With so many unknowns ahead, it’s comforting there are proven solutions to one big challenge — the aging of the population. From research, and experience, experts have identified factors for remaining independent, resilient and happy as we grow older. Key among them: nutritious meals; regular exercise; and the opportunity to engage meaningfully with friends and with the broader community.

Obvious, right? So it should be easy to integrate those components into programs and policies. Except for the fact that we’ve organized American life to make them tough to implement at any age.

We’ve grown fat on processed food and little exercise. We’ve abandoned the oldest traditions of community life in villages and towns and sprawled into the countryside. The move has isolated us from one another and exiled us to hours in automobiles commuting to every aspect of our daily lives. As a result, when we get older, we’re often stuck with habits that threaten our health and with environments that inhibit mobility and opportunities for maintaining the connections we need to avoid hospitals and nursing homes.

Demographics and economics are forcing us to take the problem seriously. Between 2000 and 2050, the U.S. population is expected to grow by 48 percent. Over the same period, the demographic category of folks aged 65 to 84 is expected to grow by 114 percent; and the percentage growth of the 85-plus group is projected at 389 percent. In North Carolina, by 2029, 17.2 percent of the population is expected to be 65 or older, compared to 12.2 percent in 2008.

Public agencies and nonprofits at all levels want to ramp up to meet the challenge. But the gap between demand and funding support is huge and getting huger, first because of the sheer numbers, and now because of the economic downturn. So it’s time for individuals and communities to start thinking of do-it-yourself strategies that build on what works for a growing senior population.

For policymakers, the most senior-friendly strategy is to help villages and towns renew walkable, mixed-use neighborhoods with diverse housing choices that serve people of all ages. For those of us who plan to get old, it’s time to take charge of this stage of our lives. If we want the infrastructure, emergency services, and amenities of in-town living, let’s build or redevelop neighborhoods in towns instead of insisting developers and county governments deliver town-like services in remote places.

For those with a gift for organization, there’s a growing movement of senior “co-housing” in which potential neighbors come together before there’s a physical neighborhood. They decide on elements of the environment they want, then hire design and construction teams to build it. Cohousing neighborhoods already exist in Asheville and throughout North Carolina. New groups are forming all the time. The idea aligns perfectly with what is already a strong desire for more alternatives for town living and with innovative developers’ projects that tap into the best tradition of compact, connected neighborhoods.

(Ben Brown is a Franklin-based writer and communications consultant who works with private sector clients and governments on Smart Growth planning. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..)

Last week, Waynesville’s town board linked up with a growing grassroots movement that is calling for increased rail capacity.

The town board unanimously passed a resolution to support a move to rail service in North Carolina.

“To me, it’s just an obvious thing,” said Alderman LeRoy Roberson. “A railroad system is going to be the way for freight to be moved. It far outstrips the economy that you’re going to find with trucking.”

While the resolution doesn’t lead to any immediate action, Waynesville has joined 120 entities across the state that have urged expansion of freight train service in North Carolina.

For Roberson and many others, the benefits of rail include better fuel efficiency and more independence from foreign oil.

“I can’t imagine any group right now that’s going to oppose that,” said Roberson, adding that rapid train service would also be far more efficient than building new roads.

The town board supported the increasing use of both freight and passenger trains. But Roberson acknowledges that passenger trains won’t be crisscrossing Western North Carolina any time soon.

“That’s not going to happen in the near future, but you’ve got to move in that direction,” Roberson said.

For now, the state has plans to bring passenger rail to Asheville — but not further west.

Currently, there are plans for five major intercity passenger service additions in the state, including the Western North Carolina Passenger Rail Service from Asheville to Salisbury. From there, passengers could continue on to Raleigh and beyond.

Budget constraints have held back the expensive multimillion-dollar projects, but progress is ongoing.

“Slow moving, but ongoing,” said N.C. Representative Ray Rapp, D-Mars Hill, who chairs the House committee dedicated to a comprehensive rail service plan for the state and is a member of the state Transportation Committee.

Rapp said the state’s first priority is to fund high-speed rail through North Carolina that will connect Washington, D.C., to Atlanta. The Salisbury-Asheville line would be a secondary branch off that main line.

According to the WNC Rail Corridor Committee, Asheville is the most frequently requested stop in the country for a new stop on Amtrak, the nation’s largest commuter rail company.

The committee represents the nine locations that are designated as future stops on the rail service from Salisbury to Asheville: Salisbury, Statesville, Hickory, Morganton, Valdese, Marion, Old Fort, Black Mountain and Asheville.

Upgrading a freight line between Salisbury and Asheville might run from $150 to $170 million, Rapp said.

While some of the nine towns have already spent millions on station upgrades, Rapp said Amtrak does not seem to have much interest in the Asheville-Salisbury line.

According to a study done by Wake Forest University, within the third year of operation, the proposed train service would carry only 70,000 passengers annually, below the desired critical mass.

