Grassroots Medicine for the community -- the Just Healthcare Clinic

"People have such simple needs, yet we have such a complex system that benefits the insurance companies, the docs, the drug companies and HMOs. Our health care in this country is irrational. We need a rational system that offers affordable access for primary care."

That's a quote by Dr. Andru Ziwasimon, co-host of this blog, from an article in the Alibi, an Albuqerque, New Mexico weekly. Back in December (yes, finally posting on it now), the Alibi published a piece called Albuquerque All Stars 2004, and Andru was one of the top innovators featured! Below is the text of some of the Alibi feature:

During his family practice residency at UNM Hospital, Dr. Andru Ziwasimon said he became aware of the profound barriers and inflated costs of medical care for low-income and uninsured people, and he decided the best way to do his part to fix the problem was start a health clinic that offers primary care to uninsured patients.

"In a lot of ways our system of medicine is so corrupt in its values around money instead of taking care of patients." said Ziwasimon. "So I decided I wanted to practice medicine in a way that was respectful to my community and met the needs of the most vulnerable people."

After months of planning and while their humble stone and stucco office in a South Valley neighborhood was still undergoing renovations, Ziwasimon, along with Sylvia Ledesma, Alma Olivas and with the help of countless volunteers, opened the Just Healthcare clinic in September.

The clinic operates on the principle that health care should be affordable and accessible to anyone. The goal, Ziwasimon said, is to integrate indigenous medicine (Ledesma's specialty), homeopathic and standard allopathic (prescribed drugs, minor surgery) practices, as well as create a clinic where community leaders can have a voice in the way health care is managed (Olivas' specialty).

Nobody pays up front. After being seen, people are asked for a $25 visit fee, and additional small fees for labs or medication. The average visit costs around $35, compared to comparable service at an emergency room for $400 or more, which is the only option for the growing stream of uninsured residents in Albuquerque. Lab costs and pharmaceuticals are priced at cost, without profit motive. To meet his own financial demands (medical school loans aren't cheap), Ziwasimon moonlights on the weekends as an emergency doctor in rural New Mexico.

"There's so much inflated cost in health care: supplies, drugs, visit charges, inflation built in to pay salaries of administrators and insurance billers," he says. "At this clinic we don't deal with the hassle and it saves us a huge amount of money. There's a belief out there that poor people don't pay their bills. But 80 percent pay us because it's a fair and affordable service."

A perfect case study was a 50-year-old man who called with full body ache and back pain and thought he had a kidney stone, because a friend told him those were the symptoms. It was 4 p.m. and the emergency room would have been his only option. At Just Healthcare, Ziwasimon administered a urine test and physical exam, then diagnosed the flu. The man didn't have any money, but returned the next day and delivered $30, then went to the pharmacy for ibuprofen and home to rest. "He's the guy I went into business for, to keep him away from the ER and a $500 bill..."

For her part, Alma Olivas has become an expert of sorts on the intricacies of our modern health care system. When her uninsured grandmother needed hip surgery two years ago, Olivas was told she would have to pay $6,500 in advance. She and her mother only had $4,500 in savings, which was being drained to cover routine visits to the emergency room to pay for her grandmother's morphine shots. She finally pulled together enough credit cards to take out cash advances to qualify for the surgery and is now $50,000 in debt to UNM Hospital and $16,000 in debt to credit card companies. During her initial struggle, Olivas became involved with the Coalition for Healthcare Access—a consortium of nurses, doctors, lawyers, caseworkers, community advocates, health department workers—that has led her to work as a community health care advocate...

The Alibi story was picked up by a number of folks in the wide blog world, including a post by Plutonium Page on Daily Kos. Check out some of the SEVENTY-FIVE comments on that link if you can -- the sheer number and diversity of personal stories on healthcare that people bring to the table is amazing. These stories and people should be driving the heatlh care debate, not politicians far-removed from it all.

