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University of Tennessee College of Medicine in Chattanooga and one of the founders of Project Access in Chattanooga.

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Award: Community Outreach award recognizes a company or organization that reached out of its normal sphere of operation to focus attention on a health care issue to help solve a community health problem.

Winner: Project Access

Accomplishment: In 12 years, Project Access has provided more than $145 million in free medical care.

Dr. Joe Cofer says he got the idea for Project Access because he decided to go to Haiti.

A fellow doctor asked him to go on a humanitarian mission and for a week and a half he performed hernia operations for free in the crowded Caribbean nation.

But when he got home, Cofer said, he had an epiphany.

"I thought, I've flown to Haiti and spent 10 days, I've fixed 23 hernias, and paid $10,000 for it. Why don't we stay here and fix hernias in Hamilton County for free?"

When Cofer became president of the Medical Society of Chattanooga and Hamilton County, he decided to pursue his idea. He'd heard about a program in Asheville, North Carolina, that provided free care, so he asked an administrator who worked there to come to Chattanooga and explain how it worked.

Although it has been more than a dozen years, Cofer vividly remembers the meeting at the Mountain City Club downtown. About a dozen of Chattanooga's top doctors and hospital administrators were present. "The CEO of Erlanger, the CEO of Parkridge and the CEO of Memorial were all there," he recalls. "That alone was a ground breaker."

The argument for providing free specialty care to those who could not afford it was straight-forward: It made much more sense for doctors to treat patients before their illnesses became serious.

"If you bring a woman in with gallstones and operate on her as an outpatient, that will prevent that woman from coming to the emergency room and spending three days in the [Intensive Care Unit]," Cofer says. "You're gonna to have to take care of her either way—you can do it electively, or you can wait until she comes into the emergency room."

Much to Cofer's surprise, "They all said 'we'll do it,'" he says. "I said. 'I can't believe this.'"

The three hospitals and the medical society all donated money, a total of about $200,000 in startup funds, and hired Rae Bond, who had worked in politics and with public policy groups such as the National Governor's Association, as executive director. Bond wrote a successful grant application for $1.9 million to help fund the first three years. "That is probably my single greatest accomplishment," Bond says, looking back at Project Access' beginnings. "I wrote it in 21 days."

Then came the hard part: figuring out who qualified for care, how they would be evaluated, and how doctors would be recruited to volunteer.

The group formed an operations council, with one member for each participating organization, and recruited physician "champions" in each specialty area, charged with recruiting doctors. Computer software was written to handle intake and billing, and a staff of counselors were hired who would work out of the second floor of the Medical Society offices on Third Street.

Dr. Cofer performed the first surgery himself, a hernia operation, if Bond remembers correctly.

Today, Project Access is a model of efficiency. Most of its cases come from primary care doctors working at the dozen-odd neighborhood health clinics that provide free basic health care for Chattanoogans who can't afford it. A major referral source is Volunteers in Medicine, a faith-based group founded by Dr. Robert Bowers that provides primary care, but cases may also come from Clinica Medicos, which serves the Hispanic community, or one of the clinics affiliated with Erlanger or CHI Memorial.

If a potential patient calls Project Access directly, they are referred back to their primary care doctors for a referral, and if they have no primary care home, Project Access sets them up with one.

The initial screening is done by phone by one of five care coordinators. The primary care doctors include a referral form when they send a patient to Project Access outlining what specialty care they believe the patient needs.

The counsellors check potential patients for eligibility. They cannot have or be eligible for any form of health insurance, they must have lived in Hamilton County for 90 days, and they cannot earn more than 150 percent of the federal poverty level.

If they meet those criteria, they are then screened in person and if accepted, they receive an ID card with dates of eligibility, just like an insurance card. "The card is entered in the [hospital] billing systems as if we were an insurer," Bond says, "so it generates the claims data that is sent to us so we can track what was done. Then their systems write it off to charity. We're like a big insurance company where nobody gets paid."

Doctors and other medical staffers who volunteer for the program state in advance how much of their time they will donate. "Most specialists commit to providing care to 10-to-20 patients a year," Bond says.

About 375 patients currently have Project Access cards and approximately 900 local doctors, nurse practitioners, physician's assistants and oral surgeons participate.

In the dozen years since the project was launched, more than 7,000 patients have received care that Project Access values at more than $145 million.

Most of the patients are what longtime Project Access medical director Dr. Walter Puckett calls "the working poor—people who are working and don't have access to health insurance. A lot are 45 to 65 years old who have worked most of their lives, who lost jobs through downsizing, and they get medically disabled."

Bond becomes emotional, her eyes tearing up as she discusses how important she believes the program has been for Hamilton County. "For a lot of our patients this has been the difference between life and death, between sight and blindness. It truly saves lives, saves people's capacity to be contributing members of society, working for themselves and caring for their families."

Joe Cofer is equally convinced. "For people in Hamilton County in a state that hasn't expanded Medicaid, it is a godsend," he says. "There are a lot of people who show up with breast cancer or colon cancer, and have nowhere to go. It will rip your guts out, the heartfelt thanks some of these people have. They have been at wits end, at the end of the road"

But while he is pleased with the success of Project Access, Cofer believes there is more to be done. Health care is a right, he said, but it is not always a reality.

"I can't count the number of times I have seen a young woman, someone 30 or 40 or 50, with breast cancer. And it is obvious the cancer has been there for six months, but she didn't tell her husband about the lump in her breast because she was afraid they would lose their house. And by that time they're not fixable," he says. "They're dead."

"That's criminal," Cofer says. "But that's the real world."

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