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Promoting COPC Through a Rural Health Care Network: Marshfielc! Clinic Dated L. Drones In the early 1970s portions of 44 of Wisconsin's 72 counties were designated physician shortage areas according tO criteria established by DHEW. To compound this problem, nearly 50 percent of Wisconsin's primary care physician were 55 years old and older, more than one-third were 60 years old and older, and approximately 11 percent were 70 years old and older. In response tO problems of physicians shortage and/or maldistribution, the federal government had established the National Health Service Corps (NHSC), however, the retention for NHSC physicians in Wisconsin and throughout the nation was less than 30 percent. The Marshfield Medical Foundation, in the spring of 1976, applied for and received a Rural Health Initiative Grant. The purpose of the project was tO develop a rural health network, a decentralized system in which first-rate primary care would be available locally and then integrated into a regional system of backup, sec- ondary, and tertiary care. Development of this network included planning, development, and op- eration of a rural health care delivery system that provides linkages to communities, tO existing medical institutions, and tO physicians seeking those elements of a medical resource center most appropriate tO meet their needs. The program offered diagnostic and technological services, consul- tation services for medical and administrative problems, and continuing educational programs for physicians in rural practices. Computerized services, telecommunication, and transportation systems were instrumental in the development of the network. An interfacing of these Marshfield Clinic systems has resulted in "one-stop shopping center" 209

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210 PART II: PRACTICAL APPLICATIONS availability for a variety of diagnostic services that are currently being pro- vided to 217 different clinics and hospitals throughout northern and central Wisconsin. This network of suport services provided the framework for the eventual development of six Marshfield Clinic primary care satellite centers. Each of these was established in response to requests from com- munities located in counties designated medically underserved and/or crit- ical manpower shortage areas. The population of these communities varies from 1,000 to 3,500, and the distance from Marshfield ranges from 10 to 100 miles. All these communities had physicians at one time, but, in spite of considerable effort, they were unable in recent years to attract and/or . . . . retain physicians. Marshfield Clinics satellite development was based on the premise that an established group practice located in or near medical manpower shortage areas could provide professional, technical, and management support critical to recruitment and retention of physicians. The model selected is analogous to medical departments in Marshfield. Satellite physicians have the oppor- tunity to become full members of the corporation and are hired under the same basis as all other clinic physicians. Marshfield Clinic "regional centers" or satellites are designed to be "part" of the greater whole and not separate organizations to be operated as different entities, even though separated geographically from the main clinic. Factors considered in evaluating potential sites for satellite centers include existing health care manpower and facilities, the economic profile of the community, demographic factors, financial considerations, satellite accept- ance, and HMO expansion potential. From the perspective of the physician considering practice in a rural area the satellite concept is attractive because this linkage with combined resources can more effectively address problems associated with rural health care practice. Those problems include coverage, absence of consultation, availability of trained administrative and technical support personnel, economic constraints, opposition by existing providers, professional isolation, and quality control. Marshfield incorporates a variety of systems and services to support its satellite program and address those problems cited as deterrents to devel- oping a rural health care practice. Coverage is best handled where possible by sufficient community-based staff. Marshfield-based physicians do provide scheduled on-site coverage where necessary. Physicians from Marshfield rotate regularly to the satellite in Strafford just 10 miles away. In Green- wood, located 35 miles from Marshfield, the community is not large enough to support more than two physicians. In this case, a telephone can diverter is employed to enable coverage every third weekend from Marshfield. The other satellites have three or more community-based physicians. Ladysmith now has nine physicians, including four family practitioners, three internists,

