 |
 |
 |
 |
Interviews
Mansoor Emam, M.D.
Medical Director, Maliheh Free Clinic
Interviewer
Describe the Maliheh Free Clinic. We've been looking at other clinics and at community health centers. How is your clinic different?
Mansoor Emam
The clinic as you know it's basically in the Salt Lake Valley and as I looked at it several years ago, there were no free clinics outside of the Fourth Street Clinic, which is downtown on Forth South and Fourth West. And to use that clinic you have to be homeless; you either live at the shelter or stay at the shelter-- or you're staying at the park or living in your car or you have to be from VOA, the Volunteers of America facility or from a Halfway House to qualify for the services. So when I looked at it several years ago, to decide whether I should do something like this, I realized that in this area, in the city the size of Salt Lake City, there was really no free clinic for the working poor, for the uninsured, under-served, and that's where we're different. I mean the community clinics, and there are a lot of lower fee clinics and walk-in clinics that are affiliated with Intermountain Health Care, other organizations or scaled down fees and easier access, but they're not free, and sometimes that $20 or $40 or $60 co-pay is what really prevents a patient from getting care. And so the way this clinic works and the way we established this clinic is for patients who are working poor and they're under-served, they have no access to healthcare, they have chronic illnesses and they need healthcare providers to take care of their long-term problems. Unfortunately based on those criteria, there are too many people for one clinic, and that's where the limitations come in--to serve that number of patients based on our number of calls we get. Our caller-ID's go to 200 for each line so we can tell we get between 600 to 800 calls in a 24 hours period. We can see 60 to 80 patients a day. So that means, you know, there's a long waiting list. Currently on April 23rd, we are scheduling patients for July that are new patients. Now patients who are established of course is different--they get in a lot faster and they get the schedule for their follow-up visits differently, and we are not scheduled as a urgent care clinic where you just walk in and be seen, although we, based on when patients don't show up for their appointment, if they have moved or their needs have changed, we usually accommodate between you know, 10 to 20 patients in a day if we can... if it's possible, depending upon the number of physicians and nurses and other volunteers here, we can usually accommodate a number of urgent visits that were not scheduled.
Interviewer
It seems like there is a need for this type of clinic in the valley. Talk a little bit more about that.
Mansoor Emam
Well the need as you know on the latest data that came out recently from the State Health Department, the number of uninsured Utahans without health care coverage, is somewhere about 306,000 patients... I think it was 306,500 or something so roughly 12% of our residents in Utah, which a great majority happen to be here in Salt Lake, are uninsured... 90,000 kids here in Utah without health insurance. So if you look at that for a city the size of Salt Lake City about roughly a million plus residents where you have 12% of the residents who have no healthcare insurance, you can imagine what the need will be for these folks to get care as far as a place that they could afford to go without having to pay, and for many of these folks, you know $40, $60, $80, $20 visit that they have to pay to get in, even in some of the discounts lower-fee community clinics etc. for some it's not possible.
Interviewer
Tell me a little bit about your patients. Describe who walks through your doors.
Mansoor Emam
Well the majority of our patients, about 1/4 of our patients are kids below age 16. We have two or three pediatricians who volunteer here on a regular basis, and the remaining 75% are adults. The majority of these folks are again the working poor who either don't work full time so they don't have the choice to get health insurance, or they do work full time for a minimum wage, and simply cannot afford to pay the premium for the health insurance that the company is asking for, and so these folks mostly are patients who have chronic illnesses. They have chronic medical problems such as diabetes, high blood pressure, coronary artery disease, arthritis, you know, metabolic syndromes where, you know hyperlipidemia and obesity and so for those folks to get the visit to see a physician, to get their labs, to get their medications simply impossible based on their income to do it otherwise.
Interviewer
You're also an Emergency Room doctor. What types of patients do you see in the ER and did that influence your desire to work in a clinic?
Mansoor Emam
Absolutely, yes, in two ways; one is where patients had, not a chronic medical problem, but a more urgent medical problem that could have been taken care of simply much easier as outpatient if an intervention was made early, rather than the patient ending up critically ill and either dying or consuming all of the resources that they would need that could have absolutely been prevented.
Interviewer
So would you see people walking through the door in just horrible condition?
