The cost of doing nothing

It has been more than a month since the federal health care reform bill was signed into law. The fallout is continuing; we’re still trying to figure out what the impact and the unintended consequences will be.

What I haven’t seen yet is much discussion of how health care reform will affect rural communities. Will it be a disaster, as some are predicting? Or will it be beneficial, if for no other reason than making health insurance more accessible?

Linkworthy 2.2: the weekend edition

If the weather forecast can be believed, it looks as if we have a perfect spring weekend ahead of us to spend outdoors. But in case you have some down time, here’s some worthwhile online reading:

Had enough yet of health care reform? I haven’t, so I found this to be an interesting commentary by Bob Doherty, who blogs about health care policy for the American College of Physicians. It appeared this week in the Annals of Internal Medicine and explores what we know – and what we don’t know – about the impact of health insurance reform. Doherty suggests "we should all take a deep breath" and try to look at the health reform bill more objectively. An excerpt:

Supporters and opponents alike must humbly recognize that no one knows how this complex legislation will play out. Some effects – like reducing the number of uninsured Americans – might be assessed with a higher degree of confidence than, say, longer-term estimates of the effects on the deficit and health-care costs.

For some online discussion and reaction to Doherty’s article, you can check out the comment thread on his blog.

How will the health reform bill affect the private insurance industry and, by extension, the industry’s customers? The Health Care Blog examines the myths and the facts. Maggie Mahar predicts there’s likely to be a shakeout in the insurance industry: "These new rules will make our health care system fairer and more affordable. But the rules also suggest that for-profit insurance may not be a viable business unless insurers learn far more about what is best for patients."

Challenges, challenges. Then again, this is nothing new in rural health care, which all too often gets overlooked when policymakers start carving out their turf. The Wisconsin State Journal of Madison recently launched an intriguing series of stories that explores the unique issues that characterize rural health. The first story addresses the doctor shortage; the second takes a look at the social and geographic factors that may be responsible for a growing gap in health status and outcomes between rural and urban/suburban residents.

The second story, "Life and Death in Park Falls," appears to have sparked some passionate debate among readers, and the comment thread is well worth reading for the extra dimension it brings to the discussion. Many people thought rural health providers didn’t get enough credit for what they do. Wrote one person, "Here in Park Falls I am not just a number, I am a neighbor. The article made it sound like we have no health care but actually we have a very good hospital and clinic and well-trained doctor and nurses."

How much of this is about being willing to make tradeoffs? "Anyone with a major health problem planning to retire in the northwoods should consider the lack of available quality health care before making that move," one person commented. But someone else countered, "Northwoods culture is not about being a hick (not to say we’re Vermont). It’s about enjoying the outdoors and a lifestyle that can only be found in our state’s natural, rural areas. I agree that rural health is a major issue, but those of us that live here are well aware of our choices."

Most of us have seen those lists of "top doctors" that get published from time to time. But are the top docs really all they’re cracked up to be – and are these rankings a good basis for choosing one’s own physician? Dr. Aidan Charles is skeptical, as he explains on his blog in "Beware the Top Docs":

It is only human to seek perceived leaders. But as sometimes seen in politics, those who have reached the pinnacles are often motivated by ambition, charisma and gamesmanship instead of altruism, sincerity and merit.

Dr. Charles also takes on the online rating sites and the insurance rankings based on quality measures.

What if the rest of life was managed like health care? Would we need preauthorization before ordering a meal at a restaurant? Would we unexpectedly get hit with a high deductible for car repairs? Dr. Rob Lamberts speculates on what it would be like in a pair of entries at his Musings of a Distractible Mind blog. The crazy world he describes is entertaining, absurd yet oh-so-close to reality.

Oh dear. Oh dear. Is it OK for doctors to Google their patients? Dr. Kevin Pho wonders on his blog about the ethics of doing this. As long as the information is publicly available, why should it matter? Patients can Google their doctors, after all. It might even be helpful in, say, the case of a psychiatric patient who’s posting threats online, or someone who arrives unconscious in the emergency room. There appear to be few guidelines that address this, Dr. Pho writes, but he suggests that ferreting out online information about a patient isn’t something physicians should routinely do. He himself has "never Googled a patient and can’t see any reason to in a primary care setting."

