Ricardo Nimo (RPSM Internal Medicine 1998): Working in Rural Mississippi
What is it that social medicine doctors do? Here is one answer from RPSM Internal Medicine graduate Dr. Ricardo Nimo:
After RPSM in the Bronx, as a foreign graduate from Uruguay, I decided to come to Mississippi as part of a waiver program in order to change my legal status in the US. Mississippi was a challenge from the start at a personal level, as an individual, and as a physician. I came to Centreville Mississippi and took over the only internal medicine practice, working along with a general surgeon (whose father, also a surgeon; is a local legend here in Mississippi and was then still practicing). Centreville is a town of 1800 with a small rural community hospital with 30 beds, an ER, PT/OT, US, CT and Nuclear Medicine Scans, among other services.
Our practice has grown from 2000 visits per year to close to 10,000. I have a roughly 50/50 mixture of outpatient primary care and inpatient practice. Six of physicians staff the ER year long. The surgeon and I receive medical students from Tulane University in New Orleans, and I have a faculty appointment with the Community Medicine Department at Tulane as an Associate Clinical Professor. I also deliver care in nursing home settings. I am medical director of the local nursing home with 80 patients. For 2 years I worked in correctional medicine at a private facility about 20 miles away with 1000 inmates. I have been involved with CME activities as well as strategic planning and policy analysis regionally and with the National Rural Health Association. Currently I am chief of staff for our hospital. Maybe I can regret not having developed any meaningful relationship with the only academic tertiary care center in MS: the University Medical Center in Jackson. This is probably a consequence of the 120 miles of distance; I am available full time over 95% of the time here locally. Also (and this is more of a personal opinion) UMC is completely disconnected from rural medicine and providers in spite of being the main academic player in a rural state. In other words, UMC functions within the academic walls of UMC in “big city” Jackson, MS. It trains MDs who have a completely different conception of medicine from the actual reality of the state.
Our hospital serves a rural community of 30,000 who live in 2 counties with Centreville located in the middle. We are in the southwest corner of MS; right on the border with Louisiana, about 50 miles from Baton Rouge and 120 miles from Jackson. It’s a place in the middle of nowhere. Although we are close to urban areas and small towns, it is still definitely rural and under-served. Most people work in Louisiana, The hospital is the second largest employer. The first is a Georgia Pacific paper mill. Agriculture, logging and timber are also dominant activities. People are generally employed in jobs with little or no benefits or don’t work as a consequence of a semi-voluntary time & generational habit. Large segments of this population are uninsured or carry policies that are of little use (i.e. a logger with a $20,000/year salary and a family of 6, whose Blue Cross policy carries a $5,ooo deductible); among active patients, dual eligibility (Medicare & Medicaid ) are predominant; sole Medicaid is a 20-30%; commercial carriers I would think less than 20%. I am speaking here of active patients. Keep in mind that the the largest group, the uninsured, don’t come to see us unless mayor crisis happens. Years ago somebody defined this community to me as one characterized by work, family, church and Friday night ball games; my personal addition is ” let’s eat something fried ” (not necessarily chicken).
Predominant problems are the usual suspects: They include obesity (Misssissippi has the highest rate in US); hypertension (unique and very difficult to treat among blacks here in the South), diabetes, coronary artery disease (also different here in the South). There is also a large amount of alcohol and drug use, but virtually no organized system to deal with substance abuse. Mental illness is common but there is a complete absence of psychiatric care in rural areas. In the year 2008 patients are still held in jail while awaiting placement after commitment. This is a whole other story. HIV disease is highly stigmatized and patients travel long distances to receive care - when they decide or can afford to do so - in order to maintain anonymity. And there is trauma of all sorts. Other characteristics of the community include a high rate of illiteracy, very low educational standards at the school system (still divided into private & white on the one hand and public & black on the other). Lots of things in Mississippi still happen in black and white; no grays. Here is a second “I owe you” for me; I have failed completely to try to introduce health related educational activities at either school system. I’m not sure if it is because of “me or them.”
