Rural health care gaps complicate pregnancies for New Mexico women

The fatal accident was an extreme consequence of the lack of vital health services in small towns in Northern New Mexico and across the state. Like a lot of rural hospitals and clinics, Alta Vista has struggled to attract and keep primary care doctors and other health care providers. Several New Mexico counties lack a primary care physician, nurse practitioner or dentist.

State health officials, lawmakers and local governments are trying to help, offering to pay the school loans of doctors and nurses who will serve in rural areas, seeking new rural residency opportunities for medical school graduates and providing tax credits to health care providers working in rural areas. Some of the measures are working, experts say, but not fast enough to make up the gap in provider vacancies.

As of March, New Mexico had 202 physician openings, 71 nurse practitioner openings, 26 physician assistant openings and 41 dentist openings, according to the 3RNet Healthcare Jobs, a site managed by New Mexico Health Resources, a recruiting organization under contract with the state.

“I suspect that’s only about half the openings,” said Jerry Harrison, director of the company.

Las Vegas, a town of about 13,000 residents on the western fringe of the Great Plains, has a university and a community college, a drive-in movie theater, a small state park, two high schools, a Wal-Mart and a nearby national forest. But the town and others like it across the state are competing with Santa Fe, Albuquerque, Denver and other regional cities that have much more to offer health care providers and their families.

Chris Wolf, CEO of Alta Vista Regional Hospital, said the 54-bed facility is currently trying to recruit a general surgeon, two obstetricians, two pediatricians, a family practice and internal medicine physician, and 10 registered nurses.

“These kinds of professionals are in demand all across the country and often choose communities with strong school systems, more abundant housing, arts and cultural amenities, and strong job prospects for spouses with professional careers,” Wolf said in an email.

Alta Vista isn’t the only hospital or clinic struggling to find and keep qualified health professionals in rural New Mexico. Taos Health Systems, which operates Holy Cross Hospital, closed its Peñasco Health Clinic on March 31 because of trouble recruiting health providers.

Behavioral health centers around the state were struggling to keep vacancies filled and meet demand when Gov. Susana Martinez’s administration accused the 15 largest providers of fraud and stopped Medicaid payments nearly three years ago. Many went out of business, and three of the out-of-state providers brought in by Martinez’s administration to take over have since abandoned the state, leaving thousands of New Mexicans without adequate mental health treatment and services.

Alta Vista, which serves a wide swath of northeastern New Mexico, from Santa Rosa to Springer, has managed to attract an orthopedic surgeon and a pain management specialist in the past year, Wolf said.

But it was unable to hold onto the two doctors needed to staff a labor and delivery service, which at least 90 women from the region needed. One of those doctors went to work instead at the state-run Miners’ Colfax Medical Center in Raton.

“I’m concerned from a community standpoint that this is not the only issue we have to deal with. I’m concerned about what do we have to offer professionals to locate there,” said longtime San Miguel County Manager Les Montoya, echoing the worries of rural officials around the state.

For expectant mothers in the region, news of Castillo’s death was a double blow after learning they could no longer have their babies at Alta Vista.

“It hit me like a ton of bricks,” said Margarita Montaño, a third-grade teacher from the village of Anton Chico, who is expecting her second child in August. “I’m scared for myself and all the soon-to-be moms.”

Ripple effects

Even before it ended its labor and delivery services, Alta Vista had to divert patients who needed obstetrics or pediatric care some 80 times last year to other hospitals because it lacked providers, according to the hospital.

Connie Trujillo, a certified nurse midwife and owner of Alumbra Women’s Health and Maternity Care in Las Vegas, said that was an early warning sign the hospital was in big trouble. She and the other two midwives in her facility have delivered about 450 babies at Alta Vista Regional Hospital in the past eight years.

They worked independently during deliveries at the hospital but had the advantage of having an obstetrician nearby if there were complications.

When Alta Vista shut down labor and delivery, Alumbra had about 90 expectant moms. Trujillo has applied for privileges to deliver babies at Christus St. Vincent, so far to no avail. Instead, she’s working with Santa Fe midwives to deliver some of the babies there when the time comes. Other clients will have to find obstetricians in Santa Fe or Raton who can take them.

Trujillo said it is hard enough not to be there during delivery with the women she’s taken care of throughout their pregnancies. And she worries about the additional driving they have to do now for special monitoring, for regular checkups as their due dates near and even for false labor.

She’s also losing out on the revenue necessary to keep Alumbra’s doors open. “It worries me about the future of this practice. Right now, we are the only game in town,” Trujillo said. “Right now, our model is built on getting some hospital business.”

