23 November 2018
Dear Interested Readers,
A Birthday of Sorts
On November 22, 2013 I resumed writing my weekly letter after a three week hiatus. As November had begun I was in the process of transitioning into retirement. The interim management team did not need me to be writing every week to the 8000 or so employees of Atrius Health so I had been encouraged to make October 25, 2013 my farewell letter. I did not know then that the reason that my “editor” wanted me to write a “final letter” was that she was having my 297 letters written over more than five years bound in leather to present to me at our annual awards dinner in late November, and they needed a month to get the job done.
I thoroughly enjoyed the process of writing a weekly letter to our organization for over five years. It was an opportunity for me to put each week into perspective and think about the road ahead. I had written the first letter after my first full week as interim CEO in February 2008. I had conceptualized the letter as a source of common information for every person who worked at Atrius. I had been amused when one of my physician colleagues complained that my language in the letter was too casual and did not sound like it was appropriate for doctors. She was surprised when I told her that I was actually writing to both her and her medical assistant, as well as to the housekeeping team at her site.
If you clicked on the first link you know that for the last five years I have been writing “Volume II.” Volume I had been addressed to “Dear Atrius Health colleagues and other interested readers.” The letters in Volume II would be sent to “Dear Interested Readers.” I owe the last five years to my good friend, Lean mentor, and guru, John Gallagher. After about two weeks of no letter to read on Friday, John called me and asked, “What happened to the letter?” He pointed out that I had over three hundred readers who were not employees of Atrius Health, and that they should not be forgotten. After John made his request, I published the letter for over a year by just mailing it out from Google Drive to the mailing list of “interested readers” who were outside of Atrius but had learned about the letter and had requested being on the distribution list. In early 2015 I was connected to Russ Morgan who quickly became a new mentor and upped the quality of the publication, all of his many efforts have been pro bono, and it is to him that I owe a great debt of gratitude that I will never be able to settle.
I do not have any idea about how long the letters will continue. You might have noticed some changes this year with the establishment of a completely new offering every Tuesday. I sometimes wonder when the well will run dry, but I continue to enjoy the discipline that writing offers to me. At Thanksgiving time it is easy for me to say that I am grateful for the opportunity to write to you. I read more, listen better, and have the opportunity to try to express my concerns all because of you. It is my hope that my expressions of both hope and concern add something to your efforts to improve the health of everyone. There is so much that needs to be done, and so much that should be said, that I know for certain that on the day that I close my laptop for the last time the conversation will have just begun and will continue, as do all things that are important.
The Challenges to Healthcare In Rural and Small Town America
If you have had a chance to read the SHC post for November 20 you may have followed the link that I gave to The Kate McMahon Lecture that the Dean of Harvard Medical School, Dr. Robert Ebert delivered at Simmons College back in 1967. Deep into the lecture after discussing the need for redefining the role of the hospital and the importance of producing a new generation of socially responsible physicians, Dr Ebert then discussed “The distribution of medical care.” He said:
…There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions…Community after community attempts to recruit new family physicians only to find that young physicians do not wish to practice alone in a small town…Once again, curiously little imagination has been exercised in seeking solutions to this problem. In an age of modern transportation, when the evacuation of wounded from the jungle by helicopter is routine, it should not be too difficult to plan the care for rural communities. It would take a different kind of organization of physicians, however, and would require a kind of teamwork with other members of the health professions which physicians have been reluctant to provide except within the walls of the hospital. It also would demand a new role for the regional community hospital…
Dr. Ebert’s idea about airlifting rural patients to more sophisticated and better staffed medical centers to which they are connected in a network was derivative of what was already happening in Vietnam. I frequently think of Dr. Ebert’s suggestion when I am reading a book on my deck or fishing from my kayak and my activity is interrupted by the characteristic whirr of helicopter blades just a few hundred feet above me. I like where I live for many reasons, but one of the best reasons I like it is that I am close to nature and less than two miles from a critical access hospital that is linked by helicopter with the Dartmouth Medical Center that is thirty miles away. It would be nice if I did not live directly under their flight path. As I watch the helicopter head north, I say a little prayer for the poor soul on board who may be having a stroke or cardiac event or perhaps has been involved in some major accident on nearby I 89. After my little prayer, I wonder how long it will be before I get to take my first ever helicopter ride. It becomes more likely everyday since I am 73.
One of the first things that I noticed about medical care in my community was that if I asked the people I met who provided their primary care many of them would name a nurse practitioner. There are a few pediatricians and internists in the office building next to the hospital, and a few more PCPs in nearby Newport where the hospital maintains a clinic. There are some medical and surgical specialty services available at the hospital, but it seems that much of the specialty care requires a trip to Lebanon/Hanover and the Dartmouth Campus, or down to Concord if not to Boston more than one hundred miles away.
