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Low-Income Health Care: Exploring Medical-Legal Partnerships

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Staying healthy is tough if you live in mold-infested housing, can't afford food or electricity, or are about to lose your home. The National Center for Medical Legal Partnership (NCMLP) brings together lawyers, doctors, nurses and social workers to help patients with problems that may have a legal remedy, such as qualifying for food stamps, getting insurance benefits or avoiding eviction.

Medical-legal partnerships (MLP's) are usually based in clinics, hospitals and other medical settings that serve low-income people. The NCMLP is affiliated with more than 81 sites in 37 states, and helped more than 13,000 individuals and families in 2009. Congress has taken notice, and the bipartisan Medical-Legal Partnership for Health Act was introduced in both the U.S. House of Representatives and the U.S. Senate on July 29, 2010. The Act calls for $10 million to be set aside each year for five years to fund medical-legal partnership demonstration projects around the country, and to study whether they improve health and reduce health care costs for hospitals and clinics.

I recently spoke with Drs. Barry Zuckerman and Megan Sandel about the NCMLP. Dr. Zuckerman founded the Medical-Legal Partnership for Children, which evolved into the NCMLP, in 1993. He is The Joel and Barbara Alpert Professor of Pediatrics at Boston University School of Medicine, Professor of Public Health at Boston University School of Public Health, and Chief of Pediatrics at Boston Medical Center. Dr. Sandel is an assistant professor of Pediatrics at the Boston University School of Medicine, the medical director of the NCMLP, and the former director of Pediatric Healthcare for the Homeless at Boston Medical Center.

EM: Why did you establish this organization?

BZ: As a pediatrician taking care of children in inner city Boston, it was upsetting for me to see children become sick and hospitalized for conditions that my children or children living in my neighborhood wouldn't suffer from. These included conditions related to inadequate food, to poor housing conditions, to utilities being shut off, to violence in the community, and other problems related to their social environment. I realized there are a lot of protections and benefits that our public officials have put into policy and I thought the best way to address these problems was to hire a lawyer to see that patients got help, and to reduce unnecessary preventable illnesses.

MS: We all know that medicine alone can't solve all health problems when there are underlying material hardships, and many adverse social conditions have legal remedies. MLP is really about integrating legal services into health care in order to address those underlying legal needs. It's not about getting people new services, it's about getting them services they were entitled to in the first place.

EM: What are the major problems MLP's address?

MS: One of the biggest is income support -- things like food stamps or welfare benefits or, if you're disabled, getting disability. Also, insurance benefits. Housing is a big area, both in terms of affordable housing but also in terms of housing conditions and keeping the utilities on. Education for kids and employment for adults -- helping people get either employment training or not be discriminated against in their jobs. Legal issues can be difficult, both immigration issues, or if someone has a criminal background that is impairing their ability to get a job. Lastly, there are personal or family issues that can really interfere with care, whether it be guardianship issues for kids or advance directives for people at the end of life. We really try to remove those legal needs from being barriers to effective care, to help patients get and stay healthy.

EM: With the downturn in the economy, have you seen an increase recently in people needing your services?

MS: When we talk to our local sites in the network, they are seeing a huge increase in not only the simple basic needs such as food stamps and people needing to get the proper amount of food stamps that they're eligible for, but also severe housing stress, families falling behind on their rent, potentially having their utilities shut off, maybe even becoming homeless and suffering from foreclosures.

The thirst for this among health care institutions that are serving low income populations is huge and unlimited. In 2005, we had 20 sites. In 2010, there are 80 programs across the country, serving over 200 hospitals and health centers. Our goal over the next five years is to get to 500 health care sites, and even then we'd only be at 15 percent of the health care institutions that serve vulnerable populations.

EM: How well do you think doctors and other health workers identify health-related legal issues?

BZ: In medical school we were all taught about psychosocial problems, and words like housing and food were always important. But nobody taught us how to ask about it, and even if they did it wasn't clear we wanted to because we wouldn't know to do about it. Now, having legal interventions available puts more of an obligation on us to identify legal problems.

It's analogous to doctors identifying domestic violence. Twenty years ago, physicians didn't identify domestic violence; they didn't know what to do. There are a lot of interventions available now, and it's unthinkable that they wouldn't do it; it's become standard of practice. I feel this will rise to the same level.

