Thought I would take a different tack today. While I love an am very passionate about agriculture, there are at least two other very large passions in my life. The first is my family and our faith. I hope you have seen enough post on this blog to show you how very important family and community are in my life. But there is another driving passion of mine – medicine.
Family medicine in a rural community has been my lifetime goal since before I can remember understanding what a goal meant. But, I have had a really hard time blogging about medicine and medical issues. I have a treasure trove of stories about my interactions with patients but due to HIPPA (the patient privacy law) I am not sure how to write about them. So, in answering a challenge from a friend to write more about medicine I am writing today about some of the challenges I face in rural Tennessee as a doctor.
First off I’d like to state that up until a recent trip to Washington, D. C., I thought I worked in a rural area. Then I met some ranch farm mom’s from Utah, Wyoming, and Arizona. These farm mom’s live on homes 80 miles from towns. They do things like buying homes in town when their kids start high school just so their children can play sports. They drive 2 hours to take their children to town to see a pediatric doctor, as a twitter friend in Montana told me. So, now with a better appreciation of my not so rural medicine practice, let me tell you a few of my trials.
1: The inefficiency of Tennessee’s TennCare (it’s our states version of Medicaid) program as it relates to rural healthcare.
In my county, about half to 2/3 of my patients at any given time are on TennCare, which is fine. We live in a poor county and have been hit hard by the “economic downturn”. (I still have patients that cannot read and write/our schools still graduate children that read at maybe 8th grade levels)
So, my staff and I spend a lot of our time dealing with TennCare. I call this a problem because they constantly change their medicine formulary. This means that every six months or so, someone decides what medicines are paired for and the list changes with NO warning. What this means to patients is medicines that they have been on may no longer be covered. They have to either come back in or call and get their medicine changed.
Also, TennCare pays specialist so slowly or so poorly that many specialist will not see these patients. In larger urban areas this may not be a problem for doctors because even if only 10 orthopedist see TennCare patients in a ten mile radius that’s not that far in Nashville. But in my area, we often have to send patients over 100 miles in search of a specialist that will see them.
Also, my nursing staff waste hours and hours each week, seeking “prior approvals” from TennCare. Now I am not disputing that there is a lot of wastefulness in medicine and over utilization of testing (mostly to prevent lawsuits), but in rural Tennessee there are times I need a more efficient way to get an emergent test instead of waiting 2-7 days. Yes, the Internet system that TennCare put into place last year has helped tremendously, but there are always emergencies when a physician needs an answer right now.
I have a perfect example, I had a small TennCare patient under two years old who fell and had significant head injury in my office. I needed a head CT. We called TennCare seeking emergent prior authorization and were told to either send the child to the Emergency room and let them do the scan or admit the child to the hospital and scan her head that way because there was no way that we would ever be able to get an approval in less than 2 days. And you wonder why the TennCare budget is out of control. It took me over 30 minutes to get a supervisor on the phone to get my test that day. The patient ended up being fine.
2: This past year Medicare changed the rules for Home health patients requiring a face to face visit with in 90 days of initiating home health. That sounds very reasonable. But in rural Tennessee, some of my home health patients have been at home, in their beds for the last 5 years. I would love to know how their families were supposed to get them to my office for a face to face visit? This is an issue in urban areas too. Unless a provider makes house calls, I am not aware of a way to work around this. Most of these “face to face visits” can be done when a patient leaves the hospital, but for those truly home bound patients I ended up making house calls.
3: My last rural medicine difficulty for the day, has been the difficulty in bringing 21rst century medicine into a very rural world. I don’t just mean medical health records, although that has been fun. I have a few elderly patients who don’t like me to bring the computer into the exam room. They are afraid I am playing a “game or something”. But even issues like trying to explain evidence based medicine about issues like not needing antibiotics for sinus infections or how narcotics are not the best treatment options for chronic lower back pain.
Well, I hope this give you a little insight into some of my challenges. I love my job and my patients. I have. Even blessed to be a part of their lives now for going on nine years and looking forward to many more. Yes, many things in the structure of medicine could be better, but what does not kill us only makes us stronger.