>> WE EXPECT ACCESS TO A HEALTHCARE PROVIDER AND A HOSPITAL WHEN WE NEED THEM.

BUT FOR GROWING NUMBER OF US, THIS MAY NOT BE TRUE MUCH LONGER.

STAY WITH US AS WE TALK WITH HEALTHCARE EXECUTIVE AND CLINICIAN Dr. STEVEN TOADVINE ABOUT THE STATUS OF RURAL HEALTHCARE IN KENTUCKY NEXT ON "KENTUCKY HEALTH."

"KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION OF A HEALTHY KENTUCKY.

RURAL AREAS ARE FACING A DOUBLE HEALTHCARE CRISIS AND WE IN KENTUCKY MAY BE IMPACTED MORE SO THAN OTHERS.

THE FIRST PROBLEM IS THAT MANY OF OUR RURAL HOSPITALS ARE AT RISK FOR CLOSING.

THESE HOSPITALS FACE FINANCIAL PRESSURES FROM LOWER REIMBURSEMENT RATES AND HIGHER COSTS ASSOCIATED WITH CARING FOR THE SICKER PATIENTS THAT THEY ARE SEEING.

IN MANY INSTANCES, THESE FINANCIAL WOES BECAME EVEN MORE ACUTE WITH THE LOSS OF THE FEDERAL FUNDS FOR PANDEMIC RELIEF.

OUR SECOND PROBLEM AND ALSO FELT BY OTHER STATES IS A MAN POWER SHORTAGE.

KENTUCKY HAS INSUFFICIENT NUMBERS OF PHYSICIANS, NURSES AND ALLIED STAFF TO MEET OUR CURRENT NEEDS.

THIS SHORTAGE WILL BE COMPOUNDED AS THOSE CURRENTLY WORKING REACH RETIREMENT AGE AND ARE NOT BEING REPLACED.

THE IMPACT OF THE STAFFING SHORTAGES WILL BE FELT MOST ACUTELY IN THE RURAL AREAS MEANING THAT RESOURCES WILL BE STRETCHED THIN AND MORE WILL BE EXPECTED FROM FEWER PEOPLE.

THERE ARE MANY REASONS FOR OUR CURRENT PREDICAMENT BUT THERE ARE ALSO SOLUTIONS AT HAND TO EITHER REVERSE THE TREND OR AT LEAST HELP US BETTER MANAGE THE RESOURCES THAT WE HAVE ON HAND.

TO GIVE US A BETTER INSIGHT INTO THE STATUS OF HEALTHCARE IN OUR RURAL AREAS, WE HAVE AS OUR GUEST TODAY Dr. STEPHEN TOAD TOADVINE.

GRADUATE OF NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF MAINTAINED, RESIDENCY AT ST. ELIZABETH MEDICAL CENTER AND FOLLOWS UP WITH A MASTER DEGREE IN PUBLIC HEALTH AT THE UNIVERSITY OF PITTSBURGH MEDICAL CENTER AND MASTERS IN MEDICAL MANAGEMENT AT THE CARNEGIE MELLON UNIVERSITY.

CURRENTLY THE C.E.O.

OF HARRISON MEMORIAL HOSPITAL IN KENTUCKY AND STILL MAINTAINS ACTIVE PURSUITS AS FAR AS WORKING WITH OTHER CLINICIANS.

Dr. TOADVINE, STEPHEN, HOW ARE YOU DOING TODAY?

>> VERY WELL, WAYNE.

THANK YOU.

APPRECIATE YOUR THE INVITATION.

>> THANK YOU FOR BEING WITH US.

I CAN'T THINK OF ANYBODY ELSE WHO PROBABLY HAS MORE EXPERIENCE WORKING IN RURAL HEALTH SETTINGS, BOTH AS A CLINICIAN AND ADMINISTRATOR THAN YOU.

HOW DID YOU HAPPEN TO GAIN THIS EXPERIENCE?

>> CONDITIONAL-- COMING OUT OF RESIDENCY AT ST. ELIZABETH'S WHICH IS A REALLY FINE FAMILY MEDICINE RESIDENCY PROGRAM IN NORTHERN KENTUCKY WHERE I HAPPENED TO GROW UP IN FLORENCE.

AND COMING OUT OF RESIDENCY WAS RECRUITED DOWN TO BAR VERVILLE KENTUCKY TO A REALLY WONDERFUL PRACTICE WITH WONDERFUL PHYSICIANS.

AT THE TIME I WAS THE THIRD PHYSICIAN IN THE GROUP THERE GOING BACK TO 1990.

SO IT'S BEEN A FEW YEARS.

BUT YOU KNOW, AT THAT TIME WE WERE FULL SERVICE FAMILY DOCTORS DELIVERING BABY, GOING TO THE HOSPITAL, DOING A LITTLE SURGERY, JUST TRYING TO TAKE CARE OF FOLKS IN OUR COMMUNITY WITH EXCELLENCE AND I'M HAPPY TO SAY THAT THAT GROUP OVER THE YEARS HAS EXPANDED TO, MY GOODNESS, I THINK THERE ARE 30 OR 40 PROVIDERS IN THE GROUP NOW OR THE SPINOFFS FROM THAT GROUP.

