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Create a business report in which you discuss the benefits of implementing telehealth-see details below. Scenario The issue of access to quality healthcare

Create a business report in which you discuss the benefits of implementing telehealth-see details below. Scenario
The issue of access to quality healthcare

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Create a business report in which you discuss the benefits of implementing telehealth-see details below. Scenario
The issue of access to quality healthcare remains a challenge in the United States. Inadequate access is more pervasive in rural communities. Most efforts to improve access have not yielded the desired results. Studies suggest that rural healthcare has changed significantly within the past decade as a result of healthcare financing, the emergence of new technologies, and the clustering of health networks and services. A lack of financial resources in rural communities coupled with provider shortages continue to have negative impacts on health outcomes.
Instructions
You are a rural community health analyst. In your role, you are attempting to find an effective strategy to address the barriers to access of care for a rural community in your state. You have determined that telehealth may be a viable solution.

Research the impact of telehealth on access to healthcare in international markets.
Discuss the possible implications of telehealth on rural communities in the U.S.
Using the California-based clinic, La Clinica de la Raza, as a benchmark, evaluate the financial report of the organization and discuss the organization’s financial performance based on your findings from the report.
After a review of the financial data, create a business report in which you discuss the benefits of implementing telehealth.

Rubric:
-Clear and thorough discussion of possible implications of telehealth on rural communities in the U.S. Includes at least three examples or supporting details from research on international markets.
-Includes a comprehensive evaluation of the financial report of La Clinica de la Raza and thoughtfully discusses the organization’s financial performance with at least three examples or supporting details.
-Comprehensive business report that thoughtfully discusses the benefits of telehealth with examples or supporting details for each benefit. C AL I FORNIA
HEALTHCARE
FOUNDATION

April 2011

Financial Analysis of
La Clínica de La Raza’s
Telehealth Experience

Prepared for
California HealtHCare foundation

by
Lori Chelius, M.B.A., M.P.H.
Julie M. Hook, M.A., M.P.H.
Michael P. Rodriguez, M.A.

JSI Research and Training Institute, Inc.

© 2010 California HealthCare Foundation

About the Authors
Lori Chelius, M.B.A., M.P.H., is an independent health care
consultant who has worked on a number of projects related to health
IT in community clinic settings, including as project manager for the
California HealthCare Foundation on the Telemedicine to Improve
Access and Efficiency in Community Clinic Networks initiative with
Open Door Community Health Centers, La Clínica de la Raza, and
Southside Coalition of Community Health Centers. Julie M. Hook,
M.A., M.P.H., and Michael P. Rodriguez, M.A., are researchers and
consultants at JSI Research and Training Institute (JSI). JSI is a
not-for-profit, public and community health research, evaluation,
and consulting organization dedicated to improving the health of
individuals and communities throughout the world. Ms. Hook
leads the domestic health information technology research efforts at
JSI, while Mr. Rodriguez manages health information technology
strategic planning, training, evaluation, and survey work in both the
international and domestic realms.

About the Foundation
The California HealthCare Foundation works as a catalyst to fulfill
the promise of better health care for all Californians. We support ideas
and innovations that improve quality, increase efficiency, and lower the
costs of care. For more information, visit us online at www.chcf.org.

Homepage

Contents

2 I. Executive Summary

3 II. Introduction

4 III. About La Clínica de La Raza

Patient Need for Specialty Care

Establishing La Clínica’s Teledermatology Program

6 IV. Financial Analysis

Methodology and Scope

Financial Model

Annualized Profit/(Loss) Results

Per-Visit Revenue/Costs Results

11 V. Conclusion

2 | California HealtHCare foundation

I. Executive Summary
tHis report analyzes finanCial aspeCts
of a new telehealth program implemented by the
urban community health center (CHC) La Clínica
de La Raza (La Clínica) through funding from
the California HealthCare Foundation’s (CHCF)
Telemedicine to Improve Access & Efficiency in
California Clinic Networks project. The goal of this
analysis is to provide guidance to other CHCs that
are considering implementing telehealth. This report
offers one framework for the budgeting of a program
through presentation of real financial data from
La Clínica’s telehealth program. A parallel report,
analyzing the financial aspects of more complex,
long-standing telehealth programs at Open Door
Community Health Centers, based in rural northern
California, is published simultaneously with this
report.

