Scott HD, Bell J, Geller S, Thomas M. Physicians Helping the UnderservedThe Reach Out Program. JAMA. 2000;283(1):99-104. doi:10.1001/jama.283.1.99
Author Affiliations: Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket.
Caring for the Uninsured and Underinsured Section
Editors: William A. Roper, MD, MPH, University of North Carolina at
Chapel Hill; Carin M. Olson, MD, Contributing Editor, JAMA.
In the current health care environment of competition and market forces,
concern has arisen that the classic principle of serving disadvantaged persons
may not be fulfilled due to pressures from managed care. Reach Out, a $12
million national program of the Robert Wood Johnson Foundation, was developed
to recruit leaders from among practicing physicians to organize projects to
care for the uninsured and underserved. Physician volunteerism was a key component
of all projects.
Thirty-nine Reach Out projects were implemented and carried out across
the United States, with average funding per project of $300,000 distributed
over a period of 4 years. Seven model types emerged, the most common of which,
the free clinic and the referral network, accounted for two thirds of the
total. At the program's conclusion, 199,584 patients were enrolled and 11,252
physicians recruited. Project execution was more complex than initially supposed,
and major progress commonly was not evident until the third or fourth year,
but at least two thirds of the projects are likely to continue with local
With strong physician leadership and a funded administrative core, organized
community efforts can develop and sustain an effective program. Programs such
as Reach Out cannot solve the national problem of access to health care, but
they can make a small but important impact on the number of uninsured and
underserved persons without access to health care.
The ethical principle to care for people in need regardless of station
or income has informed the medical profession for centuries. In the current
environment, in which competitive market forces are looked to as a solution
for many problems that beset contemporary American health care, there has
been concern that the ethical imperative to serve the disadvantaged might
be shoved aside by the pressures of managed care. Cunningham et al1 have shown that physicians involved with managed care
plans or working in areas of high managed care penetration tend to provide
less charity care than physicians with less managed care involvement.
Studies have demonstrated that the uninsured have difficulty getting
needed medical care,2 that when they are hospitalized
their illnesses and injuries are more acute and advanced than those of people
with insurance,3 and that the mortality rate
is higher for uninsured than for insured persons.4,5
In spite of a booming economy and a low unemployment rate, the ranks of the
uninsured are growing.6 Despite these trends,
we have found that organized efforts to care for the underserved can still
evoke substantial physician commitment.
In 1993, the Robert Wood Johnson Foundation initiated a national program
to encourage private physicians to expand their role in caring for the underserved.
The program was called "Reach Out: Physicians' Initiative to Expand Care to
Underserved Americans" and was based on the successful local efforts of a
number of practicing physicians.
The purpose of the Reach Out program was to support innovative community
models that use physicians in private practice to increase access to health
care for the uninsured and underserved. A principal aim was to complement
publicly funded safety net providers, such as community health centers, and
expand capacity in the private sector to care for the underserved. Voluntary
professional commitment to serve was essential. Sponsorship of projects came
from medical societies, group practices, and nonprofit or religious organizations.
Any model was acceptable, as long as it had a commitment to increasing access
to care, appropriate leadership by practicing physicians, evidence of community
support, and a realistic set of objectives.
Project directors were physicians who led by virtue of their standing
with peers and community leaders, their public commitment to help the underserved,
and their ability to motivate their colleagues and others to develop or expand
organized programs to care for the uninsured. Practicing physicians, who assumed
leadership roles, typically did not have time to undertake the daily duties
of administration. Grant funds provided for the extra help required to develop
an effective program, eg, to hire staff, purchase computers, and develop or
adapt software. The foundation committed $12 million to fund projects for
up to 4 years. Projects were funded in 2 stages. The first stage included
a 1-year development grant of up to $100,000. At the end of this development
period, grantees were eligible for implementation grants of $200,000 over
a 3-year period. Competitive proposals were reviewed in 1993 and 1994. From
more than 400 submissions, 40 projects were awarded. Locations varied from
large metropolitan areas to remote locations in Maine and Montana, and 5 projects
were statewide. One project was funded only for the first year; 20 concluded
in July 1998 and 19 in July 1999.
The National Program Office (NPO) has provided administrative direction
and technical assistance to these projects. In this role, the NPO has accumulated
a wealth of information on issues confronting community efforts to increase
access to health care. This article describes the models of care that have
evolved, illustrates what the projects have accomplished, and summarizes the
lessons learned. Access to pharmaceuticals merits comment because obtaining
prescription drugs was a challenge for all projects. The Reach Out experience
may provide a useful starting point for physicians and other health care leaders
who are trying to develop partnerships to expand access to health care in
their own communities. (The successor program to Reach Out, Volunteers in
Health Care, provides technical assistance on these issues and is available
on the Internet at http://www.volunteersinhealthcare.org.)
