Second-rate in Ruralville?

To anyone who’s familiar with the rural health care scene, a newly issued report by the UnitedHealth Group’s Center for Health Reform and Modernization doesn’t contain many major surprises about the state of rural health.

According to the report, Americans who live outside urban areas have more chronic health conditions, are more likely to qualify for Medicaid or other subsidized health coverage, and have a harder time obtaining quality care than their city and suburban counterparts. These findings echo other statistics that shape what we currently know about rural health. And they sound an early, urgent alarm for the crunch that looms ahead as more Americans obtain health coverage as a result of the Affordable Care Act.

In reality, though, a gap has been silently widening for many years between rural Americans and the rest of the population.

It’s interesting, although probably coincidental, that the U.S. Census Bureau released new numbers this week showing that the rural population (defined as communities of 50,000 or fewer) has shrunk to an all-time low: just 16 percent of the American total. Jobs and services continue to vanish as the U.S. economy becomes ever more urban-centric.

What this all bodes for rural health care ought to be concerning for anyone who lives in a rural community, as well as to policymakers.

Some statistics for Minnesota and for the U.S. in general, gleaned from the UnitedHealth Group report:

Nearly three-fourths of Minnesota’s population is now considered urban or suburban; 1.41 million Minnesotans, or 27 percent, are rural. There are 76 primary care physicians per 100,000 rural Minnesotans vs. 122 per 100,000 urban and suburban Minnesota residents.

Nationally, rural patients have an average distance of 60 miles between their local primary care clinic and a specialist’s office. And rural doctors are more likely than their city counterparts to believe there will be a shortage of physicians and mid-level clinicians in coming years.

Perhaps one of the most eye-opening findings of the report is this: In a Harris Interactive survey of 2,000 consumers and 1,000 primary care doctors conducted for the report, both groups rated the quality of rural health care lower than urban and suburban respondents did. This could be due to perception and a potential bias in favor of bigger as better. But when UHG delved into some of its own data, the analysis confirmed that in most markets, rural care indeed is measurably lower when it comes to quality.

It’s not clear what to make of this. Is rural health care truly second-rate? After all, this is the second time this month that a group of researchers has studied rural health care and found it lacking; a study in the Journal of the American Medical Association recently gave failing marks to rural hospitals.

Current yardsticks for measuring quality of care might simply be inadequate or inappropriate for rural health. Moreover, rural America is more diverse than a generalized collection of data would indicate. Relatively well-populated rural counties lying just outside a metropolitan area do not have the same challenges as counties that are remote and isolated. Many rural communities have figured out how to deliver health care services that are every bit as good, although less specialized, than those in the suburbs. Others are struggling, though, and their performance may be skewing the data and creating misleading conclusions.

Still, it’s hard to ignore a solid body of evidence that patients who live in rural areas often are shortchanged when it comes to quality health care.

What’s the solution? The UnitedHealth Group report is pinning its hopes on telemedicine to help close the rural health care gap. The report calls for expanding the use of broadband in rural America, restructuring reimbursement to make greater use of telemedicine, and reducing the technological barriers for consumers and health care professionals.

Coincidentally, an organization known as the Internet Innovation Alliance released a report yesterday that outlines 10 benefits of information technology in health care. One of the projected benefits is allowing rural residents “to receive expert diagnosis and treatment from distant medical centers.”

While this all sounds promising, it will more than likely take multiple strategies to strengthen the fabric of rural health care – and one size is not going to fit all.

Furthermore, judging from the growing amount of data suggesting that rural health care doesn’t offer the quality it should, it begs the question: Have policymakers’ efforts to support rural health care focused too much on access, in the belief that available care – even if it’s second-rate – is better than no care at all? It would seem that rural health care deserves a renewed emphasis on quality and positive outcomes. This is a gap that can and ought to be narrowed.

Additional reading:

“Quality Through Collaboration: The Future of Rural Health,” by the Institute of Medicine

The Rural Blog

– University of Minnesota Rural Health Research Center

– Minnesota Department of Health Office of Rural Health and Primary Care

Photo: Wikimedia Commons

Little white lies

 I’m tempted to buy a copy of Dr. Michelle Au’s new book for the title alone: “This Won’t Hurt a Bit (and Other White Lies): My Education in Medicine and Motherhood.”

Aha! Someone in health care actually is publicly admitting they’re not always truthful with patients.

The practice of fudging the truth seems to have a rather long history in medicine. Once upon a time it wasn’t unusual to sugarcoat or withhold bad news – not telling a patient of a cancer diagnosis, for instance, or characterizing the cancer as a “growth” rather than a malignancy.

