Domestic volunteerism: Dr. Freiwald brings surgical care to uninsured patients in San Diego

Editor’s note: The American College of Surgeons (ACS) Operation Giving Back (OGB) program presents annual Domestic and International Surgical Volunteerism Awards, which are accorded in recognition of those surgeons who are committed to giving back to society by making significant contributions to surgical care through organized volunteer activities that go above and beyond the usual professional commitments.

To further acknowledge the efforts of these volunteers, the Bulletin is publishing occasional profiles of recent recipients of these awards.¹ This month’s profile is an interview with the recipient of the 2016 Domestic Surgical Volunteerism Award, Sandra L. Freiwald, MD, FACS. Dr. Freiwald, a general surgeon in San Diego, CA, received the volunteerism award for her work with Project Access San Diego, an organization focused on improving community health and support for physicians through engaged volunteerism.²

What are Project Access San Diego and Champions for Health?

Founded in 2004 as the San Diego County Medical Society Foundation, Champions for Health is a not-for-profit organization that addresses “the unanswered healthcare needs of low-income and uninsured San Diego County residents.”³

Project Access San Diego Saturday Surgery Days is a joint project of Champions for Health and Kaiser Permanente San Diego. Since 2008, the two groups have partnered to provide free outpatient surgical services to uninsured San Diego county residents. Twice a year, for a half-day on a Saturday, hundreds of volunteers, representing general surgery, orthopaedics, ophthalmology, and other specialties donate their services to provide outpatient and clinic-based surgery and other procedures. We typically use four operating rooms, where the surgeon volunteers perform hernia repair, knee arthroscopy, and cataract removals. At the same time, physicians representing other specialties, including gastroenterology, urology, and vascular surgery, are performing colonoscopies, adult circumcisions, and vein injections for non-healing venous stasis ulcer procedures in the clinic. On a typical half-day, about 14 patients undergo surgery and another 14 to 20 will have flexible sigmoidoscopy or colonoscopy. By addressing the health care needs of the community’s most vulnerable population, Project Access San Diego helps to prevent life-threatening or chronic medical conditions in uninsured patients.⁴

How did Project Access San Diego get started?

The Project Access model started in North Carolina in 1996.⁵ The physician members of the Buncombe County Medical Society, now the Western Carolina Medical Society, recognized the need for access to all aspects of health care for low-income, uninsured residents of the community. With a demonstrated commitment from physicians and other community partners, Project Access was able to begin providing care to these individuals.^5,6 There are now approximately 100 volunteer programs similar to Project Access across the country, which indicates that this model is relatively easy to implement in other areas of the U.S.⁴

In 2008, Kaiser Permanente San Diego partnered with Champions for Health to provide two half-day events per year at Kaiser Permanente outpatient surgery centers, which are called Saturday Surgery Days. Daniel “Stony” Anderson, MD, a now-retired gastroenterologist and member of the Southern California Permanente Medical Group Board, was instrumental in obtaining support for this partnership from the leadership of Kaiser Permanente San Diego. I was invited to be the surgical lead for the project by Mark Schumacher, MD, FACS, former  medical director of operating rooms at the Kaiser Foundation Hospital in San Diego, CA, who was aware of my interest in humanitarian surgery.

What is the health care situation in the area served by Project Access San Diego?

San Diego is considered home to one of the most sophisticated health care systems in the country. San Diego hospitals hold some of the highest ratings for both overall care and unique specialties. For example, in 2016, the University of California San Diego Medical Center was named the best health care facility in the region and sixth best in the state, according to U.S. News & World Report’s annual Best Hospitals issue.⁷ San Diego is home to 25 hospitals, and more than 26,000 unique health care and social assistance establishments that employ more than 140,000 people.⁸ Unfortunately, many residents of San Diego County are unable to access these services.

What is the ratio of physicians to patients in San Diego?

The San Diego County area has approximately 64 primary care physicians (PCPs) per 100,000 residents (recommended supply is 60–80 PCPs per 100,000 residents) and 147 specialists per 100,000 residents (recommended 85–105).⁹ Overall, California rates are 64 PCP and 130 specialists per 100,000 residents.⁹

What is the uninsured rate in San Diego?

As of 2014, the uninsured rate for California was at 11.9 percent, with 10.4 percent of residents receiving Medicare and 26.5 percent receiving Medi-Cal and assistance from other public programs.⁹ A total of 34 percent of California residents have annual incomes of less than $25, 000; and that same demographic is likely to be uninsured.¹⁰ At this income level, people are potentially eligible for Medi-Cal; however, they might be ineligible for other reasons, such as not being a citizen, which is the most common cause. Of the remaining uninsured, one in four is 25–34 years old, one in three is a noncitizen, and more than half are Latino.¹⁰ Most of the uninsured (62 percent) were employed.¹⁰ The percent of uninsured individuals in San Diego is 12.4 percent.⁹

How do patients find out about Project Access San Diego?

