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    Photos by Mickie Winters

    Dr. Michael Imburgia grabs a mop and gets to work, shining up the floors at the Have a Heart Clinic in downtown Louisville. Sandy Imburgia, his wife of 31 years, who vacuums the carpeted lobby, will later joke: “I’ve never seen him do the floors at home. Never!” Right now, though, it’s just before 8 on a Saturday morning and soon patients will file in to the free cardiovascular clinic for uninsured, low-income patients. Everyone who works here — from the cardiologists and echocardiogram tech to the security guard and schedulers — are volunteers. So occasionally doctors deal with dust. But here’s the thing about Imburgia: No one asked the 59-year-old to mop. There’s no sign-up sheet or chore rotation schedule. In Imburgia’s perfect world, the quality of care, look and atmosphere of Have a Heart should match that of his private cardiovascular practice in St. Matthews. 

    Here’s another thing about Imburgia: When he reads this, his brown eyes will probably wince from behind his glasses, his forehead crinkling beneath his short salt-and-pepper hair. He may even get a touch steamed, his lips stiffening above the dimple in his chin. Imburgia really doesn’t want this story to be about him. When I ask him where he’s from, he replies, “It’s really not about me.” (His wife will later share that he spent most of his childhood in a small town south of Chicago.)

    But without Imburgia, Have a Heart would not exist. Sandy, who is a nurse, and Sue Dillon, an echo tech who has been working with Imburgia since the ’80s, also belong at the center of Have a Heart’s origin story. In 2008, after years of meeting patients who delayed care because of cost or got ignored by providers due to a lack of insurance, the trio decided to start seeing indigent patients for free on the weekends out of Imburgia’s St. Matthews office. Heart disease is the number-one killer for all men and women. It disproportionally hits low-income individuals. Eighty percent of people with uncontrolled hypertension and cholesterol are uninsured. About half of patients seen in free and charitable clinics have hypertension; a little less than half have high cholesterol. And 40 percent of all indigent care clinic visits are related to cardiovascular disease.

    For years, Imburgia and his team committed a couple Saturdays a month to indigent care in his clinic that’s affiliated with Baptist Health Louisville. Imburgia and his wife often paid (and continue to pay) for medicine patients couldn’t afford, gas cards, bus passes, take-home blood-pressure cuffs. Then in 2014, Imburgia read the “Louisville Metro Health Equity Report,” which he says “changed his life.” It showed that life expectancy in many west Louisville neighborhoods was just 68 years old, 15 years fewer than the life expectancy in east Louisville. Upon studying page 21 of the report, Imburgia grew even more unsettled. In the California/Parkland neighborhoods, there were 341 deaths related to heart disease per 100,000 people between 2006 and 2010. Portland tallied 327 per 100,000 people. The numbers were lower in the more affluent, eastern part of the map. St. Matthews, for example, showed 120 heart disease deaths per 100,000 people for that same time frame.

    Imburgia decided he had to move his free services into a space downtown. A bus ride to his St. Matthews clinic took at least one hour from south and west Louisville. (Most of Imburgia’s 140 patients in 2016 came from south Louisville.) He determined many people who needed his help probably wouldn’t or couldn’t make that trek. So in early 2017, Have a Heart moved to a rented space, a former dermatology office on East Broadway. Since the move, Imburgia says, patient volume has swelled by 75 percent.

    Imburgia is a calm presence, friendly and personable. Get him talking about the health-equity report and those qualities dim slightly, a visible, earnest irritation scratching at the surface, eyebrows furrowing and exasperated sighs escaping between thoughts. “The disparity, it should be an embarrassment for this country,” Imburgia says. “It’s not OK to have people in our country live 15 years less purely because of the situation they are born in. It’s OK to have a nice car, a nicer house. But is it really ethically OK to have people die sooner?”


    Photo: Dr. Michael Imburgia at the Have a Heart Clinic takes a moment before a busy Saturday seeing patients // Mickie Winters

    *

    As the clock nears 9 in the morning, the Have a Heart Clinic bustles. Nurses and front-office staff busy themselves with paperwork. Large takeout cups of soda collect on a counter. “What’s my password again?” the clinic’s other volunteer cardiologist hollers as he logs into his computer. The clinic is professional, familiar, a standard medical landscape — six exams rooms, pleasant artwork in the hallway of Louisville neighborhoods, a lobby with cushioned chairs, magazines and a kids’ corner.