Mansoor Emam
In the ER? Absolutely, either walking through the door or brought in by EMS--a system that absolutely could have had their visit prevent by a simple course, a $4 course of antibiotics, or controlling their high blood pressure with a $4-5 per month medication rather than come in with a major stroke, and so that's one issue from there. The other issue as an ER doc where I work in the emergency room is you would see folks that didn't need to be hospitalized--that they were ill and you would take care of their problems and you know you find out their diabetic and their blood sugars are 400 to 500 but they didn't really require... they weren't sick enough to require to be hospitalized, and you get these folks stabilized, you give them a few days of medications until they get in to see a physician to take care of them, but they had no place to go. Simply, there were no available free clinics for these folks who are not homeless to go to get that continued care, and that's where I saw the need for something of this nature, which is not unique. What we're doing is absolutely not unique. This exists, obviously, in every state in the country, and all major cities have some sort of a free clinic, whether it's a two-hour, you know 7-9 pm, two days a week vs. clinics like ours that are open, you know four days or five days a week, or seven days a week.
Interviewer
Is it frustrating only being able to help a small percentage of the uninsured?
Mansoor Emam
Well it is frustrating. The very fact that this clinic has to exist is frustrating. I think the fact that in a nation with our prosperity and our resources, the fact that this clinic even has to be here I think is a shame.
Interviewer
What would you like to see?
Mansoor Emam
Well I would like to see that at some point the access to healthcare changes from a privilege to a right for basic healthcare, for all of our citizens and residents of this country, but that's a goal I'm sure is easier to say than to accomplish obviously, but nations with a lot less resources than us have been able to do it. There should be a way, no question.
Interviewer
Why is it so important for you to serve the medically under-served? Why was it important for you to open up a clinic?
Mansoor Emam
Well, I immigrated here from a very under-served part of the world where we had no access to basic medical care, In the Southern part of Iran in a small town where we had no access to healthcare, back in those days obviously things have changed now. I haven't been there for 30+ years, but that motivated my desire to some day become a physician and provide basic healthcare or access to healthcare for patients who otherwise don't have that privilege. So it was always my goal to be able to provide that service if I could, and when I was able, two and a half years ago, to start working it, I did. It's important to me as a physician to be able to everyday, day in and day out to be able to do something...
Interviewer
So you experienced first hand growing up really saw...
Mansoor Emam
...saw the need. Saw how it would be without having simple medical care.
Interviewer
And then as a physician you were telling me why it's important to you.
Mansoor Emam
Well as a physician I think most of us go in medicine with the ideology of being able to help patients, but more so to be able to make a difference, and I think being here for me... everyday that I leave this clinic at the end of the day driving home I know for the number of patients I saw between myself and all of the other physicians and nurses and healthcare providers that we're here helping facilitate that need. There is no question at the end of the day that you have made a difference. For the number of folks you saw, out of 60-80 patients between myself and other physicians, maybe 5 could have got care somewhere else, 10 could have got care somewhere else and they used the clinic. But over 90% of them would have no access to healthcare otherwise, and that's where we are privileged to be able to be that hand that serves and make a difference.
Interviewer
Inside of that, you have a lot of volunteers--you have a lot of people who come here. When you walk through the door of this clinic it feels different. Talk about the spirit of the place and the volunteers who work here.
Mansoor Emam
Well I think it's absolutely what you say, it does feel different, and I think a lot of places who collect this type of effort where so many people from different backgrounds, from different religious and ethnic backgrounds, from different political views, different upraising come together--over 400 volunteers here--come together for the same purpose and same goal; to serve without judging, to serve without questioning the need. I think it's that collective energy that makes it feel different, and that's what you and I feel you know in this place. And I'm sure it's not unique again. I'm sure it exists in a lot of other clinics; it doesn't have to be this big and this equipped and to this magnitude. It could be a 2 hour clinic in the basement of a church or public school. When you bring that ideology that you're there to serve unconditionally, I think you feel that energy, and that's the success of this place is the community’s effort that is behind this. I think once that we establish an infrastructure for people to be there to help; I've been amazed how this whole clinic has functioned and came together.
Interviewer
I'd like you to describe an average day in the clinic. Give people a sense of what it's like to work here every day.
