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Interviews
Nell Hodo, M.D.
Family Practice Doctor
Stephen D. Ratcliffe Community Health Center
Interviewer
Community Health Centers seem to be a really unique concept. Explain to me what is a community health center?
Nell Hodo
I think a community health center is a clinic or medical facility that is located in a community where most of the people who live in that community go there for their medical care, and ideally the services that are provided are tailored to the needs community, whatever those might be, which could be different depending on language, or culture or the age range or the people living there.
Interviewer
What do you see with your patients? Is it important to them to have a health center in their neighborhood?
Nell Hodo
I think it is important to have. There is sort of this movement to have a medical home, which is basically a primary care physician that is your physician, and I think that that is an important idea. A lot of our patients have been coming to our clinic for generations, and so there are definitely many families that I take care of where twenty years ago, maybe the mom who was pregnant saw a physician there who maybe isn't there anymore and now their children and grandchildren are coming there as well, and so I do think that for families like that, it's definitely an important part of not just medical care, but an important part of their lives and raising their children.
Interviewer
Would you describe your typical patient?
Nell Hodo
Well since we're in Rose Park on the West side, our typical patient is probably an immigrant, most likely Spanish-speaking, although we do have a large Vietnamese-speaking population and we have a growing African population--mostly women and children, predominantly because I think most of the men are working multiple jobs and so even though we may see them occasionally, we don't see them as often, and really in terms of age we have a lot of younger families--40's and under with many children, but we also have a lot of grandparents and elderly and many of our elderly patients are actually of a different ethnic group. A lot of our elderly are older Caucasian people who've lived in that neighborhood for a long time because it started out, you know, back in the day as the neighborhood where the railroad workers lived and so there definitely elderly people in their 70's, 80's and 90's who've lived there since that time, and the older you get the dynamic changes a little bit in terms of what ethnic group you're seeing.
Interviewer
I notice at the health center you do more than just treat the physical need of the patients. There also seems to be a social and sometimes a psychological component.
Nell Hodo
Well I think that's really part of complete health care, I mean it's not just the medical problem. Everybody has a psychological component and obviously there are all sorts of things going on in the family that effect not only the family's health, but also their ability to do things like come to appointments or pay for visits or pay for medications and so one of the models of family medicine in general is treating the entire family and its a thought that if you're a family physician and you're seeing all of the members of the family, you get a more complete picture of what's going on because you don't just see the kid or the wife or the husband in isolation. You know, because you see the wife, that she and her husband are having problems even before he comes in to see you for his high blood pressure. So you kind of know the background, or maybe you see the child and you know that dad's out of work or whatever because you just saw mom a couple of weeks ago and she told you these things, and so I think it does make a difference in terms of how you care for the patient.
Interviewer
I think that a fair number of patients you see face barriers to treatment...
Nell Hodo
I think that's putting it mildly. It's true; I mean a lot of our patients are undocumented--at least the parents. Most of the children are citizens and were born here, but as an undocumented person it's very hard to find a job that gives you health insurance. Most people are working multiple part-time jobs, but they don't have any benefits with that, and so we do a sliding scale at the clinic based on income so people who make more pay more, people who make less pay less, but even that is sometimes too much for families, and we do have people who will cancel an appointment because they just can't pay their $20 for their clinic visit. So I think access to care is huge in that respect--the lack of insurance through their work, and then of course people who are not citizens don't qualify for Medicaid or Medicare and actually a lot of the pharmaceutical programs that are in place from the drug companies to help people get medications for little or no cost, you have to be a citizen to qualify for them--not all of them, but lots of them, so we find a lot of our adults are in a position where it's very, very hard to get them the care they need short of just sending them to the emergency room, which is sometimes the appropriate thing, but often it's not something that's that acute, so you're sort of in this limbo of trying to figure out how can I get this person a study or to see a specialist or whatever when they don't have insurance or they don't have enough money to pay for it out of pocket.
Interviewer
Is it frustrating?
Nell Hodo
It is frustrating. I think we all spend a lot of our time trying to negotiate that and trying to figure out how we can possibly get somebody a service that we think they need. For the kids it's still a problem but it's less of one because many of them do qualify for CHIP or Medicaid or other programs which are, of course, always in danger of being cut, but at the moment seem to be o.k. but then there's another hurdle of getting people to fill out the paper work and assisting them with their paperwork when they may have no literacy in English at all and they may have very, very limited literacy in whatever their native language is, and we find that quite frequently, and a lot of my patients, regardless of what their country of origin is, a lot of them only went to first or second grade at home and so most of these forms are written on at least a high school level if not more, even if you can get one that's translated into their own language, so that's another huge burden.
