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									Free Clinics
A Solution That Can Work                                                .   . Now!

Kevin C. Kelleher, MD

FREE CLINICS have formed nation-                         their volunteers and their patients, who     sweeping proposals. But many health
wide as a grass-roots effort to provide                  are often unable to leave work to seek       careplanners are taking a second look at
health care to a largely indigent and                    care. Some clinics, such as ours, have       free clinics.
disenfranchised target population.                       benefited from the commitment of hos¬           The Bradley Free Clinic of the Roa¬
Born in the radical 1960s, free clinics                  pitals, pharmaceutical companies, and        noke Valley in Roanoke, Va, received
have evolved into well-respected health                  medical and dental equipment compa¬          commendation from then-President
care   centers    providing outpatient          ser-     nies and from the cooperation of health      Reagan and recently was named one of
vices primarily to the working poor.                     departments, allowing them to provide        the "thousand points of light" by Presi¬
Their current success is testimony to                    a vast number of services. Free clinics      dent Bush, following the dedication of
their broad-based community support                      are able to operate under pharmacy for¬      our refurbished building by the First
and to the voluntarism of the medical                    mularies, thus lowering drug costs.          Lady. We have been visited by health
community. With no federal support                       Some clinics are not even "free" but in¬     care planners from nine African nations
and little local governmental support,                   stead have found a nominal fee essential     and have received inquiries from the
there are over 200 free clinics in the                   to fostering responsible use for profes¬     Soviet Union and Korea. We have been
United States, many with 15-year his-                    sional or prescription services. The         instrumental in starting eight other
tories. They are functioning with little                 point is, volunteer climes are local and     such clinics (in Christiansburg, Va; Jo-
networking and have developed inde-                      therefore flexible solutions, allowing       liet, 111; Raleigh, NC; Lynchburg, Va;
pendent solutions to the problem of pro-                 the kind of adaptability necessary to        Winchester, Va; Columbia, SC; Hine-
viding care to the uninsured. These so-                  match local need to local resources.         man, Ky; and Tupelo, Miss). Clearly,
lutions are surprisingly uniform.                            Third, free clinics are inexpensive.     this level of interest indicates that there
   First, free clinics are based in neigh-               The thrift of the free clinic concept lies   may be something to the whole idea.
borhoods where there is need. Access                     in the fact that most services are provid¬      The first objection is that the idea of
and transportation are big problems for                  ed by volunteers. If space is donated,       voluntarism on such a scale is unrealis¬
the uninsured, and accessibility is limit-               the cost of providing professional ser¬      tic. The one thing that is consistently
ed by any other solution. Familiarity                     vices can be whittled to almost nothing.    missing from the discussion of health
also encourages use. Also, a strong                      The ratio between the value of services      care planners is mention of the altruism
identification occurs with a neighbor-                    at our clinic vs the expense of the ser¬    of physicians, yet it is the reason that we
hood clinic that encourages responsibil-                  vices is more than 2:1, and this includes   are a caring profession. The volume of
ity, pride, and additional voluntarism.                   dental services and free medications,       unreimbursed care, the willingness to
   Second, free clinics are flexible in                   both high-expense items rarely men¬         be available at all hours, and even the
structure. Our own free clinic started on                 tioned in universal coverage plans (Ta¬     depth of emotional attachment is
the donated first floor of an old house,                  ble 1). Free clinics are extraordinarily    matched by no other profession. Any
with one volunteer physician and nurse                    efficient, and this encourages individual   solution that does not consider this es¬
and $250 of seed money. This may be all                   and corporate support.                      sence misses the whole point of provid¬
that some smaller communities need or
                                                         PROBLEMS WITH THE                            ing health care, and any solution that
are able to support. Professional volun¬                                                              does not recognize a caring relationship
                                                         FREE CLINIC CONCEPT
teers frequently are unable to volunteer                                                              degrades health care.
during daytime hours; thus, many clin¬                      The whole idea of approaching the            At the same time, there are many
ics have found night hours to fit both                   crisis of over 30 million uninsured          reasons to expect voluntarism to work.
                                                         Americans with a basically volunteer         By centralizing indigent care, no one
  From Back Creek Family Practice, Lewis-Gale Clinic,    program may at first seem ludicrous.         physician carries the burden of the ma¬
and Bradley Free Clinic of the Roanoke Valley, Roa-      We are all overwhelmed by the enormi¬        jority of unreimbursed care. Bad-debt
noke, Va.
  Reprint requests to Back Creek Family Practice, 7119   ty of this problem and therefore have a      patients are fewer and practice over¬
Bent Mountain Rd, Roanoke, VA 24018 (Dr Kelleher).       tendency to dismiss anything but             head is lowered. Abuse of emergency

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Table 1.—Value of Services vs   Expenditure                                                                    Table 2.—Sources of Revenue, 1990

