“I left our CAH almost 8 years ago and started a Direct Primary Care clinic. It operates purely in the free-market economy and is thriving. Small regional hospitals are now coming around to my way of thinking and are now beginning to bundle things like radiology studies, and surgery, etc. to compete with each other for cash business, and it’s making them money and saving patients money. These hospitals have to find loopholes in the bureaucracy to do this (the government and the trillion-dollar insurance companies who control the elected officials in the shadows love the status quo and want prices to stay high).“
I just read THIS ARTICLE from Forbes; it’s about the rural-urban healthcare access gap.
I could probably write pages about this topic but I’m going to TRY to be brief. I’ll start here: This author, I suspect, has not actually witnessed the difference between rural and urban healthcare. She’s not wrong about some things though.
Rural healthcare and access to it isn’t always as bad as this author indicates, although it is definitely getting worse, and in some areas, it is a big problem. In fact, it’s often better than in urban areas. It’s probably irresponsible to over-generalize this phenomenon in either direction.
I have had the unique experience where I’ve lived and practiced Family Medicine in rural Kansas for over 20 years while watching my sister and her family move from Omaha to Kansas City to Denver to Oklahoma City to Houston during those same years. There is ZERO question that the healthcare my patients have received and had access to (even when I worked inside the rural “Critical Access Hospital” (“CAH”) System before I transitioned to Direct Primary Care) is worlds better both in terms of quality and availability than the care my sister’s family received in all five of the very urban areas they’ve lived.
Stories of my “well-insured” sister’s family’s abysmal healthcare access in these urban areas could be a book of its own. Not to say the care’s not there, but it being there and it being accessible or quality are two very different things. Sure, because there are more people in the big cities, there are more doctors there. But the ratio of doctors to people is very very low, because of the huge population, so it often takes days, weeks, even months to gain that access that is claimed to exist. Meanwhile, the government-subsidized CAHs the author refers to: yes– they have fewer doctors. But the regions have WAY fewer people, often making the ratio of doctors to people at least comparable if not somewhat better than their urban counterparts, in many rural areas. I’m not saying the docs sit around twiddling their thumbs, far from it. We’re very busy out here, often too busy and burning out, with some towns far worse than others. But the healthcare access horror stories my sister unfolds for me have never occurred in my town of 4,500 people. So plainly stated: Access isn’t any worse, and at least in MY rural area, it’s much better.
Of course, how one defines “access” is relevant to this conversation. We don’t have a heart surgeon here. If you need heart surgery, you’re driving. But so what, that’s the price we pay for living in God’s country. The same thing goes for anything specialized of any kind. When I need filament for my son’s 3D printer, which I use way more than he does, it’s not available here. I’m either driving nearly 2 hours to the city or ordering it online. That’s the reality of rural life and I’m very much ok with that– I’ll trade that inconvenience for the plethora of benefits of small-town/rural life any day. We all will. But in general, in my town, patients have much better access to primary care than patients in Urban areas. I want to reiterate: this is in MY TOWN. There are rural towns where the economic realities the author of this article references have closed hospitals and patients there have to drive hours to access even basic primary care.
The next problem I have with this article is this statement: “…Patients ended up with low-quality, high-price local hospital care.” I’m going to ignore the 2nd half (regarding high-price, which is 100% true, but true everywhere and not unique to rural healthcare) for now. Here we find the worn-out bias/stereotype that rural docs like me grow VERY weary of. For some reason, people think that quality of care is somehow worse in a small town. It’s almost like “all the good docs practice in the city”. I have no idea where this stereotype comes from or why. THE. OPPOSITE. IS. TRUE. In small towns, we don’t have an army of specialists at our disposal, and we practice a MUCH wider spectrum of care than our urban counterparts, who often run little more than band-aid stations that see patients every 6 minutes and refer everything to specialists. Having no help, we often work long days, and often 7 days a week. That means we have more experience and much more practice. Not 15 minutes ago, before I sat down to write this, I reduced a fracture (“set” a broken bone), and in a few minutes, I’ll be doing a newborn circumcision on a baby. Many (most?) of my family medicine colleagues in urban America have long since abandoned such skills they learned in residency, and refer such procedures to specialists. This is mostly because the broken system has them going too fast to maintain a full spectrum of practice (which drives up healthcare costs and is why they’re all being replaced by NPs and PA’s–but that’s another story). I’d argue that rural medicine attracts the best and the brightest- where else can you practice full-spectrum medicine in the US?
A critical access hospital in a small Kansas town I know well once had 5 doctors on staff and 4 of them graduated at the top of their medical school class! Show me a family medicine clinic in any urban area that can boast that 80% of their doctors graduated at the top of their class. The Mayo Clinic can’t even boast numbers like that. Urban physicians often/usually allow much knowledge and many skills to lapse, because they have so many specialists and partners, and the benefit of crowd-sourced knowledge to lean on. So let’s ditch this bizarre and insulting notion that somehow quality of care is inferior in rural areas, which is the opposite of the truth.
I do agree with the author that artificially propping up Critical Access Hospitals with subsidies is economically stupid. Generally, any time political movements go against the basic laws of economics, everything goes sideways and bad people take advantage of it. The money being spent to help rural folks get CARE gets wasted on administration or compliance programs. I see CAH’s take advantage of these medicare subsidies and run inefficiently as a result. They do the same thing public schools do with these taxpayer dollars: hire more administrators and spend stupid money on consultants, etc. I don’t know that I agree that rural hospitals should be “outpatient only” and such, but there are ways to save HUGE amounts of money that would allow these hospitals to survive, the biggest being to relax unnecessary government regulations. The money our small hospitals are burning on the altar of EHR compliance, HIPAA compliance, and JACHO compliance, etc. is mind-boggling and is bleeding them dry. Rural hospitals could compete salary-wise for doctors, nurses, tech, and improvements if they weren’t burning money by the bushel on over-the-top bureaucratic compliance.
I left our CAH almost 8 years ago and started a Direct Primary Care clinic. It operates purely in the free-market economy and is thriving. Small regional hospitals are now coming around to my way of thinking and are now beginning to bundle things like radiology studies, and surgery, etc. to compete with each other for cash business, and it’s making them money and saving patients money. These hospitals have to find loopholes in the bureaucracy to do this (the government and the trillion-dollar insurance companies who control the elected officials in the shadows love the status quo and want prices to stay high). The fact that they are trying to move in a rational economic direction demonstrates that these hospitals can make it out here. But make no mistake: the government and its regulations are the cause of their struggles, not the solution.
How to Fix Rural Healthcare: LEAVE US ALONE.
Dr. Lassey earned his medical degree from the University of Kansas School of Medicine and completed his residency at the Smoky Hill Family Medicine Program, where he served as the chief resident. He went on to practice rural inpatient, outpatient, emergency room, and obstetric care, in Holton, Kansas. He found the calling he loved to have been hijacked by middlemen. Stuck in a broken system, mired in bureaucracy, clicking boxes, coding, not seeing his family, and hearing patients complain bitterly about medical costs he had no ability to control, Direct Primary Care (DPC) became the solution for him, his family, and his patients. He is passionate about restoring the physician-patient relationship, bringing transparency and sanity to medical costs, and advises physicians around the country on how to get out of the FFS system. He serves as an Assistant Clinical Professor at the University of Kansas School of Medicine, is the recipient of numerous clinical and teaching awards, and is a founding member and currently the President of the Direct Primary Care Alliance.
