Organizing Charity Care

In the Portland, Ore., metropolitan area, the challenge was clear: More than 300,000 people lacked health insurance, a number only likely to climb, given a weakening economy and national trends. Such uninsured people usually end up relying on charity care — physicians and hospitals that provide hundreds of millions of dollars in services at no charge.

This situation “punishes the good hearted” in the medical world who are willing to provide

SURVIVAL STRATEGIES Seek a fiscal sponsor — an established nonprofit group that can accept tax-deductible gifts on a fledgling organization’s behalf. Ask for noncash support, and be prepared to maintain a close relationship with the donors who give it. Collaborate with other organizations, and make the most of existing local resources to meet clients’ needs.

free care, says Linda Nilsen-Solares, executive director of Project Access Now, a new nonprofit group designed to spread the burden of providing free medical care in a more organized way.

“Doctors fall along on the range of sainthood,” says Ms. Nilsen-Solares, a veteran of local nonprofit health-care groups.

Doctors who are willing to take patients who cannot pay, she adds, are sent such patients repeatedly by charities, overwhelming the health-care providers. As a result, she says, some stop taking uninsured patients, which increases the load on the whole system and worsens the crisis overall.

Project Access Now, a group created in January by a coalition of charities, hospitals, and health systems in and around Portland, seeks to tackle the problems caused by the lack of health insurance.

The group found plenty of support among local medical and social-services organizations, owing in part to its emphasis on collaboration. It also discovered that a focus on seeking noncash donations helped it gather the resources it needed to get started, even though it was born just as the nation’s economy began to slump.

Starting From Scratch

The idea for Project Access Now came from a group of physicians in Buncombe County, N.C. They have spurred the creation of some 50 efforts nationwide to register patients and direct them to medical providers who have signed up to volunteer their time.

The goal is to spread the load of charity care more equally among doctors, medical labs, pharmaceutical providers, and others involved in health care.

The fledgling Portland group faced significant challenges but also had a few advantages.

On the plus side, its emphasis on collaboration had worked well in other parts of the country, and it had won a grant of $25,000 from the Medical Society of Metropolitan Portland, as well as a $50,000 grant from the now-defunct Tri-County Health Care Safety Net Enterprise. The money paid for Ms. Nilsen-Solares’s time and some database work.

But the charity needed everything else, including a greatly expanded database to coordinate all of the information about clients and volunteers, the creation of marketing materials, a means of sponsoring meetings to get all of the many players in the health-care system in the area together, and, of course, an office in which to work. All of that would take money and resources and would be tough to procure in a stressed and shaky economy.

As the executive director and the charity’s fund raiser, Ms. Nilsen-Solares decided that, at least initially, she would seek noncash donations.

First, she knew that this would be easier for her potential donors — mainly hospitals and health systems, and others involved in health-care philanthropy in the area — to provide. “They could absorb our costs within existing budgets, so it wouldn’t feel quite so hard for them,” she says.

Also, she was aware that while Project Access Now had the advantage of novelty — “the flavor of the month,” as she puts it — it also, as a result of its newness, lacked a track record that it could use to lure support and reassure donors in a time of economic uncertainty.

“We had this vision, but we had nothing concrete,” she says. “So I could say to people, if you will believe in us enough to give us in-kind support, we will create something. And then you will want to fund us.”

This approach has proved to be successful. The health-care players that Project Access Now would work with also provided its noncash support, to the tune of $125,000 worth of goods and services in the charity’s first year.

Early Supporters

Among the donors were several hospitals and medical providers. Legacy Health System provided office space and supplies and covered the new charity’s telephone expenses. Adventist Medical Center provided computers and software. Tuality Healthcare designed the charity’s Web site and keeps it running. Willamette Falls Hospital provided legal services, while CareOregon and Columbia United Providers, both regional health-insurance programs, agreed to handle all of Project Access Now’s billing paperwork.

Several organizations provided both cash and services, such as Providence Health System, whose cash gifts were supplemented by the services of its pharmacists, who helped Project Access Now to develop a program to allow it to make prescription drugs available to its clients.

And some just gave money, like Pacific Source Health Plans, a local insurance provider that provided support for creating and maintaining a database, and for collaborative meetings, as well as $100,000 to pay for a marketing campaign.

