From Invisible to a Player: The Poor in the New Health Care System

Published on
July 22, 2011

37 years ago, at the very tail of the civil rights movement, my community health center (CHC) was established in Oakland to fill an unmet and urgent need.  A growing population of immigrants were settling in downtown Oakland and had few choices for health care.  Community surveys conducted by local leaders confirmed that residents received significantly less health care than the rest of the population largely due to a shortage of providers and limited English proficiency.  And so a group of volunteers and students opened a make shift clinic with a volunteer doctor and an optometrist available for two days a week.   As demand grew this little clinic expanded hours and added staff one at a time.  Almost four decades later, the clinic has grown to 40+ doctors seeing 20,000 patients who speak any of 10 different languages.

Our clinic still keeps its doors open to everyone regardless of insurance status or ability to pay.  The people who work here are amazing.  Our staff is dedicated and hard working. Our clinic attracts prestigously educated and clinically astute doctors devoted to the care for underserved communities. In a sector that is notoriously under paid, under supported, and with few frills, my coworkers choose to work here because of it's mission driven purpose.

But change is coming.  As we march toward 2014, when the insurance expansion provisions of the Affordable Care Act (ACA) are fully implemented, it is apparent that clinics and CHCs will have to make adjustments.  Studies show that community health centers are a great deal for the health care system by providing high quality care for the fraction of the cost.  However, a recent report from the Blue Shield of California Foundation questions if this is enough.  If their conclusions are correct, the ACA will change the landscape of health care to one where low income patients have the power to choose their provider.  Clinics like mine have a challenge (or opportunity) to be their first choice.</p>

The Blue Shield of California Foundation asked 1005 Californians, all of whom where below 200% of the federal poverty level (FPL), a series of questions about preferences and satisfaction with their health care.  These are families of four making less than $45,000 a year. The five best predictors of patient satisfaction were:

* having a highly regarded personal physician

* cleanliness of the facilities

* the amount of time spent with the physician

* the courtesy of the clinical staff

* patient involvement in medical decisions.

Now only 11% of those interviewed went to a CHC for their health care.  But because the study population socioeconomically mirrors my patient population, incomes below 200% of the FPL, I find many of the expressed opinions instructive.  Overall CHCs do a good job. 45% of the CHC patients rated care as excellent or very good (private docs being 56%).  However, the fact that 42% of all the study participants want to move to another place for their health care makes me ask, "how can do better?".

This study gives us a fascinating glimpse into the future of the health care system.  As of 2014, The ACA will add 30 million more people to the health care market place through Medicaid expansion and subsidies to participate in the the health insurance exchange.  The ACA will transform low income and near low income communities from beneficiaries of "God's work" into consumers who can make choices about where they go for care. If they are unsatisfied with their health care, they will be able to take their health care dollars somewhere else. As the study authors suggest, it will be a "paradigm shift".

A quote often attributed to Gandhi states, "A customer is the most important visitor on our premises.  He is not dependent on us. We are dependent on him. He is not an interruption in our work. He is the purpose of it.

Now this isn't a radical concept.  When I go to see my doctor, I approach the clinic visit as a consumer.  I have expectations. The "am I getting my money's worth" question may creep in as I walk out the door. The facilities should be clean for all of the obvious reasons.  The staff should be warm and inviting.  I want a doctor who is good at what she does, someone I like and will be there for my future health concerns.  Poor people are no different.

I am, however, still leery about regarding my patients as customers.  The patient-doctor relationship is sacred, so much more than a mere financial transaction. But some of the principles around customer care are instructive and is reflected in the general trend toward recognizing the importance of patient satisfaction in the health care system.

To put it another way, we need to be more patient centered.

Looking with fresh eyes the clinic where I spend more waking hours than in my own home, I have to admit that my clinic does appear a little worn.  While it is still full of spirit and purpose I notice the lightly rusted trash cans and the sprayed residue under the hand sanitizer dispenser.  The floors are scuffed, and pocked with discarded dinosaur stickers.  My work area could be a bit neater.  Okay, a lot neater.  I wonder if my patients feel that their time was valued and that their concerns have been heard. I ask myself, "would I bring my kids here?".

This past week we started some minor renovations.  The walls are being repainted and we are looking into replacing some furniture.  A waiting room full of vomiting children and spitty babies tends to accelerate wear.  I am thinking a lot more about how to engage parents in decision making and how we could better measure satisfaction with the patient experience.  And I remind myself -especially on the the busiest most frustrating of days- that I am dependent on my patients and not the other way around and that an opportunity to care for my patients is never an interruption but the very purpose of my work.

I am ecstatic that our country has made a commitment to expand access to care regardless of income.  Our patients have come a long way from invisibility to recipients of indigent care to a player in the health care market.  As for CHCs, I told my staff recently, this report speaks of an opportunity.  Like many other CHCs across the country, we established to fill an unmet health care need. Now it is time for us to transition from the first providers available so many years ago to the providers of first choice.

Originally posted on sfgate: