Think Small/Pat
August 10, 2017
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All year long, the Alabama Public Radio news team has been investigating the state’s rural healthcare system. One issue is hospitals. Seven rural counties in Alabama currently don’t have one, and one more county may be added to that list by the end of the month. John Paul Jones hospital in Wilcox County says it will close after sixty years. Eighty percent of the state’s hospitals that are left are operating in the red, in part due to Medicare which pays less in rural Alabama than almost anywhere else in the nation. APR’s Pat Duggins reports one possible remedy for the state’s rural hospital shortage is to think small…
“I think people in the United States of America just don’t realize that places like Perry County, Alabama still exist.” If you want someone who’s happy with rural health care in Alabama, don’t ask Kendal Gilchrest… “We’ve actually lived in a third world country for a period of our lives. And there were more resources, and more networks of support for us as a family in that third world country, then there has been here.”
In case you were wondering which third world country… “The Dominican Republic.”
Kendal, her husband Eric, and their young three children live in Marion. The Gilchrests work at Judson College. On the subject of dealing with rural health care, Eric has an example from just last week… “My son falls out of bed, middle of the night, it’s two o’clock in the morning, and he wakes me up and he has blood rushing down his face, he had gashed his, the corner of his eye open, and there’s blood all over his face,” he recalls. “If we were living in a different area, you’d take him five minutes down the road, ten to fifteen minutes down the road, to get it stitched up and get it taken care of. It’s two o’clock in rural Alabama, what do you do?”
Between them, the Gilchrest’s have four masters degrees and a PHd. But, even that didn’t help them get around the fact that Perry County doesn’t have a hospital. The Alabama Rural Health Association says six other counties are in the same boat. When the only hospital in Wilcox County closes in a few weeks that will mean residents in eight Alabama counties could be asking questions like this one…
“Do you drive an hour and a half one way to gets some stitches, he may not even need stitches. Or, do you just put a Band-Aid on it, and wait it out, and see what happens. We waited it out to see what would happen,” says Gilchrest. “And the next day, he did need some glue, they glued it shut and it was okay. But, these are the sorts of decisions you’re making at two o’clock in the morning.”
Just one county to the north, things seem less tense. Joseph Marchant’s big concern is making sure two boys don’t fall off a four foot tall stone wall outside the Bibb Medical Center. Marchant is the CEO. This rural hospital in the town of Centerville in Bibb County is just twenty five miles north of Marion where the Gilchrests live, but it feels like world away… Along with the Hospital, Bibb Medical Center has a dental clinic and a nursing home. Marchant says finances are tight, but it works… “I think our system here is a little different, because again we’re a little more unique than some because of the diversification that we have on our campus.”
And Marchant says his hospital isn’t among the eighty percent in Alabama operating in the red. Bibb Medical Center has thirty five hospital beds. Alabama will only certify hospitals with a minimum of fifteen and Perry County where the Gilchrests live doesn’t even have that.
“Unfortunately, they have to have fifteen in Alabama…”
That’s Dale Quinney. He’s executive director of the Alabama Rural Health Association. He’s looking for something in between the feast in Bibb County and the famine in Perry…
“There are some communities that perhaps can afford a hospital, financially, their patients will make it profitable, that don’t need fifteen beds.”
That begs the question—how low can you go when it comes to the number of beds in a hospital?
“We had three…” That’s Debbie Berry.
She’s the director of operations at the Greene County Hospital in Leakesville, Mississippi. And, you heard right, she said three… “But, when you have three beds, you wonder how are you going to make it?” she asks. Dale Quinney says Leakesville does… “This hospital, fifty four employees, three beds, and as we speak it’s expanding to seven beds, is operating at a profit. So, it can be done in the right location.” So, we hit the road to have a look. Leakesville is a three hour drive southwest of Tuscaloosa, or an hour northwest if you’re coming from Mobile.
Once on the campus of Greene County Hospital, we head through a sliding glass door, and up to the reception desk.. That’s where we met Debbie Berry An automated lab unit processes blood samples from Greene County patient load. Berry says there’s a lot of samples to handle… “It went from them seeing one or two a day, when we came here—we’re seeing three hundred and fifty now, a month,” says Berry. “So, our numbers have just climbed tremendously, but we’re offering so much more now than we did.” What makes it all work?
