Access excess?

Say ahhhh: Dr. Suzanne Landis, the “mother of Project Access,” helped create the service. She is one of many doctors who help uninsured Buncombe County residents get the care they need. photo courtesy of WNC Medical Society

What happens when Buncombe County physicians offer free specialty care to uninsured, low-income patients amid a down economy? A deluge.

In Buncombe County alone, there were about 38,000 such residents in 2005, according to census data; three years later, that number had swelled to nearly 78,000. And year by year, the county has consistently surpassed both state and national averages for uninsured residents.

Project Access was launched in 1996 to help such people stabilize their health until such time as they could get insurance. Participating physicians donate their services, providing everything from routine physicals to open-heart surgery. The effort is run by the Western Carolina Medical Society (formerly the Buncombe County Medical Society).

According to Jana Kellam, director of foundation programs, the project was originally viewed as "a short-term, stopgap measure until the health-care system could be 'fixed.'"

"That was 15 years ago," she notes; meanwhile the program just keeps growing. Physicians have always seen some patients for free, Kellam points out, but a coordinated system was needed to provide specialty treatments such as cardiac care and many surgical procedures.

Now, however, the safety net is strained to the breaking point.

"The reality is, Project Access physicians are not able to see this many people," Kellam explains. In the first three months of 2011, she reveals, more than twice as many patients were referred to the project’s roughly 650 physicians as had been during the same period last year, and they’d already surpassed last year’s total patient load several months ago. The number of patients seeking free care, participating doctors say, is becoming untenable.

Overwhelmed

Private physicians have been called “the invisible giant of the nation's health-care safety net.” But like any other small business, private medical practices must either make ends meet or close up shop.

Meanwhile, Buncombe County funding, Project Access' primary income stream, was cut by 10 percent this year. And while they’re grateful for that support, "Clearly, we can't depend on the county alone," says Dr. Robert Fields, the medical society’s board president.

So in August, the WCMS Foundation’s board of directors, which runs Project Access, tightened eligibility requirements. Effective Sept. 16, clients’ household income must be less than 133 percent of federal poverty guidelines (down from 200 percent), and they must have lived in Buncombe County for a year (rather than six months).

More changes are in the works, including stricter medication policies; bringing screening, appointment setting and data management in-house; and having higher-income patients make some payment to physicians.

Other ideas still under discussion include a program encouraging patients to take more responsibility for their health and perhaps adding a "sweat equity" element akin to what Habitat for Humanity does.

"The idea is that if people had some skin in the game, they’d be more likely to value what they're being given and take better care of themselves," Kellam explains.

"Obviously, it doesn't mean they're going to go out and build houses, since we're talking about people who are sick, but there are things they can do for themselves, or for the providers, so they can give back,” she continues. “Everybody can volunteer, in some way … paying it forward. It's patient empowerment." The details are still under development, but the goal is to roll out this component of the overhaul early next year.

De facto rationing?

Project Access’ biggest contribution, says Kellam, may be keeping people out of the emergency room. "It's been shown over and over that this is a much more efficient way of doing things," she emphasizes. But in recent years, more clients have developed chronic ailments such as heart disease and diabetes, and they end up staying in the program longer.

In the beginning, many participants could have an acute condition treated, return to work and get insurance. "Now, they're not so likely to find a job, let alone one with insurance. It's a different set of circumstances, affecting our ability to get people through the system and enable new people to enroll."

One of the biggest challenges, says Kellam, is educating primary-care providers — typically the federally qualified health centers serving the region’s low-income uninsured — about appropriate referrals. “We just needed some parameters around the types of patients the physicians in our network are able to see for free,” she explains. And those facilities, notes Kellam, have also seen big increases in their patient loads.

So even though there's no government board handing out vouchers for surgeries, says Fields, "It's rationing. We're at the point where the need is so great, we're triaging — trying to figure out who needs care the most, who needs it now and who can wait."

Yet doctors, stresses Kellam, “continue to give stratospheric amounts of free care. They're participating at higher and higher levels, even though their costs are going up. It's sort of miraculous. Last year, around $14 million worth of care was donated to Project Access patients; this year, we're on pace to be much higher than that."

Against that backdrop, Kellam hopes observers see the coming changes "as a way of keeping this program available for people who really need it, rather than thinking that now the physicians aren't going to be doing as much."

— Susan Andrew is a contributing reporter for Carolina Public Press (www.carolinapublicpress.org), where a different version of this story originally appeared.

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