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Bob: An Early Pioneer
OVERVIEW
Bob is interviewed in his home and reflects on a long and satisfying career as a frontier nurse practitioner (NP). He is considered a frontier pioneer as he created a clinic and a practice nearly from scratch at a time in our recent history when many people “did not know what an NP was.” Bob was drawn to the frontier because of the independence it offered:
I had been a medic in the Air Force and a lot of that training is focused on independence. I would work in clinics in remote areas, for example, Thailand. I would function on airplanes independently, in Turkey independently, and in Alaska independently. This independence meant that you would have medical support but it was not direct, and so you were making some fairly heavy decisions, some fairly complex medical decision making, without the usual kind of institutional support. And so that kind of prepared me for wanting to function in a more independent way.
Bob’s story is given particular attention as it represents an oral history of the development of frontier NP practice. Bob’s story also provides an example of how federal policy influences frontier health care.
Bob, recently semiretired, began his frontier NP practice 38 years ago as a member of the National Health Service Corps when he accepted an assignment at a newly formed community clinic. Prior to his arrival the community had been served by rotating physicians who visited once or twice a week. The county owned a small house and allocated the main floor for use as a medical clinic. The rental fee was one dollar per year. The visiting physicians had created charts for the patients who were seen at the clinic, but other than a few charts, a small microscope, a donated x-ray machine, and some floor space, there was little infrastructure in place.
The lack of a fully equipped medical clinic wasn’t the only issue. “The Corps wasn’t real clear on what NPs could do independently in a community,” and Bob’s new state didn’t know what to do with him either, as there was no reciprocity for NPs. He was the first NP educated in another state to apply for licensure. The Corps had a contract with an NP program in Bob’s new state and after passing an oral/written/practical test Bob was granted an interim permit (which eventually led to licensure). In 1976, the state required NPs to have physician oversight: “it wasn’t a formal licensing kind of thing, you just had to say that you were working with a physician,” so the doctors who had previously been practicing in the community on a part-time basis agreed to “provide that coverage.”
Although Bob’s salary was paid by the Corps, the clinic needed revenue to pay for overhead and purchase equipment and supplies:
In 1976, Medicare did not pay for NP services. That was not approved. But, there was a program called the Physician Extender Project which was administered through the university system and you could enroll in that program.
The purpose of the Project was to gather data for the federal government to determine if paying for services provided by NPs was a useful and cost-effective way of providing care:
When the Project ended the federal government approved the Rural Health Clinic Act which then set up rural health clinics [RHC], for which we applied. By virtue of that designation, Medicare was required to pay you [an NP]. Next came Federally Qualified Health Centers [FQHC] which gave you access to a higher reimbursement rate that was cost-based. They would pay you $100 a visit no matter whether it was a blood pressure check or you did a major laceration. Then at the end of that year there was reconciliation of what the cost of the care was to provide it and the revenue that you generated.
As clinic administrator, funding health care for the community clinic meant bridging the gap between insurance revenue and clinic costs. Over the years, Bob found that revenue from grant funding and federal programs changes in response to changes in federal policies and priorities. Bob states:
There was a shift in funding priorities between passages of the Rural Health Clinic Act in 1977, which allocated federal subsidies based on geographic criteria, and the development of the FQHC program started in early 1990s, which allocated federal subsidies on geographic and/or medically underserved criteria. FQHCs located in populated areas that were considered medically underserved would compete directly with rural clinics for funding. This was the beginning of the movement to shift funding priorities away from geographically isolated clinics to population-based health care organizations.
Eight years ago grant funding dwindled; however, in 2007 the clinic was designated a Health Resources and Services Administration 330 clinic. This changed the clinic’s designation to an FQHC, which is mandated to offer a full array of health services:
For many years about 70% of our revenue was from the patients’ medical insurance and only about 30% of our funding was grant revenue. Our grant revenue sustained our 24/7 coverage to which I was committed to and so I went after money to try and support that, whether it was from foundations to buy x-ray equipment or whatever, all of those were pieces of an overall administration of frontier practice, to try and sustain it. Finally they pulled these revenue streams and we were desperate and literally we were down to our last dollar when I wrote that grant for the 330.
While Bob states that the 330 designation was a “godsend,” it has also been somewhat of a curse. To maintain the 330 designation a clinic must increase new patient visits by approximately 1,000 over the 3-year funding period. This is not possible in a frontier area where there may not be 1,000 people in the entire county. Therefore, Bob’s clinic merged with a large rural clinic in order to meet the requirement for new patient visits (the merged clinics were able to combine patient numbers). To help cut costs, Bob relinquished the administrator role in an effort to sustain health care in his frontier community and within a year he retired. Due to cost containment efforts, the new administration has cut the clinic down to 4 days a week and also ceased 24/7 medical coverage for the community.
CONCEPTS
Bob’s story reveals new concepts and provides descriptive evidence that supports concepts summarized in the literature review. Stories, or story segments, may contain one or more concepts. In this first story the concepts of insider–outsider, emergency care provider, and personal challenges become evident.
Bob narrates this story regarding his first day of frontier practice in a new community. He feels this experience helped his outsider image with the townspeople:
We got in late in the evening and there was a cable in the motel room. It looked like it was a TV cable and we had a little portable TV so I wanted to hook it up for the kids. I connected it and over the TV came a radio transmission from the sheriff’s office, which I didn’t know was right next door. I didn’t know where anything was at that point so I went to the manager and said, I think there’s an emergency call and they’re getting the ambulance. He told me to go next door and find out what’s going on, so I did. The sheriff deputy promptly threw me into his vehicle and we raced 80 mph down the road about 15 miles.
When we arrived at the scene, the tow truck had a cable going down the side of the mountain. In those days there weren’t any guard rails and a car had gone off and was on its roof with a victim inside. The car was unstable and the next ledge went all the way down, about a thousand feet, into the gorge. While they were trying to stabilize the car, I went down that cable, about 100 to 150 feet, with a couple of the fire department guys, hanging onto this cable. I didn’t even know if they had supplies but they had IV supplies and some other equipment. When I reached the victim he was unconscious but breathing and vital signs were okay. After stabilizing the car, a Stokes litter was sent down and we got that victim out of there, on a backboard, and put him on that Stokes. We then had to get another cable to take us up the side of the mountain because there was no way to do that without some help. I started an IV on the patient while I was down there and brought him up to the ambulance, there was no helicopter in those days. I went to the nearest hospital with him (55 miles away) where he ultimately died.
The next day was Sunday and I was walking up to church with the kids. On the way, I saw all these people sitting on the bench and they’re kind of pointing and talking about me, about the fact that this guy went up and over the bank, which was not something the visiting physicians had ever done. What happened after that was people were able to see that I had some credibility, clinically, because they did not know what an NP was. Before this happened a lot of them wouldn’t have come to see an NP, they would go somewhere else to see a physician. So that was a big event that really established my credibility as a provider in the community, and by happenstance it was my first day.
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