Fall 2008 Issue

Working Without a Net

Physician Assistant Joanie Kemsley ’04 is a lifeline for hardworking Charlotte County residents who just can’t afford to see a doctor.

By Rena Kizilisik

Joanie Kemsley, PA-C, who graduated from Barry's Physician Assistant Program in 2004, is the only medically trained employee at the St. Vince de Paul Community Health Care clinic in Port Charlotte, Florida. Kemsley estimates that she sees an average of 20 patients a day ¬ about 2,000 visits in the not-for-profit’s clinic's first four months of operation.

At 28, Jason McClasky is a young man. But his lungs won’t let him enjoy it. For the last six months he’s had a severe lung infection from living in a moldy apartment. As an uninsured construction worker and father of three with another one on the way, McClasky can’t afford to see a doctor – he was lucky to scrape together the cost of moving himself and his growing family into a new apartment.

Sick people – particularly working adults – who can’t afford medical treatment are nothing new to Physician Assistant Joanie Kemsley. In fact, Kemsley begins each day surrounded by stacks of patient files, stacks that continue to accumulate on and around her desk at the St. Vincent de Paul Community Health Care Inc. clinic in Port Charlotte, a small town on the west coast of Florida. Located in what’s known as “Hurricane Alley,” between the more affluent cities of Naples and Tampa, the average annual income in Port Charlotte is approximately $25,000.

As the clinic’s only medically trained employee, Kemsley often spends her mornings making calls to get free medical care for the uninsured residents of Charlotte County; to say this can be frustrating at times would be an understatement.

In Jason’s case, the doctor Kemsley initially called to see if he would treat Jason free of charge, turned her down flat. Kemsley says she believes he may be afraid that if he has to refer Jason to someone else, it would involve him asking the next health care provider for further free services – something he is not willing do.

“That’s the way it works,” she says. “I call the physician or lab and beg; many say yes and many go above and beyond. However, there are always the exceptions which make my job more difficult.”

For Jason, Kemsley will have to rely on a chest X-ray she was able to procure through her contacts in the area and a strong dose of generic antibiotics that she knows he can get for free through the Publix prescription drug program.

Better late than never

The St. Vincent de Paul clinic, founded by Drs. Marianito “Mark” Asperilla and David Klein, first opened its doors in Port Charlotte in February 2008. The doctors, both of whom have busy private practices in the area, used their previous experience with AIDS and Hepatitis C clinics when devising the model for the clinic. Asperilla drew up the original business plan on table napkins after experiencing “years of frustration” trying to get public funding to set up a free clinic in Charlotte County. “I sat down one night when I could not sleep and wrote out the business plan for the clinic on napkins at 2 in the morning,” he said.

His plan was to create a loose collaboration between local health care institutions, physicians and pharmaceutical companies in order to provide free care for those who do not qualify for Medicare or Medicaid. The central component of his model was the hiring of a single PA to manage and coordinate the day-to-day operation of the clinic. Although they felt they had a solid concept, both men knew that the key to their success would be the hiring of the PA.

“The start-up team had been interviewing PAs for weeks and had narrowed the decision down to three candidates. Joanie came in from behind; she was not even one of the original applicants, but we are grateful she came along,” Asperilla said, adding that Kemsley’s medical expertise, straightforward demeanor and just plain guts made her stand out from other PAs they interviewed. She was the only candidate who was not scared off by the huge responsibility of running a clinic virtually alone.

Kemsley’s success as a PA seems to support the old adage that there’s something to be said for coming to something later in life. After raising her son Alex as a single mom she made the decision to go back to school to not only cope with the reality of being an empty-nester but also to “find a greater purpose.”

It was always just the two of them, she says, so she needed something that would be all consuming in order to give him his space.

Approaching middle age, she had been out of school for many years, so she took a summer course in biology at the University of Vermont to prepare for the PA program. “We did a chapter a day, it was very grueling. I had flash cards pasted all over my house and studied constantly. Many nights I cried,” recalls Kemsley.

However, despite the difficulties inherent in beginning a new career later in life, Kemsley found inspiration when, on the first day, the instructor announced that he had a brain tumor and warned the students that he may have seizures during class.

