Physicians' Initiative to Expand Care to Underserved Americans

Physicians' Initiative to Expand Care to Underserved Americans
By Irene M. Wielawsk

Reach Out encourages locally based groups of physicians to design innovative approaches that expand primary care services for people who lack health insurance and the ability to pay for medical care. This chapter explains how the program works, describes some of the innovations that have been implemented, and outlines the complexity of doing volunteer work in the emerging world of market-driven health care.

Irene M. Wielawski was charged with doing an evaluation of the project, but she is far from the standard evaluator. Before accepting the Reach Out assignment, she was an investigative reporter for the Los Angeles Times. Rather than using traditional social science evaluation methods for this project, the Foundation decided that an investigative reporter was best equipped to sort through the experiences and draw lessons that might emerge from them. Narrowly defined access outcomes are of less interest in this evaluation than are the defining qualitative stories and lessons about how to encourage volunteerism. Physicians historically have provided large amounts of charity care to needy patients; the challenge considered herein is how this commitment can be translated to the 1990s medical care environment.

In the autumn of 1993, the nation's 550,000 private practicing physicians were challenged to take up the cause of people who had poor access to medical care. Behind the idea was the recognition that a large gap existed between the health care capacity those physicians represented and the actual number of people benefiting from their skills. A lack of insurance, the wrong kind of insurance, geography, location, economics, prejudice, language--all were factors separating the doctors from the needy patients. If a significant number of doctors in private practice could be mobilized to use their knowledge of the health care system on behalf of excluded patients, real progress might be made in improving access. At the same time, a badly demoralized profession might find its way back to the basic principles of altruism and social responsibility--the underpinnings of the medical profession.

It was an interesting idea for interesting times. President Bill Clinton, elected the previous November partly on a promise of overhauling the nation's patchwork system of health care, was putting the finishing touches on his comprehensive reform plan. Congress was studying other proposals. All of the proposals emphasized finding a means of payment as the way to accomplish universal access to health care. Some featured a Canadian-style government-run system, others focused on correcting inequities in the insurance market. Health reform was front-page news, and polls showed overwhelming popular support for it.

Of course, many insurance-related issues were still unsettled. Was a single payer system preferable? Should the government run it? What was the role of employers? Did anyone have a reliable cost estimate? Nevertheless, it seemed certain that government would do something for Americans without health insurance, whose numbers at that time were estimated at thirty-seven million.

Into this maelstrom sailed The Robert Wood Johnson Foundation with a $12 million, five-year program called Reach Out: Physicians' Initiative to Expand Care to Underserved Americans. Launched in September 1993, the program has encountered rough water ever since, tossed like every other player in health care by the political and economic turbulence of the 1990s: the failure of national reform, the bruising marketplace free-for-all that followed, the rise of managed care, and, more recently, uncertain signals from Washington about the future of Medicaid and Medicare. Despite the odds, thirty-nine out of forty Reach Out projects have survived, and some have proved remarkably nimble at using their small size and relatively loose structures to take advantage of opportunities presented by change.

The projects have also illustrated the portability of late House Speaker Thomas P. "Tip" O'Neill's oft-quoted wisdom that "all politics is local." Poor health and expensive crisis care may be the result of inadequate access to medical services, whether one is a non-English-speaking immigrant in East Los Angeles or a ranch hand in rural Montana. But the barriers to access are often uniquely local and not entirely defined by a lack of insurance--the issue that garnered most of the attention during the two-year debate on health reform. Indeed, the giant-sized mock-up of a Health Security Card, unveiled by President Clinton at a press conference in 1993 and reproduced in newspapers and magazines around the country, was a clever bit of marketing that came to symbolize the solution for millions of working, uninsured Americans who could not pay their medical bills. Yet many worse-off citizens who were already enrolled in the government's Medicaid program could testify to the empty promise of an insurance card in places where doctors, hospitals, testing labs, and pharmacies rejected it, or where other circumstances of poverty--lack of a car, for instance--made it impossible to obtain medical care.

The Reach Out site in Dillon, Montana, is wrestling with some of these local factors. The community's twenty-two-bed hospital and handful of physicians serve sparsely populated Beaverhead County. The county covers rugged terrain along the Continental Divide in the southwestern corner of Montana, an area roughly equivalent in size to Connecticut and Rhode Island but with fewer than ten thousand residents. A central question for the project is how to get people to come in for early, cost-effective treatment. The seasonal demands of ranching and the absence of public transportation make routine trips to the doctor inconvenient, at best. Also, ranchers are far more likely to provide bunks and meals than health insurance for their workers.

