Health Equity in Rural America

What factors do you think of when you hear the term “health equity?” Race? Age? Socioeconomic status?

Each of these aspects is significant—and play an important role in a patient’s outcomes. But I think one area that may be underestimated is location geography. If you live in an urban area, chances are you’re no more than a half-hour car ride away from your nearest provider.

But what about rural healthcare? What do you do when the closest doctor’s office is 30, 40, 50 miles away? What kind of an impact can that have on a patient’s life? To learn more, I spoke with Lukas Fischer, the CEO of Linton Regional Medical Center, a hospital I’ve frequented during my time in North Dakota. Among other insights, Lukas shared the latest on staffing, patient education, mental health, and more in rural settings.

Interview

Hal: So, Lukas, I’ve been a frequent flyer of your hospital, so to speak. I’ve had loads of injuries out on the ranch here: Bunch of broken ribs, anaphylactic shock, you name it. And I’ve always had phenomenal care. Your hospital was recognized as one of the 100 best in the nation.

Lukas: Thank you. When we initially got recognized, obviously it’s a big achievement, morale booster for staff. I think maybe a little unexpected, but now we’ve been able to accomplish that five years in a row. So, to maintain that excellence is just a great opportunity, a great recognition.

I think that staff-wise, we’ve always known that they’ve provided great care and obviously you yourself have experienced that. I feel very honored to be part of that team.

Hal: There are huge challenges in rural health care and rural medicine. Even being able to attract the right kind of providers. How challenging is that, and what do you do to get folks to come in and work at the hospital?

Lukas: So staffing providers, nursing and any amount of staff in the hospital has been difficult. I think we see that throughout the nation, definitely in rural environments. I think one of the biggest things that we struggle with is providing more specialized services to our area.

One thing that’s helped us is there has been a big push for people to move out of urban environments. And we are focused a lot more on retention of staff versus trying to constantly recruit staff, as that comes with a multitude of issues and expenses. You’ve probably seen some familiar faces, but some staff can be there 20, 30, even 40 years.

The model in rural, at least rural North Dakota, has pushed to not always having a full-time physician on staff, it’s moved to mid-level nurse practitioners and P.A.s. They primarily staffing the ER 24/7, they’re staffing the clinics, and then we have physician oversight onsite anywhere from a couple of days a month to maybe a week per month, but they’re not physically on site regularly anymore.

Hal: I love nurse practitioners. You know, I created the in-pharmacy clinic business, which was eventually purchased by Walgreens, so I had to oversee 2500 nurse practitioners, physician’s assistants, and doctors. I’ve always tried to fight for increased scope for N.P.s and P.A.s because they’ll go to school and learn more. They’re fantastic. So I applaud you for how you do staff there.

How do you decide when you can help an individual, and when they need to go somewhere else?

Lukas: So on the clinic side, we primarily do family practice, but we do try to provide as much specialty care as we can. Most of those physicians and providers in a specialty area, come out of a tertiary facility like Bismarck a couple of times a month. We try to provide whatever care we can with the amount of staffing and provider time that’s available to us

Hal: So Lukas, you provide oversight of more than just the hospital, but assisted living and ambulatory services as well. Is that a challenge?

Lukas: I think in rural anything, but especially health care, you’re going to have to wear multiple hats. There are not enough people, so you have to be able to oversee multiple facets. We do have an ambulance service that we oversee and to give you a perspective on what that means in rural, they have a service area of over 1500 square miles. We have patients that could be coming 30 or 40 miles to our facility. If we were not available to them, they would end up traveling another 60 miles to a tertiary facility. In rural it really comes down to, if you’re not available to provide at least that emergency medicine, that could be a life-or-death situation for somebody.

Hal: One of my neighbors got dragged by a horse down a ravine, and the sheriff came out, ambulance came, and a helicopter came in from Bismarck, and they airlifted him to one of the hospitals up there. So, do you have any close relationships or associations with any of the hospitals in Bismarck?