>> WELL, YOU KNOW, MANY YEARS AGO I HAD THE PLEASURE OF INTERVIEWING LATE Mr. WALTER MAY, WHO WAS THEN THE C.E.O.

OF THE PIKEVILLE MEDICAL CENTER.

AND HE SAID THAT HE DID NOT LIKE TO SEE AMBULANCES ON THE MOUNTAIN PARKWAY LEAVING PIKEVILLE ON THEIR WAY UP TO LEXINGTON.

SO IT BEGS THE QUESTION OF ME, AND OF THINK WHAT HIS POINT WAS, HOW IMPORTANT AND PRACTICAL IS IT FOR US TO PROVIDE SERVICES CLOSER TO WHERE PEOPLE LIVE RATHER THAN HAVING TO SHIP THEM TO BIGGER CENTERS?

>> WELL, YOU CERTAINLY HAVE TO THINK ABOUT WHAT IS ESSENTIAL IN A REGION.

WHEN YOU TALK ABOUT A RURAL COMMUNITY VERSUS AN URBAN, YOU ARE REALLY TALKING ABOUT TIME AND DISTANCE AND LOCAL RESOURCES SO WHEN I THINK, FOR MY OWN HOSPITAL AT HARRISON MEMORIAL IS WHAT IS REALLY CRITICAL TO OUR COMMUNITY.

WE HAVE A GREAT ARRAY OF SERVICES.

BUT WHEN I THINK OF THE REALLY ESSENTIAL ONES FOR OUR REGION, SERVING SEVERAL COUNTIES, YOU THINK ABOUT HEART ATTACK CARE, AND WHEN MINUTES MATTER, CAN YOU GET TO A CATH LAB, CAN YOU GET THE STENT PUT IN OR THAT ARTERY OPENED UP.

DELIVERING A BAY.

CAN YOU DO IT CLOSE TO HOME WHEN MINUTES MAY MATTER.

EMERGENCY ROOM CARE, TRAUMA CARE, AND THEN PRIMARY CARE, WHICH REALLY, I THINK, IS ESSENTIAL CLOSE TO HOME.

SO WE NEED, WE MUST PROVIDE THOSE, I THINK, WHERE PEOPLE LIVE.

YOU GET TO THE OTHER END OF HIGHER SPECIALIZATION TO THINK ABOUT, FOR EXAMPLE, LET'S TALK ABOUT EUROPE.

TRANSPLANT SURGEON, FOR EXAMPLE, YOU NEED A CERTAIN POPULATION BASE TO SUPPORT A TRANSPLANT SURGERY PROGRAM.

SO, NO, YOU ARE NOT GOING TO HAVE THAT IN EVERY COMMUNITY ACROSS THE STATE AND YOU CAN THINK OF OTHER SPECIALTIES AS WELL.

SO THERE ARE SOME THAT HAVE TO BE CONCENTRATED IN AN URBAN AREA OR ACADEMIC CENTER.

SO WHEN THAT AMBULANCE IS LEAVING A COMMUNITY AND GOING FOR THAT KIND OF CARE, THEN THANK GOD THERE IS AN AMBULANCE SERVICE, WHICH IS ACTUALLY ANOTHER ISSUE, TOO, FOR RURAL KENTUCKY, IS ACCESS TO GOOD EMS, GOOD SERVICES AND GOOD TRANSPORT WHEN IT'S NEEDED.

SO I THINK YOU HAVE TO REALLY THINK CRITICALLY ABOUT THE SERVICES THAT ARE ESSENTIAL FOR A COMMUNITY AND WHAT YOU CAN PROVIDE.

ONE OF THE THINGS I SAY AT OUR HOSPITAL IS, WE DO LOVE BEING ABLE TO SAY WE ARE CLOSE TO HOME FOR THE PEOPLE THAT LIVE IN OUR REGION.

WE ARE CLOSE TO HOME, BUT I DON'T WANT YOU COMTEENAGE OUR HOSPITAL BECAUSE-- I DON'T WANT YOU COMING TO OUR HOSPITAL BECAUSE WE ARE CLOSE.

I WANT YOU COMING BECAUSE WE ARE GOOD AT WHAT WE DO AND IT WILL BE AS GOOD AS PROVIDED ANYWHERE.

IF YOU ARE GOING HAVE YOUR GALL BLADDER OUT, IT SHOULD BE AS GOOD AS ANYWHERE ELSE.

THERE IS A BALANCE.

I CAN CERTAINLY COMMENCE-- I CAN COMMUNIST RATE WITH THE GREAT WALTER MAY.

I HATE TO SEE FOLKS LEAVING FOR WHAT CAN BE DONE WELL CLOSE TO HOME.