“It really depends on how much we’re willing to subsidize that operation,” said Rapp. “Upgrading track, installing signals, straightening tracks — that’s why that cost figure has continued to rise.”

But local governments are still holding out hope for the ambitious railroad plan.

Waynesville Town Manager Lee Galloway said he would especially support a passenger rail line linking Asheville to Raleigh.

“The trip from Raleigh, it gets a little old,” said Galloway. “I’d much rather get on a train.”

Roberson pointed that having rail as a transportation option could have cut down the economic impact from the Interstate 40 rockslide.

“You’ve got a road closed until March, losing $1 million a day,” said Roberson.

Dr. David Trigg, medical director at the Good Samaritan Clinic of Jackson County, doesn’t know if he should do more or less to treat the uninsured. While he and the other volunteer doctors at free clinics are their patients’ only option for health care, he sometimes feels they’re the ones propping up a broken system.

“You feel like the boy with his finger in the dyke,” Trigg said. “Not only is it not the solution to the problem, but it paralyzes you. But don’t tell our patients that. They don’t have any alternative.”

Trigg has seen the failure of health care for the poor from a number of angles. As an emergency room doctor who currently works part-time intermittent shifts in Cherokee, he has seen the way uninsured chronic care patients clog the country’s critical care facilities.

“The ER is the safety net for people who don’t have insurance, and it’s not sustainable,” Trigg said. “If emergency rooms keep getting busier, not only will the poor suffer because they’ll continue to get boarded, but the rich will begin to suffer because they’ll be so inundated they won’t get to the critical cases,” said Trigg.

As a volunteer primary care provider at a free clinic, he has seen how people without insurance work to get better, to work some more to pay their bills, without ever having any real hope of getting insured.

“The patients will break your heart. Let’s talk about a man who works three jobs and his employers deliberately won’t give him 40 hours per week so they don’t have to provide insurance,” said Trigg.

As a teaching doctor at Western Carolina University’s health science program, he has seen how the insurance reimbursement system discourages doctors from going into primary care, creating shortages.

“Part of reform has to be — not debt forgiveness — but scholarships for doctors who go into primary care,” said Trigg. “I think a lot of young people would go a year for a year. You have to pay primary care providers more and specialists less.”

For Trigg, the fact that North Carolina has 77 free clinics — the most in the nation — is neither an indictment nor a credit. It’s a reality.

“Anytime someone gets into the free clinic, they realize — consciously or subconsciously — that the system is broken. They’re not necessarily politically motivated though because they’re in survival mode,” said Trigg.

Trigg thinks part of the reason the debate over health care is so contentious is because the people who know the system is broken are too disillusioned to join the discussion.

In many ways, the health care debate is as simple as the separation between rich and poor, and the poor don’t often tell their own story as well as others tell it for them.

Becky Olson, Good Samaritan Clinic of Jackson County’s executive director, said her impression of the clinic’s patients is they don’t believe their government listens to them, so they don’t bother speaking to it.

“What I do feel and see here is a real sense of disenfranchisement,” Olson said. “I’m not sure how many of our patients vote because there is a feeling it wouldn’t make a difference. The real voices in this discussion on both sides are coming from people who don’t have to worry in the same way about where their health care comes from.”

Olson, a registered nurse who has spent the last 30 years working in a variety of settings from labor and delivery to long-term care, began volunteering at Good Samaritan when the free clinic opened in 2001 and became executive director in 2006. She is increasingly frustrated that health care has become a politicized discussion about costs, when the human cost of failing to provide affordable health care is decimating people’s lives and increasing the gap between rich and poor.

“The bottom line right now is it’s not working for a significant part of the population,” Olson said. “I haven’t heard anyone who can say with certainty how much it might cost or how much it might save to change the system.”

For Olson the issue is simple. The patients she sees everyday shouldn’t have to wait in lines at free clinics to get treated for everyday health issues like asthma, diabetes, hypertension, and back pain.

“This is not the way that health care ought to be gotten. If our clients had a better way into the system, we would with great pleasure close the doors,” Olson said.

For a long time, health care providers stayed out of the debate over health care policy. In general, doctors and nurses are practical people focused on their work, but Olson has grown increasingly exasperated by the argument that the government shouldn’t pay to provide care to the poor.

“That kind of argument ... if you don’t think the government should be running programs for poor folks, then maybe you shouldn’t take Medicare,” Olson said.

Though Sylva resident Marsha Crites had no risk factors, she suffered a major cerebellum stroke at the age of 49.

“Not only could I not walk, I couldn’t sit,” said Crites. “I would even fall out of bed for a while.”

Her health insurance covered much of the expenses but not everything.

“They covered all but $10,000, but still, that was a lot that I had to cover myself,” said Crites, who ended up fighting the insurance company for more coverage and lower costs. “They would cover occupational therapy, but not speech therapy.”

Crites said she had to argue logistics with the insurance company while she was “out of it.”

“I have always felt that you had to beg, plead and beat on the door to get the health insurance coverage that you needed,” said Crites.

