FQHCs Take the Pressure Off Financially Pressured Patients

FQHCs can treat blood pressure, too

“I’m* so embarrassed. Brianna said you could probably help, and since I have this physical scheduled anyway…”

He pauses and I am silent. I move my gaze from his face to his right knee, hoping to decrease the pressure he feels.

“I’m falling apart. I got laid off last year and I can’t find another job, and there’s only so many hours a day you can spend looking. I’m afraid I’m not going to find one ever. I don’t want to work at a coffee shop, but it’s hard to find a job around here doing insurance analytics. When our site closed, they offered to transfer me to the headquarters in the Midwest. But we grew up here, our parents are here, and our kids have friends here. My wife and I decided that we didn’t want to move. Sometimes now I wish we had. 

“I’ve gained weight, and when I used my mom’s blood pressure meter last week, I got a really scary number: 155/90. I kept checking it, and every time it went higher. My wife told me to stop. 

“I’m grouchy all the time, and that’s not fair to Brianna or the kids. I’m afraid I won’t be able to afford pills or doctor visits, especially after my COBRA ends. I’ll have a heart attack when I’m 55, and I’ll put my family into huge medical debt and then die young anyway.”

“Well, Bruce, you certainly have a whole story there. You forgot the dog dying and your doctor being hit by a bus.”

He smiled – barely.

“I know, I get carried away, but you read about stuff like this all the time. I don’t want to have a heart attack and put my family in debt. I’m beginning to worry that I’ll have to take one of those coffee shop jobs.”

“I know. It’s scary. I do have some ideas for the blood pressure and weight that won’t bankrupt you, but first, let’s go up a level.

“Our clinic here is not your typical doctors' office. We have super-powers! We’re an FQHC. An FQHC is a community-based health care organization that provides comprehensive primary care and support services to underserved populations. We are part of a nationwide network of clinics that share this special mission. About 10% of Americans get their care at an FQHC.

Map of all the FQHC and RHC centers.

“In more rural parts of the country, there is a similar kind of clinic called a Rural Healthcare Center. About 10% of Americans get their care at RHCs.”

Bruce is looking restless, but I want to be sure he knows the full scoop about FQHCs, partly because I am very proud of working at an FQHC, and partly because I think the information will help him.

“Both RHCs and FQHCs are financially supported by the federal government to take care of people who might otherwise be unable to get healthcare. The FQHC program was started in 1965, and the RHC program in 1977.

“So, don’t go thinking that you and your family will be kicked out and have no healthcare when your COBRA runs out. In particular, don’t worry about your kids. Everyone under 18 automatically qualifies for Medicaid unless their family income is over about $100,000 (currently, in NH). One of the additional services FQHCs offer is that we have social workers who help people with issues like getting their kids signed up for Medicaid.”

“Brianna thought you might have something like that. She loves her job with the rec department, but it’s part-time and they can’t offer insurance.”

“A lot of people are in your situation. We have a sliding fee scale that slides all the way down to zero. Even for people with insurance, we can sometimes slide the copay or forgive the deductible. 

“Sometimes we have grants for things like blood pressure cuffs and colonoscopies. We have programs from the state to help with things like Brianna’s pap smears and mammograms. We have a special program with one of the local pharmacies that might help you get a better price on your meds. And, because you are not the first person with these kinds of problems we’ve seen, we know all the tricks – or at least our social workers do. 

“I’m sorry you’re having to find out about these services, but this is where we shine. When we’re done talking, I’ll introduce you to our social worker.

“Also, we have therapists in-house who take our sliding fee scale. We might want to think about getting you with a therapist to help with some of the self-defeating, catastrophic talk I'm hearing from you.” 

Not relevant to Bruce’s issues right now, but FQHCs also commonly have in-house labs, obstetrics, psychiatric prescribers, and suboxone treatment programs for opioid addiction.

“We can help you with the issues about paying for healthcare, okay? And even if you can’t pay, we will never turn you away. Everything the clinic does in-house, we can do for you and your family at a sliding scale rate. We can help arrange discounts for other service providers like the hospital. We’ll get you set up with the social worker today to see what you qualify for. I hope that helps.”

“I didn’t know the clinic did all those things! That’s awesome!”