Joseph Marchant talked about the secret sauce at his hospital. The sauce at Debbie Berry’s is what patients see when they walk in the door… “We’re the first hospital in the state to have only nurse practitioners in their hospital. We don’t have any doctors in our facility.” And it’s that formula of fewer beds and no doctors that’s the rub for regulators in Alabama.
“I think it’s a bit too simplistic,” says Dr. Tom Geary with the Alabama Department of Public Health. He handles regulatory affairs, so he’s familiar with how the business model of Leakesville’s hospital will be received in Alabama. “It’s more complex on top of something that’s already complicated.” Geary says the fifteen bed minimum for rural hospitals in Alabama is due to state red tape. It means these facilities can expand if they need to, without a state relicensing process that can take years… “And so, this is a compromise situation of making a difficult situation at least feasible for smaller hospitals to get at least fifteen beds functioning.”
And when it comes to areas like Perry County that have no hospital at all, Dr. Geary has an idea on that as well… “Number one, would be to eliminate a lot of the rural hospitals…to utilize all of the land, the building, the services, the equipment, the personnel they have, as a highly efficient outpatient urgent care center.” Urgent care centers treat people on the spot and either send them home or to bigger hospitals. On the subject of nurse practitioners doing the work of doctors, Geary says Alabama prefers physicians who directly supervise nurses—unlike what Leakesville does.
Ironically, some of the staff at Greene County Hospital live in Mobile. They travel to Leakesville every day to practice the kind of medicine they can’t do in Alabama. All of this takes us back to the town of Marion, and Judson College which is one of the big employers in Perry County. The voices of its college choir are one of the few signs of hope in a situation that seems to otherwise bleak. “It’s hard for us to support each other, because we’re kind of just surviving.”
For Kendal Gilchrest and her family, there’s no clear sign that anything will get better here. “I think once we leave here, we will…I think we don’t even know how much it consumes our lives right now. And, I think once we leave, it’s only then that we’ll start to kind of unpack this.” The Gilchrests are leaving Judson for a new life in a suburb of Washington, D.C. Leaders in Perry County are looking to bring some kind of hospital to fill the void. One option is a small operation called a Critical Access Hospital with an Emergency Room and no more than twenty five beds. Even if they succeed, Kendal and her family won’t be there to see it.
Rural OBGYN
September 7, 2017
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All year long, the Alabama Public Radio news team has been investigating rural healthcare in the state. Studies often list Alabama as having the worst infant mortality rate in the nation. One factor is the lack of maternity units in rural hospitals in Alabama. This can lead to premature births or delayed care, which are often blamed for early infant death. APR’s Pat Duggins has more on one hospital business model that could help, but possible changes to the Affordable Care Act might make matters worse…
“It’s hard for us to support each other, because we’re kind of just surviving.” We met Kendal Gilchrest during our story on getting smaller hospitals in rural communities. We spoke to Kendal and her husband Eric at their home in Perry County. That’s one of seven rural counties in Alabama with no hospital. Eric summed their situation up this way…
“My son falls out of bed, middle of the night, it’s two o’clock in the morning, and he wakes me up and he has blood rushing down his face, he had gashed his, the corner of his eye open, and there’s blood all over his face. It’s two o’clock in rural Alabama, what do you do?”
The Gilchrest’s prefer the medical specialists they can get in Birmingham—that’s a three hour round trip from Perry County. Their son was okay—but the story doesn’t end there. The Gilchrests have three children.
Kendal recalls the pregnancy that might have made it four… “Early on, I got sick. And, I thought it was just a stomach bug. I’m playing phone tag with this practice that I barely know ninety miles away, talking to on-call physicians, trying to weigh is it worth driving a hundred and eighty miles round trip just be told that I have a stomach bug. I end up choosing not to go in because I have two other children at home. Then, about five weeks later when I go to my monthly appointment, I find the baby had died.
“Labor’s not fun anyway, but being jolted around in an ambulance on a rural roads is worse. It is painful.” If there’s anyone who can sympathize with Kendall Gilchrest, it’s Ashley King. She’s had her own problems with rural healthcare during childbirth. King lives in Hale County southwest of Birmingham. And, how many hours in an ambulance are we talking about…
“It was two and a half…to three.”
