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OCR for page 209
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
OCR for page 210
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,
OCR for page 211
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-
OCR for page 212
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,
OCR for page 213
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.
\
Representative terms from entire chapter:
marshfield clinic
