Rural medicine won’t be helped by health reform

by Rick Bendinger, MD

I am a rural health provider in Abbeville, Alabama and have been here almost 30 years. I originally went to school on a public health scholarship and took the private practice option. This was a program that existed in the 1980s that paid for tuition and a stipend with the obligation to go either to a prison, rural area, or Indian reservation.

Sadly the program no longer exists. Both myself and my partner went to school on this program. The thought was that once you paid off a 4 year obligation working in a rural area you would stay and for me it worked.

Currently we provide care to the county and surrounding counties but with the 21% Medicare cuts, rising costs and requirements it is going to make our job even more difficult. I have reassured my patients that in spite of the current cuts I will still be here for them but I really worry about affording to continue to care for them and what will happen when I retire.

Most primary care providers in Alabama are in their mid-fifties and we are getting little help from new students who, owing $250,000-$300,000, opt for more lucrative specialties. Many will retire with the advent of this bill and make things more difficult. Furthermore, poor counties provide poor schools and not many young professionals with children want to practice in rural areas of this state.

We treat the poor and indigent each and every day but have a hard time with their care when we want to refer for specialty care as many of the internists and specialists in the nearby “big town” are not taking new Medicare patients and won’t take indigent care. Not because they are greedy but because they are not paid enough to operate a business.

I practice in a different environment than the big city doctors. Patients are friends and like family. I have coached their children in baseball and basketball helped them with some of their homework, and been a part of the community. I see them in the grocery store and at ballgames they are friends. I have stitched them up on my kitchen table, made house calls and cried with them when they have lost a loved one. They are like family in a small town practice and that is a big difference between what I do and a big city doctor.

With that said, the new health care bill gives patients a shiny new card that is supposed to keep them out of the ER, but in reality, if they have no provider to go to that is where they will end up. You can’t just dump another 30 million folks into this system without more doctors. The requirements for their care built in this bill will require us to do more work and outcomes data without paying for the cost of doing this. Frankly, it is an impossible task.

I really noticed the uptick in non-productive work with the advent of the Medicare Part D program. Although I still fully don’t understand the rationality of things like the doughnut hole provision, we spent many visits trying to explain to patients what the program was about and many hours on the phone with their pharmacy benefit managers trying to get their medicine they had been on for years approved.

This was the tip of the iceberg because many private insurers followed suit with the prior authorizations for drugs and MRIs as well. I have one employee who does nothing but these issues. This is an example of what drives up our overhead. Medicare has not raised our rates in 10 years. Medicare monies are taken out of one big finite pot. So if we get a raise, another provider gets a cut. Promises of higher primary care payments have been empty.

Will I retire because of health reform? No, I can’t afford to leave patients without a stable provider. But this new bill will make my work even harder. My hope is that there is an effort to train and increase primary care providers. It addresses student loans, restaurant calorie counts and numerous other superfluous things that won’t bring new rural doctors.

I would like to see a Manhattan-type program, like what the government did with the bomb, that would train primary care doctors and pay them on a better scale. Medical students who come out with $300,000 in student loans can’t go into primary care for $170,000 per year. Surely, within the trillions that are being proposed for health care there could be an effort to incentivize some of the best and brightest students to go into primary care.

Nurse practitioners and physician assistants are being hired by many of the specialists to work for them — they too are often shunning primary care. We need to capture some of them, but they need to be paid as well. Currently, private insurers only pay them 80% of what they pay me to do the same thing.

Hopefully this gives some insight into what I do and how rural medicine will be affected by health care reform.

Richard Bendinger is a family physician.

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