For 50 years, the United Family Medicine clinic on St. Paul’s West Seventh Street has catered to the working poor and underinsured patients, including today many East African immigrants and neighborhood residents.
And the nonprofit health center has done so hand-in-hand with Allina Health, a 12-hospital, 90-clinic health network that has provided the majority of the clinic’s physicians, 21 medical residents, electronic records, lab services and even their phone line.
Now, Allina is in the process of pulling out all 21 medical residents and finding another location near United Hospital where the medical residents can complete their three-year rotations in family medicine.
By the end of the year, the faculty physicians are expected to follow them, leaving the clinic nearly devoid of primary care doctors. Physician assistants and nurse practitioners are expected to pick up the slack under the clinic’s new model of team-based care.
“The pandemic certainly has accelerated changes in the health care system,” said Sara Criger, president of United Hospital, who said medical residents and faculty had complained of patient scheduling and other issues at the clinic, hurting the reputation of Allina’s residency program.
Criger added: “There were problems that United Family Medicine needed to address. As the clinic made changes, we had to determine if they meet our requirements or not, and it became apparent that they did not.”
The deteriorating relationship between the community health clinic and Allina has led to finger-pointing on at least three sides.
CALLS FOR CEO TO RESIGN
Alarmed by a lengthy period of employee furloughs and other emergency management steps, a group of former United Family Medicine board members and West Seventh Street advocates have laid blame on the health clinic’s leadership and called for them to step down.
Those advocates include former United Family Medicine board chair Andrea Marboe, longtime West Seventh Street activist Marit Brock and former St. Paul City Council Member Dave Thune.
“We’ve totally lost confidence in the program and they should stop funding them,” said Thune, who is circulating a petition calling for major funders to sever ties and for United Family Medicine Chief Executive Officer Ann Nyakundi to resign.
“We want a neighborhood clinic with doctor-patient relationships, real family physicians that follow you to the hospital,” Thune said. “She walked in and six months later turned the clinic upside down. We just prefer she leave now.”
Nyakundi and Jonathan Watson, CEO of the Minnesota Association of Community Health Centers, said operations at the clinic have stabilized since the start of the pandemic.
“When I inherited the clinic, our 2020 budget at the start of the year was actually worse than it is now,” said Nayakundi, who stepped in as CEO last October after the previous CEO resigned. “We’ve done a really good job efficiently navigating the pandemic and staffing to demand. We temporarily had furloughs, but we’ve brought all of the staff back, and we’re actually in a period of growth.”
Critics, including former board members, have said some of the changes implemented under Nayakundi included reducing doctor visits with patients to 20 minutes. To keep accreditation, a residency program must allow for 40-minute visits.
Some scheduling changes conflicted with the medical residents’ required lectures. While the medical residents were not furloughed during the pandemic, their teaching space was reduced from 21 carrels to four.
In response, the seven first-year residents threatened to leave the program and find another residency, alarming Allina officials.
FEDERAL AUDIT REQUIRES CHANGES
The relationship with Allina, which was in place even before United Family Medicine officially became a federally backed, independent community health center in 2012, recently caught the notice of federal regulators, and not in a good way.
A 2018 audit by the U.S. Health Resources and Services Administration (HERSA) found that for an independent clinic, United Family Medicine wasn’t independent enough. Allina provides 90 percent of the clinic’s patient services — everything except dentistry and optometry.
Nayakundi said she reports to a majority-patient board, which guides how the clinic’s two locations deliver primary care, behavioral health and dentistry services to some 15,000 clients annually.
“HERSA’s right,” Nayakundi said. “The most effective way for a community health center to be responsive to the community it serves is not having so many strings attached. If our interests ever differ from (Allina’s), they hold a lot of cards.”
In response to the audit, an Allina physician no longer serves as the clinic’s medical director, and two Allina doctors no longer sit on the clinic’s board. Thune predicted that alone will satisfy the federal auditors, but he said Nayakundi is going much further in reorganizing the delivery of patient care.
Efforts to renegotiate physician contracts with Allina, however, have more than fallen flat. In Nayakundi’s eyes, they’ve backfired.
“We came up with a model where the (medical) residents could continue to be here, but have (additional outside) providers available to see patients,” Nayakundi said. “In the process of that, COVID hit, and Allina made the decision to withdraw the residents.”
Among the challenges in working with Allina, each of their physicians staffs United Family Medicine 16 hours per week, spending the rest of their time at Allina hospitals, Nayakundi said.
That makes scheduling clinic patients with the same primary care doctor difficult.
Whatever its fate, no one wants to see the clinic — which maintains a satellite office in the Sibley Plaza strip mall on West Seventh Street — retrench.
Before becoming a federally backed clinic, United Family Medicine got its start as the Helping Hand Health Center during the “free clinic” movement of the early 1970s. For five years in the 1980s, the clinic shared space with Mancini’s Char House on West Seventh, which offered it free rent. A side door from the clinic opened into the bar.
“You’ve got medical, dental and behavioral health all under one roof, and that’s a very unique and convenient model, especially for the working poor,” Watson said.