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Caring for the Uninsured and Underinsured |

Physicians Helping the Underserved:  The Reach Out Program FREE

H. Denman Scott, MD; Johanna Bell, MPH; Stephanie Geller, EdM; Melinda Thomas, MS
[+] Author Affiliations

Author Affiliations: Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket.


Caring for the Uninsured and Underinsured Section Editors: William A. Roper, MD, MPH, University of North Carolina at Chapel Hill; Carin M. Olson, MD, Contributing Editor, JAMA.


JAMA. 2000;283(1):99-104. doi:10.1001/jama.283.1.99.
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Published online

In the current health care environment of competition and market forces, concern has arisen that the classic principle of serving disadvantaged persons may not be fulfilled due to pressures from managed care. Reach Out, a $12 million national program of the Robert Wood Johnson Foundation, was developed to recruit leaders from among practicing physicians to organize projects to care for the uninsured and underserved. Physician volunteerism was a key component of all projects.

Thirty-nine Reach Out projects were implemented and carried out across the United States, with average funding per project of $300,000 distributed over a period of 4 years. Seven model types emerged, the most common of which, the free clinic and the referral network, accounted for two thirds of the total. At the program's conclusion, 199,584 patients were enrolled and 11,252 physicians recruited. Project execution was more complex than initially supposed, and major progress commonly was not evident until the third or fourth year, but at least two thirds of the projects are likely to continue with local support.

With strong physician leadership and a funded administrative core, organized community efforts can develop and sustain an effective program. Programs such as Reach Out cannot solve the national problem of access to health care, but they can make a small but important impact on the number of uninsured and underserved persons without access to health care.

The ethical principle to care for people in need regardless of station or income has informed the medical profession for centuries. In the current environment, in which competitive market forces are looked to as a solution for many problems that beset contemporary American health care, there has been concern that the ethical imperative to serve the disadvantaged might be shoved aside by the pressures of managed care. Cunningham et al1 have shown that physicians involved with managed care plans or working in areas of high managed care penetration tend to provide less charity care than physicians with less managed care involvement.

Studies have demonstrated that the uninsured have difficulty getting needed medical care,2 that when they are hospitalized their illnesses and injuries are more acute and advanced than those of people with insurance,3 and that the mortality rate is higher for uninsured than for insured persons.4,5 In spite of a booming economy and a low unemployment rate, the ranks of the uninsured are growing.6 Despite these trends, we have found that organized efforts to care for the underserved can still evoke substantial physician commitment.

In 1993, the Robert Wood Johnson Foundation initiated a national program to encourage private physicians to expand their role in caring for the underserved. The program was called "Reach Out: Physicians' Initiative to Expand Care to Underserved Americans" and was based on the successful local efforts of a number of practicing physicians.

The purpose of the Reach Out program was to support innovative community models that use physicians in private practice to increase access to health care for the uninsured and underserved. A principal aim was to complement publicly funded safety net providers, such as community health centers, and expand capacity in the private sector to care for the underserved. Voluntary professional commitment to serve was essential. Sponsorship of projects came from medical societies, group practices, and nonprofit or religious organizations. Any model was acceptable, as long as it had a commitment to increasing access to care, appropriate leadership by practicing physicians, evidence of community support, and a realistic set of objectives.

Project directors were physicians who led by virtue of their standing with peers and community leaders, their public commitment to help the underserved, and their ability to motivate their colleagues and others to develop or expand organized programs to care for the uninsured. Practicing physicians, who assumed leadership roles, typically did not have time to undertake the daily duties of administration. Grant funds provided for the extra help required to develop an effective program, eg, to hire staff, purchase computers, and develop or adapt software. The foundation committed $12 million to fund projects for up to 4 years. Projects were funded in 2 stages. The first stage included a 1-year development grant of up to $100,000. At the end of this development period, grantees were eligible for implementation grants of $200,000 over a 3-year period. Competitive proposals were reviewed in 1993 and 1994. From more than 400 submissions, 40 projects were awarded. Locations varied from large metropolitan areas to remote locations in Maine and Montana, and 5 projects were statewide. One project was funded only for the first year; 20 concluded in July 1998 and 19 in July 1999.

The National Program Office (NPO) has provided administrative direction and technical assistance to these projects. In this role, the NPO has accumulated a wealth of information on issues confronting community efforts to increase access to health care. This article describes the models of care that have evolved, illustrates what the projects have accomplished, and summarizes the lessons learned. Access to pharmaceuticals merits comment because obtaining prescription drugs was a challenge for all projects. The Reach Out experience may provide a useful starting point for physicians and other health care leaders who are trying to develop partnerships to expand access to health care in their own communities. (The successor program to Reach Out, Volunteers in Health Care, provides technical assistance on these issues and is available on the Internet at http://www.volunteersinhealthcare.org.)

