Saturday, March 6, 2010

Some Thoughts On Working In Southside

I work at an outpatient practice in Southside Richmond. My pediatric patients are essentially 100% Medicaid/FAMIS (Virginia's state children's health insurance program --SCHIP) and nearly 90-95% Spanish-speaking. On the adult side, probably 70% of my patients are uninsured and receive assistance from our health system's patient assistance program; another 15% or so have Medicare coverage, and the other 15% are mostly Medicaid. I've been working here for over 2 1/2 years, and have developed some thoughts about working in this setting:

--Medicaid is very poorly responsive to its patients' needs: many children are covered for 1 year after they are born, but have to reapply for coverage. Many of the letters that are sent out are in English (to Spanish-speaking families), or are hard to understand. There is no evidence of any proactive approach to avoid this, so we get a number of kids that fall through the cracks at their first birthday. Similarly, many patients are unaware that their insurance coverage includes transportation to and from doctors' visits. Our Spanish-speaking patients do not receive full value from their insurance coverage.

--It is nearly impossible to get Medicaid as an adult in Virginia. You could be destitute, living in a box near a highway, and have no employment but you still do not qualify for Medicaid assistance.

--Even $4 prescriptions are expensive. Patients receiving our health system's assistance can get prescriptions for $4 for 30 days. I have been asked more often than I imagined to identify which of the prescriptions is the most important one because they cannot afford all $4.

--Our health system provides a full scope of referrals, but doesn't really accommodate the need very well. Already I have some appointments scheduled for patients in February 2011. I am glad to have the referrals (on paper) but I wonder if we couldn't find a way to make them more meaningfully useful.

--If you are approved for Disability income, don't expect much. Disability pays most of our patients who qualify somewhere around $700-900 a month. This really isn't enough to do much of anything. People who accuse the poor of spending all their money on big-screen TVs and fancy stereos can probably find a few people who validate their claims, but for the most part these people have no idea what they are talking about.

--There are levels of poverty in our very city that would not be out of place when I work in international settings. As a nation, state and city we should be embarrassed and appalled by this.

--It is much less expensive and resource-intensive to fix problems before they develop than to play catch-up later. Many of the adult patients I care for present with multiple uncontrolled medical problems and it takes a great deal of time, effort and resources to get things under control. It would be much more efficient if these problems could have been detected, controlled or prevented long before. That, of course, would require having meaningful access to health care even if one was unable to purchase private health insurance. This is why healthcare reform is so critical--it would open access to health care for everyone.

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