Family medicine rotation

1
Family medicine rotation

• Durango with Dr. Pirnat
• Julie Thompson

2
Valley Wide Health Systems

• FQHCS Founded 1976 due to lack of health care in
  San Luis and Arkansas Valley
• 18 primary health clinics, 5 dental clinics, 12
  Counties in Southern CO

3
VWHCS

• FQHCShigher Medicare reimbursements - 84 of
  what is billed (30 for private and group
  practice doctors)
• Not eligible for supplementary federal funding in
  Durango - per capita income is too high (29,807
  in 2003)

4
VWHCS

• Offers Rx drugs at reduced cost for uninsured
  pts
• Dr.s dont have to pay malpractice insurance
  (covered by Federal Tort Claims Act)
• Dr.s can work off med school loans

5
Durango health care crisis - Timeline

• May 2006 Voters refused bill that would have
  increased property taxes to help cover the cost
  of health care
• July 2006 VW closed doors to new Medicare
  patients
• August 2006 VW announced 2008 closure of their
  Durango office
• December 2006 VW bumped up closure from 2008 to
  3/31/07

6
More on VW

• 5 full time physicians, one part time physicians,
  one PA, two NPs
• Serves 8,000-10,000 pts

7
Solutions

• On 4/1/07, Durango can apply for Health Provider
  Shortage Area (takes 6 mos)
• Individual practices could apply for Rural Health
  Clinic designation
• Medicaid reimbursement 50-70 of billed amount
• Most clinics limit Medicaid pts to 10, but
  Pediatric Partners has 60 Medicaid

8
Dr. Pirnat and Durango Family Medicine

• Dr. Pirnat, a UCHSC grad - family Dr. in Durango
  since 1977
• 2006 Family Physician of the Year Award from
  Colorado Academy of Family Physicians (1,800
  members)
• One of the few family med Drs who does
  C-sections
• Mickey Mouse Dr.

9
D.M., 75 yo white female

• Patient of Dr. Pirnats since 1995. Treated for
  HTN and COPD
• During 2002 comprehensive exam 20 wt loss in 2
  years and mild nagging cough

10
Work up of D.M.

• Chest CT lesion in left upper lobe
• Transthoracic core needle biopsy bronchoalveolar
  carcinoma
• No evidence of distant metastasis
• Opted for observation

11
Progression

• CA showed little progression until 2006
• Enlargement of LUL mass
• New masses in LLL and RML
• Planning to start erlotinib

12
Change in Course

• February 20, 2007 sudden onset stridor
• Stat CT Scan of neck soft tissue fullness in
  posterior larynx at level of cords
• Laryngoscopy bilateral vocal cord paralysis,
  thought to be secondary to carcinoma
• Emergency tracheotomy performed

13
D.M. Now

• D.M. was the last patient I saw before leaving
  Durango Tuesday afternoon.
• Came in with daughter and son.
• Mainly dealing with the issues of now having a
  trach - D.M. uses a board to communicate, has
  anxiety and trouble sleeping.
• Big change!

14
For the future

• One step at a time
• Still deciding about chemo
• Group effort by Dr. Pirnat, oncologist, and ENT
  doctor