>> DOES THAT SUGGEST THEN THAT WE HAVE A NETWORK WITHIN THE HOSPITALS HERE IN KENTUCKY THAT, IF THERE IS A CASE THAT IS TOO DIFFICULT OR RARE, AND THEREFORE MAY NOT GET THE PERSON IN THE OUTSKIRTS MAY NOT HAVE SEEN MANY OF THESE CASES, THE PATIENT MAY NEED TO GO TO A MAJOR CENTER WHERE THEY HAVE HAD A LITTLE MORE EXPERIENCE.

IS THERE A COOPERATION THAT THERE IS A WILLINGNESS TO WORK OR TAKE CARE OF THOSE PATIENTS?

>> WELL, THERE REALLY IS.

AND AS YOU MENTIONED, I'VE ACCUMULATED SOME EXPERIENCE OVER THE YEARS.

I WORKED FOR BAPTIST HEALTH FOR MANY YEARS IN ADMINISTRATIVE ROLES AS PART OF MY RESPONSIBILITIES, TOOK ME TO PADUCAH, MADISONVILLE, E-TOWN, LOUISVILLE.

MOST OF MY PRACTICE EXPERIENCE WAS ON THE EASTERN SIDE OF THE STATE, CORBIN, BARBERVILLE, WORKED IN LEXINGTON QUITE A BIT.

AND OF COURSE NOW CYNTHIANA, BUT I THINK THE COOPERATION IS REALLY, REALLY GOOD.

FOR EXAMPLE, WITH THE UNIVERSITY OF KENTUCKY, WITH THE UNIVERSITY OF LOUISVILLE, WITH THE MAJOR MED CENTERS IN TOWN, BAPTIST, NORTON, ST. JOE'S AND TO ST. ES AND WHEN WE NEED TO SEND FOLKS FOR OTHER SERVICES, I DO THINK THE COOPERATION IS GOOD.

THE WORK OF THE KENTUCKY HOSPITAL ASSOCIATION IS STRONG.

I THINK OUR NETWORKS ARE GOOD.

THERE IS SOME SENSE OF COMPETITION AND COVID REALLY CHALLENGED US WITH BED DEMAND IN THAT, YOU KNOW, SOMETIMES FOLKS MAY HAVE BEEN WILLING TO ACCEPT PATIENTS BUT WE DIDN'T HAVE BEDS.

BUT THOSE SURGES, THOSE COVID SURGES WERE REALLY CHALLENGING FOR ALL OF US.

BUT I DO THINK HOSPITALS WORK VERY WELL TOGETHER ACROSS KENTUCKY.

>> CORRECT ME IF I'M WRONG, BUT IT APPEARS RURAL HOSPITALS GET REIMBURSED AT DIFFERENT RATES THAN SOME OF THE LARGER MORE URBAN FACILITIES.

AND IF THAT'S TRUE, IT SEEMS LIKE IT IS PUTTING A SQUEEZE ON THE FINANCIAL VIABILITY OF THESE INSTITUTIONS.

ARE YOU SEEING THAT AND WHY WOULD THERE BE SOME DIFFERENCES IN THE PAY SCALE?

>> HEALTHCARE FINANCING IS INCREDIBLY COMPLEX AND YOU KNOW, FROM THE PATIENT VIEW, WE KNOW THAT EVERY TIME WHEN I GET MY OWN BILL FOR MY HEALTHCARE, MY FAMILY'S HEALTHCARE, PROBABLY YOU YOURSELF AND OUR PATIENTS, HEALTHCARE FINANCING IS COMPLEX.

BUT ON THE REIMBURSEMENT SIDE, YOU KNOW, MEDICARE HAS COMPLICATED FORMULAS.

RELATED TO GEOGRAPHY, WAGE INDEX, WHAT IT COSTS TO HIRE EMPLOYEES, THERE ARE VARIOUS STATUSES FOR HOSPITALS FROM SOLE PROVIDER TO A MEDICARE DEPENDENT TO A CRITICAL ACCESS HOSPITAL.

AND THERE ARE ISSUES WITH THE COMMERCIAL PAYERS, WHICH ARE GENERALLY MORE CONTRACT-BASED WHICH RELATE TO NEGOTIATING POWER ON EACH SIDE.

SO THE FORMULAS ARE COMPLICATED.

THERE IS A DESIGNATION FOR CRITICAL ACCESS RURAL HOSPITALS WHO ARE GENERALLY SMALL HOSPITALS, PROVIDING CRITICAL SERVICES AND THERE IS SOME ENHANCED MEDICARE FUNDING FOR THOSE.

BUT I THINK IN GENERAL, THE RURAL HOSPITALS ARE MORE CHALLENGED THAN OUR URBAN COUNTERPARTS.

>> IS THAT PUTTING A SQUEEZE ON THESE FACILITIES, AS FAR AS SERVICES THAT THEY CAN REALLY WANT TO OFFER SINCE THEY'RE NOT GETTING THE SAME REIMBURSEMENT?