Individual projects, in collaboration with the NPO, developed a minimum data set to track the number of physicians recruited and patients served. What appeared conceptually straightforward proved difficult to execute. Many hours were devoted to obtaining comparable data across sites, producing a profile of the numerical impact of the program as a whole. Thirty-seven projects reported on patient enrollment and 39 on physician recruitment.

As of July 31, 1999, 199,584 patients were enrolled in 37 projects, with an average of 5394 patients per project. These data do not include patients who left or were lost to follow-up, a number that we were not able to measure. Twelve projects (32%) enrolled fewer than 1000 patients, 15 (41%) enrolled 1000 to 5000, and 10 (27%) enrolled more than 5000. Thirty-nine sites reported a total of 11,252 physicians recruited, an average of 289 per project. Ten (26%) recruited fewer than 50 physicians; 7 (18%) recruited 50 to 100; 18 (46%) recruited 101 to 500; and 4 (10%) recruited more than 500. The number of patients enrolled and physicians recruited is not always indicative of a project's impact. For instance, projects in rural areas commonly dealt with small populations of both patients and physicians.

The Reach Out projects devised their own approaches to increasing access to care. The NPO was able to classify the projects into 7 model categories. The 2 most common models, the free clinic (n = 10) and the referral network (n = 16), accounted for two thirds of the total. Two projects comprised both a clinic and a referral network, 2 were rural primary care networks, 6 were public health private partnerships, 2 were insurance look-alikes, and 1 was organized exclusively to provide elective surgical services. Many projects had elements of 2 or more models. In these cases, the NPO classified the project according to its judgment of best fit. Table 1 lists the model type, location, and project name for each site. Except for unique models, this article does not describe individual projects. Wielawski711 has provided in-depth descriptions of a number of projects and has other accounts in preparation.

Table Graphic Jump LocationTable. Reach Out Projects by Model Type and Location
Freestanding Clinics

Freestanding clinics have facilities that provide care on the premises. For our purposes, freestanding indicates that the clinic is not physically a part of a hospital or other health care organization. Some of the projects that illustrate this model have independent governance and others are components of organizations that have functions other than providing health services. Physician volunteers may come to the clinic once a month or several times per week. Hours of operation vary from 1 to 2 evenings per week to a fully booked schedule operating all week. Primary care is the principal activity for most, but several also offer specialty and dental services. Some projects used grant funds to start a clinic, others expanded at existing locations, and some developed satellite clinics to serve patients in new locations. The most successful clinics had a salaried, either part- or full-time medical director whose support came from local monies, not from grant funding. These individuals provided overall leadership, assisted in volunteer recruitment, and oversaw clinical operations.

One project started with a vacant lot, raised support for a building, and, in 3 years, had a clinic that was caring for 1500 patients and was ready for further expansion. Another site expanded from 3 sessions to 10 sessions per week and saw patient visits grow from 5000 to more than 15,000 per year. Another already robust operation used grant funds to expand case management services, negotiate with hospitals for donation of laboratory and imaging services, and enhance its volunteer corps of specialty physicians.

Referral Networks

Usually led by physicians in full-time practice, often in coordination with a medical society executive, these projects refer uninsured patients to private physicians for treatment and follow-up. Typically, projects have networks of specialty physicians, but some also include primary care physicians. A central administrative function is crucial to the success of these projects. The administrator keeps a roster of patients and their needs and makes appointments with appropriate physicians. A key to the success of such a program is its ability to assign patients to physicians in an equitable fashion so no one physician becomes unduly burdened. Case management is also important and involves issues such as transportation to and from the doctor's office and making sure that appointments are kept. Case managers often discover that a significant proportion of referred cases are eligible for Medicaid, social security disability, or a state program that provides insurance to children.

Specialty network physicians also need access to diagnostic imaging, endoscopy suites, and operating rooms. These needs require that the project leadership and management negotiate with hospitals and imaging centers to donate their services.

One referral network, organized by a medical society in Florida, has recruited 280 specialists. In the early years, the project made 35 referrals per month. Since then, this number has grown to more than 55 per month. Since the project began, the network's central office has arranged specialty care for almost 2100 patients and provided an estimated $2.5 million in services.

Combined Clinic/Referral Model

These projects involve both freestanding clinics and referral network components. Physicians can either volunteer their time in a clinic setting or see patients in their own offices. Over the years of the Reach Out program, a number of freestanding clinics have found that specialty services are more easily arranged in private office settings. These projects often provide primary care services at the clinic and refer patients to specialists in their network of volunteer providers as needed.

