News: CJ Exclusives

The great divide: Challenges facing rural health care delivery in N.C.

Lawmakers are paying attention to medical plight of people living in rural North Carolina. But how much should they do? 

Chantilly Welch has had two major pregnancy-related health scares complicated by the distance from her home in Graham County to her doctors and hospitals in other counties. (CJ photo by Dan Way)
Chantilly Welch has had two major pregnancy-related health scares complicated by the distance from her home in Graham County to her doctors and hospitals in other counties. (CJ photo by Dan Way)

ROBBINSVILLE — Chantilly Welch remembers zig-zagging along the ribbon of two-lane highway to drive her sick baby to a doctor. 

She was a dot moving amid sprawling forests and mountains, on one of tens of thousands of outgoing health-related trips residents make annually from medically underserved Graham County. Another routine day. 

Until the crash. 

“It was raining real bad, and I hydroplaned,” Welch said. Newborn Moses escaped injury, but Welch suffered whiplash. 

The car the mother of three had depended on to make the vital prenatal and pediatric trips was reconfigured into an irredeemable mass of crumpled steel, and there was no money in the family budget to replace it. Her husband needed the second family vehicle for his work commute. 

“I would drive myself usually so he wouldn’t have to take off work because that would be money missed,” Welch said. Hers is a familiar story in the backwoods. 

The same ruggedness of remote Graham County that lures tourists to wilderness hiking, trout fishing, or whitewater rafting is the same creature-comfortless isolation that repels them from becoming permanent residents. The postcard-pretty backdrop masks a poverty rate of 20 percent, and a stark lack of sociocultural frills. 

Medical care isn’t always readily available. Medical emergencies become amplified. Routine procedures and checkups are often anything but.  

“Have you been to Robbinsville?” Sen. Jim Davis, R-Macon, an orthodontist, asked about the county seat of 636 residents, the largest community in the county. “That’s a tough nut to crack over there. Just the economics of it make it difficult for health-care providers to make a living there.” 

Should lawmakers step in, or should they leave those who choose the rural lifestyle to live as they please? Locally accessible health care or not? 

The medical plight of rural North Carolina has seized the attention of lawmakers in Raleigh, nonetheless. It’s now a constant topic in health-care committee meetings in which rural/urban, have/have not flashpoints surface when discussing reform or government intervention, and it’s the sole focus of the Committee on Access to Healthcare in Rural North Carolina. 

The just-released University of Wisconsin Population Health Institute’s 2018 County Health Rankings place Graham 96th worst of 100 North Carolina counties for clinical care. The ratio of doctors to residents is 4,310:1, more than triple the state ratio. Residents outnumber dentists 4,280:1, approaching triple the state ratio. 

Still, the vast majority of people refuse to leave for areas with better offerings. It’s not bunker mentality for them. It’s just the nature of mountain life, one after another county resident replied when asked why they stay. 

“If you need a hospital you have to drive” 45 minutes or more, said Jessica Rattler of Robbinsville, a member of the Eastern Band of Cherokee Indians. “That’s anywhere here.” 

She has children but doesn’t dwell on the possibility of youthful mishaps and the long drive to get them to a hospital. 

“I guess it doesn’t [worry her about the distance] because it’s just what you have to do. If you have that emergency then you have to go there,” Rattler said. 

It’s the reality of life in rural North Carolina. Some lawmakers, who serve in health-care laden Wake County, prefer to promote their own version of the status quo. 

“The more I look into the rural health issue the more concerning the data gets to me. This is just a huge issue that we desperately need to address,” Sen. David Curtis, R-Lincoln, co-chairman of the Committee on Access to Healthcare in Rural North Carolina, said during a committee meeting. “I am very hopeful that this committee can come up with some ideas to make our rural areas healthier.” 

Asked if the conservative position should be less government involvement, Sen. Ralph Hise, R-Mitchell, who chairs, co-chairs, and sits on several health care-related committees, replied: “It’s always hard to talk about placing the best conservative principle on an entitlement program like Medicaid.” 

He said the state has a statutorily vested interest in rural health care because of state Medicaid and State Health Plan obligations to recipients. 

