
‘Out here, it’s just me’: one doctor for 11,000 square miles - howrude
https://www.washingtonpost.com/national/out-here-its-just-me/2019/09/28/fa1df9b6-deef-11e9-be96-6adb81821e90_story.html
======
belltaco
The decades long wait times for green cards for immigrant doctors is also
hurting health care in rural America.

[https://money.cnn.com/2018/06/08/news/economy/immigrant-
doct...](https://money.cnn.com/2018/06/08/news/economy/immigrant-doctors-
green-card-backlog/index.html)

[https://www.wusa9.com/article/news/local/maryland/communitie...](https://www.wusa9.com/article/news/local/maryland/communities-
losing-doctors-due-to-battle-over-green-
cards/65-3755e73c-5148-48dd-b6ec-944ab47b7ed7)

[https://time.com/5299488/international-medical-
graduates/](https://time.com/5299488/international-medical-graduates/)

~~~
hestipod
Friend married a Russian cardiac surgeon, one with 20 years of experience,
brilliant woman. She was not allowed to practice in the US without years of
redoing residency and entry level exams and loads of money. She ended up
changing careers as it was so much bother. Patients ended up losing out on a
caring and bright provider.

~~~
honkycat
That is a feature, not a bug.

Why would a well-paid, highly regulated profession allow people to come into
their turf and undercut them?

Not saying this is a GOOD thing. Merely pointing out that the system is
working as intended.

~~~
marrone12
There is no "undercutting" in health care. Vast majority of services are
already priced out by insurance companies, there just aren't enough people to
do all of them.

~~~
ses1984
>...there just aren't enough people to do all of them.

which factors into the economics of prices negotiated between providers and
insurance companies.

------
lazyasciiart
It should be illegal for the government to detain people in areas with
inadequate access to medical care. If they want to put immigration detention
centers (or any prison) in the middle of nowhere, they should be required to
pay for a doctor to be there too.

And it isn't a case of 'well migrants cross the border in the middle of
nowhere so it's their fault' \- almost all immigrants held in this place are
transferred from another ICE detention center
([https://trac.syr.edu/immigration/detention/201509/WTXDFTX/tr...](https://trac.syr.edu/immigration/detention/201509/WTXDFTX/tran/))

~~~
vkou
The cruelty isn't an unhappy, accidental by-product. It's the whole point of
the policy.

This is what ~half the country endorses, by virtue of how it votes.

~~~
ddingus
Apparently, my earlier message did not resonate:

To be absolutely clear, this mess we are in is a function of money in
politics, voters not seeing a choice they feel good about, and a general trend
toward more authoritarian norms.

In any election, voters can and will do one of the following:

Vote Major Party Vote other No Vote

In the last election, a large number of Americans did not have a choice they
felt worthy of a vote.

Blaming them does all of us ZERO good. Fear, blame and shame politics do not
work to GOTV.

We can have a discussion about how we got here, and I think that makes sense
to do.

It's too easy to just "blame the stupid people", as if that's all there is to
any of this.

~~~
lazyasciiart
My guess is that 'half the country' in that comment was supposed to refer to
Trump voters, not non-voters.

~~~
ddingus
That's not half the country.

~~~
lazyasciiart
No, but it's a pretty common mistake and makes more sense than it being the
ones who didn't vote.

~~~
ddingus
Well, even then I do not know how much better.

People, who do not see a net positive in either choice may protest, or gamble.

Last election that kind of thing definitely happened.

Now, the subtle bit:

GOP primary picks are of the voters. Dem ones are not. Party won in court
asserting it's right to just select regardless of what voters do.

Secondly, money. It is expensive to become a choice.

Summary?

Voters may be left with two poor choices.

Conclusion:

Blaming voters is not productive.

That really is my only point. Blaming and shaming people does not help
matters.

The necessary discussion is bigger than that.

Worth a bit of karma to plant that seed.

------
honkycat
This is happening on my home town. The hospital has been scaling back more and
more. What was once a thriving hospital now only has 3 doctors.

