Dia LH Dyer has been trying to find a doctor for her family for months.
After waiting since October, she got a voicemail in January saying Yakima Valley Farm Workers Clinic finally had a spot for her. But when she called back, they said she’d never actually been on the waiting list and would have to wait at least another three months.
The Yakima mom is desperate to find a primary care provider — not just for routine medical care, but to secure referrals for her young kids to Children’s Village, so they can get needed services for autism and attention deficit-hyperactivity disorder.
“At this point, I have no idea when we’ll be able to get in to a regular doctor again, let alone an autism specialist,” Dyer wrote in an email last week. “Our insurance doesn’t cover any urgent care providers, so if we get sick, we put off medical care as long as possible, and then have no other choice but the emergency room.”
Dyer’s story is all too common in the Yakima Valley, where a nationwide shortage of primary care is made more acute by the rural, low-income nature of the county and limited number of residency slots that serve to add new doctors to the community.
Health care organizations struggle to recruit and retain providers here, while ever-increasing documentation requirements mean the providers who do stay are spending more hours on paperwork, and fewer on patients.
In the past three years, roughly 19 primary care providers left the community, said Matt Kollman, chief operating officer of Memorial Physicians, which oversees the outpatient clinics of the Virginia Mason Memorial system.
With each doctor seeing an estimated 1,500 to 2,500 patients,that loss represents a huge blow to the community, he said
Even as Memorial and other organizations continue recruiting providers as quickly as they can, clinics remain full to capacity.
“It feels like we add a lane to the freeway, and there’s just more cars that come on,” Kollman said.
And there appears to be no end in sight.
“It’s discouraging, it really is. We understand what the patient’s going through and we’re trying to alleviate the problem,” said Millard McQuaid, chief operations officer at Community Health of Central Washington. “But the demand definitely surpasses the supply in the community.”
High volume, long waits
At Central Washington Family Medicine, the wait list for new patients can be three to four months long, though it was up to six months last spring. The Lincoln Avenue clinic has about 18,000 established patients and saw 46,201 patient visits last year; system-wide, Community Health’s clinics logged 114,797 patient visits last year.
Among Memorial’s six primary care clinics, the wait list a year ago had 1,400 people on it, though many of them already had an established doctor elsewhere and were just looking to transfer, Kollman said. Memorial’s clinics added 4,245 new patients just in 2016, while the three Healthy Now convenient care centers had 24,234 patient visits. Currently, the system has 1,098 people on the wait list, though all but 338 of them have already secured a placement but just haven’t had their first appointment yet.
Yakima Neighborhood Health Services doesn’t keep a waiting list, but new patients typically have to schedule their first appointments two or three months out. Of roughly 3,500 primary care appointments a month, a little more than 1,000 are same-day appointments, where patients walk in and hope for a cancellation so a provider can see them.
At Farm Workers, wait times for new patients depend on the type of services and eligibility for certain programs. The organization’s Yakima County clinics saw a total of 211,000 patients in 2016, and they’re projecting 217,000 this year.
Both Farm Workers and Neighborhood Health have better availability at their clinics in the Lower Valley, so if patients are able to drive, staff say they can get in right away, though that’s not always the case in Yakima. At any clinic, patients will wait longer if they want a specific provider or want to only see a female doctor, for example.
Dyer said she’s burned out on the search, though it’s critical she get her daughters in for that Children’s Village referral and that she get her own prescriptions refilled, since their prior clinic stopped accepting their insurance.
“After months of being rejected by primary care providers, it’s almost like you have a weird avoidance of it,” she said. “I don’t even want to make a call.”
Primary care appointments are usually alloted 20 minutes, so providers are seeing three to four patients an hour every day. Some clinics double-book appointments in hopes that the visits will be quick and providers can bounce between patients. But when people have put off care for a while, their list of ailments may take longer to address.
Local health organizations have dedicated staff who focus solely on scheduling. Memorial has a central team that coordinates new patients for all its primary care clinics. Neighborhood Health’s Yakima clinic has an employee who only deals with same-day appointments.
They’re also working to add support staff to take some of the paperwork and documentation off doctors’ hands to free them up to see more patients. Community Health is considering trying Google Glass, where a scribe on the other end of the wireless connection does all the documentation while the provider wearing the device is free to work directly with the patient.
