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Pact pries open door to access health care

Negotiations, verification point way for future medical
by: Christopher Onstott Gastroenterologist Harry Bray performs a colonoscopy at The Oregon Clinic in Northeast Portland. All the clinic's specialists are signed up to provide occasional free care to uninsured patients sent by Project Access NOW.

Melissa Appelo had no idea what she was going to do when she started coughing up blood.

She'd already suffered through months of feeling her heart racing in the middle of the night, and cold sweats coming out of nowhere. But the Northeast Portland single mother of four, though employed as an in-home health care provider, had no health insurance, and clearly she needed more help than a primary care physician at one of the city's safety-net clinics could provide.

Appelo had seen a doctor at such a clinic in Southwest Portland. He suggested a chest X-ray for tuberculosis and that she see a specialist, a gastroenterologist. Appelo knew she could afford neither.

'I was scared for my life,' she says.

If Appelo had been in this situation five years ago, she would have had good reason to fear for her life. But the Portland area now has the country's single largest organization coordinating free specialty care to the uninsured. Nearly every type of physician is available, thanks to the emergence of Project Access NOW, as Appelo discovered.

Five years ago, specialists were mostly off limits for the approximately 300,000 Portland-area people without health insurance. In the mid-2000s, the Multnomah County Medical Society recruited more than 200 specialists who said they would take an occasional case. But for too many, providing free care became too burdensome.

A urologist would see an uninsured patient and determine that surgery was necessary, but no surgeon was available to provide free care. Or, an oncologist would spot a potential tumor, realizing the uninsured patient he had seen would never be able to pay for the next round of tests or therapies.

Or, a charity care patient wouldn't show up for an appointment, or would show up but without medical records the specialist needed to review.

In addition, doctors who agreed to provide free care began to worry that they would get called on again and again, and that their fellow specialists weren't doing as much as they were.

By January 2007, the 200 Portland-area specialists who had told the county medical society they would provide free care had dwindled to about 40.

Now, the doctors are willing to donate their time because in November, Project Access finalized an unprecedented deal in which every hospital in the metro area agreed to provide not only staff time, but free services such as operating rooms, supplies, and cash for Project Access administration.

In addition, the deal brokered for Project Access managed to overcome the fairness concerns of physicians and hospitals with a remarkable transparency agreement. Now, any physician who provides free care can call Project Access and find out how much free care other local physicians have been providing.

The same goes for hospitals. The Project Access agreement ensures that each hospital in the Portland area provides free care according to an agreed-upon formula based on its overall patient numbers, and that each hospital can check to ensure that the others are doing their share.

Frustration among doctors

Melissa Appelo was sent to a Beaverton imaging clinic for a free chest X-ray (it was negative). Then, she was provided a free appointment with a gastroenterologist at The Oregon Clinic who had her medical records when she arrived and who performed an endoscopy that determined she had acid reflux that could be held in check with prescription medication.

Linda Nilsen-Solares, executive director of Project Access NOW, headed a Hillsboro safety-net clinic so she saw firsthand the frustration among physicians who volunteered to occasionally care for the uninsured. Patients were often unreliable, and administrators had to abandon established routines to deal with them.

'When you ask people to make exceptions in very systemized settings, you're asking for trouble,' she says.

Which means Project Access has to do more than sign up doctors and send them patients. Now, most specialists don't even know if the patient they are treating carries insurance or has been sent by Project Access. That's possible because Project Access makes sure their patients arrive with the necessary medical records, and with an interpreter, if needed.

And they do arrive. Physicians abhor scheduling time for a patient who doesn't show up. Linda Sullivan, director of patient accounts for The Oregon Clinic, the largest private physician practice in the state, says that during the past three months clinic physicians have seen more than 100 Project Access patients, and every patient has made it on time. That is a marked contrast to Oregon Health Plan patients, who have a significant no-show rate, according to Sullivan and others.

'They somehow get it that they are lucky to get their appointment,' Sullivan says.

The same challenges

Every one of The Oregon Clinic's 140 providers is committed to taking Project Access patients. The clinic's 18 Northeast Portland gastroenterologists see eight free patients a month. Five urologists treat two patients a month.

It all adds up. Last year, about 2,800 uninsured Project Access patients were seen at 7,000 appointments.

