Medical care for the uninsured

Germán León’s left eye was bothering him. It was swollen and although it didn’t hurt, it got tired when he was reading. He wanted the swelling to go away.

León, 39, lives with his wife and three children in Fair Haven. He makes sandwiches at a New Haven coffee shop, but his job provides no insurance coverage. In April he was in a second-floor office at the Hospital of Saint Raphael (HSR) in New Haven, where Edna L. Cruz-Cedeño, a patient navigator, was determining his eligibility for treatment through Project Access-New Haven (pa-nh.org/).

As she explained to León, Project Access offers free medical care to the uninsured by recruiting physicians who offer their services at no charge. During the interview, Cruz-Cedeño’s goal was to determine whether León is eligible to receive care under Project Access. Patients must live in New Haven or one of its six contiguous towns. They must be without health insurance and their income must be no more than 250 percent of the federal poverty level. They must provide proof of residency and income. And their medical situation must fit within the project’s guidelines.

Cruz-Cedeño asked León about his medical history. Does he have a history of alcoholism? Arthritis? Cancer? Diabetes? High cholesterol? Asthma? “We are the first contact the patient will have,” she said. “We’ll get a referral. One of our on-call doctors reviews it. We will do the initial screening, financials, location; make sure they qualify; provide appointment information and reminders, follow-up, and communication with specialists.”

León qualified for the program and received an appointment at a private ophthalmology practice in New Haven. “After the visit, Project Access will receive the specialist return form from the physician,” said Giselle Carlotta-McDonald, a patient navigator who followed up the case the next day. “The form will specify what the next step will be for the patient, such as if they will need any lab work, imaging tests, medication, or follow-up appointment. It will also let us know if the patient doesn’t need any further treatments.”

Once accepted, patients receive a Project Access ID card valid for six months, which they present at each medical appointment. Physicians commit to seeing the patients through their treatments. HSR and Yale-New Haven Hospital (YNHH), which support the program, assume responsibility for ancillary care—including costs for lab work, imaging, operating rooms, and physical therapy. And the program takes advantage of prescription assistance from pharmaceutical companies.

Project Access-New Haven is one of 55 chapters of a nationwide program designed to provide specialty care to the uninsured. More than 250 physicians in the New Haven area have signed on to the program since it began operations in 2010.

“It’s a no-brainer,” said Peter J. Ellis, M.D., M.P.H., director of the fourth-year primary care clerkship at the School of Medicine, and one of the program’s founders. “Once physicians hear about the project, they say yes.”

An epiphany in Mississippi

The story of New Haven’s chapter of Project Access begins in Mississippi in 2006, when Suzanne P. Lagarde, M.D., HS ’77, FW ’80, was on a church trip to rebuild houses after Hurricane Katrina. “My skills were far greater in medicine than they were in Sheetrock,” said Lagarde, assistant clinical professor of medicine. So she walked down the street to the Coastal Family Health Center in Biloxi and volunteered her services as a GI specialist.

Among her many uninsured patients was a man with rectal cancer. The diagnosis took only 30 minutes, but Lagarde spent hours calling hospitals, only to learn that the earliest appointment for treatment was eight months away because the patient had no insurance. “These people have nothing for specialty care,” Lagarde said, “But if all the hospitals had were uninsured patients, they couldn’t survive either.”

This story is as familiar to physicians in New Haven as it is to those in Mississippi. As Connecticut’s unemployment rate rises—it reached 9.6 percent in February—people are losing health insurance along with their jobs. Despite the passage of the 2010 Patient Protection and Affordable Care Act, an estimated 14.9 percent of New Haven residents—more than 19,000 people—remain without health insurance. Unable to access regular medical care, they often put off treatment or turn to emergency rooms when their medical problems can no longer be ignored. On her return to New Haven, Lagarde wondered what she could do to help the uninsured here.

Then she heard about Peter Ellis. He had recently begun working in New Haven after several years in Waterbury, where he had organized a chapter of Project Access. A nationwide program founded in 1996, Project Access provides gap coverage for patients who cannot afford health insurance but aren’t eligible for such public programs as Connecticut’s State Administered General Assistance (SAGA) or Medicaid. By providing patients with pro bono primary care until they meet spend-down limits to qualify for SAGA, Project Access helps end the cycle of repeat visits to the emergency room. Ellis and Kevin D. Carr, M.D., HS ’02, an internist and attending physician at Waterbury Hospital, launched Connecticut’s first Project Access in Waterbury in 2004.

Tackling health care in New Haven

Lagarde thought that she and Ellis would work well together—he had the experience in setting up the program, and she knew the political/medical landscape of New Haven. They worked with Yale’s Robert Wood Johnson Clinical Scholars Program to analyze the problem. The Scholars’ answer was clear. “Doctors can’t get patients into specialty care,” said Scholar Katherine Goodrich, M.D., FW ’10.

“Right now,” explained Steven Wolfson, M.D., past president of the New Haven County Medical Association, Project Access board member, and associate clinical professor of medicine (cardiology) at Yale, “seeing uninsured patients happens piecemeal, in private in doctors’ offices. But then we get stuck—what do we do when they need a service we can’t provide? It’s hard enough to do pro bono work without these roadblocks in the way.”

