MONTEREY — Ann Foster’s allergies have taken her over many a mountain in search of a cure.
Foster lives in rural Highland County, where there is no hospital, no practicing physician, not even a pharmacy. To see a pulmonary specialist, Foster recently had to drive to Harrisonburg, a three-hour round trip on winding country roads.
“It shoots a day by the time you travel over the mountains, ” Foster said.
Highland County is part of the most medically underserved region in Virginia — and the worst-case example of what could be a looming statewide crunch:
With newfound health insurance required by the Patient Protection and Affordable Care Act, more patients by the thousands will soon be seeking treatment from an already strained system.
Demand for primary care physicians is expected to increase at a time when there’s already a shortage of doctors in that field, both nationally and in Virginia.
Longer waits to see a doctor – assuming one can be found – could be in store.
“Just the magnitude of the situation is getting people’s attention, ” said Mike Jurgensen, senior vice president of the Medical Society of Virginia. “There hasn’t been this significant of an increase of the insured since probably [the implementation of] Medicare in the 1960s.”
Currently in Virginia, there’s a projected shortage of about 600 patient care physicians – a gap that is expected to grow to more than 2,500 full-time equivalent positions by 2030, according a 2010 forecast by the Lewin Group for the Virginia Department of Health Professions.
Rural and inner-city regions, for the most part, represent the 78 health practitioner shortage areas in Virginia, a designation used by the U.S. Department of Health and Human Services.
Topping the list is the Highland Medical Center, a community health clinic in Monterey that serves Highland County and four surrounding counties. The center’s service area scored 19 on a scale of one to 25, making it the most medically deprived place in Virginia.
Other areas in Western Virginia with scores of 12 or higher include Northwest Roanoke, Buena Vista, Martinsville and the counties of Bedford, Bland, Buchanan, Dickenson, Henry, Rockbridge and Russell.
The paucity of primary care physicians is not adequately addressed by the Affordable Care Act, critics say.
“The bottom line is that when they created the legislation, they didn’t have a real sense of what the shortage was, ” said Ann Peton, director of the National Center for the Analysis of Healthcare Data, an organization affiliated with the Edward Via College of Osteopathic Medicine in Blacksburg.
While much has been made in recent weeks of technical problems that have hindered insurance enrollment on a government-run website, there’s also this question: What happens if people with no previous coverage get new insurance cards, but have no easy access to health care?
“Unfortunately, there’s not nearly enough in the Affordable Care Act to expand primary care capacity in this country to where it needs to be, ” said Dr. Andrew Morris-Singer, president of Primary Care Progress, a Massachusetts-based nonprofit group.
And that, Peton said, “is still the 5,000-pound gorilla that the policy makers don’t want to discuss.”
Searching for a country doctor
With a population of 2,200, Highland County can make do with just one traffic light. And that one, in the county seat of Monterey, needs only to blink yellow to control what little traffic passes through.
The big attractions here are the mountain ridges and valley farmland, for which the county is called “Virginia’s Switzerland.” It’s the kind of place that conjures up the image of a country doctor, once a trusted fixture in small-town America.
Yet there’s no doctor of any kind at the Highland Medical Center, where two nurse practitioners provide the only primary care to be found in the county.
For a year now, officials have been trying to hire someone to replace Dr. Kim Bird, who decided last December to stop seeing patients. Bird remains the clinic’s medical director, overseeing the nurse practitioners who handle nearly 10,000 patient visits a year in cramped examining rooms.
Patients in need of specialized care – Ann Foster and her struggle with allergies, for example – must drive out of the county. Inpatient emergency treatment is also out of the question.
In fact, the most frequent call to the Highland County Volunteer Rescue Squad is made from the medical center, where the most seriously ill or injured patients must be transported by ambulance or helicopter more than 50 miles to hospitals in Augusta, Bath and Rockingham counties, according to squad captain Chris Vernovai.
“We are kind of a poster child, if you will, for medically underserved, ” said Paul Klein, president of the center’s board of directors. “We are medically underserved in just about every way you can think about.”
An influx of new patients with access to insurance through the Affordable Care Act could come at a difficult time.
“It’s all the more reason why we need to get a doctor, ” said Debbie Perdue, the center’s executive director.
