Good Rural Health Care Called Possible : Health: A report recommends that towns use creative approaches such as nurse practitioners and modern emergency services to make up for shortage of doctors.

Rural advocates for years have urged more attention for the medical needs of sparsely settled areas, the small towns and farms where a fourth of America’s people live.

A recent study done for the National Rural Electric Cooperative Assn. says improved health care insurance would help as much as anything, ranking with jobs, water and sewer systems.

The association, a lobbying force on Capitol Hill, is a major backer of comprehensive rural development legislation.

Rural development is also the concern of a number of congressional leaders, including Sen. Patrick J. Leahy (D-Vt.), chairman of the Senate Agriculture Committee, who says: “We cannot have two Americas--one a land of opportunity and a second, rural America, left behind.”

Leahy said rural areas, with an estimated 61 million people and 14,000 small towns and cities, are in trouble because of higher unemployment and poverty rates than in metropolitan areas.

The problems of rural health care seem obvious to the casual observer--there are simply not enough doctors and hospitals in the countryside. A sick or injured person in the big city has a much better chance of getting quick treatment than a farmer in the middle of a pasture in Kansas or Wyoming.

But some believe that there is a more promising side to this dark coin and that there are solutions.

“Almost all rural hospitals are losing money as a result of dramatic declines in use, changes in government funding and fewer local doctors,” an Agriculture Department report said. “But that does not mean that rural residents must forgo local medical care.”

Rural areas can have a strong base for local health care, given some creativity and persistence, the report said. There are alternatives to hospitalization and sometimes to doctors themselves.

“Most patients no longer need a bed in a hospital,” the report said. “And modern emergency care techniques can stabilize patients for transport to a more distant hospital. Physician assistants and nurse practitioners can help ease the workload of the local physicians.”

The report, “Rural America and the Revolution in Health Care,” was written by Jeffrey C. Bauer, a former professor at the University of Colorado Medical Center and now head of his own rural health consulting firm. Co-author Eileen Weis, a registered nurse, is a strategic planner with the same firm, the Bauer Group of Hillrose, Colo.

“Rural areas today have too few physicians,” the report said. “Some areas have none. Unlike their city-based colleagues, many rural physicians are the only doctor in town, bearing all the burdens of being on call every evening and every weekend.”

Moreover, it said, disproportionately large numbers of government-insured or uninsured patients live in rural areas, and that means lower income for doctors.

Faced with career burnout and lower pay, many head for the cities and more lucrative fields. Hospitals built 30 or 40 years ago have vacancies galore.

“Most small and rural hospitals today fill less than 30% of their beds; 80% occupancy levels were common just 10 years ago,” the report said. “However, rural communities should not assume that their hospitals’ problems will all be solved if more doctors move into town or if hospital reimbursement rates are equalized.”

One of the basic alternatives has been the development of primary medical care without putting patients in a hospital bed.

“Up-to-date primary care practitioners can meet 80% to 90% of all health care needs without acute care hospital beds,” the report said. “Technological advances now enable primary care specialists to provide advanced diagnostic capabilities in their offices or clinics.”

Nurse practitioners and doctor assistants can perform many primary care functions with varying degrees of supervision by physicians.

The report said emergency medical services provide the other key to the future of rural health.

Because of recent scientific and technological advances, a modern emergency system “can actually be better than a typical emergency room in a rural hospital,” the report said. With a trained crew working with a fully equipped modern ambulance, most critically ill or injured patients can be stabilized at the scene.

“Thus, saving a small, rural hospital to preserve emergency care is not necessarily the best way to keep emergency care in rural areas,” the report said. “In many smaller towns, money spent toward emergency medical care is better spent on upgraded” emergency medical services.

But talk of closing hospitals can strike nerves, as Sen. Max Baucus (D-Mont.) demonstrated recently during a Veterans Affairs Committee hearing. Washington policy makers are fundamentally oblivious to the needs of rural America, he charged.

“They really don’t understand the sense of space and distance” in rural areas, Baucus said. The discussion at the time involved the possibility of closing rural veterans hospitals in Montana, a move ruled out at the hearing by Veterans Affairs Secretary Edward J. Derwinski.

The National Rural Electric Cooperative Assn. says expanded medical insurance coverage heads its list of ways to improve rural health care.

Bob Bergland, vice president and general manager of the association, said: “We want to make sure that the needs of rural Americans are considered in the current debate on medical insurance coverage and other health care problems.”

Bergland, who was secretary of agriculture in the Jimmy Carter Administration, said rural residents are less likely than city people to benefit from tax incentives and other programs aimed at making health care more available and affordable.

But he said: “Doctors and nurses will be the first to tell you that it’s not just their numbers that are important for good rural health care. We’ve got to assure things like adequate water and sewer facilities, nutrition education and preventive health care.”