In 1 North Carolina community, a volunteer clinic's patient demand strained its capacity. Physician leaders in the community succeeded in recruiting 436 physicians who were members of the local medical society (85% of the membership) to volunteer at the clinic or see patients in their offices. For fiscal year 1999, the county commissioners appropriated $240,000 to support the purchase of pharmaceuticals for eligible patients, and the hospitals support all inpatient and ancillary services. The project serves 6662 patients out of an eligible population of 13,000 in the county.

Rural Integrated Primary Care Networks

In rural areas, public health agencies, hospitals, and medical societies have joined together to form not-for-profit corporations to sustain primary care practitioners, reduce emergency department use, and make care available to the uninsured. Incorporation has permitted these communities to qualify as rural health clinics and become eligible for cost reimbursement under federal regulations that pertain to rural health.

Two rural areas, 1 in Maine and 1 in North Carolina, found their hospitals in major financial distress and their physicians overwhelmed, underpaid, and threatening to go elsewhere or retire. Jointly sponsored not-for-profit corporations have brought organizational expertise and improved reimbursement to these communities. Through their administration, they have produced improved physician coverage, decompressed the hospitals' emergency departments, and streamlined billing. The extra money stemming from the cost reimbursement formula has freed funds that can be used to provide care to people without insurance. Physician leaders, working with hospital and public health directors, have saved the health infrastructure in these rural communities.

Public Health Private Partnerships

The rural integrated primary care model has close organizational and administrative links with public health. In contrast, the public heath private partnership model focuses on clinical collaboration between public health departments and physicians in private practice. Some projects have encouraged partnerships between public health nurses and physicians in private practice. While visiting patients, nurses come to know their patients' medical, social, and economic problems. When they are able to address these issues, the visit to the physician becomes less complicated. Such simplification has made physicians much more willing to see patients with complex social and medical problems. Projects in Alabama, California, Nebraska, Oregon, and South Carolina have shown the value of this partnership.

A variation of this model was developed in a California city. The medical director of a local health department, facing a budgetary shortfall, worked with her local medical society to recruit physician volunteers to work in the public health clinics and provide specialty care or elective surgical procedures in private settings. Volunteer physicians have seen 6450 clinic patients and performed 159 surgical procedures in area hospitals.

Insurance Look-alike Model

One plan in Tennessee has made notable progress and received national recognition.12 The Memphis Plan, led by a physician who is also an ordained minister, is a health plan serviced by volunteers and designed for near–minimum wage uninsured workers of small employers. Employers cover their workers through a premium of $35 per employee per month ($20 for spouses and children aged 12 years or older; $15 for children younger than 12 years), and employees pay $5 per visit. The plan covers all sick and well outpatient care as well as inpatient care for adults and children aged 12 years or older. One hundred seven primary care physicians and 63 specialists have agreed to see Memphis Plan enrollees.

Neither physicians nor facilities are reimbursed for care. Premiums and copayments support the administration of the program, particularly marketing expenses. Reach Out grant funding provided the support needed to make the plan known to the small business community and get it launched. Enrollees have grown from 200 to 1394, and now 353 employers offer the plan. Premiums reached $226,186 in 1998.

Elective Surgical Care

Founded by surgeons at 2 of the leading teaching hospitals in the San Francisco, Calif, area, this project provides elective surgery for people who would otherwise go without care. Typical procedures include hernia repair, varicose vein removal, and biopsy or removal of soft tissue lesions. Surgeons garnered commitment to provide such procedures, which required enlisting the entire surgical team, operating room time, and supplies for the operation. Over the past 3 years, they have recruited 28 surgeons, 7 anesthesiologists, and 83 surgical support staff. The project has organized more than 385 operations, and 63 patients are on the waiting list. Two other California communities as well as communities in other locales are planning to initiate similar programs.

Without access to appropriate pharmaceuticals, the Reach Out projects could not function effectively. Given the expense of many medications, obtaining prescription drugs for patients was a notable challenge. For most projects, there was no single stable source of support. Instead, they had to cobble together a program that would meet the needs of their patients.

Grants to support generic formularies proved very useful. Support came from local charities, local governmental units, and hospitals. Some projects elicited hospital support by gathering data to convince the hospitals that the Reach Out projects were reducing emergency department use.

Pharmacy assistance programs, sponsored by pharmaceutical manufacturers, were essential to most projects. There are more than 60 programs offering more than 800 medications. Because of varying application processes, eligibility requirements, and changes in drugs offered, these programs are very difficult to use and require dedicated staff and volunteers. To simplify this process, several projects, working with the NPO, developed a Web-based program called RxAssist. This tool permits anyone to search by class of drug, generic name, brand name, or pharmaceutical company and to determine the process of obtaining a medication.