Interviewer
They also have to face transportation barriers.
Nell Hodo
Yeah, I mean we very frequently have patients that if they don't come to an appointment and we call them and say, well you missed your appointment, can we reschedule you? And often they'll say we'll I just couldn't get a ride, or I thought I had a ride, but my ride was late and they were so late I couldn't go. Our clinic is situated on the bus line so that helps a lot, but obviously it doesn't completely get rid of the problem if the bus is late or you know whatever. Transportation is a huge, huge issue, and a lot of our patients walk to our clinic if they live right in the neighborhood so... one of my patients walks about 25 blocks, Salt Lake City blocks to the clinic because they have one car and her husband uses it for work so if she or her baby need a medical visit then they walk. It's a long way to carry a baby carrier.
Interviewer
What other cultural barriers or cultural differences do you see in caring for your patients?
Nell Hodo
Expectations are very different I think is one thing. A lot people come from an area where there really is or little medical care. A lot of people come from rural areas in Mexico or other countries where they didn't have a doctor. Maybe they had somebody trained in first aid, maybe they had a midwife. They probably did have a midwife to help with deliveries, and maybe they visited a regional hospital, and so it's very different to have a physician that they see regularly or that's accessible in that way, and not everybody... some people come from urban areas, but for a lot of people just the whole concept of a clinic that has multiple physicians and nurse practitioners is different. And another thing that is different I think is the way you go about paying for care. In a lot of other countries it's a barter system or you have to... there are certain services that are really only available for the wealthy because there is no system for the poor to get those services so some people are accustomed to saving and saving and saving for years to get an appointment with whatever kind of specialist, so that happens less here and that's really different. We still have a lot of women who come in very late for prenatal care because wherever they came from they didn't have prenatal care. That wasn't something that they did, so we routinely have people that turn up at 29 weeks, third trimester, who haven't seen anybody, haven't had any testing whatsoever which of course isn't at all the norm in the United States, but it's pretty common elsewhere. And it's not that we don't have American citizens doing that too. We do, but usually the reasons are a little bit different than people who have moved here from elsewhere.
But there are other differences, I find very few of my immigrant families are behind on their immunizations. If they have missed a well-child check in clinic and didn't get their shots, they'll usually go to the health department, and I think the reason is is they know what these diseases are. They grew up in countries where people died of measles. They saw rubella. I have a patient who is a mom and is a polio survivor and has a completely withered leg and walks with a brace. Well there's no way that she's not going to get her kids immunized against polio. Whereas most of us in this country have never seen, I've never seen most of those illnesses. The few that I have seen I've seen in Africa, so you know it's a very different world where those diseases are still very present in their minds because many people in their villages may have had them. Whereas we don't see that any more--very, very rarely so... That's not to say that there aren't kids that don't get any immunizations at all, and I think that probably children who don't have access to any clinic whatsoever--who don't see us, who don't see anyone, of course they probably are behind, although they may not be. They may go to the health department. But our kids, I find, in general if they're behind it's a matter of months, it's not a kid who never had any vaccinations as an infant –it’s more like they're 8 months old and they didn't get their 6 months shots... it's more like that.
Interviewer
Besides cultural differences, it sounds like there are also language barriers. How do you deal with that?
Nell Hodo
Our staff is pretty much; I think there may be a couple of exceptions but, almost entirely bi-lingual. Most of our staff, though not all, are Latino and many of them are second or third generation here, so our phone staff and all of our medical assistants speak equally well English and Spanish. We also have a large Vietnamese community and we have one too, I think it's two half days a week where we have a Vietnamese interpreter who comes and so that tends to be when most of our Vietnamese patients come.
But yes, it's a very diverse community and a lot of these employees that we have, they are from the same community as the people that we serve. A lot of them have just been here longer or they have attained more education or they're second or third generation. And so some of our newer patients are perhaps where their parents were or where their grandparents were.
We also have an Americorps worker who is there all year and she does all of our prenatal registration. She does some of our diabetes education. She helps run our drug program and coordinates the pharmaceutical drug donation programs that we have.
