Arizona Physician Summer 2021 - FREE

Summer 2021

A P U B L I C AT I O N O F T H E M A R I C O PA C O U N T Y M E D I C A L S O C I E T Y

Rural Health Champion Holly Rooney, MD, of Globe shares her passion for rural health

10 Physicians across

the state share their experiences working in rural health

“

Village Medical is paving the way in value-based primary care. As a physician-led, operationally supported organization, Village Medical delivers high quality and cost effective care that patients need and deserve.

”

- Jared Berkowitz, MD

At Village Medical, we know the more you can connect with patients, the better care they receive. That’s why we empower providers with a patient-centered, tech-enabled model backed by a clinically integrated care team, to help you deliver better outcomes at a lower cost.

If you’re looking for a change, we’re hiring primary care physicians and advanced practice providers right now, in: • Apache Junction • Avondale

• Cave Creek • Gilbert

• Glendale • Mesa

• Peoria • Phoenix

• Scottsdale • Tempe

Join the team that’s transforming primary care.

To learn more, contact Vice President of Business Development Sam Martinez at smartinez@villagemd.com.

© 2021 Village Medical

CONTENTS IN EVERY ISSUE 4 | From the MCMS Board President VOLUME 3 • ISSUE 3

6 | From the Editor-in-Chief

Editor-In-Chief

8 | Briefs

John McElligott, MPH, CPH

Managing Editor

22 | What Arizona Docs are Saying

Edward Araujo

26 | Legal Corner

Creative Design

28 | How To

Randi Karabin, Karabincreative.com

30 | Physician Spotlight

Cover & Physician Profile Photography Advertising

Maricopa County Medical Society Board Members

Read how a small team of physicians are creating a large impact in rural Willcox.

President John Prater, DO

Immediate Past President

22

Lee Ann Kelley, MD

Treasurer & President-Elect Ricardo Correa, MD, ESD, FACP

18 C O V E R S T O R Y

Secretary

Rural Health Champion: Holly Rooney, MD, of Globe shares why she’s passionate about working in rural Arizona.

Anne Maiden-Hope, DO, FAAP Jane Lyons, MD Gerald Golner, MD, FAAP Rahul S. Rishi, DO, FAAAAI, FACAAI Shane Daley, MD, FACS Zaid Fadul, MD, FS, FAAFP

Dan Derksen, MD, Director of University of Arizona’s Center for Rural Health shares the state’s current rural health outlook.

Small Medical Team has Big Impact on Willcox

ads@arizonaphysician.com

Directors

Moonshot, Upshot, Hot Spot, Bullshot

14

Ben Scolaro, scolarodesign.com

Karyne Vinales, MD

11

What Arizona Docs are Saying

10 physicians across the state share their experiences working in rural health.

Resident & Fellow Director Anchit Mehrotra, MD

Medical Student Director Kristen Bolte, OMS-III

Digital & Social Media arizonaphysician.com ArizonaPhysician @AZPhysician @AZ_Physician

A R I ZO N A P H Y S I C I A N . C O M

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FROM THE MCMS BOARD PRESIDENT

“ M E D I C I N E S C U R E D I S E A S E S , B U T O N LY D O C T O R S C A N C U R E PAT I E N T S .” — C . J U N G

T

he best, the most competent and the most courageous of us finds a way into a career in rural medicine.

As a rural practitioner you must be able to handle every patient presentation - young, old, complex - that finds its way to your office.

My dream was to be a rural practice doc in Sugarcreek, Ohio. At Christmas time the downtown area of Sugarcreek looked identical to one you might find in Switzerland. The rolling farmland was beautiful, the people genuine. I wanted to get flavor of what practicing in a small community like that was like and looked for a rural rotation.

As a fourth-year medical student I had the distinct privilege of working with two family doctors in Middlefield, Ohio, a farming community made up of roughly 50% Amish inhabitants.

That was one of the most difficult rotations from a work standpoint that I was confronted with as a medical student. One of the physicians was the county coroner and handled all the unexplained deaths which had occurred in the community. Both doctors handled all the newborn deliveries, all the admissions including heart attacks at the small community hospital and conducted office visits 5 days weekly. It was very exciting as a young student to learn from these physicians and participate in the care of their patients that I requested the school extend my rotation with them, which they approved.

Knowing what I know now, I can look back on those experiences with not only admiration but with the knowledge that practicing in that setting really does command the care of a highly skilled physician.

But today, like those days 40 years ago in rural Ohio, a need still exists for physicians to practice in small town America. For all the difficulties that care in this setting encompasses, it is richly rewarding in the partnerships that can develop with patients and their families through generations. It demands we use the best of our instincts and hands-on care of patients over the use of technologic innovations. It provides a wholesome environment in which to raise a family, 4

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and one in which the values that have made America what it is today can still be found. And these days, given the need that exists in these communities, physicians find themselves enthusiastically welcomed and handsomely reimbursed for their services. I have worn many hats since medical school graduation, but the most satisfying has been to be in private practice and govern my own professional life.

Life circumstances did not allow me to realize my wish to practice in Sugarcreek. But I would encourage medical students to involve themselves in rotations such as have been recently offered at the University of Arizona College of Medicine Professions Program and see if it dovetails with their career aspirations. We need more physicians in these settings, not “providers” that I fear will be using the lack of adequate health care coverage to expand scope of practice privileges, which will compromise the level of care provided in rural settings.

Respectfully,

John Prater, DO

Dr. Prater moved from Ft. Myers, FL to Phoenix in 2017 and shortly thereafter became a Director on the Board of Maricopa County Medical Society. He was active at the state and local levels of organized medicine in Florida for decades where he served in several physician leadership positions, including President of the Southwest Florida Psychiatric Society and President of District Eleven of the Southwest Florida Osteopathic Medical Society. He is a board-certified psychiatrist currently practicing at the Phoenix VA Medical Center.

Creighton’s four-year medical school in Phoenix is now open.

Medicine | Nursing | Occupational Therapy | Pharmacy Physical Therapy | Physician Assistant Creighton has expanded in the Southwest with a 183,000-square-foot, state-of-the-art interprofessional campus. The expansion makes Creighton the largest Catholic health professions educator in the nation, and we’re proud to bring a full range of health sciences programs to the region.

This expansion was brought to life through the Creighton University Arizona Health Education Alliance, a partnership between Creighton University, Dignity Health St. Joseph’s Hospital and Medical Center,

Learn more at creighton.edu/phoenix

Valleywise Health, and District Medical Group. The Creighton Alliance will provide access to high-quality teaching environments for Creighton students and residents, and it’s a natural extension of our mission.

As a Jesuit, Catholic university, Creighton has been educating changemakers for more than 140 years.

We’re proud to continue that tradition in Phoenix as we partner to help passionate students become compassionate professionals.

The Creighton Alliance includes:

FROM THE EDITOR-IN-CHIEF

T H E R OA D L E S S T R AV E L E D “Two roads diverged in a wood, and I – I took the one less traveled by, And that has made all the difference.”

—An excerpt from “The Road Not Taken,” a poem by Robert Frost It is easy to become set in your ways. I often take the same route to work each day, knowing it is safe and efficient. My wife and I tend to shop at the same grocery store or get takeout from a few restaurants we know have amazing chicken mole or shiro and lamb tibs.

But there is so much more out there. It is worth going outside of your comfort zone and seeking the road less traveled. Often used figuratively, the analogy is certainly apt for physicians who literally take roads less traveled to treat patients in rural clinics and hospitals.

This issue is dedicated to them. We hope to shed some light on the issues facing physicians in rural health, why they choose to live and work outside of larger cities, and steps they’re taking to improve access and quality of care for their patients.

S P O T L IG H T ON RU R A L H E A LT H We are very thankful to Holly Rooney, MD, for sharing her perspective of practicing in Globe, Arizona. Dr. Rooney sat down with Managing Editor Edward Araujo to discuss why she is comfortable in rural medicine, the challenges she faces in recruiting physicians to work there, and how greater community integration is a lesson for city dwellers to learn from the rural docs.

For our section What Arizona Docs are Saying, we share a range of answers to why physicians work in rural Arizona, what their biggest frustration is about rural health, what pitch they would use to recruit physicians, and how telehealth improves care in rural Arizona? A common thread among the recruitment pitches is the work-life balance outside of cities.

Guest author Brian Powell, a former reporter now with the Flinn Foundation, writes about his visit to Willcox. He found the town known for

ranching and a singing cowboy movie star also has a mix of medical facilities, some of which are partnering with larger health systems to ensure access to specialists.

