On a recent Saturday afternoon, the waiting room of a doctor’s office on First Street in Santa Ana was teeming with patients – which wouldn’t be unusual except that it was a day when most medical practices are closed.

An eclectic list of treatments and conditions were posted on the clinic’s outside window, much like a restaurant menu: gynecology, chiropracty, injections, massage, sports injuries, surgery, X-rays, and impotence.

Across the street, patients in the waiting room of another doctor’s office approached the check-in window after their appointments, pulling out a roll of cash or an envelope of bills.

No cards or subscriber numbers were exchanged – this clinic and many others like it don’t accept insurance.

Storefront medical care is prolific in Santa Ana, Anaheim and other cities with large immigrant communities. Storefront clinics frequently operate outside the elaborate confines of medical insurance, meaning there are no network restrictions, co-pays or deductibles.

“This is a simpler model,” said Dr. Hitesh D. Patel, who co-owns four cash or credit medical clinics in Orange County. “You don’t have to deal with insurance. The two key players are the doctor and the patient.”

But critics of the clinics say that going without insurance is a financially and medically precarious approach to health care. The critics, who include health care experts and public clinic administrators, warn that cash care is too haphazard to treat chronic illnesses effectively. Some patients complain that the billing in storefront clinics can be deceptive.

Other patients swear by the clinics, saying the care they get is just as professional yet more affordable and accessible than they would find otherwise.

And with undocumented residents ineligible for most low-cost public insurance under the Affordable Care Act, the clinics are expected to remain a go-to source of affordable health care for a significant slice of the population.

Convenience and Cost

The clinics are more likely to be located on a busy street than tucked into a medical park. For example, three storefront clinics are neighbors to El Toro Carniceria in Santa Ana, a sprawling food marketplace that draws crowds on the weekend.

The clinics generally require no appointments and are open on weeknights and weekends. Many offer a variety of services, from a basic school physical to vitamin B12 injections for energy and weight loss, a popular though scientifically unproven treatment.

A consultation with a medical professional at a storefront clinic generally costs between $20 and $40, and from there procedures are offered on an a la carte basis, from glucose testing that could start at $10 to an ultrasound for $130 and up.

Patel’s clinics even advertise special packages on blood tests measuring cholesterol, anemia and other conditions, including the $90 “silver package” and the $275 women’s “diamond package.”

With flexible hours, the clinics are set up to accommodate people who don’t have a car or a lot of time off. Many do their own X-rays and provide medicines on site, thus eliminating additional trips to the pharmacy and radiologist.

While typically offering services in Spanish, the clinics draw patients from a variety of backgrounds. Uninsured Anglos are among clinic patients, as are insured Latino patients who prefer the simplicity of cash care. At his clinics, Patel said, 40-50 percent of patients are insured.

One distinction between clinic care and more traditional primary care is greater reliance on physician assistants, who are by law supervised by the doctor who owns the practice.

A Matter of Trust

A key reason for the storefront clinics’ success may be patient trust.

“The way we define health access in the U.S. in terms of insurance is not how many immigrant communities define it. It’s more about the relationship with the healer,” said Guitele Rahill, a professor at the University of South Florida with expertise in immigrant health issues.

A common language can enhance patient-provider trust. For example, the Spanish-speaking staff is one reason that an undocumented patient, who asked that her name not be published, remains loyal to Clinica Medica Familiar in Santa Ana. She also likes being able to show up on short notice and pay $40 for her visit.

Job loss is another reason for the clinics’ appeal. April Hooper said she was laid off from the city of Costa Mesa and found herself turning to the El Toro Medical Clinic in Lake Forest, which she described as clean and professional. Further, she appreciated the chance to buy her medicines on-site and paid $25 for the visit.

“To be frank,” she wrote in an email, “I was in shock how reasonable the office visit was and the professionalism. As for today, I have Obamacare and Blue Cross Blue Shield as my provider. I pay $60 for an office visit. I found the office of my new physician in Irvine no different than the office at El Toro Medical Clinic; however, I am paying much more.”

Critics’ Objections

Among the critics of storefront clinics are medical professionals who work in the county’s network of community clinics – nonprofit and often federally supported entities that serve as the medical safety net for low-income patients.