But still, providers can spend two or three hours a day just on charting, as some responsibilities fall on their shoulders alone. Some are moving to part-time just to make that paperwork more manageable, which doesn’t help the patient backlog.
David Hubbard, 52, was at Central Washington on Wednesday for physical therapy. He had a stroke about two years ago, developed drop-foot syndrome, then injured his neck and shoulder in a fall. He had to schedule his therapy appointment a month in advance, though he normally gets in for primary care visits right away.
“The therapy’s real hard to get into. The therapists aren’t here all the time. I’ve seen three or four different ones; it’s because there’s just not enough,” he said. “It can be frustrating.”
Under the umbrella of primary care, mental health care is another field with very limited resources in Yakima. Neighborhood Health has five mental health providers, but it’s not enough, chief operating officer Rhonda Hauff said.
“At this point, we can’t take any external referrals, because we need them to service our existing patients that are referred from our primary care providers,” she said.
“We understand that our patients are frustrated; we do have capacity issues. But it’s like a bubble — when one of the other practices stops taking new adult patients, it pushes the envelope on this end,” she said. They’re still taking new patients, “But it does put the challenge on making the most of every minute of every day.”
For providers with a long memory, the current climate is at least better than it was a few decades ago. Dr. Mike Maples, CEO of Community Health, remembers a colleague in the 1980s receiving a call from a Yakima woman: “She said, ‘I know my friend was a patient of yours, but she died, so can I have her spot?’”
Scramble for solutions
In 2016, 11 Yakima County providers left Farm Workers, while the organization hired 22, including 14 nurse practitioners and physician assistants. Memorial Physicians added seven primary care providers, four of them doctors, bringing the organization’s total to 40 primary care providers, Kollman said. That’s the most they’ve ever had.
Neighborhood Health hired five primary care providers in 2016, but lost three. Central Washington added three and lost one.
Jackie Bañuelos is a full-time provider recruiter for Farm Workers, and said the biggest challenge “is that there aren’t enough physicians to fill all of the vacancies,” not just in Yakima, but everywhere.
“I think it’s even more challenging when you’re trying to fill positions in rural communities, because a rural community doesn’t always necessarily align with what providers are looking for,” in terms of big-city amenities, she said.
Federally-qualified health centers like Farm Workers, Neighborhood Health and Community Health have to play up their advantages, she said: eligibility for loan repayment programs by working in an underserved area; low cost of living; proximity to cities like Seattle and Portland without the headache of parking, traffic and housing prices.
Beyond that, it’s emphasizing specific programs the organization does that help it stand out from the crowd or offer a new opportunity for growth for the provider.
And, of course, offering market-competitive salaries, or even extras like relocation assistance and a hiring bonus.
Most of the doctors joining both private practices and community health centers in Yakima are new physicians just completing their residencies, rather than established doctors moving mid-career.
Residency programs are the single greatest bottleneck in getting more doctors into the workforce: While medical schools have vastly increased their number of graduates in recent years, there has been no real increase in the number of residency training spots, which are paid for by Medicare dollars but were capped in 1997. Hospitals may opt to sponsor their own residency programs, but they tend to focus on lucrative specialties, exacerbating the primary care shortage. Doctors tend to settle down where they complete their residency, further disadvantaging rural areas.
Central Washington Family Medicine, the biggest program in Central Washington, has been around since 1993, and dozens of its graduates have gone on to stay in the Yakima Valley, or at least moved on to other rural, underserved areas.
Farm Workers’ Sollus family medicine residency graduated its first class of osteopathic residents in June; one of two went to work at Farm Workers’ Valley Vista clinic in Prosser. And five of six graduates of the organization’s nurse practitioner residency program have stayed to practice in the system.
But adding providers as more doctors retire or move and residency programs remain capped is like trying to hold sand in a sieve.
“Maybe we need to have a collective community-wide recruitment campaign that we all share on: ‘Why the Yakima Valley is such a great place to come and practice medicine in,’” Hauff said. “If we can put together our efforts and do a community-wide campaign, I think it would be wonderful.”
• Molly Rosbach can be reached at 509-577-7728 or firstname.lastname@example.org.