2500 Manchester Children Without Basic Healthcare

AMBI :22 kids playing outside
XFADE 2:31 with nurse's office ambi, phone

At Manchester's Beech Street Elementary, it's a typical morning for the school nurse, Jan Bross.
BROSS :?? Alright, let's see that knee.

She bandages a bloody knee, checks a scalp for lice, diagnoses a mysterious rash, and comforts a kindergartener who got into a dust-up with a 2nd grader on the way to school.
BROSS :03 this isn't even a busy day. Haha!

Bross knows the best remedy for a swollen split-lip is a popsicle.
BROSS :08 What color do you want? you take care, it should heal on its own.

But popsicles and band-aids don't make everything better. When kids have more serious injuries or illnesses, Bross has to call home.
BROSS :11 Let's say they just had a severe emergency that needs medical care. I call parent and find out this child does not have a doctor. So we have to refer to ER.

Bross says a lot of students don't have medical insurance. She tries to refer her students to a pediatrician and encourages families to sign up for HealthyKids. That's the state's low-cost, Medicaid insurance program for children. But she says it'd hard for poor families to follow through...
BROSS :07 they go to the emergency room. if they don't have a primary care doctor that's their only option until they get one.

The Healthy Manchester Leadership Council recently analyzed school records and data from the city's emergency rooms. The final report says that about 25-hundred Manchester children don't have basic healthcare. The survey also found 77% of kids who visit the city's ERs are there for basic primary care needs: scrapes and bruises, colds and flues, and belly aches. And that's not always the best place to get medical care for a sick child. Dr. Greg Baxter is the medical director of the Emergency Department at the Elliot.
BAXTER :08 a patient with a non-urgent condition is gonna to wait. They're be trumped, as you might say, by a sicker patient with heart condition.

Emergency rooms don't usually turn away sick patients, but the staffers there specialize in treating trauma and sudden illness - not earaches. Both pediatricians and emergency room doctors agree, primary care physicians are best equipped to follow up with a patient and provide preventative care, screenings, and immunizations. Dr. Baxter says his staff tries to refer families to pediatricians, without much success.
BAXTER :14 for example, one office might be full and not accepting patients. To give name even tho they're on our back up schedule for urgent follow up, won't be helpful. parents will call the office and find out not taking patients. Then back to square one.

Families don't follow up with pediatrician appointments for any of number of reasons. They don't have insurance, they can't afford it, they don't have cars or transportation, or they don't speak English. Many poor kids get health insurance through the HealthyKids Medicare program, but can't find pediatricians who will see them.
Emily knows this problem well. She's a mother of four kids, ages 11 through 6. Her husband's job as a security guard doesn't offer health insurance, so her children are covered by Medicaid. When her oldest kids were small, she had to take the bus all the way across town to the only doctor's office that would see Medicaid patients.
EMILY :21 we used to go to River Road pediatrics. And we got stranded there in a snowstorm. We couldn't find someone to pick us up and the bus didn't go there. So we had to walk to Bedford Mall and freezing. Adrian was 4 and Amber-Lee was 6 months. It wasn't fun!

But Emily wasn't stuck out in the snow because there are too few pediatricians in Manchester.
PARIS :05 there are ample number of providers to see all the children.

Dr. Steve Paris, the medical director of Dartmouth Hitchcock in Manchester, says many Manchester pediatricians and family practices don't want to take on new Medicaid patients. He helped analyze the data from the public school and the hospitals for the Leadership Council's report.
PARIS :17 and we found that several of the practices were not participating actively in Medicaid and seeing new patients. Or they had limitations in Medicaid. Very few practices offered sliding scale or free care for those uninsured children.

Paris says Medicaid doesn't reimburse doctors enough for the services they provide. So many physicians' practices in Manchester limit the number of Medicaid patients they'll see, or opt out of the program altogether.
If a parent has a sick child and can't find a doctor, it only makes sense to go to a hospital. But that's inefficient. A doctor might charge 50 dollars for a visit to diagnose a sore throat. Treating the same sick child could cost hundreds of dollars in an Emergency Room.
Dr. Rob Nordgren of Child Health Services in Manchester lead the Leadership Council's survey.
NORDGREN :25 when children or adults are using ER for routine illnesses. It's extremely inefficient. We all pay for that. Maybe state pays for Medicaid. Maybe family can't pay, so that bill gets shifted, that's called cost shifting. One reason our healthcare premiums go up.

The Healthy Manchester Leadership Council has a solution: get more kids connected with pediatricians so they go to the ER only when they really need to.
Dr. Nordgren hopes to have a brand new program up and running by the end of summer. He's enlisted the city's hospitals to help identify those 25-hundred kids when they show up in the ER, and he's asked school nurses and administrators to comb their enrollment forms for children who don't list a primary care doctor.
The city Health Department is hiring a case worker to follow up with parents and provide support services like rides and translation services. But Dr. Nordgren's first challenge is to encourage more pediatricians to enroll Medicaid patients.
NORDGREN :13 medicaid reimbursement rates are extremely low here in NH, however, anyone who's in primary care has obligation to serve entire community.

But if local pediatricians aren't persuaded by Nordgren's ethical argument, Dr. Paris offers a financial one.
PARIS :17 If we could drive a portion of those 8-10K visits into offices, and that money were avail to take care of children, we could increase reimbursement decreasing overall burden on state.

Dr. Nordgren says medical research shows children who have regular access to primary care more likely to be healthy and up-to-date on their immunizations. They are more likely to get screened and treated for things like lead-poisoning and asthma. He goes so far as to say that the primary care physician is a patient's "medical home". That term rings true with Emily, after calling dozens of doctors, she found one who would take her children's Medicaid insurance. Now she sees one of Dr. Nordgren's partners, Claudette Ramsey.
EMILY :15 She's a nurse practicioner, she's been dealing with them since they were all little. So she knows all their history. She knows me well. Very personal. it's really nice, first name basis. I really like that. They make you feel good here.

For NHPR News, I'm RMD.