This was the only moment during my visit with Bruce that he didn’t come across as dejected and defeatist.

“Yes, we are here for folks whenever they need some extra help.

“Now, as for your blood pressure, sometimes we have programs that give away blood pressure monitors. We’ll ask the nurses if we have one of those grants active right now.

“Your blood pressure reading we took today also shows that you have high blood pressure**. Blood pressure readings are tricky things. A whole host of factors affect your blood pressure, and these change moment to moment. It’s perfectly normal for people to have brief periods when their blood pressure is too high. All we have to do is wait a while and the pressure comes down. 

“Once you are put on a blood pressure medicine, unless something dramatic happens – like you lose twenty pounds – the assumption is that you’ll need to take them for the rest of your life. Because blood pressure readings fluctuate, we want to measure it many times before we conclude that you have high blood pressure.” 

When I am considering starting a patient on a blood pressure treatment, this process of getting multiple readings gives them some time to get used to the idea that they may require life-long treatment. Bruce’s blood pressure is high, but not that high. He may have elevated blood pressure readings just from being very anxious. He sure looks anxious. We need more data before we commit to pills. I suspect he needs some lifestyle modification. 

“What I’d like to do is for you to record your own blood pressure at home for a few days. We can see if we have blood pressure cuffs to give out right now, but if not, I’m sure your mom would loan you hers for a week. They cost about $50 if you have to buy one. But, of course, no sense in your having to buy one if we can avoid it. 

“I’d like you to take three readings a day and write them down. Your blood pressure will be different in different circumstances. If you check your blood pressure under all kinds of different settings - when you’re relaxed, when you’re sad, when you’re angry, when you’re hungry or tired, et cetera – that will give us a good idea of what is going on. We’ll set you up for a return visit in a few days. Bring in the blood pressure cuff and your log of readings. We’ll check to see if your blood pressure cuff gives readings close to ours to ensure we can believe those readings. Once we have all of that information, we’ll assess whether your blood pressure is chronically too high or if these couple of high readings we have are just outliers. Does that make sense?”

“Yes, but I am worried I might kind of overdo it.”

“In that case, have Brianna decide when to check your blood pressure. Tell her what I just told you. Check three times a day, but no more than that! I’ve had patients get so nervous about checking their blood pressure that when they pull the machine out, their blood pressure starts going up. You’re not the only one who can’t take their own blood pressure due to nerves. 

“Let’s do your follow-up on Monday. Normally, I’d give you a whole week, but I don’t want you sitting out there, being so nervous any longer than you have to.”

“That sounds good.”

“To give you some background about why we’re concerned about high blood pressure, it increases wear and tear on your blood vessels, especially those in your heart, your brain, and your kidneys. We can’t tell your brain, ‘This wear and tear on your blood vessels doesn’t count because it was just due to road rage or your neighbor’s dog barking for forty minutes.’ All we can do is on average lower your blood pressure across all circumstances. Of course, your blood pressure is going to go up and down as you go through the day. If we overdo lowering your blood pressure so that it is controlled in your most stressed-out moments, then in your regular moments, your blood pressure can end up too low, and you will feel cruddy. It’s all a balance - a risk/benefit analysis.”

“Analyzing risks was what I used to do at my old job at the insurance company before I was laid off.” 

“Oh, I’m so sorry, Bruce, to remind you. You must miss your job so much. You seem like you’re kind of depressed and anxious, too, both understandably enough.”

“Well, who wouldn’t be? I mean, I started this job straight out of college, and I thought I’d be doing it until I retired. I did a good job, too. Not everyone was offered a transfer when our site got closed. I was. I sometimes regret not taking it. It seemed like a good decision at the time, but it’s not been working out well. I’m kicking myself that I failed to properly assess the risk of not being able to find another job. Maybe everyone is right not to offer me a job. I mean, what kind of risk adjuster would get himself into this situation? Our savings are not going to last forever; we’re going to be living in my parents’ basement soon. At least, they’re in the same school district that the kids are already in.”

“I can’t help you there, Bruce, but I do really want to encourage you to think about meeting with one of our talk therapists. We can also think about medications. Some of the blood pressure medications may help you with anxiety symptoms, too, if it turns out you need blood pressure medication. We’ll talk more about that next week. However, there’s one thing you can start today that will probably help every problem you’ve got.” 

