6 September 2024
Dear Interested Readers,
The Healthcare Challenges In Small-town and Rural America Are Coming To The City
If you live in rural America, a small town, or in a less desirable neighborhood in America, your access to primary care, your choices in the specialists available to you, and often unfortunately your outcome, is quite different than would be your experience if you lived in an affluent neighborhood of a large metropolitan area where multiple competing medical systems are vying for your commercial insurance dollars. I practiced in Boston for almost a half-century. My family and I have received medical care from Harvard Medical School-affiliated practices and institutions for almost sixty years, so I understand the delivery of care in one of our highest quality and most forward-thinking medical communities, but even in Boston, the access to care seems to me to be declining as costs go up and institutions with long histories face growing challenges and some are purchased by for-profit entities.
For over a decade, I was on the board of the Guthrie Clinic which is a progressive and successful healthcare system that serves the middle of the Northern Tier of counties in Pennsylvania and the Southern Tier of counties in New York from Binghamton in the east to past Corning going west and as far north as Ihtica. This region is a beautiful swatch of farmland, mountains, lakes, and small towns and cities that have been made more prosperous by fracking. The “Twin Tiers” are rural, but not in the same sense as some parts of Mississippi, Alabama, or Appalachia.
I also have experience with the delivery of care to the underserved in urban populations. For many years I have been a member of the “President’s Advisory Council” of the Whittier Street Health Center, an FQHC in Roxbury, Massachusetts which serves over 30,000 patients in some of Boston’s poorest and most diverse neighborhoods. I am also currently on the board of the Family Health Project, an experiment in universal basic income. The project gives monthly payments of $400 for the first three years of a baby’s life to new mothers in financial distress. Between 2014 and 2022, I served on the board of the Boston University Medical Group which employs more than 1,000 doctors and mid-level clinicians who provide care in the Boston Medical Center and its affiliated medical clinics across many of the lower-income neighborhoods of Boston. BMC is a DSH hospital.
The practice with which I was affiliated for thirty-eight years evolved from the Harvard Community Health Plan through Harvard Pilgrim Health Care to Harvard Vanguard Medical Associates, into Atrius Health. When I retired we served more than 750,000 patients in dozens of health centers across Eastern Massachusetts from the New Hampshire border to well south of Boston toward Cape Cod. Our practice cared for patients who were from all segments of the population. Although originally, most of our patients came to us through contracts with their employers over the years we expanded our reach to include Medicaid and Medicare patients.
What I have learned from my experiences is that it is very difficult to provide care on the income collected from Medicaid and Medicare alone. In our system, like most healthcare systems, resources were blended from the higher reimbursement provided by commercial payers and the less generous forms of public funding. Our goal was to have our population reflect the demographics of our community, but the reality was that our population was always skewed toward the middle class. Many of our patients were professionals, executives, managers, academics, or public servants who chose to get their care from us because they knew that we had a progressive mission that was dedicated to quality, safety, and the elimination of waste. Before he started the IHI with other progressive medical professionals, Don Berwick was a pediatrician in our practice and was our Vice President for Quality and Safety. We were focused on being a practice consistent with the “Triple Aim” and Crossing the Quality Chasm for over twenty-five years before either was published.
I now live in New London, New Hampshire in the “Dartmouth-Lake Sunapee Region of New Hampshire” where our local “critical access” hospital is affiliated with Dartmouth Health and provides most of the care for about 30,000 people who live in the small towns of the beautiful “Kearsarge Region” of the larger Dartmouth-Lake Sunapee region. Just to add to the confusion, we are in the lower New Hampshire side of the “Upper Valley” of the Connecticut River. Some people in our region travel 100 miles to Boston for care, and others go to Concord which is about 35 miles from my home, but when more advanced care is required most of us follow our hospital’s lead and travel the 30 miles north on Interstate 89 to the huge Dartmouth Hitchcock Medical Center complex that sits in Lebanon on the edge of Hanover and just before you cross the Connecticut River into Vermont. It has been more than a decade since our hospital closed its obstetrical service which means that access for deliveries requires that mothers travel long distances. Inadequate fee-for-service payments have led to the closure of OB units in small hospitals in small towns across the country.
I reviewed my history and affiliations with you because I want to make the case for my knowledge, concerns, and experience with the state of healthcare in rural, small-town, and inner-city communities. These problems and my interest in them are not new. Dr. Robert Ebert, then Dean of Harvard Medical School, delivered an address in 1967 in which he outlined the challenges that face rural and inner-city patients. In his lecture, 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. Most of you are familiar with the problem of the rural community. Here the general practitioner is the mainstay of the medical care system, but as he grows older he is not being replaced. 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…
...The central city presents a different problem and one of greater magnitude. Few of the general practitioners who practiced in the city have been replaced, and the modern specialist serves the suburbs more than the city. The city or county hospital or large urban voluntary hospital provides most of the care for the urban poor…
That speech was delivered one month after I started medical school in the fall of 1967. It is sad to realize that over the intervening 57 years the problems that concerned Dr. Ebert have persisted and are at least as troubling today as they were back then.
