Kaiser Health News

Doctor Shortages Distress Rural America, Where Few Residency Programs Exist

Published

1 year ago

April 11, 2023

by Jazmin Orozco Rodriguez
Tue, 11 Apr 2023 09:00:00 +0000

ELKO, Nev. — Anger, devastation, and concern for her patients washed over Dr. Bridget Martinez as she learned that her residency training program in rural northeastern Nevada would be shuttered.

The doctor in training remembered telling one of her patients that, come July of this year, she would no longer be her physician. Martinez had been treating the patient for months at a local health care center for a variety of physical and psychiatric health issues.

“She was like, ‘I don't know what I'm going to do,'” Martinez said. “It almost set her back, I would say, to square one. That's so distressing to a patient.”

Martinez and three other resident physicians make up more than a third of the family practice providers at a health clinic in Elko, a city of about 20,000 people in the largely rural 500-mile stretch between Reno, Nevada, and Salt Lake City. Another patient cried and said she was unsure who her provider would be once Martinez returned to Reno to finish training.

Established in 2017, the rural family medicine training program in Elko is shutting down for a variety of reasons, including financial struggles, lack of a united support system, and a historical lack of health care investment in the area. Experts say systemic factors are common barriers to establishing and sustaining training programs for doctors throughout rural America.

More than 100 million people, or nearly one-third of the nation, have trouble accessing primary care, according to a recent study published by the National Association of Community Health Centers. This number has nearly doubled since 2014. The pandemic worsened provider shortages nationwide, but the problem is more acute in rural areas, which have long struggled to recruit and retain doctors and other medical professionals. Researchers say the relative lack of providers is one reason people living in rural areas experience worse health outcomes than people who live in urban areas.

Experts say expanding the number of medical residency training programs in rural areas is key to filling gaps in care because many doctors — including more than half of family medicine physicians — settle within 100 miles of where they train. And while the number of training programs has increased in rural areas during the past few years, research shows 98% of residencies nationwide are in urban areas.

Members of Congress have introduced several bills to address the health provider shortage, but they have not yet advanced.

Meanwhile, rural medical training programs need more state and federal investment to grow and remain sustainable, said Dr. Emily Hawes, associate professor at the University of North Carolina-Chapel Hill School of Medicine and deputy director with the federal Rural Residency Planning and Development Program.

There have been positive milestones, she said, including provisions in the Consolidated Appropriations Act of 2021 that created more flexibility in funding and accreditation for rural hospitals that want to establish residency programs.

Congress also created the Rural Residency Planning and Development Program, which Hawes helps lead. The initiative funded its first cohort in 2019. Since then, the program's parent agency, the Health Resources and Services Administration, has given more than $43 million to 58 organizations in 32 states to launch rural medical residency programs. As of last fall, the recipients had created 32 accredited training programs in family medicine, internal medicine, psychiatry, and general surgery, and received approval for more than 400 new residency positions in rural areas.

But it's still not enough, Hawes said.

For starters, the Centers for Medicare & Medicaid Services don't reimburse rural hospitals for medical residency programs at the same rate they do urban hospitals, despite rural hospitals facing similar or higher costs. Rural hospitals' lower patient volumes and higher rates of underinsured or uninsured patients affect how much the government pays to fund graduate medical education, or GME.

Hawes and other doctors argued in a research paper that rural hospitals participating in resident physician training should be paid the full cost of hosting residents, which amounts to at least $160,000 each annually.

The challenge of paying residents' salaries proved to be part of the problem for the program in Elko.

Officials at Northeastern Nevada Regional Hospital decided, when they launched their residency program six years ago, not to use CMS funds to pay salaries and instead to pay those costs out-of-pocket. That amounted to about $500,000 a year, said Dr. Daniel Spogen, a professor in the Family and Community Medicine Department at the University of Nevada-Reno School of Medicine and director of the medical residency training program in Elko.

In retrospect, Spogen said, he wishes he and other faculty had pushed the hospital to pursue CMS funding, because it would have given the program a stronger financial foundation.

In a February press release, hospital officials said the decision to close the medical training program was difficult but necessary, because of rising costs and increased requirements.

In the end, the community and residents suffer the consequences, Spogen said.

Hawes said rural communities and their resident physicians often benefit mutually: Residents experience a more diverse and involved training than they would in a larger hospital, because having fewer residents and doctors means they can take on bigger tasks. Martinez recalled treating a gunshot wound in the emergency room, something she said she probably would not have gotten to do in a Reno hospital.

