Assessment of Albany’s Current Medical Needs Prepared for Dr. Paul Ploutz PO Box 38 LEAD Group Albany, OH 45710 and Dr. Frank Barone Dr. Christine Yost Dr. Raymond Frost Dr. Arthur Marinelli Professor Larry Rogers Prepared by Team 7 Julie Dickman Amie Meczka Evan Peres Jason Ziegler October 30, 2000 14 University Terrace Athens, OH 45701 October 30, 2000 Dr. Paul Ploutz PO Box 38 Albany, OH 45710 Dear Dr. Ploutz: Here is the report you asked the Business Cluster to prepare for you on Albany’s need for health care following the retirement of Dr. William Baumgaertel. We evaluated several alternatives and after evaluation came to the conclusion that the best option for you and the greater Albany area is to establish a community health center. The set of criteria that we used to select the best option include affordability, convenience, implementation, and desirability. We felt that the best alternative for you and the greater Albany area should be one that meets all of these criteria. One alternative is to open a local doctor’s office. However, this alternative leaves full responsibility of the cost to the residents of Albany or the doctor(s) because of the lack of government funding available. A new transit system could be set up to give residents access or advice on how to deal with medical problems. Once again, government funding has gone down in regards to transportation services. A transit system also does not give the close, personal care of a doctor’s office or health center. A mobile clinic would serve citizens at their home and provide basic medical needs, but would be difficult and costly to set up. The costs of this option are way too high to be honestly considered as a true solution. Another alternative is opening a local clinic or community center, providing Albany residents with an outlet to receive acute and preventative health care. Dr. Smith’s existing building can be used for the facility. Government funding is readily available making the option affordable. Since the facility will be brought to Albany, access to medical care will be very convenient to all citizens. It is also easy to implement because the building and necessary space are already available. Finally, as showed by the survey, the community health center is desirable to the citizens of Albany. After evaluating all of the alternatives Albany has available, we have determined that building a community health center is the best option for you, Dr. Ploutz, and the greater Albany area. Thank you for giving my teammates and I the great opportunity of learning about the Albany area. We hope our information can assist you in your decisions. Sincerely, Amie Meczka i Table of Contents Letter of Transmittal ...................................................................................................... i Executive Summary ...................................................................................................... iii Introduction .....................................................................................................................1 Background of Albany....................................................................................................1 Demographics ........................................................................................1 Funding sources ....................................................................................1 Attracting doctors .................................................................................2 Criteria .............................................................................................................................2 Alternatives ......................................................................................................................3 Local doctor’s office ..................................................................................3 Local clinic or community health center ................................................5 Establishment of new transit system .......................................................6 Establishment of mobile clinic .................................................................7 Recommendation/conclusion .........................................................................................8 References ........................................................................................................................9 Appendix A: Funding Sources .....................................................................................11 Appendix B: Necessary Components ..........................................................................12 Appendix C: Background of Albany ...........................................................................15 Appendix D: Qualifications of Medical Positions ......................................................16 Appendix E: Dr. Smith’s Clinic ...................................................................................18 Appendix F: Zoning Regulations.................................................................................20 ii Executive Summary Problem Statement Due to the recent loss of Dr. Baumgaertel and the bankruptcy of Dr. Smith’s clinic, Albany does not have a convenient and practical means of health care. The Albany community is currently searching for a new way to meet their health care needs. Criteria In order to evaluate the possible solutions for the community, a standard criterion was established to determine which alternative would be the best fit for Albany. Affordability Convenience Implementation Desirability Alternatives Several alternatives exist for Albany to deal with health care problem. These options include opening a local doctor’s office, building a local clinic or health care center, creating a new transit system, or implementing a mobile clinic. Open a local doctor’s office. A doctor’s office could include a single doctor brought in to care for basic preventative needs. Build a local clinic or community health center. This option could be handled by expanding the branch of OU-COM to Albany, using faculty as doctors. Another way to implement the community health center is by using an existing facility. Establishment of a new transit system. A new transit system will give citizens access to outside medical care in Athens. Mobile Clinic. A mobile clinic provides health services while making house calls. Recommendation The best alternative for the Greater Albany Area is to launch a community health center using Dr. Smith’s existing building for the facility. A health center provides the most benefit to the to the residents while still being affordable to the community. A community health center is easy to implement and provides a convenient medical care facility that meets the wishes of the community. iii Albany Assessment 1 Due to the recent loss of Dr. Baumgaertel, and the recent bankruptcy, from bad bill collecting, of Dr. Smith’s clinic, the village of Albany is left without a convenient and practical means of health care. Residents are faced with various obstacles such as the rural, isolated nature of the region of Appalachia and its poor, aging population. The Albany community is currently searching for a new way to meet their