Rural America: A Primer for Washington Officials, Columnists and Dartmouth Economists

flying cadeuciiEarlier this week , physicians in small private practices and rural areas breathed a collective sigh of relief.  There is a possibility the implementation of changes to physician reimbursement (known as MACRA) could be delayed.  Thank you, Mr. Slavitt, for listening.  I am grateful to Orrin Hatch (R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind.  We have a window of opportunity for rural health care to survive but we must communicate our needs as physicians and patients’ loud and clear.

Whether in reference to health care or public education, trying to increase quality while simultaneously decrease costs is an unrealistic proposition.  Physicians in rural areas simply have fewer resources at their disposal.  Adding insult to injury, Medicare payments to rural physicians are dramatically less than those of their urban counterparts for equivalent services, a point driven home by the fact 470 rural hospitals have closed in the past 25 years.  Does it cost less to stitch up a laceration in a remote Alaskan village than in New York City?  I doubt it.  The expenses incurred obtaining supplies may be even greater for remote locations.

In order to set primary care physicians up for success, it is imperative those in charge understand our challenges.  Rural physicians are alone, save for our spouses running our medical practices while we see patients.   For physicians to be successful, additional revenue would be necessary to meet the expensive health IT burdens placed on us by this new payment model.  Creating “virtual” groups to consolidate reporting will still require provision of a “virtual” assistant because it is more administrative burden than we can handle.  Our profit margin is too narrow to accommodate additional employees.

I am not convinced time and money spent implementing new technology does anything to improve patient care; I am fairly certain, however, conversations with my patients provide considerable value.  Can you not extract the information from claims, like private insurance companies already do?  If we have to hire an additional employee, who is going to pay them? The solution is relatively simple; shift the burden of data collection from small practices to elsewhere or increase reimbursement so meeting your demands becomes feasible.

Preserve what we have in rural America until you have more clarity where we are heading in the future.  According to a report on Rural Participation in the Medicare Shared Savings Program, rural providers already deliver value and quality within our existing infrastructure.  Adjusted for lower volumes, Medicare spending per beneficiary is 3.5% less.  Physician spending is 18.4% lower overall compared to our urban peers. We have strong personal relationships with our patients, operate at the top of our capabilities, and keep care local whenever possible.  I fail to see the problem with our old-fashioned style of practice. In fact, maybe you should use us as models of efficiency or cost-containment for larger conglomerates.

Being in a small or rural practice is extremely challenging.  In rural America, 75% of exchange consumers had incomes less than 250% of the federal poverty level.  Every family in my practice who obtained insurance through exchanges met criteria for Medicaid, known in Washington State as Apple Health.  24% of rural children live in poverty.  We are surrounded by Health Professional Shortage Areas (HPSA’s) and Mental Health Professional Shortage Areas because primary care physicians are spread entirely too thin.   The elderly and poor in rural areas deserve access to quality health care.  What happens to those people if small practices cannot keep their doors open as a result of overreaching government mandates?

According to the National Rural Health Association, 10% of physicians practice in underserved areas despite the fact 25% of the population lives there.  One-third of automobile accidents occur in rural areas, however two-thirds of the deaths from these accidents occur on rural roads.  Rural residents are more likely to die from injury due to delays in care.  I have direct experience, recently providing road side care after an accident while awaiting EMS arrival for 15 minutes.  Delays are related to increased travel distance and personnel limitations.

Extrapolate for a moment what could happen if numerous small practices closed in rural areas.  Can you imagine if one third of strokes occurred in rural areas, but two-thirds of stroke deaths were rural due to significant delays in receiving timely treatment?  It makes no sense to cripple our livelihood when we provide lifelines to underserved and disadvantaged populations.
Rural residents have fewer resources, significant geographic obstacles, and the acuity level of their medical problems is far greater.  These detrimental conditions drive tremendous health disparity.  We need to spend our time healing, comforting, and having conversations with patients, instead of reporting their medical problems and immunization status to non-physician statisticians.

For physicians in small or rural practices with scarce resources and deteriorating infrastructure, it will require significant investment for us to undergo meaningful transformation.  Either learn more about the challenges small or rural practices face, provide waivers (like No Child Left Behind did) for exemptions, invest in our infrastructure, or leave solo physicians and our practices alone.  Do not try to fix what I am not convinced is broken.

