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Physicians’ Forum
budget cuts, the department is facing a tremendous
challenge.
As a pediatrician, I see patients from birth to age
19. I will sometimes see some of my chronically ill
patients, such as those with sickle-cell disease or
cerebral palsy, beyond that age. Most of these
patients have Medicaid coverage and they are able
to receive services as needed. We are associated with
Children’s Hospital, where we refer our more complex
patients for specialty care or those requiring
hospitalization.
WM: Working in infectious disease, I see consults
at the hospital who may be people who are fully
insured or people who have absolutely no resources
whatsoever. As part of my responsibilities here with
the UASOM Montgomery, we have a private practice
that is part of the school, similar to The Kirklin
Clinic in that we do see private patients. Typically,
I see about 30 to 35 consults a month in the hospital,
and anywhere from 10 to 15 of those patients
will be completely indigent. Currently, I’m seeing
three or four in the hospital who have catastrophic
diseases because they didn’t have access to preventive
health care. I have two others in the hospital
right now with newly diagnosed HIV infection.
In what ways has this impacted you and/or
your practice?
IF: Medicaid coverage changes from day to day, and
many times patients arrive assuming they have coverage
when they do not. Coverage may be suspended
because the patients did not reapply for coverage,
because there’s been an address change, or for various
other reasons. Occasionally, a patient needing
care will leave the clinic because of lack of coverage.
Sometimes patients will leave the clinic with a prescription
and not fill it because they have no funds
for medication. Whenever we become aware of
patients’ inability to pay we implement several creative
approaches to provide care. The health centers
and staff also contribute to funds that are administered
through the social workers to help cover medication
and some transportation costs.
WM: It impacts us quite a bit because we have
budget constraints. When you have to write off
large amounts of bad debt, the money has to come
from somewhere. We’ve been impacted by the state
budget cuts and, in a very unusual move, we are
considered a non-state agency, so our funding was
cut 75 percent.
Unlike Birmingham, we do not have a charity
hospital—there’s no Cooper Green here; we are the
area’s Cooper Green. Fortunately, we do receive
support from the county and from the city. The
amount we’ve received each year has remained the
same, and we’ve been blessed that is hasn’t been cut.
We consider that a success.
Has your patient base changed in the last five
years, and if so, how?
IF: A few years ago, we began to see an increase in
the number of Hispanic patients presenting to our
clinics. We adjusted by offering Spanish classes to
our staff as well as training in cultural diversity. At
present, most of our Hispanic patient services are
consolidated at two facilities, Central Health
Center and Chris McNair Health Center, where we
have full-time interpreters who assist staff in communicating
with and providing services to our
Hispanic patients.
Currently, more patients are presenting from the
private setting for care. Usually there is a loss of insurance
coverage or the patients may be under-insured.
WM: The patient base has stayed pretty much the
same. Because of the fact that there is no hospital in
Lowndes or Macon counties, we continue to serve
both urban and rural communities. Patients come
in from the small rural areas with very little, if any,
preventive health care.
Our main sources of patients are some of the
smaller communities near here where there is a very
high rate of either uninsured or Medicaid patients.
How does indigent care affect other physicians
and medical facilities in the area?
IF: I believe the biggest challenge we are facing in
health care is funding, or lack of it. I am sure that
private practitioners see patients who have no medical
insurance coverage, especially long-term
patients who for various reasons have lost their
insurance coverage. However, one cannot run a
practice for indigent patients unless there is some
source of funding—and providing hospital care is
almost out of the question.
WM: I think it has a big impact on some of the surgical
subspecialties. Because we don’t have a charity
hospital here, if you have an indigent patient who is
involved in a car accident or sustains a gunshot
wound, the physicians still have to treat them, and
still have to deal with their share of the costs involved.
It is also somewhat of a negative in recruiting for
our surgical colleagues. It’s an issue because they
can’t compete with communities like Birmingham,
for example, as far as reimbursement or compensation.
This is a spillover effect of indigent care.
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Do you have any ideas or suggestions for
improving indigent care in Alabama?
IF: Education of the public and funding for public
health are essential to improving health care in our
area. The Jefferson County Department of Health
is aggressively pursuing getting the public involved
in learning about healthier lifestyles. If funding is
not available, then programs that are put in place
for specific health-care issues will not be available to
those who need them most due to the cost—specifically,
issues and programs that address weight
management, increased cholesterol, and epidemic
increases in diabetes mellitus type II in pre-teen
and adolescent patients.
Funding is the central issue as always, but I think
it is also important to build a strong relationship
between the county health department and the various
health systems in the area. This relationship
should be so interrelated as to avoid duplication of
services and conserve limited funds. The community
should also have significant input as to the
design and delivery of these services.
WM: I can speak medically and I can speak politically.
Medically, I think that we need to do a better
job of supporting our health departments in
the sense that—again, this goes back to money—
they are working on shoestring budgets. They
have been cut back so badly that public-health
clinics have basically been annihilated. They’ve
cut back on important programs, such as those for
hypertension, and it’s a short-sighted move. I
think developing a more coordinated health-care
policy will be important.
The other thing is that, locally, we have a lot of
organizations that are providing indigent care, but
there’s no “czar of health care” in that regard.
Obviously, everyone is doing the best job they
can, but there is some duplication of resources. It
would be nice to have someone who is in absolute
charge to designate and better coordinate, or at
least get everyone together to formulate some sort
of long-term plan.
Also, our legislators are going to need to realize
that health care and education are so intertwined
that, unless they make courageous moves, we’re
going to continue to lag behind.
As physicians, we’ve been blessed and we need to
continue to take the noble approach of providing
the best medical care regardless of the patient’s ability
to pay. We’ve got to instill this notion in today’s
medical students from the earliest stages.