Beyond the flow charts

In 2002 an Ecuadorian showed up in a hospital emergency room in Charlotte, N.C. In broken English he tried to describe the chest pains he was experiencing. At that time, the hospital didn't have an interpreter. In frustration the man went home and called his uncle, who spoke good English. The uncle drove to his nephew's house to take him back to the hospital, but found the nephew dead of a massive heart attack.

That man was 38 and left behind a widow and young son. The tragedy was a turning point for Rusty Price, his pastor at Camino Baptist Church. Price began seeing the needs of the growing Hispanic population, and in 2004 his church opened up Betesda Centro de Salud (Bethesda Health Center), a charity clinic with a largely Hispanic clientele.

That story points to a common pattern. Across the country, in big cities, small towns, and rural areas, private citizens - often doctors - have banded together to set up charity clinics to serve the working poor who don't have insurance. According to Julie Darnell, a public health researcher at the University of Illinois at Chicago, about 1,200 charity clinics each year take care of nearly 2 million patients. Her study included only those clinics that charge patients little or nothing for visits, do not refuse treatment for those who cannot pay, and do not bill patients.

About 58 percent of the clinics, including some of the biggest, take no government money. Many target the working poor, those whose employers don't offer health insurance. The clinics rely largely on volunteer doctors, nurses, and other medical professionals. Some are affiliated with hospitals and universities, others with churches and homeless shelters. About 37 percent are religious. Some are full-time, and others are open only a few hours a week.

Since Washington policy-makers tend to focus on healthcare from a 35,000-foot perspective, we at WORLD decided to do some ground-level reporting on charity clinics around the country. Five of our writers visited clinics in Washington state, Michigan, Texas, North Carolina, and upstate New York. A sixth took a road trip from New York City to Baltimore, Washington, Nashville, Memphis, New Orleans, Mobile, and Atlanta, visiting clinics and talking to people in the neighborhoods around them.

Together, we visited 32 clinics - some Christian, some not, some government-funded, some dependent on charitable donations - and by phone interviewed directors of dozens more. Midway through the project our writers discussed over the phone what they were discovering. Four themes emerge, and they shape the stories that follow: create networks of care, change patient behavior, recruit volunteers, and find freedom from bureaucracy.

The charitable work of Dan Heffernan, 84, founder of Hope Clinic in Ypsilanti, Mich., exemplifies all four themes. Known by his staff as Dr. Dan, the trim, silver-haired physician has been providing care to poor people since the 1960s when, fresh out of medical school, he moved with his family to Midland, Mich. Heffernan saw camps of migrant workers and decided to help them get to church. Soon he saw their need for medical care, so he traveled to the camps with a nurse, carrying bandages and antibiotics: "Once they trusted me, there weren't enough hours in the day to see everyone."

Heffernan began holding a weekly evening clinic at his office, starting at 7 p.m. and continuing "until we were done." Throughout the 1960s he ran the clinic, which expanded with the help of about 150 volunteers. Hospital administrators saw his dedication and agreed to take care of his poor patients at no charge. Surgeons volunteered. Nurses and X-ray technicians told him, "Dan, if you're seeing them for nothing, we'll do it for nothing."

Heffernan learned that clinics need to function as part of a network of care. Hope is a big clinic that includes a well-outfitted dental clinic and social services, but sometimes patients need medical treatment beyond what the clinic offers. In those cases, the clinic partners with doctors from two local hospitals, relying on an informal network of physicians to provide that care.

Here's an example of how it works: Hope Clinic sends a poor patient with bleeding to a volunteer gastroenterologist, who finds cancer of the colon. The gastroenterologist calls an oncologist he knows who is willing to treat the cancer. The patient receives good treatment and learns to accept grace, while the doctors have the joy of giving. Such informality upsets those demanding neat organizational flow charts, but Heffernan said it is satisfying to see that patients "with serious medical conditions have specialists willing to see them and zip it right through."

The second theme that emerged from our research: Since lifestyles can contribute to illness, doctors who run patients through their offices as if they were machines needing a little oil are less effective than doctors who get to know their patients and talk with them about behavior.

Many clinics have wellness programs that target diet and exercise. Heffernan still spends two afternoons a week at Hope Clinic, primarily reviewing records to make sure no one falls through the cracks, and he insists upon seeing smokers: "It's crazy to give medication for their lungs and abdominal pains when it's caused by smoking, and they keep smoking." He tells them, "We'll lick this thing together."

A third theme: Charity clinics run on the work of volunteers, who seize the opportunity to take time with patients and personally help them. When Hope Clinic transformed from a Saturday-only clinic to one open during the week, Heffernan began volunteering two afternoons a week, giving up 20 percent of his private practice salary in order to staff Hope Clinic in its early days. Thirty years later, he still comes in Tuesday and Thursday afternoons. Five or six retired doctors also volunteer as often as every week, developing long-term relationships with patients "the old-fashioned way."

Heffernan says he has learned over the years not to ask doctors to volunteer too often. Hope has a regular Saturday morning rotation requiring doctors to work once every six weeks, and some doctors have done that since the clinic opened in 1982. The limited commitment is doable, leaving doctors time for their practices and family without burning out.

A fourth theme: Administrators at nearly every clinic spoke about the freedom to practice medicine without having to think about insurance or government reimbursements. They spoke of the damage government can do and the way it can transform into cash transactions what once emerged out of compassion.

Heffernan saw that firsthand. He ran his free clinic in Midland for a decade. Then federal money became available, and two neighboring counties applied for grants to create clinics for migrant workers in their areas. Heffernan says, "They got a $400,000 grant to do what we were doing for nothing."

In this issue we'll show how networks of care work and why many charitable doctors are concerned about Washington's expanding role in healthcare. WORLD's Oct. 20 issue will have Part Two of our report, with an emphasis on why doctors volunteer and how they help patients change self-destructive behavior.

Neither part is a systematic study similar to what engineers or economists might produce. We want readers to experience a little of what our writers experienced as they roamed the country. Our healthcare safety net can be understood best by immersion rather than through study of an organization chart. We were struck by the amazing assortment of clinics and helping networks, growing out of private initiative and generosity.

Nancy Pelosi famously said, "We'll have to pass the [Affordable Care Act] so that you can find out what is in it." Our writers this summer found what's in the existing charity clinic network, and were impressed. Can we preserve and expand it, or will we sing a line from an old Joni Mitchell song: "Don't know what you've got till it's gone"?

With reporting by Christina Darnell and Tiffany Owens