HEALTH & SCIENCE

Public-private partnership

Collaboration between clinicians and public health at a new family health center near Seattle reflects a trend in the integration of individual and population-based care.

By Mark Moran, AMNews staff. July 5, 1999. - Additional information.

Seattle -- Not quite your typical primary care facility and not exactly a public health clinic, the Roxbury Family Health Center is a little bit of both.

As such, its modest venue -- adjacent to a Dollar Store and Al's Auto Shop on the outskirts of Seattle -- may belie its importance as a harbinger in the landscape of American medicine.

Owned and operated by Highline Medical Enterprises, a private primary care network affiliated with nearby Highline Community Hospital, the health center is an experiment in wedding traditionally segregated disciplines of public health and clinical medicine, merging staff and services at one site. It is pledged to serve everyone in the community, regardless of ability to pay, with a sliding fee scale that slides to zero.

Such collaborative arrangements are becoming less rare: More than 400 cases of partnerships between medicine and public health -- including a number of "one-stop shopping" sites similar to Roxbury -- are recorded in Pocket Guide to Cases of Medicine and Public Health Collaboration, published last year by New York Academy of Medicine.

Yet collaboration remains outside the norm, and the story of Roxbury, which opened in March, reflects a trend in the integration of individual and population-based health care still getting up to speed.

The offspring of an agreement between Highline Community Hospital and the Seattle-King County Dept. of Public Health, the health center is not without skeptics who question whether the hospital and physician network will remain committed to caring for a large number of uninsured patients. The center replaces primary care services previously delivered by the health department's clinic in the region known as White Center; those services were withdrawn this year, in part because of budget shortfalls.

But physicians who work at Roxbury said the collaboration offers hope for improving access to underserved populations and a new model of clinical care for individual patients. "As a clinician, I enjoy being able to approach the patient as a member of a whole family or social system," said Cynthia Taylor, MD. "Working in an environment where there are services designed to address all aspects of that system is much more satisfying."

Within walking distance of Roxbury Family Health Center, in every direction, are signs of the immigration that has transformed White Center, where Roxbury is located: a Salvadoran bakery, a Vietnamese jewelry store, a Cambodian deli and the Samoan Assembly of God Church. Priced out of the housing market in downtown Seattle, these new Americans have been joined by residents of the former Soviet Union, Somalia and Yugoslavia, settling in small middle- and lower-middle-class communities south of Seattle like Burien, Auburn and Renton, as well as White Center.

It is a cultural and ethnic diversity that finds its way to the brightly lit waiting room of the Roxbury health center. Among its patients are some of the more than 20,000 immigrants from southeast Asia who have settled in the county. And a significant problem throughout the county, highlighted by a recent health department survey, is the dramatically low rate of clinical preventive services received by Vietnamese women compared with the rest of the population.

Highline provides two family physicians -- including one who speaks Vietnamese -- a Cambodian physician assistant with long-standing ties to the local Cambodian population, a Spanish-speaking medical assistant and administrative staff. In turn, the health department employs a pediatrician and family planning and public health nurses. On-site interpreters speak Vietnamese, Khmer and Spanish and a "client services specialist" screens patients for insurance status and benefits eligibility.

For many patients, the paths that bring them to White Center have been fraught with trauma. Andrew Sui, a Cambodian physician assistant at the health center, and Po Kao, a translator employed by the health department, counsel Cambodian patients who carry with them a legacy of loss: relatives, property, friends and tradition. "Almost all of our patients have one or more relatives killed by the Communists," Sui said.

Such stresses, invariably affecting patients' health, are difficult to assess in a typical primary care setting. "When you work in a private practice setting, you and your nurse are expected to do everything for patients," Dr. Taylor said. "The reality is that most doctors don't have time and in many cases may not have the skills."

Dr. Taylor believes Roxbury can be a model. "All medicine is public health," she said. "The private practitioner is looking closely at a smaller piece of the puzzle with a close-up lens, while a public health professional sees a bigger piece. But it's all the same puzzle, and the pieces interlock."

National trend

Collaborative arrangements between public health and medicine are a national trend, said Mohammad Akhter, MD, executive director of the American Public Health Assn. These agreements include many models of collaboration -- involving hospitals, medical groups, and private physicians -- in various stages of evolution.

