MILWAUKEE — Like many low-income neighborhoods, the north side of Milwaukee has seen a gradual depletion of its primary care doctors over the last two decades. One by one, they have retired or surrendered to financial reality, rarely to be replaced.
At the few remaining practices, the wait for an appointment can make it almost purposeless to seek one. When Martha Brown’s 3-year-old daughter, Loverree, woke up with a runny nose last Thursday, her doctor’s office told her it would be a week. “I couldn’t wait,” Ms. Brown said. “I had to see what was wrong with my baby. I think she’s got an infection.”
Rather than heading to an emergency room, Ms. Brown took her three children to the Milwaukee Immediate Care Center, a small nonprofit clinic that has treated the north side’s largely African-American community since 1986. The clinic, which keeps hours at night and on weekends, is the only full-time operation in the neighborhood that provides urgent care, luring patients with a sign that reads, “When You Need a Doctor Today.”
Ms. Brown’s decision made good sense, not only for her but for the state and federal taxpayers who support her health coverage through Wisconsin’s Medicaid managed care program. But whether the option will remain available is an open question.
The clinic has teetered on the brink of insolvency for years, battered by foreclosure filings, delinquent tax claims, building code violations and the loss of contracts with two major H.M.O.’s. It has had to cut its hours in half, significantly reduce its medical staff and mothball its X-ray equipment.
Patient visits have dropped to about 7,000 a year from 15,000 three years ago, before basement flooding and a leaky roof prompted the city to shut the clinic for three months. The doors stayed open this month, said its president, Perry Margoles, only because a board member provided a $10,000 loan.
It might seem the health care legislation being written in Washington, with its emphases on primary care, lowering costs and improving access, would provide answers for clinics like Milwaukee Immediate Care. But Mr. Margoles thinks things may be too far gone in his clinic’s neighborhood.
“We’re having a meltdown approaching — to use an engineering term — a catastrophic failure for much of what remains of the health care infrastructure for the northern half of the city,” Mr. Margoles said.
Yes, he said, covering more of the uninsured would help his bottom line, which has been red in each of the last two years. But the bigger problem, he said, is the below-cost reimbursement provided by Medicaid, which insures three-fourths of the clinic’s patients. For a typical office visit for which the clinic charges $75, BadgerCare Plus, as Wisconsin’s Medicaid program is known, pays $49.
Dr. Syed H. Hasnain, the clinic’s lead physician, said more was needed than simply luring medical students into primary care with grants and loan forgiveness programs. “There has to be some parity between commercial insurance and Medicaid,” Dr. Hasnain said. “Common sense dictates that otherwise, who would want to work with public insurance recipients?”
The clinic often finds itself dealing with conditions like advanced hypertension and diabetes because patients without adequate insurance may defer care. But because Mr. Margoles has never tried to transform the clinic into a federally qualified health center, it is not eligible for the higher reimbursements paid to those centers. It also is not eligible for the billions of dollars allocated to the centers in the stimulus package, or the even larger increases that may be included in a health care bill.
For Mr. Margoles, a 65-year-old nonpracticing lawyer, the stress of dodging bankruptcy may be taking its toll. Three weeks ago, he said, he began having chest pains. Dr. Hasnain diagnosed the spasms as signs of coronary artery disease and recommended he go to an emergency room.
Mr. Margoles would not go. He is uninsured. He said that since opening the clinic he has deferred his $100,000 annual salary, surviving instead on modest rental income from property he owns and the generosity of family members. Although he is old enough for Medicare, the salary deferral has meant he has not paid enough into the system to qualify for benefits.
“I can’t afford to go to the emergency room or the hospital,” he said. “I’m not going to go bankrupt to get care I can’t afford.”
Because any health care deal is certain to preserve the private insurance system, Mr. Margoles said it would do little to solve his biggest headache — the refusal of two health maintenance organizations to renew their contracts when the clinic reopened in 2007.
Mr. Margoles accused the insurers of paying him back for complaining previously to the state about their billing and claims practices.
One of the companies, UnitedHealthcare of Wisconsin, said in a statement that it declined to contract with the clinic “after thorough consideration” and “with a consistent emphasis on providing access to quality health care for our members.” A spokeswoman for Centene Corporation, the parent group of the other insurer, Managed Health Services, did not respond to requests for comment.
Jason A. Helgerson, the state Medicaid director, said he had discussed the decisions with both insurers and found no evidence of retribution. Mr. Helgerson said he had no authority to force an insurer to contract with a particular provider.
“In both cases, they raised serious concerns about his business practices and were very opposed to signing a contract with him,” Mr. Helgerson said. “I know that in general the H.M.O.’s are eager to have as many providers in their networks as they can. It’s a rare circumstance for this to happen.”
Mr. Margoles has at times considered trying to convert his clinic into a federally qualified health center but is convinced that the move would be opposed because of its proximity to one of the four centers already in Milwaukee.
Senator Bernard Sanders, a Vermont independent who has led the effort to expand community health centers, said there was no money for noncertified clinics in the bills now circulating on Capitol Hill. But Mr. Sanders said he recognized the needs of clinics like the one in Milwaukee.
“I’m well aware there are people trying to do the right thing,” he said, “and to let these clinics fall by the wayside would be a mistake.”