We have a Medicaid worker, at least for now, in the clinic. We have two men who work there. One of them is there almost every day and that's something that may be changing which will be a great shame, but for now anyway we have someone on sight who is bi-lingual who can help patients with their forms, you know, often screen out right away saying look you're not eligible, there's no point in doing the paperwork. Or actually you think you're not eligible, but you probably are and you should do this. And we'll walk them through the process and then follow up with them about where things are. And that's a huge help because we have so many people who are eligible for services and just don't know that they are, or find the application process just overwhelming. And so that's something that we feel pretty strongly about is if someone is eligible we'll help them get the service that they deserve instead of continuing with no insurance.
It might change because and again I'm not entirely clear on the details but I gather that there has been a movement on the state level to remove Medicaid workers from local clinics like ours and consolidate them with the Department of Workforce Services, which is downtown. The Department of Workforce Services also helps people get coverage, but it's mission, at least what I believe it's mission to be is slightly different because Workforce Services at the moment is really geared toward getting people off public assistance, getting people back on their feet and getting them off of programs, whereas traditionally your Medicaid worker has been geared toward getting eligible kids on programs. So we're a little concerned--first of all if we lose our Medicaid in our clinics then obviously I mean we know that a lot fewer of our kids who are eligible aren't going to get Medicaid because it's one more place to have to go. Right now they can come to the clinic, they have somebody who speaks Spanish, a lot of them know these people, they can go through their forms with them, it's sort of one-stop shopping if you will. If they are removed and they have to go downtown then it's just again transportation--a lot of people just aren't going to do it even if they're eligible. And so for us I think it will be a bad thing because people who qualify for services are not going to get them. I'm sure it's a cost saving measure. I'm sure they're trying to cut down on the number of employees, but I don't think for us and our population it will be helpful. It might save money sort of by having less people on the Medicaid roles, but if people aren't on the roles who deserve to be, then you're just racking up more costs in your emergency rooms and denying people preventive care so in the end the short term cost is less because you're not paying for these people to be on the roles, but your long term costs is much greater because now you have people with no coverage who are going to wait until they're very, very ill or use the emergency room. So I'm hoping they will choose not to pull our workers.
Interviewer
In terms of practicing medicine, what are you biggest frustrations?
Nell Hodo
I mean one thing is sort of what we touched on before--the difficulty of finding appropriate services, especially referral services for people who don't have insurance. That's a sort of day in and day out regular frustration that doesn't really change.
I guess another frustration would be when the appropriate therapy for the person is expensive. It's new-- it doesn't have a generic medication. There are substitutes but they're not as good and whatever you want to prescribe is too expensive, so trying to figure out are we going to do the second line thing or the third line thing or the fourth line thing which is affordable but maybe it's not really the standard of care, but it's what they can pay and what they can actually do, and making those kinds of compromises is hard for a lot of us. You want to do what you know is the recommended treatment, and a lot of times you just can't. It's just not something that's doable and so you do the best you can and you say wow, maybe it will, maybe it won't, it might fail, we might have to do something else and that's frustrating, and it's frustrating to have families say to you well why can't we do this? And you say because it's too expensive. This is what it costs. If you think you can do it, that's fine, I'm happy to do that, and most of the time they say, yeah, I can't do that. That's really frustrating.
Another thing there are some things that just have to do with the nature of medical care in America, I mean reimbursements for Medicare and Medicaid and basically private insurance have basically been stable for years without taking into account inflation or with minimal adjustment, and so you get paid less for what you do every year which means we al see more and more patients, and this is true of everybody, not just community health centers. I mean doctors today have, in primary care, usually have an average appointment time of 10-15 minutes. That was pretty different twenty or thirty years ago, and even though you see more and more because you're getting paid less by the insurance companies or whatever, you still barely break even at the end of the day, but you're much more tired and you don't always feel like you had as much time as you'd like to have with the patients, and I think that's a frustration that I suspect every physician in primary care, regardless of where they work, what state, what population. I think everybody has that frustration, is that it's just harder and harder to make ends meet even when you work really hard.
Interviewer
The mission of the clinic is to serve the under-served, and yet financially...