Closing any rural medical residency program ends a key opportunity to locate physicians in the areas where they're most needed, said Hawes. Martinez and her husband, who is also finishing his medical training, had planned to stay in Elko. While that's not off the table, she said, they're keeping their options open now.

Spogen said people living in Elko will go back to relying on urgent care, which is not a substitute for primary care.

The nearest city with more health care resources, 230 miles away by car, is Salt Lake City. Spogen said the patients he treats through the program don't have the financial resources to go elsewhere.

Rural medical training programs don't have to end in struggle, Hawes said. Part of her job with the Rural Residency Planning and Development Program is to ensure faculty, residents, and hospital leaders have the resources, support, and knowledge they need to sustain their programs.

Spogen estimates that a resident physician brings in about $600 a day for the hospital where they train, resulting in roughly $190,000 in revenue per year.

Experts say when programs succeed, they grow quickly, like the Wisconsin Collaborative for Rural Graduate Medical Education, part of the Rural Wisconsin Health Cooperative. When the collaborative was established in 2012, there were 25 rural medical residency training positions in Wisconsin, said Lori Rodefeld, the group's director of rural GME development and support. Last year, the collaborative supported 51 positions — more than double the number from 11 years ago.

In addition, 65% of residents have remained in rural medical practice, Rodefeld said, which is higher than the national average for physicians who did their residencies in rural areas.

“We're very, very lucky,” Rodefeld said. “I don't know of many other states that have this kind of model where they have technical assistance available to multiple existing programs and for those who want to get started.”

Martinez and her husband chose Elko to complete their medical residencies because they knew they could help fill a need.

“It's almost intoxicating,” Martinez said. “You don't want to walk away from something like that, especially when you feel so valued.”

By: Jazmin Orozco Rodriguez
Title: Doctor Shortages Distress Rural America, Where Few Residency Programs Exist
Sourced From: kffhealthnews.org/news/article/doctor-shortages-rural-residency-programs-elko-nevada/
Published Date: Tue, 11 Apr 2023 09:00:00 +0000

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Kaiser Health News

Journalists Delve Into Climate Change, Medicaid ‘Unwinding,’ and the Gap in Mortality Rates

Published

1 day ago

May 4, 2024

Staff Editor

Sat, 04 May 2024 09:00:00 +0000

KFF Health News senior correspondent Samantha Young discussed Medicaid and climate change on KCBS Radio's “On-Demand” podcast on April 29.

Click here to hear Young on KCBS
Read Young's “AC, Power Banks, Mini Fridges: Oregon Equips Medicaid Patients for Climate Change“

KFF Health News contributor Andy Miller discussed Medicaid unwinding on WUGA's “The Georgia Health Report” on April 26.

Click here to hear Miller on “The Georgia Health Report”
Read Phil Galewitz' “Millions Were Booted From Medicaid. The Insurers That Run It Gained Medicaid Revenue Anyway.“

KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed mortality rates in rural America on The Daily Yonder's “The Yonder Report” on April 24.

——————————
Title: Journalists Delve Into Climate Change, Medicaid ‘Unwinding,' and the Gap in Mortality Rates
Sourced From: kffhealthnews.org/news/article/journalists-delve-into-climate-change-medicaid-unwinding-and-the-gap-in-mortality-rates/
Published Date: Sat, 04 May 2024 09:00:00 +0000

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Kaiser Health News

Oh, Dear! Baby Gear! Why Are the Manuals So Unclear?

Published

2 days ago

May 3, 2024

Staff Editor

Darius Tahir
Fri, 03 May 2024 09:00:00 +0000

Since becoming a father a few months ago, I've been nursing a grudge against something tiny, seemingly inconsequential, and often discarded: instructional manuals. Parenthood requires a lot of gadgetry to maintain a kid's health and welfare. Those gadgets require puzzling over booklets, decoding inscrutable pictographs, and wondering whether warnings can be safely ignored or are actually disclosing a hazard.

To give an example, my daughter, typically a cooing little marsupial, quickly discovered babyhood's superpower: Infants emerge from the womb with talon-strength fingernails. She wasn't afraid to use them, against either her parents or herself. So we purchased a pistachio-green, hand-held mani-pedi device.

That was the easy part. The difficulty came when we consulted the manual, a palm-sized, two-page document.

