The Problem of Limited Access for the Uninsured and Underinsured May Not Be So Bleak
In many communities it is challenging to provide care for patients without insurance or with Medicaid, especially if they have complex or urgent health care needs. Getting approval for a diagnostic test or a timely appointment with a specialist - if it’s to happen at all - often requires several phone calls to empathic colleagues, cashing in on favors, and extensive coordination to make it all happen.
With a small pool of specialty physicians providing care for uninsured and underinsured adults, there is a limited capacity to provide timely care. Wait-times for appointments are long, and this often results in fragmented care plans, disease advancement and overuse of emergency departments and hospitals.
The supply-demand mismatch may get worse as strapped states cut Medicaid reimbursement levels to physicians and as the Patient Protection and Affordable Care Act takes effect, expanding Medicaid eligibility to an additional 15 million adults. In a recent New York Times guest editorial, Killing Medicaid the California Way, Bruce C. Vladeck, PhD, former assistant vice president of the Robert Wood Johnson Foundation (RWJF) and administrator of Medicare and Medicaid from 1993 to 1997, and Stephen I. Vladeck, JD, a professor of law at American University, give a grim account of the legal and political forces that may perpetuate provider shortages and ultimately threaten the equal access mandate.
But the problem of limited access for the uninsured and underinsured may not be so bleak. In 2008, six RWJF Scholars from Yale University (Erica S. Spatz, MD, MHS; Michael S. Phipps, MD, MHS; Katherine Goodrich, MD, MHS; Danil V. Makarov, MD, MHS; Kate V. Viola, MD, MHS; and Oliver J. Wang, MD, MBA, MHS) joined a local effort to bring a program called Project Access to New Haven, CT. Project Access expands the pool of providers for the uninsured by encouraging local specialty physicians and area hospitals to donate care; Project Access employs patients navigators to coordinate care and to address patient-level barriers to care delivery.
The six Scholars, under the mentorship of Marjorie S. Rosenthal, MD, MPH (RWJF Clinical Scholar Program ’05, assistant director of the program) and Georgina I. Lucas, MSW (deputy director of the program) adapted principles from Community Based Participatory Research (CBPR) to implement Project Access and to study its impact.
Project Access was successfully launched in August, 2010. During this two-year development and implementation phase, it was met with skepticism that charity care is not sustainable, reluctance from specialty providers who felt that they already provided a disproportionate amount of care to these patients, and passive support from stakeholders who believed in the project but were sobered by previous efforts that had failed. These challenges were stimuli for the application and reapplication of tenets from CBPR to engender support, participation and commitment from a diverse group of stakeholders.
We employed a case report approach to analyze the process by which CBPR was applied to the implementation of Project Access. This was important for two reasons: one was the realization that, as with all program interventions, the impact of this navigated care model on outcomes such as ‘quality of care delivery’ and ‘utilization of health care resources’ would, in part, be influenced by the quality of its implementation; second, lessons learned in implementing Project Access for the uninsured in New Haven may be relevant for expanding the program to Medicaid beneficiaries locally, and for communities nationwide.
We look forward to hearing your experiences in applying CBPR to health system changes, and specifically in addressing the shortage of care providers for the uninsured and underinsured.
Read more about the work of Project Access.