Dr. Jeffrey Tindall and Connie Tindall
Difficulty of attracting and retaining healthcare providers in rural communities
Dr. Tindall: I grew up here in Potosi, Missouri. It was the kind of place where kids could ride their bikes all over town without parental supervision. My friends and I would regularly ride to the Ben Franklin on Main Street to buy candy because they had the best selection. I still wonder whatever happened to peach Jolly Ranchers? Those are happy memories for me. But if you didn’t grow up here, if your family isn’t from here, it is really hard to convince a doctor to come live and work here.
Washington County used to be one of the poorest counties in the state, and we’re still in the bottom 25%. If you don’t have anything tying you to the area, you have no reason to come. And if you do manage to find a doctor who will live here, their spouse isn’t likely to agree. Besides the lack of restaurant choices, which is a particular pet peeve of my wife’s, the very high Medicaid population makes it hard for doctors to earn a living. Without the state’s Rural Health Clinic program, it would be practically impossible. I know a doctor in Farmington, for example, who doesn’t work at a rural health clinic, and he was griping about how the transportation service that brought a patient to his office got paid $70 while he only got paid $7.42 to treat that patient because they were on a bad ‘managed Medicaid’ plan. You can’t afford to treat very many patients at that rate if you want to keep the lights on.
In my experience, ‘regular’ Medicaid usually pays more like $12 to $18 per visit, whereas private insurance pays between $50 and $100. That’s a big difference. So if you’re just coming out of school and deciding where to start your career, are you going to choose a town with one restaurant and a high Medicaid population, or will you go work where each patient pays $50 to $100 per visit? The answer is pretty obvious. Honestly, without the Rural Health Clinic program, a doctor couldn’t earn a living here.
Different kinds of rural health clinics
Dr. Tindall: There are two types of rural health clinics. Everything is the same except for who owns them. If you’re a hospital-owned rural health clinic in Missouri, you get what’s called cost-based reimbursement. That means at the end of the year if it costs you $300,000 to run the clinic and you only made $200,000, they give you the difference back so you break even. That’s a pretty good deal. Unfortunately, it doesn’t work that way for independent rural health clinics, like ours. We don’t have the lobbyists that hospitals have. So if it costs
$300,000 to run our clinic, and we only make $200,000, it’s just too bad. We’re short $100,000 dollars. The benefit of having an independent rural health clinic is that at least the state tries to make up the cost difference between the rates Medicaid pays and the rates you could expect from a private insurance company. That raises the Medicaid rate to somewhere between $60 and $80, which is a lot better than $18.
So, the reason it’s worth jumping through all the hoops to become a rural health clinic is illustrated by the difference between my clinic and that doctor in Farmington I mentioned. We get paid about $78 per visit for regular Medicaid. Sometimes it’s less for the managed Medicaid companies, but it’s still not $7.42. So it’s worth all the effort to become a rural health clinic if you’re going to live here. You really couldn’t survive otherwise. The idea behind rural health clinics is to close the gap in reimbursements between rural Missouri and the more desirable places to practice, and that makes it possible for doctors to be here. Otherwise, we might all be living in Frontenac.
In business with her son for nearly 18 years
Connie Tindall: My son got hired at the hospital-owned rural health clinic right out of medical school. He said, "Mom, can you come run the office?" I thought, "How many sons actually ask their mothers to work with them? You know, most don’t even want to see their moms. They just move away." I thought, "What a compliment." Having had 25 years of teaching at that time, I was able to retire and I told him, "Okay, I will."
We were there for 15 years, but in the span of about 18 months, three of the doctors died, one retired, and one moved away. By the end, my son was one of only two doctors left there. He was taking hospital calls every other night and every other weekend. Eventually, he said "They keep promising to recruit more help, but nobody will take the job. Something has got to change. My daughter doesn’t even recognize me anymore.” So, three years ago we set up our own rural health clinic down the street, and now he has his life back. He still loves the people at the hospital, but he loves his daughter more. Now he gets to watch her grow up. Between our time at the hospital clinic and here, we’ve been working together for almost 18 years now.
Serving health needs in rural communities
Connie: A lot of doctors will not take Medicaid. They just say, "Oh, I’m sorry, we don’t take your insurance." So that’s why we’re here. Patients will ask, "What am I going to do?" Some doctors tell them, "Why don’t you call the hospital and get in with one of their doctors, or call Dr. Tindall’s rural health clinic? He’ll be happy to see you."
About 45% of our patients are on Medicaid. Most of them don’t take good care of themselves, and that’s probably because of access, their socioeconomic situation, and the fact that
nutrition isn’t taught well in our schools. Bless their hearts. Many are overweight. They come in, and you try to tell them how to improve their diet, but because of their finances, they can’t afford it. So then you have to give them medicine. My son gives every patient who’s overweight and diabetic the "here’s the good diet" talk. One lady dropped her blood sugar from 400 to normal in four days by following that diet. I gave her a big hug. I couldn’t believe it. I can assure you, this doesn’t happen very often, but she didn’t want to have to take medications. It has to be the patient’s decision.