The lesson for patients, I guess, is to be careful about your online persona. If your physician can Google you, so can everyone else. Just thinking about it has made me decide to end this post

HealthBeat photo by Anne Polta

Building boom on the prairie

There’s been a fairly significant hospital building boom out here on the Minnesota prairie over the past decade. I didn’t realize how extensive it was until I started collecting information last month for the West Central Tribune’s annual Focus section. Since 2000, virtually every hospital within a 50- to 60-mile radius has undertaken some kind of strategic or capital project. If you add up all the construction projects, they total somewhere around $150 million – and there are probably several I’ve missed.

Hospital and clinic building projects can sometimes be accompanied by ambivalence from the public. People might wonder: Do we really need this? Why is it so fancy? Is it going to drive up the cost of health care? Can’t we just get by with what we have?

To be sure, these are valid questions. The hospital industry in the U.S. has invested millions in bricks and mortar in recent years. It hasn’t always been clear whether all this construction is entirely for the benefit of patients or whether it’s aimed at enhancing marketability, particularly in communities where there’s competition.

From what I’ve seen of the health care projects in this region of Minnesota, however, the investment looks well-justified.

Most of the smaller critical access hospitals were built in the 1950s with federal Hill-Burton money and were beginning to show their age. Some had hardly been altered since the day they opened their doors. If you think back to how health care has changed over half a century, it becomes pretty clear that these hospitals won’t survive if they don’t keep up.

Some of the demands are practical – for instance, the need to accommodate technology that hadn’t even been envisioned 50 years ago. Others are a little harder to measure. If a facility isn’t up to date, how well is it going to be able to attract health care professionals who want to work there? Do patients want to come to an aging hospital or clinic, or will they decide to go somewhere else? Like it or not, amenities do matter, especially when they’re conspicuously absent.

The bigger issue at stake is whether the small rural hospitals can remain viable. If they can’t stay current, they’re risking not only their own future but the entire fabric of local health care services.

I was around when Rice Memorial Hospital started planning its four-year, $52 million building expansion and renovation more than 10 years ago. I remember the patient rooms in the west wing and how cramped they were. I remember how dark the lobby was. I remember the thick walls in the original 1937 wing and their utter resistance to anything so modern as fiber optic wiring.

If you’re really an old-timer, you might recall that at one time the CT scanner was housed in a room at the end of the radiology wing. For an imaging study, you had to don your gown in the locker area, then traipse back through the waiting room and down the hall for your scan – not very dignified or private (although it was a step up from the mobile services of the 1980s and early 1990s that required patients to go out into the parking lot to reach the trailer where the mobile scanner was housed.) The patient rooms in the old intensive care unit were so small, they barely accommodated ventilators, monitors and all the other high-tech equipment that’s now required.

That’s just my experience, albeit limited, as a former patient/visitor. Imagine what it’s like to be an employee in an older facility, trying to provide good patient care in an environment that constantly limits what you’re able to do. Imagine trying to adapt and plan for the future in a building whose structure you’ve outgrown.

All of this is to say that hospitals can’t afford to sit still when it comes to investing in their physical plant. So if I had to pick a word to describe the construction philosophy of the region’s hospitals, it would probably be “wise.”

None of these projects were lavish or overly ambitious. They met basic community needs. They took future needs into account. And they were undertaken at a time when the cost of construction and renovation was still within financial reach.

Have they raised the cost of care? If you visit the Minnesota Hospital Association’s hospital price check site, it’s pretty clear that charges for inpatient and outpatient procedures at local hospitals hover right around the median. There’s a case to be made, of course, that hospital construction around the state is helping to drive up the total overall cost of health care. But local prices do not appear to have been pushed beyond the norm as a result of the regional building boom.

The region’s hospital boards and hospital officials could have chosen not to take the risk inherent in financing a construction project. They could have made do with what they had. Ultimately, though, I don’t think this would have made them good stewards of local health care resources. There was a chance here to be smart and forward-thinking, and they seized it. And in the long haul, I suspect the region’s health care infrastructure will be better off because of it.

