Sorry, baby: Delivery docs in short supply Up North

Kristin and Warren Scaife fishtailed along the gravel road that winds south out of Grand Marais, on the rocky shores of Lake Superior. Kristin was in labor, but she couldn’t go to the closest hospital. Helen Newberry Joy Hospital didn’t have a birthing unit. A decade earlier, Kristin’s mother-in-law had found that out when she rushed to Newberry for a delivery of her own, only to be told she should keep driving. The baby wouldn’t wait, and she gave birth at Newberry without an obstetrician.

Kristin couldn’t drive to the second-nearest hospital either; Munising Memorial Hospital hadn’t had a maternity ward for more than 20 years.

So the Scaifes' Chevy Prizm tore down the gravel Adams Trail on the first leg of a nerve-wracking two-hour trip to the nearest medical facility with an obstetrics department, Marquette General Hospital.

“We made it in time,” recalls Scaife, 29, an elementary school teacher in Grand Marais who is expecting another baby in August. “In today’s world, where everything is at your fingertips, to be so far removed (from medical care) is a shock.”

You can have a baby anyplace, but if you want an obstetrician in the room, you’d better live in the bottom half of Michigan or near a city. Large swaths of the northeast Lower Peninsula and the eastern Upper Peninsula lack easy access to a hospital with a maternity ward. More than a quarter of Michigan counties don’t have a single practicing OB/GYN physician.

And it’s likely to get worse. Losing money on most births, small hospitals are mothballing maternity wards, while rural communities struggle to attract and keep doctors who typically can make more money in urban areas.

Michigan’s no-delivery zone is a glaring example of medical service shortages across the state – shortages that some hope will be addressed by the growth in medical schools in the state.

Michigan has checkerboard of access

Scaife grew up in Oakland County, which is home to 396 OB/GYNs, the most in the state, according to data from the U.S. Department of Human and Health Services. 

“My mother’s a nurse,” Scaife says. “She’s not crazy about (the distance her daughter must travel for obstetric care).”

It’s not just expectant mothers who have trouble finding care. The geographic disparity of medical services in Michigan is sobering. Consider:

* More than 1.8 million Michigan residents live in areas that are considered underserved by primary care physicians, according to the U.S. Health Resources and Services Administration.

* The state needs an additional 192 primary care doctors in underserved areas, 10th highest in the nation.

* There are no Level 1 trauma centers in the northern half of Michigan, and no Level 1 pediatric trauma centers north of Grand Rapids, according to the American College of Surgeons. Level 1 trauma centers provide the highest level of surgical care. 

* There are 22 counties without a practicing OB/GYN. By comparison, every county has a veterinarian.

* There are 30 counties without hospital-based obstetric services, ranging from Cass County on the Indiana border to Ontonagon County at the western edge of the Upper Peninsula.

Washtenaw County has more OB/GYNs (130) than 62 Michigan counties combined. There’s one OB/GYN for every 2,653 residents in Washtenaw County, the highest rate in the state, one for every 22 pregnant women, based on the number of live births in the county.

By contrast, there is one practicing OB/GYN in Allegan County to serve a population of 111,000, a rate 40 times higher. (Allegan residents do have access to OB/GYNs and hospital obstetric units across the county borders to the north and south.)

Population is a factor, but it doesn’t completely explain the state’s no-delivery zones. For example, there are four OB/GYNs in Alpena County, with a population of 29,500, but none in Roscommon County, population 24,500.

Demographics drive doc distribution

The no-delivery zones are a result both of medical economics and a rapidly aging population in Northern Michigan. In the 21 counties in the northern third of the Lower Peninsula (going north from Manistee County on the west and Iosco County on the east), the population is shrinking and aging. One in five residents is over the age of 65, compared to one in seven in the state as a whole. In the 2010 Census, only 15 percent of the residents in those rural northern Michigan counties are women of childbearing age (15-45).

Fewer pregnancies means less work for OB/GYNs, explains Kathy Garthe, vice president of regional system development at Munson Medical Center in Traverse City.

“There are about 5,000 deliveries across 21 counties and about 2,000 are in the Traverse City area,” Garthe says. “For example, one hospital averages 183 deliveries per year. Since (obstetrics work) happens 24/7, you tend to need to have three or four doctors to handle all the calls. Can you have three or four doctors with an OB practice in an area with so few births?”

Meanwhile, hospitals lose money on births covered by Medicaid, which pays for more than half the births in Michigan, according to the Michigan Health and Hospital Association.

“Medicaid pays less than it costs to staff and operate a labor and delivery service,” William Russell, CEO of Three Rivers Health, said in testimony before the House Appropriations Subcommittee on the Community Health Budget in March. “In Three Rivers, 70 percent of our labor and delivery services are to Medicaid patients. A delivery costs roughly $5,000, and Medicaid pays us just under $3,000 for mother and child.

“When you lose significant dollars on every delivery, it is only a matter of time before that service must be eliminated.”