Crites suspected finding another health insurance policy would be nearly impossible even though she fully recovered from the stroke. She was right.

After Crites lost her insurance policy due to a divorce, she became “uninsurable.”

Crites was turned down by insurance companies left and right. She finally settled for temporary insurance, which only works for six months at a time. She pays about $250 a month, but her deductible is $3,500.

“I get no preventative care, none,” said Crites. “If you get really sick in those six months, they won’t renew it.”

As a self-employed landscape designer, Crites said there’s no way she could afford individual insurance even if she had been approved for it.

“Personally, I think it’s embarrassing for me as an American that we don’t have universal health care,” said Crites. “It is so much cheaper to cover everybody to provide preventative care.”

Crites asked if the people who complain about government control would want to take away benefits for veterans, social security, Medicare, Medicaid, and health insurance for Congress.

“Why do some people get government help and others not?” asked Crites, adding she is willing to pay more taxes to get everybody covered. “There’s no way my taxes would equal what I’m paying for premiums.”

Crites said there’s an urgent need to pass health care reform in the U.S. now.

“I just see so much tragedy,” said Crites. “This is not just about it’s inconvenient or it’s expensive. People are dying because we as the supposedly most progressive country on Earth can’t take care of our people.”

As if dealing with the trauma of breast cancer wasn’t enough, Martha Yonce, 62, was also hit with a devastating $80,000 in out-of-pocket expenses for her surgery, chemotherapy and radiation.

Yonce, a Franklin resident, thought she had her bases covered with the equivalent of a state employee’s health insurance policy. She received the insurance through her husband, who was a science teacher at Macon Middle School at the time.

Yonce’s insurance company had agreed to pay 80 percent of the cost but left her to deal with the remaining 20 percent in whatever way she could.

Coming up with such a large sum of money proved to be a major struggle, as Yonce and her family neared the brink of bankruptcy and almost lost their home.

“We wiped out what savings we had,” Yonce said. “It just took everything we had. That was nine years ago, and we’ve never really recovered financially.”

To make matters even worse, Yonce and her husband were recently denied insurance coverage that would supplement Medicare due to pre-existing conditions, including her breast cancer, and his diabetes and heart problems.

Even though Yonce has been cancer-free for years, she said the worry about recurrence never goes away.

“Good days are days you don’t think about cancer,” said Yonce. “You know that if it recurs, you are going to have a tremendous financial burden. You’re going to do all you can to save your life and treatment costs money — even with insurance.”

Yonce said she recalled taking medication for nausea that cost $100 a pill, while other women went without because they simply could not afford it.

“The thought of somebody that’s kneeling at the toilet vomiting and there’s a medication out there that can help them and they can’t afford it, that’s sad, that really is,” said Yonce, who has actively been calling for health care reform in the past year.

Yonce has attended rallies and made frequent calls to representatives and fellow citizens in the past few months. She hopes that Congress will pass a health care bill that places a cap on out of pocket expenses.

Yonce said she was surprised by how many sad stories she came across while working at a phone bank. She once talked to a man who was asked to pay $900 cash for anti-rejection medication after receiving a kidney transplant and a woman who broke her hip but could not afford to go to the hospital.

Despite all the gloomy stories she’s heard, Yonce has managed to retain a sense of humor.

On a recent afternoon, Yonce prepared to go door-to-door to distribute flyers that featured a man named Vernon whose inadequate health insurance left him $28,000 in debt.

“This guy is not in as bad shape as me,” joked Yonce. “Vernon, you don’t know how good you’ve got it.”

Nothing could have prepared Franklin sisters Suzanne Thomas and Karen Rice for the total financial ruin that followed their injuries.

Thomas, 63, and Rice, 70, are still coping with the impact of astronomical medical costs from nearly a decade ago, while another sister Shirley Ches, 74, is dealing with a health insurance bill that already scoops up about 33 percent of her household income and continues to climb significantly each year.

Thomas had to file for bankruptcy, while Rice had to move into a mobile home, giving up electricity and washing machines in the meantime. What astonished the sisters most about their plight was that they both had what they considered good health insurance when their injuries occurred.

Ches, Rice and Thomas have channeled the anger and frustration of their experience into an active fight for healthcare reform across the country, helping to organize vigils, sending petitions to Washington and sharing their story with crowds of strangers.

“We have all made a career out of writing letters to the editor,” said Ches.

Through their activism, the sisters have realized they are far from alone in their hardships.

“When you go to these things, you find people with phenomenal stories,” said Ches. “We’re shoulder to shoulder with so many people.”

Losing it all

Thomas had been perfectly happy with her health insurance before she suffered a major shoulder injury due to a fall in 2000.

“I had wonderful insurance. I didn’t worry about a thing,” said Thomas, who never hesitated to visit the doctor, the dentist or optometrist.

