- Policy & Research
- About KHI
Sept. 2, 2008
GREELEY COUNTY There are fewer people here than anyplace else in Kansas.
That makes it the most "frontier" of the state's 31 counties labeled so by demographers because they have fewer than six inhabitants per square mile.
Tribune, the county seat, holds 835 of the 1,534 residents, according to the 2000 federal census. It is situated in sagebrush and corporate dairy farm country on the high plains, 150 miles from the nearest shopping mall, closer to Denver than Wichita or Topeka, but not all that close to Denver.
Tourists, including some willing to pay $450 a day for a guided hunt, show up in fall and winter to shoot pheasants or maybe antelope.
Many doctors and other health care professionals won't consider work in remote places like this because the loads tend to be heavier, the pay lower and the professional and personal amenities sparse compared to those found in cities and suburbs.
Because there are few specialists in places like this, it's not unusual for doctors from cities to make rounds in multiple small towns, flying in and out with their own small airplanes.
Civic leaders from frontier counties in Kansas and elsewhere around the U.S. prowl for doctors to recruit, part of the struggle to keep their communities from becoming ghost towns.
→ Currently reading: Overcoming health care problems in rural Kansas
Various dusty task force reports show that rural decline has been a topic off and on at the Kansas Statehouse and other places where policymakers gather on the Great Plains for going on 30 years. But no one seems to know how to reverse it. Some consider the problem intractable.
In 1930, the beginning of the Dust Bowl, there were more than twice as many people living in Kansas" frontier counties as there are today. Those still left are older on average than other Kansans, which usually means sicker.
Dr. Michael Kennedy, a rural health expert at the University of Kansas School of Medicine who has practiced rural medicine himself in Burlington, predicts "a perfect storm" will arrive in Kansas about 2016. That's when a wave of current rural doctors is expected to reach retirement age coincidental with the Baby Boom becoming the Geriatrics Boom.
If everyone who enrolled at KU to become a doctor next year graduated seven years later and moved to rural Kansas to practice medicine, that still wouldn't be enough doctors to meet the crisis Kennedy and others see on the horizon.
But there are a few notable successes despite that backdrop of problems, including one here in Greeley County, that some say might one day serve as a model for providing rural care in Kansas and elsewhere.
Unlike some remote places that struggle to keep one doctor, Greeley County Health Services now has four physicians with a fifth scheduled to start work next month. That will be about one doctor for every 300 people in the county. One of the newest to arrive to Tribune, Dr. Robyn Liu, is a young woman with a Harvard degree who chose this place over Portland, Ore. Those who hired her say she could have gone anywhere.
The system here, which once consisted of a hospital and a single doctor in private practice, now is the umbrella organization
for the five doctors, two hospitals, two nursing homes and three clinics, all stretched along a 60-mile corridor of Highway 27. It serves about 15,000 patients, most from three small towns and three counties abutting the Colorado border. The emphasis is on "a continuum of care."
Greeley County Health Services employs 163 people, 50 of whom were added in the past three years. It is Tribune's largest employer. The town has formed an "action committee" to do something about its housing shortage.
There's been some reversal here of the rural brain drain. Two of the system's young administrators, Chris Ekrem and Jeff Colburn, employees of a Greeley management subsidiary called Southwind Health Resources,
came from the California cities of Newport Beach and San Francisco after they heard about the interesting things happening here.
"This place is crazy. It's totally in love with itself," Liu said, describing the attraction of living and working in Tribune, despite first interviewing here when it was "12 degrees and the wind was blowing 40-50 miles per hour.
"Here we felt like they were a team, doing something that was demonstrably making the town better," Liu said, explaining why she and her husband chose Tribune over trendier and much bigger Portland.
Liu, who has special interests in obstetrics, preventive medicine and alternative transportation, said she and her husband also like the fact they can bicycle around town and leave the car parked.
"We don't drive in town," she said. "We ride bikes or walk."
Her husband, an artist, is helping renovate the town's movie theater, which was recently purchased by the community and is run by volunteers.
Liu, 32, is fondly referred to by some as "our hippie doctor."
The entire Greeley County Health Services system is using electronic medical records that give workers at any of its locations access to patient records. Having demonstrated its success locally, Greeley, through its Southwind subsidiary,
at the beginning of the year began offering management services to other hospitals, including those in Syracuse and Kinsley, where it also manages a rural health center and a 10-bed psychiatric unit for geriatric patients.
Those hospitals also will have access to the digital records system. That is beyond what some hospitals in larger communities are doing, cutting edge stuff in the medical industry, which has computerized slower than most.
"They would be considered one of the industry leaders in terms of utilizing the technology that is available," Chad Austin of the Kansas Hospital Association said, describing Greeley County Health Services' information technology. Lead administrator Todd Burch said Greeley plans further upgrades to its digital system.
