April 12, 2024

Where going to the doctor is a day trip and how the state helps

This story is part of The Salt Lake Tribune’s ongoing commitment to finding solutions to Utah’s biggest challenges through the work of the Innovation Lab. [Subscribe to our newsletter here]

For Darlene Nelson, going to the doctor is an all-day affair.

Nelson’s drive from Moab to Price and back takes nearly two hours each way and visits three counties. The appointment itself takes about an hour.

“It’s always a day out,” Nelson said. “If you live in the countryside, you kind of get used to it.”

Utah’s rural counties generally have fewer than one doctor per 1,000 residents, and some have none at all.

Those numbers improve somewhat when you add osteopathic physicians, physician assistants and advanced practice nurses, but nearly all of Utah’s rural counties have a shortage of health care providers.

That makes it less likely that people will go to the doctor for routine care, said Brady Bradford, health officer for the Southeast Utah Health Department.

“We end up with people who are not as willing and able to visit a doctor for a physical exam, a checkup to get symptoms if it’s early,” Bradford said.

By the time they get to a doctor, they are dealing with emergencies and later stages of illness, he said.

Danielle Pendergrass, who founded Eastern Utah Women’s Health in Price a little more than a decade ago, said there was a high rate of breast cancer among her patients because women weren’t getting mammograms.

Pendergrass — a board-certified, doctorate-prepared women’s nurse originally from Carbon County — also saw a “huge gap in contraceptive care,” along with undiagnosed diabetes, hypertension, smoking and substance use disorders .

The problem isn’t unique to Utah, says Marc Watterson, or even to rural areas. Watterson, who heads the state’s Office of Primary Care and Rural Health, said there is a nationwide shortage of doctors.

According to the U.S. Health Resources and Services Administration, all but five of Utah’s 29 counties have a geographic shortage of primary care physicians for at least part of the county.

Bradford emphasized that physicians practicing in rural Utah are “dealing with a lot of issues and doing a very good job dealing with them.”

But a lack of access to health care does lead to worse outcomes, he said.

Utah has several grants and programs that work together to attract more providers to rural areas and the state as a whole, Watterson said, and they help in rural communities.

(Trent Nelson | The Salt Lake Tribune) The City of Price on Wednesday, March 13, 2024.

In 2021, the number of physicians and advanced practice nurses per 1,000 residents ranged from none in Piute County to 8.8 in Summit County, and averaged three providers for 1,000 residents, based on data from the U.S. Health Resources and Services Administration.

For Nelson and others, that means driving hours to even see a doctor.

Pendergrass has patients who drive about 2.5 hours to see her.

Gina Gagon, who helped her husband run his medical practice in Price for more than 20 years, said there are people who drive from Roosevelt, Vernal, St. George and Mesquite, Nev.

Many of those patients lived in the area when they established care at Gagon Family Medicine, Gagon said — and continued to come after they moved elsewhere. (The practice also has a clinic in Huntington, in neighboring Emery County.)

Because of that long drive, Shlisa Hughes says, people often don’t get medical care. Hughes, who lives in Green River and works for the Association for Utah Community Health, said that applies even to her.

“It’s hard to take an extra day to go riding,” she said.

From her home it is a three-hour journey to get a mammogram: an hour to the nearest facility that can do one, an hour for the appointment and an hour home.

Green River Medical Center is the only medical facility near Hughes’ home, and she said the nearest one is more than 60 miles away.

Emery County, where Green River is located, had seven mid-level physicians and health care providers in 2021, according to federal data.

That’s 0.7 providers per 1,000 residents, the lowest rate other than Piute County, which has no providers.

Emery County is one of 18 counties in Utah that are below the state average of three providers per 1,000 residents. Most of the counties below that average are rural, although some have smaller cities and two – Iron and Wasatch – are considered metropolitan because they have at least one city with a population of 50,000 or more.

Only two rural counties have more providers per 1,000 residents than the state average.

Even if a county has service providers, it can take some time to get an appointment.

Nelson said even if you’re sick, it can take six weeks to get an appointment — and you’ll “rarely” see your provider unless you schedule it in advance.

Pendergrass, who has been seeing Nelson for more than a decade, is an exception.

