A dearth of specialists and a generation of surgeons approaching retirement age are together, a growing cause for concern in some rural regions.
There's a general surgery crisis in rural America, suggest preliminary research findings from the Washington-Wyoming-Alaska-Montana-Idaho (WWAMI) Rural Health Research Center.
The problem is twofold. First, although the number of general surgeons is declining around the country, the shortage is more acutely felt in rural areas.
"In urban areas, much of that decline can be offset with general surgery subspecialists," Mark Doescher, MD, MSPH, director of the WWAMI Rural Health Research Center, said in an interview. "But in rural areas where you don't have the population density to support the specialists, that impact becomes much more significant because there isn't an easy way to offset some of those services."
Moreover, the research points to a lack of training among newly minted general surgeons in obstetrics/gynecology and orthopedics. According to Doescher, they're less likely to do "in-a-pinch" c-sections and other basic procedures that general surgeons a generation ago would have performed.
"We're producing general surgeons who are probably not comfortable practicing in rural environments based on the skill set they have," he says. "There needs to be a wakeup call that there is still a need for people with some general skill sets."
Although there's a perception that rural general surgeons need to be prepared for every kind of surgery under the sun, the preliminary study findings actually show that "rural hospitals concentrate on relatively narrow set of low complexity inpatient procedures performed on relatively low?risk patients."
"In reality most of what's being done are, if you will, the bread-and-butter general-surgical types of procedures," says Doescher. "The take-home message from the study is that in rural locations compared to urban locations, general surgeons focus actually on the most common types of procedures."
According to Doescher, the findings suggest a need for training within general surgery residencies that equips general surgeons in rural areas to perform not only general surgery procedures, but also the basics of other specialties, too.
"Really we need an emphasis on training tracks that can produce rural general surgeons with this bread-and-butter type of skill set, with the addition of things that currently fall outside of general surgery training," Doescher says.
For example, after completing a program like this, Doescher says general surgeons should also be able to perform basic obstetrics procedures such as c-sections; orthopedics procedures such as pinning a hip after a hip fracture; and possess good endoscopic skills in the outpatient arena.
If that happened, he says "you'd actually be producing a very viable, rural, general surgery workforce."
Although much of this shift needs to happen at the medical-school and residency level, Doescher says it's an issue that should also be top-of-mind for rural hospital executives.
"If it isn't, they need to be thinking about it," he says. "This is a big issue because it ties in with the attractiveness of primary care in rural hospitals. If you don't have the surgical backup it's harder to get primary care providers. It ties in with the trauma system in rural areas; it ties in with the financial viability of services provided."
He believes that rural hospital administrators should take the lead in thinking about what "they need to produce locally and what would better fit within a more standardized referral network." For example, executives might consider using traveling surgeons to perform scheduled procedures and local surgeons who are available for emergency back-up. In addition, he says rural hospital executives should work closely with referral hospitals about coordinating care.
"What I have is a small piece of a bigger puzzle, which is: How do you produce the workforce that's needed in rural areas, and how do you create the right climate to attract surgeons in rural settings?" says Doescher. "A lot of that's medical education overall, but the rural hospitals have a big piece on trying to figure out how that make that a manageable career choice."
The ink on Texas Gov. Rick Perry's signature was barely dry before John Marshall Henderson, CEO of Childress Regional Medical Center in Childress, TX, started getting inquiries from physicians about employment.
"I've actually had two or three questions in the last week," related to legislation that was signed May 12, he told HealthLeaders Media in an interview.
The new law will allow rural Texas hospitals to employ physicians, ending a longstanding ban which had prevented hospitals from doing so. Specifically, senate bill 894 will allow critical access hospitals, sole community hospitals, and hospitals in counties of 50,000 or fewer to employ physicians.
Physician recruitment is already a problem in rural communities, so prohibiting employment of physicians was another roadblock for Texas hospitals, especially since nearby states allow physician employment, proponents of the law say.
"Over time it has become increasingly difficult to recruit primary care physicians in particular to more rural, isolated areas of the state, and this is another tool or option or incentive to attract physicians," Henderson said. "There was an argument to be made before this passed that the prohibition against employment actually drove physicians out of Texas because those that would prefer an employment relationship could go to Louisiana or Oklahoma or New Mexico."
"We're very optimistic that this will be huge step toward enhancing access to healthcare in rural Texas by virtue of being able to recruit more physicians into rural areas," he said in an interview. "There's no one solution, but we do think a big barrier was this antiquated Texas law."