When health care professionals have done this, it has generally been with good intentions. Often it’s because they don’t want to unduly frighten or discourage the patient. Sometimes they simply don’t want to overwhelm a layperson with too much information or complexity.

And sometimes, let’s face it, a little white lie or two just makes it easier to manage the patient. We’ve all heard the fibs, and I would guess most of us haven’t been fooled by them:

– “The doctor will be with you shortly.” Translation: “Find a good magazine to read because it’s going to be awhile.”

– “This may sting a little.” Translation: “This is definitely going to sting a whole lot.”

– “I’ve never had a patient vomit/pass out/die from this procedure.” Translation: “None of the above has happened to me yet but there’s a first time for everything.”

– “I don’t want to alarm you.” Translation: “Be alarmed. Be very, very alarmed.”

Is it ever OK to be not entirely truthful with patients, even in a minor situation? Even if a little dishonesty seems to be in the patient’s best interests?

Ethicists have debated this issue extensively. While it’s generally agreed that truth-telling belongs at the heart of the patient-clinician relationship, there are a lot of gray areas. One example: smoothing over the truth to help an elderly patient avoid becoming overly upset or exposed to information they don’t need to know. There’s actually a name for this – the “geriatric fiblet” – and it can be deployed in a variety of situations, such as concealing information from an older person at the request of their adult children.

What about some of the deeper ethical complexities? How truthful can clinicians be in the face of medical uncertainty? What if the patient explicitly says he or she doesn’t want to know certain information?

The right thing to do can sometimes depend on the circumstances. In general, though, the foremost principle should be to preserve the patient’s autonomy, explains an article published last month by the Center for Health Ethics at the University of Missouri School of Medicine:

Ordinarily physicians and other providers are considered to be bound by obligations to the patient of respect for patient autonomy, acting for the benefit of the patient, and refraining from anything that would harm the patient. Truth-telling or honesty is seen as a basic moral principle, rule, or value. Withholding information or otherwise deceiving the patient would seem to at least disrespect patient autonomy and potentially harm the patient. Respecting patient autonomy means allowing patients to make their own decisions about whether to have certain tests, procedures, or treatments, or other interventions recommended by the healthcare provider. It means allowing patients to be in control of their lives to the extent possible. But no one can be in control of their healthcare decisions and lives if the choices are being made on the basis of significantly incomplete information or outright deception.

Here’s something else to consider: When clinicians tell little white lies, are they also more likely to fib when it comes to larger issues?

Since we’re talking about honesty, there definitely are times in health care when patients would probably rather not hear the blunt truth.

Several years ago I had to undergo a throat swab for what later turned out to be strep throat. The swab in the lab technician’s hand looked like it was a mile long. I was not thrilled about it, and I could feel my gag reflex getting ready to activate. “Is this going to make me vomit?” I blurted out.

The tech could have told a white lie – “Oh, no, you’re going to be just fine” – but she stuck to the truth: “You might” was her reply.

At the moment, it wasn’t exactly a reassuring response. On the other hand, at least I had a realistic idea of what to expect and was ready for it. And guess what? I appreciated that she was straightforward with me. (The throat swab went fine, in case anyone is wondering.) A little honesty, even in the small things, can go a long way.

How do readers feel about white lies told by health care providers? Do you think they’re OK in certain circumstances, or would you rather have total honesty? Please share your thoughts in the comment section.

Money on the table

For patients and their families, it’s bad enough to have something go wrong with their care. It often adds insult to injury when they’re expected to bear the cost of fixing it.

But from the health care organization’s point of view, the reasoning can go something like this: We fixed it. We said we were sorry. What more do they want from us – money?

Yet there’s a growing body of evidence that in order for patients to truly be made whole after an adverse event, the package needs to include compensation, along with accountability and an apology.

It’s a component of the process that’s often missing when hospitals, insurers and medical practices put together policies on what to do when things go wrong and a patient is harmed, writes Doug Wojcieszak, the founder of Sorry Works!, a pioneering organization in the field of disclosure advocacy and training.

Why should this matter? Wojcieszak explains in a recent edition of the Sorry Works! newsletter:

Apologies without compensation are often hollow and meaningless. Critics will say, “It’s always about the damm money,” but, who are we kidding? Patients and families need to be fairly reimbursed for lost time, expenses, pain and suffering, and, yes, crippling injuries or even death. However, we always tell people when you apologize the money stuff gets a lot less scary because the anger is dissipated and you can have a rational adult discussion with patients and/or families to learn their needs – and sometimes it has nothing to do with money!

Wojcieszak hopes to bring this perspective to a revision of one of the landmark documents in the disclosure movement, a white paper on “Respectful Management of Serious Clinical Adverse Events,” released last year by the Massachusetts-based Institute for Healthcare Improvement.