health care needs. This assessment outlines various alternatives available, including establishing a local doctor’s office, health clinic or community health center, setting up a new local transit system, and implementing a mobile clinic. Each alternative is weighed against the established criteria and a recommendation is given as to the best possible solution. Background of Albany The village of Albany is located in Athens County of Southeast Ohio. Albany is part of the greater region known as Appalachia, known for high poverty rates and high health care needs. Demographics Albany has a small population of around 900, but the greater Albany area encompasses regions such as Lee, population 2,404, and Alexander Township, population 2,483, for a total of 5,787 residents (Census Homepage, 2000). The population of Athens County is 61,490 people (Ohio County Profiles, 1999). The greater Albany area represents nine percent of the county’s total population. The poverty rate in Athens County is estimated to include 20.1percent of the population, and the median household income is only $26,020 (Census Homepage, 2000). In a sample of the Albany population, 39 percent of the people were either ages 65 and over or 18 and under (Class Survey, 2000). These two age groups represent the section of the entire population that uses medical care most often, proving the need for a more convenient medical facility. Funding Sources As of October 1999 Athens County was designated a Health Professional Shortage Area (HPSA) in the area of primary health care (Health Resources and Services Administration homepage, 2000). This designation is used by the Health Care Financing Administration in determining grant/loan eligibility as well as qualifications for increased levels of Medicare and Medicaid reimbursement. The village of Albany is eligible for several types of financial assistance from both the state and federal governments. These types of programs include loan repayment for physicians serving in shortage areas, state and federal grants for funding of new clinics, assistance in recruiting new physicians, and increased government reimbursement plans. See Appendix A for a description of several programs available to the village of Albany. Attracting Doctors Albany Assessment 2 One problem that the Greater Albany Area has to consider is attracting physicians to the area. Albany is a small town, in rural Southeastern Ohio. The town may have trouble attracting a doctor to come to practice medicine, no matter what type of facility it is. There are federal grants that aid an underserved area like Albany in recruiting doctors. Some offer to pay off a part of a doctor’s medical school debt in exchange for a set number of years of service in the area. For a listing of these grants refer to Appendix A. There are attractive qualities in practicing medicine in the Greater Albany area. The class survey showed that over 81 percent of the persons polled have some form of medical insurance, and only 16 percent of these are covered by Medicare (Class Survey, 2000). Therefore, a physician can be guaranteed payment from at least 81 percent of the patients for services rendered under some form of an insurance plan. Another attractive quality is if the medical facility becomes a part of a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO). This will ensure a definite client base for a new doctor in town. The doctor will not have to go out and recruit clients. Ohio University employees belong to Unicare/DCA. If the facility in Albany belongs to DCA, then many of the University’s employees will attend this facility for medical care. In a DCA approved office, the patient is only required to pay 20 percent of the cost, while the HMO will pay 80 percent with no deductible (University, 2000). The Albany area has much strength, most lying in its location. Albany village is located within reasonable driving distance of two major hospitals, O’Bleness and Holzer. It is also positioned in close proximity to Ohio University on the Appalachian Highway. Potential for growth in this region exists through the expansion of the Ohio University airport and the Hocking College eco-tourism program at Lake Snowden. Such future growth could provide the financial opportunity for bringing better health care to Albany’s citizens. Several solutions exist to take advantage of this opportunity and provide health care for the entire community. Criteria In evaluating the various potential solutions, the following criteria were established to determine which alternative would be most beneficial to the people of Albany. Affordability. The best alternative would be one that could be financed mostly from the outside, without placing much of an extra tax burden on the residents of Albany. Convenience. A survey taken of the Albany population shows that only 5 percent of residents do not currently travel for health care or seek medical care at all (Class Survey, 2000). This survey also shows that 75 percent of the population would see a doctor more often if it were more accessible. With this information in mind, it is Albany Assessment 3 important to consider whether or not any alternative is accessible to 100 percent of the residents and convenient for anyone who should choose to take advantage of it. Implementation. The need for medical care in Albany is immediate. A solution must be found now and quickly implemented. Each alternative needs to be weighed according to the length of time necessary to actually implement. Desirability. Is the alternative something that the residents desire to have and will it benefit the community? Alternatives Several alternatives are available to the residents and have been evaluated based on the above criteria. The alternatives include opening a local doctor’s office, building a local clinic or community health center, setting up a new local transit system, and implementing a mobile clinic. Open a local doctor’s office A local doctor’s office could be set up within the village of Albany. It would operate with business hours from 8am-5pm on weekdays, and an emergency number would be available for after-hours medical needs. It is unnecessary for an office in Albany to feature a lab or an X-Ray room. Lab work can be outsourced and those in need of x-rays can refer to another facility like O’Bleness or Holzer. Dr. Larry Spoljaric owns his own solo medical practice (Spoljaric, 2000). In an interview he discussed all of the various necessities for running a practice. He said that a solo practice in a rural area only needs to contain a business area, including a waiting room and receptionist’s office, an office for the doctor’s and nurses to use, a procedure room, and three exam rooms. The following are the variations of a doctor’s office. Single doctor brought in to care for basic preventative needs. A single doctor’s office would keep costs as low as possible. There would only be one physician, one receptionist, and one nurse needed, reducing the number of salaries that have to be paid. Another advantage of this option is the individuality that the physician will be able to keep. The practice will be run exactly how the physician likes. Having just one doctor in town also allows for