconscious Crisis of the Uninsured

Tap-In is trying to help find more doctors, nurses, PAs, NPs and dentists to staff free clinics. This dire need flies below the conscious radar of most Americans as they deal with what they've got on their own plates.

Unless you are uninsured, or have the prospect staring you in the face with a suspected layoff or failure of the business that employs you, you may not be aware of how ridiculously urgent the situation is becoming. Then again, maybe you've been uninsured before, or have gone bankrupt yourself from medical bills not covered by a health plan.

But if you're reading this blog, you're probably very much aware of the problem and how the economic crisis is adding fuel to the flames.

My scans of the news bring me stories like the following every day, and the curve is trending upward.

From Missouri: Study finds a third of state uninsured.

From North Carolina: Uninsured strain NC Free Clinics

From Georgia: Safety net health centers struggle to meet demand

Kansas City: Free clinics are flooded with new patients

Iowa Families Pack Free Health Clinics

Health Workforce Solutions Now Available on the Web

It's not only our free clinics that are understaffed these days. The entire health care system is seeing critical shortages of doctors, nurses and allied health care workers, all across the country.

The U.S. Department of Health and Human Services now provides a Web site called the Health Workforce Information Center (HWIC) where you can find "information on health workforce solutions in one centralized and easy-to-access online location."

Funded by the U.S. Department of Health and Human Services Health Resources and Services Administration and operated by the University of North Dakota (UND) School of Medicine and Health Sciences, the center will offer the latest on health workforce programs and funding sources; workforce data, research and policy; educational opportunities and models; and news and events, also available through e-mail updates.

Visitors will have a broad range of publications and other resources at their fingertips. The site also offers free, customized assistance from information specialists (digital librarians), who will search databases on workforce topics and funding resources, furnish relevant publications, and connect users to workforce experts and federal programs, among others.

“Many people in government and private and nonprofit organizations need access to the type of quickly assembled, user-friendly data the center will make available,” said Kristine Sande, HWIC deputy director at the UND School of Medicine and Health Sciences. “Accurate information on the health workforce will be vitally important in the ongoing health care debate, and we provide a way for individuals to get it from a single, trusted source.”

ERs are the New (Beleagured) Safety Net

In California, the wave of unemployed and uninsured is breaking on hospital emergency rooms, over-taxing staff and resources, and putting a dangerous load on hospital finances. The overload situation is having increasing impact on seniors.

When Dr. Tony Musielewicz walks through Dominican Hospital's emergency room, he muses that it often "looks like a nursing home."

But Musielewicz, the emergency department's medical director, doesn't mean that in a bad way. In fact, he's angry about the rising numbers of Medicare patients who are forced to rely on the ER or urgent care clinics to treat common problems that should be monitored by a primary care physician.

"One is too many if there is even one senior citizen who doesn't have access to a primary care physician," said Musielewicz, who has worked at Dominican for 10 years.

The problem: Fewer primary care doctors are opening practices in Santa Cruz County because of low reimbursement rates compared to counties over the hill. Those who have patient openings are likely to accept the privately insured over retirees bearing Medicare cards. Even seniors who have regular doctors sometimes are forced to wait weeks to get in.

Given all this, "We're the safety net for everyone," Musielewicz said.

* * *

At San Joaquin General's emergency room, Dr. Richard Buys has seen a marked increase in volume, while at the same time, hospital admissions from the ER have been flat.

That tells him that people who normally would have gone elsewhere for care, such as a physician's office or same-day clinic, are seeking out the ER because it does not require payment upfront.

"On a personal note, I've noticed more often that when I ask a patient if they need a note for school or work, the answer used to be 'yes' or 'no.' Now it's, 'I just lost my job.' The number of times I used to hear that was virtually nil. It puts a more human touch on what is going on, and they don't say it with a smile," Buys said.

* * *

Urgent care clinics also see a wave of seniors who can't get into their doctor or can't find one. The Santa Cruz Medical Foundation, which is part of the nonprofit Sutter Health network, has a freeze on all new Medicare patients who are not part of an HMO network, but will continue to see seniors in its urgent care areas.