The paper is slated to be discussed in October at the annual meeting of the American Society of Healthcare Risk Management. The authors are looking for ideas and suggestions on how to improve or update it, along with real-life examples of how the paper has been used.

“Respectful Management of Serious Clinical Adverse Events” essentially is a blueprint for how health care organizations can develop a crisis management plan ahead of time, rather than scrambling after something bad has taken place and possibly making poor decisions. The paper makes a case for prioritizing the needs of the patient, family, staff and organization and responding in ways that build empathy, learning and improvement. When health care organizations fail to do this, the result can be a loss of trust and the risk of lawsuits and negative publicity. More to the point, a failure to learn from what went wrong can doom the organization to repeating the same mistakes and endangering future patients.

Inserting the money issue into the discussion can be sensitive, but Wojcieszak, whose family sued when his brother died of a heart attack after a series of diagnostic missteps, argues that it needs to be part of the process of fixing what wrong. “Simply saying sorry and hoping you don’t get sued because the patient/family seems placated is unacceptable,” he writes:

If you want to truly restore your ethical reputation as well as learn from the mistake (i.e. improve quality) you have to fix the problems you create. And, yes, this means sometimes offering things to patients and families they might not otherwise think to ask for. The truth of the matter is many patients and families are emotionally traumatized post-adverse event and have no idea what they need or can ask for… you need to help in a fair and honest way.

Sometimes this might entail waiving a bill or offering a gift card, Wojcieszak writes. Other times it might take more than this, especially if a serious injury or death is involved. When organizations put restitution squarely on the table, it often helps defuse some of the patient’s and family’s anger and paves the way for everyone to start healing, he writes.

It’s hard to know how many health care organizations might be willing to take this approach. After all, the industry still struggles with the concept of honesty in the wake of an adverse event. Although the Joint Commission, the main accrediting body for hospitals in the U.S., now requires its member hospitals to have a disclosure policy, it’s not clear whether organizations are actually putting this into practice or how well it’s enforced. And although most health care leaders and physicians would probably say patients and families deserve fair compensation when something goes wrong, to date there’s little evidence of any widespread movement in this direction.

Yet when organizations have been bold enough to try it, they’ve gotten results. One of the most widely cited examples is that of Veterans Affairs Medical Center in Lexington, Ky., which saw payouts decrease dramatically after adopting a policy of transparency and compensation. From 1990 to 1996, the Lexington VA had 88 malpractice claims and paid an average of $15,622 per claim. For the VA system as a whole, claims during the same period averaged $720,000 for court judgements and $205,000 for out-of-court settlements.

In an article published in 2007 in Proto magazine, Dr. Steven Kraman, former chief of staff at the Lexington VA, said, “We settled almost every case at the hospital, and patients were usually willing to negotiate on the basis of real financial losses rather than out of a desire for revenge.”

The Proto article offers another example of how this can work:

In a closely watched experiment that began in 2000, COPIC Insurance Company, which insures 7,000 private-practice doctors in Colorado and Nebraska, gives physicians the chance to stay in the good graces of patients with an offer of as much as $30,000 to compensate for hardships caused by an adverse outcome. Physicians are encouraged to communicate openly, and if appropriate, apologize. And because patients don’t make a formal written demand for compensation or waive their right to sue later (after they accept the check), doctors avoid having their errors reported to the National Practitioner Data Bank and the state licensing board.

Some patients and families undoubtedly will sue regardless. But the evidence suggests that when organizations are proactive about confronting the money question, it can help ease a bad situation. The evidence also suggests that patients and families often are far more willing to be reasonable than they’re given credit for.

What do patients want when something goes wrong? What they want, says Wojcieszak, is full disclosure about what happened, a sincere apology, a promise to fix the systems involved in the error, and a timely offer of compensation. If the hospital where his brother died had offered these four things, “what would we have sued over? Nothing,” he said. “If you treat us with respect, we don’t want to own your hospital, your speedboat or your kids’ college fund. We just want what’s fair so we can move on with our lives.”

77 innovations for moms and babies

If you ask for ideas about improving the health of mothers and newborns in remote areas of the globe, they will come.

Back in March, a partnership consisting of the U.S. Agency for International Development, the Norwegian government, the Bill and Melinda Gates Foundation, Grand Challenges Canada and the World Bank issued a global call for novel ways to reduce maternal and infant mortality in rural areas of the world where access to health care is scant.

The project is known as Saving Lives at Birth: A Grand Challenge for Development. Ideas that were submitted had to address one or more of three key areas: technology, service delivery and/or demand.

