SAMARITAN HEALTH SERVICE Phoenix, Arizona Samaritan Health Service had its inception with the merger of Good Samaritan Hospital of Phoenix and Southside Hospital of Mesa in 1968. The system has expanded since then and now includes eight hospitals. The primary function and purpose of the Service is to provide more efficient and economical use of health facilities through a single corporate management. The hospitals in the Samaritan system are located in Phoenix, Grand Canyon, Holbrook, Lakeside, Glendale, Mesa, and Springerville. With the exception of Phoenix, these are small varied communities with no consistent ethnic or economic pattern. The two Phoenix Hospitals serve a broad cross section of the population; Springerville and Lakeside are mountain towns, and there is a substantial Indian population in Lakeside; Holbrook and Grand Canyon have large tourist patient loads. The Samaritan Health Service hospitals outside the Phoenix area are the only ones in their respective towns. The Indian Health Service of DHEW has some hospitals in the area but, except for Phoenix, they are not in the same towns nor do they treat non-Indians. In Arizona, public health services are provided by individual counties, and they differ according to county. There are few, if any, extended care facility beds in the communities. All eight hospitals in the Service are general hospitals. The system can provide almost any service, including hemodialysis, kidney transplants, and rehabilitation. The system has cobalt units, a cardiovascular institute, and open-heart surgical teams. It coordinates services with its own air transport which can move patients from one hospital to another and can send specialized personnel and equipment to hospitals needing them. In addition to the two planes operated by the Service, others are available for emergency use. Each hospital has a social service system. Home health aids are being used on a trial basis in Phoenix. A respiratory therapy outreach program is conducted with vehicles computer-dispatched to patients. In Phoenix, ambulance companies handle emergencies; in Holbrook, the SHS plans to train drivers in emergency skills. The reported case-load for the system in 1970 was over 350,000 outpatient visits and 47,850 inpatient admissions. Hospital occupancy rates range upward from 88 percent, except in Grand Canyon, which has about 110 percent occupancy in the three-month tourist season and less than 40 percent the remainder of the year. The Samaritan Health Service has a 28-member Board of Trustees for the Service and the eight hospitals comprising it. Three hospitals (Good Samaritan, Northwest, and Southside) entered the system through merger, with their assets and liabilities being consolidated; members of their boards were placed on the composite board. Maryvale was purchased and there was no board carry-over. The other four hospitals are operated under lease-management contracts, with SHS managing the hospitals and with local advisory boards operating in conjunction with the SHS board. The chiefs of staff of the four owned hospitals are full members of the board, and the President of SHS is also the President of the Board of Trustees. One of the SHS principles is that the local community must desire to be part of SHS, either through merger or lease-management contract. In September 1970, the Samaritan Health Service began a research project under the auspices of the Health Services Research Center (a combination American Hospital Association and Northwestern University research group) of Chicago. The research program, "Demonstration and Evaluation of Integrated Health Care Facilities, Samaritan Health Service," is designed to evaluate the service from a pre- and post-merger point of view using a variety of criteria. This study is scheduled for completion in late 1972. There is a continuing effort to centralize corporate services in SHS. Examples are increasing standardization of forms and computer input from all hospitals and using a centralized warehouse and supply center located near the airport and near main expressways to facilitate moving supplies to hospitals. SURGICENTER Phoenix, Arizona Surgicenter is a facility developed by two Phoenix anesthesiologists, John Ford, MD, and Wallace Reed, MD. It is designed to reduce the costs of surgery and eliminate charges for hospital rooms by providing a facility where surgery not requiring hospitalization can be performed. Thus the time of both patient and physician is saved. The Surgicenter serves the Phoenix area primarily. Patients treated at the Center have come from various ethnic and economic backgrounds. The facility is modern and air-conditioned and is located about one block from Good Samaritan Hospital. The patient waiting room has a seating capacity of 12; there are four 17' x 16' operating rooms and a nine-bed recovery area. A small laboratory handles tests of blood and urine, and there is a small pharmacy stock. Lounges are provided for nurses and physicians. Disposable uniforms are used in the operating areas and no inflammable anesthetics are used, thus saving on construction costs and laundry. Maximum use is made of disposable supplies. In addition to Drs. Ford and Reed, the staff includes one additional fulltime anesthesiologist, nine registered nurses, an orderly, and four secretaries. Any physician who uses the Center must be a member of his appropriate specialty society or academy of general practice and have hospital privileges at one of the local hospitals that has JCAH accreditation. During the first 17 months of the Center's operation, 220 different physicians used the facility and about 4,900 procedures