As medical director of the Barrier Islands Free Medical Clinic in Johns Island, South Carolina, Richard Ulmer, MD., knows the challenges patients in rural areas face when it comes to receiving appropriate medical care and accessing physician specialists.
The clinic, which opened its doors in 2008, serves uninsured adults living at or below 200% of the Federal Poverty level who live or work in Johns, James and Wadmalaw Island or Folly Beach. This past June, the clinic was selected to participate in the national MAVEN (Medical Alumni Volunteer Expert Network) Project Initiative that connects volunteer physicians to underserved clinics using telehealth technology.
“Although we have access to some internal referrals for specialists, our partnership with MAVEN allows us to expand our expertise,” Ulmer says. “We think MAVEN can help us streamline our specialty referrals and offer greater access to our uninsured patients.”
Launched in 2014 by Laurie Green, MD, a San Francisco obstetrician-gynecologist, the MAVEN Project links retired rheumatologists and other specialists to clinics and organizations in underserved and rural communities in nine states: California, Florida, Massachusetts, New York, Pennsylvania, South Carolina, South Dakota, Virginia, and Washington.
“Approximately half of U.S. health centers serve patients who live in low-income or rural areas where they often have to travel several hours or wait a number of months to see a specialist,” says Green, who got the idea for MAVEN while serving as president of the Harvard Medical School Alumni Association in 2013.
“As I spoke with doctors, I kept hearing how many who were nearing retirement age wanted to stay active in the medical world, but couldn’t find a place to lend their expertise,” Green says. “I remember thinking how great it would be to link these qualified physicians with patients who have little or no access to medical care and insurance.”
While the entire country is currently facing a physician shortage, Green says the lack of qualified physician specialists is expected to become worse in the years to come and to hit rural areas the hardest. A 2016 physician workforce report released last April by the Association of American Medical Colleges (AAMC), found the U.S. will experience a significant physician shortage over the next decade. By 2025, the study estimates a shortfall of between 14,900 and 35,600 primary care physicians and a shortfall of between 37,400 and 60,300 physician specialists.
In addition, some rural areas are also affected by a lack of hospitals. According to a report from the U.S. Government Accountability Office, about a dozen rural hospitals shut down every year, and more than three-quarters of recent closures have occurred in the South.
A Unique Model of Care
“Community health clinics are often faced with conditions beyond the scope of practice of the primary care providers that are staffing the clinics,” Green says. “Specialists who treat these conditions are in short supply and often inaccessible, not just for rural, but also for inner city and uninsured patients.”
By linking their network of volunteer physicians with federally qualified health centers and public health centers, MAVEN doctors can mentor, educate and advise primary care providers in a variety of ways.
At the Barrier Islands Free Medical Clinic, Ulmer says the clinic’s 40 volunteer physicians have attended “Lunch and Learn” telehealth presentations led by a MAVEN physician.
“We have many patients who are diabetic, overweight, and have been diagnosed with chronic lung disease,” Ulmer says. “It’s important for our doctors to be familiar with the most up-to-date medical treatments.”
Charles Schulman, MD, a cardiologist in Chelsea, Mass., who still practices medicine, recently provided a group consult to physicians at the Barrier Islands Free Clinic.
“We discussed patients with cholesterol disorders and the treatment approach, given the new guidelines released by the American College of Cardiology and American Heart Association last year,” Schulman says. “I believe that having MAVEN physicians provide specialty consultations assists providers in caring for their patients, and allows for much faster access to specialty opinions. “
Deborah Brigell, MD, an endocrinologist in Boston, Mass., has consulted with the Barrier Islands Clinic primarily on diabetes, thyroid, osteoporosis and low testosterone.
Brigell, who is semi-retired finds it satisfying to lend her expertise to support community clinic providers and help patients who might not otherwise have access to a specialist.
“By providing specialty guidance to community clinic providers, they can more confidently manage their patients,” Brigell says. “I’ve found many providers that are interested in education related to diabetes management, especially the role of the newer drugs for Type 2 diabetes.”
Providing Specialty Care to the Working Poor
In the Florida Keys, a 125-mile long chain of islands, uninsured and low-income residents use The Good Health Clinic as their primary care provider.
Kate Banick, executive director, says the clinic offers care to over 600 individuals living at or below 200% of the Federal Poverty Level.
The majority of patients at The Good Health Clinic are what Banick classifies as “the working poor.” Many are employed in the hospitality industry or work in the fishing trade, at grocery stores or gas stations.
“Many of our patients don’t have reliable transportation and would need to take a day off work and somehow drive over three hours to a specialty physician that offers charitable care,” Banick says. “MAVEN offers us a pathway to care.”
Heidi Shale, MD, a retired neurologist in Walnut Creek, Calif., has consulted with The Good Health Clinic on a variety of neurological issues.
“The most common questions have been about treatment of headaches and seizures, though I’ve also given advice on work-up of strokes,” Shale says. “The questions we’ve discussed are routine for a neurologist, but for the practitioners I’ve consulted with (they have been PAs, NPs, and MDs), particularly those who treat patients in remote areas or patients who are uninsured, it can be difficult to have access to lab tests, radiologic modalities like MRIs, and newer medications.”
With a large number of seniors in the Florida Keys, Dr. David Hurwitz, a retired rheumatologist from Woodland Hills, Calif., often finds himself offering consults on rheumatic conditions such as different forms of arthritis.
Hurwitz says providers at community health clinics who provide first-line care, often haven’t encountered complex cases of rheumatoid arthritis (RA) and may not feel comfortable prescribing methotrexate, which needs to be monitored closely and is recommended for use by rheumatologists who have knowledge and experience with antimetabolite therapy.
“Some patients are also unable or reluctant to take methotrexate and in those cases, we can start by using less toxic medications,” says Hurwitz who retired ten years ago. “Volunteering with MAVEN gives me the opportunity to be of service and also gives me a reason to keep up with continuing medical education.”
Managing Diabetes in Rural and Underserved Areas
Alan Cole, MD, an endocrinologist in Natick, Mass. has volunteered with MAVEN for the last eight months, educating community health clinic providers on issues surrounding diabetes management. Although he continues to work full-time in his own practice, Cole keeps his calendar free three days a week during lunch to offer assessments and consults to providers at community health clinics, including The Good Health Clinic.
“Many of the calls I get center around complex cases of diabetes and hyperthyroidism,” Cole says. “While they may be fairly routine for me, they’re cases not commonly seen by providers in community health clinics.”
Cole notes that diabetes disproportionately affects rural areas, a fact confirmed by research funded by the Health Resources and Social Services Administration (HRSA) and released last year. The study found that in rural areas, the likelihood of dying due to diabetes-related hospitalizations was higher in rural areas than in urban ones. Mortality rates were highest in rural areas within the South and Midwest regions.
“In addition to access, many patients with diabetes have trouble affording insulin,” Cole says. “Many community clinics aren’t aware of more affordable options, including Walmart that sells Novo Nordisk’s Novolin ReliOn Insulin for less than $25.”
Cole acknowledges that it’s impossible for any doctor to know everything about every health condition. By lending his expertise to community health clinics, he believes he’s helping MAVEN fill an important gap in care, while also giving back to the community.
“It gives me pleasure to help patients in both rural and urban areas who might not have access to specialty care,” Cole says.