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A health director shares her views on doctor shortage, Affordable Care Act

"In the exam room when the patient says, ‘I’ll take my blood-pressure medication,’ they mean it. They’re not bulling you. Then the door opens and their life smacks them in the face." 
– Joanne E. Haefner, executive director, Neighborhood Health Center. (Sharon Cantillon/Buffalo News photo)

By Scott Scanlon

Refresh Editor

The Neighborhood Health Center, which just completed a $1.5 million renovation of its headquarters on Lawn Street in Riverside, also has two other locations – the Mattina center on the West Side and the Southtowns OB/GYN center in Hamburg.

The locations may treat a growing number of underserved patients from across Western New York, but its staff of about 130 also serves as a model for health care laid out in the Affordable Care Act, which underlines the need for more preventative and organized medical care.

Executive Director Joanne E. Haefner sat down with me last week to talk about how the center operates, as well as the renovations. That interview, conducted for the In the Field segment of WNY Refresh, also is available in a previous Refresh Buffalo blog entry.

During that interview, Haefner talked in more detail about the center and how health care reform will start reshaping the regional health care system in the months to come. She also talked about how the center works to plug its patients in with hard-to-get doctor specialists.

Here are more excerpts of our conversation:

What services are available?

We have pediatrics, adult health, family health, OB/GYN, so we deliver babies in the community and take care of pregnant women. We have podiatry services on site in two of the three offices. We have behavioral health counselors who do adult and child counseling here on site. We have nutritional services specialists who do nutritional counseling in terms of dietary intake and obesity prevention, dental services and then we have our community health workers who help patients link to the services they need and provide outreach into the community and tell people about the services we have.

We also help existing patients learn about the services that we have and services available in the community and we  just started with the Health care for the Homeless Department.

How many patients do you see?

We saw 18,500 people last year. Our visits were around 66,000 between the three sites.

What percentage would you say have health insurance?

Eighty-five percent of our patients have some kind of insurance for some of the year. People will lose coverage. That patient could be insured for some of their visits during the year but we’re helping them to get insurance. They’ll have a lapse in their insurance or we’re helping them get Medicaid or some other type of insurance coverage. We try to help them get connected back into care.

Of those insured, what percentage are on Medicaid?

More than 50 percent.

Medicare patients?

Only 5 to 10 percent but we’re certainly happy to help people along the life span.

How will what you do change with new facets of the Affordable Care Act starting next year?

Some of the things we’ve historically been known for is what the Affordable Care Act is asking primary care to do – to work in a team model, not just within your office but with other partners in the community who might be better at things than you are, really cooperating and having partnerships. We’ve done that historically, but now it’s even more important for us to be able to create partnerships with other organizations and make sure there’s a community based approach to the patient getting the services that they need.

Then there’s the reimbursement issue. That reimbursement model will be changing, so really understanding that one, being in those partnerships and relationships is part of getting paid in the future, and two, making sure that we help patients as the exchanges open – 15 to 20 percent of peoples’ insurances are going to change – and to help them shift into the best available insurance for them is part of our goal.

Do you expect more patients as a result of the insurance exchanges and people being required to have health insurance?

We expect primary care to be more important in peoples’ minds now that they’ll be able to access health care with health insurance, so the issue is can we be prepared for the additional people who are going to want care?

The thing that keeps people out of prevention is that prevention’s not free, so people wait until they have an issue to deal with. So when there’s health insurance coverage that includes that, certainly people will see preventative health as a higher priority.

Do you have a sense of what happens next year in terms of patient numbers?

Statewide and nationally, there’s an expectation there is going to be an increase in patients. We’re guessing it’ll be at least 10 percent.

First exchange open enrollment, starting October 1, is going to be the test. We think that probably the most glaring issue is people who have some current product and how that’s shifting, and then really focusing on uninsured who’ve never thought about themselves as someone who could get insurance coverage.

What do non-insured people need to know about the changes on the horizon?

Right now, there is someplace to get care already. That there’s a sliding fee scale available which is based upon financial parameters and there’s a support system that exists already. Our model is the federally qualified health center model. There are certainly other organizations in Western New York who we partner with who aren’t federally qualified health centers but who still take care of a lot of Medicaid patients. There’s a safety net and we all try to work together to assure that there are not big gaps in access to care.

You really don’t have to wait till you’re sick to get care. There’s a network already.

It’s like buying your first computer, you’ve just got to get in the game. I think it’s overwhelming to people to think about how hard will it be to apply and what information will they need. Inquire. Come in and ask. That’s why we do outreach, to ask people what’s their barrier to come in and get care.

Does it take a special doctor or dentist to do this Neighborhood Health Center work?

This is not for everybody, the diversity of the patients, the complicated nature of the variety of insurances that we take – we take over 100 different insurances. And our patients face a lot of barriers, and having the compassion to understand how hard it is to be a person, how hard it is to be a patient, the people who feel good about coming here are the people who get that.

And that truly isn’t for everybody. The term ‘non-compliance’ comes from you believing you’re right and being a patient means, ‘I really get a choice in this.’ So if I decide I’m not going to do what you say, sometimes that could be dangerous but most of the time it’s me flexing my choice in my health. Doctors and medical practitioners who understand the difference do better here.

There are some doctors who see themselves almost as Godlike, in terms of their commands. To have patients come in and those doctors to have to ask, ‘What do you mean you’re not taking your blood pressure medication?’ must be really frustrating.

The thing is, in the exam room when the patient says, ‘I’ll take my blood-pressure medication,’ they mean it. They’re not bulling you. Then the door opens and their life smacks them in the face: They’re getting kicked out of their apartment or their kid just got suspended, they don’t have enough money to pay all their bills and buy the medicine. Some medical professionals are not recognizing that they’re just a person, like I’m a person. This, I think, is what gets in the way of us creating a long-term relationship with somebody.

The first time somebody comes in, you can just see they feel that nobody’s ever listened to them. They’re articulation of their problems today is particularly overt.  We’re not special. We’re just people who get that people are people, and so are we.

Talking to a couple of specialists for a recent story, they’re overwhelmed and they feel they can’t get to every patient who needs their help, and these doctors have gatekeepers who can really be difficult for patients to deal with.

It’s not always elegant, but we try our best. That’s what’s being human is all about. This is what the community health worker does. … Our referral person who works as a community caseworker, she’s magical. She knows everybody in the (specialty medical) office, who will take what insurance, what the patient will need to get in, here’s the form this doctor is going to need, which doctors need records first or they’re not going to get in. She knows all of that. What an invaluable resource. She’s the most efficient at the secret handshake.

You go into subspecialty because you see something that’s fascinating and you want to make a difference, and then this is a community that can’t support many of the things we want because of decreasing size and reimbursement. You’re not going to attract a lot of international specialists in a lot of things. The ones we have, we have to protect.

But that’s the primary care model. Primary care does its best to maintain a patient’s health, find a subspecialist to find out what’s going on, bring them back and manage things themselves. When we do that, we open the door for more people to be cared for.

That newer model – where younger (doctors and other health-care workers) people refer, refer, refer – and gatekeep? There are a lot of things we can do. Sometimes, you just need a second set of eyes on something. Nurse practitioners, for example, can do 90 percent of what a physician can do. Everybody needs to know their limit and should be working up to what they should do in a system which doesn’t have enough providers.


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