>> I THINK REIMBURSEMENT IS ONE ISSUE, PAYER MIX HAS BEEN MENTIONED AS ANOTHER IN THAT THE RATES OF UNINSURED ARE HIGHER IN RURAL AREAS.

THE INCOME IS LOWER IN RURAL AREAS TYPICALLY, AT LEAST THAT'S TRUE ACROSS KENTUCKY.

POVERTY RATES ARE HIGHER ACROSS RURAL KENTUCKY.

SO THE PATIENT'S ABILITY TO PAY AND SOME OF THE PAYER MIX IS DIFFERENT FOR THE RURAL HOSPITALS.

I THINK A LOT OF THE CHALLENGES TO RURAL HOSPITALS REALLY RELATE TO THE COST STRUCTURE.

IT'S HARD TO REALLY MAXIMIZE EFFICIENCY IN TERMS OF VOLUMES; FOR EXAMPLE, THERE MAY BE A SMALL TOWN HOSPITAL SOMEWHERE WITH AN E.R., MUCH NEEDED SERVICE.

AND YOU NEED A DOCTOR THERE 24 HOURS A DAY.

MAYBE ONLY SEEING A FEW PATIENTS BUT THAT E.R.

HAS TO BE OPEN.

HAVE YOU TO HAVE NURSING.

YOU HAVE TO HAVE TECHS, YOU HAVE TO HAVE RADIOLOGY READY TO GO.

YOU MAY HAVE A SMALL TOWN TWO COUNTIES OVER THAT HAS TWICE AS MANY PATIENTS EVERY DAY BUT YOU ONLY NEED THE SAME STAFF.

SO I THINK THE EFFICIENCIES CONDITIONAL RURAL HOSPITALS IN MATERIALS OF VOLUME BECAUSE HAVE YOU TO HAVE THE SERVICE, BUT YOU HAVE MORE ABILITY TO MAXIMIZE EFFICIENCY WHEN YOU ARE RUNNING HIGHER VOLUMES IN GENERAL SO I THINK THE COST STRUCTURE OF RURAL HOSPITALS IS A CHALLENGE.

THE ABILITY TO RECRUIT HIGHLY SKILLED HEALTHCARE WORKERS IS A CHALLENGE, ESPECIALLY IF WE ARE HAVING TO COMPETE AGAINST RATES AND WAGES THAT ARE OFFERED IN OTHER PLACES.

AND THEN FOR RURAL HOSPITALS, TOO, MANY ARE CHALLENGED BY THE LACK OF REALLY HAVING SIGNIFICANT CASH RESERVES, WHICH SOME OF THE LARGER HOSPITALS AND SYSTEMS HAVE BEEN ABLE TO REALLY RELY ON OVER THE YEARS SO THAT IT WILL ONE OR TWO POOR YEARS ARE NOT AS THREATENING TO A RURAL HOSPITAL WHEN YOU REALLY DON'T HAVE THAT KIND OF BUFFERING CAPACITY.

SO RURAL HOSPITALS DO FACE A LOT OF RISKS THAT ARE UNIQUE.

>> YOU KNOW, YOU BROUGHT IN THIS IDEA ABOUT STAFFING.

AND I WANT TO GO AND TALK A MINUTE ABOUT THAT.

WE HAVE A SHORTAGE OF PHYSICIANS AND OTHER HEALTHCARE PROVIDERS.

AND EVERYBODY SEEMS TO BE COMPETING TO GET AT EACH OTHER'S , YOU KNOW, RESIDENCE OR OTHER PHYSICIANS.

IS THAT SHORTAGE MORE ACUTE IN RURAL AREAS AND WHAT IS GOING TO BE THE IMPACT?

I MEAN YOU ALLUDED TO SOME OF IT ALREADY BUT HOW DO YOU SEE THIS DOWN THE ROAD FOR US?

>> I THINK ESPECIALLY AS IT RELATES TO PHYSICIANS, IT'S GOING TO GET MORE AND MORE CHALLENGING FOR RURAL COMMUNITIES.

DURING COVID, I THINK IT WAS HARD TO KNOW WHAT NORMAL WAS GOING TO END UP LOOKING LIKE WITH SO MANY OPPORTUNITIES FOR TRAVEL WORKERS TO, YOU KNOW, TO LEAVE THEIR MAIN JOB AND GO WORK TEMPORARILY AT ANOTHER SITE THAT HAD CRITICAL NEEDS.

SO I THINK WE ARE STABILIZING.

