Blue Promise: Small Towns Have Big Health Care Concerns (Part 1)

Of the 254 counties in Texas, more than two-thirds are deemed "rural" by the Texas Department of Agriculture and the Texas Department of State Health Services. There are increasing challenges to accessing health care in these communities. In this Blue Promise conversation, Dr. Nancy Dickey, Executive Director of A&M Rural and Community Health Institute, and Dr. Bob Morrow, Southeast Texas Market President at Blue Cross and Blue Shield of Texas, address this growing crisis.You can also listen to this discussion in podcast form on Apple Podcasts and SoundCloud 

Blue Promise: Small Towns Have Big Health Care Concerns Part 2

Blue Promise is a podcast and online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas, and his co-host, Ross Blackstone, Director of Strategic Influence. 

Show Transcript

DAN: Of the 254 counties in Texas more than two thirds are deemed rural. In this addition of Blue Promise we're going to talk about the challenge of accessing health care in these communities. I'm Dr. Dan McCoy. I'm the President of Blue Cross and Blue Shield of Texas. I'm here with my co-host Ross Blackstone.

ROSS: Thank you, Dr. McCoy. We have two distinguished guests here with us, Dr. Nancy Dickey is Executive Director of the Texas A & M Rural and Community Health Institute. And Dr. Bob Morrow is Southeast Texas Market President for Blue Cross and Blue Shield of Texas. Thank you both for being here.

BOB: Great to be here.

ROSS: So, Dr. Dickey tell us a little about your role at Texas A & M Rural and Community Health Institute and what you're doing to address access to care in rural parts of Texas.

NANCY: The institute was created 15 years ago actually in order to support small hospitals. We discovered as we reached out to physicians across the state that the small hospitals didn't have the capacity, didn't have the depth of staffing, they didn't have the capacity to go buy computer systems for reporting systems, quality improvement systems, peer review systems. So, the institute lovingly called Archie. Began to create those programs in a fashion that we could afford to sell service to small hospitals at a rate they could afford. In the last five years we've become much more involved in researching whether those hospitals are actually going to be able to keep their doors open. Health care continues to change, and the challenge becomes ever worse in terms of them trying to maintain financial viability.

ROSS: Okay. So, do you guys work directly with providers in Texas?

NANCY: We have contracts with several hundred physicians and nearly 100 rural hospitals.

ROSS: Okay. So, we're gonna dig in in a minute much deeper to get to some of those issues. But first Dr. Morrow you have some experience dealing with rural health care issues as well, right.

BOB: Well actually it turns out I do and to back up actually for me a bit, my experience started as a fourth-year medical student when I did a rural preceptorship program actually with Dr. Dickey as a fourth-year medical student. I spent a month with her in her practice in Richmond / Rosenberg Texas which was really probably my first true introduction to maybe some of the challenges and opportunities of a small rural based practice. And then fast forward a number of years I actually was medical director for quality for the Rural Community Health Institute at Texas A&M.; And at that time, I actually spent quite a bit of my time going around the state visiting with physicians working in rural areas with the hospital administrators who were working in rural areas and really gaining a I think a pretty good understanding of some of the unique challenges that they face as they try to provide access to health care for their communities.

DAN: I grew up in a small town, so I grew up in rural Texas so... Nancy you and I've known each other a long time. Most people would look at this rural health crisis and they think is this just about keeping rural hospitals open or is the process more complicated.