Saheli Datta also blogged about the clinic and the Alibi article, and brought to our attention the touching follow-up piece that the authors of the Alibi article wrote:

Since our piece on Dr. Andru Ziwasimon, Alma Olivas and Sylvia Ledesma appeared last week, I've received a steady flow of emails and phone calls from people wanting to learn more about the South Valley health clinic these folks founded in September. Although all other organizations mentioned in our “Heroes of 2004” feature included contact info, the number for Just Healthcare was conspicuously absent. Who knew that I'd receive calls from people with an eye infection, toe inflammation or colic-stricken baby wanting to make an appointment? And then there was a nurse who wanted to volunteer and an Albuquerque resident who posted the story on [Daily Kos] blog. The posting led to an out-of-state doctor wanting to volunteer at the clinic as well.

It was Dr. Ziwasimon's request that we not publish the clinic phone number, which I think is actually his cell phone, because he is attending a medical conference in California until Jan. 8. The clinic also did not want to turn any patients away, and I believe they are currently getting a full load of walk-ins just from word-of-mouth referrals.

The story further illuminates the point already touched upon in the article—that our American health care system is irrational and incompetent when it comes to offering primary care to the people that need it the most. We'll try to follow-up on the clinic's work in the next few months for more info.

Meanwhile, I felt sorry as hell listening to a crying baby in the background, as a young woman asked me if I could help her get an appointment.

On a fundraising note, the Just Healthcare clinic is raising some dough for an ultrasound machine (cost: $21,000). Check THIS -- currently, for profit companies charge $300-$500 per ultrasound exam. Once the clinic owns its own ultrasound machine, it can provide ultrasounds for $20-70 (including the professional radiologist read when indicated). The clinic has already received more than $5000 for this purchase!

For those interested, a tax-deductible donation can be sent to:
Kalpulli Izkalli
ultrasound machine
1028 Ann Avenue SW
Albuquerque, New Mexico 87105

If you have further questions about donations -- you can email one of us (info on the right sidebar of the blog).

As Andru says "If they're going to charge inflated prices, we're gonna get our own machine!"

Health insurance - "mandatory" versus "mandatory"?

What's the difference between "mandatory health insurance" and a tax-funded system of health insurance for all? Nathan Newman, one of my favorite bloggers, takes Judge Posner and conservatives to task on this:

The phobia of conservatives against taxes is often bizarre, since they'll impose the equivalent on the population, but do anything to label it a fee, a fine, or, ahem, mandatory health insurance, a solution to the health care crisis in the view of conservative judge Richard Posner. He argues that forcing people to pay for health insurance is a better alternative than "socialized medicine," but, really, what's the difference?

Posner even supports government subsidies to pay for the health care of the poor, so you have a system where some people pay a large percentage of their income to pay for government-mandated payments for health care and others pay very little. Seems to quack like a tax to me...

Mal-Practice

Alot of folks have balked at the idea of me not carrying mal-practice insurance. my friends who love what i'm doing and want to join are held back by this concern. perhaps they are right, only history will ever know and it will only ever be known if some of us try it.

which, by the way, richer more powerful doctors than i are doing just that. there's a large group of OB-GYN docs in florida who have been without coverage for 5 years without a single lawsuit if what i've heard recently is correct.

so i'd like to lay out my understanding of the forces and realities of mal-practice insurance for those interested. i'm not unaware of the possibility of someone "crazy" suing me for cause or without justification but in the balance, i feel like i am more likely to be bitten by a shark or killed in a nuclear war sparked by oil greed or religious intolerance.

for me, malpractice insurance represents a big fat target for frustration and cynicism. the very act of having it invites lawsuits. this dynamic, i've seen in action. patients may even love you as their doctor, but they feel they are "sticking it to the man" by getting money from a big old greedy insurance company, and guess what, they need that money to pay their outrageous medical bill and future medical costs.

when i moonlight in other people's systems where the culture is adversarial, i carry malpractice insurance (particularly in ER's). for my practice, the pace, context, setting, fair costs, fair payment options, depth of relationships, community presence, time spent, etc are all forms of mal-practice protection.