The goal of La Clínica’s telehealth project was
to provide access to specialist dermatology care for
it patients. La Clínica did so by contracting with
a dermatologist at the University of California,
San Francisco (UCSF) in order to provide
teledermatology (telederm) consultations through
a store-and-forward model: La Clínica providers
produced and forwarded digital images and clinical
notes to the specialist, using Second Opinion™
software, showing and describing the patient’s
dermatology issue; the dermatologist then reviewed
these and sent back written recommendations
for treatment or for in-person follow-up to the
La Clínica providers. The UCSF dermatologist also
provided an in-person clinic at La Clínica’s central
site in Oakland once a month for follow-ups. Under
the contract, the dermatologist provided up to

720 consultations (telederm and in-person) for a
period of one year, for a flat fee of $40,000.

The following analysis presents real data from
La Clínica’s telederm program annualized from the
six-month time period of October 2009 through
March 2010. Depending on whether all in-person
dermatology-related revenue and technology
expenses were included, the program generated a
net loss of between $7,209 and $43,991. While
the program is not fully self-sustainable under the
current financial and contractual arrangements, the
prospects for financial sustainability could be quite
different if La Clínica contracted for specialty care
under alternative terms. Moreover, the question
of sustainability should be viewed in the broader
context of the increased access to care that the
program provides.

Financial Analysis of La Clínica de La Raza’s Telehealth Experience | 3

II. Introduction
WHile tHe use of teleHealtH Can inCrease
access to both primary and specialty care for
community clinics, its widespread adoption has
been slowed by significant barriers, most notably
implementation costs and low, inconsistent
reimbursement for care. Many pilot programs have
been initiated throughout the country with support
from private and government start-up-funding but
ceased operations once these grants ended. A major
challenge to these programs is building sustainability
beyond the initial funding.

This report analyzes data from La Clínica de
La Raza (La Clínica), based in Oakland, which was
funded by the California HealthCare Foundation
(CHCF) through the Telemedicine to Improve
Access & Efficiency in California Clinic Networks
project, to add a new teledermatology (telederm)
program offering specialty care to its mostly low-
income patients. It is a companion report to a case
study, Telehealth in Community Clinics: Three Case
Studies in Implementation (www.chcf.org), which
examines the process and structure of that telederm
program. The goal of this analysis is to provide
other community health centers (CHC) that are
considering implementing telehealth programs with
a framework for considering initial and sustainable
long-term budgeting for such a program, as well
as providing real economic data from an existing
telehealth program. Published simultaneously with
this report is a similar financial analysis of more
complex, ongoing telehealth programs at Open Door
Community Health Centers, a multi-site community
health organization in rural Northern California
(Financial Analysis of Open Door Community Health
Centers’ Telemedicine Experience, www.chcf.org).

http://www.chcf.org/publications/2010/11/implementation-telehealth-community-clinics

http://www.chcf.org/publications/2010/11/implementation-telehealth-community-clinics

4 | California HealtHCare foundation

III. About La Clínica de La Raza
la ClíniCa is a federally Qualified HealtH
Center (FQHC) with 26 sites in Alameda, Contra
Costa, and Solano Counties in Northern California.
From its inception in 1971 as a single storefront
clinic in East Oakland staffed by five volunteers,
La Clínica has grown to provide 304,198 patient
care visits to 61,909 individual patients in 2009.
Two-thirds (66 percent) of La Clínica patients
have incomes at or below the Federal Poverty Level
and 94 percent of patients are either uninsured
or have public health insurance. The racial/ethnic
composition of its patient population is 71 percent
Latino, 14 percent white, 9 percent African
American, and 6 percent Asian. La Clínica provides
the following services to its patients: medical; dental;
optical; women’s health; prenatal and postnatal care;
preventive medicine; health and nutrition education;
adolescent services; mental health; behavioral health;
case management; referral; pharmacy; radiology; and
laboratory.

Patient Need for Specialty Care
Similar to other underserved populations, access to
specialty care is a significant issue for La Clínica’s
patient population and often translates into lengthy
wait times or, even more troubling, complete lack
of access. When planning for its telederm program,
La Clínica found a significant need for dermatology
care among its patients, both insured and uninsured.
La Clínica sampled referral data for five of its
clinics from a two-week period prior to telederm
implementation and found that the average wait
time for access to dermatology appointments ranged
from ten days at one clinic to more than 117 days,
excluding holidays and weekends, at another. The

average wait time from referral date to appointment
date for a dermatology visit across all the clinic sites
was more than two months (62.3 days). For patients
without insurance, wait times for a dermatology
appointment at Highland Hospital, the Alameda
County facility to which many of La Clínica’s
uninsured patients are referred, were sometimes up to
a year.

