FROM DESERT TO OASIS Improving Health Care Access in Arkansas

By John Callahan

n some ways, Arkansas punches far above its weight in terms of health care, with institutions standing at the forefront of research and at times performing some of the most advanced treatments in the world. Despite this impressive record, The Natural State consistently ranks among the lowest in the nation for health care; US News & World Report ranks Arkansas at No. 45. While high-quality health care exists in the state, one of the main challenges faced by Arkansans is a lack of access to that care. Areas where sufficient care is inaccessible are known as medical or health care deserts.

A health care desert can stem from various root causes. Rural areas, which are home to 41 percent of Arkansas’ population, may lack enough doctors or the economic foundation to keep a hospital running. Alternatively, deserts can exist in urban areas where infrastructure is lacking, as in the case of hospitals with too few beds to support the size of the population. But the rural makeup of Arkansas makes the former causes more prevalent.

“We have 75 counties and about 24 of them, so close to a third, do not have a hospital within their boundaries,” said Shashank Kraleti, M.D., chair of the Family Medicine Department at the University of Arkansas for Medical Sciences (UAMS). “An additional 50 percent that do have hospitals have less than 100 beds. Close to 25 percent of counties do not have good access to primary care, and close to 40 percent do not have access to good pharmacies and medications.”

The consequences of this lack of medical care are dangerous on their own, but they often combine with other factors found in rural areas – an aging population, poverty, insufficient health education – to create a perfect storm that contributes to one of the nation’s lowest life expectancies and its highest rate of maternal mortality.

“People who live in a rural area and don’t have access to health care have a higher incidence of obesity, a lower overall life expectancy, more cardiovascular disease, more diabetes, all of those problems that could have been prevented if they had been seeing [a doctor] all along,” said Dr. Sherry Turner, associate dean of graduate medical education at Arkansas Colleges of Health Education (ACHE) in Fort Smith.

“Every-

where has those problems; they’re just compounded when you don’t have the opportunity to see that doctor. You aren’t going early enough when you start having symptoms, because you don’t have the time or the money to travel two hours to go see someone and get home.”

The first step to solving the issue of health care deserts is to figure out what medical care people really need. In a perfect world, every county would have a facility with doctors capable of performing heart surgery, but this is neither practical nor necessary.

For Baptist Health President and CEO Troy Wells, part of the problem is defining what constitutes a health care desert. “What are the expectations for health care access? Is it in your town, in the county, down the road, an hour by car and two by boat? What does that mean, to have access?” effects of a health care desert, and Arkansas is lucky compared to some neighboring states in that it has not experienced a great deal of rural hospital closures. Thanks in large part to an expansion of the Medicaid program, many rural communities have been able to keep their hospitals open. If just a few of these hospitals did close, they would leave serious gaps in coverage.

Wells identified three types of care as basic necessities that all people should have within a reasonable distance: primary, emergency and maternal. A drive of an hour or more may well be too late to help in the case of a serious medical emergency or unexpected labor and can discourage people from seeking preventative or prenatal care in the first place.

While hospitals do exist in rural areas, they often lack enough personnel to cover the needs of the population. A rural hospital may, for example, have only one OB-GYN. Should that doctor retire, the hospital can no longer provide meaningful maternal care and will struggle to find a replacement, as few new doctors choose to move to rural areas.

Wells said having a hospital within an hour can lessen the Sherry Turner

Providing quality care at consistent levels across Arkansas’ rural areas will be neither quick nor easy, but there are a number of short-term solutions that can help provide access while more permanent solutions are put in place, providers say.

One such solution is telehealth, which arose out of necessity during the pandemic but has since proven to be a convenient way to provide medical care. Though there is only so much a provider can do over the phone, telehealth has the benefit of reaching anywhere with a cell signal or landline.

UAMS, meanwhile, has been investing in more direct approaches. If a patient can’t come to the clinic, UAMS will bring the clinic to the patient.

“We have four mobile health units that we started this year,” Kraleti said. “They will be going to these health care deserts and recruiting patients, bringing them into the health care system, providing access, immunizations and screenings, primarily reducing preventable illness and death. We also are working on an omni-channel approach of providing care, which means that we are not restricted to patients coming into the clinic. With our house calls program, we now offer a hospital-at-home program where patients don’t need to be admitted to the hospital, but we actually take care of them in their home, which has shown to lead to better outcomes.”

In the longer term, perhaps the most crucial factor in ending health care deserts is the training of doctors, nurses and other professionals who can provide the care that is missing across much of the state. Numerous efforts are being made across Arkansas to this end; indeed, the primary mission of ACHE is to provide physicians to rural areas.

