FEATURE
RURAL HEALTH CARE
AUTHOR Eugene H. Shively, MD, FACS
I
have practiced General Surgery in Campbellsville
for over 42 years. We made grand
progress for the first 32 or so years at that
time. The hospitals in the area gradually
improved, mainly because we had both
general surgeons and primary care at
Taylor Regional Hospital. In the 90s, we
were one of the first to develop a Level
III Trauma Center. We also had doctors from the area who moved
back to practice ENT, gynecology and urology.
We developed a cancer center and presently take care of approximately
90% of the cancer patients in the area. Prior to our cancer
patients at home getting chemo and radiation, they would ride in
a van to Louisville and back. They were often sick and spending
an hour and a half on the road each way. It was not a pleasant
experience.
In South Central Kentucky there has been a gradual decrease in
acuity of care, especially in counties surrounding Taylor County.
We must continue to provide access to care in rural communities,
or we will continue to see higher morbidity and mortality in rural
America.
We already know that Medicaid expansion saves lives and mortality.
Patients in states with Medicaid expansion get more mammograms
and colonoscopies with earlier diagnoses and more lives
saved. 1,2,3
If the US wants to address health care in America, they have
to include rural health. The crisis in rural health started before
COVID-19. If we want to reverse the increased morbidity and
mortality in America, compared to the other wealthy countries,
we have to address rural health. 4
In order for rural hospitals to be able to compete, they need to
be compensated fairly; equal pay for equal work. We need to have
primary care physicians who are broadly trained and can take care
of more complicated patients than their urban colleagues.
Most hospitals make money on radiology, physical therapy and
surgery. Most rural hospitals cannot exist without a broadly trained
general surgeon. There are multiple threats to rural surgery today.
They include lack of broad-based training, increased specialization,
lifestyle issues, decreased interest in general surgery, decreased
reimbursement, increased expenses, increased expectations by the
general public and malpractice costs. I think it is almost impossible
to go into practice on your own. Rural hospitals have to hire their
own surgeons. 5
Solutions to help get surgeons in rural hospitals include 1.)
Finding and supporting residencies and fellowships for training
surgeons who are interested in practicing in rural areas and thirdworld
countries as medical missionaries, 2.) Collaborating with
university tertiary care hospitals, 3.) Equal pay for equal work, 4.)
Liability reform, and 5.) Regionalization of rural surgery centers
so that multiple surgeons can work as a team, so that lifestyle/call/
coverage issues can be addressed.
Rural health care can only be partially addressed with telehealth
and clinics. There must be broadly trained primary care physicians
and surgeons who live in the community and know the citizens.
References:
1
Ajkay, N., Bhutiani, N., Huang, B., et al, “Early Impact of Medicaid Expansion
and Quality of Breast Cancer in Kentucky,” Journal American College of Surgeons
(April 2018); 226: 498-504.
2
Yoshiko, T, Eun, J., Premartne, I, Chiuzan, C., Rohde, C., “Affordable Care Act
State-Specific Medicaid Expansion: Impact on Health Insurance Coverage and
Breast Cancer Screening Rate,” Journal American College of Surgeons, Vol. 230,
Issue 5, (May 2020); 230:775-783.
3
Tong, G., Sinner, H., Walling, S., et al, “Impact of the Affordable Care Act on
Colorectal Cancer Screening, Incidence and Survival,” Journal American College
of Surgeons, Vol. 228, Issue 4, (April 2019), 230:342-353.
4
Papanicolas, I., Woskie, L., Jha, A., “Health Care Spending in the United States
and Other High-Income Countries,” JAMA, (2018) 319(10):1024-1039.
5
Shively, E., Shively, S., “Threats to Rural Surgery,” The American Journal of
Surgery, 190:200-205.
Dr. Shively trained in general surgery in Louisville with Dr. Hiram C. Polk, in the same
group as Dr. Frank Miller and Dr. Neal Garrison. He practiced general surgery for 42
years in Campbellsville, Kentucky at Taylor Regional Hospital.
SEPTEMBER 2020 21