In rural Georgia, Senate study committee looks at how to address medical workforce concerns

The Georgia Senate Rural Medical Personnel Recruitment Study Committee convened for its first meeting on Wednesday at the Northeast Georgia Medical Center Habersham in Demorest.

Committee chair Sen. Bo Hatchett of Cornelia said the study committee focuses on recognizing issues affecting rural Georgia regarding the medical system before deciding what they’ll potentially concentrate on for the 2024 legislative session.

“What this study committee is going to do is first take a broad approach with this meeting in identifying some issues that we’re seeing across the state and rural areas, and trying to pinpoint things that this committee believes the state can help with,” he said to the committee. “As we move forward, we’ll take a more surgical approach with some issues we identify that we’re particularly interested in.”

The study committee heard testimonies from several speakers with state departments, non-profit organizations or committees, and those with experience working in the medical field about issues they see affecting the rural Georgia area.

Rural breakdown

One speaker at the meetings was Nita Ham, director of the state Office of Rural Health with the Department of Community Health, who provided the study committee an insight into rural Georgia medical setup by map.

According to Ham, of the 159 counties in Georgia, 120 are classified as rural, meaning they have a population of less than 50,000.

“Out of all the people that live in Georgia, only about 26% of Georgia residents live outside of our urban centers, and every year, our rural population continues to decline,” Ham said. “However, we have a higher death rate for heart disease, stroke, cancer, motor vehicle accidents, and an increased prevalence of chronic conditions.

Ham explained that in the 120 rural counties, there are 67 small rural and critical access hospitals. When broken down, Ham shows that the real problem lies in the lack of hospitals in many of those counties.

“Those [67 hospitals] are broken down into 37 rural PPS (Medicare Protective Payment System) hospitals and 30 critical access hospitals,” she said. “Fifty-four counties do not have rural hospitals at all; we have clusters of counties with no hospitals anywhere in sight.”

According to Ham, these 54 counties are classified as Health Professional Shortage Areas, which “is a shortage of primary care, mental health and dental health providers in a geographic area population group or facility.”

The Health Resources and Services Administration (HRSA) requires that the State Office of Rural Health calculates and updates the HPSA scores every three years, and, Ham said, “the higher the scores, the higher the needs.”

According to a map Ham presented to the committee, “the map indicates that 88 of 120 rural counties scored in the high levels between 15 and 25.”

To address issues with staff shortages, Dr. Zachary Taylor, the district health director for District 2, which goes from Cherokee County up through Whitfield County, spoke to the committee at the Georgia Department for Public Health.

Staff issues

Taylor's focus on staff shortages involved public health nurses within his district who are what they call expanded role nurses.

"They are a nursing graduate who comes out of nursing school or even a nurse who has worked in a hospital for several years and is not ready to be a public health nurse because of the expanded role that they have, which involves essentially assessing patients and providing treatment based on protocols that are developed and they have to have training for," Taylor said.

He further explains their responsibilities: "We don't have a public health nurse until they've been with us for nine months to one year. They access and provide treatment, make referrals, give vaccinations, and follow these protocols, or they contact me, and I give them directions on treatment or assessment of the patient or further referral for that patient."

Some staffing difficulties with hiring nurses in the district come from the disconnect between what younger people seek in a job.

"We do have good benefits or the same benefits state employees enjoy that includes medical, dental, vision, 13 holidays, paid annual and sick leave, and a 401k match program and even a pension, if you work for us long enough," he said. But, he added, "Younger people aren't concerned with those things, so attracting and hiring a younger workforce has a struggle."

Another factor drawing young people away is wanting the flexibility of shift work over set office hours 5 days a week. Taylor explained that the lack of tuition reimbursement programs specific to public health is yet another concern.

"We can, in some instances, access the HRSA (Health Resources and Services Administration) programs for tuition reimbursement to pay for their schooling, but most of our nurses that we hire are not coming directly from school, and that's less of an issue for them," he said.

Pay is also a struggle affecting staffing.

"We start our nurses at $49,000 to $59,000, and we go up $63,000 to $66,000 for nurses who have been with us longer and have completed all of the training required to become a public health nurse," Taylor said.

However, the fixed pay of $66,000 is usually the starting pay of a new nurse out of nursing school at a hospital, and Taylor brought awareness that their pay is lower than what nurses can earn in the private sector.

The commute to work for many nurses who may live in one rural county but work in another also affects staffing shortages. This factor was especially concerning during a period of rising fuel prices.

"If they have an opportunity to work closer to home, they'll take it," Taylor said. "We had a real problem when gas prices were much higher last year. We lost several people because of the cost of their commute."

When asked by committee member Sen. Kim Jackson where District 2 currently was with staffing, Taylor said, "In our district, just talking about our rural counties, we have about four open positions."

He added, "In a county like Habersham, we have about three public health nurses, so in smaller counties, we may only have two. We try to have more than one because there's no coverage at all if they're sick or on vacation."

Hospital closures

CEO of Hometown Health, Jimmy Lewis, provided insight into the factors contributing to hospital operations and what leads rural hospitals to close down.

Hometown Health is a self-funded organization formed around 1999 to do whatever it takes to save rural hospitals from closing, per Lewis at the committee meeting.

"The function that we provide is that of a resource of many facets that include anything non-clinical," he said. "We don't get involved in the clinical side of the hospital because that's a little over our pay grade. Rather, we deal with the operational, reimbursement and financial side of what goes on."

The height of COVID-19 and the pandemic showed that Hometown Health was dealing with hospitals that couldn't make payroll and struggled to do so, so in turn, they needed the federal government's assistance, which didn't benefit them in the long run.

"The federal government came down and gave us a lot of money, and that was good for the time it lasted," he said. "Then we found out they wanted it back, and when they wanted it back, it's hard to take back money from an operation; it's so difficult to deal with. From a financial stress standpoint, we then had — and today now have — many hospitals operating with less than two days' to 10 days' cash. And if you're running a $20 million operation with 10 days cash, I don't have to tell you what kind of pain that is."

Inflation rates are also dragging rural hospitals down because they can range from 4% to 6% to 10% to 12%, and most of the time, hospitals are in fixed contracts that they cannot change.

"If you've got fixed contracts that you don't have the opportunity to negotiate, a higher rate and inflation going up at 10% means you can't get another 2% in the next five years," he said. "You're automatically putting yourself out of business."

The following is a list of hospitals "that could close at any given day depending on what happens with the particular operation in the hospital," according to Lewis:

• Dooly County (Vienna)
• Hancock County (Sparta)
• Telfair County (McRae)
• Calhoun County (Arlington)
• Stewart County (Richland)
• Charlton County (Folkston)
• Wheeler County (Glenwood)
• Hart County (Hartwell)
• Gilmer County (Ellijay)
• Lumpkin County (Chestatee)
• Banks County (Commerce)
• Randolph County (Cuthbert)

Lewis says at least six more hospitals that are not on the list could close as well.

The study committee scheduled its second meeting for Oct. 24, 2023, at the Medical College of Georgia at the Augusta University Medical Center.