Helpful link

Physician pay figures

In the 1980s, there were more than 220 Michigan hospitals, virtually all independent. Now there are only 137, with 87 offering obstetrics units, according to the Lansing-based Michigan Health and Hospital Association. Six Michigan hospitals have closed obstetrics units in the past three years, with four of them in Mid- or Northern Michigan: West Branch, Cheboygan, Shelby and Clare.

“It’s not a shortage of services, it’s mal-distribution,” said Donna Jaksic, executive director of the U.P. Association of Rural Health Centers. “Services are not always as easily accessible because of cost or perceived cost.”

Rural communities have trouble attracting doctors, who often emerge from medical school with more than $100,000 in student debt and congregate in metropolitan hospitals offering higher wages.

“The market is in their favor,” Jaksic says. “Sometimes we offer (a prospective physician) a good package, and they can make twice as much in the south. Sometimes it’s a challenge of an occupation of their spouse. We’ve interviewed physicians whose spouse was an aeronautical engineer.”

CMU looks to fill a gap

The physician shortage in Northern Michigan is one of the reasons Central Michigan University is opening a medical school in the fall of 2013. “We have a shortage of physicians in Michigan and that shortage contributes to problems accessing health care in rural areas,” said Ernie Yoder, dean of the CMU College of Medicine. “The shortage is more severe north of Mt. Pleasant.”

Yoder believes the greatest shortage up north is psychiatric services, followed by general surgery, OB/GYN and primary care. Jaksic adds dermatology and orthopedics. “We have people traveling hundreds of miles to get to a dentist who accepts Medicaid,” Jaksic said.

Because of geographic disparities in medical care, rural Michiganians pay a premium for seeing a doctor -- a premium paid in time, gasoline and wear-and-tear on their vehicles.

It’s not surprising to hear Scaife say she doesn’t make the two-hour trip to Marquette each month for a pre-natal visit. “It’s such a long drive,” she says. “I wish there were something else available. But we live where we are because we have jobs.

“Luckily not a lot of people here have babies,” Scaife says with a laugh. “To be pregnant and have a child in this town is a pretty big thing.”

Senior Writer Ron French joined Bridge in 2011 after having won more than 40 national and state journalism awards since he joined the Detroit News in 1995. French has a long track record of uncovering emerging issues and changing the public policy debate through his work. In 2006, he foretold the coming crisis in the auto industry in a special report detailing how worker health-care costs threatened to bankrupt General Motors.

