Cure for the health care crisis?

It's a humble setting where doctors are salaried so there's no incentive to do unnecessary procedures. Physicians and nurses coordinate care so patients are more likely to stay well. They don't own expensive equipment, so there's no motive for costly tests when a simple consultation will do. Oh, and because they're federally funded, the doctors can't be individually sued.

The approach at Central and other community clinics sounds similar to the themes for health care reform that Obama sketched in a speech this month to the American Medical Association: Emphasizing primary care. Changing financial incentives to reward quality, not quantity. Protecting doctors from malpractice liability so they don't practice defensive medicine. Freeing doctors from being bean counters to let them do what they went to medical school to do -- heal.

Their methods have won financial support both from Obama and the Bush White House that preceded him. That's beginning to focus unfamiliar attention on clinics like Central.

"We're kind of a well-kept secret, I guess," said Jonathan Watson, director of public policy for the Minnesota Association of Community Health Centers.

Not for long. The nation's community clinics, found mostly in inner-city and rural areas, have grown rapidly in the past decade to become the biggest single system of primary care, with more than 7,200 sites, according to the Kaiser Family Foundation. Their volume has nearly doubled, to 16 million patients in 2007.

"In light of their location, their mission and their performance, health centers appear to lie at the nexus of this broadened concept of health reform," Kaiser concluded in a report in March.

A typical clinic visit

On a recent morning at Central Clinic, a new patient walks in.

She had spotted a flier for the Sage Screening program, funded by the federal Centers for Disease Control and Prevention and the state to provide free breast and cervical cancer screening.

She is 52 and uninsured. Her last visit to a doctor? Four years ago. Through a Spanish-language interpreter, she says she's worried about cancer since her mother had cancer of the mouth and tongue. Dr. Rahshana Price-Isuk assures her that sort of cancer is rare and not considered hereditary.

Price-Isuk feels the patient's breasts for lumps and performs a Pap smear. She tells the patient a mole on her back looks normal, but says she should get her husband to keep checking it for changes of color or shape.

The doctor takes the opportunity to recommend a blood test for diabetes, cholesterol and thyroid function. Those tests are not covered by Sage. Would the patient like them anyway? Yes. The price: $29.

A 2007 report by the National Association of Community Clinics found that people who get their care mainly at a community clinic incur on average $2,569 a year in total medical costs. That's 41 percent lower than the $4,379 for those who don't use a community clinic, partly because they cut down on expensive visits to emergency rooms.

"Our absolute bias is to try and find inexpensive care for our patients," said Dr. Ron Jankowski, medical director for Fremont Community Clinics, a group of three clinics that includes Central Clinic.

Jankowski took a pay cut when he quit a long career at a private clinic chain. He felt his employer was too money-oriented, and he was frustrated that his work overseeing medical residents wasn't valued because it didn't bring in direct revenue.

Competing on cost, quality

In Minnesota, community clinics last year served roughly 180,000 patients, or about 3 percent of Minnesotans -- a third of them uninsured.

In some outstate areas such as Cook and Grand Marais, community clinics are the only primary care provider regardless of patients' insurance status.

Generally, most patients are uninsured or on public health care programs, pigeon-holing community clinics as the place for those with no other options.

But the clinics feel they can compete on cost and quality with private practitioners.

Pick any one of a number of popular reform buzzwords circulating -- the "medical home,'' for example, or patient-centered care -- and community clinics already are doing it.

A medical home is another name for getting close, dependable attention from a doctor and coordinated care that anticipates problems. Nurses call pregnant women to come in for check-ups. They call parents to let them know a child is due for a shot. They help families get food stamps and organize transport to get patients in for appointments.

As a result, only 4.8 percent of babies born to women seen at community clinics were of low birth weight, compared with the state average of 6.8 percent, according to the state association. In addition, 98.4 percent of children seen at community clinics had all their vaccinations by age 2, compared with the state average of 81.4 percent.

Where community clinics don't come out as well in state rankings is with chronic conditions such as diabetes or cardiovascular care. Community clinics serve a disproportionately low-income and sick population. Managing something such as diabetes requires major changes in exercise and diet over a lifetime, tougher for a patient worrying about how to pay rent or buy any food at all.

Washington policymakers have enough confidence in this care model that the 2009 federal economic stimulus bill included hundreds of millions of dollars for community clinics.

This year, Minnesota's 74 community clinics received $4.7 million in stimulus funds to add providers and support staff, and extend hours to cope with the growing number of uninsured. The clinics also are vying for tens of millions in federal grants to add equipment, and install electronic medical records.

Lower fees, lower salaries

At Central Clinic, the third of patients who are uninsured typically pay $20 a visit plus a sliding fee based on income.

Another third are in public programs such as Medical Assistance. A final third have private insurance and choose to come because they like the care. "Our patients range from the homeless to college professors," Jankowski said.

To make sure doctors aren't rushed, they are limited to 20 patients a day. (Private practice doctors see as many as 35 patients a day.)

With finances tight, clinic doctors have to really want to practice there. They are paid 15 to 20 percent less than in private practice, about $110,000 to $115,000 for a doctor who's just finished a residency.

But for Jankowski, the reward is practicing medicine the way he always hoped to and helping patients who appreciate his skills.

"When I was in private practice, I was exhausted," he said. "I drive home now with a smile on my face.''

Chen May Yee • 612-6737434