Desert Companion

No country for sick men

With rural health care in crisis in Nevada and beyond, providers are searching for a cure

Jeff Martin’s eyes sparkle as he rattles off the exhibits at the Tonopah Historic Mining Park, where he works. He loves the park, he says, and the town that he and his wife moved to from Southern California four years ago, when she landed a job at the nearby Crescent Dunes solar plant.

“I’ll never go anyplace else,” he says.

There’s just one problem with Tonopah, located a couple clicks southwest of Nevada’s center. “Our biggest issue right now is, our hospital closed down at the end of last year,” Martin says. Is there any clinic or mobile medic for urgent care? “There’s nothing here. Nothing. The only thing Tonopah has for medical services are the life flights, and they’ve been a great help to the whole community.”

They’ve been a great help to Martin in particular. He’s taken two emergency airplane trips to Reno for painful ruptures of his diverticulitis.

It’s easy to see why this situation is not ideal. The only thing more burdensome than the 100-mile drive that Tonopah residents have to make for regular checkups in Hawthorne, Nevada, is the cost of flying twice that distance, to Las Vegas or Reno, for an acute episode. A medical flight via helicopter can cost as much as $30,000 and may not be covered by a patient’s insurance.

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Tonopah residents aren’t alone in lacking access to medical services. Research  firm Ivantage Health Analytics reported this year that 76 rural hospitals have closed since 2010 and another 673 are vulnerable to closure. That includes seven in Nevada.

And they need these services — at least as much as city dwellers, if not more. Rural residents face unique obstacles to good health, such as higher rates of fatal car crashes, poverty, and teens abusing alcohol and tobacco, according to the National Rural Health Association. A 2014 study published in the American Journal of Preventive Medicine found that the life expectancy of rural residents was almost three years shorter than that of metropolitan residents — and that the gap is growing.

Aging populations in rural areas aggravate the situation. According to U.S. census data, 29 percent of residents in Nye County, of which Tonopah is the seat, are age 65 or older. Treating chronic diseases in these populations, the Centers for Disease Control says, soaks up two-thirds of the country’s health care budget.

Nye Regional Medical Center

Nye Regional Medical Center.  Photo by Christopher Smith

The Nye County Regional Medical Center’s closure a year ago prompted Rep. Cresent Hardy to co-sponsor legislation dubbed the Rural HEALTH Act. The bill, which has gone through the commerce and agriculture committees and is currently in the commodity exchanges subcommittee, calls for Health and Human Services to resume its annual study of state rural health organizations, suspended since 2003. It would also reauthorize a grant program providing $15 million for five years, including a carve-out for facility construction and upgrades.

“It’s a small amount,” Hardy says, “but you have to have the study before you start throwing money at things.”

 Although professionals in the field welcome the study, they have a different view on the funding. From specialty centers in Las Vegas that have had to cut remote programs, to nonprofit clinics struggling to cover costs with scant office visits, they say a little cash tossed their way would help improve access to care.

Nye Regional Medical Center“Financing is still a big issue,” says Gerald Ackerman, head of Nevada’s State Office of Rural Health, based in the University of Nevada School of Medicine (now the UNR School of Medicine). “When you look at costs for health care, someone always has to pay, whether it’s you or your insurance company or the county, under indigent care. If it wasn’t for the tax base in certain communities, some health clinics wouldn’t make it.”

The Affordable Care Act (aka “Obamacare”) didn’t make matters worse, insiders say, but it didn’t help much either, since reimbursements for small providers are still too low to cover their costs. To help fill the gap, Ackerman’s office uses a federal grant for rural hospitals to fund the Nevada Flex Program, which offers cost-based reimbursements to providers that meet certain requirements. But that’s just one function of the multi-faceted program that has received only $3.3 million since 1999.

“Hospitals have been good at getting their rates adjusted up,” says Barbara Atkinson, founding dean of the UNLV School of Medicine. “Physicians haven’t done so well. And community providers don’t have any reimbursement, so we need to work on that in the next legislative session.”

The providers themselves aren’t holding their breath for more money or policy reform. Instead, they’re looking for creative ways to stretch every dollar to its max. Three developments — mobile medicine, telemedicine and specialty teleconferences called ECHO clinics — have shown promise, and more innovation may be on the way.


A tough sell

Around 100 miles northwest of Tonopah, in Gabbs, Nevada, an apron-clad Ken House is loitering outside the senior center puffing on a cigar. He and his wife, Kathleen House, have just finished making biscuits and gravy for the breakfast that they serve at the center every other Friday.

House, who moved to the town of 250 from California’s Bay Area when he retired six years ago, is on its advisory board and volunteers at both the library and fire department. He also used to drive the local ambulance, but gave up his first-responder certification a few years back.

