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Ann Thorac Surg 2000;70:354-355
© 2000 The Society of Thoracic Surgeons
a Section of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Jersey, USA
b Concord Hospital, Concord, New Hampshire, USA
c Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire, USA
d Department of Family and Community Medicine and Department of Preventive Medicine, University of Kansas School of Medicine, Wichita, Kansas, USA
Address correspondence to Dr Uhlig, Memorial Building, Suite 103, 246 Pleasant St, Concord, NH03301
e-mail: paul.n.uhlig{at}dartmouth.edu
Health care in the United States exists presently in a state of suspended transformation. A strong economy and widespread public resistance to managed care have temporarily stalled powerful forces of change that have swept across the health care landscape for much of the past decade. We stand cautiously with our patients at the threshold of whatever is left of our former institutions and peer out, testing what is still standing and wondering whether the fury has indeed spent itself or if, in fact, the worst is yet to come. Undecided, we resume our work—not quite as before but familiar enough to be comfortable. All the while we watch and wait: for new ideas, for a renewed sense of direction, for signs of what will happen next.
The most foreboding sign, stark in clarity and unambiguous in significance, is the rising number of people without health insurance in the United States. Despite unprecedented economic prosperity, this number continues to increase at a rate of nearly a million new persons each year. Recent estimates suggest that more than 44 million Americans, nearly 1 in 6, do not have health insurance. The majority of the uninsured are employed, often at more than one job, but do not have affordable health insurance benefits. As their number grows, the reality of the lack of insurance hits closer and closer to home. Many of us have neighbors, friends, and even family members without health insurance, and we wonder how they will cope with the financial realities of serious illness.
We know from our own practices that, eventually, uninsured patients receive care. However, this care often comes late in the course of illness when the likelihood of complications is much greater and the cost, much higher. Beyond the personal consequences for the individuals involved, the growing burden of illness in the population caused by lack of insurance initiates a cascade of other problems that reverberates through all aspects of community life. The dollar cost of care for the uninsured is borne by the entire health-care system; the overall consequences of the lack of insurance are borne throughout society as a whole.
When health care is considered from this societal perspective, it is clear that more changes, substantial changes, are inevitable. Whether we like it or not, our professional future—our livelihood and our ability to care well for our patients—will be determined by decisions and actions that originate far from our offices and operating rooms. To care properly for our patients and our profession, we must become leaders of this process of change. We must be counted among those who ask the questions and find the answers that chart the new course for health care. Leadership roles will not be given to us solely because of position and training. If we want to lead, we must show that our leadership is in the best interest of patients and society at large.
Project Access is an innovative program for the care of uninsured people that demonstrates this kind of effective physician leadership in action. Understanding Project Access—what it can do for communities and what it means for physicians—is important. Developed in Asheville, NC and then replicated successfully in Wichita, KS, Project Access is a physician-led community-based partnership that brings together the medical resources of the community in a comprehensive program of voluntary service for the low-income uninsured. Physician leadership is essential for the success of the program, both for the direct patient care that physicians provide and for the unique ability of physicians to mobilize the other community resources necessary to give comprehensive care to this population.
This is how the program works. Through their local medical society, physicians in each community make a commitment to see a few extra Project Access patients each year at no charge. The specific commitment requested is 10 extra patients each year for primary care physicians and 20 extra consultations each year for specialists. Alternatively, physicians can choose to volunteer a certain number of hours per month in existing clinics for low-income patients. In Asheville, where the program has been operating for more than 4 years, almost 90% of physicians participate. In Wichita, where the program is less than a year old, more than 50% of physicians already are involved. Because the patient load is shared so broadly, this small additional commitment by each physician, plus the capacity of the low-income clinics meets or exceeds the needs of the uninsured population for physician care in each community.
Following the leadership of the physicians, hospitals in the communities agree to care for Project Access patients without charge. When a physician admits a Project Access patient for hospital care, the procedures followed are the same as those for a patient with insurance except no bill is sent. In similar fashion, pharmacists in the communities agree to provide their services to Project Access patients without charge, although they are reimbursed by the program for the cost of the medications they dispense. Patients make a payment of $4 for each prescription to cover administrative costs. Funds for medications are provided by local government; elected officials have been excited to support a program that leverages their contribution by a multiple of 15 or more in terms of the overall value of services provided to the community.
Other community agencies and organizations also participate. Local Medicaid agencies provide screening and eligibility services for the program and place eligibility workers at initial care sites so that patients do not have to travel elsewhere for this assessment. Regional health plans in both Asheville and Wichita process encounter data for the programs to provide precise tracking of the care given and the value of that care. Regional foundations and philanthropic associations contribute funds toward the operation of the program offices. Academic medical institutions in both communities participate and provide resources for program evaluation. Donations of computers, office equipment, media services, and other in-kind contributions were made by local corporations during the start-up of the program in Wichita.
With so many parts of the community stepping forward in an organized way, Project Access allows the health care needs of the uninsured to be met without placing an undue burden on any one group or organization. In Asheville, with a population of 250,000 including 15,000 low-income uninsured residents, Project Access provides $4 million worth of care to the uninsured each year. The cost is about $125,000 to operate the program office and approximately $250,000 for medication purchases. In Wichita, with a metropolitan population of 450,000 including 25,000 low-income uninsured residents, it is estimated that Project Access will provide care with an annual value of approximately $7.5 million at a cost of $250,000 for the program office and approximately $500,000 for medications.
Through Project Access, clinics that treat low income uninsured people can refer patients with unresolved specialty needs to other practitioners and facilities in the community. By allowing primary care resources to be used more appropriately, Project Access increases the effective primary-care capacity of existing low-income clinics. More patients can be seen, both for acute care and preventive services, and their needs are met comprehensively. Early evidence suggests that because of the program, hospital costs for care of the uninsured are decreasing, and the health status of the uninsured population is improving. Project Access has fostered a sense of civic pride in both Asheville and Wichita and has brought local, regional, and national recognition for innovative leadership to physicians and other community leaders involved in its development.
Project Access establishes a forum that allows health care and community leaders to work side by side across usual boundaries to solve shared problems. The two fundamental ideas behind Project Access are that people genuinely care about and are willing to help others if given an effective way to do so and that through coordinated effort across a community, resources can be aligned to do much more good than any one entity can accomplish alone. The work of the many dedicated leaders who helped create Project Access, first in Asheville and then in Wichita, demonstrates these basic principles in action. Physician leadership is the key ingredient for this success.
Project Access is not a long-term solution for the problem of lack of insurance, but it is a beginning. This problem and others such as cost and quality will remain national concerns until innovative solutions are found. Project Access demonstrates the kind of collaborative problem solving that is needed to create a better health-care system.
In a study entitled "Health care reform: who will lead?," Samuel Their [1] describes the unwritten contract between society and the health professions. The contract is a simple one: society grants to the health professions the privilege of caring for its sick and many attendant honors and rewards in exchange for a promise that the needs of patients will always come first. The power of this social contract and society’s insistence that it be upheld are evident nationwide in the outpouring of editorials and legislation regarding managed care. We violate this social contract at our peril. By honoring it—through participation in Project Access and other examples of physician leadership in action—we reclaim the privilege of shaping our professional future.
Footnotes
1 Address reprint requests to Carolyn S. Earnest, RN, c/o Central Plains Regional Health Care Foundation, 1102 South Hillside, Wichita, KS 67211. 
References
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