“I thought, ‘If this poor young guy with a brain tumor can stand in the basement, in the sweltering heat, and teach this basic biology class, then I can overcome my own limitations as an adult learner,’ ” says Kemsley, who jokes that she found Barry “the hard way.”

On her way to vacation in Key West before starting a PA program in Pennsylvania, Kemsley visited Barry’s campus and felt inspired. “I stood on the campus in the sunshine, under the palms, listening to the wild parrots and knew this was where I needed to be,” she said, adding that she’s never regretted losing her $500 deposit for the Pennsylvania program.

Going without

Andrew, a patient of Kemsley’s, meets with her for a follow-up session after undergoing alcohol and drug detoxification. He is relieved to get a clean bill of health after 40 years of drug abuse.

Perhaps it is her life experience, such as taking care of her father when he was terminally ill, or her desire to find an all consuming passion that makes Kemsley comfortable working in an environment in which practicality is at a premium and ego a hindrance.

In order to keep costs down, Kemsley has no staff physicians to regularly consult with, instead she relies on Asperilla and Klein’s off-site supervision or input from one of the dozen or so physicians who volunteer their time at the clinic. There is no billing system as the clinic is free. There are no labs or imaging services available except through institutions that are willing to donate services. A simple blood test becomes a luxury.

“All we can supply is a safety net for the uninsured in our local area,” says Klein. “The scope of practice of the PA allows us to provide care to those who would otherwise go without.”

And, unfortunately, there are many going without. The U.S. Census recently reported that 45.7 million Americans were uninsured in 2007. In addition, a report released in October by the U.S. Census Bureau estimated that more than one in five Floridians younger than 65 lack health insurance. In Charlotte County, 19 percent of the population is uninsured, slightly above the national average of 17.3 percent.

Statistics in and of themselves cannot put a face on the uninsured, but if it they could, the face could easily be one of a working adult between the ages of 18-65 who has a full-time job. In fact, the National Scorecard on U.S. Health System Performance (2008) states that 42 percent of all working age adults in the United States are either uninsured or underinsured. Although some disagree on what qualifies someone as underinsured, it is generally taken to include anyone who is unable to obtain needed care because their insurance coverage is inadequate.

Those employed by small businesses - less likely than larger corporations to offer their employees affordable health plans - are among the hardest hit, Kemsley says.

Taking her lumps

Mary, the sole employee at a small UPS franchise, was hit hard.

The franchise does not provide her with health care coverage, and, like so many working people, she lives paycheck to paycheck. She can’t afford to pay for her own health insurance, so, needless to say, regular mammograms are out of the question.

About a year ago, Mary found a lump in her breast. Initially, she wasn’t too worried because she had a history of breast cysts and assumed it would fade away on its own as the others had. But as time went on, the lump continued to grow and cause her increasing discomfort. When a friend told her about the free clinic, Mary called immediately to get an appointment.

As soon as she examined Mary, Kemsley knew there was cause for concern. The lump in Mary’s breast actually did not technically qualify as a “lump” as it took up more than 50 percent of the breast tissue, she says. Knowing that time was critical, Kemsley’s first step was to get a biopsy free of charge. After a week passed and she still had no luck getting the biopsy scheduled, Kemsley and a doctor who volunteers at the clinic decided to do the biopsy themselves. The sample was sent to a lab, which revealed that the lump was malignant, confirming Kemsley’s suspicions.

As is so often the case, Kemsley again took to the phones and was able to get Mary into a clinical study at the H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida in Tampa. Not only would Moffit treat Mary free of charge but, as part of the clinical study, she would also be eligible for free prescriptions, have a place to stay during radiation treatments, and a coupon for their salon to be fitted for a wig when she loses her hair.

“I consider Joanie a blessing from above. I am being treated like a queen at Moffit,” Mary says, adding that she hopes others will be helped through what they learn from her case.

Putting the ‘emergency’ back in ER

Dustin, an uninsured day laborer in the construction industry, comes to the clinic seeking treatment for a toothache.