“There were problems getting the paperwork from the state in a timely manner,” he says. “And there was a lot involved for a volunteer thing. It was, like, 80 hours, and then it’s good for two years. A year was already up before I completed all my paperwork and certification, and we do have two EMTs here and a few first responders, so we had enough at the time.”

House has just listed all the healthcare professionals in Gabbs. There’s no medical clinic there; it shut down several years ago. House says he and his wife go to a clinic that Reno-based Renown Health operates in Fallon, nearly 80 miles away. Like Jeff Martin in Tonopah, they rely on flights for emergencies.

“It could be better,” House says. “If we did have a clinic here, that would be the best-case scenario. It’s a very small community, though, so it’s hard to justify.”

Slow business, and the resulting low revenue, is not the only deterrent to clinics in towns like Gabbs. Another big one: Few doctors want to work in rural areas, and almost no one wants to work in so-called “frontier towns,” the industry term for places 60 miles or farther from the nearest hospital.

nurse practitioner Diane McGinnis hopes to launch a mobile clinic to serve rural areas“Some people just can’t handle not having a grocery store, pharmacy, dentist, vet,” says Diane McGinnis, a doctor of nursing practice with Searchlight Healthcare. “And you may be able to find a provider who’s willing to do it, but then their spouse can’t work in the same town.”

That was the case for McGinnis, who spent nearly four years in Beatty, a frontier town of around 1,000 residents, while her husband and three children remained in Las Vegas. From December 2011 to October 2015, she would make the 115-mile commute to Beatty on Sunday evenings, returning on Fridays to spend the weekend with her family.

“I have a terrific husband,” she says.

She also has a commitment to rural healthcare. Although McGinnis was only in Beatty five days out of the week, she was very involved in the community — volunteering for the fire department, serving on the museum board and leading a Boy Scouts troop.

“I enjoy doing personal medicine,” she says. “I like knowing about the whole patient, what they’re doing, their family. I think I can give better medical care if I know that their mom just died or their child is ill. You see your patients after hours. You live with them.”

McGinnis maintains her community ties to Beatty, hinting at her larger goal: to operate a full-fledged mobile clinic. Right now, in addition to manning Searchlight Health’s Henderson office during regular business hours, she operates McGinnis Mica Medical on the side. That’s her nurse practitioner house-call business, or, as she describes it, “clinic without walls.” She’ll see patients anywhere they want: home, the library, a park — she even had one appointment at Walmart. Instead of the traditional black bag, McGinnis’ SUV carries a couple large plastic tubs stocked with a blood pressure cuff, otoscope, stethoscope, etcetera.

“I’m qualified to give immunizations, but they have to be kept at a specific temperature, and you have to have Internet capability for the data logger,” she says. “If I had an RV, I could set that up.”

United Health Care currently operates such an RV. Its 45-foot-long Medicine on the Move truck goes to churches, community centers and homeless shelters to provide primary care to patients who typically don’t seek it because of barriers such as child-care and transportation. The truck goes to rural Nevada towns such as Mesquite and Yerington, but no frontier towns.

That’s where McGinnis comes in. Just as she sat down to talk with Desert Companion, she answered a call from someone needing a urine sample to be taken from a patient in Tonopah. She told the caller that, in addition to the fee for her service, she’d have to be reimbursed for the six- to seven-hour round-trip drive, another $240.

“You can’t see enough patients in one day to sustain a clinic because of the driving time,” she says. “You only see the patients that the insurance companies (you’re contracted with) pay you for. And I only get paid 85 percent of what a physician would by certain insurances, even though I offer the same services.”

Through Mica Medical, McGinnis can help patients who wouldn’t otherwise get care, but she acknowledges it won’t solve the rural healthcare problem. For that, many are looking to telemedicine.


Beam me out, Scotty

Scattered around Gabriel Léger’s desk at the Cleveland Clinic Lou Ruvo Center for Brain Health are signs of a busy mind: a stack of Neurology magazines, an apple (still uneaten at 3:30 p.m.), a Southwest Airlines ticket jacket. Hovering above this clutter are two large computer monitors. On the right, live video of three women, Mary Goicoechea and her niece and daughter, sitting in padded armchairs in a small office at Elko’s Morningstar Health Center. On the left-hand screen are the data-crammed windows of a complicated medical app that allows Léger to see Goicoechea’s medical chart, pull up brain scans and test results, and log notes. Goicoechea, a resident of a town with no neurologists, is in an appointment with an Alzheimer’s specialist 425 miles away.

After chatting with the two younger women about how Goicoechea has been doing, Léger turns his attention to the patient.

