The future of primary care in Kentucky
Maybe it starts in Fulton in the southwest, maybe Paris in the northeast. A critical access hospital closes, and a county fiscal court modestly subsidizes a primary care physician to retain some kind of healthcare for the community. It goes unnoticed til repeated by another fiscal court in another county. There's a letter to the editor, approving or complaining, a facebook thread or a lawsuit.
Legislative review
Legislators in the Kentucky General Assembly privately discuss their concerns and hopes about counties sponsoring primary care providers. The Kentucky Senate or House assigns the issue to their Health Services committee.
Hearings during recess investigate support for primary care physicians as a public service. The committee discovers big insurers don't object -- Blue Cross/Blue Shield, United Healthcare, Cigna, Aetna, and Humana don't want primary care physicians. They want specialists, nurse practitioners, physician assistants, emergency medicine physicians, hospitalists, and AI prompting. The Health Services committee studies concerns about preventing favoritism and corruption, problems they can't fully solve.
Public service primary care physician program
With the help of the Legislative Research Commission and Governor's office, the Health Services committee produces a standard fee schedule for public service primary care physicians, deemed a ceiling. Primary care physicians who charge less may bid for public service contracts with counties or municipalities.
The legislature lets counties and municipalities extend malpractice suit immunity to contracted public service primary care physicians, and lets them use a state-administered defense fund. The program extends the one that immunizes state employees, like the Federal Tort Claims Act Medical Malpractice Program. Not having to buy malpractice insurance lowers operating expenses for public service primary care physicians.
Public service primary care physicians may participate in the state employees' pension plan. Some counties buy their student loan debt and forgive it piecemeal as the primary care physician serves. Should either party end the public service agreement, the county sells remaining debt to the previous loan servicer, who must repurchase it.
Some municipalities and counties provide county or city-owned commercial or residential property for their contracted public service primary care physicians' residence or office. It's at no cost, or (more commonly) a discount below market rate. Some counties provide an administrative assistant paid by the health department.
Counties may not give or sell property to public service primary care physicians at a preferential rate, pay them, or provide direct financial incentives.
Contracts and payers
Contract agreements differ between counties. Most prohibit taking patients from outside the county, prohibit discrimination against the poor or uninsured, prohibit billing uninsured residents more than fee ceiling rates, require generating reports to facilitate oversight, and require audit access to financial records. Some expressly prohibit abortion and gender-affirming care. Others expressly encourage palliative care over heroic measures. Some also contract with public service dentists.
In Louisville, public service primary care providers are restricted to practice in a contracting magistrate's district. The city resolves a lawsuit contesting this practice. Over time, with the help of city councils, fiscal courts, and a state association, some public service primary care physicians gain admitting privileges at nearby hospitals.
Some public service primary care physicians take insurance. Some run sliding-scale concierge practices combined with charity programs funded by churches or rotary clubs. Some write grants and run free clinics or Federally Qualified Health Centers. Some primarily serve Amish or Holiness churches who pool money in group medical savings accounts.
Finding enough primary care physicians
Wealthier counties like Bourbon and Madison have more to offer and benefit accordingly. The University of Kentucky Center of Excellence in Rural Health suggests no less than one primary care physician per every 3,000 residents, with the public service program targeted at health shortage areas.
42 of Kentucky's 86 rural counties are health shortage areas, 32 acutely short. 14 of 34 urban counties are short. Nearly all far western Delta counties are short. How will Kentucky find at least 2,000 primary care physicians willing to spread evenly across the state?
A few of the poorest Delta and Appalachian counties will be unable to attract public service primary care physicians their constituents desperately want. They briefly succeed in an audacious (some say crazy) plan to work with their US Representative to get work visas for five doctors from Cuba.
Frontier Nursing University either licenses the physicians as Nurse Practitioners or the legislature exempts them from repeat residency. Because they are physicians counties may contract with them.
Over the next decade southeast mountain counties and west Kentucky river counties sponsor a handful of bright students to study at ELAM, the no-tuition Latin American School of Medicine in Cuba. Sponsor counties try to organize US residencies. The program is perennially controversial. Some students don't return to the US. Some don't find residencies.
The ELAM sponsor program faces insurmountable obstacles. It ceases being possible after fifteen years, when a new US president imposes new sanctions on Cuba. It introduces a dozen or more primary care physicians with no student loan debt and new ideas into long-term public service primary care practice.
Auxiliary house call staff
A decade after the program starts there will be nowhere near enough primary care physicians. Of 2,000 primary care physicians in Kentucky, only about 300 will be in contracted public service, 1 to every 13,000 Kentuckians. Half of Kentucky's primary care physicians will still practice in its two biggest cities. Many Kentuckians will still have no doctor, no nearby hospital, no ambulance service.
A new idea will be auxiliary house call staff. County health departments, the state association of public service primary care physicians and dentists, and the University of Kentucky Center of Excellence in Rural Health will train community nurse aides, primary care techs, and community paramedics. These auxiliaries will work under supervision of RNs in public service primary care physician offices.
The medics will do diabetes education, follow-up to ensure compliance, assess for barriers and resources, problem-solve, and provide urgent first-aid and mental health first aid. Like other medical and mental health techs, many will go on to nursing school or social work. Some will become new primary care physicians.
How it will go
The public service primary care physician program will never live up to its full promise. It will preserve the discipline of medicine in a patchwork of Kentucky counties as massive disruptions and widespread closures beset large segments of the former healthcare industry.
Funding won't always be available. There will be favoritism and corruption. There will, however, be some hundred outpatient internal medicine, family medicine, general surgery, pediatrics, OB/GYN, and psychiatry physicians with long careers serving the people of Kentucky from birth to death.
The average office will consist of a physician, a nurse practitioner or assistant physician, a registered nurse or two, one or two administrative staff, and a contracted cleaning service. After the healthcare industry deteriorates further, some offices will supervise four community aides.
Pharmacy will be another matter.
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