close contact with the community, building a sense of loyalty and trust. The drawbacks to a solo practice include difficulties in attracting a doctor who is willing to move to rural Ohio and accept such great responsibility for a community. This doctor would be the one relied upon for all diagnosis and would feel pressured to always be “on-call” for patients and neighbors. Albany Assessment 4 Rotating Staff of Doctors. Several doctors would rotate through a part time position of caring for the people of Albany. A less pressured environment would result from this option. The physicians would have others to consult with and share the burden of time and commitment. The staff could alternate nights of being on-call and would be able to take necessary time off. However, having a rotating staff of doctors will increase the costs for the facility. Three physicians, one receptionist, and two nurses will be needed to aid when the doctor’s shifts overlap. The average cost of running a single doctor’s practice is $80,000-100,000 per year (Spoljaric, 2000). This does not include the rent paid monthly depending on the property, and also the remodeling that would need to be done to set up the office including around $20,000 for the furniture. See Appendix B for more information on the costs involved in setting up a medical practice. Affordability is where the problem occurs. Setting up an office involves serious costs. As shown in their recent problems passing school levies, the citizens of Albany do not have extra money to spend on higher taxes for a medical facility (Progress, 2000). The most logical way that this option could be financially feasible is if the doctor(s) who were brought in invested their own money to start up the office. For a further description of Albany refer to Appendix C. Seventy-five percent of the residents surveyed informed us that they would go to a medical facility or office more often if it was more accessible (Class Survey, 2000). A doctor’s office in Albany would be a great convenience to the citizens because it will cut down on driving time to other cities for medical care and make it more likely for citizens to see a doctor. The implementation would not be difficult as long as the funds are there to support the facility. Implementation would include setting up the practice, in a new or old structure, hiring the staff, acquiring equipment and supplies, and finding new patients. This would be able to be done in a reasonable amount of time. Currently, the majority of residents in Albany travel to another city for preventative healthcare (Class Survey, 2000). There is not a need for a hospital in town because O’Bleness Hospital is located only ten miles from Albany with Rt. 32 East connecting the two cities. However, there has been a desire expressed by certain citizens, including Paul Ploutz, for a general practitioner in the Albany area. A doctor’s office may be what the town of Albany is looking for, but it is not the best alternative available. The costs will be left to the citizens of the greater Albany area or to the doctor who begins a practice. There are other options available to Albany that are more affordable and beneficial. Albany Assessment 5 Build a local clinic or community health center A clinic or community health center would be a place where families could receive acute and preventative health care from doctors with a variety of areas of expertise. Doctors would be able to provide for the specific needs of the young and older population. A location within the Albany area would fulfill the desire to have convenient access to primary health care in a familiar setting. Health centers and clinics such as this have already been established in several other rural communities. One example is in Lincoln County, West Virginia, where citizens renovated an old grocery store to provide a place for primary health care services for their community. They saved money in renovating the structure by using community volunteers, but funding from the Appalachian Regional Commission and National Health Service Corps also supported construction costs and partial physician salaries. The clinic is currently open 92 hours a week, 364 days a year. Fees are based on a sliding scale with no one being turned away due to lack of money (Rural Development Administration, 2000). This type of facility can best be implemented in one of two ways: Expand the branch of OU-COM to Albany, using faculty as doctors. A branch of OU-COM would offer the opportunity for OU faculty to serve the local community at the same time as having a place where medical students can have more first-hand experience with patients and apply their knowledge. This type of facility currently exists in Cooleville, Ohio and has been successful in meeting both the needs of the community and OU’s Osteopathic Medical Center. The College of Osteopathic Medicine (COM) is currently exploring the possibility of an Albany expansion, but such a move is unlikely due to a lack of funding (Marazon, D. personal communication, 2000). Use existing facilities to open a community health center. The difference between a clinic and health center exists mostly in the services and type of staffing used. A community health center could provide for basic needs of the community such as medical, dental and prenatal care in one location. Primarily physicians’ assistants could staff the office, as long a regular physician is on-call at least one day per week. Costs are lower due to salaries for physicians’ assistants being less than half that of physicians. See Appendix D for a further description of qualifications. Several government programs exist with the sole purpose of funding such endeavors within rural communities making it an affordable option. A clinic established by COM would be financed by Ohio University and both the state and federal governments would support a community health center. Location within the greater Albany area fits the criteria of being accessible to 100 percent of the targeted population. Other clinics in a similar setting have even offered shuttle service to Albany Assessment 6 more isolated members of the community. This is a possibility for the future in order to ensure easy access to health care for all. This option offers long-term practicality for the community as it can be readily expanded to meet the growing needs of the developing Albany area. Such a clinic could be quickly put into operation because there is no need to construct a new facility and funds can be obtained without difficulty through government funding. Dr. Smith’s clinic, currently up for sale, is located just off of the Appalachian Highway in Albany (McDaniel, J. personal communication, October 23, 2000). This facility would have sufficient space to house the basic services needed to provide primary health care to the greater Albany area. See Appendix E for more information on Dr. Smith’s clinic. The drawbacks in this option include lack of trust and loyalty built up in the community for one doctor. Residents would begin to trust the clinic as a whole over time. A desire has been expressed to see primary health care brought to this growing area and this option would be one that would grow