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11 replies »

  1. Certainly, feel free to use my quote. Click on my name and read other similar ones on my blog 🙂

  2. Thank you for your comments. I love your quote: “Don’t make us use technology that makes it harder to care for the sick.” It summarizes the entire problem with our health care system perfectly. Roadblocks are continually being placed between us and the sick. I would like to use that sentence/idea as a starting off point for one of my next posts… if that is ok with you? Thank you for reading and I agree, I wish the pundits would read this post closely. I will obviously have to keep writing…

  3. An important post, and your answers to John Irvine’s questions are equally important for the pundits to read. Here we are, you and I both working in underserved areas under Government mandates that decrease our ability to take care of our sick patients by overemphasizing data collection and reporting. Here we are, taking up much of the precious little time we have with our patients, doing public health work that could just as easily be done by non-physicians.

    I agree with your words:

    “Rural residents have fewer resources, significant geographic obstacles, and the acuity level of their medical problems is far greater. These detrimental conditions drive tremendous health disparity. We need to spend our time healing, comforting, and having conversations with patients, instead of reporting their medical problems and immunization status to non-physician statisticians.”

    Regarding the comment section:

    Of course, technology or no technology isn’t the issue. The issue is: Don’t make us use technology that makes it harder to care for the sick. Because, dear pundits, politicians and healthcare business people, caring for the sick is what rural America needs their shrinking pool of primary care doctors to do. Rural citizens with chest pain, pneumonia, lacerations, diabetes, depression and vague symptoms that could be trivial or life threatening need timely access to qualified primary care where they live.

  4. Exactly my point! We save lives with our hands and minds. That is the larger issue facing health care. They are taking the basic tools away from us.

  5. Well said Niran.
    ” For basic primary care, I need a stethoscope, otoscope/ophthalmoscope, BP cuff, and a pen. And That’s all folks!”

    Much good medicine is practiced in needy areas outside of this country with just those tools.

  6. In Washington State 19-33% of the population lives in a rural or underserved area. They are ignoring 1/5 – 1/3 of the population!

  7. What great questions John — I am so glad you asked. I will answer them in order as best as I can.

    In an ideal world, our needs are so simple, it is ridiculous. When my father and I changed office buildings (7 years ago), we closed on a Friday to allow three full move days. We saw patients in the parking lot (seriously) who were sick, as the movers were loading the truck. He said, “All we need to care for patients is a stethoscope, otoscope, and a pen.” Obviously this is a slight exaggeration to do every day, but it worked fine and I have never forgotten his good advice.

    In order to provide high quality care to my patient population, I need TIME to do it and $ to survive. I would like to own a home, pay for food, some activities for my children, and an occasional babysitter when I need one. I can do that right now, but may not be able to in the future.

    Needed resources would be, a behavioral therapist 2 days/week, a social worker 3 days per week, a lactation consultant 2days/week, a family counselor 1day /week, a nurse to do home visits for newborns, and a child psychiatrist one day/month. Access to a dermatologist on occasion would be pretty awesome also, but I won’t go overboard.

    As to what I would do for my patients: I would keep doing exactly what I am doing now, only I would eliminate all the complicating garbage. Stop prior authorizations, service requests, re-credentialing, and MOC. One Medicaid plan, NOT six in one state. Each with a different rule, different formulary, and weird idiosyncrasies that interfere with the practice of medicine. Trust the physician to treat the patient.

    Patients need a physician who can look at their face and know if they are “sick” or “not sick.” Do you realize how rare and valuable that is? After 15 years taking care of the same child over and over, I know them like the back of my hand. I can read their minds. That is the true practice of medicine. The thing missing most from health care today is the long-term relationship built over time between the physician and patient. I do not need a CEO, CFO, CMO, or BSO to tell me how to practice. I have 11 years of post high school education. My knowledge base and experience make me valuable (and my sweet, compassionate nature, of course.) There is little use for red-tape under the guise of technology and accountability.