Mansoor Emam
Well an average day both myself and one of the two nurse co-directors of the clinic, we usually get here between somewhere 8 to 8:30 in the morning and get the place ready to open at 9 and we generally have a number of patients who are outside the door by 9 am waiting to get in. Most of these folks are scheduled to be here to follow up their diabetes or their high blood pressure or their chronic medical conditions, or they're here to have their labs drawn or get their medications, but basically again in an average day between--it varies obviously again depending on the number of other providers that are here--someday we have an orthopedic surgeon here volunteering and we have a counselor here seeing our patients, we have an ophthalmologist or a pediatrician or a nephrologists or other providers here, so if you look at that in an average day, you know between 50 to 60 to 80 patients--the highest has been 87 patients--who between 9 am and 4 pm are taken care of here, whether they are here for their initial visit to get their basic information to see what are their needs to be taken care of and or whether they're here for follow up. We have a number of nurses who come in--the volunteer nurses who either triage patients-- get their information and put them in the rooms, give their medications that they have to administer here in the clinic if somebody is ill and walks in and simply cannot be scheduled, or if they have an asthma exacerbation where you simply have to take care of them. And then basically the patients come in and get their visit by a physician, see the nurses, get their labs, get their medications through the patient-assistant program that is available from pharmaceuticals. We have one or two nurses everyday signing up every single patient to the programs that are available to get their medications, simply filling out the forms and completing the information they need and I write prescriptions and we mail them in and we get their medications, and then all of the other issues that are involved with taking care of patients--you know some of these patients clearly qualify for other services--some are eligible for Medicare and they have never applied, some are eligible for Medicaid or PCN or CHIP. They have never simply had the time or put the effort to get that service because they were unaware that was available to them, so it's a collective effort, you know we have aside from the physicians and nurses and dentists and other specialists, we have clerks who volunteer here answering phones and helping patients fill our papers. We have interpreters, we have social workers, we have pharmacists who help with different aspects, physical therapists, so it's a collective effort. Again it's just a community effort that makes it worthwhile.
Interviewer
Sounds like you offer many different services.
Mansoor Emam
Not enough. We offer quite a few services that were not available two years ago to patients who are uninsured here, but we don’t have every specialty, neither do we have the resources and equipment to take care of all of the medical problems that we see, so one of the roles of... and a lot of the folks that we see have ignored getting their health issues addressed for so long, not by choice, simply because they could not afford it, that they have a laundry bag of needs and one of the things we do in 15 to 20, 30 minutes of time that we have these patients for the first time is to prioritize--see what is most important to take care of, you know if they have a blood pressure of 220 over 130 and their blood sugar is 450 you know we simply tell them lets prioritize--getting these two issues first taken care of, then we'll get to the ingrown toenail in the 6th visit. But it's a challenge, it's a challenge. We don’t have everything and but we have services that again wasn't available two years ago.
Interviewer
Patients of yours, Gay and Gale Peckham, we interviewed them for our show. Are they typical patients for this clinic?
Mansoor Emam
Yes... absolutely... They both have chronic illnesses and illnesses and the chronic medical conditions that really need follow-up. Simply if you are an diabetic, insulin-dependent diabetic, you can do a lot of things, ancillary things, but if you don’t have your insulin, and if the difference between getting your insulin and not have groceries for your family or buy insulin, a lot of them will forgo the insulin and then they get very ill, so Gale and Gay are pretty typical of a large portion of our patients. We actually have done... we keep track of all of the objective data in our clinic--where our patients are coming from--what zip codes, what ethnic backgrounds, what are their medical problems, and one of the... to constantly be able to evolve and be able to better serve, we have to get objective information, and one of the things that we have done is look at coding, you know that we have the coding numbers that we have for different diagnosis of patients that we see if they have a different CPT code for diabetes or high blood pressure etc., and when we have looked at a number of data on a number of patients, a thousand patient coding data, we have found out that about half of our patients suffer from metabolic disorders--diabetes, obesity, hyperlipidemia, hypertension, and a combination, so that's a whole lot of people. You know we have had... in three weeks this clinic... it will be two years since we opened this clinic, and we have had almost 19,000 patient visits, so if you look at, you know that percentage--fifty percent of 19,000 patient visits, you can imagine what a large group that would be that have these chronic illnesses that need absolute regular follow-up and care.
