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Internal medicine physician Edward Hoffer discusses his article, “Can rural health care be saved?” He outlines the significant health care disparities facing rural communities, including higher death rates from major diseases, increased opioid overdoses, ongoing hospital closures, and an aging physician workforce without adequate replacement. Edward questions the effectiveness of programs like the Critical Access Hospital designation, suggesting they may sometimes support lower-quality care, and shares a personal anecdote illustrating the dire consequences of specialist shortages in isolated settings. He proposes several potential solutions to improve rural health care: enhancing transportation, including establishing fairly-priced air ambulance services; expanding the use of telemedicine for specialty consultations and patient access; better utilizing EMTs and paramedics with remote support; considering strategic consolidation of rural hospitals for improved quality despite potentially longer travel; and focusing medical school recruitment on students from rural backgrounds. Edward underscores the complexity of the rural health care challenge and advises awareness of resource limitations.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Edward Hoffer; he’s an internal medicine physician and cardiologist. Today’s KevinMD article is, “Can rural health care be saved?” Edward, welcome back to the show.
Edward Hoffer: Thank you very much, Kevin. Glad to join you.
Kevin Pho: What led you to write this article, and tell the audience what it’s about for those who haven’t had a chance to read it?
Edward Hoffer: As you probably know, I am not a big fan of the U.S. health care system. In fact, I have written a book called Prescription for Bankruptcy discussing some of the reasons the U.S. spends roughly twice as much per capita on health care as most Western countries and yet has mediocre at best health outcomes.
One of the problems we have is the wide disparities in health care that someone receives. If you happen to be a well-to-do white person living in Rochester, Minnesota, or New York City, you’ll probably get world-class care. But if you don’t fit that description, your care is probably, in many cases, not a lot better than what you’d get in some of the poorer Eastern European countries.
I gave a talk at a local hospital a couple of weeks ago on disparities in health care. I don’t think anyone was surprised to learn that if you happen to be black in America, your health care is compromised. What seemed to be a little bit of a surprise to many in the audience was you could say the same thing if you happen to live in rural America; rural Americans have poorer outcomes by any number of measures we have.
Take cardiovascular disease, where the mortality from cardiovascular disease between 2010 and the present has improved a little bit, whereas in rural America, it’s actually gotten a little bit worse. Hospitals are closing all over rural America. And with hospitals closing, you’re having trouble getting surgery.
It’s inconvenient if you need surgery. If you’re an expectant mother, it’s a huge problem. Fifteen years ago, about 30 percent of urban hospitals and about 45 percent of rural hospitals did not offer obstetric care. These days it’s gone up a little bit in urban hospitals, and now about 35 percent of urban hospitals, but over half of rural hospitals are not prepared to do deliveries.
Of course, if you’re in a city and your favorite hospital has closed its maternity ward, it may be annoying, but there are going to be two or three others that are willing to offer obstetric care. If you happen to live in the middle of Iowa and your local hospital has shut its maternity ward, you may be looking at a 200-mile drive when the time comes.
So, cervical cancer mortality, probably because rural women don’t have the access to preventive care that their urban counterparts do, is about 40 percent higher for rural women than it is for urban women. You can come up with numbers like that all across the board. It just says that living in rural America means you are a second-class citizen when it comes to medical care.
In the paper I wrote, I included a little personal anecdote. I was moonlighting one summer years ago at a small, isolated hospital. I had a patient come in who clearly had acute appendicitis. The disposition was easy: Call the one surgeon that we had on staff, only to be told, “Sorry, Dr. X has been partying and has had a few too many. He is in no shape to operate.”
Again, if you’re in a major hospital, no problem, but when Dr. X is the only surgeon on staff, there is a problem. As a cardiology fellow, I ended up having to do an appendectomy. Thankfully, I was guided by some very good OR nurses who told me where to cut and where to stitch. But this is the kind of thing that, again, would be implausible or impossible in an urban setting but all too real in a small, isolated rural hospital. We need to fix that.
Kevin Pho: Tell us the root causes why so many rural hospitals are shutting down, and why is it that a lot of rural patients just can’t get even the appropriate primary care? What are some of the root causes behind that?
Edward Hoffer: One reason is the lack of physicians willing to practice in those areas. The federal government started a program to put physicians into underserved areas, but these are time-limited. You get your medical school tuition paid, and in return, you have to give a number of years in an underserved area. But as soon as that number of years is up, most of the doctors are saying, “Thank God, let’s get back to the city,” and leaving the practice empty again.
A lot of rural hospitals are more dependent than their urban counterparts on Medicaid or people who simply have no health insurance, and they’re going broke. They can’t keep the doors open when they have so few people with commercial insurance that buoys the bottom line of the urban hospital. I think that is probably those are the two major causes.
Kevin Pho: When you talk about rural health care prior in this podcast, a lot of people suggest that telemedicine would be kind of a panacea to help with that access. What are your thoughts on that?
