A Foothills Forum/Rappahannock News Special Report
In Rappahannock, health care headaches for an aging community
It’s a rainy summer afternoon, and about a dozen of the regulars at the Rappahannock Senior Center in Scrabble are gathered around a table for an after-lunch conversation. The subject is health care, but not the details of contentious legislation, nor comparisons of personal aches and pains and bodies gone wrong.
No, they are talking about the logistics of health care, of getting to appointments, of picking up prescriptions, of jammed doctors’ schedules.
“Sometimes it’s just very hard to get a ride,” says Daniel, from across the table, and nearby, heads start to nod. Those here know that’s a hard reality of senior life in Rappahannock. One of the women admits she sometimes doesn’t get prescriptions refilled because that means a drive to another county.
Most, like Daniel, are in their 70s and 80s, deep into the “What if?” phase of their lives. “What if I have a heart attack at two in the morning . . . will the rescue squad be able to get to me in time?” “What if they can’t do the test I need at Culpeper, and they say I have to go to Charlottesville? How will I get there?”
They’ve also reached the stage where what once was welcome solitude can devolve into social isolation. That takes its own toll.
Says a woman named Irene: “If my daughter wasn’t here, I’d be in a straitjacket.”
Many in the room have spent much, if not all, of their lives in Rappahannock. They understand why people love its open spaces. But they also now know something else about it.
It can be a hard place to grow old.
Where we stand
That’s true of much of rural America these days. Access to a dwindling number of doctors and medical services has made it more challenging to stay healthy, and tougher to get treatment when you’re not.
In some ways, Rappahannock is better off than many of its neighbors.
According to the latest County Health Rankings and Roadmaps, an annual report sponsored by the Robert Wood Johnson Foundation, Rappahannock ranks 30th among the state’s 133 counties and cities in a category called “Health Behaviors.” It reflects such things as tobacco and alcohol use, physical activity, access to healthy foods, and sexually transmitted diseases. That falls behind Fauquier County (26th), but ahead of Culpeper (52nd), Warren (61st), Page (64th) and Madison (70th).
Rappahannock ranks even higher (27th) in the “Length of Life” category. It measures the risk of dying before 75 and is based on the number of years lost by people who have died before then. Again, the county falls slightly lower than Fauquier (26th), but does better than Madison (47th), Warren (55th), Culpeper (61st) and Page (102nd).
Now the bad news. The county is above the national average in the use of prescription drugs for high cholesterol and diabetes, according to the latest Community Health Needs Assessment of the PATH Foundation, Fauquier Health and the Rappahannock-Rapidan Health District. Also, among neighboring counties, only Madison has a higher percentage (11.1 percent) of its population diagnosed with diabetes than Rappahannock (10.8 percent). And, while it’s lower than the levels for both Virginia and the U.S., Rappahannock’s obesity rate (26.4 percent) is rising.
Then, there’s the county’s aging population. That’s common knowledge, but the numbers present a stark snapshot of a community leaning into its senior years. The largest adult age group is people in their 60s — about 18 percent — and almost a third of Rappahannock’s estimated 7,308 residents now are older than 60, according to the U.S. Census Bureau.
In that context, it’s disconcerting to see where in the County Health Rankings Rappahannock performs most poorly. It’s a category called “Clinical Care,” and it reflects access to medical services. With no hospitals, three doctors — including one who is here one day a week — and a high rate of uninsured adults (18 percent) and children (11 percent), the county doesn’t stack up very well. It ranks 80th out of 133.
Here’s another reflection of Rappahannock’s health care shortcomings. The Health Resources and Services Administration, a federal agency, designates some communities as “Medically Underserved Areas” and “Health Professional Shortage Areas.” It uses a formula based on such things as the ratio of health care providers to the population, number of residents under the poverty level, the percentage of people over 65, and the distance to the nearest source of care.
For years, Rappahannock has been considered both.
Rural doctors, challenging realities
Back in 1974, Jerry Martin, then a young physician, joined Dr. Werner Krebser in opening a practice on Gay Street in Washington. Dr. Martin was very ambitious — there was even an X-ray machine in the office, and he would reset bones and do other minor surgery. He says he saw as many as 30 patients a day.
“I kind of envisioned this as providing a whole spectrum of care,” he remembers. “Over a period of time, I realized it was not feasible.”
He cut back on emergency care, although he still treats his share of sprains and infections. His practice changed in other ways, too. He began spending almost as much time on paperwork as he did with patients. Now, he sees closer to a dozen people a day, most for chronic conditions — diabetes, hypertension, lung disease, joint pain.
Martin, now 74, says he can’t see how a doctor today would be able to do what he and Krebser did way back when. “I’m a dinosaur, the last of a dying breed,” he said. “It would be financially prohibitive for someone to start out the way I did.”