More on King’s story in a moment. This four month old is getting a checkup at University of Medical Center in Tuscaloosa. This hospital in west central Alabama attracts pregnant women from rural counties up to ninety miles away. That’s roughly twenty four counties. “Well, the average patient either does not have a job, or works in a fast food restaurant, a gas station… Dr. Catherine Skinner directs the Obstetrical Unit at the center. She says many of her patients from rural Alabama tell a similar story when the baby comes…
“They will need transportation, so they’ll have to get their friend to drive them. That friend will probably miss work the next day so they lose that income. They need gas money to get here. And, child care if they have other children.”
That one out of every five pregnancies Dr. Skinner sees every day. The reason University Medical Center is so popular with rural families comes down to the numbers, Alabama has fifty four rural counties. Seven of these counties have no hospital at all. Of those that are left, only a fraction delivery babies…
“Today, only sixteen.” That’s Dale Quinney. He’s executive director of the Alabama Rural Health Association. Quinney says it often boils down to the cost…
“You have to have the specially trained staff, and of course your specially trained family medicine physicians, or OBGYNS. You have to have the labs, the incubators, special equipment. Those cost money. And you have to have that whether you have ten births or a thousand.”
And, the financial burden isn’t just because of staff and equipment… “With obstetrics, there are huge liabilities as well.” That’s James Marchant. He’s CEO of Bibb Medical Center in the rural town of Centerville south of Birmingham. We met him during our story about smaller hospitals for rural communities. Marchant’s hospital stopped delivering babies in the year 2000.
“There’s a lot of risk. And when you have risk that certainly means there could be substantial costs or problems if you have a bad outcome.”
And, Ashley King’s case appears to fall into that category. She first became pregnant when she was just sixteen years old. Then, roughly twelve weeks before she was due…this happened “I started having chest pains, labor pains, migraines, I was blacking out…driving down the road in Dallas County.” Dallas County is about an hour east of where King lives. Just heading home wasn’t an option because Hale County only has a small clinic… “They can do stitches, and broken bones. Other than that, everything else goes to Tuscaloosa or Birmingham.
King and her baby needed specialized care at UAB Hospital in Birmingham. That’s two hours away. “I remember bits and pieces of the ambulance ride and the very…I remember first getting in the ambulance and how bad it hurt to be jolted around in full blown labor. It’s not fun.”
A two hour ambulance could have been expensive. But, King’s family owned the ambulance company, and she knew everyone riding with her… “My friend Wes was driving and my friend Chris was in the back with me. And, I remember him holding my hand saying ‘we’re gonna be okay, we’re gonna back, I promise we’re gonna be okay.”
Facing a premature birth and a two hour ambulance ride may sound bad enough. Then, King had premature baby number two… “The first time was a twenty seven week, one pound seven ounce baby, the second time was a twenty eight week, one pound twelve ounce baby…yeah.” FX Marchant shows us around Bibb…
And King isn’t alone. Women in Bibb County faced similar challenges finding obstetrical help when Bibb Medical Center stopped delivering babies in the year 2000 James Marchant was in grade school when that decision was made. When he took the job of CEO at Bibb, he felt something was missing…
“We had people who were delivered here in the 1960’s and 70’s and will come back and say how the campus has changed…” Two years ago that led Marchant to pose a question to the hospital’s board and its staff members… “What would re-opening obstetrics mean to the other parts of the system?”
In 2015, after juggling the budget at Bibb Medical Center, they did…
The newly opened maternity unit has one recovery room and a small waiting room. Bibb celebrated its one hundredth birth since deliveries started again in 2015, and financially it’s breaking even. But, all may not be well. How the system works that could be its greatest weakness. Marchant says the doctors that handle births at hospital don’t technically work for him…
“The group that’s covering the labor and delivery that isn’t employed by the hospital. They actually operate a medical practice here in Centreville. And they’re an independent that work out of a federal qualified health center.” That federally qualified health center is paid for by a grant through the Affordable Care Act, or Obamacare. And, all the talk in Congress about repealing and replacing the Affordable Care Act has Marchant wondering how long the unit can stay open… “We look at what’s working, we look at what’s not working. We try to effect the things that don’t work positively, and we try to enhance the things that do work. It seems, in Congress that’s not the way they do things.”