Insurance pays a global price for prenatal, labor, delivery and follow-up care. “We made a considerable amount of our income through that, and now it is gone,” Trujillo said.

If Alumbra closes, women from around the region will not only have to deliver their babies in Santa Fe or Raton — 100 miles to the north along the Colorado border — but seek prenatal and follow-up care there as well.

Some of those doctors are full and won’t take new patients, as Castillo found out. Others won’t take Medicaid patients, especially as the state looks at trimming payments to providers. “We have over 60 percent Medicaid patients,” Trujillo said.

Cuts to Medicare and Medicaid, along with regulations and tight competition for providers, have forced many rural hospitals and clinics to close across the nation.

That could also happen in New Mexico as the state considers trimming Medicaid reimbursements to providers in order to close an $85 million funding gap.

“Unfortunately, with Medicaid cuts, rural hospitals are going to take a hit,” said Lorie MacIver, president of District 1199 of the National Union of Hospital and Heath Care Employees and a registered nurse at The University of New Mexico Hospital. “A lot of rural hospitals work hard to keep their doors open. They have to make hard choices about what services to keep. Cuts to Medicaid will compound the problem.”

For Trujillo, it’s frustrating. “My primary goal was to keep the services available locally. I’ve worked really hard to recruit the providers we have. I want to keep them in town. If we can’t keep the practice open, we are going to lose the providers.”

Rural challenges

Anton Chico, a village of fewer than 200 people where schoolteacher Montaño lives and works, is 35 miles from Alta Vista and 84 miles from Christus St. Vincent. She is lucky. She had a cesarean section with her first baby and knows she’ll have to have a C-section again this time. She can schedule her delivery ahead of time with a Santa Fe doctor. But as a teacher, she can’t afford the extra time to drive to Santa Fe for appointments until school is finished in May.

Alta Vista serves the region. So pregnant women from villages north of Las Vegas, such as Mora, will have even farther to go to reach services.

Megan Baca, 20, is six months pregnant with her second baby. She lives five minutes from Alta Vista. With her first baby, she didn’t know she was in labor until her son was well on his way. She’s scared the same thing will happen again, and this time she will have to travel 60-plus miles. Financially, it will be hard if she has to travel several times to see the doctor before the baby is born.

Castillo worked at Wal-Mart. Instead of needing only an hour off from work to see a doctor at Alta Vista, she had to take more than a half-day off to travel to Santa Fe for her sonogram, the day she died. Other women may have a hard time, as Castillo did, finding an obstetrician who will take new patients.

Trujillo said those are some of the additional challenges facing pregnant women in the region.

“Some people don’t have a car to make the trip. Through Medicaid, they can get Safe Ride, but they have to give 24-hour notice to get the ride. And you can’t take anyone with you,” Trujillo said.

She said she didn’t know why Alta Vista has had a hard time finding and keeping obstetricians. She said one problem can be balancing the number of doctors with the number of patients. “Rural patient volume is very different from what you would find in an urban area,” she said. “From a recruiting standpoint, it is harder because you need a certain volume of patients to make money, but at same time, it needs to be work-life friendly so doctors aren’t on call all the time.”

If a hospital only has two obstetricians, each would have to be on call 15 days a month to maintain full coverage while still covering their regular rounds.

The loss of the labor and delivery services at Alta Vista was the second health care setback to the Las Vegas community in less than a year. In August, a beloved and prominent primary care physician, Dr. Bradley Kanode, took his own life after a reaction to medication, according to family members. They were unable to find a doctor to take over his longtime practice and closed it.

Doing a lot with a little

UNM Hospital has one of the best family medicine programs in the nation, MacIver said. The state also has top-notch nursing, occupational therapy, physical therapy and physician assistant educational programs. Getting the talented graduates to stay in New Mexico and work in rural areas is the challenge.

The state has some programs available to train and retain more providers in rural, underserved areas. But those programs rely on state appropriations.

Dr. Daniel Derksen, director of the Arizona Rural Health Center in the College of Public Health at the University of Arizona and architect of New Mexico’s health insurance exchange, said the state has some innovative programs in place.

New Mexico offers a tax credit to doctors and other health providers who work in underserved areas. The state also has expanded its medical residency programs in rural areas.

“There is evidence that when you train people in rural areas, they tend to stay,” said Derksen, who worked at UNM Hospital for more than two decades. “If they are from a rural area or their spouse comes from a rural area, they tend to stay.”

