Access to care: Communities aim to fill health care gap

Growing numbers of local programs are connecting volunteer physicians with people in need.

By Doug Trapp — Posted April 5, 2010

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Jason Yamaguchi knows all too well about the gaps in the U.S. health system. The 37-year-old New Haven, Conn., resident has type 2 diabetes and diabetic retinopathy. His eyesight began deteriorating about five years ago. He was working as a bartender then, but unwittingly he allowed COBRA coverage to expire after he left that job. He also acknowledges that he didn't pay enough attention to his health.

So now Yamaguchi faces a dilemma. He earns less than $15,000 a year as a part-time cook, too much to qualify for public assistance, but not enough to cover the roughly $75,000 in medical bills he has faced. His friends and family have helped: organizing a charity golf event, a haircut-a-thon, and a cookie sale promotion. But he's still in debt and needs follow-up care.

Yamaguchi's predicament is just the kind of situation that Project Access-New Haven is expected to address when it begins enrollment in June. The program will coordinate free specialty and hospital care and prescriptions for low-income uninsured people who aren't eligible for public coverage. Some 200 area physicians and two hospitals already have volunteered their services, according to otolaryngologist Paul Fortgang, MD, the organization's president and a past president of the New Haven County Medical Assn.

Project Access-New Haven is one of a growing number of independent programs based on a model developed in the mid-1990s by the Buncombe County Medical Society in western North Carolina. That program provides free health care to people whose medical conditions limit their ability to work. To participate, patients must promise to show up on time for appointments and visit emergency departments only for true emergencies, among other requirements.

Local medical societies are behind many of the more than 90 Project Access programs around the country, including one in Waterbury, Conn., that has been a blueprint for the New Haven startup. Steven Wolfson, MD, a cardiologist and past president of the New Haven County Medical Assn., said the Waterbury organization made him realize immediately that a similar effort was needed in his town.

Word of mouth has helped promote Project Access widely. "We pretty much pattern our programs after each other," said Carrie Logsdon, director of Project Health in Indianapolis.

The initiatives appear to be showing positive results. Project Access physicians say they provide tens of millions of dollars worth of care to many thousands of patients each year. In the Indianapolis program, patients have cut emergency department visits by more than 70%.

Making charity care more effective

Physicians in Asheville, N.C., launched the first Project Access chapter in 1996. The effort that led to the program began with a basic question: How could local people obtain better access to care?

The Robert Wood Johnson Foundation offered money to research the issue. Suzanne Landis, MD, an internist, helped obtain grants that enabled the Buncombe County Medical Society to devise ways to increase access.

Focus groups revealed that doctors were already seeing patients for free, but the patients didn't always have access to lab tests, prescriptions and specialty care, Dr. Landis said.

She and two colleagues visited groups of surgeons, psychiatrists, ob-gyns, and others, asking each group to provide free care for 10 to 20 patients each year. One by one, the groups agreed. The local hospital system signed on to provide free lab tests and other services. Before long, about 90% of the doctors in the county were offering free care to Project Access members.

Start-up funding for Project Access programs often comes from foundations and nonprofits, but local governments have contributed as well. Since the Buncombe County program began, it has relied on about $500,000 annually from the local county commission. About a third of that money pays for full-time program staff.

"It wasn't a tremendous amount of money, but the neat thing was how much money it's leveraged," said Tom Sobol, who was president of the county commission then. Last year, doctors, hospitals and others donated about $14 million in free care and services, said Jana Kellam, the medical society's director of foundation programs. At least 85% of physicians in the county still participate.

Preventing medical disasters

In Connecticut, Raymond Lush said he would probably be dead without Waterbury Project Access. The 53-year-old security guard began feeling tightness in his chest last October. The two-pack-a-day smoker thought his habit might have led to bronchitis or another lung problem. So Lush, who works at a medical complex, approached a physician and described his symptoms. The doctor, Daniel G. Tobin, MD, medical director at the Chase Outpatient Center, told Lush to come in for an electrocardiogram.

"You look like somebody who just might have had a heart attack," Dr. Tobin told Lush afterward. A stress test revealed that at least four of the patient's coronary arteries were blocked. Lush had a series of stents implanted within days and soon went back to work.

After the stent surgery, Lush was prescribed cholesterol-lowering medication, but money was again an issue: The brand-name medicine cost $130 for a 20-day supply. "There's no way. I had like $20 in my pocket," Lush said. He called Waterbury Project Access staff, who arranged for free medicine within a couple of hours through a related program.

Lush was grateful for the help. He now qualifies for state medical assistance, and his cholesterol numbers have improved.

Waterbury Project Access offers lessons on the value of steady care coordination, said Dr. Tobin, an assistant professor at Yale School of Medicine in New Haven, Conn. "This is a way for us to actually get [patients] the care they need so that our input is meaningful."