MS: Doctors can make the connection that social conditions affect health, but they have a very hard time envisioning this as part of their job. The MLP can train them on how to screen for these issues, particularly early before they reach a crisis proportion. Because the lawyers are integrated into the health care team, doctors now have an intervention that can be part of their treatment plan.

EM: Your website states that MLP's foster prevention. How?

BZ: We're hopefully preventing health exacerbations or health problems by addressing the sources of it instead of treating the consequences, whether it's housing conditions or inadequate food or all those things. Our job is to identify the legal problem before it becomes a catastrophe, which will then become a medical health problem.

MS: If you can detect the legal problem early, the intervention actually takes fewer hours than waiting until it's a catastrophe. Eviction is a classic example. You know you're falling behind on your rent, you know your utilities have been shut off. If we can identify those underlying warning signs early, we can intervene with a few hours of time, sometimes not even with a lawyer. That can be an efficient use of limited resources in the community.

EM: What is the financial effect of an MLP on a hospital or clinic?

BZ: Depending on the hospital, the MLP can help with what's called health care recovery dollars, when hospitals don't get paid by insurers. The lawyers can also intervene to make sure people get signed up for insurance.

MS: It just takes a couple of really expensive cases to pay for everyone else to get the legal service. Patients who have cancer, for instance, sometimes need to stay in the hospital for longer periods of time or may not have their insurance up to date because they've lost their job. MLP's sometimes can help the patients get discharged earlier, or can help the hospital get compensated for care that they gave. We had an MLP based out of a cancer center, and over the course of three years, they had a three-to-one return on investment based on just a handful of cases -- really, just 10 or 20 percent of the cases that then paid for the rest of the entire program.

EM: Your website has a map showing your network. But what if you need help and live in an area that lacks an MLP?

MS: Every area has a legal services agency. The legal services corporation federally funds such services across the country, and locally there can be bar associations or pro bono networks. In our experience, most patients don't realize that their adverse condition has a legal remedy, and it's only in crisis like an eviction notice or a certain complaint that they seek legal assistance. Part of why MLP's are so innovative is that by bringing legal services into the medical home, you can detect problems earlier.

EM: The Medical-Legal Partnership for Health Act was recently introduced in the U.S. House and Senate. What does this legislation entail?

MS: It calls for a federal demonstration project for the U.S. Department of Health and Human Services to implement over the next five years, to try to prove that the model has health benefits and to do a cost analysis and evaluate the model for future investment. It's a similar approach to other demonstration projects . One model that we were looking to is the hospice model. Twenty years ago hospice was an informal service that sometimes was in church basements and other places, and now it's a 3-4 billion dollar industry.

EM: People don't usually think of doctors and lawyers as allies. Has it been tough to create such alliances?

BZ: It's a very simple idea, and yet its complex to implement. We've medicalized the whole thing, and our lawyers are like any specialists available for advice or to see patients when the health care team gets stuck. But there are issues about confidentiality and just styles of practice. I tell the lawyers that this is like a cross-cultural experience for them.

MS: A lot of the technical assistance that our national center provides is helping the lawyers understand how to talk to physicians, how to talk to nurses, how to talk to social workers, how to understand the hierarchy of the medical sites, because it can be a real mythic experience for them.

EM: What adjustments do doctors need to make when working with legal services?

MS: The expectation for feedback is important. They're not going to hear every nuance of the legal case.

Just like a doctor would use a specialist like a cardiologist, they have to get very comfortable being able to ask a couple of questions to decide on the treatment plan. We want (doctors and nurses) to get comfortable thinking, "OK, I've screened (these patients) for food insecurity, do I need to send them to a pantry, do I need to send them for food stamps, or have they been wrongfully denied and is there a legal issue?" They need to be able to think about the question in a decision tree format, and this requires a familiarity with the law.

BZ: As physicians, we witness how policies play out, both in their effectiveness and ineffectiveness. By having lawyers in a health care setting, we have the capacity to change health institutions and help them evolve, just like when social work came through and changes were made. MLP's can change how health institutions see themselves and can change systems and policies for the greater good.

A similar version of this interview originally appeared on the website of New America Media.

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