In rural, central Utah, hard-working health care providers, along with public and private entities, have cobbled together a way to deliver quality primary care to those who make it to the doctor's office. Unfortunately, not everyone does.
Many, such as Kristen Cervantes, 18, don't have a family physician or insurance. After throwing up for five days, she went to the Sevier Valley Medical Center's emergency room.
A California native, Cervantes lives with her grandmother, Bobbie Lee, who is on Medicare.
"My grandmother made me come," said Cervantes, who is without a job and applying for Medicaid. After tests revealed no emergency, the hospital referred her to a Richfield-area physician for follow-up.
It's difficult to know how many rural Utahns are uninsured and, as such, skip regular checkups that could identify and head off serious medical problems. The Utah Department of Health estimates at least 300,000 Utahns have no insurance, but it doesn't break that number down by regions of the state.
What is known is that rural Americans in general face significant challenges in accessing health care, according to a U.S. Department of Health and Human Services report released last month, shortly before the U.S. House on Nov. 7 passed its health care reform bill. Workers who typically are self-employed or work for small operations have trouble getting and keeping insurance, according to the report. Those who live outside major cities often must travel long distances to get health care and physicians are scarce.
Nonetheless, as the debate moves to the Senate this week, the prospect of a health care overhaul frightens many rural Utahns. "Leave it alone," is the common refrain.
"I have yet to meet one patient who is enthused about what is going on in Washington," Richfield family practitioner Mark Greenwood Jr. said.
Feds already play a role
A one-hour drive east of Richfield at the Wayne County Community Health Center in Bicknell, half the clients are without insurance.
But because it is a federally qualified health center -- one of 11 such organizations in Utah -- bolstered by grant funding, patients who meet poverty guidelines get top-notch primary care for as little as $10 per doctor visit.
The facility also has a pharmacy that qualifies under a related federal program to offer low cost prescriptions.
Not least, the private, nonprofit community-based center provides dental care, including crowns and root canals. Those services are more expensive than doctor visits, but patients who qualify are charged on a sliding scale, making dental care affordable.
It's no wonder the center's patients -- many of whom drive an hour or more to the clinic -- aren't looking for change. The irony is, without government aid, there would be no clinic, executive director Gina Flanagan explained.
It's an excellent health care model, but it works well only because most of the center's other patients pay through Medicare and private insurance, she said. Along with federal grants, those programs cover costs incurred by the uninsured.
Susan Chappell visited the clinic after taking a tumble and opening a gash in her head. She's a retired school teacher insured through Utah's Public Employees Health Program (PEHP). Her husband, Bill, drove her to the Bicknell clinic from nearby Loa. Unlike in urban areas, patients usually don't have to wait to see a provider. Nurse practitioner Sherree Rechtsteiner was on hand and in just minutes applied six staples to Susan's scalp.
"I remember when we didn't have a clinic," Bill Chappell said. "Emergencies were a big problem."
The House bill would increase funding for such community health centers by $12 billion over the next five years. The Senate bill would increase funding as well, but the amount is not yet certain.
Wanted: More doctors
According to statistics from the Utah Office of Primary Care and Rural Health, some counties are designated as "underserved" because they have fewer than one care provider for every 3,000 residents.
In central Utah, Piute, Sanpete and Garfield counties meet that designation. Wayne, Sevier and Millard counties have been removed from that list, according to Shelly Phillips, research analyst. "We've made great strides in bringing care into these areas."
Work as a health care provider in rural Utah requires dedication. At the Bicknell center, Rechtsteiner, physician Jeff Chappell, and Brett Hilton, a physician's assistant, and their support staff, keep the clinic open from 9 a.m. to 5 p.m. weekdays and from 9 a.m. to 1 p.m. Saturday. In addition, one of the three providers is on call 24-7.
As onerous as that seems, it's less daunting than Chappell's previous position as a family practitioner in Richfield, where he regularly put in 60 to 80 hours a week.
"Something that is quite frightening to me is the manpower shortages we could face," he said. "Fewer family practitioners want to relocate to rural areas."
Both House and Senate versions of reform legislation would boost payments to primary care providers. The House bill also would give those providers a Medicare bonus payment, with larger bonuses going to people serving in "Health Professional Shortage Areas" starting in 2011.
In addition, the Senate bill would increase the number of graduate medical education training positions, with priority given to primary care. It also would ensure the availability of these programs in rural and underserved areas.
Realities of rural life
Even if rural areas gain more family practitioners, patients still will have to travel long distances for specialized care. That can be life threatening.
"We do primary care very well, but medicine is complicated. Sometimes, you must rely on specialists. When the patient can't get that kind of care, it's a shame," Chappell said. "In some cases, people will mortgage the farm and come up with the money. Others will do without."
Specialized care often means seeking out a constellation of clinics and hospitals Intermountain Healthcare operates in rural Utah.
In tiny Circleville, a one-hour drive south of Richfield, Intermountain keeps office hours twice a week in a small clinic to augment services from its hospitals in Richfield, Panguich, Fillmore and Cedar City.
Richard Birch is one of five Panguitch-based physicians who rotate through four such clinics in central Utah.
"The uninsured are a huge problem, but no one will be turned away," he said, recalling a patient diagnosed with a brain tumor he transferred for treatment to Intermountain's Utah Valley Regional Medical Center in Provo.
For patients who can't qualify for Medicaid, Intermountain will -- depending on a patient's financial status -- waive costs or offer discount rates that include payment plans.
Other patients, such as Deanna Mills, 67, are covered by insurance and Medicare. In October, she had three spinal disks fused at Intermountain's Cedar City hospital. She visits the Circleville clinic near her home for checkups following the surgery. Her husband, Len, is retired from the Utah Department of Transportation and the couple are covered through the state's PEHP insurance as well as Medicare.
"As we get older, health care is a real issue to us," she said. "It scares me to death to think that if we didn't have insurance, we wouldn't have these services."
Still, Birch and Mills fear a massive overhaul led by congressional Democrats could hinder the system that now works for them.
Shane and Sherri Millett, who live not far from the Millses in Kingston, share that sentiment. When Shane's nose wouldn't stop bleeding on a day when the Circleville clinic was not open, the couple drove the 50-plus miles to the emergency room in Richfield.
There, Greenwood, the Richfield physician, cauterized a blood vessel and sent the couple on their way. The Milletts live about half way between Intermountain's Richfield and Panguitch hospitals. It's an hour's drive either way. They chose Richfield this day because they wanted to get some shopping done, too.
Shane Millet is the Piute County treasurer and also is covered by PEHP.
"I've had babies in both places," Sherri said of the hospitals. "I feel blessed that we are pretty close to care."
By Christopher Smart, Salt Lake Tribune.
Tribune reporter Matt Canham contributed to this story.
