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SEPTEMBER 2014
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Health Network

A new program brings affordable health care to the uninsured of Las Vegas. It started in Nevada - but it's creating a stir across the nation

In 2007, Reno security guard Ron Watson lost his job - and his health insurance. At his doctor's recommendation, he applied for membership with Access to Healthcare Network, a then brand-new discount health care provider for the uninsured poor. Two years later, he was fighting prostate cancer, which meant 10 biopsies, a battery of tests and 45 sessions of radiation, five a week. But his connection with Access, which operated only in the Reno area, proved invaluable.

During his radiation treatment, he met with his doctor weekly. The regular fee for office visits was $751; he paid only $70. (These savings multiplied over the nine weeks of treatment.) An arm implant to lower his testosterone levels ordinarily cost $5,000; he paid $250. The network also helped connect Watson with other sources of financial aid, courtesy of the American Cancer Foundation and the American Cancer Society. Watson even had his own care coordinator who scheduled his appointments.

The treatments saved his life; the innovative health care network saved him thousands of dollars. Now his cancer is in remission and he's feeling fine.

"They came through with flying colors," he says of Access to Healthcare Network.

On the other hand, most Americans came through this year's debate over health care reform with a giant question mark. What got reformed exactly? Who were the winners and losers? Health care may have galvanized Tea Partiers, but it's unclear whether they have any more idea about the state of our system than anyone else.

By contrast, Access to Healthcare Network represents an almost embarrassingly straightforward idea: Connecting Americans with no insurance and limited means to pay for care with a comprehensive network of health care providers willing to provide medical services at a steep discount. Since its 2006 debut in Washoe County, the network has engaged more than 700 health care providers to serve more than 7,000 county residents. Now Access is headed south. In December, the network begins accepting clients in Southern Nevada.

It all started in... Reno?

The need has never been higher. More than 600,000 Nevadans don't have health insurance, according to the Great Basin Primary Care Association, a statewide group of primary care clinics. Two-thirds of those uninsured are in Southern Nevada. Nationally, 58 million lack adequate health care.

And to think the epicenter of an experiment that might solve this problem is and Reno? Sherri Rice, the charismatic director of the non-profit network, is quick to remind that we're in Nevada, a state where, like the Titanic, we're "arranging the deck chairs every day in this state." In other words: Sometimes the best medicine comes from the sickest places.

Access traces its roots to a handful of stakeholders in Reno - Renown and St. Mary's hospitals, Washoe county officials, a smattering of health care and business professionals - who were trying to provide primary health care to the uninsured poor.

Rice, who's lived in Washoe County for 33 years, has a background in consulting nonprofits. She calls herself a "systems expert. I come in and really overhaul the systems." When she was brought into run the network, her mandate was to design a comprehensive health care model from the ground up. That meant developing a shared responsibility model - in which patients became active stakeholders - and greatly expanding the scope of services the program required. Primary care alone wouldn't cut it.

"In the beginning everyone was a skeptic," says Rice. "Even me. I wondered if anyone was going to pay. It's like opening a restaurant and hoping people come in to eat."

Access to Healthcare Network is not an insurance plan. Here's how it works: If you're poor and uninsured, and if you make between 100 percent and 250 percent of the federal poverty level, you can join its network of discounted health care providers. In three short years, Rice has brought together 700 providers in Northern Nevada.

Insurance broker Valery Clark had a friend whose daughter was involved in an accident and required surgery. Her friend had no insurance for his daughter; paying for her bills would have put him in bankruptcy.

"They got her enrolled on the plan, and everything was totally by the book," says Clark. "His daughter's entire top-to-bottom cost was probably around $1,000."

The network is about much more than a simple co-op model, however. For instance, it launched a special fund to help patients with particularly challenging diseases such as HIV or cancer, and has taken in $500,000 in donations over the last three years. On top of that, Access has also begun an individual development account pilot program in partnership with Wells Fargo and Charles Schwab. Members (40 so far) who open an account with the bank and receive financial literacy training can put in a minimum of $25 a month into a special account to help pay for medical services. The plan will match it in donated dollars, up to $500 a year.

Unlike fly-by-night discount plans that aren't regulated by the state, the state's Division of Insurance oversees the network.

"Her program is very unique," says Kim Everett, acting chief of the Nevada Health and Life Section of the Division of Insurance. "I think you'd be hard-pressed to find anything similar to it." The Division of Insurance has received no complaints about the network.

"I don't think there's any type of similar entity in the United States. I don't think of any health care program that's not insurance," says Donald van Dyken, a family practice physician in Reno. "If you didn't see them at your office, you'd see them at the emergency room."

But then again, Reno is a small, tightly knit community. There are only a few hospitals. Getting stakeholders together in one room is a manageable proposition. But how would Access to Healthcare Network fare in rural Nevada, with its spare and spread-out population? And how will it fare in Southern Nevada? By the end of the year, we should start to find out, because the network is expanding across rural Nevada and straight into the Las Vegas Valley.

Friends with (health) benefits
On a day in early September, the staff at Access to Healthcare Network is moving into new offices near McCarran Airport. Kara Jenkins, who runs the network's operations in Southern Nevada, is as busy making sure the office furniture is in place as she is hiring staff. She likens patient care to finding a good hairdresser - quality service leads to quality word of mouth.

"It's a pretty straightforward model and program," says Jenkins, "but it takes a lot of courage to do this." Right now, Jenkins, Rice and their staff are recruiting providers in the Las Vegas Valley. Given that there are some 400,000 uninsured in Las Vegas (that's more people than in all of Reno), it's not an easy task. Still, Rice says the Reno model "barely had to be tweaked" to come into Vegas. "Helping the uninsured poor is helping the uninsured poor." Eighty percent of Rice's members are working; 65 percent work full-time.