Dr. Lou Libby, a pulmonary specialist at The Oregon Clinic, says the ability of Project Access to coordinate care makes physicians more willing to participate.

'I hate to sit with a patient and suggest all sorts of things their insurance isn't going to cover,' Libby says.

Libby especially likes Project Access' willingness to tell him if other heart doctors in the area are providing as much charity care as he.

'There's still this feeling that everyone's shunting their low-pay, no-pay patients to someone else,' Libby says. 'Project Access has gotten around that very nicely.'

Which isn't to say Project Access provides all the health care uninsured Portlanders need. Ironically, Melissa Appelo was told by pharmacists that her Project Access card wouldn't cover the medicine that had been prescribed. She couldn't afford the cost - $175 a month - so, as of two weeks ago, she had been going without, yet still thankful.

'At least I found out I didn't have cancer,' she says.

Nilsen-Solares says that Project Access does have coverage for a version of the medicine prescribed for Appelo, but that the physicians she had been seeing weren't aware of the coverage. Which, Nilsen-Solares says, only means that Appelo was being treated no better or worse than most people with health insurance.

'We're not able to fix the system as much as say we want uninsured people to have only the same challenges as insured people,' she says.


• Hospital cooperation offers a glimpse of health care's future

Having signed up about 3,000 Portland-area physicians, nurse practitioners and physicians assistants willing to provide free care, Project Access NOW is bucking a national trend.

It also may provide a peek into the future of the state's plan to provide health care for the uninsured.

In most U.S. cities, fewer physicians are willing to provide charity care than a decade ago. A 2005 survey of physicians from the Washington, D.C., Center for Studying Healthy System Change revealed that 68 percent were providing charity care, a drop from 76 percent in 1997. Peter Cunningham, author of the center's reports, says he has continued studying the subject and is certain the trend has continued.

'If anything, charity care nationally has decreased, primarily because physicians are feeling a lot of financial pressure,' Cunningham says. 'Their incomes haven't been going up.'

And yet, during the past five years, the number of Portland-area physicians willing to take on free patients through Project Access has exploded from about 40.

Under Project Access, chief financial officers of all the region's hospital systems meet four times a year to review how many free patients they've seen and how much free care they've provided. To do that, they had to agree on an equation so each hospital could donate its fair share.

Reporting a dollar amount of provided free care was a stumbling block, because hospitals each bill services differently. They had to agree on a Project Access formula so all their services were valued similarly.

'Nobody thought it could be done,' says Priscilla Lewis, executive director for community services and development at Providence Health and Services. Lewis and Andy Davidson, executive director of the Oregon Association of Hospitals and Health Systems, are credited with brokering the deal.

All this matters, because much of the health care reform about to hit Oregon is based on the idea of new coordinated care organizations for Medicare patients. The organizations are supposed to bring down health care costs by getting all the area's hospitals and physician groups to work together on individual patients who may need care from a number of different providers.

Coordinated care organizations will succeed if all the local hospitals trust each other. That's why the deal brokered by Project Access is seen by many as a breakthrough.

More cooperation

Davidson sees the Project Access agreement as part of a recent trend of hospitals cooperating with each other after having addressed a critical question: 'What is the trigger point for folks today to lay down their arms and come into the room together?'

Part of the answer has been the growing cost of providing health care, much of it free health care provided by hospitals when uninsured patients show up in their emergency departments. Hospitals' nonprofit status is predicated on the fact that they provide charity care and treat those patients. In theory, a small donation to Project Access which helps the uninsured get treatment on the front end, keeps those patients from showing up at the emergency department sicker and needing more expensive care later.

'It's been a really great experiment,' Davidson says.

James Hicks, an Oregon Health and Science University anesthesiologist who started recruiting local physicians in the lead up to Project Access, says that without across-the-board coordination provided by Project Access, Portland doctors probably would behave much like their counterparts around the country.

Federal rules discourage doctors who bill for Medicare patients from treating patients for free, Hicks says. And more physicians work for hospitals or in large practice groups, with rules that keep them from making their own choices on charity care.

'Most physicians want to do the right thing and the modern system doesn't let us do that,' Hicks says. 'It's hard to give away care.'

- Peter Korn