How to Mend Obstetric Deserts in the USA
The good news is that obstetric deserts <https://www.marchofdimes.org/maternity-care-deserts-report> can be successfully addressed and mended. The bad news is that the repair will happen neither in the near future, nor will it happen easily. There are many obstacles to repairing obstetric deserts, and they all need to be addressed and mended simultaneously...and that’s the hard part.
For 24 years I was involved with teaching family practice doctors how to provide rural obstetrics. This included the ability to recognize and manage fetal and maternal distress and to have the necessary people, equipment, and skills available to rapidly do a c-section. For 15 years I was the obstetric director for the South East Area Health Education Center (AHEC), overseeing the obstetric component of the family practice residency program and overseeing that obstetric training in that quarter of the state of North Dakota. This program was part of a larger UND effort to address North Dakota healthcare deserts in the state. This program actually started in the late 60s and continued through the 70s, 80s and 90s.
Our goal was to provide trained family practice doctors to practice obstetrics well in the many healthcare deserts of North Dakota. The program didn’t work exactly as we had planned because most of the young doctors who remained to practice in the state chose to settle in the more populated urban areas. Very few actually chose to practice in healthcare deserts. At least we addressed the training part so that if the young doctors had chosen to do rural healthcare, they were well trained and able to do rural obstetrics well. We certainly had addressed the training of the family practice doctors to be able to do rural obstetrics well. But many obstacles remained over which we had no control.
With more than four decades of managing health care in obstetric deserts, I know what does and what does not work, and what should work, but doesn’t. Since North Dakota is 80 percent healthcare desert, it follows that obstetric deserts have been my practice environment for a large part of my medical career.
State and Federal legislation or lack of it was a large problem. There are errors of omission and commission, including medical malpractice insurance, big business medicine, the American College of Obstetricians and Gynecologists (ACOG), hospital boards, chief executive officers (CEOs), obstetrical nursing, county and city commissioners, mayors, and state and federal representatives.
State and federal legislators have the opportunity to create legislation that protects the public from harm. Big business medicine does not help the public in any way. Big business has a lot of money at their disposal and they can create a lot of advertising, but when push comes to shove, the interest of big business is in making money for themselves and the stockholders. That means promoting goods and services which they think make money and eliminating services which are less lucrative.
Often a huge organization comprised of several hundred hospitals such as the Catholic Health Initiatives (CHI) will come into a state and purchase a hospital, a hospital that the community has often founded and supported for 30 or 40 years. Once CHI purchases a hospital (at least in North Dakota) it soon closes obstetrics. In North Dakota, CHI has purchased 4 community hospitals and relatively quickly brought about the closure of these hospital obstetric programs. To me, this is a strange mission for a catholic organization to espouse. Closing obstetrics isn’t good for the community. As a matter fact, it’s bad for the community. Closing obstetrics may help CHI make its budget look a little more profitable, which is good for the CHI stockholders, but obviously NOT GOOD for the communities CHI claims to serve.
In a North Dakota winter, having to travel 80 or 100 miles for delivery can be deadly. Complications can occur at home or in the car on the way to the hospital. Or worse, your car might get stalled in a snowdrift. Sometimes the North Dakota Highway Department advises no travel—and that means NO travel. The gates on the interstate ramps are closed. If you happen to live a mile or two from the hospital, you can always make the trip by snowmobile, but you will not be able to snowmobile 80 miles in a blizzard.
I have heard many times the CEOs of rural hospitals claim they have to discontinue obstetrics services because of the risk. They want to minimize their risk as an institution. But in so doing they create risk for the community they’re supposed to be serving. What the CEOs and hospital boards fail to acknowledge is the risk doesn’t go away. The risk just gets transferred from the hospital to the pregnant woman and her baby, creating actually more risk for the community. It’s obvious that big business medicine has placed its own interest and benefit above those in the community they are supposed to be serving.
In one CHI hospital where I was practicing, the community wanted the hospital to purchase a mammogram machine so women in the community could get breast exams locally. The group advocating for the mammogram machine was told there simply was no money for a mammogram machine. The hospital CEO told the women they should have an ice cream social to raise money for the machine. The next week the hospital repaved the parking lot, something that was truly not needed at the time. In the meantime, the people in the community are supposed to have bake sales to buy a mammogram machine which once it is purchased, becomes property of the big business hospital.
Now, our federal or state legislators could put a stop to this big business plundering with legislation, but they would first need to recognize the problem and secondly, care enough to take action to prevent the plundering of rural hospitals by big business medicine.