Contrast the challenges in Montana with those faced by two projects in Los Angeles trying to augment the capacity of overwhelmed public agencies through partnerships with the city's abundant supply of private physicians and hospitals. On paper, it looks simple, a win-win situation for everyone--most of all needy patients. But the key partner here, the Los Angeles County Department of Health Services, is in turmoil, a victim of California's deep recession, antiquated facilities, and shortsighted management. The headlines in the last few years have focused not on patients but on the latest budget crisis or administrative overhaul. Besides the instability of their major partner, the projects must contend with the sheer volume of need in Los Angeles County, where by some estimates 2.7 million people lack health insurance. One project, headed by a pediatrician, Neal D. Kaufman, is trying to recruit physicians in private practice to help care for children in Los Angeles County's vast foster care system. Kaufman's goal is to assign each child to a network of trained pediatricians, so that even if the foster home changes, as it frequently does, the medical care remains consistently in the hands of physicians familiar with the special needs of foster children, and each child's medical history. But the project is contending with a county caseload that averages seventy-three thousand children at any one time and shifts by about fifteen thousand each month as children are reunited with families, are adopted, or otherwise leave the system, according to Elena Halpert-Schilts, the project manager. "We are trying to put together a small pilot effort and hope that it works well enough to become a model for the larger system," she said.

It is too soon to measure Reach Out's collective impact on health care access, and impossible to predict whether these community-based experiments will carry sufficient momentum nationally to significantly lessen hardships faced by underserved Americans. Indeed, estimates of the uninsured are creeping ever upward, totaling some forty-one million in 1996--four million more than when Reach Out began. Some projects, though, are clearly succeeding in keeping the needs of the underserved on the radar screen, no small accomplishment in these profit-driven times when mergers, acquisitions, and price-earnings ratios dominate the conversation in health care circles.

Reach Out has thirty-nine sites in twenty-four states and the District of Columbia. They are provided with direction and technical support by a national program office based at the Brown University Center for Primary Care and Prevention in Pawtucket, Rhode Island. The office is headed by H. Denman Scott, an internist who is associate dean at Brown University School of Medicine. Its deputy director is Melinda L. Thomas, who comes from a health policy and planning background. Chaired by James G. Nuckolls, a rural physician from Galax, Virginia, a fourteen-member national advisory committee assisted in choosing the grantees from two separate applicant pools and continues to advise the project. In the first application round, 244 proposals were received and 22 were selected for funding in August 1994. A second call for proposals yielded 194 more applicants; of these, 18 were chosen in August 1995. Each successful applicant received a one-year planning grant of up to $100,000, and each was eligible for three-year implementation grants of up to $200,000, with eligibility based on a readiness to carry out goals formulated in the planning year. None of the money can be used to pay for the treatment of underserved patients. This restriction encourages grantees to reorganize their communities' existing resources into a system from which greater numbers can benefit. Grantees are expected to find permanent, local funding after four years of Robert Wood Johnson Foundation support.

What is a typical Reach Out project? There isn't one, largely because of the variability in local conditions illustrated by the Montana and Los Angeles examples. The design of each project was also left to the physician leaders and their local partners, in the belief that they best knew their community's needs and how physicians might be used to alleviate those needs. The result is a smorgasbord of approaches, with certain conceptual similarities.

The majority of the Reach Out projects rely on a cadre of volunteer physicians, but some projects use a free-clinic approach while others strive to integrate underserved patients directly into the practices of participating physicians. Not all projects define the underserved as uninsured. In Montgomery, Alabama, for example, the Child Health Access Project is trying to increase the number of private pediatricians willing to see children insured by Medicaid. The project, headed by Robert Beshear and A. Z. Holloway, Jr., both pediatricians, is building on a successful obstetrical access project and seeks to remedy a situation in which more than half of the low-income and Medicaid-insured babies born in a four-county area do not receive recommended pediatric screenings and timely immunizations. The majority of these children have no access to regular pediatric care and must rely instead on bare-bones public clinics and hospital emergency rooms for crisis care.