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Promoting COPC Through ~ Rural Health Care Network 211 a pediatrician, and a general surgeon. Four-digit direct-dial telephone access between all centers facilitates medical and management consultation. The medical records system is "on-line" with the center in Marshfield. The usual complement of on-site support staff includes medical assistants, nurses, and lab and x-ray technicians, as well as medical record, steno, receptionist, business management, and patient education personnel. All patient billing is done centrally in Marshfield. Marshfield's on-site physician consultation program brings staff specialists to satellites on a monthly or bimonthly basis. Cardiologists, orthopedic surgeons, neurologists, psychiatrists, dermatolo- gists, urologists, rheumatologists, and obstetricians participate in this pro- grarn. Continuing medical education opportunities include individualized teaching rounds conducted in Marshfield, Category I accredited conferences held at regularly scheduled times at the satellites, cooperative workshops and seminars, and a regional video network. The same quality-control pro- grams used in Marshfield are incorporated as an integral part of the satellite program. Each satellite has its own on-site medical chairman. In Marshfield an Extramural Practice Committee (EMPC), consisting of medical and admin- istrative staff, meets once a week to address issues relating to satellite centers and regional support services. Physicians selected from this committee pro- vide a liaison to each satellite. These physicians meet on-site with satellite physicians on a monthly basis. Also, a dinner meeting is conducted monthly with satellite physicians and EMPC members in Marshfield. This is held for convenience on the same day as the Clinic Board of Directors meeting, a meeting that all Marshfield Clinic physicians are asked to attend. Dr. Boyd Groth, Marshfield Clinic's first satellite-based physician, has expressed his thoughts about the system as follows, "I know that my prob- lems are someone elses problems, too. That community attitude is really important. For this kind of a system to work, you need a real sense of commitment not just 'testing the waters'and you need to feel that the institution has a real sense of responsibility for rural health care." Also. Dr. Groth says, "You need someone in administration with a drive and interest to make it go, someone for whom it is not a sideline. Remember, what gets doctors interested in being in a satellite in the first place is freedom from administrative problems." Nineteen board-certified or board-eligible physicians have thus far been recruited for Marshfield satellites. Linkage systems and communications developed between Marshfield Clinic and its satellites provide mechanisms to facilitate and expedite access to the level of care (primary, secondary, or tertiary) most appropriate to meet patients' needs. Expansion of the Marsh- field prepaid health plan into satellite areas offers an attractive option for patients tO finance their health care. Patient questionnaires, an incident-

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212 PART II: PRACTICAL APPLICATIONS reporting program, and regularly scheduled meetings with hospital boards and update reports to service clubs in satellite communities followed by question and answer sessions are conducted as part of an ongoing effort to maintain a feel for the pulse of patient response to services being provided. A high standard of excellence in quality of care is perhaps the single most important factor to ensure success in satellite~development. It is imperative to success, however, that the financial implications of providing that care be understood. The rural community satellite concept involves three major constituencies: the parent group or established group practice, the satellite group, and the rural community itself. The space constraints of this summary report make it impossible to adequately describe the peculiar set of mo- tivations of each constituent as it relates to the involvement of Marshfield's six satellites, much less the financial data relative to each practice. Marsh- field's experience, however, has been that satellite requirements the first year of a three-physician practice include capital expenses (building and equipment) of approximately $400,000, developmental expenses (person- nel time and travel, and physicians recruitment) of approximately $84,000, and operational expenses and funding of accounts receivable of approxi- mately S150,000; this represents a total of $634,000 for first-year start-up costs. The motivation for satellite development by any of the three identified rural community satellite constituencies has to be tempered by these figures. Marshfield Clinic's operational objective for its satellite centers is to break even on a direct-cost basis within a 3-year period. Patient and ancillary services referrals from the satellites help generate revenue to offset indirect expenses and facilitate continued development. Communication, cooper- ation, and understanding on the part of all three constituencies regarding the financial commitment necessary to establish a rural medical practice is extremely important to facilitate the development of satellite centers. Pos- itive indicators and areas of consideration are identified and reviewed for each satellite on a monthly-basis by Marshfield Clinic administrative staff. Strategies are developed, where appropriate, to address problem areas. The familiar rural complaint of physician shortage is often heard loudest and most frequently from the smaller towns seeking the return of country doctors they once had. The economic or ethical validity unfortunately is often little understood. The evidence calls for a multifaceted solution with improved cooperation and understanding on the part of both consumer and provider. Communities that want to attract physicians would do well to understand the professional and economic environments needed to support physicians. Marshfield Clinic's experience has reinforced an initial premise that local leadership, with a transcendent sense of community responsibility,

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P~~- COPE ^~~ ~ Amp/ H~~6 C~~ ~~ 2 I ~ creadve inteU~ence, Ad persona e~cdveness, ~ critics to estabUshment and maintenance of successful ram medico pracdces. E~edence has also demonstrated that the survive of these practices ~ becoming incre~i~y dependent Won the degree to Rich ankle can be developed between providers. \