On April 24, a special election will determine whether Orcas Island will have a public hospital district. PHD commissioner candidates are set to be elected on the same day as the district.
Richard Fralick is running unopposed for hospital commissioner one; Pegi Groundwater is running unopposed for position two; Arthur (Art) Lange and Leif (mononymous) are running for position three; John Dann, Richard (R.J.) Myers, Diane Boteler and Bill Bangs are running for position four; and Patricia Miller is running unopposed for position five.
For more about the candidates, see our article about the first candidate forum.
The Sounder asked the candidates the following questions about the public hospital district.
Richard Fralick
Running unopposed for position one
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
I believe all existing primary care providers on Orcas Island should be able to request PHD support. As regards to support for the UW Medicine Orcas Island Clinic and the Orcas Family Health Clinic, a detailed financial analysis of both clinics must be completed. Obtaining patient census and visit data will be critical to the study. Once obtained, the information will be used to determine the correct level of assistance to be provided to each. Through negotiation and monetary incentives, I would encourage both clinics to work together to streamline delivery of services, sharing of overheads and capital equipment. Whether this would ultimately lead to consolidation of the practices cannot be predicted at this time. Depending on developing circumstances, such an outcome might become practicable.
How do you think urgent care and after-hours care should be addressed?
The cost of current levels of urgent and after-hours care must be quantified. A cost/benefit analysis for improving these services must then be made. After the level of assistance required to sustainably support primary care is determined, residual taxing capacity should be evaluated and a determination made as to whether or not these available funds should be collected and how they should be apportioned. Improvement of urgent and after-hours care is a priority. The long-term financial sustainability of the PHD must also be considered, particularly as it relates to debt service and a rainy-day reserve fund. The Board of Commissioners will then make a considered decision as to how much should be spent on each.
How can the district ensure that the funded facilities are meeting the needs of the public?
The PHD should use satisfaction metrics to ensure that funded facilities are meeting the needs of the community. Such metrics should be included in any contract for services, and there should be clearly spelled-out consequences for nonperformance up to and including loss of PHD funding.
Satisfaction metrics are obtained from the patients of the providers after an office visit. They are semi-subjective, typically provided by a survey filled out by the patient post-visit. They [should] measure satisfaction overall, access to care, communication, coordination, etc. I would not expect the board to see individual surveys but rather summaries showing overall perceptions/measures of the medical provider’s performance.
A community needs assessment should also be conducted by the PHD to determine if additional services should be added to those available.
Pegi Groundwater
Running unopposed for position two
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
I believe that the PHD should fund both primary care practices on Orcas to the extent required to ensure ongoing operations while carefully reviewing [its] financial operations to make sure that taxpayer dollars are not wasted. I think the PHD should also explore ways to reduce the duplicative overhead associated with having more than one practice on the island. For instance, if large pieces of new equipment need to be purchased, I believe the equipment should be owned by the PHD and its use shared by all primary care providers. Perhaps the PHD can find a way for all primary care providers to work out of the Medical Center building.
How do you think urgent care and after-hours care should be addressed?
Our primary care providers already provide urgent care during office hours, but UW experienced some significant issues as they established their practice on Orcas. They seem to have resolved some problems and are working on solutions to others like courtesy blood draws. The PHD commission and superintendent should work with our medical providers to make sure that urgent care is available on a timely basis for all islanders. After-hours urgent care seems to be the larger issue. Both the Family Health Center and UW provide some form of after-hours urgent care, but that does not necessarily mean that a doctor is available to see a patient after hours if necessary. I believe the PHD should bring our EMS team and our primary care providers together to create a system that ensures that a doctor is available to meet with a patient after hours if medically necessary.
How can the district ensure that the funded facilities are meeting the needs of the public?
The PHD can require the medical practices to provide their quality metrics and patient complaint data to the PHD (in a manner that protects patient privacy and complies with HIPPA laws) as a condition of funding to make sure Orcas patients are receiving quality care. In addition, the PHD will carry out periodic public-needs assessments to make sure that the practices that receive PHD financial support are providing the medical services that Orcas residents want and are willing to support financially. The PHD meetings are open public meetings and will provide Orcas residents with an opportunity to speak to the commissioners about their vision of health care on Orcas.
Art Lange
Running for position three
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
All existing primary/urgent-care providers should be eligible to request PHD assistance. While the process of applying has to be decided by the elected commissioners, I would expect that each provider would make a specific request for assistance. The commissioners would carefully review in detail the specific request and the budgets of those making requests; negotiate the provision of specific services, their cost, metrics for measuring patient satisfaction; and [determine] how the PHD will monitor performance. The commissioners would then work with each provider to reach a mutually acceptable contract.
How do you think urgent care and after-hours care should be addressed?
I would like to see two things:
Patients needing treatment for urgent care problems during regular office hours should have quick access to a provider (a doctor, NP, PA, nurse) who would be able to make a determination that the patient needs to be seen “urgently.” Once that determination is made, the patient should be able to see a provider quickly (depending on the nature of the presenting problem, that same day or the next day, if such delay is medically appropriate).