One of the concerns with allowing physician employment was whether hospitals would try to influence physicians' medical judgment, but provisions in the legislation aim to prevent that from happening.
"While a hospital can employ a physician, a hospital cannot take any action or develop any policies that might impede physicians' medical decision making," Charles Bailey, SVP and general counsel for the Texas Hospital Association, said in an interview.
For example, the law places the responsibility for all clinical matters, including bylaws, credentialing, utilization review, and peer review, under the medical staff. It also requires the medical staff to designate a chief medical officer who is approved by the hospital board. The chief medical officer must report to the Texas Medical Board that the hospital is hiring physicians under the law, as well as report any instances of interference from the hospital.
Although not all physicians want to become employees, Henderson says the family practice physicians in his community supported the legislation. In fact, he says that at least two of them made the roughly 375-mile trip from Childress to Austin to testify in support of the bill.
"That was a big deal because hospital administrators can say it's a good thing all day long but there's real impact when a physician takes unpaid time to go to Austin and talk about how important the issue is to them," he says.
Although the bill took effect immediately, Henderson says his organization is aiming to be able to offer employment packages to physicians—including retirement, health insurance, and other benefits—by October.
He acknowledges that employing physicians might be more expensive.
"But my perspective is it's worth it when you're talking about an isolated rural community that just needs a physician," he said.
Amidst fields of cotton, cabbage, and other northeastern North Carolina crops, volunteer nurses and others set up camp to provide services to the area's migrant and seasonal farm workers. They arrive in the evening, just as the workers are coming out of the fields, with care tables and coolers of ice water and snacks, standing ready to monitor blood pressure and glucose levels, run TB skin tests, or perform rapid HIV screenings.
According to an HHS report released this week, uninsured families can only afford to pay in full for about 12% of hospital stays, resulting in tens of billions of dollars worth of uncompensated care each year.
Elizabeth City, NC-based Albemarle Health is no exception: According to its 2010 annual report, it provided nearly $27.5 million in unreimbursed community care.
Rural hospitals and health systems throughout the country face this same challenge, and the best solutions are unique and based on the specific needs of the regions that they serve.
"We're constantly assessing what's going on in the community and figuring out, 'How can we address it?'" Nancy Easterday, RN, MBA, executive director of safety net clinics at Albemarle Health, said in an interview. "Northeast North Carolina is very rural, very agricultural, has limited access to four-lane highways. We're either covered by farmland or swampland, and that definitely affects our programs and services."
Albemarle Health serves people across a 1,947 square-mile swath of one of the country's poorest regions. While a portion of the community is made up of migrant and seasonal workers, others are uninsured permanent residents without access to primary care. Supported by grants and donated healthcare services, Albemarle Health and its Albemarle Hospital Foundation is trying to confront those issues and improve the health of its community—as well as its own bottom line.
Problem: Migrant and seasonal farm workers across nearly 2,000 square miles.
Solution: Although there are programs serving migrant and seasonal farm workers throughout the country, Easterday says theirs is unique in North Carolina. Beginning last year, Albemarle Health started delivering healthcare directly to the workers, setting up field clinics about once a week during the growing season, which runs about May-November. She says whereas other programs provide workers with transportation to health clinics, Albemarle's large geographical area makes doing that impractical.
Since workers don't typically get out of the fields until 6 or 7 pm, "if we were giving them a ride to the clinic, it would be 8 or 9 o'clock, and that's just really difficult," she says. Instead, Albemarle staff perform health screenings in the field and provide needed follow-up care, such as giving free medication or even facilitating surgery, like they did for one worker with an abdominal hernia. "We were able to get him into a local surgeon right away," Easterday says.
Problem: Uninsured and low-income population
Solution: Albemarle Project Access was introduced in September 2010 in an effort to increase access to primary care and specialty services. The program uses physicians who actually volunteer their services to care for patients. Some physicians pledge a number of visits, others a dollar amount. During the first six months of the program, physicians—many of whom are not employed within the Albemarle system—provided $90,000 of donated services. In addition to reducing the strain on the Albemarle ED, the program also links patients with other resources; for example, it might help patients realize their eligibility for and enroll in Medicaid or disability benefits.
One patient who repeatedly visited the ED with dental issues was able to received donated treatment from an oral surgeon. Another was able to receive treatment for colon cancer, which otherwise would have likely gone undetected for a long time. Easterday says the program should reduce at least some of the strain from patients arriving at the ED with minor medical problems. "It can't fix the entire issue," she says. "But it certainly makes a difference."
