WEIGH IN: Rural health, distance, money - give us your story
Posted at 1:30 PM on August 18, 2011
by Dave Peters
(8 Comments)
They see patients plead with neighbors to drive to the hospital to save on the ambulance. They see a heart attack victim trying to drive himself to an emergency room with a lower insurance co-pay. They see jawbones dissolve and vision deteriorate because people can't drive or can't afford the care to prevent it.
We asked nine doctors, nurses, paramedics and others around Minnesota to show us what it looks like where patient and provider meet. Read what they told us here and then help continue telling this story by sharing your experience in the comment box at the bottom of the page. We'd like your comment, whether you are a patient, a provider or simply an interested resident with a thought to share.
If you want to weigh in on another question, go here to talk about one fix you would make or here to tell us whether you think things are going to get better or worse.
You can read more of Ground Level's rural health care reporting here, and in the coming weeks, we'll pose more questions and answers on the topic.
QUESTION
Please share an anecdote or an incident that serves as an example of how a patient in need of help faced a barrier of distance or inability to pay. What happened?
Share your own comment on this story below...
Clinton MacKinney, St. Joseph MN. Doctor in St. Gabriel's Hospital Emergency Department in Little Falls and rural health policy analyst at the Department of Health Policy and Management of the University of Iowa.
A middle age man was driving to his home about 30 miles away when he began to experience chest pain. His health insurance co-pay was less at his home community's hospital than at ours, so he considered driving on.
But the chest pain was getting worse, so he change his mind and decided to get briefly checked out at our Emergency Department. As I walked into the exam room to introduce myself and begin the exam the patient said, "I feel funny...." and his heart stopped.
I immediately defibrillated or "shocked" the patient, his heart restarted, and he promptly woke back up. His first words were, "What happened?" I explained that he had experienced a cardiac arrest and had, admittedly briefly, died.
He thought for a moment, and then said, "Thank goodness I didn't drive on to my home hospital." Indeed! This experience should cause us to wonder why we tolerate a health care system that would cause a patient to bypass, or even forgo, life-saving care.
"He agreed but I don't know if he ever went for treatment."
Vicki Brady, Cloquet MN. Nurse practitioner for Essentia East Superior Hospital.
I saw a 27-year-old patient in the Emergency Department for an abscessed tooth. He had been treating the tooth through the ER off and on for five years because he had no insurance. I, once again, treated him with antibiotics and pain medications but this time he got worse, not better.
He came back a week later with a fever and his cheek so swollen he appeared to be storing nuts for the winter. I gave him IV antibiotics and did a CT scan which showed the infection had invaded his jaw bone and the bone was dissolving. (This is called osteomyelitis and is very dangerous.)
He needed to have surgery, which I arranged with a local oral surgeon, but the patient refused to go due to cost. The oral surgeon, his family and I begged him to go and the doctor said they could "work something out" regarding the bill. He agreed but I don't know if he ever went for treatment.
I also know of a 24-year-old who died from complications of "strep throat" because he did not have insurance and refused to come in to be seen because he didn't want to incur a bill he could not pay. There was nothing to do about the hospital/clinic bill, but the antibiotics to treat him would have been $4 on the Walmart $4 Pharmacy list.
Curtis Louwagie, Marshall MN. Ophthalmologist for Avera Medical Group in Marshall.
In ophthalmology, wet macular degeneration is a disorder that requires frequent treatment to maintain vision. These patients often require monthly injections of medication given by an ophthalmologist.
In much of rural Minnesota, there are not ophthalmologists available to provide this treatment. These patients had to make monthly trips to larger cities such as the Twin Cities, St. Cloud, Rochester, Mankato, Duluth, Fargo, or Sioux Falls for their care. Most of these patients are elderly and many don't see well enough to drive so they need transportation assistance.
Because of the expense and difficulty of transportation, some of these patients will forgo their appointments and necessary treatments. This often leads to disabling, permanent vision loss.
Heidi Korstad, Bigfork MN. director of emergency room services, Bigfork Valley Hospital.
"Daily, I see patients who refuse treatments, preventive care and prescriptions due to finances."
Daily, I see patients who refuse treatments, preventive care and prescriptions due to finances. Those with Medicare coverage stop important medications when they get to the donut hole. They refuse hospitalization due to high co pays.
Daily, I write prescriptions for antibiotics only to have the patient return from the pharmacy being unable to afford them. Those with insurance also struggle due to high deductibles and co pays.
I currently am treating a lovely 60-year-old woman whose husband is an employed logger. She did get regular physicals under a woman's health care program, but refused colonoscopy due to financial burden. She now has widely metastatic colon cancer that could have been prevented. Her current care is very costly!
Mike Wilcox, New Prague MN. Scott County medical director, overseeing of community paramedic program.