Individual projects, in collaboration with the NPO, developed a minimum
data set to track the number of physicians recruited and patients served.
What appeared conceptually straightforward proved difficult to execute. Many
hours were devoted to obtaining comparable data across sites, producing a
profile of the numerical impact of the program as a whole. Thirty-seven projects
reported on patient enrollment and 39 on physician recruitment.
As of July 31, 1999, 199,584 patients were enrolled in 37 projects,
with an average of 5394 patients per project. These data do not include patients
who left or were lost to follow-up, a number that we were not able to measure.
Twelve projects (32%) enrolled fewer than 1000 patients, 15 (41%) enrolled
1000 to 5000, and 10 (27%) enrolled more than 5000. Thirty-nine sites reported
a total of 11,252 physicians recruited, an average of 289 per project. Ten
(26%) recruited fewer than 50 physicians; 7 (18%) recruited 50 to 100; 18
(46%) recruited 101 to 500; and 4 (10%) recruited more than 500. The number
of patients enrolled and physicians recruited is not always indicative of
a project's impact. For instance, projects in rural areas commonly dealt with
small populations of both patients and physicians.
The Reach Out projects devised their own approaches to increasing access
to care. The NPO was able to classify the projects into 7 model categories.
The 2 most common models, the free clinic (n = 10) and the referral network
(n = 16), accounted for two thirds of the total. Two projects comprised both
a clinic and a referral network, 2 were rural primary care networks, 6 were
public health private partnerships, 2 were insurance look-alikes, and 1 was
organized exclusively to provide elective surgical services. Many projects
had elements of 2 or more models. In these cases, the NPO classified the project
according to its judgment of best fit.
Table 1 lists the model type, location, and project name for each
site. Except for unique models, this article does not describe individual
projects. Wielawski7- 11
has provided in-depth descriptions of a number of projects and has other accounts
Freestanding clinics have facilities that provide care on the premises.
For our purposes, freestanding indicates that the
clinic is not physically a part of a hospital or other health care organization.
Some of the projects that illustrate this model have independent governance
and others are components of organizations that have functions other than
providing health services. Physician volunteers may come to the clinic once
a month or several times per week. Hours of operation vary from 1 to 2 evenings
per week to a fully booked schedule operating all week. Primary care is the
principal activity for most, but several also offer specialty and dental services.
Some projects used grant funds to start a clinic, others expanded at existing
locations, and some developed satellite clinics to serve patients in new locations.
The most successful clinics had a salaried, either part- or full-time medical
director whose support came from local monies, not from grant funding. These
individuals provided overall leadership, assisted in volunteer recruitment,
and oversaw clinical operations.
One project started with a vacant lot, raised support for a building,
and, in 3 years, had a clinic that was caring for 1500 patients and was ready
for further expansion. Another site expanded from 3 sessions to 10 sessions
per week and saw patient visits grow from 5000 to more than 15,000 per year.
Another already robust operation used grant funds to expand case management
services, negotiate with hospitals for donation of laboratory and imaging
services, and enhance its volunteer corps of specialty physicians.
Usually led by physicians in full-time practice, often in coordination
with a medical society executive, these projects refer uninsured patients
to private physicians for treatment and follow-up. Typically, projects have
networks of specialty physicians, but some also include primary care physicians.
A central administrative function is crucial to the success of these projects.
The administrator keeps a roster of patients and their needs and makes appointments
with appropriate physicians. A key to the success of such a program is its
ability to assign patients to physicians in an equitable fashion so no one
physician becomes unduly burdened. Case management is also important and involves
issues such as transportation to and from the doctor's office and making sure
that appointments are kept. Case managers often discover that a significant
proportion of referred cases are eligible for Medicaid, social security disability,
or a state program that provides insurance to children.
Specialty network physicians also need access to diagnostic imaging,
endoscopy suites, and operating rooms. These needs require that the project
leadership and management negotiate with hospitals and imaging centers to
donate their services.
One referral network, organized by a medical society in Florida, has
recruited 280 specialists. In the early years, the project made 35 referrals
per month. Since then, this number has grown to more than 55 per month. Since
the project began, the network's central office has arranged specialty care
for almost 2100 patients and provided an estimated $2.5 million in services.
These projects involve both freestanding clinics and referral network
components. Physicians can either volunteer their time in a clinic setting
or see patients in their own offices. Over the years of the Reach Out program,
a number of freestanding clinics have found that specialty services are more
easily arranged in private office settings. These projects often provide primary
care services at the clinic and refer patients to specialists in their network
of volunteer providers as needed.