Back at University Medical Center, a rural mother to be is getting a check-up after driving forty five minutes. Or more specifically, her grandfather drove her and her husband to the appointment. If Bibb County loses federal funding, and its labor and deliver unit closes, it could mean more than just extra work for the doctors in Tuscaloosa. “We know that when labor and delivery units close, the infant mortality rate in that county rises.? For Dr. Catherine Skinner, that could lead to more examples of what she calls her nightmare patient scenario. “She knew she was having contractions. She knew it was time. And, she arrived too late to be able to stop labor and the baby was born prematurely.” And, studies indicate Alabama already has one of the highest infant mortality rates in the nation. PD, APR news, in Tuscaloosa.
Scars of Tuskegee
All year long at Alabama Public Radio, we’ve been looking at rural health. Many of the challenges residents of these communities face are a lack of doctors and hospitals, and the money to pay for care. For many African-Americans in Alabama, a lack of trust of outsiders and the government. This issue can be traced back to a study conducted by the U.S. government on black men living around Tuskegee. This year marks a twenty year milestone in a federal study of syphilis which still resonates across the country.
“You remember the Rodney King affair right? Police beat the **** out of the guy. The Tuskegee story is the Rodney King story of medicine.”
Meet Peter Buxtun. He’s known as the whistleblower on The Tuskegee Study of Untreated Syphilis on the Negro Male. In popular culture, it’s also called the “Tuskegee Syphilis Experiment.”
Buxtun was the guest of honor at a ceremony at Tuskegee History Center. It marked the twentieth anniversary of the official White House apology for the syphilis experiment. The audience in Tuskegee included family members of the men involved in the study. They were all helped when Buxtun and the Associated Press broke the story in 1972. He says, back then, the turning point was a lunchroom chat with a co-worker at the U.S. Public Health Service.
“I’ll never forget what he was saying, he said “the patient was insane and desperate need of some kind of help, the family didn’t know what to do, they weren’t sure what was going on.””
This lead Buxtun to dig deeper. What he found was a medical conspiracy…
“There is the study being run down in this place called Tuskegee and everyone in the study is black. What’s going to happen with the civil rights movement when they find out about it, so eventually the civil rights movement found out and people were very unhappy about it.”
Buxtun uncovered a program at the Public Health Service of finding African-American men from rural Alabama who had syphilis. Instead of treating these patients, the disease was allowed to progress while researchers took notes. It had been going on since 1932. Buxtun recalls one doctor in Tuskegee who got into trouble for trying to treat one of the subjects with antibiotics…
“The poor doctor who did the right thing had the medical society and the county health authorities jump down his throat, “look what you’ve done, you treated one of these guys, and you’re not supposed to treat them.” If he had had, let’s say pneumonia, there would have been a procedure to go through, some paper work, to get permission to save the guys life for Christ’s sake…ah, you don’t know what to make out of a thing like that.”
Buxtun tipped off a reporter from the Associated Press and the story soon broke.
“While the men started out just wanting just for me to settle their lawsuit and get an apology.”
That’s attorney Fred Gray. Before Tuskegee, his client list included civil rights icon Rosa Parks.
“They wanted a permanent memorial here.”
“And without remembering it, we cannot make amends and we cannot go forward.
Gray sued, the government settled, and in 1997 President Clinton gave the subjects of the Tuskegee Syphilis Study the words they wanted to hear…
“What the United States’ government did was shameful,” said President Clinton. “And, I am sorry.”
“This is actually a copy of my great granddaddy’s death certificate, and it actually indicates that he died from syphilis…”
That is Lloyd Clements. He attended a gathering over the summer to remember the twentieth anniversary of President Clinton’s apology. Clements is from Tuskegee and several of his family members were a part of the study…
“Initially my great grandfather Dan Collis, he was a member of the Tuskegee Syphilis Study and his son, Sylvester Collis was also a part of the Tuskegee Syphilis Study and his grandson Ludie Clements was also a part.”
Clements says his family has gone through a variety of emotions being a part of one of the dark chapters of Alabama and U.S. history…
“Initially there was a lot of hurt and anger involved knowing my family was involved in it. Then the initial hurt turned to grief and sadness then finally it turned to forgiveness on my part for my family.”