Regarding after-hours calls, patients should have access to a physically present provider when it is determined that that is medically appropriate. There may be a process of triage to make that determination, but being able to receive treatment from a physically present provider should be the end result when that is medically appropriate.
I do not believe we, as a community, can afford the cost of a fully staffed, 24/7 walk-in clinic. There is just not enough use to justify the considerable expense, but I believe that providers can be available when it is medically appropriate to see patients after-hours.
I would also like to see expanded clinic hours both during the week and on weekends wherever possible. It is estimated that such expanded hours would greatly reduce the number of after-hours calls.
How can the district ensure that the funded facilities are meeting the needs of the public?
There are, at least, two questions regarding “meeting the needs of the public”: one, are services being provided at very high levels of patient satisfaction throughout the patient experience at the practices that are supported by the PHD? and two, are the practices providing the service that patients want and need? Number one focuses on the issues of quality and number two focuses on the issue of what types of services are wanted/needed.
The first issue would be addressed by including very specific metrics in the contract with each provider, measuring patient satisfaction on all the aspects of their medical experience. However, having data alone will not ensure that patients will be well served. There must also be clear consequences articulated in the contract for non-performance. There has to be some form of tangible accountability. Frankly, the only way the PHD can incentivize high levels of performance is with the provision or withholding of its funding.
The second issue can be addressed by surveying the members of our community to clearly understand what additional specific services folks want from their primary and urgent-care providers that are not being offered at that time and how much they would be willing to increase the levy to receive them. Certainly, it is very possible that some additional services might not require any additional cost.
Once the primary/urgent care needs have been met satisfactorily, the commissioners can then survey the members of our community to identify what other health care services they would like the PHD to support and how much they would be willing to increase the levy to receive them.
Leif
Running for position three
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
The distribution of funds should take into consideration three factors, all determine what will deliver the best value to Orcas health care:
First, what is fair? We are heir to a history; ignoring it is an illness that undermines health. For one moment we have the chance to ask the accountants and business people to step aside and consider that this community and its providers are traumatized by the violence done in boardrooms making dysfunction our “norm.”
We have a long history of accounting too. Numbers were generated under a real-life “stress test” and can be taken as a very good approximation of financial need. This should be used as a baseline for future estimation.
How do you think urgent care and after-hours care should be addressed?
“Urgent care” is an uninformed misnomer revealing the difficulty of oversight in health care. Without informed advocates, serious misunderstandings develop between professional providers and community debate. [For example:] caring for a sick relative is not a qualification as a community health care advocate; and EMS cannot replace ongoing professional care. On Orcas, we need to be much more careful in our choices about who represents our “needs.” Having popularity or money cannot replace being qualified. Qualifications are verifiable facts and skills.
“After-hours medical care” is, for Orcas, the test of successful collaboration between our providers including EMS. It is a constant drain on resources, professional and financial, but it is only sparsely remunerated, so it becomes largely unrecoverable overhead, like having the heater on all the time.
How can the district ensure that the funded facilities are meeting the needs of the public?
This is an illustration of points one and two (above). What will deliver the best value to Orcas health care?
A successful collaboration between the community, its legitimate local advocates and the professional team. We have come to this critical juncture portending the loss of primary care on Orcas because of a pattern of complicity giving undue influence to those without sufficient standing, leading to abuses of governance, sapping our limited resources and destroying confidence in our providers thus rupturing the professional safety net, thus allowing our most vulnerable to fall through.
Financial stresses on the cusp of [Baby] Boomer senescence has merely exposed this metastatic cancer. No level of management restructuring or financial bailout will substitute for addressing this root cause finally.
Bill Bangs
Running for position four
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
Our ultimate goal should be a single, integrated practice at the existing clinic (Deye Lane) that meets the primary and urgent-care needs of our community at minimum cost. We have two separate practices and facilities that, in spite of skill, dedication and good intentions, are not yet meeting our needs and expectations. In the long term, we might not have either of the existing practices. In the short term, we need to negotiate minimum cost contracts to ensure continuity of care as we establish the vision for our future. I believe we can fund our immediate health care needs, including seven-day urgent care, with a tax rate of fewer than 50 cents per $1,000. We must insist on efficiency and collaboration with whoever receives public funds.
How do you think urgent care and after-hours care should be addressed?
Our non-life-threatening urgent-care needs should be met both during and after normal clinic hours. We should be able to walk in during normal hours as well as receive same-day or next-morning urgent appointments, seven days a week. We should have 24/7 call-in access to either physician or nurse practitioner clinicians who can triage our issues so that we can be counseled to call 911, rely on self-care or receive a prompt appointment at our clinic. This can be provided seven days a week by having local doctors on-call on Saturday and Sunday. With four doctors, each needs only be on-call once every other weekend, and the cost to the taxpayer, assuming current market rates for a call, would be less than 2 cents per $1,000.
