Health care in the country

Small-town hospitals save lives. Dustin Cox knows this from personal experience. In Feb­ruary 2019, two of his coworkers at MFA Agri Services in Trenton, Mo., noticed he was having trouble speaking and called 911. As it turned out, Cox was having a stroke.

“If it wasn’t for our local hospital, I’m not sure what the outcome would have been,” said Cox, manager of MFA in Trenton, population 6,000. “You seldom hear good things about rural hospitals, but I received spot-on care. I’m a prime example of how local hospitals are essential.”

For stroke patients, it’s critical to get treatment within an hour. The local ambulance service arrived within five minutes and transferred him to Trenton’s Wright Memorial Hospital, where medical staff members quickly diagnosed and stabilized him. The nearest urban hospital is in Kan­sas City, normally a 90-minute drive from Trenton. Within an hour of Cox’s arrival at Wright Memorial Hospital, he was airlifted to the Marion Bloch Neuroscience Institute in Kansas City for further treatment. Both hospitals are part of the St. Luke’s Hospital system.

Cox was back at work within a week of having the stroke, grateful to MFA employees Justin Anderson and Kevin Kirk, who realized something was wrong and called immediately for emergency help.

“Not everyone would recognize stroke symptoms,” Cox said. “Especially since I’m 45, and I’m not in the typical stroke age range.”

Doctors at the institute discovered a small hole between the upper two chambers of Cox’s heart that allowed a blood clot to travel to his brain and cause the stroke. He recently underwent a successful outpatient surgery to repair this common heart defect.

“I’m glad I’m able to stick around and be with my fam­ily in my home town,” said Cox, who lives on a farm in Trenton with his wife, Mandy, and their three children.

Unfortunately, not all small-town hospitals like Wright Memorial succeed, leaving a gap in health care for many rural residents. Nine rural hospitals in Missouri have closed since 2014 from a total of approximately 120 full-service acute-care hospitals in the state, according to Dave Dillon, vice president of public and media relations for the Missouri Hospital Association. Of Missouri’s 143 licensed hospitals, 69 are in rural counties, leaving 32 rural counties without a hospital.

“It will take a variety of approaches to address the shortage,” Dillon said, “including rethinking how hospi­tals, physicians and other caregivers work together.”

Rural clinics and hospitals face several financial hurdles, Dillon explained. They serve lower income populations, have a higher share of Medicare and Medicaid patients and a lower share of commercial insurance patients. Hospitals are reimbursed less than cost through Medicare and Medicaid and don’t have the volume of commercially insured or self-pay patients to make up the difference. Rural areas also have a higher percentage of seniors, who tend to suffer from chronic health conditions.

I-70 Hospital in Sweet Springs, Mo., is one of the state’s now-abandoned hospitals. After experiencing many of these financial challenges, the facility closed its doors in February 2019, leaving the town of 1,500, located an hour east of Kansas City, without emergency care. Dennis Dohr­man, a farmer and chairman of the Sweet Springs Ambu­lance District Board, has been working to bring it back.

“It usually takes an extra hour to get to an emergency room now,” said Dohrman, a member of MFA Agri Services of Sweet Springs. “We have a lot of senior citizens in the area, and that extra hour can be critical—especially for stroke patients.”

In December 2019, another out-of-state healthcare enterprise purchased I-70 Hospital. Dohrman said that he’s heard the building is slated to become a “medical mall” with offices for doctors, dentists and other such service providers. Without a full-scale, acute-care hospital in Sweet Springs’ future, he and other local residents are working on a solution.

“We hope to set up a hospital tax district that would fund a 24-hour emergency room,” Dohrman said.

Attracting rural caregivers

While many rural communities are finding it difficult to provide adequate health care, Brookfield, Mo., population 4,500, is overcoming the problem, thanks in part to Dr. Kendal Geno.

“I wanted to be a doctor from the age of 4 or 5,” said Geno, whose family moved to Brookfield when he was 7. “I like the small-town atmosphere, and I always wanted to be a primary-care physician.”

Missouri has 114 counties, 101 of which are considered rural. Of those, 99 have been designated as Primary Medi­cal Care Health Professional Shortage Areas by the federal Health Resources and Services Administration. Linn Coun­ty, where Brookfield is located, is one of them.

“Our health facilities are prime examples of the shortage in our state,” said Geno, who works at Applegate Medical Group and is affiliated with the Pershing Health System, a 25-bed critical-access hospital. “I’m the first new doctor they’ve had here in 15 years.”