Image: Kirk Stensrud, CEO of Glacial Ridge Health System, outside the new entrance of the hospital and clinic in Glenwood. The $10 million project was completed a year ago. West Central Tribune photo by Tom Cherveny.

Growing our own


I have a cousin who’s a long-time family practice physician in the southern Minnesota town where he grew up. He probably could have gone anywhere, but he chose to settle in his home town after finishing medical school and he’s been a doctor there ever since.

When it comes to recruiting rural physicians, this would be considered a success story. Many times, however, it doesn’t work out this way.

Rural communities generally find it harder to attract and keep physicians and other health care professionals. If you don’t believe this, take a look at the numbers in this study by the Minnesota Department of Health’s Office of Rural Health and Primary Care. Doctors are not distributed equally throughout Minnesota. The seven-county metro area accounts for 54 percent of the state’s population and has 60 percent of the state’s practicing doctors. Rural Minnesota has 46 percent of the population but only 40 percent of the physicians.

Some of this maldistribution is simply due to a higher concentration of specialists in urban centers. Rural communities, after all, don’t have a large enough population to sustain some of the narrower specialties such as neurosurgery. But it’s also more difficult for rural communities to compete for physicians, period.

It’s not impossible, however. Indeed, some of the best successes happen when rural communities adopt careful, purposeful strategies to nurture local interest in health care careers and support future health care professionals while they’re undergoing training – in effect, growing their own workforce.

I bring this up because Kathy Huntley, the executive director of the Southern Minnesota Area Health Education Center, retired at the beginning of October. She has been the first executive director of this still relatively new program and has had the challenge of developing new programs and partnerships to encourage health care careers in rural southwestern Minnesota.

It might sound hard to believe, but until 2002 Minnesota didn’t have a formal, statewide program devoted to building a rural health care professional workforce. There are now four Area Health Education Centers (a fifth is in the process of being established) whose main academic partner is the University of Minnesota. Rice Memorial Hospital in Willmar is the host site for the Southern Minnesota AHEC, which covers more than 20 counties.

Most people are probably unaware of the magnitude of the effort to foster rural health care careers. A couple of years ago I had the opportunity to visit the Lac qui Parle Valley High School on a day when Wendy Foley, the Southern Minnesota AHEC program coordinator, was giving a great interactive and hands-on presentation to the students. Not all kids have the desire or the aptitude to go into health care, of course, but for those with even a glimmer of interest, this is exactly the kind of program that can help light the spark.

Nurturing health care careers among school-aged youngsters is one of the AHEC’s roles. Connecting students in the health professions with training opportunities in rural areas is another. Both of these are strategies that have been shown to work. Health care professionals – physicians, nurses, pharmacists, nurse practitioners and so on – who grew up in a rural community are more likely to live and practice in a rural setting. Students in the health professions who’ve had a chance to experience rural health care also are more apt to choose a rural practice when they complete their training.

These are the figures for the University of Minnesota Medical School’s Rural Physician Associate Program, a nine-month rural rotation that’s available to students during their third year of medical school. From 1971 to 2008, 63.5 percent of the students who participated in the program are now doctors in Minnesota, and 38.4 percent of them are in rural communities. That’s 366 physicians practicing in rural Minnesota who might otherwise have gone somewhere else.

Accomplishing this isn’t easy and it doesn’t happen overnight. Youths interested in a health care career need to start exploring their options early, preferably by ninth or 10th grade, so they can get involved in the coursework and extracurriculars that’ll best prepare them for their future training. Even at this pace, it can still be 15 years or longer before they graduate from high school, graduate from college, finish their training and are fully qualified to care for patients.

For students in the health professions, it’s also critical to have hands-on clinical experience and to be exposed to rural health care early in their training. What many people may not recognize is that in order for a community to be a training site for these students, it takes time and resources. This is especially the case for small rural clinics and hospitals. It’s labor-intensive to mentor medical and nursing and pharmacy students, to supervise them and to plan learning experiences that will be enriching and beneficial. Willmar has been one of the leading – and most successful – sites for the Rural Physician Associate Program but there’s a cost for doing so, and this cost often remains invisible to most people.

