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Is There A Doctor — Or Nurse Practitioner — In The House? Not In Rural Missouri

(Credit: Wikimedia Commons/Steve Morgan)

Part one of a three part series:

He woke up in the middle of the night late last year, one hand swollen and the rest of his body was shaking all over.

John Redford realized the symptoms were the consequences of several bites and scratches the day before from his struggle to put the family's 40-pound cat into a cage. He managed to calm himself enough that night and drive an old Mustang 50 miles to a hospital emergency room  in Jefferson City. There doctors began weeks of  treatment  and ultimately saved Redford from losing a finger.

If being seriously wounded when trying to cage a cat seems unusual to some, so does the distance that rural residents like Redford have to travel to get medical care. He lives in Chamois, Mo., which is in Osage County: population 13,000. It's one of Missouri's 41 rural counties that have no hospitals. In fact, there are no full-time primary care doctors in Redford's county. In fact, there is an acute shortage of dental and mental health services in most rural Missouri counties.

The shortages are becoming a growing issue as the demand for health services rises. As of March 1, more than 4.2 million people had signed up nation-wide for health insurance under the Affordable Care Act's marketplace program. Open enrollment  for the new health care program ends March 31.

So far, more than 74,000 urban and rural consumers in Missouri have signed up for marketplace  insurance, along with 113,000 in Illinois, federal officials report. The added enrollment is welcome by health advocates like Joe Pierle, CEO of the Missouri Primary Care Association.  His only cautionary note as he embraces the promise of ACA is that “having access to health insurance won’t mean much if you live in rural Missouri and can’t find a doctor.”

He can’t overlook the irony. Notwithstanding the state’s prominence as a training ground for outstanding physicians worldwide, it struggles to attract enough doctors to rural areas such as Chamois. Studies by the Missouri Foundation for Health and the Healthcare Foundation of Greater Kansas City found in 2011 that 40 percent of Missouri’s population lives in rural communities, but only 25 percent of the state’s physicians practice in those areas.

The foundations also found that the number of medical providers in Missouri fell short in relation to some other states. Missouri had roughly 116 primary care doctors per 100,000 people compared to the U.S. rate of 128. It also had 11 physician assistants per 100,000 people compared to a U.S. rate of 24. These numbers rank Missouri 47th in the country. Missouri ranked 33rd for the number of dentists per capita. For nurse practitioners, the state ranked 24th with 75 per 100,000, compared to a U.S. rate of 51 per 100,000.

The numbers are a moving target

People who collect such data urge that such numbers be interpreted with caution. A report released in January by the Missouri Health Initiative noted that the numbers become outdated almost the minute they are published because providers move in and out of a region or retire. The Health Initiative's inventory of doctors practicing in a big chunk of Missouri is probably more accurate than most because it’s culled from medical claims submitted for payments.

Using information about doctors registered to practice in Missouri, you can see which ZIP codes lack doctors. Note that the state's public records only include doctors who have listed a business address, not a home address. Explore which ZIP code has the most and least doctors, then continue reading about the difficulty of accessing health care in rural Missouri.

On the surface at least, the Missouri Board of Healing Arts doesn’t seem to pay any attention to the uneven distribution of doctors in the state. When asked about specific rural areas where the shortage is most acute, a board spokesperson said the agency didn’t keep track of where the doctors practiced but did say 24,106 doctors, including nearly 5,000 primary care doctors, were licensed to practice in the state, along with 887 physician assistants.

But some physicians and medical groups are concerned about the absence of more specifics in such data. Missouri “hasn’t really done a good job in defining what our workforce needs are, and in tracking what we actually have,” says Dr. F. David Schneider, chair of the Department of Family and Community Medicine at Saint Louis University.

“When you talk to legislators in Jefferson City, there are some who really believe (that the issue )should be left to the marketplace,” Schneider said. It’s unclear whether that approach will help level the field and address the greater need for more primary care doctors in places such as Osage County.

A new state report, titled "Health in Rural Missouri," explained that more attention needs to be paid to rural medical needs because the residents tend to be less healthy. Data collected between 2006 and 2010 showed that:

  • The average life expectancy in rural areas was 76.5 years, compared to 77.5 for urban dwellers.
  • Rural Missourians demonstrate increased levels of health risk factors with higher rates of smoking, lower levels of physical activity, increased rates of obesity, higher rates of high blood pressure and high cholesterol; and lower rates of preventive screening, such as mammograms and colonoscopies.
  • Higher numbers of urban dwellers get hospital treatment for diseases, such as cancer, while a higher rate of rural residents die from such diseases.

Obstacles to Access

Impediments to good health in rural Missouri aren’t always obvious. Clinic care for residents in Chamois, for example, is available in the county seat of Linn, which might seem like a relatively close 30 miles away. People who assume as much don’t appreciate the struggles that life poses for those living in small-town Missouri, says Mike Bumgarner, superintendent of  the highly regarded Osage County R-1 School District in Chamois where 60 percent of students are eligible for free or reduce lunches because they come from poor families. Although the school district is a draw, he says people also are lured to Chamois in part because of family connections and affordable housing.

