By Rose Hoban
Members of a committee examining access to care for people in rural North Carolina hit the road last week, bringing lobbyists, lawmakers and legislative staff to Columbus County, two hours southeast of Raleigh, for a hearing.
Three members of the Committee on Access to Healthcare in Rural North Carolina held their third meeting at the Columbus Regional Healthcare System hospital in Whiteville, pop. 5,509, the administrative seat of a county with only about 61 people per square mile.
“Whiteville is a very unique place in that it is a very rural community, still has a very traditional rural-based economy, but it is a community that still is somewhat vibrant,” said committee co-chair Rep. David Lewis (R-Dunn). “So we thought this would let us see the challenges that are faced by even a more successful or more wealthy community. Certainly, if this hospital faces them then one in a poorer community will have more challenges.”
Committee members heard formal presentations from the head of hospitals in Columbus, Robeson and Scotland counties, all facilities serving primarily rural populations. The three counties consistently rank at the very bottom of annual county health rankings, and each has some of the highest rates of poverty in the state.
The three hospital CEOs talked through their telehealth initiatives, the challenges of recruiting and keeping health care providers, and emergency departments jammed with behavioral health patients.
The presentations were followed by a relatively freewheeling lunchtime discussion with the hospital leaders, something usually not allowed for in an ordinary hearing. The CEOs discussed what they need to survive in an increasingly consolidated and competitive health care marketplace marked by non-paying and uninsured patients, decreasing reimbursements from commercial insurance plans, and uncertainty facing governmental payers such as Medicaid and Medicare.
“We’re serious about trying to make a difference and improve access to health care,” Lewis told the CEOs.
Call a doctor
Each hospital leaders described their use of telehealth services to fill some of the gaps in care created by personnel shortages.
Columbus Regional chief nursing officer Terri Veneziano described her organization’s expanding use of services such as telepsychiatry and participation in a telestroke network.
Veneziano, who relocated last year from New York City, said she never had an appreciation of what these types of services could mean to a rural community.
It costs $12,000 per month just for the telepsychiatry service, Veneziano said. Despite paying for the telestroke and telepsychiatry services to be present in their facilities, she said the hospital can’t bill for them, in part because the services use physicians who are in other states to deliver the consultations.
But Scotland Health Care System CEO Greg Wood said the hospitals can come out ahead, despite the cost. Wood told of how one of his former board members was on the receiving end of telestroke services during the previous week.
“This little R2D2 camera wheeled right in!” Wood said his board member told him. The man thought he was having a stroke. Within two minutes in the ER, he had a neurologist on the line to confirm that he did not need a stroke-busting drug.
The physician on the telestroke service was also able to determine the patient didn’t need to go to a larger medical center to see a neurologist, so he was able to have tests and recuperate in a hospital close to home for several days.
“It worked out well for the patient,” Wood said. “We’d never be able to recruit that capacity to a small town.”
Recruitment strategy: Attract residents
Wood and the others said that problems with recruiting medical talent was ongoing, describing difficulties finding doctors, nurses and other professionals for their facilities.
“We currently need 19 primary care physicians and 11 specialty providers,” said Southeastern Regional Medical Center CEO Joann Anderson. “We have had two OB physicians leave our community; a third is in the process of leaving. That leaves me with one full-time OB/GYN and one GYN.”
Each year, 1,500 babies are delivered at her facility.
“If you Google Robeson County, the statistics that come up are negative statistics, in terms of where you might want to live,” she said.
Anderson described her facility’s long-term recruitment strategy: Becoming a site for medical residents, who are more likely to stay in the communities where they train.
Anderson’s facility has partnered with Campbell University to provide a place for osteopathic physicians from the new medical school to perform post-academic training. But that comes with a big price tag.
“It was a little over $11 million for this year,” Anderson said. “The cost of that was the salaries for each of the residents, faculty costs, the location, the space that we had to provide for them, all the equipment they had to have. For example, we had to buy three ultrasound machines for them to use, each costs thousands of dollars.”
“A lot of things went into that figure.”
Anderson said she’s only starting to see the return on investment, four of the nine primary care residents completing training will stay there.
“We have four who have signed to stay in Lumberton, a fifth is in negotiations with me today, two … will stay in North Carolina in the western part of the state,” she said. “That’s just the beginning.”
She also said the hospital had more than 600 applicants for six slots for emergency medical residents.
On top of costs for residents, Anderson said her hospital spent about $8 million on contract nurses last year because of a local shortage.
Wood also spent millions on contract nurses and reiterated the need to train nurses at the local community college to keep them. He also pointed to the increasing trend of hospitals having to hire their physicians. To keep their long-time ear, nose and throat specialist, Wood had to pay dearly.
“He’s been pushing us for three years to help him run his practice, he keeps losing money,” Wood said. “He finally showed up and said I have two offers to leave town. He’s the only ENT in town. Do you want to employ me or do you want to see your ENT service lose?”
To employ him, Wood had to fix up his office, replace his computer system, hire more staff and pay him more.
“I had to go to the board and say, ‘We want to employ this ENT physician, something we used to get for free for his services and it’ll cost us a few hundred thousand dollars,’” he said.
His board approved.
Tip of the iceberg
The CEOs also discussed the skyrocketing costs for behavioral health patients that are currently filling emergency department beds, competition in their urgent care business, and high rates of uninsured, Medicare and Medicaid patients, who bring with them poor reimbursement.
Add to these challenges the federal budget has made cuts to programs to provide loan repayment for providers willing to serve in high poverty rural areas.
After tours of the emergency department and the cancer treatment center, Lewis said he was looking to roll out some relief in the upcoming legislative short session, that begins in May. He mused that the relief might take the form of changes to residency training reimbursement and paying for telehealth services.
“We said, if we can make one thing better, if we can make one person just a little bit healthier, then this will have been well spent,” Lewis said.