Not due to demand, but because there are not enough doctors. Doctors do not
want to live in a podunk town, no matter how much the hospitals are willing to
pay.

~~~
SolaceQuantum
Theoretically if the podunk town is willing to pay 5x, 10x, 100x, etc. A
doctor would definitely take up that. Hell, I would do software development in
a podunk town for a million dollar salary. Maybe even a 750k salary.

~~~
rohit2412
Yeah that's a dynamic I can't understand. Most software professionals talk
about relocating away from the cities the first chance they get, but everybody
else is rushing to the same cities that only software developers seem to be
able to afford.

This dynamic extends beyond usa. Even in India, doctors command high salaries
in rural areas, often 2-3x what they can in metropolitan cities.

~~~
novok
I think people are more talking about working towns and cities that aren't SF
levels of prices, which can be non rural towns of +100k people.

------
castratikron
The picture at the end of the article says it all, "No services next 74
miles".

If you choose to live in rural US, you are signing up for this kind of
lifestyle; you're on your own. As long as that's advertised I don't see a real
problem. If you need health care then you should live near health care. Don't
expect the same level of support in rural MN as you would get in NYC.

~~~
EliRivers
I understand a lot of poor people in these regions lack the resources to move
to more populated areas. Would you support a federal or state rehousing
program to enable that?

It's a genuine question; should the US taxpayer pony up so poor people trapped
in rural areas can move to population centres and enjoy the benefits thereof?

~~~
jandrewrogers
In most cases, people live there because that is where their lives and family
are, not because they are poor _per se_ or "trapped". In fact, many of them
are not poor by any constructive definition. These populations, while
shrinking and aging, have productive lives often related to resource
extraction industries such as farming and mining which are not going away.
People are simply choosing to remain in the areas where they built their life.

Labor shortages are a critical problem in many of these communities. Young
locals often move to the cities and rarely move back, and while automation has
helped support the local industries it has not nearly covered the shortfall.
Much of the working age labor that does move into these areas is either
illegal immigrants or ex-convicts looking for a fresh start. Due to shortages,
minimally skilled physical labor often commands 3-4x minimum wage in my
experience.

It is a mistake to think that people want to be rescued from these areas.
Maybe some do but most have reasons for living where they live.

~~~
cududa
Show some data on this, because by and large, people in rural America are
absolutely poor. [https://www.ers.usda.gov/topics/rural-economy-
population/rur...](https://www.ers.usda.gov/topics/rural-economy-
population/rural-poverty-well-being/)

~~~
rayiner
The story flips if you use the Supplemental Poverty Measure, which adjusts for
cost of living: [https://www.irp.wisc.edu/wp/wp-
content/uploads/2019/01/Focus...](https://www.irp.wisc.edu/wp/wp-
content/uploads/2019/01/Focus-34-3b.pdf). Rural poverty has consistently been
similar to urban poverty, and was measurably lower during the great recession.
Rural areas also have lower long-term poverty (where a family was poor for two
successive measurement years). About 4% in 2016 for rural areas, versus 5.5%
in urban areas.

The states with the lowest SPM poverty rates are midwestern states with large
rural populations, like Iowa and Nebraska:
[https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ...](https://en.wikipedia.org/wiki/List_of_U.S._states_and_territories_by_poverty_rate).
(California's poverty rate is almost double those states'.)

~~~
haimez
Sure, but during a recession no one is moving into those areas and a LOT of
unemployed are moving AWAY from them. The metrics look good because they
misrepresent what’s actually happening.

~~~
rayiner
Actually the opposite is true:
[https://www.ers.usda.gov/webdocs/publications/90556/eib-200....](https://www.ers.usda.gov/webdocs/publications/90556/eib-200.pdf).
There was a significant rural to urban net migration during boom economies
which slowed to zero during both the early 2000s recession and the 2008
recession. And in fact there was a small migration from urban back to rural
during the last recession.

The unemployment rate in Iowa peaked at a little more than half the national
unemployment rate in 2009-2010.

------
neonate
[http://archive.is/GcW6Z](http://archive.is/GcW6Z)

------
beerandt
Obamacare set rules that require large scale-out to be affordable, especially
billing and electronic medical records. This is why so many smaller practices,
even in large cities, had no choice but to be absorbed by local hospitals or
merge with competitors; they couldn't afford that cost of regulation on their
own.

This also means that in areas lacking a certain critical mass of patients,
practicing medicine won't make financial sense.