Establishing La Clínica’s
Teledermatology Program
In 2007, with support from a CHCF grant, La
Clínica began implementing a telehealth program
as one tool with which to address its specialty access
difficulties. As a first step, La Clínica conducted a
Web-based survey to solicit feedback from medical,
mental health, and health education staff regarding
their experience with telehealth, their receptiveness
to technology use for maximizing access, their
identification of needs for specialty care, and the
training they would need regarding telehealth
technology. The planning process also assessed what
the most appropriate telehealth program would be,
surveying providers across La Clínica to determine
their priority areas and balancing clinical importance
with ease of implementation. The top three priorities
identified were health education, dental services, and
dermatology. Health education was eliminated based
on its perceived lower clinical importance, while
dental was eliminated because of the complexity
of implementing a teledental program. Telederm
was chosen as it seemed to provide the best balance
between high clinical importance and ease of
technical implementation.

Financial Analysis of La Clínica de La Raza’s Telehealth Experience | 5

To implement the program, La Clínica
contracted with a dermatologist at the University
of California, San Francisco (UCSF) to provide
telederm consultations via a store-and-forward
model. Under this model, La Clínica providers
forward digital images and clinical notes, using
Second Opinion™ software, to show and describe a
patient’s dermatology issue to the specialist at UCSF.
The dermatologist reviews these and provides written
treatment or in-person follow-up recommendations
to the La Clínica providers. As part of the overall new
dermatology program provided by La Clínica, the
contract also called for the UCSF dermatologist to
provide an in-person clinic at La Clínica’s central site
in Oakland once a month, during which follow-up
issues could be addressed. Prior to conducting these
in-person visits, La Clínica needed Health Resources
and Services Administration (HRSA) permission
to conduct dermatology services on its premises, as
this specialty was not included in its FQHC scope
of services. This request was initially denied for
technical reasons, but after a delay of several months,
La Clínica received HRSA approval to offer in-
person dermatology services. The contract called for
the dermatologist to provide up to 720 consultations
(telederm and in-person) for a period of one year,
for a flat fee of $40,000. The 720 consultations
figure was a projection by La Clínica of how many
consultations would occur in the first year of the
program, based on its existing dermatology referral
patterns.

6 | California HealtHCare foundation

IV. Financial Analysis
Methodology and Scope
To help analyze the financial sustainability of a
telederm program, La Clínica developed a budgeting
model that compared projected revenue from the
program and projected costs. For the purposes of the
financial analysis presented in this report, this model
was populated with actual data from the telederm
program. Although La Clínica began implementation
of its telederm program in June 2009, it was not
until October 2009 that it was implemented at all
seven sites selected to participate. Therefore, the data
presented in this analysis are annualized based on the
six-month period of October 2009 through March
2010. These data were obtained from La Clínica’s
telemedicine program coordinator and reviewed
by La Clínica’s chief financial officer. (Of note, the
numbers in this report do not take into account a
three-month no-cost extension that La Clínica was
able to negotiate with the dermatologist at UCSF.)
An update to the financial analysis, using data
from La Clínica’s program from July 2010 through
December 2010 and reflecting the new terms of their
current dermatology specialist contract, is presented
in the Appendix to this report.

Financial Model
La Clínica developed a budget model during its
planning phase to analyze the potential financial
sustainability of the telederm program. La Clínica’s
original plan had been to contract with a specialist
who would bill Medi-Cal and other third parties
for telederm services delivered to insured patients.
La Clínica was unable to find a specialist to do
so, however, and as a result structured its financial

model to reflect the fact that the costs of this
consulting dermatologist were to be borne entirely
by La Clínica, except to the extent that insured and
sliding-scale self-pay patients were seen in-person.
The specialist contract is the program’s single biggest
cost driver. It should be emphasized, however, that
alternative contracting models — including one in
which the specialist bills third-party payers — could
potentially result in a very different, more positive
picture of financial sustainability.