NANCY: It's actually much more complicated than that. Many of these rural hospitals got there when everything we knew how to do. I hate to say it maybe when you and I were growing up in small towns could fit in that iconic doctor's black bag. And he could get in the back of his truck or his conveyance of some kind go to the house and all modern medicine was right there. Modern medicines changed and a great deal of the technology that we want access to if we're the patient simply can't be supported in a very small hospital. Yet 20 percent of the population of Texas, 20 percent of the population of the country live in rural areas. That's 60 million people across the country, 3 million people here in Texas so, if you have got great big cities but then people scattered hundreds of miles out and you can't take the technology to them how do you get access to health care and that's the real question. What can we do in small towns? How can we make sure if you choose to live there and oh farm the food that I eat and pump the gas that you put in your car? How do we make sure you have appropriate timely access to health care? That's the real bottom line question. It just happens that health care in the United States currently revolves around hospitals

DAN: Okay, so I'm going, kind of go down that path because I like that analogy, I always tell people that fuel, fiber and food that the country's greatest assets right come from these rural areas. And so mobility has become part of the issue right. I mean in some respects getting people to move to these areas is challenging because they don't have access to healthcare services. And the flipside is also true people within these areas are leaving the community for services which may be truly appropriate. But America's health care funding is often geared toward those procedures and not geared toward many of the things that need to be supported in the community, true?

NANCY: Extraordinarily well said, the things that actually provide the meat and potatoes to a hospital are procedures, high tech care and yet we know that the best health care rests on the foundation of primary care, on chronic disease management, on prevention and early detection. Those things all should, could, and ought to happen in the small towns but how do you get physicians, nurses, pharmacists to go to a small town when you say to them by the way the nearest hospital is 75 miles from here. How do you get patients to understand that's high quality care in a small town even though when they need their hip replacement or their heart bypass, we're going to send them to the next nearest big city? Part of it's a communication problem, part of it's a culture change problem.

DAN: So, we, Bob and I had a recent opportunity to travel up to D.C. and we were talking about some of these challenges. Talk a little bit, Bob, about the uninsured. That's a huge, huge challenge right for these rural areas because often the uninsured and poverty levels are much higher in these communities.

BOB: Well absolutely. The uninsured poverty levels are higher. And we also know that we tend to be dealing in the rural areas with an older population and actually with a population with a little bit of a higher burden of chronic illnesses than in the urban areas and unfortunately in Texas we are sort of we're very far down the list in terms actually far up the list in terms of the numbers of uninsured. And to your point that's even worse in our rural areas. So it's sort of a bad perfect storm if you will in terms of an older population, a sicker population and a populations that that is less likely to be insured in a state with a high, high population of uninsured.

NANCY: And go back to your mobility issue, all right. We talk about the mobility of you may have to go to the health care but older, poorer, sicker, those are people that generally don't have meaningful transportation to either take a day and drive into the city or a car that they think will make it from small town to big city or the money to put gas in the tank to get there. So now you have a population that needs the care and has no way to access.

ROSS: So, let me just share a couple of statistics to put things into perspective for our listeners and our viewers. There are one hundred and eighty-five counties in the state of Texas that have no psychiatrist. One hundred and forty-seven counties that have no obstetrician. There are 68 counties that have no hospital. And 35 counties have no physician at all. So, my question to you guys then is, is that what we have to work with or is it actually getting worse. Are hospitals closing down or physicians just not entering into the workforce or they’re choosing other occupations. What's the situation like, is it getting any worse? Or is....

NANCY: Getting worse. We have all across the country, okay but Texas, as we often do, leads the nation is closing rural hospitals. We've closed 20 rural hospitals in the last decade and a half. And there are several that are sitting right on the edge of closing now. We graduate more medical students from Texas medical schools than we ever have in history, but we still aren't training enough primary care. Plenty of people going into medicine. But we talked about the fact that high tech is what pays the overhead for big hospitals, high tech run by highly paid specialists. We don't value and therefore we don't pay for primary care. The neurosurgeon, the neonatal specialist are unlikely to live in tiny town. But primary care physicians are badly needed in tiny town. And yet, we tell these kids in medical school you're going to be one of the lowest paid people around and then you're gonna have to go someplace where you're worried about whether your kids can get an education and way where you by the way probably drive for your health care as well. So, the problem is getting worse and we don't want that to be the problem for forcing even more people out of rural areas because as Dr. McCoy said that's where our food, fiber and fuel comes from.

