The Enid News and Eagle, Enid, OK

February 23, 2013

The challenges of rural health care

Communities continue to find ways to keep health care facilities open, services available

By James Neal, Staff Writer
Enid News and Eagle

ENID, Okla. — As the nation’s health care industry adjusts to implementation of Patient Protection and Affordable Care Act, or so-called “ObamaCare,” some of the greatest challenges and changes may be seen in delivery of health care to rural areas.

Autonomous rural hospitals, already in decline before 2010, are increasingly moving toward affiliation with larger, corporately-held hospitals to better manage the bureaucratic requirements of new federal health care mandates.

Changing models

Jeff Tarrant, president of Integris Bass Baptist Health Center, already is familiar with the model of rural clinics connected to larger metro hospitals.

From Enid, Integris staffs and manages clinics in Garber, Hennessey, Medford, Waynoka, Cherokee and Caldwell, Kansas.

Tarrant said some of the affiliated rural clinic staff work full-time at their clinic location, while others split their time between Enid and the remote clinics.

He said staffing rural clinics is “based on the size of the community and the need for our presence.”

Integris also works out of clinic space in rural hospitals, as it does at Seiling Municipal Hospital.

The challenge for any rural health care provider, Tarrant said, is in filling the patient volume needed to meet staff and facilities overhead.

“That issue is typically related to community size, and with a clinic in a community the size of Waynoka — that’s a wonderful service and it’s a wonderful community, but there’s a fixed overhead expense just to have that facility open, and it’s a challenge.”

Tarrant said many communities, like Waynoka, would not have local health care without affiliated clinics.

“That’s a great example of a community that, without that clinic being there, people would have to travel quite a ways to receive care, and we see that as an extension of our mission.”

Tarrant said challenges of patient volume in rural areas can be overcome by tailoring services to community needs. He said that kind of creative efficiency becomes more necessary as the federal health care law reaches full implementation.

“I’d like to say (the future of rural health care) is as bright as ever, but the tone for health care across the country is that things don’t get easier from here,” Tarrant said. “They’re going to get tougher. I hope that’s a message to our industry that we need to operate more efficiently. I would be shocked if we don’t see some evolution of how things have traditionally been done.”

Tarrant said that evolution in rural health care likely will entail most unafilliated rural hospitals seeking affiliation with larger providers, in order to benefit from larger administrative structures and stronger purchasing power.

“In terms of gaining efficiencies and economies of scale, having an affiliated provider can help make those hospitals a more financially viable option,” Tarrant said. “I think we will see more of that affiliation, and smaller hospitals will look for affiliation to gain that economy of scale.”

He said affiliation isn’t something that should cause concern for rural residents.

“If that (affiliation) solidifies the delivery of health care in some of the communities in northwest Oklahoma, I think that’s something even the communities should celebrate,” Tarrant said. “The loss of autonomy is a lot less onerous than the potential loss of health care.”

Administering duties

Roger Knak, CEO and administrator of Fairview Regional Medical Center, said the transition to affiliation is necessary because of payment structures and increased administrative overhead associated with new federal health care mandates.

“The days of the true, stand-alone small hospital are coming to a rapid close,” Knak said.

Those days came in January for Fairview Regional Medical Center, when the board of the previously unaffiliated hospital voted to sign and affiliation agreement with St. Anthony Hospital of Oklahoma City.

Knak said Fairview Regional Medical Center will retain its name, local board control and essential autonomy but will receive “strategic support” from St. Anthony in administrative support and health care planning.

“It’s really hard for a small, community hospital to do all those things,” Knak said.

He said the partnership with St. Anthony Hospital will “allow them to take care of more of the federal health care mandates for us, and give us stronger physician alliances to help keep our physicians up to date with the changing world around us.”

Okeene Municipal Hospital also is seeking stronger affiliation, strengthening an already-existing agreement with St. Anthony Hospital.

Shelly Dunham, CEO of Okeene Municipal Hospital, said the hospital has had an affiliation agreement with St. Anthony Hospital for five years. She said she and the hospital’s board are “looking at a different agreement to tighten that affiliation.”

“Small, rural hospitals without an affiliation just can’t continue to survive with the health care reform law and the call for ACOs (accountable care organizations),” Dunham said. “As a small hospital, it’s hard to do that.”

Tough shoes to fill

Aside from the adjustments in affiliation brought on by the new federal mandates, Dunham said an ongoing challenge is recruiting physicians to serve in rural areas.

She said one of her physicians is retiring in March, leaving a space that is increasingly difficult to fill.

“It’s not easy for a small community to recruit a physician,” Dunham said. “We’ve been working with a recruiter, but that’s a lot of money to pay the recruiters, and it’s a challenge.”

Tim Starkey, CEO of Great Salt Plains Health Center, also said physician recruitment is his biggest ongoing challenge.

GSPHC operates two clinics, in Cherokee and Medford. Both clinics operate with the assistance of Health Resources and Services Administration Health Center Program grants, which provide partial compensation for providing health care to uninsured and low-income families.

“It’s just tough to get doctors to come to rural communities,” Starkey said. “It’s definitely a competition between communities, and the small towns just lose out sometimes.”

Starkey said he has been working with a recruiter for six months to attract a physician to the GSPHC clinic in Medford, but the position remains open.

Starkey said it is easier in rural areas to recruit nurse practitioners and physician assistants, “but rural folks want to see a doctor in their community.”

Overcoming obstacles

Despite the ongoing challenge of recruiting doctors, Starkey said GSPHC is considering expanding its grant-funded clinics to a third community.

He said the GSPHC board has considered several communities, but nothing has been finalized, and GSPHC is in the early stages of applying for the extra grant.

“We’re applying for the grant, but it’s very competitive, and only 25 sites will be selected nationwide,” Starkey said. “The likelihood of us getting funded is fairly low at this point. We think it’s worth going ahead and sending in the application in case there’s more funding down the road.”

Starkey said GSPHC will look for a community not already being served by primary health care services, if they receive the additional grant funding.

“It’s really about working with the local communities,” Starkey said. “Some communities already have primary care practices. We’re looking for communities where we can go in and not compete with other providers already in the community. Our mission is to serve communities that have lost their hospital, or don’t have a hospital in the rural areas.”

Opportunities out there

As rural health care providers continue to adjust to changing federal health care mandates, changing affiliations, and changes in available funding, some see a bright spot on the other side of all the change.

“Health care is sitting in a scary place right now, but it’s also a great opportunity,” Knak said.

He said the new health care structure’s increased emphasis on prevention “moves us from sick care to health care.”

“That’s what we need to get more into the market of,” Knak said, “is making our community healthier, so they don’t need as much health care.”