Rural doctors struggle with more seniors, fewer resources
By Oakley Brooks
"Do you ever get fatigued?" Dr. Renee Grandi often asks her elderly patients this question at her small medical clinic in Enterprise.
Most can recall a time when, yes, they did feel more drained than they used to, so she checks off the box marked "fatigue." Medicare, the federal health care program for senior and disabled citizens, pays for two blood tests for fatigue. Grandi says she might use them to probe for more serious things that the plan won't pay for.
"It's stupid stuff," she admits, "But it's the game you learn to beat Medicare."
So far, Grandi, a sunny 38-year-old former health food worker, is winning. Barely. The life of a rural doctor in Northeast Oregon has never been easy — postings in the sticks have always offered lower pay and longer hours than big-city jobs. Rising malpractice premiums and large numbers of poor uninsured patients complicate matters.
But coming Medicare cuts and rapidly aging populations in isolated rural communities such as Enterprise are becoming a deep concern to Grandi and other physicians.
This month, the federal government is expected to cut Medicare payments to physicians by 4.4%. Oregon rural health advocates are hoping that Congress will soften the blow at the last minute, which has happened in the past. But looking long term, a full one-quarter of payments is to be lopped off over the next six years and additional cuts seem inevitable as more seniors, less revenue and a new prescription drug plan burden the system.
Meanwhile, Enterprise, the seat of Wallowa County and its largest town, is experiencing a senior boom. The over-65 population in the county grew 5% over the past five years, and is expected to jump another 20% by 2015. More and more local patients are on Medicare, and as reimbursements often fail to cover the costs of medical treatment, the demographic shift is starting to eat away at the bottom line of private clinics in Enterprise.
Doctors in private practice in midsized towns such as Bend, Medford, even Pendleton, are assessing the worsening Medicare payment situation and refusing new patients on the plan. In places with a lot of working people, it's a shrewd business decision. "You can afford to do it in those communities — there are plenty of privately insured people," says Karen Whitaker Knapp, vice provost of rural health at Oregon Health & Science University's rural health office.
But in 2,000-person Enterprise, tucked up against the towering Wallowa Mountains, things are different. There are only two large employers to speak of — the government and the local hospital — and two places to go for a checkup. The town may be shifting from its timber-dependent past, with more urban refugees consulting and commuting via coaxial cable, but people are still woven closely together. Kicking seniors to the curb seems like a cruel medical realpolitik that Renee Grandi doesn't think she can stomach. Looking across a cozy bookstore-coffeeshop-art gallery on Main Street one recent afternoon, Grandi finds some would-be casualties.
"The two gentlemen standing in line at the counter are on Medicare, two sitting at that table and there's one hiding around the corner over there that I know is on Medicare," she says. "What do you do? Walk up to them and say, 'Sorry, the government doesn't pay us enough to treat you anymore'? It's your neighbor. When you're in the city and you don't run into these people in the grocery store, it's a different story."
And, yet, in a hint of the grim health scenarios we may all be facing in the next generation, the unthinkable has been seriously considered in medical circles in town.
OVER THE PAST YEAR, Dr. Kaare Tingelstad, a 36-year-old osteopath who recently opened Frontier Family Medicine, Enterprise's second clinic, has faced the harsh reality of treating people on federal plans.
In March, he performed three hours of emergency work on a patient suffering from a brain aneurysm — for which he says he was reimbursed $70. Later, when a Medicaid patient needed a tubal ligation, Tingelstad had to absorb the cost. Fed up, Tingelstad has fired off several e-mails to Grandi, asking her to join him in limiting federally covered patients at their two clinics.
Grandi, a partner in Enterprise's other clinic, Winding Waters, has so far told Tingelstad no. "I'm too much of socialist," she says. But Grandi hasn't totally dismissed the idea, especially in the face of long-term scheduled Medicare cuts. "That may close my practice to new Medicare patients," she says bluntly.
Old-time doctors in town say they'd never consider turning away new patients because of reimbursement cuts. "I couldn't do it; I'd have to move," says Lowell Euhus, a colleague of Grandi's at Winding Waters who'll retire this year, 33 years after he first began practicing in Enterprise.
