Rural doctors fear reforms will hurt them

April 28, 1993|By Ann LoLordo

Minnesota lawmakers haven't put the final touches on their health care reform legislation, but already Dr. Darrell L. Carter is feeling the effects. Two partners in his southwestern Minnesota practice are considering leaving.

That would mean Granite Falls (population 3,083) would have only three doctors to care for 15,000 patients, some of whom drive 20 miles to the physicians' office.

Minnesota's proposed health care reforms, which would create large competing networks of health care providers, may be exactly what some policy-makers in Washington believe the nation needs. But rural doctors -- 25 percent of Americans live in nonmetropolitan areas -- say the concept of managed competition is just that, a concept.

Doctors ask: How can you create a system that relies on strength in numbers in an area where people may travel an hour to see a doctor, physicians are in short supply, patients are increasingly elderly and government reimbursement for their care, at best, covers the cost?

"The attitude in many of the rural areas is, 'Why bother to try and work with a system that you don't know is going to work?' " says Dr. Carter, 46, who has practiced for nearly 20 years in Granite Falls, 125 miles west of Minneapolis. "We don't have the manpower nor the time."

Also, he said, the state's proposed service networks appear to be like big health maintenance organizations. "The HMOs tried to move into our marketplace and they all went belly up," he said.

Dr. Barbara Yawn, a member of the Minnesota Center for Rural Health, said rural doctors operate more independently, generally earn less money, rely less on technology and feel they have been more efficient than their urban colleagues.

"They don't see anything better coming for their patients and they don't see anything better coming for themselves," said Dr. Yawn, a former small-town physician who now studies rural health care.

Even the architects of the managed-competition strategy say it won't work in rural areas, Dr. Yawn says, adding that a patient base of 250,000 is considered necessary to foster true competition. "But that hasn't stopped the policy makers in St. Paul or in Washington."

In his own practice, Dr. Carter said the proposed state health reforms have convinced one partner, a 31-year-old physician, to move to Texas and a second colleague, who is 50, to think about early retirement instead of change the way they practice medicine.

Philip J. Stone, a hospital administrator in International Falls, Minn., a town of 16,000 at the Canadian border, said his 64-bed hospital wouldn't qualify as a provider under the state plan because it doesn't have adequate financial reserves. And if he wanted to join forces with another hospital, the closest one is 67 miles away and is smaller than his own.

Some rural health care providers, however, are trying to reduce costs and overhead by organizing into cooperatives. In Granite Falls, where the closest movie theater is 40 miles away and the only fast food in town is at the Dairy Queen, Dr. Carter is working on a program he calls "The Clinic Without Walls."

The proposal would have rural clinics, independent physicians and small group practices share some expenses. The providers would retain their financial autonomy, but jointly negotiate for equipment, paper products and services to cut costs.

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