were performed. About 96 percent of the surgery is done by specialists and 4 percent by general practitioners. After a patient is referred to the Surgicenter, he is screened by an anesthesiologist under the overall direction of a Medical Audit Team. A very minimal number of preoperative patients have been found to require hospitalization. If the patient contacts the Center directly, he is furnished with the names of three practicing physicians and an explanation is given that each patient must be under the continuing care and management of his own physician. When a patient is admitted, a tape recorder is used for dictating a medical record that follows the patient throughout the Center. The physician can dictate his notes as soon as he has completed the procedure in the operating room. After surgery, the patient is moved to the nine-bed recovery area. Eighty-two percent of the procedures are performed under general 31-151 O 74 Pt. 1 - 40 anesthesia. Hours at the Center are 8:00 a.m. to 5:00 p.m. Monday through Friday. Patients using the Center pay the surgeon, anesthesiologist, and pathologist (if needed) on a fee-for-service basis. Charges for the services of the facility are based on a fixed fee schedule for each procedure, with a $75 minimum. This helps to eliminate operations that can be done in a doctor's office. The maximum facility fee for an operation performed at the Surgicenter is $140. The estimated break-even point is 250 patients per month, a level that has been reached. Due to legal restrictions, Medicare does not yet recognize the Surgicenter for payment under Part A, but patients eligible for Medicare are required to pay only 20% of the fee. The Center is making an effort to obtain Medicare approval, but in the meantime it is absorbing the loss. Most insurers, however, do recognize and pay for Surgicenter services. The Center is privately financed through a bank loan; the facility and its equipment cost approximately $300,000. The Comprehensive Health Planning Agency and The Maricopa County Medical Society have approved the facility. The directors have consulted with the state health commissioners. and a law was introduced and passed to cover the facility's licensing. The Surgicenter has had a large impact upon health care delivery. The community has been impressed with the reduced waiting period and briefer stays. The physicians appear to be highly satisfied with the Center. The Center has a large volume and, as a result of this competition, some area hospitals have reduced outpatient surgery charges. Introduction of many additional surgical procedures that can be performed safely on an outpatient basis has increased the total number of ambulatory surgical cases. even in the hospitals, by the physicians of the community. A great deal of interest in the Surgicenter has been shown from outside the Phoenix area. MISSION NEIGHBORHOOD HEALTH CENTER The Mission Neighborhood Health Center (MNHC), an OEO Center in San Francisco, is a program of the Citizens' Health Affairs Program (CHAP) with the goal of increasing health care service to the Mission area of San Francisco. The CHAP, which is the delegate agency of the Mission Center, was an out-growth of cooperative efforts with the San Francisco Medical Society. OEO's local Economic Opportunity Council, San Francisco Dental Society, San Francisco Public Health Department, and the University of California School of Medicine. The CHAP board also has representation from the people living in the area. The area has 123,000 residents, of whom 39,000 are presently being served by the program. A majority of area residents and MNHC staff are either Spanish-speaking or black. Median income is under $4,500, and about 12 percent of the residents receive public assistance. Area employment is mostly in the trade services, but unemployment is very high. The average education level is 8 years. The leading causes of illness are psychosomatic disorders, hypertension, heart disease, arthritis, venereal disease, tuberculosis, viral infections, and communicable diseases resulting from the low immunization level of children. The Health Center staff includes ten physicians, 11 nurses, and 75 allied health personnel. The services provided by the staff include general and specialized medical care, podiatry, optometry, physical therapy, x-ray, EKG, laboratory, pharmaceutical services, nursing and public health nursing, and home visits by public health nurses and family health workers. There are also a number of social services available under the project. Health and consumer education programs are made available to the community through a general community orientation program and also through specific education programs on dental health, health care, community organization, and legal rights. The allied health personnel are, for the most part, residents of the Mission community, and they receive training under the project. Training is offered in health and nursing skills and in social work methods and techniques. Volunteers are not used extensively in the project because there are few facilities to train and to direct volunteers. The Mission Neighborhood Health Center staff is organized in teams, with each team having a physician, dentist, nurse, public health nurse, family health worker, and social workers as consultants. Prospective patients are screened for eligibility and, if they are found to be eligible, they are assigned to specific health teams according to their residence in a census tract. About 20 percent of the residents in the Mission area are recipients of the project's services, and they represent about 85 percent of those eligible