The Montgomery project so far has succeeded in doubling the number of private pediatricians who accept Medicaid-insured children into their practices. But its greater accomplishment over time may be in breaking down long-standing attitudinal barriers to serving these children. Because of a shortage of pediatricians in greater Montgomery, those in private practice have found it relatively easy to claim high caseload as an excuse for excluding poor children. The underlying reasons, however, are more insidious: deep-seated mistrust and confusion about the state's Medicaid program, and a private-practice medical culture that has seen poor children as primarily the responsibility of public agencies. This scenario is more typical than not in Reach Out projects. The hope is that these negative attitudes, like other forms of prejudice, will moderate, in this case through new exposure to Medicaid-insured youngsters and their parents, better education about the state's Medicaid program, and case management provided by the Reach Out staff.

Case management is seen by Beshear and Holloway as critical to the project's success, so that low-income patients with problems that exceed the resources of a pediatrician's office--transportation, child care, social service needs, for example--are linked up with appropriate community services.

Some Reach Out projects are statewide efforts. In South Carolina, a project led by Charleston neurosurgeon Bartolo M. Barone has greatly simplified the bureaucratic process of obtaining drugs from the charity programs of pharmaceutical manufacturers, making it possible for needy patients to get prescriptions filled free at their local pharmacies.

Other Reach Out projects are much more local, targeting a special population in a single municipality. In Louisville, Kentucky, for example, the Reach Out effort, headed by two internists, Mary A. Henry and Will W. Ward, Jr., has helped bring volunteer medical services to shelters for the homeless, recovering drug addicts, and alcoholics. Some urban Reach Out projects are working with new immigrants and others for whom language and culture form significant barriers to care. Other projects are in rural areas, where distance, geography, and a dearth of physicians limit access. Some projects, notably the seven in California, are operating in markets saturated by managed care. Others are in areas where the majority of physicians are still practicing fee-for-service medicine.

Finally, not all Reach Out projects are primary-care models. In San Francisco--a city with an enviable network of volunteer and county-run clinics and a large, full-service public hospital--surgeon William P. Schecter's Reach Out project runs a free Saturday-morning surgery program for uninsured people with hernias or other minor problems that can be treated on an outpatient basis. Because their conditions are not life threatening, these patients fall through the cracks even in a comprehensive public health care system like San Francisco's.

Another project, in Tallahassee, Florida, discovered that primary care was available to poor and uninsured residents from a network of county and federally funded health centers in the city and surrounding rural counties of Florida's Panhandle. But health center patients with complicated or chronic problems had almost no access to specialists or hospital-based treatment. The Reach Out effort, led by James W. Stockwell, a gastroenterologist, bridges that local gap with an extensive network of private specialist physicians willing to donate their services. Through contacts it has cultivated at each referral site, and through computerized case management, the Reach Out project is emerging as an important link between uninsured patients and the resources of the larger medical community.

The project made it possible for Fanny Strickland, a fifty-three-year-old grandmother living alone in a trailer near the Ochlocknee River, to regain the use of her arm and live pain-free for the first time in three years. A benign fatty tumor on her right shoulder had grown to grapefruit size, putting pressure on a joint already damaged by a rotator cuff injury. But Strickland lacked insurance to cover the cost of corrective surgery. By the time the Reach Out project found her, through contacts at public clinics, she had been sleeping upright in a living-room chair for two months, unable to lie down because of the pain. A volunteer orthopedic surgeon with the Reach Out project, Mark E. Fahey, removed the tumor and repaired the torn rotator cuff without pay, and Tallahassee Community Hospital, another Reach Out partner, wrote off the charges.

Stockwell has not found the Reach Out mission to be a hard sell in the Tallahassee area. The project is sponsored by the influential Capital Medical Society, which counts 80 percent of the practicing physicians in greater Tallahassee as members. As for the hospitals, Tallahassee's emergency rooms inevitably wind up with the expensive consequences of medical neglect in the Panhandle--catastrophic strokes that could have been prevented with blood-pressure screening and medication, for example, or similarly preventable diabetic crises. So it has been relatively easy to persuade them of the cost-effectiveness of donating services to patients referred by the Reach Out project. The key, according to Stockwell, is managing the distribution of the uninsured caseload equitably and making assignments on the basis of what each volunteer physician, laboratory, or hospital can reasonably handle. He thinks of the Reach Out project as a neutral organizing mechanism for voluntarism.