“Mary, I see your head is shaking a little bit,” he says. She seems surprised.

The doctor asks Goicoechea to take off her glasses, and, using a menu that looks like a joystick, zooms the camera, which is atop the computer monitor several feet from his patient, in for a close-up. The resolution is so high that you can almost see the blood vessels in her eyes.

“Without moving your head, look all the way down,” he tells her.

Though she’s wearing headphones, Goicoechea seems to have a little trouble hearing Léger. The camera’s panning and zooming functions also give the doctor a little trouble. Still, he’s able to do as thorough an exam as he would in his Las Vegas office. And Goicoechea’s family is able to get help with her disease from a highly qualified behavioral neurologist.

“The first time, it was weird. I’d never done anything like that,” says Veronica Eldridge, Goicoechea’s daughter, who’d been driving her mother three hours to Salt Lake City before hearing about the Ruvo Center’s telemedicine program from a friend a year ago. “I was like, maybe this isn’t going to work. But he (Léger) is so good at his job. I definitely think it’s really good now.”

Nevada is progressive in telemedicine relative to other U.S. states, and champions of it will give you many reasons why the state is an ideal test case. For starters, the distance between Nevada towns is greater than in most other states, so people can’t just drive 15 minutes to the next burg and find a doctor. Specialists are even farther away. Nevada is short on doctors in general — current numbers are 200 for every 100,000 people, 48th in the country — and specialists in particular. If folks are unlikely to drive an hour for a general checkup, then they’re even less likely to drive three hours for a specialized consultation. (And if the state can’t convince recent medical school graduates to work in its cities, then it’s even less likely to convince them to work in small towns.) There is also little home care in rural areas to follow up and make sure patients are taking their meds, going to physical therapy and so on.

Telemedicine programs like the Ruvo Center’s are an ideal solution to these problems. So, why aren’t there more of them?

“Money is part of it, like it always is,” says Charles Bernick, associate medical director at the Ruvo Center. “Most of our patients are Medicare patients. You can bill Medicare, but the amount you get back doesn’t cover the time you spend. … To be honest, unless you’re a state entity and get some funding, or you’re a hospital and you want patients to come to you for surgery, it’s hard to make money. It has to be a (nonprofit) organization, like ours, that can absorb the cost.”

Bernick says a brewing partnership with Renown Health, which recently applied for a grant to establish several telemedicine sites, would allow the Ruvo Center to expand its services beyond Elko. He’d like to see other players that are currently working separately band together to share their strengths and costs.

Gerald Ackerman, of the State Office of Rural Health, says another challenge, besides money, is staff. Someone has to facilitate a telemedicine appointment on the patient’s end, and practitioners staffing small clinics may not have time.

Bernick, who’s been doing telemedicine for some 20 years, gets around this obstacle by hiring staff like Tami Charters, the medical assistant who facilitates appointments with Ruvo Center patients in Elko. Although she has training in office medical management and as a nurse’s assistant, Charters is not a physician or advanced practitioner. She is, as she says, “the chief cook and bottle-washer” — running the office, scheduling appointments, checking patients in, administering tests, taking their vitals and tracking down prescriptions.

The UNLV School of Medicine’s Barbara Atkinson believes more training programs for people like Charters would help telemedicine grow. Her school is cooperating with CSN to certify community health workers, who could fill this role. Atkinson says she’s also encouraged by a bill that passed in the 2015 Nevada legislative session, allowing physicians to bill telemedicine at the same rate as office visits, and the facility hosting the patient to bill for the visit as well.

As for the physicians themselves, the UNLV School of Medicine, expected to accept its first class next year, is incorporating a robust telemedicine program into its curriculum and clinical practice. Vice Dean Tracey Green is visiting schools in Alabama, Mississippi and Utah to see examples of successful programs as she develops UNLV’s.

“This will really help people in rural areas stay close to home,” Atkinson says.


And they tell two friends ...

When Sanjeev Arora, a liver disease specialist in Albuquerque, tried using telemedicine to help him treat New Mexico’s thousands of rural patients with hepatitis C, he was unimpressed. He could still only see one patient at a time, whether in person or on a computer. Thinking about the available technology, he had another idea: What if he shared his basic knowledge of hep c with rural primary care providers? Then, they could each see dozens of people and get the treatment ball rolling. The effect would be multiplied exponentially. After trying out his idea for a while, Arora found that the rural providers’ patient outcomes were just as good as his.