If Kemsley and the clinic hadn’t been available to Mary, the chances are that she would have eventually ended up at the emergency room. A far more costly alternative to a clinic or doctor’s office, the ER is the first and last resort for many sick Americans. In fact, the National Hospital Ambulatory Medical Care Survey of 2006 places the number of emergency room visits in the U.S. at 119.2 million, some 40.5 visits per 100 people. In Charlotte County alone there were close to 70,000 ER visits in 2007, according to estimates from the Florida Health Planning Council of Southwest Florida.

“It is our hope that the clinic is serving to reduce the number of emergency room visits in our area,” Kemsley says. “The number of cases we see each day at the clinic makes clear the dire need for health care for the uninsured in the area.”

In the short amount of time the clinic has been open Kemsley estimates that she has seen an average of 20 patients a day - some 2,000 visits in its first four months. The clinic is open from 5 p.m. to 9 p.m., Monday through Friday, in order to accommodate the average worker’s schedule. There is also a county-funded transportation service that charges only a dollar to take patients who do not have transportation to their appointments at St. Vincent’s clinic.

Blood, sweat and tears

As Kemsley begins to examine Robert, who has come to the clinic with a toothache, he apologizes to her for being sweaty. “I’ve been working on the roof all day so I probably stink,” he says as they begin to chat. Kemsley says guys like Robert are the reason she becomes so angry and frustrated when faced with working people who aren’t getting access to health care. Robert works hard as a roofer all day long and has from a very young age, a tough job which the South Florida sun makes even more grueling.

“To think that a man who has worked as hard as Robert would have to go to the emergency room for a toothache is just not the way it should to be,” says Kemsley.

Although not much about the health care system as Jason, Robert and Mary experience it is as it should be, Kemsley and the clinic staff and volunteers remain focused on working with the what is, and on doing what they can to improve the lives and health of every patient who comes through their doors – a utilitarian, needs-based approach more often associated with developing countries than with 21st century U.S. health care.

“We are about practical solutions which can help right now, one patient at a time,” says Executive Director James Sidbury, who estimates that more than 8,000 patients will visit the clinic by the end of its first year of operation.

And as the number of patients continues to increase, the question of how the clinic can continue to serve the community most effectively is one that is constantly revisited.

Paramount to the success of the clinic model is that it continues to provide services free of charge. The clinic currently provides treatment to any individual within Charlotte County who is uninsured and can show income of no more than $28,000 per year. This figure is based on a scale of 200 percent of poverty level, which is currently calculated at $14,000 per year for a two-person household by the U.S. Department of Health and Human Services.

“We are part of the Society of St. Vincent de Paul, an international Catholic network of charities, which provides us with volunteers. Funding comes from various sources such as the county, grants and help from the local hospitals,” says Development Director Lauren Schmidt, adding that the clinic recently received a $100,000 grant from the Blue Foundation for a Healthy Florida Inc., a philanthropic affiliate of Blue Cross and Blue Shield of Florida.

Although the county provides some support to the clinic through grant funds allocated by the State of Florida through the volunteer Health Care Provider Program, administrators have so far not sought federal funds due to federal mandates regarding race, ethnicity and indigence.

“We have avoided a federal designation as we are not interested in a sliding scale or a demographic quota and we are not waiting around for legislation to solve the health care crisis in Florida,” Sidbury says.

Clean bill of health

Kemsley’s last patient of the day is Andrew, an imposing man with a bald head and a boxer’s grin. Andrew first met Kemsley through his wife who volunteers at the clinic one night a week. Talking to Kemsley, tears come to his eyes and he goes on to tell his story to anyone who will listen.

At 63 years of age, Andrew has started to rehab after more than 40 years of hard drug abuse which included a 19-year stay in a federal penitentiary. He is three weeks clean and credits Kemsley with getting him into rehab. “She just told me not to come back if I was not at least willing to try,” he said. “Somebody cared enough about this old drug addict to offer to fight the health care system.”

And fighting the system is something Kemsley, the ‘accidental’ advocate says she will continue to do one patient at a time.

“There are so many uninsured in Port Charlotte alone that I know I can’t help them all. If I can help one person feel better today, my job has been done,” Kemsley says.