Rural doctors and patients alike need support, the president of the American Medical Association said, in discussing health care disparities and the risk of physician burnout.
“Rural health is neglected often. People only tend to think about the large, urban areas, but every physician in every community needs to know they’re supported by their state, county and national medical association,” Dr. Barbara McAneny said Wednesday.
McAneny earlier Wednesday presented to staff and administration at Montrose Memorial Hospital, as well as board members of Montrose Memorial Hospital Inc., which manages the hospital as a not-for-profit corporation.
“One of the concerns we have, particularly in rural areas is that the infrastructure of health care is very fragile,” McAneny said.
“Part of the fragility is that with doctors burning out and wanting to leave the practice early, it’s going to affect rural communities as the front line. So we want every physician to know they are supported and we’re working for them, and we hear their issues, plus I need to hear the issues from the community to be able to take them back to AMA as we’re shaping policy.”
Physician and medical staff recruitment is challenging for rural areas and small hospitals, as is retaining critical medical personnel and services.
When a small hospital seeks staff, it is competing in a national market, which poses a challenge. Further, physicians today may be looking at earlier retirement than they did in the past, which also can serve to burden rural areas where provider pools are already shallow.
“Much of the politics of medicine centers around urban settings and rural stuff gets kind of the short shrift,” Dr. Tamara Stoner, an MMH anesthesiologist, said.
Those who come to Montrose are often attracted by lifestyle opportunities, as pay is higher in urban areas; or, like her, they may be from the Western Slope to begin with.
“I love working at an independent hospital and I like to care for people in the community,” Stoner said.
“Burnout is a huge issue across medical professions, not just physicians. The biggest thing is the administrative load. We do this because we want to take care of people, not because we want to be tied to a computer or fight with an insurance company … or have someone with no medical background at all telling us how to practice,” she added.
“We’re very concerned about physician burnout,” McAneny said.
“In rural areas, one of the issues for physicians is they feel isolated and they don’t have a support system. … They’re doing hard work in rural areas and they need to know we’ve got their back.”
Stoner said she was glad to see the AMA take a direct interest in Montrose.
“I think it’s only more recently where the AMA has shifted to a position where they really focus on patient benefit, and that’s a big improvement for me. In the past, their political positions have been not always with the patient’s best interest. In the last few years, that’s changed pretty dramatically,” she said.
AMA’s policy goals are to promote medicine and the betterment of public health; past policy pushes have included tobacco-cessation and wider seat belt use. More recently, the AMA has been concerned with opioid overdoses, suicides and gun-related deaths.
“So we have our fingers in education; we’re looking significantly at health disparities as the major push,” said McAneny. “We’re looking at population health in terms of trying to make sure the country is healthier. We’re the doctors of America. We want healthy patients.”
The AMA works with legislatures in all 50 states, as well as with multiple medical societies to achieve broad outreach for patients.
“We’re aware that in rural communities, the current system of ensuring quality does not take into account the social determinants of health,” McAneny said.
Such determinants include income levels, access to healthful foods, education and clean environments.
Doctors are judged by metrics indicating how well their patients are doing. But if those patients have to choose between medical care and putting food on the table, or paying the rent, they will likely prioritize their immediate economic needs.
“Physicians can only do so much, in terms of trying manage these chronic diseases that affect so many Americans if we’re not even able to measure what’s going on with the social determinants,” McAneny said.
Standard metrics for health care aren’t always the most accurate measure, either, she explained.
For example, if the standard for trauma care is to have someone in the operating room within an hour, and in a rural area, that takes three hours, the hospital will not hit the metric.
“That does not mean this doctors in this area are not doing their jobs. It means we have a flawed measurement system,” McAneny said.
The simple fact is that it costs more to deliver the same level of health care to rural areas than it does to provide health care in urban centers, she said.
“It costs more for me to hire a nurse, a doctor, a pharmacists, anybody I need to have in my clinic.”
Then there is the matter of reimbursements under Medicaid and Medicare, which pay doctors less than the costs of doing businesses in places like Montrose, she later said.
More than 70 percent of Montrose Memorial Hospital’s revenue comes from such federal benefits programs as Medicaid or Medicare, which hospital officials previously said, pay about 30 cents on the dollar.
“They (the programs) adjust … the payment rate based on what they think the local expenses are, and they use things like apartment rent. Well, this isn’t an apartment,” McAneny said Wednesday, indicating the hospital building in which she sat. “It simply costs more in a rural community to have the personnel.”
She said the AMA does not look with favor on the push for work requirements for Medicaid recipients. The program was created in part for children and pregnant women, and Medicaid is also now the biggest funder of long-term care, such as nursing homes.
Expectant mothers will have difficulty getting a job; children are not employable, and obviously, people in long-term care are unable to work, McAneny said.
“We have estimated the number of people who could potentially get a job who are on Medicaid is less than 10 percent,” she said.
Further, people can fall into a vicious cycle when their health is so poor that they lose their jobs and then, their insurance.
“If we take away their health care, how do they ever climb out of that circle? We need to be able to take care of people at the most appropriate time, in the most appropriate setting, and their health care is secure, be able to help them get back to work, but it’s a separate program,” McAneny said.
Further, sometimes if people make even minimum wage, they make too much for Medicaid, yet nowhere near enough to afford health care.
“So you put this family in this terrible double bind-up: ‘If I work, then I lose my health care, and if I don’t work and lose my job, I can have health care, but I can’t have both.’ We think you ought to be able to have both,” McAneny said.
When it comes to health care disparities, there are some factors that can be controlled more, she said.
Health care spending and spending on addressing social disparities of health, when added together, are in line with other countries.
“We spend less on social supports and more on health care and they do the reverse and get better outcomes. The AMA believes that we will not be able to curb health care expenses by carving people out of the system. … We think that’s wrong,” McAneny said.
“We think trying to cut individual prices is going to be a difficult thing, but we do think we can use our resources a lot more wisely.”
For instance, high administrative overhead costs can be addressed, and more money could be spent on disease management to tackle health woes at the front end.
“If we’re not spending money to manage chronic disease, but we’re happy to put people in the hospital … we’re treating it too little, too late. When we have uninsured people in the emergency department with end-stage disease, or severe disabilities, then we’ve taken somebody who could have a productive, happy life, and turn them into a customer of the health care system for the rest of their time,” said McAneny.
“We need to focus more on keeping people healthy and that’s how we’re going to save money and have a healthier population.”
Doctors treat real people, who may not take perfect care of themselves, or who have had the bad luck to experience trauma, but the medical care system and doctors do not exist to judge or punish people who need care, McAneny said.
“We’re there to try to help people be as healthy as we can possibly help them be,” she said.
Katharhynn Heidelberg is an award-winning journalist and the senior writer for the Montrose Daily Press. Follow her on Twitter @kathMDP.