Tuesday, November 8, 2011


A federally-qualified health center (FQHC) is a practice that receives grants from the Health Resources and Services Administration (HRSA, the same people that offer rural loan forgiveness to medical students and residents). I read more about them here.

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.
  1. The Republican in me: our taxes are paying for what? (Not all these patients are here legally!)
  2. The ethicist in me: where money is on the line, who can provide patient, solid counseling to patients?
  3. 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).
  4. The idealist in me: why is the patient's good bad for doctors?
There must be some better way to take care of the poorest of the poor; some way that does not involve government programs and conflict of interest, some way to provide true education and quality care. FQHC's make me sad because they're so close to a solution, but at the same time so problematic! Our system seems so misguided.


  1. Government solutions are typically expensive and inflexible. This is true at the DMV, the military, and in the post office. Examples can be seen all over the world.

    One reason is that good intentions, written into law; simply can't anticipate how implementation looks on the ground 5 or 10 years later. The fact that many government solutions don't follow the principle of subsidiarity often exacerbates this effect.

    In addition, the goal of being efficient; usually takes a back seat to other aims. The legislators, for example, may prefer to speak about how many jobs were created; even if some of the jobs are make-work.

  2. I'm glad you mentioned subsidiarity! The Church heavily emphasizes this principle.

    What you said about intention vs. effect reminds me of Aristotle's Politics: Aristotle knew that laws are universal in character and need constant reevaluation to apply them over time to particular cases.

    Thanks for reading!