In my work in Scott County, I have had the opportunity to work in a Free Clinic, which is provided to citizens who cannot afford to see a physician because of lack of insurance and/or the lack of a job.
These patients are not "deadbeats" who have lived on welfare assistance all of their lives. They are citizens who have been highly productive until the economy took a downturn in 2008. They wish to remain healthy but have been faced with an obstacle to health care because of lack of funds to see a physician or to pay for expensive drugs.
In an effort to assist them, Scott County in partnership with the Sioux Community, has provided a Free Clinic, which travels around the county every two weeks. Through it, a provider is available to do exams, write prescriptions, and provide follow-up for various medical problems.
It provides access to health care which was not available before. To the citizens of Scott County, it has provided some relief to the health care needs of which we are speaking.
Kai Hjermstad, Savage MN. Paramedic for Northfield Ambulance, emergency preparedness specialist for Scott County Public Health and instructor at Hennepin Technical College.
I have been providing paramedic services to patients for many years in both urban and rural communities. I have responded to numerous calls where a patient has been very sick and needs emergent medical care, (i.e. cardiac symptoms, respiratory distress, trauma etc.) and they are hesitant or will refuse to be transported because they don't have insurance.
This extra concern poses increased stress on the patient in critical situations. The patient or patient's family's first concern is often, "I don't have insurance" or "How much will this cost"? and/or "I can't afford it, I will drive myself in".
During these critical life or death situations, should they/patients base their care on insurance or money concerns, rather than life saving medical needs?
Ruth A. Pallansch, Henning MN. Retired nurse practitioner for Tricounty Hospital in Wadena.
At 10:30 p.m., an elderly woman in the rural area, on coumadin "blood thinner" therapy, develops a severe epistaxis "nose bleed". Her equally elderly husband, age 80, cannot drive at night due to vision deterioration. All children live more than three hours away. The woman, 79, cannot drive due to the bleeding.
Her choices are: call an ambulance for a "non-emergency" transfer that may not be paid by insurance costing several thousand dollars, or seek the help of a neighbor who can transport her to the hospital 28 miles away.
Fortunately, the neighbor, age 69, was agreeable to drive their vehicle, a foreign stick shift car, to the hospital, and stayed the several hours when the bleed was controlled and woman was sent home. Volunteer drivers are scarce, but so crucial to help with such situations. Medicabs, etc, are not available. Some express vans require a 24-48 hour notice to transport.
Jane Hovland, Duluth MN. Nurse, licensed psychologist and associate professor in behavioral science at the University of Minnesota Medical School Duluth.
Through our rural telemental health project, I see a patient for mental health services who has a number of chronic conditions impacting her life and mobility. She is receiving Social Security disability support of about $600 per month. She does live in Section 8 housing so pays only a portion of her income toward rent. However, her co-pays for psychiatric and cardiac medications account for almost $250 per month. She does not qualify for further reductions in her medication costs, and she is unable to pay the co-pays for her health care visits, which average about two per month.
She recently had a serious problem with hypertension - a new problem for her, which landed her in the emergency department for care. The physician asked her to buy a home blood pressure monitor that was "only $65." She faces the choice of not eating very well (she does use the local food pantry) or spending her food money on the blood pressure monitor (and eating popcorn instead).
Interestingly, this patient also receives lubricating knee injections that cannot be performed at her local clinic. The county she lives in will pay a driver to transport her over 200 miles round trip so she receives these specialized injections. The driver is not allowed to stop anywhere except at the referral clinic, even though there are a number of food shelves with fresh fruit and vegetables on the route to and from the clinic. There is also a used medical supply distribution place where she could obtain a home blood pressure machine, but a stop there is also prohibited. While I think that her mobility is important, especially to her mental and physical well being, she is not likely to die from bad knees. However, her hypertension is life threatening and it seems more important that it be monitored closely. The frustration is that there are many programs available to help, but some do not seem very rational in their implementation. I hate to admit this, but I truly suspect this patient's story is repeated every day in our country.
"She needed to start chemo immediately; my job was to coordinate her care."
Joyce Kramer, Stillwater MN. Nurse and oncology clinical coordinator, Lakeview Health
This takes place in a rural cancer center. A self-sufficient young woman, working part-time in her hometown, was in the process of starting college when she was diagnosed with a very serious cancer. During her physical exam, it was found that she had several teeth needing evaluation and treatment from a dentist. Typically, dental work is not done while receiving chemotherapy because it poses a risk to develop a life-threatening infection. She needed to start chemo immediately; my job was to coordinate her care.
I contacted several dentists in the area, all willing to see her, but when it came to the part about her being on Medial Assistance, the response was always the same, " we don't take MA patients." Over and over again this was the response I got. Social Services were involved at the hospital, trying to find a provider that would see her to no avail. We finally contacted the local paper, they found the story compelling and ran the story, within a couple of days from printing a local dentist called and made arrangements to take care of our young lady at no cost.
