Under pressure 

Rough transitions at Partnership Health Center

Partnership Health Center (PHC) is where people without access to private providers of health care in Missoula go for care. The community clinic—jointly supported by private physicians, the Missoula City-County Health Department, St. Patrick Hospital, Community Medical Center, the Robert Wood Johnson Foundation and the U.S. Bureau of Primary Health Care—provides medical services for an income-appropriate fee to anyone who needs them.

When the clinic started in 1992, critics of the concept charged that concentrating the medically indigent in a single location, rather than providing them vouchers for care at existing clinics, would leave those patients vulnerable to the fortunes of a single provider.

According to Dr. Deanna Phinney, PHC’s medical director until Jan. 31, 2006, those critics were right. Since Phinney’s departure, temporary doctors hired on short-term contracts have overseen mid-level medical staff who cannot work without a physician in a supervisory role; the arrangement ensures that PHC patients have a doctor to see, but Phinney believes the discontinuity diminishes the quality of care received by patients.

Phinney, who began as medical director of PHC on Jan. 1, 2005, had been working without a contract since the provisional contract under which she was hired expired on June 30, 2005. When an offer to revise the contract was tendered by PHC Executive Director Kate Bratches in early January 2006, the number of annual patient encounters expected of Phinney was bumped up from a 3,600-to-3,800 range to a total of 5,085; in addition, the revised contract included further changes to her administrative responsibilities—changes Phinney felt diminished her ability to advocate on behalf of a medical staff she believed was already beleaguered.

Rather than accept the revised contract, Phinney resigned from the organization at the end of January, following a contentious correspondence with Bratches in which Phinney threatened to resign if Bratches did not make “a valid contract offer” by the end of the month Bratches chose not to renegotiate, instead notifying all staff in an e-mail that Phinney “has given a two week notice.” Bratches then sent a letter to Phinney’s patients notifying them of the resignation and “assur[ing] you that the providers at Partnership will continue to provide you the quality medical care that you are accustomed to receiving.”

That care, according to Bratches, has since Phinney’s departure been offered through short-term contracts with temporary doctors, as well as through increased hours worked by part-time staff physician Mike Curtis. Curtis, a six-year PHC veteran, submitted his own resignation at the end of January, scheduled to take effect at the beginning of June, coinciding with Curtis’ plans to join the staff of a local hospital.

Phinney admits that the correspondence surrounding her contract with Bratches was ill-considered—she attributes some of her distemper to caring for her mother, who was undergoing chemotherapy at the time—but says the way her termination was handled is troubling for more reasons than that.

In particular, and in contradiction to Bratches’ assurances, Phinney asserts that quality of care has suffered as a result. “When patients lose their doctor, it is a big deal…Nobody gave [those patients] a chance to find somebody else. They didn’t have another doc in place. There’s nobody there now to transition to.”

Bratches, for her part, places the blame for any lapses on Phinney: “That was her choice. She never said she wanted to stay longer than two weeks, never talked to me or said otherwise.” Bratches adds that while a new medical director has yet to be hired, “great candidates are being interviewed.”

The rancor over Phinney’s contract was fueled in particular by pressure from PHC administration to serve increasing numbers of patients. “They wanted me to spend 40 hours, patient contact hours, which means a minimum of 50 hours in the clinic. And then there’s paperwork and then there’s medical director stuff to do on top of that,” Phinney says.

“You don’t just see patients, you know; you take care of them and that means getting them to the people they need to go to, it means calling them back, it means phoning in drugs, it means all of those things and there was no allowance for that.”

Phinney’s complaints about the proposed contract speak to her concern that the clinical staff was already overworked. “It was almost as though the work that you did, you did in spite of the organization, not because they helped you, which was backwards…They just didn’t understand how hard it was to take care of really sick people, very complicated patients…Mike [Curtis] and I were working as fast as we could all the time in the hospital and in the clinic because there was such a tremendous need, you know there’s just more and more people.”

Curtis agrees that PHC is a demanding place to practice medicine, particularly before the clinic recently turned over care of hospitalized patients to hospitalist doctors in an effort to reduce the clinic’s workload. “Before that we were overloaded. There was too much work to be done and not enough hands to do it.”