Community clinic staff members say they often get patients who are unsatisfied with the level of care delivered at the storefront clinics.

“Patients feel half treated,” when their doctor prescribes a number of tests, each of which carries a separate fee, and they can only afford to pay for some of them, said Karen McGlinn, CEO of Share Ourselves, which operates several nonprofit medical and dental community clinics in Orange County.

Yadira Gomez, senior case manager at Share Ourselves, said patients regularly report being lured in by the $20 consultation and then facing an extensive bill for itemized services that would be included in most doctor visits.

However, McGlinn’s biggest concern about storefront clinics relates to chronic illnesses, which affect lower-income people disproportionately. These diseases require frequent access to medical professionals, particularly in the early stages of diagnosis, to adjust medicines, educate patients on a healthy lifestyle and stabilize their condition.

“Hypertension and diabetes need consistent care. To achieve a state of well-being, you need a primary care setting,” McGlinn said. “You need to learn preventive health…If you are untreated and your care is episodic, you are constantly in an urgent state.”

Clinic owner Dr. Patel said he does more than just write prescriptions for the 20 to 30 percent of patients who come to him for chronic conditions like diabetes and hypertension. He also educates them on needed lifestyle changes, he said. But if a patient’s case is worsening, he advises him or her “to start thinking about insurance.”

Health care outside of insurance could leave patients without recourse if they face serious illnesses, said Professor Dylan Roby of the UCLA Fielding School of Public Health.

“If you are not a user of health care and you don’t perceive health risks… you may perceive cash payments as straightforward and a good deal,” Roby said. “If you’re uninsured and it turns into something serious, you could be uninsured for the rest of your illness. You could end up with dialysis or chemotherapy.”

Where Are the Watchdogs?

Official oversight of the clinics is minimal.

They are essentially private practices subject to the same rules as traditional doctors’ offices, which means they need a city business license, a permit to practice under a fictitious name rather than the doctor’s name (such as “Clinica Medica,” for example) and a professional license with The Medical Board of California.

Cash and credit medical clinics don’t always make it easy to find out the names and credentials of doctors and staff, unlike in traditional medical practices where this information is found readily on the practice’s website.

And some accountability issues have arisen at clinics in the past. In 2005, Dr. Alonzo Lockhart, of the Samuel Clinic in Santa Ana, was suspended from practicing medicine after his unlicensed assistant was treating patients and prescribing medicines. Lockhart’s license was later fully reinstated, according to the records of the state Medical Board. The clinic is still in operation.

Storefront Clinics and the Affordable Care Act

Some storefront clinics participate in the public health insurance system, Medi-Cal, though they appear to be in the minority. One Santa Ana clinic sees insured patients during the week and cash patients on the weekend.

But there may be incentives for more storefront clinics to begin accepting Medi-Cal, given the surge in Medi-Cal’s enrollment under the ACA and the need for more primary care doctors to serve these newly insured patients.

Getting state-approved to treat Medi-Cal patients is no simple undertaking, however; it requires inspections and extensive staff training, said clinic owner Patel, who is not planning to seek Medi-Cal certification.

And some patients of storefront clinics don’t seem to be in a hurry for a more regulated, insured medical environment.

Miguel Cruz, a mechanic from Santa Ana, feels certain he would qualify for medical insurance, but he prefers to pay cash for a visit at Clinica Medica Guadalupana in Santa Ana, or even travel to Mexico for medical procedures.

He knows he may face a fine under the ACA for not signing up for an insurance plan but seems reluctant to enroll, saying, “I’ll figure it out when the time comes around.”

As Cruz’s comments suggest, cash or credit clinics may have an undermining effect on health care reform, by offering an alternative to insurance coverage and consistent primary care.

Case in point: Josh Hardie of Mission Viejo likes the El Toro Medical Clinic in Lake Forest and plans to continue going there rather than seek insurance, despite the penalty for lack of coverage.

“For the time being it’s actually cheaper for me to pay the fine and save a little extra for the rare occasion I need to see a doctor than it is to enroll in a mandatory health insurance plan that still requires me to pay crazy deductibles and almost no reduced cost on prescriptions,” he said.

Amy DePaul is a Voice of OC contributing writer and lecturer in the University of California, Irvine Literary Journalism program. You can reach her directly at depaula@uci.edu

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