Liability concerns need not deter free clinics.
Liability is the biggest anxiety for physicians who want to volunteer, but the idea that patients served by clinics sue more than other patients is a myth, said Dr. Nadkarni of the department of internal medicine at the University of Virginia, and founder of the Charlottesville (Va.) Free Clinic.
A 2003 national liability survey of 153 free clinics conducted by the National Association of Free Clinics (NAFC) found that patients who visit free clinics actually sue less often than those of higher socioeconomic status. Only seven claims were collectively brought against the clinics surveyed, and three were eventually dropped. Two are pending, and the other two settled for about $67,000, "well below the average payout for settlement," Dr. Nadkarni said. Data from the American Medical Association show that the average jury award is currently $3.9 million.
When establishing a free clinic, physicians have several mechanisms available to protect them and their staffs from liability, Dr. Nadkarni said.
Many states have extensions of "Good Samaritan" laws that protect emergency personnel. "If you're working at a free clinic, you can gain that sort of coverage," he said. Most states that offer coverage raise the bar for what someone can sue for.
"Rather than sue for simple negligence, you have to get up to the level of proof of gross negligence, or recklessness, or wanton disregard. So that really stems the possibilities for suits."
Other states allow free clinics to buy into a state risk pool and to get a better deal on malpractice insurance. A few states, such as Kentucky, reimburse free clinics for the cost of their malpractice insurance coverage, Dr. Nadkarni said.
Clinics that don't charge patients can register with the Federal Tort and Claims Act, which has a defense fund that provides malpractice coverage for people who volunteer. To do this, "you have to preregister. You can't do that in retrospect," he said.
The clinic's board members need insurance coverage as well, he added. As nonphysicians making decisions about the free clinic, they're also subject to liability.
Free clinics served 3.5 million patients and received $300 million in donations in 2003, according to the NAFC, which estimates there are at least 800 free clinics nationwide.
Conducting a needs assessment and targeting the area's patient population are some initial steps to establishing the clinic, Dr. Nadkarni said. Physicians should decide what type of model they want, and where it should be located.
"You may have a hospital-based, church-based, or freestanding clinic." Then there's the "clinic without walls" model, a clearinghouse where patients may contact a central source and be farmed out to various participating doctors in the community.
Decide what types of services will be offered, and whether clinic staff will refer to private offices for subspecialty care. Continuity of care is something free clinics always struggle with, said Dr. Nadkarni, whose own clinic hired care coordinators to ensure continuity of care.
There are other services to consider, such as social work, dentistry, and psychiatry, as well as inpatient care. "You may be able to do it all, or you may only be able to do a small part of it, but decide in advance what you want to do." Otherwise, "you can go down a road where you destroy the clinic if you use up lots of resources you don't have," he said.
Clinics can get funding from a number of sources, including government, businesses, churches, or philanthropies. Dr. Nadkarni said his clinic received small grants from the county council and county board of supervisors. Many banks are chartered to give back certain amounts of their capital to local resources. "If you can get on their docket, they generally support lots of local institutions."
If a clinic stays around long enough and grows in size, Dr. Nadkarni suggested hiring other health care providers such as nurse-practitioners and dentists. The clinic may need local grants to help support those extra salaries.
"You really want the community you're serving to have input on this," he said. This means building up public-private partnerships, and interacting with others members of the health care community. To accommodate patients, "you should make sure the clinic is on bus lines."
If no one knows about your clinic, it will be difficult to attract patients, he said. Gain publicity by asking local newspapers and newsletters to donate space, or by getting local radio and television stations to make public service announcements. Another approach is to follow the local populations.
"If you're dealing with the working poor, you can target local restaurants that don't [offer] health insurance to their staff." His clinic took this approach, along with contacting major companies in the area that didn't have a good health insurance plan.
A clinic's board of directors should represent "work, wisdom, or wealth," to represent a variety of contributory sources, he added.
RELATED ARTICLE: What Makes Charlottesville's Free Clinic Tick
Dr. Nadkarni's clinic started off in 1992 with two residents carrying beepers as the administrative support. "Luckily, we got a local grant that enabled us to hire an executive director. And that made things move along much more quickly."
The Charlottesville (Va.) Free Clinic now sees more than 3,000 visits per year. "We are open three nights per week for clinical work, each night seeing 35 patients," he said. The volunteers include more than 150 primary care physicians and the ob.gyns. Residents from the University of Virginia, Charlottesville, also participate.
"We have a special diabetes clinic, and we also provide limited psychiatric services," Dr. Nadkarni said.
The clinic makes referrals to community specialists who provide free or discounted care, and has an acute dentistry program, with local dentists volunteering at their own office sites.
Patients qualify for care at the clinic if they're uninsured or do not qualify for free care elsewhere in the community. "We also hook patients up with various Medicaid/FAMIS [Family Access to Medical Insurance Security Plan] programs if they qualify," he said.
The clinic receives support in terms of donated laboratories and x-rays as well as donated funds from University of Virginia Health Systems and Martha Jefferson Hospital in Charlottesville. "However, we are a separate, nonprofit entity," he noted.
As far as the liability issue in Virginia is concerned, the state is "very free-clinic friendly," Dr. Nadkarni said. An extension of the state's good samaritan law provides malpractice coverage to registered free clinic providers and providers are immune from suits based on simple negligence. "We have never been sued," he said.
BY JENNIFER SILVERMAN
Associate Editor, Practice Trends
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|Title Annotation:||Practice Trends|
|Publication:||Clinical Psychiatry News|
|Date:||Jul 1, 2004|
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