Maybe the best person to see the full view of rural health in Arizona is Daniel Derksen, M.D., Walter H. Pearce Endowed Chair and Director of the University of Arizona Center for Rural Health. Dr. Derksen shares data on the continued inadequate funding for the rural workforce, disparities between urban and rural health socioeconomic conditions, and urges us to take a “balanced, clear-eyed view of the rural health ecosystem.”

In our section Legal Corner, attorney Miranda Preston presents information about the recent expansion of telehealth. When Governor Doug Ducey signed House Bill 2454 into law, Arizona made permanent exceptions to policy that were temporary during the COVID-19 pandemic. These include audioonly encounters with a patient and allowing physicians licensed out of state to care for patients in Arizona.

Finally, Jeanne Varner Powell describes how federal practice guidelines expand buprenorphine prescribing. A Senior Legal Risk Management Consultant for MICA, Jeanne frames why the opioid partial agonist buprenorphine is an important tool in the fight to decrease deaths from opioid use. It is now easier for doctors to receive an X-waiver and exemption from training often required before prescribing buprenorphine as a part of medicationassisted treatment. The goal is to put this tool in the hands of more doctors, especially those practicing in rural areas where the “per capita overdose rate was nearly 45% higher” than urban counties.

We are looking for article contributors, podcast guests, and virtual event presenters.

Contact us at info@arizonaphysician.com for these and many more opportunities.

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Enjoy the magazine.

By John E. McElligott, MPH, CPH

BRIEFS

NEWS AND NOTES FROM THE FIELD

5 Notable Early Arizona Physicians

B

8

efore Arizona joined the union, most of the territory was rural. The frontier was a mix of military physicians at remote forts and doctors caring for American Indians and miners.

Others moved to Arizona for its climate or opportunities to own land and expand medical services in the region.

NELSON CHARLES BLEDSOE, MD |

JOSHUA A. MILLER, MD | Born

Graduate of USC, Nelson practiced in Bisbee and then Tucson. He had the first X-ray machine in Arizona, which took ten minutes to take a picture.

Nelson specialized in bullet removal and responded to mine cave-ins to aid the wounded and perform field amputations.

in Missouri, Miller arrived in Yavapai County in 1889 to practice medicine and mining.

He helped to establish the Yavapai County Medical Society, Maricopa County Medical Society, and Arizona Medical Association.

JOHN TABER ALSAP, MD | After

JOHN W. FLINN, MD | Hailing from

earning law and medical degrees from New York College, Alsap practiced medicine in Prescott while mining and running the first saloon there. He was surgeon for an expedition against the Apaches in 1865, became the first territorial treasurer, and served in the legislature, as mayor of Phoenix, and a judge.

Nova Scotia, Flinn graduated from McGill University and held license number 40. He founded the PAMSETGAAF tuberculosis camp in Prescott in 1903. The name comes from the therapies offered: pure air, maximum sunshine, equitable temperatures, good accommodations, and food.

Known as the “Dean of Arizona Surgeons,” Palmer grew the surgical capacity of St. Joseph’s Hospital from operating atop carpenter sawhorses in a twelve-bed brick cottage to a modern multi-storied facility for over 300 patients. He also initiated highway aid stations and was a champion for hospital standards.

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ERROL PAYNE PALMER, MD |

7 COOL TOWNS TO VISIT IN ARIZONA

Small, charming towns dotted around Arizona offer outdoor activities and a dose of the past. As the summer heat bears down, here are seven towns you should visit.

JEROME | Founded in 1876, overlooking the Verde Valley at 5066 feet, this former booming copper-mining town in central Arizona has something for everyone. Jerome is only two hours north of the Phoenix Metro area. Art galleries and small wineries line the downtown area. The Jerome Historical Society Mine Museum helps you see unique details of this town that once was the largest producer of copper, silver, and gold in the state.

BISBEE | Founded in 1880, sitting at 5,538 feet above sea level, was a former booming copper, gold, and silver mining

town. Bisbee is three hours southeast of the Phoenix Metro area. Many came to Bisbee in the early 1900s through the promotion of Bisbee Blue, a high-quality turquoise. As mining declined, tourism helped shape Bisbee since the 1960s with “Old Bisbee” now home to a thriving cultural scene that houses Victorian-style homes and an Art Deco county courthouse.

TOMBSTONE | Founded in 1879, this southeastern Arizona town is well known for its Wild West history. Tombstone sits only 2.5 hours southeast from the Phoenix area. From the O.K. Corral and Boothill Cemetery to the bullet-riddled Bird Cage Theatre and saloons, Tombstone will take you back in time. Drive 2.5 hours southeast of the Phoenix valley.

SONOITA/ELGIN | Founded in 1882, these charming southeastern Arizona towns have lately become known for their vineyards and wineries. Both

towns are only 2.5 hours south of the Phoenix Metro area.

Fort Crittenden and Fort Buchanan both lay in the outskirts of Sonoita. Autumn Sage Vineyards and Wilhelm Family Vineyard are just two of the 12 wineries along Route 82.

GREER | Founded in 1879, Greer is in Apache County. At 8,356 feet, it is the highest town in Arizona. Greer is four hours northeast of the Phoenix Metro area. Greer has great outdoors and wilderness activities and affordable cabins/lodging.

CORNVILLE/PAGE SPRINGS | Founded in 1887, Cornville and Page Springs lie on the edges of Oak Creek, only 1.5 hours north of Phoenix. Javelina Leap Vineyard, Winery & Bistro and Oak Creek Vineyards & Winery are two of eight wineries where you can enjoy some awardwinning grapes like petite

sirah or riesling, listen to live music, and order a wine and cheese plate. The Cornville/ Page Springs area is just east of Cottonwood.

SEDONA | Founded in 1876 by a squatter that made it into a ranching and farming settlement.

Sedona is only a 2-hour drive north of the Phoenix Metro area.

Sedona’s array of beautiful red sandstone formations, hiking trails, and seductively peaceful outlook help distinguish it from other small towns. With spa treatments, hiking, and new age minerals, Sedona has a lot for you to see and experience.

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A R I ZO N A P H Y S I C I A N . C O M

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7 Restaurants in Rural Arizona You Should Patronize

THE GROTTO CAFE |

BIG NOSE KATE’S SALOON | Tombstone |

RENDEZVOUS DINER | Greer | Blink and

Goldie’s Over-Stuffed Reuben is the most popular item at this mainstay named after Doc Holliday’s girlfriend.

Known for burgers and pizza, the saloon is near the O.K. Corral and offers live music and maybe some ghosts.

you’ll miss Greer. The restaurant’s décor draws travelers, but the home cooking brings them back for more.

Enjoy omelets, pancakes, and freshberry cobblers.

NURDBERGER CAFE | Globe | If you like

video games and outer space, this quirky burger joint is the place to be.

Check out the 1 Up Mushroom Berger and Imperial Shakes.

BOBBY D’S BBQ | Jerome | In the

historic English Kitchen building, Bobby D’s is the oldest operating dining facility in Arizona. Treat your taste buds to slow-smoked BBQ and delicious cornbread.

Cave Creek | This charming cafe is an hidden oasis in the desert, complete with two enchanting outdoor patios, locally roasted coffee, and homemade pastries. From breakfast to dessert (and everything in between), there’s something scrumptious for every meal and palate.

FOXFIRE | Alpine | Near Devil’s

Highway, Foxfire offers sinful favorites like sausage sandwiches and salted caramel cheesecake. Adorning the walls are paintings from local artists.

ELVIRA’S | Tubac | Speaking of art, it’s

everywhere in Tubac, including Evira’s. They serve up yummy Tex-Mex classics with a twist.

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Ali Gardiner Hill | (602) 819-9971 | ahill@pcaemail.com 10 n

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Moonshot, Upshot, Hot Spot, Bullshot ONE IN FIVE AMERICANS LIVES IN A RURAL AREA. Yet it’s been 25 years since the U.S. invested in its rural health infrastructure through Hill Burton funding (1947-1997) based on community need. While 18-20% of the nation’s population lives in a rural area, just 10% of primary care physicians and 7% of specialist physicians reside there.

MOONSHOT

UPSHOT

The Great Society Programs of the 1960s intended to address the 25% of Americans living below the Federal Poverty Level, and even higher (33% below FPL) in rural areas, and included creating a Job Corps, Head Start, Medicare, Medicaid, and other programs to expand affordable health care, education, and housing. Over that decade rural poverty dropped to 17.9%.

