Project Access is a partnership formed 8 years ago between county government, county physicians, county service agencies, the hospital, and pharmacists. The Health Department could handle primary care needs but specialty care had always been a problem until Project Access. The community doctors wanted to do their share but not get "slammed." Through Project Access 90% of practicing physicians in Buncombe County (over 600) now see 10-20 individuals referred into their program with no expectation of payment. The County provides seed money, and the Medical Society runs the program, and the hospital absorbs patient costs. Access to primary care services has been raised from 78% in 1995 to an astounding 93% in the year 2000.
This program responds to the basic human need for access to health care. While access alone will not solve all of the health care ails of the population, until the access problem is solved, most of the problems simply cannot be addressed. A low-income mother with a respiratory infection who has a child whose ear has ached for the last week simply is not interested in learning about the value of exercise and proper nutrition. Project Access and the primary care program of the Buncombe County Health Center fulfills a basic human need that then opens the door to all kinds of other collaboration within the community. It is innovative in that it spreads the indigent care burden across the entire medical community so that no single individual is ever required to see more than 20 clients. That represents less than 1% of the average practice and that burden is happily borne by local physicians.
The Buncombe County Health Center is the primary provider of indigent medical care in the community with over 15,000 active clients. Before Project Access, the Department spent an inordinate amount of time trying to locate specialists to take indigent referrals. Specialty care needs were often going unresolved. Through this program the agency was able to almost double its primary care capacity because all local physicians now readily receive referrals on an equitably distributed system freeing the agency to do what it does best, primary care, and spreading specialty indigent care both across over 600 physicians. The County Commissioners contributed almost $500,000 a year to pay for the drugs dispensed through this program as well as the administrative costs borne by the Medical Society and all safety net providers in the community are given access to refer into the Project Access program for specialty care, pharmaceuticals, and hospitalization.
The direct costs of the program are $390,000. The value of private physician services extended to the patients referred into Project Access was nearly $3.6 million for 2001. It is clear that the county government sees value in this program and their support has been unwavering since the project began. The private physicians are happy with the outcomes and delighted that no single individual or practice is being asked to carry more than a fair share.
Since its inception, the program has been evaluated by the research staff from the Mountain Area Health Education Center located here in Asheville. The key results include a reduction over the years in cost of service per patient by 22% suggesting that more inexpensive and preventive care is being delivered than expensive hospital care. Overall, hospital charity care costs have decreased by 23% from 1997 to 1999 because the care is now being provided in the community setting rather than within the hospital. Further evaluation data is available on request.
First and foremost, it was learned that any community who wants to address access to primary care for its indigent population can do so and do so effectively with the resources they already have on hand. For those who are waiting for the solution for access to primary care to come from Washington or even the state capital, the wait may go unrewarded. Buncombe County took the “bull by the horn” and charted its own future. The patients are much better served today, the Health Center much more efficient, the physicians in the community are delighted to participate because no one is being asked to carry more than his or her fair share, and the hospital is happy because their overall indigent care cost has actually decreased. Computer systems have been developed to automate the enrollment of clients in Project Access and to monitor their utilization and the percentage of physicians who volunteer to see patients in the doctor’s free medical clinic has increased.
People in Asheville know that physicians indeed care very deeply about low income individuals and if a proper system is put in place so that no single physician is asked to carry a disproportionate share of the burden, virtually all will volunteer their time and energy. This program is a very strong reinforcement to physicians of why they went to medical school in the first place. They get positive reinforcement for their community service and the patients are getting comprehensive, state-of-the-art treatment, using a Project Access card just as the insured population would use their Blue Cross card.
Project Access has received national recognition and through a special grant from the federal government, the Medical Society now has a staff that is available to help local communities replicate what was done in Asheville. There are now over 20 communities with Project Access type systems and many more are in the planning phase. The American Project Access Network staff located here in Buncombe County is now engaged with over 100 communities who are interested in starting their own Project Access system and the number grows almost daily.