Nell Hodo
Financially the problem is... although we do get federal grants and we do get some money from the state, it's my understanding that those funds have been effectively frozen for years, so again, not adjusting for inflation. And obviously if you come to the clinic and because of the sliding scale you pay $20 for your visit, obviously that $20 in no way covers the cost of 15 or 20 minutes of time plus whatever lab work you've had done. It obviously doesn't come near to it. If you were an insured patient, your insurance would probably be billed around $150 for that, not that they would pay all of that, but at least they would be billed that. Because of what we do, we know we're not going to make money on that at all. And the problem is that there just isn't the funding coming in, at least that's my understanding, there's not the funding coming in on the federal and state level to continue supporting clinics like ours. So we do have some insured patients obviously. We have Medicare and Medicaid patients and we do get reimbursed for those. But it's sort of a constant balance of, you get reimbursed for some patients so that's the money you have coming in plus a little bit of grant and you try and stretch all of that to try and cover the care you're doing for everybody and it doesn't always work. It actually hasn't been working for the past years or so.
I know that in the beginning that in the calendar year that we were negative over a million dollars and there has been a problem of increasing efficiency trying to get people to see more patients. We started charging fees for people who don't come to their appointments, which we didn't use to do. We started really enforcing the sliding scale fee that we have, saying well you have to pay your $20 with some exceptions obviously if the person is really, really ill and the physician decides they really have to be seen anyway. Most things can be rescheduled. That was something that I think we weren't in the habit of doing as an organization, we would just say, “oh well you can't pay today.” We stopped doing that, and there are issues with that. There are sort of moral and ethical issues with that, but at this point it's my understanding that the organization, the financial side of it, doesn't really feel like they have a choice because if they don't at least make people pay their co-pays and pay their late fees, then there's just no way we're going to catch up or get out of the hole. And that's not a complete solution obviously, and it gets you in a little bit of a precarious situation I think. I think it's hard, it's hard for me to say, “Wow you know, I need to see more insured patients for the financial well-being of the clinic”, but that's not really what I went into medicine to do per se, and that's not the overall mission of the clinic. So I think we all have a little bit of a struggle saying, this is what we need to do to survive, and if we don't survive we can't provide anybody with any services. But at the same time, it's difficult because that's not necessarily what we want to be doing. And obviously more grant money would help. That is not something that has been forthcoming with the current administration for the past six years. I guess it remains to be seen if that's something that will change. All of the community health centers in the country get money from the federal government, but they have to vote to increase the funding on the federal level for us to see the difference here, and then the other part is the state legislature, which historically does not fund community health centers at all well compared with other states in the country.
Interviewer
I know it’s tough to predict the future, but how do you think it will look?
Nell Hodo
Well I don't know. I mean I have some optimism that perhaps things will be better on a federal level because there is more and more of a push for some healthcare reform and it strikes me that some of that reform might include better funding of community health centers, so I think that that's a possibility, and obviously any kind of reform that provided a basic, basic level of coverage for everybody would be a huge improvement for the country as a whole, not just for our population here. So I'm hopeful maybe something will happen, but I don't know. It gets very complicated and political and bureaucratic and I don't know. I'm not aware of anything on the state level to, at this point, to attempt to increase funding for community health centers, and it seems to me unlikely given the recent battles over dental coverage for Medicaid and even renewing CHIP and so forth. I sort of feel if that's the attitude at the highest levels of our state legislature that it's unlikely to me that it's unlikely that they're going to increase funding for clinics like ours.
Interviewer
It seems like you have a lot of challenges. Why did you originally go into medicine?
Nell Hodo
Well I knew since I was very little that I knew I wanted to be a physician, and when I was growing up my grandfather was a general surgeon in a small town in Alabama, and back in the '30s and '40s he was one physician in the town and there was one other one who was a family physician, so they did everything. Now days a general surgeon takes out your appendix, takes out your gallbladder. That wasn't what it was like in rural Alabama then. He delivered babies, he treated strep throat, he set broken bones, and he also took out your gallbladder and your appendix and your tonsils and everything else, and when I was little it was still very much like that. The town really hasn't grown significantly in about 30 or 40 years--I think it may have shrunk, and so he still did a lot of general medicine as well as general surgery and he saw everybody; people in the hospitals, people in the clinic. He still did house calls, you know people paid him in bushels of tomatoes and watermelons and stuff when they couldn't pay and to me that was what medicine was about. It wasn't about just seeing the people who could pay the bills, it was about seeing Mr. Johnson who said, well Doc I can give you a watermelon for my visit, that's all I got, and that was o.k. with my grandfather. Of course medicine was different then because back in the '50s and '60s and even in the '80s physicians got reimbursed so much more per visit that your income was sufficient that you could easily cover seeing lots of patients for free, which I don't think is the case anymore. So that was really always the kind of physician I wanted to be and I discovered pretty quickly in medical school that the only kinds of physicians who are really like that anymore are primary care physicians. I looked at general surgery and it's a different animal than it was, you know, back in the day. It's not the same thing, so that was why I picked family medicine, because I wanted to take care of families and I wanted to take care of communities, and I wanted to do something where there was at least a possibility that I would be able to take care of people regardless of their ability to pay, so there's that.
