– from Orcas Medical Foundation –
For 60 years, Orcas Medical Foundation (OMF) has been dedicated to serving the medical needs of all on Orcas Island. We have always sought the best possible medical care available. Our Orcas Medical Center staff has been there for patients and non-patients alike, during regular office hours and after hours, and OMC has never turned away a patient who lacked ability to pay for needed care.
We have done our best, as have other practices on Orcas, and we believe our long-term goals are the same. However, we believe we have reached a time when our community needs to look to the future, beyond past differences and beyond the time when two of our island’s practicing physicians retire. We need long-term stability and lasting assurance of the highest quality of care possible. We need for our remote community to keep up with advances in medical practice, research and technology. We need this for ourselves, our children and our grandchildren – for our whole community. These are the reasons OMF reached out to the University of Washington.
UW Medicine responded with a letter of intent, and now we have before us a one-time opportunity to form an alliance with a renowned institution that is rated #1 in the Nation for Primary Care, Family Medicine and Rural Medicine.
OMF has sought this alliance on behalf of the entire community. A UW Neighborhood Clinic on Orcas Island would be available to all. It would be operated and managed by UW Medicine, which would train and update staff through programs from the UW School of Medicine. UW Medicine would make all staffing decisions and be able to expand as needed, drawing upon its Residency and Advanced Registered Nurse Practitioner programs for seasonal expansion.
There would be many immediate patient benefits. We would be linked to UW Medicine’s amazing network of diagnostic and treatment services, but still able to choose non-UW Medicine providers and services. Patients’ electronic medical records would be accessible throughout the UW Medicine network, speeding referrals, appointment making and patient information processes, including access to X-rays and lab results from home.
After our OMF announcement and public meeting about the UW Medicine letter of intent, a flurry of statements, many inaccurate, have been written to dissuade support for this effort. We see no gain in arguing about these inaccuracies or past differences; nor do we believe that combining two or more money-losing practices would achieve our goal of long-term sustainability.
UW Medicine already operates and manages 12 successful Neighborhood Clinics. They can share best practices to benefit us on Orcas – and provide the strength and support of their vast research, education, and technology resources. Their non-profit goal is to serve outlying communities such as ours. UW Medicine can provide world-class primary care and long-term sustainability for all on Orcas Island.
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Definitely the very best thing that could happen to the island would be for this relationship to come to fruition. I sincerely hope the OMF Board, community and other phyisicians will come together to make this happen. Have spent the past 25+ years as an employee benefit consultant, as well as as senior leadership roles within the largest healthcare companies (including Kaiser Permanente) and employer purchasers in the country I realize how critically important it is for us to seize this opportunity. Please look forward and do what’s necessary to maintain high quality, affordable healthcare to all islanders.
Could someone on the OMF board please answer the following questions:
1) What does the UW letter of intent promise to the Orcas community for 750k start-up and 300k annually other than the EMR, the telemedicine visits, and rotating provider trainees?
2) Will the new electronic medical record only communicate with UW and its affiliates?
3) Will the telemedicine benefit provide just an electronic visit with a specialist and would it be covered by Medicare?
4) Where would you go to access the network of diagnostic and treatment services?
5) Will there be continuity of care – in other words – will I be able to see the same provider at each visit or will they constantly change? Will there be fully trained and licensed primary care providers (MD, PA, NP) in the clinic on a permanent basis?
6) Who owns OMCs building?
7) How are OMF board members chosen and who are they accountable to?
8) Has the letter of intent already been agreed to or is it contingent on the money being raised.
Thank you for your answers to these questions. You will need the community to support this endeavor since it is a large sum on an ongoing basis. Please bring some clarity to these discussions.
The first thing OMC needs to address is the rotating door of doctors. We’re new on island, only having been here 8 years full time, but I’ve lost track of how many doctors have come and gone. Perhaps I’m old school, but I believe in a long term relationship between my doctor and myself. I don’t want Dr du Jour. Perhaps if OMC would resolve whatever internal issues they have, or make what ever upper levels changes need to be made so that doctors will stay more than a year or two, OMC might attract more patients and not have the financial problems they have.
I was dismayed by the OMF attitude as expressed in this Guest Opinion. I expect that the same lofty ambitions and predictions were made in the launch of previous alliances with the likes of Island Hospital.