The results are now in: 600 innovative proposals from around the world. After much deliberation, they have been narrowed to 77 finalists whose ideas will be reviewed next week at a development exchange in Washington, D.C. During this three-day open marketplace, innovators will have the chance to share and discuss their ideas with development experts, fellow innovators and potential funders. Final awards will be announced during a ceremony on Thursday, July 28.

The list of the 77 finalist projects is varied, creative and global. For example, a Seattle-based organization known as the Program for Appropriate Technology in Health, or PATH, has proposed a low-cost, lightweight, solar-powered infant warmer to care for very small newborns at risk of hypothermia.

Changamka Microhealth Ltd. of Nairobi, Kenya, has put together a proposal that addresses the financial and information barriers faced by poor rural women. It involves a system of prepaid e-vouchers and transportation subsidies delivered via mobile phone, along with information through SMS messaging, participatory networks and radio.

Other novel ideas address low-cost and rapid ways of diagnosing and treating conditions among mothers and newborns such as infection, jaundice and blood loss.

Citizens of developed nations are accustomed to thinking of childbirth as a happy occasion for welcoming a healthy new infant into the world. Globally, however, pregnancy, delivery and and the first few days of life are often an extremely fragile time with less than positive outcomes.

The Saving Lives at Birth website contains some sobering information. Globally, a woman dies in childbirth every two minutes. Women in sub-Saharan Africa are 136 times more likely to die in childbirth than women in developed countries.

The most vulnerable time starts with the onset of labor and doesn’t begin to ease until 48 hours after birth. During these critical hours, there are an estimated 150,000 maternal deaths, 1.6 million newborn deaths and 1.2 million stillbirths each year. The medical threats range from hemorrhage and obstructed labor in the mother to infection, birth asphyxia and complications of pre-term birth among infants.

The majority of deaths occur in low- and mid-income nations, particularly in sub-Saharan Africa and South Asia where women often lack access to health care services and information. In many of these remote rural areas, even things taken for granted such as clean water, electricity and transportation may be in short supply or absent altogether.

There in fact are many barriers to healthy birth outcomes in rural areas of the developing world: lack of medical technology, a shortage of trained, equipped and motivated health care professionals, and a lack of information among mothers-to-be about the benefits of prenatal care and what they can do to increase the likelihood of a healthy pregnancy and delivery.

When the challenge is this huge, can a handful of individual projects make a difference? The Saving Lives at Birth project seems to be one way to find the answer to this question.

For more global stories about the power of small-scale projects to achieve results, check out these videos posted online by the Bill and Melinda Gates Foundation. You can also vote here for your favorite innovative idea submitted to the Saving Lives at Birth challenge. The winner of the People’s Choice award will be announced Thursday, July 28. The public has until 5 p.m. EST Wednesday, July 27, to cast online votes.

Update: Nineteen nominees were selected Thursday for seed grants. The winners’ list is here. They will now enter final negotiations before the grant money is awarded in 2012. The winner of the People’s Choice award is the University of California-San Francisco, Bixby Center and ARMMAN collaboration team for a project utilizing voice messaging and animation. Monash University of Australia won the Peer Choice award for proposing an innovative way of administering oxytocin without needles or the need for refrigeration.

Photo: Wikimedia Commons


Migraines: an inside view

It’s draining, and every throb, every “stab” hurts more, until you just want to beat your brains out, because you’re mad that your head would ever hurt you like this. The pain is not ignorable. It demands more and more of your attention, until it’s all you can think about, until you’re crippled in bed or next to the toilet, and it keeps spiraling, getting worse, worse, worse, and you just want to knock yourself out because you need to escape this maddening pain.

This is how a writer at The Experience Project describes what it’s like to have a migraine headache.

The news that Rep. Michele Bachmann, a Republican from Minnesota and aspiring presidential candidate, suffers from migraines has suddenly focused attention on a medical condition that’s all too often misunderstood.

Diana Lee, who has chronic migraines and blogs at Somebody Heal Me, welcomes the opportunity to educate – and implores the media and the public to get their facts straight.

There’s nothing about migraine disease that would make Bachmann unqualified to be president, Lee wrote in a guest column posted this week at

It’s appalling enough for anyone to be speculating about how incapacitated she might be by this disease based entirely on rumors from former members of her staff. But what’s much worse to me is the incorrect characterization of her problem as “stress-related episodes.” What year is this? 2011? You could have fooled me into thinking it was 1911 when migraine was treated as a woman’s trouble and weakness suffered by those who couldn’t handle the ordinary stresses of everyday life.

Nor should the Congresswoman be judged for what one source called “heavy pill use,”
 Lee wrote. “Hey, guess what? Most chronic migraineurs take a lot of pills. Why the need to make it sound like she’s an addict in need of rehab because she takes medications for a chronic medical condition?”