Interviewer
How many patients do you treat? You said 19,000 patient visits, but people can come back more than once.
Mansoor Emam
Yeah one way to look at it--an average per patient per year is somewhere between three and four. When I looked at it for the first year it was 3.2 patient visits average per patient per year. Granted we may see someone who comes in with and ear infection and you see them once and they're gone and you may not see them for two years, but an average patient records between three to four visits per year.
Interviewer
Gay and Gale talked about the frustrations they had of trying to find a clinic that would take them, and the difficulty of affording their medicine. Do you find that with your patients that a lot of them are experiencing that frustration? What do they tell you?
Mansoor Emam
Yeah that's not an uncommon scenario. A lot of them had given up not by choice, by simple necessities of how they prioritized to get food or rent or shelter versus medication or paying a doctor visit. They basically had given up and that is the sad part again in a nation with our resources that we have to have that. And these are not just immigrants and homeless and the average stereotype that we look at when we say people who need free clinics. When we have looked at it again objectively half of these folks are U.S. citizens and 36% of our patients are Caucasian born and raised here and 80%, 81% are either U.S. citizens or permanent residents. We're not looking at just illegal immigrants or homeless when we talk about free clinics, and that's the sad part.
Interviewer
Do you think that as a state we do enough, that we care enough?
Mansoor Emam
Oh I'm sure we care. There's no question that people care but do we do enough, have we done enough? I think the answer is pretty obvious. I think you know that as I mentioned we get between 600 to 800 calls a day and we see 60 patients to 80 patients. What happens to the other, you know 600 to 700 patients? Where do they go? Where do they get their care? It's obvious that you know we could have four of these clinics in this valley seven days a week and we still would not meet the need.
Interviewer
You mentioned many of your patients have chronic illnesses. How important is it that people get preventative care?
Mansoor Emam
Well I think it's very important. If you look at patients with chronic illnesses, whether it's high blood pressure or the example again is diabetes that we have so many patients that have the conditions, if you control their blood sugars, and we have ways of monitoring with tests that we can tell over a period of three to four months how well they are managing their blood sugar--not just the day we see them here--if they control it with certain numbers that we look at, those criteria, if they're well-controlled, the complications, the morbidity they get from diabetes affecting their eyes where actually this is the leading cause of blindness in our country--where their diabetes affects there kidney where they can end up on dialysis, and where their diabetes affects their nerve--why patients with diabetes lose limbs--is tremendously reduced with controlling their blood sugars long term. So it's a simple fact that by preventing, by controlling their long-term illness--chronic medical condition--you are preventing major catastrophes down the road.
Another example, is smoking cessation. One of the awards you see on the wall is from the state of Utah quit line and it's as, as you'll notice on the plaque it says we referred more patients than any other clinic the program was able to help them quit smoking. This is a free program available through the state of Utah that helps patients with smoking cessation and it's very simple, so every patient who smokes we ask them... we tell them the scientific facts about the effect of smoking and ask them if they are willing to stop, and not everybody says yes, but those who do we'll just simply help them fill in a simple form, we fax it in and they are contacted by the quit line staff, and a great majority of them end up stopping smoking. And you look at the long-term effects of a person that stops smoking verses people who continue to smoke... I think the answer is pretty obvious.
Interviewer
It seems that there are simple steps that people can take to really affect their health.
Mansoor Emam
Oh absolutely. Absolutely. Again weight loss and exercise. I mean the list can go on and on.
Interviewer
You talked about being able to get patients, like the Peckhams, on medicine. Doctors have mentioned to me that they are often frustrated because they can write a prescription for a patient, but they know full well that it won’t do any good because the patient can't afford medicine. Have you run into that scenario?