along with the community. Establishment of a New Transit System The current situation in Albany shows that citizens are relying on Athens to provide health care. In the class survey of Albany, 67 percent of poll participants stated that they go to Athens for at least some sort of medical treatment (2000). While this may give the inclination that bringing health care to Albany is unnecessary, the fact is that 75 percent of Albany citizens surveyed said they would go more often to a clinic that is more accessible. The survey shows that while most citizens are able to adjust to the current situation, a closer medical facility is something they desire. Albany could set up a transportation system to deliver people to Athens to receive necessary check-ups or medication. Since senior citizens take up such a large proportion of the population and the low per capita has resulted in a lack of cars, many people in the Albany community need the availability of transportation (Ohio County Profiles, 1999). A new transportation system is more affordable than establishing a clinic or doctor’s office, but is still expensive. Funding for transit has been steadily decreased because Congress is attempting to eventually cut it completely. The following shows the cuts in funding of Ohio transit systems from 1995 to 1996 (Transit, 2000). Transit funding in rural areas cut 16 percent from $6 million to $5 million. Specialized transit systems serving elderly and disabled cut from $2.4 million to $2.1 million. These numbers indicate that funding is dropping quickly and steadily, which will make it difficult for Albany to be able to conjure enough funds from the government to start a whole new transit system. Even if they were able to start a transit system, the quality of service Albany Assessment 7 would be low, and fares would be extremely high. In an area such as Albany, citizens will be unable to afford such steep costs. The plan also lacks convenience. Without a local doctor’s office or clinic, it presents major accessibility problems for citizens. If transportation is provided, only a small, rotating staff would be necessary to be on call, and arrival and departure times could be set for citizens to be picked up and taken home after receiving necessary treatment. Although this plan is feasible, it will be very difficult to satisfy each citizen’s demands and time constraints. Acquiring a new transit system will take a great deal of time and effort to organize. It is also unknown whether or not the community will use the transit system. The time and expense is a risky investment serving only a small portion of the population. The desirability level will not be high with fares increasing while service is decreasing. The residents of Albany have also expressed a desire for more personalized care and this option does not offer the doctor-patient relationship many would like to have. Mobile Clinic The purpose of a mobile clinic is to provide quality health services while making house calls like an old-fashioned doctor. They are accessible for all types of needs, including calls for medical advice or on-site visits to patients. Despite the positive aspects mobile clinics provide, Albany is not likely able to afford it. Doctors are paid 30 percent more for house visits than in an office (Uzelac, 1999). Since doctors already obtain high salaries, this option is out of the payable range for Albany. Also, a large staff is necessary to make the mobile clinic work, making the rates even higher. Mobile clinics are a convenient alternative, but would not be able to serve as many people that would be able to visit a clinic within a day. Patients can call for advice or request a visit, so accessibility is not a problem. Since it is so expensive, residents are unlikely to be willing to pay for it. Implementation is an aspect that could present a problem. The details of the system would be hard to organize and the large staff will be difficult to acquire and integrate. A mobile clinic staff requires the following (Homeless, 2000): Two physicians (pediatrician and internist) Three nurse practitioners Three drivers Albany Assessment 8 The following services will be available for Albany citizens through a mobile clinic (Homeless, 2000): Pediatric and Adult services: o Well-child check-ups o Immunizations o Acute (sick) care o Health maintenance evaluations o Immunizations o STD and HIV screening o Acute and chronic disease clinics o Diabetes Education Program Recommendation The best alternative for the Greater Albany Area is to launch a community health center using Dr. Smith’s existing building for the facility. This option provides the most benefit to the residents while still being affordable to the community. A community health center is easy to implement and provides a convenient medical care facility that meets the desires of the community. The class survey proved that the citizens of Albany would go to a medical facility more often if it were more accessible to them. The convenience of a community health center has the chance to improve the greater Albany area’s overall health by preventing and treating disease early. Those who are not currently seeing a physician will now have medical care close at hand. Long range plans for such a facility include recruitment of staff through specialized government programs designed to aid in that process. Government grants and loans will provide the health center with the financing necessary to get up and running, at which point it will function independently of the Village of Albany, operating off of its own revenues. Specific services can be outsourced and patients needing specialized treatments can be referred to larger clinics or hospitals in surrounding areas. The Village of Albany is currently beginning to grow and improve. The expansion of the Ohio University airport and the eco-tourism program through Hocking College will make Albany a more desirable place to live. If all aspects of the community are improving, from the expansion of the airport to the new sewer system, health care facilities need to keep pace with the changes. Bringing a community health center to the area is a step in the right direction of creating a higher standard of living in the Albany area. Albany Assessment 9 References American Medical Association (1996). Starting a Medical Practice: the Physician’s Handbook for Successful Practice Startup. Norcross, GA: The Coker Group. Census homepage (2000). Retrieved on October 18, 2000 from the World Wide Web: http://www.census.gov City of Athens Code Enforcement (2000). Retrieved on October 18, 2000 from the World Wide Web: http://ci.athens.oh.us. Class Survey (2000, October 27). Retrieved on October 27, 2000 from the World Wide Web: http://intranet.cob.ohiou.edu/cluster/bus202ia01/. Conference of American College of Healthcare Executives (September 2000). Charleston, South Carolina. Grants to Rural Providers. Retrieved on October18, 2000 from the World Wide Web: http://www.ruralhealth.hrsa.gov/funding.htm. Health Professional Shortage Areas and Medically Underserved Areas (2000). Retrieved on October 20, 2000 from the World Wide Web: http://www.med.und.nodak.edu/depts/rural/hpsa.htm. Health Resources and