Most projects used professional samples. While helpful, they have the disadvantage of small-dose packaging and the medications available are newer, more expensive classes of drugs. Relying on them for chronic conditions such as hypertension is problematic.

Following the example of Kentucky and Arkansas, a Reach Out project in South Carolina convinced several pharmaceutical companies to develop a statewide formulary for the benefit of project enrollees. Physicians in their offices write prescriptions for eligible patients, who then fill them at their local pharmacies. The pharmacies are subsequently restocked by the drug company at no cost. Several thousand patients have received medication through the program. While the impact is modest relative to statewide need, it is a promising approach with potential for growth.

The Reach Out experience illustrates a variety of approaches to care for the underserved. All of these models can work. Success has been most difficult to achieve in urban centers, where the numbers of underserved were vast. Which model a community might choose to pursue depends on local circumstances, including the background and inclination of local physician leadership and the availability of other services in the community. Persons planning such projects should be mindful of the following lessons:

  • Physician leadership was an indispensable ingredient for the success of the projects. Physicians' ethical commitment and persuasive powers brought their colleagues into the projects. Development of clinical services would not have occurred without their guidance.

  • Physician time devoted to clinical work was not excessive. Typically, physicians in volunteer clinics spent between 1 and 4 half-day or evening sessions per month; the physicians in private offices saw only a few patients per month.

  • Physician concern about malpractice regularly surfaced. This issue was solved in a variety of ways. Physician recruitment did not suffer, and no malpractice suits have been filed. The impression that the underserved might be more litigious than insured individuals has not been borne out.13

  • Physicians in the private office setting saw not only those without insurance but, in many projects, they also opened their practices to Medicaid patients. Willingness to see uninsured and Medicaid patients was enabled by collaboration with public health nurses. This approach deserves serious consideration in many communities.

  • From time to time, patients presented with complex problems for which projects did not have the resources or referral base to meet contemporary standards of care. A San Diego, Calif, Reach Out project directly faced this conundrum.11

  • Through case management, projects frequently found that patients who presented without insurance were eligible for a publicly supported program, such as Medicaid, or, because of disability, Medicare.

  • Carrying out these projects was more complex than expected. Significant progress often did not appear until late in the third or the fourth year of grant funding. Projects had to recruit and schedule physicians to provide care; arrange for the laboratory, diagnostic, and pharmacy services; know their prospective patient base and make the project known to those patients; and determine eligibility requirements. Language competencies, transportation of patients, and the complex social and financial problems of patients emerged as challenges. Skills in working with community groups and finding local sources of support in dollars or in kind were also essential.

  • Programs need a funded administrative structure. The tasks of recruitment, scheduling, marketing, information management, and case management require paid staff. The staff need not be large to be effective.

  • Bringing project leaders together is very valuable. Many Reach Out leaders have worked on the problems of the uninsured against great odds. Many have expressed a sense of frustration and fear of burnout. Coming to know colleagues from around the country has been an immense source of support and has provided the opportunity to exchange ideas and best practices.

  • More than two thirds of the Reach Out projects are likely to sustain themselves once grant funding ends. By demonstrating effectiveness to local foundations and public agencies, sources of support have come forward.

The Reach Out program was the first nationwide effort to mobilize private practicing physicians to collaborate with other stakeholders to increase access to care for the underserved. The success of this effort, in both the number of patients served and the number of physicians involved, demonstrates the effectiveness of these partnerships. Given that there are now more than 44 million uninsured people in the United States,14 the comparatively modest efforts of the Reach Out projects may seem like a drop in the ocean. On the other hand, a view from the local communities shows gathering momentum, more and more people being served, and a sense that the financial resources can be found to sustain core administrative functions. This is the view from the bottom up—from 0 patients seen to several hundred or several thousand being cared for.

Rigorous evaluation with specified outcomes was not feasible. Reach Out happened in many different settings and without a defined model. Thus, we could not address such questions as what sources of care, if any, patients might have used in the absence of the Reach Out project. However, direct observation of many flourishing projects supports a claim of real impact on the lives of many.

A major expansion of Reach Out would not solve the growing problem of access to health care. One thousand organized programs, performing as the Reach Out projects have on average, would provide care to about 5 million uninsured and underserved persons, a small but important fraction of the large national problem. Moreover, 1000 projects would recruit nearly 300,000 physicians, a very high proportion of practicing clinicians in the nation. Sensitizing this large cadre of physicians to the problems of underserved persons would draw respected voices that otherwise might be silent into the political debate over access. It just might be possible to build the will for change through the daily care of those outside the system—looking in.

