Community Clinics Diagnose a Way to Stay Healthy

TOPPENISH, Wash. — By all appearances, Sara Guendulein and Debra Meyer have little in common.

Guendulein, a Mexican immigrant expecting her fifth child, earns low wages picking cucumbers in the fields east of the Cascades. She can only afford state-subsidized insurance and receives prenatal care at a community health clinic.

Meyer, meanwhile, paid for in-vitro fertilization to get pregnant with her fourth child. But she receives prenatal care at the clinic, because it offers the rare attentions of a female gynecologist in central Washington.

In the past, Meyer might have been considered an anomaly at the Yakima Valley Farm Workers Clinic -- a patient with private insurance who chooses a community clinic for care.

But as the economy pushes more people out of jobs, community clinics here and throughout the country face added pressure to keep their doors open. One solution -- though few will say it aloud -- is to attract more paying patients like Meyer.

“Community clinics are developing themselves beyond just being the poor person’s clinic,” said Mary Looker of the state health department. “The future is that they will be a huge part of the health care system. They aren’t the last resort anymore.”

Meyer agreed, explaining: “The main reason I’m here is that I want to see a woman. I think I get the same amount of care here that I would get at a private practice.”

The trend may protect clinics in communities where health care is hard to come by for some people, such as migrant farm workers or the homeless, or in rural communities where patients otherwise would travel hundreds of miles to see a doctor. It also could signal a shift in how millions of Americans get health care.

A five-year initiative by President Bush calls for 645 new health centers and 555 expanded health centers nationwide by 2006, with a goal of increasing the number of patients served from 10 million to 16 million.

The federal dollars for the project are directed to serving the uninsured, which the Census Bureau estimated last year at 44 million Americans.

Federal dollars, though, account for only a small portion of clinics’ funds -- some as low as 10%. And state budget cuts are limiting clinics’ ability to offer the one-stop shopping for which they are known: dental care, substance abuse treatment, mental health services and pharmacies.

Clinics are responding with specialized programs and access to services that attract patients with insurance, who shore up the financial bottom line.

Some clinics in Florida are offering patients a paperless, electronic record of their health visits -- information that eventually will be available online.

“Insured patients are using the Internet more and more to look for quality of care, to look for who’s available and to interact with their providers,” said Betsey Cooke, president and CEO of Health Choice Network, which is owned by 10 corporations operating more than 80 clinics in southern Florida.

In Texas, several clinics developed programs geared toward managing care of chronic diseases, such as diabetes and heart disease. The programs were so successful that privately insured patients showed up.

“We’re being chosen because we’re responding to a community need,” said Jose Camacho, executive director of the Primary Care Assn., which represents 36 health care corporations operating 147 clinics in Texas.

The idea of mixing insured and uninsured patients isn’t new. Twenty years ago, a clinic in Harlingen, Texas, recruited a pediatrician who became so popular that the mayor’s children were patients.

“Somehow, it wasn’t the poor folks’ place on the other side of the tracks. This was good quality care,” said Dan Hawkins, former director of that clinic and now policy director for the Washington, D.C.-based National Assn. of Community Health Centers.

But no clinic will flat-out admit to marketing itself to the paying public, he said, because it seems contrary to their mission.

“I personally think there are good reasons to do that,” Hawkins said. “But most not so much consciously market themselves to an insured population, as much as they offer the highest quality, most cost-effective care they can.”

The Yakima Valley clinic, located on the edge of the Yakama Indian Reservation, offers medical and dental care, mental health services, a pharmacy and some surgical procedures. The clinic also employs three of the region’s five female gynecologists. A fourth works at a clinic 18 miles away.

Dr. Patricia Hernandez had no intention of staying when she came to the clinic as a National Service Corps grad 12 years ago.

“I stayed because of the people,” Hernandez said in a quiet hallway tucked away from the bustling waiting room. “It is truly wonderful to see patients grow and change.”

Her patient list has grown in recent years, in part because the largely Latino migrant population wants a female doctor. And the town’s two private-practice doctors recommend the clinic to their patients.

“It’s just a comfort level,” said Darnell Dent, chief executive of the Community Health Network of Washington, which operates the clinic. “We are seeing growing numbers of people saying that the community health center is a home to them.”

One of the challenges is to continue to market clinics to the privately insured, Dent said, while not losing sight of the mission: serving low-income people.

“We know that we have to diversify as a health plan, just from a revenue stability standpoint,” he said. “Strategically, it’s very important to us -- for survival.”