How Much Help Can We Stand?

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

It looks to me as though rural community health care is being torn to bits by several unrelated program developments and trends. These program developments can be beneficial to some individuals, but the larger impacts are dangerous to many vulnerable people. Maybe these effects differ by region. Is what I’m seeing different from what’s happening in your part of the country?

First, long-term financial pressure, and the need for technical support, is forcing most rural hospitals into various sorts of management network relationships with larger urban hospitals. This has been going on for decades. The truly independent rural hospital is almost as rare as the solo primary care physician. The accelerating emphasis on information technology will complete the process of extinction.

Most of these hospital network arrangements seem to work to the benefit of the community, but the details are truly critical. The local hospital may wind up strengthened or eviscerated. Is the local hospital’s accreditation being maintained? Who is staffing the emergency room? Are appropriate emergency referral agreements in place, such that, for example, the cardiac cath team is ready at the receiving hospital when the patient arrives? The traditional and dangerous, “Send the evolving heart attack patient down and we’ll take a look” arrangement is intolerable (e.g., where the rural patient will arrive in an unprepared, referral hospital and complete his/her heart attack, dying or becoming a cardiac cripple because the cardiologist in the urban center didn’t want to start preparations until s/he saw the patient personally). Is the physical plant being properly maintained? In the financial accounting, the rural community should insist that it receive recognition for the profitable business it sends the referral hospital. Overall such a network arrangement can contribute to a strong community health system though the referral hospital is outside the local community.

Community Health Centers have seen enormous expansion over the past decade. In this sector anecdotal reports are mixed. Certainly care is available to people with limited or no ability to pay in very many places where such care was not accessible before. But I have seen existing community health centers stretch their governing boards many, many miles to open new points of service in remote and unrelated communities. In such cases a single new member was added to the distant governing board from the newly served community to comply with federal governance regulations and keep the new grant funds in the hands of current grantees. Such arrangements certainly meet the letter of the regulation but not their intent in requiring that a governing board be made up of a majority of clinic users. The clinic governing board, based in some distant city and drawn by expansion grant funds, is unlikely to pay much attention to the community health system of its new service town.

A historical digression: There is a long-standing pattern of tension between community health centers, rural hospitals and physicians, which has outlived all rationality. I’m afraid I understand it. I’d like to pass along my version of its origin in hopes of helping wind it down.

Circa 1970, at the birth of the health center movement, feelings were running high in some rural areas. Opposition to the Vietnam War was seen as unpatriotic. Medicaid, authorized in 1965, had begun to flow to some physician patriarchs. When some generally urban, idealistic, long-haired young people came to town in the early 1970’s, the idea of “a hippie clinic” met rigid, even violent, resistance from the older medical community. I’m aware of clinics in the final stages of construction that burned in Arkansas, Ohio and Kentucky. I’m sure there were others. Today the docs who were assumed to have been involved have been dead and buried for decades, but the idealistic young clinic folk are now elders in the health center movement. Some clinic activists still see the medical community as the enemy. I hope we can put this miserable chapter behind us and not wait for the final round of funerals for more progress.

Another new player in rural health care is the U.S. Department of Veterans Affairs (VA). As has become well known in recent years, the VA is disproportionately urban while the population of veterans is disproportionately rural. I, and probably many others, advised the VA to build its expanded rural presence upon the existing rural health care community so rural vets would have access to better care ‘round the clock seven days per week. Unfortunately the new services seem to be built on a strictly part-time itinerant, segregated model, where vets receive care from mobile or satellite clinics, when available. Protection of the agency seems to be the primary consideration. There’s no vision of a community health system here.

In short, some communities are seeing their health care become increasingly fragmented. Who worries about the overall health of the community? The CEO of the flagship hospital is in city A, the lead Health Center is in City B, the VA regional office is in City C. None of the local managers in My town has enough resources to cover the needs of the community 168 hours per week. But that’s nobody’s responsibility.

It may be necessary to draft the Rural Community Health Programs Act of 2013 to pull back against these centrifugal forces.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

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