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Dr. John Rugge founded the Hudson Headwaters Health Network in 1974, with his first clinic in Chestertown.  HHHN now operates fifteen clinics.  Photo:  Brian Mann
Dr. John Rugge founded the Hudson Headwaters Health Network in 1974, with his first clinic in Chestertown. HHHN now operates fifteen clinics. Photo: Brian Mann

North Country health care reforms and unravels

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These are the best of times and the worst of times for healthcare in the North Country.

The region is at the center of a new wave of innovation, experimentation, and reform -- including the "medical home" pilot project, funded in part by New York state. But the North Country's health care industry also face an unprecedented level of uncertainty and risk.

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Nursing homes and hospitals are at risk of closure. The region's hospitals have seen waves of lay-offs and downsizings. There is also a painful and persistent doctor shortage.  Even the region's ambulance crews are struggling to find resources and volunteers.

Today, we begin an on-going series where we'll be talking with some of healthcare's most innovative and influential people. The goal is to go behind the moments of crisis and the short-term debates, to sort out where all this might lead.

Will there be emergency rooms close enough to keep us safe?  Will there be nursing homes for those who need senior care? What will happen to the thousands of people in the region who lack health insurance and basic access to medical care?

Hudson Headwaters Health Network's headquarters in Queensbury. Photo:  Brian Mann
Hudson Headwaters Health Network's headquarters in Queensbury. Photo: Brian Mann
We begin with a conversation with Dr. John Rugge, co-founder of the Hudson Headwaters Health Network headquartered in Queensbury. Hudson Headwaters operates fifteen clinics in some of the most rural parts of the North Country, from the central and eastern Adirondacks to Lake George and the Champlain Valley.

Brian: Well, Dr. John Rugge, thank you very much for taking a few minutes to talk about this. Let me begin with where I think a lot of people in the North Country are right now and that is, frankly, at a real place of real fear and uncertainty. The headlines these days are “emergency rooms possibly closing”, “nursing homes being privatized or closing”, “doctor shortage”, “hospitals threatened.” So there is this sense from all these different little points of information, that there may be some sort of unraveling of the rural health care system that the North Country has depended on.

Dr. Rugge: It is the entire nation. We have this strange place. We are spending more on health care in the US than any other country. We have outcomes which are not so good and we need to change. And yet in the process of change, we seem to be threatening almost everything. There is a failure to produce enough primary physicians, hospitals are beleaguered, nursing homes are struggling, and what extenuates is that in a rural area like ours everything is worse. The stresses mount up and there are fewer places to go for help.

Brian: Could we get to the stage where you just can’t find a nursing home for your elderly mom or dad or when you need emergency care it’s truly over the horizon and not safely local?

A partial map of Hudson Headwaters' clinics.  The network has also opened a facility in northern Clinton County.  Image: HHHN
A partial map of Hudson Headwaters' clinics. The network has also opened a facility in northern Clinton County. Image: HHHN
Dr. Rugge: Five years ago, when the providers came together with a little planning exercise, the challenge was “Can we identify one overriding health care problem?” The problem we identified was potential lack of primary care, exodus of physicians from our communities, and knowing that all our small towns have is primary care. If you lose primary care you lose an essential service, so everything else leaves town, too.

We tried to address that by proposing a medical home model, more robust primary care, and I think we’ve at least stabilized and strengthened the primary care system even during the last three to three and a half years. Ironically, part of the impetuous and the rational for more primary care is to keep people out of hospitals. Because we’ve done this, we are seeing the hospital census sometimes plummet. Double digit decreases year by year which then threatens the hospitals which we also depend upon.

It’s like pulling a string on a sweater; there are unexpected consequences for what we do, although everything we’ve done has been necessary. What we need now is not to undo that, but to find new remedies for the problems as they keep emerging.

Brian: Many parts of the North Country are rural or hyper-rural and yet we’ve had little hospitals, Elizabethtown, Clifton-Fine, etc. In the new world of medical care in America, with the budget constraints, with the new technology, with ObamaCare, and all the different moving pieces, is that realistic? Are we still going to see these little hospitals where we can go in and expect something comparable to an urban hospital experience?

Dr. Ruggie: When I first arrived we also had hospitals in Granville, Corinth, and Keene Valley. Even Cambridge. These hospitals are no longer there because of the changes that have been sweeping through the system. We’re now seeing acceleration. I think rather than thinking in terms of the disappearance of hospitals, we need to think about their transformation. So we will have the same old services in brand new bottles.