For its overall dermatology program, La Clínica
received revenue from two sources: (1) in-person
dermatology office visits, and (2) recall visits where
patients returned to the clinic to visit the primary
care provider for review of the telederm consult
results and to discuss treatment. In the model below,
two financial analysis scenarios are presented — with
and without revenue from recall visits included.

La Clínica estimated the number of monthly
telederm consults it would need (60) by examining
its own patient demand as well as the volume of
other telederm programs, including the program at
Open Door Community Health Centers in Arcata,
and scaled these other programs’ number of consults
to reflect its own patient volume. La Clínica then
estimated that approximately 25 percent of those
consults would require a follow-up visit at its in-
person dermatology clinic, and used its payer mix to
calculate the revenue associated with those in-person
visits: 40 percent insured at $190 a visit (its average
rate for insured patients) and 60 percent uninsured
at $50 a visit (its average sliding-scale payment
rate). In addition to revenue associated with the in-
person visits, La Clínica assumed that approximately

Financial Analysis of La Clínica de La Raza’s Telehealth Experience | 7

50 percent of telederm consults would require a recall
visit and again used its payer mix to calculate the
revenue associated with those recall visits.

Table 1 outlines these revenue streams in
La Clínica’s projected budget. The two different
scenarios are offered to permit a CHC considering
such a program to recognize that there are distinct
ways of thinking about its financing: Revenue from
recall primary care visits stems from the telederm

project, but as a matter of purely financial calculation
it might also be argued that many if not most of
these primary care visits would have been filled in
any case by non-dermatology patients.

On the expense side, the largest cost of the
telederm program is the contract with the specialist
for $40,000 per year. In addition, La Clínica
included staff time and the ongoing costs of its
software in its original project expenses estimate, as
outlined in Table 2.

Table 2. Projected Expenses,
La Clínica Telederm Program

Specialist Contract $40,000

Telehealth Specialist (0.2 FTE) $10,736

Medical Assistant (4 hours/month) $1,089

Billing Staff (8 hours/month) $1,920

Software* $2,000

Total Costs $55,744†

*Software costs only included the ongoing costs of software maintenance;
the initial license fees were covered by the CHCF telederm start-up grant.

†Figure may vary slightly due to rounding.

Source: La Clínica de La Raza.

Taken together, the revenue and expenses
projected for the program are outlined in Table 3,
both with and without the inclusion of revenue from
recall visits.

Table 3. Projected Annual Profit/(Loss),
La Clínica Telederm Program

R e v e n u e f R o m R e c a l l v i s i t s
N O T I N C L u d E d I N C L u d E d

Total Revenue $19,080 $57,240

Total Expense 2 $55,744 2 $55,744

Net Profit/(Loss) ($36,664) $1,496

Source: La Clínica de La Raza.

Table 1. Projected Revenue,
La Clínica Telederm Program

monthly telederm consults

Total (A) 60

Insured (B 5 A 3 .40) 24

uninsured (C 5 A 3 .60) 36

in-Person Derm office visits

Total 15

Insured (d 5 B 3 .25) 6

uninsured (E 5 C 3 .25) 9

Recall visits

Total (G 5 A 3 .50) 30

Insured (H 5 G 3 .40) 12

uninsured (I 5 G 3 .60) 18

Projected Revenue

In-Person derm Clinic
(F 5 ($190 3 d) 1 ($50 3 E))

$1,590

Recall Visits
(J 5 (190 3 H) 1 ($50 3 I))

$3,180

Total Monthly (in-person and recall)
(K 5 F 1 J)

$4,770

Annual In-Person Only
(L 5 F 3 12)

$19,080

Total Annual (in-person and recall)
(M 5 K 3 12)

$57,240

Source: La Clínica de La Raza.

8 | California HealtHCare foundation

Based on these projected volume and expense
numbers, the telederm program had the potential to
be financially sustainable if recall visits were included
as a revenue source and the volume assumptions of
the projected budget were realized. However, when
revenue from the recall visits was not included,
the program did not appear to be fully financially
self-sustainable. The following section examines the
sustainability question based on actual data from the
first six months of the program’s full implementation.

Annualized Profit/(Loss) Results
This section presents real data annualized from the
six-month period of October 2009 through March
2010. This period reflects the first six months during
which all seven of La Clínica’s chosen sites were
fully operational with the telederm program. (The
program’s start-up costs are not included in this
analysis since they were covered by the initial grant
from CHCF; these start-up expenses are detailed in
the accompanying sidebar.)