The law requires the state to provide network adequacy for both programs, and rural recipients should have access to medical attention urban residents can get. That means a certain amount of medical care should be available within a certain distance, and a huge imbalance of program funds shouldn’t be pooled in urban areas. 

Hise said he thinks those costs will begin to equalize once the state’s Medicaid reform is in place, as more easily enforced standards and measurements can be placed on managed care organizations that will set up statewide medical networks. 

Until then, Beth Booth, director of the Graham County Health Department, paints a dismal portrait. 

The Talullah Community Health Center, a part of Appalachian Mountain Community Health Centers, remains Graham County’s bedrock medical clinic. It operates full steam five days a week on extended hours with two full-time doctors, one part-time physician, three advanced practice nurses, a small pharmacy, and 16 exam rooms. 

Smoky Mountain Urgent Care just opened in Robbinsville on April 2. That will relieve some pressure from Talullah, but still leave much to be desired. 

There are no obstetricians or gynecologists in the county. “There’s no pediatrician full time. There’s no orthopedics. There’s no vision. There are two dentists. No hospital,” Booth said. 

“If somebody falls on the Appalachian Trail or whatever, you either have to go 45 minutes to Murphy Medical Center in Cherokee County, or you have to go 45 minutes to Sylva to Harris Regional Hospital,” Booth said. “We do a lot of helicopter rides, basically because of all of the inaccessibility. If somebody has any kind of potential heart attack, things like that, they’re all flown.” 

Like most rural areas of North Carolina, the population is old and getting older. The median age of North Carolina residents is 38.3, census data released in December says. In Graham County it’s 44.8. 

“We have a higher than state average [sexually transmitted disease] rate, a huge problem with substance abuse, a very high rate of uninsured” — 21 percent, compared to 16 percent statewide, Booth said. “So when you combine all of that together, the state of the county … is not good.” 

Welch understands better than most. She’s a certified nurse assistant who worked an hour away at Cherokee Indian Hospital on the Eastern Band of Cherokee Indians’ tribal land in Cherokee, spanning Jackson and Swain counties. Her husband, sons Walosi and Moses, and daughter Tiara get medical care there because they’re enrolled tribal members. She is white and isn’t eligible for tribal services. Her primary care doctor is in Bryson City. 

When she was pregnant with Walosi, her OB-GYN doctor was in Waynesville. The round trip to Haywood County was three hours, and she made the trek twice a week because she had a series of health problems. 

“We almost died,” Welch said. She had an undetected condition known as preeclampsia, in which the placenta malfunctions, endangering mother and unborn baby. Her baby frequently stopped moving. 

She drove 45 minutes to an OB-GYN doctor in Murphy — Cherokee County — while pregnant with Moses. She went into early labor and was admitted to Murphy Medical Center, then transferred to a hospital in the Erlanger Health System in Tennessee. While hospitalized her placenta tore, and she underwent an emergency C-section. 

If Welch had not gone into early labor and been in the hospital when her placenta ruptured, the results could have been tragic. 

“I would have bled to death because there’s nothing closer,” she said.  

Graham County’s medical predicament is far from exclusive. It’s one of 26 counties with no general surgeon, 79 counties designated as a primary care health professional shortage area, 84 counties designated a mental health professional shortage area, and 73 counties listed as dental health professional shortage areas. An entire county can be listed as a shortage area, even though only a portion is underserved. 

Three free-market reform possibilities are getting attention from legislative health care committees and professional organizations tackling the problems. 

Telehealth is a promising, technology-driven alternative to a doctor in a brick-and-mortar setting. It allows primary care or specialty doctors to live elsewhere, but do consultations, some exams, and prescriptions remotely via electronic tablets or smartphones. 

Peeling back certificate-of-need laws is an idea under review. North Carolina has the fourth-highest number of restrictions among the 50 states requiring government approval of high-cost equipment or to open non-hospital ambulatory surgery centers. 

Eliminating the scope-of-practice chokehold is another possibility. That would allow advanced practice registered nurses to operate independently of physicians as is mandated. 

If lawmakers scaled back scope-of-practice laws, women — like Chantilly Welch — in areas without prenatal and birth-care medical providers would benefit, said Anayah Sangodele-Ayoka of Charlotte, a certified nurse midwife. 

