Sunday 2010 10 24
Some wind this morning from the predicted storm but little rain. Water tank at 10 feet.
Suzanne, moderator for the Orcas Island Unitarian Universalist Fellowship the last two years reported that her recent moose hunting adventure with husband John in the Bella Coola Valley had been a great success. They had come back with a large supply of moose meat (no, they didn’t bring the head), they enjoyed the friendliness of the guides and locals, but most of all, she said, she appreciated the time with John, being part of an activity he enjoyed and had mastered, hunting, that she was both ignorant and tentative about.
The UU fellowship was formed in 2000 by Nanette, a Santa Barbara refugee, and when it was clear she would have to move to Bellingham to be closer to major medical care, I volunteered to be responsible for services, to be the moderator. Nanette’s style was cruise director lite. The services were her party and she made certain everyone had a good time. The congregation grew. My style is lectures on serious topics. The congregation shrunk. After five years duty, I resigned and Suzanne took over. Her style is poetic and intuitive. We’ve switched from rows of seating facing the lectern and chalice to a semi-circle; from show with Nanette to lecture with me to conversation with Suzanne. She has a gift and could have been a Unitarian minister if her life had taken a different turn.
After Suzanne lights the chalice candle, the light of truth and fellowship, and some of us come up to light additional candles sharing a joy or concern, David, president of the Orcas Medical Center Board, fills us in on the state of health care on the island. From the outside, the system looks healthy and robust. From the inside, it’s sick and unsustainable. I think about the fir I found Labor Day on my morning walk on Crane. It had broken off about 15 feet from the ground and lay across Circle Road. There was no sign of rot from the outside. There had been no wind. But the tree couldn’t stand.
Until this summer Orcas was home to five primary care physicians for a population of 5000. A more practical ratio, David says, is one doctor to every 2500. Two doctors have moved off the island because they couldn’t make a living. One doctor operates within the Medical Center, a state of the art facility built with donations and connected to a sustaining foundation. He is subsidized by the Medical Center. The other two doctors have their own offices and staffs. One takes no money out of his practice. The other appears satisfied with low pay in exchange for living on Orcas and practicing in a low-key way.
In David’s view primary care health delivery on Orcas is underfunded by $750,000 each year. Part of that deficit is made up by donations and the Medical Center foundation; the remainder by physicians out of their own pockets. That’s nice for benefitting islanders – who have great care and don’t need to adequately fund it – but as the doctors retire or leave Orcas and as donations dry up, Orcas may find itself in the same boat as many other rural communities – no local health care.
What is to be done? One alternative that the Medical Center has pursued is to reduce island medial care overhead (how many separate bookkeeping departments are really needed)? and redundancy (how many x-ray machines and office buildings are needed?) by encouraging the two outlier doctors to come into the Medical Center, operate independently but share the building and administrative overhead. So far neither is interested.
A second possibility would be to create an Orcas medical care taxing district as San Juan Island did a few years ago. Orcas has a taxing district to subsidize the public library. Why not do the same for medical care? Past efforts have failed and given an anti-tax mood, David says the Medical Center Board won’t attempt a referendum.
A third possibility relates to the way insurance companies and medicare/medicaid reimburse primary care physicians – fees for certain services. David reports that primary care physicians have to spend more time providing services they cannot collect for than services they can. They are reimbursed for office visits but not for writing and tracking prescriptions, telephone calls, and reading x-rays – even though they must do these things to care for a patient. They can’t make up the difference by charging more for office visits because the payers limit the amount they’ll pay for visits.
Primary care physicians – family practice, internists, and pediatricians – track individuals over time and can contribute greatly to a person’s long term health. Specialists see patients for a specific purpose and may never see them again. They deal with a situation, not the person. But specialists make double the income of primary care physicians on average, reimbursed at a higher percentage of costs than primary care.
The trick is to move primary care up the food chain. The closer it can come to the specialists/hospital world, the lower the subsidy required. San Juan Island is taking this step by working with Peace Health, a not-for-profit hospital group, to create an emergency room/small hospital in Friday Harbor. The center will house the island’s primary care physicians, who will then be affiliated with the hospital. Reimbursement will be more substantial and islanders will be able to get non-critical medical procedures without having to go to Anacortes or Bellingham. Were the Orcas physician’s community centralized in the Medical Center and were a taxing district in place, Peace Health would be inclined to invite Orcas to participate in its Friday Harbor center, scheduled for 2012 operation.
But is that likely to happen? David doesn’t have much confidence. The Orcas doctors value what they take to be their freedom and they’re willing to sacrifice financially to have it. The Orcas population is perfectly happy with the health care they get – no waiting days for an appointment, for instance. San Juan Island came to understand they would all benefit from cooperation and shared responsibility. Maybe Orcas will get to that point once health care delivery slips as temporary, hidden, subsidies fade away.
This afternoon, I called Noah, our oldest son, living with his family on the water on Harstine Island, South Sound, just north of Olympia and talked first to his wife Natasha about Jonathan Franzen’s new book Freedom. She loved the writing but was disappointed in Franzen’s portrayal of Patti Berglund. Too passive. Yvonne had said the same thing. No woman would act that way. Noah thought that the author’s summary execution of his most interesting female character, Lalitha, via a car crash, was because Franzen feared she would run away with the novel, as Mercutio was doing to Shakspeare in Romeo and Juliet so the Bard had him stabbed by Tybalt, under Romeo’s arm, as he intervened to stop the fight. And we talked about Franzen’s take on freedom.
© 2019 – 2020, johnashenhurst. All rights reserved.