Patients who live far away from big cities face special challenges in accessing health care.
Those who live in small towns might not have a clinic nearby. They might have to drive half an hour or more to their appointments, and those who can’t drive by themselves face further problems still.
There are also challenges facing rural health care providers. Jefferson County Supervisor Dee Sandquist said she’s concerned about how rural health care providers are faring under privatized Medicaid. In 2016, Iowa moved its Medicaid program to managed care whereby private health plans are paid by the state. Health care providers are reimbursed by managed care organizations, but Sandquist said the MCOs are often slow in issuing the payments.
“It’s hard for small providers to make ends meet,” she said.
Iowa House Rep. Joe Mitchell, a Republican from Wayland representing District 84 covering all of Henry County and portions of Washington, Jefferson and Lee counties, said the Iowa Legislature has done its part in supporting rural health care.
“This past year, we gave additional money to rural critical access hospitals to address staffing problems and accessibility,” he said. “I would like to increase money for EMS and also have a solid recruiting plan on how to recruit new doctors to our small communities.”
On the subject of privatizing Medicaid, Mitchell said it has come with positives and negatives.
“Looking at the state budget for Medicaid, the state-run option clearly wasn’t working and was costing the state millions [of dollars] more each year,” he said. “However, I think there were a few bumps in the beginning that have since been started to be worked over.”
Why not just get in a car?
Jefferson County Public Health Administrator Chris Estle said there is a disparity in the care rural patients receive from those in urban areas.
“People sometimes ask, ‘Can’t they [rural residents] just get in their car and drive?’ and the answer is, ‘Not necessarily,’” she said. “Maybe they can’t drive, or maybe they don’t have a car. And not every specialist comes to our health center, especially if you’re a [Veterans Affairs] client.”
Estle noted that Jefferson County is considered a “rural” county, but there are many counties more rural than it. The National Rural Health Association groups locales into four categories: urban, suburban, rural and frontier. “Frontier” refers to the most remote areas of the country, with population densities equal to or lesser than 11 persons per square mile. As an example, the state of Alaska has 1.3 persons per square mile, and Wyoming, the second least densely populated state, has six persons per square mile. Iowa is the 36th most densely populated state with 55.6 persons per square mile.
Estle said Jefferson County residents are fortunate to have the Jefferson County Health Center in Fairfield, and to have others like the University of Iowa Hospitals and Clinics and Mercy Medical Center close by.
“I know some of the Medicaid MCOs provide funding for rides, but coordinating that can be overwhelming,” Estle said. “People don’t realize how difficult it is to coordinate a ride to Iowa City or even Burlington, especially if you’re in a wheelchair or you need a special vehicle.”
Even for those people who have found transportation to a neighboring town, they face another problem: not all their appointments are on the same day, so they’ve got to make multiple trips out of town.
“People think you can get it all done in one day, but that’s not how it really works,” Estle said.
Estle said one of the problems in health care is that Iowa and the federal government have different rules for reimbursement. For instance, in Iowa, nurse practitioners have more autonomy than in other states, because in Iowa they can order services for home care. The trouble is, Medicare patients must follow federal rules, and the federal government does not accept homecare service orders from nurse practitioners, only from allopathic doctors or osteopathic doctors.
“It’s created delays in patient care,” Estle said. “Patients end up getting the care, but it’s frustrating on the case managers because it necessitates phone calls and redundant busy work that serves no purpose.”
MCO numbers dropping
Washington County Public Health Administrator Danielle Pettit-Majewski said that those on Medicaid can have their medical transports covered, but they have to schedule them in advance. She said the MCO should schedule the ride to the hospital for non-emergency transportation.
That said, working with MCOs is not always easy. When the state privatized Medicaid in 2016, there were four MCOs. In November 2017, AmeriHealth Caritas of Iowa withdrew from the managed-care program. According to The Gazette, AmeriHealth reported a loss of $133 million in the first year of the program.
In March of this year, the Iowa Department of Human Services announced that UnitedHealthcare was departing from the state’s $5 billion privatized program. That meant the 425,000 people on the company’s health plan had to go to one of the two remaining insurers, Amerigroup or Iowa Total Care. UnitedHealthcare issued a statement indicating it had lost $250 million since joining the privatized system.
Pettit-Majewski said each MCO has different billing and prior authorization requirements, presenting a unique set of hoops to jump through.
“If you are a Medicaid client trying to choose which MCO to go with, you might find that your primary care doctor has a contract with a certain company but your cardiologist does not,” she said. “Should you pick the MCO of your primary doctor or that of your cardiologist? That’s been a problem since [privatization] started 3.5 years ago.”
Pettit-Majewski said some health care providers have said they are not taking Medicaid patients or are taking fewer of them because they’re not being reimbursed in a timely fashion or sometimes at all.
“Across the state, providers have closed their doors to Medicaid patients,” Pettit-Majewski said.
Cris Gaughan is the director of Washington County Mini Bus. She said the mini bus contracts with MCOs, which send the mini bus information about each passenger. If someone is not a Medicaid patient, they must call the mini bus office to schedule their ride. If they are going to Iowa City or anywhere out of the county, they must call 24 hours in advance. The cost of the ride depends on their pick up and drop off location. A roundtrip from Washington to Iowa City costs $42.
Gaughan said the mini bus is open to the public, and all of its vehicles are handicap accessible.
Washington County residents are fortunate in that they have several health care providers to choose from, such as the Washington County Hospital and Clinics in Washington, a Mercy clinic in Kalona, a branch of the University of Iowa Hospitals and Clinics in Riverside, and Megan Squiers’ Wellman Family Practice in Wellman.
Pettit-Majewski’s own agency, Washington County Public Health, offers different services from those providers and primary care hospitals. WCPH provides free vaccines for children 0-18 years of age, for the uninsured or those covered by Medicaid or who are Native American or Alaska native. WCPH does home care, serving people in every corner of the county. It does home visits for Parents with Teachers, post-partum visits with new mothers, and vision screenings and developmental screenings.
Lynn Fisher is a public health nurse with WCPH and the county’s immunization program coordinator. She said the department runs an immunization clinic five days a month in Washington and one day a month in Kalona. Fisher said the Kalona clinic serves the Amish population that lives in the area.
“Amish people accept immunizations required for school, and might start the [immunization] schedule a little later with their children,” she said. “They rely on church elders for guidance, and we respect that. We listen to their concerns and answer questions the best we can.”
Fisher said sometimes she spends extra time counseling Amish people about why vaccines are recommended, since they tend to have a lot of questions about them.
The Union asked Fisher if she considered expanding the immunization clinic to other towns in the county. She said she’d love to do that, but the health department would need to find space first. Mercy does not charge the health department to use its space one day a month.
“We also need some privacy to go through all the protected health information with the person,” Fisher said. “Usually, other offices have patients coming and going. Mercy lets us use three exam rooms, and the patients check in at the same lobby area [as the rest of the clinic].”