County providers consider more-unified efforts
“If there was no health care in Okanogan County and we had to build it from scratch, what would it look like? That’s the basic question when I lie awake at night,” said Peter Rutherford, CEO of Confluence Health. “That’s where we need to go.”
Rutherford was one of some 60 participants in a recent summit about the state of health care in Okanogan County. The July 25 meeting brought together the county’s three hospitals, clinics, health care providers and legislators to brainstorm about providing health care in a rural area.
Hospitals, physical and behavioral health care providers, and EMS services confront many similar issues. They were proud to be taking a unified approach, rather than a competitive one, said Mikaela Marion, director of public relations and marketing at Mid-Valley Hospital in Omak.
Alan Fisher, Mid-Valley’s CEO, itemized the stark numbers and geographical challenges at the summit in Okanogan. “Our three hospitals cover an area of 5,315 square miles with a total population of 41,000. The population has only grown by 2.5% in the past nine years. Twenty percent of the people live in poverty and 15% do not have health care insurance, all of this compounded by an 8% unemployment rate,” Fisher said.
Those numbers mean that hospitals regularly provide more services than they actually get paid for. Combined, the three hospitals have lost $3.6 million since 2012, Fisher said.
Few businesses can stay solvent if they don’t get paid for everything they bill, but health care is regularly asked to do that, said Scott Graham, CEO for both Three Rivers Hospital in Brewster and North Valley Hospital in Tonasket.
“As health care is a volume-based business, these statistics present a frightening picture of the future of health care in the county,” Fisher said.
While patient demographics at the three hospitals are similar, there are some differences. Two-thirds of Mid-Valley’s patients are covered by either Medicaid or Medicare. At Three Rivers, a third are covered by Medicare and a third by Medicaid. At North Valley, almost half are covered by Medicare and a third by Medicaid.
Medicaid pays just 48 cents on the dollar. Medicare comes closer to covering costs, but only for certain “allowable” services, Fisher said. The Medicaid reimbursement only goes toward the discounted cost, he said. “Health care reimbursement by itself is a nightmare,” Fisher said. “To survive, rural hospitals need to grow, but it doesn’t add up.”
The problem is not unique to Okanogan County — 107 rural hospitals across the country have closed in the past nine years, said Jacqueline Barton True, senior director of the Washington State Hospital Association.
In places like the Methow Valley, where there’s no 24-hour medical care, Aero Methow Rescue Service becomes the de facto health care provider, said Cindy Button, director of services.
Even during the day, some residents treat Aero Methow as their primary-care provider. The week before the summit, two people turned up at Aero Methow facility in Twisp, driving past two clinics to get there, Button said. But Aero Methow only gets reimbursed when it transports a patient to the hospital, she said.
Mental health care faces a unique set of challenges, said Lisa Appel, interim CEO at Okanogan Behavioral Healthcare (OBHC). When someone needs in-patient care, OBHC has to send the individual to a facility hours away. “How can they heal if their family can’t visit?” she said. “We have an agreement with local hospitals to have in-patient mental health care, but the reimbursement rate makes it impossible. It’s so disheartening,” Appel said.
Shifts in services
While some services have been decreasing, others are going up. Over the past year, Mid-Valley has seen a 28% drop in in-patient services, mirroring a national trend. Meanwhile, surgery is up 17% overall, and even more for outpatient procedures. And Mid-Valley is seeing 32% more patients for observation. Emergency-room visits have increased slightly, and more people who need to be hospitalized receive care locally, Fisher said.
State-of-the-art equipment has enabled local hospitals to diagnose and treat more conditions without sending people out of county.
But other services have been dropping consistently. Childbirths have dropped by 30% at Mid-Valley and North Valley. Births at Three Rivers, which has Baby Friendly USA certification, have been more stable.
North Valley had to stop doing deliveries as of Aug. 1 because Confluence Health could no longer meet the minimum staffing requirements — a decision reached after years of trying to recruit providers. “That’s the unfortunate place where we got to our decision. I don’t think it’s a unique problem,” said Rutherford.
Attracting physicians and nurses overall is a major hurdle. Recruiting a family practitioner takes two to three years, and it’s even longer to find a specialist or OB/GYN, said Fisher. It’s also expensive — the average cost to recruit one physician is about $100,000. The biggest obstacle is that candidates perceive a lack of social and recreational opportunities in this area, he said. A national shortage of physicians and nurses exacerbates the problem.
Okanogan County’s hospital and clinic administrators believe that the solution is to develop local training programs, starting in high school. They have been partnering with schools and universities to create scholarships and support advanced training programs.
There are some bright spots. Family Health Centers succeeded in recruiting four young dentists to practice in the county, said CEO Jesús Hernández.
The federal government is expected to issue a new model for rural health care later this year. But those ideas are often tailored to places like Louisiana and don’t translate to Washington, with its spread-out population and mountainous landscape, said Barton True.
Rural health care is different from urban health care in many ways, said Mike Pruett, chair of the Three Rivers board of commissioners. He urged legislators to take these different needs — and economics — into account.
As demographics and the economics of health care change, Okanogan County’s three hospitals may need to specialize, said Lauri Jones, community health director for Okanogan County. She suggested that each hospital could specialize.
Telemedicine has proven effective in some areas, including behavioral health and neurology, although it requires a cultural shift for both doctors and patients, Rutherford said. And it has its own payment issues. “To get the business model to really work is still a bit murky,” he said.
Beyond direct patient care, running a hospital or clinic and processing insurance claims demands many people behind the scenes. While they don’t directly add to the quality of care, they do add to the providers’ costs, said John McReynolds, North Valley’s operating officer. Factor in the need for facilities and equipment upgrades, and the county’s hospital administrators are feeling even more squeezed.
Although the summit was just a first step in navigating the health care landscape, the county’s hospitals see a need to reinvent themselves to deal with the realities of inadequate reimbursement, the decrease in patients, and the transition to more outpatient procedures.
The hospitals have already begun to collaborate in innovative ways. Three Rivers and North Valley teamed up a year ago to share a CEO and other administrative services. They hope to be able to share other resources as well. “My fantasy is complete interoperability between the hospitals,” said Graham.