As in Tallahassee, most Reach Out grantees have discovered the importance of community partners--hospitals, health departments, civic organizations, social service agencies, and elected and business leaders--in doing the job effectively. Physicians are essential, no question, and not solely for the medical care they provide. They are proving to be a significant asset to the projects politically as well, because of the entrée--and clout--they have with decision makers in their communities. Still, those projects which started out believing that they could solve the problem of health care access simply by harnessing the skills and the good will of doctors quickly revised their thinking.

"Medicine today is a team sport," said B. Dale Magee, an obstetrician, who is the president of the Worcester, Massachusetts, District Medical Society, one of the sponsors of a Reach Out project in that industrial city. "A doctor can do only so much if the patient can't afford to fill the prescription or pay for diagnostic tests or follow through on anything else."

So in both the planning and implementation phases, Reach Out grantees have spent more time than anticipated cataloguing local health resources and potentially relevant community services such as transportation and housing, and even literacy and translation services. In effect, the Reach Out project endeavors to become the thread that binds up holes in the local health care safety net.

Of course, that is what President Clinton hoped to do nationally with the Health Security Act. But if anything certain can be said about American health care in the 1990s, it is that times change. The optimistic environment in which Reach Out was launched in 1993 was history by the time the first twenty-two grantees got their money. Having proposed models that they saw as temporary bridges for the uninsured until some universal payment system was in place, the project leaders suddenly found themselves to be virtually the only ones in their communities still talking about the needs of the underserved. Only two months after the first grants were awarded, in August 1994, Congress threw in the towel on health reform. Bitterly divided party leaders called press conferences to proclaim the death of the entire health reform movement and confer partisan blame for its demise.

Those in the second round of grantees were only slightly better off. They had the benefit of knowing that there would be no quick solution to the problems of underserved patients, but they had no way of anticipating the rapidity with which managed care, mergers, and other market forces would upend the traditional structure and relationships in their health care communities. One Reach Out physician, busy signing up volunteers among her largely fee-for-service colleagues, was stunned by the reaction of these colleagues and, in some cases, personal friends, when her physician group became one of the first in the area to sign a managed care contract. The next time she was doing rounds at the local hospital, she found her name posted on the door of the doctors' lounge under the heading "Wall of Shame." Needless to say, that incident set recruiting back a bit, until the project was able to persuade physicians of the neutrality of its goals.

Perhaps the best way to understand the ups and downs of Reach Out is by looking at a few projects closely to see how the world has treated them. Asheville, North Carolina; Lincoln, Nebraska; and Sacramento, California, all have Reach Out projects, in distinctly different health care environments. How they've ridden out the storm of the last two years offers lessons in flexibility, shrewd management, and sheer stubbornness of purpose--qualities that in Reach Out are proving to be at least equal in importance to the health reform model being tested.

On the surface, Asheville does not seem to lack for anything. A picturesque city tucked into a hollow of the Blue Ridge Mountains, it has been a tourist mecca since the turn of the century. Today, the Blue Ridge Parkway brings thousands of visitors, some to stay in Asheville's Victorian bed-and-breakfasts and poke through its craft shops, others bent on hiking in nearby Great Smoky Mountain National Park.

The city's medical resources are as abundant as the local scenery. Asheville's hospitals are referral centers for much of western North Carolina. Some 460 physicians practice in the city and surrounding Buncombe County. If they were to focus solely on serving their own community, that would be a ratio of one physician for every 413 residents.

Not everyone in Buncombe County benefits from this medical abundance, however. Nine percent of the adults lack health insurance, as do 13 percent of the households with children. Cost and lack of public transportation in the county are the major barriers to timely medical care. Yet uninsured patients are more than twice as likely as those with private health insurance to use hospital emergency rooms, the most costly setting for treatment. Out of a hundred thousand annual emergency room visits, one third were made by uninsured patients, representing a significant loss to the city's hospitals. The hospitals estimated that 25-40 percent of these visits could have been handled more appropriately in a physician's office.

These were among the findings of extensive community surveys conducted by the leaders of Asheville's Reach Out project: Suzanne E. Landis, an internist; Philip C. Davis, an obstetrician-gynecologist; and their sponsor, the Buncombe County Medical Society. They also documented subtler access barriers. Although Asheville has what many would consider a doctor surplus, the vast majority are specialists. Fewer than a hundred are in primary care fields. Their caseload is heavy. Even insured patients report waits of two months or more for appointments. The market in Asheville is still overwhelmingly fee-for-service; managed care accounts for only about 8 percent of insured patients.