The wandlike tool is topped with a whirring disc. One can apparently adjust the speed of its rotation using a sliding toggle on the wand. But the product manual offered confusing advice: “Please do not use round center position grinding,” it said. Instead, “Please use the outer circle position to grinding.” It also proclaimed, “Stay away from children.” In finer print, the manual revealed the potential combination of kids and the device's smaller parts was the reason for concern.

One would hope for more clarity about a doodad that could inadvertently cause pain.

Later, I noticed another warning: “If you do not use this product for a long time, please remove the battery.” Was it dangerous? Or simply an unclear and unhelpful yet innocuous heads-up? We didn't know what to do with this information.

We now notice shoddy instructions everywhere.

One baby carrier insert told us to use the product for infants with “adequate” head, neck, and torso control — a vague phrase. (The manufacturer declined to comment.)

Another manual, this one online and for a car seat — a device that's supposed to protect your kid — informed readers with words and images that a model baby was “properly positioned” relative to the top of the headrest “structure” when more than one inch from the top. Just pixels away, the same model, slumped further down, was deemed improperly positioned: “The headrest should not be more than 1” from the top of her head,” it said, in tension with its earlier instructions. Which was it, more than one inch or not? So we fiddle and hope for the best.

I acknowledge this sounds like new-parent paranoia. But we're not entirely crazy: Manuals are important, and ones for baby products “are notoriously difficult to write,” Paul Ballard, the managing director of 3di Information Solutions, a technical writing firm, told me.

Deborah Girasek, a professor of social and behavior sciences at the Uniformed Services University of the Health Sciences, told me that for decades, for the young and middle-aged alike, unintentional injury has been the leading cause of death. That's drownings, fires, suffocation, car crashes. The USU is a federal service academy training medical students destined for the armed services or other parts of the government.

Some of these deaths are caused by lack of effective communication — that is, the failure of instruction about how to avoid injury.

And these problems stretch from cheap devices to the most sophisticated products of research and development.

It's a shortcoming that's prompted several regulatory agencies charged with keeping Americans healthy, including the Consumer Product Safety Commission, the Food and Drug Administration, and the National Highway Traffic Safety Administration, to prod companies into providing more helpful instructions.

By some lights, they've had success. NHTSA, for example, has employees who actually read manuals. The agency says about three-quarters of car seats' manuals rate four or five stars out of five, up from 38% in 2008. Then again, our car seat's has a five-star rating. But it turns out the agency doesn't evaluate online material.

Medical product manuals sometimes don't fare too well either. Raj Ratwani, director of MedStar Health's Human Factors program, told me that, for a class he teaches to nurses and doctors, he prompted students to evaluate the instructions for covid-19 tests. The results were poor. One time, instructions detailed two swabs. The kit had only one.

Technical writers I spoke with identified this kind of mistake as a symptom of cost cutting. Maybe a company creates one manual meant to cover a range of products. Maybe it puts together the manual at the last moment. Maybe it farms out the task to marketers, who don't necessarily think about how manuals need to evolve as the products do.

For some of these cost-cutting tactics, “the motivation for doing it can be cynical,” Ballard said.

Who knows.

Some corners of the technical writing world are gloomy. People worry their jobs aren't secure, that they're going to be replaced by someone overseas or artificial intelligence. Indeed, multiple people I spoke with said they'd heard about generative AI experiments in this area.

Even before AI has had its effect, the job market has weighed in. According to the federal government, the number of technical writers fell by a third from 2001, its recent peak, to 2023.

One solution for people like us — frustrated by inscrutable instructions — is to turn to another uncharted world: social media. YouTube, for instance, has helped us figure out a lot of the baby gadgets we have acquired. But those videos also are part of a wild West, where creators offer helpful tips on baby products then refer us to their other productions (read: ads) touting things like weight loss services. Everyone's got to make a living, of course; but I'd rather they not make a buck off viewers' postpartum anxiety.

It reminds me of an old insight that became a digital-age cliché: Information wants to be free. Everyone forgets the second half: Information also wants to be expensive. It's cheap to share information once produced, but producing that information is costly — and a process that can't easily or cheaply be replaced. Someone must pay. Instruction manuals are just another example.

——————————
By: Darius Tahir
Title: Oh, Dear! Baby Gear! Why Are the Manuals So Unclear?
Sourced From: kffhealthnews.org/news/article/baby-product-instruction-manuals-confusing-technical-writing/
Published Date: Fri, 03 May 2024 09:00:00 +0000

Post Views: 26

Kaiser Health News

California Floats Extending Health Insurance Subsidies to All Adult Immigrants

Published

2 days ago

May 3, 2024

Staff Editor

Jasmine Aguilera, El Tímpano
Fri, 03 May 2024 09:00:00 +0000

Marisol Pantoja Toribio found a lump in her breast in early January. Uninsured and living in California without legal status and without her family, the usually happy-go-lucky 43-year-old quickly realized how limited her options were.

