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This past September, a group of medical residents at my institution began seeing primary care patients at a free clinic down the street from our tertiary academic medical center (“hospital clinic”). Far from my expectations, the care we are able to provide at our free clinic is in many ways better than our hospital clinic. Somewhat paradoxically, the experience has given me a taste of what the practice of medicine is like in single payer health care systems like Canada’s.

When I volunteered to start seeing patients at a nearby free clinic, I had little idea what I was signing up for. The term “free clinic” conjured up memories as a medical student in East Baltimore tending to patients at a local homeless shelter with severe frostbite or at a student-run clinic rummaging through the storage room for anti-hypertensive medications. I expected our patients to be terribly poor, the clinic to be little more than a warehouse, for supplies and medications to be few and far between, and for the care we provided to be more about putting out fires than delivering high-quality primary care.

But the place I have come to cherish working at is none of these things. A surprising number of our patients have stable lives and regular jobs – it’s just that their jobs don’t offer health insurance (including some who work in health care!). Patients call for appointments. When they arrive they are triaged by a nurse who takes their vitals and asks about their chief complaint before putting them in an exam room. We provide comprehensive primary care complete with routine lab tests for cholesterol and diabetes, age appropriate vaccinations, and referrals for mammograms and colon cancer screening.

In short, to the untrained eye, our clinic is less a free clinic than it is simply a community-based primary care clinic that happens to be free. While this is largely true, subtle yet important differences between the care I provide at the free clinic and my hospital clinic suggest that being free is more than just happenstance – it fundamentally changes the way we deliver health care and in ways that are largely for the better.

1. Perhaps the greatest difference is in dispensing medications. At our free clinic routine medications are provided to patients free-of-charge. For most patients, I write out a prescription, which is then filled by clinic staff and made ready for pickup in 1 to 3 days. For medications that a patient needs right away or for patients who can’t easily come back, I fill the medication myself from the stock room (picture: counting out pills into empty pill containers, filling out prescription bottle labels). Though I can only prescribe medications on our clinic formulary, I take comfort in knowing that my patients have their medications in hand. In my hospital clinic, I can write for any prescription I want but I’m never sure whether the prescription gets filled or how much the medication costs. Sometimes I write a prescription for one type of cholesterol-lowering agent only to find out a month later my patient had to pay hundreds of dollars for it or more commonly because of the price didn’t fill it at all, or get a notice from their insurance company telling me that I should write for a different medication or requesting pre-authorization. Less obviously, handing patients their medications has changed the doctor-patient dialogue. It’s less transactional and more didactic. Often as I hand patients their pill bottle I find myself telling them about what side effects to look out for and how and when to take the medication. Between free access to medications and better counseling I can’t but wonder if their adherence to these medications is better. At the same time, the medications themselves become a check on the patient following up. We rarely give out more than 3 months of medication at a time. When their pill bottles start running out, patients know it’s time to come back to clinic, which keeps me seeing them at more regular intervals and lowers the risk of someone slipping through the cracks.
2. Another important difference is in our charting. In my hospital clinic, medical documentation is an ordeal. In American health care, medical records serve three roles — medical, billing, and legal. As a result we spend hours filling out billing sheets, dictating complete physical exams and review of systems, often with little benefit to patient care. Charts become unmanageably large, with low signal-to-noise ratios and “meaning-less” use health information. I can easily find a patient’s insurance information but have to wade through sheets of paper to find out when their last mammogram was. At the free clinic, I document what actually matters. The chart is meant to support high-quality patient care – any information that detracts from this goal is not included.
3. The services we provide are also different. The free clinic as a whole does what makes sense for patient care and not the bottom line. The clinic is a run by a non-profit entity whose mission it is “to deliver comprehensive, patient-centered health care at no cost to low-income, uninsured individuals”.[1] Clearly the clinic is constrained by its finite resources. But within those bounds, they offer services that they feel will fulfill their mission. At my hospital clinic we offer services based on reimbursement and margins. It’s no surprise then that my uninsured patients at my free clinic have access to weight loss counseling and general nutrition counseling while my insured patients at my hospital clinic do not.

Overall in the free clinic service is divorced from financial concerns. Money is not a factor for patients who don’t have to worry about getting a huge bill at home or paying for expensive medicines. And it’s not a factor for me in the way I choose which services to provide and document billing and charges. Instead the patient just focuses on doing what makes sense for him or her, and I do what makes sense for the patient. If it’s ordering an expensive test, so be it. If it’s telling them they are fine and don’t need to see me again for another year, then that’s fine too.

Clearly in the free clinic there are some drawbacks. Patients have longer wait times for referrals. Like the rest of us, specialists offer their time on a voluntary basis and routine referrals for dental care or GI specialists may take a few months. But these delays while inconvenient have not negatively impacted clinic outcomes.

Overall the differences between my hospital clinic and free clinic parallel the differences between the American fee-for-service health care system and a single payor health system like Canada’s. In the American system the care we provide patients is largely dictated by rules of reimbursement. Patients receive services that are paid for by insurance companies, not necessarily those that are best for their health. They often have co-pays for doctor visits and medications, which lead to decreased adherence and worse health outcomes, particularly in low-income populations. Those with expansive health insurance plans often get “more” health care (though not necessarily better care) than those with less or no insurance. In the Canadian system, patients are offered services that are made available by the government based on national guidelines and individual patient-doctor decision-making. Services including medications are free, and everyone receives the same care regardless of socioeconomic status.

At the risk of being political, which system do I prefer? Using the litmus test, which clinic do I prefer working in and which clinic would I prefer to be a patient? On both accounts I’ll take the free clinic down the street.

- Shantanu Nundy, M.D.

[1] www.communityhealth.org