Some facts from the Migraine Research Foundation: An estimated 36 million Americans – about 10 percent of the population – suffer from migraines. Although migraine disease affects people of all ages, including children, it’s most common among adults in the prime of life, between 25 and 55.

Few of us get through life without experiencing at least one severe headache. Migraine is much more than a had headache, however. It’s actually neurologic in origin and the pain is usually intense and debilitating. For some people it can become a chronic daily condition that seriously interferes with their quality of life.

On top of this, it’s often under-recognized, undiagnosed and undertreated. Although new classes of medication are now available to help manage and prevent migraines, research is lagging on what causes migraines and how to effectively treat them.

It all adds up to a picture that begs not to be seen as one-size-fits-all. MinnPost health blogger Susan Perry talked this week to Dr. Miles Belgrade, a neurologist at the Fairview Pain Management Center in Minneapolis, who explained that migraines can range from “hardly bothersome at all to completely devastating, where you have people who are basically nonfunctioning.” Nor does everyone respond well to treatment, Dr. Belgrade said.

The bottom line, according to Dr. Belgrade, is that while some people might well be incapacitated by chronic migraines, the condition is something that can be managed.

There’s a strong note of realism, though, in some of the online discussion by individuals who know firsthand what it’s like to live with migraine disease.

“If we are being honest, I really do think that most of us here know it can very well be incapacitating sometimes,” one person wrote in response to Lee’s guest column.

At the New York Times, someone else wrote: “I’m a chronic migraine patient – without my current treatment regimen, I’d have migraines just about every day or every other day. From experience, I know that while I *can* function during a migraine, I’m nowhere near the top of my game and I can’t always focus on what I’m supposed to be doing.”

The political spin – Can She Run the Country If She Has Migraines? – seems to be the aspect of the story that has captured most people’s attention. But I’d say the real story is about the experience of ordinary people who have migraine disease and simply want to live their lives as well as they can.

Do you have severe headaches? Are they migraines? How well controlled are they? This online self-assessment by the Mayo Clinic can help you find out.

Photo: 13th-century caryatid clutching its head in apparent pain. Wikimedia Commons, courtesy of the Geograph Project.


Hot enough for everyone

The heat is on, and as we dash from our air-conditioned vehicles into air-conditioned buildings, one can’t help wondering how people coped with extreme summer heat in the pre-technology era.

Were they vulnerable to heat exhaustion and heat stroke? Or were they simply tougher than we are?

If you look back through history, it becomes clear that people have long been wise to various strategies for cool living. They built dwellings of stone or adobe, for instance, that kept out the worst of the summer heat. The ancient Egyptians hung damp mats or placed clay jars of water in their homes to cool the surrounding air. During the glory days of the Roman empire, the nobility had their summer gardens filled with snow transported from the mountains.

Visit an older house in the United States and you’re likely to notice the high ceilings, open stairwells and large attics allowing warm air to rise. Homes were often designed with windows and halls that created cross-ventilation. Porches or verandas helped provide shade and a place to sit (or sleep) outdoors in the evening. Plantations and farms frequently had summer kitchens – a separate building where a stove or wood fire could be stoked up for cooking without heating the entire house.

This doesn’t mean people somehow were immune to heat exhaustion or heat stroke. After all, there’s only so much the human body can tolerate.

Heat-related illness happens when the body’s temperature-regulating mechanisms break down under stress or exposure to heat. Children and older adults are the most vulnerable, as are individuals with chronic health conditions such as heart disease. But even healthy young adults can fall prey to heat exhaustion or heat stroke if they overexert themselves in hot weather.

Formal statistics might not have been collected 100 or 500 years ago, but people throughout history have died of heat stroke or succumbed to heat exhaustion. For example, accounts of the Crusades, which lasted from 1047 to 1291, describe how medieval knights, hampered by hot, heavy armor, were often outmatched by Saracen armies better equipped and adapted for fighting in the hot desert conditions of the Middle East. Camp followers, camels and soldiers were felled by the hundreds as Alexander the Great marched his troops across the Gedrosian desert in the year 325.

In this sense, it’s unlikely our ancestors were that much tougher than we are. Nor did they have to deal with modern-day factors that have turned up the heat – the heat islands created by urban environments, for instance, or the oven-like temperatures inside a parked car, or the use of prescription medications such as diuretics and beta blockers that inhibit the body’s ability to cope with hot weather.

Back in the day, however, when people were routinely exposed to weather extremes, they may simply have been more physically adapted to tolerate it. Some interesting studies carried out over the past few decades have found that when athletes train in hot environments, they can improve their physiological response – in other words, they become acclimated and better able to tolerate exercise in hot conditions.