    Imburgia calls to the volunteer translator — “Maria, can you help?” — as he heads to one of his first patients of the day. They greet a Hispanic man in his 30s dressed in a ball cap and jeans. The man sits with his legs crossed at the ankles, nervously shaking one foot.

    “I like your work boots,” Imburgia says after greeting him.

    “Gracias,” replies the man, who was referred to Imburgia from a free healthcare clinic run out of the basement of a Catholic church. 

    Imburgia jots notes as his patient relays symptoms — pain that bursts into one arm, then spills across his chest into his other arm. 

    “When’s the last time he had it?” Imburgia asks the translator.  

    “It started three days ago and (he) still has it now,” she responds.

    Like nearly all of Have a Heart’s patients, the man lacks insurance. The Affordable Care Act, better known as Obamacare, helped fill gaps in insurance coverage. In 2013, the year before the ACA went into effect, 43 million Americans lacked coverage. By 2015, that number was down to 28 million. As of 2016 more than 30 states, including Kentucky, expanded their Medicaid coverage to include adults with an income at or below 138 percent of the federal poverty line. (That comes out to about $16,000 for an individual, $33,500 for a family of four.) With the expansion, Kentucky’s uninsured rate plummeted — from nearly 19 percent to 7 percent.

    Still, low-income individuals and minorities continue to lack insurance at high rates. Imburgia says many immigrants don’t qualify for Obamacare because they have not been in the United States long enough. Also, some of his patients fall just above the income guidelines. “We see a lot of people at 200 percent of the poverty level,” Imburgia says. For that group, employers often don’t offer insurance and patients simply can’t afford the premiums offered through the ACA Marketplace, even with the tax credits that Obamacare has made available to cushion the cost. (According to the Kaiser Family Foundation, in 2016 40 percent of people with ACA Marketplace coverage said they were dissatisfied with their monthly premium and 46 percent were dissatisfied with their deductible.)

    Imburgia listens to the man’s heart with a stethoscope. “Has he ever been told he had a heart murmur?” he says to the translator. 

    “No,” the man replies quietly. 

    He’s lucky to have found medical care. More than half of uninsured Americans skip preventative services because they don’t have someplace to go. Medicaid recipients face a different challenge, Imburgia says. They may have access to a primary-care doctor, but specialists, like cardiologists, often deny Medicaid. “Medicaid is the worst-paying insurer out there,” says Imburgia, adding that providers may also have another motive for avoiding this population. “These people have a lot of issues. Not that they asked for them. But I think a lot of providers don’t want to deal with those complicated patients.” In about an hour, Imburgia will see a middle-aged woman battling addiction, depression and homelessness. With tears in her eyes, she’ll report that she’s often so exhausted it’s a struggle to breathe. Her arms ache. Her legs throb. Imburgia will run some tests. Her heart function will look normal. So he will do all he can do — listen as she unloads her burdens and nudge her toward a drug-treatment facility that can address mental health.

    Imburgia senses worry in the patient with the murmur, who now sits on an exam table. Imburgia looks to the translator. “A murmur, it’s really just an extra sound (in your heart),” he says. “It could be nothing. It may be a leaky valve and sometimes that can cause some funny pains.” Imburgia pauses. “How’s life at home?” he asks. 

    The man says he works long hours and is the father of four. 

    “That’s why you’re having chest pains,” Imburgia jokes. 

    The man nods and laughs. Imburgia sends him to an exam room across the hall for an ultrasound, which spots a minor leaky heart valve. 

    Imburgia says about 80 percent of his patients are one-time visitors whose evaluations rule out heart trouble. The other 20 percent involve an ongoing issue that requires routine care. For some, that follow-up may be minimal, perhaps just medicine and monitoring their heart function every few months. Some will have to go to the hospital to have stents put in to unblock arteries or undergo more invasive, complicated surgeries. “It costs us over $80 billion a year to take care of the uninsured (in this country),” Imburgia says. “And $50-something billion of that is paid for by the government. So we’re paying for it anyhow.” 

