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Low-Cost Health Clinics Bear the COVID-19 Burden of the Uninsured

Those that have survived are finding ways to shift to telehealth and alternative means of service.

Throughout Dallas, a network of free and low-cost clinics has always done the job of providing health care in the nation’s least insured state. In the midst of a global pandemic, over 600,000 more Texans lost health insurance, most tied to jobs erased by the worst economy in decades. Now, these community clinics are working overtime, serving newly uninsured populations and caring for COVID-19 patients, all while battling the same financial hardships of the rest of the country.

Despite the increased focus on health care nationwide, many clinics without the capacity for social distancing were forced to close when the pandemic began. The Agape Clinic in Old East Dallas shut down for a week in March to cleanse the facility after a patient appeared with flu-like symptoms. “That was sort of our wake up call that we needed to come up with a protocol,” says Dr. Barbara Baxter, founder and medical director of The Agape Clinic.

The patient eventually tested negative for coronavirus, but the clinic drastically changed operations. The majority of visits shifted to telehealth services, allowing doctors and patients to communicate via phone or video chat. The Agape Clinic recorded one of its highest numbers of patient encounters in April with the help of telemedicine as other free clinics remained closed.

Dr. Jeffrey Zsohar, the medical director of Baylor Scott & White Community Care Clinics, was initially worried that patients might not have smartphones or sufficient internet connections to access telehealth services. “I think we’re surprised at the volume,” he says. “Many patients did have the access and the ability to do that. There certainly were those that were at risk that didn’t, so those patients we would make other accommodations to do phone encounters or otherwise to be able to maintain their care.”

At Los Barrios Unidos Community Clinic, CEO Leonor Marquez estimates 30 percent of their business now occurs via telehealth. For MD Medical Group, CEO Alvaro Saenz puts that number closer to 15 percent, but his team has devised other socially distanced ways to see patients. MD is offering curbside appointments as an alternative to telehealth for people who still fear going to the doctor. It’s not just their typical working-class patients using this service, Saenz says. This method of care has attracted customers from Highland Park and Preston Hollow.

“If you’re a chronic patient, that chronic illness is not going away, COVID or no COVID,” Saenz says. “So in order for you to [keep] yourself healthy, you must have a regimen of a  certain amount of care. And we wanted to make sure we were available for you. And that’s why we started these things like curbside.”

The Agape Clinic took a different approach to curbside services.  Patients who are prescribed free medication during their telehealth appointment receive a brown bag of medicine in a drive-by setting. Baylor Scott & White has expanded its tenets of care to those that rely on its community clinics. It polled patients to determine how they were dealing with the additional stressors of a nationwide crisis and coordinated to provide appropriate care packages.

“Those that had the need, we tried to provide some wraparound services to address their social needs, so that they could maintain their health and maintain engagement with the clinic that was so successful in changing health outcomes,” Zsohar says.

Because these centers target those most in need, they’re already poised to serve vulnerable populations. And now they are finding themselves primarily caring for COVID-19 patients via telehealth. The 75211 zip code where LBUCC is located, a heavily Latinx area, has been one of those most affected by the pandemic. In Texas, 61 percent of those uninsured are Hispanic.

Testing has become a part of everyday operations. In April, MD had tested around 4,000 patients in total. Now, MD runs roughly 2,000 tests per day. The explosive demand for that service has provided a much-needed revenue source in a time when the clinic’s pediatric service, which usually constitutes around 75 percent of their business, has fallen by a third.

“The uncertainty of that revenue makes it so that you don’t feel like ‘Oh yay!’ You know? Because you just don’t know,” Saenz says. “If there’s another lockdown in place or stay-at-home order, it will change things dramatically for us very quickly. As soon as the availability of tests changes, that will change our ability to do what we’re doing.”

Even free clinics like Agape have felt the financial impact of the pandemic. In-person visitors often leave small cash donations that add up. Baxter says those donations finance around 30 percent of their annual budget. LBUCC transitioned to a cashless facility to reduce contact. But billing patients doesn’t just delay payments. Some patients might not recognize the bill or have a checking account.

“Even though the demand initially went down, we’ve done everything we can to maintain jobs,” Marquez says. “Still, our priority is seeing patients rather than collecting money and collecting their copay.” Clinics including LBUCC have been able to subsidize some of their usual income from additional funding and PPP loans. “That doesn’t make up for the loss of revenue, but it did help,” Marquez says.

According to the Kaiser Family Foundation, relief for health centers in the form of federal rapid response grants totals $1.98 billion. However, that only represents 7 percent of total health center revenues from 2018. “There has been very marked and clear detrimental effects on the financial front, no different in so many ways than small businesses and restaurants that, you name it, you go down the list, there’s been an impact,” says Dr. Mark Casanova, president of the Dallas County Medical Society. “So, it’s really an interesting dichotomy, because you have some physicians and nurses and therapists and others who are crazy busy right now and almost drowning in service to patients. And then you have others who have this  really stark contrast to that.”

Despite these financial challenges, health care workers like Zsohar hope that the innovative care these clinics are providing for the most vulnerable can help pave the path forward for the whole industry. “We know there’s going to be more patients and individuals who are at risk who don’t have insurance,” Zsohar says. “And so being a part of the community response to that, not just us but our partners in this work as well, we all want to be a part of taking on that care and providing the necessary resources and canopies individuals need.”



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