There is a long history of animosity and mistrust in Klamath County between independent nurse practitioners and the local coordinated care organization, Cascade Health Alliance, which dates back more than two decades. In recent months, however, the frustration of the healthcare providers, and the access to primary care for residents of the rural area, have both taken a turn for the worse.
The independent nurse practitioner is a dying breed in Klamath County, and they say that’s exactly the intention of Cascade and Sky Lakes Medical Center, the only hospital in a 10,000-square-mile area in south-central Oregon and northeastern California.
“Cascade absolutely abhors nurse practitioners in independent practice and will do anything it can to shut them down in the county,” said Michael Sheets, a nurse practitioner who is the only healthcare provider in the 100-mile stretch between Klamath Falls and Lakeview. “If you’re not owned by the hospital or you’re not overseen by a physician, you’re a second-class citizen.”
Nurse practitioners, nurse midwives, and other independent providers interviewed for this article said they are unfairly excluded from the coordinated care organization at a time when their primary care services are needed more than ever. Not only are they ready to help, but their level of care has been proven to be cost effective.
Nena Herrera, a nurse practitioner at the Klamath Walk In Care Center, has watched as Cascade took her patients away from her, reassigning them to Sky Lakes providers upon discharge from the hospital.
She’s had to turn away patients because she’s not a contracted provider with Cascade, and seen them go to the emergency room for a sore throat, rather than wait two months to see their designated provider.
“We have people with true healthcare needs who aren’t able to get those needs met,” Herrera said.
Marilynn Sutherland, the county’s public health director, does not believe there are enough primary care providers in Klamath County. “Access has improved, but the resources, from our perspective, are getting sucked up faster than demand can be met,” she said.
The problem is the result of what Sutherland described as a “perfect storm” of events—Medicaid expansion flooding the local healthcare system with an aging and unhealthy population, many of whom have not had insurance for many years and had grown accustomed to using the emergency room as a substitute for a doctor’s office. On top of that, recruiting new providers to the area is difficult. Still, Sutherland said, “We know [Sky Lakes] has been aggressively recruiting.”
Cascade's enrollment in Klamath County skyrocketed 50 percent between June and December last year, from 11,314 to 16,976. The percentage of county residents enrolled in the coordinated care organization jumped from 58 percent to more than 83 percent in that time. So many new patients were signing up last summer that Cascade simply couldn’t keep up with demand.
An inadequate capacity of healthcare providers led the Oregon Health Authority to close Cascade to enrollment last summer. The Division of Medical Assistance Programs, which oversees contracts between the state and coordinated care organizations, allowed it to reopen in August.
Even still, there aren’t enough.
Patients waiting six months for an appointment
“I’m hearing it’s a six- to eight-month wait to get an appointment as a new patient with the [Cascade] clinics that cover Oregon Health Plan,” said Julie Ryder, a psychiatric-mental health nurse practitioner who runs her own practice in Klamath Falls.
Meanwhile, the health of local residents is among the worst in Oregon. Klamath County ranks dead last in the state in length of life and quality of life measures, according to an annual study conducted by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.
There are an estimated 66,000 residents of Klamath County, and 82 primary care providers to serve them (56 physicians, 19 nurse practitioners, and 7 physician assistants), according to the Oregon Health Authority’s 2013-2014 Health Care Workforce database. However, the Oregon Office of Rural Health reports a much lower ratio of 6.7 physicians per 10,000 county residents.
Last summer, the emergency department at Sky Lakes Medical Center saw a record-breaking number of patients, as many as 100 in a single day, 50 percent more than the beginning of the year. Ron Woita, the director of emergency services, attributed the surge of patients to “the greater number of people with health insurance through the Affordable Care Act, and the lack of access to primary care physicians,” according to an article in the Herald and News last July.
“You need to increase primary care availability,” Sheets said. “If you plug little holes, then you don’t have people going to the emergency room.”
Overall, emergency room use at Sky Lakes increased 20 percent in the first six months last year and is still up 10 percent year over year, Paul Stewart, president and chief executive officer of Sky Lakes Medical Center, told The Lund Report.
“For us, our fixed expenses are fixed. If I see 60 patients in a day versus 90, the cost structure doesn’t change,” Stewart said. “We don’t change the number of doctors in the emergency room. We might change the staffing a little bit, but not a lot.”
He disputes the notion that the county’s capacity of primary care providers is inadequate. Sky Lakes hired 13 new providers last year, including nine in primary care, and purchased two buildings in Klamath Falls that have been converted into primary care clinics to take serve Medicaid patients.
The first to open, Sky Lakes Primary Care Clinic on Almond Street, is at 60 percent capacity now. Once it reaches 75 percent, the second location on Clover Street will open its doors.
“The model is a physician and several nurse practitioners supervised by that physician. That’s the model that we continue to replicate,” said Stewart, who also is a member of the board of directors for Cascade Health Alliance.
If there’s a problem, it’s that people are not aware that the Almond Street clinic is open, he said. “That capacity is available. Educating people about how to access it takes time. One of the fundamental flaws with the Medicaid system is it does not create incentives to choose judiciously where they get their care,” he said, referring to emergency room use.
Stewart added that simply because enrollees in Cascade increased 50 percent at the end of 2014, that doesn’t mean the number of providers should grow by a similar rate, because the total number of patients is too small.
“Technically speaking three or four full-time primary care providers can take care of 5,000 enrollees. We have over 35 primary care providers in the community. We didn’t have to bring in 17 more in order to take care of 5,000 people,” he said.
Because Klamath County is rural, recruiting new providers has been tough for Sky Lakes, and the population is large enough that the area doesn’t qualify for student loan assistance. In response, Cascade has stepped in and paid a bonus of $10,000 to $20,000 to help convince a handful of new providers to move to Klamath Falls.
Maggie G. Polson, director of operations for Cascade Health Alliance and until earlier this month its interim CEO, did not return repeated calls for comment for this story. Tayo Akins was named CEO Feb. 16.
Next Week: A look into Cascade Health Alliance and Sky Lakes Medical Center.
Christopher can be reached at [email protected]
response to Fred Matthies
Of course, collaboration between providers is ideal. But even in clinics where there is a mix of providers, physicians are not "supervising" nurse practioners. NPs have their own panel of clients, who do not generally see their NP one visit and a MD the next. In Oregon, as in many states, nurse practitioners are independently licensed, do not require supervision by physicians, and are able to practice independently. Most NPs do not hesitate to seek consult or refer to a physician or other specialist when a client's complexity is beyond their scope of practice.
As this article so aptly reveals, in Klamath County, unlike most other areas of the state, NPs in private practice are not extended contracts to provide primary care for OHP clients, nor are they able to obtain admitting priveleges at the only hospital in the county. Thus, OHP clients are denied their right to choose a NP in private practice to be their primary care provider, and NPs are experiencing restraint of trade.
Better the physician see patients too, in which case one or two FNPs are a better ration to supervise, rather than "several." Patient care benefits when some visits are to the physician to make sure no loose ends exist. And the same can be said for having FNPs, who are demonstrably better listeners than physicians, add to the patients' records.