The new health care law requires nearly everyone to have insurance by March 31 or pay a tax penalty. Many low- to moderate-income people not covered by Medicare or Medicaid, the government insurance programs for senior citizens and the poor and disabled, can purchase insurance at subsidized rates on a government-run website.
An expansion of Medicaid, called for by the Affordable Care Act but optional on a state-by-state basis, is still under consideration in Virginia.
Should the program’s eligibility requirements be broadened to cover those who make up to 138 percent of the federal poverty guideline, it could mean another 1,300 Medicaid patients at the Highland Medical Center.
Many of those people already receive discounted care at the center. But more would likely seek treatment from an operation that is already stretched thin.
Said Klein: “We’re pressed against the walls in order to deliver all the services that we want to deliver.”
A looming shortage of physicians
Although the situation is not as dire in more populated places, they nonetheless face some of the same challenges that have made finding a physician so difficult in Highland County.
Namely, a shortage of primary care providers. Just 32 percent of physicians in the United State are primary care doctors, according to Primary Care Progress.
Why? One reason is that primary care physicians make about half of what specialists earn, a gap that can be a career decision-maker for medical school graduates with an average student loan debt of $160,000 to $200,000.
With such a pay disparity, “we have been discouraging people from going into primary care for years, ” said Morris-Singer of Primary Care Progress.
The number of primary care doctors in Virginia – 40 percent of more than 17,000 physicians – is higher than the national average.
But according to the state Department of Health Professions, the median age of those physicians is 51. And nearly 20 percent of them are planning to retire within the next five years.
“That could be really scary, ” said Dr. Dixie Tooke-Rawlins, dean and provost of the Edward Via College of Osteopathic Medicine.
The mission of VCOM, which opened 10 years ago, is to produce primary care physicians willing to practice in medically underserved areas.
Medical school enrollment has increased by 15 percent in Virginia since 2008, partly because of new schools such as VCOM and the Virginia Tech Carilion School of Medicine in Roanoke.
However, the number of residencies – the on-the-job training required of medical school graduates before they can practice on their own – is not keeping pace with the growing number of aspiring doctors.
Since 1997, Congress has frozen funding for residency programs. While the goal then was for more efficiency under the managed care model, the reality today is something different.
“There are flat out not enough residency slots to handle the number of students graduating nationwide, which is creating a bottleneck for these slots, ” said Beth O’Connor, executive director of the Virginia Rural Health Association.
More health care jobs coming?
It seems simple: Making health insurance more accessible will make more work for the health care industry.
Although that’s certainly true – one study projects 30,000 new jobs if Virginia expands Medicaid – the Affordable Care Act’s effect on the medical work force remains unclear in Southwest Virginia.
It’s not like the floodgates will open on Jan. 1, the earliest date that new insurance policies purchased under the new law will take effect.
Enrollment on HealthCare.Gov, already going slowly because of technical problems, will continue through March 31 for 2014 plans. It will take several more years to reach a national goal of 29 million people with coverage purchased through the government and state-run exchanges.
The law’s rollout will be further delayed in Virginia, where next July is the earliest possible starting date for an expanded Medicaid – should that come to be. And many of the low-income patients who would benefit from the program are already receiving some medical treatment, either through free clinics or charity care programs offered by hospitals, where the uninsured often seek treatment in the emergency room.
In the Roanoke and New River valleys, where health care is a top employer, providers are assessing the need for more services that all the changes might bring.
“It really could have a dramatic increase, ” said Dr. Michael Jeremiah, head of Family and Community Medicine for Carilion Clinic. “We’re looking ahead to say, ‘what can we do?'”
Although new jobs are possible, Jeremiah said Carilion would also attempt to better manage existing resources to meet a higher demand at its 45 primary care practices across Southwest Virginia.
For example, if doctors are doing too much paperwork, a team-based approach that already exists would be tweaked to free them up to see more patients.
Jeremiah declined to estimate how many new jobs might be created, should the need persist. “It would be too much of a wild guess, ” he said.
At LewisGale Regional Health System, president Jon Bartlett said the system of four hospitals and 700 affiliated physicians has already been growing to meet demands that would exist without the health care law, such as those caused by the region’s aging population.