Services Administration Homepage (2000). Retrieved on October 25, 2000 from the World Wide Web: http://www.bphc.hrsa.dhhs.gov/databases/newhpsa/newhpsa.cfm. Homeless Outreach Medical Services (Homes). Retrieved on October 27, 2000 from The World Wide Web: wysiwyg://46http://www3.utsouthwestern.edu/parkland/homes. Loan Repayment/Forgiveness Fact Sheet. Retrieved on October 18, 2000 from the World Web Web: http://www.aamc.org/about/gsa/stloan/oh.htm. Malecki, Donald S. (1996). Commercial Liability Insurance and Risk Management. Third Edition. Volume 2. Malvern, PA: American Institute for CPCU. Medical Waste Considerations (2000). Retrieved on October 25, 2000 from the World Wide Web: http://www.deg.state.la.us/permits/sw/swbiohaz.htm. Occupational Outlook Handbook (2000). Retrieved on October 23, 2000 from the World Wide Web: http://stats.bls.gov/oco/ocos074.htm. Albany Assessment 10 Ohio County Profiles: Ohio department of Development office of Strategic Research. (1999). Progress Report (2000, October 23). The Post, pp. 2. Rural Development Administration. Case Study: Lincoln County, West Virginia. Retrieved on October 20, 2000 from the World Wide Web: http://www.rurdev.usda.gov/ideas/case 37.html. Salary.com homepage (2000). Retrieved on October 25, 2000 from the World Wide Web: http://www.salary.com. Sole & Bloom Realtors homepage (2000). Retrieved on October 28, 2000 from the World Wide Web: http://www.soleandbloom.com/todays_message.html. Spoljaric, Dr. Larry (2000, October 21). Personal interview with Brian Roach. Transit in Ohio. Retrieved on October 26, 2000 from the World Wide Web: http://www.fta.dot.gov/library/money/fy96cut/OH7.HTM. University Human Resources (2000, February 23). Retrieved on October 27, 2000 from the World Wide Web: http://www.uhr.ohiou.edu/benefits/Providers/default.htm. Uzelac, Ellen (1999, July). The Doctor’s in the House. USA Weekend. Retrieved from The World Wide Web: http://www.mobiledoctors.com/news.htm. Albany Assessment 11 Appendix A Funding and Assistance for Health Professional Shortage Areas Several state and federal programs have been established for the sole purpose of providing support to rural communities (Grants, 2000). The following is a partial list of grants, loan, and other programs that are available to the village of Albany in assistance to establishing a means for health care. The Rural Health Clinic Act allows for Medicare and Medicaid cost-based reimbursement of services provided in rural HPSAs. National Health Service Corps is in charge of recruiting health care professionals for areas that do not have sufficient access to primary care services (Loan, 2000). Loan Repayment Program provides the opportunity for primary health care professionals in HPSAs to receive educational loan repayment. Health Resources and Services Administration is dedicated to seeing 100percent access to primary health care services where no disparities exist in shortage areas. Community and Migrant Health Centers Grant promote the development of Community Health Centers in medically underserved areas. 250 grants are awarded to support this promotion. Public Health Service Act established programs designed specifically to support Community Health Centers and Health Care for the Homeless. J-1 Visa Waiver Program is for foreign medical graduates who wish to pursue a medical education in the United States. Obtaining this waiver allows the physician to continue their education in the US without needing the traditional two-year home residency rule. Instead, physicians will be required to practice primary health care in HPSAs. Rural Health Network Development Program is designed to support the planning and development of rural health care networks. These networks must be composed of three different types of providers dedicated to providing local delivery systems to meet the health care needs of the rural community. Community Facilities Loans are available through the Rural Development Administration (division of the USDA) to fund construction or other improvement to community facilities providing vital services to rural area residents. Albany Assessment 12 Appendix B Necessary Components of Setting Up a Medical Facility Involved in planning a medical office includes the cost of the facility, equipment, salaries, and malpractice insurance. The costs of the equipment does not change due to region, however, the salaries do vary (salary.com). Facility In Albany there is already a clinic that has been built but has not yet been used. Dr. Smith, a former physician in Albany, built this clinic before he had the funds to pay for it. It still stands empty in Albany today. The purchase price for Dr. Smith’s clinic is $600,000. This would be cheaper than constructing a brand new building. (McDaniel J. personal communication, October 23, 2000). Equipment A doctor’s office or clinic needs the same medical equipment. The price is steep for the various items needed, but they are a necessity in a medical facility. Dr. Larry Spoljaric owns his own single doctor practice, and listed below are the approximate costs for the equipment he needs (Spoljaric, 2000). Computer system for billing-$6100 Phone system (multiple lines)-$1200 for set up plus monthly charges Table-$1200 Lamp-$200 Otophthalmoscope-$400 BP cuff and wall unit-$100 Suture supplies, swabs, bandaids, etc.-$2000 a year These supplies are one per room, except the supplies, phone system, and billing computer, so the price will increase depending on the number of exam rooms. Not included in the above list is the cost of office supplies, including paper, pens, etc., which would be approximately 1.5-2.3 percent of the total cost (Conference, 2000). Salaries The salaries for the staff that would need to be attained for a medical facility vary. There are ways to cut costs by hiring staff with different titles. Here are the average salaries for most positions needed in a medical facility (Salary.com homepage): Physician-$132,454 Albany Assessment 13 Physician’s Assistant-$62,200 Registered Nurse-$40,690 LPN-$32,985 Receptionist-$22,429 Billing consultant-$24,773 The necessary staff includes a physician and a receptionist, but after these the choices vary depending on the physician’s preference (Spoljaric, 2000). Malpractice Insurance Medical malpractice insurance is a type of professional liability insurance designed for physicians. The law is well established in that physicians can be held liable under negligence principles for injuries to their patients (Malecki, 2000). A physician’s basic duty is to use reasonable care to avoid injury to their patients. Medical malpractice claims against physicians are often based on improper diagnoses, improper tests, lack of informed consent and improper administration of drugs (Malecki, 2000). Informed consent means that the physician must disclose to the patient the nature of their problem, the purpose of the treatment that the physician is suggesting, the risks associated with the treatment, the anticipated benefits of the treatment, and any alternative treatments. If the doctor fails to inform the patient of any of the information listed, the patient is able to sue the doctor. Medical malpractice insurance is used to insure physicians