Collective Wisdom

On a cold and blustery March morning in 2013, Philip Lovejoy, the executive director of the Harvard Alumni Association, delivered a presentation on alumni engagement to members of the HMS Alumni Council. He ended by posing two challenging questions: how will you better engage your alumni, and what is HMS doing for them? His challenge gave me pause; as I was the council’s president-elect at the time, I knew we should explore the questions further during my year as president.

We did. And I could never have predicted where that exploration would lead us.

Nurtured sprout

The year was 2014 and the Affordable Care Act was about to be implemented. Council members had been discussing the fact that this would mean that millions of previously uninsured people in this country would be accorded health insurance, but that coverage would not confer access. They also recognized that our alumni ranks were filled with altruistic, world-class physicians who enjoyed teaching and giving back.

Could we develop a program that would not only marshal the spirit and skill of our alumni and help them re-engage with the School but also offer them the chance to help solve the nation’s looming health care access problems? Could such a program also allow our alumni to reinvest their skills and reclaim their spirit of altruism?

These discussions led to the crystallization of an idea we called the MAVEN (Medical Alumni Volunteer Expert Network) Project. That idea was then given a functional form by a proof-of-concept assessment, generously provided by the HMS Center for Primary Care and its director, Russell Phillips, and by the support of alumni of the University of California at San Francisco and Stanford, Yale, and Tufts universities, who signed on to our affirmed vision. We were on our way.

Many hands

The mission of the MAVEN Project is to connect a corps of world-class volunteer physicians with underserved clinics using advanced telehealth technology. This mission also strategically positions the project at the intersection of need (the underinsured and uninsured), opportunity (volunteer physicians), and technology.

Physicians who volunteer with the MAVEN Project are credentialed, and periodically recredentialed and provided with malpractice coverage and technical support. Through online and in-person meetings and social events, a robust community of like-minded, purpose-driven volunteers has emerged.

Among the project’s first efforts were direct-to-patient telehealth consultations with clinics in Lynn and Greenfield, Massachusetts, and the Central Valley of California. The project added staff and began to expand its reach. Guided by a summative evaluation supported by a California Health Care Foundation grant and authored by RAND Corporation experts, the project developed its current programs as well as a new model to support the delivery of primary care and improve the quality of such care for underserved and uninsured populations.

Dire straits

No matter how many times we may hear it, it bears repeating: in this country, people who need medical care are not receiving it, there are too few doctors to deliver care, and the high cost of care puts it out of reach for far too many people. This is a major crisis in human, medical, social, economic, and ethical terms.

The numbers tell the stark story.

More than 100 million people in this country—one of every three of us—is uninsured or underinsured. This means that people endure illness, disease, or injury unnecessarily and for long periods or they die prematurely due to limited access to appropriate treatment.

These inequities are magnified by the dwindling supply of physicians. Forty-three percent of U.S. doctors are over the age of 55. California data indicate that less than half of that state’s 139,000 physicians provide twenty or more hours of patient care per week. Burnout caused by high job demands, inefficiency in practice, and loss of autonomy contribute to these low patient-care hours.

The American Association of Medical Colleges projects a shortage of up to 55,200 primary care physicians and 61,800 specialists by 2030, with the crisis so acute in rural parts of this nation that the New England Journal of Medicine published a lead report in July 2019. The current thinning of our nation’s physician supply means that one of every five people in this country lives in an area that does not have the number of doctors needed to serve the population. Specialists are particularly in short supply. Faced with declining Medicaid reimbursement rates, these physicians are increasingly unwilling to serve individuals who depend on this public health insurance program. In the high-need area of psychiatry, only 36 percent of these specialists accepted new Medicaid patients. It’s a percentage that is sadly reflective of other specialties as well.

Whether their illness is acute or chronic, patients with little to no access to medical care or insurance to pay for such care have little hope of receiving specialty treatment. They therefore end up in emergency rooms or morgues. The lack of effective and appropriate care is one of the primary reasons for the twenty-year gap in life expectancy between the rich and the poor in this country. In addition, the inability to pay medical bills often creates insurmountable financial burdens, sometimes leading to bankruptcy or homelessness.

The ripple effects of all this dysfunction are felt in higher health care costs, physician burnout, political infighting, and ultimately harm to society.

Community support

These factors also conspire to further threaten the integrity of the already fragile health care safety net provided by the nine thousand federally qualified health centers (FQHCs) and free clinics comprising the nation’s community health center (CHC) network. The CHCs provide primary care services for more than 28 million economically or geographically disadvantaged patients, regardless of a patient’s ability to pay. Fifty percent of those patients are covered by Medicaid, and nearly 25 percent are uninsured, despite passage of the Affordable Care Act. Staffed largely by nurse practitioners, physician assistants, and physicians who lack specialty expertise, CHC clinicians provide basic primary care but too often encounter conditions beyond their scope of practice, challenging their ability to provide consistent, expert management of the chronic diseases disproportionately affecting vulnerable populations.

