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What happens when a host of independent Western North Carolina physicians open their doors to a community of uninsured, low-income patients in need of free specialty care? The answer: a deluge.

In Buncombe County alone, the number of residents who were low-income and uninsured was an estimated 38,000 in 2005; three years later, that number swelled to nearly 43,500, according to the U.S. Census Bureau. In any year it’s been estimated, Buncombe County numbers its uninsured at a higher level than both state and national averages.

Project Access was launched to help low-income, uninsured Buncombe County residents stabilize their health so that health insurance would be more attainable. Project Access physicians donate their services, providing everything from routine physicals to open heart surgery. The effort is run by the Western Carolina Medical Society (formerly known as the Buncombe County Medical Society), a group representing local physicians.

According to Jana Kellam, director of foundation programs for the society, the project was originally intended to be “a short-term, stop-gap measure, until the health-care system could be ‘fixed’.”

“That was 16 years ago,” Kellam said, and the program keeps growing. Physicians have always seen people for free, Kellam pointed out, but there was a need for a coordinated system to provide the specialty treatment front-line providers can’t give, such as cardiology, and many surgical procedures.

But this portion of the safety net is straining.

“The reality is, Project Access physicians are not able to see this many people,” Kellam said. “Last year they served 3,800; this year they’ve already seen over 4,000 – and the year’s not over yet.” The volume of patients referred to Project Access physicians more than doubled in the first six months of 2011, she says, compared to the same period in previous years. About that time, project directors started hearing from participating medical practices: the volume of patients sent to them for free care was becoming untenable.

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Private physicians have been called the “invisible giant,” a major component of the nation’s health care safety net for the uninsured. But doctors in private practice are like any small business; they must either make ends meet, or close up shop.

Meanwhile, Project Access’ primary source of income is from Buncombe County, and this year, that funding was cut by 10 percent. “Clearly, we can’t depend on the county,” said WCMS president Dr. Robert Fields.

So this past August, the WCMS Foundation Board of Directors, which runs Project Access, made plans to overhaul the program. And effective Sept. 16, participants must be below 133 percent of federal poverty benchmarks rather than the prior requirement of 200 percent. Participants also must now have lived in Buncombe County for one year compared with the previous requirement of six months.

The Board approved additional changes that have yet to be fully developed but will be phased in over the coming six to twelve months: plans to tighten medication policies are on the way, plus bringing screening, appointment making, and data management in-house, along with a tiered system of payments to physicians.

There’s also a nascent plan to control costs by boosting patient accountability for maintaining their own health, perhaps through an effort like Mission Health System’s My Healthy Life, a chronic disease self-management program. They’ve also discussed implementing a “sweat equity” element similar to that used by Habitat for Humanity.

“The idea is that if people had some skin in the game,” Kellam told Carolina Public Press, “they would be more likely to value what they’re being given, and take better care of themselves.”

“Obviously, it doesn’t mean they’re going to go out and build houses, since we’re talking about people who are sick,” Kellam explained, “but there are things they can do for themselves, or for the providers, so they can give back. 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 part of the overhaul early in 2012.

The Project’s greatest value may be in 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,” Kellam said. But in recent years, more people have developed chronic diseases such as heart disease and diabetes, and they end up staying in Project Access for longer.

When the project started in 1996, she said, many participants could get an acute condition addressed, then go back to work and get insurance. “Now, they’re not so likely to find a job, let alone find one with insurance. So it’s a different set of circumstances affecting our ability to get people through the system, and enable new people to enroll.”

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Part of the challenge, Kellam said, is increasing awareness within the existing healthcare safety net about appropriate referrals. Many of their referrals come from the federally qualified health centers who provide care for the low-income uninsured in our region, such as the Minnie Jones Center in downtown Asheville, Blue Ridge Community Health Services in Henderson County, or Hot Springs Health Program in Madison County. Those centers have had to cope with large increases in their patient numbers as the local economy has soured, she said.

And while there’s no government board handing out vouchers for surgeries: “It’s rationing,” Fields said. “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 the caregivers keep on. “Somehow, physicians continue to give stratospheric amounts of free care,” Kellam says. “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.”

With some 650 participating physicians, Kellam says she wants observers to 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.”

Editor’s note: An earlier version of this story contained a different figure for the number of Buncombe County residents who were low-income and uninsured in 2008.

Susan Andrew

Susan Andrew is contributing reporter for Carolina Public Press. Contact her at waterthrush@bellsouth.net.

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