I paused for effect. He didn’t bite. 

“Exercise. It’s good for your mood, your blood pressure, and your weight.” 

“I had a membership at the local gym once. I used it faithfully for the first week of January, then never went again. I cancelled it.”

“I think if you exercise even a little bit, regularly, it will really help your mood. It will also help lower your blood pressure.”

“I can try to walk around the neighborhood, but I really don’t think I’m going to be able to get myself to go to a gym. I tried that. It’s just not for me.”

“Okay. I won’t push harder right now on that, but I wish you would walk around the neighborhood. 

“There are other things you can do to lower your blood pressure. Eating the DASH diet helps. Who does the cooking in your house?”

“Brianna used to, but she cleans houses on the side now and is always busy. I do the cooking now. The shopping, too. I’m a good cook, but I don’t know how to cook vegetables very well. I never liked them, so I never learned. I grill a lot in the summer and make corn on the cob, so we do okay in the summer. I bet the DASH diet says to eat more vegetables. I’ll look it up. I don’t think my kids will eat vegetables even if I learn to cook them.”

“Well, please give it some thought and a try. Maybe you could enlist the kids’ help with vegetable recipes. It wouldn’t be a bad thing for them to learn to cook anyway. If they like it, it might be a fun activity to do together.” 

I’ve been giving him so much non-stop advice and correction that I don’t have the heart to tell him corn barely qualifies as a vegetable.

“This brings me to the next thing you can do for your blood pressure: decrease salt. Most Americans can lower their blood pressure 5 or 10 points just by eating less salt. Do you have a sense of how much salt you eat?”

“I never use it when I cook, but I do sometimes eat potato chips. Brianna knew not to buy them because if they’re in the house, I’ll eat them, but I buy them. When the kids come home from school and they’re hungry, it’s easy to just give them a bowl of potato chips. Sometimes we’ll sit at the table and eat them together. It’s the only nice time we spend together because they’re always out playing sports or in their rooms on their computers. I’m afraid if I started serving a healthy snack when they came home, that they’d just turn their nose up and go straight upstairs.”

“Maybe you could have a bowl of cut-up carrots on the table in addition to the potato chips? If they’re into sports, they should be at least a little bit into nutrition, too.”

“Yeah, maybe. I don’t think it will work, but maybe I’ll try it.”

“Now, back to you and your blood pressure, the final thing you can do to lower your blood pressure is to drink less alcohol. A lot of people drink more when they get laid off. Has that been your pattern, too?”

“I guess so. I only drink light beer now because it’s cheaper and has fewer calories.”

“How many do you drink?”

“Yeah, it probably really comes out even because I drink more of the light beer. It’s really the only thing to do in the late evening. We often spend the early evening at the kids’ sports practices. When I come home from those events, I feel like I should get a reward. It’s so nice to just sit quietly and relax with a few beers.”

“It’s so hard! You have interlocking problems, don’t you? I can see why you’d feel that way about drinking beer at the end of the day. But I do have to tell you that drinking less beer will help your blood pressure go down. Even though you’re drinking light beer, it still adds up. 

“I feel like I’ve given you a lot of instructions today: get more exercise, drink less beer, eat more veggies, use less salt. I feel like none of these are things you think you can do, which makes me wonder about your mood. Let’s move on to the rest of your physical. We can talk more about whether you might be depressed while I examine you.”

I pull out the otoscope and get going on the exam. We talk about depression. Bruce doesn’t want to do anything about it. I take Bruce to the scheduler, and we get him set up to come back in on Monday. I’d already alerted the social worker. She arrives at the front desk to take him back to her office. 

We will chip away at Bruce’s problems slowly. I fear the most difficult one to help will be his difficulties with his attitude. After being with him a while, I find his defeatist attitude has rubbed off on me. I pause to take a couple of deep breaths before heading to see my next patient. 

* Bruce and his family are patient and family amalgams, constructed from hundreds of patients with similar stories and their families. Any relationship to real people or real families is coincidental.

**Nothing in this article is personal medical advice. If you think you might have high blood pressure, talk to your doctor. If you do not have a doctor, go to your nearest FQHC and get one.

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