Up to 50 percent of all CHC patients require specialty referrals for services not available in the CHCs, equaling nearly 105 million referrals annually. Wait periods for these services are often excessive and complicated by patients' inability to travel long distances and suspend their work and home responsibilities to accommodate appointments. As a result, diagnoses are missed, chronic diseases are poorly treated, and patients and their families are left to deal with pain and financial hardship.

A call away

Soon after its launch, the MAVEN Project pivoted to respond to this need, moving from direct patient care to full-scale support of CHC primary care providers (PCPs). Distinct from other organizations that exchange medical data or offer a standardized case-based learning program, those who serve in the MAVEN Project mentor, educate, and advise primary care providers in the field, in whichever way works best for the provider.

To participate, a clinician can log in to a HIPAA-compliant technology platform and view a marketplace of specialties. They can review a volunteer’s background and decide whether to partner with a particular specialist or to discuss issues with an available volunteer. Conversations may occur via video, text, email, or phone.

More than one hundred seasoned volunteer physicians, most with academic backgrounds and all with years of clinical experience, representing forty-two specialties and more than twenty-five medical schools, are available to answer questions immediately so that plans of care can be completed during a patient’s office visit. Alternatively, a conversation can occur asynchronously to allow for in-depth discussions of individual or grouped cases.

This community goes beyond medical consultations. The project’s mentorship program is designed to help primary care providers tackle the multifaceted challenges of clinical practice in underresourced environments. Those being mentored meet at least twice a month with a matched physician volunteer. Topics are individualized and may include practice management and self-care, managing social complexities, stress reduction, and case review. The volunteer mentors, with their extensive clinical, academic, and administrative experience, provide independent, confidential, and nonjudgmental coaching and advice designed to reduce burnout among primary care providers, improve their job satisfaction and wellness, and minimize clinic turnover.

Education sessions are delivered via live video and customized based on clinical interests and needs. All sessions are 45-minute didactics with 15 minutes of Q&A. Volunteers understand that no question is too small, and that PCPs—many of whom are nonphysician practitioners with wide-ranging clinical experience—need up-to-date, practical information rather than mechanisms of disease and research results. PCPs may also receive CME credits, conferred through our partnership with UCLA’s Geffen School of Medicine.

The MAVEN Project teaches the art and the science of medicine, creating enduring partnerships with clinics, promoting provider well-being, and expanding PCP skills so that patients receive comprehensive, cost-effective, and culturally competent care in their local primary care medical home.

Spread the word

Since operations began, the MAVEN Project has established programs in nine states—California, Florida, Massachusetts, New York, Pennsylvania, South Carolina, South Dakota, Virginia, and Washington—with more than eighty clinic-site partners. To date, the MAVEN Project's volunteers have performed more than one thousand advisory consults, one thousand educational sessions, six hundred mentoring sessions, and nearly two thousand direct-to-patient encounters.

Over the past five years, the project has been gathering data that prove the value of these services. Based on more than 270 pre- and post-consultation surveys, in 74 percent of cases our advisory consultations enabled PCPs to avoid referring patients to outside specialists. Encounters have affirmed care plans in 44 percent of cases and augmented care plans in 82 percent of cases. Of equal importance, 74 percent of the PCPs surveyed stated that the consultations provided education they could apply to their current and future patient panel. This multiplier effect has had profound beneficial effects on the cost and convenience of patient care.

Mentoring sessions have been particularly well-received. When participating PCPs were asked to rate these encounters on a scale of 1 to 5, with 5 being the highest score, the average experience score for consultations and sessions was 4.83. Ongoing provider feedback often emphasizes how the encounters provide a sense of empowerment, give practical advice, share clinical pearls, and, in general, offer much-appreciated support. Other glowing provider comments can be found at www.mavenproject.org.

Professional GPS

The MAVEN Project’s corps of volunteer physicians have become an integral part of the PCP support system for the clinics it serves, extending the scope of care and helping coordinate services when complex questions or interventions are required. Most important, members of the MAVEN Project have realized that the holistic approach and the relationships we offer are as important to sustaining the PCP network as the medical advice we share.

As a physician who has been with the MAVEN Project since its inception, I think I speak for our staff and our volunteers when I say that we are on our way to achieving our “true north” goal of being the leading national convener of volunteer physician services for medically underserved patients, maximizing the potential of telemedicine and the humanitarianism of our colleagues to benefit medically vulnerable individuals nationwide. And these accomplishments are due in no small measure to a challenge presented to the School’s Alumni Council on that blustery winter day and the HMS alumni and faculty who recognized all we could achieve.

Laurie Green, MD ’76, is a founding partner of Pacific Women’s OB/GYN Medical Group in San Francisco; one of seven public health commissioners for the city and county of San Francisco; and founder, president, and chair of the board of the MAVEN Project.

Images: Gretchen Ertl (top); Suzanne Sizer