I am also concerned that the issues that are problematic in those challenged environments are beginning to be a problem across all of healthcare. I believe that our system of care is vulnerable everywhere and eventually what seems to be a rural, small-town, or inner-city problem will be a concern across our entire system of care. So what are the current concerns in the delivery of care in rural and small-town America?
As you might have noticed, I have become a fan of ChatGPT. My position is that AI can effectively organize information if you ask it the right questions. It is also important to have enough prior knowledge to recognize when the answer you get is incomplete or inaccurate. So, once again, I ask your indulgence. I asked the Chatbot:
Discuss the current healthcare challenges in small towns and rural America.
ChatGPT answered:
Healthcare in small towns and rural areas of the United States faces unique challenges that impact the accessibility, quality, and affordability of care for residents. These challenges are multifaceted and stem from a combination of demographic, economic, and systemic factors. Here are some of the key issues:
1. Healthcare Workforce Shortages
- Limited Availability of Providers: Rural areas often struggle with a shortage of healthcare providers, including primary care physicians, specialists, nurses, and mental health professionals. This shortage can lead to longer wait times for appointments, increased travel distances to receive care, and a reliance on fewer healthcare facilities. The Health Resources and Services Administration (HRSA) has designated many rural areas as Health Professional Shortage Areas (HPSAs) due to these deficits.
- Aging Workforce: In many rural areas, the existing healthcare workforce is aging, with many providers nearing retirement age. The lack of younger professionals to replace them exacerbates the shortage.
2. Access to Healthcare Facilities
- Hospital Closures: Over the past decade, more than 130 rural hospitals have closed, primarily due to financial challenges. The closure of these hospitals can force residents to travel long distances for emergency and specialized care, which can be life-threatening in critical situations.
- Limited Specialty Care: Rural residents often have limited access to specialized services such as cardiology, oncology, and obstetrics. This lack of local specialists can result in delayed diagnoses and treatment, as well as increased healthcare costs due to the need for travel.
3. Economic Barriers
- Lower Income and Higher Uninsured Rates: Rural populations tend to have lower incomes compared to urban areas, and higher rates of uninsured or underinsured individuals. This financial strain can make it difficult for residents to afford healthcare services, prescription medications, and preventive care.
- High Costs of Healthcare Delivery: Operating healthcare facilities in rural areas can be more expensive due to lower patient volumes and higher costs associated with staffing and maintaining facilities. These financial challenges contribute to the risk of closure for rural hospitals and clinics.
4. Health Disparities and Outcomes
- Higher Prevalence of Chronic Conditions: Rural populations have higher rates of chronic conditions such as diabetes, heart disease, and obesity. The combination of these health issues with limited access to care can lead to poorer health outcomes.
- Mental Health and Substance Use Disorders: Mental health services are often scarce in rural areas, and there is a higher prevalence of substance use disorders, particularly opioid addiction. The lack of mental health providers and treatment facilities exacerbates these issues.
5. Technological Barriers
- Limited Broadband Access: Telehealth has been promoted as a solution to improve access to care in rural areas, but limited broadband infrastructure remains a significant barrier. Many rural communities lack reliable high-speed internet, which is necessary for effective telemedicine services.
- Digital Literacy: Even when broadband is available, there may be gaps in digital literacy, particularly among older adults, which can limit the effectiveness of telehealth and other digital health interventions.
6. Transportation Issues
- Long Distances to Care: The geographic spread of rural areas means that residents often have to travel long distances to access healthcare services. This is particularly challenging for elderly individuals, those with disabilities, and low-income residents who may lack reliable transportation.
7. Public Health Infrastructure
- Underfunded Public Health Services: Public health departments in rural areas often face funding shortages, limiting their ability to provide essential services such as immunizations, disease prevention programs, and health education. This can contribute to higher rates of preventable diseases and poor health outcomes.
Addressing These Challenges
Efforts to address healthcare challenges in rural areas include expanding telehealth services, increasing funding for rural health facilities, incentivizing healthcare providers to practice in rural areas through loan forgiveness programs, and enhancing public health initiatives tailored to rural communities. However, these efforts require sustained policy attention and investment to effectively reduce disparities and improve health outcomes in rural America. (The bolding is my addition.)
You may not have been personally impacted yet by the deficiencies in our healthcare system, but it is my concern that several of those issues that are currently a concern in rural and small-town systems are already problems that impact care everywhere. The headings in the ChatGPT analysis are:
- Workforce issues–retirements, rural locations
- Access to care–hospital closures, lack of specialty care
- Economic issues–lower incomes, higher numbers without insurance, high cost of healthcare operations,
- Health disparities and outcomes–higher rates of chronic disease, mental heath and substance abuse issues
- Technological issues–lack of internet connections, digital literacy
- Transportation issues
- Deficient public health infrastructure
Workforce issues, timely access to care, economic issues, healthcare disparities, and a deficient public health infrastructure plague all of our systems. I don’t think that any community has the mental health resources that are needed to contend with the despair, isolation, drug addiction, and traumas that are a part of life everywhere we look. The shortages in trained personnel and effective programs of care may not be as problematic in large urban academic centers as they are in the Mississippi Delta, Appalachia, or small-town Nebraska, but they are a growing concern everywhere.
