The representatives of 28 nations got a surprise when they gathered in Charleston, West Virginia, for an international medical conference on aging in 2000. "We didn’t meet their expectations," grins Richard Kennedy, the executive director of Charleston, West Virginia’s chamber of commerce. That’s because no one anticipated such a sophisticated metropolitan atmosphere wrapped in a small town package.
Just as the Kanawha River ribbons through Charleston, yesterday’s stereotypes weave through the medical community in this state capital, both protecting and hindering daily practice. Robert Gray, the vice president at Thomas Memorial Hospital on the city’s south side, spends a lot of time separating myth from fact about this Appalachian city in order to convince doctors to visit.
To prove it, recruiters here invite prospects to attend a ballet performance or Charleston’s West Virginia Symphony, which enjoys the highest per capita symphony subscription rate of any American city. (It’s the only symphony in the country to also offer full-production opera as standard programming, too.) The Charleston Civic Center holds 13,500, and residents count on this venue to host headliners from Sesame Street Live to Alan Jackson to Def Leppard. And residents proudly escort you to the nearest window to point out their new $130 million arts center on the horizon. The finished building will house a 1,880-seat concert hall, art museum, science center, 70mm large film theater, planetarium, and other hands-on exhibits for visitors.
Internist Lakshmanan Rama, MD, swims frequently at the YMCA’s pool while his wife, a medical resident, is actively involved in the India Association of Greater Charleston. Thanks to the business community’s draw for Japanese-based companies like Toyota and NGK Spark Plug, this city also embraces a growing Asian-American population.
"We have a number of physicians that make up strong Filipino and Pakistani communities, too," says Gray. "There’s a mosque here for Hindus, which you usually have to travel to a much bigger city than this to find. That’s important for physicians who want their children brought up with cultural ties with their heritage. No one feels left out or alone."
Maria Rendinell Buechler confesses she bought into the perception of substandard public schools when she first moved to the city to work as the director of physician services for Saint Francis Hospital. She quickly backtracked when her children enrolled. She discovered that West Virginia has posted the highest education marks in Education Week’s Quality Counts report four consecutive years. And since the state implemented a classroom computer initiative back in 1989, today’s graduates have 13 years of computing experience under their belts. On average, 2,500 students graduate from Charleston public schools annually, which reflects a 97-percent promotion rate.
T. Edgar Huang, MD, a member of Charleston Area Medical Center’s pathology department, praises the class sizes - student-to-teacher ratios average 15:1 - as a way to allow his children more time to participate in extracurricular activities. "Everybody is more relaxed, with a happy family life," he says.
A 96 rating on the cost-of-living scale versus the nationwide benchmark of 100 means this city is affordable. Just $209,500 buys a 3,700-square-foot home with an indoor pool; $750,000 reaps an 8,000-square-foot custom brick mansion on three acres. Other lifestyle necessities look just as good in comparison. "When my in-laws visit from upstate New York, they can’t believe gas is only $1.50 a gallon," says Rama. "School, restaurants,house cleaning, dry cleaning - everything is at least 20 percent cheaper here." Transplants also marvel at the low crime rates. Indeed, FBI crime statistics rank West Virginia as one of the safest states with the lowest property crime rate of all 50 states and Washington, DC.
For organizations such as Business & Industrial Development Corporation (BIDCO) the area ’s plentiful and willing workforce is an important selling point. When BIDCO vice president Harry Mills recently ate lunch with EDS officials planning to set up operations in Charleston, the executives indicated they’d received more than a handful of unsolicited calls from job seekers.
Toyota fielded 30,000 inquiries for 300 openings at its nearby Buffalo, West Virginia site. And when AT&T announced it would close its call center in Charleston in 1995, the work production numbers actually increased, compared to other axed centers that dealt with sabotage. Thanks to the employee goodwill, the company not only rescinded its initial decision, it expanded employment opportunities here.
"We always have a reserve of people who’d like to return home to Charleston. If there’s a good job, they’ll come," says Mills. Currently, the state’s workforce ranks among the nation’s top 10 in worker productivity, adding $20,000 per year more production value per worker than the U.S. average. These statistics lured EDS IT consulting to town to join Toyota’s 1998 plant (now expanded to produce engines and transmissions for the Lexus RX 300 sports utility vehicle) and NGK Spark Plug, which has also expanded operations since arriving in 1995.
If workers want to come to West Virginia and find opportunities, Charleston’s tremendous recreational potential usually seals the deal. The four seasons lend themselves to outdoor enthusiasts who have discovered the mountains’ skiing challenges. And the nearly 200 miles of area rivers support world-class whitewater rafting. Of course, where there’s water there’s also canoeing, boating, and fishing. Birders travel from as far as Canada to seek out the 19 species of wood warblers that inhabit the Kanawha State Forest’s 9,300 acres. Conde Nast Traveler’s Readers’ Choice resort, The Greenbrier, is only a couple of hours’ drive away. In addition to $500-a-night lodging and pampering, The Greenbrier presents three championship golf courses and a Sam Snead Golf Academy. Naturally, such attention has attracted competitive resorts and golf courses to the area as well.