Researchers also have found that when people are passively exposed to heat, they become somewhat acclimatized, especially in their body’s ability to dissipate heat.

Whether air conditioning has turned us into a society of wimps is hard to say. Over the course of history, humanity has certainly been forced to endure extreme weather conditions and there’s no doubt that countless people have suffered and died because of it. On the other hand, heat exhaustion and heat stroke have become preventable illnesses that needn’t claim the number of lives they have in the past. So why sweat when there’s a safe and comfortable alternative?

A dental divide

From the minute the doors opened at the Rice Regional Dental Clinic in Willmar, Minn., late in 2007, it was clear there was an overwhelming need for access to dental care, especially among low-income adults and children. The staff reported being inundated with phone calls for appointments.

For anyone who has ever visited the dental clinic or is familiar with the services it provides, it surely must have been no surprise when the Institute of Medicine issued a report this week on the state of oral health care for America’s low-income and vulnerable citizens.

The report’s main conclusion: Millions of Americans are not receiving necessary dental care because of “persistent and systemic” barriers. Children, seniors, minorities and the poor are especially affected.

Perhaps the most compelling point of the report is this: Although dental care is a basic need for people of all ages, it’s one of the areas in which disparities are the widest. The authors wrote,

More than half of the population does not visit a dentist each year. Poor and minority children are substantially less likely to have access to oral health care than are their nonpoor and nonminority peers. Americans living in rural areas have poorer oral health status and more unmet dental needs than their urban counterparts. Older adults, especially those living in long-term care facilities, have a high prevalence of oral health problems and difficulty accessing care by individuals trained in their special needs. Disabled individuals uniformly confront access barriers, regardless of their financial resources. The consequences of these disparities in access to oral health care have a strong influence not only on oral health but on overall health as well.

The report identifies multiple reasons for this troubling state of affairs. For one thing, the cost of dental care is an issue for many households. According to the IOM report, an estimated 4.6 million children did not receive needed dental care in 2008 because their family couldn’t afford it. Among older adults on Medicare, fewer than half have dental coverage.

What your smile looks like is in fact a dead giveaway of socioeconomic status, an observation that has been confirmed by several studies. Teeth that are discolored, crooked or missing are often a marker of poverty and/or inadequate dental care. The burden of oral diseases such as tooth decay also falls primarily on the poor.

Even having dental insurance doesn’t necessarily guarantee access to care, however. Many dentists don’t accept clients on publicly funded programs such as Medicaid or MinnesotaCare because the reimbursement is so low. And rural and inner-city regions of the United States have a shortage of dental professionals, period. I’ve seen projections indicating Minnesota’s dental workforce is aging and that it may be increasingly difficult to replace these professionals when they retire.

What can be done to change this? The IOM report makes several recommendations. Chief among them is increasing the reimbursement rate for Medicaid and the Children’s Health Insurance Program so dentists have a greater incentive to see these patients. Another recommendation is to give dentistry students more opportunities to gain skills in treating patients with special needs.

The report also calls for enlisting other parts of the health care delivery system to provide some aspects of oral health care. For example, mid-level professionals could do screenings for oral disease and offer basic preventive care. A measure that creates licensing standards in Minnesota for two new types of mid-level providers – dental therapists and advanced dental therapists – was passed by the Legislature in 2009.

This is a ground-breaking initiative that has the potential to make a difference. It’s too soon to know, however, whether it will truly help improve access to dental care, especially to those who are the most underserved. It should also be noted that many dentists have raised concerns about training and supervision of these mid-level professionals.

In spite of the deep disparities that exist in access to oral health care, there are a handful of bright spots – projects and programs that are creative, innovative and that help shrink the gulf of unmet needs. The IOM report doesn’t list them by name, but I’d like to single out one of them: the Rice Regional Dental Clinic in Willmar, a partnership between Rice Memorial Hospital and the University of Minnesota. Here, students in the university’s dentistry and dental hygiene programs gain hands-on experience with a wide variety of patients in a rural setting. In exchange, low-income and uninsured individuals in the region can receive much-needed dental care.

According to statistics collected by the dental clinic, the majority of patients are children and young adults. For many of these youngsters, it’s the first time they’ve ever been seen by a dentist. I’ve spoken to public health nurses in the region who have expressed hope that 10 years from now, or 20 years from now, dental decay among poor rural children in west central Minnesota will become much less prevalent as a result of the services the Rice Regional Dental Clinic is providing.

At the time the program was established, in 2007, it was believed to be the only one like it in the United States. As far as I’m aware, the Rice Regional Dental Clinic is still unique – proof that solutions are possible, especially when the right partners can come together.

