An innovative, rational approach to rural health care

Medical Hypotheses 4:

362-366,

1978.

AN INNOVATIVE,RATIONALAPPROACHTO RURAL HEALTH CARE M.H. Kirsch. University Health Service, Southern Illinois University, Edwardsville, Illinois, U.S.A. 62026 ABSTRACT Parts of rural, southern Illinois, like many rural areas throughout the world, are medically underserved. An innovative, rational solution to the physician shortage in those parts of rural, southern Illinois, which may be applied to other medically underserved areas, rural or urban, is proposed in this manuscript. To attract physicians to or near medically underserved, rural areas in southern Illinois it is proposed that Primary Care and Referral Centers be set up in southern Illinois. This could be done by adding well trained general practitioners, family physicians, or general internists to the staff of each emergency center of the Total Emergency Medical Service System for (southern) Illinois that is located in or near an otherwise medically underserved, rural area of southern Illinois. These additional physicians would diagnose and treat within their capabilities all non-emergency cases coming to the primary care centers and refer non-emergency cases needing referrals. Referrals would be either for secondary or tertiary health care. The Primary Care and Referral Centers should be selfasupporting from pre-paid patient fees. For almost ten years a health center like a Primary Care and Referral Center has been operating at SIU/Edwardsville. emergency health care non-emergency health care rural primary health care and referral centers Delivery of Health Care Emergency Health Services Emergency Medicine Health Services Primary Health Care Rural Health

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INTRODUCTION One of the reasons rural areas in the U.S.A. and in other countries have a severe shortage of physicians is that few physicians wish to have a 24 hours per day, seven days per week job of diagnosing and treating all kinds To solve the of emergencies and non-emergencies in isolated surroundings. problem of the shortage of physicians in rural areas rationally, I have proposed in this manuscript a model rural health care delivery system based on an emergency health care delivery system that now exists in southern Illinois. Illinois has a Total Emergency Medical Service System which is primarily designed to handle trauma on the highways of Illinois at various emergency (trauma) centers in selected hospitals throughout Illinois. Some of these emergency centers in southern Illinois are located in community hospitals in or near otherwise medically underserved, rural areas, i.e., rural areas with insufficient physicians in both quantity and expertise for all the people of the area. The SIU School of Medicine was established to improve health care in southern Illinois by producing more physicians for southern Illinois; however, this is only part of the solution to the problem of improved health care in southern Illinois. Rural areas in southern Illinois which need more physicians than they now have would attract those physicians if those areas were made more attractive places to practice than they are. To attract more physicians to or near these medically underserved, rural areas in southern Illinois I propose establishing Primary Care and Referral Centers in or near these rural areas by expanding the Total Emergency Medical Service System for (southern) Illinois in a manner which I will outline later. If one or a few pilot Primary Care and Referral Centers in or near medically underserved, rural areas were successful, then others could be established in southern Illinois in or near other medically underserved, rural areas. PROPOSAL DETAILS The Primary Care and Referral Centers should be administratively headquartered in two places; in the Health Service at SIU/Edwardsville and at the SIU School of Medicine/Springfield. The advantage of having one of the administrative headquarters at SIU/Edwardsville is that it would be close to consultants on the staff of the Washington University Medical Center of St. Louis and the St. Louis University Medical Center in case meetings between some administrators of the Primary Care and Referral Centers and consultants from St. Louis are necessary. These consultants in St. Louis could receive some of the referrals from the Primary Care and Referral Centers in southern Illinois. A second administrative headquarters should be at the SIU School of Medicine/ Springfield to handle referrals sent to consultants on the staffs of hospitals associated with the SIU School of Medicine/Springfield. My proposal is to expand the Total Emergency Medical Service System for (southern) Illinois into a Primary Medical Care and Referral System for medically underserved, rural areas of southern Illinois, meaning that in addition to emergencies, non-emergencies either not requiring or requiring a consultant's or consultants' care with or without hospitalization would be diagnosed and treated as completely as possible in the primary care centers. Emergencies would be handled by the primary care centers as they are now by the

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Total Emergency Medical Service System for (southern) Illinois. If the emergency or non-emergency required consultation(s) with or without hospitalization, an appropriate referral and, if necessary, transportation to the best resource for definitive care in the Bi-State Region would be provided. For a relatively less complex emergency or non-emergency case, referral would be to the appropriate consultant(s) on the staff of or near the community hospital associated with the Primary Care and Referral Center (secondary health care).(l: For a relatively more complex, emergency or non-emergency case, referral would be to the appropriate consultant(s) on the staff of or near one of the three urban medical centers mentioned above (tertiary health care). (1) The emergency or non-emergency patient would have a free choice of which consultant(s) he wanted to see for secondary and tertiary health care. Essentially what I am proposing is that well trained general practitioners, family physicians, or general internists be added to the staffs of emergency centers in the Total Emergency Medical Service System for (southern) Illinois that are located in or near otherwise medically underserved, rural areas in southern Illinois. It would be the responsibilities of these general practitioners, family physicians, or general internists to diagnose, treat, and refer, when necessary, the non-emergency cases coming to the Primary Care and Referral Centers. The physician handling the non-emergenoies would be assisted by a minimum staff and necessary facilities, viz., a receptionist, nurses, medical records room and clerical staff, a laboratory and lab technician, a pharmacy and a pharmacist, and a transportation service. The minimum staff for the non-emergency physicians could be partially the same as the one for the emergency physicians of the Primary Care and Referral Centers, thus avoiding expensive duplication of manpower. The non-emergency physicians would have regular hours, e.g., 8 AM or 9 AM to 5 PM daily with a five day work-week, and would have vacations. Their salaries would be competitive. If X-rays not requiring hospitalization, e.g., chest X-rays, skull X-rays, sinus X-rays, cervical, thoracic, or lumbosacral spine X-rays, long bone X-rays, joint X-rays, upper GI and small bowel series, gall bladder series, barium enemas, or IVPs, were required of the non-emergency patient, the patient would be referred to a private radiologist or to the radiology department of the community hospital associated with the primary care center. For secondary health care the non-emergency physician handling the case would arrange for this referral through face-to-face or telephone communication and also with written conrmunicationwith the best available consultant(s) in or near the community hospital associated with the Primary Care and Referral Center. For tertiary health care the non-emergency physician would arrange for this referral through telephone and written communication with the best available consultant(s) in St. Louis or Springfield, Ill., who are on the staff or near one of the previously mentioned three urban medical centers. I at the Health Service at SIUZEdwardsville could be utilized as an intermediary between the non-emergency physicians and consultants on the staff of the Washington University Medical Center of St. Louis, as I know many of these consultants. The financing of this non-emergency medical staff would be done by having all residents of southern Illinois who want to receive non-emergency care in the Primary Care and Referral Centers pay only an arithmetically determined, fixed fee per year which would entitle them to an unlimited number 364