Interviewer
It sounds like you’re passionate for medicine. What do you like about your job?
Nell Hodo
I love the people I take care of. I love seeing multiple members of the same family, you know, seeing somebody come in and you already know their family history. You know what's going on with other members of their family. You often have some idea about stressful things--if someone has recently died, if somebody is struggling with drugs and alcohol or whatever, and I like that I'll start out seeing maybe a pregnant woman and a couple of her kids and within a year I've got grandma and grandpa and a couple of cousins and the next door neighbor, and that's really neat. It really is a community in that sense. And the other thing that's really interesting to me is a lot of our employees’ families see us in our clinic for care.
And I love doing OB (obstetrics) --I love delivering babies and taking care of women during pregnancy. It's really the only time I think in medicine that you see somebody that frequently--you see a physician every month and as you get farther along every week to two weeks, and that's a lot of visits. That's a lot of time to really get to know a person and their partner, if they have one and there family, and that makes a very different bond afterward I think. Once the baby is born and it's years down the road and now you're taking care of their toddlers because you saw them so regularly during that time, and I think that's something really special.
Interviewer
How did community health centers get started?
Nell Hodo
The community health center movement really started in the late ‘60’s. There was this community based primary care movement that started at the WHO (World Health Organization) and it was basically a concept that if you provided clinics in people's communities rather than in just big cities or large medical centers, that you would improve the overall care of the community. And that was something that was pushed by the WHO as a model initially for Africa, but it was adopted in Canada and in the United States as well, and that's where the initial community health center funding came from.
It was the concept that rather than bring the people to the clinic, bring the clinic to the people and you will have better outcomes and you will have better compliance with vaccinations and all the preventative care which will overall save you money even though there's a huge initial startup cost because you have to go and build clinic and staff them out in rural areas where you know people don't necessarily want to do that. I think we adopted that model in this country vigorously in the '70s and I think we've been moving away from it ever since, which I think is a mistake.
Interviewer
Why is it a mistake?
Nell Hodo
Because I still think that it's true. I still think it's true that if you have medical care within communities, especially under-served and high risk communities, that that is the only way to provide the preventive care that will, in the long run, save lives and of course save money. You cannot expect people who do not have transportation, whether they live in a inner city or whether they live in a rural area, you cannot expect them to haul themselves to the nearest major city or across a city for every healthcare need. And there are so many people with chronic conditions like diabetes or high blood pressure that may need very frequent visits, initially at least, to get it under control. And frequent visits are not going to happen if someone has to spend a significant amount of money in transportation or have to spend a significant amount of time to get to the clinic. For our poor communities and our rural communities and inner city communities, I still think it's an issue. And there's a reason that a lot of people walk to our clinic -- they don't have a car, and we don't have the world's best public transportation in Salt Lake. It's getting a lot better and I think when they expand Tracks that's going to hugely affect some of the options that are available to our patients. Right now it's hard for a lot of them to get to the hospital just to get an x-ray you know because there is no tracks on the west side, so how are you going to get to the University Hospital or to Primary Children’s Hospital? It's a lot of buses or taking time off of work or finding a friend or somebody who can drive you and it's complicated.
Interviewer
Do you find that there’s a gap between the demand for services at your clinic versus your resources?
Nell Hodo
Oh definitely! We aren't accepting new patients currently. There are plenty of patients that need care, but at the moment all of our nurse practitioners and PA's and physicians have as many as we can handle.
So yes we would love to have more physicians, we would love to have a bigger building, but that requires money and we don't have it. I think we probably have the demand and are looking into hiring another provider whether it's a nurse practitioner or a physician but it's the financial concern--that's really the sticking point is the money. It's always the bottom line.
Interviewer
Is that pretty common where someone doesn't get the care they need and then you have to figure out at way around it?