                                                                     Fiscal Year                               Contributions (private, churches,
                                                                                                                  foundations, civic groups)              $113 531
                             1990              1989                1988            1987     1986      1985     United Way                                  $76 003
Operating expense, $       247 306*       190 398t               162 158      153 469      124 224   101 452   Local governments                           $26 528
                                                                                                               Patient donations                             $3392
Value of services, $                      438 211                379 716      339 049      303 738   279 816   Endowment investment income                 $23 142
No. of patient visits         6682              6164                                                           Interest                                       $702
                                                                                                               Other                                         $4008
No. of   patients}:           3129              2700                                                           Total Support and Revenue                  $247 306
No. of   prescriptions      10 591              8942                7477            6614     5270      5668

  *See Table 2 for sources of revenue.
  tEstimated due to accounting change.
  ÍData on number of patients were not kept   prior to   1989.
                                                                                                               this day of large group                and
                                                                                                               immediate care centers,       well as the
                                                                                                               voluntary fragmentation of care
departments is lessened, and therefore                           tion, basic education regarding self-care     through self-referral, the effect this has
cost shifting takes place. Volunteers are                        and hygiene, prenatal care and nutri¬         on outcome could be debated. Free clin¬
recognized and honored by their com¬                             tion, sexual behavior, and other health       ics as primary care centers may, in fact,
munities. The patients themselves rec¬                           issues is often taken for granted in a        encourage less fragmentation through
ognize the volunteer effort, and they are                        private office. Free clinics can offer this   the "gatekeeper" principle. However,
appreciative and less likely to abuse re¬                        instruction as a matter of routine.           in the final analysis, some care is better
sources  than under an entitlement. Vol¬                            Free clinics, at present, do not ad¬       than no care at all.
unteers   develop a camaraderie that is                          dress the problem of hospital care or            Finally, though funding a free clinic
reinforcing. The recently passed Na¬                             long-term care. However, 95% of health        can be extremely inexpensive, there
tional Service Act offers education cred¬                        care can be met through outpatient            must be some source of revenue. The
its to volunteers, and there certainly is                        care, and this, combined with preven¬         United Way was instrumental in sup¬
broad political support for volunteer ini¬                       tive care and health education, can be        porting our free clinic through the
tiatives. America has a long history of                          expected to provide for the large major¬      years. In turn, the Bradley Free Clinic
voluntarism, and it has worked in the                            ity of immediate needs of the predomi¬        has become a model during our local
past to solve many national and interna¬                         nantly younger population represented         United Way campaign for the wise and
tional problems.                                                 by the uninsured.                             efficient use of contributions. We have
   The proof, though, is in the attempt.                            The quality of the care provided can       garnered support from our local medical
Every community can develop a small                              be expected to be similar to that expect¬     and dental societies, hospitals, and local
core of volunteers to get started, as we                         ed of the private sector. Reviews of our      and state governments. The support of
did 16 years ago. We now have almost                             patient population reveal that, in broad      individuals has been most gratifying,
400 volunteers. In our community there                           terms, the clinical problems are similar      and we are currently establishing en¬
are 411 physicians: 80 actively volun¬                           in distribution. Quality assurance re¬        dowments to provide ongoing funding in
teer at the clinic, 40 specialists take re¬                      views are essential when so many pro¬         future years. Pharmaceutical compa¬
ferrals, and 128 physicians have made                            viders are involved in an individual's        nies have been very helpful in providing
donations to our annual fund drive and                           care. As an example, our own quality          medications, and the business commu¬
recent capital campaign. Our volun¬                              review of hypertensive care revealed no       nity has been very interested in the
teers include 58 nurses, 29 pharmacists,                         significant trends of poor control. Con¬      Bradley Free Clinic's help in keeping
12 laboratory technicians, 20 dentists,                          stant chart review and nurse-initiated        the working poor working and off wel¬
and 15 dental assistants. In short, 34%                          protocols have maintained a high level        fare rolls. We have received several
of the physicians in our community vol¬                          of quality. Simplified charting, patient      grants from national corporations, and
unteer. Should we not expect similar                             medication records, and computerized          local business leaders were invaluable
results in most communities? Volunta¬                            dispensing records have significantly         in our recent capital campaign (Table 2).
rism can work, especially if it is part of a                     reduced medication errors. Quality can           These examples illustrate the kind of
concrete and efficient program with ex¬                          be ensured by the same reviews applica¬       funding that is currently available to
perienced guidance.                                              ble to any private office.                    any community. We believe that we
   The second most common objection is                              The services available to our patients     have made a significant impact in pro¬
that free clinics represent a two-tiered                         include any laboratory test or radiologi¬     viding care to the uninsured of our com¬
health care system and therefore inferi¬                         cal procedure. The donated services of        munity. Based on the size of our commu¬
or care. There is no system that is not                          our local hospitals and the regional          nity and the number of uninsured
two-tiered. Under nationalized health                            "send-off laboratory, as well as our on-      expected on the basis of national fig¬
care systems, the wealthier have access                          site basic office laboratory, have provid¬    ures, we estimate that we are meeting
to fee-for-service care. Differences in                          ed everything we have needed for 16           the needs of 16% of the uninsured. We
the form of health care are not the prob¬                        years. As mentioned earlier, we have a        have expanded our clinic from 2500 sq ft
lem; more important is the question of                           large number of specialists available for     and five examination rooms (partitioned
quality and appropriateness of care.                             almost any type of referral, and by mon¬      with shower curtains) to 7000 sq ft, nine
   In many ways, free clinic care is supe¬                       itoring the need for referral and the dis¬    examination rooms, and four state-of-
rior. By centralizing indigent care, the                         tribution not one has felt burdened. It is    the-art dental operatories. This expan¬
free clinic staff is able to tailor its capa¬                    clear that in the best of circumstances       sion has already resulted in a 30% in¬
bilities to the special needs of its clients.                    there is little restriction on services       crease in patient visits, and the full
Free clinics are able to take full advan¬                        available.                                    impact is still being evaluated. At mini¬
tage of available social services and                               At the same time, some will argue          mum, our community has a substantial
health care agencies that a private office                       that because of multiple providers, con¬      "safety net" protecting the health care
may not be adept at providing. In addi-                          tinuity of care is bound to be affected. In   of the uninsured.

