by Cole Petrochko

The nation’s free clinics provide medical service to 1.8 million patients annually — more than half of those clinics operate without government funding and serve patients who are almost all uninsured — according to the first census of free clinics in 40 years.

Responses to a national mail survey by 764 free clinics in the U.S., reported in the June issue of the Archives of Internal Medicine, revealed that new and recurring patients waited an average of 12 and 11 days respectively for clinic appointments, suggesting far greater demand than can be met by the time and number of volunteer clinicians at the limited number of available clinics.

“Our nation’s 46 million uninsured often delay or forgo needed healthcare because the cost is prohibitive,” said study author Julie S. Darnell, PhD, MHSA, then of the University of Chicago and now with the School of Public Health at the University of Illinois at Chicago. The mean cost for a doctor visit for uninsured patients is around $50, Darnell wrote.

Traditional sources of care, including public clinics and federal health centers, both charge fees and bill patients. “Aside from cost considerations, care is frequently difficult to find, especially for those with the least resources,” Darnell added. For many poor, uninsured, and underserved patients, the only sources of care are emergency rooms or free clinics.

At the time of the survey, 1,007 free clinics were known to be operating throughout 49 states and the District of Columbia (Alaska was the lone exception).

Free clinics were defined as a private, nonprofit organization or component of an organization that provided medical, dental, or mental healthcare or medication directly to patients who were mostly (more than 50%) uninsured and charged no or nominal fees ($20 or less) for service.

Those defined as free clinics could also not bill patients, deny, or delay service if payment could not be made and did not belong to a Federally Qualified Health Center (FQHC) or Title X family planning clinic. Sites that only offered pregnancy or sexually transmitted disease-related services were also excluded from the operating definition used in the study.

The survey revealed that free clinics operate an average of 18 hours a week, an average three days a week, on a mean budget of $287,810, with 95.2% providing medical treatment, said Darnell.

Nearly three-fifths (58.7%) receive no government-supplied revenue, and slightly more than a quarter (26%) receive less than a fourth of their budget from any government source.

A whopping 92.2% of patients going to the free clinics are uninsured, and more than half (56.1%) earn below the poverty level. Only 40.8% are at or earn up to two times the poverty level, while the remaining 3.1% earn more than 200% poverty level.

A large number of patients using free clinics belong to special populations, including:

* Homeless (41.9%)
* Immigrant (39.3)
* Substance abuse disorder (18.5)
* HIV/AIDS (9.5)

The medical staffs at the free clinics surveyed were mostly volunteers, including physicians, nurses, and nurse practitioners/physician assistants (82.1%, 72.6%, and 54.9% volunteer, respectively). Roughly, only 19% of nurses and 15% of nurse practitioners and physical assistants receive part- or full-time pay (18.1% of nurses and 14.1% of nurse practitioners and physician assistants receive full-time pay, while 20.5% and 16.2% receive part-time). Only 6.8% of physicians receive full-time pay and 12.6% receive part-time pay.

Executive directors of free clinics mostly (43.2%) receive full-time pay, while 22.6% receive part-time pay and 27.1% are volunteers.

Most free clinics (97.7%) have at least some volunteer staff, contributing an average 4,237 volunteer hours per clinic.

More than half (56.6%) are independent, while the remaining clinics are part of or affiliated with another organization.

The survey compared free clinics with health centers in uninsured patient volume (1.8 million for the clinics versus 6 million at health centers), budget ($290 million from all sources versus $1.8 billion in federal money), cost per patient ($600 versus $562), primary care services offered (basic with medications versus comprehensive with reduced price medications), staff (mostly volunteer versus paid staff), and average cost to uninsured patients ($9.30 versus a tiered structure).

Uninsured patients in health centers pay an average $5 to $24 with income below the poverty line, $47 at up to 150% of the poverty line, and $87 at 200%.

The author concludes that the findings challenge the belief that free clinics will phase out with the introduction of healthcare reform — that free clinics are gap-fillers and that an average 7.5% of patients in free clinics already have insurance. The heavy burden on free clinics would be offset with additional support from safety net systems, such as coverage through healthcare insurance reform, which should strengthen the overall healthcare system and free clinics, Darnell added.

Sources were originally compiled from sources including member lists of free clinics, directories, online databases, and Internet searches, initially resulting in a pool of 2,545 potential free clinics.

The study’s operating criteria narrowed the initial pool to 1,188 sites, which was further reduced by 181 when many were found to charge more than $20, were duplicate entries, billed patients, served mostly insured patients, were an FQHC, or for another general reason were deemed ineligible. The survey was then sent to 1,188 free clinics between October 2005 and December 2006; 764 clinics returning the survey were classified as eligible for study.

Limitations of the study include its cross-sectional design, potential sampling bias, the disparate sources used to identify free clinics (the smallest, youngest, and least formal free clinics were more likely to be excluded), and only free clinics currently in operation at the time of the survey were described.

Cole Petrochko is a MedPage Today staff writer.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.