— by Susan McBain, Orcas Issues reporter —
At their regular meeting on July 16, the commissioners of the Orcas Island Health Care District considered a number of topics of interest to the public.
Consultant. The commissioners have been exploring different clinic structures that could maximize reimbursement from payors such as Medicare and Medicaid. Alternatives could include designation as, or affiliation with, a Rural Health Clinic, a Federally Qualified Health Center, and/or a Critical Access Hospital. (Orcas Family Health Center [OFHC] is already a Rural Health Clinic.) Because of the complexity of the various alternatives, they decided to hire a consultant who could help analyze our current island health care delivery system and recommend the best approach. Factors in the decision could include short-term versus long-term benefits of each alternative; the advantages and disadvantages of consolidating island practices; the complexity and length of the application process; and any availability for grants.
The commissioners are preparing a scope of work to send to several consultants they have identified who appear to be best qualified to help. They hope to select a consultant and obtain cost estimates by their August 6 meeting.
Budget Schedule. It is already time to begin working on the District’s budget for 2020. Scheduling to meet required deadlines will begin in August; the first look at five-year projections and the draft 2020 budget will occur on September 3. The draft budget should be finalized in early October to be ready for consideration at the public hearing on November 5. Possible new expense categories include the consultant mentioned above and an administrative assistant for Superintendent Anne Presson.
Additional Funds for OFHC. OFHC had requested additional funding of approximately $50,000 for its fourth fiscal quarter, which ends September 30. The commissioners did not consider a mid-year change in funding to be feasible, but will consider the request at the start of negotiations for the new fiscal year. The Board had previously discussed making an adjustment to the July–September subsidy payment because Dr. Shinstrom was on disability leave for a month. Rather than apply the usual reduction for having less than a full time MD present, the Board approved the recommended adjustment, which kept funding close to the originally budgeted amount.
Communications. The next of a series of articles on District activities is in preparation, giving more detail on the issues the consultant will help to address. (An earlier article, “Health Care on Orcas at a Crossroads,” gave an outline of those issues.) Although the commissioners feel that keeping the public informed of potential changes is important, they also stressed that they “greatly respect the current practices and the people in them. The problem is costs.”
Replacement of Kaiser with LifeWise. Presson announced that under the new LifeWise insurance program (which for 2020 will replace Kaiser in the individual and small group markets), both the Orcas UW Neighborhood Clinic (UWNC) and OFHC will be considered to be in network. In addition, LifeWise has approved a benefit exception to allow UWNC patients to be referred to UW specialists and be covered in network.
The District’s next regular meeting will be August 6 at 5 p.m. at the Eastsound Fire Hall.
So once again, someone is going to pay a consultant who is supposed to provide a path for more, higher quality, health care at a lower cost, to an aging population that has increasing needs. As a physician of 35 years, I can assure you that the waste and excess was wrung out of medicine 10-15 years ago. The public needs to stop believing that you can get more for less every year. Quality and access cost money and the margins are already slim at the local level, so don’t get your hopes up too high.
Just a question. Are the taxes to be paid included in the assessment of the total medical care costs?
We’ve gone from private philanthropy subsidizing practices to a hospital district tax subsidizing practices. Are we soon to be paying taxes for the operation of an entire clinic? I believe that undertaking direct provision of care through a District-operated clinic will lead to taxpayers being forced to pay increasing taxes with no end in sight–unless, of course, we actually do get action on health system reform at the national level. Don’t hold your breath.
The District should focus on obtaining proposals from physicians or physician groups to operate the existing clinic, which is a community resource. Those proposals should require efficient operation of a freestanding clinic, including reasonable after-hours care–which was the reason the District proposal was passed. UW’s financial demands have materially increased because it insisted on making our existing physicians faculty members at UW pay rates and benefits. Why not look for physicians not affiliated with major university overhead?
P.S. Resource materials being used by the District include information on Critical Access Hospitals! I shudder to think that we could possibly be going down the same unfortunate path as San Juan Island. Having taxpayers on the hook for the operation of a hospital and having residents paying the much higher costs for physician visits in a hospital clinic is no answer to our problems here.
Also, we should remember what happened with the Great Recession, because economics suggests that we’re headed for another. Tax revenues dropped precipitously then, putting the County–which had just replaced a free-spending Board of Commissioners–in crisis. It has taken the County a considerable amount of time and the rising tide of revenues to recover. The District will be far less able to address a precipitous drop in revenues, and if committed to the direct operation of a facility–clinic or hospital–will be in serious trouble.
From my observer’s seat: The advantage of having a healthcare commission to oversee publicly funded delivery of Primary Care on Orcas is that we have for the first time, the chance of addressing our needs and goals in an orderly and appropriate fashion.
In healthcare astronomically paid consultants are frequently a tool to get literal ‘buy-in’ for a predetermined course of action. Consultants are not hired to give skilled assessment or provide insight, but to legitimize with reams of numbers, diagrams and dense pages of verbiage “the way forward.” Often having any answer at all is perceived as better than any kind of uncertainty, and consultants exist to patch that need. Denial costs what you can pay.
In my study of management mismanagement in the clinical setting we, Orcas have lucked out in finding a group that recognizes uncertainty without relinquishing responsibility in unfavorable circumstances. They have scoped out a number of possible options for structuring Orcas healthcare. You might say this is a meta-level to the professional-practice level necessary to provide care.
