M.Basheer Ahmed M.D., Chairman
In this country, 47 million Americans do not have health insurance.4 Twenty-five percent of Texas residents are neither covered under any insurance plan nor eligible for public medical services. Ninety-seven thousand illegal immigrants reside in Tarrant County, which includes Fort Worth and Arlington, and do not have insurance coverage.5 Unfortunately, people without health insurance are sicker and die at a relatively younger age. Due to lack of insurance, they delay physician visits and do not receive medical care for common medical problems such as hypertension and diabetes until they develop full blown symptoms or complications. Another sad fact is that hospitals and physicians agree to bill and receive negotiated discounted prices for their services from private and governmental third party payers but bill the full amount to individuals who do not have any insurance coverage. Many uninsured individuals in an emergency situation have to give their entire life’s savings for surgery or treatment in intensive care units. The number of uninsured Americans has been rising inexorably over the past eight years due to a variety of reasons.6 Families who have good insurance may lose it if the bread-winner loses his/her job. Individuals who are earning more than poverty level are not eligible to receive care at public hospitals and clinics. Visitors to the United States and illegal residents andare not eligible for care at the public hospitals or clinics.
Regardless of age, legal status, or insurance coverage, immigrants receive much less health care than native born Americans. Based on data collected from 1996-1998, a high percentage of immigrants are uninsured and they consume 55% less services than non-immigrants. Financial, cultural, and language difficulties make it hard for immigrants to access care. Immigrant children had 74% lower per capita health care expenditures than U.S. born children.
Immigrants also have difficulty in following directions and often are non compliant. Many immigrants do not understand the significance of elevated blood pressure or high cholesterol as long as they are not experiencing any symptoms. Compared to non-immigrants, immigrants pay little attention towards preventive measures such as diet and exercise. Many elderly immigrants who have not worked in the U.S. are not eligible for Medicare coverage.
Charitable Medical Services – Al-Shifa Clinic
In view of the health care issues discussed above, the Al-Shifa Clinic was opened in October 1998. The clinic is a private not-for-profit agency providing culturally appropriate primary care to medically underserved populations. Indigent patients and visitors from overseas without insurance coverage also come to the clinic. The weekly clinic provides services for general medical problems such as diabetes, hypertension, high cholesterol and minor infections. If these problems are not treated at an early stage, they may lead to more serious problems such as heart disease, stroke, or kidney failure, which can result in more serious consequences for the patients and their families. All surgical and complicated medical cases are referred to public hospitals in this area. Fifteen area physicians come on rotation on Saturdays and donate their time. In addition to free consultation, generic or free medications (donated samples) are also prescribed or dispensed. In 2002, discounted rates were negotiated for lab work, and now laboratory services are also provided. Most of the physicians at the MCCHS clinic are internists and primary care physicians. Some area specialists see patients for free consultation in their own offices when referred by Al-Shifa. Students from local medical school also help at the clinic, getting credit for their work. Foreign medical graduates applying for residency program also attend the clinic as “observers” and work under supervision of the attending physicians.
Initially the clinic was open every Saturday for four hours. Many Muslim women prefer to see female physicians due to religious and cultural modesty. Therefore, beginning in 2007, the clinic opened on Sundays for women and children only. Female physicians and a pediatrician volunteer their time at the women’s clinic.
Eye Clinic and Dental Clinic
In July 2008, an eye clinic opened once a month for minor ophthalmologic problems and glasses for visual correction. MCCHS is also planning to open a dental clinic in the middle of 2009.
Staffing the Clinic
Prior to establishing the clinic several area physicians were contacted to discuss the feasibility of opening the charitable clinic. Fifty physicians expressed interest in volunteering. However, only 15 made the commitment to come to the clinic for three to four hours once in two months. The major question physicians had related to malpractice insurance. It was recommended that physicians who are in private practice must notify their insurance carrier about their work at the clinic and get appropriate malpractice insurance coverage. Physicians working at the United States Veterans Administration or other governmental institutions cannot get the coverage through their insurance company. MCCHS contacted the Texas Medical Association, and it provided extensive information on good Samaritan laws governing charitable medical clinics and the protection they offers to physicians. The Texas medical liability insurance provides coverage to retired physicians providing volunteer services at charitable clinics for the nominal charge of $250 per year. The federal government also offers malpractice coverage with no cost to physicians who are providing free services at charitable clinics.
Recruiting and keeping physicians interested in the charitable clinic is a challenging task. Since the inception of the clinic MCCHS has lost a few physicians to family responsibilities and other commitments. MCCHS constantly recruits new physicians to replace them.
A part-time officer manager is hired to make appointments, maintain medical records, supervise non-physician volunteers and arrange the lab work. The medical record contains the physician’s initial work up, progress notes, lab work and a list of prescribed medications. A pharmacist comes to the clinic periodically and sets up policies for recording the use of sample medications and disposal of expired medications. A physician dispenses the medication from the pharmacy, which is a locked room where the medications are stored.
The clinic only accepts patients who have no insurance and are unable to pay the physician’s fee in private practice. It is difficult to do a financial assessment on every patient who comes to the clinic due to lack of staff and the high logistical costs. However, MCCHS believes that 90% of the patients meet its criteria for free medical care.
Al-Shifa clinic served 1200 patients in year 2006, 1500 in 2007 and the number of patients has increased to 1800 in the year 2008. Ninety-five percent of the patients at the clinic are adults. The clinic sees a small number of children whenever the pediatrician is able to come to the clinic. Seventy percent of the patients at the clinic are female and 30% are male. The most common problems treated at the clinic are diabetes (30%), heart disease including hypertension and high cholesterol (40%), infections and other minor ailments (15%) and depression, anxiety and other psychiatric problems (15%). Al-Shifa refers patients with acute medical problems such as chest pain, acute infections, surgical problems and chronic medical conditions t o public hospitals.
Most of the patients at the clinic have no other source of receiving treatment. The clinic does reduce the burden of public hospitals and emergency rooms. Patients also feel more comfortable with physicians who understand their culture, language and religious beliefs.