Investments in individual health insurance coverage started with amendments to the Social Security Act that created Medicare and Medicaid in 1965, added the Children’s Health Insurance Program in 1997, and in 2014 expanded Medicaid and subsidized private health insurance for 20 million Americans via the Affordable Care Act. These investments helped stabilize finances in rural hospitals and clinics. However, many community clinics, rural and critical access hospitals operate on thin margins without reserves to weather economic downturns.

In 2021, intractable rural versus urban socioeconomic and health disparities persist.

Rural counties are often defined simply as having a population of less than 50,000. There are more precise designations such as federal-state determinations for Health Professional Shortage Areas, Rural Urban Commuting Areas (RUCAs), and other subclassifications.

Rural America is demographically and economically diverse, suggesting that while some commonalities exist (rural populations tend to be older, have lower incomes, and higher rates of certain chronic diseases), policy and programmatic interventions should be customized to meet diverse rural community needs. While rural age adjusted death rates per 100,000 are improving for cancer, coronary heart disease and stroke – they are not improving as much as in metro areas. Rural death rates are worsening for COPD, diabetes, unintentional injury and suicide.

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OPPOSITE PAGE: The map shows a mix of Critical Access Hospitals, Indian Health Service facilities, Federally Qualified Health Centers, and other clinics that make up Arizona’s rural health safety net.

Credit: Arizona Center for Rural Health.

Of the 69 million Americans living in rural areas, 13 million are people of color, and 2 million are immigrants. Rural residents who are Black, Latinx/Hispanic and American Indian have social determinants that contribute to poorer health outcomes including higher rates of poverty, lower educational attainment, and less access to affordable housing and health insurance coverage and services.

FACTOR

RURAL METRO

Poverty Rate

16.1%

12.6%

Children (<5 yrs.) in Poverty

25.0%

18.6%

Food Insecure Households

15.5%

12.5%

PCP per 100,000 Population

39

53

Population > age 65

18%

14%

Smoking Rate

19.1%

15.8%

Obesity Rate

31.5%

26.7%

HOT SPOT The sixth largest state, Arizona’s 114,000 square miles is 55% federal and state government land, and 28% is owned by 22 federally recognized American Indian tribes. Arizona has 15 large counties, four of which share the 377-mile Arizona-Mexico border. Maricopa County (4.5 million) and Pima County (1.1 million) comprise over 75% of Arizona’s 7.3 million population.

In its 13 other counties, rural Arizonans have poorer health outcomes, higher uninsured rates, less access to health services, and alarming disparities in COVID-19 infection, hospitalization and death rates in American Indian, Latinx, African American, and elderly populations.

For death rates per 100,000 population, heart disease (rate of 134 in 2019), cancer (131.1), accidents (58.7), chronic lower respiratory disease (38.1), and Alzheimer’s disease (32.3) are usually the leading causes of death in Arizona.

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COVID-19 became the leading cause of death in 2020-21, with a rate of 246 per 100,000 population. COVID-19 hit rural Arizona hard.

Apache County, home to 75% of the American Indians in Arizona, had a death rate of 603, over three times the US mortality rate of 179.

Yuma County, where 65% of the population is Hispanic/Latinx, had a death rate of 367, over twice the US mortality rate.

BULLSHOT Painting rosy, utopian pictures of rural America can be as misleading and misdirected as conveying only rural challenges and disparities.

A balanced, clear-eyed view of the rural health ecosystem — in the context of a community’s assets, cultural diversity, and challenges — can be enhanced by monitoring progress (vital signs) and engaging the community in thoughtful ways to improve the health and well-being of its population.

Contemporary approaches to eliminating rural disparities must go beyond myopic, constrained, commodity models of cost, quality and access as a zero-sum game, where improving one element comes at the expense of another and cannot simultaneously be improved without tradeoffs.

As detailed by Don Berwick, Tom Nolan, and John Whittington, the Triple Aim is a compelling vision of improving the patient experience of care, improving the health of a population, and reducing the per capita costs of care. In Arizona, key partners that form the strands of Arizona’s rural health safety net include county public health departments, the state’s Medicaid program (AHCCCS), state health department (ADHS), legislators, the governor’s office, private physicians, advocacy organizations, and clinicians and staff. ■

Daniel Derksen, M.D. Walter H. Pearce Endowed Chair and Director University of Arizona Center for Rural Health dderksen@arizona.edu

Arizona’s Health Safety Arizona’s RuralRural Health Safety Net Net Design: Paul Akmajian (Updated 8/15/20) Design: Paul Akmajian (Updated 8/15/20)