    Imburgia sits facing a white wall near the nurses’ station, dictating notes on the young Hispanic patient and other people he has visited so far this morning. A homeless man with stringy, gray hair and a pained shuffle walks behind him toward the clinic’s exit. “Kidney failure,” a fellow doctor who examined the man says, leaning back in his chair so Imburgia can hear him. Some who overhear look confused as to how he wound up here. “No clue,” Imburgia says, before mentioning to a nurse who handles referrals that there’s a local kidney specialist who “has said” he’d see Have a Heart clients at no charge. This patient may never find a specialist willing to see him. He may tumble out of the healthcare system until popping back up in an ER in critical condition. 


    Photo: Sue Dillon, an echocardiogram tech with Have a Heart, performs an ultrasound
    on the heart of a young patient with an irregular valve // Mickie Winters

    *

    The mood at Have a Heart doesn’t reflect the reality — working without pay on a sunny Saturday in June. If anyone arrives begrudgingly, they bury it well. Between taking medical histories and setting stethoscope to flesh to eavesdrop on the thump-thump, thump-thump within, staffers keep it light, humorous. When Imburgia looks stumped over a mystery surgery a patient tried to describe during the exam, Sue Dillon, the echo tech, pipes in: “Didn’t you go to medical school?” 

    “I dropped out early,” Imburgia says, smiling. “Back in the ’70s and ’80s, you just had to show you were interested.”

    Some 50 volunteers make the Have a Heart Clinic possible. And that number continues to rise, so much so that the clinic hopes to add additional days. In 2016, Have a Heart provided more than $40,000 in free outpatient care. In the last five years, it has provided about $250,000 in services. (On Aug. 26, the clinic is holding a fundraiser at Copper & Kings.) The clinic now offers a Patient Advocate program that involves nurses and social workers tracking especially vulnerable patients, checking in with them routinely to ensure they take prescribed medications and that all medical needs are being met. Many Have a Heart volunteers say they’re drawn to the clinic’s mission, and that they stay because of its leader. “(Imburgia) is the light of the lighthouse,” Dillon says, far from earshot of her longtime friend and colleague who would undoubtedly cringe at the sentiment. “Everyone wants to make that light work. He never takes credit for anything. But he’s the guiding light.”

    A few volunteers started as patients. Detra Gentry began volunteering for Have a Heart this spring. The 47-year-old first encountered Imburgia in 2012 after weeks of weakness and dizziness, her heart periodically sprinting beneath her chest. Imburgia diagnosed her with a mitral valve prolapse, a condition that, in her case, was serious enough that blood was flowing backward through the mitral valve with each heartbeat. She needed surgery. At first, Gentry delayed it. Her daughter was in the midst of eighth-grade finals. Plus Gentry was between jobs and, though she was on her husband’s insurance, it wouldn’t cover the roughly $100,000 surgery and recovery. “I was scared,” she recalls. “I wasn’t going to have it.” Imburgia and his staff urged Gentry not to wait, helping to connect her to Baptist Hospital’s charity program. She ended up paying about $1,000. 

    Now a medical assistant in an OB/GYN practice, Gentry spent a Saturday in May greeting Have a Heart patients, taking their blood pressure and pulse rate. She occasionally performed an EKG, a test that checks for problems with the heart’s electrical activity. During this test on a few patients, she spotted a familiar scar — about five inches, center of the sternum — that matches her own. Around her neck, just an inch or so above the scar, she wears a necklace with a dangling heart and the date of her surgery — 5/31/2012 — etched into a silver charm. It sits inches from the mechanical valve that clicks — tick, tick, tick — to keep her heart functioning normally. When it’s quiet, like when she lies in bed at night, she can hear it — tick, tick, tick. “I call it my Rolex,” she says. “I want to hear it. Because I’m here.”

    Imburgia says that when a patient needs surgery, he works with hospitals (often calling administration personally) to get it covered. It’s tricky. “No one is hanging up a sign saying send me all your uninsured,” he says. “And yet it’s in all of their mission statements. They say they are there to serve the community. That drives me crazy. And I understand. They need to make money to survive.” Imburgia says that when an uninsured patient arrives at a hospital, the first thing the hospital will want to do is enroll them in insurance, even if it’s just a temporary Medicaid card. It may not always be the best route. “The reimbursement is never going to be enough” to cover the cost, he says. Without insurance, medical supply companies often donate equipment (like mechanical valves) to needy patients. And the uninsured can qualify for some indigent-care programs that often reimburse at a better rate than Medicaid.