Women’s’ Health and obstetrics deserves special attention because one of the concerns about the high number of closures of rural and small town hospitals across the country is the requirement that many rural women must travel long distances to deliver their babies. In my town the delivery room is “seamlessly” located thirty miles north and the hospital is still open!
Pre and postnatal services (available only in the New London office above) are offered through an affiliation with Dartmouth-Hitchcock Medical Center. Certified nurse midwives from DHMC offer pre and postnatal care in New London with a seamless transition to labor and delivery at DHMC.
My community is lucky. It is located in a very desirable recreational area. The schools are good and cultural amenities are easily accessed. In many ways we are just a distant suburb of Boston. Many small town and rural environments are not such desirable places to live and have difficulty recruiting doctors and nurses. They may be located in “flyover America” or somewhere where the land is flat, the weather is hot and humid for seventy five percent of the year, high school graduation rates are low, manufacturing jobs have departed, and city amenities are several hundreds miles away. Ironically, many of these communities are located in “red states.”
About a month ago Alan Frakt who is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health published an article in The New York Times, “A Sense of Alarm as Rural Hospitals Keep Closing,” that describes many of the healthcare issues for rural America. The article is loaded with links to excellent studies that reveal some alarming facts. An excellent resource that he sites is a white paper: Rural Relevance – Vulnerability to Value 2016: A Hospital Strength INDEX® Study. The authors point out that many rural hospitals are functioning in an environment rife with healthcare disparities. They are able to accurately identify whether a given hospital is at risk by using an index created by measuring environmental variables:
The twelve metrics that compose the Health Disparities Index are as follows:
- Adult Obesity Rate: Percent of adults with a BMI greater than or equal to 30
- Child Poverty Rate: Percentage of children under age 18 living in poverty
- Unemployment: Number of people age 16+ unemployed and looking for work
- Uninsured: Percentage of residents under age 65 without health insurance
- Costs: Composite Medicare spend per beneficiary in each hospital’s market (inpatient, outpatient, and physician)
- Smoking: Percentage of adults who report currently smoking
- Housing Problems: Percentage of households reporting at least 1 severe housing problem (e.g. overcrowding, high costs, lack of plumbing)
- Mental Health Providers: Number of mental health providers per 100,000 residents
- High School Graduation Rate
- Diabetes Screening Rate: Percentage of diabetic Medicare enrollees receiving HbA1c screening
- Primary Care Physicians: Number of primary care physicians per 100,000 residents
- Dental Providers: Number of dentists per 100,000 residents
The health of the population is an index of how well the hospital and medical community are doing and it seems that the reverse is true. When a significant number of people in the the population are unhealthy, economically disadvantaged, and faced with enormous social problems, the local hospital is also often on the skids.
There is a huge literature about the potential harm for patients and communities associated with hospital closings. The title to a New York Times article last summer tells all: “It’s 4 A.M. The Baby’s Coming. But the Hospital Is 100 Miles Away.” It is a dramatic story.
Ms. Abernathy, 21, staggered out of bed and yelled for her mother, Lynn, who had been lying awake on the living-room couch. They grabbed a few bags, scooped up Ms. Abernathy’s 2-year-old son and were soon hurtling across this poor patch of southeast Missouri in their Pontiac Bonneville, racing for help. The old hospital used to be around the corner. Now, her new doctor and hospital were nearly 100 miles away…
She was having twins two months early. Her experience is not unique. The article reports:
Today, researchers estimate that fewer than half of the country’s rural counties still have a hospital that offers obstetric care, an absence that adds to the obstacles rural women face in getting health care. Specialists are increasingly clustered in bigger cities. Clinics that provide abortions, long-term birth control and other reproductive services have been forced to close in many smaller towns.
Frakt sites articles that worry that the increasing number of hospital closures in rural America and the elimination of obstetrical services in some that remain open are a looming problem for women and children. There is a growing concern that the closure rate of rural hospitals in states that have not accepted the Medicaid expansion of the ACA are proceeding at a faster rate than the rural hospitals in “blue” states.
Frakt reports that the loss of trauma coverage in rural environments is also increasing:
The closure of trauma centers has also accelerated since 2001, and disproportionately in rural areas, according to a study in Health Affairs. The resulting increased travel time for trauma cases heightens the risk of adverse outcomes, including death…Another study found that greater travel time to hospitals is associated with higher mortality rates for coronary artery bypass graft patients.
It is a reality that in many rural communities the hospital is the largest employer and when the hospital goes down so does the community. Some hospital closures are appropriate, especially if there is a better hospital within a reasonable distance. The problem is that hospitals are closing not because they are not needed or because there has been some sort of analysis that suggests a better alternative. Hospitals close for financial reasons and to some degree because of their inability to attract appropriate staff which then escalates the financial dysfunction. Frakt quotes a concerned researcher.