So the Reach Out project, called Project Access, had some immediate obstacles to achieving its stated goal of improving medical care for uninsured patients who are below 200 percent of the federal poverty level: a lopsided four-to-one ratio of specialists to primary care physicians, a fairly isolated rural population, and no obvious source of money to cover the ancillary costs of the project. Physician volunteers were the conceptual mainstay of Project Access, but how could it meet needs for medicine, diagnostic tests, and even hospitalization? Community sources of health-related financial support were limited, and what there was had been claimed for years by the major health care institutions in Asheville: the hospitals and the local health department.

But Project Access also had some things going for it. Members of the Buncombe County Medical Society were concerned about access to health care even before President Clinton made it a national issue. Since 1991, about a hundred of them had volunteered regularly at a free three-night-a-week clinic cosponsored by the Asheville Buncombe Community Christian Ministry. And the city's two private hospitals, though competitors, both supported the clinic with some funding as well as free laboratory and x-ray services. Finally, Buncombe County's governing commissioners had long recognized that indigent health care was a community responsibility. Their traditional means of providing such care, however, was to allocate about $600,000 a year to the hospitals to offset losses from charity care and to augment the budget of the Buncombe County Health Department.

One of the first things Project Access helped to change was those funding priorities. Presented with the project's survey results, the county commissioners decided in fiscal 1996 to shift their subsidy from hospital bad debt to programs aimed at preventing serious illness and improving community health. "Six hundred thousand looks like a lot of money, but it doesn't go very far when you give it to hospitals," said Tom Sobol, a county commissioner for twelve years.

The commissioners earmarked $75,000 for prescription drugs for patients certified by Project Access, a sum that will increase to $250,000 by 1998. They also allocated $20,000 to the free clinic. Project Access, meanwhile, recruited more physician volunteers so that hours at the clinic could be expanded. The project also significantly increased the number of doctors willing to see Project Access patients at no cost in their offices. By doubling the number of physicians participating in indigent care--a goal it expects to achieve by 1998--Project Access estimates that seventy-three hundred of the roughly nine thousand uninsured Buncombe County residents with incomes below twice the federal poverty line will have access to regular medical care.

Project Access began its work with a community advisory board of more than one hundred Buncombe County health care and business leaders, as well as consumers. The size of the group was unwieldy, to say the least. At an early planning meeting, in the largest conference room available, it still wasn't possible to get everyone a place at the table, and some had to sit in folding chairs with papers balanced in their laps, or stand along the wall. Predictably, in those first meetings participants clung to the narrow interests of their constituency, the business community desiring to reduce the cost of health benefits, the health department determined to preserve programs. Yet the arduous effort required to achieve consensus paid off. The dimensions of the access problems in Buncombe County and their possible solutions became well understood by community leaders outside the health care establishment. Improving access to health care was thus transformed from the pet project of philanthropically minded doctors to a broad-based community undertaking.

This inclusionary process has also positioned the project to benefit from the latest market convulsion in Asheville. Out of the blue, the city's two private hospitals--Memorial Mission Hospital (418 beds) and St. Joseph's Hospital (292 beds)--announced in late 1995 that they were, in effect, merging. To win an antitrust exemption under North Carolina law, the hospitals had to promise that $74.2 million in projected operational savings over five years would be passed on to needy patients in low-cost or no-cost health services. The hospitals, now known as the Mission + St. Joseph's Health System, can count free care in their emergency rooms as part of that public benefit. But if institutional charity falls short of $74.2 million, the hospitals must contribute the balance to community-based health programs, according to the Certificate of Public Advantage (COPA) issued by the North Carolina attorney general's office.

Landis believes that Project Access presents an ideal vehicle for the hospitals to document compliance. They have already assumed a "much more proactive role" toward the project, she noted, prodded not only by requirements of the COPA but also by the commissioners' surprise reallocation of indigent care dollars. The hospitals have also dropped their case-by-case posture on charity and are now committed to waiving hospital inpatient and outpatient charges for all Project Access patients.

"Many of us are cautiously optimistic, especially with the COPA," Landis said of Project Access. "Anything the hospitals donate--staff, time, services, money--helps them satisfy their COPA requirements. So we become useful to each other." Ultimately, the biggest beneficiaries may be the medically needy residents of Buncombe County.