The state has loan repayment programs and scholarship programs for medical providers who agree to work in rural areas for a minimum of two or three years. The average debt for physicians out of medical school is $180,000, according to the American Association of Medical Colleges.

Derksen said actions by Republican Gov. Martinez to create the insurance exchange and expand Medicaid helped rural hospitals and clinics. But the Medicaid expansion, along with the passage of the Affordable Care Act, also has increased the demand they face because more rural New Mexicans finally have health insurance and are seeking care.

Adding to the increased demand, the state’s population is aging — by 2030, more than a third of the state’s residents will be over 60, up from about a fifth four years ago, according to a 2013 study by the state’s Legislative Finance Committee.

In a daunting signal for the future, New Mexico also has the highest percent of practicing doctors nearing retirement age in the nation and the third fewest physicians under age 40, according to the American Association of Medical Colleges. More than a third of the state’s doctors were over age 60 in 2014.

“New Mexico has done so much with such preciously few resources,” Derksen said. “One of the paths forward for New Mexico is to invest in its health infrastructure, which provides good jobs and provides tax revenues. There’s evidence that when you have good infrastructure in health care, it tends to draw other industries.”

While solutions exist, it takes commitment and communication between rural health providers and the communities they serve to find the right ones.

Alta Vista is seeking designation as a Rural Health Clinic so it can become a National Health Service Corps site, said the hospital’s spokeswoman. Such a designation would allow the hospital to pay back the medical and nursing school loans of providers who agree to stay at least two years in Las Vegas.

Anger and worry

Plenty of people in Las Vegas are sympathetic with the hospital’s plight. At the same time, many are angry at hospital officials for giving only six days’ notice before closing the labor and delivery services.

“It’s ludicrous. It’s offensive,” said Montaño, who received a copy of the hospital’s letter from Alumbra. “It kind of sends the signal that patients were not a priority in that decision.”

“Surely there had to be an alternative,” she added. “It seems like they came up to an obstacle and just kind of threw their hands up without seeking a solution that would benefit everyone.”

San Miguel County Commissioner Nicolas Leger, a Las Vegas attorney, said he wasn’t aware the hospital was having so many problems providing labor and delivery services until it shut down the department. At Tuesday’s commission meeting, he proposed a health task force to dig into what had happened. “We don’t want to beat up on the hospital,” he said. “We want them to tell us why they got to this point and how do we get this unit back open. If attracting providers is the problem, then how do we address it?”

There’s already a San Miguel County Health Council, of which Alta Vista’s CEO Wolf is a member.

“We’ve tried to be very clear and transparent about the challenges we’ve faced in maintaining our OB program,” Wolf said in an email. “We simply have not been able to recruit and retain the clinical professionals necessary to maintain the program. To appropriately staff and operate a labor and delivery service in a hospital, at least two OBGYNs and approximately 10 OB nurses are required, as well as two additional pediatricians. Despite our best efforts over the last year, we have not been able to attract the necessary clinical talent.”

Newly elected Las Vegas Mayor Tonita Gurule-Girón, who had her two children at Alta Vista, was blunt. “Women should not be traveling, if there is an emergency, to Santa Fe or Raton because we can’t provide services here. That is unacceptable,” she said. “This decision, frankly, paints a clear picture as to why we cannot allow profit to be the primary motivation in the provision of medical care.”

Gurule-Girón said she felt the hospital had violated community trust. “I believe all options should be on the table, including the construction of a free-standing birthing facility and the transitioning of Alta Vista Regional Hospital to a community owned and operated facility,” she wrote in a public letter.

In a statement, Alta Vista said closing the obstetrics services is temporary. “We suspended these services because it is not in our patients’ or community’s best interest to continue an OB program without consistent coverage,” said Linda Leyba, communications director for the hospital. “We have tried several approaches to secure doctors and nurses who are available 24/7 for OB and pediatric services, but none have solved the issue over the past year.”

A few women have had their babies at Alta Vista since the obstetrics office closed — in the emergency room.

Two lives cut short

Castillo’s mother holds Alta Vista partially responsible for her daughter’s death. “She lived only three blocks from the hospital. She was a patient there,” said Valdez from her home in Villanueva, a small village near Las Vegas. “She should have been able to be seen there.”

Castillo would have turned 27 on April 25.

Her family and friends held a birthday party for her and thought of her son they would never meet. “It’s still unreal,” Valdez said.

“Why didn’t the hospital just take care of the patients they had until the babies were born and just not take new patients?” Valdez said. “Then they could have closed.”

Contact Staci Matlock at 505-986-3055 or smatlock@sfnewmexican.com. Follow her on Twitter @StaciMatlock.