Community health centers and PCPs who provide services to uninsured individuals may refer these patients to Project Access San Diego for necessary specialty care. The Champions for Health medical director reviews referrals to ensure physicians assist those patients most in need of their services. (Extensive referral guidelines are posted on the Champions for Health website.) Once approved, a Project Access care manager becomes the primary contact for the patient and provides this individual with one-on-one assistance in navigating the health care system, as well as assistance with transportation and translation services.

What are the criteria to receive care through Project Access San Diego?

Patients must meet the clinical criteria for specialty referral laid out on the Champions for Health website, have a health care need of limited scope or duration, be at least 18 years old, and must earn less than 350 percent of the federal poverty level. For 2017, the federal poverty level is $12,060 for a household with one individual, and $24,600 for a household of four.¹¹

They must be residents of San Diego County and must not have any health insurance or workers’ compensation coverage. Patients must be ineligible for any publicly sponsored programs including Medi-Cal, Medicare, or Covered California—the state’s official health care marketplace, where individuals, families, and small businesses can obtain health insurance under the Affordable Care Act. It is the only place to get federal premium assistance to help buy private insurance or get health insurance through the state’s Medi-Cal program.¹²

Patients must agree to follow Project Access San Diego’s rules, as well as the prescribed treatment plan. Patients must promptly supply any information requested by the program, notify Project Access of income changes, apply for Medi-Cal or other programs at the request of Project Access, and be on time for all appointments.⁴

What are the leading causes of death in the area where Project Access San Diego provides service?

The leading causes of death among San Diego County residents in 2010–2012 were malignant neoplasms, heart disease, Alzheimer’s disease, chronic lower respiratory diseases, and cerebrovascular diseases.¹³

How did you become interested in the health care challenges facing patients in San Diego?

In 2006 and 2007, I had the privilege of working on a surgical project in Monrovia, Liberia, with Médecins Sans Frontières/Doctors Without Borders (DWB). It was an eye-opening and life-changing experience. It codified my belief that health care is a basic human right. The desire to be healthy and have your medical needs met is fundamental to our humanity. I anticipated continuing to use the generous sabbatical program the Southern California Permanente Medical Group offers to return to work with DWB. However, I gave birth to my only child in 2009, when I was 40 years old. Her arrival changed my level of comfort with traveling to potentially risky environments to provide surgical care to people in need. With that change in my life, I turned my attention to my own community, where, sadly, there are a large number of people who are unable to access specialty care.

How did you get funding for Saturday Surgery Days?

Since 2008, Kaiser Permanente San Diego has hosted 17 Saturday Surgery Days. More than 570 patients have been served and more than $3 million in care has been provided. The funding for the Saturday Surgery Days comes from the Kaiser Foundation Hospital (KFH), through its community benefit program. KFH provides the use of its facilities and other services pro bono. All of the physicians and non-union employees volunteer their time during Saturday Surgery Days. Union members also volunteer in a fashion approved by their unions—they are paid for their work and subsequently donate that money to Champions for Health.

What licensing and government approvals were needed to start the program?

Our Saturday Surgery Days are done in Kaiser Permanente facilities. Patients are provided 90 days of Kaiser coverage around the time of their operations (more if needed). The care is provided under the licensing of Kaiser Permanente.

How many health care professionals provide health care services through the Project Access network?

Throughout the county, the Project Access network includes more than 80 referring community clinics; more than 625 medical professionals who volunteer to provide pro bono care; 10 hospitals; 14 outpatient surgical centers and ancillary health services including imaging, labs, medical equipment, physical therapy; and so on.⁴ Through March 2016, more than 1,400 operations and procedures have been provided, with a value of care of more than $10.9 million.⁴ Approximately 4,500 uninsured patients have been assisted through this program and more than 11,627 specialty care appointments have occurred.⁴ These numbers are for the entire county, including the Saturday Surgery Days that I help plan at Kaiser Permanente San Diego.⁴

Where do you see the future of health care in San Diego heading?

Who knows where the health care situation is heading under the current presidential administration? It’s hard to imagine it will get any easier for the patients we serve to get access to health care. Our undocumented patients may have more reservations about seeking care due to fears of increased risk of deportation.

What advice would you give to other health care providers who want to start similar programs in their areas to work with uninsured patients domestically?

I’d suggest investigating whether their communities have a program similar to Project Access. Other programs may have already laid the groundwork for patient recruitment and referrals. The next step would be organizing your health care organization, partners, colleagues, hospitals, and surgery centers to host a day or half-day of volunteer operations.

