In the 30 years that Robert DeLuca has been a small-town doctor, he has become accustomed to the lack of privacy.
Patients call at all hours or stop him on the street for advice. But one recent encounter really stuck out.
“I had a guy stop me at Wal-Mart,” DeLuca said. “I didn’t even know who he was. He said, ‘How much are vasectomies?” I said, ‘If we go back to the hardware department, it’s about $50.’ ”
Such is life in Eastland, about 90 miles west of Fort Worth, where the local mechanic will come and get DeLuca’s car if it’s on the fritz — and leave a loaner — or the local plumber will swing by his house to fix a leaky faucet while DeLuca is still at work.
In a small town, they take care of you.
Robert DeLuca, Eastland phyiscian
“In a small town, they take care of you,” DeLuca said.
But DeLuca, 64, is worried about the future of small-town doctors.
With the long hours, increasing medical school debt and the challenges of running a stand-alone practice, DeLuca isn’t sure if many will follow him.
“When you ask somebody to come to a rural area, you’re asking them to give up a lot,” DeLuca said. “You’re asking to take calls in the middle of the night. You’re asking them to do a lot more in their practice than they would in the city.”
And new rules in the Medicare Access & CHIP Reauthorization Act of 2015 (also known as MACRA) will change the way many doctors are paid for a big chunk of their practice.
The new rules are expected to go into effect in 2017.
I feel like those of us who are independent providers — we’re not going to be around very long.
Eastland doctor Kevin Cunningham
DeLuca, who is vice president of the American College of Osteopathic Family Physicians, has visited Washington to urge officials to make the law more friendly to small-town doctors. Initially, he was concerned that it could put single practitioners out of business but now he sounds more hopeful.
“They are reducing the number of measures for quality and informational performance,” DeLuca said. “And if a clinician sends in some type of data, they will avoid a penalty.”
Lifestyle is another obstacle. Quite simply, doctors can make more money in a city and can often work fewer hours.
Any physician coming out of medical school is also likely to be carrying $100,000 to $300,000 in debt, according to the American Association of Medical Colleges, making it harder for small towns to compete.
“You have to start with who wants to move and live in a rural area,” said John Bowling, who retired in August as assistant dean and oversaw the UNT Health Science Center’s Office of Rural Medical Education.
“Statistics show the best way to recruit students is to find ones that are from there,” Bowling said. “That’s what we tried to do. But I recently lost two rural physicians [who] moved back to a more populated area because they don’t feel the school systems were strong enough for their kids.”
You have to start with who wants to move and live in a rural area.
John Bowling, former UNT Health Science Center assistant dean who oversaw the Office of Rural Medical Education
At his practice in Eastland, DeLuca said 75 percent of patients come from within the county while others come from as far away as Albany, Breckenridge, Strawn, DeLeon, Dublin and even Sweetwater. His wife, Valerie DeLuca, also decided to become a doctor and graduated from the UNT Health Science Center in 2011.
“The area is predominately Medicare and Medicaid,” DeLuca said. “Only 20 to 25 percent have health insurance. We have a lot of uninsured patients. We didn’t see a lot of that change when the ACA [Affordable Care Act] came out because they still couldn’t afford the premiums.”
As the only hospital along Interstate 20 between Weatherford and Abilene, Eastland deals with its share of accidents — fatal wrecks were commonplace until TxDOT made changes to the notorious Ranger Hill.
“It’s always difficult to keep a rural hospital open,” DeLuca said. “You’re always right on the edge. There are programs for rural hospitals. You have to have a good administrator to find those funds. We’re in good shape right now. We have six months of funds in reserve but it’s always a challenge.”
DeLuca is hopeful that more rural doctors will be coming from a new school of osteopathic medicine at Incarnate Word University in San Antonio as well as the UNT Health Science Center. Texas Tech University has funneled its share of small-town doctors across West Texas and has its own Rural and Community Health program.
Standing on the sidewalk in front of Eastland Memorial Hospital, Dr. Kevin Cunningham, 42, is also worried about the future.
“We’re still the hole in the donut,” Cunningham said. “We have a high uninsured population with a lot of need. Texas Health hasn’t got here yet. Baylor, Scott and White hasn’t got here yet and Hendrick in Abilene hasn’t gotten here yet.”
Like DeLuca, he grew up in the Metroplex, in Crowley. But Cunningham now has doubts about how long he can go it alone.
“I feel like those of us who are independent providers — we’re not going to be around very long,” Cunningham said. “We’re going to be bought up. We’re going to sell out. Whether the industry is going to make that happen or we’re going to be pushed out, I don’t know.”