Tag: Doctors

With Its Two Doctors Planning to Retire, an Alabama Town Patches Together Health Care Options

LaFAYETTE, Ala. — Charity Hodge had mixed feelings when she spotted a Facebook post announcing that her longtime primary care doctor was ready to retire after decades of serving their rural community.

“I was like, ‘Oh my gosh, no!’” Hodge recalled while sitting in an exam room on a July afternoon, waiting to see the physician, Terry Vester. “Well, I’m happy for the retirement part, but that’s my favorite doctor, so I’m crying on the inside.”

Hodge, a 29-year-old customer service representative, has been seeing Vester for nine years. She had come to check in on her diabetes management and to ask for anti-nausea medication in preparation for a cruise.

LaFayette — pronounced “luh-FAY-it” by most residents — and surrounding Chambers County face high rates of disease and chronic illness. Yet Terry Vester and her husband, Al, are the only primary care doctors in the town of 2,700 residents, surrounded by farms and other small communities.

The Vesters are in their late 60s and would like to retire soon. Terry Vester wants to spend more time with her grandson and aging parents. But she can’t imagine abandoning her patients, some of whom she has cared for since they were born.

“There are people here that still need in-town doctors,” said Vester, who sometimes visits patients in their homes. “So we want to stay here to take care of them until someone else is here to take care of them.”

Terry Vester’s worry — leaving her town with no doctors — is already reality across much of rural America, where many residents have health problems but few health care professionals to turn to.

LaFayette, in east-central Alabama near the border with Georgia, is a 30-minute drive to the nearest sizable city, the college town of Auburn. Its lush, wooded neighborhoods include elegant, restored homes with wraparound porches and massive lawns. But the town also has formerly grand houses that have fallen into disrepair, plus mobile homes and public housing.

The town’s median household income is much lower than the state’s and country’s. Black residents — who make up 70% of the population — are much more likely to live in poverty than white residents. They are also more likely to attend the public high school, whose student body is 90% Black and which is scheduled to close and consolidate with a majority-white school in another community.

The Vesters have worked in LaFayette since the early 1980s and saw the local hospital close in 1988. The nearest emergency room is now in another town 20 minutes away along a rolling road. So are the nearest urgent care clinic and pediatrician’s office.

To fill that void, residents turn to the one place in LaFayette where medical professionals are always on the clock: the city fire department, staffed with full-time firefighters and emergency medics.

A photo of a man standing in front of a fire engine.
LaFayette’s fire chief, Jim Doody, said that without an emergency room or urgent care clinic, residents regularly bring their health problems to the fire station. (Arielle Zionts/KFF Health News)
A photo of the interior of a fire station.
The LaFayette fire station’s makeshift exam area within its small entryway includes a bench, defibrillator machine, and cabinet filled with medical supplies. (Arielle Zionts/KFF Health News)

Fire Chief Jim Doody worked for 13 years as the fire chief at Bagram Airfield in Afghanistan. He arrived in LaFayette in 2020, just as the county was about to be hit by one of the worst covid-19 outbreaks in Alabama.

Doody said most of the station’s ambulance runs are for nonemergency situations. Other calls involve urgent issues that could have been headed off if patients had better access to preventive care.

People from LaFayette regularly walk or drive themselves to the fire station to ask for help, Doody said. The station has a makeshift exam area within its small entryway, containing a bench, defibrillator machine, and cabinet filled with medical supplies.

Firefighter Tanner Hill said people often arrive with concerns about fatigue, blood sugar levels, breathing difficulties, or heart trouble. He recalled helping a man who walked into the station after getting hit by a car.

“He was just like, ‘Hey, I just got run over.’ And I was like, ‘Oh, OK, well, let me check you out.’ And sure enough, he got run over,” Hill said.

Hill determined the man’s leg was broken and sent him by ambulance to the nearest hospital.

This de facto walk-in clinic option isn’t available in most other rural areas, where emergency medical services are often run by volunteers who aren’t posted at a station all day, Doody said. But he’s noticed fewer LaFayette residents relying on the fire department since a new telehealth service arrived in town.

Rickey Whitlow was recently driving in LaFayette when he saw a sign touting the new option.

The 61-year-old was intrigued. He parked his car and walked into a new health center that also houses an OnMed Care Station, a large booth stocked with a video screen and high-tech health monitoring equipment.

Whitlow was scheduled for his monthly diabetes checkup with physician Al Vester in a few weeks. But his feet felt like they were burning, and he needed relief now.

Whitlow stepped into the telehealth kiosk, pressed a button, and saw a nurse practitioner appear on a large vertical video screen positioned at eye level. After consulting with the provider, he left the free appointment with a prescription for a cream to relieve his foot pain.