“The problem is that we don’t have a systematic approach to determine which services are critical to provide locally, and which are best kept at referral centers.”
We are back to an old problem. It’s not that we do not know what is good; it is that we are inept at practically applying what we know to the problem of providing quality care in rural America. There are three interlocking problems. First, there are huge financial pressures on hospitals that are paid for volume when they should be valued for the necessity, and the additional benefit of proximity to the critical services that would be optimal for them to provide their communities, even when there is a waiting helicopter. Second, many medical professionals, both doctors and nurses, do not want to live and raise their families in a declining rural community. Recruiting and retaining professionals is a challenge, especially when the medical community is stifled by a negative financial environment. Third, a professional environment that is understaffed produces an environment that is a challenge for professional satisfaction and may be an environment where quality is harder to produce.
Dr. Ebert’s idea that a hub and spoke medical system with high speed connections between the periphery and the hub was prescient. He could see the problem today before it was fully developed and was able to offer a suggestion that was a practical improvement if not the complete solution. Another more recent and potentially powerful idea is the ECHO project at the University of New Mexico. ECHO (Extension for Community Healthcare Outcomes) is an innovative process that promotes medical education and provides specialty support for clinicians in a rural environment using telecommunications. Another innovative approach that some communities are trying is to focus on community regeneration with the hope that by improving the business and cultural climate of the community they will attract a more diverse professional population and that the rising tide of economic success and regeneration will float all boats and will also improve the delivery of healthcare by creating an environment that will attract medical professionals. That sounds like a chicken and egg problem to me. Can the business environment improve in a healthcare desert, or must healthcare delivery be improved in an impoverished community before the economic environment can improve?
I can only ask questions and advance concerns based on observations. I think the idea that rural healthcare may be better in “blue” states than in “red” states needs further exploration. It is hard to envision an improvement in rural health, or in the rural economies, without a revival of state and federal initiatives working in concert to insure healthcare equity for the citizens of rural America. I also think researching how to solve the staffing problems of rural America should focus first on primary care and nursing in all of its evolving forms. Perhaps it is harsh to say that the healthcare environment and the healthcare problems of rural America have been neglected, but I do believe they need more attention.
I Was Not Dreaming of a “White Thanksgiving”
Yesterday my wife and I rose at dawn to pack up Thanksgiving dinner and begin the long drive to Brooklyn where our son and daughter-in-law were eagerly awaiting our arrival. Our daughter-in-law worked for many years in the Middle East for the UN helping refugees who were fleeing the horrors of war. More recently she has worked stateside in Manhattan for a group that assists refugees once they arrive here. Now that the stream of people getting into the country has been slowed to a drip, she has decided to go to law school and study to become an immigration lawyer. As a first year law student she is buried under an enormous amount of work so we were happy to bring Thanksgiving to them. Outside the sliders that open on to our deck the sky was clear and the sun was very bright, but the temp was zero and there was a light wind blowing snow around on the recently frozen lake. I wondered when “ice out” would be this year, before Opening Day or by Easter? As we pulled out of the garage my fingers were wrapped around a hot cup of coffee. I noticed that an additional two or three inches of snow had fallen overnight after our drive had been plowed.
It is the rare year that the old Thanksgiving song “Over the River and Through the Woods” is not a fantasy. This year it was a gross under call. We had more than enough “white and drifted snow” blocking our departure.
Over the river and through the woods,
To grandmother’s house we go;
The horse knows the way to carry the sleigh,
Through (the) white and drifted snow!
Over the river and through the woods,
Oh, how the wind does blow!
It stings the toes and bites the nose,
As over the ground we go.
Over the river and through the woods,
To have a first-rate play;
Oh, hear the bells ring, “Ting-a-ling-ling!”
Hurrah for Thanksgiving Day!
About ten miles from our home we drive through Newport, New Hampshire on our way to catching I 91 south toward New York. Newport is a very poor community these days. I know it well because I have volunteered there in an after school program for fourth, fifth and sixth graders. It’s major industry now is a gun manufacturer, Ruger Firearms. They make a popular assault rifle. For that I am not thankful. As we approached Newport from the east I pointed out to my wife the roadside historical marker for the home of Sarah Josepha Buell Hale. She had a long life, October 24, 1788 – April 30, 1879 during which she was an influential poet, writer and publisher. She is most famous as the woman who convinced Abraham Lincoln to make Thanksgiving a national holiday. She also takes credit for “Mary Had A Little Lamb” and was instrumental in the creation of the Bunker Hill Monument.
I hope that wherever you were for Thanksgiving it was a very pleasant day and that you got a little postprandial exercise to compensate for the extra calories. if you did travel for Thanksgiving and now face the return home, I hope that your travels will be safe and efficient.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
