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Mending the safety net: How doctors in some states are aiding those without care

Physicians are making up for gaps in federal and state health coverage by volunteering their time to help uninsured patients.

By Joel B. Finkelstein, amednews staff. Nov. 3, 2003.

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Rather than just watch a bad situation get worse, physicians are acting on the problem of the nation's uninsured.

New figures show that the ranks of the uninsured grew to 43.6 million in 2002. With more cuts to Medicaid expected, the weak economy persisting and little help from the federal government in sight, the problem is likely to get worse before it gets better, experts predict.

So doctors in many communities are trying to fill the void. With the help of state medical societies and social service agencies, these physicians have taken it upon themselves to tie together the frayed ends of the health care safety net, a patchwork of projects and institutions that provide medical care for the country's uninsured patients.

Those physicians who can still afford to are choosing to take a hit to their profit margins to continue providing charity care. Others are streamlining care for uninsured patients while finding they can improve relationships with the low-income patients they are already treating.

Programs adopted by physicians in three states provide insight into the types of strategies that are working for these communities.

Strength in numbers

In the mid-1990s, Delaware's Medicaid program took the managed care plunge. This resulted in slightly higher payment rates and greater physician participation, but ended the need for the Voluntary Initiative Program, which matched doctors with the state's neediest patients.

Rather than abandon the program altogether, physicians shifted their focus. They created VIP Phase II to address the growing needs of another population -- the working poor.

"Physicians feel some obligation to help with the issue of the uninsured, and it's a lot better to do it as a ... whole bunch of doctors," said James Gill, MD, a family physician at Foulk Road Family Medicine Center in Wilmington, Del.

The responsibility to care for the community's uninsured is important to most physicians, but "no money, no mission," said Joseph A. Lieberman III, MD, a professor of family medicine at Jefferson Medical College in Philadelphia. He has helped build the program and recruit Delaware physicians into the volunteer network.

The program includes 334 physician volunteers. It determines patients' eligibility for public coverage, finds them a doctor, refers them to specialists or imaging services, and soon will help them get prescriptions and laboratory tests.

"What this does is allow the doctors to participate in a program that takes care of medically indigent patients, but [the doctor is] not inundated or overwhelmed or forced into bankruptcy because they have got to take care of too many [uninsured people]," Dr. Lieberman said.

Since its launch in 2001, the project has referred 773 patients to physician volunteers. Participating physicians not only agree to take on new uninsured patients but also can get the uninsured patients they are already seeing enrolled.

"If you're already treating an uninsured patient, why get them into this program?" Dr. Gill asked. "Because they can get access to other doctors, like specialists, by doing that." The network includes 196 volunteer specialists.

To encourage physicians to join, the program offers volunteers a lot of flexibility. The physicians determine how many patients they will accept, as well as whether they will provide care for free or on a sliding scale. A popular service of the project is a sliding-scale calculator that doctors can easily adopt in their practices.

The program conducts financial analysis of patients to see if they are eligible for Medicaid, veterans benefits or other public coverage, potentially turning them into paying patients. This has the extra benefit of relieving physicians from such administrative duties as determining patients' economic status or sending out bills and dunning notices to someone who can't pay.

"The doctor knows, based on the patient's standing in the program, where they are in the income scale," Dr. Lieberman said. "The doctor doesn't have to sit down and go through tax returns."

The social service agencies that run the project also become de facto case managers for patients, not only helping them navigate the health care system but steering them toward other resources, such as disease management, housing and food programs.

"We're trying to build a fairly comprehensive program in Delaware to have a seamless system where patients can get into a medical home, but also can have other needs met," Dr. Lieberman said. "Pretty much the bulk of services that patients would need, we can get for them through this program."

The result for patients is obvious, not only in terms of better access to physicians and medical services, but in reduced hospital times and visits to the emergency department.

But physicians benefit too.

"They get to practice medicine, which is really refreshing," Dr. Lieberman said.

Dialing for doctors

A few years ago, Arizona physicians planning annual Doctors Day events decided that the celebration of physician contributions to society also could be a perfect opportunity for physicians to demonstrate their activism.

So began the Arizona Medical Assn.'s annual Doctors Day phone bank. The event, coordinated with local television and radio stations, gives needy patients all over the state the opportunity to speak with physicians about their symptoms, medical problems and concerns.

Anita Murcko, MD, a Phoenix internist, helps recruit volunteers for the Doctors Day call-in, which involves more than 100 physicians manning 30 phones over 12 hours. The program, which has been held for the past seven years, allows physicians to talk with patients without the usual constraints of an office environment.

"There's no time clock. You don't have the sense of pressure of day-to-day practice," she said. "It gets back to your roots."

The event is hassle-free for volunteers. "The way the program was set up was very conducive for the physicians to just step in, do the work and not have to be part of the organizing," said Mark R. Wallace, MD, a Phoenix internist.

The approach has some drawbacks, though. Physicians miss out on the face-to-face interactions of an office visit, they can't do a physical exam, and they lack the ability to follow up with patients. But the phone-bank volunteers are given a list of clinics and agencies across the state that offer free or sliding-scale services to which they can refer patients for further help.

The program offers a viable alternative to cutting out charitable work altogether, Dr. Murcko said. "It is becoming very difficult for physicians to offer reduced rates."

Dr. Wallace said he was looking for ways to become involved with the community without placing extra financial strain on his practice.

Performing charitable work outside the office "is probably the only way it is going to work out for our business," he said.

A satisfying interaction with patients also seems to be an important motivator for physicians to volunteer.

"The patients expressed their appreciation more than I ever heard in any other setting," said Dr. Wallace, who has participated in the phone-bank program for the past six years.

Vouchers for the uninsured

Physicians in northeastern Indiana, which has been hit hard by factory closures and the recession, recognized a growing problem in their community.

"I'm seeing more people with no insurance or decreased ability to pay," said Thomas Miller, MD, a family physician in Angola, Ind.

In response to this rising need, but without the resources to build, equip or man a freestanding clinic, Dr. Miller and six other primary care physicians got together to discuss options. They decided that developing a voucher system would be the most cost-effective way to address the needs of the community. Their program was set to launch Nov. 1.

"Basically, if someone needs to be seen, they present themselves ... and they get a voucher, and they can come see us for free," Dr. Miller said.

He said physicians in his rural community always were willing to provide free care, but that was not obvious to social workers or uninsured patients, so people were putting off or going without care.

With only four doctors serving Medicaid patients, Angola is part of a health-professional shortage area, said John White, chair of the Steuben County Health Resources Committee, which is responsible for administering the vouchers. Patients who want to participate in the program will have to fill out a short income survey, but the emphasis will be on getting people medical attention, rather than waiting until they need to go to the emergency department, White said.

"We're not going to be turning anybody away," he said.

By having each physician agree to take two patients with vouchers per week, the committee and the physicians will know exactly what to expect. The voucher system also will allow both parties to assess need and whether it is being met in the county.

The community's two surgeons and one obstetrician-gynecologist also have agreed to accept, without charge, referrals of patients with vouchers from the seven participating primary care physicians.

The voucher initiative is just getting off the ground, but Dr. Miller is convinced it was a wise move that will be a success.

"It costs no government money; we didn't have to do a big study. People in the community saw a need, we got together and we talked about it reasonably," he said. "We came up with a solution for it, and I think everyone feels pretty good about it."

The proof, he said, will be in the doctor-patient relationship.

"To do it this way and not send a bill to someone who can't pay it, I think that's great. If people know going into it that it's an entirely charitable act, I think the relationship is a lot better."

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