Dr. Monica Sweeney offers a diagnosis of one of her patients: A woman, 290 pounds, five feet six, asthmatic, obese, has congestive heart failure, is pre-diabetic, has sinusitis and smokes. “This is not a patient you can take care of on $20 a month,” she observes. “This is not the Upper East Side. People here are sick.”
Sweeney is medical director of the Bedford Stuyvesant Family Health Center, whose windowless presence on Fulton Street near New York Avenue does little to describe the clinic’s importance in the neighborhood. Since 1978, the center has been a health care haven for central Brooklyn, armed with a mandate and a little money from the federal government to treat everyone, regardless of ability to pay.
Here, it doesn’t matter if you don’t have health insurance, or speak Spanish, Creole, Hindi or Bengali. All you need is a body and a desire to keep it working. Ten percent of the patients here are uninsured and pay on a sliding scale starting at $30. “Life is rough,” says 51-year-old Norman Riley, a Vietnam vet who relies on the clinic for cheap health care. “You work all your life and you get nothing back.”
What it takes for the staff here to handle 45,000 patient visits a year has gotten more complicated and expensive since the facility opened. The 15-minute basic exam once centered around a blood-pressure check and test for diabetes. Now, patients also have to be tested for HIV and sexually transmitted diseases and are questioned about drug use, gun violence and domestic abuse. And these efforts go beyond the beige and gray walls of the examining rooms; the center also sends a mobile team out to provide medical and social services at soup kitchens and shelters in the neighborhood.
These days, however, the center has been facing a crisis of its own. New York State is in the process of transfering virtually every person who receives health insurance under Medicaid to managed care. In the new medical order, the patients sign up with a primary health care provider, which receives a flat monthly payment of $14 to $20, no matter how often or infrequently a patient comes for care. Suddenly, each person enrolled in Medicaid is a precious commodity–and hospitals and private clinics have been vying aggressively for their business.
It’s a fight for survival. Until now, fee-for-service Medicaid payments offered health care providers in low-income neighborhoods a financial lifeline: $99 from New York State every time a patient visited. But now, an array of health maintenance organizations are middlemen between the state and doctors, and they are taking a heavy bite out of hospital and clinic income. Though hospitals will be getting $1.25 billion in state and federal aid over the next five years to ease them through the transition, they are already reporting devastating financial losses.
But Medicaid managed care is equally bad news for Bed Stuy and 29 other community health centers located in New York City. From their establishment three decades ago, the centers were virtually synonymous with the federal health program. In fact, they were created to accept Medicaid when private doctors refused. The Family Health Center was once able to count on getting about $350 for each Medicaid patient a year, based on an average of 3.5 visits each. Now, it is getting about $162 a year; HMOs take the rest. “They turn around and skim half the money off the top for their operation,” explains a financial consultant who has worked with the center for nearly a decade. “That’s literally half our costs.”
For now, the federal government is chipping in with an extra $32 per visit, but it still leaves the centers shortchanged. Last year, with about half of its 11,000 Medicaid patients already in managed care, the center lost $500,000 treating them. By the middle of next year, the transition to managed care is scheduled to be complete, and the losses are expected to double. If the clinic has to rely on Medicaid managed care alone, says one senior staff member, “I’ll be looking for another job.”
Before tomorrow comes, executive director Ulysses Kilgore III has to fill the breach, however he can. The center’s planned remedy, already underway: an aggressive effort to become the medical center of choice for local people who have a choice. City workers with private health insurance; college students enrolled in university health plans; local workers in Bedford-Stuyvesant, like bank employees–these, Kilgore and his staff hope, will be among the new faces at the clinic.
To stay alive as the doctor of last resort, the Bedford Stuyvesant Family Health Center has to reinvent itself to make sure that it’s the first, too.
Seated at a table in his cramped second-floor offices, the center’s director talks about the health care rights of the poor with a passion unexpected from a man who spent 10 years in management with Pfizer and Brooklyn Union Gas. A stint as CFO of Syndeham Hospital–later shut down by the budget-crunched city in the 1970s, to the outrage of Harlem residents–brought him face-to-face with patients and pain, and a new calling as an administrator of community health centers. “We have a moral commitment to be here,” says Kilgore, who has run the Bed Stuy center for 19 years. “We have a human bottom line.”
But already, Kilgore is nearly in the red, and his clinic isn’t the one-stop shop for emotional and physical care it used to be. Until a couple of years ago, the center had all kinds of neighborhood outreach programs. A primary care coordinator greeted patients at the door and showed them a video about healthy eating. The center launched one initiative to decrease infant mortality, going out in the community to encourage pregnant mothers to come in for prenatal care; another program weaned substance-abusing mothers off drugs, offering them counseling and giving them tips on how to look for and keep jobs. There used to be a diabetes class, to help patients understand the disease. At one point, the center was participating in a nationwide study on chronic care illness, but had to drop out because staff didn’t have enough time to devote to it.
“We had a free breast and cervical screening program. That ended five years ago,” says Sweeney. “We had a school health care program.” Once upon a time they went out into the community to give people free blood pressure tests. That’s long gone too. They have no development director, and Sweeney, who refers to herself as “chief cook and bottle washer,” says she and the other doctors are too busy juggling paperwork for the HMOs to hunt for grants. “So much stuff is going and nothing is replacing it,” she says, tears of frustration standing in her eyes. “It shouldn’t be this way.”
In truth, however, the clinic is adding new services, aimed at attracting new customers–ones who bring dollars with them. Two years ago, after reading that consumer spending on alternative medicine was growing faster than any other kind of care, Kilgore began offering acupuncture and herbal medicine. He was determined to offer the services, and keep the dollars, at home in Bedford-Stuyvesant. “We don’t want people to go to Manhattan. We want them to be able to get all the things they need right here.”
Government’s exit from health care administration is not entirely bad news for Kilgore. In January, the center won a three-year deal to serve as the health headquarters for veterans in central Brooklyn, a job formerly handled by a VA hospital. Another contract makes Bed Stuy a medical provider for the city’s Department of Juvenile Justice. Kilgore’s also negotiating with a local church to open a diabetes clinic in space the church owns, and talking to Medgar Evers College officials about opening up a clinic on campus.
Most of this takes not just dollars, but space the center currently doesn’t have. Walking the twisting halls of the clinic is like navigating a mosaic by M.C. Escher. An indoor garage converted into a waiting room juts off from a corridor, blocked with four thrumming copy machines. That hall leads to an even narrower passageway lined with exam rooms, but not enough of them to meet the demand when all nine doctors are on duty at once. The emphasis in the crowded seating area is on “waiting,” not “room”–delays of two hours to see a doctor are common.
Already, some patients are going elsewhere; the number of visits has dropped, from roughly 50,000 in 1998 to 45,000 last year. Relief is a full two years away. With a $15 million loan from the Primary Care Development Corporation, the Bedford Stuyvesant center will move to a 30,000-square-foot space across the street–three times its current size.
Kilgore knows he has to move fast. “Back in the days of the Great Society, we could just focus on serving the people,” he says. “The reality is, now you have to make sure the dollars are in place.” He’s learning, by trying whatever works, how to do both. If the clinic can’t provide top-notch care for everyone, he says humbly, “there is no reason for me to exist.”
Ruth Ford is a reporter for the Brooklyn Papers.