A photo of the outside of a telehealth booth.
OnMed, a private company, is opening high-tech telehealth booths in rural towns across the country. (Arielle Zionts/KFF Health News)
A photo of a medical worker appearing on a large screen via video call.
Patients using OnMed booths are greeted by remote providers who appear on large, vertical video screens. (Arielle Zionts/KFF Health News)

OnMed patients use an automated blood pressure cuff and other devices to collect their vital signs, and the data is sent to the provider treating them from a distance. Patients can also hold a stethoscope to their chest to transmit the sounds of their heart and lungs. A special camera captures internal temperatures, which can be used to diagnose infections. A hand-held camera lets providers examine problems such as rashes, irritated eyes, and swollen throats. In some states, the stations can dispense medications.

OnMed, a Florida-based company, has another kiosk in rural Texas and hopes to open several dozen more in various states next year. The company wants to keep its services free for patients, with funding from universities, health systems, nonprofits, and insurance companies.

The kiosks can stay open on evenings and weekends and are much cheaper to operate than brick-and-mortar doctor’s offices, said CEO Tom Vanderheyden. They also make telehealth available to rural residents whose home internet connections are too weak for video appointments.

LaFayette’s OnMed kiosk is part of a new health center inside a building that has seen several medical facilities come and go.

The Chambers County Community Health and Wellness Center is operated by Auburn University, whose students and faculty travel there to host vaccination and diagnostic clinics, such as speech and hearing exams. They also offer health education events on topics such as healthy eating and maternal health.

The university plans to bring similar centers and OnMed kiosks to other rural Alabama towns.

Vester, the longtime primary care physician, is excited about the new health care resources in LaFayette. But she said it’s still important to have doctors in town.

“You know everyone, or you have a connection with someone,” Vester said.

Vester’s statement rang true during recent appointments as she asked about her patients’ lives and relatives.

“Deep breath,” Vester instructed as she placed a stethoscope on Hodge’s chest.  “Are you still at home with your mother? Is she doing good?”

“Yes, she’s doing very well,” Hodge said.

Earlier that day, Vester treated a patient who had throat pain and difficultly speaking after surviving a choking incident. During the appointment, the patient mentioned an upcoming funeral.

A photo of a doctor examining a patient's throat.
Terry Vester examines the throat of Joann Calloway, who recently survived a choking incident, at Vester’s clinic in LaFayette, Alabama.(Arielle Zionts/KFF Health News)

Vester knew about the funeral. It was for a woman she once treated.

“I see her daughters and then their children, and they have children — so that’s four generations right there,” Vester said. “And so, you sort of know the whole story, you know the context.”

Vester plans to reach out to Alabama medical schools to let them know she’s looking for doctors to take over for her and her husband. But she said not everyone wants to live in rural areas like LaFayette.

The doctor hopes some of the Auburn students will want to serve in LaFayette after seeing what it’s like working at the new health center. She said it’s nice to live in a small, quiet town that’s relatively close to larger cities, and to run an independent clinic rather than work for a larger health system.

Vester said the charm of LaFayette and its residents is also a selling point.

“All they have to do is pretty much come here and spend a day and go through what we do, and I think they would enjoy it,” she said.

As More Patients Email Doctors, Health Systems Start Charging Fees

Meg Bakewell, who has cancer and cancer-related heart disease, sometimes emails her primary care physician, oncologist, and cardiologist asking them for medical advice when she experiences urgent symptoms such as pain or shortness of breath.

But she was a little surprised when, for the first time, she got a bill — a $13 copay — for an emailed consultation she had with her primary care doctor at University of Michigan Health. The health system had begun charging in 2020 for “e-visits” through its MyChart portal. Even though her out-of-pocket cost on the $37 charge was small, now she’s worried about how much she’ll have to pay for future e-visits, which help her decide whether she needs to see one of her doctors in person. Her standard copay for an office visit is $25.

“If I send a message to all three doctors, that could be three copays, or $75,” said Bakewell, a University of Michigan teaching consultant who lives in Ypsilanti, Michigan, and is on long-term disability leave. “It’s the vagueness of the whole thing. You don’t know if you’ll get into a copay or not. It just makes me hesitate.”

Spurred by the sharp rise in email messaging during the covid pandemic, a growing number of health systems around the country have started charging patients when physicians and other clinicians send replies to their messages. Health systems that have adopted billing for some e-visits include a number of the nation’s premier medical institutions: Cleveland Clinic, Mayo Clinic, San Francisco-based UCSF Health, Vanderbilt Health, St. Louis-based BJC HealthCare, Chicago-based Northwestern Medicine, and the U.S. Department of Veterans Affairs.

Billing for e-visits, however, raises knotty questions about the balance between fairly compensating providers for their time and enhancing patients’ access to care. Physicians and patient advocates fret particularly about the potential financial impact on lower-income people and those whose health conditions make it hard for them to see providers in person or talk to them on the phone or through video.