“I said, ‘What am I going to do?'” she said in Spanish, quickly getting emotional. She immediately worried she might have cancer. “I went back and forth — I have [cancer], I don't have it, I have it, I don't have it.” And if she was sick, she added, she wouldn't be able to work or pay her rent. Without health insurance, Pantoja Toribio couldn't afford to find out if she had a serious condition.

Beginning this year, Medi-Cal, California's Medicaid program, expanded to include immigrants lacking legal residency, timing that could have worked out perfectly for Pantoja Toribio, who has lived in the Bay Area city of Brentwood for three years. But her application for Medi-Cal was quickly rejected: As a farmworker earning $16 an hour, her annual income of roughly $24,000 was too high to qualify for the program.

California is the first state to expand Medicaid to all qualifying adults regardless of immigration status, a move celebrated by health advocates and political leaders across the state. But many immigrants without permanent legal status, especially those who live in parts of California where the cost of living is highest, earn slightly too much money to qualify for Medi-Cal.

The state is footing the bill for the Medi-Cal expansion, but federal law bars those it calls “undocumented” from receiving insurance subsidies or other benefits from the Affordable Care Act, leaving many employed but without viable health insurance options.

Now, the same health advocates who fought for the Medi-Cal expansion say the next step in achieving health equity is expanding Covered California, the state's ACA marketplace, to all immigrant adults by passing AB 4.

“There are people in this state who work and are the backbone of so many sectors of our economy and contribute their labor and even taxes … but they are locked out of our social safety net,” said Sarah Dar, policy director at the California Immigrant Policy Center, one of two organizations sponsoring the bill, dubbed #Health4All.

To qualify for Medi-Cal, an individual cannot earn more than 138% of the federal poverty level, which currently amounts to nearly $21,000 a year for a single person. A family of three would need to earn less than $35,632 a year.

For people above those thresholds, the Covered California marketplace offers various health plans, often with federal and state subsidies, yielding premiums as low as $10 a month. The hope is to create what advocates call a “mirror marketplace” on the Covered California website so that immigrants regardless of status can be offered the same health plans that would be subsidized only by the state.

Despite a Democratic supermajority in the legislature, the bill might struggle to pass, with the state facing a projected budget deficit for next year of anywhere from $38 billion to $73 billion. Gov. Gavin Newsom and legislative leaders announced a $17 billion package to start reducing the gap, but significant spending cuts appear inevitable.

It's not clear how much it would cost to extend Covered California to all immigrants, according to Assembly member Joaquin Arambula, the Fresno Democrat who introduced the bill.

The immigrant policy center estimates that setting up the marketplace would cost at least $15 million. If the bill passes, sponsors would then need to secure funding for the subsidies, which could run into the billions of dollars annually.

“It is a tough time to be asking for new expenditures,” Dar said. “The mirror marketplace startup cost is a relatively very low number. So we're hopeful that it's still within the realm of possibility.”

Arambula said he's optimistic the state will continue to lead in improving access to health care for immigrants who lack legal residency.

“I believe we will continue to stand up, as we are working to make this a California for all,” he said.

The bill passed the Assembly last July on a 64-9 vote and now awaits action by the Senate Appropriations Committee, Arambula's office said.

An estimated 520,000 people in California would qualify for a Covered California plan if not for their lack of legal status, according to the labor research center at the University of California-Berkeley. Pantoja Toribio, who emigrated alone from Mexico after leaving an abusive relationship, said she was lucky. She learned about alternative health care options when she made her weekly visit to a food pantry at Hijas del Campo, a Contra Costa County farmworker advocacy organization, where they told her she might qualify for a plan for low-income people through Kaiser Permanente.

Pantoja Toribio applied just before open enrollment closed at the end of January. Through the plan, she learned that the lump in her breast was not cancerous.

“God heard me,” she said. “Thank God.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

——————————
By: Jasmine Aguilera, El Tímpano
Title: California Floats Extending Health Insurance Subsidies to All Adult Immigrants
Sourced From: kffhealthnews.org/news/article/california-legislation-medicaid-subsidies-all-adult-immigrants/
Published Date: Fri, 03 May 2024 09:00:00 +0000

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