For whatever reason, oral health doesn’t always receive the same level of attention as the rest of health care. It reminds me of a poster my dentist used to have in his office that read, “Ignore your teeth and eventually they’ll go away.” Oral health often tends to be ignored – but the need doesn’t go away, and the consequences are becoming too large to be overlooked anymore.

West Central Tribune photos: Rice Regional Dental Clinic

Critical condition

Do patients receive worse care when they’re admitted to a critical access rural hospital? A new study suggests they do, and that these smaller hospitals not only have lower-quality processes of care and fewer resources but also have worse outcomes for their patients.

The study appears in the latest issue of the Journal of the American Medical Association. In a way, it’s ground-breaking. Although there’s been considerable research on the economics and the social impact of small rural hospitals, much less is known about the quality of care they provide.

The authors of the study analyzed Medicare data from more than 4,700 hospitals – both critical access and non-critical access facilities – for patients admitted with acute heart attack, congestive heart failure or pneumonia. They also collected information on patient and community demographics, hospital characteristics such as size and staffing levels, and reportable quality measures.

Among the findings:

– Critical access hospitals have fewer clinical resources than other hospitals and are more likely to be located in counties with fewer medical specialists.

– Critical access hospitals are less likely to have electronic medical records.

– These hospitals have lower performance on measures of quality care, even after adjusting for factors such as hospital characteristics and the patient case mix.

– Critical access hospitals have a higher 30-day mortality rate for acute heart attack, congestive heart failure and pneumonia than other hospitals.

The study’s authors reach a rather dispiriting conclusion:

Despite more than a decade of concerted policy efforts to improve rural health care, our findings suggest that substantial challenges remain. Although CAHs provide much-needed access to care for many of the nation’s rural citizens, we found that these hospitals, with their fewer clinical and technological resources, less often provided care consistent with standard quality metrics and generally had worse outcomes than non-CAHs.

This is one way to spin the story. It’s not the only way, however.

What is the role, exactly, of the critical access hospital? Virtually all of these hospitals have fewer than 25 beds and are the only source of hospital care in their immediate community. Although a handful are located in suburbs or inner cities, the vast majority are in the rural United States.

Whether they provide quality care to patients is a valid and important question. If the question is going to be asked, however, it ought to be framed within the proper context.

In the JAMA study, one of the yardsticks against which critical access hospitals were measured was whether they had an intensive care unit, surgical capabilities or a cardiac catheterization lab. Is this a standard that’s realistic or even appropriate for smaller rural hospitals?

Comparisons also are challenging because of the characteristics that make small rural hospitals unique. It’s intuitive that they would have fewer clinical resources and less access to technology and specialized care. When you stack them against larger hospitals, the contrast is bound to be obvious, but these limitations are simply part of the terrain inhabited by critical access hospitals. Many critical access hospitals are very good at being exactly who they are – small rural critical access hospitals.

The authors of the JAMA study acknowledge another important point: The performance measures they analyzed were limited because many of the small rural hospitals either didn’t report the data or their sample size was too small.

For anyone who lives in a rural community or has ever been a patient at a critical access hospital, the findings of this study should trigger thoughtful discussion. Although the financial viability of small rural hospitals is important, policymakers and health care leaders ought to be placing more focus on quality of care and how this can be achieved at hospitals with limited resources. Better methods need to be developed for capturing performance data at facilities where patient numbers are small, and providing tools that help rural hospitals accurately and realistically benchmark how they’re doing. Perhaps even the definition of quality needs to be reshaped to better reflect the role and capabilities of the critical access hospital.

Finally, it seems the entire conversation about critical access hospitals is in need of reframing. There’s a lot of talk about what they aren’t. Perhaps we should be talking instead about what they are and how they can be supported, for the sake of their patients, to do their best as critical access hospitals.

Image: National Sunflower Association/Associated Press

‘Nice patients finish first’

Is there an advantage to being a “nice” patient? Perhaps there is, speculates a commentary in the latest issue of the Journal of the American Medical Association.

The authors ask: Do nice patients receive better care?

If the same standard of care is to be applied to everyone, the patient’s demeanor shouldn’t make a difference. In the real world, however, “anyone on the front lines of clinical medicine knows that there is considerable variation in the way patients interact with their health care professionals,” wrote Drs. Allan S. Detsky and Mark O. Baerlocher.

At one end of the spectrum are patients who “communicate well, understand their problems, are able to make decisions, adhere to diagnostic and treatment plans, are pleasant, and express gratitude for the services they receive.” At the other end are patients who… well, do not fit any part of this description.