The profit/(loss) results are examined in three
different scenarios, under the following assumptions:

Scenario 1.◾◾ Revenue from both recall visits and
in-person dermatology clinic visits is included; on
the expense side, only specialist contract costs are
included.

Scenario 2.◾◾ Revenue from both recall visits and
in-person dermatology clinic visits is included; on
the expense side, specialist contract and software
maintenance/staff time are both included.

Scenario 3.◾◾ Revenue from in-person dermatology
clinic only is included; on the expense side,
specialist contract and software maintenance/staff
time are both included.

As noted previously, with regard to the inclusion
or not of revenue from recall primary care patient
visits, it is certainly true that these recall visits are
related to the telederm project. On the other hand,
with regard to the effect of the telederm program on
overall health center revenue, there is the likelihood
that many if not most of these primary care recall
visit patient “slots” would have been filled anyway
by patients for non-dermatology visits. Hence, both
inclusive and exclusive revenue figures are offered
here for consideration. Similarly, figures are included
both with and without expenses for staff time: The
actual costs for staff time during the initial six-month
implementation period were covered by the start-up
grant from CHCF, but such costs would have to be
borne by the health center over the longer term.

Start-Up Expenses
Expenses incurred by La Clínica to initially implement
its telederm program are detailed below. Because
these expenses were covered by the CHCF start-up
grant, they were not included in the financial analysis
in this report, which is designed to examine the
long-term sustainability of the program. (Note: The
following expenses do not include internal staff time
dedicated to the development of the program.)

Server $6,000

Cameras $8,110

Consumables $2,722

Forms development $600

Internal Training $1,083

Software Application $24,008

Total $42,523

Source: La Clínica de La Raza.

Financial Analysis of La Clínica de La Raza’s Telehealth Experience | 9

Table 4. Annualized Revenue,
La Clínica Telederm Program

telederm consults

Total (A) 314

Insured (B 5 A 3 .51) 160

uninsured (C 5 A 3 .49) 154

in-Person Derm office visits

Total (d) 74

Insured (E 5 d 3 .49) 36

uninsured (F 5 d 3 .51) 38

Recall visits*

Total (H 5 A 3 .50) 157

Insured (I 5 H 3 .60) 94

uninsured (J 5 H 3 .40) 63

Revenue

In-Person derm Clinic (G) $11,753

Recall Visits† (K 5 (190 3 I) 1 ($50 3 J)) $21,038

Total Annualized Revenue (L 5 G 1 K) $32,791

*Recall visits are estimated based on patient encounters for which the primary diagnosis
was dermatology-related.

†Recall visit reimbursement is estimated based on an average of $190 for insured
patients and $50 for uninsured patients, using La Clínica historical data.

Source: La Clínica de La Raza.

On the expense side, La Clínica paid $40,000
for a one-year contract for the dermatologist. In
Scenario 1 in Table 5, this is the only expense
included since capital expenses and staff time were
covered by the CHCF start-up grant for the period
in question. In Scenario 2, the additional expenses of
staff and software maintenance, part of the budgeting
model, are included. In Scenario 3, all expenses are
included but revenue from recall visits is not.

Table 5. Projected Annual Profit/(Loss), by Scenario,
La Clínica Telederm Program

s c e n a R i o
1 2 3

Total Revenue $32,791 $32,791 $11,753

Total Expense $40,000 $55,744 $55,744

Net Profit/(Loss) ($7,209) ($22,953) ($43,991)

Source: La Clínica de La Raza.

Based on the actual results presented in the tables
above, it is clear that the specialist contract is the
most significant barrier to the financial sustainability
of La Clínica’s telederm program. If La Clínica were
able to set up a comparable program with a specialist
who was willing to bill third parties, or to negotiate
different terms under its existing model, the financial
sustainability equation could be very different.