THERE IS A SHORTAGE OF EVERY AREA OF HEALTHCARE THAT YOU WANT TO TALK ABOUT AS YOU LOOK IN THE FUTURE, FUTURE DEMANDS, DEMANDS FOR CARE, IT'S GOING TO BE A CHALLENGE FOR ALL HOSPITALS, I THINK FOR RURAL HOSPITALS, PARTICULARLY AS IT COMES TO PHYSICIANS, ONE OF THE THINGS THAT'S HAPPENED, WHICH IS A GOOD THING, IS BY AND LARGE, AS KNOWLEDGE IS INCREASED AND TECHNOLOGY IS INCREASED, AND MEDICINE HAS BECOME MORE SPECIALIZED, WHICH OFFERS A LOT OF ADVANTAGES, IS THAT IN A RURAL SETTING, YOU REALLY NEED PHYSICIANS WHO ARE MORE GENERALISTS IN TERMS OF RADIOLOGY, IF YOU GO BACK A FEW YEARS AGO, YOU COULD HAVE ONE RADIOLOGIST WHO READ MAMMOGRAPHY, C.T.s, MRIS, DID PROCEDURES, YOU KNOW, MULTITALENTED OR BROAD SCOPE OF PRACTICE, AND NOW YOUNG RADIOLOGISTS COMING OUT OF TRAINING, TYPICALLY SUBSPECIALIZED AND IF I HAD TO HAVE THEM ON SITE IN THE HOSPITAL, TO COVER ALL OUR NEEDS, I WOULD PROBABLY NEED FIVE, WHERE A COUPLE YEARS AGO I ONLY HAD ONE.

OUR INTERVENTIONAL CARDIOLOGIST, AWESOME PHYSICIAN, BROAD SCOPE OF PRACTICE, DOING PERIPHERAL ARTERIAL WORK, RENAL WORK LET ALONE THE CARDIAC WORK, PACE MAKERS, WORKING ON PULMONARY EMBOLI, WHICH IS TRUE F. WE REPLACED WHAT HE COULD DO WITH THE YOUNGER DOCS COMING RIGHT OUT OF TRAINING, I WOULD PROBABLY NEED THREE OR FOUR TO REPLACE THE ONE OF HIM.

SO I THINK THIS INCREASING SPECIALIZATION OF MEDICINE MAKES IT A CHALLENGE FOR RURAL HOSPITALS IN THAT WE STILL REALLY NEED GENERALIST PHYSICIANS NOT JUST GENERALIST PRIMARY CARE DOCS BUT GENERAL ORTHOPEDICS.

A LOT OF THE TRAINING AS YOU KNOW IS COMING OUT OF ORTHOPAEDICS, I DO SHOULDER, I DO KNEES.

I DO FEET.

I DO SPORTS MEDICINE.

MOST RURAL HOSPITALS NEED ONE GOOD GENERAL ORTHOPEDIC DOCTOR.

SO THE TRAINING NEEDS TO RECOGNIZE, FOR FOLKS WHO ARE INTERESTED IN RURAL PRACTICE, THAT THEY STILL NEED TO REALLY HAVE GENERAL BROAD-BASED SKILLS.

AND IT IS A CHALLENGE, A CHALLENGE TO KEEP UP TO DATE ON EVERYTHING WHEN YOU ARE MORE BROAD BASED.

>> RIGHT.

>> AND ALSO, I WOULD IMAGINE THERE IS, WHEN YOU TALK ABOUT HAVING ONE OF SOMEBODY, THERE IS A CERTAIN COLLEGIAL EXPERIENCE THAT GOES ALONG WITH HAVING MULTIPLE-- YOU TALK ABOUT THE GROUP THAT YOU JOINED.

YOU WENT FROM THREE TO MULTIPLES OF 10.

IS THAT A PROBLEM WHEN TRYING TO ATTRACT THAT INDIVIDUAL TO AN AREA?

YOU SAY HEY, YOU ARE GOING TO BE ONE OF ONE.

YOU ARE ALWAYS ON.

IS THAT DIFFICULTY?

>> YOU GOT THAT RIGHT.

TOTALLY RIGHT ON THAT FRONT.

I DON'T WANT TO RELATE EVERYTHING TO MY OWN HOSPITAL.

WE HAVE AN AWESOME HOSPITAL WITH A GREAT ARRAY OF SERVICES.

AND MOST OF OUR SPECIALTIES ARE NOT JUST ONE.

WE JUST HAD A YOUNG CARDIOLOGIST JOIN US FROM BOSTON WHO SPECIALIZES IN ADVANCED IMAGING, WHICH IS PRETTY SPECIAL FOR US.

WE JUST STARTED CARDIAC MRI ACTUALLY YESTERDAY FORMALLY.

>> WOW.

>> BUT WHEN YOU LOOK AT THESE SPECIALTY AREAS, AND IN A SMALL RURAL HOSPITAL WHERE YOU HAVE THE DAYTIME VOLUME, THE DAYTIME NEED FOR CLINIC VISITS OR OPERATIONS, YOU HAVE THE DAYTIME NEED FOR ONE OR TWO IN A SPECIALTY, ONE IS COLLEGIALITY AND CAMARADERIE, WHICH I THINK REALLY CAN EXIST ACROSS THE SPECIALTIES.

IN A LOT OF WAYS, IT'S CLOSER IN A RURAL HOSPITAL BECAUSE WE ARE CLOSER KNIT.

BUT THEN YOU ADD ON THE ON CALL BURDEN.

IF YOU HAVE GENERAL SURGERY IN A HOSPITAL, HAVE YOU TO COVER THAT 24/7, 365.

