Is your patient sick—or hungry?

Take this course
In response to the results of the provider survey conducted by the Childhood Hunger Initiative of Oregon, a team at the Oregon State University Extension Service developed an online training program. The free 5-module course, available at http://oregonstate.edu/instruct/dce/chi/modules.html, addresses the impact of childhood hunger and provides screening and intervention tips.²⁴

A recommended strategy is to incorporate a question related to hunger and food insecurity into the medical history or physical assessment. Noting that you’ll learn more by asking whether a family has sufficient resources to provide a healthy diet than by simply inquiring about a balanced diet, a narrator uses this wording:

“In the past month, was there any day when you or anyone in your family went hungry because you didn’t have enough money for food?”²⁴

What you can do to help needy patients

Some patients who are out of work, uninsured, and barely able to pay for food and shelter will simply put off doctor visits—or come in only after their condition is so dire that you have no recourse but to send them to the emergency department (ED). The result, of course, is just the opposite of what they had hoped for. They end up with a much larger bill—or, if they have coverage, with a much bigger copay—not to mention a far more serious condition than they would likely have had if they’d come in sooner.

Here are some ways you can help.

Discuss costs with uninsured patients. To encourage uninsured patients to come in before their condition worsens, make them aware of the comparatively low cost of a visit to your office vs that of, say, imaging studies, specialist visits, and lab tests, as well as ED costs. That’s one of the interventions recommended by Robert A. Forester, MD, and Richard J. Heck, MD, the authors of “What You Can Do to Help Your Uninsured Patients.”²⁵ Consider offering discounts to low-income patients (within the bounds of Medicare and other insurance provisions), they also suggest.

Use fewer diagnostic tests. Ordering a battery of tests when a diagnosis is not readily apparent is a “cost-insensitive” way to practice medicine, authors Forester and Heck observe. Spending additional time with such patients, using your cognitive and diagnostic skills and performing a complete history and physical, frequently results in a diagnosis and treatment plan, they note.²⁵ If patients are aware that you’re trying to minimize costs, they’ll often consent to a step-by-step diagnostic work-up that can be stopped at any time it is appropriate.

Do it yourself. Expand your practice to include a variety of minor procedures, such as removal or biopsy of common skin lesions, colposcopy, or setting simple fractures. These measures can help keep costs down to better serve poor and low-income patients. The American Academy of Family Physicians offers courses and training in various procedures that family physicians can competently perform in their own offices.

Request a courtesy consult. On occasion, you may be able to avoid a costly referral by calling a colleague and asking for a courtesy consult. The specialist will often tell you how he or she would handle a clinical presentation like the one you describe and suggest you try a similar approach, suggests Doug Campos-Outcalt, MD, MPA. Dr. Campos-Outcalt, a faculty member at the University of Arizona College of Medicine and the author of JFP’s bimonthly Practice Alert column, has extensive experience working with underserved communities.

Connect patients with community services. Poor patients typically have many social and psychological needs, as well as the need for medical care, and integrated care is particularly important for those facing hunger, homelessness, and chronic illness, says Jonathan Cartsonis, MD, medical director of Healthcare for the Homeless in Phoenix. Maintain contact with hospital social services and emergency psychiatric services, and have information—and handouts—about local food banks, homeless shelters, and community clinics, among other resources. (See the resources listed in the box.)

In Seattle, for example, “Project Access” is an organization that helps give the underserved access to specialists. And in many parts of the country, local Rotary clubs sponsor free clinics staffed with volunteer and retired physicians, working cooperatively with local pharmacies to provide at-cost generic drugs.