Working in a Community Health Clinic: One Member’s Experience

When I began studying medicine, I envisioned practicing general primary care as a naturopathic physician helping the underserved. Since starting work at HealthPoint in 2006, I’ve been able to accomplish just that.

Healthpoint (formerly known as Community Health Centers of King County) is a large community health care organization assisting underserved populations of greater King County through 9 main medical clinics, 2 school-based clinics, and 5 dental clinics. Our patient population is incredibly diverse. People from all over the world are represented, most of whom are low income. While the majority of medical providers practice conventional medicine (MD/DO/NP/PAs), HealthPoint also employs “natural medicine” providers, including NDs, acupuncturists, and nutritionists. It is the first community health care center in the nation to receive public funding for an integrated natural medicine program. Providers work as a team to deliver high quality patient care, regardless of income.

Healthpoint patients present with a spectrum of acute and chronic conditions which are often complicated by psychosocial stressors and a myriad of burdens that poverty presents. Patients are appreciative to have access to an ND, but most are happy to receive competent care, regardless of credentials.

Many of my patients are Hispanic and prefer to use a natural medicine approach, but they will use conventional medicine when really needed or when a natural option is unaffordable.Many can’t afford anything beyond what is covered by insurance (if they are lucky enough to be insured), so we work with conventional medications and emphasize diet and lifestyle modification to minimize medication needs. Luckily, the tool belt of an ND is quite rich, so I often draw upon other natural therapies (such as physical medicine techniques). I also provide acupuncture services, especially for acute and chronic pain conditions.

When I started with HealthPoint in 2006, NDs in Washington were working within a prescriptive scope that included a hodgepodge of approved conventional medications. Unfortunately, our scope fell far short of what was needed to practice comprehensive primary care. I remember how embarrassed I felt when forced to ask another provider to prescribe something as basic as an albuterol inhaler. Patients also had difficulty understanding how someone who called themselves “doctor” and went to a medical school didn’t possess the authority to prescribe common medications.

Thanks to the work of NDs involved in the WANP and our amazing lobbyist, Terry Kohl, a progressive prescriptive scope expansion was passed in 2007. NDs were finally able to practice much closer to the level of their training, manage patients with appropriate medications, and schedule just about anyone for most primary care needs. One year in, I felt like my practice at HealthPoint was blossoming into everything I envisioned. But alas, there was still the looming issue of insurance coverage.

Most patients lucky enough to have health insurance at our clinics use a State plan, such as Community Health Plan of Washington (CHPW). For the CHPW patients, prescriptions and imaging I ordered were covered, but the plan would not reimburse HealthPoint for any of my office visits. Medicaid patients had to sign a waiver and pay a sliding scale fee, but I could not order labs, imaging or conventional Rx without the assistance of a covered provider or “partnered visit”. Pharmacies would often reject prescriptions I wrote for Medicaid patients. Frequently, a Medicaid patient would schedule an appointment with me but cancel at the front desk when faced with a $20 appointment fee. It may be hard to fathom for some in private practice, but an extra $20 charge can be an unbearable burden for low-income families.

Additionally, when a patient signed a waiver and paid the fee, the sliding scale charge was far less than the actual clinic cost for the visit. Ultimately, our clinics lost money every time a Medicaid-insured patient used an ND versus a conventionally covered provider. I don’t even want to think about all the money our clinics have lost over the years due to the lack of ND inclusion in Medicaid plans. I’d wager that this issue is a big reason why other community health centers in Washington have not yet hired NDs as permanent providers.

Thankfully, committed folks at the WANP, along with the help of Terry Kohl, continued to plug away at this issue and, incredibly, they succeeded! As of January 1st, 2014, NDs in Washington are eligible to participate and be reimbursed for their work as primary care providers in Medicaid plans (aka “Apple Health” in Washington State.)

Just a few weeks into Medicaid coverage, I’ve already seen an increase in pediatric visits, and patients previously lost due to Medicaid barriers are beginning to come back. I’ve seen more walk-in patients, more acute triage patients, and more of Medicaid’s most difficult patients – those on disability. NDs will likely have to start participating in the somewhat dreaded “DSHS evaluations”, where providers are expected to determine in a short visit if someone really qualifies for disability. Nevertheless, if we are going to claim equal rights as PCPs, we should share the burden of managing the more challenging patients as well.

Medicare is a federally controlled program, and unfortunately they still exclude NDs from participation. Hopefully, the inclusion of NDs in Washington’s Medicaid system will further demonstrate and solidify our role as PCPs and show the federal folks that NDs can be equal partners in the healthcare world. My greatest hope is that our recognition and inclusion as PCPs in Medicaid will help open doors, expand patient access to naturopathic medical providers, and create more ND employment opportunities in healthcare organizations like HealthPoint. The need is there, and opportunities for our doctors will grow now that clinics are being reimbursed for our Medicaid services. Of course, it’s going to take ongoing diligence and legislative work by the WANP to ensure that ND’s are treated as equals in the new world of the Affordable Care Act, but this is a huge step forward for our profession.

The future looks bright. With that said, let’s all raise our glasses to the committed, hard working NDs in the WANP and others who made this game-changing Medicaid inclusion possible. Onward and upward – cheers!

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