In the three decades Dr. David Krueger worked as a cardiologist at Yakima Heart Center, he would have referred, at most, one or two patients a month to hospitals or offices outside the Yakima Valley for treatment.
Now Krueger and his colleagues at Heart Central of Washington find it’s not unusual to refer people elsewhere once or twice a week.
“It’s not just in an emergency,” said Krueger, who opened Heart Central of Washington in West Yakima with several other former Yakima Heart Center providers earlier this year. “I’ve seen routine elective procedures go out of town.”
He said those with resources often end up heading to Seattle or Tri-Cities to get a procedure done sooner.
Krueger and other local medical providers have voiced concern about growing deficiencies in several specialty areas of Yakima Valley health care.
Many of the gaps are tied to the closure of Astria Regional Medical Center in January 2020, as well as subsequent clinic closings by parent organization Astria Health. For example, as of February 2020, four of six cardiologists that once worked at the Astria Regional and the neighboring Astria Health Center cardiology clinic had their contracts terminated.
Today, Astria Health has four cardiologists in the Lower Yakima Valley.
Some cardiac and thoracic services are no longer available in the Yakima Valley after the closure of Astria Regional.
“We had probably the finest cardiac surgical team in the state,” said Dr. John Boucher, 77, a retired general surgeon. “Their statistics were as good if not better than anywhere in the country. The administration at Astria absolutely torpedoed that program. We lost it. We don’t have it anymore. Nothing has come to replace it.”
Those in the health care community are looking to Yakima Valley Memorial, now the only hospital in Yakima and one of the largest health care systems in Central Washington, to respond to those gaps in care.
In recent months, a vocal and growing group of medical providers — active and retired — have criticized Memorial over several issues, including its treatment of its providers and staff. They say the hospital is not doing enough to stem a local decline in some health care specialties and isn’t communicating its plans.
The sole hospital in Yakima
Given the extensive changes in local health care access over the past year, the criticism takes on a sense of urgency.
But Memorial continues to face financial challenges. As of 2019, the latest full year data was available, 80.5% of the hospital’s 13,972 admissions were from Medicare or Medicaid payers. And out of 333,755 outpatient visits, 68.4% were from Medicare or Medicaid payers.
In the past several years, Medicare and Medicaid reimbursements have declined, making it difficult for hospitals to cover costs. Astria Health officials say its payer mix contributed to its financial issues, and health care experts said when the percentage of Medicare/Medicaid payer percentages rises above 50% or 60%, remaining financially sustainable is more difficult because there are not enough commercial insurance patients to offset costs.
She said it wasn’t financially sustainable for two hospitals to operate in Yakima.
But critics are concerned that Memorial has focused too much on its financials and not enough on the community’s increasing inability to meet health care needs, driving patients to other parts of the state.
“We think there’s a real understanding in the community at large of what we lost by having our medical community diminished,” said Richard Twiss, a retired Yakima cardiologist.
Twiss is part of a group of retired medical providers who have voiced concerns regarding Memorial and health care access in the Valley.
Health care is “really is one of the critical features of a community, when people are looking for a place to live, or businesses are looking for a place to settle or developers are looking for a place that would be reasonable for starting a residential community,” Twiss said. “The lack of medical care at their disposal is going to be a big negative.”
Starting in late May, Memorial officials turned down repeated requests to be interviewed and did not provide a response when told about the topics outlined in this story.
Peet “simply has no availability at this time,” a hospital spokeswoman said in a May 28 email.
Control over collaboration
Other concerns come from independent providers who have worked closely with Memorial.
In February, the Seattle Science Foundation YouTube channel posted a presentation that Dr. Tom Kennedy made to the Washington State Orthopedic Association for its Regional Education Outreach program. Kennedy is a Yakima orthopedic surgeon and president of Orthopedics Northwest.
The presentation has been circulating in the Yakima Valley medical community.
Called “A Cautionary Tale of the Business of Medicine in Yakima,” it paints a gloomy picture about health care in the Yakima Valley.
Kennedy talks about the loss of medical specialists, which has led to numerous services — including open-heart surgery — being no longer available in the Yakima Valley.
Kennedy also discusses how Memorial tried to exercise more control over providers in the last year.
He said in 2015, Orthopedics Northwest entered into a professional services arrangement with Memorial and was collaborating on an orthopedic center based at the hospital’s surgical center. Under such an arrangement, the medical practice is independent, and the hospital provides administrative services, like billing.
Plans for the orthopedic center were canceled during the pandemic, and just days before the professional services arrangement expired last year, Memorial decided — with no negotiation or notice — that it would not renew the agreement. Instead, it offered to hire Orthopedic Northwest’s providers.
Ultimately, none of them decided to work for Memorial, and the group remains independent.
Kennedy said they had told Memorial officials of their interest in working with the hospital to provide affordable and accessible health care.
“Unfortunately, we have not seen an effort by the hospital administration to be a good partner,” he said during his presentation.
He notes that weeks after providers from Orthopedics Northwest were involved in a local investment group that purchased the former Astria Regional building a neighboring medical office building, Peet approached them about negotiating a new service arrangement.
Kennedy said he could not comment beyond what’s contained in the video, but said Memorial and Orthopedics Northwest agreed earlier this year to renew their previous agreement until the fall. However, the two parties have not been able to agree on a longer-term service arrangement.
Kennedy noted in his presentation that a similar scenario, with a different result, happened with providers at the Yakima Heart Center.
The center, which closed earlier this year after serving patients for several decades, had a long-standing agreement with Memorial.