A large part of the motivation for the billing is to reduce the messaging. Soon after the pandemic hit, health systems saw a 50% increase in emails from patients, with primary care physicians facing the biggest burden, said A Jay Holmgren, an assistant professor of health informatics at UCSF, the University of California-San Francisco. System executives sought to compensate doctors and other providers for the extensive time they were spending answering emails, while prodding patients to think more carefully about whether an in-person visit might be more appropriate than a lengthy message.

After UCSF started charging in November 2021, the rate of patient messaging dipped slightly, by about 2%, Holmgren and his colleagues found.

Like UCSF, many other health systems now charge fees when doctors or other clinicians respond to patient messages that take five minutes or more of the provider’s time over a seven-day period and require medical expertise. They use three billing codes for e-visits, implemented in 2020 by the federal Centers for Medicare & Medicaid Services.

E-visits that are eligible for billing include those relating to changes in medication, new symptoms, changes or checkups related to a long-term condition, and requests to complete medical forms. There’s no charge for messages about appointment scheduling, prescription refills, or other routine matters that don’t require medical expertise.

So far, UCSF patients are being billed for only 2% to 3% of eligible e-visits, at least partly because it takes clinicians extra time and effort to figure out whether an email encounter qualifies for billing, Holmgren said.

At Cleveland Clinic, only 1.8% of eligible email visits are being billed to patients, said Eric Boose, the system’s associate chief medical information officer. There are three billing rates based on the time the clinician takes to prepare the message — five to 10 minutes, 11 to 20 minutes, and 21 minutes or more. He said patients haven’t complained about the new billing policy, which started last November, and that they’ve become “a little smarter and more succinct” in their messages, rather than sending multiple messages a week.

The doctors at Cleveland Clinic, like those at most health systems that bill for e-visits, don’t personally pocket the payments. Instead, they get productivity credits, which theoretically enables them to reduce their hours seeing patients in the office.

“Most of our physicians said it’s about time we’re getting compensated for our time in messaging,” Boose said. “We’re hoping this helps them feel less stressed and burned out, and that they can get home to their families earlier.”

“It’s been a frustration for many physicians for many years that we weren’t reimbursed for our ‘pajama-time’ work,” said Sterling Ransone, the chair of the American Academy of Family Physicians’ Board of Directors. Ransone’s employer, Riverside Health System in Virginia, started billing for e-visits in 2020. “We do it because it’s the right thing for patients. But rarely do you see other professions do all this online work for free,” he said.

“We see physicians working two to four hours every evening on their patient emails after their shift is over, and that’s not sustainable,” said CT Lin, the chief medical information officer at University of Colorado Health, which has not yet adopted billing for email visits. “But we worry that patients with complex disease will stop messaging us entirely because of this copay risk.”

Many health care professionals share the fear that billing for messages will adversely affect medically and socially vulnerable patients. Even a relatively small copay could discourage patients from emailing their clinicians for medical advice in appropriate situations, said Caitlin Donovan, a senior director at the National Patient Advocate Foundation, citing studies showing the dramatic negative impact of copays on medication adherence.

Holmgren said that while patients with minor acute conditions may not mind paying for an email visit rather than coming into the office, the new billing policies could dissuade patients with serious chronic conditions from messaging their doctors. “We don’t know who is negatively affected,” he said. “Are we discouraging high-value messages that produce a lot of health gains? That is a serious concern.”

Due to this worry, Lin said, University of Colorado Health is experimenting with an alternative way of easing the time burden of e-visits on physicians. Working with Epic, the dominant electronic health record vendor, it will have an artificial intelligence chatbot draft email replies to patient messages. The chatbot’s draft message will then be edited by the provider. Several other health systems are already using the tool.

There also are questions about price transparency — whether patients can know when and how much they’ll have to pay for an email visit, especially since much depends on their health plan’s deductibles and copays.

While Medicare, Medicaid, and most private health plans cover email visits, not all do, experts say. Coverage may depend on the contract between a health system and an insurer. Ransone said Elevance Health, a Blue Cross Blue Shield carrier, recently told his health system it would no longer pay for email or telephonic visits in its commercial or Medicaid plans in Virginia. An Elevance spokesperson declined to comment.

Another price concern is that patients who are uninsured or have high-deductible plans may face the full cost of an email visit, which could run as high as $160.

At University of Michigan Health, where Bakewell receives her care, patients receive a portal alert prior to sending a message that there may be a charge; they must click a box indicating they understand, said spokesperson Mary Masson.

But Donovan said that leaves a lot of room for uncertainty. “How is the patient supposed to know whether something will take five minutes?” Donovan said. “And knowing what you’ll be charged is impossible because of health plan design. Just saying patients could be charged is not providing transparency.”