プライマリー・ケア医師の枯渇/米国医療事情 医療制度改革

 多くの貧困地域と同様、北部ミルウォーキーでは最近20年間で徐々にプライマリー・ケア医師が枯渇してきている。1人また1人と、引退したり、資金的に行き詰まったりしており、代わりの医師が来てくれることはめったにない。
 残っているわずかな診療所では予約待ち時間が長くほとんど目的に適わず役に立たない。マーサ・ブラウンの3歳の娘の場合、鼻水が止まらなかったが診察は1週間待ちと言われてもとても待てなかった。ブラウンさんはERではなく、1986年から北部のアフリカ系アメリカ人の治療をしているMilwaukee Immediate Care Center という小さな非営利クリニックに3人の子どもを連れて行った。「今日医師が必要な時」という看板を掲げ、夜間と週末も休みなく地域の緊急医療を担っている。
 ウィスコンシン州のメディケイド医療補助がカバーする保険プログラムを利用するために選択したが、オプションが受けられるかどうかはわからない。
 クリニックは、数年にわたり支払い不能で納税義務不履行となり2つの主要なHMOから契約失効を言い渡されている。営業時間を半分に減らし、医療スタッフを減らしX線装置をしまい込まざるをえなくなった。
 地下が水浸しとなり、屋根は雨漏りし、市から3ヶ月間閉鎖するよう言われ、患者数は3年前の年間15,000人から7,000人まで減った。役員が10,000ドルの貸し付けを提供したため今月は開業できている。
 コストを下げ、アクセスを改善し、プライマリー・ケアを重要視するワシントンで計画中の医療法がクリニックに答えを提供するだろうか。すでにクリニック周辺は行き着くところまで来てしまったという。市北部地域の医療インフラは壊滅的な状態となっている。
 無保険者をカバーすることはこのクリニックの患者の底辺を支えるが、より大きな問題はクリニック患者の3/4を保障するメディケイドの医療費の還付割合の低さである。クリニックの標準的な診療費75ドルに対して、ウィスコンシンのメディケイド・プログラムであるBadgerCare Plus では49ドルが支払われるのみである。
 医学生への奨学金プログラムのみではプライマリー・ケア医師への希望が増えるとは思えない。私的保険とメディケイドが同じようにならないといけない。
 適切な保険がない患者が治療を先延ばしするため、クリニックでしばしば重症の高血圧や糖尿病の治療をすることになる。クリニックを連邦政府公認の保健センターにしようとは思わないので、給付率は低いままである。景気刺激策による資金援助の資格もない。
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医療制度改革を揺るがすプライマリケア医の不足/米国医療事情 オバマ政権
http://kurie.at.webry.info/200906/article_30.html
医師不足がオバマ政権の医療改革に大きな障害/米国医療事情 オバマ政権 医療制度改革
http://kurie.at.webry.info/200904/article_40.html
プライマリ・ケア医の危機 危険なビジネスモデル/米国医療事情
http://kurie.at.webry.info/200812/article_27.html
医師はどこへ行った/米国医療事情 プライマリー・ケア医の不足
http://kurie.at.webry.info/200812/article_22.html
プライマリ・ケア崩壊へ/米国医療
http://kurie.at.webry.info/200706/article_49.html
優秀な医学生がめざす分野/米国医学生事情
http://kurie.at.webry.info/200803/article_32.html
皆保険により逼迫するマサチューセッツの医療/米国医療事情
http://kurie.at.webry.info/200804/article_9.html
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A Milwaukee Clinic Fills a Need but Faces Failure
By KEVIN SACK
Published: September 1, 2009
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Sally Ryan for The New York Times
The Milwaukee Immediate Care Center is finding it harder to provide care in an underserved area. More Photos >

MILWAUKEE ― Like many low-income neighborhoods, the north side of Milwaukee has seen a gradual depletion of its primary care doctors over the last two decades. One by one, they have retired or surrendered to financial reality, rarely to be replaced.

At the few remaining practices, the wait for an appointment can make it almost purposeless to seek one. When Martha Brown’s 3-year-old daughter, Loverree, woke up with a runny nose last Thursday, her doctor’s office told her it would be a week. “I couldn’t wait,” Ms. Brown said. “I had to see what was wrong with my baby. I think she’s got an infection.”

Rather than heading to an emergency room, Ms. Brown took her three children to the Milwaukee Immediate Care Center, a small nonprofit clinic that has treated the north side’s largely African-American community since 1986. The clinic, which keeps hours at night and on weekends, is the only full-time operation in the neighborhood that provides urgent care, luring patients with a sign that reads, “When You Need a Doctor Today.”