Nell Hodo
Yes, I think a lot of people avoid seeing their physician because they can't pay their co-payment and that's even true for insured people--some people can't pay their co-payment so they avoid the preventive care appointments or they don't buy their medications because their medications are too expensive and so they don't treat whatever their illness is and then they have some complication. They don't treat their diabetes. They don't treat their high blood pressure. They end up with a stroke or a heart attack or something and then they're in the ER with a very serious condition, a very expensive condition which possibly could have been prevented, but the day to day, the sort of up front payment was just too difficult for them. And I definitely see with a lot of our patients for sure avoidance of the ER because they're afraid of the bill, so it kind of goes both ways. There's people who go to the ER that probably don't need to that you know could easily be seen in clinic and you think, oh why did they go there, why didn't they come see me? And there's other people that you just wish they would go away and they won't. But I think that gets into... there's a lot of reasons why our ER are overcrowded, one of them is people who don't have a doctor, who don't have insurance and who don't have anywhere else to go, and the other one is people who really just put off the day to day care until they have something major happen, and that's not uncommon.
Interviewer
It seems tragic.
Nell Hodo
It is tragic, and I think the most tragic ones are the ones that you know would have been preventable; the women who show up with cervical cancer because they never had a pap smear because they couldn't afford it, or they couldn't find somebody to see them. Those are the ones that just really... or breast cancer because they never had a mammogram because the same sort of thing. It is... it's very sad.
I think it's tough for a lot of physicians to see. I suspect that a lot of emergency room physicians feel the same way. I think there's probably a frustration... oh why didn't they take care of this before? But I also think this is really sad, this is really sad that this person is here with us. I mean I remember being in medical school and seeing women in the ER with huge breast cancers and they came in because it was so painful or because it was bleeding through their clothes. How tragic is that? It's awful. But I really think our ER physicians see this so commonly because that's where you go if you have nothing because that's who has to see you by law and that's, you know... even if it's not an emergency you still have to be seen by law, so that's automatically... I mean they're overwhelmed, they're swamped, but I bet you could ask any of them and they would not only feel frustrated but they would feel sad about the state of things.
Interviewer
It seems like you care about your patients too.
Nell Hodo
I don't know if this is normal, but patients are kind of like... they're almost like family in a way. I mean they are and they're not. You don't know them on a personal level you know the way you would a family member. But in general I find most of the time that if the emergency room calls me and one of my patients is there I usually know who it is. I usually know something about their healthcare and there's often some other level to it. Well yes she's in there because she has a headache, but really what's going on is her son is dying of cancer and all of her headaches have gotten worse since that started happening. And I think you do get attached, especially to the ones you see frequently, which is often young families with really little kids who are coming in a lot, or the pregnant women, or sometimes some of the elderly who often don't have a very large extended family and who come in frequently for medical checks. Sometimes people come in and I can't always figure out why they're there, and I think it's just because they want to come in and have that contact. It wasn't a scheduled appointment. It wasn't something they were told to come in. They're just there, and that's kind of nice, but it's also you know... there's a cost to that for them obviously. But I also think that it kind of just speaks to the lack of community that we have that there are all of these people who are very, very alone--elderly people, single people, who don't really have that connection to family or friends. When I see somebody coming in frequently and I'm not sure why because they aren't really ill I always worry about, you know, are they being abused? What's going on? Is there some incredible financial stress and usually there's something but they honestly don't have the support network to deal with it. They don't have maybe a spouse or they don't have kids that they can talk to or they don't have a friendly neighbor. And so I think, to some extent, that’s part of what the community health center, and probably every medical clinic to some extent, is there for—it’s that place you can go even when things are bad.
Interviewer
Does this address a larger issue—do you think something is lacking in mental health services?
Nell Hodo
Oh yes. Oh my heavens yes. I mean as bad as things are for medical care in this country, it's so much worse for mental health care. We have a great system in the valley, the Valley Mental Health program, which is specifically designed to help uninsured and underinsured, and Medicaid people get mental health services, but there's just not enough of them. There are more patients with problems than there are appointments and they do a great job, but they're swamped. They need more funding. They need more funding. They need more psychiatrists and psychologists and social workers, I mean they're really on the same boat that so many of us are. They need more support because they do a great job but there's just not enough.
Interviewer
Another aspect of our medical system that appears to be lacking is the number of primary care practitioners. It seems like there aren't a lot of people like you going into family medicine.