Euhus, 62, spent his childhood moving among small Oregon towns with his father, a Baptist minister, and he's been a strong advocate for frontier medicine since he arrived in Enterprise. He organized a rural health summit in neighboring Joseph in 1988, which brought state and federal lawmakers to town and led to the passage of a $5,000 annual state tax credit for rural doctors. OHSU also began rotating its family medicine interns through small-town clinics, exposing them to new opportunities.
The consensus between Euhus and another longtime partner at Winding Waters, Scott Siebe, is that conditions are better for local doctors than they once were. Still, Euhus doesn't discount what younger doctors will face in coming decades. "Medicare sucks, there's no other way about it," he says, adding that the country hasn't fully addressed how the fast-growing over-65 population will change health care.
As Enterprise ages, families — well-insured ones at that — are disappearing along with sawmill and U.S. Forest Service jobs. As an indicator, the school population in Enterprise has dropped by about 300 students over the past five to seven years.
"You don't have that nucleus of privately insured people to rely on," Tingelstad says.
Tingelstad says almost two-thirds of his patients are now on Medicare. He's being reimbursed 58% percent of what he charges Medicare patients for a typical half hour office visit, and he needs at least 60% of charges to cover overhead. So he says he's losing money on every office visit by government-insured seniors.
Winding Waters hasn't fully caluclated its losses on Medicare patients. But Euhus notes that his loyal patient roster — somebody's mother, a retired Forest Service worker, a California exile — is as high as 80% Medicare-supported.
Some of Oregon's rural clinics have special designations that insulate them from further cuts on Medicare reimbursement. But Wallowa County is neither suffering from an acute shortage of physicians nor does it score low on indicators such as infant mortality — the two red flags for health regulators.
Having hit a dead end with federal rules, OHSU's Knapp will now pursue special status for Wallowa as well as Lake County clinics with Gov. Ted Kulongoski. "Otherwise,'' she adds, "these clinics just absorb those continued and growing losses."
Without denying care to federally insured patients (and finding privately insured people to replace them), Grandi says a 4.4% cut this year in Medicare payments might mean Winding Waters doesn't replace its broken heart monitor or foists its blood-drawing procedures on Wallowa Memorial Hospital up the street. "If we have to absorb it all, it could mean cutting an employee," she says.
Tingelstad says he can't get more efficient at Frontier Family Medicine. He says he's streamlined his operation with an electronic records system and eliminated nurses. The only option he sees is taking on more clerical work himself and working more than his current 75 to 80 hours a week.
LOCAL SYMPATHY FOR THE PLIGHT is muted, even from those in the medical field. Larry Davy, CEO of Wallowa County Health Care District, which runs Wallowa Memorial, chalks up some of doctors' struggles to their own fussy ways.
"I don't think we're in imminent danger with this issue," Davy says. "Physicians tend to get tunnel vision focused on patient care. When society pushes other issues into their lap they get frustrated and grumpy."
Both Tingelstad and Grandi realize how their complaints play in a town where quality jobs are scarce, and so tend not to voice certain opinions very loudly, if at all.
"I still make five times what other people make. I have horses. I go on vacation," Grandi says. "So it's hard to cry to the public about it."
The Wallowa County community rallied to support doctors in 1989 when Euhus and Siebe were the only physicians covering the Wallowa Memorial emergency room. The two convinced the county to pay a third doctor to pinch hit in the ER three days a month, but only when they threatened to both leave town one weekend with their fishing poles.
Davy doubts that Wallowa County, now building a new hospital, would step up again to help doctors stretched by Medicare.
Euhus is not sure, however. Life may have been more difficult for his generation of local practitioners, but it's the new generation of doctors — in demand across the country and often in a lot of medical school debt — that will serve the community. And that's the reality Enterprise has to live with.
"In the past, you'd pull up your bootstraps and get on with your life," he says. "But I can see a lot of doctors flinging up their hands and leaving. I would hate to see docs leaving here, but sometimes it takes a jolt to get someone's attention."
Already, one doctor in town is unclear about his future, especially if the federal payment picture worsens.
"I would love to stay here," Tingelstad says. "But we're not silly enough to stay and risk too much."