Last year, a construction worker in New Haven, Conn., had a seizure at work. He was laid off, lost his employer-provided health insurance coverage and couldn’t afford the medication he needed to control his seizures.
Because of his medical condition, he couldn’t get a new job or new health insurance. As it is for countless other patients in the nation, health care was a Catch-22 for him.
“He was stuck in a cycle,” said his physician, Michael Phipps, M.D., a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2008-2011) at Yale University. Phipps, a neurologist, decided to step in. He found a way for the patient to pay reduced rates for laboratory analyses, radiological imaging and prescription drugs.
Phipps is now working to help others in his community in similar situations through Project Access-New Haven, a program he helped start in his first year of the RWJF Clinical Scholars program. The project is a coordinated system of physicians, hospitals and community organizations working together to provide donated specialty health care for people who have the most trouble getting it: the poor and uninsured.
The program does that by helping eligible applicants jump the many hurdles to specialty health care.
These barriers include lack of insurance coverage; a shortage of specialists willing to treat uninsured patients; and lack of coordinated care for minority groups—particularly Blacks and Latinos—and others with low health literacy. Low-income uninsured people also often face additional barriers related to finances, transportation, language and cultural differences, and fear and mistrust of the health care system, making access to care next to impossible for many in need of specialized treatment.
Project Access-New Haven aims to help patients in need surmount these hurdles by providing them with a patient navigator who offers everything from transportation assistance to language interpretation to explanations of financial obligations. Sometimes, the navigator merely comes along for the ride to the doctor’s office. “We try to take out the hassle,” Phipps says.
The project’s goals go beyond helping patients get the care they need. Project Access-New Haven organizers also aim to narrow health disparities, collect and report data on care utilization and associated costs, and create a blueprint for other specialty care health systems.
This work satisfies one of the core missions of the RWJF Clinical Scholars program: to work with community members to meet community health needs. “For too long, academic centers have ignored the needs of the populations around them,” said Harlan Krumholz, M.D., S.M., director of the Clinical Scholars program at Yale University. “With the Foundation’s support, we are seeking to train physicians and leave a legacy of contribution to the community through scholarship and service.”
Modeled on similar programs in more than 50 U.S. cities, Project-Access New Haven opened its doors in September with a budget of less than $300,000. It currently employs two patient navigators who have helped 46 patients access care. Organizers have built an information system to monitor the impact of the program on the local health care system and on the patients it serves.
The program got its start in 2008, when Erica Spatz, M.D., a Clinical Scholar (2008-2011) at Yale University, Phipps, and three other scholars sought to improve health care in the New Haven community. They were joined the following year by Oliver Wang, M.D., M.B.A., a cardiologist and a Clinical Scholar in the 2009-2011 cohort.
After discussions with representatives from community health centers, nonprofit agencies and community leaders, they learned that vulnerable community members had relatively easy access to affordable, high quality primary care services, but they lacked access to specialty care.
Physicians Who Treat the Uninsured Struggle with Personal and Corporate ‘Burn-out’
Physicians were also struggling under the system, they found.
The shortage of specialists willing to treat uninsured patients contributes to physician ‘burn out’ and unsustainable business models for those physicians who do provide care for this population. Physicians also struggle with administrative hassles involving uninsured patients, which can compromise the delivery of quality care.
Spatz experienced these difficulties herself while treating an uninsured patient in New York who did not speak English and who suffered from a prominent heart murmur. Spatz managed to obtain a free test for the woman, who was then diagnosed with a severe heart problem that needed urgent attention. Spatz was ultimately able to find a cardiothoracic surgeon who was willing to operate without charge, but it took “a lot of begging and pleading and time on the phone.”
The surgeon couldn’t admit the patient to the hospital on his own, however, so the patient had to go to the emergency room and recite a planned script in order to be admitted to the hospital. “This story illustrates the enormous amount of time on the provider end to arrange for all of this,” Spatz says. “It’s so much easier and cheaper to give our patients care on the outpatient level if it is possible to do so.”
Turning that vision into a reality is what Spatz, Phipps, Wang and their colleagues hope to accomplish through Project Access-New Haven—and they are doing so by working with the New Haven County Medical Association and local health providers.
The scholars have also reached out to community organizations representing Blacks, Latinos and low-income people, inviting representatives to serve on the Project Access-New Haven board. They are collecting data about average wait times, patient needs, and patient and physician satisfaction with the program. The data will provide new knowledge about the needs for specialty care and the costs of emergency room use.
A significant challenge has been fundraising during tough economic times. While other Project Access programs rely on funding from the federal government, Spatz says the recession posed a problem in New Haven, in part based on when the project there launched. Federal money included in stimulus programs was aimed at keeping existing organizations alive but not starting new ones, and private philanthropies had little room in their budgets to expand their giving, she said.
Local foundations and hospitals stepped in with enough funding to hire two patient navigators. And in October, the project received a $150,000 grant that will keep it afloat in the coming years. The scholars plan to expand the program as more funding becomes available and they may broaden their focus to include patients on Medicaid who also have difficulty accessing specialty care.
The longer-term goal is to create a blueprint that other organizations in other cities can use to help vulnerable populations get the specialty care they need. “This isn’t just a one off,” Wang says. “We really can replicate this.”
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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