ITS TOTALLY ESSENTIAL FOR A HOSPITAL AND I THINK IT'S BASICALLY A REQUIREMENT THAT WE HAVE TO MAINTAIN IN MOST OF OUR COMMUNITIES.

BUT IF YOU ONLY HAVE ONE OR TWO GENERAL SURGEONS, WELL, THAT MEANS THEY'RE GOING TO BE ON CALL, EACH OF THEM, HALF THE YEAR.

WHICH IS NOT THE TYPICAL SITUATION YOU ARE GOING TO GET IF YOU TAKE A JOB IN LOUISVILLE OR LEXINGTON.

YOU MAY BE ON CALL ONCE A WEEK, YOU KNOW, ONCE EVERY OTHER WEEK IF YOU ARE IN A BIG GROUP.

SO THE CALL BURDEN, THE AVAILABILITY IS UNIQUE, WHICH MAKES IT A LITTLE BIT HARDER TO RECRUIT TO.

OR ON THE OTHER SIDE, IF WE BRING IN WHAT WE CALL PART-TIME TEMPORARY COVERAGE, THAT TENDS TO BE VERY EXPENSIVE AND IF RURAL HOSPITALS ARE HAVING TO DO MUCH OF THAT, THAT'S A BIG EXPENSE ON THE COST SIDE.

BUT SOMETIMES ESSENTIAL TO HAVE TO DO.

WE HAVE ONE FULL-TIME INTERVENTIONAL CARD OL CARDIOLOGIST AND THANKFUL HE IS HAPPY TO TAKE CALLS 330 NIGHTS A YEAR BUT HE IS A UNIQUE INDIVIDUAL.

BUT THE REMAINDER OF THE TIME WORKS WE DO FUND TO HAVE, YOU KNOW, SKILLED INTERVENTIONIST PRESENT BECAUSE HE NEEDS TO TAKE VACATIONS SOMETIMES.

>> RIGHT.

WE ARE ALL TRAINED EQUALLY.

BUT IS THERE SOMETHING DIFFERENT ABOUT THAT INDIVIDUAL WHO IS GOING TO COME AND PRACTICE IN THE RURAL AREA?

IS THERE A DIFFERENT MIND SET IN THAT PERSON AS OPPOSED TO THE PERSON WHO IS GOING TO GO TO THE URBAN AREA?

>> WELL, I THINK SO.

I THINK SO.

YOU KNOW, ALL OF US, AS PHYSICIAN, HEALTHCARE WORKERS, NURSES, PHARMACISTS, YOU KNOW, WE NEED TO ALWAYS REMEMBER WHY WE ARE DOING WHAT WE ARE DOING TO SERVE, THAT OUR WORK IS A SERVICE TO OTHERS, TO CARE FOR OTHERS, THAT HEALTHCARE TO US IS NOT SIMPLY A COMMODITY.

SO THAT REALLY, I THINK, IS REALLY EMPHASIZED IN THE RURAL ENVIRONMENTS BECAUSE IT IS SUCH-- SO MUCH ABOUT CARING FOR OUR COMMUNITIES.

IT'S THE ONLY REASON WE ARE THERE.

SO I THINK THE SERVICE MIND SET HAS TO BE THERE.

BUT THEN THE ATTRACTION TO LIVING IN A SMALLER TOWN, SMALL TOWN LIFE IS WONDERFUL.

I ENJOY IT.

I ENJOY THE SPACE.

I ENJOY THE RELATIONSHIPS.

BUT AS FAR AS HEALTHCARE WORKER COMING INTO ENVIRONMENT THAT MAYBE DIDN'T GROW UP IN THAT ENVIRONMENT, I THINK WE MENTIONED TWO CHALLENGES ALREADY.

1: IS TO BE BROADER BASED IN YOUR SKILLS AND TO MAINTAIN THAT OVER A CAREER.

2: IS TO REALIZE YOU MAY HAVE TO BE MORE AVAILABLE IN TERMS OF CALL COVERAGE OR BEING CALLED IN AT ANY TIME VERSUS, YOU KNOW, A LARGER GROUP IN A CITY.

3: YOU HAVE TO REALLY ENJOY THE LIFE IN THE SMALLER COMMUNITY.

WHAT IT MEANS TO YOU AND YOUR FAMILY, THE SPOUSE, THE KIDS, THE SCHOOL, THE ACTIVITIES, THE RECREATION, HOW THAT WORKS FOR YOUR FAMILY.

AND THIS IS KIND OF-- I DON'T MEAN THIS TO BE TRITE, BUT IF YOU ARE GOING TO LIVE AND WORK IN A SMALL TOWN, WHICH IF YOU ARE WORKING, I THINK YOU OUGHT TO LIVE THERE IDEALLY, IS YOU NEED TO GET COMFORTABLE WITH WHEN YOU ARE AT WAL-MART THAT ONE OF YOUR PATIENTS COMES UP TO YOU AND ASKS YOU A QUESTION.