Dr. Rueben Warren is a professor of Bioethics and the Director of the National Center for Bioethics and Research in Healthcare at Tuskegee University. The center was established as part of the apology from the government. Warren says there was a particular reason the men in that area were used for the study…
“People in Macon County, particularly African Americans, were vulnerable. Were vulnerable because, not because they were uneducated, but because they were under educated, not that they were poor, because many of the men were not, but many of them were low income. So there were challenges around being black in the south that made them vulnerable.”
Warren says those running the study used trusted institutions like Tuskegee University and the area churches...
“They went to Shiloh Baptist Church to pick up the men right, and what young public health students are taught and researchers are taught, if you want to get populations for your research, particularly African Americans or Hispanics, where do you go? Go to the church.”
Warren says the researchers were taking advantage of the culture of the area…
‘They were lied to, they were deceived. They were kind of being treated, they called it “Bad Blood” but I don’t know what bad blood is, so I think their willingness to continue in spite of the pain of getting spinal taps, because there was some good intent beyond their own personal benefit. I think part of it is the psyche of community.”
Warren says they couldn’t have pulled the study off somewhere else…
“Couldn’t have done on it on the west coast, new York or Chicago, different kind of community, far less trusting. So I think it was intentional picking the place and picking the people.”
Warren says there needs to be a major change in how researchers present themselves…
“We ask to be trusted but we don’t talk about trustworthiness. I would suggest that we shift the paradigm from “do you trust me?” to “am I trustworthy?” once I prove myself trustworthy, then trust comes automatic so that paradigm shift is critically important and not talked about and I think we need to talk about it.”
Because of the Public Health Service’s treatment of those involved in the syphilis study massive changes were made in the way information is gathered. Participants must be informed they are part of a study, they must be made aware of how the information will be used and what the possible effects of the study could be. However, I asked Dr. Warren if something like the syphilis study could happen today…
“Absolutely. I think there are instances of bioethics and public health ethics violations as we speak that are occurring. So you have to think about the effort of ethics particularly around health, first look at the place, the people and the principal. If you do that the principal is generalizable. It’s the difference between informed consent and consent. Are people being truly informed when they’re consenting, so we need to look at that, the review boards are important but they need to be revisited.
Warren says the study done at Tuskegee still has an impact on minorities to this day…
“Clinical trials are critical. But the proportion of African Americans, other people of color in clinical trials is terribly poor. So if we’re not engaged in clinical trials then the results of the clinical trials may not be applicable to those populations.”
The changes brought on because of the Tuskegee Syphilis study are supposed to protect the public. However, in rural Alabama, the memory of the study is still there and the lingering distrust is clearly visible.
Connecting Doctors and Patients
All year long on Alabama Public Radio, we’ve been looking at rural health care. Advocates of rural health in Alabama say one of the biggest issues is access to health care in rural areas. The state is facing a massive shortage of physicians, and the doctors we do have are largely concentrated in metropolitan areas.
The situation gets worse when it comes to specialty and subspecialty care. The vast majority of the state’s specialists are in Birmingham, Huntsville or Mobile. But doctors are now starting to use technology to bring specialty care into rural Alabama.
“So how is everything today?”
“It’s good. Everything’s good.”
Mary Epp is 84 years old and a home dialysis patient. She’s at a routine followup appointment with her endocrinologist Dr. Eric Wallace at the University of Alabama at Birmingham School of Medicine. But Mrs. Epp isn’t in Birmingham. She’s at the Dallas County Health Department, about 75 miles to the south.
“They can not only see each other face-to-face, but they can use enhancements to listen to the heart rate, to monitor the EKG, to look into the ears, the eyes, the nose, the throat...”
Dr. Walter Geary is the Medical Director for the Alabama Department of Public Health. Thanks to telemedicine equipment at dozens of county health departments across the state, Dr. Wallace is able to provide Mrs. Epp and many other patients a full-fledged checkup hundreds of miles apart.
I caught up with Dr. Wallace at a statewide conference on telehealth.
“Probably 80 percent of what physicians need to do can be done by listening to the patient. But we also need a physical exam. So what happens is I use a telestethoscope to listen to the patient's heart and lungs and abdomen. I use specialized cameras to look at lesions -- in dialysis patients, the exit site...”
Dr. Wallace says providing care remotely is more than a convenience for these patients. He says it’s quickly becoming a necessity, given the state of health care in Alabama.