Such roadblocks take their toll. Although physicians like Wolfson continue to provide free care to the uninsured, according to a 2006 report by the Center for Studying Health System Change, a nonpartisan policy research organization in Washington, D.C., physicians are donating fewer hours of charity care and fewer physicians are choosing to provide this care than was the case in the 1990s. In 2005, about 68 percent of the physicians surveyed donated time to uninsured patients, down from 76 percent in 1997.

Katrina Clark, M.P.H. ’71, director of the Fair Haven Community Health Center, said efforts by physicians on behalf of individual patients are crucial but do not address the global need for an organized and consistent means of providing the uninsured with health care. The barriers that doctors and their patients face are mostly organizational, according to Clark. If a patient does get an “uncompensated care” appointment at YNHH, communications between primary care doctors and specialists often falter, resulting in poor continuity of care. And many physicians, said Erica Spatz, M.D., a Robert Wood Johnson Clinical Scholar, don’t provide specialty care to the uninsured. “So then it falls to a small group of physicians to attend to those patients, and they get asked again and again, so wait times increase.”

“We don’t want a little more free care for a few more people a month,” Clark said. Instead she and her colleagues are hoping for a systemic change in providing uninsured patients continuity of care and access to all the services they need.

As Peter N. Herbert, M.D. ’67, HS ’69, senior vice president for medical affairs and chief of staff at YNHH, phrases it, “Physicians, we want philanthropy from you in the form of your care, but it won’t be such that it will bankrupt you.”

Project Access encourages doctors to take on a few patients—usually two or three per month—to ensure that no individual care provider must bear an overwhelming burden. “We look for parity, because no good deed goes unpunished,” said Patrick Curley, Project Access’ executive director.

Patients have responsibilities, too. There is a two-strike policy in place to reduce the number of no-show appointments and wasted resources. “You miss one appointment, that’s fine,” said Curley. “Two strikes, you’re out.”

According to Curley, each patient case will have between eight and 10 “touch points,” or points of contact with the patient navigator. “It is our goal to try to get them their care in a reasonable amount of time,” he said.

These contact points also allow Project Access staff to measure the project’s impact, Ellis said. “How many patients have you seen? What is the quality of care? Are you impacting the number of ER visits? Everyone wants to save money, and there is a lot of interest in using patient navigators to keep people out of the hospital,” he said.

“We want to measure who does what when, every time a doctor saw someone and something was done,” said Curley. “We want to know the value of work that has been done.”

Support for Project Access comes from New Haven’s two hospitals, such donors as the Community Foundation for Greater New Haven, and the medical staffs at both hospitals. HSR has provided office space and computers for an executive director, a consultant who recruits physicians, and two patient navigators—one full- and one part-time—who steer patients to volunteer specialists. Originally referrals came only from the health center in Fair Haven; in its first few months Project Access enrolled 102 patients. “It just seemed natural to start small,” said Ellis. Now the program is accepting referrals from the emergency department at YNHH and the primary care clinic at HSR. YNHH is also providing 3.5 staff positions to support and monitor the program. The hospitals stand to benefit from the program as well. Studies around the country have shown, said Curley, that each dollar spent on the program saves at least $5 in the emergency department.

For physicians in the emergency room, Project Access fills another need. Ian Schwartz, M.D., HS ’06, medical director of the emergency department at YNHH, said that of the 80,000 adult visits each year, only 20 or 25 percent qualify as true emergencies. Many patients come because they lack insurance or because they can’t get an appointment for urgent or specialty care through their primary care provider. “We need to make arrangements, whatever their problem is, to get them followed on an outpatient basis so they’re not right back in the emergency department a few days later with another problem,” Schwartz said. “We aspire to deliver the highest quality care to our patients, whether they’re admitted to the hospital or go home. We are a triage center and a diagnosis center, but there’s a next step of really good outpatient care—aggressive care—that’s needed. We spend a large amount of time trying to make sure that there is a reasonable, practical outpatient plan.” Through Project Access, Schwartz said, emergency room physicians can arrange follow-up care that might not otherwise be possible.

Stephanie L. Arlis-Mayor, M.D., director of the outpatient clinic at HSR, said that Project Access ensures that patients are better able to navigate the health care system. “It allows our patients to be seen in the right place by the right person at the right time,” said Arlis-Mayor, who also sits on the Project Access board. “That’s advantageous to any health care system. It decreases the stretch and stress on the resources. There are cost savings overall because patients are being seen in the ambulatory world, where it’s far less expensive to see patients than it is in the emergency or inpatient world.”

“Project Access will not cure all the ills of people,” said Herbert. “But it is an approach to a certain segment of the population that could make a specific difference. That’s why [Project Access] deserves the full support of the hospital and the community, because they represent all that is good about medicine.” YM

Ayelet Amittay is a 2010 graduate of the Yale School of Nursing. Additional reporting by John Curtis.