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THE FUTURE OF FREE CLINICS                      of Virginia) and the one recently passed     of medical reimbursement and coverage
   To make a significant impact on the          in North Carolina. Volunteers should be      under federal control or mandate has a
enormous national problem of the unin¬          allowed tax credits to encourage partici¬    cleansing appeal, it will not happen
sured, a dramatic expansion of free clin¬       pation. Federal- and state-pooled phar¬      soon. The congressional subcommittee
ics is necessary and, fortunately, quite        maceutical purchases should be extend¬       formed to study the problem of the unin¬
possible. The first step is the funding of      ed to free clinics, combined with            sured, the Pepper Commission, con¬
a national foundation to encourage and          formulary restraints. Grants and ongo¬       cluded that such a proposal would cost
assist in the establishment offree clinics      ing support should be provided to re¬        $43 billion in a time of federal spending
in any community wishing to partici¬            gions of highest need. Ongoing studies       cuts and a huge deficit.2 As stated by the
pate. The recently published Directory          of health care strategies of preventive      chairman of the Commission, Senator
of Free and Community Clinics in the            care, education, and cost-effective          Rockefeller, currently there is no con¬
 United States1 lists more than 1500 not-       treatment should be supported and            sensus and "politicians see more to lose
for-profit, free, and community clinics.        implemented.                                 than to gain in taking a stand" on univer¬
Although only a few hundred of these              Free clinics should be allowed to          sal coverage.
clinics fit the free clinic model, many         evolve and improve in response to local         Voluntarism through the formation of
could be encouraged to expand their             need. Staffed by volunteers, they would      free clinics may not be the ultimate solu¬
services. In addition, new clinics can          not compete with the private sector, but     tion to the problem of the uninsured. In
easily be established by interested com¬        would enhance it by decreasing bad debt      fact, there probably is no ultimate solu¬
munities with some organized advice.            and abuse. They would encourage the          tion, only interim ones. This, however,
With a moderate amount of publicity             working poor to continue working, rath¬      is a solution that trusts in our humanity
 and support from the medical communi¬          er than slip backward onto welfare de¬       and our willingness to care for one an¬
ty, the seeds of expansion can be               pendency, and at the same time would         other and immediately provides help to
planted.                                        improve their health and quality of life.    our citizens in crisis.
   Second, the national foundation              Free clinics would be a source of pride in      The reader is referred to the May 15,1991, issue,
should clearly analyze the cost-effec¬          each community and would enhance the         which was dedicated to caring for the uninsured and
tiveness and quality of such efforts. In        image of health care providers, serving      under-insured.
                                                                                                I am indebted to John Burkhart, PhD, and Edith
other words, these clinics can serve as         as shining examples of their com¬
                                                                                             Parker, MPH, for their assistance in gathering and
practical and inexpensive models. Pres¬         passion.                                     analyzing statistical data.
ently, free clinics are hampered by mis¬           The final outcome of a large initiative     This article is dedicated to Richard M. Surrusco,
conceptions and doubts. Only a large,           would be the swift formation of a net¬       MD, and John M. Garvín, MD, the first physicians
                                                work of free clinics throughout the Unit¬    at the Bradley Free Clinic of the Roanoke Valley.
unbiased study of free clinics can estab¬                                                    Their altruism and enthusiasm continues to be a
lish their current and potential                ed States to serve most of the needs of      source of inspiration.
effectiveness.                                  the uninsured. This network could, in
                                                the future, be the foundation on which       References
   Last, if the free clinic model proves
itself a viable alternative, federal sup¬       any number of evolutions could be based      1. Bess  GM, Hiller M. Directory of Free and Com-
port should be forthcoming in several           (eg, an expanded public health system,       munity Clinics in the United States. Los Angeles,
forms. Legislators should act to hold           a national clinic system, or simply acces¬   Calif: Los Angeles Free Clinic and the Free Medical
                                                sible clinics under a national health in¬    Clinic of Greater Cleveland; 1990.
volunteers at free clinics free of liability,                                                2. Rockefeller JDIV. The Pepper Commission Re-
much like the statute enacted in our            suranceprogram).                             port on comprehensive health care. N Engl J Med.
state (Chapter 1 of Title 54-1.2:2, Code          Although a complete reorganization         1990;323:1005-1007.

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