bottom line is that we all do "mal" practice, we all make mistakes in this work. and we all need protections, but is malpractice insurance really protection? research shows that apologizing is a powerful form of mal-practice protection, but if you have mal-practice insurance or are part of an HMO or mega-system, you will be advised not to admit fault! who does this protect? who is harmed? i apologize when i mess up, it's a basic form of courtesy.

people are good but when you lie to them, when you are arrogant or perceived as arrogant and uncaring, they fight back.

do you have a way to hear your patients when you have messed up? can you apologize? can you refund their money? can you fix the error? can you use the mistake as a learning opportunity for yourself, your staff, the patients empowerment? are you defensive or open?

here's another angle to consider... i'm working with hard working people most of whom would be categorized as poor. i'm also working with substance abuse addicted individuals and refugees from the public health care systems like medicaid and county indigent health plans. most of these folks do not sue, they are frustrated and tired of the run-around and just plain thankful to have someone who listens and helps them make a plan of action, which sometimes actually includes joining in a discrimination lawsuit or such against one of the mega-systems...

so there it is. and i'm not alone. others have found this source of sanity. it requires a shift in how one sees one's relationship to the patient, it requires some savvy financial planning and frankly, some faith in our fellow humans. and just remember, this isn't legal advice, if you choose not to have mal-practice insurance and you get sued, don't go blaming me! take responsibility for your own choice - enjoy the freedom and live with the consequences.

:>

aziwa

can't history ever do anything different?

i got all caught up with intricate math problems in my last post and left out some fascinating power plays happening here in albuquerque. remember that you read it here first when the fan starts spinning shit in all directions.

this week we've had a media blitz by our publc hospital leadership. front page news every day about how poor the hopsital is, going bankrupt, because they serve so many poor people. the president of the university exclaimed that the hospital is like a lifeboat already overwhelmed with poor people and more swimming towards it. "the sky is falling!" "the hordes of barbarians are coming!" the british are coming!" well, all i have to say on this is, why oh why are people aloud to lie so loudly in public and get away with it?

our public hospital may well go bankrupt, but not because of poor people, it's because of poor leadership, really bad decision-making and a cynical political process that allows cynical people to exercise their bigotry by scapegoating the poor and people of color as the problem.

a few points to share:
1. our hospital and medical school are in deficit, $2.5Million.
2. administrators claim they do over $95Million per year in uncompensated care to the poor
3. admin just signed a $233Million mortgage on the existing hospital to build a new WING named after our Governor that will cost us $14Million a year to pay off. this small building project happens to be the single largest public building project happening in New Mexico with contracts for developers and builders. what's in the building? a big ER, a big ICU, a big NICU and about 70 adult medical beds. all types of medical care paid for by MEDICAID and insurance. and here's a little known and critical fact about this new wing. it's being built right outside of the county owned land (where the old hospital sits) on privately owned land...
4. the hospital board recently passed a new STRATEGIC PLAN that specifically and systematically alters the payor mix (insured to uninsured) effectively pushing out uninsured patients onto the already overburdened safety-net clinics who are resisting this move. (this by the way is the reason i opened my own clinic in albuquerque.) this is the first OFFICIAL step in creating a two tiered medical system - those with and those without insurance. prior to this, we've already known that insured patients get seen sooner in faculty clinics.
5. the legislature is in session now and our hospital has hired the best lobbyists in New Mexico (with public money) to get as much extra cash as they can from this SUDDEN CRISIS... front page news... money... cynicism... nothing new.


a few points of reality to share:
1. our hospital, a public hospital, gets $56Million a year from the county to cover uncompensated care costs.
2. our hospital, a public hospital, gets over $120Million a year from the state for various programs and support so that it can fulfill it's mission.
3. the claim of $95Million in uncompensated care is being challenged. imagine this. you are uninsured and need to be seen for a terrible sore throat. you cannot get in to any clinics, there is no urgent care so you go to the ER. if that patient doesn't pay their bill, then what should have been calculated as $50 in uncompensated care is now being calculated as $400 or more for the ER visit. so take that $95Million and subtract at least $30Million... and guess who cut out the urgent care and guess who underfunds primary care? that's right, hosiptal administrators who are scapegoating poor people.
4. the new STRATEGIC PLAN is being opposed by many providers and staff in the hospital. whether the admin realizes it or not, they are going to be facing the battle of their lives. doctors are writing scathing letters to elected officials about the deteriorating care in the ER and in primary care and rightly blaming administrators, not patients, for this horrible and deadly state of affairs.

