By Peter Slevin
Washington Post Staff Writer
Saturday, July 25, 2009
CHICAGO -- On the sprawling South Side of one of the nation's largest cities, the logic of health care is haphazard, at best. For tens of thousands of the working poor and the unemployed poorer, the concept of a regular doctor and easy access to affordable care is a fantasy.
Clinics are scattered and family doctors few. Too many patients get too little care until small problems become big ones. Others who are not very sick go straight to hospital emergency rooms, where the care is costly and the wait is often long.
To put it simply, there is no health-care system for the 1.1 million residents of Chicago's South Side, said Eric E. Whitaker, a physician and public health specialist who is leading an ambitious and controversial University of Chicago project to remake the delivery of care.
With moral support from close friends in the White House, Whitaker and his Urban Health Initiative team are trying to produce a major expansion of community care that will improve patient health and reduce costs -- goals central to President Obama's health-care reforms.
Obama, who traveled to Ohio last week to tout the Cleveland Clinic as a model of low-cost collaboration between nurses and doctors, hospitals and clinics, is well-versed in the Chicago experiment. Whitaker, a friend since they met at Harvard 20 years ago, is a frequent White House visitor and participated in the early health-care discussions. He told the City Club of Chicago in April: "I need your help. The president needs your help."
Whitaker was lured to his job as executive vice president of the University of Chicago Medical Center by Michelle Obama and by Valerie Jarrett. Obama, who launched the South Side Health Collaborative in 2005, was leading the hospital's outreach program and Jarrett, now a presidential adviser, chaired the medical center board.
On June 29, Michelle Obama announced $851 million in federal stimulus grants to upgrade community health centers, saying their work "has never been more important."
Described by Yale University professor Harlan M. Krumholz as the largest effort of its kind in the country, the Urban Health Initiative seeks to improve health and reduce reliance on emergency rooms by encouraging "medical homes" -- a clinic or doctor's office where patients can turn for routine needs and chronic conditions.
The initiative reinforces local institutions with university doctors and connects people to primary-care physicians and community hospitals. Success will require changes in expectations and behavior from patients and doctors, along with technology and shoe leather to make it happen and test what works -- and what doesn't.
'A System Where People Can Go'If that sounds similar to the promise and peril of reforms being debated in Congress, it may be because Chicago's quandary is representative of the daunting dysfunction that defines the health industry in many other places.
"We have to create a system where people can go. It doesn't exist and we're trying to build it," said Whitaker, who worked for seven years in a South Side clinic and once ran the Illinois Public Health Department.
Whitaker, who spends much of his time negotiating with doctors, community groups, government officials and university skeptics, calls these the "very early" days in "a decade, two-decade experiment."
On the South Side, where distrust of the university is old, especially among African Americans, the urban health project and a broader hospital restructuring have drawn strong criticism. Rep. Bobby L. Rush (D-Ill.), a former congressional opponent of Obama, requested an inquiry in May to determine whether the hospital is dumping some of its poorest patients to save money.
The Illinois College of Emergency Physicians warned hospital trustees in February that plans to shrink the emergency department as part of $100 million in budget cuts could compromise patient safety. The group said the university, which treats one in 10 South Side residents, appeared to be "shifting UCMC's responsibility to other community hospitals whenever possible."
"We aren't dumping patients. There's no evidence of that. We are trying to deploy resources more effectively," said hospital chief executive James L. Madara. One way to do that is by "making sure you match the expense of the platform to the need of the disease."
Many emergency room patients have ailments that could be treated effectively in clinics or in smaller hospitals that are eager for the business, Madara said. An appointment that costs $100 at a family doctor's office costs the hospital $1,100, but 27 percent of the patients say they have no regular doctor.
Much of the grumbling, Madara said, can be traced to the nature of change: "There is a resounding chorus of the following phrase: Health care in America doesn't work; don't change anything."
If this is a fight for change, Semeca Johnson is on the front lines. She bears the title of "patient advocate" when she reports to her desk near the emergency room. Her role is to redirect patients who do not need urgent care.
Some show up with pinkeye, a minor rash, an allergic reaction, a broken leg. Some need specialists or a new prescription. An elderly woman with pneumonia needs a hospital bed, but should it be provided by the University Medical Center, a major teaching hospital?
"We just don't have the capacity," Johnson said. On a recent summer morning, one person had been waiting 29 hours for a bed. Ten others had waited at least four hours to see a doctor.
Working the phones, Johnson redirected 15 patients who did not need immediate attention. Among them, five were reconnected with local doctors and five accepted future appointments with specialists.
Seeking a 'Behavior Change'With the help of university money and doctors, the independent Friend Family Health Center, just five minutes north of the hospital, is expanding into the gap. Last year, the clinic recorded 45,000 patient visits. Managers expect to attract new patients from the emergency room and from two recently closed university-run clinics.
The center aims to persuade patients to return for routine visits and other care, although no-show rates are as high as 50 percent. "People are so used to going to the emergency department," said Laura Derks, the university's chief liaison to the community clinics. "The behavior change is really hard."
Farther south, the Urban Health Initiative is collaborating with the Chicago Family Health Center, a group of four clinics where patient numbers are rising. More than 40 percent of the roughly 20,000 patients -- 98 percent African American or Hispanic -- are uninsured.
To keep the lights on and pay the staff, the nonprofit center collects money from Medicaid and Medicare, as well as other federal grants, private fundraising and the university. A sliding-fee scale starts at $10 for a visit and lab study.
"It's all about providing care as close to home as we possibly can," spokeswoman Barbara Tieder said.
Kohar Jones, a University of Chicago family physician, spends four days each week at the clinics, which draw on 27 doctors and four dentists. She speaks of improvements such as patient awareness and clinic and hospital access, calling them a "shift in the way we perceive health and health care."
One conundrum is how to monitor the health of patients distant from the system.
Investigators hope to persuade the city to supply broadband lines to certain hard-to-reach households to see whether connectedness would improve health. The university is deploying doctors and medical students to staff clinics and undergraduates to work at help desks. Some medical school graduates who return to the community will receive a $40,000 annual bonus for four years.
One of the most nettlesome barriers is the shortage of family doctors, blamed in part on Medicaid's low reimbursement rate. Mishka Terplan, who oversaw a women's clinic recently closed by the university, said doctors sought about $1 million from Medicaid last year but collected $100,000.
Addressing Whitaker's project, Terplan said community clinics handling routine cases do not "provide better or worse care" than the university hospital. But he worries that patients could fall through the cracks and that some who need advanced care may not receive it.
Whitaker said the university will step in when "there is not capacity in the community." Mindful of how many are watching, he counseled patience: "The tale will be told five years from now, whether all the directions we're going will pay off in the ways I think they will."
Obama and members of Congress will not have the luxury of knowing how the experiment turns out before any legislation reaches his desk. Only the beginnings are clear.