against these types of allegations (Malecki, 2000). This type of insurance can also be adapted to cover nurses as well. The insurance covers the damages the physician is legally obligated to pay because of their negligent acts or omissions. The average cost for medical malpractice per year for a general practitioner is $5000 (Joel Kaiser, personal communication, October 26, 2000). There are some things a physician can do to avoid being sued (Malecki, 2000). They should make sure they know the patient well; make sure they communicate with the patient; keep thorough and accurate records; diagnose and test thoroughly; don’t take on too many patients; and make sure they know what their staff is doing as well. OSHA Regulations on Exposure to Blood borne Pathogens A medical facility in Athens, or anywhere, must abide by the OSHA Regulations on exposure to blood borne pathogens. Failure to do so could result in the harm of others or personal harm, and also in strict fines from the OSHA. Under the OSHA rule, exposure includes skin, eye, mucous membrane (mouth and nasal) contact with blood or other potentially infectious materials (Medical Waste, 2000). Blood Albany Assessment 14 means human blood, blood products, or blood components. Other potentially infectious materials include all body fluids in situations where it is difficult or impossible to distinguish between body fluids. If the circumstances are such that different body fluids cannot be distinguished from each other, all should be treated as potentially infectious. Employers must prepare an “Exposure Control Plan” (Medical Waste, 2000). This plan must contain separate lists of job classifications where some or all of the employees may be exposed and a list of job tasks in which exposure may occur. The Exposure Plan must also contain a timetable for implementing various provisions of the regulations and a description of the procedure that will be followed if in fact exposure occurs. The plan must be made accessible to all employees. Employers are required to employ “engineering and workplace controls” wherever possible to minimize or even eliminate employee exposure (Medical Waste, 2000). Engineering controls either remove the hazard or isolate the worker from exposure. Employers are required to examine, maintain, and replace engineering controls on a regular basis to ensure effectiveness. Appropriate personal protective equipment must be used to reduce the risk of worker exposure (Medical Waste, 2000). Employers are required to provide this equipment at no cost to the employee. Protective equipment must prevent such materials from passing through an employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the equipment is in use. Personal Protective Equipment consists of gloves, face shields, masks, and eye protection, gowns, aprons, and similar items (Medical Waste, 2000). Employers must ensure that appropriate personal protective equipment is used and used in the correct manner. Employers must also make sure that the equipment used is cleaned, laundered, repaired, replaced, or disposed of as needed, at no cost to the employee. Employers must provide handwashing facilities that are readily accessible to all employees (Medical Waste, 2000). When this is not feasible, they must provide antiseptic towlettes. Employers must ensure that employees wash their hands as soon as possible after removing gloves and other personal protective equipment, or after contact with potentially infectious material. The disposal of medical wastes must be in accordance with all applicable federal, state, and local regulations (Medical Waste, 2000). There are services that will dispose of medical waste, including biohazardous material for a fairly cheap price (Spoljaric, 2000). Training all persons with a potential for exposure must be provided (Medical Waste, 2000). Training must include a general explanation of the modes of transmission, symptoms, warning signals relating to possible exposure, and procedures to follow if exposure occurs. The employer must also keep medical records and records of training sessions (Medical Waste, 2000). Records must be kept confidential, however an employee may see a copy of his/her records upon request, and must be maintained for thirty years after employment has ended. Albany Assessment 15 Appendix C Background of Albany, Ohio The Greater Albany area is experiencing other needs besides the one for local medical care. The Alexander school system, which includes Albany village, has been unsuccessful several times in trying to pass a levy to build a new campus for the schools (Ploutz, P. personal communication, October 17,2000). The school system would receive $17-19 million from the government if they could pass the levy to raise $5 million from the cities. The levy will be voted on in the election on November 7 again to determine if Alexander School Systems has a chance to improve (Progress, 2000). Another issue important to the village of Albany is the EPA’s requirement to install a sewer line in the city (Ploutz, P. personal communication, October 17,2000). Albany currently uses a septic system, but the health issues with the system have become too large to ignore. The cost of this sewer line will cost residents $38 a month, which many may not be able to afford. The ground breaking for this project will begin in three to six months. Albany Assessment 16 Appendix D Qualifications of Medical Positions A medical facility has different options available to them when staffing the facility. There are ways to cut costs by hiring a more qualified person, or by hiring a person with a lower average salary. Physicians There are two types of physicians available: the Doctor of Medicine (MD) and the Doctor of Osteopathic Medicine (DO). DOs are the likely fit for Albany because they provide more primary care than MDs. Physicians must go through a heavy load of education and training in order to become certified (Occupational, 2000). Four years of undergraduate school, four years of medical school, and three to eight years of internship and residency are required before someone can go into practice as a physician. This makes it more unlikely for a physician to be willing to start out in an unstable environment like Albany and take on the initial high debt levels. Education costs are increasing, while student financial aid is not (Occupational, 2000). With this fact in mind, Albany could create an option for a student to have their entire education paid for if they commit to serving Albany after their school tenure is concluded. Another problem with acquiring a physician revolves around the annual salary. The average annual salary of a physician was $164,000 in 1997 (Occupational, 2000). This cost is a lot to bear for such a poor community. However, since the cost of living is not high in Albany, the salary of a physician may become significantly less. Physician Assistants Physician assistants provide a lot of the same services as physicians, except they are not as qualified, making physician supervision necessary (Occupational, 2000). Despite this limitation, they may provide care in rural and inner city clinics where a physician must only be present one or two days per week. Since