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Originally published Monday, January 15, 2007 at 12:00 AM

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Poor gaining access to medical specialists

When a stone grinder sliced through Armando Morales' left hand at a construction site last month, fracturing his finger and ripping a tendon...

Seattle Times staff reporter

When a stone grinder sliced through Armando Morales' left hand at a construction site last month, fracturing his finger and ripping a tendon, he had to find a skilled orthopedic surgeon quickly or risk permanent disfigurement. Trouble was, Morales didn't have any insurance.

Hospitals will treat any emergency patient. Community and public health clinics will provide primary care regardless of income. But medical specialists have been the missing link in charity care because no law requires them to accept patients without charge.

Even so, Dr. John Miyano, an experienced hand surgeon, treated the Burien man the very next day.

Miyano is a volunteer at Swedish Medical Center's Mother Joseph Clinic in Seattle, a clinic for uninsured and low-income patients who need specialty care. It's part of an ambitious and expanding plan in King County that makes it easier for specialty doctors such as Miyano to give back to the community.

King County Project Access aims to fill the medical chasm that has left many patients with nowhere to turn for their nonurgent but serious conditions.

Begun as a pilot effort two years ago, Project Access enlists specialists by removing many issues that have dissuaded them from volunteering: unreliable patients, language barriers, and the need to coordinate logistics for patients needing hospital services as well.

If you need a specialist


Project Access is open to any King County resident without health insurance whose income is less than 200 percent of the federal poverty level but who is not eligible for Medicaid or Medicare. That would be a limit of $26,400 for a couple. Typically, patients must be referred from a primary-care doctor at a public health clinic or community health center.

Last year the program arranged about 800 free patient visits in a dozen specialties such as neurology, podiatry and cardiology. Its leaders estimate that Project Access could set up as many as 12,000 patient visits a year when it is fully established.

But to get there, it will have to persuade a lot more specialists to make room in their lucrative practices for patients who can't pay.

Hurdles to overcome

The lack of access to specialists isn't for lack of altruism. Rather, experts say, the health-care system isn't set up to encourage it.

For starters, many specialists don't accept Medicaid patients because the government doesn't reimburse enough to make it worthwhile, and specialists "are busy enough with paying customers," says Dr. Rayburn Lewis, medical director at the Mother Joseph clinic, where half of the patients are Project Access clients.

Specialists in demand


A quarter of low-income and uninsured patients visiting community or public health clinics need referrals to specialists. Here are the specialties in most demand:

Physical therapy: 15 percent

Gastroenterology: 11 percent

Eye services: 11 percent

Orthopedics: 8 percent

General surgery: 7 percent

Cardiology: 7 percent

Dermatology: 7 percent

Otolaryngology (ear, nose, throat): 7 percent

Obstetrics/gynecology: 5 percent

Neurology: 5 percent

Source: Community Health Council of Seattle & King County. Data for 12 months ending Aug. 31, 2004.

Orthopedic surgeons and dermatologists in particular are busy tending to baby boomers' aging knees and creasing skin.

Specialists also carry high overhead for special equipment, liability insurance, big medical-school debts and other logistical hurdles. It all inhibits donating services to uninsured patients.

A surgeon who takes on an uninsured patient, for instance, may be committing three months or more for follow-up care, Lewis said. And specialists need seamless access to hospital services, such as diagnostic machines and operating rooms and nurses.

"If you give a doctor the opportunity to do good, they will do it," Lewis says.

Even when specialists agree to see uninsured people, they're too often frustrated by patients who skip appointments, lack medical records and fail to follow through on treatment regimen.

Easing the way

To battle those impediments, Project Access assigns case managers to guide patients. They book appointments, screen patients for eligibility for public-assistance programs, assist with arranging transportation, provide interpreters and act as liaisons between patients and the specialists.

Project Access is trying to enlist more King County hospitals to coordinate their charity care with the volunteer specialists. Hospitals by law must provide charity care by writing off charges for patients who can't pay. So working with a hospital assures a volunteer surgeon, for instance, that he or she can enlist the services of a radiologist or an anesthesiologist who also won't bill the patient.

Project Access aims to liberate primary-care doctors from having to awkwardly call colleagues — and colleagues of colleagues — to try to line up free care.

"Our goal is to turn that into a system," says Sallie Neillie, the project's executive director. "Each person giving a little bit makes an amazing difference."

Project Access is open to uninsured King County residents who earn less than 200 percent of the federal poverty level, or a limit of about $40,000 for a family of four. Most patients are referred to the program from community clinics. An estimated 190,000 adults in King County lacked health insurance in 2004.

So far, three-quarters of all of Project Access' volunteer doctors are affiliated with Kirkland's Evergreen Hospital Medical Center, where two physician leaders recently took charge of recruiting fellow doctors. A few physicians at Group Health Cooperative and Pacific Medical Centers also have taken a pledge to accept two new uninsured patients a month.

Those who signed up include cardiologists, urologists, gastroenterologists, ophthalmologists and others. But one in-demand specialty, dermatology, so far is missing.

Miyano, the hand surgeon who has his own practice, Seattle Hand Surgery Group, has been volunteering for two years. He comes to Mother Joseph twice a month and treats as many as 10 patients each time.

He says his volunteering cuts into potential income. But it's gratifying to help people, he says.

Especially when he meets people such as Morales, who needed his hand fixed so he could return to work.

Morales cradled his injured hand, where Miyano previously had inserted two pins to stabilize the broken bone. With the help of a Spanish interpreter, Morales explained that he understood Miyano was donating his care free of charge.

With a slight bow and a smile, Morales turned to Miyano and offered his good hand.

"Thank you," he said.

Kyung Song: 206-464-2423 or ksong@seattletimes.com

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