Ms. Brown’s decision made good sense, not only for her but for the state and federal taxpayers who support her health coverage through Wisconsin’s Medicaid managed care program. But whether the option will remain available is an open question.

The clinic has teetered on the brink of insolvency for years, battered by foreclosure filings, delinquent tax claims, building code violations and the loss of contracts with two major H.M.O.’s. It has had to cut its hours in half, significantly reduce its medical staff and mothball its X-ray equipment.

Patient visits have dropped to about 7,000 a year from 15,000 three years ago, before basement flooding and a leaky roof prompted the city to shut the clinic for three months. The doors stayed open this month, said its president, Perry Margoles, only because a board member provided a $10,000 loan.

It might seem the health care legislation being written in Washington, with its emphases on primary care, lowering costs and improving access, would provide answers for clinics like Milwaukee Immediate Care. But Mr. Margoles thinks things may be too far gone in his clinic’s neighborhood.

“We’re having a meltdown approaching ― to use an engineering term ― a catastrophic failure for much of what remains of the health care infrastructure for the northern half of the city,” Mr. Margoles said.

Yes, he said, covering more of the uninsured would help his bottom line, which has been red in each of the last two years. But the bigger problem, he said, is the below-cost reimbursement provided by Medicaid, which insures three-fourths of the clinic’s patients. For a typical office visit for which the clinic charges $75, BadgerCare Plus, as Wisconsin’s Medicaid program is known, pays $49.

Dr. Syed H. Hasnain, the clinic’s lead physician, said more was needed than simply luring medical students into primary care with grants and loan forgiveness programs. “There has to be some parity between commercial insurance and Medicaid,” Dr. Hasnain said. “Common sense dictates that otherwise, who would want to work with public insurance recipients?”

The clinic often finds itself dealing with conditions like advanced hypertension and diabetes because patients without adequate insurance may defer care. But because Mr. Margoles has never tried to transform the clinic into a federally qualified health center, it is not eligible for the higher reimbursements paid to those centers. It also is not eligible for the billions of dollars allocated to the centers in the stimulus package, or the even larger increases that may be included in a health care bill.

For Mr. Margoles, a 65-year-old nonpracticing lawyer, the stress of dodging bankruptcy may be taking its toll. Three weeks ago, he said, he began having chest pains. Dr. Hasnain diagnosed the spasms as signs of coronary artery disease and recommended he go to an emergency room.

Mr. Margoles would not go. He is uninsured. He said that since opening the clinic he has deferred his $100,000 annual salary, surviving instead on modest rental income from property he owns and the generosity of family members. Although he is old enough for Medicare, the salary deferral has meant he has not paid enough into the system to qualify for benefits.

“I can’t afford to go to the emergency room or the hospital,” he said. “I’m not going to go bankrupt to get care I can’t afford.”

Because any health care deal is certain to preserve the private insurance system, Mr. Margoles said it would do little to solve his biggest headache ― the refusal of two health maintenance organizations to renew their contracts when the clinic reopened in 2007.

Mr. Margoles accused the insurers of paying him back for complaining previously to the state about their billing and claims practices.

One of the companies, UnitedHealthcare of Wisconsin, said in a statement that it declined to contract with the clinic “after thorough consideration” and “with a consistent emphasis on providing access to quality health care for our members.” A spokeswoman for Centene Corporation, the parent group of the other insurer, Managed Health Services, did not respond to requests for comment.

Jason A. Helgerson, the state Medicaid director, said he had discussed the decisions with both insurers and found no evidence of retribution. Mr. Helgerson said he had no authority to force an insurer to contract with a particular provider.

“In both cases, they raised serious concerns about his business practices and were very opposed to signing a contract with him,” Mr. Helgerson said. “I know that in general the H.M.O.’s are eager to have as many providers in their networks as they can. It’s a rare circumstance for this to happen.”

Mr. Margoles has at times considered trying to convert his clinic into a federally qualified health center but is convinced that the move would be opposed because of its proximity to one of the four centers already in Milwaukee.

Senator Bernard Sanders, a Vermont independent who has led the effort to expand community health centers, said there was no money for noncertified clinics in the bills now circulating on Capitol Hill. But Mr. Sanders said he recognized the needs of clinics like the one in Milwaukee.

“I’m well aware there are people trying to do the right thing,” he said, “and to let these clinics fall by the wayside would be a mistake.”

Next: A profile of a young woman in San Diego who has received two kidney transplants.

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