How can large health systems support dispersed and underserved populations in remote, underfunded, and often understaffed rural facilities with obstetric and surgical needs? Rochester, New York, Danville, Pennsylvania, and Marshfield, Wisconsin, are not similar, but the populations supported by the University of Rochester Medical Center, Geisinger Health System, and Marshfield Clinic are. The University of Rochester and its affiliates serve a 50-mile-wide swath from Rochester to the Pennsylvania state line. The Geisinger Health System serves a population of about 3 million spread over two-thirds of Pennsylvania from Scranton to Lewistown. The Marshfield Clinic serves 1.5 million people in large areas of north and central Wisconsin and in Michigan’s upper peninsula. Geisinger and Marshfield are integrated nonprofit health systems, and URMC is the primary site for the University of Rochester School of Medicine and Dentistry and Tertiary Medical Center Health system with seven independent affiliated not-for-profit hospitals. The challenges faced by these three organizations are representative of the common challenges of health care in America.
“In our systems, we are attempting to build shared pools of staffing that can allow the providers to select the area that they prefer to work in, with access to the urban amenities desired, through novel scheduling patterns. Shared staff pools can allow providers to select preferred primary work settings, balanced with consideration for intermittent needs to shift to alternate sites when necessary.”
Surgery cannot be economically provided where utilization is low, and Medicare and Medicaid populations are a large portion of the insurance mix. But obstetric, surgical, and emergency services are necessary. Travel from remote locations to urban centers, where patients may be meeting their surgeon and anesthesiologist for the first time, is a measure of deficiency of access. Cancellations, caused by discovery of unrecognized contraindications, are distressing. Patients may return to their homes inadequately served with postoperative supports, attention to potential complications, or access to rehabilitation. Employing anesthesia professionals and surgeons is necessary, but where utilization is low, this can be prohibitively expensive, and recruiting is exceptionally difficult. Salaries, benefits, vacation, and CME support must be comparable to urban settings. But candidates who are a “good fit” in rural practices usually have priorities that extend beyond the salaries and benefits. Low cost of living, good schools, and the implied safety of smaller communities are attractive, but for many families these attributes are not sufficient. A revolving door of staffing turnover is often the result of recruitment mismatching, which undermines patient-provider relationships and continuity. Silo attitudes can contribute to the mismatch of staff to community, and “the good old days,” when providers were “theirs” and lived locally for decades, is a common bias. “We have never shared staff” is frequently true, but currently this history interferes with recruitment and retention. It is simply no longer possible to reproduce the ethos of the rural anesthesiologist(s) described in the opening editorial of this series of articles. Staffing stability requires creativity, and innovative approaches to scheduling are required.
In our systems, we are attempting to build shared pools of staffing that can allow the providers to select the area that they prefer to work in, with access to the urban amenities desired, through novel scheduling patterns. Shared staff pools can allow providers to select preferred primary work settings, balanced with consideration for intermittent needs to shift to alternate sites when necessary. Duty assignments minimizing commuting while maximizing contiguous days off, using serial days of service and call sequence to reduce commuting, allow more and longer free time intervals with family. Shared schedules allow people to live in one community while practicing in another. Several URMC providers choose to not work full time at any single facility, preferring variety combined with extended intervals of time off. Pooled participation in coverage expands the “bench” at all facilities, making it easier to match time off with clinical demands and peak clinical schedule needs. The Geisinger system credentials providers at all of its facilities, while most work assignments are at a primary location. When travel is required, mileage compensation and hotel accommodations are provided. Scheduling network infrastructure also reduces professional isolation and allows for coverage of short notice personal and family leave needs. The clinical responsibilities in rural locations can often allow time for nonclinical activities, CME, or teaching, and feature strong personal relationship development between specialties.