Nell Hodo
It's hard to go into family medicine and it's hard to go into general pediatrics, and it's hard to go into general internal medicine--all of this sort of big primary care field. If you look at a spectrum of physician income, those are the bottom three always. You know at the top are your plastic surgeons and radiologists and other things, and unfortunately what's happened in this country is that the cost of college education and post-graduate education has grown exponentially much faster than inflation and so you have kids leaving college and medical school with up to... well when I graduated our average for my class was about 150 grand in debt and I'm sure it's more now because that was five years ago, so I think the national average is close to $200,000. So you've got a young person, 24, finishing medical school, $200,000 of debt. Why on earth would they pick a career where they're going to make maybe $100,000 a year? That's after their residency, and in their residency they'll make about, depending on where you live, $35,000-$50,000, which is barely enough to live on when you're paying off your debts which come due as soon as you finish. They don't wait until you're done with residency--they start right away. So you have people with debt that who maybe starting families because they're in that late twenty age group who are working really, really hard as residents and not making a large amount of money, certainly not when the expenses of loans are taken into account. And then most people want to go into a career where they're not going to have to fret so much about their finances. And so primary care, being the lowest paid doctors that there are, just isn't financially attractive to young people with debt, even if it's what they think they want to do. It's hard to make that argument, you know. I mean you have people who want to buy a house, they want to buy a kid and they look at the finances and say, “Wow I don't even think I can do that.” I certainly had friends in medical school who said, “Wow you know I'd love to be a general pediatrician, but I don't think I can afford to do that.”
That's wrong and it's sad that it's like that but it all kind of comes back to what our medical system reimburses and our medical system does not reimburse preventive care well at all. It reimburses intervention and procedures and surgeries. It doesn't reimburse, you know, prevention of diabetes or counseling about obesity or anything like that. If I have thirty patients in a clinic day and I do one biopsy of something that might be a skin cancer than I'm worried about, and sew up one kid that cut up his arm, I will get paid more for those two procedures than for the 28 other patients combined, even if those other patients are pregnant or diabetic or have high blood pressure it doesn't matter. And that's because of the way the system was designed back in the day when they invented Medicare and Medicaid and all of the insurance companies take their reimbursement tone from the government. And back in the day there weren't that many procedures that you did. I mean you didn't have cardiac catheterizations, you didn't have all of the surgeries that we have now, you didn't have some of the advanced radiologic techniques that we have now, and so at the time it made sense, but it doesn't anymore. The formula hasn't been changed, and so until that gets fixed primary care is going to become less and less attractive to people who are leaving with more and more debt. I guess you can either fix the formula and pay more for preventative care, or you can improve funding so that people's costs and debts aren't so large when they get out of medical school, but otherwise I don't think you're going to see a reversal in the trend. I mean it's pretty much straight down, and if you look at the family medicine numbers it's like this and the number of, I think it was something like (I could be wrong), but I feel like the last statistics I saw only 40% of the residency slots for family physicians in this country were taken by American medical graduates and the rest we either left empty or were taken by international graduates. Not that there's anything wrong with that, but it tells us that the people we're graduating from our medical schools don't want to do this as a career for whatever reason, and I honestly think that a lot of it is financial. A lot of it is financial.
Interviewer
Changing gears a bit, many of the patients you see are uninsured. But If I am insured, if the system appears to be working for me, why should I care about fixing the healthcare system?
Nell Hodo
You should care because what you pay for your medications and for your doctors visits, what you pay for your insurance premiums isn't about you at all, it's about everybody else because when a hospital charges you for X amount for an x-ray or for a lab test it isn't really the cost of the x-ray or the lab test, it's your cost plus a chunk of the cost of all the people who they are gonna get paid for, so you're paying more to cover everybody else and basically your costs are greater because other people aren't covered, and I think it's important as a society because you are going to have a longer wait in an emergency room as a patient when the emergency room is filled with people who don't have a physician, don't have insurance and can't see anybody for their cold or their sore throat and everything else. You are going to have a longer wait; you are going to have a less ideal experience. Probably the people who treat you are going to be busier and more flustered and so I think that affects you.
And it affects you because of your taxes--your tax dollars at work here. I mean it costs society money to have people who are uninsured because who is going to pay those bills? Nobody, except the only way to cover that is everybody's costs go up, so everybody is paying for it everyday, it's just that we don't break it down that way.