Mansoor Emam
Yeah that was one of my motivations from my ER experience that you will see somebody, you give them a prescription and then they simply can't afford the prescription so therefore you really didn't provide a meaningful service if they were ill and could not pay for the antibiotics then it would have been the same if they didn't actually see you. So here the way we address that is first of all we get quite a bit of samples from pharmaceutical companies so if I'm seeing a patient that has diabetes and I want to try them on a new medication, I can simply give them a day or two or three days of samples that are given to us by pharmaceutical reps and have them try it to see if they will tolerate the medication or does it work for their condition. Then once we know that there is no adverse reaction to the medication, that they can actually tolerate it, if these medications are not generic and they're not available through discounts prices--as you know as several retail chains including Wal-Mart and Target and K-mart--they have programs where patients can get hundreds of medications that are on this list that these retail chains have that they can get their prescription medication for a lot of different chronic conditions, and some for even acute conditions such as antibiotics and pain medications etc. for $4 per month. So we ask the patients simply if they can afford $4 per month for that medication and for a good number of patients actually can, so they elect to... they want to be involved in their own care and so if they simply can pay their $4 a month for their medication they will say yes we can and they will get enrolled in that program from those retail chains. A number of patients cannot take generic medications or they are on medications that are not available in these lists, but they are fully eligible for getting these medications from pharmaceutical companies, and that's a huge program, and it involves knowing the system, it involves being able to have access to the internet and a computer where you pull these forms from their site of the pharmaceutical companies and involves somebody who knows the forms to help you to fill them out, but some patients can do it at home.
So we... every patient that any of us physicians see that requires a medication that is available from pharmaceutical companies, we have dedicated nurses here every day that that's all they do--they sign up every patient to these programs. So as a result we get... and we have actually charted these you know we put the retail value of these medicines that have come in from pharmaceutical companies for a period of time and looked at the cost savings to our patients and we get between $15,000 to $20,000 medications per week from pharmaceutical companies that are shipped here. We basically then, they are saved here in our in our alphabetical boxes and we call the patients, they pick them up three months at a time and they're eligible to get them for a period of a year to a year and a half from pharmaceutical companies. So we establish every patient on these programs that are available.
And then lastly we have an account with a retail pharmacy that is only a mile from here and there is a bus that goes from here for those folks that absolutely need medications and they have no way of getting the medications and we provide a voucher and simply emboss their prescription with a raised stamp so the pharmacist knows that the cost of medication comes from our account, and we don't do that for every medication, but certainly for medications that we feel that patients absolutely have to have, we try to facilitate that by paying for the prescription.
Interviewer
Although the clinic and the over-arching safety net help a lot of people, there are some critics who say that these types of clinics, in the long run, actually hurt the uninsured. Because they make it seem as if we’re addressing the need when we really aren’t. We aren’t creating over-all reform. That all we're doing is trying to put little band-aids on a gushing wound -- we're actually preventing real change from happening.
Mansoor Emam
Well that's one way of looking at it, but when I was going to open this clinic, one of my partners asked me, he said, “You're at the peak of your career... why are you doing this? I mean you’re obviously not going to solve the issue. This system is broke and the politicians and people in charge haven't been able to fix it. What can you do as an individual that you think would be worthwhile?” And my philosophy and answer to him was simply that if you see a problem that is so fundamentally broken, so fundamentally wrong, if you sit back and say it's beyond fixing, therefore I'm not going to do anything about it I think is more wrong than what the actual problem is. So true, we could be criticized for what we do, but the simple fact is that for the number of patients that we see, for the 19,000 patient visits that we have had, the majority of the folks wouldn't have had their care otherwise, so we do make a difference for that group of patients that we do see. Again, it may be a band-aid, but the band-aid is better than nothing so we continue with that philosophy that as long as we make a difference one patient at a time, and as long as the need is there, we'll do it.
Interviewer
While we’re talking about critics, some people like to refer to some of the uninsured as the “young immortals” or “freeloaders”, those who supposedly can afford the cost of health insurance, but choose not to buy it. You offer free care. How do you make sure you’re not assisting people who are basically “freeloaders”?
Mansoor Emam
Some of the criteria that we have established for the patients to be eligible for the clinic actually address that. If you actually simply made a choice not to get insurance because young, and you feel like you're not vulnerable and you're not going to get ill or anything that you need insurance and you make an income that is above 150% federal poverty guideline and you call the clinic, by the screening process we know that you don't qualify, that your lack of insurance is simply your choice. And that's one of the ways that we look at it simply as that by establishing guidelines of who qualifies for the clinic. This is an honor system. We take their word for it, but again you have to agree that most people are decent and honest and will give us the right information, which I fully believe, and a few that they don't is the tax that we have to pay to take care of the 95% plus that do qualify for the services, and the fact that they don't have insurance is not by their choice.