Healthcare leaders: we'd love to hear from you. What are some of the ways you are confronting the unique care challenges that face your organization?
International medical school graduates can be a boon to rural hospitals that have trouble attracting physicians. But there are a limited number of H-1B visas—visas for people whose jobs require a minimum of a bachelor's degree—issued every year, and there are often aren't enough of them to go around, especially since that limit applies to all industries, not just healthcare.
But this year will likely mark the first time in several years that there will be enough H-1B visas for the entire year. And because the application period began April 1, now is the time for hospitals to be recruiting international medical school graduates.
"This year, my prediction is they will last all year long, so I think it's a great opportunity for employers in the U.S. who want to hire international medical graduates," Los Angeles-based immigration attorney Carl Shusterman said in an interview. "The U.S. has really used these foreign medical graduates as the device for serving people in these [rural] areas where they could not get American doctors to go and serve."
One physician executive who's experienced this first hand is Brian Bossard, MD, FACP, FHM, who is the CEO, founder, and director of Inpatient Physician Associates, LLP, a Lincoln, Nebraska-based hospital medicine group which also has programs serving two very rural areas.
"There was a provider shortage," he said in an interview. "In hospital medicine in particular, there's been a real need for H-1B visas to fill that void."
Bossard says he's hired close to 10 H-1B visa physicians as attending hospital medicine physicians. He says that one of biggest advantages for hiring these physicians is the fact that they're willing to work in rural areas.
"There's a greater willingness for them to reach out to the rural areas and provide care there," Bossard says. "No question, smaller communities around the country have a harder time recruiting U.S. graduate physicians."
That only adds to the rural physician shortage. Citing statistics from Rural Healthy People 2010, the National Rural Health Association says that only about 10% of physicians practice in rural America, despite the fact that these areas are home to nearly 25% of the population.
According to Shusterman, the lowered demand for H-1B visas can be blamed on a soured economy and the fact that companies in other industries, such as technology, aren't hiring as much.
"The last couple of years, all of a sudden, the demand really went down," he says. "When the economy goes bad, then these companies don't hire a lot of people for H-1B visas."
He says since this year's application period has just begun and residency programs are winding down, now is the perfect time for hospital executives to recruit international medical graduate candidates.
"They should be selecting people right now out of residencies and fellowship programs," he says.
Bossard says there are, of course, advantages to hiring U.S. graduates, who don't come with the legal processing and attorney fees associated with hiring H-1B physicians. But when U.S. grads aren't an option, H-1B doctors can be lifesavers.
"There are some strings attached to the visa candidates," Bossard says. "But for me I wouldn't have been able to maintain my business without their help. They've been a huge asset for me, and as a result, a huge asset for the hospital systems that we work with."
Surgeons rely on their peers for support, professional interaction, and advancing patient care. But when they're working alone in a rural area, that support can be hard to come by.
That's why the American College of Surgeons, which counts more than 3,500 rural surgeons among its members, is launching an online community aimed at linking them together. We're isolated, sometimes separated 50 miles, or sometimes 500 miles, from each other. So the professional interaction to get that reinforcement of what you're learning is heard to come by," said Tyler Hughes, MD, FACS, co-community editor of the Rural Surgeons Web Portal and a rural surgeon himself. He describes the effort as a realtime, interactive tool that allows its members to "geographically hop over the distances and develop real relationships."
The site, which will go live on May 5 at the Rural Surgery Symposium and Workshop in Chicago, will include interactive discussions and networking on patient cases and care; interactive online events; online educational opportunities; and a profile tool that allows users to filter information and discussions by their own interests and practice areas, among other features.
Hughes is careful to point out that this community will not be Facebook for surgeons. Although it's technically a social network, the topics of discussion will not be trivial ones.
"Our emphasis is not 'what did you have for breakfast?' Our emphasis is on professional networking with the intent of improving surgical care," he said. "This is a mechanism that can change the outcome of a patient today because it imparts information at the speed of light."
Hughes said the network stems from the popularity of the rural surgeon community on the ASC's Web portal.
"We went from a few hundred hits on the portal up to almost 5,000," Hughes said, so the organization wanted to know: "How do we take this to the next level to make it a true community?"
He said the goal of the new community will be to change rural surgeons' information seeking efforts and also connect with them via multiple platforms, including personal computers, laptops, and mobile devices, so surgeons can talk to each other and discuss the information that they learn about in isolation.
"It's one thing to read about it in a journal or be informed about a new event but you really want to interact with your colleagues, in terms of, 'Do you believe this? I'm not sure I believe that.' Or 'Have you tried this and did it work?'" he said.
