Chilkat Valley News - Serving Haines and Klukwan, Alaska since 1966

Private practices face challenges


When reached Wednesday afternoon at Family Medical Clinic in Delta Junction, Stacy Chappelle, who supervises the clinic’s office work and dispensary, said the private practice was having something of a hard day.

Dr. Raymond Andreassen, the clinic’s owner, could not be reached and was not answering texts. He had gone to Seattle for a medical training. But he was having difficulty returning to Delta Junction due to 50 mph winds that were shaking the town, causing power outages and affecting the clinic’s electricity.

“It’s been flickering off and on today,” Chappelle said.

Power outages are the least of Family Medical Clinic’s worries. The business, Chappelle said, was just keeping its head above water.

“We’re paycheck to paycheck,” said Chappelle. “Sometimes we have to hold paychecks.”

The situation faced by the Family Medical Clinic, though perhaps more dramatic, sheds light on the difficulties facing private medical clinics throughout Alaska—including Dr. Linda Keirstead’s Chilkat Valley Medical Center.

Keirstead, who last week announced the closure of Chilkat Valley Medical Center, Haines’ last private medical clinic, declined to provide details beyond what was written in a letter sent to all her patients. That letter blames “the enormous and escalating administrative burden” for the clinic’s decision.

But the number of obstacles standing in the way of attracting medical professionals to rural Alaska means it may be unlikely that Haines will see the opening of another private clinic.

“Access in primary care is hard across the state of Alaska,” said Sarah Hargraves, the regional manager for Southeast Public Health Nursing.

The difficulties are neatly summed up in the situation facing Stacy Chappelle in Delta Junction.

For one, treating Medicare and Medicaid patients, which make up a good amount of Family Medical Center’s patients, is not nearly as profitable as treating the privately insured. For the same procedure, Chappelle said, the clinic can receive up to three times as much from private insurers as they do from Medicare.

Plus, billing patients for the remainder of the costs, especially elderly, fixed-income patients, is often difficult. Patients may be forced to make small monthly payments, which means that money trickles in slowly, accruing more paperwork and accounting costs. And sometimes patients are flat-out unable to afford the co-payment, which can leave providers in a tough position.

“We tend to be really lenient on people so we tend to not collect a lot,” Chappelle said.

In an attempt to treat poorer community members, Family Medical Clinic implements “hardship discount services” and trades medical care for services.

Larger institutions could help pay the travel costs for training and medical courses for their providers. But the owners of private practices, like Raymond Andreassen, have to pay out of pocket. And in remote parts of Alaska, travel can be expensive and subject to unexpected delays—which means less time with patients and less income.

In addition to long winters, severe weather and isolation, as well as lack of access to equipment and facilities, increased regulation has become more of a burden, said Sarah Hargraves of Southeast Public Health Nursing.

“There are federal and state requirements to make a billing system,” Hargraves said. “There’s more quality metrics for hospitals, more quality metrics for tribal organizations, more quality metrics for primary care.”

Dave McCandless, the medical director at Southeast Alaska Regional Health Consortium, said the changing medical industry is hard to navigate. The introduction and expansion of Medicare and other third-party insurers, McCandless said, have made it more and more difficult for small clinics to keep up with paperwork and regulations.

“That’s the key to why our system is the way it is, third-party payers,” said McCandless, who ran a private clinic in Wrangell 20 years ago.

Because of the expansion of insurers, McCandless said, the field of medicine has changed from a “cottage industry” of private practices to corporate business.

In Haines, the problem is made worse by the town’s unique demographics. The elderly receive more medical care than any other age group, because they have more health problems. But Haines’ aging population — it has the oldest residents in the state, according to a 2015 Alaska Department of Labor study — means that the elderly make up an even larger percentage of patients.

Clinics have to wade through even more Medicare paperwork in order to serve elderly patients—and receive less money for it.

Medicare and Medicaid claims systems, as well as medical records, are increasingly moving to electronic formats as well. These platforms can have a steep learning curve and can also be more vulnerable to power outages.

In addition to wrestling with insurers and billing requirements, doctors must undergo constant training and take continuing medical education courses to keep up with the quickly-evolving field of medical technology and research. Large medical centers and hospitals can provide doctors with institutional support and defray the costs of these courses. But private practice doctors—like Keirstead and Andreassen—are often on their own.

Dave McCandless of SEARHC said that the agency hopes to add Keirstead to its staff, but no deals have been struck.

“We would very much (like to) recruit Dr. Keirstead to work with us,” McCandless said. “Talks are in progress on that concept.”

Dr. Len Feldman, who ran a clinic in Haines for 30 years before retiring, said that keeping up with increasing amounts of red tape took its toll.

“They just nickel and dime you to death,” said Feldman, who estimates he is owed thousands of dollars through claims lost in the Medicare and Medicaid bureaucracy.

Still, he said, some of the challenges of practicing medicine in a small town were the same things that made it rewarding. In the Alaska culture of self-sufficiency, patients would only visit the doctor under very serious circumstances—meaning the cases Feldman worked on were more interesting.

“I did not see much in the way of runny noses,” Feldman said.

Haines Borough Manager Bill Seward said he was concerned about the coming lack of choice between medical options in Haines.

“When you have choice, folks can find what fits them,” Seward said. He said he was worried that Haines would not see another private clinic opening.

“All we can hope is that Haines itself continues to be the attraction for any physician,” he said.


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