I do not have a primary care physician on Orcas so I do not have a “horse in this race” but it is not brain surgery to understand that the OMF blanket statement “nor do we believe that combining two or more money-losing practices would achieve our goal of long-term sustainability” is rejecting the logical cost savings and after-hours care benefits that could come from combining practices for scale & economic efficiency. I guess the OMF model must assume that the community is simply going to be willing to provide an annual funding to subsidize their aspiration to partner with UW Medicine.
Lastly the Guest Opinion started out with a broad statement of “Our Orcas Medical Center staff has been there for patients and non-patients alike, during regular office hours and after hours”. I recently called the Orcas Medical Center asking if I could get a flu vaccination since I was going to be off-island when the shots were going to be administered at the Senior Center. I was categorically told that I could only be vaccinated at the Orcas Medical Center if I was already one their established patients. I was looking for convenience and I was happy to pay cash for the service but I was turned away. Apparently they neither want nor need more business.
The OMF BOD should wake up and ask the Orcas residents what they believe is best for Orcas Island rather than presenting us with the OMF pre-ordained conclusion AND having the audacity to ask us to help fund their vision.
Hello All,
We (Dr. Russell’s practice) rarely get involved in these discussions because they often are not fruitful, except to stir the pot of emotion. As such, I will insert some commentary, and then excuse myself from the discussion.
Many consider the Medical Center to be “our” medical center, however, there is a private business within the walls of the building. That private business deserves the respect we provide to any other private business. One issue which affects the medical center is that people tend to forget the private business aspect. The building is, to the best of my knowledge, owned by the Medical Foundation, a 501c-3, and as such is not owned by the community. They have their bylaws and are subject to them and the laws regulating such entities. The Medical Foundation is not a public organization, is supported by private donations not tax-dollars, and has every right to conduct the affairs of their non-profit as they see fit (within the constraints of their bylaws and applicable state/federal law, of course). People may or may not agree with how they tend to their affairs, but they are their affairs. Having said that, it seems to be in their best interest to listen to public opinion and factor that in to any decisions they make. However, public opinion may or may not be in the best interest of the organization! Only they can decide that – their communication of the reasoning behind their decisions may be more at fault than the reasoning itself.
Much has been expressed about all 3 practices joining under one roof. First, there is not enough room. There is room for two, not three. Second, without an extraordinary change, Dr. Russell would not be interested in joining the threesome.
Dr. Russell’s practice is the only one of the three in question which is privately supported: there is no non-profit standing behind him to provide a cushion if what is billed and collected is insufficient for the month. If there is not enough money one month, it comes directly from him to make up the shortage. So, to insinuate that all three practices are losing-money is incorrect. I have no knowledge of Orcas Family Health Center’s practices, but for Dr. Russell’s practice, any money loss over even a short-period of time would mean the closure of the business.
To practice medicine in a rural area requires sacrifices on the part of both physician and patient. The physician must often accept a much-lower salary and works longer hours. He may drive a 20-yr old car and take one vacation every ten years. Patients must do all they can to pay their bills, for without money coming in, the practice will falter. They must also be considerate of their physicians’ time.
Dr. Russell and Dr. Shinstrom have enjoyed many years of cooperation in sharing of call and other areas (lab draws, x-rays, etc). Rural physicians must cooperate with each other for the good of all – themselves as well as the patients they serve. It does behoove the community to work together, but that requires give and take from all parties.
Additionally, Dr. Shinstrom’s practice has provided a necessary service in the care of all, even those who do not have the financial means to pay. He and his practice should be commended and thanked for the service they have provided for well over a decade, and continue to provide. He and his office do much which the community at-large does not see.
The Medical Center is not fully utilized without at least two full time providers, however the bandied about “efficiency” of combining the practices is not necessarily a reality. “Medical Economics” has published many articles over the years which show efficiency decreases or does not improve with the move from a solo office to a 2-provider office. Improved efficiency is not seen until the office grows to 3 providers and is at its greatest with 4-6. Rent-free space, and whatever other amenities the Medical Center offers a physician-practice, may change those numbers, but medicine is not an efficiency-driven business. Looking only or primarily at efficiency arguments can lead to looking past the most important aspect: the care of the patient and the community’s health.