That led to the birth of Project ECHO at the UNM School of Medicine in 2003. The basic model — teleconferences in which medical specialists study rural primary care providers’ cases and empower them to provide certain specialty services — has not changed, although the technology has evolved and licensees have adapted it to their needs, creating new uses. Today, there are 89 Project ECHO replications in 30 U.S. states and 14 other countries. The Department of Defense uses it; so does the Veterans Administration. The UNR School of Medicine was one of the first 10 adopters, starting its ECHO program in 2012.

“Nevada is a strong U.S. hub,” Erika Harding, Project ECHO’s director of replication initiatives, says. “And they grew fast. Evan Klass (a former endocrinologist at UNR, who’s still director of the program) and his team launched seven ECHOs in 18 months, which was a record then. They took on diseases and conditions that others didn’t.”

Chris Marchand, the UNR program’s coordinator, says that, as with telemedicine, Nevada’s geography and demographics make it an ideal laboratory for Project ECHO.

“Let’s say a patient has diabetes,” he says. “His primary care provider doesn’t do diabetes management, so he refers the patient to an endocrinologist in Reno. It could take that patient six to 12 months to go see the endocrinologist, and often, the questions asked during the initial referral are questions that could have been asked during an ECHO clinic, saving the patient the travel time, lost wages, child care costs and other inconveniences.”

UNR’s Project ECHO Nevada offers primary care providers training in sports medicine and office orthopedics, public health, gastrointestinal medicine, pain management, diabetes and endocrinology, geriatrics, and behavioral health in primary care.

One pillar of the model is patient confidentiality. “Not using protected health information allows ECHO to do what it does,” Marchand says. “Discussion of the primary care providers’ cases is important, so you have to make sure patient information is protected.”

Another pillar is that it’s free, Harding says. “Sanjeev (Arora) has always pushed back against the view of medicine as being fee-for-service. We believe that by positioning ECHO for rapid ramp-up, we can demonstrate its value and its return on investment to the healthcare education system, so we’ll be able to convince government — not just ours, but those of the countries where it operates around the world — of the value and get them to pay for it, whether it’s small clinics in rural Nevada or the super-hub of Ireland that includes 20 different diseases.”

Marchand says his biggest hurdle is the voluntary nature of the program.

“It’s difficult to expand and grow when everybody is short-staffed and overloaded with work,” he says. “Over the last few years, we’ve been slowly growing what we do, and becoming more involved with other health organizations around the state. But there’s a lot more we want to do.”


Group chat

There’s a lot more that others want to do, too. Take Walter Davis, CEO of Nevada Health Centers, a nonprofit that gets federal funding to operate clinics in under-served communities. Davis has lots of ideas, starting with the simple task of educating rural communities to embrace advanced practitioners such as McGinnis, who can give the same level of care as traditional MDs but cost less, meaning reimbursements for their services go further.

Unlike most providers, Davis believes there’s enough funding available to expand healthcare to the rural communities that need it. The problem, he says, is adherence to an outdated budget model. Instead of health plans, hospitals and medical groups fighting over the same dollars, he says, the state should foster population health management.

“We need to build budgets around communities instead of individual sites,” he says. “Patients need access to both hospitals and primary care. Hospitals want to fill beds, but if we’re doing healthcare right, we would need fewer beds. We have to spend more time on prevention than on feeding a large system that’s challenged by insurance plans and infrastructure investments to keep the business running.”

In small ways, Nevada Health Centers is already implementing this approach. The company runs a discharge clinic at Carson Tahoe Regional Medical Center in Carson City, giving the hospital access to its schedule to book patients for follow-up care in order to reduce readmission rates. A visiting nurse program in Lockwood paired a nurse with a sheriff, who had been frequently finding people in need of medical assistance during welfare calls.

But Davis’ most radical idea may be for group appointments. In this model, a physician and facilitator with a clinical background see eight to 10 patients at a time. Having all signed confidentiality waivers, they take turns talking with the physician, stepping out for treatment as needed. The entire group gets an hour and 15 minutes of care instead of 10 minutes per person.

“I learned about this maybe 10 years ago,” Davis says. “I was taken aback by the patients’ lack of fear to talk about what’s going on with them. One 75-year-old brought up his libido issues. At the end of the session, I asked them why they felt so comfortable, and they said, ‘We all face the same issues, and we’re learning.’”

Other, less radical ideas are also chipping away at the problem. Ackerman’s office is working to establish rural residency programs around the state; state grants offset student loans for medical and nursing students who commit to working in out-of-the-way areas; and the federal government regularly identifies ZIP codes where qualified operators like Nevada Health Centers can compete to open new clinics when funding becomes available. Ackerman says a final, important piece of the puzzle is pipeline programs to prepare high school kids — particularly those from rural towns — to go into medical professions.

“I definitely hope we don’t give up on rural clinics,” McGinnis says. “It breaks my heart to see these people abandoned.”

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