Curtis points to “medical providers [being] asked to escalate their workload” in response to a $560,000 deficit discovered in 2002. At the time, the Montana Primary Care Association’s newsletter reported, “The problem, according to Partnership Health Center’s [then-] Executive Director, Ed Mahn, was not necessarily financial mismanagement, but one of strong dedication to the mission.”

Phinney attributes the demands being laid upon the clinical staff to the “initial perception…that [the deficit] was the medical clinic’s fault,” saying that, even years later during her tenure, the pressure to process patients affected not just doctors but also the mid-level support staff. “Everybody there worked hard. The nurse practitioner and [physician’s assistant] were two of the best mid-levels I’ve ever worked with; they did things they shouldn’t have to do, dealt with more complicated medical problems than they should have had to. It’s just a darn good thing they were good.”

Bratches and Curtis both echo Phinney’s praise for the care offered by mid-level clinic staff. But despite the agreed upon competence, at least two patients have expressed discontent stemming from PHC’s personnel changes.

Phinney illustrates how her termination impacted patient care with the story of visiting a patient she had cared for at PHC in the nursing home where the woman lives. “She was so mad. And I said, ‘why are you so mad at me?’ And she said ‘because you abandoned me.’ I said ‘I didn’t abandon you. Didn’t anybody tell you what happened?’ No.

“How do I explain to someone who is totally dependent on other people for everything, how do I make that up to her? There’s no way she can understand that…She went through two months of thinking that I didn’t care at all and that there was nobody to care…And there’s a lot of people mentally who are just as vulnerable as she is and there’s no way I can make it right for them either.”

While Phinney’s relationship with that patient was disrupted by her transition out of PHC, the case of Dawn Alexander speaks to the pressures on PHC as an organization since Phinney’s departure.

Alexander, who’s had five back surgeries and currently takes medication for chronic pain in addition to being recently diagnosed as a diabetic, went to PHC several weeks after Phinney’s departure, thinking another doctor would treat her. Instead, after arriving for her appointment, Alexander says the person she saw at PHC told her PHC “could no longer take care of her health needs.”

When Alexander asked about treatment for her diabetes, “[the clinician] said she didn’t have an answer for that, that they were really short-staffed and really couldn’t keep me as a patient.”

Phinney thinks PHC’s refusal to care for Alexander endangered the patient’s well-being.

“She’s trying really hard; she has two kids who are just getting their way through school and she’s lost 50 pounds and then for someone to tell her that she can’t be seen—it just tells her that she’s not worth it.”

Bratches says she cannot respond to Alexander’s specific charge about denial of care because federal privacy law forbids disclosing any patient information without a signed consent form. As for the general quality of care at PHC, Bratches has no doubts: “We provide the only sliding fee scale in Missoula, and we’ve had stellar evaluations through our national accreditation organization…I think we give really great care. I’m really proud to be part of Partnership and feel fortunate to have this position.”

And Alexander is grateful to be back under the care of Phinney, who is working as a temporary doctor at Fort Missoula Medical Associates.

“She’s such a good doctor. She worries so much about her patients. She genuinely cares. When you find a doctor who cares, you don’t want to lose that. Her caring makes it so much easier for me to deal.”

The prospects for other patients who want to follow Phinney is complicated by her current temporary status, which means Medicaid patients either need a referral from PHC or a non-temporary doctor who agrees to assume their care for billing purposes. As for patients without insurance coverage, PHC remains Missoula County’s default option for clinic care.

With respect to PHC’s organizational health, physician Curtis expresses confidence in Executive Director Bratches’ leadership. “I would just say that I have a lot of confidence in our new executive director, Kate Bratches. There has been a lot of turmoil but she is a very straightforward, hard-working person who is going to get things working pretty efficiently there…I have confidence now that PHC will rededicate themselves to quality primary care.”

What matters, says everyone concerned, is that people who need it get quality care. According to Phinney, “people voting with their feet would be the surest way to ensure that’s the case.” For PHC patients, though, that’s not always an option.


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