Community Cooperative Clinic Proposal for Barrio “27 de Noviembre”

nsagjhathgioIn Argentina, half the population has health insurance through their workplace or through private prepaid health plans. The other half are uninsured workers in the informal economy of day laborers, nannies, taxi drivers, small shop owners, recyclers (“cartoneros”), and street vendors who receive care in free public clinics and hospitals.

So when I talk about creating private health care for low-income Argentine households, some people have the first impression that I am trying to sell ice to Eskimos.

Why would people pay for health care when they can have it for free? From the perspective of a small NGO working in Peru and Argentina, however, that’s like asking Fedex, “Why would anyone pay $30 to send a letter when they can send it ‘first class’ for  49 cents?”.  The answer is, “The customer perceives that, in the case of a particular letter, Fedex offers 60 times or greater value”. Low-income families are price-sensitive. They are also value-conscious.

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Barrio “17 de Noviembre” in Lomas de Zamora, Gran Buenos Aires

Low-income communities become excited about the idea of their own clinic where they pay for health care. Why is that? Poor people in the provinces of Peru and Argentina  already pay for most of their health care out of their own pockets. As long as they’re paying, they want to purchase good value. What?! Poor people have free public clinics but they pay for most of their health care out of their own pockets?! How is that possible? Those questions remind me of my grandmother’s soup. My paternal grandparents were poor. They moved to the Ozarks of southern Missouri to escape the Dust Bowl in Kansas. There they found themselves trying to grow corn on a rocky hill during the Great Depression. During those hard times men wandered in search of work. When they showed up on my grandmother’s front porch looking for a meal she didn’t turn them away.  She would say, “No problem. We’ll just add water to the soup”. When Grandad would come home without any money, she would say, “No problem.  We’ll have today’s soup tomorrow also. We’ll add more water to the soup”. Now, at some point you don’t have very good soup. It’s watery and not very satisfying. That’s how poor people describe free health care in Barrio “27 de Noviembre” in the city of Lomas de Zamora in Greater Buenos Aires.

They want an alternative to the “watered down soup” of free health care that shifts costs to them. The free clinic doesn’t have many doctors nor medicines. The visit is free if you can wait days or weeks or months for an appointment. The medications are free if they’re in stock; often they’re not.  A mother with a sick child is unwilling to wait so she sees a private pedatrician.  Yesterday a mother told me she spent 200 pesos ($20) on the pediatrician visit and another 80 pesos ($8) for 12 amoxicillin tablets (125 mg), about one-quarter of monthly household income. The median household income in the USA is about $52K per year ($4,333 per month) (US Census Bureau 2013). Can you imagine spending one-quarter of a month’s salary or $1,100 to take your child to the pediatrician? It would be upsetting but most of us could find a way to afford it. We would eat out less often or re-think vacation plans. The mother in Barrio “27 de Noviembre”  has no such discretionary funds to draw from. To make matters worse, those 12 Amoxicillin tablets cost $3.18 in the USA (www.drugs.com). Normally prices are less in Argentina so I think she overpaid by quite a lot. There is a general feeling among women in “27 de Noviembre” that alternatives to the free clinic are exorbitantly priced. Perhaps surprisingly to outsiders, efficient use of health care dollars is a topic that generates animated discussion in a low-income community …. that has access to free health care.

We are proposing a cooperative community-owned clinic in “27 de Noviembre”.  The community will be in charge because the large majority of the clinic’s Board of Directors will be residents of the community. We will employ physicians who will report to an Executive Director that is accountable to the Board for both financial and clinical outcomes. This has been a dream of mine for nearly as long as I’ve been a physician. Can you imagine? A clinic where the doctors work as the patients’ employees and account to a Board of their patients for how well they practice and what results they achieve.  How great would that be?  I imagine a discussion between patients. “My doctor achieved 30% of diabetics who met all their targets”. “Ah, that’s nothing! My doctor achieved 50%!”. It is an unfortunate that, in the age of the internet and Google, a baseball fan knows a pitcher’s earned run average but a patient doesn’t know whether her gynecologist routinely tries an inexpensive, safe and effective medical treatment of abnormal uterine bleeding before resorting to a recommendation for hysterectomy.

The Board of Directors will approve the cooperative clinic’s budget and set clinic user fees. Ideally user fee income will be sufficient to meet costs. However, we will set user fees low enough to keep clinic usage high. We will solicit donations to make up the difference between income and costs as long as we can foresee an achievable path to sustainability.  For example, there will be first-year capital costs (durable equipment) the replacement of which will spread out over time. The clinic might need help with those high first-year capital costs. The community will donate space so the clinic will not pay rent. We will buy commonly prescribed medications wholesale (discounted) prices in order to keep treatment costs low.