“There will be an increased demand regardless, ” he said. “There will be an enhanced increased demand should certain variables play out. How quickly that increased demand materializes, none of us knows for sure.”
Like Jeremiah at Carilion, Bartlett declined to estimate how many new jobs might result from higher use of the health care system.
In Northwest Roanoke, one of the medically underserved areas identified by the federal government, the New Horizons Healthcare center has increased its full-time equivalent staff from 31 in 2011 to 44 this year.
While some of that growth was planned as part of the center’s expanded location, the Affordable Care Act was also a factor, New Horizons CEO Eileen Lepro said.
“We just don’t want to get stretched to the point where patients have to wait a month or longer to get in, ” Lepro said. “That’s just not good access.”
A rural hospital closes its doors
In Lee County, at the far Southwestern tip of Virginia, access to health care just became more difficult.
Lee Regional Medical Center, the county’s only hospital, shut its doors Oct. 1. Wellmont Health System, which ran the hospital, said the closure was partly the result of cuts in Medicare reimbursements under the Affordable Care Act.
The reduction in federal funds was supposed to be offset by expanding Medicaid to cover more indigent patients, a population that many hospitals treat for free or at discounted rates.
But that assurance fell through when the U.S. Supreme Court ruled last year that states cannot be forced to expand their Medicaid programs as part of the health care overhaul. A legislative commission is debating whether Virginia should expand Medicaid, a step already taken by 25 other states.
Meanwhile, Medicare payment reductions that took effect Oct. 1 “profoundly impacted” Lee Regional Medical Center, according to the president and CEO of Wellmont.
“These political decisions clearly can have dire ramifications for small communities and the hospitals that serve them, ” Denny DeNarvaez said in a statement at the time.
Wellmont also blamed the closure on low use of the hospital and difficulties in finding local physicians to be on call.
The hospital is the first in Virginia to close as a result of Medicare payment reductions, according to O’Connor. But the head of the Virginia Rural Health Association is worried that more small-town hospitals could be next.
The cuts “are just one more hit for a small, rural facility that was already walking on the edge, ” she said.
Hospitals are often major employers, and losing one can be a financial blow for a locality.
“Just from a tax-base, never mind the whole human suffering element, the difference between having and not having a hospital in a small community is huge, ” O’Connor said.
Dr. Art Van Zee, who practices in Lee County, said Wellmont’s blaming of the Affordable Care Act is “an invented, if not spun, reason for the closure.”
Van Zee said Wellmont shuttered the hospital with the expectation that patients would go to other hospitals it runs in neighboring counties, protecting its bottom line – if not the residents of Lee County.
“Many lives are at risk, ” Van Zee said, “and some lives without question are going to be lost.”
‘A long ride across the mountains’
On a recent Friday afternoon, Ann Foster was back at the Highland Medical Center, waiting for lab test results and another referral elsewhere for her persistent allergy problem.
As a longtime resident of a tiny community (she teaches all 14 of the county’s kindergarten students), Foster knows well the trade-offs between city and country living.
“If you’re sick after 4 o’clock, you might not get your medicine, ” she said of a system in which prescriptions from the medical center are filled at a Bath County pharmacy and then driven by courier to Monterey once a day.
Despite the inconveniences, Foster had high praise for the medical center staff.
And while it might sound bad to be the state’s most medically underserved area, officials at the center hope the recent ranking might actually help in their search for a physician.
Klein said the ranking puts Highland County at the top of a list compiled by the National Health Service Corps, which pays the student loan debt of new doctors who commit to practicing where they are needed the most. Under the Affordable Care Act, the program received more than $284 million, allowing about 4,500 loan repayments and scholarships in the most recent fiscal year.
The health care law seeks to bolster primary care in other ways: boosting Medicare reimbursements for family physicians, providing training and recruitment programs, and encouraging more use of nurse practitioners and physician assistants in patient-centered medical homes. But critics say it’s not enough.
So in places like Highland County, help remains a long way away.
“It’s a long ride across the mountains with a really sick person, I can tell you that, ” said Beth Armstrong, a longtime member of the local rescue squad. “You don’t know until you’re in the back of an ambulance how long it can be to that hospital.”