At Duke University, an experiment in community health care

By Darryl Fears
Washington Post Staff Writer
Saturday, November 6, 2010; 5:27 PM

DURHAM, N.C. - This so-called City of Medicine has long represented the highs and lows of the U.S. medical system: It has a private medical school with a proud and profitable tradition of producing experts in such specialties as neurology and gynecology - and a population riven by diabetes, obesity and other chronic illnesses.

But in a turnabout, Duke University has been focusing closer attention on the neighborhood that surrounds it by forming a partnership with Durham's Federally Qualified Health Center. It's an experiment in community care that began well before health care became a heated political battle. It's one that has been closely watched by the Obama administration as a model for its vision of widespread reform. And perhaps most significantly, it's one that could survive and even thrive if the new law is never fully implemented or is ultimately repealed, as some newly elected Republican members of Congress advocate.

The project's aim is simple: reduce chronic illnesses that plague the uninsured to keep them from making expensive visits to hospital emergency rooms. The most immediate beneficiaries are poor men, women and children such as Jasmine Bond, 24, and her son Antayvion, 4, who wailed in protest recently as his mother held him down for routine immunizations at a clinic opened a year ago under Duke's partnership with the Lincoln Community Health Center.

Patients like Bond said in surveys that they would have gone to hospital emergency rooms if the three clinics built by the partnership over the past seven years had not been there, generating pricey and often unnecessary bills that Duke pays because the patients cannot.

In the longer term, experts say, such experiments in delivering community care - as well as medical schools and federally qualified clinics in at least eight other cities - have the potential to reduce overall health-care costs and even help heal other festering wounds such as race relations.

The universities "see the problems in their neighborhoods and they feel a new sense of urgency to go out and attack that problem," said Darrell G. Kirch, president and chief executive of the Association of American Medical Colleges.

"I think people realize the Affordable Care Act will be limited in how much change it can make in the delivery system," Kirch said. "They're showing us how you make new delivery models that will improve health status."

The chancellor of Duke's health affairs, Victor J. Dzau, and the chairman of its department of community and family health, J. Lloyd Michener, said they meet frequently with officials in Washington.

"If you look at this country, the best medical centers sit in places with the worst health statistics," Dzau said he told the officials. "We can't be an ivory tower. We can't just wait for sick people to come to us."

Michener said Durham wasn't living up to its lofty City of Medicine moniker.

"Let me be blunt: Durham has more doctors per capita than any place and our community isn't as healthy as it should be," Michener said.

Non-acute emergencies

At the Holton Wellness Center, which celebrated its first anniversary in August, Jasmine Bond was the face of the problem - and its solution.

Bond said she was overjoyed when the clinic scheduled her son's appointment for polio and chicken pox immunizations two weeks after she called in. She ignored the icy stare Antayvion gave her when a nurse pulled out two hypodermic needles and held him down as he shouted, "Let me go!"

Antayvion's kicking and wailing was less annoying than the two-month wait it ordinarily took to schedule a shot at the Lincoln Community Health Center, Bond said. Lincoln, overburdened with patients, schedules by priority. People with acute conditions go first.

Bond isn't so patient. In February 2009, she said she awoke feeling "like somebody was stabbing me in the ear canal." Her son, who also had an ear infection, cried through the night.

The action Bond took is one that plagues hospital administrations across the nation: She called emergency medical services for an emergency room visit. The ride cost $600, plus $9 per mile.

The Motrin and care she and her son were given by emergency room nurses and technicians totaled about $350, according to a hospital spokesman. In essence, the mother and child had $1,000 earaches.

A visit to one of the partnership's clinics would have cost Bond $20, plus about $15 for a cab ride. Duke University Hospital sees such non-acute emergency room visits by the thousands each year, so it behooved them to act.

In 2009, Duke claimed in a report that it ate $45 million in unreimbursed care for patients who couldn't pay. It swallowed another $50 million in costs when Medicaid reimbursement didn't cover the full bill for care it delivered.

With a smaller yearly expense - $7.5 million to the Lincoln Community Center - Duke hopes to cut costs by expanding primary-care services and making the community healthier.

Better racial relations

Under its partnership, Lincoln and Duke Community Health have created three clinics in recent years. They complement the main Lincoln Community Health Center, the county's health-care safety net, the Lincoln clinic for the homeless and its HIV clinic.

The newer clinics - Lyon Park, Walltown and Holton - receive about 7,500 unique visitors a year, half of them African American, 80 percent of them uninsured. Thirty-eight percent of the visitors declined to divulge their race or national orientation, and 34 percent were not English speakers.

An additional program, Just for Us, provides primary care for indigent elderly patients in their Durham County homes. The result: a 49 percent drop in ambulance-related emergencies and 41 percent fewer emergency room visits in the county, according to a report by the Gerontological Society of America.

Duke also staffed and subsidized a clinic at Southern High School in Durham after administrators and teachers complained that students who often attend school with chronic illnesses "are too sick to learn." It sees about 1,750 visitors per year, has three examination rooms and a full service pharmacy.

The university's outlay has been substantial. It provided a quarter of a million dollars to the city and county to renovate a shuttered middle school that now houses the Holton Wellness Center.

In Walltown, Duke leased a house for $1,800 a month, a steep price for the impoverished section where it sits. Duke also paid to convert the house into the Walltown Neighborhood Clinic and fund much of the operation, school officials said.

The Duke Endowment contributed an additional $216,000 to enlarge and equip the Lyon Park Clinic the first to open under the partnership in 2003, according to a report published in the Journal of Health Care for the Poor and Uninsured.

Between July 2005 and June 2006, Duke ate more than half of the $72-per-visit cost at Lyon Park, about $182,000 a year.

The investment in health has yielded an added benefit, said MaryAnn Black, associate vice president of community relations. Duke has an improved image and better relations with black and Latino communities.

Black, a former chairman of the Durham County Board of Commissioners, repeated a comment she heard about Duke from several black residents: "'They just want to experiment on us'"- an allusion to the infamous decades-long Tuskeegee, Ala., experiment where black men with syphillis were studied but not treated. Because of Duke's outreach, those comments have died down, Black said.

And when news broke in 2006 that a black woman had accused three white members of Duke's lacrosse team of rape during a party at which she was hired to dance, racial tension in the community was high, Black said, but not as high as it could have been.

As the drama played out across the country, Black said the local reaction was somewhat tempered. If the woman had made the accusations before the school's community engagement, Black said, tension between the school and the black community "would have been much worse."

'You name it, we see it'

At Holton, down the hall from where Bond cradled her son Antayvion, Andre Houze, 53 and uninsured, sat on an examination table with a bad shoulder.

He said he appreciates the clinic, built in Northeast Central Durham by Lincoln and Duke mostly with Duke's finances. If the clinic didn't exist, he said, "I would be at Duke emergency room right now."

Speaking softly, eyes down, he said that he was diagnosed with diabetes on an earlier visit to Holton. The rate of diabetes for people Houze's age is 13 percent. For African Americans like him, it is far worse.

"You name it, we see it," said Corliss Galloway, project coordinator at Holton. "We've seen diabetes, hypertension, a lot of chronic diseases."

Durham residents are southerners who cherish unhealthy fried foods, said Evelyn Schmidt, chief executive of Lincoln Community Health Center's medical division.

When told a story about an overweight African American woman who ate greasy strips of bacon at the front desk of a major hotel chain while assisting guests, Schmidt wasn't surprised.

"That's Durham," she said.

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