The unwillingness or inability of states and cities to finance “community clinics” that serve poor/uninsured and otherwise access-disadvantaged residents is putting great strain on hospitals, emergency rooms, and private physicians who end up “inheriting” such patients when they need care but either are not eligible for or cannot get in to see providers at such clinics in time. These “safety net” clinics are having increasing difficulty remaining open, or serving the ever-increasing number of people who cannot afford to use care offered by traditional sources.

One of the arguments favoring the funding of such clinics, aside from the social justice one, is that the clinics can keep people from using more expensive resources, such as inpatient and ER care, by serving as a lower-cost source, taking care of problems before they become disasters, or preventing such problems in the first place through free immunizations, or catching them early through screenings. When these clinics must cut back on services or whom they serve due to budget cuts, they increase the burden on the rest of the system.

Recently, the idea of using community clinics to save money for all through disease management’s (DM) ability to minimize the crises, complications and worsening of chronic diseases that create the majority of sickness care costs. By becoming DM providers for the patients to whom they provide sickness care, and even expanding those numbers for DM services only, community clinics could end up preventing more sickness care use and expense than it costs to operate them.

Los Angeles is trying one approach to this idea, using the onsite pharmacists at the community clinics to help people with diabetes control their condition. This usually requires a combination of compliance with drug regimens, and adherence to lifestyle recommendations. Pharmacists have already proven their ability to perform the DM function for employees with diabetes in Asheville, North Carolina.

In this case, the federal government is providing seed money for the University of California to operate the program. Medicare already will pay pharmacists to consult on DM issues with elderly and disabled beneficiaries with “poly-pharmacy”. [“Los Angeles Clinic Shows Flaws in Diabetes Care” New York Times Oct 8, 2007]

CareSouth Carolina had earlier demonstrated how its rural community clinics can manage patients with diabetes for as little as $343 per patient per year, compared to other primary physicians in the state, though it was not being paid any extra to do so. [R. Chaufournier & K. Reims “Hidden Opportunities for Cost Savings in Disease Management” Healthcare Savings Chronicle (Coalition America, Inc.) Mar 10, 2005]

The added costs of managing patients with chronic diseases, or even those at risk of such diseases, including those with high but “pre-disease” levels of blood pressure, sugar and cholesterol, has long kept traditional private practices from engaging in DM for their patients. There is a certain amount of “cannibalization” involved when such practices keep their patients from getting sick, since that reduces the number of services and procedures they need to use, thereby reducing the “customer value” of chronic disease patients. But with community clinics, all avoided sickness care use represents success, and the ability to serve more patients, rather than lost revenue.

The challenge for state and local governments is the same as it is for the federal government. Investing in DM, and particularly in health/risk management (H/RM) efforts to reduce the incidence and prevalence of chronic conditions, will increase their investment in the short run, while decreasing it only in the long run. With governments focused on being able to live with tight budgets this year, few are able or willing to go for additional funding, despite the significant savings potential. As long as this myopia is institutionalized into the budget process and operation of community clinics, they will probably never be able to realize the DM and H/RM potential of shifting resources more toward prevention, and we will all pay for this failure in the long run.