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Thu, 07/19/2012 - 8:29am
Thanks for a great article discussing this critical shortage. Kudos to families who manage their pregnancies around travel time and scarcity along with the all the other joys and challenges of becoming a parent. Adequate prenatal care leads to healthier outcomes for families and can prevent or reduce many of the problems that lead to developmental delays in the early years. All children born healthy starts with healthy parents and regular care.
Pamela S. Ovshinsky
Thu, 07/19/2012 - 9:36am
I'm glad you are bringing this to the public and policy makers attention, however I believe the problem is less about doctor shortage and more about hospital finance and priorities. They have plenty of doctors. They just won't allow them to provide that service! Norther Michigan McLaren closed its neonatal unit. The doctors still practice up here, but they must send their patients, elsewhere.
Thu, 07/19/2012 - 9:52am
Thank you for helping bring awareness to what many of us consider to a huge measure of quality of life. Adequate access to OB/GYN care is critical to improving health outcomes for women and children and is directly linked to the worst case scenarios where we lose mother or baby. While the Governor has done a great job highlighting that Michigan continues to struggle with our infant mortality rate (39th in the country) we are also 50th (only Washington DC ranks worse) in maternal mortality when a woman dies during pregnancy or within one year giving birth. Now we need attention and resources dedicated to the factors you presented to improve the odds for our future in Michigan.
Thu, 07/19/2012 - 9:59am
I was delinquent in adding thanks to Sen. John Moolenaar who has recognized this need in northern Michigan and worked hard to address one of the underlying issue in the 2012-13 state budget - OB/GYN's will receive a 20% increase in Medicaid reimbursement due to his efforts.
Bill Kandler
Thu, 07/19/2012 - 10:13am
Thanks for bringing attention to the problem of access to OB services in many parts of Michigan. This is a very complex issue with many elements. However, the fact that over 50% of Michigan babies are Medicaid cases is a huge contributing factor. Michigan Medicaid rates are near the lowest, if not the lowest, in the nation. One bright spot--the fiscal year 2013 Medicaid budget for Michigan includes a 20% increase for OB rates which was championed by Senator John Moolenaar (R MIdland). While this is much appreciated, it will increase OB reimbursements only to about 80% of what could be expected under Medicare. We still have a way to go to solve this problem. If we do not make it possible for physicians to make a living and hospitals to cover their costs, who will deliver our babies?
Thu, 07/19/2012 - 10:26am
Another medical school won't be an answer if hospital residencies aren't available and students can't afford the education; only a portion of physician training is done in medical schools, the rest is done in hospitals. The new school also won't solve the problem of physicians being trained in Michigan but practicing out-of-state or in areas with an overabundance of physicians in whatever specialty the physician chooses. Wouldn't it be a lot easier and less expensive to enlarge the existing medical schools rather than creating a new one? How about taxpayers doing more to fund medical student's education and allowing people to enter the profession who are not already wealthy? There could be a quid pro quo, we'll pay for your education, but you have to agree to working in Michigan for some number of years. If I was an 18 year old and looking at $100,000 debt to become a doctor, I wouldn't do it and frankly wonder why anyone would. Why do all our physicians need to be licensed M.D.s and D.O.s, can't specialized services be done by people without this broad training? The whole medical provider shortage problem is going to get much bigger when an additional 30 million U.S. citizens suddenly have medical insurance in 2014.
Michele Strasz
Thu, 07/19/2012 - 10:28am
Thank you for highlighting this critical issue for women and health care in Michigan. The Governor has made infant mortality one of two priorities on his health dashboard. Providing access to high quality OB and midwifery care across the state is critical to preventing maternal and infant mortality.
Charles Richards
Thu, 07/19/2012 - 1:41pm
The problem can't be solved by adding medical school capacity, or the number of residencies. The basic problem is that a delivery costs $5,000, while Medicaid pays $3,000 ($3,600 with the twenty percent increase). In higher income areas a high enough percentage of births are paid for by private insurance to subsidize Medicaid births. That is not the case in Northern Michigan where seventy percent of births are paid for by Medicaid. The only answer for that area is to increase the Medicaid payment to the level where cross-subsidization is sufficient to cover overall costs.
Thu, 07/19/2012 - 4:37pm
Perhaps much of our problem stems from expecting too much from our physicians in the first place. Lawsuits and long hours keep many from even becoming OB/GYN's. With many women in the medical world who also have families, it is difficult to deliver babies all night long, and then go be a mother, too...and then when something does go wrong, be sued for it and have her life in turmoil because of constant court demands. Secondly, I would think because we have advanced services, such as Neonatal and Infant Care Facilities (that are extremely expensive to maintain with up to the minute technology, prominent physicians, and every gadget ever made to help a delivery), everyone who lives in rural areas expects to have all of these amenities because it was on the Discovery Channel or last night's national news. It is just not fair and not equal...or even possible for every hospital to keep up. So, those who choose to live in a rural area must take that into consideration by living there. Perhaps a midwife or a local physician will be fine. And, when things go wrong, we cannot blame every doctor with a lawsuit---these doctors likely have less amenities, less technology, and MAYBE even less training than someone from a larger hospital who meets weekly with several colleagues to learn from one another. In a rural setting, the doctor may be the ONLY one who knows about a certain specialty. The risk should be placed on those who choose to travel to large hospitals or those who choose to stay local. And by the way, what is the actual risk? How often does this happen? I see that we are high statistically, but what is the actual number of deaths? And, is there a common factor for those that are in this statistic. Last, I would like to offer that more physicians added to the mix is likely not the answer....people will choose to live and work in areas they love. The suggestion of having a system where people give so many years of service in an under served area in exchange for an education may work, but the military and Indian Health Services has been trying to do this for years with many professionals, and I think they struggle to find people to agree. Since earning potentials are anywhere from 60,000 to much more, I would agree to 100,000 debt any day and choose to live where I want to live. The saturation of physicians with more medical schools may help this inadvertently to drive down supply and demand issues, which will make the 60,000 earnings dip and may make those type of programs more tempting. But, to think it will help spread out the services to rural under served areas is hopeful at best in my opinion.
Sun, 09/02/2012 - 2:13pm
Lisa, you are spot on with your comments. People who choose to live in remote yet beautiful areas must be aware of the disadvantages associated with this choice. It is not possible to have "the best of everything for everyone, everywhere" is a truism. Life is a compromise and is usually not fair, pick and choose carefully. Wolves live in the wilderness and are often cloaked in lawyer's clothing. Rural OB Doc's are easy prey!
M. Murphy
Fri, 07/20/2012 - 12:35pm
I think many people are not aware that there are trained doctors who cannot practice medicine because they cannot secure a medical residency - there are too few residencies (numbered in the thousands) for the number of available trained graduates. Opening new medical schools does not help. In fact, it adds more graduates to the mix of trained professionals who cannot get their license because they can't get a residency. How is this happening in the U.S.? If citizens are concerned about all health care delivery - obsetrics included - they should advocate for changes in the law. We could have more clinicians who are not "specialists". We could have limited licensed doctors who practice side by side with established practioners in settings other than teaching hospitals. Get involved! Let your legislator know what your concerns are. There's a senate bill out there right now advocating for change - Senate Bill 1201.
David Waymire
Sat, 07/21/2012 - 11:29am
If we just cut taxes, this problem will go away.