More people in Bristol Bay during the summer means more patients seeking care at the Camai Health Clinic.
Health care in the Bristol Bay Borough is far from simple with a population of less than 1,000, accessible only by plane and an international hub for the hazardous industry of commercial fishing.
The Camai Community Health Center in Naknek serves about 3,000 patients a year, with almost half being unique, or new, patients just last year, Stephen Herting, executive director of the clinic, said.
“All of a sudden about May the Herring start to run and people start to show up in town here in Naknek- King Salmon,” he said, “and when they show up they are very busy people and sometimes they are overworked and sometimes they make mistakes and cut fingers and hurt themselves and strain their backs and so forth. So we see a bit more patients.”
Herting said between May and early August is the clinic’s busiest time of the year. In the winter there are typically two to 10 patients per day, in the pre-salmon season it is 15 to 20 and by early July the clinic is seeing up to 50 patients per day.
Hertig is strategic in planning for the summer surge. Camai hires five providers in the summer, three more than in winter, providers being nurse practitioners or physician assistants.
For the second year the clinic opened a second temporary location. It is housed in the LMI boat yard in a container, making it a convenient location for canneries on the East side of town.
Herting said he tends to overstaff during the summer to avoid any lack of resources, adding that his worst fear is not having a medical provider available.
“What we don’t have is an infinite pipeline of medical providers, so if you run out you don’t have one, there aren’t any in the town, you can’t borrow one from anybody,” Herting said. “My worst fear is the ambulance comes to the backdoor with your grandma in the back and I don’t have a medical provider. I try to make sure that doesn’t happen.”
The clinic can provide health care for primary care needs, including x-rays, minor surgeries, pharmaceutical, behavioral health, etc. However, if there is an emergency this requires a medevac, or medical evacuation.
For example, if something life threatening occurs the clinic has the ability to stabilize the patient. Then an emergency team will fly from Anchorage to King Salmon, a 288 mile trip, to pick up the patient from the ambulance, with a turnaround time of three to four hours, Herting said.
“And that sounds like a lot but if you’ve ever been in Los Angeles and tried to go to the emergency room you might not get to see a doctor any quicker – even if you walked right in the door,” he said.
This typically costs around $30,000 to $40,000, so Herting said he always recommends residents or even summer workers get medevac insurance.
Last year there were 50 medevacs, with the majority in the summer. This year, Herting said it is about 30 so far. Given the distance boats can be from the harbor, Herting said sometimes even medevac is too slow.
“Now if somebody is out on the boat and they have a real bad accident, they gotta get in to the port they gotta transfer over to us, we gotta call into medevac and it could be a lot longer,” he said. “Over the years we’ve had some pretty serious things, life and limb threatening things, and a few people who didn’t make it.”
The most typical injury from seasonal workers is cuts, Herting said, as the majority of cannery workers are filleting fish on little sleep. Aside from the flu or common cold, Herting said another major issue is behavioral health.
Because of this the clinic has a tele-medicine service where patients can speak with a counselor over video. The clinic houses a small therapy room with native artwork, a plush sofa, box of tissues and across, a big screen T.V.
The face on this T.V. conducting the therapy session is Pete Tallman.
“Telemedicine is probably whether we like it or not is the future of service delivery in rural Alaska,” Tallman said. “It’s relatively inexpensive, it’s very accessible and as internet gets better it basically connects people in rural communities with trained professionals in all disciplines.”
For a week once a month Tallman comes to the clinic to see his patients in person. He said there are two levels of behavior health consultation. One is the traditional long-term counseling that is indefinite, whereas the other is a brief solution-focused session provided to patients in the primary care setting, where the goal is to address medical concerns with a behavioral health component. The latter plays a big role for the seasonal fishery workers, Tallman said.
“Everyone is out fishing or working and so people aren’t necessarily caring for their mental health needs and in a long-term way, they’re just trying to get through the summer,” he said.
Tallman said he sees an increase in acute mental illness issues in the summer, such as psychotic and depressive episodes. He added this is often a result of sleep deprivation, being far away from home, limited access to normal coping skills, etc.
Specific to the Camai Community Health Center is during the summer many patients are not only not from Alaska, but not from the U.S. Herting said the clinic has invested in a medical translating service to avoid miscommunication.
“In the past there have been patients who have been cannery workers here who come from third-world countries who maybe have never seen a Western medical provider before,” Herting said. “So it’s a first time event for them.”
Herting said a quarter of patients do not have insurance. Therefore, the clinic operates on a sliding scale fee, which is a component of a Federally Qualified Health Center, or FQHC.
The Camai clinic is non-profit and funded primarily through the FQHC grant, making it one of 1,400 clinics of its type across the nation. The grant originated as a way to help provide free or affordable health care to impoverished areas. The annual budget for the clinic is $2 million.
“So if you come in to see me about a respiratory illness it cost me on the average $800 for that visit,” Herting said. “If you have insurance typically I will get $200 to $300 dollars for it. If you have Medicaid I’ll get $240. If you have Medicare I’ll get $130. If you have the sliding scale fee and you’re eligible for that I’ll get $25 from you.”
Herting said any future changes to the Affordable Care Act will likely not affect his patients, given most have Medicare, Medicaid or no insurance. He said the clinic does not have the ability to thoroughly check insurance documentation, so if someone claims the $25 sliding scale fee, the clinic takes their word for it.
But this is all part of rural health care, Herting said, adding that it is almost an ‘impossible’ job given the many hurdles of living out in the ‘Alaskan Bush.’ It is not only difficult to hire people who will stay longer than a year, but also to find people who can fulfill multiple positions.
“It is unique. I call it almost an impossible job, because a lot of the rules you would have in a normal civic or more populated area don’t apply here,” he said.
The summer surge of patients will parallel the salmon run, slowing by mid-August. Camai will return to two physicians and the temporary clinic will close. Even Herting will leave this fall, as he retires in September. The search continues for his replacement.
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