Comments (8)
We're getting a number of comments on our Facebook page from people who say they take pains to bypass some rural facilities to get to others.
Care in Springfield and Fosston gets kudos, for example. Others not so much. What makes the difference?
Jenny, on our Facebook page, has a twist on the value of personal touch and hometown feel that some people find in small town care.
She goes elsewhere at least partly out of concerns about confidentiality.
By law (HIPPA), health care workers are not allowed to look at patients' records unless they are directly involved with their care. I would hope that all hospital staff abide by this law,no matter what their size or location.
For some patient's, waiting in a lobby can be over exposure in a small community. Making a trip down the road to a larger facility, where you're less likely to be recognized is perfectly understandable and probably less stressful.
For others, knowing everyone and chatting about their life is exactly what they desire and find it comforting.
Carolynne from the Park Rapids area notes in the Facebook conversation about this that staffing issues have led to inconsistent care for her uncle. She thinks some staffing rotation is causing problems.
Is that a bigger problem for rural facilities than it would be in the Twin Cities?
One answer- Gillette Children's has one of the most extensive community outreach program in the country. We take our orthotics, wheelchair and adaptive equipment show on the road to at least 17 different "out state" greater MN communities so our clients don't have to travel as far for services. We often have Dr.s, nurses and other specialists like Rehab Engineers join these outreach trips, partnering with local community resoucres to do what we can to maximize outcomes and quality of life for our patients, their families and their communities.
I'm sorry Carolynne that you are seeing changes in the quality of care your uncle is receiving. I hope you will discuss this with the manager of the department.
Staffing is a complex issue, and in constant motion for both rural and urban hospitals. Here are some common ways hospitals try to fix a staffing problem.
Most hospitals use an acuity scale to measure complexity of care, this determines how many nurses are needed. For example, if you are a nurse working in an ICU, you may have one patient or three depending on the patient's level of care. When staffing to acuity isn't balanced, the work load is heavy and patient care may be compromised.
Another issue is lack of staff. Hospitals typically manage this in one of two ways. Nurses stay and work double shifts, or they float a nurse from another area to cover the shift(s).
Urban hospitals have steady volumes and a better reserve of staff. Rural has fluctuating volumes, with limited staff, you never know what type of patient will walk through the door, which can throw staffing plans off in a heart-beat.
No matter what the staffing issue is, there should never be inconsistencies in care- this may be a good old-fashioned communciation problem.
Joyce Kramer, RN
Oncologoy Clinical Coordinator
Lakeview Health
Stillwater, MN
I recently had an appointment in the only local source of medical care....an outpatient clinic affiliated with the large regional health care system. I was rather amazed at the difference between this and the type of medical care I had used before moving to MN 10 yrs ago. The time spent with the doctor amounted to perhaps 10 minutes, he ordered two basic and usually inexpensive tests, and the charge for the visit was $288.
My condition was possibly life threatening and yet no followup call was ever made to see if the medication was working. They certainly DID follow up to ask for payment of the remainder of the bill. The day I attended the clinic I had paid $100; mistakenly thought that would cover most of the cost. Their "coding" person was not on duty at the time I attended the clinic so they could not tell me how much I owed at time of services provided.......and would not even give me an estimate.
I have two observations:
1) the payment of the bill was more important to this system than any concern for my health
2)for basic services the cost is too high. Not many self pay patients would feel they received value for their money for such a superficial exam. I do not care about attractive buildings and fancy landscaping. I would like to see caring health care professionals and real care given to improve the health of the patient, rather than trying to impress them with the richness of the facility.
Gazing at a pretty landscape and sitting on an expensive chair while waiting does not substitute for care and concern when a patient is ill.
This comment came in to my blog post from Lora Krall, a registered nurse in Winona, and is worth posting here. Thanks, Lora.
I work as a telephone triage nurse. I daily receive phone calls from people who have no contact with neighbors or friends and family often lives miles away. They have limited access to resources and often little or no insurance.
One night, I took a call from an elderly women who developed sudden lose of vision in one eye. She and her husband were in their 70's and did not know their neighbors. They lived and still worked on their farm. Their children had moved away and were "not available." I tried to get the patient to have her husband drive her in and she said, "he worked all day and is tired. I will let him sleep." I stressed the need to be seen and the possible complications steming from no immedicate care and she said, "oh it won't be that bad." She finally told me she had no insurance and they were in danger of losing their farm. They ate once a day to save money and had been fine on their own. "We don't need any charity." In her area, there were no emergency services and I could not even send an ambulance to help her. I got the caller to agree to at least keep in contact with me and by the end of my shift she called to tell me her vision was "a little better." The next day she did come to see an MD and she had suffered a stroke losing vision in her eye.
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