    In the morning I spent with Imburgia, he guards personal details well, save for one. One of four children, he was quite close with his father, Anthony Joseph Imburgia, known lovingly as “Papa Tony.” Over the years, the Sicilian patriarch, who owned an electronics corporation, would often listen to his son’s frustration with medicine. As a young doctor, he wanted to help more people, give more time, but he had young children and was already putting in long hours. “He always used to say, ‘You’re young. You have a young family. Your time will come,’” Imburgia says. “And the time came.”

    His wife Sandy says some of their friends wonder why her husband won’t just gleefully scoop up retirement like most men his age. Quite the opposite, she says. After a few hours at Have a Heart, he’s giddy. “He’s like, ‘Oh, my God, it was great. We did so good today,’” she says. “In fact, this morning he got mad at me because it’s 7:15 and I’m not ready to go.” She laughs, then her voice drops soft and low, loving and proud. “He’ll die with his stethoscope around his neck. He’ll never stop doing this.”

    *

    The clinic will total 14 patients this Saturday, a little under the average. Imburgia will suspect a faulty pacemaker in an older woman from Ghana. He will inform a Cuban immigrant that his heart muscle appears damaged from a recent heart attack, and he will prescribe medicine and a follow-up appointment. Imburgia and Have a Heart’s board of directors have decided that, for the clinic to remain sustainable, they will have to start seeing paying patients soon. But with the future of Obamacare up in the air, with the possibility of millions of people losing health insurance, Imburgia says it’s hard to know when to “flip the switch” and find a balance between paying and non-paying patients. “We won’t turn anyone away,” Imburgia says. “It would be nice to know what’s going to happen.”

    One of the last patients Imburgia will see today is a 49-year-old woman with light-brown skin and freckles that stretch cheekbone to cheekbone. Lately, she has been experiencing crippling fatigue. She manages a Rally’s and works 10- or 11-hour days, often clocking out at 2 or 3 in the morning. She lives with her 29-year-old epileptic son. “I’m always tired,” she tells Imburgia, sighing. “I think I do need more exercise. I walked yesterday and it felt great.”

    She recently wound up in the ER with shortness of breath and chest pain. No evidence of a heart attack, but a doctor recommended she undergo a nuclear stress test, a procedure that involves taking images of the heart pumping while at rest and while stressed. The test can expose areas of low blood flow or damaged heart muscle. Imburgia’s eyes squint a bit, as if questioning the recommendation. The patient doesn’t have consistent chest tightness or other troubling symptoms. She does have high blood pressure. And he wonders whether perhaps the medication may be to blame for her fatigue.

    “You have insurance?” he asks.

    “No,” she replies.

    “So the test they want you to get, if charity care doesn’t pay for it (at the hospital), it can cost $3,000.” 

    The woman loudly gulps. Her eyes widen and bulge. She already owes a couple thousand dollars to the ER for her recent visit.

    “And I’m just not sure you need it,” Imburgia says. (Have a Heart cannot do nuclear stress tests on site.) He writes her a prescription for different blood-pressure medication and advises her to cancel the nuclear stress test scheduled for the following Monday.

    “Do you have a blood-pressure cuff?” Imburgia asks. 

    “Yes,” she says.

    “Promise me you’ll call me and let me know you’re feeling better,” he says, reaching out his hand for a handshake that lingers as he speaks to her, looking at her directly in the eyes. “So you’re gonna call me in a few weeks?” he reiterates. She nods. If she doesn’t feel better, Imburgia will proceed with a stress test. 

    “Don’t go until I call you and tell you it’s free,” he says, still clutching her hand. “Because I really do believe that if you don’t qualify for charity care, you’ll pay.”

    “That will put me into cardiac arrest for real,” the woman jokes, smiling.

    Imburgia laughs as he lets go of her hand and walks out to see his next patient.

    Have A Heart Foundation is holding a fundraiser at Copper & Kings on Saturday, August 26th. For more info, click here. To learn more about the Have A Heart Clinic and the foundation, visit their website here.

    To view Louisville Magazine's Top Doctors 2017, click here.

    This originally appeared in the August 2017 issue of Louisville Magazine. To subscribe to Louisville Magazine, click here. To find your very own copy of Louisville Magazine, click here. 

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