In 1 North Carolina community, a volunteer clinic's patient demand strained
its capacity. Physician leaders in the community succeeded in recruiting 436
physicians who were members of the local medical society (85% of the membership)
to volunteer at the clinic or see patients in their offices. For fiscal year
1999, the county commissioners appropriated $240,000 to support the purchase
of pharmaceuticals for eligible patients, and the hospitals support all inpatient
and ancillary services. The project serves 6662 patients out of an eligible
population of 13,000 in the county.
In rural areas, public health agencies, hospitals, and medical societies
have joined together to form not-for-profit corporations to sustain primary
care practitioners, reduce emergency department use, and make care available
to the uninsured. Incorporation has permitted these communities to qualify
as rural health clinics and become eligible for cost reimbursement under federal
regulations that pertain to rural health.
Two rural areas, 1 in Maine and 1 in North Carolina, found their hospitals
in major financial distress and their physicians overwhelmed, underpaid, and
threatening to go elsewhere or retire. Jointly sponsored not-for-profit corporations
have brought organizational expertise and improved reimbursement to these
communities. Through their administration, they have produced improved physician
coverage, decompressed the hospitals' emergency departments, and streamlined
billing. The extra money stemming from the cost reimbursement formula has
freed funds that can be used to provide care to people without insurance.
Physician leaders, working with hospital and public health directors, have
saved the health infrastructure in these rural communities.
The rural integrated primary care model has close organizational and
administrative links with public health. In contrast, the public heath private
partnership model focuses on clinical collaboration between public health
departments and physicians in private practice. Some projects have encouraged
partnerships between public health nurses and physicians in private practice.
While visiting patients, nurses come to know their patients' medical, social,
and economic problems. When they are able to address these issues, the visit
to the physician becomes less complicated. Such simplification has made physicians
much more willing to see patients with complex social and medical problems.
Projects in Alabama, California, Nebraska, Oregon, and South Carolina have
shown the value of this partnership.
A variation of this model was developed in a California city. The medical
director of a local health department, facing a budgetary shortfall, worked
with her local medical society to recruit physician volunteers to work in
the public health clinics and provide specialty care or elective surgical
procedures in private settings. Volunteer physicians have seen 6450 clinic
patients and performed 159 surgical procedures in area hospitals.
One plan in Tennessee has made notable progress and received national
recognition.12 The Memphis Plan, led by a physician
who is also an ordained minister, is a health plan serviced by volunteers
and designed for near–minimum wage uninsured workers of small employers.
Employers cover their workers through a premium of $35 per employee per month
($20 for spouses and children aged 12 years or older; $15 for children younger
than 12 years), and employees pay $5 per visit. The plan covers all sick and
well outpatient care as well as inpatient care for adults and children aged
12 years or older. One hundred seven primary care physicians and 63 specialists
have agreed to see Memphis Plan enrollees.
Neither physicians nor facilities are reimbursed for care. Premiums
and copayments support the administration of the program, particularly marketing
expenses. Reach Out grant funding provided the support needed to make the
plan known to the small business community and get it launched. Enrollees
have grown from 200 to 1394, and now 353 employers offer the plan. Premiums
reached $226,186 in 1998.
Founded by surgeons at 2 of the leading teaching hospitals in the San
Francisco, Calif, area, this project provides elective surgery for people
who would otherwise go without care. Typical procedures include hernia repair,
varicose vein removal, and biopsy or removal of soft tissue lesions. Surgeons
garnered commitment to provide such procedures, which required enlisting the
entire surgical team, operating room time, and supplies for the operation.
Over the past 3 years, they have recruited 28 surgeons, 7 anesthesiologists,
and 83 surgical support staff. The project has organized more than 385 operations,
and 63 patients are on the waiting list. Two other California communities
as well as communities in other locales are planning to initiate similar programs.
Without access to appropriate pharmaceuticals, the Reach Out projects
could not function effectively. Given the expense of many medications, obtaining
prescription drugs for patients was a notable challenge. For most projects,
there was no single stable source of support. Instead, they had to cobble
together a program that would meet the needs of their patients.
Grants to support generic formularies proved very useful. Support came
from local charities, local governmental units, and hospitals. Some projects
elicited hospital support by gathering data to convince the hospitals that
the Reach Out projects were reducing emergency department use.
Pharmacy assistance programs, sponsored by pharmaceutical manufacturers,
were essential to most projects. There are more than 60 programs offering
more than 800 medications. Because of varying application processes, eligibility
requirements, and changes in drugs offered, these programs are very difficult
to use and require dedicated staff and volunteers. To simplify this process,
several projects, working with the NPO, developed a Web-based program called
RxAssist. This tool permits anyone to search by class of drug, generic name,
brand name, or pharmaceutical company and to determine the process of obtaining
Most projects used professional samples. While helpful, they have the
disadvantage of small-dose packaging and the medications available are newer,
more expensive classes of drugs. Relying on them for chronic conditions such
as hypertension is problematic.