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Center of Yavapai, Center, Camp Verde Overgaard White Mountain North Country HealthCare, Community Health North Country Prescott North Country Lake Havasu City Regional Medical Center, Center of Yavapai, HealthCare, White Mountain HealthCare, Payson BannerNorth Payson Prescott Show Low North Country Country Regional MedicalSpringerville Center, HealthCare, Medical Center HealthCare, Payson Banner Payson IHS Parker Indian Show Low Cibecue Springerville North Country Pleasant Valley HealthCare, Medical Center Health Center North Community Hospital Community Medical IHS Parker Indian Health Center Country Summit Healthcare Round Valley Cibecue Clinic, Congress Pleasant Valley Center, Young Pediatrics, Show Low HealthCare, Health Center Summit Healthcare Community Hospital Health CenterLa Paz Regional Community Medical Round Valley Clinic, Congress Center, Young Pediatrics, Show Low Community Wickenburg Whiteriver La Paz Regional Hospital, Parker Native American Hospital Clinic, IHS Hospital Community Health Community Hospital, Parker Bouse Medical Community Wickenburg Wassaja Memorial Wickenburg Whiteriver Native American Parker Medical Center, Phoenix Hospital Clinic, Bouse Health Center, Hospital Clinic, IHS Hospital Community Health Community Center, Parker Bouse Medical Wassaja Memorial Wickenburg Ft McDowell Parker Medical Adelante Tonto Basin AdelanteCenter, Phoenix Hospital Clinic, Bouse Health Center, Colorado Healthcare, Clinic Center, Parker Healthcare, Ft McDowell AdelanteWickenburg Tonto Peoria River Reservation Salt Basin River Health Adelante Phoenix Colorado Healthcare, Clinic Ft Apache Reservation Center, Scottsdale Healthcare, Tri-Valley Medical Peoria River Reservation Salt Indian River Health Phoenix Center, Salome Wickenburg Ft McDowell Ft Apache Reservation Center, Scottsdale La PazMedical Medical Medical Tri-Valley Indian Reservation Services, Quartzsite Cobre Valley FtCenter McDowell Hau'pal (Red Tail Hawk) Center, Salome La Paz Medical Medical Adelante Reservation Regional Medical Services, Quartzsite Health Center, Healthcare, Center Cobre Valley San Carlos Reservation Hau'pal (Red Tail Hawk) Chandler Adelante Surprise Center, Globe Life Medical Komatke Health Center, Salt River RegionalSun Healthcare, San Carlos Reservation Apache Health Canter, Chandler Surprise Center, Globe Cobre Valley Reservation Sun Life Izeé Baarr Gowah Junction Superior Clinic Salt River Laveen Village Komatke Apache Health Canter, San Carlos Apache Cobre Valley Reservation rr Izeé Baa Gowah Junction Gila River 638 Healthcare, Peridot Hu Hu Kam Laveen Village Superior Clinic Reservation Carlos Apache Canyonlands Cobre Valley Memorial Hospital, Gila River 638 San Hu Hu Kam Healthcare, Globe Healthcare, Peridot Globe Clinics (4) Clarence Wesley Reservation Sun Life Maricopa Sacaton Canyonlands Cobre Valley Canyonlands Memorial Hospital, Health Center, Family Healthcare & Wellness, Globe Clinics (4) Healthcare, Globe Mountain HealthClarence Healthcare, Wesley Gila River Bylas Sacaton Sun Life Maricopa Kearny Outpatient Canyonlands Sun Life Family Health Clifton Health Center, Maricopa Health Family Healthcare Healthcare, Center, Mountain Health & Wellness, Care Corp 638 Gila Reservation River Bylas Gila Bend Kearny Outpatient Sun Life Family Health Florence Clifton Maricopa Health Ak-Chin Reservation 638 Center, Cobre Valley Reservation Care Corp Gila Bend Health Clinic,Florence Ft Yuma Mt. Graham Regional Kearny Clinic Sun Life Coolidge Ak-Chin Sun Life Maricopa Reservation Cobre Valley IHS Hospital Ft Yuma Family Healthcare Medical Center, Adelante Heathcare, Health Clinic, Casa Grande Ft Yuma Reservation Mt. Graham Regional Kearny Clinic Sun Life Coolidge Sun Life Gila Bend Maricopa Family Healthcare Safford IHS Hospital Sunset Community Ft Yuma Family Healthcare Sunset Sonoran Family Medical Center, Casa Grande Adelante Heathcare, Canyonlands Reservation Health Center, Community Practica, Coolidge Gila Bend Family Healthcare Safford Sunset Community Healthcare, Yuma Sunset Sonoran Family Copper Mountain Health Center, Sunset Community Canyonlands Sun Life San Manuel Health Center, Safford Community Practica, Coolidge Clinic, Safford Canyonlands Somerton Health Center, Wellton Healthcare, Yuma Family Healthcare Copper Mountain Glia Valley Health Center, Sunset Community Healthcare, Safford Cocopah Sun Life San Manuel Clinic, Safford Somerton Clinic, Safford San Luis Walk-in Clinic, Somerton Canyonlands Health Center, Wellton Reservation Sun Life Eloy Duncan Family Healthcare Glia Valley Healthcare, Cocopah Family Healthcare Sun Life Oracle San Luis Urgent Care, San Luis Clinic, Safford San Luis Walk-in Clinic, Somerton Reservation Sun Life Eloy Duncan Family Healthcare Northern Cochise Sunset Community Marana FamilyNation Healthcare Tohono O'odham San Luis Sun Life Oracle San Luis Urgent Care, San Luis Health Center, San Luis Health Community Hospital, Desert Senita Community Clinic Family Healthcare Sunset Walk-in Community Northern Cochise Marana Center Health Center & O'odham Dental Center, San Luis Tohono Nation Willcox Health Health Center, San Luis Santa Rosa Community Desert Senita CommunityAjo Tucson Area Hospital, Walk-in Clinic Pascua Yaqui Clinic Center Health Center & Dental Center, Health Services, IHSWillcox Office Santa Rosa Ajo Pascua Yaqui TucsonTucson Area Clinic IHS Office Sulphur Springs Health Services, Tucson San Xavier Health Medical Center, Sulphur Springs Willcox Center San Simon United Community Medical Center, San Xavier Health Health Center Health Center at San Xavier Willcox Center San Simon United Community Old Vail Middle School Benson Hospital Reservation Health Center Health Center at San Xavier Sells IHS Old Vail Community Middle School Benson Hospital Sunsites Medical United Reservation Hospital Clinic, Pearce Health Center, Sells IHS United Community Sunsites Medical Chiricahua Green Valley Hospital Clinic,Community Pearce Health Center, Chiricahua Community Chiricahua Green Valley Health Centers, Benson Hospital Health Centers United Community Community Family Health Care Benson Chiricahua Community Cliff Whetten Clinic, Elfrida Health Center, Amado Benson Hospital Health Centers, Health Centers United Community Family Health Care Benson Mariposa Cliff Whetten Clinic, Elfrida Copper Queen Health Center, Amado United Community Community Community Hospital, Mariposa Copper Queen Bisbee Health Center, United CommunityHealth Chiricahua Rio Rico Community Health Center, Center, Community Hospital, Mariposa Community Health Bisbee Copper Queen Chiricahua Rio Rico Arivaca Health Centers, Community Center, Medical Associates, Douglas Community Mariposa Health Center, Sierra Vista Arivaca Copper Queen Health Centers, Patagonia Community Carondelet Holy Medical Associates, Douglas Chiricahua Community Health Center, Sierra Vista Hereford Rural Health Centers: Jennifer 'Ginger' Chiricahua Patagonia Health Clinic, Copper Community Carondelet Holy Cross Hospital, Chiricahua Community Ryan Clinic & 15th Street Pediatric Mariposa Community Hereford Rural Palominas HealthCenters, Centers: Jennifer 'Ginger' Chiricahua Queen Cross Hospital, Nogales Center of Excellence, Douglas Health Health Centers Clinic, Ryan Clinic Copper Community Medical Bisbee Clinic& 15th Street Pediatric Mariposa Community (5 locations), Nogales Nogales Palominas Health Centers, Queen Health Centers Associates, Center of Excellence, Douglas Medical Bisbee Clinic Bisbee (5 locations), Nogales Associates, Bisbee Peach Springs Indian Health North Country CanterNorth Country HealthCare, HealthCare, Seligman Kingman

YAVAPAI

North Country HealthCare, Seligman

YAVAPAI

APACHE

APACHE

New Mexico

New Mexico

Ramah Navajo Res.

California California

IHS

IHS

LA PAZ

LA PAZ

MARICOPA

IHS

IHS

YUMA

IHSIHS

IHS

IHS

GILA

GILA

IHS

IHS

MARICOPA

GREENLEE

GRAHAM

YUMA

PINAL

Mexico Mexico

GRAHAM

PINAL

IHS

PIMA

GREENLEE

IHS

COCHISE

COCHISE

PIMA

SANTA CRUZ SANTA CRUZ

Gulf of California Gulf of California

SHIP participating CAH + Tribal Operated Considering CAH SHIP participating hospitals CAH + Tribal Operated 638 (PL Consideringstatus CAH 638 Site) hospitals (PL 638 Site) status Tribal Operated IHS Navajo Area IHS = Urban Indian IHS Tucson Area IHS IHS Phoenix Area IHS Tribal Operated (PL 638 Site) IHS Navajo Area IHS IHS Tucson Area IHS = Urban Indian Health Centers IHS Phoenix Area IHS (PL 638 Site) Health Centers Federally Qualified Health Centers Rural Health Clinics in rural areas Federally Qualified Health Centers Rural Health Clinics in rural areas IHS Critical Access + Critical Access Critical Access IHS+Hospital Hospital (CAH) IHS Critical Access IHS Hospital 638 Hospital (CAH)

Dan Derksen MD, Director Dan Derksen MD, Director Heather Carter EdD, Co-Director Heather Carter EdD, Co-Director

crh.arizona.edu/map-room crh.arizona.edu/map-room

Jill Bullock, Associate Director Jill Bullock, Director Agnes Attakai,Associate Dir. Health Disparities Outreach Agnes Attakai, Dir. Health Disparities Outreach

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Small Medical Team has

BIG Impact on Willcox

W Dawn Walker, D.O., outside of Walker Family Medicine in Willcox, AZ.

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hen Dr. Dawn Walker first arrived in Willcox, the doctor of osteopathic medicine was one of eight physicians in this rural southeast Arizona town best known for its ranching, farming, and singing cowboy movie star.

About two decades later, the owner of Walker Family Medicine and chief of staff at Northern Cochise Community Hospital is currently the only physician—MD or DO— providing daily primary care services.

Willcox has a 24-bed critical access hospital with emergency services, and nurse practitioners serve at both Walker’s office and the two rural health clinics operated by the hospital. Chiricahua Community Health Centers, a nonprofit federally qualified health center, provides preventative and

A R I ZO N A P H Y S I C I A N M A G A Z I N E

primary care services in the area a couple of days a week through a mobile unit.

But since April, the hospital’s two rural health clinics that primarily provide primary care services—Sulphur Springs Medical Center in Willcox and Sunsites Medical Clinic in Pearce, about 30 miles to the southwest— have been without a physician, highlighting the medical challenges in a rural town.

“It’s difficult, it’s really difficult, to get doctors to come to a rural community where there is typically less funding available and when you are competing against metro areas that have a lot to offer,” said Robin Allen, rural health clinic manager. “Typically, those that do are from the area and want to return home.”

Mo Sheldon, who was named CEO of Northern Cochise Community Hospital last year, says it takes a certain type of person to want to serve as a physician in a small

The sun sets over Willcox in southeastern Arizona.

The Willcox Historic Theater on Railroad Avenue.

By Brian Powell Communications Manager Flinn Foundation bpowell@flinn.org

community—someone with a breadth of knowledge and interested in whole-person care who is comfortable being seen around town at the grocery store or the high school football game.

“Anonymity is not something you get in a rural community, but you are well respected and regarded and very much appreciated,” Sheldon said.

Sheldon grew up in the Cochise County city of Sierra Vista and has spent most of her adult life working at rural hospitals in Texas and eastern Washington.

The hiring of a new physician, who has traditionally been an MD, is one piece of the puzzle to provide the necessary services to the people of the hospital district, Sheldon said. In June, the hospital aligned with TMC HealthCare, which is anchored by Tucson Medical Center. And coming up is a critical November election that will go a long way in determining the long-term financial stability of the hospital.