Edward Hoffer: I think telemedicine offers something. Clearly, during the COVID pandemic, as we saw a great increase in the use of telemedicine, we saw that a lot of things that you do face-to-face can be done over telemedicine but not everything by a long shot. One interesting study I saw recently showed that if you mailed out stool fit cards to people who didn’t have easy access to come in for primary care, you could increase the screening rate and the colon cancer detection rate.
But that’s a small part. Obviously, a lot of mental health things can be done by telemedicine and are badly needed, but it’s where you can’t do lab tests via telemedicine. You can’t really put hands on the belly or listen to the chest. I would say telemedicine and expansion of telemedicine is a good step in the right direction but hardly a panacea.
Kevin Pho: In your article, you talk about the critical access hospital designation. Tell us more about that and why you feel that may be inadequate.
Edward Hoffer: Part of it is that the government has increased payment rates to hospitals that are below a certain size and serve a very isolated population. One of the problems with that is when you get down to very small hospitals, the care is not the same quality as it is in a more substantial hospital. When you have a 35-bed hospital with a medical staff of two or three, by definition, you’re not going to be able to deal with anything but the most straightforward, simple conditions.
I think it’s a stop-gap, again, like telemedicine, but it is not going to solve the real problem. Part of what we need to do is get a lot better joint working relationships between the smaller isolated hospitals and a bigger urban counterpart. We need to get circuit-riding specialists who are willing to come out and have patients ready to be seen, make it an efficient use of their time, and take the ones where there’s not an urgent need to be seen and get them all seen efficiently by somebody who knows what he’s doing in a given specialty.
Allow more teleconsults for the isolated family doctor who is trying to deal with an onslaught of complicated patients. Let them get easy, one-call access to a specialist at an affiliated urban hospital. I think that will help a lot.
As far as diagnostic help, I think we’re going to be seeing more and more done by artificial intelligence. I can easily see within the next one to two years that it will provide a lot of needed consultative help to the rural physician and, in many cases, directly to the patient. I think that is definitely on the horizon. At the moment, it’s not quite ready for prime time. We haven’t solved the hallucination problem. We haven’t solved the problem of needing to put your inquiry into just the right format to get a good answer. But I think it is clearly coming and I think it, again, will help.
Another thing that we need to do is improve access via better ambulances and better payment for people to access the larger hospitals. I’m sure most of your listeners are aware of the surprise medical bill problem, and a lot of those came from air ambulances—people for whom it was obvious that in the middle of the prairies they needed urgent surgery, got a helicopter, got in, got the surgery, went home, and discovered they had a $12,000 ambulance bill that was not covered.
I think you either need to negotiate with the ambulance providers to get reasonable rates, or states and major hospitals need to subsidize that because neither telemedicine, teleconsultation, nor AI are going to help if you have a dissecting aneurysm. You’ve got to get into the urban center, and you’ve got to get in there quickly.
Kevin Pho: I want to talk about bringing more clinicians to rural settings because sometimes I think it may be more than money, right? Because sometimes no matter how much money you offer these clinicians, they may just opt for a more urban lifestyle, and it takes more than just a monetary sum to bring them to rural areas. What do you think about that? What is your path in terms of bringing more physicians to rural settings?
Edward Hoffer: Kevin, you’ve hit the nail on the head with that one. There actually is limited but fairly solid data saying the way to get more physicians practicing in rural areas is to admit more medical students who grew up in those areas. You are not going to get somebody whose whole life has been in Chicago and for whom the opera and the museums are an important part of their lifestyle to go into a small town in rural America.
The people who are going to go into rural America and make it their career, make it their life, are the people who grew up there, who feel ties to the local area, who feel ties to the people, and who are not, in fact, so concerned about some of the other lifestyle issues that the urban physician values so much—and the urban physician’s spouse.
I think if we really want to get doctors who will settle in and make their career in rural America, we need to get more medical students from those communities. It’ll do much more than any kind of feasible financial incentive would do.
Kevin Pho: If you were in charge of our health care system and you wanted to improve the status of what rural health care is, just tell us the next immediate steps that you would implement to fix this.
Edward Hoffer: Immediate steps, I think, are things we’ve touched on. Number one is expand the payment for telemedicine services to make them more equitably available.
Get hookups between urban and rural hospitals so that the physicians in rural hospitals have very easy access to specialists and to get their patients seen promptly when they need to be.
I think we need to have either state governments, state Medicaid, and/or the bigger academic hospitals providing rapid air evacuation services for critically ill patients.
And I think we need to start seeing that 10 to 15 percent of our admitted medical class are people who grew up in and want to return to rural America.
Kevin Pho: We’re talking to Edward Hoffer. He’s an internal medicine physician and cardiologist. Today’s KevinMD article is, “Can rural health care be saved?” Edward, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Edward Hoffer: I would say, if you have thought about it, there is a lot of quality in rural America, but don’t go there simply because the government pays you to do so. All you’ll be doing is putting a Band-Aid on the wound. We want to get people into rural America who like rural America, want to practice there, want to live and die there. And I think there’s also a lot that both the government and the academic centers can do to make that a more attractive place to practice and for patients to get care.
Kevin Pho: Edward, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Edward Hoffer: Thank you, Kevin. I enjoyed it.