IF YOU HAPPEN TO HAVE PRIVATE HEALTH INSURANCE through your employer, you won’t come to Multnomah County’s Mid-County Health Center for medical care. The clinic is housed in a concrete box of a building on SE Division Street near 127th Avenue—its exterior unembellished save for the blue-and-green M that is the county logo. Just past the entrance, a security guard watches over the parking lot; another sits near the intake bays of the waiting area, just beneath the sign reading “Welcome to Mid-County Health Center” in five languages.
The Mid-County Health Center is one of the Portland metro area’s seventy-five community health clinics—those nonprofit or community-run clinics that are eligible for federal funding and serve very low-income people as well as the uninsured. Between 70 and 75 percent of the patients on its roster are enrolled in the Oregon Health Plan, the state’s Medicaid program, which covers some 386,000 people. The other 25 percent (besides the small number of patients on Medicare) have no insurance at all.
Owing to the clinic’s contract with the US Department of Health and Human Services, refugees who settle in Oregon receive their very first medical checkups in the United States here, and many stay on as long-term patients. At last count, Mid-County was serving clients who spoke fifty-two different languages; to manage this diverse pool of patients, it employs five full-time interpreters.
One morning in November, I meet Mid-County’s program manager, Deborah Cockrell, in one of the clinic’s two large waiting areas, where fifty or so chrome-and-plastic chairs line the walls and sit in long, economically arranged rows. Thanks to a federal grant, the space is getting a face-lift. (“And boy, we needed it,” Cockrell says.) Wood beams, new intake desks, and warmer colors will transform the institutional space into a friendlier one.
Cockrell leads me through a door marked “Employees Only” (in English, Spanish, and Russian this time) and down a long hall decorated with posters—one that’s titled “Peoples of Mainland Southeast Asia,” one listing the immunizations that new refugees need—and lined on both sides by exam rooms, twenty-six in all. When I remark with surprise at the size of the place, Cockrell responds with a laugh. “Well,” she says, “we’re pretty busy.”
That turns out to be something of an understatement: the Mid-County Health Center, which opened in 1993, is the busiest community clinic in the metro area. Its twelve doctors and nurse practitioners, nine registered nurses, two licensed social workers, and two licensed practical nurses see, on average, 150 people per day; in 2008, the clinic was on schedule to have logged some forty thousand patient visits.
Given the many challenges the clinic faces every day (the volume of clients, the logistical problem of finding someone who can say “blood sugar test” in an East African language), it seems an unlikely setting from which a major health care innovation might emerge. But in summer 2007, the clinic decided to implement an entirely new approach to caring for its many patients by joining Primary Care Renewal, a project funded and led by CareOregon, the Portland-based nonprofit medical plan administrator that serves Oregon Health Plan enrollees. (Mid-County was joined by four other health centers: Central City Concern’s Old Town Clinic, which primarily serves Portland’s homeless population; Virginia Garcia’s Cornelius Center, which serves migrant and low-income families in Washington County; Oregon Health & Science University’s Family Medicine Clinic at Richmond; and Legacy Emanuel’s internal medicine clinic, both resident clinics).
Primary Care Renewal’s goals are deceptively simple: the clinics want to prove that they can improve their patients’ overall health as opposed to simply treating acute problems like the flu; make doctors and patients happier with their health care experience; and, perhaps most important, reduce costs to the health care system overall. “It makes sense that if you can keep people healthier, then your costs will be under control, because primary care is relatively inexpensive compared to hospital stays or emergency care,” says CareOregon medical director David Labby, who helped design and launch the project. If this new model for primary care, called the “medical home” or the “primary care home,” proves successful, these five clinics could become showcases for primary care reform around the country.
Before embarking on the project, Mid-County Health Center took care of its patients the way many primary care clinics do—including those that accept only patients with private health insurance. Its doctors, whose schedules were “filled to overfilled,” as Cockrell puts it, saw as many patients as possible in a day, a necessity because of the high demand for appointments, and because Medicaid, like most health insurance plans, reimburses clinics only for the visits in which patients actually see physicians.
During the twenty minutes allotted for each appointment, Mid-County’s doctors treated everything from lacerations and rashes to chronic conditions like Type II diabetes, hepatitis C, and hypertension. Patients rarely met with their designated doctors, and they certainly didn’t know nurses or medical assistants by name. Even more troubling, the doctors and nurses and medical assistants didn’t know their patients as well as they could have; staff had no big-picture strategy for monitoring, say, whether a fifty-year-old patient with Type II diabetes was current with blood sugar tests. “We didn’t put a lot of attention into tracking chronic conditions,” Cockrell says. With demand for the clinic’s services so great, “We were just focused on trying to get people who needed an appointment in to see someone.”