Credit (Credit: Robert Joiner)
School superintendent Mike Bumgarner: people move to Chamois for its community values, but access to healthcare is a challenge.

“If you are a family in what we call generational poverty, Linn might as well be Kansas City, because if you don’t have transportation, how are you going to get to Linn from Chamois?” 

Transportation is probably the second highest priority among rural residents when they talk about health needs. The Rev. Frank Husted understands this all too well. Husted holds separate Sunday worship services for two dwindling congregations struggling to figure out how to maintain their full-time pastor.

The minister has had enough personal encounters with the region’s health care system to realize the difficulties it poses for the area’s needy. One evening last year, his he suffered an allergy attack so severe that he was taken by ambulance about 50 miles to Capital Regional Hospital in Jefferson City. 

Credit (Credit: Frank Husted)
The Rev. Frank Husted has personal experience taking an ambulance 50 miles to Kansas City. Transportation is one of the largest hurdles.

“I got my first ambulance ride but I don’t recommend it,” he says with a chuckle. “I got treated at the hospital and slept all the way home. We have a great team of first responders, but I hated to ask for the bill. That ride cost me $1,000.”

The good news for Husted is that he has health insurance. The bad news: “My deductible is a thousand dollars." He's paying $50 a month to pay off the bill. "I’m happy with that,” he said.

Husted's personal experience pales in comparison to some people he knows.  

“If I had needed to drive to Jefferson City, I have good transportation, reasonably good cars," Husted said. "But we have a number of people who are poor, who have no transportation or who have a car they probably bought for a thousand dollars from somebody’s uncle and it isn’t reliable enough to make it to Jefferson City. Plus, unlike me, they have no health insurance. Imagine what it would be like for them to get to a hospital 50 miles away?”

Searching for a solution

The health care issue is such a pressing one, said Bumgarner, the school superintendent, that having a clinic open even one day a week in Chamois would make a big difference.

He says people experiencing generational poverty, whether they live in Chamois or Appalachia, tend to figure out ways to solve problems, partly by relying on one another. For example, he says, an impoverished resident might ask a neighbor “whether you can pick up a loaf of bread for me when you go to Linn. Or can you buy some eggs when you are in Linn? Or the next time you go to the grocery store, can I ride with you?”  On the other hand, he acknowledges that the chronically poor can also lose hope before they find answers. But he says the feeling of hopelessness in Chamois is offset in some ways by the energy instilled in residents by leaders of the  Central Missouri Community Action office of Osage County, based in Linn.  The group, he says, has been one of the forces behind community efforts to bring health care services, such as a clinic, to communities like Chamois.

A similar characterization of  energy in towns like Chamois comes from Husted, the minister. “Ours is a town of survivors,” he said. “They are going to work things out. They are used to having to work it out and are used to dealing with difficulties.”

Rhonda J. Mitchem, senior vice president of Heritage Community Bank, can remember the departure years ago of the last physician who practiced in Chamois, with office hours once a week.

“Seems like when he was in town, you’d go past his office and there were cars parked everywhere,” she said. “Everybody waited till that time to go see the doctor.”

Credit (Credit: Robert Joiner)
Rhonda J. Mitchem recalls when there used to be a doctor who had office hours in Chamois. She said the line went out the door

On the other hand, she said the one institution that lures people to Chamois is its school system. Young couples, such as her son-in-law and daughter, moved to the community partly because of the school system. But young parents are realizing that no health services are nearby in the event a child needs to see a doctor. If Mitchem or her husband can’t meet the daughter with the kids who needs medical treatment, it means the daughter has to drive for about an hour  to Chamois from her job in Jefferson City, pick up the children, visit the doctor, and drive them back to Chamois.

“That means she’s missing more work, plus the time it takes to get in to see the doctor,” Mitchem said. “A lot of people here don’t have a second car. Plus some parents may work on production lines, and they lose money if they take off for their kids. This issue is a big concern.”

She said that is one reason growing numbers of people in the community are working with the Central Missouri Community Action office to try to get a nurse practitioner or physician to set up shop in Chamois.

Among those joining this movement is Lisa Collins, the girlfriend of the John Redford, the cat attack victim.

“Back in the day, doctors used to make house visits in rural communities" Collins said. "Our voices could make a difference here and in other rural areas. We need something here. It doesn’t have to be a big clinic, just something to take care of routine things.”

Credit (Credit: Robert Joiner)
Lisa Collins is working with the Central Missouri Action Office to bring doctors to Osage County.

Meanwhile, Redford, the boyfriend, explains the cat’s behavior. He was trying to cage the animal to bring it into the house.

“It’s a huge cat with a head this big,” Redford said, raising and widening hands whose knuckles still bear the pink scars from cat claws.

The medical bill for his trouble was between $6,000 and $7,000, he said, adding that he lacks health insurance.

Collins, the girlfriend, added, “I had no idea the cat would cause so much damage.”

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.