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Dr. FoleySummer 2008 - Vol.3, No.2

The Lancaster Medical Community's Finest Hour,
Providing Medical Care to the Uninsured
T. Raymond Foley, M.D.
Chief, Division of Gastroenterology Lancaster General Hospital
Board Vice President PALCO

     "We make a living by what we get, but we make a life by what we give."

                                                                                                 -Sir Winston Churchill

The enormity of the problem of uninsured Americans is staggering. Newly released CDC data reveal that in 2006, 14.8% of Americans or 43.6 million Americans were currently without health insurance. Among working adults, age 18 to 64, 19.8% did not have health insurance in 2006, a 5% increase from the preceding year. Uninsured patients visit the emergency department at about twice the rate of insured Americans, who are far more likely to visit physicians’ offices. This is a critical issue not only for the patients, but for society in general. In February, researchers sponsored by the American Cancer Society reported that uninsured Americans with cancer are far more likely than those with private coverage to have advanced disease when diagnosed. In 2005, a study funded by the Robert Wood Johnson Foundation of uninsured Americans with chronic health conditions (diabetes, hypertension, arthritis-related conditions, high cholesterol, asthma, and heart disease) revealed some startling statistics:

  • Nearly half of all uninsured non-elderly adults report having a chronic condition;
  • Many uninsured adults with a chronic condition, do not have a usual source of healthcare;
  • Almost half of uninsured adults with chronic conditions forego needed medical care or prescription drugs due to cost.

Compared with insured Americans, uninsured adults with chronic conditions:

  • forego needed medical care and prescription drugs at much higher rates;
  • are far less likely to visit health professionals.

The conclusion is inescapable: uninsured adults with chronic conditions suffer serious identifiable gaps in needed medical care. This is a critical problem not only nationally, but locally. Despite the rhetoric of our political candidates it seems unlikely that a viable solution to this problem will soon be forthcoming from either Washington, D.C. or Harrisburg, Pennsylvania. Fortunately for the citizens of Lancaster County, however, Project Access in Lancaster County (PALCO) has now come into being. I have received a number of inquiries regarding PALCO since it was first conceived almost two years ago, and feel that I can best address these in a Q&A format.

1.  What is PALCO?

PALCO is a physician-led volunteer community effort that provides free healthcare to low income uninsured individuals who meet predetermined financial parameters. This effort does not replace current government programs, but rather covers those with enough income to disqualify them from government coverage. They are uninsured Lancaster County residents who do not qualify for Medicaid or other insurance, and whose annual income is less than 200% of the federal poverty level.

PALCO It is a coordinated system of charity care that provides the full continuum of medical care to eligible patients. The goal is not to insure these patients indefinitely, but to get them through a difficult time in their lives. By providing free medical care to these individuals we hope not only to improve their health, but also to help them avoid financial catastrophe due to overwhelming medical bills.

2.  Why does PALCO work?

The essence of PALCO is volunteerism, the willingness to work on behalf of others without the expectation of pay or other tangible gain; and partnership, a relationship between groups that is characterized by mutual cooperation and responsibility for the achievement of a specified goal. Project Access can only work if physicians volunteer to see patients for free. In addition, in order to make PALCO successful, physicians must partner with hospitals, pharmacists, other healthcare providers, and community organizations.

3.  How did PALCO get started in Lancaster County?

William Fife, M.D., formerly a Resident at Lancaster General Hospital and now Medical Director at Southeast Lancaster Health Services (SLHS), identified a need for his patients to receive improved access to medical care, particularly specialty care. With continuous and untiring encouragement from Helen Jones, a social worker at SLHS, Dr. Fife researched the problem, discovered the American Project Access Network and presented the concept at several meetings. This effort got the PALCO ball rolling. Lancaster General Hospital generously provided the necessary start-up funds, and the other county hospitals have all agreed to participate. A pharmacy initiative led by Coleen Kayden, RPh at Williams Apothecary was begun. The Lancaster City and County Medical Society agreed to house the Project Access initiative. United Way is donating fiduciary services. Fox Rothschild offered to provide the legal assistance necessary to establish a not-for-profit Foundation, and this is in the process of being done in coordination with the Lancaster County Medical Society. Financial assistance initially came from a number of groups including United Way, Lancaster Osteopathic Health Foundation, the Ferree Foundation, the Steinman Foundation, Lancaster County Community Foundation, the Seraph Foundation, Physicians Alliance of Lancaster, and Cornerstone Ministry Services. Other community members have subsequently provided support.

4.  Who is participating in PALCO?

At present, more than 600 physicians and other providers, plus pharmacists, social workers, and all 4 county hospitals, have agreed to provide unreimbursed care. Physicians provide free professional services, and the hospitals provide free inpatient care and outpatient services, including laboratory and radiologic services.

In addition, there has been broad participation from a variety of other entities. Our community partners have provided financial support, accounting services, and legal services. Hospice of Lancaster County and VNA have been our most recent additions. We have an active and dedicated Board consisting of respected community leaders. Lancaster City and County Medical Society has agreed to rent PALCO office space.

5.  Why do physicians participate?

The physicians, hospitals, and other members of the Lancaster County medical community have a long history of providing medical care to patients without regard to their ability to pay. Now our patients can receive coordinated medical care which in the long run is better and more cost-effective for all involved. In addition, we can quantify that care and recognize the medical community for its generosity and hard work.

6.  What have been the results to date?

In the first six months of being fully operational, PALCO physicians have seen over 500 patients! There have been only 4 emergency room visits! Together, the doctors and hospitals have provided over 1.4 million dollars in medical care.