Like most good ideas, the Reach Out proposal of the Lancaster County Medical Society was a simple one. Even better, it had been field tested. The model was a successful Medicaid access project under way since 1991 in Lincoln, the county seat. Referral systems, record keeping, patient follow-up--all had been designed and refined. Over three years, nearly nine thousand Medicaid patients had been matched with private physicians, 84 percent of whom signed up with the program. Before that, physician participation in Medicaid had been so low that new Medicaid patients couldn't get an appointment. In effect, their insurance cards were useless outside hospital emergency rooms and a few public clinics.

The Lancaster County effort was a partnership between the medical society, the county health department, and the state social services agency. The core of the program was a telephone hotline, staffed by public health nurses who assessed the immediacy of callers' medical needs and matched patients with doctors. People with transportation problems were given cab vouchers. Paperwork burdens on physicians were minimized, and there were few reimbursement snafus--a chronic complaint about the state's Medicaid program. Doctors also were happy that the load of these relatively low-paying patients was being equitably shared by most of their colleagues.

Buoyed by success, the Lancaster County Medical Society and the county health department decided to expand the program to include physicians, Medicaid patients, and low-income uninsured residents of fifteen rural counties surrounding Lincoln. Their winning application for a Reach Out grant in 1994 described how access problems in those counties were worse than what Lincoln's Medicaid patients ever experienced. Doctors were few and widely scattered, poverty was widespread, and the public health infrastructure was almost nonexistent. At the time, Nebraska ranked dead last among the states in per capita spending for public health. Twelve of the sixteen target counties were either wholly or partly classified as medically underserved areas, and four counties were areas that had a health professional shortage, federally defined by a ratio of more than thirty-five hundred people for every doctor.

The Reach Out project, called Community Access to Coordinated Healthcare, or CATCH, and led by a rural physician, Darroll J. Loschen, planned to tie these counties into the referral service already established in Lancaster County. It would offer overburdened rural practitioners the resources of specialists in Lincoln as well as support from nurses and social workers in the five counties with public health and social service offices. In effect, the project would pull together a regional network of public and private health care providers in order to make medical services more accessible, regardless of where needy patients lived.

The planners overlooked one small but critical detail: the determination of Nebraska's political leaders to be part of the managed care revolution sweeping the country. The state legislature laid the groundwork in 1993, mandating managed care for Medicaid recipients. But it delayed the implementation of this plan for two years, pending the report of a study commission on the best models for Nebraska's diverse regions. The proud architects of Lincoln's Medicaid access project, now Reach Out leaders, were confident that their low-cost, public/private model would win state approval, and they built that assumption into the design of the rural expansion.

In awarding contracts, however, state officials were influenced less by track records than by their own insecurities about whether they knew enough to manage managed care in-house, according to Sen. Don Wesley, chairman of the Nebraska legislature's Health and Human Services Committee. The state social services agency, which had authority over the Medicaid contracts, opted in late 1994 to invite bids from national managed care companies, citing their expertise in other states. One of these commercial bidders won the Medicaid contract in Lincoln, effectively shutting down the medical society/health department referral system.

"As a state, we were really dazzled by the big corporate managed care companies," says Wesley, whose committee created Nebraska's managed care mandate but lost control over its implementation. "We didn't have enough confidence to build upon what we already had."

The decision was a severe blow to the Reach Out project, which, having lost its base in Lincoln, now had to figure out how to improve access with only the meager resources of the rural counties.

"We began talking to the doctors, to county commissioners, the nurses in the health department offices, and anybody else we could get to sit down with us to figure out what could be done," said Natalie Clark, the executive director of the Lancaster County Medical Society and comanager of the Reach Out project. "We were very cognizant that we could not be the people from Lincoln marching in and telling people what to do."

Project leaders discovered that Nebraska's rural physicians, unlike their urban counterparts, were quite isolated from one another, many of them working long hours in solo practices. The doctors also knew very little about managed care. One of the first things the project did was to invite all the rural doctors to an informational meeting on managed care. There, project leaders explained how better coordination with community-based public health and social services could expand their capacity for taking care of Medicaid patients. Uninsured patients--and there were significant numbers among the farm and processing-plant workers in these small towns--could also benefit from these services. The Reach Out project offered to play the coordinating and referral role pioneered in Lincoln, while simultaneously acquainting needy patients with other health services in their communities, such as free immunization clinics and lead screenings. A toll-free phone line, answered by local public health nurses, was established. Meanwhile, the physicians organized the South East Rural Physicians Alliance, to work collectively with the Reach Out project.

