When I first heard of FQHC's, I thought they were a good idea and even thought I'd like to practice in one. It's a good idea to provide care to people who need it, yes? And these are the poorest of the poor, yes?
But on Friday I shadowed a pediatrician in an FQHC. I'm not a fan any more.
I was surprised by the sick-child visits. Children came in with no true complaint. I thought this must be due to low health literacy. (A 99° fever is not a reason to worry, especially if the fever doesn't register on a thermometer and the only reason for the visit is "he feels hot to the touch.") I asked the the doctor I was shadowing about this. She agreed with my assessment, but added another reason for these empty visits.
"It's so cheap" to come in, she said, that patients come in at the drop of a hat. She added that sometimes they are using their visit to skip school. If I were a provider to this population, I would much prefer these patients get good phone advice and go to school! But the doctor again surprised me.
She laughs at these empty visits and says it's "good for the numbers." An FQHC must maintain a certain volume of visits, otherwise it loses its funding. Upshot: he better the education she provides, the worse the numbers. Moreover, the more FQHC's that are established in an area (the fewer visits at each one), the worse the numbers. "Bad for business," this doctor sighed when she told me three satellite clinics were being established this year.
Now I have problems with FQHC's.
- The Republican in me: our taxes are paying for what? (Not all these patients are here legally!)
- The ethicist in me: where money is on the line, who can provide patient, solid counseling to patients?
- The patient advocate in me: this arrangement is worse for patients; they become dependent on the doctor because they are not taught how to take care of themselves, the underlying cause of their visit (problems in school?) aren't addressed, and they receive poor-quality care (this was my experience yesterday and might not be universal).
- The idealist in me: why is the patient's good bad for doctors?