“If we had 500 doctors to land in Alabama today, we still wouldn't have enough.”
Ron Sparks is a rural health care and telehealth advocate.
“If we had 250 dentists land in Alabama today, we wouldn't have enough. So access to health care is definitely a problem in the state of Alabama. Using technology and using telemedicine is a way to reach folks who don't have access to health care.”
Sparks previously headed the state’s Office of Rural Development under Governor Robert Bentley. He says the expansion of telemedicine is inevitable.
“You've either used telemedicine, or you will use telemedicine. It's gonna happen.”
There are currently a collection of different small, regional telehealth networks offering various telemedicine services. Dr. Wallace says he wants to see those providers work together.
“My real vision for Alabama is that you have one overriding way of linking all of those networks together to create, really, a comprehensive network that is far-reaching and able to link any provider with any patient across the state.”
The Alabama Department of Public Health is taking the lead on developing that network. Jessica Hardy is the director of the Office of Women’s Health at ADPH.
“We have a very new telehealth program within the Department of Public Health, so we are growing, and we are being charged to try to go into eleven different areas of subspecialty at this time.”
Public health medical director Dr. Walter Geary says the possibilities for specialty care delivered remotely are nearly endless.
“That could be done for just the entire state of Alabama, if we had the bandwidth to do that, for a huge variety of problems and complications. All kinds of chronic illnesses, from diabetes to Chron's disease, to ulcerative colitis, to diabetic ulcers of the feet... All those kinds of things require daily treatment management, but intermittent physician oversight.”
Bandwidth is one potential hurdle to a widespread adoption of telehealth. Many rural areas in the state don’t have consistent cell service, much less broadband internet. And supporting high-resolution video conferencing along with medical data in a telehealth visit requires a lot of bandwidth.
Ron Sparks says it’s hard to understate the importance of quality internet.
“If you live in rural Alabama in today's world and you don't have access to broadband, that's like cutting off one of your main arteries to your heart. You're just not going to function very well. Big industry is not going to look at you. You're not going to have the health care that you deserve. You possibly could not have the emergency care, the public safety care...”
But the Alabama Department of Public Health has an unusual leg up. Thanks to a state mandate, county health departments have special broadband infrastructure and 60 of Alabama’s 66 county health departments currently have the bandwidth for telehealth, even if other areas of those counties fall short.
Another telehealth model is gaining lots of steam across the border in Georgia – telemedicine systems in school.
“The child's there at school all the time. That school nurse probably knows that child pretty well.”
Sherrie Williams works with the Global Partnership for Telehealth, based in Georgia.
“What if she is able to take that child to the next level by providing these care services into the mix? So it really becomes a whole lot bigger than just that primary care model. It truly can create a system of care.”
Williams says school-based telehealth can fill major gaps in community health care, especially after rural clinics or hospitals in those areas close.
“When a hospital closes, usually those primary care doctors leave also, so you're left with a huge void. Not only for the children, but you're talking about entire populations at this point in time. So I think being able to put telehealth inside the schools is a huge step in the right direction in figuring out how to fill that health disparity in our rural communities.”
Unfortunately, the model in Georgia isn’t possible in Alabama, at least not yet, because of Medicaid regulations. State Medicaid rules don’t consider schools an acceptable place to receive healthcare.
That’s not the only way Medicaid regulations are posing a bigger problem to telehealth. Alabama doesn’t have what’s called a “parity law” in place. That assures doctors get paid the same rate whether they see a patient remotely or in person. Georgia does, as well as Mississippi.
“Just across the border in Mississippi, their telehealth program has been going on 15, 16 years now.
Michael Smith is the director of telehealth for the Alabama Department of Public Health.
“They have about 6,000 telehealth encounters each and every month. We can benefit from the successes that they have made, but still have a lot of work to do in terms of development of our program.”
Alabama is starting on the back foot in terms of telemedicine. But Dr. Wallace is optimistic about the near future. ?
“What I foresee, with all the progress we’ve made thus far in the state, I foresee that this time next year, you will have multiple subspecialties at UAB providing care across the state. Important care, care that we need to actually improve the outcomes of patients in our state.”
Meaning patients like Mary Epp, dealing with a variety of complicated medical issues, can get quality health care a lot closer to home.
