Sick and must travel

Dr. Andrew Miller was leaving Northern Valley Indian Health’s clinic in Willows last Thursday (Sept. 1) when he spotted a longtime patient traveling alongside a rural road on her electric scooter. She wasn’t riding over concrete or pavement; she had to traverse the uneven surface of an undeveloped route.

“I have had plenty of patients that didn’t have cars—they would hope their Jazzy scooters had enough battery power to get them from wherever they lived to our clinic,” he said. “That was a person in Willows yesterday, but the same thing can be true in any of our places; we just have more sidewalks here [in Chico].”

Seeing her served as a reminder of how far—literally and symbolically—many North State residents must go to get health care.

Miller is the medical director for NVIH, which operates three outpatient facilities in Chico, along with clinics in Red Bluff, Woodland and Willows. NVIH offers medical, dental and behavioral health services to underserved populations: Native Americans as well as lower-income adults and families, particularly those insured by government-funded Medi-Cal.

In this rural region, many miles often separate patients from sites of their appointments. Physical mobility issues make matters more difficult, particularly when necessitating vehicles specially equipped to accommodate wheelchairs.

“For plenty of our patients, getting across the room is a real struggle,” Miller said, “so if that patient has to figure out how to get to transportation and get from transportation into our clinic, for that subset of people, it’s a significant problem.”

NVIH locates its clinics by bus stops, but buses don’t stop near every residence and not every mobility-challenged resident qualifies for paratransit service. The expense of a transit van or taxi can prove prohibitive. All together, such obstacles can be a disincentive to visit the doctor.

Missed doctor visits, in turn, can have a negative impact on health.

Patients with the most serious conditions, which usually require follow-up attention, are most likely to deteriorate to a degree that, Miller said, “end up in the emergency room or the hospital. If they can get good outpatient care, we’ll do our darnedest to keep them stable so they don’t need to go, don’t have to get that sick for an ambulance to come get them at their home.”

The California Legislature has responded to the problem. In the home stretch of the legislative session, which ended Aug. 31, both the Assembly and Senate passed Assembly Bill 2394—a bill to authorize Medi-Cal payments for “nonmedical transportation” (i.e., not in an ambulance). As of the CN&R’s deadline, Gov. Jerry Brown had not signed it; if he does so by the Sept. 30 deadline, the insurance plan would reimburse patients for their travel expenses to facilities for health care. The bill passed both houses—all committee and floor votes—unanimously.

AB 2394 is just one bill aimed at bolstering rural medicine. The other, AB 2024, would allow critical-access hospitals (remote and rural with 25 or fewer beds) to hire physicians, overriding the state’s restriction on the “corporate practice of medicine” prohibiting direct employment. The restriction was created to prevent medical centers from inducing or instructing doctors to drive up billing—on ordering tests and procedures, authorizing inpatient stays—by direct control of their income.

Federal accountability regulations have grown stricter, so many states have relaxed hiring laws. California is among the final holdouts. In 2011, Texas became the last large state with a blanket prohibition, granting permission to rural hospitals.

AB 2024 passed the Assembly and got revised before passing the Senate; the amended version did not get out of the Assembly before the session ended.

Both bills demonstrate legislators’ efforts to address issues in rural parts of the state.

“California has been fairly sympathetic to underserved areas,” said Mike Wiltermood, CEO of Enloe Medical Center. “But there have been so many things pulling at the government. I think the budget has gotten reasonably under control; maybe some attention can be paid to some of these health professional shortage areas.”

AB 2394, the transportation bill, carries an estimated cost of between $3 million and $6 million a year. The variance not only stems from how many Medi-Cal patients use the benefit, but also the potential savings by reducing ambulance transportation, emergency room visits and hospital admissions.

Steve Stark, CEO of Orchard Hospital in Gridley, is not convinced that AB 2394 will prove a boon—at least for his community. Orchard (formerly Biggs-Gridley Memorial) is one of California’s 34 critical-access hospitals, so it would stand to benefit from directly hiring doctors with the passage of AB 2024. That’s where he sees a bigger impact, because staffing affects the ability of patients to get appointments in the first place.

“It’s never been a transport issue, in my opinion; it’s been an access issue,” Stark said. “If I have a patient who has an acute illness and they call to get into a provider [for the first time] and they hear, ‘You’re three months out,’ they’re just going to go to the [ER].”

As for the hiring law, both Stark and Wiltermood said they hope it would help independent hospitals (Enloe also being one) compete for physicians against larger health systems such as Kaiser Permanente and Sutter Health.

Stark calls AB 2024 “a gateway idea” that could expand beyond critical-access hospitals if implemented. That includes Enloe, which draws from a rural region.

“While Chico is technically classified as a metro area,” Wiltermood said, “I’d argue that we’re woefully underserved. Chico is the hub for a lot of specialty medicine, and we’re short in a lot of areas.”