A recent peer-reviewed national study correlating hundreds of laws and regulations to health outcomes for moms and babies when nurse midwives are fully integrated into the health-care system ranked North Carolina dead last. It got 17 points on a 100-point scale. 

“Before doctors existed, before obstetric care existed, midwives existed,” Sangodele-Ayoka said. Midwives are medical providers trained to prescribe medication, attend to medical emergencies, collaborate with and refer to physician partners when needed, and keep women and babies safe through holistic care. 

Studies have shown robust midwifery components in health-care delivery reduce C-sections, increase vaginal delivery rates, cut back on induced births and interventions that can cause dangerous complications, and boost breastfeeding rates, Sangodele-Ayoka said. 

But North Carolina law requires her to work under contract with a supervising physician, who receives financial compensation for the arrangement. He also can dictate what services she can provide. 

“Even though I’ve gone to graduate school, got my training and clinicals, I’ve taken my national board exam, and been certified on a national board level,” Sangodele-Ayoka said. 

“Having a supervising doctor is just a relationship. It doesn’t mean they’re physically supervising. So none of the births that I do is there ever a doctor present,” she said. 

Doctors seldom, if ever, check patient charts, do consultations, or diagnose illnesses on advanced practice nurses’ cases. 

Dr. Randall Castor, who opened his fourth Smoky Mountain Urgent Care clinic in Robbinsville on April 2, employs family nurse practitioners. He’s open to snipping the statutory tether between advanced practice nurses and supervising physicians because it could lead to more clinics in medically deprived areas. 

“I think in certain situations that would be perfectly fine. I helped a nurse practitioner open her own practice in Franklin,” Castor said. “She’s really doing everything pretty independently. Some nurse practitioners and physician assistants are really talented and experienced, and they certainly would be fine on their own.” 

As long as they possess enough experience, knowledge, and skill. 

“If it’s just basic primary care, I don’t see any reason why they need a supervising physician,” Castor said. 

House Bill 88, the Modernize Nursing Practice Act, was introduced to curtail limits on advanced nurse practitioners, including certified nurse midwives. The N.C. Nurses Association said similar legislation in Arizona boosted the number of advanced practice nurses in rural areas by 73 percent within five years. 

A similar legislative effort failed in 2015. At the time, Duke University researcher Chris Conover said allowing lower-cost nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and clinical nurse specialists to practice more independently could save the state from $443 million to $4.3 billion annually and increase the number of medical providers in rural areas. 

“We have historically opposed the relaxation of supervision of advanced practice registered nurses because we see real value” in that relationship, said Chip Baggett, vice president and associate general counsel at the N.C. Medical Society. 

He said existing law doesn’t prevent advanced nurse practitioners from practicing to the full scope of their training or from going into rural communities. Some already practice in rural satellite offices. Any increase in nurse practitioners opening practices in rural areas after regulations were lifted, Baggett said, are nominal. 

“Most of the evidence that we have seen from states that have done it is a 1 or 2 percent increase.” 

There’s no silver bullet for improving rural health care, Baggett said. Some combination of telemedicine, or loan repayments and other incentives [for doctors], investment in the local schools and the communities, he said, would go a long way toward that goal. 

Robert Graboyes, a senior research fellow and health-care scholar at the Mercatus Center of George Mason University, thinks resistance to scope-of-practice reform is largely tied to doctors protecting their monopolies. 

He said about 20 states offer greater freedom to nurse practitioners than North Carolina. 

“You don’t have people dying in the streets, and you do have people in remote rural areas that are getting good care,” Graboyes said. “In some cases, because they are a specialty of sorts, some things they can do better than the doctors can do.” 

The pushback against independence for advanced practice nurses and CON reform reminds him of the frenzy in Oregon after a law took effect in January allowing self-serve gasoline in 15 rural counties. 

“The state of Oregon went absolutely nut-case on this situation: ‘How are people going to know how to pump gas? And won’t they get it all over their clothes? It’s very dangerous. It could blow up.’ And the whole state was in a panic,” Graboyes said. 

“The doctors who are talking to you, I would say, are very likely in a very similar mind set,’” Graboyes said. “They can’t imagine how this could work for the same reason Oregonians can’t imagine how anyone can pump their own gas.”