Brian: As we move these pieces around on the playing field, one of the big evolutions here is just simply the availability or lack of availability of dollars. Part of what ObamaCare did, is that it attempted to push medical providers toward more efficient delivery of services, squeezing Medicare and Medicaid reimbursements. Have we gone too far, too fast, in terms of saying to hospitals and saying to nursing homes, you’ve got to get more efficient fast, we’re not going to give you as much money per patient per day, or does the industry need to catch up and deliver these services more efficiently and cheaply?

Dr. Ruggie: Yeah it’s all of that. I mean if you listen to the talk about budget deficits, we can’t go fast enough. And so for healthcare and for us as providers it can seem way too fast. When we look at the entire society, maybe it’s not fast enough. And that’s where we have to rely on a political process which right now seems very broken in terms of how do we get it right.

There’s another very complicated bit of arithmetic going on inside of health reform, Obamacare. And that is on the one side there are decreases in Medicaid and Medicare reimbursement on a per-visit basis, but the expectation there will be more people insured and therefore more insurance dollars going into the system. And yet no matter how smart they are with arithmetic can they be sure of getting it right. And so therefore we’ve got to go back and back and back again to make sure that while we’re going through this transition we’re not losing key services, key institutions, or entire regions.

Brian: One of the really interesting things about healthcare reform is that it’s become part of this larger social tension in America. its’ a culture war issue as much as it’s a health care issue and a lot of people just don’t trust it. Do you think we’re on a path that Americans and North Country people should generally be trusting, or are you skeptical that this is all going to fit together?

I think we have the building blocks here for a healthy Adirondack region, but are going to struggle for a long time...
Dr. Ruggie: It’s a huge enterprise. Health reform is enormous and so complicated it’s no wonder the people don’t understand it. For most people not much is going to change. For some people their lives are going to change, in terms of having access to healthcare they didn’t have before. I think the pessimistic aspect is this is going to have to be adapted and changed. What we need to do is realize we’ve got to change the healthcare system, we’ve got to start. It’s not perfect; it’s going to need to be revised and we’d better find a way to do it together.

Brian: You still feel confident that the healthcare act, Obamacare, is a legitimate first step—more reform needed, more change needed—but as your organization is entering this new world, you feel like this is still a legitimate place to start?

Dr. Ruggie: Yeah, this is the necessary starting point. I mean the fundamental decisions were: we’re not going to have universal healthcare, we’re not going to have government run healthcare, we’re not going to have a single payer. We are going to build on the system we have, which means federal-based care. Lots of different insurance companies, lots of experimentation at the state level, with lots of authority at the local level, in terms of how it’s to take place. We need to learn from the best results and adapt to them. Again, reminded that the same kind of political attacks were made on social security and on Medicare when they were first implemented—this can’t work, this is going to be a bad law, we can’t afford it. They too had to be adapted and eventually became part of our life.

Brian: You know, the basic reality, the basic fundamental question is, how healthy is the north country, how healthy are people here? My sense as I drive through communities, as I meet with people, talk to people, is that there is a substantial level of poor health in our region. I see people with bad teeth, they can’t walk properly, they look like they’re probably disabled, not because they need to be disabled but because they’ve lacked basic healthcare. Even walking down the street, sitting in Stewarts, I think this can’t be the outcome that we really want. Is that a fair assessment, are we getting a fairly low grade in our overall health outcomes right now?

Dr. Ruggie: In federal jargon, there is talk about the new morbidities. AIDS being a very important new morbidity and, unfortunately, we do see AIDS. But mostly what we struggle with are the old morbidities. Tobacco smoke and alcohol abuse, and the consequences of self-neglect though financial impoverishment. In other ways, I think we’ve very much kept up with the rest of the world.

I like to tell my patients that when I first came to town, our little practice (and it was little, then) characteristically had four or five people in the coronary care unit having or recovering from their fresh heart attacks. We don’t see this anymore. We saw people dying of complications of diabetes. That’s not going to happen anymore because they are getting care. And it is available. It’s not that expensive. And it involves patients taking care of themselves, with lower direction rather than depending on doctors to do everything for them. So I think we’ve got the building blocks for a healthy Adirondack region, but are going to struggle for a long time with cultural issues and poverty issues.

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