~~~
jdc
What are the specific requirements? Perhaps there's another way to reduce
costs.

~~~
beerandt
Sustaining the infrastructure and support to maintain electronic medical
records is probably the biggest. There are so many problems with the current
systems that it's hard to know where to start.

But related to the context of the article: You can't spread that cost out as a
stand alone doctor practicing on rural areas. On top of this is added cost of
data entry compared to old paper charts, the cost of training staff to be able
to do it efficiently, and the extra time it takes doctors to keep notes and
sign-off on electronic charts.

Check out some of the recent articles on physician burn-out, especially in
emergency medicine, family practice, and general practice. Doctors are
deciding it's not worth the hassle, financially or psychologically.

Edit: a couple of recent related articles on the topic:

[https://blogs.scientificamerican.com/observations/electronic...](https://blogs.scientificamerican.com/observations/electronic-
health-records-and-doctor-burnout/)

[https://fortune.com/longform/medical-
records/amp/](https://fortune.com/longform/medical-records/amp/)

~~~
perl4ever
If computerizing a business makes it more expensive and labor intensive,
someone's doing something wrong.

~~~
beerandt
Agreed... Yet that's what's happening nationwide.

The electronic systems aren't simply recording what the doctor does and making
a record of it, as charting is supposed to accomplish. The software is
dictating (or at least heavily influencing) the behavior and workflow of the
doctor. And anytime something is done out of order results in interrupting
that workflow, searching through 10 other screens to find the appropriate
checkbox, and then trying to return to your train of thought. The focus ends
up being on the data entry instead of the patient.

This is amplified the less specialized the practice is, hence emergency
medicine, family practice, and general practice being the most affected. And
rural doctors being affected the most since: 1) they generally are expected to
handle whatever gets thrown at them since there are no specialists around and
2) they have the smallest practices (can't share costs with other doctors).

Opting out of the system essentially means going cash only, which obviously
limits your patients, among other drawbacks. Which leaves burn-out and early
retirement or joining a bigger practice in the city. Or concierge medicine,
which is one reason why it's becoming more popular.

~~~
perl4ever
I applied for a few jobs at places that did things like practice management
software over the years, e.g. athenahealth but never worked in the industry,
so I don't have any insight on what it's like on the inside. But I assume
there are systemic reasons.

It's easy to say concierge medicine, but I'm not clear on why that should
work, if funneling the same amount of money every month through an insurance
company doesn't. What is the difference, other than the marketing terminology?

~~~
beerandt
Edited:

Easy... They don't take insurance. They're typically cash only, which allows
them freedom to do things like charge for house calls.

Or they have contracts directly with employers to do checkups and on-demand
visits onsite. Employers that are either big enough -or financially successful
enough- to be self insured are essentially paying cash for office visits and
most covered services anyway. (Many companies that are ~200+ employees self
insure, but still pay an insurance company just to manage it all. An in house
or concierge doctor on contract might cut out enough paperwork to get rid of
the middleman.)

I've also seen some setup as prepaid membership operations. But the common
denominator is they cut out insurance and medicare/medicaid, which cuts out
90% of the regulations... Including electronic medical records.

~~~
perl4ever
I was only aware of them being a thing in the DC area, and not being mutually
exclusive of insurance.

Anyway, if the loss ratio of an insurance company is more than 85% by law, it
seems like you can gain only so much by bypassing them.