Albany is so close to Ohio University, the supervision of a physician is not hard to find. A physician assistant’s educational requirements are also less time consuming and less costly. Most PAs graduate with a bachelor’s degree; while others may receive a certificate, associate degree, or master’s degree (Occupational, 2000). PA programs normally last two years. Another significant factor is that physician assistants have a much lower average income than physicians (Occupational, 2000). The average salary for physician assistants in 1998 was $62,200. The overall cost of training and compensating a physician’s assistant is much lower than that of a physician, and the discrepancy between the qualification levels of physicians and physician assistants is not very high Albany Assessment 17 Registered Nurses Registered nurses provide more basic primary health care than physicians and physician assistants (Occupational, 2000). They are trained to diagnose and treat common illnesses and injuries. RNs are also qualified to prescribe medications. In order to become a registered nurse, students must graduate from a nursing program and pass a national licensing examination to earn a license (Occupational, 2000). The associate degree in nursing takes two years, the Bachelor of Science degree in nursing takes four to five years, and hospital diploma programs take two to three years. The cost of sending a registered nurse through school is lower than both physicians and physician assistants, however the qualifications extended to an RN are far lower. The average annual income of registered nurses was $40,690 in 1998, just over $20,000 less than the average salary of a physician assistant (Occupational, 2000). While costs of acquiring a registered nurse are lower than other related occupations, they are not capable of providing a great deal of primary health care services. Albany Assessment 18 Appendix E Dr. Smith’s Clinic In Albany there is already a clinic that has been built but has not yet been used. Dr. Smith, a former physician in Albany, built this clinic before he had the funds to pay for it (McDaniel, J. personal communication, October 23, 2000). He had problems keeping track of the books and was not getting paid by his patients, therefore causing his bankruptcy. He never even began to practice in his new clinic. It still stands empty in Albany today. The clinic’s total area is approximately 9600 square feet and includes the following (Sole & Bloom, 2000): All furnishings, excluding medical equipment Mini-lab Fifty acres of land The clinic is located at the intersection of SR 50/32 and SR 143 (Sole & Bloom, 2000). The clinic can be purchased with the land or by itself, and the land can be purchased by itself. Sole and Bloom Realtors have the site listed on their webpage if more information is desired (Sole & Bloom, 2000). The purchase price for Dr. Smith’s clinic is $600,000. This would be cheaper than constructing a brand new building. (Jeff McDaniel personal communication, October 23, 2000). Albany Assessment 19 Here are pictures of Dr. Smith’s Albany clinic: Albany Assessment 20 Appendix F Zoning Regulations in Athens It has been decided to build a medical facility at 385 Richland Avenue, which is located in the B-2 Downtown Business District area (City, 2000). The property includes three bedrooms and a full bath with a new roof. The property will have to be remodeled to be suitable for a medical facility. This location was chosen due to the close proximity of Highway 33, providing easy access to the facility from surrounding areas. It is essential that the medical providers of the facility obtain a state license to provide healthcare in the city of Athens, Ohio (City, 2000). This is the first step that must be taken before any types of medical services are provided to patients. There are two alternatives in establishing a medical facility in Athens; buy an existing building, or construct a medical facility from scratch. The two alternatives are discussed below. In buying out an existing building, an occupancy permit must first be obtained from the Zoning office (see 23.08.01. Enforcement (E) Occupancy permits). An occupancy permit is attained through a zoning certificate by the zoning inspector (City, 2000). The zoning inspector must first approve such a certificate before commencement of the medical facility can take place (see 23.08.01. Enforcement). If the development is approved, then the construction may take place and the required fees must be paid (see 23.08.01. Enforcement (2) Fees). However, if disapproved, the medical facility team may appeal the decision, and possibly undergo a trial in the Court of Common Pleas The other alternative is building a medical facility from scratch. This requires a more in depth analysis because constructing a building requires an architect. First, a building permit must be obtained by getting a zoning certificate through the zoning inspector (City, 2000). The licensed architect must submit his construction plans to the state. Commencement of the building starts lawfully within a one year period of obtaining the zoning certificate (see 23.03.22. Construction commencement period). The zones are ranked in order of restrictiveness starting from the B-1 Neighborhood business zone, which is the most restrictive (City, 2000). The B- General business district zone is less restrictive, and any uses in the B-2 General business district are permitted if it is allowed in a more restrictive zone, like the B-1 district (see 23.02.04. Degree of restrictiveness). There are certain types of permitted uses that are entailed when beginning a business, whether pre-built or not. The first permitted use is the principal building permitted uses. The principal building permitted uses include any local retail business or service establishment supplying products or services primarily for residents of the neighborhood. Albany Assessment 21 This states that the business, including the medical facility, must be within an enclosed building. It is necessary for the medical facility to obtain signs in recognition of the business (City, 2000). First, however, a sign permit must be attained (see 23.03.13. Sign regulations). There are many regulations and many different types of signs that are allowed in the B-2 district, but it must meet zoning regulations. Our proposed medical facility would have to include off-street parking to accommodate those in need of medical care (City, 2000). There are certain provisions of a parking lot that must be complied with, such as being enclosed by a fence, the proximity of the parking lot with adjacent dwellings and others listed in 23.10.05., development and maintenance of parking areas and structures and loading areas. The structure located on Richland Avenue does not have to abide by Zoning restrictions that pertain to height and yard restrictions since it is an existing structure (see 23.07.01. Existing non-conforming uses; “Grandfather Clause”). The Grandfather clause does not apply to parking, however. For every 200 feet of floor space of the building, one parking space is permitted. If not, variances must be acquired. 