Perhaps more concerning than not being able to find and retain providers is the risk that their underutilized skills may degrade over time. Timely ultrasound-guided central venous access, fiberoptic intubation, or MH management may be required only rarely but can be lifesaving when needed. Health systems can support maintenance of competency for infrequently used skills through coordinated remote education, rotation to facilities with higher acuity, or efficient simulation lab offerings supported by robust IT networks that reduce the impact of physical distances.
Natural transition in models of care delivery
In the 1980s, when I (Dr. Roberts) trained to be a CRNA, some well-trained CRNAs exited the newly formed master’s in science training programs to facilities in rural America. We practiced in lucrative or heavily subsidized positions, but most of these CRNAs have aged and many are retired or working in less strenuous positions. The subsequent generations of now doctorate-level trained CRNAs exit training with much higher debt loads. Practices in rural settings are less attractive than the urban practices competing to employ them, often without participation in call. Rural facilities recognize the need to match urban salaries. CRNA salaries continue to rise, and call payment costs increase, approaching the rates of MDs. It is possible that a transition may occur from rural CRNA staffing to consultant physician staffing in smaller facilities as a natural outcome of costs intersecting, especially for hospitals that cannot afford, and do not value, an anesthesia team model. It is possible that an organic transition can occur, from solo CRNA rural staffing to rural consultant anesthesiologist staffing, simply on the basis of costs and availability. This will only occur, however, if anesthesiologists in training are made aware of the opportunity and its merits. If we train anesthesiologists to see rural practice as a specific attractive subspecialty of anesthesiology, with tangible lifestyle benefits, rural communities will have greater access to consultant anesthesiologists. Teaching in rural facilities and understanding the challenges of rural settings may be key to avoiding a catastrophic collapse of service delivery in rural settings as patient populations and providers age and the acuity of rural care increases.
The evolution of affiliate relationships with outlying facilities has created the opportunity for development of specific training opportunities directed at anesthesiology, emergency medicine, and primary care residencies in rural settings. Offering a curriculum and electives at our rural affiliates with consent of the ACGME resulted in expansion of the URMC residency complement, in part to that specific purpose. URMC also provides a clinical rotation for SRNAs from a CRNA program in Buffalo, including access to one of our rural affiliates. The Marshfield Clinic has a pending application for an anesthesiology residency, is the main site for Wisconsin Academy for Rural Medicine medical students, and has a research institute that engages agricultural research to improve farm medicine outcomes. Marshfield also provides major rotations for SRNAs from three CRNA schools in the Midwest. Geisinger’s anesthesiology residency program (1989 to 2002) produced six of the current anesthesiologists, who are still practicing there 20 years later. Resuming the residency in 2013 has produced retained graduates and has resulted in one addition to the staff at Marshfield. Geisinger also hopes to expand its resident complement and has had an affiliated school of nurse anesthesia since 1955. It is a training site for SRNAs from other schools, with good SRNA experiences contributing to retention of graduate CRNAs.
There is much that the “mother ships” can do
In addition to training and the introductions of trainees to rural environments, organizations like URMC, Geisinger, and Marshfield can support young rural consultants with vacation cross coverage, salary and benefit packages, call ratio assurances, and other social amenities. Rural consultancy is possibly more desirable than conventional urban positions. Supports for family medical leave, emotional need support when providers or their family members have unforeseen health issues or family crises, and childcare and elder care assistance can be absorbed in pretax benefits and funding of preschool resources. Reimbursement to extended family members for childcare services as a component of contemporary benefit plans or sign-on bonuses can be offered. Telemedicine preoperative evaluation and optimization services can enhance outcomes while reducing the hours of tedious obligation for the rural consultants who must otherwise screen cases themselves. Perhaps most importantly, tuition abatement can be offered as a component of benefits. Geisinger Commonwealth School of Medicine addresses the challenge of training and retaining clinicians in northeastern and central Pennsylvania with the Abigail Geisinger Scholars Program, essentially a “Berry Plan” commitment linking tuition abatement to service. Collaborations could also enhance access of skilled J1 visa candidates, trained in U.S. residencies, to locate to rural communities, which often have visas available to issue.