Not So Healthy
These are turbulent times for health care in rural America. Its supply of doctors is dwindling, and its hospitals are closing at an accelerating rate — almost 90 have shut down since 2010. That disheartens Dr. Jerry Martin, who before retiring last month, had spent almost half a century as an archetypal country doctor in Rappahannock. His career here dates to 1974, when he joined Dr. Werner Krebser in opening a practice on Gay Street in Washington.
Dr. Martin’s worried not only about what will happen with his patients, but also, more broadly, about where health care is headed. He’s seen how the enormous cost of a medical education has discouraged people from becoming primary care physicians, particularly in rural areas, where doctors earn less and can struggle to pay off their debts. And, he’s witnessed firsthand how already staggering medical costs keep climbing.
“What concerns me the most about the state of health care is that when a patient comes in, I should be able to give them my undivided attention,” he said. “But the big medical organizations and the insurance companies have become beholden to their stockholders instead of the people you’re trying to serve.
“Reimbursement is skewed toward procedures,” Martin added. “You don’t get paid for sitting and talking to someone for 20 minutes.”
The impact of these trends is likely to be particularly profound in rural communities, where doctors like Martin will increasingly be replaced by nurse practitioners and physicians’ assistants, and more and more medical appointments will occur online.
Overall, there’s good news and bad news regarding the state of the county’s health and care. According to the 2018 County Health Rankings and Roadmaps, an annual report sponsored by the Robert Wood Johnson Foundation, Rappahannock ranks 15th among the state’s 133 counties and cities in a category called “Health Behaviors.” It reflects tobacco and alcohol use, physical activity, access to healthy foods, and sexually transmitted diseases. In the previous report, the county ranked 30th.
Rappahannock also rose to 12th place from 27th in a category called “Length of Life,” which measures the risk of dying before 75, and is based on the number of years lost by people who have died before then.
On the negative side, the county dropped all the way down to 110th in a category called “Clinical Care,” where it had ranked 80th. This reflects access to doctors, dentists and mental health professionals. In a county like Rappahannock, which has so few health professionals, a small change can have a big impact on its ranking. The category also takes into account the percentage of residents without health insurance. That’s estimated at 15 percent, while the Virginia average is 10 percent.
Rappahannock’s obesity rate of 30 percent, according to the report, is also above the state average, as is the percentage of residents over 20 who have been diagnosed with diabetes — 12 percent.
Dr. Martin’s retirement leaves the county with just three primary care physicians — Dr. John McCue, who began practicing here in 1998; Dr. Brooke Miller, who with his wife, Ann, a nurse practitioner, sees patients at the Valley Health System clinic near Washington; and Dr. Christopher Nagle, who last year opened his Wilderness Medicine practice in the Mountainside Physical Therapy building on Route 211.
Dr. Nagle hopes to soon begin accepting payments through Medicare and some private insurers after initially exploring the concept of having patients pay him directly.
He felt that by avoiding the administrative costs and time demands of dealing with insurance claims, he could keep his expenses low. But he concluded that the model probably wouldn’t work in an aging, sparsely populated community like Rappahannock.
Dr. Nagle’s practice is part of a small network of health-care services located in the Mountainside building, with the core component being the physical therapy business owned by Anne Williams. She said it now gets about 500 patient visits a month, but could handle more if she could find more certified physical therapists in this area.
A state law passed in 2015 allowing patients direct access to physical therapy without a referral from a doctor could be a boon to the Mountainside business. “People with orthopedic problems can now come to a physical therapist as a first point of access into the medical system,” Williams said. “A lot of people still aren’t aware of that.”
Given the growing shortage of rural doctors, it has become that much more critical to train local residents for healthcare careers, according to Travis Clark, vice president of operations for Valley Health’s Southern Region and president of Page Memorial Hospital in Luray. He cited the efforts of RappU, where in the past two years, 52 people have enrolled in classes to become certified for such health-care jobs as nurse aide or clinical medical assistant. Another 16 students have taken a nurse aide course at Rappahannock High School.
Another development that will likely have an impact is the decision by the Virginia legislature in May 2018 to expand Medicaid; an estimated 300 to 400 additional Rappahannock residents are now eligible for coverage. A work requirement included in the law still needs to be approved by the Trump administration.
The effect will also be felt by Virginia hospitals, Clark noted. About 11 percent of his hospital’s revenue, he said, is lost to “uncompensated care” when patients can’t pay.
“If we can get a person established with Medicaid instead of them using the emergency room for primary care, that’s a big win for us, and more importantly, the patient,” he said.
As in any aging community, more of the focus of health care in Rappahannock will be on managing chronic conditions, such as diabetes, heart disease and cancer. That can really be a challenge when patients have to travel long distances for doctors’ appointments or to pick up prescriptions.
One promising development is that the Valley Health clinic is considering providing limited pharmacy services, according to Dr. Miller.
Dr. Nagle said he hopes that eventually much of his practice will be built around telemedicine. But for it to be effective, a health professional needs to know the patients he or she connects with digitally.
“It’s key that I know the person before I can remove the face-to-face aspect,” he said. “You need to know their physical state. You need to know if they tend to be more stoic in their description of their health concerns. Maybe they typically understate things.”
Another telemedicine approach is a chronic care management program called RevUp. It’s available to Medicare patients with at least two chronic conditions. Once a person signs up, he or she is contacted by a “nurse navigator” once a month to see how the patient is doing in sticking to their treatment plan.
RevUp became available at the Valley Health clinic last May, and so far about 10 percent of the eligible patients there have signed up, according to Clark. He thinks it has promise as a way to keep more isolated people engaged with their health care.
“A nurse navigator can answer questions and maybe make a doctor’s appointment unnecessary,” Clark said. “And, it could help avoid unnecessary trips to the hospital. That’s what really drives up the cost of health care.”
But Brooke Miller, who is increasing his time at the Valley Health clinic from four to six days a month, is less sanguine. He grew up in Rappahannock and knows how a lot of locals feel about calls from strangers.
“I already see my chronic care patients every three months,” he said. “I do tell people about this program if I think it will help them. But a lot of people think it’s an intrusion and don’t want to be bothered with the calls.”
Dr. Brooke Miller, with his wife, Ann, a nurse practitioner, at the Valley Health clinic near Washington.