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

Texas is home to some of the most advanced health care in the world. Unfortunately, the most rural parts of our state struggle to receive health care services at all. So what's being done about it? 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, share potential solutions to 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 1

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: Texas is home to some of the most advanced health care in the world. Unfortunately, though the more rural parts of our state struggle to receive some health care services at all. So, what's being done? Find out in this episode of Blue Promise. Thanks for joining us for this edition of Blue Promise. I'm Dr. Dan McCoy and 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 guests here with us today 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. So, you know in our previous segment we talked about some of the issues outlining and defining some of the issues impacting healthcare in rural parts of Texas. Now let's start talking about some of the potential solutions. Dr. Bob I'll start with you. What are some of the preliminary ideas that we have to address this issue?

BOB: A little over a year ago, we had a conversation about some of the issues facing rural communities as they strive to have access to quality affordable health care for the people who live there. And I’m very excited that as those conversations sort of evolved, what has materialized out of that is actually, I think, a very robust collaboration with us and the Texas A&M Health Science Center and the Rural and Community Health Institute around really trying to identify, I would say, innovative solutions for providing access to health care in rural areas.

NANCY: We hope that one of the great strengths will be the ability to take really big data and ask ourselves, “What happens when a hospital closes and health care providers leave a town?” People obviously go somewhere for the care, but do they end up going too late? Do they have worse outcomes? Is the cost greater because they didn’t get care in a timely fashion?”

BOB: When I sort of look overall at some of the think that really excite me about this project I think the word “innovation” comes to mind, because this is not about just finding a way to just funnel more resources into a model that is probably a 70 or 80 year-old model that just is not effective now. This is really about (1) using big data to identify which communities might be at risk, why they might be at risk. And then develop new ideas and go into those communities and say, “You know, this is probably a better way to provide access to health care for the people who live there.”

NANCY: I think that by putting people together and saying to them, “Not more of the same. Not tweaking around the edges, but let’s think outside the box.” That we can really come up with some solutions, not just for Texas, but probably for the country.

BOB: And I think that’s key. And that’s part of another reason I’m excited about this collaboration. I do think a lot of people will be looking at us and this collaboration in terms of, “Are there models that might be developed through this that can serve the rest of the country?”

DAN: Bob and I have had the blessing or misfortune of recently been put on the spot by a member of Congress, kinda asking what's the solution, right. Because I mean you just spit it out. You're going to A&M; to ask you to do this work. But what's the solution? And I had to come up with an off the cuff solution so I’m gonna throw it out and I'm going to throw these out to you Dr. Dickey. You know I want you to kind of respond and see how close I was. And I want to get the tough one on the table right out right out the gate because I think there's some funding issue here. Do you think? Tell me a little bit about the role of needed…. we may need to fund more infrastructure in the form of Medicaid and Medicare and government dollars than we've historically done.

NANCY: That is in fact a primary solution to almost any of the others we're going to put on the table. The single most common thread in terms of places closing is they can't bring in enough money to support the infrastructure even if they shrink the infrastructure. They probably can't afford that. So, with a heavy Medicaid, Medicare population we need to pay at a rate that takes into account what is backwards in a lot of people's minds they think it's cheaper to live in small towns. Well it's not if you're having to bring in professionals and you've got to ask them to do a different kind of workload than they would perhaps do if they were living in the city.

DAN: And that was actually one of the components that I got asked about was that you know it's it may be okay that things are more inefficient to be delivered in a small town if you're going to support the fuel, fiber, and food. You may have to pay more to get that delivered because it's just not as efficient. You don't have fifty thousand people to scale a lab around there, is that fair?

NANCY: Exactly, so, very good answer. You may have to pay more to say to somebody you know you could get a job in Dallas or you can go to a small town but we'll pay you 10 percent more than you would for that same job if you stayed in Dallas and again sometimes it's the reverse of that when you start looking at pay scales. Although many small towns tell me their rural primary care physicians, family physicians get paid pretty well but they work extraordinarily hard. I think in addition, well go ahead. So that's the solution one I think you were right on the nail.

