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Creative Solutions May Ease Rural Health Care Crisis

Look around you. Try to touch something natural that was made in a big city. Dale Quinney, executive director of the Alabama Rural Health Association, said, “Every time I have asked that question during my presentations, no one can give me an answer.”

In one of his recent presentations to the Southern Alabama Area Health Education Center (AHEC), he pointed out that Jefferson County agriculture, forestry, and related industries produced $5.9 billion dollars and 55,837 jobs.

The lives of those who live and work in rural communities affect everyone, and they are a driving force behind our nation’s economy. Yet, the health of Alabama’s rural areas is declining, Quinney said.

He outlined the causes and consequences of a crisis in rural health care and offered suggestions for moving ahead.

It has been said the infant mortality rate is the “thermometer” for the health of an entire population.  Alabama has the second highest infant mortality rate in the nation. This problem arises from the decline in obstetrical services being offered in rural hospitals.

According to the Alabama Department of Public Health, Office of Primary Care and Rural Health and the Alabama Rural Health Association, in 1980, 45 of the 54 rural counties had hospitals providing obstetrical services. Today, that number has diminished to just 16.

This problem stems from the high cost of malpractice insurance and fixed costs associated with maintaining a hospital’s obstetrics unit. Rural hospitals also do not deliver enough babies to keep their doors open. According to Quinney, “Hospitals end up losing money on babies.”

On the opposite end of the health spectrum, Alabamians have a life expectancy three years less than the national average. If you live in Linden’s neighboring county, Wilcox County, life expectancy is nine years less than the nation’s average.

There is a strong correlation between poverty and healthcare. Quinney said, “Rural residents make 21 percent less than urban residents.” Poverty is rampant in our rural counties of Alabama, where almost half (47 percent) of all children are eligible for Medicaid, and one in every five residents is eligible for Medicaid.

This is a major problem for rural community healthcare offices and hospitals. Hospitals cannot sustain themselves on a clientele of mostly Medicaid and Medicare patients.

Eight counties currently do not have a hospital within its boundaries. Many hospitals in other rural counties are on the verge of closing simply because there are not enough patients in the hospital to keep the doors open.

Quinney said he believes a possible solution for counties without hospitals could be establishing small-bed hospitals in rural communities. Critical access hospitals have an emergency room department with no more than 25 beds.

Quinney explained, “These hospitals are the frontline defense [for rural communities] and could take care of motor accident victims, stroke victims, and gunshot wounds. They can stay overnight and transfer [to larger hospitals]. There is no point of building beds that will never be filled. We need to focus on what we need, not meeting regulations.”

Many rural hospitals like these and federally qualified health centers in small communities have begun to be reimbursed by the government at 101 percent for serving Medicaid and Medicare patients. This practice allows these healthcare facilities to stay afloat financially while serving an underserved population.

However, for a community to have a hospital, it must first have doctors and other healthcare professionals to work in it. Only five counties in the state are not entirely or partially classified as experiencing a shortage of primary care health professionals. This is not good news as the “baby boomer” generation begins to age. In ten years, it is projected that primary care physicians will have 1,185,000 additional patient visits than they did in 2009.

Many traditional medical students are disinterested in primary care medicine because of longer hours and less pay than specialists. To combat the primary care physician shortage, osteopathic medical schools have begun to increase their class size. More osteopathic schools are opening, including the Edward Via College of Osteopathic Medicine at Auburn’s campus, which will admit its first class this fall.

Osteopathic schools are equivalent to traditional medical schools, but place special emphasis on holistic medicine and prevention. Half of osteopathic medical students pursue careers in primary care.

For rural communities specifically, Alabama universities have established programs to attract young medical students to the rural medicine path. UAB, University of Alabama, and Auburn University have collaborated to form the Rural Medicine Program and the Rural Medical Scholars program. Both of these programs train physicians to work in rural programs and offer special financial assistance for students who commit to working in rural communities after graduation.

The effects of these programs can be seen in rural communities today. In 2012, zero physicians under the age of 30 were practicing primary care in Alabama counties. This year, there are more than 50, and that number is expected to rise as more medical students graduate from these programs.

Quinney and the Alabama Rural Health Association also advocate for reaching younger students, preparing them for careers in health and science. Quinney said, “In 2009, UAB admitted 162 students, 102 were from Jefferson County (Birmingham area). Only 25 students came from rural counties. This tells me we are not doing enough to prepare rural students to be competitive.”

The Alabama Rural Health Association is working to provide shadowing opportunities for rural high school students and to help continue education for healthcare professionals already working in small communities across the state. They are also considering a plan to partner with the Poarch Band of Creek Indians to establish a student-run Alabama Rural Health Association at every private and public college in the state. 

A surprising answer to the problems arising from rural medicine is universal broadband access, according to Quinney. Teleducation could potentially connect rural students with teachers in other cities. This would give them more educational opportunities and make them more competitive against their urban peers.

Universal broadband access would also help usher into Alabama a new facet of healthcare, telemedicine. Telemedicine is the use of information technology to provide medical services at a distance. It can eliminate distance barriers between patient and physician, giving new healthcare access to rural communities. In the second part of this article, I will share about telemedicine happening right here in Marengo County.

The data presented in this article is from the Alabama Rural Health Association, Alabama Office of Primary Care and Rural Health, and Alabama Department of Public Health.

To find out more about the Rural Medicine Program,

To find out more about the Rural Medical Scholars Program,

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