In a sector funded almost entirely through third-party payors, the healthcare one is able to ultimately receive/provide can be severely constrained or greatly enhanced by how one positions and defines your service in relation to them. The multi-clinic experience on Orcas plus those of our disciplined partners on Lopez (and the chaos on San Juan), instruct us.
Take the historically awful management data collection on Orcas then, infer its future implications finally, run the reimbursement rules of these third-party payers for the organizational structures under consideration. And don’t forget, Congress and the Centers for Medicare and Medicaid Services, CMS, have been actively rehashing healthcare affecting many basic assumptions.
A consultant is being chosen with experience and expertise in answering just these kinds of questions, SO THAT matters of quality, access and clinic operations may be addressed in good order. They are indeed already under consideration, but the solution is UNKNOWN as yet. We are still gathering needed resources, with all deliberate haste.
As it is, we have ongoing services at negotiated rates. In the past our uncertainty was in part due to how our care was being funded AND managed, with large off-island institutions playing a huge role in our uncertainty. If anything, our experience has taught us that though Orcas is a microcosm of the larger whole in US healthcare, the particulars of our situation both accentuate unsustainability, yet provide insight into appropriate solutions. By forming this PHD we have taken control of our destiny, however uncertain it may remain.
..IMHO is my take. Pardon all the “we”s lol. It is a privilege.
Healthier and happier communities, less class disparities, less overhead, a system not dependent upon nor affected by a cyclical economy and extremely fluctuating tax revenue – What is it about “single payer” that is not understood?
Joe, as a physician who has looked at this for many years, I heartily agree that single payer is the way to go. So long as there is profit in denying care, the entire thing is unethical and assures fewer dollars going to patient care since so much is going to management.
Joe–As a health care lawyer for 40+ years, I too am convinced that single payer is the only way to go. If only we could count on that occurring in our lifetimes.
US healthcare has a long history of providing perverse incentives that over time have caused massive inflation of the price we pay vs. the quality we receive. I think Baylor was the first to create “health insurance” just to lure customers into using their services at all. Think of a transition from doctors on horseback in remote areas to the urbanization of American life in the Anthropocene era..
The Federal government started paying healthcare institutions inflated fees for specific services in the understanding that this was in effect a subsidy that would be used across the organization to fund the broad range of expanding services modern medicine had to offer. This was called “cross-subsidization.”
But as healthcare became a multibillion dollar enterprize, these quaint understandings became a massive wealth generator and cross-subsidization became fraud by another name. And the name of this game was profit through federally sanctioned regional monopoly. Think of the US Postal Service or or Ma Bell or railroad barons. This kind of societal strategy extended the reach of healthcare monopoly into the workplace, giving control to employers as well.
Emergency services are the remnant of this system, obliged to service walk-ins at an increasing loss, by Federal rules. This is why the measure of dysfunction in a local system is the use of the ED over Primary Care at great financial cost and lost continuity of care, ultimately resulting in poorer health and thus even greater costs.
Times have changed. Ma Bell is gone, and Fed Ex has left USPS the least profitable routes. Similarly rural areas are caught in the eddys and cross-currents as healthcare has favored larger urban areas with the ability to mask inefficiency with high volume and poor ethics with good business.
Connect the dots to see how Orcas fits into this, and what we must do to maintain basic care. But also open up to the advantages that small communities have and the opportunity our own history can lead us to… dysfunction being educational, if painful.
Stay tuned.
“Single Payer” is nice because it’s two words, but at what cost? if we do not acknowledge our roots or improve our ethics.
Leif,
our historical analysis is very good but as a frequent user of medical services who has seen serious decline in both availability and quality there are a couple of issues (at least) that eluded your take on this issue.
1: Med School Debt has created a whole new set of pressures on younger practitioners (at this point, that’s pretty much all of them) to provide quality car, take the time to listen to patients and to level with them about why their Medicare payments are inadequate to the task at hand of caring for ageing patients
2: Digitized Medical Records may be more efficient, time saving and such but only add to the perfunctory care being offered. If practitioners take the time to read a chart then they don’t walk in blind to your fifteen minute slot.
3: Single payer is more than a succinct two word phrase in as much as we now operate under not one, but two single payer systems; Medicare and Veterans. Both are efficient and take far less time away from patients and practitioners.
4: Yes, it’s all about the Benjamin’s. As long as Capitalism is allowed to cat paw its way into all aspects of daily life then we are left with the spoils. I will argue the non – efficacy of ‘free markets’ till the cows come home but clearly health care is one place they do not work or belong. Single payer is cheaper all around.
Erase all student debt and then we will see if ‘markets’ are all that they are cracked up to be.
Joe, I think we really agree about the important things. It is easy to get lost in this, I wanted to contribute some helpful perspective broader than the political moment. I really feel that Orcas has a chance of doing something unique because of our local niche both in history and on this planet.
One follow-up..
If “Single Payer” were instituted tomorrow it would not change the PHD’s present conundrum as all options under consideration are structured WITHIN existing CMS regulations, the basis for any single payer solution..
The multi-payer system influences payer-mix, the UW clinic as part of a large organization is able to demand larger payments from insurance companies, whereas the smaller OFHC depends on [much lower] payments from CMS. Yet the cost to the PHD was much higher for UW because of costly institutional baggage.
Interestingly our previous relationship with Island Hospital allowed large payments from CMS, but ultimately failed us in our unique circumstances… due to costly institutional baggage.
So it seems that the problem comes back to local advocacy: deal with our own baggage, develop our own resources, and define our external relations.
Have I used the word “collaboration” recently?