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In rural Md., few doctors but plenty of health woes

ANNAPOLIS — Kerry Palakanis has spent most of her career as a nurse practitioner working in rural communities.

In Somerset County, where she owns and operates the Crisfield Clinic, she comes face to face with the everyday challenges of providing health care in a rural area.

“The patients are very sick, and the resources are very scarce,” Palakanis said.

A lack of health care providers in Somerset County and other rural areas around Maryland is contributing to health disparities that include higher rates of heart disease and obesity and lower life expectancy rates.

“The other way I describe it … is we’re akin to a Third World country,” Palakanis said. “When I see people going off to foreign countries to help with health care, I think, ‘Why not come to Somerset County?’ We have all the same issues here. You don’t even need a passport.”

In the national 2014 County Health Rankings released by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, five of the 10 least healthy jurisdictions in Maryland are considered partially or completely rural by federal standards. Three others in the bottom 10 — Allegany, Cecil and Wicomico counties — fall under the state’s broader definition of rural.

The annual rankings, released in March, are based on health outcomes that incorporate the length and quality of life for residents of each jurisdiction.

In rural Caroline County, which ranks second-to-last in health outcomes, ahead of only Baltimore city, life expectancy is seven years shorter than in top-ranked suburban Montgomery County, according to the most recent Maryland Vital Statistics Annual Report, released by the Department of Health and Mental Hygiene in 2012.

Rural health experts and advocates link the disparities to the scarcity of health care providers in rural areas and the decreased access to care that is a result.

The ratio of primary care providers to residents in Caroline County is one to 2,915, according to the Department of Health and Mental Hygiene. That ratio, the worst in the state, amounts to just 11 primary care providers for the entire county.

Maryland as whole has one primary care provider for every 1,647 residents.

While rural Talbot County boasts the best ratio, with 35 primary care providers lending the jurisdiction a ratio of one to 1,056, six of the 10 worst ratios belong to federally designated rural counties. Caroline, Somerset, Dorchester and Garrett counties — all rural — hold the bottom four spots.

As a result, people living in rural areas often have to travel long distances for health care, a disincentive to getting even the basic preventative care they should be receiving, according to Dr. Claudia Baquet, an associate dean at the University of Maryland School of Medicine and the director of the school’s Center for Health Disparities.

The rate of specialty care providers in rural areas throughout the state is often worse, and Palakanis regularly sees the effects of that in her clinic.

Palakanis said the clinic can fit in anyone who is willing to come for primary care, but if they need specialty care, she has to send them to Salisbury, where she said resources are “overstretched at best,” or Baltimore, which is almost three hours away.

And in a county like Somerset, where poverty and unemployment rates are high, getting patients to take a day off work to seek health care can be challenging.

“For my patients to get to Baltimore, it would be just as easy for me to say, ‘I’m going to send you to the moon,’” Palakanis said.

For years, rural health advocates looking to bridge the gap between rural populations and the hubs of medical resources in urban and suburban areas have focused on the expansion of telemedicine, which allows patients to connect with health care providers and specialists through an Internet platform like Skype. Supporters say telemedicine encourages people to seek care and follow-up consultations they might otherwise neglect.

But much of the campaign for improved rural health centers around efforts to recruit and retain health care providers to practice in rural communities.

The workforce shortage in rural areas is the biggest barrier to care, said Michelle Clark, executive director of the Maryland Rural Health Association. She said she expects the issue to “bubble up to the forefront” soon with the implementation of the Affordable Care Act.

“We know the people who had insurance before we expanded our insurance pool couldn’t [easily] find access to care,” she said. “Now you have a greater number of insured who are going to be looking to access the health care delivery system for the first time.”

Rural health experts have been pushing to expand programs that offer incentives to providers to practice in underserved areas.

They say incentive programs are critical because of the level of debt that students emerge from medical school with — roughly $160,000 on average, according to Dr. Milford Foxwell, associate dean for admissions at the University of Maryland School of Medicine.

In an effort to pull themselves out of debt as quickly as possible, many medical school graduates choose to practice in urban areas, which generally have better reimbursement rates. They are also drawn to fields other than primary care, which tends to pay less than certain subspecialty areas.

In Maryland, the Loan Assistance Repayment Program awards up to $30,000 to graduates who agree to practice in underserved areas.

But rural health advocates say the reach of that program and others like it is limited by the federal standards that determine which areas qualify as rural.

Jake Frego, executive director of the Eastern Shore Area Health Education Center, said national data shows that about half of all physicians choose to practice within a 50-mile radius of where they do their residency.

“So out of the pool of docs who … graduate to residency, automatically about 50 percent we lose because of [the] absence of a residency program,” Frego said.

Palakanis said the interns that come to work for her in Crisfield learn very quickly about the challenges of rural health. But Palakanis sees the rewards in that.

“I find the population to be interesting, and always a challenge,” she said with a laugh.

“You have to learn to do a lot with little.”

Life Expectancy at Birth, by County, 2012

Montgomery County 84.1

Howard County 82.3

Talbot County 81.0

Frederick County 80.9

Kent County 80.3

Anne Arundel County 79.8

Carroll County 79.8

Saint Mary’s County 79.6

Calvert County 79.4

Queen Anne’s County 79.4

Harford County 79.3

Baltimore County 79.2

Prince George’s County 79.2

Worcester County 79.1

Garrett County 78.7

Charles County 78.6

Washington County 78.4

Dorchester County 78.1

Allegany County 78.0

Wicomico County 78.0

Somerset County 77.4

Cecil County 77.0

Caroline County 76.9

Baltimore City

Maryland statewide 73.9

79.5

-Counties in bold are federally designated as rural

-Source: Maryland Vital Statistics Annual Report, 2012

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