Dr. Lawrence deGhetaldi, the foundation president, said urgent care doctors in his six clinics are seeing older patients for high blood pressure, diabetes and medication refills. But when the seniors seek ongoing general care, they are shut out because the clinic's primary care doctors are at capacity for Medicare patients.

And that is a shame, Musielewicz said.

"Our health care system is breaking," Musielewicz said. "The fact that the elderly have difficulty finding primary care is something the community, the county, the state and the nation have to work on as a whole."

Rationing Free Clinic Care

The Washington, D.C. area is one of the more affluent regions in America, yet the numbers of uninsured are swamping the capacity of networks of free clinics in suburban Virginia and Maryland.

Rising unemployment in the D.C. area has more and more uninsured people turning to free clinics to receive care.

One report shows about 54 percent of Americans who are unemployed are also uninsured. They often can't afford coverage and aren't eligible for Medicaid.

Unemployed, uninsured and unable to afford private care, the Arlington Free Clinic was Richard Templeton's only option.

"We're one of the folks that has to choose between food and medicine sometimes and that's what we've been doing lately," Templeton said.

* * *

People young and old crowd the hallway outside the locked door of the Arlington Free Clinic. They grip small pieces of paper that will determine whether they get in -- or give up and go home.

It's lottery day, and 45 county residents who lack health insurance and money to pay for medical care are competing for 30 openings on a cold afternoon in January.

Mary Gleason, a clinic volunteer, draws letters from a plastic box. Those holding matching letters will be ushered through the door for interviews. If they meet the clinic's criteria, they'll return in a couple of weeks to see doctors or other staff.

The lottery is just one example of the fate of the newly uninsured -- the growing numbers who once had jobs and insurance and now seek treatment with neither. Although most of the clinic's clients have low incomes, the nonprofit, privately funded operation and others like it in the region are seeing more people who used to be solidly middle-class. Victims of the deepening recession, they're now wondering where to turn for help.

Neither rich nor poor, this group doesn't readily qualify for public programs such as Medicaid but often can't afford to buy insurance or pay hospital, doctor and drug bills. The Democrats' economic stimulus package would significantly enhance options for the unemployed and their families through insurance subsidies and a possible expansion of Medicaid, a package that some experts say would ease the financial dilemma.

Reform and Crisis Management - There's a Big Difference

If tens of millions of Americans were becoming malnourished, would we wait on meeting their basic needs through years of discussion and argument about reform of the food system?

I would hope that we'd address the crisis immediately even if more permanent solutions would take a while to be agreed upon. In the case of health care, we know of the existing crisis, but there's very little action being taken towards mitigating it. People are suffering and dying invisibly.

I've just been reading the latest articles posted on the Cover the Uninsured website. Of course, we are in total agreement that a great country like America should have no uninsured residents, and that the government should be urged to devise a program to make that a reality. That's important for economic as well as social and cultural reasons. The approach taken by Cover the Uninsured - a project of the Robert Wood Johnson Foundation - is one of raising awareness without directly advocating that services be provided immediately to the 46 million Americans living without coverage.

Clearly, health care reform is needed, but even with reform millions are likely to remain without options for treatment. We are in a crisis where ill people are dying, hospitals are becoming insolvent and fewer doctors are treating ever more patients. Our health care system is collapsing and the only stopgap alternatives for the working poor are the free clinics staffed by volunteers who are, themselves, working over capacity. Reinforcements are needed now.

Aside from the occasional articles lauding the volunteerism that keeps these clinics operating or announcing the opening of new clinics or describing the financial challenges facing existing clinics, there is precious little explanation or discussion of how crucial these services are in caring for our neighbors in need while taking the load off of hospital emergency rooms.

The collapsing global economy is only adding to the crisis as more people lose jobs and health insurance. And even those with coverage are putting off treatment to avoid rising copayments deductibles. Tap-In is about finding more volunteers for free clinics - our finger in the dike - to preserve alternative resources for the uninsured until the day when comprehensive reform has taken place. What we learn through staffing and operating free clinics will be useful in the design of new health care institutions for America.