“We exist to serve this community, and I believe a rural hospital has a different relationship with the community,” Sheldon said. “We frequently take care of people we know or have a relationship that is far more personal than you might find in an urban medical center.”

who grew up on a ranch outside of Willcox and starred in movies, radio, and television shows.

The surrounding mountain ranges and sandhill cranes draw visitors to the high desert landscape dotted with vineyards, dairies, pecan and pistachio orchards, cotton, and alfalfa.

More than 80% of the grapes used in Arizona wines are grown in the Willcox area. Tasting rooms are opening in the downtown area across from the historic railroad park, where trains regularly roll right through a town that has maintained its Western vibe while offering new locales to sip wine and espresso.

The Rex Allen Museum showcases items from “the Arizona Cowboy,” deceased actor Rex Elvie Allen who was born in Willcox.

WILLCOX, ARIZONA Willcox is a city of about 4,000 people—or about 15,000 when including the surrounding area—80 miles east of Tucson along Interstate 10. Through the years, the annual Rex Allen Days has been the big draw for the city known as the “Cattle Capital of the World,” celebrating the life of the singing “Arizona Cowboy”

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Located between the freeway and downtown are the medical services in town—the one-story hospital with its 24-hour emergency room, Sulphur Springs, Walker’s medical office, and the town’s two pharmacies.

NORTHERN COCHISE COMMUNIT Y HOSPITAL’S ROADMAP FOR SUCCESS Today, like many rural hospitals, Northern Cochise Community Hospital is relinquishing some of its independence to forge a partnership with a larger health system.

Sheldon said the alignment with TMC, which expands on an existing relationship, will provide additional medical and training resources, improve financial stability, and provide more seamless patient transfers, the majority of which were already going to Tucson Medical Center. The alignment will also help solve the difficulty of a small, independent hospital negotiating favorable equipment pricing and reimbursement rates.

Financial struggles have impacted hospital operations in the past. In 2016, the city’s only long-term care facility—which was housed in a wing of the 1968 brick hospital building—was forced to close.

Yet to reach the desired long-term stability, the alignment with TMC is not enough, Sheldon said. The five-year health care district tax must be renewed in the November election, or the hospital will lose about $2 million annually, Sheldon said.

Chief nursing officer Helen Kilpatrick worked in several Arizona hospitals before accepting her position last year in Willcox, where her family has ranched and farmed since the 1800s.

Kilpatrick provided examples of acute care at the hospital, such as respiratory issues in the elderly, child injuries or illness, care for the area’s migrant farmworkers, and traumas from freeway car accidents. There is no intensive care unit, chemotherapy, or births, except in an emergency, but the hospital does rent space to specialists who typically visit once or twice a month.

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The physical and occupational therapists treat hospital patients recovering from surgery, for instance, plus the rehabilitation center serves as an outpatient clinic providing the only in-town option for residents needing physical therapy, rehabilitation manager Welton Wittwer said.

Wittwer, who grew up in rural Wyoming and has worked in big cities and small towns, said he enjoys the amount of time he can spend with each patient, sometimes 45 minutes to an hour one-on-one, which is rare in urban areas.

“We hear from patients, ‘We are so glad you are here,’ and we have a great rapport with the community,” Wittwer said.

But as with physicians, recruitment can be tough.

For instance, the center has had a vacant speech therapist position for an extended time, Wittwer said.

From left, physical therapist Welton Wittwer and Jonelle Wartenberg in the rehabilitation center.

DR. WALKER: THE TOWN DOCTOR Walker grew up in Tucson but acknowledges she never heard of Willcox until meeting her college roommate— a Willcox resident—at Northern Arizona University.

Years later, when she had the opportunity to move her young family to Willcox, she took it with the blessing of her husband, a fourth-generation Arizonan who was comfortable with small-town life. That was the summer of 1999.

Her practice, Walker Family Medicine, takes appointments as well as same-day walk-ins and can treat injuries or conduct rapid testing commonly seen in urgent care facilities in larger cities. In addition to Walker, three nurse practitioners see patients, who range from infants to seniors.

In addition to primary and preventative care, Walker is an advocate for more local psychiatry services and was the co-founder of the Willcox Meth Task Force in 2006.

As patients have become more comfortable with telemedicine and telehealth, and with the approval of new state legislation, Walker said she is pleased with the opportunities Willcox residents will have, including enhanced opportunities for counseling sessions.

Last year, Walker was appointed by Gov. Doug Ducey to a five-year term on the Arizona Board of Osteopathic Examiners in Medicine and Surgery. The board licenses and regulates more than 3,000 doctors of osteopathic medicine and regulates about 400 osteopathic interns

and residents receiving post-graduate training in Arizona hospitals and clinics, according to the board’s description.

“My hope is to make us a stronger medical community in Willcox by bringing back what I learn and making us more aware of the regulatory information,” Walker said.

A SMALL-TOWN HOSPITAL’S BIG IMPACT As new residents began moving to Willcox during the COVID-19 pandemic, Walker said the hospital’s presence was important to some. But for others, it was not on their radar.

Yet without the hospital, jobs would be eliminated, and some residents would think twice about relocating or opening a business—or possibly staying and aging in their hometown.

“Economically we are critical to the survival of a community,” Sheldon said. “If you look at some communities that have lost their hospitals, you will find more bare storefronts than you do here.”

Mary Peterson, the Willcox Chamber of Commerce and Agriculture board president and co-owner of vin·tage and Bear’s Vintage Thrift in downtown Willcox, said having a hospital in town attracts people and businesses to Willcox, plus it makes people feel safe.

“This community is lucky to have a hospital, and we should do everything we can to support it and help it thrive,” Peterson said. ■

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Rural Health Champion

Holly Rooney, MD

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S

he does not wear a white coat.

She does not always carry a stethoscope in hand. Yet she is packed with an infectiously warm smile and enthusiasm for her community. Holly Rooney, MD, is truly a rural health champion. She leaves you with a lasting impression of fealty to her community.

Nestled an hour and a half east of Phoenix, the trip to Globe hits you with a 10-12 degree drop in temperature as you weave your way through two-lane canyon roads onto its higher valley. With a population of 7,348, Globe is a mixture of 21st century fast food joints and the Old West, as several buildings from its founding in 1875 dot the nearby hills.

There, one street above the old historic district stands the Chrysocolla Inn and its beautiful gardens. This bed & breakfast has been completely renovated over the last eleven years by owner/operator Holly Rooney, MD, and her mother Rosemary Rooney. They have owned the bed & breakfast for 21 years and operated it for 11. What may have once been a late-19th century brothel for gunfighter Doc Holiday’s common-law wife Mary Katherine HoronyCummings (a.k.a. Big Nose Kate) now has seven rooms and takes you back in time.

A RURAL BEGINNING Dr. Rooney grew up in Globe. She attended University of Arizona for her undergraduate studies. Majoring in English and minoring in both French and biology, medicine was not on her mind until she took a genetics class.

The one class spurred her enthusiasm and Dr. Rooney matriculated at the University of Arizona College of Medicine in Tucson.

After selecting family medicine as her specialty, Dr. Rooney completed her residency at the University of Nevada – Reno. Yet, she longed for Arizona. She had a choice: Tucson, Oracle, or Globe. Michael Durham, MD, a local physician in Globe, helped push Dr. Rooney back to her hometown. He would go on to become a mentor and consultant to her as she began her career.

Dr. Rooney started as a sole practitioner, moving her office from time to time. Then, an opportunity came to merge her practice with a physician assistant she was already supervising.

Their joint venture led them to purchase their

Dining Hall at Chrysocolla Inn in Globe

own building. The result was Hope Family Care Center, LLC, one of the largest medical practices in Globe. The building was originally Sears in the 1950s and was completely renovated by Dr. Rooney’s husband in the historic district of Globe. In addition to the practice and owning the bed & breakfast, Dr. Rooney recently became the Medical Director of THEMA Health Services in Globe-Miami.

WHAT DRAWS PHYSICIANS TO RURAL ARIZONA Dr. Rooney initially chose rural Arizona because of all the outdoor activities she could do. As she grew as a doctor, Dr. Rooney’s perspective changed. It helped to speak with fellow physicians, medical students, and other practitioners who were not from Globe. She found that “community integration” is something that happens more in rural settings than in larger cities and draws physicians to small towns like Globe.

“I live here. I work here. I feel I know my patients, many of them…most of them, really well,” she says.

That sense of community is displayed in the fact that she frequents her patients’ businesses just as much as they frequent hers. In most cases, Dr. Rooney grew up with her patients. Now their children, parents, and relatives have also become her patients. That makes her feel even more connected to her town. That is a draw you cannot usually find in the city. “That sense of community integration leads to better patient care,” she states. Dr. Rooney also has continuity, in which she sees her patients not just once or twice but in many cases over their lifetimes. She has built patient relationships that became friendships and help to make her an integral part of Globe’s community.