Interviewer
In other interviews, I've heard you refer to the clinic as a “bridge”. What does that mean?
Mansoor Emam
Again if you look at the need that is in the valley and our size of our clinic, there's no way that we could follow everybody in the area that has the need and qualifies for the clinic long term. Simply, it's not possible based on the physical restraints of the facility. So we tell patients that we'll help them with their... again prioritize their need and help them get their labs, their medications, their follow-up, the sub-specialty care that is available through here until they're able to healthcare through other means, so some of our patients will get a job and at some point they're actually able to pay the premium... their share of the premium for healthcare insurance and they will actually move on to clinic that accept those private insurances. We have patients, again, that qualify for Medicare or Medicaid or PCN or CHIP. Once they get that access we ask them that they need to go to the clinics and we help give them, you know... these are the clinics that will accept PCN and we help facilitate that step because otherwise if everybody was to stay and get their care from here, we would not be able to serve. So that's the bridge. I mean basically we serve until they no longer need us; they have other ways of getting... some of them move, and some get jobs and some get healthcare insurance, but that's what I meant by the bridge--it's that we are not meant to be the long-term primary care provider for these folks, although at some point we serve as that, but that's not the intent of the clinic.
Interviewer
It sounds like you're the conduit.
Mansoor Emam
We're the conduit, and for about 30% of these patients, as we look at this data again objectively, for about 1/3 of these patients, we are actually their provider until we're no longer here or something happens, but for the majority of them we are able to, you know either they get jobs or they move or they get access otherwise.
Interviewer
Could you sum up what the Maliheh Clinic is?
Mansoor Emam
Basically the clinic is a privately funded, community-supported private clinic that serves the medical needs of the un-insured and the underserved population of the Salt Lake Valley, and I say Salt Lake Valley, but we know based again on our zip code analysis--we have patients coming from Tooele and Idaho and Evanston and Springville, so it's not just Salt Lake Valley, but we have patients drawn to the clinic that they were not able to get some of the care in their communities for free, and so again it's a community effort and it works.
Interviewer
What does Maliheh mean?
Mansoor Emam
Maliheh is the name of the grandmother of our benefactor, the initial funding for the clinic came from the Semnani Foundation - and Mr. Khosrow Semnani was the main... one of the two main benefactors that started the clinic--the Semnani and the Holmes family, and Ms. Maliheh ? Is the name of the grandmother of Mr. Semnani? Maliheh means comfort and beauty in Persian, in Farsi, which is very fitting for the type of the clinic we run.
Interviewer
Do you find a particular emotional connection or do you relate to your patients in a certain way? What is your relationship with the people who walk through the door?
Mansoor Emam
Well our role is that we take care of these patients without judging and basically fully realizing that we are their advocate and maybe their only advocate as it comes to their health-care issues. And so we relate in that sense that we basically are providing a care for them that they were not able to get otherwise. Maybe it's not a perfect system, but again at the end of the day if you make somebody stop smoking or get their diabetes under control, or exercise--simple things--you are making a difference and our connection comes simply from, the joy comes from simply seeing our patients and their follow up where their cholesterol was 400 coming down with a normal cholesterol in three months. So the long-term affect of managing their chronic medical conditions, that's the joy. That's the paycheck.
Interviewer
Is there anything that you want to add that you think is important...
Mansoor Emam
I think it is important for people to understand that the need is great and the clinic runs on limited resources and it is the physical size and the number of volunteers and what we can do does not meet the demand, and so sometimes there is frustration about why it takes so long to get in and why are we only here four days a week... and the limitations of what we can do, but people who come here to volunteer, which a lot do, simply clear their day off to be here to serve. We face the challenge of making sure they're not bored, but making sure they're not burned out. So to create that balance is where we are now. We can serve that many patients, but again, not every need. We wish we could do more, but again you know this is a service that is here that wasn't here two years ago. We also recognize the fact that we are very fortunate, blessed and privileged to be able to do this.