And why would you want to eliminate medical records?

~~~
beerandt
I shouldn't say they're 100% mutually exclusive, but they tend to be for most
routine services. They're probably still going to file a catastrophic claim if
they find cancer, etc...

>it seems like you can gain only so much by bypassing them.

You do, but self-insuring on it's own saves a big chunk, so what's left is
really just the complicated paperwork. The only reason it exists is to
complicate insurance dictated rate structures, so get rid of the complicated
rate structures for the 80-90% most common visits by contracting a doctor
directly and there just isn't the need to pay someone else to manage it
anymore.

Then the real gain is paying the doctor based on a simplified negotiated rate,
and in return he gets a whole company of regular patients, and can send just
one summarized bill to the company for everyone he sees in a week. Not having
to file any additional billing paperwork per patient is just a happy side-
effect, for both the doctor, the patients, and the sponsoring company.

>And why would you want to eliminate medical records?

It's not to eliminate medical records, it's just a matter not being forced to
do them in a certain way. I think most doctors would have loved to start by
scanning paper charts at the end of the day, then let some data people convert
that into something the computer understands.

But the way it's setup (and mandated), the database is the official record
(not the attached notes) so it all has to be done personally by the doctor, or
signed-off by the doctor if a nurse or mid-level or medtech enters anything.
They basically make the doctors responsible for data entry QAQC, with their
malpractice insurance at risk for a screw up.

Doctors are used to mostly freeform notes with a few fill-in-the-blanks and
check boxes for orders or standardized info like heart rate, bp, etc. Most
software tries to cram 99% of this into a mess of a structured relational
database. These also have freeform typing boxes for notes, but getting paid
depends on duplicating most of the note information across a huge range of
screens and tables so that the billing software understands what was done, and
_understands it in such a way that is covered by the patient 's provider._

They are probably a 6-digit number of ways to code for giving the patient
aspirin, but half might not be covered, and the other half might range in
price from free to thousands of dollars of copay. _And this changes with every
different insurance policy, and every different doctors office /hospital
system,_ (depending on negotiated rates with insurance) so that even the most
expert billing tech might not know the correct way to bill a particular
patient the first time. And oh, if they need to change it later to get
insurance to cover it, the doctor usually has to sign-off on it again as if he
performed a different exam than was recorded the first time.

It's a lot easier to just scratch down on paper (or in a computer) "gave
patient exam and aspirin, bill for a level 2 and rx" or something similar, and
then your receptionist knows what to collect or bill. All of a sudden you
don't need a staff of billing techs on the phone with insurance companies all
day, or a software support contract that your billing depends on.

Now imagine getting all the doctors approaching retirement and working in
small practices that switching is worth the expense and hassle.

So it's not being against medical records, but the freedom to do them as you
see fit, while avoiding the hassle of compliance.

And one of the few remaining ways to do that is go for the market that can pay
cash, which overlaps nicely with both the concierge market and self-insured
employers. (and some niche co-op style wellness "clubs", but I'm not familiar)

~~~
perl4ever
"You do, but self-insuring on it's own saves a big chunk"

That doesn't _save_ money because then you don't have insurance! The part of
your premium that covers unexpected events can't be saved; only the part that
pays for routine care. The word that comes to mind is "optionality" although
I'm not sure it is the right jargon.