Work and life are always close for Dr. Rooney. She begins her day by checking in with her cousin who manages the Chrysocolla Inn. After exercising, she heads to her office, which is a block and half away from the bed & breakfast. Home is just a few blocks further. Not much in Globe is more than a walk or short drive.

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NOT ALL IS BLISS IN RURAL MEDICINE Dr. Rooney’s day-to-day does have similarities to practicing in bigger towns or cities. Some patient care takes a back seat to the time required for medical charting, which has become more extensive over the years. Dr. Rooney maintains a full schedule of patients on Tuesdays and splits Monday and Thursday between patients and charting. The rest of her week is taken by a new role in hospice, or anything needed at the bed & breakfast, a labor of love.

Aside from charting getting harder each year, Dr. Rooney is frustrated by specialties that are not available in Globe, making it difficult to search for the needle in a haystack for patient referrals. Mental health is a good example.

There is one behavioral health group in town, but they only serve patients with Medicaid. Dr. Rooney often recommends patients to eastern parts of Maricopa County, like Mesa. That is still a long drive, but Tucson is even further.

Health system analysts cite less access to care, insufficient staffing, and a lack of cultural understanding as just a few issues holding back rural Arizonans from seeing improved health care.

Dr. Rooney believes staffing is a huge problem.

It comes down to whether a doctor is comfortable either permanently moving to a rural area or commuting several days a week. Dr. Rooney states, “Access to care is improving but could get better if more specialists would be willing to come up at least once a week or two. They would realize what a gem it is working with patients who are integrated with the community.”

WHAT KEEPS DOCS RURAL What makes Holly Rooney a good rural doctor?

Maybe we should determine what characteristics

a rural physician needs to be successful in Arizona. First, you manage more areas of a patient’s health compared to family practice or internal medicine in the city. Physicians in family medicine must get comfortable with managing a lot of issues without direct consultation with the specialists. Physicians must be comfortable dealing with a shortage of their peers. Globe currently has five primary care physicians, with one leaving soon. Yet, Dr. Rooney states, “At least four of the five have some form of connection to small town America,” giving hope for towns like Globe to retain them.

Second, physicians considering rural health should appreciate the opportunity for independence. Dr. Rooney can decide her own schedule. Doing so is not as common in larger settings.

Third, practice ownership is another factor that can keep physicians in rural health. With her name on the line, Dr. Rooney says she is more driven to deliver quality care for patients. On the financial side, going the extra mile is very important and rewarding because you earn what you put in.

A SUCCESSFUL PRACTICE AMONGST HOSPITAL NET WORKS Hope Family Care Center plays a pivotal role in Globe.

Dr. Rooney’s practice has the largest number of patients in town. Her business partner, physician assistant Chad Campbell, offers integrative medicine and diabetes education. Chad is the business engine, providing creative ideas to recruit patients throughout the area.

Although Dr. Rooney did not mention pressure to sell her practice, she is aware of the local hospital’s interest in primary care practices. Two other practices have already sold with a third considering it. Dr. Rooney states, “The natural evolution of aging physicians is that patient record maintenance is so much harder now. Physicians in private practice, as they get closer to retirement, don’t want to deal with the upkeep of records, so they’ll sell.” Plus, higher compensation also pushes older physicians to a hospital as those ancillary services they were already outsourcing can now be fully compensated.

RECRUITING PHYSICIANS TO RURAL ARIZONA Dr. Rooney believes loan repayment programs through hospitals or organizations like the National Health Service Corps or University of Arizona’s primary care program are great tools to encourage physicians to relocate to a rural underserved area. Using a similar program allowed her to repay student loans within five years after graduating medical school.

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“I live here. I work here. I feel I know my patients, many of them… most of them, really well.”

On the Personal Side with Holly Rooney, MD Q: If you could describe yourself in one word, what would that be?

A: Happy Q: Do you have family? Pets?

A: I am married with kids, and I am a big lover of cats — We have 2 at home and more cats at other properties

Q: Do you have a hidden talent most people would not know about you?

A: Perhaps, talents for creation of beautiful spaces, indoors and outdoors alike

Q: What career would you be doing if you were not a physician?

A: If I were not a physician currently....

I would be an inventor.

Q: What book are you reading right now, or recently?

A: Jamaica Inn by Daphne DuMaurier Q: What is your favorite movie?

A: Housesitter with Goldie Hawn and Steve Martin Q: What is your favorite food?

A: Pinto beans with fresh tomatoes Q: What is your favorite local restaurant?

A: Too many great restaurants here to choose from

Dr. Rooney believes that Globe is not always awarded loan repayment opportunities because the ranking system and the monies available to these programs may be inadequate. Certain factors in the ranking system make Globe fall lower on the scale, so only at certain times over the years has it been able to access the designation with its repayment opportunities. That means there’s then less interest in medical students choosing Globe or towns like it.

Improving funding for rural schools will help, as well. Dr. Rooney knows colleagues with children who do not want to uproot their families from a city and take the chances at what may be perceived as lower quality schools.

While virtual continuing medical education is common for rural physicians, Dr. Rooney would like to see more in-person opportunities offered locally, as driving either to Phoenix or Tucson gets expensive and time consuming.

Finally, access to capital is another aspect of rural medicine that should be reformed. The few physicians in Globe have more difficulty accessing business loans for their practices or other business ventures.

THE PITCH FOR RURAL ARIZONA …GLOBE I asked Dr. Rooney for an elevator pitch for Globe. She states, “Well, I get up in the morning and go kayaking in the lake close to my house, then I’m back in time to work in the afternoon.” She encourages physicians to keep an open mind to the possibilities in rural Arizona. She is confident they would enjoy Globe, as it is well-positioned between Phoenix, Payson, and Tucson. There, you will find the White Mountains, Roosevelt Lake and Apache Lake, and a lot more greenery than in urban areas. The altitude provides longer spring and fall seasons. Patients are diverse and nice and want to get to know you and what makes you tick. She says, “Globe gives you a small-town feel, and you will enjoy it. There is a niceness about it not many other places have.” ■

— I love so many of them!

Q: Do you have a favorite sports team?

What is it?

A: Arizona Wildcats Q: What is your favorite activity outside of medicine?

A: Swimming

By Edward Araujo Managing Editor, Arizona Physician earaujo@mcmsonline.com A R I ZO N A P H Y S I C I A N . C O M

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What

Arizona

DOCS are Saying Why do you work in rural Arizona?

To improve access to high quality integrated healthcare to rural communities. —Arthur Chou, MD I grew up in rural areas and it is where I always wanted to work and practice.

—Jose L. Vega III, MD I have a passion for serving communities like the one in Yuma, where I grew up.

I am bilingual and enjoy providing care to Spanish-speaking patients.

—Mary Garcia-Kumirov, MD Family ties to the area on and around Navajo Nation. I have the opportunity to bring services to traditionally underserved and marginalized communities. —Mathew Nelson, DO

I was drawn to the peaceful lifestyle, the leadership of the organization and the knowledge that I was needed and could make an impact on the community I was to serve. —Darlene Melk, MD

I grew up in a rural town in Washington state and felt that rural areas often lack access to healthcare and other resources.

—Janeen Bjork, MD

I like the more relaxed pace, short commute, and chance to get to know people better. —J.R. LaVoy, MD

I like to help patients to be healthier and make a difference in their lives.

—Ching Wang, MD

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I love helping underserved patients in the area that I am from. —Benjamin Williams, DO Having lived in northern Arizona since 2004, I enjoy the diversity and complexity of rural medicine and rural communities.

—Ann Newland, MD

Learn more about the participating physicians Arthur Chou, MD PRACTICE | Horizon Health & Wellness | Apache Junction PHONE | (833) 431-4449 WEBSITE | hhwaz.org

What is your biggest frustration about rural health in Arizona?

Low reimbursement rates, challenges with recruitment, and the tendency for systems to be urban-centric when trying to develop policies that will affect rural areas. —Arthur Chou, MD Availability and access to certain specialists.

— Jose L. Vega III, MD Lack of access to essential resources, like specialty care and mental health services.

—Mary Garcia-Kumirov, MD Lack of readily available resources for my patients such as specialized diagnostic testing.

—Mathew Nelson, DO Distance to travel to specialists and lack of specialists willing to come into town.

—Janeen Bjork, MD Lack of certain specialized care.