And then finally you know our health care outcomes are not that good compared to other developed countries; our infant mortality is worse, our incidence of coronary disease is greater which is probably because Americans are more obese and exercise less than a lot of other Western developed countries, but the other thing is you know all of these other countries--every single last one of them has national health coverage and none of them tie it to employers, none of them is it the bosses job to pay for the employees benefits. It doesn't matter--Canada, New Zealand, Australia, every country in Western Europe has some kind of basic coverage and every single one of them has better statistics than we do, so there is a connection there and bad statistics mean more strokes, that means more disability that means more disability funding from the government that is needed. More diabetes means more amputations which means more disability which means more funding, so all of these things, all of the preventative care that isn't happening and all of the worsening in statistics means more money. Less prenatal care means more pre-term births, that means more cerebral palsy; it means more kids in the intensive care unit who have long term disability. It all costs, and it just doesn't cost the family, it costs everybody. So I think that you cannot ignore the statistics that for spending more per capita in the world, we are no where near the top of the pile, so we're not... there's obviously stuff we're not doing right.
Interviewer
Do you think that the American healthcare system is broken?
Nell Hodo
I think it's a mistake to call it a system. I don't think there is an American healthcare system. I think there is a hodgepodge of stuff that doesn't always work together and that has so many holes that it's not a system at all, it's a non-system. There's a system if you are wealthy enough to have insurance and pay your premiums and even then you may find that things are excluded—there are pre-existing condition exclusions. There are so many restrictions that even then you may find it very difficult to get the care you need. Maybe you can't find the right kind of doctor to accept the insurance you've got. Maybe you've got an insurance that not many people take. There are still challenges even if you are one of the lucky, the insured people.
And of course there are tons of people who aren't insured at all --millions and millions--I think the latest is close to 50 million people, a lot of whom are children. That isn't a system at all. That's just a mess. And yes there's a system for Medicaid and Medicare; that's another mini system, but because the reimbursements are so abysmal so many people won't take them. I mean you look at a kid on Medicaid and you ask the parents how many offices did you call before you found a pediatrician or a family physician who would take care of your child? And usually they've called several, and the reason doctors aren't taking the insurance isn't because they don't want to see poor kids, it's not because they don't care, it's because they get paid so little that they actually lose money for every visit that they have and these people run a business--they have to keep the doors open. How are you going to keep the doors open if you lose money with every visit? And that's why people don't take it. It's not because they're not good doctors and it's not because they're not good people. So even when you have private insurance and Medicaid and Medicare, you have huge challenges trying to get care—enormous.
And then if you have nothing of course it's infinitely worse so I don't think that that's a system at all and just the messes that we've seen the last couple of years with the drug plan of Medicare and how complex that has been for our seniors and how many hoops must be jumped through--I don't even understand it and I have a medical degree, so how in heaven's name is an 85 year old lady who may or may not have the world's best memory and may not even have a high school education suppose to wade through it? We've allowed it to become so bureaucratized that even that the programs we have in place are inaccessible to people, even educated people, but we're just not even scraping the surface of what needs to be done. It's about the only thing we have is universal is vaccinations. It doesn't matter if you're a citizen. It doesn't matter if you're insured; you can get your kids vaccinations at whatever your local health department is. That's about the only universal coverage I would say that we really have. Everything else is patchy.
Interviewer
So do you see any solutions?
Nell Hodo
Well I think the problem is that any solution that would radically change things for the better is going to challenge so many special interests--it's going to be so difficult.
There a lot of national health care systems in this world, none of them are without problems, most of them are in financial distress. So there's not really a perfect system to look at and say oh we'll just build that, and that doesn't exist and so that makes it even more difficult to sort of say what do we do? Anything that is a general basic start... anything that covers well child examines, women's pap smears, prenatal care, vaccinations and accident and emergency services--that would be basic; blood pressure checks, diabetes checks, that kind of stuff. Beyond that I don't know. There should be something. There should be something that if you get hit by a bus you don't go bankrupt. There should be something that if you're uninsured and you're unlucky enough to get appendicitis you don't have to drop out of college and go to work to pay your medical bills. There's got to be some kind of a middle ground. But beyond some kind of basic, basic low-level coverage for everybody I don't really know. And I feel like even basic low-level coverage would be really hard to get passed, even though it sounds very sensible the logistics of how you do it of course are complicated. I'd like to think that we're going to really see a change but I don't know. It's finally gotten bad enough that enough people who vote are upset about it... maybe. Maybe something good will happen.