An additional purpose was to educate themselves about managed care and political developments in health care at the state and national levels. Having been burned once, the Reach Out participants did not want to lose what they built in rural Nebraska because of a disconnect with decision makers in the capital. Medicaid managed care was implemented in urban areas only in 1995, and the deadline for the rest of the state was set for 1997.

The Nebraska project's Phoenix-like tenacity is being rewarded these days with political leaders' new interest in public-private partnerships. The managed care companies that won Medicaid contracts in 1995 have not had an easy time of it. Patient enrollment was slower than promised, and the companies have been publicly criticized for failing to contract with enough physicians to manage the caseload. Commercial managed care companies also have shown little interest in Nebraska's rural areas, where people working without health insurance on ranches and farms far outnumber those eligible for Medicaid.

"The upshot of all that we have experienced is a realization that the delivery systems of these services have to be community-based--exactly as the original Lincoln project developed," Senator Wesley says. "The big national experts can bring good ideas; I don't want to blame them for our mistakes. But I think we're beginning to realize that we may be smarter about how to implement these ideas in Nebraska."

Two historic events have given Sacramento a claim to fame beyond the boundaries of California. One was the Gold Rush of 1849, which made the city a destination point for adventurers, cardsharps, dreamers, and scalawags from around the globe. The other was the managed care revolution of the 1990s, which by mid-decade had bestowed on Sacramento the distinction of being the nation's most highly managed health care market. Some 90 percent of the insured population are enrolled in health maintenance organizations. No other urban area comes close.

The reasons for the popularity of managed care with residents of Sacramento are various, and not entirely a matter of personal choice. Kaiser Permanente established itself in the city in the 1960s and became a major provider of care to state employees, who are numerous in the California capital. Three nearby military bases with thousands of civilian employees also contracted with HMOs, making these enterprises the largest players in the private health care market. Finally, in 1992 the state legislature authorized the gradual movement of 5,750,000 Medicaid beneficiaries (the $17 billion California program is called Medi-Cal) into managed care. Four experimental implementation models were designed, and Sacramento County was chosen as one of the first test sites in 1994. The Medi-Cal contracts, covering 160,000 beneficiaries, wiped out the last major pocket of fee-for-service medicine in Sacramento. It also intensified competition in a market now dominated by five major physician organizations and their affiliated hospital systems.

The result is that individual doctors have very little say in how business is done or in how they spend their time. As employees or partners in medical groups of thirty or more physicians, many of them are not at liberty, say, to take an afternoon off to volunteer at a free clinic, or accept an uninsured patient into their office practice for free treatment. And with so many physicians locked into closed systems of care for members only, the uninsured have few options outside the nine public clinics run by the county health agency.

The staff of those nine clinics, however, was severely reduced by budget cuts in 1992. Hours and days of operation were curtailed. Growing numbers of the sick poor were turned away because there weren't enough physicians to see them. One clinic slated for closure was the Capitol Health Center, the only health care provider in Alkali Flats, an impoverished inner city neighborhood of about thirty-three thousand people, many of whom are unemployed, disabled, or homeless.

As medical director of the county clinics, Glennah Trochet was acutely aware of the crisis. A family practitioner, she also was a member of the local Sacramento-El Dorado Medical Society. The dual role led to her 1994 Reach Out proposal to increase the capacity of the public clinics by augmenting the staff with volunteer private physicians. The medical society sponsored the project, called SPIRIT (Sacramento Physicians Initiative to Reach Out, Innovate, and Teach), and the three major hospital systems were recruited as collaborators.

In a fee-for-service market, the support of these key health care institutions would have provided entrée to medical staffs as well as the possibility of funding and donated supplies and services. But in Sacramento, physicians admitting patients to the hospitals owe their first allegiance to their medical group. Even those with control over their schedules may be so pressed by managed care production goals that the choice to volunteer has significant consequences for income. Sacramento also has a surplus of specialists, while its primary care physicians are swamped by the gatekeeper responsibilities that managed care confers on them.

On top of this is the cutthroat nature of the competition in Sacramento. SPIRIT board meetings are one of the few places where representatives of the hospital systems and physician groups sit together in anything that resembles common purpose. The project has the delicate task of trying to create a communitywide network in the name of service to a population that represents no market advantage to any of the competing participants. It was an uneasy alliance at first, and there continues to be tension about whether one group is donating more than the other.

