Critics: Jackson Health System cuts hurt primary care for poor

By John Dorschner

jdorschner@MiamiHerald.com

When Myrtle Holmes, 56, wants to get an appointment at Jackson’s clinic in Overtown, she says she sometimes has a hard time getting through on the phone. When she does, she’s often told it may take 60 to 90 days to see a doctor — a huge wait for a diabetic with several chronic conditions.

“I’m smart. I know what I have to do when I need care,” says Holmes, who until recently was uninsured. “I go to the emergency room.”

That often ends up costing taxpayers huge sums at Jackson Memorial Hospital, say healthcare experts, rather than a few bucks spent on her primary care at Jefferson Reaves Sr. Health Center, which is operated by the Jackson Health System.

“It doesn’t make sense,” says Darryl Reaves, son of the man the clinic is named after and a member of its board. “We’re trying to explain to Jackson that we can save money for their system and keep people healthier.”

Leaders of the Reaves center and another Jackson-run clinic — the Dr. Rafael A. Peñalver Clinic in Little Havana — complain that in its financial distress, Jackson has damaged primary care for the poor by cutbacks, elimination of pharmacy services and dental care, and forcing uninsured patients to go to Jackson Memorial to register for discount services before returning to the clinics for treatment. Jackson has also raised fees the poor must pay out of their own pockets for their care.

Jackson eventually restored the pharmacy at Peñalver. Jackson spokeswoman Lorraine Nelson says the other services were not discontinued, simply consolidated on the main campus, with free vans to transport clinic patients. “Providing healthcare for patients who live in impoverished areas is a part of that mission” — for which the system gets $350 million in funding from sales tax and property taxes.

Even so, Peñalver’s board became fed up with Jackson’s cost-cutting and recently decided to contract with an outside firm to provide care at the nonprofit clinic starting next month, says Boris Alvarez, Peñalver’s executive director. “We want to save money for the taxpayer and enhance the services that Jackson was providing.”

At the Reaves clinic, “we’re looking at all the options,” says Gregory Gay, president of the board. That includes finding another provider, hiring its own staff or getting someone to offer services in the vacant rooms that Jackson no longer uses.

Jackson executives are trying to stem its massive losses, which totaled $337 million the past two years and $75 million so far this fiscal year. The system closed two of its six clinics at the end of 2009. Last year, it lost $20 million on the four remaining clinics. New Chief Executive Carlos Migoya said he wants to expand the number of primary care centers, but he’s looking at affluent suburban areas with lots of paying customers.

“They have a difficult task,” says Robert Schwartz, University of Miami’s chair of family medicine who oversees residents practicing at the Reaves clinic. What’s happening at Reaves is “an example of what the country is struggling with,” Schwartz says, because America’s healthcare system focuses on paying for expensive hospital care and spending little on the primary care designed to keep people well.

Darryl Reaves says the number of patients at the Overtown center has dropped about 25 percent recently, partly because patients now have to go to an office at Jackson Memorial to qualify for what’s called a “Jackson Card,” which offers charity or reduced-fee care depending on income level — an enrollment that used to be performed quickly at the clinics.

Jackson Vice President Carmen Pla says in June a staffer was placed in Overtown to get information on patient finances. Reaves says a staffer is being trained to do such intake but hasn’t started yet.

Reaves, a former state representative, says other patients have been deterred by Jackson’s raising fees for the uninsured. While the poorest continue to pay nothing for a primary care visit, some uninsured patients are now asked to pay $50 or $80 per visit.

The number of patients at the Little Havana clinic also have declined, Alvarez said, for the same reasons — fee hikes and the trip to Jackson Memorial for processing. “This is a big problem.” He said he understands the philosophy of having patients pay part of their costs but sometimes the result is that the system ends up paying more at hospitals than it saves at its clinics.

Jackson spokesman Edwin O’Dell said Friday that the executives couldn’t immediately estimate how much clinic cost-cutting had saved the system, but Migoya has said repeatedly that his goal is to provide high-quality care at reasonable cost.

Alvarez says Jackson re-opened the pharmacy at Peñalver because Little Havana patients were clogging the Jackson Memorial pharmacy. He has also managed to get the dental clinic reopened with an outside grant.

UM’s Schwartz says he’d love funds to re-open the two-chair dental unit in Overtown. “You can’t separate oral health from the rest of the body.” An infection from decaying teeth can easily extend through the rest of the body.

Gay, the Reaves leader, says that when patients are forced to make an extra trip to Jackson Memorial for care or processing, some don’t go, even though it’s only a two-mile trip. “We don’t want people going back and forth. You lose them in transit. They say, ‘This pain really isn’t that bad.’ So they wait until they get really bad and then they end up at Jackson Memorial costing taxpayers a lot of money. We’re trying to break that cycle.”

Jackson has long had a lack of support for primary care, say the Overtown leaders. “The problem is that the poor don’t have a voice,” says Darryl Reaves. The Reaves pharmacy closed in 2006. The dental office shut in 2010.

Spokeswoman Nelson says centralizing services has caused the Reaves staff to drop from 44 persons in 2009 to 29 this year.

“The care is good,” says Holmes, the diabetic. “It is just the way we get cared for,” with long waits to be seen.

“We’re fighting in the trenches,” says Darren Thornton, a second-year resident. Most of the patients he sees at the Reaves clinic have multiple problems. “My goal is to keep the damn patient out of the hospital.”

One recent patient, a woman in her mid-50s, came in with her blood pressure above 200 — sky high. She said she had once been given a prescription for high blood pressure, but hadn’t used it for a while. She also showed an empty bottle of diabetic medication from 2010. She needed a mammogram, had gastric bleeding and part of her heart was enlarged.

Medically, such a patient is “noncompliant” — not following doctors’ orders on medications and other matters.

“But ‘noncompliance’ is just a term,” says UM’s Schwartz. “The question is why she is noncompliant.” Maybe she can’t afford the prescriptions or hasn’t been educated on why they are important.

Schwartz teaches residents at the clinic to listen to patients and explain why it’s important to take their medications. But he acknowledges that in America’s healthcare system, primary care doctors often have little time. “Insurance companies tend to pay a lot for procedures, not talk.”

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