Analysis by the American Association of Medical Col­leges projected a shortage of up to 49,000 primary care doctors in Missouri by 2030. Rural places have fewer doc­tors than urban areas, and Missouri’s rural/urban divide is more pronounced than the nation as a whole. According to a Missouri Hospital Association study, the state has 56 primary care physicians per 100,000 rural residents, com­pared to 139 per 100,000 urban residents.

“Research shows that a major determinant in the deci­sion to serve a rural area is if you’re originally from a rural area, like me,” Geno said. 

The 33-year-old returned to Brookfield in 2016 after attending Truman State University in Kirksville, Mo., as an undergraduate, earning a degree from the University of Missouri medical school, and completing his residency at MU University Hospital in Columbia—all of which took 12 years.

Three programs helped Geno in his quest to practice in a rural area. MU’s Rural Track Pipeline Program introduc­es prospective medical students to rural health care. As a sophomore at MU, Geno was accepted into the pipeline’s Bryant Scholars Program, which led him to a pre-accepted spot in the School of Medicine. The university recently received a federal grant of $4 million to train more rural doctors through the pipeline. Missouri was one of eight states to receive the grant.

The state-sponsored Primary Care Resource Initiative for Missouri (PRIMO) forgives loans to med students who commit to practice primary care for five years in under­served areas in Missouri. Geno has one year left of his five-year commitment.

The Missouri Area Health Education Center exposes college students to health professions and prepares them to be accepted in health programs and practices.

Students may be attracted to medicine because of its relatively high pay compared to other professions. Physi­cian compensation in the South Central region of the U.S., which includes Missouri, averages $303,000 annually, according to the 2018 Medscape Physician Compensation Report.

However, newly fledged doctors don’t start out on that pay scale. And the cost of education has escalated. Kathleen Quinn, associate dean for rural health at the MU School of Medicine, reported that the combined cost of eight years of undergraduate and med school studies at MU runs about $346,143. You get paid for your residency, but the pay doesn’t compare to what you earn after completing it. According to the American Association of Medical Colleges, 76% of medical school graduates had a median education debt of $190,000 in 2016.

“I was blessed,” Geno admits. “I got a full-ride scholarship for my undergraduate years, and my medical school costs will be forgiven through PRIMO. I will be debt-free. Help is out there, but you have to look for programs and make a commitment to rural areas.”

Doctors who invest in further training for careers such as cardiology or neurology generally earn more than fam­ily doctors.

“But I would be bored as a specialist,” Geno said. “I love the broad scope of primary care. I can do about every­thing, which is useful in a rural area where you don’t find as many specialists.”

Closing the rural/urban divide

The Missouri Hospital Association’s Dillon points out that making health insurance more available and affordable would help attract and retain small-town providers. Rural residents typically earn less and often can’t afford health insurance. Farmers, who work in one of the most danger­ous occupations, can rarely access group health benefits, he added.

“Farmers in particular are far more likely to be underin­sured,” Geno said. “At the same time, they’re the least like­ly to want to drive an hour and a half to see a specialist.”

John Groves, one of Geno’s patients and a member of Brookfield MFA Agri Services, raises corn, soybeans, wheat and cattle while also working full time as a self-employed carpenter. Three years ago, he fell off a grain bin and broke his leg, which Geno successfully treated at the Brookfield clinic while consulting with a specialist.

“Dr. Geno is a wonderful man, and fortunately I have health insurance, but insurance costs keep rising,” Groves said. “I have to pay a $5,000 deductible before insurance covers any medical expenses. The prices farmers get for soybeans and corn are about the same as they were 20 years ago, but health insurance costs have gone up much faster.”

Accessing government-covered health benefits for low-income people is another hurdle for rural Missouri­ans.

“We’re one of 14 states that hasn’t adopted Medicaid ex­pansion,” Dillon explained. “Fewer people here can access health coverage compared to what would be available in an expansion state.”

The 2010 Affordable Care Act offered states addition­al federal Medicaid dollars to cover more low-income Americans. According to healthinsurance.org, 933,441 Missourians were covered by Medicaid as of July 2018, and about 352,000 additional people would be covered today if the state accepted federal expansion dollars. The Kaiser Family Foundation puts that additional number of eligible people at 232,000.

Missouri has found other ways to address rural health­care problems. In 2013, the legislature allowed first re­sponders to provide additional care in rural communities. In 2014, the legislature expanded telehealth technology, which links experts to local providers. In 2018, Missouri Gov. Mike Parson held a rural health summit that led to a “Reimagine Rural Health” agenda. The plan recommends policies that include expanding access to primary care providers as well as nurse practitioners, physician assis­tants and other caregivers.