DAN: Okay. The other one and Bob may want to chime in on this one too is that alternative practice models. So you know we tend to think about traditional care, the Marcus Welby, the hospital that sort of thing in a rural community. But we may have to get creative and some of these technologically advanced ways to practice maybe part of the solution.

NANCY: I'm going to agree with you partially, alright. I do think that we have to become very innovative in terms of what can safely and effectively be delivered in small towns. I want to be very careful as we do that that we not somehow tell people in small towns that they should and must accept a different standard of care. So, while I believe that all of health care is moving to team care where we have an advanced practice nurse, we have a P.A., we have a couple of physicians, we have pharmacists. To tell people that having an NP is the same as having a doctor is simply not true. We're trained differently. We're trained to do different things and when we come together as a team we're powerful. But to suggest as some would that we'll replace physicians with non-physicians and that'll be good enough. I think that saying to the rural area we'll make sure you have access to band-aids and mercurochrome but we're not really going to give you access to the best of health care, so new models, yes as long as they're based on something that says here's the standard of care and we're gonna meet it.

BOB: And I think that's actually very important and I think in that model in that team-based model that would be a physician driven model. There may be opportunity things like repurpose or retrain individuals who are already in those communities because most of them have somebody who functions as an EMT and they also have a population as we've already, we discussed the last segment that has carries a high chronic disease. Maybe they can actually help act on behalf or in a team-based care model to make sure that those people get their needed screenings that they're getting you know access to the pharmaceuticals things like that in an appropriate fashion.

DAN: Well I love you both but I'm pretty sure earlier that we heard some statistics that I think 93 counties in Texas don't have a psychiatrist so I'm going to tell you right up front…

ROSS: One hundred and eighty-five… twice as many

DAN: One hundred and eighty-five, twice as many. So the size of so I guess where I was going to the path was there may be some creativity around putting social workers that are video enabled in to family physician's office to help manage depression better to improve everything from diabetes care to cholesterol adherence.

NANCY: And that is maintaining exactly what Bob and I were referring to, standard care, telemedicine for behavioral health works beautifully, actually telemedicine for post-operative care often works very well, you want to check the wound make sure it's not infected and so forth, telemedicine to deliver babies, yeah, doesn't work so well. So telemedicine is a solution for a chunk of this, watching the chronic patient things that maybe we've been doing in the doctor's office and didn't need to be. We had a student that actually said mailman go to the door of almost every house every day. Could we give him a little training to check in on Mrs. Smith and say, how your sugar has been running Mrs. Smith, have you been checking ‘em. When's the last time you saw the doctor. I thought that was a pretty inventive solution. Community health workers, kids coming out of high school with the training like a certified nursing assistant maybe six eight 10 weeks, but they can help get people to the doctor's office follow up and make sure they fill their prescriptions help them get their next appointment. Those don't require an advanced practitioner. They don't require a physician. They require somebody to help the elderly the folks who perhaps aren't quite as tuned in to how to use technology to make things happen and they end up getting better health care. So, I think it is in fact a team approach. It's using people we haven't traditionally used whether it's our EMT or a new group called Community Health Workers or maybe even the mailman. But it's also back to that community message that some things you probably have to leave town for and we got to find the right way to get you timely to the right level of care and then hopefully quickly back into your community.

DAN: Okay. And the final one you'll see if you agree with me on this one was alternative payment models. So, what's happened is as is the world is kind of gone along. We've developed these accountable care organizations in big cities and they've been out to add additional value which basically means they deliver high quality care, more of it at a lower cost. And I would argue that a lot of those were generated in urban areas because health care in urban areas is extraordinarily expensive because of the amount of technology and the access to these expensive treatments and that sort nature. But if there ever was a place in America where we needed to deliver more with less and deliver high value and high quality, I would argue it's rural America. So respond to that.

