Cuénto cuesta?” the worried parents of a mildly ill child asked when I recommended a routine well-child visit at my clinic in South Central Los Angeles. How much would it cost? Not to worry, I assured them. We are a free clinic. “Pero pagamos 40 dolares,” the father said. I went out to our registration desk and learned that, indeed, for the last two weeks, patients had been charged $40 for a physical, $20 for an urgent-care visit.

We had run out of Public Private Partnership funds in December and burned through our Emergency Access to Primary Care dollars shortly thereafter, the two largest health care funding sources for uninsured Angelenos. The effects of budget shortfalls in California and Los Angeles County have already touched some of the most disempowered shadow members of our local community—the undocumented and the uninsured. The California legislature quickly approved the proposed 10 percent cut in Medicaid reimbursement, in a state that already had one of the lowest reimbursement rates in the country. The Los Angeles mayor has proposed closing 11 of 12 county primary care clinics. In this plan, the thousands of displaced patients would be deflected to the private nonprofit clinics in the area, namely us.

Pressure Drop

In my clinic, financial pressures are a constant concern. In recent months, as county and state funds dwindled, our business office sent weekly, then daily, then multiple daily e-mails urging us to shift patients to “alternative payment streams” whenever possible. While we burst at the seams with patients, our CEO looks for ways to get the providers to bill more and more (preferably Medicaid-insured) visits to make up for our deficit. Without notice, short Saturday shifts have become long Saturdays, and the “occasional” Saturday clinic responsibility has quickly become three weekends per month to increase the number of patients seen.

At a recent provider meeting, our medical director distributed a sheet listing each provider’s productivity based on the goal of 25 visits per day. Most of us hovered between 75 and 85 percent of that, with a few notable outliers who were much lower. None of us had achieved the productivity target. At a well-organized clinic, such a goal would be quite feasible. But our reality is far from organized. Patients typically line up outside our door at 8 a.m., and the front staff accepts appointments and as many walk-ins as they feel appropriate. By 10 a.m. on an average day, the wall racks are spilling over with charts. Scheduled patients are still arriving, bumping the walk-ins, whose waits extend two, four, even six hours. By the afternoon, we are back-pedaling, sometimes even turning away scheduled appointments to get finished by the end of the workday. Our neighborhood is too dangerous to ask staff to stay late.

The financial pressures have engendered an administration on the rampage and an embittered medical staff. Providers are casually and arbitrarily shifted among our four clinics, particularly to protect prenatal and well-child care, the most reliably reimbursed “payment streams.” In response to the circulated productivity report, my colleague playfully posted a productivity thermometer to gauge how productive we feel on a given day. Hers remains firmly in the red. The financial pressures have made it impossible for our administrators to nurture the daily effort we make to patch together care with limited resources and a scarcity of specialty input. Quantity trumps quality.

Rewards

Each day at work brings new issues. Medications are on back order and purchase orders have been canceled. A patient lying on the exam table points out the gigantic cockroaches crawling in the ceiling light fixtures. The dispensary is filled with “donations” of medications one month from the expiration date. A medical assistant is arrested in the parking lot, a registration clerk is rude to a member of the board checking in as a patient. A talented and resourceful case manager quits for a better job.

The challenges of working in a free clinic extend beyond language barriers and cultural differences. The unforgiving system is tough, both for patients and for providers. But while daily life is hectic, it is rarely bleak. That afternoon in clinic, we found that the child with the cold would be eligible for a state-funded free physical and scheduled it for the following week. We reimbursed them the $20 they had been mistakenly overcharged for their urgent-care visit. His parents were beaming when they left. They had the reassurance they needed, they had a plan for the routine care they wanted, and they had the promise of a healthy future.

Ellen Rothman, HMS ’98, practices at a community health center in Los Angeles.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.