Keeping the ‘volunteer safety net’ healthy

Dennis Hayes came home from the hospital on Christmas Day 2006 with a new stent in his heart, more than $50,000 in medical bills, and no health insurance to cover them.

As he recovered from his heart attack, Hayes wondered what follow-up care he really needed, and what he could afford.

“I’m saying to myself, OK, what medications do I really, really need?” he said.

Four years later, Hayes does not ration his prescriptions or doctor visits, and his diabetes and hypertension are under control. He never did get insurance; the cost is out of reach for Hayes, and he’s not poor enough for Medicaid or other state programs.

Instead, Hayes receives medical care through Waterbury Project Access, a network of volunteer doctors and care coordinators intended to help those who, like Hayes, fall outside the state safety net. In four years, the program has served close to 1,200 patients and provided more than $4.6 million in donated care, lab work and medication.

A similar program in New Haven began treating patients in August, and other Project Access programs operate in cities across the country.

“I’m very grateful, because I am on a lot of medication, and I’m sure if I wasn’t on [Project Access], I’d be falling into the state’s hands,” Hayes said recently at his Wolcott home. “They would be forced to take care of me because I would have nothing.”

The “volunteer safety net” of medical professionals donating services has a long history. But research suggests that the amount of free care doctors provide has been falling in recent years.

Some of the decline stems from changes in physicians’ work environments. More doctors now work for hospitals or clinics and have less control over how they spend their time than they would in their own practices.

Some doctors express frustration that patients don’t show up for free appointments. And there are limits to what doctors can do if an uninsured patient requires a referral, or an expensive test, or a costly brand-name medication.

“The problem is, once you have done what you can with your eyes, your ears, your hands and your stethoscope in the office, if patients need more than that, you then need to go to a medical tool known as begging,” said Dr. Steven Wolfson, a cardiologist and member of the Project Access New Haven board. “We have to plead with hospitals to get tests done. We have to plead with our friends to help with the care of these people, and that takes more time than what we ourselves do for people.”

Project Access is aimed at removing those barriers. The programs have case managers or patient navigators who make sure patients keep their appointments and stay out of emergency rooms. They get patients free or low-cost medications, some of which are available through pharmaceutical companies. Lab work and tests are donated, and the Waterbury and New Haven hospitals don’t charge for inpatient care if Project Access patients need it. And because of the network of doctors participating, doctors can make a referral without resorting to begging.

“We are saying to the doctors, if you will volunteer to be a doctor, we’ll let you just be the doctor,” said Dr. Suzanne Lagarde, a gastroenterologist and president of the Project Access New Haven board. “We’ll get you the patient and we’ll take care of all the other obstacles that you encounter when you volunteer your services to care for this patient population.”

Avoiding Emergencies

The New Haven and Waterbury programs both began through the local medical associations and limit participation to uninsured people earning less than 250 percent of the federal poverty level. They screen patients to make sure they don’t qualify for state programs like HUSKY or a Medicaid program for low-income adults.

Waterbury Project Access includes primary care doctors and serves as a medical home for its patients. But in New Haven, the organizers determined that primary care needs were fairly well met by the city’s community health centers and hospital-based clinics.

Specialty care was another matter. An informal study found that uninsured patients had to wait between four to six months, and in some cases, more than a year, to get an appointment with a specialist, Lagarde said. So Project Access New Haven focuses on specialty care for patients with urgent, needs–conditions that don’t require a visit to the emergency room or hospitalization, but will if they’re not treated promptly. More than 200 specialists now volunteer.

Without Project Access, Lagarde said, care is available, but it can take a long time. “Lots of things can happen in the meantime, including unnecessary emergency department visits, and people getting sicker.”

One recent patient was a 37-year-old woman who went to the emergency department and was told she had gallstones and needed her gallbladder removed. She didn’t have the resources for surgery.

She returned to the emergency department a month later, this time with complications–a stone had passed into her bile duct. She spent five days in the hospital, where the gallstone was removed, but her gallbladder wasn’t.

The woman began the process of applying for free hospital care so she could get the surgery. One of her health care providers also referred her to Project Access, which got her in to see a gastroenterologist and, ultimately, surgery, within three weeks.

Months later, she got a postcard from the hospital: She was approved for free care.

Had she waited, Lagarde said, the woman could have ended up in the emergency room multiple times, perhaps with more severe complications.

Can’t Buy Benefits, Can’t Get Them

Part of coordinating care is ensuring that patients don’t go to the emergency room unless they need to. In Waterbury, the number of non-emergency visits to emergency rooms has dropped since Project Access began.

“It’s a really coordinated effort to keep our population healthy,” said Leslie Swiderski, program coordinator for Waterbury Project Access.

Dr. Craig Czarsty, a Watertown family doctor who helped start the Waterbury program, refers patients who tell him, “Doc, I can’t come anymore. I don’t have insurance, I can’t afford it.”

Czarsty would treat them anyway. But on his own, he wouldn’t be able to get them the lab work, medications and referrals Project Access does.

Like many doctors, Czarsty provides free care through other programs. He started a foundation to support medical care he and other doctors provide in the Dominican Republic. But he considers Project Access the easiest.

“Patients come to my office,” he said. “The patients like it too, because they don’t have to go someplace unfamiliar. They’re treated like regular patients, and they come to their own doctor’s office, and they have their own doctor.”

Hayes used to have insurance and a high-paying job. When he got laid off, he paid to maintain his health coverage through COBRA as he looked for work and, later, began his own business.

But COBRA ran out after 18 months, and when he tried to buy his own insurance policy, he was told it would cost between $2,500 and $3,000 a month.

So he was uninsured when he had his heart attack. Hayes sold some of his possessions to cover his medical bills.

When a doctor referred him to Waterbury Project Access, he received, like all patients, a financial screening to determine if he could get coverage through a public program instead. Hayes, who has a seasonal job driving a truck delivering pool water, remembers getting a letter telling him he didn’t qualify for a state insurance program. “I’m screwed,” he told Swiderski. “I can’t buy benefits, and I can’t get benefits.”

“She said, ‘don’t worry,’” he recalled. “‘You’re in this program.’”

Hayes doesn’t know exactly where he’d be without it. But he has an idea.

“I wouldn’t be going to doctors, and I wouldn’t be getting medication,” he said. “And I’d probably be in the hospital somewhere…and going bankrupt and whatever needed to be done because I would never be able to afford to pay the bills.”