7.  What challenges does PALCO face?

Ongoing support is crucial to the success of PALCO and its recipients. We have been fortunate in the support we have received to date, both in financial contributions and donated services, but we must continue to communicate our message in a way that encourages ongoing support.

8.  Have there been any disappointments?

Most certainly we have had disappointments. We have had to suspend our pharmacy benefit program because it threatened the financial viability of the entire project. In the first 5 months of PALCO’s existence, we supplied over $50,000 in pharmaceuticals. Obviously, we could not continue this level of support so we suspended the program and are currently looking at alternatives.

We have also had a few specialties where we had hoped for broader physician involvement. Most of that need has been successfully addressed, although we continue to recruit physicians.

We had one patient who seemed to take advantage of the system, though otherwise, we have found PALCO patients to be extremely grateful. One of more than 500 patients does not seem so bad, but that patient’s actions were enough to drive one of our participating physicians away. We are very sensitive to this issue and committed to not letting it happen again if at all possible.

9.  Has Project Access been successful elsewhere?

The answer is a resounding yes!
Project Access was first started by Dr. Suzanne Landis in Ashville, North Carolina in the mid 1990’s. Project Access organizations are active in at least 30 communities across the nation. PALCO is the first Project Access program that is currently running in Pennsylvania.

There are several striking success stories throughout the nation. In Ashville, North Carolina, the Boncombe County Medical Society received the Harvard University Award for Innovations in American Government, for its Project Access program. They announced that after 5 years, 87% of the uninsured population reported good or excellent health, which compared favorably with 84% of the insured population. Previously, physicians in Ashville cared for 6,000 patients who averaged 5.2 visits per patient annually (30,000 visits/yr.). Physicians there now see approximately 10,000 uninsured patients with an average of less than 3 visits per patient annually. Thus, physicians are able to care for 70% more patients with the same amount of time and effort.

In Spokane, Washington, 700 physicians and 6 hospitals participate in a Project Access program that has returned $9.75 of care for every dollar invested. Over 2 years, they provided 5.5 million dollars in charity care. Project Access has now spread to 5 other counties in the state of Washington.

In Indianapolis, Indiana, non-urgent emergency room visits decreased from 64% of uninsured patients in 2004 to only 1% in 2006, as a direct result of these patients having “a medical home.”

In Kentucky, almost $11 million in free brand-name pharmaceuticals have been provided to Project Access patients. In Dallas, Texas, approximately $8 million in free medical care has been provided annually, divided equally between physicians and hospitals.
10.  Who is eligible for PALCO?

PALCO is available to patients without health insurance who live in Lancaster County. Typically, these patients are between the ages of 18 to 64, do not qualify for Medicaid or Medicare, and - as noted earlier - they have a gross household income of less than 200% of the federal poverty level. Patients referred to PALCO by their primary-care provider, specialist, or social worker, are required to complete an application process and meet eligibility criteria in order to enroll in the program.

11.  Are patients enrolled in Project Access indefinitely?

No they are not. Once they have qualified for Project Access, patients have coverage for 6 months, after which they are reviewed. Experience in Ashville, North Carolina showed that after one year more than 50% of the patients in Project Access were employed and had health insurance.

12.  As a physician, I already provide free medical care. Why should I participate in Project Access in Lancaster County?

PALCO was built on the long tradition of doctors and hospitals in Lancaster County taking care of our own. For years, we have provided care for our insured and uninsured patients regardless of their ability to pay. Even though we already provide free care, by providing this care in a coordinated and timely fashion we can improve the health of our community and conceivably even lower health care costs.

In addition, when you care for patients with a PALCO card your staff does not have to spend their time making sure the patients are eligible for free care, as their financial status has already been investigated and assured by PALCO. When you participate in PALCO, there is no additional paperwork and you are not dealing with a government agency that may eventually refuse to pay anyway.

13.  Won’t Project Access and other programs deter the government from finding a solution to the problem of the underinsured in America?

These patients need help now, and realistically, there is not going to be any change in government policy in the immediate future. Plus, a physician participating in PALCO can always withdraw. PALCO is certainly not the only answer but it could be an important part of any solution and it can be implemented in a much more timely fashion. Moreover, what could the Government do better with health care than local physicians and hospitals can do? The problem with the uninsured needs to be addressed nationally and statewide, but locally, who can better address this problem than physicians and hospitals?

14.  What does the immediate future look like for PALCO?

By the time this article is published we hope to have our not-for-profit Foundation established; to have a fuller complement of providers; to have extended our community involvement at the Board level; and to have secured ongoing financial support from our prior supporters as well as from new sources.

15. How would I refer a patient to PALCO?

Patients can contact PALCO directly at 392-1595. Alternatively, a physician’s office can call PALCO and PALCO can fax an application to the physician’s office. Our experience thus far suggests it is best that the patient contact the PALCO office directly. Once the patient has completed his or her application it usually takes one week for him/her to become eligible for PALCO benefits providing they meet the eligibility requirements. PALCO exists to establish and sustain a coordinated system of charity care for the uninsured patients of Lancaster County.

We are excited about the level of enthusiasm exhibited by physicians, hospitals, and other partners so far. We hope to acquire even greater participation through sharing the message of Project Access; i.e., physicians see charity patients in a coordinated fashion, more patients are seen, they receive the ancillary services they need, and physician care is measured and reported to the community. A small effort for many physicians can have a huge impact on increasing access to healthcare. On behalf of our board, our administrative staff, and most importantly our patients, I would like to thank all of our participants and encourage anyone who is interested to contact me, Lisa Riffanacht, our PALCO director, or any of our Board members for further information.

T. Raymond Foley M.D.
Regional Gastroenterology Associates of Lancaster, Ltd.
2104 Harrisburg Pike, Suite 300
Lancaster, PA 17604