Dr. John McCue would agree. He first began practicing in Rappahannock in 1998, working with Dr. Martin. Then, in 2001, he went out on his own, opening Mountainside Medicine on Route 211, just west of Little Washington. He likewise refers to himself as a dinosaur.
“In rural areas, there are more people with Medicare and Medicaid,” he said. “The reimbursements are lower, and it can be tremendous stress just to keep your practice open. I’m a freestanding practice, and that is so financially challenging.”
McCue, who’s 61, makes monthly visits to nursing homes in Warrenton and Manassas, in part to provide care to elderly patients, but also to help his bottom line. And, he often spends time on the phone working out treatment plans with specialists who, he knows, his patients may not ever be able to see.
“The challenge of getting to treatments discourages patients,” he said. “It presents a barrier. It really does.”
Off 211, an outpost of the future?
So, if Jerry Martin and John McCue are remnants of the past, what’s the future of the country doctor?
It might be more like what you’d find in a little white building just down 211 from McCue’s office. Formally known as “Valley Health Page Memorial Hospital Family Medicine Washington,” it’s essentially a Rappahannock outpost of the Valley Health System. In this region, it operates Warren Memorial Hospital in Front Royal, Page Memorial in Luray, and Winchester Medical Center.
The office was opened last November by Dr. Brooke Miller and his wife, Ann, a nurse practitioner. For now, Brooke, 56, who’s on the staff at Page Memorial, is in the Rappahannock office one day a week, although he hopes to add another day by the end of the summer; Ann sees patients the rest of the time.
Nurse practitioners can perform a wide range of medical tasks, including diagnosing and treating health conditions, prescribing medications, ordering and analyzing diagnostic tests and lab work, and doing in-office procedures, such as suturing wounds.
For Valley Health, a hospital system trying to establish a higher profile in Rappahannock, the Millers were a smart choice. He’s a native of Little Washington, and their home is on the other side of the highway from the office, on land that’s been in his family.
“We’ve been trying to get back to Rappahannock for years,” Ann noted. “With health care the way it is, we knew we could not financially open up a practice of our own. We needed security.”
“I think people are more likely to practice in a rural community if they grew up in one,” said Dr. Miller. “One of the reasons I wanted to go into primary care medicine is that I wanted to be in Rappahannock County. I was interested in plastic surgery and neurosurgery, but I knew I couldn’t live in a rural place if I did either of those.”
That’s because in sparsely-populated communities, medical specialists can’t get enough patients. Rural hospitals struggle to recruit them. So, it frustrates him that primary care physicians are reimbursed at lower levels than specialists.
“I could do a procedure here, but what the insurance companies will reimburse is completely different and much lower than if a specialist did the same thing,” he said. “That doesn’t make sense, especially if you want to increase the number of primary care physicians.”
Trials and risks
“The primary care shortage is real, and it’s only going to get worse,” explained Travis Clark. He’s the vice president of operations for Valley Health’s Southern Region and president of Page Memorial Hospital in Luray and Shenandoah Memorial Hospital in Woodstock. He’s also the person most responsible for setting up the clinic in Rappahannock.
Clark gives a handful of reasons. There’s the Millers’ personal connection, of course, and the opportunity to raise the Valley Health flag in a community that has generally gravitated toward hospitals in Fauquier and Culpeper. Also, because Rappahannock is a “Health Professional Shortage Area,” a rural health clinic here receives a higher level of federal reimbursement than it would in Warrenton. And, there was interest in testing the waters for what could become a model for rural health care.
“The idea is to start introducing nurse practitioners and physician’s assistants into these communities because we know it’s going to be very hard to recruit primary care physicians,” Clark said. “The business model also has a little more flexibility in it. You have Brooke and Ann providing medical care, but it opens it up for us to start looking at other services, like case management to help manage patients between emergency department visits and clinic visits.”
But with trial comes risk. An Express Care office that Novant Health opened in Marshall closed in April after just nine months. Chad Melton, who’s been CEO of Fauquier Health since early this year, thinks that office probably needed to average 25 to 30 patients a day. That didn’t happen, and the result is a cautionary tale in an industry that understands caution.
“We’d like to open up clinics, but how do you sustain that?” asked Melton. “The question is would we have enough patients to sustain someone in Rappahannock. We have to make sound business decisions.”
Thin margins, but a big need for doctors
These are precarious times for rural hospitals. Since 2010, almost 80 in the U.S. have closed, and the National Rural Health Association estimates that more than 200 of the remaining 1,800 are at “extreme risk” of shutting down. The communities they serve are both shrinking and getting older, and rural residents are less likely to have jobs that come with health insurance. So, with a heavy cluster of Medicare, Medicaid or uninsured patients—frequently more than two-thirds — they’re operating on very thin margins.