People always say that insurance is too expensive because it covers routine
care, and I've never understood what that is about. It costs essentially zero
to transfer money from one account to another, so just because you don't gain
anything by having insurance pay, you (on average) shouldn't lose anything
either. There can't be any fundamental problem with them providing a payment
service.

~~~
beerandt
>That doesn't save money because then you don't have insurance.

The employees are still insured, it just means the employer absorbs the risk
instead of the insurance company. At a certain point, this becomes cheaper
than paying the insurance company. But then the company might take out a
separate catastrophic policy that covers anything over $X million in a year.

>The part of your premium that covers unexpected events can't be saved

This is just wrong. A significant portion of that amount can be saved. Some of
it is statistics, and some financial structuring.

The insurance company isn't going to absorb a company's risk for free, but
there are savings beyond the profit and (overly conservative) risk margins.
Segregating your risk pool allows additional control over it, then you can
reduce risk in a number of ways, but especially with wellness programs. (My
premium contributions at work were cut 75% for participating in the company
wellness program.)

I _think " a company is also able to hold it's own reserve assets that are
backing their risk, and there are additional tax savings with how money
changes hands fewer times, but I'm fuzzy on the details.

Anecdotal, but my last two employers were extremely eager to qualify to self-
insure, even while still using the insurance company to manage policies.
(There's a multi year process to qualify involving financial stability, risk
pool evaluation, and sometimes even reorganizing the company structure or re-
incorporating.)

>People always say that insurance is too expensive because it covers routine
care, and I've never understood what that is about.

They say that because it's no longer medical insurance, it's pre-paid health
care plus medical insurance packaged together.

The biggest problem people have with the pre-paid routine care is that it's
basically pooled just like the insurance part, and what's routine for me might
not be routine for you.

Nonsmoker's, even if they're priced as tobacco-free, have to pay for a policy
with smoking cessation coverage. Nuns and 80 year olds must have coverage for
birth control. There's mandatory coverage for prenatal visits and
labor/delivery, even if you never want to (or can't) have kids.

Insurance is meant to mitigate high cost risks, not be a bureaucratic middle-
man for every routine cost. Affordable "risks" shouldn't be insured. Insurance
that covers _expected* costs isn't insurance. It's just quasi-socialized
healthcare with the word "market" attached for political deniability.

In the non-segregatated pools, there's no incentive to keep costs down. You'll
be paying for a portion of the weekly doc visits of the bored little old lady
who goes and gets every little bruise and goosebump checked out, because why
not? It's a no-cost routine visit for her.

Also, you have to pay for coverage for services you might already have free
access to. Like if you work for a clinic and they offer employees free visits.
You still have to pay for that coverage. Or I want to see a particular doctor
that's out of network. I've got to pay out of pocket for a service that I've
already paid for. If you forget to get pre-authorization before going to get a
mole removed by the dermatologist? Same thing. They might not pay it, because
you did it without their permission.

All of these "routine" costs are built into the price of your policy, and for
most people it would be cheaper and much less of a hassle to pay-as-you-go for
everything thats not catastrophic.

>It costs essentially zero to transfer money from one account to another

Except your money got thrown into slush fund shared with thousands of
strangers, and you'll never get as much out as you put in (Unless you're
talking about the case of a self-insured employer paying 100%, which is rare.)

>There can't be any fundamental problem with them providing a payment service.

If that was all they did, and you got rid of the pooled routine costs, and got
rid of the billing-code/ coverage roulette, and got rid of the copay/
deductable/ out-of-pocket calculation hassles, and if it would just work as
constantly as a debit card, then I think people wouldn't have a problem with
it.

But that's sort what an HSA does (which is through the bank, not the insurance
company.) In practice they're restricted to certain policy types, and don't
really eliminate any of those problems, just reduces them.

------
brown9-2
Very odd that this article never mentions that Texas has refused to expand
Medicaid under the ACA.

~~~
selimthegrim
Louisiana did, it’s hardly giving us a comparative advantage to Texas - see
[https://www.theadvocate.com/acadiana/news/business/article_a...](https://www.theadvocate.com/acadiana/news/business/article_aec4dfc0-d661-11e9-9d88-1f67861da349.html)

------
anonytrary
11,000mi^2 is quite a hyperbolic way of saying "nearest service within 100mi".
It is also true that there's just one doctor for 1,150,000mi^3, but we
typically don't talk about volumes since almost everything we do on earth is
distributed over the surface.

------
gumby
Pff, everything is within driving distance. n Australia they have to fly:
[https://en.wikipedia.org/wiki/Royal_Flying_Doctor_Service_of...](https://en.wikipedia.org/wiki/Royal_Flying_Doctor_Service_of_Australia)