The phenomenon is driven in part by tumult in the health care market: as Medicaid has increasingly been turned over to managed care, public health departments have lost revenues traditionally used to support care of uninsured patients at public health clinics in areas like White Center. But the private sector, picking up where traditional public health clinics are closing, is finding itself overwhelmed with the task of providing services to culturally diverse populations with multiple health needs.

"The [existing] infrastructure simply isn't sufficient to deal with all the problems," said Alonzo Plough, PhD, director of the Seattle-King County Dept. of Public Health. "As large physician practices have gone at risk, they have discovered prevention needs to be a key component of what they do. They want to learn from us."

Such collaboration can only help the clinician. "Many times when people talk about medicine and public health collaboration, it's as though doctors are supposed to be doing something in addition to their clinical work," said Roz Lasker, MD, co-editor of the Pocket Guide to Cases of Medicine and Public Health Collaboration. "We found that when physicians are involved in collaborations, they get important support to help them deliver medical care."

The Roxbury partnership had its genesis last year when the health department identified a gap in clinical services for adolescents in nearby Burien. A request for proposals attracted a number of provider groups, including Highline Medical Enterprises, and before the year was out, the medical group was operating an adolescent health clinic.

The project proved successful and a useful staging ground for collaboration with the health department, said Ron Singler, MD, medical director of Highline Medical Enterprises.

Based on that experience, the partners began to seek out areas of mutual need, in ways that mirror the national trend. When the health department ceased providing medical services at its clinic in White Center, the hospital saw a gap in clinical services within its mission area and a market to capture that included a substantial number of Medicaid-eligible and insured patients.

Yet Dr. Singler's group recognized a need for services only the health department could provide: prevention, outreach to the community and translation services. "The health department made a decision that primary care was not its forte," Dr. Singler said. "Meanwhile, we became aware of the need for their services. Each side came to view what the other was doing as complementary."

Critical to success, he said, is the acumen and economies of scale that a sizable medical practice can bring to making a primary care health center -- one that opens its door to anyone, regardless of ability to pay -- financially sustainable.

"Since we run office practices, we are much more tuned into the billing and administrative issues of a primary care practice," Dr. Singler said. "We are not planning on losing our shirt with this. The health center is not going to be in the black, but we hope it will be sufficiently balanced to meet the expected budget of loss."

Highline invested an estimated $350,000 in start-up costs, while the health department is providing an estimated $180,000 of in-kind services. Highline's expected losses the first year are $194,844, diminishing to an estimated $55,897 in the third year.

Dr. Singler said the health center can be made viable, without sacrificing care for the uninsured, by bringing Medicaid-eligible and insured patients into the Highline Community Hospital network.

Yet some in the community, including physicians, question whether the Highline physician network will sustain a commitment to serving a large number of uninsured patients.

Family physician Barry Saver, MD, of Harborview Hospital in Seattle, said that in time the center's sliding scale may tilt upward and, before long, Roxbury could be a site only for the insured. He is critical of the health department, which he said has portrayed the collaboration as a "reconfiguration of services to improve access," when it is bailing out of direct medical care because of a budget shortfall.

Dr. Singler said that Highline has a commitment to the community that will endure. And a spokesman for the health department said it has vowed to monitor charity care at the health center and report to the community regularly.

But Dr. Saver's skepticism underscores the threat to collaboration everywhere.

"Where does the money come from?" he asked. "Most primary care providers aren't in it to lose money."

The long-term viability of collaboration between medicine and public health awaits broad systemic change and an investment in population-based care by health plans and managed care. "The real obstacle is that the health care system is going through a transition," Dr. Akhter said. "Managed care companies are in such a competitive rut that they have not had a chance to look at the community in which they operate."

Meanwhile, clinicians and staff at Roxbury are forging relationships with patients in the community they serve.

In the colorful ambiance of the health center's pediatric office, Loris Hwang, MD, conducts a familiar conversation with Roxanna R., a Mexican-American mother of 8-month-old twins: Are the two babies feeding vigorously? Sleeping well? Tolerating medication?

The conversation is assisted by a Spanish translator and punctuated by the cheerful tumult of Roxanna's 2-year-old boy.

The family is well known to all: receptionist, office manager, client services specialist, nurses and doctors. Born prematurely, the twins have been seen regularly at the center; today they are thriving.

Roxanna fretted about where to go for care when the health department ceased providing medical services. For a period she traveled a distance to a private physician but left frustrated by the lack of a translator.

After four months at Roxbury, the young mother says, "Me siento en casa." "It feels just like home."

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