Providing free care alone isn't enough to get patients to use it, said Edd Eason, director of community health navigation for Project Access Dallas. Eason's staff of seven helps as many as 200 people a month obtain needed health care. "We're constantly calling them, we're going by to visit them," he said.

Eason said program staffers provide bus passes to Project Access members and money for co-pays. This also helps patients follow through on their medical care. "It's not because they don't want to [obtain health care] or that they're undependable."

Patients are more likely to show up for appointments if they have member cards, allowing them to blend in with the privately insured, said Paula Hall, MD, Indianapolis Medical Society Foundation president. She added that physicians also stress to patients that the coverage is temporary.

Tought times bring more takers

The enrollment in Project Access Dallas, which launched in 2001, is projected to go from nearly 2,000 people to 5,000 by 2013, said Cheryl Prelow, program vice president. The expansion is possible because of $8 million in federal funding secured by a partnership between four Dallas safety-net hospitals, the Dallas County Medical Society Foundation and others.

Eason said the expansion can't happen quickly enough. People wait at least a month for care coordination help. "We need to be doing this for 40,000 people," he added.

Although the Dallas budget is growing quickly, Project Health in Indianapolis is running out of money. Some of the chapter's major foundation grants expired, and the program is not eligible for federal grants, Logsdon said.

But despite the ongoing recession, physician participation has remained stable or increased in Buncombe County, Dallas, Indianapolis, and Waterbury, Conn., according to program administrators. Physicians tend to join when they know other doctors are joining, Logsdon said.

Recruiting doctors for the newest iteration, Project Access-New Haven, has not been very difficult, said Stephanie Arlis-Mayor, MD, a project board member and medical director of the Family Health Center and Surgical Specialty Clinics at Hospital of Saint Raphael in New Haven. "We've not been worried at all about getting physician buy-in."

Program leaders also have raised more than $180,000 in grants, Dr. Fortgang said. But many foundations were less willing to donate while Congress was working on national health system reform bills that promised a significant expansion in access to coverage.

Meanwhile, Yamaguchi, the type 2 diabetic with retinopathy in New Haven, hopes for some kind of additional financial help should he need more surgeries. For now, controlling his diabetes is key to maintaining what eyesight he has left. He could qualify for state assistance if he were declared legally blind or if he quit his job. But his mother says being able to work is a point of personal pride for her son.

"I can't sit back and say I can't do anything until it gets better," Yamaguchi said. "I've got to continue with my life the best that I can."

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How Project Access works

The Project Access model -- first developed by North Carolina physicians in the mid-1990s -- connects needy people with physicians and hospitals willing to provide free specialty care. Typically, Project Access programs:

  • Help uninsured, local working people who earn less than 200% of the federal poverty level -- about $22,000 for an individual. Candidates cannot qualify for Medicaid or other public coverage.
  • Employ care coordinators to enroll patients and refer them to the appropriate physicians and hospitals.
  • Provide access to free or discounted medications with limited or no co-pays.
  • Allow physicians to see as many or as few patients as they prefer.
  • Provide membership cards similar to those used by private health plans. Enrollees typically renew memberships every three to six months, based on need.
  • Start up using grants from nonprofit organizations such as the Robert Wood Johnson Foundation or the United Way, or from local governments. Some local hospitals also financially support Project Access programs to help reduce the load on emergency departments.

Sources: Buncombe County Medical Assn., Physicians' Innovation Network

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Dollars of prevention, dollars of cure

Some of the more than 90 Project Access programs around the U.S. provided millions worth of free care to thousands of patients in 2009.

Project Access (Buncombe County, N.C.)

Patients served: 3,602
Physician volunteers: 638
Value of physician care: $5.1 million
Value of hospital care: $8.7 million
Budget: $500,000
Employees: 3 full time, 3 part time
Launched: 1996
Web site: link

Project Access Dallas

Patients served: 2,064
Physician volunteers: 1,878
Value of physician care: $1.7 million
Value of hospital care: $2.6 million
Budget: $4.4 million (Includes $1 million in new funding for a pending program expansion.)
Employees: 8 full time
Launched: 2002
Web site: link

Project Health (Indianapolis)

Patients served: 1,660
Physician volunteers: 998
Value of physician care: $3.9 millio
Value of hospital care: $10.5 million
Budget: $250,000
Employees: 3 full time
Launched: 2003
Web site: link

Waterbury (Conn.) Project Access

Patients served: 475
Physician volunteers: 339
Value of physician care: $42,842
Value of hospital care: $383,657
Budget: $115,000 (approximately)
Employees: 1.5 full time
Launched: 2004
Web site: n/a

Sources: Buncombe County Medical Society, Dallas County Medical Society, Indianapolis Medical Society, Waterbury Health Access Program

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External links

Project Access (link)

Project Access, Buncombe County (N.C.) Medical Society (link)

Physicians' Innovation Network on starting a Project Access system of care (link)

Communities Joined in Action on Project Access (link)

Project Access Dallas, Dallas County Medical Society (link)

Project Health, Indianapolis Medical Society (link)

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