Nelson said the Price doctor will “do her very best” to accommodate her and will pick her up the next day if necessary.

Gagon said the family’s clinic has done things to help reduce the long wait times, including hiring a second doctor. Currently, there is a three-week wait before care can be provided by a physician, she said, but someone can see a nurse practitioner the same day.

“We’ve tried to be proactive for our particular practice,” she said, adding that their private practice allows them to be more nimble than clinics that are part of a health care system.

While providers are rare, specialists are rarer.

Based on federal data, 11 Utah counties had no specialists in 2021, and the highest rate of any county was 1.6 specialists per 1,000 residents.

Only two counties – Salt Lake and Summit – had more than one specialist per 1,000 residents in 2021.

Nelson said seeing a specialist has always been more challenging.

When she was diagnosed with breast cancer, it took weeks, she said, because she had to wait two weeks for someone to read a mammogram, then another week for the biopsy, and a week for someone to read the biopsy. Five or six weeks passed between her mammogram and her diagnosis, she said, but that was just the process.

General providers have expertise, Gagon said, but it doesn’t work out. Once patients need to see a specialist such as a neurologist or urologist, that could take six months, she said.

Increasing the number of providers in rural Utah is not easy.

“It’s very difficult to recruit doctors in rural areas,” says Gagon. The second doctor Gagon Family Medicine hired rotated with the practice as a medical student, she said.

Utah is doing things to help, Watterson said, such as using state and federal funds for various grants and programs.

Much of the funding will go toward loan repayments, he said, which helps rural hospitals and clinics recruit because providers can get help paying off their student loans for each year they live and work in rural areas .

Hospitals sometimes offer matching funds, Watterson said, and “everyone has a piece in the game” to try to bring more medical providers to rural areas.

The state is also working with the U.S. Department of State through a visa program that allows people who were not born in the United States but trained here to continue working in the country, he said.

Those people with a J-1 visa waiver are typically specialists, Watterson said, and the state works with those visa applicants to fill gaps in coverage.

Another subsidy will help cover costs as providers care for underinsured and uninsured patients, he said, specifically to bridge the gap between those payments and what private insurance would reimburse them.

It’s sometimes harder for rural hospitals and clinics to keep things together financially because they see so many patients who are on Medicaid or Medicare or who are uninsured, he said, and that helps offset some costs.

Watterson compared the state programs to a band. ‘You have different instruments playing. There are a few that might be on at different times so you can actually see them playing,” he said. “If one or two are missing, it just doesn’t sound quite right.”

Telehealth — the ability for patients to see providers virtually — can help, Watterson said, but it only solves part of the problem because there are a “finite number of providers.”

There is a lot of pressure to get more people to choose medicine as a career, he said, and state lawmakers have given more money to graduate programs in medical education and removed potential barriers to licensure.

Pendergrass said she would also like to see policies to address transportation, fair compensation for telehealth, broadband access and affordable health insurance.

Transportation is a big problem, Gagon said, because there is no public transportation in rural Utah. Some patients will call an ambulance and go to the emergency room, she said, because that is their only way to get to a health care provider.

Policy should support the efforts doctors are making in rural areas, Pendergrass said, such as using telehealth and nurses to fill gaps.

“I can make this dream of unicorns and rainbows come true, but if we don’t have policies to support that, it’s harder,” she said.

Bradford, the health officer for the Southeast Utah Health Department, said his agency is trying to counter the effects of the shortage in a different way — by emphasizing preventive care. The department includes Emery, Carbon and Grand counties, which rank in the bottom half of Utah counties for health outcomes.

“For our part, we believe that it is much more important that we have an impact in the field of public health and in the field of prevention,” he said.

The department, Bradford said, emphasizes healthy behaviors such as eating well, eating with family, getting outside and exercising, and going to the doctor for checkups.

The department believes these efforts will help “reduce the burden placed on our acute health care system,” he said, and improve health outcomes.

There are risks associated with living in rural Utah, Bradford said, including less access to health care — but there are also “tremendous benefits.”

No one in rural Utah is hanging their heads about the health outcomes, he said. Instead, they work together to find a better solution.

Megan Banta is The Salt Lake Tribune’s data enterprise reporter, a philanthropically supported position. The Tribune retains control over all editorial decisions.

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