Health Care District Holds Complex Meeting

— by Leif–

Orcas Island Health Care District Commissioners met Monday June 11 to discuss together with community participants a full slate of issues. The agenda posted June 8 provided the framework.

The context of this meeting is the impending June 30 demise of the OMF, Orcas Medical Foundation, accelerated by the passage of the Public Health Care District. This prioritizes continued funding of services by the University of Washington Medicine clinic at the Medical Center, requiring the newly-minted PHD Commission to formulate basic principles for providing healthcare services to the Orcas Island community, generally.

Those who have been following this tale will know that the basic legal and financial foundation is poured and while that firms up, the framing in of key architecture has started even as detailed plans are still being sketched in. This meeting envisions the rudiments of how healthcare on Orcas will feel to us in the future: the interplay of what we need for healthy living with how we make for its provision. Commissioners took no action, but found consensus on several topics, which will lead to action later.

The meeting was composed of four periods of discussion by Commissioners followed by a period for comments by community members which was acknowledged during the next period of discussion. Commissioners Diane Boteler and Pegi Groundwater expressed a need to conduct listening sessions, surveys or town hall meetings soon to hear public comments on the concepts being articulated here today.

Richard Fralick talked of the hard deadlines coming up relating to the sustainable funding of the two clinics.

• OMF cannot subsidize UWM past June 30, which is earlier than expected.
• OFHC has issues with expected funding through September.
• Special funding from the County is contingent on the Council’s action coming up.
• Further monies from them for the remainder of the funds required to insure continuity of service is contingent upon this Commission finalizing a budget and levy rate with the advice of this community.

Continuing as per their outline, Art Lange and Boteler discussed the definition of “urgent care” and what is appropriate for Orcas. Lange defined it as “physically accessible provider when necessary.” Boteler defined it as “non-emergent conditions that could progress in a short period. An unexpected need.” They discussed the need for providers with community commitment and broad capabilities from pediatrics to pain management to trauma, for example, recognizing that we live on an island far from specialists.

Commissioners held a colloquy on the underlying philosophy of primary care and how to manage the kind of care that would be best and most cost effective for Orcas. Lange mentioned the concept of a “Medical Home” that supports a broad definition of “health” for islanders. Groundwater contrasted the past ‘silo-ing’ of services with a systematic solution that includes all providers including EMS and community resources, mental health and public health.

What is our “Umbrella?” There was a long discussion of clinic hours and the mix with after hours care; the practical need for sharing after hours “call” among providers, the advantages of sharing administrative staff and medical equipment like an X-ray, ultrasound or laboratory, and the problem of accommodating multiple philosophies of care viz Friday Harbor’s multiple PHD example.

There seemed to be a consensus that continually identifying new areas of improving service or efficiency, like the sharing of the X-ray machine (and of one governing body) was the process needed to find an Orcas-specific answer.

The public in attendance offered comments.

• Drs. Dale Heisinger and Steve Hulley agreed that “shifting hours” might help so that on different days/weeks clinic hours would change to accommodate the varying work schedules of locals and thus markedly deplete the after-hours need as well.
• Leif suggested the PHD as not the funder of local healthcare, but the organizer of many varied revenue streams.
• Pierrette Guimond reminded us that we can’t fund everything.

The next segment of discussion replayed and extended the discussion of staffing after-hours care, the practicalities of finding providers for a 1:6 ratio of days on/off call; how to share with EMS providers, and the need for real data to determine demand and particulars of this service. The term “collaboration” came up again as part of the answer to best service/care, best economics, most flexibility and least provider burnout. One problem is determining the willingness of this community to accept Urgent care from a combined team of providers not their preferred one, the other is the ability of providers to collaborate well to provide immediate care if required.

But the upshot was to ask if the parameters for services as defined here has brought the Commission to the point of being able to contract equitably and with respect for the preferences of all with both primary care services on Orcas: this of pressing importance come July first.

Public comments then included:

• the offering by Bill Bangs of a copy of Military standards of care for health.
• Leif suggested the real negotiating power with providers comes from truly understanding the interests of this community, and with off-island health networks from how fully integrated this local network can become, improving quality in the interchange.
• Steve Hulley suggested that the advantage of having two fully functioning clinics is that they have quite alot of insight into providing healthcare to this population, and possess much historical data on that service. Lange replied that they are interviewing clinic staff for their ideas for managing care.

After the break, Lange expressed the range of concerns that must be considered in contracting talks. Fralick said that obtaining additional input from the community could provide a stepping stone to address these concerns with service providers. Patty Miller suggested creating a preliminary document for public discussion prior to contract talks.

As per the agenda the Commissioners discussed the role of metrics in contracting with providers. Miller said she sees metrics as very important, and relate to standards of care. Groundwater talked about when patient satisfaction surveys are done and evaluating clinic/provider performance overall. Boteler related her experience at the Lopez clinic and how they survey patients. There was a question about how much OFHC collects this data. UWM has an outside firm to collect feedback. Miller wants to measure community satisfaction with PHD services. Groundwater wants to gauge feedback from EMS and clinics about quality of care.

Miller wants to use RVU’s (relative value units – used by for medical billing). Groundwater want to know how one measures quality of care. Boteler discussed metrics for treating different diseases. There was much discussion about how to use metrics, what penalties and rewards might be and what they ultimately mean. The discussion of how to relate quality of care to metrics, and then to finance and contracting, was difficult to follow and seemed akin to a scholarly discussion of the necessity for a grammar of an unknown language.

Miller suggested discussing metrics with the clinics over the next year and setting that time frame as the goal for defining what we’ll measure and making it uniform across clinics. There was a general consensus that they did not understand metrics in healthcare, but needed to research it more. Lange suggested that practically they would get an introduction to them in the review of the clinics’ financials.

Lange wanted to research how to obtain improved CMS (Medicare & Medicaid)  reimbursement rates and to make sure that both clinics participate in a community needs assessment together. Miller wants to find out relative reimbursement rates as a RHC, Rural Health Clinic, and reevaluate UWM’s non-participation in that program. Lange wants to ensure that both clinics will see patients after hours and in a short time frame, even if they are not their Primary Care provider. He wants to evaluate this entire patient experience.

Public comments came from:

• Dr. Vincent Shu about quality incentives by Group Health.
• Leif brought up the possibility of improved CMS payments by obtaining FQHC, Federally Qualified Health Clinic status possible when combining both clinics, and by improving outcomes-based payments.

In the final round of conversations the Commissioners framed in the pressing need for a continuing contract with UWM providers with the impending demise of OMF. However, the Commission though feeling this pressure, is determined to attend to first principles as detailed above, and to enter the contracting process deliberately, taking nothing for granted.

Financing to ensure continued operation by the established clinics is on the way, step-by-step. But an interim contract is required to ensure continued care without prejudicing the contract negotiations to come that will ensure a more extended relationship that this community can build on into the future. In contrast to the discussion of metrics, great insight, experience and thought was evident in this exchange.

Our Commissioners were frank in expressing dissatisfaction with the previous contract and the relationship with UWM and the desire to do better on their, and the community’s, own terms. There is the perception that UWM management is open to considering all means necessary for success, but the foregoing discussions of first principles and legal backing indicates the Orcas Health Care District is willing to assemble a team that will represent Orcas in all the present details as well as in protecting future innovation, data collection and quality. And this will not be easy.

Useful resources at https://orcashealth.org/