Low-income families can afford basic health care when those costs are constant over time. Modest cost surges, easily absorbed by middle-class families “with a little belt tightening”, can devastate low-income families to the extent that they sell assets or go hungry or pull their children from school so they can work. Affordable credit to pay for health emergencies is generally unavailable to low-income families. When sold assets are also families’ income generators, then these health-related financial “shocks” have long-lasting effects. For that reason we will try to avoid volatility in the cost of care at the cooperative clinic. The pricing model will have cost and risk sharing features. A woman who has a normal Pap smear has a low cost of cervical cancer prevention. Another woman who has an abnormal Pap smear needs additional testing, biopsies, and procedures. Her cost of cervical cancer prevention is high. We will charge a “fee per program”.  Both of the women in this example, the one who needed less and the one who needed more,  will pay the same fee to enter the cervical cancer prevention program. Diabetics need to take a lot of medications every day, month after month, usually for the rest of their lives. The visit fee will include medications. A diabetic visit will cost the same as a visit for a urinary tract infection even though the former requires a lot of medications and the latter only a single dose of antibiotics. This is one of the “cooperative” features of the clinic. Low-cost visits will support high-cost visits so that patients have a relatively flat cost of care over time. There may be costs too great to share. Or the community may decide that it is not equitable to share certain costs.  In that case we will provide financing to convert short-term high costs into long-term low monthly payments.   There are also perverse economic incentives that we can realign by financing. The safest and most effective method of birth control is the levonogrestrel intrauterine system (Mirena IUS sold by Bayer). It is the most expensive in terms of up-front cost (about $800 wholesale for a physician in the USA) but, because it lasts for five years, it is also the least expensive long-term solution ($13 per month). That is about half of what birth control pills cost. In this example the clinic would provide interest-free or low-cost financing of a Mirena IUS for a term of five years so that a patient can have a low monthly cost of contraception.

Other differences between our version of a cooperative community-owned clinic and other clinic models (public, private non-profit and private for-profit) are shown in the table.

Please consider supporting our efforts to bring community-owned private non-profit health care to Latin American low-income communities.

Feature Public clinic Community Cooperative Clinic Private clinic (non-profit) Private clinic (for profit)
Owner Government Community Non-profit organization Physicians (typically)
Governance Bureaucratic Board of Directors (mostly community members) Board of Directors (some community members) Governed by physician(s)
Profit Public Non-profit Non-profit For profit
Physicians Employees Employees Employees Owners
Building Own or rent Use donated space Own or rent or use donated space Own or rent
User fees Free if available Decided by board, sliding scale, accepts insurance Decided  by board, sliding scale, accepts insurance Decided by physicians,  possibly with sliding scale, accepts insurance
Medications included in user fee Yes (if available, few) Yes (if available, most) No No
Laboratory services included in user fee Yes (if available, most) Yes (if available, most) No No
Imaging Yes (if available) Abdominal and pelvic ultrasound, possible mammography Possibly (limited) Possibly (limited)
Risk-sharing No fee (risk shared by tax payers) if available Fee for program * Fee for service Fee for service
Financing No Yes  ** No No
Enrollment Sick persons (patient registry) Entire population of geographical area (census) Sick persons (patient registry) Sick persons (patient registry)
Can identify the “well” for preventive services No Yes  *** No No
Specialized care Possibly No Possibly Possibly
Emergency care Possibly No No No
Group purchasing power Yes (limited formulary) Yes (limited formulary) No No
Hours of Attention Typically 9A-5P, M-F Evenings and weekends **** Variable Variable
Appointments Yes Care on demand Yes, typically Yes, typically
Community health workers No Yes No No
Community “botiquin” (small pharmacy) No Yes No No

* example: one fee for cervical cancer prevention whether it costs a little (normal Pap) or a lot (abnormal Pap)

** for example, finance the $800 cost of a Mirena IUS with 60 payments of $13.

*** The census identifies reproductive-age women whom we survey to identify family planning needs and then provide birth control. From that survey and family planning visits in the clinic registry, we know all reproductive age women who are not using birth control and provide folic acid supplementation (reduces certain kinds of birth defects especially if taken before conceiving). We will know BMI from health surveys and provide carbohydrate nutrition education to all overweight and obese individuals. Women aged 25 to 60 years old will be selected from the census for cervical cancer prevention. The census will identify all 40+ year-old adults who need diabetes, blood pressure and cholesterol screening.

****  Example: 4 AM-noon (Mon, Th); Noon-8PM (Tue,  Fri); 4PM-MN (Wed, Sat). During any 3-day period the clinic will cover all hours except MN to 4 AM with the exception of Sunday when the clinic is closed.

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