for the program. Medical and Medicare patients are not encouraged to use the facilities but, by law, they must not be refused treatment if they are otherwise eligible. The hours of the Center are 8:00 a.m. to 8:00 p.m. Monday through Friday and 8:00 a.m. to 12:00 noon on Saturday. Emergency health care is administered at the San Francisco County Hospital and the Mission Emergency Center. Transportation is generally available for patients of the Mission Center through public transportation and two mini-buses furnished by the Center. The facility is an old factory, which has been remodeled and renovated with funds from an FHA mortgage loan with the Office of Economic Opportunity as co-mortgagee. There are 22 examining rooms and x-ray, laboratory, and dental facilities. Patients requiring hospital care may be referred to any of the accredited hospitals in San Francisco by the physician, but those patients with insurance inadequate to cover the cost of a hospital stay are referred only to San Francisco General Hospital or other hospitals that have agreed to receive these patients. The referring physician is responsible for following the patient in the hospital to assure continuity of care. Community acceptance of the Health Center is very good. The Mission Neighborhood Health Council has 21 elected representatives from the consumers of MNHC services, and it advises the MNHC administration. The Medical Advisory Board, which is composed of local physicians, representatives of the University of California School of Medicine, pharmacists, and dentists, advises the Project Director and the CHAP in matters concerning professional policy and administration of the Center. The Center is serving persons who might otherwise not be treated because of lack of funds or transportation problems. Through its health education program and community programs the Health Center emphasizes the need for preventive health care as well as treatment. PRESBYTERIAN MEDICAL SERVICES The Presbyterian Medical Services (PMS) originated as a branch of the Board of National Missions of the United Presbyterian Church and operates the Mission Health Services in the Southwest, primarily in New Mexico. Nevada, and Colorado. In 1969, PMS became a separate nonprofit corporation with a contractual relationship with the Presbyterian Church. Two significant components of the program are the ongoing efforts of PMS to meet the problem of physician maldistribution in northern New Mexico and Colorado through the staffing of five health centers and a project (under consideration) to develop what PMS refers to as a "dispersed rural group practice" to staff these centers. The centers are located in the mountain area north of Santa Fe, in northcentral New Mexico, and just across the border in Colorado. The New Mexico centers are at Santa Rosa, Embudo, Questa, Mora, and Taos; the Colorado center is at San Luis. The population served is primarily SpanishAmerican with low family incomes. Santa Rosa and Taos have some income from tourism; the other towns are dependent mostly upon ranching. Only Questa is described as having a good economy; Embudo and San Luis have about half their populations on welfare; Mora has almost 90 percent of its population on welfare. About 10 percent of people in PMS areas have some college education, and another 50 percent have completed high school. San Luis and Mora have mostly older persons but in the other villages there is a fairly good age distribution. PMS provides the only health care services available to non-Indians in the area except in Taos, where private practicing physicians and health department clinics are available. The USPHS provides care for the Indian population. In Santa Rosa, New Mexico, the Guadalupe General Hospital is operated and staffed by PMS and provides both inpatient and ambulatory care. A comprehensive health care center is soon to be opened for the CubaCheckerboard area, and there will be outreach clinics for Spanish-Americans and the Navajo population. The overall clinical activities of PMS are under the supervision of a Health Services Director, who is a board-certified internist. Of the 13 physician openings, 10 are presently filled by family-practice physicians. Specialists services in pathology and radiology are obtained by contract, and other specialists' services are purchased as required. Both ambulatory care and inpatient care are provided at the respective facilities, which have clinical laboratory, x-ray, EKG, and other supportive services. All facilities provide 24-hour coverage. San Luis has a social service program for which OEO finances a home health aide service. Most physicians come from outside the area. The 13 physicians operate as a group practice and are on salary. Fringe benefits for physicians include health, major medical, malpractice, and life insurance, a retirement program, and vacations of one month. Some physicians are recruited through the church, some by word of mouth, and others through advertising. Of eight physicians for whom ages were obtained, five are age 30 or under, two are between 34 and 45, and one is 62; five of these eight have children. Medical staff turnover is somewhat high due to the isolation of the areas. The supporting staff includes those usually found in hospitals-nurses and aides, laboratory and x-ray technicians, medical record librarians, pharmacists, and dieticians. Most of these supportive personnel come from the area served. The main staffing problem is finding nurses. Salaries for nonphysician staff are comparable to those paid elsewhere in the area. Overall, the financing picture is somewhat complex. Most of the facilities |