Cunningham PJ, Grossman JM, St Peter RF, Lesser CS. Managed care and physicians' provision of charity care.  JAMA.1999;281:1087-1092.
Donelan K, Blendon RJ, Hill CA.  et al.  Whatever happened to the health insurance crisis in the United States?  JAMA.1996;276:1346-1350.
Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately insured hospital patients.  JAMA.1991;265:374-379.
Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort.  JAMA.1993;270:737-741.
Carrasquillo O, Himmelstein DU, Woolhandler S, Bor DH. Going bare: trends in health insurance coverage, 1989 through 1996.  Am J Public Health.1999;89:36-42.
Kuttner R. The American health care system: health insurance coverage.  N Engl J Med.1999;340:163-168.
Wielawski IM. Managed care eludes only Congress: Washington should pay attention to reforms occurring at the grass-roots level.  Los Angeles Times.September 30, 1994:B7.
Wielawski IM. The Blue Hill cure: while the nation struggles to fix its ailing health care system, the doctors and patients of this remote Maine region are taking care of business by taking care of each other.  Boston Globe Magazine.October 15, 1995:12, 26-30, 34-38.
Wielawski IM. Keep it simple: HMOs' image will improve when the complexity imposed on patients is removed.  Mod Healthcare.1997;27:56.
Wielawski IM. Reach Out: Physicians' Initiative to Expand Care to Underserved Americans. In: Isaacs SL, Knickman JR, eds. To Improve Health and Health Care 1997. San Francisco, Calif: Jossey-Bass Publishers; 1997:1-20.
Wielawski IM. Rationing medical care: the growing gulf between what's medically available and what's affordable.  Advances.1998;No. 4(suppl):1-4.
Morris GS. Memphis's medical Graceland: traditional health care neglects the working poor; a church-based clinic steps in.  J Am Citizenship Policy Rev.1998;89:45-48.
Burstin HR, Johnson WG, Lipsitz SR, Brennan TA. Do the poor sue more? a case-control study of malpractice claims and socioeconomic status.  JAMA.1993;270:1697-1701.
Campbell JA. Health Insurance Coverage: Consumer Income, 1998. Washington, DC: US Census Bureau; October 1999.

Figures

Tables

Table Graphic Jump LocationTable. Reach Out Projects by Model Type and Location

References

Cunningham PJ, Grossman JM, St Peter RF, Lesser CS. Managed care and physicians' provision of charity care.  JAMA.1999;281:1087-1092.
Donelan K, Blendon RJ, Hill CA.  et al.  Whatever happened to the health insurance crisis in the United States?  JAMA.1996;276:1346-1350.
Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately insured hospital patients.  JAMA.1991;265:374-379.
Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort.  JAMA.1993;270:737-741.
Carrasquillo O, Himmelstein DU, Woolhandler S, Bor DH. Going bare: trends in health insurance coverage, 1989 through 1996.  Am J Public Health.1999;89:36-42.
Kuttner R. The American health care system: health insurance coverage.  N Engl J Med.1999;340:163-168.
Wielawski IM. Managed care eludes only Congress: Washington should pay attention to reforms occurring at the grass-roots level.  Los Angeles Times.September 30, 1994:B7.
Wielawski IM. The Blue Hill cure: while the nation struggles to fix its ailing health care system, the doctors and patients of this remote Maine region are taking care of business by taking care of each other.  Boston Globe Magazine.October 15, 1995:12, 26-30, 34-38.
Wielawski IM. Keep it simple: HMOs' image will improve when the complexity imposed on patients is removed.  Mod Healthcare.1997;27:56.
Wielawski IM. Reach Out: Physicians' Initiative to Expand Care to Underserved Americans. In: Isaacs SL, Knickman JR, eds. To Improve Health and Health Care 1997. San Francisco, Calif: Jossey-Bass Publishers; 1997:1-20.
Wielawski IM. Rationing medical care: the growing gulf between what's medically available and what's affordable.  Advances.1998;No. 4(suppl):1-4.
Morris GS. Memphis's medical Graceland: traditional health care neglects the working poor; a church-based clinic steps in.  J Am Citizenship Policy Rev.1998;89:45-48.
Burstin HR, Johnson WG, Lipsitz SR, Brennan TA. Do the poor sue more? a case-control study of malpractice claims and socioeconomic status.  JAMA.1993;270:1697-1701.
Campbell JA. Health Insurance Coverage: Consumer Income, 1998. Washington, DC: US Census Bureau; October 1999.
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