23.08.01. Enforcement D) Use prohibited without zoning certificate. It shall be unlawful for an owner to use or to permit the use of any structure, building or land, or part thereof, hereafter created, erected, changed, converted or enlarged wholly or partly, until a zoning certificate, which may be part of the building permit, shall have been issued by the zoning inspector. Such zoning certificate shall show that such building or premises or a part thereof, and the proposed use thereof, are in conformity with the provisions of this code. It shall be the duty of the zoning inspector to issue a zoning certificate, provided he is satisfied that the structure, building or premises, and the proposed use thereof, and the proposed methods of water supply and disposal of sanitary wastes conform with all applicable requirements of this code. E) Occupancy permits The purpose of an occupancy permit is to certify that the premises comply with the provisions of this and all other local codes and ordinances and is being used for the purposes set forth in the occupancy permit. Prior to the use or occupancy of any land or building for which a zoning certificate is required, or for any change of use of any existing building or for any change of use of land, an occupancy permit shall be secured from the zoning inspector. A copy of the occupancy permit shall be kept upon the premises and shall be displayed upon request made by any officer of the city. All applications for occupancy permits shall be in writing on forms to be furnished by the zoning inspector Albany Assessment 22 (2) Fees - No fee shall be charged for an original zoning certificate applied for with the application for a building permit, where such permit is required and issued prior to commencement of construction or remodeling under the building code of the city. For all other zoning certificates, there shall be a fee and the charge thereof, shall be as follows: (a) Remodeling Minimum fee $15 where a permit is issued prior to commencement of construction or $115 where a permit is issued after commencement of construction for the first $1,000 or under remodeling cost, plus a $1.50 charge for each $1,000 additional cost or fraction thereof. (b) New construction Minimum fee $20 where a permit is issued prior to commencement of construction or $120 where a permit is issued after commencement of construction, plus $.02 per square foot of building area. The higher minimum fee charged where a permit is issued after commencement of construction is intended to compensate the city for additional administrative expense. 3) Fee exemptions--Local, state or federal government agencies, and churches shall be exempt from the payment of fees required in paragraph (D) (2) above. 23.03.22. Construction commencement period. Construction of a new building, repair, alteration or addition to an existing building shall commence within a year period from the date of issuance of the zoning certificate. Failure to start construction within this one year period shall void the zoning certificate. (Ord. 0-30-69, passed 4/7/69) 23.02.04. Degree of restrictiveness Where a use is specifically enumerated in a less restrictive zone, such use shall not be permitted in a more restrictive zone, unless it is specifically enumerated as a permitted use therein 23.03.13. Sign regulations *Sign Application and Permit: A sign permit shall be required for all signs, other than real estate and political signs, in any zoning district. Albany Assessment 23 (L) STANDARDS FOR SIGNS IN B-2, B-3, AND M DISTRICTS Unless otherwise permitted in this section, no off-site signs shall be permitted in the B-2 Business District. The following signs shall be permitted: (1) Building Signs. (a) Business Identification Sign - Multiple Use. In a business area containing more than one building, designed and developed as a coordinated unit, or where a business building contains more than one business unit, an individual store identification sign for each business unit may be attached to the building or unit thereof. (3) Free-Standing Signs: Placement. Free-standing signs shall be not less than ten (10) feet from another business lot and not less than fifty (50) feet from any residential district line. The pole or sign structure of a free-standing sign shall be set back a minimum of five (5) feet from the street right-of-way line. The horizontal clearance between the sign's outer dimension and the curb line shall not be less than two (2) feet. No free-standing sign shall be allowed within a triangle formed between points on the front and side street right-of-way lines within ten (10) feet from their intersection. 23.10.05. Development and maintenance of parking areas and structures and loading areas. Every parcel of land hereafter used as a public or private parking area for three or more cars, or structure used as a parking garage, or loading area, including a commercial parking lot, shall be developed and maintained in accordance with the following requirements. Plans for such areas shall be reviewed by the city engineer to insure compliance with these regulations. (A) Off-street parking areas or structures and off-street loading areas shall be effectively screened by a fence or hedge. The screening shall be on the sides, which adjoin, about, are adjacent to, or face premises situated in any residential zone or institutional building. (B) No off-street loading area or parking area or part thereof shall be closer than 10 feet to any dwelling, school, hospital or institution for human care located on an adjoining or adjacent lot. (C) Any off-street parking area or off-street loading area shall be paved with asphalt, brick, or concrete to create a hard and durable surface. Crushed stone and gravel surfaces are prohibited. All areas shall be marked so as to provide for the orderly and safe loading, parking and storage of automobiles or trucks. Albany Assessment 24 (D) Any lighting used to illuminate any off-street parking or loading area shall be so arranged as to reflect the light away from adjoining premises. Off-street parking facilities for multi-family structures containing 4 or more (E) Any off-street parking area and off-street loading area shall be graded and drained so as to dispose of all surface water without detriment to surrounding uses. (F) Parking shall be permitted on the roof of any structure, provided a 4 foot wall is constructed around the perimeter of the roof. 23.07.01. Existing non-conforming uses Except as hereinafter specified, the lawful use of a building or premises existing at the time of the adoption or amendment of this code may be continued, although such use, building or structure does not conform with the provisions of this code for the district in which it is located. Dimension Requirements for a B-2 Downtown Business Zone Minimum Lot Area per Dwelling unit (sq. ft.): No minimum lot area restrictions apply. Minimum Lot Width: No minimum lot width applies. Maximum Height (feet/story): Maximum height is 75/6. Minimum Front Yard (feet): There is no minimum front yard restriction that applies. Side Yard one/both (feet): No side yard restrictions apply. Minimum Rear Yard (feet): No minimum rear yard restrictions apply. Maximum Lot Coverage (percent): No maximum lot coverage percentage applies.