Doctor-lawyer advocacy: When medicine isn't enough

A 2-year-old boy had all the symptoms of severe eczema when his mother brought him to JoseAlberto Betances, MD. Before seeing the pediatrician at Boston Medical Center, the single mother of four had taken her son to another facility, where higher doses of medication did not appear to resolve his condition.

After a few questions, Dr. Betances discovered that more than allergies were ailing the child. The family had been battling their landlord over a roach infestation in their public housing apartment. The boy was known to be allergic to the bugs, which lurked in the floors, refrigerator and sinks.

That's when Dr. Betances picked up the phone and called a specialist. Only this time, it was not another doctor. It was a lawyer.

"Sometimes, medically you can only do so much," Dr. Betances said. "You realize that, as specialized as your training has been, you still can't help the health of this family. But it's not because medicine is failing."

Through that call, Dr. Betances was connected with Edward Rice, a housing expert and a staff attorney at the Volunteer Lawyers Project of the Boston Bar Assn., which provides free legal assistance to low-income residents primarily through pro bono services of private lawyers. Rice began building a case to convince housing authorities that the roach problem was harming the boy's health and to compel the landlord to act.

"As a lawyer, I can argue there is [a connection], but I can't prove it without the doctor," Rice said. "So we hit the problem from both sides."

Boston Medical Center's Medical-Legal Partnership is among 90 such programs in 225 hospitals and health care centers in 38 states, according to 2010 figures from the National Center for Medical-Legal Partnership. By teaming physicians and lawyers, the partnerships aim to address what often turn out to be unmet legal and social needs that prevent low-income populations from getting the health care they need.

"What medical-legal partnerships do is help people understand how intertwined the medical and nonmedical issues are for so many vulnerable families," said Ellen Lawton, the national center's executive director.

Low-income families have on average two legal needs that go unaddressed because they either are unaware of their rights or cannot afford assistance, she said. Those problems include substandard housing conditions, employment, income benefits denials, special education needs and violence protection -- so-called social determinants that ultimately can affect patients' health and welfare.

Though social workers can help resolve some social or legal needs, they typically are not qualified to engage in legal advocacy and enforce the laws and regulations that may be at play in certain circumstances, Lawton said.

The partnership approach has won support from the medical and legal communities, as well as federal lawmakers, as a way to improve not only patients' health but also efficiencies in the health care system.

At the American Medical Association Annual Meeting in June 2010, the AMA Board of Trustees recommended that the Association encourage physicians to develop medical-legal partnerships and work with other stakeholders to educate physicians about legal issues that can affect patient health. American Bar Assn. policy similarly encourages its members to volunteer with MLPs.

Congress introduced bipartisan legislation in July 2010 that would dedicate $10 million to test the impact of MLPs, typically funded by local grants. A similar proposal is expected this year, Lawton said.

The first MLP started at Boston Medical Center in 1993, when its founder, pediatrician Barry Zuckerman, MD, lamented to an attorney friend that many of his low-income patients returned with the same ailments because socioeconomic complications undermined his efforts.

"I realized that there were laws put in place to protect people's health that were not being adhered to," said Dr. Zuckerman, BMC chief of pediatrics. "The next step was to see that they were enforced. And there's nothing like having a lawyer to get things moving."

The concept initially developed to provide services to children, but has since expanded to assist a range of people. As the idea caught on, the National Center for Medical-Legal Partnership formed in 2009 to assist and coordinate other sites.

Forming a partnership

A partnership begins with training doctors how to screen patients for potential legal issues, said Diane Goffinet, supervising attorney at the Medical-Legal Partnership of Southern Illinois. Like many MLPs, the Carbondale, Ill., program is a partnership between the local legal aid clinic and nearby health care facilities -- Land of Lincoln Legal Assistance Foundation, where Goffinet is senior staff attorney, and Southern Illinois Healthcare.

"The goal is to start to integrate legal knowledge into medical practice," she said.

Informally, or as part of a medical history, doctors learn to ask basic questions about such necessities as access to food, safe housing and public benefits. Physicians can fill out a prepared form checking off what they think a patient's legal issue might be and immediately refer the patient to the MLP.