In one of the last conversations I had with Kathy Huntley, she made the observation that when she first became the Southern Minnesota AHEC executive director and began traveling to hospitals and clinics around the region, one of the things she kept hearing was that they didn’t have the time or the staff to supervise students in the health professions. They didn’t have the resources to offer job-shadowing or classroom experiences for interested high school students. But more recently, Kathy has seen this change as more and more communities realize the stake they have in helping grow their own health care workforce.

It’s a pretty impressive legacy for someone to leave for the future.

Update, Oct. 14: Here’s another take, from the New York Times, on a Utah community that boasts homegrown medicine.

HealthBeat photo by Anne Polta

A gulf of disparity

Geographic disparities in Medicare payment rates have long been talked about – and complained about – among the nation’s rural health care organizations and practitioners, especially in the rural Midwest. But it took an eye-opening article in The New Yorker, and the looming prospect of health care reform, to finally get policymakers to sit up and really take notice.

In his now-famous article, Dr. Atul Gawande uses McAllen, Texas, as an illustration of the wide regional differences in how much Medicare spends per person:

It is one of the most expensive health-care markets in the country. Only Miami – which has much higher labor and living costs – spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average.

There have always been geographic variations in health care spending, physician practice patterns and health care consumption patterns. The rural Midwest, for instance, tends to be more conservative, both in its use of high-dollar health care services and its overall spending on health care.

Even so, most people are taken aback when they see these patterns visually represented on a map:

The map was developed by the Dartmouth Atlas of Health Care, which has been tracking this data for more than two decades. The darkest areas on the map show where Medicare reimbursements per enrollee are highest. You’ll notice the lightest areas, where Medicare spending is lowest, include almost the entire state of Minnesota.

If you were to go back in time to 1965, when the federal Medicare program was established, the map likely would look very similar. In fact, Medicare payment rates were originally established using a formula based on prevailing costs in a given geographic area. Over the years, these regional variations have become more or less cemented into place, and in many cases the gap has widened even further.

The Dartmouth Atlas Project notes, for instance, that between 1992 and 2006, inflation-adjusted spending on Medicare rose 3.5 percent each year. In Miami, however, it grew faster, at the rate of 5 percent a year. In San Francisco it grew a slower 2.4 percent annually. If Medicare spending in all other regions in the U.S. grew at the same rate as that in San Francisco, a cumulative savings of $1.42 trillion could be achieved by 2023, the Dartmouth analysts estimate.

What’s especially intriguing is that the quality of care doesn’t appear to be any better in high-cost regions of the U.S. than it is in the regions that spend less on health care. In fact, the lower-cost regions usually score better on quality measures.

There can be many reasons why health care spending is higher in certain communities. Perhaps the population is older or sicker or has a higher incidence of chronic disease. Maybe there’s a higher concentration of medical services or medical specialties. In areas that spend less, poverty may be more prevalent.

The Dartmouth researchers believe there’s an overriding reason, however, for the geographic variation in health care spending. They sum it up in two words: local context. It’s in how local physicians run their practices and the types of interventions they provide for their patients. It’s in how local hospitals and health care organizations make strategic decisions, such as acquiring new technology or adding new services. It’s hard to imagine that patient expectations – surgery, for instance, vs. trying more conservative treatment first – don’t contribute as well.

Put another way, it’s about local culture – the values, attitudes and behaviors that often are so ingrained, we rarely notice or question them.

So here’s the really big question: If some states, such as Minnesota, can spend below the national average yet still provide good care, why can’t all states do this? If all states did this, could costs be lowered without sacrificing quality?

One of the fears being voiced at town halls and in online forums is that if we reduce health care spending, someone will have to go without. But if the Dartmouth Atlas data is any indication, many states are already doing this and managing to preserve some quality besides.

Changing local culture can be incredibly hard, especially when so many Americans have been conditioned to think that more health care is invariably better. And when all is said and done, the culture of local health care communities is still a single small slice of an enormous, complicated system. Achieving genuine change will take far more than realigning local or regional habits and expectations of how health care should be provided.