The lack of doctors in rural areas, Turner explained, “stems from the way we train our medical professionals, our students and our residents. When students come through, [they may never be] exposed to the option of a rural practice. Rural practice is very different from urban practice. When you’re out there by yourself, you have to have a broader depth of knowledge of multiple things. Rural doctors do a lot of things themselves. They don’t refer patients to a specialist; they manage those things. And it can range from behavioral health to surgical problems, and they still treat that spectrum of patients.”

Historically, the majority of residency programs has been in urban centers around large medical institutions. Osteopathic professions have, by and large, been an exception to that rule, and as osteopathic medicine has begun to gain wider acceptance, more residency programs have been moved into rural areas. Multiple national studies have shown that physicians are most likely to practice near where they were trained — doctors who attend medical school in Arkansas have roughly a 50 percent chance of remaining in the state, and there is a nearly 74 percent chance that they will stay within 50 miles of where they complete their residency.

At ACHE, most students receive at least some of their training in rural settings, with some training entirely in rural hospitals. Thus far, 75 percent or more of ACHE’s students have gone into primary care, which is the most urgently needed specialty in health care deserts. Since ACHE is a young institution, graduating its first class in 2021, more time is needed to collect data on how successful these programs have been. But the results are promising so far.

ACHE is hardly the only organization invested in rural residencies — UAMS has begun a residency program in Berryville, with two more to be developed in Crossett and El Dorado with plans to expand further. UAMS has also partnered with Baptist Health and other medical institutions to support and expand resi- dencies across the state.

Another educational institution, the New York Institute of Technology College of Osteopathic Medicine, which has a location at Arkansas State University, has also been investing heavily into this model.

“Before we opened our doors, we knew we’d need to help create places in Arkansas for our graduates to go for residency if we wanted them to stay in the state, which is a huge part of our mission,” said Casey Pearce, the institute’s director of external relations and marketing. “In 2015, a year before we opened, we received a $250,000 grant from Arkansas Blue Cross Blue Shield that we used to do things like host ‘GME Readiness’ [Graduate Medical Education] events to educate health care leaders on the process of creating residencies, to send potential program directors to necessary training and to have a consultant show hospitals the financials associated with starting programs.”

That program, in cooperation with others around the state, has seen significant results. According to Pearce, prior to 2015, Arkansas had only one internal medicine residency program with just 16 annual positions. That has since become 10 with 93 positions. The number of family medicine residency programs has also doubled from seven with 57 positions to 14 with 99. In just seven years, NYIT has seen numerous graduates sign contracts to practice in places like Wynne, Piggott, Mena, Manila and Dardanelle after their residencies.

“The problem is that you can’t just do it in three years and fix the problem,” Wells said. “It’s going to take decades of work to change that physician dynamic. Keep in mind, we’re retiring doctors as fast as we’re making doctors, so we’re also fighting that demographic shift in the United States.”

Kraleti, Turner and Wells agree that solving the problem of health care deserts will require collaboration between health systems and educational institutes across the state; no one organization can tackle the issue alone. And as Turner explained, there’s more to it than just putting a doc- tor in a small town. Proper health care requires dentists, nurses, physical therapists, pharmacists and the transportation to reach them, all of which needs to be built into a community.

Legislation is yet another long-term solution that will be crucial to any concerted attempt to expand health care access.

“Congress has not been very interested in giving money to hospitals to train more physicians, so we keep working on that,” Wells said. “We have a really good delegation in Arkansas that has been supportive of expanding graduate medical education, but we need more people across the country willing to put money into that, so we can continue to train physicians from all parts of the country.”

As they did with Medicare expansion, rural hospitals may find themselves relying on legislation to provide a solid financial foundation. Between sparse populations, poverty and the rising costs of health care, making enough money to stay open is a struggle for many rural hospitals. Programs like Medicare make it possible for more people to receive care while providing hospitals with an essential payer source. Yet, according to Wells, Arkansas also has among the lowest levels of reimbursement from Medicare of any state.

“Trying to pay for a labor and delivery service in a community that only delivers 500 babies is not economically very sound. So, it takes the resources of a health system that takes funding from somewhere to make all this happen, to provide mental health care, to invest in technology for telehealth across the state. All of that takes money, and when you’re funded at a rate less than most others around the United States, it makes it really hard to provide all of those things.”

Turning a desert into an oasis is never an easy task, but it can be done, Arkansas medical leaders said. It will take time and collaboration, but Arkansas has the potential to turn things around and provide for the health of its citizens.