Two years later, Thomas had not only lost that health insurance, but also her job, her home and her good credit. Thomas had to file for bankruptcy and move from her two-bedroom apartment in rural Michigan to Ches’s home in Franklin about seven years ago.

It was all the result of a ruptured spleen that doctors didn’t even discover until two days after her accident. Thomas had complained about stomach pain, but her doctors wrote it off as a side effect of her pain medication and sent her home to await shoulder surgery.

Thomas began throwing up frequently and continued to suffer excruciating pain. Her friends decided to rush her back to the hospital as she floated in and out of consciousness.

After making the 32-mile ambulance trip to the hospital, Thomas summoned up enough strength to sign off for the splenectomy surgeons said she needed to stop her internal bleeding.

Along with the splenectomy, Thomas had five surgeries on her arm, and physical and occupational therapy over the next year and a half. Her hospital stay alone rang up $35,000.

When the time to pay the medical bills rolled around, the insurance company refused to pay for the splenectomy — Thomas had never gotten pre-approval for it.

Thomas was appalled that the insurance company expected her to give them a ring during the emergency ambulance transport.

“I was half-dead,” said Thomas.

Thomas couldn’t work her full-time job as she recovered, so she ended up losing her health insurance along with her job.

“You can only do Cobra for so long and afford it,” said Thomas.

Though Thomas tried to take on spot jobs, including a stint harvesting grapes with her non-dominant hand during Michigan’s chilly fall, she could not make enough to keep up with her monthly bills.

At one point, Thomas had to run outside as a tow truck began to pull away with her repossessed car to salvage all her belongings from the vehicle.

At a time when just getting dressed proved to be a struggle, Thomas had to deal with a steady stream of hospital bills and an unsuccessful legal battle to appeal the charges. Thomas had no recourse but to file for bankruptcy and move into Ches’s basement apartment.

According to Thomas, most people in the U.S. are not immune from suffering the same ordeal.

“I paid my bills. I had good credit,“ sad Thomas. “Yes, you have a job right now. Yes, you have health insurance right now, but ... maybe you’re going to end up having to pay.”

Thomas currently works as a cashier at Harrah’s Casino in Cherokee, mostly because the job provides health insurance.

“I never thought I would be working at this age,” Thomas said.

Extreme sacrifices

Because of her own shoulder injury, Rice now finds herself living in a single-wide mobile home in Franklin.

After several months of physical therapy and doctor’s visits, Rice had to pay between $25,000 and $30,000 in out-of-pocket expenses.

Rice said she checked in with the insurance company each time she went to the doctor’s office to make sure she had enough coverage. It turned out her insurance company had not yet processed her bills, so they were not aware her coverage had already run out.

“I would have said ‘Look, I’m running out of money. I will settle for a certain level of disability, find an alternative source of treatment I can afford, or save up until I can afford to continue,’” said Rice.

Instead, Rice had to sell her 200,000-square-foot home and move to a single-wide trailer in Franklin to be closer to her two sisters and save up for the “next healthcare disaster,” Rice said.

Rice, who said she always paid her bills on time and never carried credit card balances, saw her credit ruined since she couldn’t keep up with medical payments.

But Rice decided to take a proactive approach after that financial catastrophe.

Rice slashed every expense that she could, using candles instead of electricity and washing all her clothes by hand. She stopped traveling to see her children and no longer sent them any gifts. Rice consolidated trips to the grocery store, going only every two or three weeks, to save on gas.

“If it wasn’t something I absolutely needed to survive, I didn’t spend the money,” said Rice, who didn’t meet her youngest grandson until he was three years old and came to the area to attend Rice’s husband’s funeral.

Now that Rice believes she’s saved up enough of a cushion, she has started using electricity again, though she continues to wash her clothes by hand.

Rice hopes the money she has saved will be sufficient to cover her future medical costs without relying on others.

“All seniors are afraid that we’re one disaster away from ruin,” said Rice. “I do not want to be a burden on my neighbors, friends, church and society.”

Rice said she had previously been ashamed about her financial turmoil, wondering what she could have possibly done wrong. But she decided to share her story because many others were experiencing similar predicaments.

“I’m not alone. I’m not unique,” said Rice. “That’s the sad part about it.”

Rice said she does not want health care reform for just her or her sisters.

“We want this for others, our children and grandchildren, for everyone,” said Rice.

A broken system

Ches said she and her husband are being punished unfairly for simply growing one year older. Her insurance costs have gone up by 15 percent this year.

“It has gone up for no reason,” said Ches. “We have not been sick. We haven’t even used the amount of money that we’ve paid into it.”

Ches wonders what will happen if she has a medical emergency like those her sisters experienced.

“We’ll join the mob in the emergency room,” said Ches. “Then, all the people currently have health insurance will be impacted negatively.”

After having such a terrible experience with the American health care system, the three sisters feel very strongly about passing health care reform.

“The people who have insurance don’t realize that they can lose it,” said Rice. “The people who have insurance are very happy with the status quo.”