What's in it for the providers? For doctors, "If it works for them to have a lot of cash pay patients who may pay less than some other patients but there are more of them, they see it as a balance," says Lise Mousel-Martini, the network's provider recruitment manager. "For some of the specialists who charge very high dollars to begin with or their practice is full, they either don't have the room or really don't see a reason to add another level of patient care that is at a lower rate."

As for hospitals, non-profit facilities are bound by statute to do charitable care. For-profit hospitals have their altruistic side, too, but they still have to worry about the bottom line. With Access, for-profit hospitals may help direct the uninsured poor out of emergency rooms - venues where hospitals have to treat whoever comes in. "The most expensive care you can get is an emergency room setting," Rice says.

Emergency rooms are expensive, in part, because you need staffing for everything: a cold or sore throat, a heart attack or head trauma. The value proposition the network offers hospitals is this: Can they cut costs by seeing more uninsured patients, and seeing them at a discount, or by waiting for those patients to turn up in an emergency room, where expenses are high?

"Nobody in Las Vegas wants to take care of any more than they have now," says Rice. "Nobody. So, also it's an issue of [needing] to get almost all the hospitals to come on so there's a shared responsibility. We can't ask one hospital to do this."

One brick at a time

Access is negotiating with the Clark County Social Service Department for a pilot project, which will include University Medical Center, and Rice is in negotiation with the other hospital systems in the valley. She thinks they will be "generous of spirit and come on." But for Access to work, it has to be more than doctors, patients and hospitals. The rest of the elephantine medical-industrial complex has to be involved as well. This includes labs and manufacturers. Wheelchairs and crutches. Podiatrists and dentists. Discounts need to be negotiated in advance; otherwise, they need to be negotiated on the spot.

Three lab and diagnostic centers - Nevada Imaging Center, LMC Pathology and Primex Lab - have signed on, along with 60 physicians, though Mousel says they need many more. Still, she is upbeat.

"We're doing pretty well getting the pieces in place we need so we can offer our members a full complement of care," she adds. "We're building a wall a brick at a time and so far we're finding most of the bricks that we need."

The program with the county is still being finalized, but Nancy McLane, the director of Clark County Social Service, expects it to be finalized by year's end. She says the contract with the network will allow the county to offer patients who don't qualify for county-run programs a viable health care alternative. Some patients who are already in the county's system will be able to access the network for specialist care that UMC can't meet, such as dermatology, orthopedics and some radiology. Third, Access to Healthcare Network will treat undocumented workers, which should lower medical costs for the county.

"If there's another way for them to get care before they get sick, it benefits us financially," McLane says, "and it also keeps the emergency rooms from being backlogged [with patients] who could be treated elsewhere." Still, Rice has been careful about rolling out the program too quickly. When asked how she plans to get the word out, she cautions that, in a strange way, she doesn't want the word to get out. For her, quality control is everything, and it's why, in order to keep the program humming, she and her staff are keeping tight reins on it. In Northern Nevada, Access receives no more than 200 new patients a month; the network won't take any more than 100 to 150 people for the first year in Southern Nevada.

"If we were to be inundated with thousands of people at a time," says Rice, "which we could be, our quality would go down and then people would say, 'Access to Healthcare Network sucks.'"

The program is stingy, too. There's no online application; patients must come in person to fill out an application and meet with a care coordinator. No-shows? Try again in three months. And members who don't bring cash to their appointments don't get seen. It's as simple as that. This means that the program self-selects those most likely to be successful.

The plus side is that of 7,000 members in Washoe County, Rice has only had to ask 40 people to leave for non-payment.

"We made getting into Access a form of responsibility. That's why we've been so successful." On the other hand, there are 130,000 uninsured in Northern Nevada, 80,000 in Washoe County.

Access goes to Washington

Rice is a hell of a saleswoman. She says she "could sell a book with no paper if I believe in the program."

But this may be her biggest sales job yet. For the last couple years, she has been traveling to Washington, D.C., meeting with Obama administration officials like Health and Human Services Secretary Kathleen Sebelius and Nancy-Ann DeParle, director of the White House Office of Health Reform.

Peggy Tighe, a partner with Strategic Health Care, a Washington, DC-based hospital lobby, met Rice in 2008 and found herself a quick convert to Access's model.

"This was jaw-dropping to me. We have spent years talking about all the different pieces and parts of what health care reform should contain, and AHN contains all of these things."

Rice's Washington trips led to a small section in the health care bill that seeks to replicate the network and "provide access to comprehensive heath care services to the uninsured at reduced fees." The plan calls for a three-year pilot project in 10 states.

The problem? The health care bill was not entirely funded; so Access will have to wait until next year to determine whether funds to roll out a version of the program elsewhere will come through. Rice says she's broached the idea of franchising the model- and she's talking with a patent attorney about copyrighting aspects of the program - but she's uneasy with being responsible for the quality of, say, an Access to Healthcare Network franchise in Ohio.

"We're not sure we want little McDonald's all over the place." Consulting, she adds, might prove to be a better model.

Either way, Rice's work may help us reclaim a piece of our health care system. It's a model that's rooted in values that the left and the right should be able to get behind: It requires that everyone, especially patients, have skin in the game, but it also shows what happens when public and private partners can join forces and consider something greater than the bottom line.

"You don't need a planning grant," says Rice. "You don't have to wait until the cows come home. We've got the model. You could start in six months and get people the care they need."

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