Charging patients at Philadelphia's "free clinics"

Right now Philadelphia’s city-run health clinics rarely ask uninsured patients to chip in for the cost of their care; that may change soon.

More than 86,000 people get care at one of the eight city-run health centers each year. About half of them are uninsured. Charging those patients for office visits is one idea Philadelphia officials are considering as they struggle to close the city’s $170 million budget gap. [audio:sci20090317clinics.mp3]

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Under federal rules, the city-run health centers are supposed to charge every patient something, based on each person’s income. But right now, that doesn’t really happen. Many residents think Philadelphia operates free clinics, and administrators say that reputation draws cash-strapped people to the city-run centers.

Bettigole: If people are cleaning houses for a living and they are sending money to their home country and they’re supporting however many family members there just not a lot of dollars to spare.

Dr. Cheryl Bettigole directs Health Center No. 10 in the Northeast. Many of her uninsured patients work. Bettigole says they struggle to pay for health care out of pocket, but earn too much to qualify for government health programs, like Medicaid. She calls that situation: the middle place.

Nesmith: I don’t have insurance, but I got a pretty good job, so, I guess I fall there too.

Will Nesmith from South Philadelphia works a maintenance job that offers health benefits. But he says he can’t afford the premiums. He’s borderline diabetic and visits Health Clinic No. 3 in University City every month to pick up his medication.

When Nesmith learned the city may ask patients to share the cost of their health care, he didn’t like the idea.

Nesmith: Diabetes that’s kinda small, but just imagine if you have something that you readily need it for. Somewhere along the line Big Brother has to pick it up. He has to.

When Nesmith discovered the fees could be as low as five dollars, he reconsidered.

Nesmith: For what I get, they can get 10. Because I work and I’m blessed, yeah, I would pay, if I had to.

Dr. Bettigole says lots of her patients would be willing to pay, too.

Bettigole: The real fear is the person who finds out about it and simply stops coming. It’s a working poor population. These people are proud, and if they can’t pay, they may not come.

City officials say they’re looking to charge fees that won’t create undue barriers to care. They’re already thinking about patient education and guidelines for waiving fees.

The city has also considered the impact of shutting down health centers. At recent citywide budget workshops, citizens overwhelmingly rejected that idea. They were divided, though, on the topic of charging fees for office visits. Dr. Bettigole sees hard choices all around.

Bettigole: We need to stay open. So it’s not that I’m saying we should never charge anything for anybody. But it is a very complicated issue.

Philadelphia may be able to raise as much as a million dollars a year by collecting co-payments from uninsured patients. Health Department Chief of Staff Nan Feyler said there’d be no additional charge for prescription drugs, lab work or diagnostic tests, but she knows the plan makes many people anxious.

Feyler: The other issue is handling money which the staff and the union is very nervous about. We’re looking at, can we have some sort of card, like the parking card you can use in meters and stuff. So we are doing some planning.

The dean of the Jefferson School of Population Health David Nash says it’s reasonable to ask people to contribute to the cost of their care. But he says Philadelphia will have to plan carefully.

Nash: Five dollars may be an actual powerful deterrent, which then would mean these persons would not get care, would not take their medications and would end up in the Jefferson Hospital Emergency Room. Thereby costing everybody a lot more.