Big organizations have lots of money. And big money talks big time. Money can purchase lobbyists who can influence dozens of legislators. The state of North Dakota, for example, could require companies such as CHI to retain obstetric services in the hospitals they propose to purchase. Had this been done, there would now be four additional rural hospitals in North Dakota which still offered obstetrics.
Suggested Legislation in North Dakota to Protect Rural Consumers
from Big Business Medicine
I have proposed a few legislative suggestions for possible ways to help mediate the problem of obstetric deserts.
Stop all purchases of hospitals by out-of-state companies.
Require all large healthcare organizations which purchase hospitals or clinics in the state to maintain the existing services, including obstetrics.
Require the restoration of services eliminated by big business purchases of local clinics and hospital, in particular obstetrics.
Require large corporate health organizations to comply or leave the state. If the big business entity decides to pull out of that community, return control of the hospital back to the community.
Prevent the duplication of the local services already available at the hospital or clinics in the area.
Some additional legislative incentives might include:
Affordable state-serviced medical malpractice insurance could be made available to doctors who practice in rural communities.
As in workers comp court cases, the lawyer’s portion of any malpractice payments could be limited, for example, to 10 percent or $5000.
All physician medical school debt could be eliminated or paid for by the state with a five-year commitment to stay in the rural community.
There are other harms created when a large healthcare organization purchases a hospital for $900 million. Where does that money come from and who ultimately pays for the hospital? Any money coming out of the corporate healthcare pocket is going to eventually be recaptured by an increase in the cost of the healthcare provided. Big business healthcare is present to make money and make money it will.
Big healthcare businesses make their money from insurance premiums that the public is forced to purchase. To recover the $900 million, the price of insurance will increase so the $900 million is ultimately recovered from the consumer’s rising health insurance premium. Again, our legislators should protect our public (that’s their main job) from ever-increasing insurance premiums brought on by big business healthcare designed to increase corporate profits. To say that the mess is ever increasing is an understatement, and our legislators are asleep at the switch.
Years ago when I moved to a small town to revive its failing obstetrical environment, I met with the CEO and the hospital board in April. They said if I got there in June, they would have a nurse anesthetist there by August. By the time I arrived in June, the CEO had been fired and replaced by a CEO who thought that anesthetists who were called from a hospital 85 miles away would be the same thing as having a nurse anesthetist available on site. If the CEO would have told me this before I began work there, I probably would have said, “See you when you get your act together.”
I gave my honest commitment to this community hospital, but I didn’t get a good commitment from the hospital CEO or the hospital board. A one-sided commitment is a bad way to do business. Although the states require certain minimum behavior standards from local hospital boards, there is little to no actual inspections of hospital board actions to measure adherence to state regulations. If small hospital board members attend meetings primarily for the free pizza, nobody knows. The state health department doesn’t follow the workings of small hospital boards closely, checking that the boards adhere to state law.
The Hospital CEO Used to Be Supportive of Physicians
Status and function of the CEO has changed remarkably over the years. Forty years ago, CEOs were physicians’ friends. They would work to provide a smoothly running hospital and make sure that quality healthcare was important. Today the CEOs are no longer called hospital administrators. They are called healthcare leaders. I can only imagine that this is something they learn in their training. So, the Masters in Business Administration (MBA) program starts with arrogant young people and make them more arrogant. Today a hospital administrator can wreck anything or anybody in less than half an hour, including physicians who care about their patients.
ACOG is another barrier to obstetric care in rural healthcare deserts. Boarding in obstetrics is denied obstetricians who see men in their practice. It is very difficult to practice obstetrics in a small town and not see men as well as women in the clinic or hospital. Indeed, you may be the only doctor in the town. Fortunately, there is now boarding available to obstetricians who see men by the National Board of Physicians and Surgeons (NBPAS).
Repair of Obstetrical Deserts Will Be Difficult
Yes, it is possible to repair our rural healthcare deserts, but it’s not likely to happen soon or easily. There is too much private investment at stake, whether it’s the predatory nature of big business healthcare or the interference of insurance companies, Big Pharma, or the inability of state and federal legislators to see why the problem exists and work to bring about repair of the system. Thirty years ago when we published Modern Medicine: What You’re Dying to Know, we thought voters could talk to their legislators and work to bring about healthcare reform. Perhaps it’s time to see legislators with a backbone raise their hands. Consumers should literally and legally pack the halls of Congress to let their representatives know what is needed to repair obstetric deserts.