Style Weekly's Losing Patience

Style Weekly's Losing Patience

Losing Patience

    April 08, 2009 NEWS & FEATURES » COVER STORY

  Despite $104 million in federal funds, VCU's indigent health care program leaves some patients in a lurch. Critics say it's all part of the plan.

 BY CHRIS DOVI

Janet Armstead considers every trip to the doctor's office a blessing. But the road she takes sometimes seems more painful than the cure.
Suffering chronic effects of a past bout with Lyme disease, the usually boisterous woman with short-cropped hair and dark, expressive eyes arrived for her Feb. 2 doctor's appointment wracked by crippling pain.

“My hip was killing me,” says Armstead, an animated and vivacious woman whose constant motion belies the pain she suffers. “The doctor sent me for X-rays. And he wanted me to go to an orthopedic clinic too.”

It's a routine referral to a specialist that most patients with health insurance take for granted: Within a week or two, most people can get an appointment with the primary care physician and then with a specialist. It's the sort of trip that's supposed to be routine for Armstead too, despite her meager means, lack of insurance or money to cover the bill. That's because she has basic health benefits under Virginia Commonwealth University Health System's indigent patient program, Virginia Coordinated Care for the Uninsured, known by the initials VCC.

Instead, Armstead says, “it took [VCC] two weeks to even make the appointment,” which then was scheduled another week or more out without consulting her on the date. When she finally was back at her primary care doctor for the follow-up to that initial Feb. 2 appointment, it was March 16 — more than a month without relief from the pain. And still no date with a specialist.

“The worst part is in between that time the doctor's office called me to tell me they'd made an appointment to the orthopedic clinic,” she says, laughing at how expediently she'd be seen for the second referral: “July 10. I'll be either dead or crazy by then.”

Even getting approval to go crazy or die may get an indefinite extension because of bureaucratic red tape: Armstead's orthopedic appointment is two months after her membership in the coordinated care program expires.

“They want you to forget it,” Armstead says of the equally complicated two-month renewal process to remain in the program. “And then when you go to the doctor's and you realize you don't have [coverage], it's embarrassing.”

Armstead counts herself fortunate to have some kind of health care coverage, but her months-long trips to the doctor are becoming increasingly commonplace. She isn't the only one.

The bureaucratic red tape that mars VCU Health System's indigent program has come under fire of late. Physicians and hospitals that participate in the program and a vocal interfaith advocacy group say the program's inefficiency has a crippling effect on the uninsured.

For the city's poorest residents, the university's coordinated care program is supposed to bridge a growing gap in health care. It offers indigent patients perhaps their only option when it comes to preventative care — covering regular doctor's visits to catch ailments early, especially for aging patients. Without it, often the only option is a trip to the emergency room.

VCU has acknowledged there are problems and inefficiencies and promises to retool its broader indigent care program, which brings more than $104 million in federal funding to the university every year.

But there are larger forces at work, critics say. The complaints about the program are varied and range from inefficiency and towering bureaucracy — like what Armstead faced — to suggestions by some critics in the medical community that VCU intentionally holds back on the larger pot of federal money that could be doing much more good in the community.

Federal regulations require the $104 million of federal money be spent within VCU's walls, but some doctors suspect that VCU has intentionally hedged on applying for a federal spending waiver that would allow the school to spread some of its wealth out into the community. It would allow hospitals and doctors not directly part of the university to create an indigent care safety net that would mean better care for more patients at a decreased cost, they say, but would also mean a smaller piece of the funding pie for VCU.

“I think for any program there are always areas for improvement,” says Sheryl Garland, vice president for community outreach at VCU Health System, who defends the university's record with the indigent care program and the federal money it protects. “One of the things we are working on is identifying those [improvement] areas with our community partners and with our patients.”

VCU Health System sees more than 40,000 indigent patents every year — people from all over the greater Richmond area and from all walks of life. Few of them are indigent in the common sense of the word. Most are working poor, like Armstead, with jobs that provide minimum-wage pay. They work hard but they struggle to stay afloat.

The indigent care program that covers Armstead serves about half of the 40,000 indigents, those meeting specific federal eligibility guidelines. The program was developed about nine years ago as an alternative to caring for the region's growing indigent population. In essence, it established a health-care safety net of community doctors. They'd see patients who in the past relied almost exclusively on expensive hospital emergency room visits for conditions as varied as from routine medical checkups to life-threatening injuries.

The yearly cost of this highly effective — if sometimes frustrating — program is paid separately out of the $104 million in federal funds. VCU directly foots its comparatively meager $4 million price tag, with the basic premise being that by spending that money the university can distribute the $104 million in federal dollars to improve care for all indigent patients across a broader spectrum.

In essence, an ounce of prevention is worth a pound of cure. Patients develop healthy relationships with family doctors, and by seeing them regularly catch serious maladies early when they're less costly to treat.

In many respects, the strategy is working. Emergency room visits at the university for nonemergency care are down among patients enrolled in the indigent care program, according to Garland, even while they're up overall among all other indigent patients.

In spite of the improvements VCU says it's made, community doctors who participate in the coordinated care program think more could be done with $104 million.

“As we talk about reforming our [national] health care system, as people begin to lose their jobs and lose their health benefits, they have to have somewhere to go,” says Dr. Lerla Joseph, owner and president of Charles City Medical Group on Hull Street.

“Treating those patients in a private-practice, primary-care setting, hospitalizing them when they need to and getting diagnostic tests that they need to have done,” she says — “If we were able to do that for 20,000 patients on [$4 million] then the expenditure and the use of the funds could be much better managed.”

Despite the evidence that increased care by primary care physicians saves money and improves patient outcomes, the health system nearly shut down much of the program just a few weeks ago.

On March 4, university officials, including Garland and Sheldon Retchen, chief executive of VCU Health System, met with the program's community doctors to inform them that the hospital would see as many as half of their patients directly. The $5 monthly maintenance fees on remaining patients might also be reduced, doctors were told. Bon Secours Richmond Community Hospital, a major treater of overflow program and other indigent patients, also was to be cut out of the program.

Major pushback from doctors caused the university to rescind the planned changes.

“The doctor network is mitigating [care cost] increases,” Garland acknowledges. “It's because patients have access to primary care.”

But it's a shame the hospital had to be reminded of that fact, Dr. Joseph says.

“I see the program being improved as a result of having this recent controversy developing,” says Joseph, though she remains disappointed that the university hasn't yet seen the importance of keeping Community Hospital also in the VCC program. The hospital remains scheduled to lose its VCC contract May 16, Garland confirms.

Joseph says this decision remains one without any evident logical purpose.

“I asked about [Richmond Community Hospital's] cost per hospital stay versus a stay at VCU, and [VCU] acknowledged the cost was much lower at Richmond Community,” she says. “It seemed to me the … decision was not a proper decision based on the cost savings they had realized.”

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