OR IF YOU ARE AT THE BALL GAME ON FRIDAY NIGHT, YOU NEED TO KNOW THAT YOU ARE THE DOCTOR FOR, YOU KNOW, 25% OF THE PEOPLE IN THE STANDS.

OR IF YOU ARE AT LITTLE LEAGUE AND ONE EVER YOUR PATIENT'S KIDS WIPE OUT YOUR KID AND YOU SEE THE PATIENT NEXT DAY IN THE OFFICE, YOU NEED TO BE ABLE TO DEAL WITH SOME PRETTY INTENSE RELATIONSHIPS AND INTERPERSONAL ACCOUNTABILITY AND I'VE SIMPLY HAD, I CAN TELL YOU I'VE HAD PHYSICIANS INTERVIEW AND TELL ME I CAN'T HANDLE THAT.

I CAN'T HANDLE SEEING MY PATIENT AT WAL-MART.

I NEED TO BE IN A BIGGER ENVIRONMENT.

SO, YEAH,... >> YEAH, YEAH.

>> PART OF RECRUITMENT IS, YOU KNOW, I LIKE TO SEE YOU SHAKING YOUR HEAD.

THAT MAKES ME FEEL LIKE YOU ARE TRACKING ON SOME OF THOSE ISSUES, BUT... [LAUGHTER] SO PART OF THE RECRUITMENT CHALLENGE IS, YEAH, YOU DON'T WANT TO PUT YOU KNOW, SQUARE PEGS IN ROUND HOLES OR VICE VERSA.

I MEAN YOU LOOK FOR PEOPLE TO ATTRACT TO YOUR COMMUNITY THAT ARE GOING TO ENJOY IT AND ARE GOING TO SUCCEED CARING FOR PATIENTS THERE.

WE'VE HAD SOME WONDERFUL DOCTORS JOIN US LATELY.

I'M THRILLED ABOUT EVERYONE WHO HAS COME AND THEY'VE FOUND THEIR NICHE AND ARE ENJOYING LIFE AND WORK WITH US.

IT'S BEEN A WONDERFUL THING FOR ME TO SEE IN MY BRIEF TIME IN CYNTHIANA.

>> TELL ME, WHAT THE ROLE THAT YOU SEE IN TELEMEDICINE?

IS IT MORE IMPORTANT DO YOU THINK IN THE RURAL AREA THAN URBAN OR LARGER METROPOLITAN AREA?

>> I THINK IT CAN BE.

I DON'T KNOW THAT WE'VE REALLY-- WE CERTAINLY HAVEN'T DEVELOPED THE POTENTIAL OF IT YET.

SOME FS ISES-- SOME SERVICES I THINK IS INCLUSIVE WITHIN TELEMEDICINE.

TELERADIOLOGY IS SOMETHING THAT IS FAIRLY SIMPLE AND EASY TO DO AS I MENTIONED EARLIER.

IT IS HARD TO FIND ONE RADIOLOGIST THAT WILL READ MULTIPLE MODALITIES BUT WE CONTRACT WITH A LARGER GROUP THAT READS REMOTE THEIR.

AND SUPPLIES SOME ON SITE PROCEDURES.

SO THAT'S A PRETTY SIMPLE ONE.

IF YOU ARE LOOKING FOR SUB SPECIALTY CARE THAT MAYBE COULD ASSIST US IN THE HOSPITAL, MAYBE IN THE NEUROLOGY CONSULT IF A HOSPITAL DOESN'T HAVE ONE OF THOSE PHYSICIANS ON STAFF, I COULD SEE THAT BEING HELPFUL.

SO I DON'T THINK IT'S PLAYED OUT WELL ENOUGH.

THE PATIENTS WHO DO NOT HAVE ACCESS TO SPECIALISTS TO BE ABLE TO SAY COME TO A PRIMARY CARE OFFICE AT HOME AND GET IN FRONT OF THE SCREEN WITH A SPECIALIST, ACADEMIC CENTER, I THINK, THAT COULD BE HELPFUL.

THE FUNDING OF THAT COULD BE A CHALLENGE, TOO.

I MEAN IF THERE IS GRANT FUNDING FOR THAT, WHICH IS HELPFUL, IF THE MONEY IS ALL-- I HATE TO PUT IT THAT WAY, IF THE MONEY IS LEAVING TOWN AND BEING PAID TO NATIONAL TELEMEDICINE GROUP, THAT'S NOT A HELPFUL FOR THE LOCAL COMMUNITY.

BUT I DO SEE A BIG ROLE FOR IT THAT WE NEED TO, YOU KNOW, CAREFULLY DEVELOP.

BUT, YEAH, I THINK THERE IS OPPORTUNITY THERE.

>> GIVE ME YOUR ONE-MINUTE OR SO ANSWER WITH THIS: ARE RURAL HOSPITALS IN DANGER AND WHAT CAN WE DO TO KEEP THEM OPEN?

>> A LOT OF RURAL HOSPITALS ARE IN DANGER.

