Not So Healthy

Rappahannock News - - RAPPAHANNOCK SNAPSHOT - This up­dates the Foothills Fo­rum/Rappahannock News three-part se­ries, “A Trou­bling Di­ag­no­sis,” pub­lished July 20, Aug. 3 and Aug. 17, 2017. By Randy Rieland Foothills Fo­rum

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.

THE LAT­EST

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.

WHAT’S NEXT

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.

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