Still, challenges continue to pile up. Geno reports that the Brookfield hospital is one of many rural hospitals that no longer delivers babies because of a lack of obstetri­cians. Pregnant women must travel to larger hospitals.

“Having an OB specialist can be expensive because patient volume is low compared to more populated areas,” Dillon said. “Also, OB physicians have some of the highest costs for malpractice insurance.”

For Geno, however, the rural lifestyle of Brookfield gives him and his wife, Amy, a good place to raise their six children and allows them to be active in the community. Besides his practice, Geno is health director for the Linn County Health Department, teaches health classes at area schools and acts as physician at local sporting events.

Recently, while watching his son at a wrestling match, the small-town doc treated a student with a broken finger and another with a fractured collar­bone.

On the down side, he said, other doctors often choose not to work in rural places because they may have to give up big-city amenities and access to medical colleagues and specialty resources. Plus, being a primary-care physician in a small town means keeping odd hours and wearing lots of hats.

“I don’t get much down time,” Geno admitted. “And I have treated people in my living room.”

Keeping caregivers local

In 2020, about 128 students will graduate from MU’s medical school, the smallest in Missouri. Other med schools in the state are at Washington University in St. Louis, the University of Missou­ri-Kansas City, St. Louis University and Kansas City University.

MU exports fewer graduates to other states compared to oth­er Missouri medical schools, according to Quinn, who oversees the Rural Track Pipeline Program.

“Other med schools have more out-of-state students, many of whom end up practicing in other states due to a shortage of Missouri residency positions,” she added.

Katherine Meidl, a fourth-year med student at MU, has been a Pipeline participant since the summer following her sophomore year. This year, Meidl looks forward to returning to her home­town of Hannibal, Mo., population 17,500, to do a medical training rotation at Hannibal Regional Healthcare System, an independent system that serves rural areas. Hannibal Regional Healthcare System and the Hannibal Clinic are training sites for MU’s program.

“When I set my heart on rural medicine, it was through the lens of my parents,” Meidl said, explaining that both her mother and father are physicians at the Hannibal Clinic.

Since this is only the fourth year that Hannibal Regional Healthcare has participated in the pipeline program, there hasn’t been time for the med students to join the system as doc­tors, said Susan Wathen, vice president of human resources.

“The goal is to recruit some of those doctors back here,” she said. “In the future, we will see the fruit of our effort.”

In 2019, the Pipeline led to a summer job for Meidl in a rural clinic in Mound City, Mo., population 1,000, where she created a resource guide. She also created a mental health community guide for St. Joseph.

“There’s a huge need, especially in rural communities, for mental healthcare,” said Meidl, who would eventually like to practice psychiatry through telemedicine connections or by traveling to rural communities.

Like many small-town hospitals, Citizens Memorial Hospi­tal in Bolivar, Mo., had trouble recruiting medical staff. So it developed its own incentives. The hospital’s nonprofit foun­dation raises funds for a Medical Excellence Scholarship that has helped about 500 med and nursing students and others. Today, 50 scholarships are awarded annually. The system also partners with Bolivar Technical College to assist about 30 registered and licensed practical nurses, paramedics and surgical technicians each year and has worked with South­west Baptist University to develop a bachelor’s degree in nursing. Most of this year’s 23 graduates from Southwest Baptist will be local.

“There are a lot of good, rural hospitals,” said Don­ald Babb, who was with Citizens Memorial Hos­pital for 38 years before retiring as CEO Jan. 30. “Unfortunately rural populations are changing as young people move to cities for jobs.”

Under Babb’s leader­ship, the system expanded into eight counties with a second hospital, 35 clinics, seven long-term care facilities and other op­erations, but he admits it takes a lot of hard work to make rural hospitals thrive. In recent decades, several physician-owned clinics around Bolivar found it difficult to survive on their own.

“We’ve worked with physicians who want to partner with us to purchase their clinics,” Babb said.

And while Citizens Memorial may have found the right formula for keeping its facilities staffed, Brookfield’s Dr. Geno encourages more young people to pursue rural medicine to help fill the gaps elsewhere in the state.

“Rural communities need people in the medical profession,” he said. “You can Google clinic jobs almost any­where in the state and find openings that have gone unfilled for years. Oth­er doctors here are nearing retirement, and I can’t do it all.”

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