YOU'VE SEEN THE PUBLISHED REPORTS.

VIRUS TIMES YOU'LL HAVE-- VIRUS TIMES YOU-- VARIOUS TIMES WILL YOU HAVE A LIST OF HOSPITALS FINANCIALLY IN DANGER.

THANKFULLY THIS PAST YEAR THANKS TO THE KENTUCKY LEGISLATURE, THANKS TO THE KHA AND THANKS 209 FEDERAL GOVERNMENT, WE DO HAVE A SIGNIFICANTLY ENHANCED REIMBURSEMENT FOR CARE OF PATIENTS WHO ARE ON MEDICAID INSURANCE.

THAT'S BEEN VERY HELPFUL THIS YEAR.

SO HIVE BUT THAT'S NOT RURAL HOSPITALS.

THAT'S ALL HOSPITALS IN KENTUCKY, URBAN OR NOT.

I THINK THE HOSPITALS-- YOU KNOW, HOSPITALS THIS THE COMMUNITY WILL THRIVE OR NOT TOGETHER.

SO PART OF THE-- I THINK PART OF THE CHALLENGE FOR EVERY RURAL COMMUNITY IS WORKING TOGETHER AS A COMMUNITY.

THE COMMUNITY-- RECRUITING NEW PHYSICIANS OR OTHER WORKERS TO A HOSPITAL IS NOT JUST ABOUT THE HOSPITAL OR SOMETHING THAT'S JUST SOLELY THE RESPONSIBILITY OF THOSE INSIDE MEDICINE.

BUT YOU KNOW, WHAT IS THE COMMUNITY DOING IN TERMS OF DEVELOPING ITS OWN SCHOOLS, DEVELOPING IT'S OWN PARKS AND RECREATION, HIGH-SPEED INTERNET.

SO I THINK THERE IS A SYMBIOTIC RELATIONSHIP BETWEEN THE HEALTHCARE AND OTHER ASPECTS OF THE COMMUNITY.

AND MOST HEALTHCARE ORGANIZATIONS ARE MAJOR EMPLOYERS IN THE COMMUNITY.

SO VITAL TO THE LOCAL ECONOMY.

SO IT'S BIGGER THAN JUST A HOSPITAL OR JUST WHAT A MEDICAL SCHOOL CAN DO TO SUPPORT A COMMUNITY.

IT INVOLVES THE COMMUNITY AS A WHOLE.

IT'S NOT HEALTHCARE THAT'S DEVASTATING TO A TOWN OR TO AN ECONOMY AND YOU CAN LOOK BACK AT THE HOSPITALS THAT HAVE CLOSED IN KENTUCKY.

THIS IS NOT JUST-- I MEAN HEALTHCARE IS THE MAIN THING.

KEEPING FOLKS HEALTHY, PREVENTATIVE CARE, ACCESS TO SERVICES.

BUT WHETHER YOU SEE A HOSPITAL CLOSE, IT IS A DEVASTATING THING FOR A COMMUNITY IN EVERY WAY IMAGINABLE.

>> I THINK YOU SAID IT BEST WHEN YOU SAID IT'S A SYMBIOTIC RELATIONSHIP.

ONE BENEFITS THE OTHER VERY NICELY.

Dr. TOADVINE, STEPHEN, THANK YOU VERY MUCH FOR BEING WITH US.

YOU HAVE BROUGHT UP SOME VERY, VERY GOOD POINTS AND A LOT FOR US TO THINK ABOUT.

I ALSO THINK THAT WE MAY FACE SOME PROBLEMS IN MAINTAINING THE QUALITY AND QUANTITY OF CARE THAT WE EXPECT AND DESERVE.

BUT THESE ARE NOT INSURMOUNTABLE PROBLEMS.

THE HOSPITALS AND MEMBERS OF THE HEALTHCARE TEAM IN RURAL AREAS ARE DOING GREAT JOBS.

BUT AS Dr. TOADVINE ALLUDED TO, THEY NEED OUR SUPPORT.

WE CANNOT ALLOW THESE INSTITUTIONS TO FAIL BECAUSE IF THEY DO, WE WILL ALL SUFFER THE CONSEQUENCES.

IF YOU WISH TO WATCH THIS SHOW AGAIN OR WATCH AN ARCHIVED VERSION OF PAST SHOWS, PLEASE GO TO WWW.CLORK/HEALTH.

IF YOU HAVE HIVE KET.ORG/HEALTH OR KYLEGISLATE@ ket.org.

I LOOK FORWARD TO SEEING YOU ON THE NEXT "KENTUCKY HEALTH."

AND IF YOU HAVE CONCERNS ABOUT YOUR OWN PERSONAL HEALTH, SEE YOUR PROVIDERS.

TALK TO THEM EARLIER RATHER THAN LATER AND LET'S SUPPORT THE LOCAL HOSPITALS BECAUSE THEY NEED US AS MUCH AS WE NEED THEM.

SEE YOU NEXT WEEK.

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR A HEALTHY KENTUCKY.