Those who live here also are impressed with what they've got and say it has lured new residents to the community.
"It's easier here with health care than almost any place in the world," said Dan Epp, co-publisher of the hometown weekly newspaper, the Greeley County Republican. "Not only can you get in to see the doctor, but they know your name. That's attractive to retired people, as well, so we've had a number of retired people who have moved here, some coming back to the community. We have a woman now in her 50s looking for a house to buy because her parents moved here and are retired."
How it happened
What happened here? The simple answer is one provided by Chrysanne Grund, whose job includes grant writing for Greeley County Health Services and overseeing the community's annual women's health conference
"This is the house that Bob built," Grund said.
Bob is Dr. Robert Moser, the 2006 Kansas Academy Family Physician of the Year, a hometown boy who came here after graduating from the KU medical school and completing his residency in Salina in 1988.
Most people here and elsewhere credit Moser for getting the ball rolling.
Moser said he and his wife they both grew up here came back to Tribune after he finished medical school never intending to stay. They thought he would work off his scholarship obligation to doctor for a while in an underserved area and then leave.
"The final determinant was that I owed the state four years," Moser said. "We thought we'd go to Tribune and then four years later move back to Lawrence. Twenty years later, we're still here."
For about two years, after the town's older physician unexpectedly left for a job in Rawlins County, Moser was on call around the clock.
In that interval, he also became the doctor for nearby Sharon Springs after that town's physician retired. He also saw patients for a while in Leoti, another nearby town, after they lost their doctor.
By the time Dr. Wendel Ellis was recruited in 1993, Moser was seeing 40 patients a day, missing Christmases with his family to deliver babies or handle other calls.
"My wife kind of mentioned she might send me a postcard from where they were moving to" if he didn't get some backup, he recalled.
Moser and Ellis are generally viewed here as the Batman and Robin of Greeley County Health Services, a dynamic duo that became the cornerstone of what the organization now is, a group of progressive and community-minded health professionals, committed to delivering quality care to all in an unlikely place.
From the outset of his work here, Moser insisted he be on salary to the Tribune hospital instead of being in private practice.
"When I moved out, the older doc thought I was going to be his employee," Moser said. "I said, no, that's not the way it's going to be."
That tradition has carried through as Greeley County Health Services developed and grew. All the doctors are salaried by the non-profit agency, instead of operating private practices. The doctors praise that arrangement, saying it frees them to focus on medical decision making instead of business worries.
"Dr. Ellis calls it 'recruiting like-minded people,'" Moser said, explaining the core beliefs that animate the people who work here.
"Nobody goes without care here," boasted administrator Burch, the man who manages the business side of things while the doctors focus on practicing medicine.
More than half the patients are on Medicare. Less than 5 percent are on Medicaid. The rest are privately insured or pay their own way.
Burch said fees for those paying their own way are based on a sliding scale that pegs off federal poverty guidelines. Those earning
less than 100 percent of poverty but uninsured by government programs are not obliged to pay.
Austin and others credit much of Greeley's success to the shared vision of the administrators and doctors. Burch and Moser have a close working relationship.
"Isn't that amazing what they've done," said Kennedy, the KU rural health expert. "That's a model that actually seems to work pretty well. It takes a great deal of cooperation and a tremendous amount of community support. The success of this is quite recent, within the last five or 10 years. I think it just might be emerging as a model," that could be used in other rural, underserved areas.
Kennedy said there are two other places in rural Kansas with similarly dynamic health care operations: Quinter and Burlington. Each has four or five very committed doctors. In Quinter, two of the doctors are a husband-wife team.
Kennedy said one of the keys to make the systems work in Greeley, Burlington and elsewhere, is enough doctors so that each is able to carve out enough time to have a life outside work.
"If you have doctors who are going to share on-call responsibilities, you're not going to get stranded," doing everything yourself, Kennedy said.
In Tribune, Dr. Randall Farenholtz had enough spare time to build his own airplane from a kit.
Dr. Ellis and his wife have spent the past five years doing hands-on remodeling of the town's old Lutheran church into a large and unique home for themselves and their four home-schooled children.
Exception not the rule
Kennedy called Greeley, Quinter and Burlington 'shining stars,' exceptions to the problem of finding enough doctors for rural Kansas.
"It's quite bleak, actually," he said.
Kennedy said KU graduates a higher percentage of primary care doctors than any other medical school but that's still a minority of graduates.
He said high education debt discourages students from choosing primary care over specialty practice, which can pay twice as much.
He and Moser both predicted rural doctors will become more scarce unless the federal and state governments revise their Medicare and Medicaid reimbursement schedules to help correct that imbalance.