NANCY: The problem and I think Bob might have been at Archie at the time we hosted something called the Tyranny of Small Values Conference. When you've got small numbers, say you've got a town of thirty-five hundred. It's hard you know when you talk about ACOs you guys talk about 100, 200, 500 thousand patients It might take 20 of my small towns to come anywhere close to that. So, can we put together value base in a fashion that unlike most ACOs says got to take all comers cause it's everybody in this small town not just the ones who were insured by a particular entity. It's keeping in mind that you're going to have to send a lot of the high-ticket items out so where do I get measured on my savings, on what I do locally or what I ship out of town or someplace. I do think, I think there's a great variety of roles we've actually talked to some small towns and said, we know everybody from this town goes to that next biggest city to get any meaningful hospitalization, you need to be down there knocking on the door and saying to them, when you discharge that patient they're coming back to tiny town and if we give them good care, they won't be a readmission for you. But if we don't know they're coming, we don't know what their medicines are, you haven't communicated with us, we'll double or triple your readmission rate for the people from our town. Now the big city gets the ACO and they get to pocket the savings, if I do my work well. Small towns need to be in there saying I want my share of that because I'm the one that helped create it. So, there are ways even in the existing value base that we ought to be recognizing where some of those savings come from.

DAN: And Bob's certainly can have an opinion on this one and this was the fourth one which I didn't really talk much about with the congressman. But I think it's important, I'd love your response about it and that is social determinants. You know a lot of people talk about rural health care, but I know in my hometown where I grew up, there is no grocery store, there's a convenience store. So, people are eating and buying their food you know out of a convenience store. There’re people in that community that clearly qualify for things like tax credits for their children or enrolling their children in the Affordable Care Act products of some nature. But there's no social support network locally to support telling them how to do it or to teach them walk them through the process. So how important are maybe solving some of these social determinants of rural living.

BOB: That's a very significant problem, a huge problem. I mean actually interestingly enough that's a big problem even in urban areas. The whole issue of the social determinants in health and how that impacts sort of the overall health of a population is significant urban areas. It's significant in rural areas. And if you really want to move the needle on actual health of a population, you're really not going to be all that successful or at least not completely successful if you don't pay significant attention to those social determinants and of course those are very, very difficult to move. One, often they're very cultural. Two, we don't have good at all payment mechanisms to recognize how you move the needle on the social determinants of health. I think as we move towards value-based care and particularly primary care driven model where a practice has true accountability for a population and is rewarded for effectively caring for that population the ones that are ahead of the pack are the ones are going to figure out ways to meaningfully address social determinants of health. I would suggest then I'd be interested in Nancy's opinion on this, but I would suggest while it's a similar problem I think to solutions in rural areas and in urban areas may actually be very different.

NANCY: Well I think there's need for infrastructure particularly in the rural areas. I think urban areas tend to have not for profits or even government agencies that can tell you where to get your food stamps or if you qualify for food stamps. If I'm a practitioner I can say go down to the county health department or wherever. Small towns often don't have that infrastructure of where do I go to even get the answers. But I agree with Bob, they're very similar social determinants issues, urban and rural and a big piece of the problem is that it's not a matter of recognizing, okay. But if you have food insecurity in Texas, it's very difficult to qualify for food stamps or SNAP in order to have somebody help you buy food. If you have housing insecurity, we're actually having this discussion locally, the cheapest housing in Bryan College Station is very old mobile home technology, often has mold, leaks and it's not terribly safe, but if that's all you can afford, that's probably better than being on the street. I don't think that the things that normally pay for health care are able or having their focus that food and housing and support networks are part of the solution. And yet those are the very things that cause a lot of the chronic illnesses to continue being as bad as they are. We talk about the opioid crisis which is ostensibly worse in rural areas. Part of the problem again is where's the physical therapists, where's the massage therapist, where's the behavioral health counselling piece. So, if all I'm left with is a prescription pad for narcotics, guess what my chronic pain patients are likely to get. Now we know those other things all help who's going to put ‘em there and who's going to pay for them once they get there. So I think we have to address the social determinants in order for this to happen. But that's really a society problem. It's not a health care problem. Other than the fact that if we don't address them. We don't get to maximum health.

DAN: Well I think I can honestly say I'm excited to see the work and to see what comes out of this report and I think there's a large part of America that's going to be looking toward the results of this work to see what the direction needs to be and what the solutions are. So, Dr. Dickey and Dr. Bob thanks for being here today for this this episode of Blue Promise and thanks for joining us.


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