Perhaps most crucially, the United Way of the Columbia-Willamette, in Portland, served as the charity’s fiscal sponsor, accepting tax-exempt donations on its behalf and performing all its bookkeeping, before the new group received its public charity status from the Internal Revenue Service this summer.

Additionally, the United Way donated $75,000 and $155,000 in the 2007 and 2008 fiscal years, respectively.

While Project Access Now ran on $196,000 in cash during its first six months of existence, it expects a budget of $469,560 in its current fiscal year, according to Ms. Nilsen-Solares.

Close Ties

A noncash donation is perhaps easier for a cost-conscious donor to absorb, but the transaction involves a closer relationship between giver and recipient than simply writing a check. The mission of charity and supporter must be well aligned, says Kari Stanley, Legacy Health System’s director of community relations and community programs.

For instance, Legacy, which provided Project Access Now with its office space, also offers the same donation of space to other charities (11 groups, for a total cash value of $350,000).

But Ms. Stanley says she fields many more requests for office space than she can possibly accommodate.

“Whether it’s a request for a cash donation or in kind, our first question is, what’s your relationship to our health system? What’s our year-round relationship?” she says. “There are thousands of great nonprofits in Oregon, and unfortunately we don’t have the money or the resources for every one.”

In the case of Project Access Now, Ms. Stanley says, the answers to her questions were clear.

“Their mission is to provide health care just like our mission is, and they are helping to provide health care to the uninsured, which is a cost to us,” she says. “Last year, we had $62-million in charity-care costs in our system — that’s a huge amount of money, and that’s not even counting the additional costs for care that could have been avoided should someone have had access to primary care or been treated sooner.”

Flexibility Needed

Like Legacy Health System, the United Way of the Columbia-Willamette saw in Project Access Now a tight fit with one of its missions — improving access to health care — but also was attracted by the collaborative approach it followed, according to Maileen Hamto, a United Way spokeswoman.

“We focus a lot on collaboration and getting people in the community to work with one another to solve problems,” she says. “Project Access Now is a perfect example of this.”

Charities that are considering seeking noncash donations to bolster budgets hit by the economic downturn should be aware that accepting this sort of gift does require a certain mind-set, says Ms. Nilsen-Solares.

“When you go to a vendor, and you have a contract, you can expect to get what you pay for. But that’s not how it works with an in-kind partnership,” she says.

She compares it to the challenge of asking a staff member to tackle a chore versus enlisting a volunteer to do it — flexibility is the key, and timetables need a lot of padding.

“When you need something from a partner, you might not always get it at the time you want, or in the quality you want, and you need to relax your control over that,” Ms. Nilsen-Solares says. This requires a charity leader to let go of any impulses to oversee every detail, and it also requires a charity to manage expectations with the people who rely on it.

For instance, the physicians who volunteer to aid Project Access Now have a “gentleman’s agreement” with the charity not to bill patients for services that are referred to them through the program, says Ms. Nilsen-Solares.

But no contracts are signed, so “there is a possibility that someone might get a bill, so we have to be honest and manage expectations with our patients, and say, this is a volunteer program, and we can’t promise you anything,”she says.

“But we will do the very best we can to make sure you don’t get billed, and help you access every single resource, and we will walk through the fires with you if necessary,” Ms. Nilsen-Solares says.

The charity leader adds: “Now I’m confident that 99.9 percent of everyone who goes through Project Access Now is going to have their bills paid for, but gosh, I’m not in control of the entire health-care system.”

Project Access Now has just started to work with patients. Some 200 have been referred to the charity so far, and about half of those patients are in the process of being referred to physicians who have agreed to donate their services.

As the organization begins its work in earnest, Ms. Nilsen-Solares says she will be more likely to seek cash contributions rather than goods and services.

She is optimistic about the new charity’s ability to draw continued support.

“I feel that the return on investment to the community will be such that it is going to make sense for people to support us, from all different sectors,” says Ms. Nilsen-Solares.

But she is also aware that those initial investments in Project Access Now were made on faith.

“We have to prove that the efforts that we are making are providing what they say they’re going to provide,” she says. “We’re in our honeymoon still, and it’s a year from now that our mettle is really going to be tested.”

And, she notes, “if it were simple, it would have been done already.”