Structured approach helps St. John connect uninsured to specialists

December 15, 2011

Physicians Who Care functions as formal referral network for uninsured in Detroit


When it comes to getting specialty care, uninsured people in Detroit have supply and demand working against them. They live in a state with a lack of specialists, and a city with a high level of uninsurance.

The result? There are a lot of people in Detroit seeking care from a limited number of specialists, and the uninsured have a hard time competing for appointment times against insured patients.

"This causes the uninsured to delay care until they are seriously ill — and sometimes they end up having to go to the emergency department with conditions that have progressed to a serious level," explained Cynthia Taueg, vice president, community health, St. John Providence Health System, Warren, Mich.

That system and its five acute care hospitals in southeast Michigan have developed a network of specialists called Physicians Who Care that eases access to specialty care for uninsured patients. In place of the informal and uncoordinated patchwork of relationships that serves as the default referral network for the uninsured in many communities, St. John has created a structured network of specialists who are willing to treat uninsured people who qualify for St. John's charity care program.

There is no charge for the services for people whose household incomes fall below 200 percent of the federal poverty level, which is the qualification level for St. John's charity care program. Patients whose income exceeds that level cannot receive treatment through Physicians Who Care, but St. John hospitals can help those patients through sliding scale discounts, income-based financial assistance and referrals to federally funded aid programs.

Constant recruiting
Taueg said St. John created Physicians Who Care because hospital leaders recognized that the "can you do me a favor" way referrals used to be made did not effectively meet the needs of the many uninsured people seeking specialty care, nor did it work well for St. John's specialists willing to provide charity care to nonpaying patients. Under the old, informal method, many poor patients fell through the cracks, and certain specialists became overburdened with charity care patients.

St. John developed and piloted the network in 2003 and implemented it throughout its hospitals in 2004. St. John developed a database for monitoring how many charity care patients each specialist has agreed to treat, and how many each has seen in a given period of time. This helps to prevent any one practitioner from being overloaded with charity care patients. St. John provides some support, such as malpractice insurance, said Taueg.

A Physicians Who Care coordinator recruits specialists into the network, aided by a participating specialist who attends St. John hospitals' medical staff meetings, talking up Physicians Who Care, and engaging senior leaders in recruiting new specialists to the network.

St. John has recruited more than 400 specialists into Physicians Who Care, some of them employed by St. John, most of them affiliated. Taueg said once specialists join the effort, most stay. And, yet, "there is a constant need to recruit more," to meet ongoing patient demand, she said.

One recruiting challenge, she said, is a result of Detroit's hobbled economy. "Many of (the specialists') patients become unemployed and uninsured, and the physicians try to continue serving them. This makes it a bit difficult to recruit new physicians who may already have a fairly significant caseload of uninsured patients."

Giving back — smartly
And yet, Taueg said, the Physicians Who Care recruiters have been successful in attracting specialists, and the volunteers who join the network like the system because "they want to give back to the community — they just want to do it in an organized way."

Dr. Minuchehr Kashef is among St. John specialists on the Physicians Who Care roster. He has provided ob-gyn services to more than 500 women through the program. He said he knows of no other Detroit-area hospitals or health systems offering such efficient access to specialty care for the uninsured.

Dr. Suchitra Zambare, a St. John's endocrinologist, said she joined Physicians Who Care because of her concern that people with uncontrolled diabetes may go without care and medication because of lack of insurance. She said when high-risk diabetics don't get the insulin they need — or when they find ways to get insulin without a prescription and thus without medical guidance — their lives are at risk. "Especially people with type one diabetes — they can die without insulin," she said. She works through St. John's pharmacy assistance program to help her low-income patients access the medications they need, often through pharmaceutical company programs.

Care coordination
The formal structure of Physicians Who Care also benefits patients. Physicians Who Care's on-staff coordinator helps ensure patients move through the system smoothly; and an administrative medical assistant processes referrals and helps patients make their appointments.

The vast majority of patients are referred in — using a specific care protocol — from the Voices of Detroit Initiative. VODI is a collaborative of primary care sites for the underserved that includes St. John facilities. Patients pay for primary care received through VODI facilities on a sliding scale based on their income.

Taueg said that Physicians Who Care is making a dent in meeting the specialty care needs of Detroit's uninsured. Participating specialists have seen about 8,000-plus patients since the program's inception.

The pressure and access problems for the uninsured have been unrelenting, according to Taueg, due to Detroit's gloomy employment and insurance picture. The Bureau of Labor Statistics says the Detroit-

Livonia-Dearborn, Mich., area has a 13.1 percent jobless rate. The Michigan Household Survey on Health Insurance says the city of Detroit has an 18 percent uninsurance rate, as compared with the nation's 16 percent uninsurance rate.

Taueg said St. John is looking into how best to determine the impact the program is having on specialty care access for Detroit's nearly 300,000 uninsured residents. But, for now, she said, success is reflected in the stories of the individual lives improved — or even saved.

Thankful patients
St. John patient Victoria Alan Smith, age 63, of Detroit, is among the success stories. She calls Physicians Who Care a blessing.

Smith had undergone surgery for colon and uterine cancer in 2002 when she was insured. However, when she lost her health insurance in 2007 because of a job change, she was not able to afford follow-up monitoring and testing from her oncologist. She now visits specialists at St. John for that ongoing cancer care follow-up and other care.

Barbara Patterson has never had private health insurance. She does not qualify for Medicaid, and, at 57, she isn't old enough to qualify for Medicare. About 10 years ago, she began experiencing a constellation of medical problems. She has had gynecological ailments and has been diagnosed with diabetes and high blood pressure — some of her care requires specialist treatment. She said her conditions were interfering with her life until she was able to get care through VODI and Physicians Who Care. "I'm grateful, and I love that I have a place to go for my care," she said.

Taueg said meeting the needs of patients like Smith and Patterson is an extension of St. John's mission. "It really speaks to our mission of providing care of the poor. And the way we do it — in an organized, measured manner — is a win for everyone involved."

Most in-demand specialists

These specialists are most in demand in the Physicians Who Care network:

  • Orthopedists
  • Urologists
  • Neurologists
  • Ear, nose and throat specialists
  • Rheumatologists


Copyright © 2011 by the Catholic Health Association of the United States
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