Doctors, county team up to offer free health care

Care for 13,000 patients costs $250,000 a year

Physicians in the mountain community of Buncombe County, NC, had been frustrated for years at the level of care for low-income, uninsured patients. They saw those patients return again and again to primary-care free clinics for problems that could only be resolved through specialty care, surgery, or some other treatment the patients couldn’t afford.

Meanwhile, government leaders in the county were frustrated that the free clinics were full of people who couldn’t be properly helped there and who were taking appointments away from people who could. This resulted in public money going to indigent care without improving the health of many patients.

So the two groups worked together to solve the problem. Their idea was to form a public/private partnership to give low-income, uninsured county residents full, free access to physicians, specialists, and medications. The idea was so successful that it recently became one of 10 winners of the Innovations in American Government Awards, a $100,000 grant from the Ford Foundation in Detroit. The awards, which recognize government initiatives that solve tough problems, are designed to encourage replication in other communities around the country.

The Buncombe County Medical Society (BCMS) already has hosted one benchmarking site visit from a group in Wichita, KS, and hopes to do more, says Alan McKenzie, executive director of the Buncombe County Medical Society and leader of the program, called BCMS Project Access.

"We’re creating a logical, coordinated approach to providing appropriate access to care for low-income, uninsured people in our community," McKenzie says. "Project Access takes the best principles of managed care and uses them to create a system that can effectively and efficiently provide access to health care for those who can’t afford to pay for it. It uses the basic principle of early intervention and prevention in a primary care setting but with ready access to specialty care, hospital services, and medications."

Physicians, pharmacists, free clinics, the health department, the hospital, and the social services department all work together to provide free access to the continuum of health care for patients who meet the criteria of having no insurance and an income below 200% of the federal poverty level ($26,660 for a family of three). The patients must first be seen at one of the county’s five free clinics and must have a health care need beyond the scope of services available there.

In the last year, 13,000 of the estimated 15,000 patients in that category were seen at least once in the free clinics. Approximately 3,000 were referred to specialty care or primary care for a chronic need, and half now have full-time jobs with health benefits, McKenzie says. Many of those patients had been unable to work because of their health problem. More than 80% of patients who were surveyed in an outcomes study said their health is better now than when they first enrolled in the project.

Another big benefit of Project Access is better use of money for medical care. Before the project began, many of the patients were using the emergency room for primary care purposes. But with the free access to physicians, the value of care the local hospital was donating for these patients has dropped $60,000 a month, from $160,000, he says. "We’ve shifted from using emergency room care as an access point to providing hospital services related to specialty care, such as the outpatient surgical center, and lab work," he says.

The cost per patient is also half what it was when the program began. Two years ago, the average value of services each month was $600. Now it’s $300 a month. "We’re seeing twice as many patients for the same value of services," McKenzie says.

About 500 private practice physicians — 85% of the BCMS membership — volunteer to take 10 patients into their practices each year or volunteer to spend a certain number of hours in a free clinic. Specialists volunteer to take 20 referrals a year. A database keeps track of which patients are sent to which physicians and removes physicians from the volunteer list when they’ve met the requirement.

"Most doctors are committed to seeing patients regardless of their ability to pay, but they don’t want to be the only doctor doing it," McKenzie says. "If everybody does his fair share, it won’t be too much for any of us."

The county puts up $250,000 a year to pay for medications and administrative costs. Wanda Greene, Buncombe County manager, says that’s some of the best money the local government has ever spent. "We want to make sure our citizens have access to health care, and to do that through a partnership that delivers it in such an effective and low-cost way is well worth our investment," she says. "For our $250,000 investment, this year we’ve leveraged $3.5 million worth of free health care. The community sees this as a societal problem and is really committed to providing good health care."

Greene says the response from the community has been positive. "We were giving the money to the hospitals anyway to help with indigent care, and I think people just thought it was going into some kind of black hole," she says. "With this program, they can see it going to help specific people."

The key to the program is removing barriers to health care access, McKenzie says. Enrolled patients are given identification cards that they can present for automatic free care at the hospital or for prescriptions at any pharmacy in the county. The pharmacies provide the medications at cost and bill BCMS for the difference. Because patients have access to care early in the course of their problems, less money is spent.

"If, for example, we get patients the medications they need to control hypertension, it helps us avoid an emergency admission to the hospital that might require bypass surgery," McKenzie says. "If you avoid one bypass surgery, you can buy a lot of hypertension medications."

Before the project began, the local health department was seeing 6,000 patients. Now, the same clinical staff are able to see 9,000 patients. "You can see a primary care physician as many times as you want to, but if what you need is gall bladder surgery, it won’t be resolved," he says.

"We provided access to the physician to perform that surgery. Once that specialty need is resolved, suddenly that primary care practice is only seeing that patient once or twice a year. That opens up those extra visits for a new patient," adds McKenzie.

For more information on Project Access, contact Buncombe County Medical Society, 530 Hendersonville Road, Asheville, NC 28803. Telephone: (828) 274- 2267.