The health care system organization has changed in recent years. Four original free-standing and private clinics have evolved into 3 hospital run clinics with physicians employed by Field Memorial Community Hospital (now known as Hospital & Clinics). They are staffed by one surgeon, 2 internists, 3 FPs and a GP (he’s the busiest one; his father was a nearby town sheriff; therefore part of his “allure”); 3 Nurse Practitioners; one per clinic. Having a CFNP allows the clinics to qualify for what is called “rural health denomination”; this is a cost-based reimbursement system which compensates for part of the uncompensated care we deliver. Collection rates are sometimes less than 50 % of billings. The Hospital take over of these clinics resulted from the 2002 malpractice insurance crisis. All of the MD’s lost our coverage when our former carrier left Mississippi because of the legal climate. We all became uninsurable, unless we were willing to pay six-figure rates for coverage. The solution? We all became employed by the hospital which is privately operated but county-owned. Thus, we all became state employees; and therefore qualified to have caps on our malpractice liability. In this way we were able to afford insurance. Six years later, things are more stable (or maybe we all got used to the situation). I still pay around $40,000/ year for malpractice insurance. Having shifted the administrative tasks to the hospital (which is a Critical Access Hospital and is also reimbursed based on a cost basis rate rather than DRGs ) has had a good impact on the practices and there is a mutual benefit for both parties. This has allowed us to both survive and continue serving patients locally. No physicians were lost to the malpractice insurance crisis of 2002 in this area.
Nonetheless; provider retention rate is low. Since 1999 I can think of 5 physicians and 4 CFNPs coming here; all others I have mentioned before were born and raised here. Only one of the nine remains: me. I am probably one of the few success stories of the J-1 waiver program which is meant to recruit providers to under-served rural areas. However, the vast majority leave after an initial commitment of 3-4 years. I had a 4 year contract and now I am on my 9th year and have no plans to leave. Somebody recently asked if I was planning to stay and my answer was that I was not planning to leave; staying is more complex and depends on other factors. There is such a delicate balance in a small rural practice that every so often there is a general sense of uncertainty. Having said that, I have probably survived a mayor crisis in our practice every year; so, again the “get used” factor at play is big. Our most current source of anxiety in Mississippi is the debate on a Medicaid tax for hospitals which has been proposed by the state legislature and Governor Haley Barbour. Governor Barbour has a long track record as a tobacco lobbyist in DC and has blocked efforts at taxing cigarettes as an alternative way to close the current 380 million deficit of the Medicaid program for this fiscal year. Small hospitals like ours are particularly threatened by this tax and by the loss of Medicaid dollars. They are a much need source of cash flow and are particularly useful by small institutions who get paid based on cost and disproportionate share formulas. You can imagine that it doesn’t really matter if Medicaid drops reimbursement or even if Medicare cuts MDs payments. Where are our patients going to go? Or, to look at the issue from the other side: who will be able to continue to see them?
Why stay? The easy answer includes a certain laziness. Start all over somewhere else ? After all these years here ? However, a less mentioned fact is that rural MDs are fairly well compensated and have lower operational and living costs. But they do have to work. It is not uncommon to have 80-90 hour weeks on average all year long. In the final analysis I don’t think I can live & practice anywhere else for now at least.
In my opinion primary care and internal medicine in a rural community are more challenging than in urban or suburban settings. There are far greater rewards at the personal level. You need a solid training background and constant updating. Delivering standard levels of care in tertiary care settings is easier and less challenging than taking care of patients in a small hospital or clinic in the middle of nowhere. Here resources are very often limited, but we still maintain a sense of standards of care. Furthermore, small rural community hospitals have a social and vital reason to survive and remain in business. They are needed locally. I will always be an outsider in Mississippi, and that is absolutely fine with me. It actually works to my advantage in helping to maintain my sanity and avoid burn out. But, still, for me the clinic and hospital is where my life is happening everyday for the last 9 years.