The sisters say those who are sick should not be spending their time wondering about how they would pay for treatment.

“I think something is really broken here,” said Rice. “I have to be afraid to spend a penny because I’m afraid of a medical emergency.”

Ches said those who receive health insurance through their employer and believe they are safe from similar scenarios are living in a “fool’s paradise.”

“You have employer subsidized insurance until you are out of work,” said Ches.

According to Rice, the U.S. must ultimately come up with its own solution rather than following how other countries run their health care system.

Though all three sisters say they would like to see a single-payer system, Rice said she has had “wonderful conversations” and found common ground with those who oppose exactly what she supports.

“Fox, CNN, MSNBC – I watch all of them. I will listen to all sides, the truth is somewhere in between,” said Rice, who is disappointed that the health care debate has taken such an ugly turn.

“This should not have become a partisan issue, the people need to realize that,” Rice said.

It was late September, and Travis George, a 27-year-old Waynesville resident, was almost done mowing his grandmother’s yard. With just five minutes left, his foot accidentally slipped right under the mower, chopping off three of his toes and part of his foot.

George was rushed to Mission Hospital in Asheville, where doctors performed surgery and cleaned up the gaping wound. A month later, George had to undergo skin graft surgery.

George was able to get Medicaid to pay much of the $30,000 bill, and he received about $1,000 from his grandmother’s homeowner’s insurance, but $7,000 must come out of his own pockets.

Unfortunately, George has not been able to find a new job after being laid off from his job as land surveyor last Christmas.

Now he’s caught in the middle. George no longer qualifies for unemployment, since he is no longer able to work. Yet he cannot receive disability benefits because he will be able to return to work in less than a year.

“Ever since I got hurt, I have no income,” said George.

George said he almost didn’t qualify for Medicaid because of his wife’s income as a bank employee. While her health insurance covers their two children, George said adding him to the policy would result in outrageous costs.

“She would end up paying more for our family’s insurance than she would take home,” said George “It’s unreal.”

For George, the problem with the health care industry is tied to the greed of insurance companies. Despite taxpayers picking up the tab for part of his medical bill, George said the government should not be responsible for everyone’s health care.

George supports opening up competition among insurance companies across state lines to lower prices instead.

“I don’t think the government should make everybody pay,” said George. “I had a terrible accident, trying to get help as I can, but the rest of it I’m responsible for. That’s the way it should be.”

Two Waynesville companies recently decided to assist George by holding a chilly cook-off fundraiser to raise donations for his $7,000 payment.

“That’s helped out a little bit,” said George. “Other than that, I don’t know how I’m going to pay that balance.”

Bridget Nelson, 40, graduate student at Western North Carolina

Nelson was required to get health insurance after enrolling at WCU though she said not having insurance previously didn’t bother her.

“I view insurance companies as legalized organized crime.”

Nelson considers herself a healthy individual who would probably only use health insurance for medical emergencies.

While working for a nonprofit, she once faced the awkward situation of receiving good insurance coverage through her employer but being unable to extend that coverage to her two children. Nelson eventually acquired Medicaid benefits for her kids, which helped cover costs when her daughter broke her arm.

In Nelson’s view, health care reform should be a national priority. She said a single payer system would make more economic sense than the current wars in Iraq and Afghanistan.

“We’ve spent trillions on apparently useless wars, so if you’re willing to spend on that but not health care, there’s a priority problem.”

Amy Tucker, 24, server at Ryan’s Family Steak House in Sylva

Tucker is on her father’s company health insurance policy but has a $5,000 deductible, which means she usually pays for “pretty much everything.”

Tucker says she is against the health care bill. “I don’t think that it should be free for everyone,” said Tucker, “[But] everyone should have some kind of coverage.”

Tucker said she’s more in favor of an assistance program than universal health care.

Sunshine Cochran, 33, server at Ryan’s Family Steak House in Sylva

Cochran is considering buying health insurance through her job, but as of now, she has none. She said the health insurance rates through Ryan’s are pretty reasonable. “I just gotta make sure it fits my budget.”

Cochran has received Medicaid benefits when she was pregnant with her five kids, who are all on Medicaid now. But she is still paying off a $15,000 debt she incurred after breaking her arm in a car racing accident.

Cochran was able to pay the $900 upfront cost, but she hopes to avoid landing in the same situation in the future.

“I try to stay away from getting hurt.”

Kirk Childress, 22, manager of Black Rock Outdoor Company in Sylva

Childress will soon get a monthly allowance for health insurance after being promoted to manager at the store. Before that, however, Childress did not have health insurance of any kind. For Childress, the choice was between paying for health insurance or paying for a car. He chose the car.

“I’ve always been healthy. I’ve never had a problem.”

Childress says his approach to health care has been more reactive than pro-active. He once had a serious spider bite that needed to be treated. A friend’s father, who happened to be a doctor, was able to call in a prescription for antibiotics to take care of it.

Childress said those who cannot afford health care should be given the minimum for family doctor visits and emergencies, but he said most people should purchase health care for themselves.