Recruiting volunteers is the easiest part of my job. I can send an e-mail to my partners and within minutes have more surgeons than I can use at an event. The devil is in the details in terms of making an event like Saturday Surgery Days run smoothly. Our planning committee includes leaders from surgery and anesthesia, as well as nursing administration, pharmacy, radiology, security, environmental services, media relations, engineering and facilities, and the laboratory. I’m happy to be a resource to anyone who has questions about setting up a similar program.

Describe some of the program’s success stories.

The most memorable stories are those of the people in whom we diagnose malignancies, which we then treat. In 2011, a 38-year-old gentleman presented to us for colonoscopy for hematochezia and iron-deficiency anemia. He underwent a colonoscopy, which showed Stage III rectal adenocarcinoma and familial adenomatous polyposis. After diagnosis, Project Access and Kaiser Permanente San Diego provided him with neoadjuvant chemo-radiotherapy. He then underwent pelvic exenteration by a team of Kaiser surgeons. His family, including his children, was also screened for familial adenomatous polyposis. He is alive, well, and without evidence of disease and recently celebrated his daughter’s quinceañera, her 15th birthday.

What can the ACS and OGB do to help further your mission and domestic volunteerism?

The ACS is doing a great job of getting the word out about domestic and international volunteerism. The awards for humanitarianism and international and domestic volunteerism highlight some of the work ACS members are doing at home and abroad. The ACS is also providing a variety of lectures and hands-on courses at the annual Clinical Congress on volunteerism, humanitarian projects, and practical knowledge for working in low-resource settings. The Bulletin often highlights the work of Fellows in various underserved settings. Exposing surgeons to their peers’ volunteer work can inspire others to get involved.

It can be challenging to find a project for surgeons who are interested in volunteering. The OGB website is a wonderful resource for health care providers to easily access a long list of volunteer opportunities both at home and abroad. This list includes short- and long-term postings with secular and religious groups, for a wide variety of surgical specialties and for surgeons-in-training, in practice, or retired. This makes it easy for interested individuals to match their abilities and interests with patients who could benefit from their care.

Author’s note

For more information about Project Access San Diego and similar programs, visit the OGB website and the Project Access San Diego website.

OGB launched a new portal in early 2017 called the Volunteer and Partner Portal, where volunteers and partners can sign up to find and post domestic and global volunteer opportunities. Visit the website.

The ACS is interested in learning more about what members of the College are doing in their own communities regarding surgical domestic volunteer and service opportunities. E-mail ogb@facs.org to share your story.

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References

1. Fox M. Fellows honored for volunteerism and humanitarianism. Bull Am Coll Surg. 2016;101(9):62-67. Available at: bulletin.facs.org/2016/09/fellows-honored-volunteerism-humanitarianism/. Accessed April 18, 2017.
2. American College of Surgeons. 2016 Domestic Volunteer Award: Sandra L. Freiwald. Available at: www.facs.org/ogb/award-winners/domestic/freiwald. Accessed April 18, 2017.
3. Champions for Health. Our story. Available at: championsforhealth.org/our-story/. Accessed April 11, 2017.
4. Champions for Health. Project Access San Diego. Available at: championsforhealth.org/programs/project-access-san-diego/. Accessed April 11, 2017.
5. Western Carolina Medical Society. Project Access. Available at: www.mywcms.org/projectaccess. Accessed April 12, 2017.
6. Western Carolina Medical Society. Buncombe County Medical Society changes name to reflect growth in region. Available at: www.mywcms.org/news-and-events/newsroom/buncombe-county-medical-society-changes-name-to-re. Accessed April 12, 2017.
7. U.S News & World Report. Best hospitals in San Diego. Available at: health.usnews.com/best-hospitals/area/san-diego-ca. Accessed April 18, 2017.
8. San Diego Regional Economic Development Corporation. Healthcare. Available at: sandiegobusiness.org/our-economy/healthcare. Accessed April 12, 2017.
9. California Health Care Foundation. California regional markets: San Diego. Available at: www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20A/PDF%20AlmanacRegMktQRGSanDiego16.pdf. Accessed April 12, 2017.
10. California Health Care Foundation. California’s uninsured. Available at: www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CaliforniaUninsuredQuickRefGuideDec2016.pdf. Accessed April 12, 2017.
11. U.S. Centers for Medicare & Medicaid Services. HealthCare.gov. Federal poverty level (FPL). Available at: www.healthcare.gov/glossary/federal-poverty-level-FPL/. Accessed April 18, 2017.
12. Covered California. Medi-Cal overview. Available at: www.coveredca.com/medi-cal/. Accessed April 18, 2017.
13. San Diego County. Health and Human Services Agency. Leading causes of death among San Diego County residents, 2010–2012. Available at: www.sandiegocounty.gov/hhsa/programs/phs/documents/LeadingCausesofDeath2010-2012.pdf. Accessed April 12, 2017.