In launching the community, ASC will also undertake an outreach effort to engage its rural surgeon members. But Hughes said hospital leaders can promote the community themselves throughout their own organizations, by doing things like putting information about the community in their hospital newsletters.
"We can compress the time-lag it takes between really good surgical discoveries and techniques into weeks or months instead of years. That's really the challenge we have as surgeons today, since things change so rapidly," he said.
He adds that the site is also a way to build the collective knowledgebase. For example, rural surgeons might do only hundreds of endoscopies individually, but do thousands collectively.
"To bring them all together to share their collective experience [has] got to improve performance," he said.
The CDC's Healthy Communities Program has released "Research to Practice: Building Our Understanding," a series of reports that focus on health communication practices.
Community and rural hospital executives are among the intended audiences for the reports that aim to help hospitals and health systems improve their organizations.
Stephanie Sargent Weaver, PhD, MPH, CHES, senior evaluator for the Healthy Communities program, designed the tools as quick, how-to guides for health leaders who might not have the time or resources to do a lot of research. Instead, she did the research for them, compiling information from expert interviews, marketing and communication research, and CDC-licensed consumer databases.
"I started with the premise that people are extremely busy," she said in an interview. "So if they don't have the time or they don't have the resources here it is: a one-stop-shop."
The first four reports, which are available now, address topics ranging the most effective ways to communicate with the Hispanic and Latino communities to helping users apply effective evaluation strategies.
"For example, there are two [reports] out right now that are focused on evaluation," Weaver said. "[They] could suggest ways that the hospital executive could look at a certain area within the hospital and use these use these strategies or steps to conduct a review and find out what's working and what's not, hopefully with the intention that they would use the results to help improve the system."
In addition, Weaver said there's another report that's due for release which deals with people living in different geographic regions, specifically rural communities. One of the topics covered includes how rural communities get information and the best ways to communicate with them. For example, rather than using social media channels or the media, which might work well in more urban locations, rural communities tend to respond better to information from trusted community leaders.
"In rural communities, what works is just good old word of mouth," Weaver said. "If you find an opinion leader in the community—somebody who may work at the hospital, who may be connected to the hospital in some way that others look up to—they'll get the message."
Weaver also said she tried to pepper the reports with tips and takeaways from the subject matter experts that she interviewed. For example, she included in the report "Cultural Insights – Communication with Hispanic/Latinos" is practical information about interacting with these patients.
"When you're first talking with them in the healthcare setting, they don't like to be touched," she said. "It's little things like that."
There are four reports available now and several others in the clearance and development phases, with the goal of releasing new reports over the next several months. Additional topics will include ones that cover communicating with Asian Americans and African Americans, as well as several about how to use the principles of persuasion and one about people living in different geographical areas.
Weaver said that in surveys that she's conducted, public health professionals specifically mentioned that resources like these would be very helpful to them, so she hopes that these reports will help hospital executives and others get information they need without having to also go to other resources.
The American Hospital Association is throwing its weight behind the Rural Hospital Protection Act, legislation that would ensure that critical access hospitals continue to be reimbursed for provider taxes they pay to states.
As it currently stands, CAHs are allowed to include provider taxes in their Medicare cost reports as long as they relate to "costs actually incurred" for the "reasonable and necessary cost of providing patient care." However, a "clarification" in the 2011 final Hospital Inpatient Prospective Payment System (IPPS) rule calls for Medicare contractors to determine on a case-by-case basis whether the provider taxes are allowable.
Although the Centers for Medicare & Medicaid Services says this is simply a clarification of a longstanding rule, the AHA counters that reimbursements for provider taxes should always be allowed.
"It's a regular old tax. It's our position that, as any other tax, you should be able to claim that on your cost report and be reimbursed for the Medicare portion," Joanna Kim, AHA senior associate director of policy, said in an interview with HealthLeaders Media.
Although CMS says the clarification would have "no financial impact" on CAHs, AHA said in AHA News Now that "the agency's policy is jeopardizing the financial sustainability of CAHs." Kim maintains that the clarification would have a significant financial impact on CAHs, potentially reducing their revenues by as much as 5%.
"When you're a really small hospital that has such limited cash flow you don't have a lot of ability to absorb those kinds of cuts," she says. "Even though CMS said they will review the specific circumstances, we don't feel that under any circumstances should they not be allowed to be claimed."