We actually had one man who said, "No, I want to eat donuts and cake and ice cream after supper, before bed. Just give me an insulin pump." So I see a lot of folks who would rather take medicine than change their behavior. It’s easier to run through a fast food restaurant than it is to cook a healthy meal at home. Healthy food is available, but it’s more expensive, and not the kind of food they’re used to eating. Often the problem is making a lifestyle change.
Rural communities face significant challenges
Connie: We’re one of the lowest income counties in the State of Missouri. It’s hard to make a living here. There aren’t a lot of companies available offering jobs. There’s the shoe factory and this new company out at the edge of town that does all kinds of embroidery on hats and shirts. The prison is always hiring and can’t keep people staffed because of how dangerous it is to work there. There’s a new state warden who prioritizes the inmates over the guards so most of the seasoned ones have quit. Those who are left are all working constant mandatory overtime.
We also have a lot of people on disability. Some of them really need it, but there are plenty who are gaming the system. We see it every day. As part of the patient’s history, my son will ask what caused them to be disabled, and you’d be surprised how many of them don’t even know. They’ll say their lawyer took care of that stuff. I think if I had injuries so catastrophic that I could never again be a productive member of society and have to rely on others to support me for the rest of my life, I could probably remember what caused them. That can be a bit frustrating, but it’s also just sad. They don’t understand how much more there is to life if they would just get up the nerve to try.
Teaching health and the desire for change
Connie: When I taught in St. Louis, I taught health. I watched kids go to rehab for drugs and then come back completely clean. And what did they do next? They’d run back to the same group that got them into drugs in the first place, and in a few weeks, they were right back where they started. It’s really sad. I watched it happen over 20 years in Jefferson County.
I had a man from Alcoholics Anonymous come into class to speak to the kids. He lost his house, his car, his wife, his kids, and his job. But he said, "It wasn’t until I woke up in a gutter naked one morning and didn’t know how I got there that I said, 'This has to change.'"
That’s what I mean — you can’t force change on people. We can try to help, but they've got to want it in their head, and it’s got to be their decision.
Moving to Potosi
Connie: My husband was a lawyer in Charleston, Missouri, and he couldn’t stand it there. He had a very good law partner, but my husband didn’t like the area because it was flat with no trees. His law partner, who was old and well to do, built his house on the highest hill in the county. It was only three inches higher than any other place in the county, so that tells you how flat it was. And the farmers really liked it that way because it was wonderful for growing their cotton, corn, rice, wheat, etcetera. My husband was a country boy, and he missed his hills and trees.
Well, he and I were driving around one day and ended up in Potosi. We went into a little restaurant on Main Street and started visiting with this man who said, ‘I’m the prosecuting attorney, and I need help. If you move here, I’ll make you the assistant prosecuting attorney of Washington County.’ This was one of those God moments — it seemed so serendipitous for us to just walk into a restaurant, strike up a conversation with some random person, and then find out that not only was he the prosecuting attorney, but he was so overwhelmed with work that he was willing to offer my husband a job on the spot. We felt like it must be a sign from God, so my husband said, ‘I’ll take it.’ And two weeks later we moved.
Patients are like family
Connie: We moved to Potosi when my son was nine months old. When you go to medical school, you have to write an essay on why you want to be a doctor. His grandpa was a little hometown doctor, so my son wrote, ‘I want to be a hometown doctor like my grandpa. I want to take care of people from the time they’re born until they die.’
We take one-day-olds all the way to 99-year-olds and older. And we even go to their funerals. We know about our patients’ lives. They’re our family. It’s not a cold exchange where you go in this room, you see a different nurse practitioner every time, and you finally see a doctor years later. I see our patients in Walmart, and they give me a hug. I don’t know that all rural health clinics are that way. Some of them have four or five nurse practitioners, you see a different one every time, and you don’t build up that relationship. But my son’s very caring and he listens and talks about people’s kids and their dogs and their lives. So I would say we’re kind of unique in that sense.
We have a very loving staff, too. They will bend over backward to get referrals to another doctor and to get medications in on time. Some of our patients have been coming the entire 17 plus years we’ve been open. They’ll say ‘I tell all my friends I wouldn’t go to anybody else.’ Patients can call and say, ‘I’ve got a bladder infection. Can you send in some medicine?’ And we don’t say, ‘No, you have to be seen.’ ‘We say, sure, we’ll send something in.’ It’s not all about the money, so why make them come in when they were here just two weeks ago? That’s how you kind of make them family.
Following in the footsteps of an old country doctor - Jeffrey's grandfather
Dr. Tindall: My grandfather started practice as a country doctor in Jackson, Missouri back in 1940. He was one of the only doctors left in town during World War II, so he had no shortage of patients. Back then, the government tried to leave one or two doctors behind to serve the town while the rest were called up for the war effort.
My grandfather took care of a lot of people over his career and maintained a solo practice until
he retired in the 1980s. He was the old-fashioned country doctor you see in the movies. He made house calls regularly and delivered babies at people’s homes in the middle of the night. It was a different time then. It means a lot to know his history and to carry on that tradition in at least some small way as a country doctor serving another rural community in need.
Dr. Jeffrey Tindall and Connie Tindall
Midwest Rural Convenient Care