"There is a cost to voluntarism," one high-ranking administrator pointed out. "To the extent that you contribute more than your competitor, you weaken your position." Another said, "Even if we personally believe in this mission, which frankly is the glue that holds SPIRIT together, all of us have to report to bean counters in our own organizations, some of whom aren't even based in Sacramento."

In short, SPIRIT has to sell the message of altruism in an environment where the incomes of prospective physician volunteers are plummeting, and even the institutions cannot anticipate what new belt-tightening will be called for a few months hence. For SPIRIT, the consequences of such market instability are direct and profound. Early in the planning year, the project lost an enthusiastic and highly placed backer in one hospital system when that system eliminated her entire department as part of a cost-cutting reorganization. Two members of SPIRIT's original governing board were gone inside of a year because their jobs were eliminated.

Yet there are traditions of community service in Sacramento's health care establishment that lie beneath the surface of the current market turbulence. Some physicians have found ways within their complex organizations to carve out time for volunteering. The Capitol Health Center in Alkali Flats now has seven volunteers. It also was saved from closing in 1993 by cash contributions from two of the hospital systems.

Trochet says the setbacks of the first year have made SPIRIT leaders more sophisticated about tailoring traditional volunteer recruitment methods to the managed care environment. The project still appeals to individual physicians, but it is also targeting medical group managers, challenging them to come up with structural innovations that encourage voluntarism. Release time without financial penalty is one concept, in organizations where physicians are employees. And the message is conveyed in new language. Thom Atkins, a SPIRIT board member and chief operating officer of a one-hundred-member multispecialty group, bases his pitch to members on the cost/volume idea of managed care. "My approach is not to go to just the good people I know and ask them to do this," he said. "My approach has been to say to the group, 'Hey, if every one of you donated four hours every six months we could staff one of these clinics entirely on our own.'"

Finally, a new development in California's fast-paced health care revolution may add some fiscal glue to the SPIRIT alliance. A state law that took effect in 1995 requires nonprofit health care institutions to quantify community contributions justifying their tax-exempt status. As in Asheville, North Carolina, the Sacramento Reach Out project is positioned to help local hospitals comply with that requirement by documenting the monetary value of whatever the hospitals contribute to SPIRIT to help improve access for medically needy residents.

As The Robert Wood Johnson Foundation prepared to launch Reach Out, a nagging uncertainty dogged the planners. Would anyone apply for a grant?

Private physicians--the group from which Reach Out leaders were expected to emerge--were not a happy bunch in 1993. They had been handled roughly by the polemicists of national health reform, denounced for excessive fees and lavish lifestyles while thirty-seven million uninsured Americans went without care. The rhetorical bashing came as many doctors were beginning to experience a reality that belied their public portrayal: declining incomes and increasing workloads brought on by managed care. There were, of course, doctors who fit the public stereotype. But the greater number--like the ethical, hard-working core of any profession--did not. Many of them had consistently, albeit quietly, upheld medicine's altruistic traditions, volunteering in clinics, writing off bills, and using their influence in hospitals and elsewhere to see that poor patients were cared for.

Still, more than one observer predicted the initiative would be dead on arrival, a nice idea shelved for lack of interest. But the opposite occurred. An unexpectedly large number of applicants responded to the Foundation's published request for proposals. That response, and the more than two thousand colleagues these physician leaders have recruited to the effort, form the primary lesson of Reach Out so far: voluntarism, even in these bottom-line-driven times, is still a powerful force within the health care professions.

The imperatives of the bottom line, however, cannot be ignored if Reach Out projects are to achieve significance beyond their philanthropic origins. This is the harder road ahead for Reach Out. On the most basic level, project leaders have discovered that appeals to busy colleagues, hospitals, and other providers to "do the right thing" don't go very far without an organizational structure to effectively channel contributions. Even the most good-hearted individuals and corporate and government partners are going to do a hard-headed analysis of the risks and benefits of participation. Reach Out leaders must be prepared to make their case in those terms. In Asheville, this has meant poring through complex legal documents of a hospital merger in order to find a sustaining niche for Reach Out. In Sacramento, it has meant analyzing the rapidly changing structure of health care decision making. In Lincoln, it has meant learning how to talk politics with the pros at the State Capitol. Reach Out's physician leaders frequently refer to how much they have had to learn--painfully, sometimes--about the workings of the health care system. Beyond the patients Reach Out projects serve, these lessons hold promise for illuminating the process of reform.