Sheryl Rudd, 49, and Dieter Kuhn, 54, co-owners of Heinzelmannchen Brewery in Sylva

Rudd and Kuhn choose not to pay for health insurance, relying on natural medicine and wellness instead. They had been paying monthly premiums for a policy with a $5,000 deductible but decided to drop the insurance.

“Nothing was being covered,” said Rudd, adding that the insurance company would not help pay for her to see her preferred doctor.

Kuhn admits that not having health insurance places more responsibility on the individual to stay well and handle any resulting financial responsibilities.

When it comes to health care reform, Rudd said she is not in favor of placing more burdens on businesses through regulations.

“That’s not fair,” said Rudd. “That takes my choice away.”

Instead, Rudd would like to see everyone in the country get the same health insurance that Congress receives.

“But what they’re proposing, I’m against,” said Rudd.

In an effort to boost recruitment of doctors to the region, hospitals across Western North Carolina are following in the footsteps of a national trend to employ physicians in-house.

Historically, doctors set up independent, private practices.

But doctors are increasingly being squeezed by rising overhead and lower reimbursements for Medicare and Medicaid patients. As a result, doctors are gravitating toward a new model of being employed directly by hospitals. The hospitals keep the revenue generated from the patients, while providing a steady salary to the doctors.

“It allows them to do what they were trained for, the clinical work, and let someone else handle the administrative side,” said Tim Hubbs, CEO of Angel Medical Center in Franklin.

Whether it’s disciplining chronically late employees, shopping malpractice rates or billing insurance companies, “It is nice to say ‘Hey, can you all just handle that?’” Hubbs said.

Sylva-based WestCare is leading the hospitals west of Asheville in the number of physicians employed in-house. WestCare employs 19 physicians across six practices. Angel Medical Center employs 13, while Haywood Regional Medical Center employs five.

WestCare CEO Mark Leonard said the trend reflects a generational preference among younger doctors. He cited a recent survey of medical school grads at Duke University where 74 percent said they would rather be employed upon graduating than go into their own private practice.

“This really reflects a generational shift on the part of new physicians entering into medicine,” Leonard said. “It was incumbent on us to shift and embrace this new way of doing business.”

Leonard said he understands why the new model is attractive to today’s younger doctors, citing the long shifts doctors pull simply to care for their patients.

“When you put on top of that being a business owner and doing the taxes and the personnel issues, that causes the hours to stack up,” Leonard said. “These new physicians coming out say, ‘I just went to medical school and I want to emphasize the clinical side of medicine.”

Haywood CEO Mike Poore added that young doctors aren’t eager to follow the rigorous on-call schedule that had their older peers chained to beepers most of their lives. They want a steady salary and more free time.

Balancing autonomy

The only downfall of the model is a potential loss of autonomy. Doctors can suddenly find themselves answering to a hospital CEO, unlike a private practice model where they answer to no one but their patients.

All three hospital CEOs interviewed for this story said they recognize the concern.

“When I go to my personal physician, I don’t want to be thinking that there is a suit in another room influencing how he is going to care for me, my wife or my children,” Leonard said. “I want his decision to be based on what’s in my best interest as a patient.”

At WestCare, Leonard said he has laid the foundation of trust between physicians and administration and a collaborative decision-making model, which should in turn allay such fears.

“I am not a physician. I did not go to medical school. I am going to rely on and trust the physician’s judgment when it comes to clinical decision-making,” Leonard said.

Hubbs also pledged a hands-off management style when it comes to medical care.

“If a physician says I think we need a CAT scan on this, we are not going to second guess that,” Leonard said.

For Dr. Bruce Lobitz, an ER doctor who joined a team of hospital-employed doctors in the Angel emergency room this year, the possibility of hospital administration intruding on his care of patients was a top concern.

“That was one of my hesitations,” Lobitz said, who has found it not to be the case, however. “Here, there is very little of that.”

While it might give some physicians pause, the positves seem to outweigh the negatives.

“There is some trepidation in the loss of autonomy,” said Dr. Charles Trenthem. “But if you look at the trends nationally, this is what’s happening.”

While the nonprofit hospitals in the mountains have a community minded philosophy, larger for-profit hospitals could take advantage of the employment model.

“They do have a profit model, and they do push the providers at all levels to see that one extra patient, to generate that one extra charge,” said Dr. David Farley, an internist at Angel Medical. “I have not seen that be an issue here.”

Hubbs said there are external controls to ensure hospitals don’t prod physicians to order more costly tests than a patient really needs just to boost revenue. The insurance companies or Medicare who get stuck with the bill would notice an outlier ordering gobs of tests, Hubbs said.

There is one upside for patients: fewer bills. Anyone faced with a hospital stay braces for a litany of separate bills trickling in for lab tests, X-rays, various specialists and the hospital itself. Poore said bundled payments — where the bill for doctors is included with the bill from the hospital — is a model that shows promise.