"Our foliage change in fall is magnificent," says Buechler. "The high mountains turn colors first, and it ripples down week by week."
No wonder Gray boasts a 70 percent signing rate among the doctors who make the trek. "Now they won’t leave for anything," he says, producing statistics that show only two doctors have left during Gray’s 20 years with Thomas Memorial.
Yet all specialties remain wide open, nearly begging for physicians. Since West Virginia ranks as the oldest state in the United States, beating out even Florida for the honor, many physicians have reached their retirement years. Buechler remains alert to bring in orthopedic surgeons, neurosurgeons, and urologists in particular.
On the younger side, West Virginia supports three medical schools within its borders and a significant number of residency programs. As a result, Gray often is able to recruit residents who train at his hospital. He estimates the city presently has 175 residents in family practice, internal medicine, pediatrics, psychology, and general surgery. That is, in part, why the average age of Thomas Memorial’s medical staff hovers at 37. Gray counts more physicians under 30 than over 50 at his organization. "But we’ve never put a family practitioner into practice that struggled to build his patient base," he adds. "It just doesn’t happen here."
Gray typically finds new blood through referrals. "I don’t like to recruit west of the Mississippi," he says. "You can’t bring a guy from Oregon who has no previous ties to West Virginia and make him happy. And I really don’t to go down much below the Carolinas."
Buechler finds a lot of interest from physicians in New York, and Southern California professionals looking to escape the stifling regulations. However, a majority of her recruits set up their first practices here.
Huang moved here from a northern suburb of Detroit, where he practiced pathology for more than eight years after finishing his training. "Charleston offered the opportunity to work as hard as before but under less stress," he says. Since his arrival in January 1997, he’s pursued a full-time clinical practice, as well as clinical assistant professor appointments at West Virginia University and Marshall University medical schools. "A lot of my current status was never going to be possible
at my old job in Michigan."
Rama selected this city four years ago from among offers in Texas, Florida, and New York City where he completed his residency. In early 2001 he switched from an outpatient practice to a hospitalist position with Saint Francis Hospital to maintain his edge. "An outpatient practice was very boring," Rama notes. "I had the feeling I was losing my in-patient skills and that I wasn’t keeping up with the technologies and advances. Now I see more varied illnesses and challenges."
Both doctors praise the patients they work with. "In New York, they want you to do this, this, and this. They are very demanding and stick to their opinion," says Rama. "Here I very rarely see a rude or disrespectful patient." He estimates that three percent of his patients come in with preset ideas on treatment paths, but even they still politely accept the doctor’s opinion and follow Rama’s
The aging population shakes out to a payer mix high in Medicare - nearly 70 percent of the overall picture, says Buechler. Medicaid accounts for between five and eight percent, and private insurance covers the remainder. Primary-care physicians can expect 55 percent of their patients to present Medicare paperwork. "That affects what they collect, obviously. But that doesn’t seem to be a concern with newer doctors, especially," she adds. The professional support from the physician community more than makes up for it in most of the conversations she has.
Gray emphasizes that physicians here make more money than their counterparts in bigger cities, thanks to the state’s incredibly low managed-care saturation: a mere 10 percent according to the West Virginia State Medical Association. The strong fee-for-service base throws back to the truth behind the state’s rural stereotype; West Virginia’s population is too spread out and underserved
for managed care to work. "For managed care to be successful, you need too many doctors, too many hospitals, and insurers bidding them off against each other," Gray explains.
On the contrary, according to Gray, "Volume is not our problem in 2001. Our outpatient programs are full every day. All 400 physicians on our staff are busy," he says.
The population structure makes the system a secure one for physicians in other ways as well. The steady patient stream evens out most Medicare financial pitfalls, and the lack of physicians and services in the rural locations earns numerous areas official status as medically underserved from the federal government.
Charleston city limits encompass three major hospital systems with an aggregate of 1,600 licensed hospital beds. Charleston Area Medical Center covers three campuses under its umbrella: a women’s and children’s hospital, General downtown, and the Memorial division at the south end of city. Saint Francis was purchased by Columbia HCA in 1995, but this for-profit entity agreed to abide with the Catholic health-care ethic in order to keep the recognized name. "There was a little fear about the change but we were able to meld the two philosophies quite well," Buechler reports. "Everybody has a bottom line, but to get to it you have to provide good, quality care."
Gray describes Thomas Memorial as a $200 million business, "big enough to have the latest in technology and still small enough to know employees and patients by first name. It’s neighbors taking care of neighbors." Thomas Memorial specializes in surgery, cancer treatment, and ob/gyn.