Following the example of Kentucky and Arkansas, a Reach Out project
in South Carolina convinced several pharmaceutical companies to develop a
statewide formulary for the benefit of project enrollees. Physicians in their
offices write prescriptions for eligible patients, who then fill them at their
local pharmacies. The pharmacies are subsequently restocked by the drug company
at no cost. Several thousand patients have received medication through the
program. While the impact is modest relative to statewide need, it is a promising
approach with potential for growth.
The Reach Out experience illustrates a variety of approaches to care
for the underserved. All of these models can work. Success has been most difficult
to achieve in urban centers, where the numbers of underserved were vast. Which
model a community might choose to pursue depends on local circumstances, including
the background and inclination of local physician leadership and the availability
of other services in the community. Persons planning such projects should
be mindful of the following lessons:
Physician leadership was an indispensable ingredient for the success
of the projects. Physicians' ethical commitment and persuasive powers brought
their colleagues into the projects. Development of clinical services would
not have occurred without their guidance.
Physician time devoted to clinical work was not excessive. Typically,
physicians in volunteer clinics spent between 1 and 4 half-day or evening
sessions per month; the physicians in private offices saw only a few patients
Physician concern about malpractice regularly surfaced. This issue
was solved in a variety of ways. Physician recruitment did not suffer, and
no malpractice suits have been filed. The impression that the underserved
might be more litigious than insured individuals has not been borne out.13
Physicians in the private office setting saw not only those without
insurance but, in many projects, they also opened their practices to Medicaid
patients. Willingness to see uninsured and Medicaid patients was enabled by
collaboration with public health nurses. This approach deserves serious consideration
in many communities.
From time to time, patients presented with complex problems for
which projects did not have the resources or referral base to meet contemporary
standards of care. A San Diego, Calif, Reach Out project directly faced this
Through case management, projects frequently found that patients
who presented without insurance were eligible for a publicly supported program,
such as Medicaid, or, because of disability, Medicare.
Carrying out these projects was more complex than expected. Significant
progress often did not appear until late in the third or the fourth year of
grant funding. Projects had to recruit and schedule physicians to provide
care; arrange for the laboratory, diagnostic, and pharmacy services; know
their prospective patient base and make the project known to those patients;
and determine eligibility requirements. Language competencies, transportation
of patients, and the complex social and financial problems of patients emerged
as challenges. Skills in working with community groups and finding local sources
of support in dollars or in kind were also essential.
Programs need a funded administrative structure. The tasks of
recruitment, scheduling, marketing, information management, and case management
require paid staff. The staff need not be large to be effective.
Bringing project leaders together is very valuable. Many Reach
Out leaders have worked on the problems of the uninsured against great odds.
Many have expressed a sense of frustration and fear of burnout. Coming to
know colleagues from around the country has been an immense source of support
and has provided the opportunity to exchange ideas and best practices.
More than two thirds of the Reach Out projects are likely to sustain
themselves once grant funding ends. By demonstrating effectiveness to local
foundations and public agencies, sources of support have come forward.
The Reach Out program was the first nationwide effort to mobilize private
practicing physicians to collaborate with other stakeholders to increase access
to care for the underserved. The success of this effort, in both the number
of patients served and the number of physicians involved, demonstrates the
effectiveness of these partnerships. Given that there are now more than 44
million uninsured people in the United States,14
the comparatively modest efforts of the Reach Out projects may seem like a
drop in the ocean. On the other hand, a view from the local communities shows
gathering momentum, more and more people being served, and a sense that the
financial resources can be found to sustain core administrative functions.
This is the view from the bottom up—from 0 patients seen to several
hundred or several thousand being cared for.
Rigorous evaluation with specified outcomes was not feasible. Reach
Out happened in many different settings and without a defined model. Thus,
we could not address such questions as what sources of care, if any, patients
might have used in the absence of the Reach Out project. However, direct observation
of many flourishing projects supports a claim of real impact on the lives
A major expansion of Reach Out would not solve the growing problem of
access to health care. One thousand organized programs, performing as the
Reach Out projects have on average, would provide care to about 5 million
uninsured and underserved persons, a small but important fraction of the large
national problem. Moreover, 1000 projects would recruit nearly 300,000 physicians,
a very high proportion of practicing clinicians in the nation. Sensitizing
this large cadre of physicians to the problems of underserved persons would
draw respected voices that otherwise might be silent into the political debate
over access. It just might be possible to build the will for change through
the daily care of those outside the system—looking in.