Lukas: We work very closely with all tertiary facilities and have contracts in place where we can move people around easily because we have limited capabilities. So, we’re able to triage, take care of that patient initially, but for any type of long-term care like surgical procedures, we don’t offer surgery on site, especially if there’s trauma involved. So we would triage and transfer.

There are staffing shortages, hospitals are full, not enough staff, can’t take patients. We’ve unfortunately had to transfer patients across the state, across multiple states. We transfer to Minnesota, to Montana, and even as far as Denver just to get a patient seen unfortunately.

Hal: So you’re almost like a hub. People come in, and you make the decisions as to where they go and have these relationships so they can get evaluated, which maybe they wouldn’t have been able to in in the first place.

Lukas: Definitely. We definitely keep everybody that we can. We don’t want to overload and tax the system in the tertiary facilities. So, they work closely with us. Say that nurse practitioners in the E.R. and we’re seeing a patient, they’re able to easily contact a specialty provider at a tertiary facility in Bismarck and determine if they’re able to keep that patient local with the help of maybe some consulting services, or if we would have to transfer them to a higher level of care.

Hal: Do your providers experience burnout like a lot of other providers in other settings?

Lukas: Definitely. Looking at the size of our facility, the staff size is small, so we have a very limited amount of providers. They’re doing all of the clinic coverage, all of the E.R. coverage, they’re taking all of the night calls, the weekend calls. So burnout is a huge issue. Sometimes, you might not have a lot of hours at night and might be up the entire night and then still have to perform in the clinic the next day. So burnout is definitely an issue.

Hal: What are your thoughts on rural health care in the future and areas you might look to innovate?

Lukas: Telemedicine has become much bigger as we’ve seen out of the COVID era, and I think we’ll see that progress over time. That’s a way to get specialty services to an area like Linton easily. You set up the equipment one time and multiple providers can access it. I think that would be a big benefit in the future, maybe even seeing your provider on your phone.

Hal: Here we are in ranch country and there are a lot of exogenous events that take place like a drought or worrying about if the next thunderstorm’s going to have hail and damage the crops, which can create anxiety. Does that play a role in people’s minds?

Lukas: Definitely. I would say that mental health, behavioral health, depression, all of those are probably underdiagnosed in a rural population. I think many of those people don’t want to talk about that to anybody, including their provider, so that leads to a multitude of other chronic illnesses that are kept bottled up inside. We see that in many studies that that’s a big issue.

Even so, there’s not a lot of support and not a lot of specialty services for them to seek as well. The main provider is family practice, but they don’t have access to the specialty services that they need, psychiatrists and things like that. There is limited access across the board.

We had brought in a pediatrician onsite a few years ago. And unfortunately, there are a lot of pediatric patients that have never seen a pediatrician. I was surprised by the number of patients that pediatricians started seeing at our clinic. So it’s about access. Again, some of those kids probably did see family practice once or twice, but some of them hadn’t seen anybody in their entire life since they first left the hospital.

Hal: So what would you say is your major challenge at this point in rural health care?

Lukas: I’d say there’s a couple of major ones. Staffing is definitely an issue. we hear that there’s a mass exodus of health care providers leaving, which isn’t going to make it any easier in the future, and getting people to move to a rural community has its hardships as well.

I’d say the second thing is funding. The last couple of years, expenses have drastically increased where reimbursement and payments have pretty much stayed stagnant. You have to have outside funding sources to really even stay viable at this point, because reimbursement really hasn’t kept up with expenses.

Hal: Well, I want to thank you for all you do and overseeing the hospital and the regional area. You’ve been great for my family. You’re great for my neighbors. I don’t think anybody could really live out here without having your hospital. And so we very much appreciate it.

Making Waves is a series of conversations between New Ocean Health Solutions CEO Hal Rosenbluth and a variety of executives from a wide range of industries and areas of expertise. The below article has been edited for length and clarity from the podcast version of Hal’s interview with Lukas.