Public Health Feature - February 2006
By Erin Prather
Last year, a Robert Wood Johnson Foundation survey revealed that Texas has the nation's highest percentage of adults and children without health insurance. Many are employed, but their employers do not provide health insurance.
That's why physicians in Austin and Dallas elected to start Project Access in their cities. Project Access provides medical, hospital, pharmacy, and social services at minimal cost to eligible patients. It's based on a program that originated in Asheville, N.C., in 1996.
The Dallas effort to help cover the uninsured stems from the late 1990s when the Central Dallas Ministries and the Health Texas Provider Network's (HTPN's) Volunteers in Medicine wanted to expand their after-hours volunteer clinic to provide affordable primary care for the medically indigent living in downtown Dallas. However, says, Project Access Dallas Medical Director James Walton, DO, they soon found out that up to 15 percent of those patients required specialty care, but were limited by long waiting periods at the public hospital.
"The hospitals became a last resort for care because the uninsured could not afford care beyond the charitable clinics," said Dr. Walton. "This in turn caused a long waiting period, sometimes up to three months for a hospital appointment. That created a backup at the clinics, which frustrated volunteer physicians and staff. They began seeing patients repeatedly for the same problem because the patients could not attain that next level of care."
HTPN partnered with the Dallas County Medical Society (DCMS) to find a better answer. Their search led to Asheville. The program there has been a success. Visits to emergency rooms there have declined 28 percent, and 80 percent of Project Access users say their health has improved since entering the program.
DCMS elected to start a similar program there and aligned itself with local hospitals and business, faith, and community organizations. In January 2002, Project Access Dallas (PAD) began recruiting physicians and other health care professionals. They agreed to donate their services and see a set number of patients per year. On April 1, 2002, the first patient enrolled.
Patients eligible for PAD must be employed but make less than 200 percent of the federal poverty level. They cannot qualify for Medicaid or Medicare or have private insurance. Program officials assigned primary care physicians, specialist referrals, and follow-ups through a database of volunteer physicians.
Patients who need surgery are referred to participating hospitals. Pharmaceuticals, lab tests, and other ancillary services are available to patients at little or no cost. Neighborhood and faith-based clinics have developed care coordination plans that include translation services and transportation. These services make sure patients can navigate the system and access social services that enable them to continue to receive adequate care and attain health insurance. Grants and donations to the Dallas Academy of Medicine, the medical society's charitable foundation, fund the program.
"Originally, the program was designed to help physicians who provided volunteer services at the charity clinics," said Dr. Walton. "It grew to include physicians who saw charity patients in their own offices or at the hospitals. We started getting program referrals from physicians in private practice, physicians who worked in hospitals, physicians in the emergency rooms or hospital partners, and physicians at charity clinics. Right now, we have 600 patients enrolled each month in the program. Every six months, patient cases are evaluated to determine if the patients need to be reenrolled or can go off the program."
Currently, 700 physicians participate in the program. A recent impact study of PAD performed by the Institute for Faith Health Research-Dallas reported that the program saved $1,444,272 in direct and indirect hospital related costs (emergency department utilization fell 61 percent and average length of stay for hospitalization fell 75 percent) for uninsured patients enrolled in the program. It predicts the savings to reach $2,447,919 this year if enrollment reaches 800 enrollees per month.
Barbara Carter is just one of many Dallas enrollees who has benefited from PAD. Her story, posted on www.projectaccess.info , shares that although she worked part time as an assistant manager at a bookstore and coffee shop, she did not receive health insurance nor could she afford a policy of her own. She made too much money to qualify for government assistance.
It was not until receiving care at the Central Dallas Ministries' Community Health Clinic that Ms. Carter was treated for hypertension. During treatment, a family physician noticed an abscess under Ms. Carter's arm, something she had suffered with on and off for more than two decades. At times she would lance the boils herself. On several occasions, she went to the emergency room at Parkland Hospital when the pain became overwhelming. Her condition was diagnosed as hidradenitis suppurativa, a chronic inflammation of the apocrine sweat glands. Ms. Carter could not afford to see a dermatologist for treatment.
At the time, PAD was just getting under way. Ms. Carter was referred to the program, and a dermatologist treated the abscess and started her on hydrocortisone injections and antibiotics to manage her condition.
A President's Vision
Tom S. McHorse, MD, an Austin internist and former president of the Travis County Medical Society (TCMS), has donated his services at that city's Volunteer Healthcare Clinic since 1976. Like Dallas, Austin has many uninsured patients.
Dr. McHorse also traveled to Asheville during his presidency, and TCMS later hosted a summit on Project Access, which drew more than 80 medical society members.
Project Access Travis County began in March 2003. A coordinated system of volunteer physician and hospital care, diagnostic services, and pharmaceutical assistance was created to serve Travis County's low-income and uninsured patients.
TCMS has yet to do a formal outcomes study such as those in Asheville or Dallas. But Project Access Travis County Director Cliff Ames said that patient encounter data "indicate that less than 1 percent of all encounters were ER visits." He said the highest percentage of encounters "are primary care office visits, followed by specialty care office visits. This suggests the Travis County program is experiencing similar results."
Dr. McHorse says the Austin program "has been invaluable to physicians who want to donate their time because it allows parties to work together effortlessly. If a primary care physician needs to refer a patient to a specialist, Project Access is contacted and that patient is assigned to a specialist who has volunteered. Assignments are done on rotation so one specialist is not overwhelmed."
Currently, 848 physicians participate. Funding has been secured through the Travis County Healthcare District until October 2006. Last fall a 5K fundraiser walk raised $20,000.
Additionally, the Dallas and Austin programs will benefit from a $986,529 grant awarded to Practice Net Solutions, a joint project of the Dallas Academy of Medicine, the Travis County Medical Society Foundation, and the El Paso County Medical Society Foundation. That grant came from the Physician's Foundation for Health Systems Excellence, a grant-making foundation with assets of $98 million. It was established by settlements of the Aetna and CIGNA portions of a federal antiracketeering lawsuit against many of the nation's largest for-profit HMOs by TMA and others.
The TMA Foundation helped both projects get off the ground.
"Project Access helps physicians accomplish a lot more for individual patients, as well as do a lot more for a larger number of patients," Dr. McHorse said. "Working through the medical society allows this to happen. A program could certainly happen without it, but in almost every place where a Project Access program has been effective, it has been under the direction of a county medical society. It requires significant organizational effort to set up a system like this and, with regards to Austin, I think it is time well spent."
Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at Erin Prather.
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