—Ching Wang, MD

Jose L. Vega III, MD PRACTICE | Sunset Health | Yuma PHONE | (928) 819-8999 WEBSITE | mysunsethealth.org Mary Garcia-Kumirov, MD PRACTICE | Mariposa Community Health Center | Nogales PHONE | (520) 281-1550 WEBSITE | mariposachc.net Matthew Nelson, DO, MPH, MA PRACTICE | Canyonlands Healthcare | Page PHONE | (877) 645-9675 WEBSITE | canyonlandschc.org Janeen Bjork, MD PRACTICE | Canyonlands Healthcare | Page PHONE | (877) 645-9675 WEBSITE | canyonlandschc.org Ching Wang, MD PRACTICE | Sunset Health | Yuma PHONE | (928) 819-8999 WEBSITE | mysunsethealth.org Darlene Melk, MD PRACTICE | Chiricahua Community Health Centers | Douglas PHONE | (520) 364-1429 WEBSITE | cchci.org

It is very difficult to retain good primary care providers. In addition, it is hard to see patients struggle to get the services they need due to our rural location. —Darlene Melk, MD

J.R. LaVoy, MD PRACTICE | Desert Senita Community Health Centers | Ajo PHONE | (520) 387-5651 WEBSITE | desertsenita.org

Difficulty recruiting skilled staff, distance to sub specialists in the city. —J.R. Lavoy, MD

Benjamin Williams, DO PRACTICE | Creek Valley Health Clinic | Colorado City PHONE | (435) 900-1104 WEBSITE | creekvalleyhc.com

Difficulty getting patients into specialists and lack of resources. —Benjamin Williams, DO Recruiting and retaining highly qualified clinicians! —Anne Newland, MD

Anne Newland, MD, MPH PRACTICE | North Country Healthcare | Flagstaff PHONE | (928) 522-9400 WEBSITE | northcountryhealthcare.org

Read more about what these Docs are saying regarding rural health in Arizona at arizonaphysician.com.

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What

Continued from previous page

Arizona

DOCS

are Saying

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PLATFORM OF SERVICES New Lease Negotiations

What is your pitch to recruit physicians to practice in your town?

Great opportunity to develop innovative programs, make a large positive impact on those who really struggle to get access to high quality care, hone their clinical skills with highly complex patients, enjoy the benefits of rural towns (low traffic, great outdoors, great cost of living), and be an important and influential member of small and tight communities. —Arthur Chou, MD Lifestyle and more enjoyment of your own time.

—Jose L. Vega III, MD If you are looking to serve a rural community with excellent food choices and easy access to the cultural haven that is Mexico, then practicing in Nogales, AZ is for you. —Mary Garcia-Kumirov, MD

Lease Renewal & Negotiations Lease vs. Own Scenarios Occupancy & Operation Cost Analysis

I cannot imagine a more rewarding experience than building sustainable bridges across the oft-times deep chasms between illness and wellness... and we have a Walmart! —Mathew Nelson, DO

Site Evaluation Demographic & Market Analysis Space Planning Negotiating Tenant Improvement Allowances

SELECT TENANT CLIENTS

QUESTIONS? CONTACT US.

Beautiful area, work-life balance but not for everyone.

—Janeen Bjork, MD Medium size city, balance of work and life, less stress, no rush hour, close to several large cities within driving distance, organization’s mission. —Ching Wang, MD Our health center offers a reasonable pace (lower volume) with support staff in place to assist with bridging barriers to care. We offer providers the opportunity to participate in leadership or provider led projects. —Darlene Melk, MD The overall ambiance of our practice. Also, we completed a complete remodeling of the facility and we are building a new facility at our second location. —J.R. Lavoy, MD Great location with plenty of outdoor activities nearby with an awesome team and people that desperately need care. —Benjamin Williams, DO

FLETCHER PERRY 602.513.5124 fletcher.perry@kidder.com

MICHAEL DUPUY 602.513.5123 michael.dupuy@kidder.com

BROOKS KLASSEN 602.513.5153 brooks.klassen@kidder.com

KIDDER.COM

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Practicing in a rural community lets you grow your skill set as a clinician because you have to be able to handle a wide variety of conditions. You are also able to be more connected to the community you serve because you get to know leaders very quickly. —Anne Newland, MD

How does telehealth improve the care you deliver?

It is crucial to reach patients in rural areas since transportation can be a major social determinant of health (SDOH).

—Arthur Chou, MD It helps patients with busy schedules and who have difficulty with access to transportation.

—Jose L. Vega III, MD It provides patients with an alternative model of care, especially those still weary of close contact with others in the era of COVID-19.

—Mary Garcia-Kumirov, MD Provides patients with a safe and convenient avenue to care. It removes barriers and provides wider access. —Mathew Nelson, DO Has been especially important with COVID and allowing patients the safety of getting care from their homes. —Janeen Bjork, MD Access medical care with less exposure, travel and/or work. —Ching Wang, MD Telehealth allows me to see patients who live remotely and have trouble seeing our providers in the clinic. —Darlene Melk, MD We have a limited number of patients who have the necessary skills & equipment to participate in telehealth activities. —J.R. Lavoy, MD Increased availability to specialty care without the 6-hour drive to Phoenix.

—Benjamin Williams, DO Telehealth can make it easier for patients to see their providers, if they have good broadband access! —Anne Newland, MD ■

PRIMARY CARE PRACTICES WANTED FOR ACQUISITION

Matrix Associates, LLC Represents a Large, Local Physician-led and Physician-run, Multi-specialty Practice Seeking to acquire PRIMARY CARE PRACT Primary Care Practices Primary CareFOR Practices In the Metropolitan Phoenix Area WANTED ACQUISI

Wanted for Aquisition

For Further Information, Please Contact:

Matrix Associates, LLC Represents a Large, Loc Physician-led and Physician Multi-specialty Practice Jeff Heinemann Seeking to acquire MatrixJeff Associates, LLC represents Heinemann aMatrix large, local physician-led and Associates, LLC Primary Care Practices PRIMARY CARE PRACTICES physician-run, multi-specialty practice (602) 370-7764 In Metropolitan Phoenix WANTED FOR ACQUISITION seeking tothe acquire primary care practices jeff@matrixphoenix.com

in the Metropolitan Phoenix area.

Matrix Associates, LLC represents a large,and Please (All requests are confidential For Further Information, FOR FURTHER INFORMATION , local physician-led and physician-run, PLEASE CONTACT: All Fees are paid by our Client) multi-specialty practice seeking to acquire primary care practices in the Jeff Heinemann Metropolitan Phoenix area.

Matrix Associates, LLC

C

(602) 370-7764 For Further Information, Please Contact: jeff@matrixphoenix.com Jeff Heinemann Jeff Heinemann

Jeff Heinemann

(All requests are confidential and all fees are paid by our client)

Matrix Associates, LLC Matrix AAssociates, LLC (602) 370-7764 R I ZO N A P H Y S I C I A N . C O M 25 jeff@matrixphoenix.com (602) 370-7764

PRIMARY CARE PRACTICES WANTED FOR ACQUISITION

LEGAL CORNER

Expansion of Telehealth in Arizona: I M P L I C AT I O N S F O R R U R A L H E A LT H C A R E C O M M U N I T I E S

O

ne of the silver linings of the COVID-19 pandemic is that it brought on a rapid transition to telehealth. A Public Health Emergency (“PHE”) has existed in Arizona since March 11, 2020. During the PHE, Governor Ducey expanded access to telehealth in Arizona through a series of Executive Orders. However, all of the benefits achieved by the Executive Orders are set to expire at the conclusion of the PHE. Legislative action was required to make the temporary telehealth exceptions permanent.

In recognition of the benefits achieved by the temporary loosening of the telehealth requirements during the

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pandemic, on May 5, 2021, Arizona adopted a comprehensive telehealth bill (House Bill 2454, the “Bill”) that has the promise to drastically decrease barriers to healthcare access faced by residents of Arizona’s rural communities, as well as simplify the process for providing care to patients living in rural Arizona. Two components of the Bill that could significantly benefit rural communities are provisions allowing physicians to provide telehealth via audio-only encounters, and allowing physicians who are licensed out of state to provide telehealth services to Arizona patients.

For more information on this article please visit arizonaphysician.com/hb2454.

AU DIO - ON LY E NC OU N T E R S A N D T H E DIG I TA L DI V I DE Telehealth has undoubtedly expanded access to care. Despite that, there are concerns that its increased use will intensify health inequities among populations affected by the digital divide. Individuals living in rural areas are more likely to be disadvantaged by the digital divide than those living in urban areas. This is because many individuals living in rural areas lack access to broadband internet, which is a prerequisite for most telehealth platforms.