DAN: So, Nancy we've done a couple of things here. So, we haven’t just set around. We've made some policy decisions that were meant to address some of this. So, let me kind of run through a couple of those because I think it's the law of unintended consequences right. So, three years ago I sat and watched in the gallery legislature as they passed some enabling legislation around free standing emergency rooms and one of the things that was talked about was we needed access to emergency care, is that helped or hurt?

NANCY: Yes. It has given us the capacity to put freestanding emergency rooms in rural areas and for many of these communities the demographics, the number of people say what they really need is chronic primary care and emergency care, not a hospital. All right, unfortunately that legislation didn't say you can only put those where there are no other hospital access and so we have freestanding emergency centers which tend to go where the population is, in the urban areas where we really don’t need them.

DAN: Which probably sucked emergency physicians to some degree out of those areas.

NANCY: I absolutely agree. I know people living in small towns who drive to the city to work in urgent care.

DAN: Okay, it's not our first rodeo here so I’m gonna go down the list here. What about financing? Have we done things through public policy and financing that's hurt rural hospitals and health care communities as well?

NANCY: We've done some good things. I mean I'll give some credit where we can, the ability to do loan repayment if you practice in a rural area has in fact attracted a number of doctors at least long enough to pay off their loans. And some of those will then fall in love with the lifestyle in and stick around. Unfortunately, Medicare and Medicaid don't pay well. That's the preponderance of payers in rural areas and they probably pay at least as poorly if not more poorly in the rural areas.

ROSS: So that makes up 45 percent of most rural hospital’s income, Medicare.

NANCY: Exactly right. Yeah. So, no I don't think we have done anything that would fix that. And then we continue to keep things on. So, you talked about the number of counties that didn't have OB GYN. Lots of those counties did had family physicians that delivered babies. But we've recently passed regulation in the state of Texas that says in order to be able to take care of most pregnant women, as you might need to do a C-section, you need an OB GYN, not somebody who can do a C-section, you need an OB GYN 24/7 within 30 minutes to the hospital. So, we're going to see a whole bunch of places that have been delivering babies close their doors.

DAN: And delivering babies is not something you can deliver via telemedicine right.

NANCY: It's tough, it’s really hard.

BOB: Very tough. 

ROSS: Were you going to add something? 

BOB: I was just going to add to your stats because it is kind of compelling talking about OB’s when you mentioned the 147 counties don't have an OB’s in the state of Texas if you actually put those together that would be like saying Nebraska does not have an OB.

DAN: Let me kind of get, well we're kind of close this topic but I want to kind of focus on one other challenge I think we have. Would you say it's hard to talk about these issues to some degree because everybody starts to think oh my goodness you're going to close our hospital and if you do it's going to kill our community. You may remember our schools, gonna kill our community. But there's is an issue where we really need to start talking about holistic solutions right, but that hospital issue is political.

NANCY: It's extraordinarily political and I've actually watched it happen. If you can't get the conversation out in front of the decision-making then towns can be in serious trouble. So, I watched a small town, their hospital with very little notice, close the doors and within two weeks most of the providers; doctors, advanced practice nurses left town, found another practice someplace. So, it's terribly important that we have the conversation with communities, not with the hospital board, not with the school board but with the community to talk about everything says, that within the next three to five years this hospital is going to close. You cannot financially keep it open. So, let's talk about an alternative that will hopefully keep your doctors here, keep your nurse practitioners here, keep access to care here, even though you don't keep inpatient care here and that conversation is actually one of the things that our institute is investing a great deal of time and energy in is, how do you approach the conversation, how do you keep people at the table long enough to talk about alternatives because the minute they hear possible closure. They close the conversation and walk out the door.

DAN: Well that's what we're going to do here. So, we're going to spend the next segment actually talking about solutions and I think you're right on point. I think many times people walk away from this conversation because they think they need to keep the hospital open in any other kind of thing is not politically correct and what ends up happening is you put money in failing infrastructure that's crumbling because you can't really generate the investments because the dollars aren't there and then you wind up with the door shutting with little notice. Thanks for joining us for this edition of Blue Promise.


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