Hospitals employing a critical mass of in-house doctors will often house them in a joint practice, even if they aren’t in the same specialty. It allows for integrated patient care, providing quick access to charts and reducing the chances of two doctors ordering the same test.

“Really it is kind of a data flow issue that is so clumsy in medicine right now,” Farley said. “If you’re housed in the same unit, you can walk down the hall and say ‘What did you think of Mrs. So-and-so this morning? Should I be concerned about this?’ You don’t have that when you are all scattered around in separate pods around town.”

Making the transition

While urban hospitals have launched a large-scale transition toward employing doctors, rural hospitals are using the model primarily to lure new recruits or to stabilize a faltering practice in a specialty the hospital can’t afford to lose within its medical community, said Dr. David Farley, an internist at Angel Medical.

“In this town, most of the employed physicians are the new recruits,” Farley said. “The existing doctors have remained solo, but I don’t think you can predict that will continue.”

Farley said the new model could be enticing to physicians at different points in their career, like a physician nearing retirement who wants to go part-time and no longer wants to deal with the hassle of managing a private practice.

As the new model develops, the result is a hybrid of traditional private practices and hospital-employed physicians within the community, Leonard said. Leonard largely follows the preferences of the doctor being recruited. If there is an existing private practice in the community the doctor wants to join, the hospital simply plays matchmaker.

When a doctor joins an existing practice, they are often expected to make an upfront investment.

“They buy in to do their fair share,” Poore said.

In Haywood County, both models exist within the same orthopedics office. Western Carolina Orthopedic Specialists has three doctors, two of whom own the private practice, while a third, Dr. Gerald King, is an employee of the hospital.

The hospital pays Western Carolina Orthopedic Specialists a management fee to covers King’s share of overhead, from office space to secretarial staff. The hospital also pays Kings salary.

In exchange, the hospital gets 100 percent of the revenue generated from King’s patients. It also benefits from having an orthopedist in the county who will bring business through the doors of the hospital. The hospital was suffering from a chronic orthopedist shortage that led patients unable to get appointments locally to take their business outside the county.

Haywood Regional Medical Center recently bought out Haywood Women’s Medical Center, the only Ob-Gyn practice in the county. The hospital now owns the practice and the doctors are employees of the hospital.

It was one of the first moves toward hospital-employed physicians in Haywood. The Ob-Gyn practice was a good starting place for several reasons, Poore said.

For one, doctors who deliver babies have some of the highest overhead.

“The malpractice is unbelievably high,” Poore said.

But the service is so crucial, no well-rounded hospital could afford to be without it.

“Our goals was to keep a viable Ob-Gyn practice in Haywood County,” Poore said.

Buying out an existing practice is more complicated than setting up the arrangement from the get-go with new hires. The process took six months and required outside consultants to help arrive at a fair purchase price.

Getting squeezed

The new model is particularly attractive to doctors in a climate of decreasing reimbursement rates for Medicare and Medicaid patients. Doctors take a bigger hit in rural areas, where a higher percentage of patients are likely to be on Medicare or Medicaid. It makes the offer of employment — and the steady salary that goes with it despite the poverty level of patients — an even more important recruiting tool in rural areas, according to Dr. Charles Trenthem, an anesthesiologist and chief of staff at Angel Medical Center.

“If we weren’t employing physicians and subsidizing their practices, the health care in Western North Carolina would suffer,” Trenthem said.

Angel Medical recently got a special “critical access” designation for its hospital that gets it a higher reimbursement rate from Medicare and Medicaid. Physicians employed by the hospital also enjoy the higher reimbursement rate, since billing is done by the hospital itself.

The issue is particularly acute in emergency room settings, where doctors are likely to see a higher number of patients without insurance who have no means to pay their bills.

While ER doctors theoretically treat patients without regard for whether they can pay, it can influence doctors on a subconscious level, said Dr. Bruce Lobitz, an ER doctor at Angel. But as a hospital-employed physician with a steady salary regardless, it makes it easier for doctors to ignore a patient’s ability to pay when providing care.

“I don’t care about the patient’s payer status. The hospital takes care of all that,” Lobitz said.

The hospital is left to absorb the hit, which can be a problem for rural hospitals already operating on a paper-thin margin, Trenthem said. The model also saddles hospitals with the upfront investment of setting up a new doctor and shouldering the risk if patient revenue falls short.

“Costs are being shifted to these smaller hospitals,” Trenthem said.

But given the trend, they had no choice but step up to the plate and adopt the model.

“The days of a physician going out and hanging a shingle are kind of over now,” Trenthem said.

Several western counties have been scrambling to create an in-house child support enforcement program after the state announced it would no longer handle the job of tracking down delinquent parents.

Swain, Macon, Cherokee and Graham counties, along with the Eastern Band of Cherokee Indians, have all been affected by the unanticipated drop by the state and are creating programs to handle child support enforcement locally.

