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The Family Practice Clinic has offered the following broad services:
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Preventative and wellness exams, including immunization services
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Diagnosis, treatment, and monitoring of chronic conditions
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Acute illness and urgent issues for existing patients, including fracture care
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Sports medicine
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Physicals for Department of Transportation, Merchant Marine, FAA Flight Physicals
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Labor and Industries claims (worker’s compensation)
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Nursing home and Hospice rounds
Up until October 2007, after hours call was shared among three Clinicians and involved taking call one out of every three nights. Call could be taken from home as long as the Clinicians lived within 20 minutes of the clinic. After hours phone advice was provided by the on-call Clinician. Hospital patient management and provision of medical direction to the Wahkiakum County Emergency Medical Services was also provided by the on call Clinician. Taking all these calls could interrupt both normal office hours as well the nights and weekends.
The Clinic refers patients requiring hospitalization to St. Johns Medical Center, operated by PeaceHealth, in Longview, Washington. There are normally two to three patients in the hospital on any given day. St. Johns has 346 licensed beds with 193 in regular use. The facility is accredited by the Joint Commission of Accreditation for Health Care. Units include medical, maternity, critical and cardiac care, dialysis, and cancer care. The surgical and psychiatric services both have inpatient and outpatient care. Rehabilitation and respiratory services are also available at the hospital. The Emergency Department is a Level 3 trauma center, staffed 24/7 with Emergency Room physicians, full imaging and radiology services, lab, and pathology, with a variety of specialists for consultation.
Please see Appendix 2 for additional information on regional medical resources.
Family Practice Clinic Performance
The Family Practice Clinic has experienced a considerable amount of change in the years from 2000 to the present. Beginning in 1999, the Clinic was under pressure from PeaceHealth to increase productivity and revenues. In addition, the problems in the national health care system were growing increasingly challenging, especially the pressures from insurers to manage care, cuts costs, and improve efficiency. Along with this, the increasing costs of malpractice insurance, especially for those providing obstetrical care, made it very challenging for the Family Practice Clinic to meet PeaceHealth’s financial targets.
Beginning in 2000, PeaceHealth began consolidating services into its larger facilities and closed smaller, satellite clinics. The Family Practice Clinic became a target for closure and the County Commissioners believed that intervention to save the Clinic was required. They initiated a dialogue with the Clinicians and with PeaceHealth to explore the best way to save the Clinic. Several options were explored and rejected, including the private ownership of the Clinic by the current Clinicians. In what appeared to be a last resort, the County agreed to purchase the building from the Avalon Family and assume responsibility for the Clinic in a public-private partnership with the Clinicians (e.g., Avalon, Wright, and Godfrey). This arrangement was finalized in January 1, 2005 and the Clinic came under County ownership.
At the beginning of the negotiation process with PeaceHealth and throughout the transition period leading to County acquisition of the Clinic, the Board of County Commissioners worked closely with the Clinicians, the Office of Rural Health Care (State Department of Health) and other experts to determine the best configuration for the Family Practice Clinic. During these debates, the potential for making the Family Practice Clinic a Federally Qualified Health Clinic (FQHC) approach was thoroughly considered. While the FQHC model has many merits, there are also many requirements and these requirements have financial implications. For example, FQHCs must have a licensed Nutritionist, must provide for patient transportation, and must meet the needs of those without insurance, covered by Medicare and Medicaid, prior to the meeting the needs of insured and cash paying customers. The Board of County Commissioners weighed the pros and cons of the FQHC model very carefully before finally determining that this would not provide the best level of care for the community at large.
The County Commissioners and the Clinicians agreed to a five year plan for the Clinic. The Commissioners recognized that they would need to subsidize the costs of operations for a period of time. The expectation was that the Clinic would manage its operations and bring costs and revenues into alignment. Unfortunately, this did not occur as planned. The operating results are presented in Figure 4.
The Clinic has come under increasing pressure from the Commissioners to bring the revenues and costs into alignment. This pressure reached a breaking point in 2007, when the only solution for reducing the subsidy required by the Clinic was to reduce positions. Two positions (i.e., RN and Transcriptionist) were cut, yet the County still needed to provide a $225,000 subsidy for the Clinic in 2007.
The upheaval created by this budget crisis resulted in the departure of the senior Clinician, Dr. Richard Avalon, son of the founder and long-term presence in the community. In addition to Dr. Avalon’s departure, one additional staff person decided to leave and search for new employment. When Dr. Avalon left, one Medical Assistant was laid off. The staffing level at the Clinic at the end of 2007 was 9 positions. Finally, in late 2007, Dr. Keith Wright officially announced his intention to leave the Clinic in June 2008.
Figure 4. Clinic Revenues versus Costs (2005 to 2007)
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2005 Actual
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2006 Actual
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2007 Actual
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2008 Budget
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Revenue
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Beginning Cash
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Grants
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$5,900
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--
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--
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Patient Service Fees
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$788,704
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$971,002
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$947,836
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$906,941
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Donations
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$11,960
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$3,091
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$2,100
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Subsidy from County
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Loan
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$100,000
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$182,000
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$100,000
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--
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Subsidy
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$300,000
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$100,000
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$125,000
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$225,000
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Subtotal Revenues
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$1,188,704
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$1,270,862
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$1,175,927
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$1,144,041
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Expenses
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Personnel
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$719,188
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$773,251
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712,363
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654,209
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Personnel Benefits
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$184,853
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$211,105
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187,334
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200,000
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Goods and Services
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$180,155
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$157,284
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147,247
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142,252
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Minor Equipment
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0
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Capital Equipment
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$70,202
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$18,654
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9,864
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12,000
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Travel
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$5,507
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$8,069
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12,680
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12,500
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Medical Malpractice
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$117,760
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$55,940
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55,856
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46,000
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Other Insurance
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0
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0
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Facility Costs
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$32,954
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$21,087
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21,353
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33,180
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Taxes
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$11,814
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$10,942
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17,980
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13,500
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County Services
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$11,500
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$13,500
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11,600
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14,500
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Miscellaneous
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$14,948
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$14,550
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20,107
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15900
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Total Expenses
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$1,348,881
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$1,284,382
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$1,196,384
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$1,144,041
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