A Conversation on Rural Health Care
by Fred D. Baldwin
Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health in 1990 and served as its director for seven years. The center works with other agencies to train rural people in health professions and, under Myers' direction, became one of two recipients of a 1997 award for primary care education from the Pew Health Professions Commission. Myers accepted his present post as director of the Office of Rural Health Policy in the Department of Health and Human Services' Health Resources and Services Administration in 1998 after well over two decades of leading or consulting for rural health projects in this country and abroad, or, as he puts it, "trying to get health professions training moved out of academic medical centers and into the country."
ARC: What do you see as the main issues in Appalachian rural health today?
MYERS: Poverty, transportation, and getting the right people in the right places to do the work. There are a lot of poor people in Appalachia that are not getting appropriate medical services. They're not getting dental services, and they're not getting appropriate, timely mental health services.
ARC: Is there a specific underserved population in Appalachia?
MYERS: The people who are covered with some sort of health plan or program, be it private or Medicaid or Medicare, have a fighting chance. Those who are not on any kind of coverage usually find their way into charity care when things really get awful, but the care they get tends to be late, and things have deteriorated by that time. They tend to be mainly males and the people who are making a little bit too much to be on Medicaid.
ARC: Why aren't they getting served?
MYERS: The simplest answer is cost. We spend enough money to get everybody health care, but we don't always spend it where we get the most bang for the buck.
ARC: Why don't people have insurance coverage or Medicaid?
MYERS: It costs a lot of money, and the percentage of jobs in rural areas that provide health insurance is lower than in urban areas. Employers in rural areas tend to be smaller, and unemployment remains very high.
ARC: Is there a general health manpower shortage in the Region, especially in Central Appalachia?
MYERS: Yes, [but] not as severe as 20 years ago or 10 years ago when the National Health Service Corps was pretty diminished. Since then, the corps is back to strength, the J1 Visa Waiver Program is a very real factor, the training of nurse practitioners and, maybe to a lesser extent, physician's assistants is much stronger. There has also been a concerted effort on the part of some of the states and the medical schools to provide a rural rotation for medical students so that they get exposed to rural practice. I know West Virginia does require that.
ARC: Are J-1 doctors staying in the Region?
MYERS: Lyle Snider, with the [University of Kentucky] Center for Rural Health in Hazard, looked at that. In the counties that he looked at, about a quarter of doctors had come under J-1 waivers and stayed. It looks to me like the health care system in eastern Kentucky pretty much would have collapsed without the J-1 doctors. J-1 places something over 1,500 physicians a year—a physician stream that's three times as large as the National Health Service Corps.
ARC: Why are doctors hesitant to practice in rural areas?
MYERS: The professional aspects of that question may have been overplayed compared with [the issue of] where spouses and kids want to live. Money may not be the problem. There are some numbers that say rural physicians make as much money as metropolitan physicians, if you look at tax returns. Their pay per unit of care is lower, but they work more hours and they do more.
ARC: What else can be done to meet the needs of underserved areas?
MYERS: I'm a big believer in training local people to do the things that need to be done. People with less than doctoral-level training can do a whole lot of health care.
ARC: Could you give us some examples?
MYERS: You've got a community college system that's pretty well distributed across the country. You've got a nursing workforce that's better distributed than most of the health care workforce. There are very bright, very able, ambitious people who don't want to leave their communities. In these days of interactive video and pretty good roads, you can bring nurse-practitioner training to place-committed people and train them in Hazard. I think we graduated 36 or 38 master's degree nurse practitioners [in Hazard] and lost only one or two from the region.
ARC: What is the health care system like in rural areas?
MYERS: Fee-for-service continues to be the main system. It's still almost a cottage industry in terms of medical practitioners. The hospitals tend to be more private not-for-profit than municipally owned. Most rural counties don't have community health centers. Only two or three Appalachian counties have academic medical centers or a teaching hospital.
ARC: What's the status of managed care in the Region?
MYERS: It tapers off real quickly when you get away from the metropolitan areas.
ARC: What about health departments and clinics?
MYERS: Too often we speak of the health departments as the "safety net." They do immunizations, family planning, maternal and child health—that is, particular things for which there's funding, at least during schedulable hours. When somebody has a heart attack at one o'clock in the morning, that system is not relevant to that emergency. The real safety net in Appalachia is pretty much the practitioners and the hospitals that are taking care of the needy because that's what they're supposed to do.
ARC: Are statistical categories like Health Professional Shortage Area and Medically Underserved Area telling us what we need to know to make decisions?
MYERS: The extent to which those definitions work depends on the program. They may pick out the places that are in the worst need, but you cannot make the conceptual jump to say, if you're not one of those areas, then your supply is adequate. Managed care systems that have gone out of their way to attract healthy people use a ratio of one primary care doctor per 1,700 people. When you deal with the sicker, older, poorer population, you can't say that one primary care person for 3,000 folks is enough. It's not enough.
ARC: Is there a need for more health planning by community leaders?
MYERS: There is a need for community leaders to get involved in promoting the quality and accessibility of local health care. Harlan County, Kentucky, added millions to its local economy by upgrading local health and hospital services, keeping spending in the community that used to be spent elsewhere. The health professionals can't do this kind of system change. It takes guidance and drive from the community at large.
ARC: So what are some of the things they can do?
MYERS: They can work with the local hospital and the local practitioners to make their services more attractive or inspire greater confidence. If their hospital is not doing well, they can encourage that hospital board and administrator to undertake community market surveys, define what needs to be done, and then get on with doing it.
ARC: Can telemedicine solve the access problem?
MYERS: No. It can make specialty services more accessible, but so far it hasn't helped with access to basic/primary care.
ARC: What does telemedicine hold for the future, and are there any impediments to it?
MYERS: Look for innovation in monitoring patients at home, supporting nurse practitioners and physician's assistants in remote clinics, and some particular niches such as pre-anesthesia consultation and examination. As far as impediments, one is [the issue of] payment for services delivered electronically; another is that the primary care workforce is already overloaded. Current rules require primary care practitioners to "present" their cases over video linkage to the specialist. When you're having to see 40-plus patients per day, there just isn't time for this add-on.
ARC: What do you find encouraging about the state of rural health care?
MYERS: I do think that specialty care is becoming more available in rural areas, because managed care is cutting down the amount of specialty work in the metro areas. In some cases it's specialists moving to rural areas, in some cases itinerant clinics, and in some cases telehealth.
More generally, rural health and health care are improving, particularly in Appalachia, and ARC has contributed a lot to these changes. Health professionals are more available. Some mountain hospitals are very impressive. These days you may get stuck on a mountain road behind a mobile magnetic resonance imaging van as well as a coal truck. Roads are better. Water and sewage systems are more widely available. Underlying all this is the fundamental issue of jobs and economic development. There remains so much to be done, but rural people are stepping up to the challenge and taking responsibility for their own communities.
This interview was conducted by Jack Russell, director of ARC's Customer Relations and External Affairs Division, and by freelance writer Fred D. Baldwin.