of visits to non-emergency physicians at no extra cost, free basic laboratory tests (CBC, urinalysis, sed rate, throat culture, and serology), and the privilege of buying their medicines at reduced costs in the pharmacy. The fees for X-rays, special laboratory tests or other diagnostic tests that cannot be done in the primary care center's laboratory, consultation(s), or hospitalization(s) would be the responsibility of the patient or his medical insurance. The visits to the non-emergency physicians would be on an appointment basis, rather than on a non-appointment basis as would exist for bona fide emergencies. A reasonable scheduling of appointments for each non-emergency physician might be one patient every 15 minutes. The laboratory would be equipped with modern equipment, e.g., a Coulter Counter for white blood counts and a Technicon Auto-Analyzer II for blood screening tests. Is this idea of Primary Care and Referral Centers for medically underserved, rural areas of southern Illinois feasible? I believe it is, as a health center like a Primary Care and Referral Center has been operating at SIU/Edwardsville for almost ten years. I am a general internist. I was the first physician on the University Health Service staff at SIU/Edwardsville and I have seen it develop into a health center like a Primary Care and Referral Center for a population of about 13,000, i.e., the total number of students, faculty, and staff at SIU/Edwardsville in the Fall of 1977, serviced now by one full-time physician and one part-time physician. In 1976-77 there were approximately 11,000 patient visits to the Health Service at SIU/Edwardsville. To implement this program discussions should begin immediately with the Illinois Department of Public Health (Division of Emergency Medical Services and Highway Safety), Washington University Medical Center of St. Louis, St. Louis University Medical Center, and the SIU School of Medicine at Springfield, Illinois, about the feasibility of adding to those emergency centers of the Total Emergency Medical Service System in (southern) Illinois which are located in or near otherwise medically underserved, rural areas in southern Illinois well trained general practitioners, family physicians, or general internists to function as the non-emergency physicians of the Primary Care and Referral Centers. I estimate it would take at least one year to have one or a few Primary Care and Referral Centers operating. To evaluate the effectiveness of my plan, the following information should be collected about each Primary Care and Referral Center: The number of subscribers, the number of patient visits, number a. of different laboratory visits and tests, number and destinations of referrals, breakdown of patient visits by disease categories, number of personnel, square feet of facilities of the Primary Care and Referral Center, cost per subscriber of operating the non-emergency facility of each Primary Care and Referral Center, and patient expenditure per prescription filled in the primary care center's pharmacy (on the average). Interviews of the patients and workers of each Primary Care b. and Referral Center by social workers concerning ways to improve care delivered by each Primary Care and Referral Center.

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CONCLUSIONS The ideas in this manuscript are based on the premise that rural health care delivery can be rationalized. The rational health care delivery system presented in this paper for medically underserved, rural areas of southern Illinois could be developed in other medically underserved, rural areas and, possibly, medically underserved, urban areas. This rational health care delivery system provides different emergency and non-emergency physicians for primary, secondary, and tertiary health care. The secondary health care would be in a consultant's office or consultants' offices close to the Primary Care and Referral Center, in a clinic or clinics associated with the community hospital associated with the Primary Care and Referral Center, or would be inpatient care in the community hospital where the Primary Care and Referral Center is located. The tertiary health care would be in an urban consultant's office or consultants' offices, in an urban medical center clinic or clinics or would be inpatient care in an urban medical center. The above ideas are feasible in a rural area which has an emergency health care delivery system such as southern Illinois. Certainly an emergency health care delivery system is the minimum health care delivery system a rural area or any area should have in a civilized country. Where such an emergency system exists as in southern Illinois, why not build onto the emergency system a nonemergency health care delivery system such as I have proposed in this manuscrip for people who previously were medically underserved, but who will pay for the non-emergency health care delivery sytem? In essence I propose that one or a few pilot Primary Care and Referral Centers be established in or near rural areas in southern Illinois that have a severe shortage of physicians by converting an emergency center for such an area into a primary care center for that area. Eakh primary care center would have physicians responsible for emergency care and different physicians for non-emergency care. There would be referrals, when necessary, of emergency and non-emergency patients to consultants for secondary or tertiary health care. The Primary Care and Referral Centers, if successful, would be self-supporting from pre-paid patient fees. Each Primary Care and Referral Center could also be expanded to include pediatricians and gynecologists, the other primary health care providers. 1.

Rural Health Initiative, Program Guidance Material for RHI/HURA Grants, Appendix A. U.S. Department of Health, Education, and Welfare, Public Health Service, Health Services Administration, Bureau of Community Health Services, Rockville, Maryland, 20857. December, 1976.

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