There are many questions which need to be asked and answered in this debate, but they should be asked and answered in an atmosphere of respect. It is too easy to be disrespectful in a forum such as this. I doubt there is one right answer, but there are many opportunities for cooperation and improvement, especially in this moment of change.
This topic should be the focus of a constructive community debate, because we all want medical care available for our residents and guests. And because two of our Island’s clinics periodically seek donations from the public, the public has a legitimate interest in how they operate — including potential “unification”.
I suggest the community deserves a study that might identify potential solutions to the problem that OMF describes as “two money losing practices”. During my career, I was involved with half a dozen mergers/unifications. Each was triggered by financial instability, but each negotiation still had to analyze what specific benefits a merger actually would bring. Sometimes we asked a mutually agreeable third party to do a study, so the potential would be clearer to both sides.
The Sounder reported that OMC loses $250,000 or more per year, and quotes a UW representative as saying “It’s because of scale”. Talk about “scale” typically indicates either (1) you have unused capacity in your facility, or (2) your current facility needs more space or better equipment to ever be able to achieve economic viability. Those two types of “scale” problems call for quite different solutions.
Dr. Shinstrom and Ken Speck have commented that “unification” could improve the economics and the service. OMF now questions whether “combining two or more money-losing practices” would bring financial stability. Yet combining two money losing operations often DOES increase scale and improve profitability in certain situations.
As Michelle Russell says, the implications of a clinic unification deserve a careful analysis of what it might mean for patients, as well as economic viability for the clinic. Would it limit choice, if a patient were unhappy with a particular doctor? And of course insurance choice also is a huge concern – for example, at one point Group Health’s Medicare program did not allow subscriptions to be filled at Ray’s Pharmacy. Could a unified clinic honor all the employer insurance and Medicare and Obamacare options available in San Juan County?
The OMF/OMC contract with Island Hospital expires in a few weeks, so OMF now must focus on a new arrangement. But UW Medicine might see unification as a benefit. I urge OMF and UW Medicine to develop a transition plan that includes formal consideration of unification, followed by a report to the community.
Kate Yturri– I am not on the OFM board, however I can answer your question #3 and have a web link with more info:
Medical coding and billing is complicated. Rural Health Clinic coding and billing is even more complicated. The answer to Virtual Telehealth being covered by Medicare and secondary/supplement in a RHC is a two part answer. The first, is NO, it is not a covered patient service by Medicare in a Rural Health Clinic. Only in person office visits, home visits, and Skilled Nursing Facility visits are covered by Medicare (and secondary insurers who follow Medicare rules). Medicare requires an in person face-to-face encounter between the provider (MD, PA, NP) and the patient. The second part of the answer is that a patient can go to a Rural Health Clinic, be hosted in that clinic with the required live streaming technology, have a virtual encounter with a provider who is somewhere else, and the Rural Health Clinic can collect from Medicare a “hosting” fee of about $25 because it has acted as the originating site. The actual payment for the virtual encounter goes to the provider on the other end of the live stream. The provider on the other end of the stream may not be in a Rural Health Clinic. The downside is that none of the costs for being the originating site can be included in the cost report to Medicare at the end of the fiscal year. The cost report calculates what the average cost is to see a patient, which Medicare uses to determine what the next years payment per visit (or All Inclusive Rate–AIR) is going to be. As I mentioned, it’s complicated. If you are interested, the following link is to a very nice summary about Rural Health Clinics. Telehealth is addressed on page 4.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf
Thank you Aaimee!
I heartily agree with Doug Marshall. This is very complicated and the public needs much more information before making any decisions. We need to hear from all three active health care provider practices; we need to know what the Foundation’s role is; why the Medical Center has lost and is expected to lose $200-300,000 a year; and what could be done to change that. There’s also the question of $750,000 to be found somewhere.
A thorough discussion by the community now might help us prepare for what seems to be a dark future for health care coverage.
Aaimee–I’ve practiced in health care reimbursement for nigh unto 40 years and couldn’t have summarized the telemedicine rules better!
Comments in the Guest Columns of Orcas Issues about the future of medical care on Orcas have been both discouraging and heartening. I am discouraged to realize there are some misconceptions going around, but am heartened and grateful that so many of us care about this issue and are deeply concerned about the future. It sounds like many of us would like to see a merger of practices, improvement in relations, and reduction of waste. Quite so!
