Given a total of 1,476 unduplicated individuals (Table 2), the 9,494 total contacts averaged out to 6.4 contacts per patient or 3.2 contacts per patient per year.
Eighty-four percent of presentations to Health Links were managed at the point of contact with Health Links volunteers, staff or volunteer nurses, or physicians volunteering at one of the two weekly walk-in sites. In other words, the vast majority of patient presentations were managed either by telephone or at one of the sites.
A total of 1,515 contacts resulted in referrals for further office-based, standard-quality care, representing just 16% of total Health Links contacts, or one referral per patient over the study period and 0.5 referrals per patient per year. These are very telling numbers. Although the clinical appropriateness of triage decisions cannot be second-guessed and no conclusive interpretation can be drawn, the fact that 84% of patients presenting to Health Links did not go on to receive office-based standard-quality care suggests that a very high threshold for such referrals existed. Further, the numbers suggest that the projects primary activity was not providing access to care, but rather stringent gatekeeping, that is, withholding of standard-quality health care resources.
The limited volume of referrals for office-based care may have been driven by physicians’ reluctance to provide substantial free care. Table 3 shows provider participation by specialty. Medical referrals—referrals to physicians, physician assistants, certified nurse midwives or nurse practitioners—accounted for 1337 or 88%, of total referrals. The other 178, or 12% of referrals, were for general dentistry, oral surgery (these combined accounted for 152, or 10% of all referrals), podiatry (9 referrals, 0.6% of total), and chiropractic treatment (17 referrals, or 1.1% of total referrals).
Nearly all community physicians—89%—agreed to accept referrals to see Health Links patients in their offices. Participating providers accepted a mean of 12.2 Health Links office referrals per year, or just 1.0 per month. However, the volumes seen by different specialists varied dramatically, ranging from an average of two referrals per provider per year or 0.17 per month (nephrology) to 18.6 referrals per provider per year or 1.6 per month (obstetrics/gynecology).
The level of commitment by the local medical community to provide free care was limited, variable, and fragile throughout the study period. One specialty practice never accepted the premise that Health Links patients should not be billed, and did in fact bill patients for a percentage (usually 50%) of their standard charge. One physician dropped out of the program during the study period; since he was the sole provider of services in a major medical subspecialty, this left a large access gap in services. Other specialists were able to pick up some of the referrals; however, Health Links staff continued to feel that access to care was at the whim of individuals possessing local monopolies on vital specialty sendees.
The single non-participating general internist claimed that he routinely negotiated directly with patients to offer his services at no charge or under a barter arrangement. He viewed Health Links as an unnecessary intermediary, performing a redundant administrative function in determining patients’ medical and financial needs. He stated that he preferred to continue practicing the older model of direct dispensation of charity care (Personal communication, Barry Poret, MD, Greenfield, MA, September 1999). Most physicians took an opposite approach, however, informing all patients unable to pay for their care that they could only be seen as part of the Health Links referral process.
The most generous practitioners saw fewer than two Health Links patients a month, while the least generous saw only two patients per year. The overall volume of care was quite modest, given the high number of uninsured patients in Franklin County.
The low rate of participation by the dental community bears special mention. Only three of 23 practicing dentists accepted Health Links referrals. These same three practitioners were also the only local dentists accepting MassHealth (Medicaid) payments. Nonparticipants explained this to Health Links staff in terms of simple economic self-interest.