In Arizona, the percentage of residents with access to broadband internet ranges from an average of 93.7% of the population living in urban areas, to an average of 39.1% of the population living in rural areas. In Apache County, less than 2% of the population has access to broadband internet.

Before the enactment of the Bill, telehealth services could not be provided via an audio-only encounter. The Bill now expressly permits audio-only encounters if the health care provider determines that, “an audio-visual telehealth encounter is not reasonably available due to the patient’s functional status, the patient’s lack of technology or telecommunications infrastructure limits,” provided that: (a) the provider and patient have an established relationship; or (b) if the provider and patient do not have an established relationship, that the services are for behavioral health or substance use disorders. Passage of the Bill means that residents of rural areas of Arizona who previously had limited or no access to broadband internet can now receive healthcare services (for which the providers will be reimbursed), via phone.

burdensome administrative process for physicians and their employers. Before the enactment of the Bill, a healthcare provider could not provide care via telehealth to patients located in Arizona unless the provider was licensed in Arizona. During the pandemic Arizona passed an emergency measure allowing providers licensed in other states to treat patients in Arizona via telehealth, and many other states passed similar measures. The Bill creates a permanent exception to Arizona’s provider licensing requirements, for providers who will provide telehealth to patients located in Arizona.

Under this new exception, health care providers who are licensed in another state, and who have no prior disciplinary actions, can provide telehealth services to patients located in Arizona if the provider: (1) registers with their licensing board; (2) pays the registration fee; (3) complies with Arizona’s laws and regulations; and (4) consents to jurisdiction in Arizona for legal or disciplinary actions. These providers may not provide any in-person health care services to patients located in Arizona, or open an office in Arizona without becoming licensed in Arizona. There are a few exceptions to the registration requirements, which are set forth in A.R.S. § 36-3606(E).

This new licensing exception has the potential to drastically reduce the disparities in health outcomes between Arizona residents living in urban versus rural areas. This means that Arizona’s rural residents will now have access to the medical services of a large number of additional physicians, including worldrenowned specialists, where prior access was simply not possible. ■

L IC E NS E P OR TA BI L I T Y Provider licensing has long been a significant barrier to the expansion of telehealth programs. State licensure requirements are an important mechanism for the protection of patients. However, licensing can be a

Miranda A. Preston, JD Associate Attorney Milligan Lawless, P.C. miranda@milliganlawless.com

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HOW TO

New Practice Guidelines Expand Buprenorphine Prescribing

T

he U.S. Department of Health and Human Services (“HHS”) recently released Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder to address the increase in overdose deaths and to expand access to evidence-based treatments in ambulatory settings by removing potential opioid use disorder treatment barriers. The Guidelines are a step towards increasing the number of buprenorphine prescribers in rural and underserved areas.

Prior to 2000, medication-assisted treatment (“MAT”) was available only through federally approved opioid treatment programs, and buprenorphine was not yet approved by the FDA for opioid use disorder treatment. Since enactment of the Drug Addiction and Treatment Act of 2000, physicians outside an opioid treatment program have been able to apply for a Drug Enforcement Administration (“DEA”) X-waiver to prescribe and/or dispense Schedule III, IV, or V medications approved by the FDA for treatment of opioid dependency.

Application for the X-waiver has historically required that physicians complete an 8-hour training course and certify their capacity to make counseling and ancillary services available to patients. Over the past 20 years,

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demand for MAT has outpaced the number of waivered prescribers.

Research indicates that treatment with either buprenorphine or methadone reduces over-dose related and all-cause mortality risk in opioid use disorder patients by approximately 50%. Yet, according to the National Academy of Medicine, as of 2019 only 35% of these patients receive such treatment, leaving an estimated 2.2 million untreated.

Roughly half of all rural counties lack a single waivered prescriber, even though statistics indicate that the 2018 per capita overdose rate was nearly 45% higher in rural areas. As the demand for MAT has increased, a growing number of physicians have criticized the training requirement as an outdated barrier to treatment.

The new HHS Guidelines address the training and certification hurdles. Eligible physicians may now apply for an X-waiver and exemption from the 8-hour training course and certification of the capacity to provide patients with counseling and ancillary services. Practitioners utilizing the new exemptions are limited to prescribing buprenorphine to 30 patients at a time. To obtain a waiver, physicians must have an active state medical license, be registered with the DEA to prescribe controlled substances, and submit a Notice of Intent through the Substance Abuse and Mental Health Services Administration (“SAMHSA”).

If buprenorphine MAT under the Guidelines for an X-waiver is right for you and your patients, you should prepare to apply for the X-waiver and exemption and make the necessary changes to your practice:  Earn continuing medical education credit on related topics, such as comprehensive care for patients diagnosed with opioid use disorder.  Consult evidence-based guidelines from your specialty organization, SAMHSA, or ASAM.

 Develop protocols, clinical workflows, diversion policies, consent forms, and treatment agreements with your clinical team.  Assess staff training needs and coordinate staff education.  Read the Preparations for Treating Opioid Use Disorder in the Office, HHS’s Buprenorphine Quick Start Guide, and ASAM’s and SAMHSA’s templates and resources.  Notify your medical professional liability carrier when adding MAT to your practice.

Physicians and practice administration professionals should read the Guidelines and consult an attorney, if necessary, before implementing new buprenorphine MAT processes. Legislative and regulatory summaries and news articles may not contain details needed for compliance. ■

The content of this publication or presentation is intended for educational purposes only; is not an official position statement of Mutual Insurance Company of Arizona (MICA); and should not be considered or relied upon as professional, medical, or legal advice or as a substitute for your professional judgment. Consult your attorney about your individual situation and the applicable laws. The authors, presenters, and editors made a reasonable effort to ensure the accuracy of the information at the time of publication or presentation but do not warrant or guarantee accuracy, completeness, or currency of such information. As medical and legal information is constantly changing and evolving, check for updated information and consult your attorney before making decisions.

Jeanne E. Varner Powell, JD Senior Legal Risk Management Consultant, Risk Management Services Mutual Insurance Company of Arizona JVarnerPowell@mica-insurance.com

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PHYSICIAN SPOTLIGHT Judith Hunt, MD of Ponderosa Family Care in Payson shares her thoughts on rural health in Arizona.

Q: You were the first pediatrician

in Payson. What drew you to practice in “The Heart of Arizona?”

Q: Are there ways for physicians in urban

A: I grew up rural, a town with more cows than people. Lack of access to medical care for rural people encouraged me to choose rural medicine. While I was at the Good Samaritan Regional Medical Center for my Internal Medicine/Pediatrics residencies, my attending physicians knew of my desire to return to a rural area. Dr. Paul Bergeson, a gifted pediatrician, took me up to his pediatric clinic in Payson. Immediately, I felt as if Payson was the home for me and my daughter. Dr. Bergeson should have been paid as a recruiter!

A: COVID has spurred the development of telemedicine consults from the office and patients’ home. They allow patients to get the specialty care without the 3-hour drive.

Q: What motivates you now to practice

in rural health?

A: Twenty-five years later, my patients of Rim Country are my neighbors, friends, and their children. I was there for many of their first breaths. A rural physician has a commitment to both patients and a community. This was highlighted during COVID. We have a small medical staff and never have we worked harder to be both public health physicians as well as primary care/specialists.

settings to care for patients in rural Arizona?

Q: Do you see more interest from medical

students wanting to train in rural health?

A: Those who choose rural are those who grew up rural or have had the most rural time in their training. I think the longer we have the students and residents in the rural communities, the more likely the choice will be rural. University of Arizona College of Medicine — Phoenix (UACOM-P) and the Payson medical community developed the first Longitudinal Integrated Clerkship (LIC) program in Arizona. With more LIC opportunities and creativity of the state residency programs, I think the people of rural Arizona will have more dedicated and talented physicians. I am looking forward to training my replacement! ■

Q: How do you recruit physicians to

rural Arizona?

A: Recruitment is more than filling an empty position. Often, we are recruiting a family to an area without the same choices of restaurants, shopping, and schools. This family needs to be convinced that the rural community is best.

Thankfully, the University of Arizona Center for Rural Health and the University of Arizona Area Health Education Centers (AHEC) have supported rotations in rural and underserved areas for all health professions for many years. These rotations allow us to find the few physicians who want to work in rural health.

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JUDITH A. HUNT, MD Adolescent Medicine, Internal Medicine, and Pediatrics Ponderosa Family Care paysonfamilycare.com

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