She says CMS's reasoning for the clarification is that since "providers pay this tax, and in return, they might receive Medicaid DSH (disproportionate share hospital) payments, for example," it's not a real cost to the hospital. But Kim says that from AHA's perspective there is no quid pro quo; CAHs don't pay five dollars in taxes and get five dollars in DSH payments.
"They're two separate payments," she says. "We think that they're a legitimate tax cost that should be able to be reimbursed."
So if all of these taxes are legitimate, reviewing them on a case-by-case basis shouldn't be a problem, then, right?
"In theory," that's correct, Kim says. "But the problem is that it was sort of vague."
And the promise of case-by-case reviews doesn't bode well in itself.
"They don't say that unless they have a reason to," Kim says. Although she is careful not to speak for CMS, she adds that AHA thinks the addition of the clarification "does indicate some intent. And we have heard from some hospitals that there are reviews [of cost reports] going on, that there is action being taken."
The Rural Hospital Protection Act (H.R. 1398), was introduced last week by Reps. Sam Graves (R-MO) and Ron Kind (D- WI), and Kim urges CAHs to advocate for its passage.
"I would suggest that they contact their Congressman and tell them about the importance of the Medicare program and reimbursing them for their costs, tell them of much of their costs these taxes represent, and urge their Congressman to support the bill," she says. "We're optimistic that the Congress will pay attention to this."
Although academic medical centers have seen an 18% increase in transfers from community hospitals into their facilities over the past three years, the mortality rate for transferred patients has actually declined. That's according to data submitted from 86 university hospitals to the University HealthSystem Consortium (UHC), which represents more than 90% of the nation's nonprofit academic medical centers.
UHC attributes this improvement to better communication and partnerships between community hospitals and academic medical centers. According UHC Chief Medical Officer and SVP Mark A. Keroack, MD, MPH, advance planning is critical because decisions about transfers shouldn't be made on-the-fly.
"A lot of our member organizations have developed relationships with these community hospitals," he said in an interview. "They tend to have conversations about certain case types at a time when things are kind of cooler; when there's not a desperately ill patient right in front of you."
Keroack said community hospitals should have a transfer protocol in place long before a sick or injured person comes through the door. Here are a few steps to improve the transfer process at your organization:
1.Identify the primary referral destination: Although this may sound obvious, it may not be when there are several AMCs to choose from. Whatever the case, don't leave the choice about referral destinations to an individual's arbitrary discretion. Also remember that there "might be different destinations for different kinds of patients," Keroack said.
2.Form relationships: When transferring patients, it helps to have established professional relationship with staff at the destination, rather than picking up the phone and talking with a stranger. According to Keroack the hospital CEO and the chief medical officer, medical director, or other lead physician executive should be spearheading these relationships with AMCs. "A community hospital really ought to insist on that level of cooperation," Keroack said. "If I were running a community hospital, I'd say, 'It's my job to make sure that those conversations are happening."
3.Establish care protocols: "Even if you do know what the destination is, that doesn't necessarily mean you've had a conversation about what's the best care," Keroack said. Work with destination hospitals to develop specific care and transfer protocols for common conditions, such as stroke, sepsis, and trauma. Decide "what kinds of patients should be cared for at the university, what kinds of patients should be cared for at the community, what are reasonable treatments for these sorts of patients," Keroack said. "At least for the common case types it should be possible to have a sort of road map for how you're going to do things and at what point you're going to say: 'This is a patient who needs to travel.'"
4.Know when not to transfer: Having conversations about when to transfer may actually lead to fewer of them. If a patient has no hope of survival, she shouldn't be transferred far away from her family and familiar doctors and surroundings, Keroack said. In other cases, community hospitals may discover they're perfectly capable of dealing with certain patients themselves. "Many community hospitals are more able than they think they are to handle some of these cases, as long as they feel confident that whatever they're doing would be exactly what the destination hospital would do," Keroack said.
5.Start treatments at home: When patients have to travel long distances to an AMC, they lose valuable treatment time, Keroack said. One solution is to start treatment en-route. He points to the University of Kansas Medical Center, which was losing a lot of transfer patients to sepsis. "They were coming in pretty bad shape after traveling several hours," he said. "The folks at Kansas began a campaign to sort of coordinate the care of those patients so that once you recognize the diagnosis you would begin the first few steps of treatment out there in the field."
"Those treatments were essentially having their effect as the patient was traveling," he adds.
6.Be ready for follow-up care: "Whenever the university hospital finishes whatever it's going to do, the follow-up care needs to be at the community hospital or with some physician that's affiliated with the community hospital," Keroack said. "There needs to be good communication there and also a willingness to take the patients back."