Goffinet and her team then meet with the patient and, if needed, make calls or write letters to appropriate authorities, coordinating with the doctor over necessary medical documentation.

To avoid privacy issues, attorneys make sure they receive patient consent before accessing patient information, said Lucas Caldwell-McMillan, who oversees the Children's Health Advocacy Project, an MLP in St. Louis.

It's not about creating more work for physicians, he said. Instead, lawyers aim to lighten doctors' workload and make care more efficient.

"We're not teaching them to be lawyers or social workers, but just get them to a point where they can say, 'Hmm, that just doesn't sound right,' " Caldwell-McMillan said.

Poor patients generally don't seek legal help on their own, but they do seek medical help, making doctors the first line of intervention, he added. "Just like preventive medicine, we're trying to practice preventive law and get there before an issue becomes a crisis."

Doctors welcome the help.

Now, when Carbondale, Ill., family physician Penelope Tippy, MD, hears from patients that they cannot afford treatment because they did not qualify for disability benefits, she knows it's not the end of the road.

"The biggest thing is we have someone to follow through," said Dr. Tippy, who is active in the Illinois MLP. "Sometimes I would call agencies, but did we spend enough time and effort following through? The answer would probably be no, because it's not [doctors'] primary responsibility. It for sure wasn't my area of expertise."

Lawyers also welcome the collaboration. But getting evidence, such as medical records, can be difficult, Rice said.

"Usually if I leave a message for a doctor, they get confused or are afraid: 'Why is this lawyer calling me?' They don't want to write a letter or don't know how, or they get worried they'll get roped into a lawsuit against a landlord," he said.

Having an MLP arrangement, on the other hand, helps open communication lines and expedite cases.

Dr. Betances accompanied Rice to a court hearing on behalf of his patient after written requests for new housing were denied twice. Though most cases are resolved out of court and with minimal physician involvement, the pediatrician's testimony about the child's condition "made all the difference in the world," Rice said.

A judge found in favor of the boy's family and ordered housing authorities to relocate them.

In some cases, MLP attorneys also recognize the need to win doctors' trust.

"There is on both sides that antagonistic history ... but showing good results for their patients is the easiest way to overcome it," Caldwell-McMillan said.

In surveys of families assisted by the St. Louis MLP, 93% reported improvements in their children's health and well-being.

"This makes doctors look really good," Dr. Betances said.

More than medicine

In addition to helping patients, the partnerships can benefit the overall health care system. Between 2002 and 2009, the MLP of Southern Illinois recovered for patients $3.5 million in Medicaid benefits and $2 million in Social Security benefits. The program also recouped for Southern Illinois Healthcare more than $800,000 in Medicaid payments through appeals.

Pilot studies are under way to track the impact of such legal advocacy on health outcomes, such as chronic diseases, with early anecdotal evidence showing reductions in hospitalizations and emergency visits, according to the National Center for Medical-Legal Partnership.

Such results have prompted 28 medical schools, 46 residency programs and 38 law schools across the country to incorporate MLP training into their curricula, the center's data show.

Meanwhile, some MLPs are working to leverage the programs to affect public policy to get ahead of the social and legal problems that take a toll on the health care system.

The Children's Health Advocacy Project is working with St. Louis school districts to reform access to special education to prevent what Sarah Garwood, MD, says is a lack of follow-through by schools in providing individual education plans to developmentally challenged patients entitled to the services. Dr. Garwood specializes in adolescent medicine at Washington University School of Medicine in St. Louis, one of the MLP's several health care partners.

In Boston, MLP activities led to the creation of a citywide "Breathe Easy Program," a partnership of city, public health and housing officials designed to track asthma patients and ensure timely housing inspections and resolution of substandard conditions.

Thanks to a medical-legal partnership, the eczema that Dr. Betances' young patient had is a nonissue, he said. The pediatrician said he is better off because of the partnership, too.

"It's a complete change from helplessness to helpfulness. ... I'm not sure what someone can come to me with now that I won't be able to help them with."