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What approaches would help close the gap in orthopedic care provided in rural areas?
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Opportunities with telemedicine
I have been privileged to practice in the rural Mountain States for the entirety of my 18-year career. I practiced for a little more than 1 year in a “big city” with a population of 50,000 people, but for the remainder of my 17 years I have practiced in small western towns with fewer than 10,000 people. I chose to be here, as I have a passion for all things western — skiing, horses, shooting, hunting; and I love the people in rural America. Currently, I practice in North Central Montana where I am the only orthopedic surgeon for hundreds of miles. The scarcity of access to orthopedic care provides the biggest challenges to the rural orthopedic surgeon. My patients often must travel for 2 to 3 hours to reach us. These long distances in the often-harsh weather of the Mountain States provides the biggest impediment to emergency and non-emergent orthopedic care.
Telemedicine would seem to provide opportunities to lessen the travel burden and improve access to care; however, Medicare’s requirements for telemedicine are onerous and make implementing true telemedicine visits into a busy practice difficult. Specialty specific guidelines that would allow routine follow-up visits without exhaustive documentation would improve access to medical care.
Emergency care requires well-developed relationships with our urban colleagues. In small hospitals, hundreds of miles from advanced resources, there are many patients we just cannot handle. We must consider the entire patient. Rural hospitals do not have intensivists, interventional radiologists and vascular surgeons, and often we do not have another orthopedist to discuss a case with. If there are multi-system injuries, comorbidities or concerns that there could be a major complication, we owe it to the patient to transfer him or her to a higher level of care. Rural hospitals often only have one orthopedist and do not have full-time orthopedic coverage. If you are the “big city” surgeon, please understand these are limitations. Transfers are initiated out of concern for what is best for the patient’s care and resources they need.
Michelle Cameron Donaldson, MD, is director of orthopedics and sports medicine at Northern Montana Hospital in Havre, Montana.
Disclosure: Donaldson reports no relevant financial disclosures.
Co-management arrangements
The challenge for smaller, rural hospitals today is finding the right combination of medical and financial resources to fulfill their orthopedic needs. With fewer patients for the orthopedic specialty, the rural hospitals simply do not have the financial volume to offset the cost of hiring a full-time orthopedic surgeon and providing medical coverage 24 hours a day, 7 days a week.
A more effective alternative, in these scenarios, is having orthopedic groups engage rural hospitals in co-management arrangements that allow both institutions to benefit. Orthopedic groups could supply specialty trained orthopedic surgeons on a scheduled basis to visit rural institutions and bring highly skilled and specialized care to those localities. This is a way larger orthopedic groups can grow additional practices and engage specialty trained orthopedic surgeons in doing what they love to do while providing beneficial opportunities to those hospitals.
Successful co-management partnerships between rural hospitals and orthopedic practices rely on the hospital’s resources and a business plan that creates mutually beneficial endeavors that would not detract from the orthopedic practices in larger cities.
Having subspecialty care in these smaller hospitals is of benefit to the people who live in these rural areas. Providing services locally can decrease the need for travel back and forth to larger communities, especially when the population consists of a substantial number of elderly patients for whom this would be difficult. This type of arrangement also creates opportunities for marketing exposure and business expansion which can help the hospital stay viable from a financial standpoint.
Craig R. Mahoney, MD, a hip and knee surgeon, practices at Iowa Ortho in Des Moines, Iowa.
Disclosure: Mahoney reports no relevant financial disclosures.