What makes a patient “nice” is, of course, somewhat in the eye of the beholder. There’s nothing wrong with challenging the doctor’s opinion or assessment, and indeed there may be times when the patient’s health depends on speaking up. Nor is there necessarily anything wrong with well-placed criticism of aspects of the doctor’s practice that are unhelpful or outright dysfunctional.

But it’s human nature to prefer the company of people who are “nice” and to want to help them more than those who aren’t so nice.

This is a lesson that many patients (although not all) seem to have learned well. “Being ‘nice’ has to start from the moment you walk into the clinic. If you make the receptionist or nurse mad you are doomed even before you see the doctor,” someone in an online cancer forum wrote in response to the JAMA commentary.

The therapeutic relationship also seems to be more successful when the doctor and patient genuinely enjoy each other’s company.

Whether a bias in favor of niceness is best for patients, though, isn’t so clear. Doctors who want to go the extra mile for a patient whom they like might be more aggressive about ordering tests or recommending procedures that can be expensive, not particularly beneficial or possibly even harmful, the JAMA commentary points out. Sometimes doctors allow “nice” patients to get away with stupid stuff rather than holding them accountable.

What does this all mean for patient care? Maybe not much, since the clinical guidelines tend to be the same regardless of whether the patient is nice or unpleasant. Now that the question has been raised, however, doctors (and patients) might be more aware of the biases – positive as well as negative – that can creep into the relationship.

The doctor is late? Here’s my bill

After waiting two hours to see her doctor for a scheduled appointment, Elaine Farstad got angry. She went home, calculated her hourly pay and sent a bill to the doctor for her time.

“It’s ludicrous – why would I wait for free?” Farstad told CNN in a recent story for its Empowered Patient series. Over the years she has billed six doctors who were more than 30 minutes late; half of them paid her.

Few things rile up patients more than long waits at the doctor’s office. For years, most people simply complained and put up with it. But when patients like Farstad start sending invoices for their time, it seems the balance of power decidedly is changing. Especially if the physician actually agrees to pay the bill.

It’s not clear what to make of this trend, if it indeed is a trend. CNN talked to a doctor in New York who gives patients $5 in cash if they have to wait longer than 15 minutes for their appointment. Another physician in Oregon gives gifts of handmade soap or lotion whenever patients have more than a 10-minute wait to see her. Is this the norm? I doubt it (although it sounds nice).

Judging from the 1,200-plus comments, the CNN article obviously hit a nerve. A similar discussion has been raging at Kevin, MD, here and here.

The debate might seem simple. Beleaguered patients vs. greedy doctors. Hard-working doctors vs. demanding, self-entitled patients. If one thing emerges from the discussion, though, it’s that both patients and doctors are frustrated by the wait-time issue.

Do doctors often keep patients waiting? Of course they do, for a variety of reasons they can’t necessarily control. Dr. Emily Gibson writes:

The patient who is angry about waiting for me to arrive in the exam room can’t know that three patients before them I saw a woman who found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self-injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection, but is showing signs of a pulmonary embolism caused by oral contraceptives.

Patients themselves can contribute to the doctor’s lateness by showing up tardy for the appointment, rambling instead of answering the doctor’s questions directly, raising too many issues to address in a single appointment, and waiting until the doctor’s hand is on the doorknob to bring up their most important concern.

The other side of the story? Some practices are disorganized and inefficient, resulting in a physician who’s consistently behind schedule. Sometimes appointment slots are double- or even triple-booked. Some organizations seem tone-deaf to patients’ frustrations with long waits – for instance, clinics like this one, who don’t book appointments for X-rays and thus force patients to literally stand in line waiting their turn. And what about practices who charge patients a late fee if they don’t show up on time, yet don’t hold themselves to the same standard?

Some of the research on patient satisfaction suggests it isn’t the lengthy waiting time that upsets patients; it’s lengthy waiting times with no information. Studies on this issue have found that when patients know the doctor is behind schedule, they want to be told – and they also want to be given the option of coming in later or rescheduling the appointment.

In another study, researchers analyzed patient satisfaction data that included wait times and the amount of time spent with the doctor. Their conclusion: Although long wait times are associated with lower patient satisfaction, what seems to matter most is the quality of time spent with the doctor. Patients who spent a long time in the waiting room and then were hurried through their appointment reported the lowest satisfaction. But when patients felt they had adequate face time with the doctor, they were more likely to view a longer wait as an acceptable tradeoff

What do readers think? At what point does the wait become too long – 20 minutes? Half an hour? Do you think it’s acceptable to bill the doctor for your time? (For what it’s worth, I think this is a bad idea – sure to tarnish the relationship and put the physician on the defensive, as well as being a poor use of health care dollars.) Share your thoughts in the comment section. If there are any clinicians out there, I’d be interested in your reaction as well.

Photo: Wikimedia Commons