We know there are tens of thousands of retired health care professionals and many more who are considering retirement. We also know that many of you retired or retiring doctors, nurses, social workers, PAs and NPs have gained most of your professional satisfaction from treating patients - not from doing the business of running a medical practice. We say to you that there's a current and critical need for your expertise, experience and compassion. Tap-In is one route for your connection to the free clinics that need your services during this worsening health care crisis.

Crisis in Staffing for California Clinics

Reflecting the worsening situation across most of the nation, California is running up against the reality of a growing number of uninsured people and a shrinking number of people available to serve their medical needs. What is left of the safety net is being strained to its limits.

California's nonprofit community medical clinics - a critical link in the maze of safety net health care providers - are having a difficult time hiring and retaining skilled health care workers.

The problems are stressing clinics' resources and staffs when patient loads are growing due to rising unemployment and fewer people with adequate insurance.

Findings from a new statewide survey of community clinics - funded through a grant from the California Wellness Foundation - show that more than eight in 10 reported challenges involve keeping health positions filled with qualified, trained personnel. Positions such as licensed vocational nurses, dental assistants and case managers are among the hardest to keep staffed.

“Volunteers are not paid; not because they are worthless, but because they are priceless.”

So reads a sign in the break room of the Arthur Nagel Community Clinic in Bandera, Texas.

The clinic makes preventive and primary care available to Bandera County residents at no cost or low cost – depending on family income – to those who are uninsured. Chronic conditions, such as diabetes, high blood pressure, obesity and depression are all dealt with through Risk Busters, the clinic’s preventive healthcare program.

The Nagel Clinic fills a definite need in our county as evidenced by the fact that:

• There is no hospital or emergency care facility in Bandera County – a county with a population of more than 20,000.

• A report by the Texas Department of State Health Services indicated that there were 9,488 residents per direct-care physician in Bandera County. Statewide, there are 661 people per physician.

• The county has been designated a Medically Underserved Area since 1978.

• Those without insurance – estimated to be one in four Bandera residents – often do not seek medical care until they are seriously ill and must call the EMS for transport to emergency care in another county.

You may ask how a private not-for-profit clinic can operate in today’s high-cost medical marketplace without charging the outrageous fees characteristic of our nation’s for-profit health insurance system.

Make a visit to the Arthur Nagel Community Clinic on the campus of Helping Hand in downtown Bandera and you will find the answer in a single word: volunteerism. There is a sign in the coffee break room that reflects the operating philosophy: “Volunteers are not paid; not because they are worthless, but because they are priceless.”

Volunteers raised the money to build and operate the clinic. Pat Breedlove and his “Fun Raising” Committee raised $127,000 in Bandera County for the clinic’s first year of operation.

The clinic is operated by three employees and a volunteer staff of 20, half of whom are medical professionals. Here are some examples of just a few of the dedicated volunteers:

• Medical Director Saleh Jaafar, M.D., reviews patients’ charts. He takes time away from his own family practice to serve the Community Clinic without compensation.

• Cheryl Finch manages the Prescription Assistance Program and works two 10-hour days every week to make sure clinic patients have the medications they need.

• Donna Graham works long hours as a receptionist volunteers her time.

Our community clinic also benefits from volunteerism on a state and national level. As a member of the National Association of Free Clinics and the Lone Star Association of Charitable Clinics, the Nagel Clinic receives free equipment and free and low-cost medications. Both are nonprofit corporations, run entirely by unpaid volunteers who work with pharmaceutical companies to provide free and low-cost prescriptions to patients who otherwise would go without.

Hundreds of Bandera County volunteers are working right now to raise money to help pay the clinic’s 2009 operating costs. Some are selling tickets to the Jan. 24 and 25 stage production of “Always…Patsy Cline.” Others are signing up to compete in the February Stationary Marathon, hosted by Comprehensive Physical Therapy & Bandera Fitness. Every committee member and every donor is a clinic volunteer and part of the clinic’s healthcare team.

Virginia Clinics Setting Higher Standards

The Virginia Association of Free Clinics has an accreditation program that requires a review. Three clinics have recently been accredited, as described in this article in the AARP Bulletin.

With the rapid rise in the number of people seeking care through free clinics, it became clear that a set of standards for operation could help clinics scale their services to meet that demand.