Krueger said, like Kennedy, the providers at the Yakima Heart Center expected to expand their agreement with Memorial.
However, in January 2020, after several months of negotiations, Memorial notified Krueger and his colleagues that it would end its agreement with the Yakima Heart Center and start operating its practice a year from now.
Several cardiologists work for Memorial, which opened a heart center at the former Yakima Heart Center. Krueger and other providers formed their practice, Heart Central of Washington.
He said there’s plenty of patients for both practices. Still, he believes the sudden and unexplained halt to negotiations shows how Memorial treats providers.
Krueger said there had been growing dissatisfaction among providers employed by Memorial, which was reflected in various internal surveys he saw.
“They have to listen to their providers regarding patient care,” he said.
And that’s resulted in providers leaving the region. Kruger often hears of these changes from his patients, who lament about losing their primary care provider or having to go through a series of them in a short time.
Providers “have been here their whole life, and all of a sudden, doctors are leaving,” he said. “They often would say, ‘The doctors are good, but then they left.’”
Good quality, low quantity
A decade ago, a group of several retired medical providers and physicians in the Yakima Valley started meeting. The group has grown and now includes a few dozen providers.
The group came into the public’s eye — and Memorial’s — when it urged Memorial to end its affiliation with Virginia Mason in light of the Seattle organization’s merger with CHI Franciscan. Members of the group, including Twiss, believed the merger would further reduce health care services in the community.
“It made Memorial hospital a way station to Virginia Mason,” said Boucher, the retired surgeon. “We became a clinic for Virginia Mason.”
Members of the group said they were glad to see Memorial end its affiliation with Virginia Mason. But Memorial still has to respond to several issues, including the ongoing reduction of services once readily available in the Yakima Valley.
In an interview with the Yakima Herald-Republic, several retired providers recalled a time, two decades ago, when the Yakima Valley had a strong roster of primary care and specialty providers. Back then, they said, transfers were rare.
Twiss said their concerns are not a criticism of individual health care professionals. The region still has great medical providers, he said, but there aren’t enough of them.
“We lost specialists in my critical areas,” Twiss said. Now, “all these things require transfers.”
In a document provided to the Yakima Herald-Republic, the retired doctors group outlined several conditions — including several considered life-threatening — where there is a deficiency of local specialists. They include heart attacks, strokes, head injuries, chest trauma, ruptured arteries and blood clots.
Some of the deficiencies are a result from cuts at Astria Health. When Astria Regional closed, open heart surgery and neurosurgery were no longer available. Subsequent closures of specialty clinics meant more providers leaving the region. The group noted the loss of heart surgeons affected other areas, such as cancer care, as they helped oncologists with biopsies or other chest procedures.
But the group has observed a drop in providers and services from Memorial as well. One example cited by the group was in oncology, where they note that patients no longer had the option of participating in phase 1 or 2 clinical trials locally.
In phase 1 and 2 clinical trials, researchers try to learn if a new treatment is safe, identify its side effects and determine the proper frequency or dosage, according to the National Cancer Institute at the National Institutes of Health
The retired physicians group has also been alarmed at the rapid turnover of family doctors in the area, including at Memorial facilities, such as Cornerstone, Memorial’s primary clinic for Medicare patients.
The loss of those doctors means referrals outside the Yakima Valley. And given the high percentage of those on Medicaid or Medicare insurance, it’s highly likely a sizable percentage of the Yakima Valley doesn’t have the means or support to make frequent trips to other parts of the state.
Dr. Sam Booth, a retired emergency physician, recalled in an email how he cared for a patient who had a broken neck. He noted that the patient received the care he needed locally, thanks to a neurosurgeon and other specialists.
Now a patient with such an injury would likely be transferred to Seattle, he said — and that extra travel could put a patient in a precarious position, depending on the situation.
Meanwhile, those who do have the means and likely have private insurance head out of town, which further impacts a payer mix that’s already heavy on Medicare and Medicaid users.
“What we’re doing is shrinking the pool of well-financed patients,” Twiss said.
While the providers and physicians are sympathetic to Memorial’s financial challenges, the physicians group believes the hospital can tap into other funding sources, such as charitable giving.
The providers also believe Memorial can make the case it’s part of an underserved community and thus qualifies for additional federal and state assistance.
A continued decline in specialists in the region also could impact primary care providers, they say.
A primary care provider “looks at a community and asks, ‘Who is going to back me up?’” Booth said.
A need to succeed
Those who criticize and have been voicing concerns about Memorial emphasize that they are speaking out because its success is crucial to health care access in the Yakima Valley.
“They have been the anchor — the one stable element in medical care,” Boucher said.
Krueger, the cardiologist at Heart Central of Washington, also wants Memorial to succeed. He and the other Heart Central providers continue to work closely with the Memorial heart clinic, often referring patients for services they don’t offer.
But if Memorial ultimately employs more providers, he’s concerned about turnover. Memorial must devise a strategy that will help it recruit and retain providers, not just in his field but in everything from family medicine to oncology, he said.
“How can Memorial build those relationships not to have that high turnover?” he asked.
In addition, Krueger and his colleagues still have to do procedures at Memorial. One reason he’s had to refer patients out of town because of a shortage of available catheterization laboratories for cardiac procedures. Astria Regional had several of those labs before it closed. At Memorial, one is open and the other is closed for scheduled upgrades.
“I want them to succeed. I want them to thrive in cardiology. I want them to have longevity. There are a ton of patients who need to be seen,” Krueger said.