How can the district ensure that the funded facilities are meeting the needs of the public?
Any practice or facility funded by the PHD should agree to meet several conditions, including the acceptance of insurance and providing financial assistance. The practices should report on a number of quantitative measures of effectiveness, both for patient experience and for financial performance. These measures should include patient load, the number of visits per month, patient satisfaction, waiting times for routine appointments, and waiting times for urgent appointments. These measures should also include operating expenses per patient visit and expense recovery from all sources. All of these measures would be published on the district website for public review and comment. The district should also provide a complaint management system on its website for public comment and resolution. All such reports will factor into contract renegotiations.
Diane Boteler
Running for position four
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
Funds should be allocated based on the ability of each clinic to provide primary and urgent care to all islanders and participate in an after-hours urgent care system in collaboration with EMS. This evaluation would require a scientific needs assessment conducted over the first year of the district. Additionally, each clinic requesting funds would be required to provide detailed financial and patient visit information to support any subsidy request. The details of what information must be provided would be developed and published by the board with public input. The commissioners should also look at how clinics compare to other rural clinics in efficiency measures such as administrative costs, billing recovery from insurance companies, and staff-to-provider ratios.
How would you feel urgent care and after-hours care should be addressed?
Any subsidized clinic should have appointments available for patients with acute medical needs to be seen ideally the same day.
After-hours care first-contact could be by phone to island-savvy nurses. EMS would continue to evaluate acute illness and injuries. Physicians or providers would be available by phone to back up triage nurses, to discuss patients with EMS and to assure follow up care and to see patients needing acute treatment or evaluation.
The system should be accessible to all islanders and visitors with urgent health care needs without barriers based on primary care registration, insurance status or ability to pay. My hope would be to facilitate building a system for urgent and after-hours care easily accessible to all and appropriate in time and place of care.
How can the district ensure that the funded facilities are meeting the needs of the public?
We think we know what our essential health care needs are, primary and urgent care, but without a formal assessment, we are making ill-supported decisions. A scientifically designed and administered health-needs assessment should be done in the first months of the District that includes all islanders. Each clinic should be required to provide quarterly metrics to assess meeting those needs. Metrics should include specific measurements of care provided, such as the number of unique patients and encounters, timeliness of access to care and patient satisfaction and complaints. The district superintendent will be tasked with ensuring the accuracy of the reports and working with the board and the clinics to ensure identified needs are met.
John Dann
Running for position four
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
I would distribute funds based upon patient volumes treated on a monthly basis to include after-hours care. Asking for any more detailed data could be fraught with inaccuracy.
How do you think urgent care and after-hours care should be addressed?
I would stipulate funding of individual practices predicated upon developing an after-hours call network from the practices being subsidized.
How can the district ensure that the funded facilities are meeting the needs of the public?
The hospital district should receive a periodic report of patient volumes under active treatment. Additionally, HIPPA notwithstanding, the hospital district should be privy to information regarding patient complaints of providers and the ultimate resolution of those complaints by providers.
Richard (RJ) Myers
Running for position four
Answers were unavailable by press time.
Patty Miller
Running unopposed for position five
If the hospital district is approved, how do you think funds should be distributed among the existing facilities?
RCW 70.44.140 spells out the requirements for how contracts can be awarded for services sought by a PHD. I anticipate that the initial desired services will be similar to what is currently provided by the existing facilities and that funds may be distributed to support their current models of operation. Collaborative solutions to address the biggest gaps in urgent care should also be evaluated. Customer satisfaction and economic metrics should be established and contracts should include penalties for failing to meet these metrics.
Metrics should evolve to measure the complexity and volume of visits and include incentives to achieve efficiencies within each practice and between practices. Industry metrics exist for compensating practitioners and measuring efficiency, which could be used to determine the level of reimbursement.
How do you think urgent care and after-hours care should be addressed?
Both clinics currently offer some level of 24/7 after-hours and critical care support. The commissioners must evaluate the current services, including EMS, then clarify the gaps.
Collaboration between the main practices and EMS will be essential to the development of island appropriate service. I expect that the final solution might include a combination of one, limited expansion of regular hours of operation and limited hours on Saturdays; two, a more robust on-call system that offers over the phone triage to determine appropriate care; three, recognition by the community that a needs-based system, where an on-call medical practitioner deems what situations require immediate on-site after-hours service may be what is available; and four, some additional compensation to practitioners delivering that immediate on-site care.
How can the district ensure that the funded facilities are meeting the needs of the public?
This is a question of if the PHD is focused on delivering not only the right services but also are they being delivered in the right manner. I expect that the commission will conduct a health care needs assessment and gap analysis for the community in the early stages of the PHD. This will help establish the priorities as well as identify the biggest gaps in services to determine where the public’s needs are not being met. This analysis, combined with the implementation and tracking of appropriate performance metrics for the participating clinics, should clarify if the services that are being delivered are meeting the needs of the public.