in the meantime, the hospital is threatening to charge patients 100% up front in punishment for being poor.

history will alter it's course as and when enough of us decide that enough is enough. no matter what it takes. cynicism cannot lead us to a better place. each of us must find our voice and our role to build the story of love and compassion and break the grip of systemic violence permeating our world.

peace in struggle,

aziwa

Do the math: running a clinic without accepting health insurance

i've been wanting to post for a few weeks now about a number of crazy and amazing things happening here in albuquerque. here goes...

the clinic is finally up and running. we had a few snags like our water gave out and was just replumbed today so the toilet flushes. that's always a good thing in a health clinic! :> we've had a steady, small stream of patients, about 4-6 a day, with no advertising. i've been torn on the advertising piece because we have the capacity to see more, probably 10-15 a day, and the need is there, but there is something really sweet about growing a clinic practice by word of mouth. it takes longer, but it really requires you to do good work, to build a reputation, to put alot of care into each visit. if the community likes you, they send friends and family your way.

on the financial end, alot of people have asked how this place could function without taking health insurance. let me put out a few notes of eath based reality on this. poor people pay their bills, and usually with less grumbling than los ricos when they are treated with respect and charged fair prices. i've had a 90% repayment rate so far. i charge $25 for a visit with a $10 charge for a brief follow up visit. it's roughly on par with what the other federally qualified poverty clinics charge as copays and below most insurance co-pays. so how do we do it?

low overhead.

i've been blessed to live in a country with a vast amount of excess so most of my medical equipment has been donated. that saved me probably $25-35,000.00 in startup costs. my startup costs were roughly $6,000.00 for disability access and paiting and odds/ends. by not taking insurance i don't need any other employees but myself. i don't pay for malpractice coverage, which would be $8-20,000.00 per year, depending on whether they considered my practice a doctors office or an urgent care. my rent and utilities are low.

so let's do some math.

at $25/visit working 6 hours a day (2-8pm, i'm dedicated and lazy at the same time), i can see 12 patients on average. that's $300 per day of work. i charge a bit more for supplies, labs and meds used which makes those items cost neutral to the business.

in the "real" world of medical practice, moonlighting for other doctors, i can get paid $50 per hour.

in my world, i have some overhead costs which bring down the overall income but i also have total control over my practice, no paperwork headache, as much or as little followup as i think is necessary, a profound amount of satisfaction, the ability to barter some care for folks, etc...

unless my calculator isn't working right, at four days a week for 50 weeks a year, that's $60,000.00. i choose to work a short week, do the math for what you want your work week to be.

on another level, i was thinking today about why docs work for insurance companies. and i don't get it. i'm working with really poor people, not homeless, but usually within a paycheck or two. imagine if you chose to work with the uninsured middle class. charge $50 or so per visit. work four days a week, see 10 patients a day for 48 weeks a year and you are pulling in $96,000.00 a year. subtract off overhead and fees and liscences and CME and such and you'll be down to perhaps $80,000.00 before taxes... and that's being lazy like me.

let's do one more math experiment.
at $50 per visit, 20 patients a day, 5 days a week and 50 weeks a year = $250,000!!! someone please check my math. okay, but there is a limit, once you start getting busy you need a secretary or medical assistant to order your supplies and answer the phone, so at some point you have to pay someone $30-40,000.00 a year to help out.

with 43Million uninsured patients and many more underinsured and even with well insured patients blocked from timely access to see their doctors, you will be full in this market. do the math for the type of work week you want to have.

aziwa