The movement toward concierge care may seem logical to you from your personal point of view, but it is driven by the fear and universal concerns about access and systems with deficient patient-centredness. I have long been disturbed by the movement which in my opinion increases the inequities in healthcare. If you need to pay several thousand dollars a year to have access to care that seems appropriate to you, it seems that you have already decided that the system of care available to you through your commercial insurance plan is deficient. If you have chosen to protect the access to care of you and your family with a concierge practice, I hope that you are also actively engaged in the efforts to improve the access and care of less fortunate neighbors.
The Republican Party’s healthcare platform places great confidence in the ability of the “market” and competition to improve the cost and quality of care. We all know that the definition of insanity is doing the same thing over and over again expecting different results. For decades, the market has failed to improve the cost and access to care for the majority of Americans. Those who do not feel compromised probably have not needed to use the system or have inexhaustible personal resources and advantageous connections. COVID-19 disproportionately killed people who lived with Social Determinants of Health that put them at risk, but our public health response was inadequate to protect many very privileged citizens. In time the defects in the system will spread to diminish the care experience of everyone.
There is much to make a thoughtful person concerned. A significant concern for me is the growing presence of venture capital in medicine. I have no problem with the market, if regulated, stimulating the development of new pharmaceuticals, improvements in healthcare, the advancement and spread of effective IT processes, or new medical devices, but I don’t think it benefits us to have hospitals and medical practices owned by large financial entities. The Steward Health bankruptcy will eventually cost the Commonwealth of Massachusetts hundreds of millions of dollars and is a great example of what concerns me. When the practice of medicine and the maintenance of the system become vulnerable to shareholder value and the greed of unscrupulous managers your care in an urban environment may be as problematic as if you live in a healthcare desert. At a minimum, we need to have healthcare policies that quickly improve care in rural, small-town, and inner-city communities. Perhaps what we learn will beneficially apply to the care of everyone in America.
It Was A Good Last Weekend
The header for today’s letter was taken at a friend’s home in Falmouth on Cape Cod. My wife and I have been celebrating the Labor Day weekend with our friends in Falmouth for several years. We lived just a few blocks apart in Wellesley for more than thirty years, attended the same church, and our children went to the same schools. The husband and I were running buddies. My sunfish sailboat was a hand-me-down from my old running buddy at a previous Labor Day weekend gathering.
Between 1989 and about 2007 our families attended a “Labor Day” Family Conference at Geneva Point on Moultonboro Neck on Lake Winnipesaukee. The connections run deep. Other attendees at the current Labor Day gathering are a combination of other couples from Wellesley and our hosts’ new friends in Falmouth.
I love our Labor Day tradition. I hope that it continues for many more years. I look forward each year to the gathering which is much larger than the circle of chairs in the yard suggests. I think there may have been close to forty attendees this year. We arrive the day before the party, and we usually stay with our friends at their spacious home from where I enjoy bicycling on the scenic “Shining Sea Bikeway” which runs for almost eleven miles from North Falmouth to Woods Hole. It is a great final weekend of the summer that engenders mixed feelings. It is great to be with old friends. It is sad to know that when the party is over so is the summer. Sure, there will be more sunshine and some warm days before the snow falls, but psychologically summer for this year is over. Summer is always over too soon!
My youngest son who is the new father of my most recent grandson seems to have the same feelings about the end of summer that I have. He has expressed his feelings on many subjects through his music each Monday of every week without fail for almost fourteen years. His post for this Labor Day Monday (# 720) was entitled “The Very Last Day of Summer.” As usual, the intro to his post demonstrates a positive outlook. To introduce his song, he wrote:
Technically speaking, according to whoever decides this sort of thing in an official capacity, summer will last until September 22nd. But the sun has set on Labor Day. With it, our culture has put summer 2024 to bed. I had a lovely summer that I believe will linger with me for some time. I’ve saved up enough sunshine to tide me over for a while, but I won’t need it. I’ve got my little family to keep me warm as I head into the colder months, and that’s more than enough for me.
There is simple poetry in his songs.
The Very Last Day of Summer
Love is still true
Without all this sunshine
My heart will still beat
Out in the cold
The very last day of summer
Is over
I’m feeling okay about the change
To come
The light through the trees
Is shining on you
And I can attest
You’re shining too
The very last day of summer
Is over
I’m feeling okay about the change
To come
Summer is over, but like my son, I am feeling OK about the inevitable change of season. I am hoping for a beautiful fall season. “Fall” seems to be off to a good start where I am, and I hope it is beautiful wherever you are this weekend
Be well,
Gene