Lackey Free Clinic in York County, the Gloucester-Mathews Free Clinic in Hayes and the American Red Cross Dental Clinic in Norfolk are the first in the state to be accredited.

The accreditation program is designed to help clinics improve operations, thus allowing more time to be devoted to patients, the association said in a news release.

Lackey was the first to be reviewed, said Jim Shaw, medical director.

"What we're trying to do is set a high standard for all the free clinics in the state, so that we'll all operate on somewhat similar criteria," Shaw said.

"What it means for the patient is that if they walk into Lackey or any other clinic that's accredited, they'll have a high standard of record-keeping, a high standard of employee or volunteer credentialing -- just like you would if you walked into a hospital because hospitals have accreditation systems."

Kay Bradley, executive director of the Gloucester-Mathews Free Clinic, said the accreditation was an assurance to patients that they were getting top-quality service.

"The accreditation process has been a wonderful planning tool for the board and management to help us focus on areas of system improvement," she said.

"We plan to utilize this tool to continue upgrading our program, so that we can stay on the cutting edge of service delivery to our patients."

Increase in Community Health Centers - What about Free Clinics?

The NY Times ran an article about the increase in funding for community health centers - Expansion of Clinics Shapes a Bush Legacy

An interesting article, but one major piece missing is the impact of free clinics, with the model of locally-run, volunteer-based services to the uninsured.  The article does talk about the fact that, growth of health centers or not, there still is a shortage of primary care physicians that has to be solved.  That's where the TAP-IN model of re-engaging retired health care professionals via volunteering at free clinics comes in...

The other misconception is that, because these health centers take Medicare, all is well because Medicare takes care of everyone.  Fact is, Medicare covers but a small fraction of the uninsured, and is very limiting.  Just sorting through the rules of who is eligible can be daunting.

That's why we at TAP-IN believe working with free clinics and local communities, with the help of volunteer physicians, is the right approach.  While indeed one may accuse free clinics and other safety net providers of being a 'bandaid' and not the solution, until others smarter than me figure out the solution, the free clinics and others will continue on, TODAY, helping the uninsured.  Probably a wise move not to wait on the solution, since we've been hearing talk of solving this for well over 30 years now...

Retail Clinics - Are They a Solution to the Problems of the Uninsured?

Is there a convenient alternative to free clinics just down the block from where you live?

You may have seen them, or you may be making use of them. Retail clinics that take drop-in patients in drug stores and Wal-Marts were touted as an answer to the lack of affordable health care services for the uninsured and under-insured, but a recent study challenges the belief that they are filling those gaps.

As reported in the Wall Street Journal:

Despite the Hype, Patients’ Use of Retail Clinics Is ‘Modest’

The number of patients who’ve tried out retail clinics turns out to be modest, but that’s shouldn’t be all that surprising, some health wonks say.

The clinics are still young, and while they’ve spread rapidly (and then slowed down), they’re still not everywhere, note the authors of a study from the Center for Studying Health System Change.

Only 3.4 million American families, or 2.3%, had used a retail clinic as of 2007, according to survey results. More highlights:

• Among families that used retail clinics in the past year, 27% had at least one member who was uninsured.
• Families who’d said they’d either not gotten or had delays getting needed care over the past year were nearly 2.5 times as likely to have used retail clinics as families without such problems.
• Families with respondents age 18 to 34 were more than twice as likely as families with respondents aged 50 to 64 to have used a retail clinic.
• 48% of consumers using retail clinics said they’d done so for diagnosis and treatment of a new illness or symptom, and 47% said their visit had included a prescription renewal.

The study’s authors noted that retail clinics have turned out to be more complex and costly to operate than expected, and some doctors in traditional physician practices are responding by extending their own office hours and doing more same-day scheduling.

Another recent study of patients who visited retail clinics in chains that included Wal-Mart, CVS and Walgreen found roughly 90% of patients had one of 10 relatively simple treatments. The Top 10 list included ear infections, upper respiratory infections, immunizations and blood pressure checks. Insurance paid for 67% of visits. And most patients said they didn’t have a primary care provider.