Saint Francis doesn’t deliver babies these days, but it does offer the city’s only wound care center and hyperbolic oxygen chamber. Meanwhile, as a tertiary center, CAMC’s campuses overlap with most of these areas, with a lock on trauma and heart surgery. "No one else tried to go there because they do it best and there’s no sense trying to fight it," Buechler says.
Most outsiders scratch their heads at such medical wealth for a city of 60,000. Even when counting all of Kanawha County and its neighbor, Putnam County, census takers only come up with 254,000 for the metro area. But because the next large cities are Cincinnati to the west, Charlotte to the
southeast, and Pittsburgh to the north - all more than 200 miles away and out of state - Charleston facilities see patients from all over West Virginia. This hub status only fuels competition between the hospital systems; if one purchases a PET scanner or nuclear camera, bet the others follow suit. "We try harder to stay updated," Buechler admits. Physicians, who typically carry privileges at two of the three hospitals, simply expect to have the tools to care for their patients from cradle to grave.
"My job is to put them out of business, their job is to put us out of business," says Gray. "But when it comes to two things - a threat from the outside or patient care concerns - we huddle together. If someone needs a piece of equipment, any of us would lend it without question."
The outside threat today swirls around malpractice issues. Although more than 60 insurance companies have the authorization to do business in West Virginia, only four actually waded into the liability morass currently clogging court dockets. In 2001, Insurance Commissioner Jane Cline nixed OHIC’s 75 percent requested rate hike but approved a 15 percent rate increase for St. Paul. Medical Insurance anticipated winning a 30-percent rate hike by the end of the year. Medicare
data shows the state now has the second highest premium rates in the nation behind Michigan. An ob/gyn in Charleston would pay $80,000 annually for the same coverage a colleague in Ohio gets for $46,000, in Kentucky for $40,000, or in Virginia for $25,000, says Evan Jenkins, the executive director for the West Virginia State Medical Association (WVSMA).
Then the other shoe dropped: In late August, St. Paul dropped ob/gyn and ER physicians nationally.
The hospitals and WVSMA gathered to meet with the governor for emergency relief. Jenkins is fighting for several long-term solutions, beginning with predictability in the legal environment. "We are doing amazing things in medicine and sometimes you’re a victim of your own success. We’ve created an expectation of a perfect outcome every time, and that’s not always possible," Jenkins explains. He says the case outcomes are not always bad, but the cost of the suits is still
prohibitive. "We have a significant number of suits dropped or the jury returns a verdict vindicating the doctor. But the insurance company can spend well over $100,000 defending
these baseless claims."
Step two involves working with the Board of Medicine to develop tighter quality-of care parameters to help ensure poor doctors are weeded from the system. And finally, WVSMA is pushing to take better control of this profession’s destiny by proposing a mutual insurance program. Jenkins cites the Kansas Medical System as a model, where physicians obtain primary insurance coverage up to $200,000 to $300,000 from the private sector commercial market. A state-administered fund covers up to $1 million as secondary coverage. In a nutshell, physicians capitalize it and manage their own risk. "Our doctors aren’t so naive to think that we can be successful in a climate where the professional insurance folks are not," he says. But when coupled with liability reforms on the table, it’s certainly worth a feasibility study in his book.
The association has strung up recent victories in the legislature. The state has repealed it’s two-percent provider tax to fund the Medicaid program. Starting July 1, 2001, the tax dropped to 1.8 percent and will decline by .2 each year until it is just a memory. WVSMA also won a prompt payment proposal and uniform credentialing applications.
"Getting physicians together is like herding cats," says Amy Tolliver, a government specialist with WVSMA. "But once physicians get involved as a group, we have a tremendous momentum. "There’s frustration but an enthusiasm, too. Our meetings are better attended than they’ve been in years. They recognize this is a ’fight for your practice and patients’ moment or you won’t survive."
One of the most difficult truths facing West Virginia is revealed in the studies labeling it one of the most unhealthy states in the country. A study by the Office for Social Environmental and Health Research at West Virginia University and the Centers for Disease Control and Prevention in 2001 discovered men over 35 are most likely to die from heart disease in Mississippi, West Virginia, and Kentucky in that order. Buechler notes the city is also high in diabetes cases. More than 25 percent of Charleston’s population smokes cigarettes; more than 30 percent of people age 18 through 54 use tobacco. The habit costs Kanawha County residents $289 each per year. To help the situation, WVSMA has poured $125,000 of its received grant money into tobacco use education programs.
Perhaps West Virginia residents’ poor health is one reason the doctors are so busy. It also means the doctors have their work cut out for them if they want to help dispel the stereotypes that cling to the state like the fog that clings in the mountain valleys around Charleston.
Julie Sturgeon is a regular contributor to Unique Opportunities. She wrote "Handling the Well-Informed Patient" in the September/October issue.