As a former employee of the OMC who had a lot of contact with the Orcas Medical Foundation (OMF) board of directors, I hope to clear up a few misconceptions here. In a future column, I hope to discuss the quandary we face in health care, and my thoughts about a possible solution. My intent here is to be unbiased, with respect for all concerned. (And with my thanks to Aaimee, who has answered a complicated question about Medicare billing in Rural Health Clinics, above.) Here’s a bit of history, as I understand it that I hope will answer some questions:
The OMF is a 501(c)3 non-profit that was founded 60 years ago with the mission to support medical services for all on Orcas Island. That mission has not changed. Board members serve a term of three years, and up to three partial or complete terms. OMF (under its prior name, Orcas Island Medical Building Association) raised the funds to construct the medical center building, which was completed in 1992. There is no mortgage; OMF owns the building outright. From 1993 – 2003 (roughly) Island Hospital had a contract with OMF to operate the practice. During that time, the Hospital contracted with Dr. Shinstrom and a few other practitioners to provide medical services. The practice lost money and in 2003, the hospital ended its contract. There may also have been an issue with some doctors leaving for other pursuits, but I don’t know much about that aspect. The OMF board sought the help of a consulting firm for guidance. I don’t know the nature of the negotiations that took place, only that OMF and Dr. Shinstrom did not renew their contract. Subsequently, Dr. Shinstrom established Orcas Family Health Center, a Rural Health Clinic and 501(c)3 non-profit. Around 2004(?), OMF contracted with Dr. Russell to establish a private practice at OMC. In 2005, Dr. Giefer was hired by OMF to be the second physician at OMC. At the end of 2005, Dr. Russell decided to leave and establish his own private practice. Then OMF asked Dr. Giefer to establish a private practice at OMC, which he did from Jan. 2006 to Aug. 2011. For a variety of very legitimate reasons, OMC still struggled to make ends meet and the OMF board sought a larger, outside partner. Peace Health was considered but – take note – they said the three island practices would have to be joined, and Orcas Island would need a hospital district before they would get involved. Then Island Hospital stepped in and negotiated with OMF to administer the practice at OMC. In Aug. 2011, OMC staff and practitioners became employees of Island Hospital. In 2012, OMC obtained RHC status. Around 2011 – I believe at Dr. Shinstrom’s request – the Dept. of Health sent a representative to determine the feasibility of setting up a Federally Qualified Health Center (FQHC) on Orcas. The conclusion was that an FQHC needs a minimum of 4,000 patients to operate successfully and only functions well when the whole community is behind it. With its disparate medical practices, Orcas did not qualify. Currently, the contract between OMF and Island Hospital ends on 6/30/2017.
Collaboration: it has been asked why OMF made no effort to collaborate with the other island practices. It did. In 2010-2011, extensive efforts were made by the OMF board to make it possible for Drs. Shinstrom and Russell to relocate to the OMC building and operate as separate practices under one roof while administrative, billing, and nursing services would be provided for a fee. Those efforts did not bear fruit. More recently, Dr. Fleming met with Drs. Shinstrom and Russell to explore ways the practices could work together. And I believe the most recent efforts by OMF board members, to collaborate on after-hours call, have also been rejected. It’s important to note: any practice’s rejections of offers to collaborate are not simply a blanket unwillingness to cooperate. It generally means that some of the conditions posed by one party are not tolerable to the other. So far, it seems no one has been able to get beyond this point, but it’s not for lack of trying!
The statement that OMC only cares for 25% of the island’s population is questionable. I ran those data for OMC back in 2011 and again in 2013, using a specific set of parameters. I would estimate that the percentage was closer to 40% of the island’s population, after correcting for visitors, etc. Those numbers fluctuate from year to year, and some patients tend to use more than one doctor depending on the type of visit. It can get complicated. Unless all practices use the same parameters and time period for their data queries, it’s really difficult to pin those numbers down with any accuracy.
Regarding Group Health – yes this is a problem if you want to go you the UW hospital. Generally, Group Health refers its members to Virginia Mason for tertiary care. However, the Group Health primary care network includes contracts with many primary care clinics and the UW representative, Ms. Gussin, was confident that a UWNC clinic on Orcas would also be able to contract with Group Health.