The point, though, is that we often overlook the local. We tend to search instead for outside explanations and solutions, when all along we could be looking a lot closer to home.

Paying for sickness, penalizing for prevention

In case you missed it, the Minneapolis Star Tribune ran a thought-provoking commentary Sunday on how out of whack the Medicare payment system has become.

An excerpt:

Simply put, Medicare pays for putting patients in the hospital but not for keeping them out. So for every (congestive heart failure) patient in the program who avoids a hospital stay, Park Nicollet loses about $4,600.

Talk about rewarding success with punishment. What medical center grappling with this economy can afford to add a program further weakening its institutional bottom line?

Providers call this the "perverse incentive" issue. The goal should be to keep patients healthy. Yet providers are only rewarded when patients get sick enough to come into a clinic or need hospital admission.

The Willmar community received a painful lesson about perverse incentives last year when Rice Memorial Hospital eliminated two outpatient chronic disease management programs, one for diabetes education and the other for congestive heart failure. Both were long-standing programs; the diabetes program had been around since the 1980s. Willmar providers recognized a long time ago that if diabetes and congestive heart failure could be managed more intensively, patients would fare better and would be less likely to experience costly complications or an expensive hospital stay. By all accounts, these were excellent programs that provided a valuable service to patients. More importantly, they resulted in better outcomes.

But they also were money-losers for the hospital. The diabetes program alone lost more than $1 million last year before it was terminated in mid-September. And Medicare isn’t the only culprit here. Many of the private-sector health plans for the younger, working-age population are unwilling to pay for the level of clinical management and patient education it often takes for someone to live well with a chronic disease.

Rice Hospital’s image took a hit for making the tough decision to eliminate services. Patients and the public were upset and unhappy. As harsh as it sounds, however, the financial reality is that a 99-bed community hospital like Rice can’t indefinitely absorb this kind of loss without jeopardizing other services.

Luckily for local patients, Willmar medical providers stepped in to save both programs. The congestive heart failure program is now being offered by Family Practice Medical Center. The diabetes program, now known as the Willmar Diabetes Center, has been taken over by Willmar Medical Services, a joint venture between Affiliated Community Medical Centers and Rice Hospital.

Given how the payment system is misaligned, it frankly took a leap of faith, along with a strong dose of community-mindedness, for these organizations to accept the risk, knowing they might lose money by doing so.

It’s to be hoped that in a different setting, with economies of scale, the diabetes and congestive heart failure programs can keep going. The payment disincentives haven’t gone away, after all. They’ve just been transferred to other organizations who now have the challenge of trying to provide good care for patients – and save money for the health care system overall – without hurting their own bottom  line.

Does any of this make sense? It’s not fair that providers get financially punished for keeping their patients well, yet are rewarded for using costly services when people become sick. It’s not better for patients either, who are paying for this too in the form of higher insurance premiums and higher out-of-pocket expenses.

But until it gets fixed, this is the system we have, perverse incentives and all.

Top 10 rural issues for health care reform

In the national discussion on health care reform, it’s important not to ignore or overlook the needs of the rural United States, contends the Center for Rural Affairs.

The think tank has put together a list of the top 10 issues that deserve consideration. The paper’s author, Jon M. Bailey, suggests using it as a checklist against which bills and policy proposals can be evaluated.

Here are Bailey’s top 10:

– Health insurance access and affordability, especially for small businesses and the self-employed.

– The strength of publicly funded health programs such as Medicaid and SCHIP, on which many rural residents rely.

– The rural health care delivery system.

– The rural health care work force.

– The needs of rural seniors.

– Access to health care services and coverage for rural people who have chronic conditions and/or disabilities.

– Preventive care and wellness resources.

– Access to mental health services.

– Health information technology.

– Emergency medical services.

If you’d like to weigh this list against the White House’s current proposals for health care reform, you can read more extensively about the Obama administration’s priorities at And there’s more information at the Center for Rural Affairs Web site about its own agenda for health care reform.