HUNTINGTON PARK, Calif. – The so-called bodega clinicas that line the streets of Los Angeles’ immigrant neighborhoods blend into a dense forest of commerce. Wedged between money order kiosks and pawn shops, these storefront doctors’ offices treat ailments for cash: a doctor’s visit is $20 to $40, a podiatry exam is $120 and at one bustling clinica, a colonoscopy is advertised on an erasable white board for $700.
County health officials describe the clinicas as a parallel health care system, servicing a vast number of uninsured Latino residents, yet the officials say they have little understanding of who owns and operates them, how they are regulated and the quality of the medical care they provide. Staffed with Spanish speaking medical providers, few of these low-rent clinics accept private insurance or participate in Medicaid managed care plans.
“Someone has to figure out if there’s a basic level of competence,” said Dr. Patrick Dowling, professor and chair of the department of family medicine at the David Geffen School of Medicine at the University of California, Los Angeles.
Not that researchers haven’t tried. Dr. Dowling, for one, has canvassed the local clinicas for years as part of his research for the state to document physician shortages. What he and others have found, however, is that clinca owners were reluctant to answer their questions.
What is certain, though, is that despite their name, many of these clinicas are actually private doctor’s offices, not licensed clinics which are required to report regularly to federal and state oversight bodies. It is a distinction that deeply concerns Kimberly Wyard, chief executive of Northeast Valley Health Corporation, a non-profit group which runs 13 accredited health clinics for low-income Southern Californians. “They are off the radar screen,” said Wyard of the clinicas, “and it’s unclear what they’re doing.”
But driven by fast-approaching deadlines set by the Affordable Care Act, health officials in Los Angeles are vexed over whether to embrace bodega clinicas and bring them – selectively and gingerly – into the network of tightly regulated public and non-profit health centers that are driven more by mission than by profit to serve the uninsured.
Health officials see in the clinicas the tantalizing opportunity to fill persistent and profound gaps in the county’s strained safety net, including a chronic shortage of primary care physicians. By January 2014, up to 2 million currently uninsured Angelenos will need to enroll in Medicaid or buy insurance and find primary care. And the clinicas, public health officials note, are already well established in the county’s poorest neighborhoods where they are meeting the needs of Spanish-speaking residents. The clinicas also could continue to serve a market that the Affordable Care Act does not touch: undocumented immigrants who are prohibited from getting health insurance under the law.
Dr. Mark Ghaly, deputy director for Community Health at the Los Angeles County Department of Health Services, said bodega clinicas, a term he seems to have coined, that agree to some scrutiny could be a good way of addressing the physician shortage in these neighborhoods.
“Where are we going to find those providers?” he said. “One logical place to consider looking is these clinics.”
Los Angeles is not the only city with a sizable Latino population where clinicas have become a part of the street scape. Health care providers in Phoenix and Miami say clinicas are in many Latino neighborhoods.
But their presence in parts of Los Angeles can be striking, with dozens of storefront doctors’ offices in certain areas. Visits to more than two dozen clinicas in South Los Angeles and the San Fernando Valley found Latino women in brightly colored nurses scrubs handing out cards and coupons that promise everything from pregnancy tests to tubal ligations. Others advertise evening and weekend hours, and, some 24-hour a day operations trumpet that they are “nunca cerramos” – never closed. That all-hours access – and up-front pricing – is critical, Latino health experts say, to a population that often works low-wage, around-the-clock jobs.
Also important, officials say, is that new immigrants from Mexico and Central America are more accustomed to a corner clinica, which is common in their home countries, than to the sprawling medical complexes or large community health centers found in the United States. And they can get the kind of medical treatments – including injections of hypertension drugs, vitamin solutions delivered intravenously and liberally dispensed antibiotics – that are frowned upon in traditional American medicine.
Many Latino immigrants have a “preference for injectables,” said Dr. Yelba Castellon-Lopez, a family medicine resident at UCLA raised in South Los Angeles who treats patients at a licensed clinic. And since common antibiotics are available over-the-counter in Mexico and other Latin American countries, patients often demand a prescription for the drugs even when it is not medically prudent. “If you try to explain they don’t need an antibiotic,” Ms. Castellon said, “people tend to walk out very dissatisfied.”
The waiting rooms at the bodega clinicas reflect the everyday maladies of peoples’ lives: a glassy-eyed child rests listlessly on his mother’s lap; a fit-looking young woman waits with a bag of ice on her wrist; a pensive middle-aged man in work boots stares straight ahead. For patients with ordinary complaints, the medical care at these bodega clinicas may be suitable, say county health officials and medical experts. But they say problems arise when the illness exceeds the boundaries of a physician’s skills or the patient’s ability to pay cash.
Dr. Raul Joaquin Bendana, who has been practicing general medicine since 1987 in South Los Angeles, said bodega clinicas will refer patients to him when, for example, they have uncontrolled diabetes. “They refer to me because they don’t know how to handle the situation,” he said. The clinica physicians by and large appear to have current medical licenses, a sample showed, but experts say they are unlikely to be board certified as specialists or have admitting privileges at area hospitals. That can mean some clinicas attempt to continue to treat patients who face serious illness.
Olivia Cardenas, a 40-year-old restaurant worker who lives in Woodland Hills, Calif., got a free pap smear at a clinica that advertises “especialistas” including gynecology. The pap smear came back abnormal, and the doctor told Cardenas she had cervical cancer. “Come back in a week with $5,000 in cash, and I’ll operate on you,” Cardenas said the doctor told her. “Otherwise you could die.”
Although Ms. Cardenas had gone to the clinica for years, and her husband had received ‘sueros’ there (IV therapy) she was shocked by the directive. She declined to pay the $5,000. Instead, a family friend helped her apply for Medicaid and she went to a licensed hospital for treatment. The diagnosis, it turned out, was correct.
Health care experts say clinicas’ medical practices would come under greater scrutiny if they were brought closer into the fold. Howard Kahn, chief executive of L.A. Care Health Plan, the nation’s largest public health plan, which contracts with private managed care companies, said: “I’m big on the idea that connectedness breeds quality.” Some here hold an uneasy hope that the clinicas could learn from licensed health centers how to follow their patients’ diabetes, hypertension and asthma, adopt electronic medical records and employ medical assistants to keep patients on track.
But being connected would mean the clinicas’ cash-only business model would need to change. Dowling, the UCLA researcher, said the lure of newly insured patients in 2014 might draw them in: “To the extent there are payments available, the legitimate ones might step up to the plate.”
Calls to a half dozen such clinics were met with no comment or were unreturned.There is at least one early indication that the clinicas may sit this one out: Clinica Mi Pueblo, regarded as scrupulous and well-run, recently sold four of its 11 clinics to a health maintenance organization over concerns that when the Affordable Care Act takes hold next year, it will lose a significant portion of its cash business.