Alison, the measure of market share is more accurate if the measure is revenue, not patients. Can’t pay the bills with patients. The latest numbers taken from filings made to the State indicate OMF revenue is $223,000, OFMC is $521,000 and while Russell doesn’t report to the State it would be a good educated guess that his revenue, did he report, would be close to $200,000. The total island revenue, using those numbers, is $944,000. The OMC share is 24%, Russell is 21% and OFMC is 55%.
Mr. Binford makes a valid point regarding revenue as the more accurate indicator of market share. However, a practice which cares for a greater number of patients on the Medicaid-expansion plans might have a larger number of patients and patient visits but a markedly lower revenue due to the decreased reimbursement for those visits – so it is slightly more complicated than looking only at revenue. Also, how a practice counts “patient visits” will factor in to their reported patient numbers.
Ms. Shaw is quite correct that there have been some efforts at collaboration, though none recently of which I am aware. Unfortunately, she is also correct that collaboration has always hit a snag of one kind or another. Still, Dr.’s Shinstrom and Russell continue their several years’ collaboration.
(FYI, Dr. Russell’s practice revenue is considerably greater than $200,000. That amount would not even cover overhead.)
Thank you Ms. Johnson for answering my question 3 and the detailed information about RHCs. Thank you Ms. Russell for all the information you have shared. Thank you Ms. Shaw for your answers to my questions 6 and 7 and the medical community history.
It would still be helpful to hear from an actual OMF board member, specifically to answer the questions I posted in a previous e-mail. I am in agreement with many that there is no question UW Medical might bring much to the island. However I am still not convinced we can sustain this plan financially; or that it will bring consistent, ongoing primary health care to our young families and elderly .
Here are the unanswered questions:
1) What does the UW letter of intent promise to the Orcas community for 750k start-up and 300k annually other than the EMR, the telemedicine visits, and rotating provider trainees?
2) Will the new electronic medical record only communicate with UW and its affiliates?
4) Where would you go to access the network of diagnostic and treatment services?
5) Will there be continuity of care – in other words – will I be able to see the same provider at each visit or will they constantly change? Will there be fully trained and licensed primary care providers (MD, PA, NP) in the clinic on a permanent basis?
8) Has the letter of intent already been agreed to or is it contingent on the money being raised.
Thank you for your answers to these questions.
Just a quick comment about revenues. Orcas Medical Foundation (OMF) is completely separate from the practice, called Orcas Medical Center (OMC). Mr. Binford, I believe you have reported donations made to the Foundation in your comment above. Because OMC is currently a clinic of Island Hospital, its revenues go there and are in no way connected with contributions made to the Foundation. When I was at OMC, our revenues were definitely higher than $500k. (I don’t have access to the figures for the last 1.5 years.). And Michele is quite right that revenues are not an accurate indicator of patient activity. But it would be sad to dwell on this point. More important is HOW we go forward and secure financial stability for all practices here. The sooner we realize we’re in this together, the sooner we can work together toward solutions.
A few points.
The citizens of Orcas have little organized and consistent information to use to evaluate what should be done with respect to OMC. Rather than commit to spending $750,000 just to enter a contract with UW, plus several hundred thousands a year to cover anticipated losses, we should be seeking the counsel of a neutral consultant who has access to complete financial and other data from EACH of the practices on the island and can look at island demographics to provide a recommendation or, at least, whole island information to form the basis for a rational decision that represents a long-term solution.
There are serious issues with proposing a hospital district and levy that does not at least make a serious effort to include all qualified providers. There is no reason to conclude that the proceeds of such a levy would necessarily go to OMC. That would be a decision for the elected members of the hospital district board to decide.
The citizens of San Juan voted for a hospital district a few years back with insufficient attention to the legal and practical consequences and it resulted in increased costs (because they indeed have a hospital, with the higher overhead costs) and major controversies that split the community. We should work to avoid that.
Finally, we as patients and our physicians as providers face great uncertainty in the future as our new Congress is threatening not only to repeal the ACA but also to restructure or eliminate Medicare–which is the program that created the rural health clinic structure upon which two of the island practices rely.
The UW commitment is a very expensive bandaid with no long-term guarantee of stability.