Melton explained that Fauquier Hospital relies on patients with private insurance to “carry all the other payers.” Greg Napps, CEO at Novant Health UVa Culpeper Medical Center, offered another perspective. He pointed out that about one out of four people who come to the Culpeper emergency department don’t have insurance. “It begins to tell the tale of what hospitals are dealing with,” he said. “If one in four people coming into a business — any business — isn’t able to pay, that makes it really tough.”
Another big challenge is recruiting doctors, and then holding on to them. And, not just specialists. Family practice doctors with huge medical school loans often balk at what they would make at a rural hospital.
“The average debt of a doctor who’s attended medical school at VCOM (Edward Via College of Osteopathic Medicine in Blacksburg), for instance, is $300,000,” said Melton. “They worry they won’t make enough money to repay the loan.”
Napps said Culpeper is able to take advantage of its relationship with the University of Virginia Medical Center to attract doctors. “Without that,” he conceded, “it would be difficult to bring people to a small community.”
For his part, Travis Clark promotes the uniqueness of working in a rural community, how a doctor can not only make a difference, but see the difference they make.
“We also sell our quality of life, our natural beauty,” he said. “We tell them if you like the outdoors, this is where you want to be. But when you’re recruiting to rural areas, the other challenge is the spouse. They’ll say ‘I can be a doctor here, but is there a job for my spouse?’”
And so, Clark observes, it’s not just the patients in rural communities who are getting older. “So are the nurses, so are the doctors, so are the lab techs, so are the emergency crews.”
‘The number one underserved area’
There’s another big gap in rural health care, one that widens as a place gets older. There aren’t nearly enough professionals to help those struggling with mental health issues that often deepen with age and isolation. Much of that role falls to doctors who can only do so much.
Sallie Morgan, director of the Mental Health Association of Fauquier County and a resident of Rappahannock, has seen this time and again. “So much of the mental health care in this community is provided by primary care doctors,” she said. “So, they’re prescribing medications, but people aren’t getting therapy. And these physicians have said to us, ‘We’re not equipped to do this.’ “
Dr. McCue has witnessed firsthand how physical and mental health are intertwined. “You can’t separate them. The Greeks were right,” he said. “If you have mental health issues — you’re not sleeping, you’re anxious, you’re depressed — you wind up with disease. They feed into each other.
“Remoteness, isolation, I’ve found it to be a fairly common problem,” he added. “I really think mental health is the number one underserved area in rural communities.”
A number of groups and organizations — from Rapp at Home to Aging Together to the Senior Center — offer programs to keep older folks active and engaged. But for many, friends and family have moved away, leaving them to lose connections when they need them most. The rural culture itself probably doesn’t help, suggested Sallie Morgan. “I think the tradition of not seeking help, of being self-sufficient, is probably stronger in areas like this,” she said.
Darcy Canton, who runs the Senior Center, thinks there’s something to that. Four days a week, a group of regulars come to the old Scrabble School for lunch and crafts and conversation, all to a background soundtrack of music from their younger days.
“There are so many people I know who are isolated, she said, “and our program is meant to help counter that — not allowing them to get isolated so that it doesn’t lead to other issues. But there are still a lot of people who need the socialization who are reluctant to go to a senior center. They’ll say, ‘I don’t need a senior center.’
“Rappahannock people are a very proud people. They want to be able to provide for themselves.”
But for all the virtue of those values, they may not serve well those hit by what’s been called the “Silver Tsunami,” a coming wave of Baby Boomers who will develop dementia. It could be particularly damaging in a rapidly aging community like Rappahannock.
That concerns Danny Wilson, a psychotherapist and gerontology expert who moved to the county in 2010, and has coordinated a number of support groups for older adults. Among them is one for people who provide care for family members or friends. They meet twice a month and talk about the demands and rewards of caregiving, often for those with Alzheimer’s disease.
He says he’s heartened to see how much people here look out for each other, more so than he saw when he lived in Washington, D.C. Yet, he also knows how insidious a condition dementia can be, and that one of the big challenges is having its victims acknowledge they’re changing.
“This can-do, self-sufficient attitude can get in our way the older we get,” he said. “We’re living in a society that prizes independence. But the older we get, the more we have to start figuring out how to be interdependent.
“I see so many, including myself, who go from ‘I can do it’ to ‘I can’t do it,’ and jump past that middle phase of ‘I can do it with someone else’s help.’”
Part one of a three-part series
Part 2 (August 3): How long can an older community rely on aging volunteers to handle its emergencies?
Part 3 (August 17): A community takes on its health care challenges. Plus, a peek into the future.