Per-Visit Revenue/Costs Results
This section examines the program’s per-visit
revenue and expenses. For these calculations, both
Scenario 2 and Scenario 3 are used. From a per-
visit standpoint — based on the combined total of
both telederm (314) and in-person dermatology
(74) visits — the figures presented in the previous
section translate into $85 per consult in revenue
if recall primary care visit revenue is included
($32,791 for 388 consults) and $30 per consult
if recall visit revenue is not included ($11,753 for
388 consults). On the expense side, this translates
into $144 per consult ($55,744 for 388 consults).
This figure remains the same whether or not recall
visits are included because, importantly, there are
no additional costs assumed in the scenario where
revenue from recall visits is included.

10 | California HealtHCare foundation

Table 6. Per-Visit Profit/(Loss),
La Clínica Telederm Program

R e v e n u e c o s t
P R o f i t /
( l o s s )

( A ) ( B ) ( C 5 A 2 B )

Recall Revenue Included $85 $144 ($59)

No Recall Revenue $30 $144 ($113)*

*Figure varies slightly due to rounding.

Since the specialist contract assumed 720 visits
(telederm and in-person combined), this would
translate into a per-visit cost of $77 if 720 visits
($55,744 / 720) were achieved during the 12 months
of the contract. A profit/(loss) equation reflecting full
use of the contracted visits is illustrated in Table 7. It
is important to note that, based on these figures, it
appears that the program could achieve a profit —
even under the existing cost structure — if revenue
from recall visits is included and La Clínica were able
to reach the number of visits originally projected.

Table 7. Per-Visit Profit/(Loss) with Full Specialist
Utilization, La Clínica Telederm Program

R e v e n u e * c o s t †
P R o f i t /
( l o s s )

( A ) ( B ) ( C 5 A 2 B )

Recall Revenue Included $85 $77 $8

No Recall Revenue $30 $77 ($47)

*Revenue based on existing volume.

†Cost based on 720 visits.

Source: La Clínica de La Raza.

Financial Analysis of La Clínica de La Raza’s Telehealth Experience | 11

V. Conclusion
Based on the analysis done for this
report, the current structure of La Clínica’s telederm
program does not appear to be financially fully
self-sustaining (if viewed solely from a revenue and
expense standpoint). One of the biggest limitations
in this regard is the terms of its specialist contract.
If La Clínica were able to identify a specialist
willing to bill third party payers, or if it were able to
negotiate different terms under its existing program,
the financial equation could be quite different. For
example, if La Clínica could negotiate a per-visit
telederm consultation fee that was in line with
program support expenses, the financial equation
would be more favorable.

La Clínica has now renegotiated its contract with
the specialist, based on their first-year telehealth
experience and volume — unlimited telehealth
consults and a once-a-month in-person clinic for a
reduced annual fee. Under the new contract terms
the program still operates at a financial loss, but a
smaller one. (See the Appendix to this report for a
discussion of the updated financial data.) Similarly,
even under the current contract, if La Clínica were
able to fill all the contracted dermatology visits,
the program would be much closer to full financial
self-support.

Based on La Clínica’s experience, other CHCs
that are considering implementing a telehealth
program might want to approach their volume
estimates conservatively. La Clínica based
its estimates on volume from another CHC
organization, but that telehealth program was
more established, and there may be many factors
that influence actual volume, including provider
preference. Anecdotally, such overestimation of

volume has been a familiar theme across other
programs.

For other CHCs exploring similar types of
projects, La Clínica’s model presents one way to
structure a telehealth program and relationship with
a consulting specialist. But as La Clínica and other
safety-net CHCs think through the broader question
of sustainability, it is crucial for each organization
to determine how much value — in terms of access
and therefore long-term health — such a program
can provide to its patients, beyond simply making a
purely numerical profit/(loss) assessment. Once this
broader issue of value is determined, it should be
balanced with the financial figures to help determine
and structure — with, to an appropriate extent,
internal subsidies — a sustainable program.

12 | California HealtHCare foundation

Appendix: Financial Analysis Update

This appendix, prepared in April 2011, presents an
update to the financial analysis of the first year of
La Clínica’s telehealth program, which appears in the
body of this report. The new data in this appendix
derives from the six-month period July through
December 2010.

The structure of the program remains the same.
Using Second Opinion™ Software, La Clínica
providers forward digital images and clinical notes
documenting and describing a patient’s dermatology
issue to the specialist at UCSF. The UCSF
dermatologist reviews these and provides written
treatment or in-person follow-up recommendations
to the La Clínica providers. Once a month, the
dermatologist also staffs an in-person clinic at
La Clínica’s central site in Oakland, …

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