    I would pay myself for my time. If I spend an hour with a patient, what the heck does the government or insurance think I was doing, playing tidily-winks? I was talking and exchanging information. Do you know how long it takes to answer questions for a vaccine-hesitant parent? It can take an hour or more. That time is well spent, believe me. I wish a government health beauracrat could spend an day with me while I discussed immunizations with families or explained conditions to help a parent make important decisions for their child? Those “business of medicine” people would pull their hair out. Talking is a primary care physicians job, let me do it and stay out of my work.

    Accountability is fairly simple in pediatrics. Look at outcomes. How many visited my office and then visited the ER within 24 hours? Happens rarely. Do NOT look at how many patients from my panel went to the ER? That is ludicrous to measure and does not reflect care provided in any way; it does not provide tangible information. What percentage of patients came in for well child checks? NOT what percentage are fully immunized. I do not control that. Parents have a right to refuse. How many asthmatics were hospitalized by me because they were not on a steroid inhaler? The answer for my office would be zero in the last 15 years. You get the idea. I have like 20 metrics off the top of my head that would make sense to track and could easily be gleaned from claims data.

    For technology to be useful in primary care… it would allow for completion in 60 seconds per patient. I see a patient, write the script, go back to my desk, dictate, circle the code on the super bill, and hand it up to my front office staff. 60 seconds. If I see 15-20 patients per day, it takes me 15-20 minutes to finish documenting and go home. Clicking boxes is not a good use of my time or expertise. Who exactly benefits from that activity? If the insurance or government wants the information put into a specific format, send me a person to do it in my office. No problem. The alternative is to design a device patients have that allows them to compile their own records which they keep track of and help providers access when needed.

    I would almost totally unplug my computer, if given the choice.

    I already use text messages or Facebook Messenger for communication with patients. A little boy I love dearly split his head open today and mom let me know what happened over Messenger and updated me with important care information so I know when I see him in follow up. My patients are amazing! They do not seek medical advice much after hours except for true emergencies and they respect my time. They love the “9am rule.” If anything happens and you want to be seen the following day for acute illness, accident etc… then just walk in at 9 am and we fit you into the schedule — no matter what. Do you know how comfortable that makes a family feel? They are never afraid to stay home and OUT of the ER because they know they can find me. That type of service is both popular and should be properly reimbursed. I wish coordinating care like that over Messenger could be paid. It would be phenomenal. It saves so much money in the long run.

    I don’t even understand how I would drop them into a Google doc and call it a day. 🙂

    Here is what I wish those writing laws understood: For basic primary care, I need a stethoscope, otoscope/ophthalmoscope, BP cuff, and a pen. And That’s all folks!

  8. Here’s my question —

    Dr. Al-Agba –

    What do you need to provide high quality care to your rural population?

    If you ruled the world (always a dangerous proposition), what resources would you ask for and what laws would you make disappear? Remember, as a dictator, you don’t have to answer to the will of the people, but paying attention to their reactions probably isn’t a bad idea.

    A few specific questions:

    – What would you do for your patients? What do they really need?
    – How would you pay yourself?
    – How would you hold yourself accountable?
    – How would use technology to make your practice smarter?

    Would you unplug your computer?

    Use text messages to communicate with your patients?

    Drop your patients en-mass into a Google doc and call it a day?

  9. Niran, I practiced in an area that was rapidly growing. It was much harder to practice when specialists and high-tech weren’t as available. Washington is a big city with big money and that money doesn’t come in such large bundles from rural communities. Money and power is what talks in Washington so I believe in too many cases rural communities are invisible.

  10. Perry- Thank you for reading and commenting. I am surprised no one has said anything as of yet. I believe it is because the ivory tower and big city medically-involved individuals have NO idea what we do on a daily basis out on the front lines. I just got off the phone with another practice in a rural area that has 70% Medicaid children and NO specialists to even refer patients who need it.
    Saurabh Jha said “MACRA in rural America. A bit like mandating fine china plates in a famine.” I could not have said it better.
    I will keep writing and hopefully publishing (thanks to places like TheHealthCare Blog, as long as there are those willing to read and listen. Thank you again.

  11. No comments here yet, but I’m hoping all the above will read this and take note.