Swain County commissioners adopted a plan at their meeting this week after struggling with how best to handle the unfunded mandate, something the cash-strapped county can hardly afford.

The state will save about $4 million each year by cutting the program, which now serves 28 out of 100 counties in North Carolina. The rest of the counties, including Haywood and Jackson, already handle the program in-house.

For a successful takeover, the affected counties must learn how to set child support payments and how to punish deadbeat parents who don’t pay by withholding wages, revoking driver’s licenses, and even sending them to jail. Agents will also be responsible for establishing paternity in some cases.

Agents who work for the tribe will be able to deduct child support payments from the per capita checks all tribe members regularly receive.

Bob Cochran, the director of Jackson County’s Department of Social Services, said the program is a good investment for the community since it strengthens families, affects children’s development and brings some of them out of poverty.

The state DSS has a transition team acting as a liaison to help counties absorb the completely new service.

Plans for these counties’ pick-up of the program must be in place by Jan. 1, with an official takeover slated for July 2010.

A federal reimbursement would cover 66 percent of staff salaries, while performance incentives could help further offset the cost of the new program.

Child support enforcement programs in Haywood and Jackson counties, as well as the state office in Bryson City, have regularly ranked among the top five programs in the state.

Swain’s dilemma

Swain County faced three options for taking over the child support enforcement program: housing it under county DSS, costing about $28,000; creating a new department, costing about $57,000, or contracting everything out, costing more than $100,000, according to County Manager Kevin King.

In the face of a budget crisis, Swain naturally went with the cheapest option, which did include an estimated $8,000 raise for DSS Director Tammy Cagle.

About a month ago, the county commissioners denied Cagle the $8,800 raise she requested on a 3-2 vote. Cagle later told King that she was unwilling to take on the extra workload without being properly compensated. King claimed the county could not force Cagle to do the job without the raise since she answers to the DSS board and not the county.

At their meeting this week, commissioners reversed that decision and approved a raise after all. To help get the raise passed, King embedded the program in an overarching budget amendment that would save the county about $493,000.

County Commissioner David Monteith said he felt caught in the middle, since he wanted to vote for the rest of the items in the budget amendment but did not support the idea of giving Cagle a raise.

“You’re damned if you do, damned if you don’t,” said Monteith, adding that the raise comes at a time when other employees have had to take mandatory furloughs.

County Commissioner Genevieve Lindsay pointed out that even with the raise, the DSS plan would cost a lot less than the other two options. Both Lindsay and Chairman Glenn Jones said something had to be done regardless, so it was best to go with the least expensive option. The motion for the budget amendment, including the child support enforcement program, passed unanimously.

Challenges ahead

According to Jane Kimsey, director of social services for Macon County, not much will change for the parents who use the child support enforcement program with the county’s takeover. They would continue to come to the same location for the service, since two state agents were already based at the DSS office.

Chief Justice Bill Boyum with the Eastern Band said that all tribal child support cases will come through tribal court as they had in the past. The tribe is planning for a child support program that will function like other counties’ programs. It will link up to the same computer system that is used statewide.

Some funding for the new program will come from a grant from the Modoc tribe of Oklahoma.

Shannon Cowan, supervisor for the Bryson City office, said there would be an undeniable impact on clientele with the state’s handover. Most of her new employees take two years to really grasp the program and figure out which parents regularly miss their payments.

“It’s not something where a new person could walk in the door and go to work,” said Cowan.

Counties that are likely to offer less money and cannot always accept state employees’ accrued benefits may have trouble luring agents who might move on to other state jobs.

According to Cowan, most of the employees at the Bryson City office have worked there for about 15 years. Cowan said as a state employee, she never expected to lose her job.

“Certainly, we’re all devastated and worried,” said Cowan. “We really don’t know what our future holds.”

Christi Hooper, child support lead agent for Jackson County said it would take “extensive training” just to become familiar with the computer software used across the state.

“The philosophy behind it, the legality, all that is quite complex and then you have to throw in a computer system with 450 screens. It’s big,” said Hooper.

The main message that local and state authorities are frenetically broadcasting to the world is that Western North Carolina is still open for business even though a major rockslide will likely shut down a portion of Interstate 40 near the Tennessee border for at least four months.

Governor Beverly Perdue echoed that message last Wednesday after declaring the rockslide an emergency, thereby qualifying the state to receive federal money for the cleanup.

“We are open and very, very safe,” said Perdue, who rushed to the rockslide site after returning from a two-week cultural and trade mission to China and Japan. “If you want to see beauty and glory, you come right now.”

Perdue anticipates that the federal government will cover 100 percent of the cleanup cost, as it typically does after a natural disaster. In addition, Perdue hopes to launch a short-term co-op marketing campaign, funded by federal, state and local money, to publicize alternate routes into WNC.

Perdue toured the rockslide site on Wednesday (Oct. 28), along with Secretary of Transportation Gene Conti and Deputy Commerce Secretary Dale Carroll, and N.C. Reps. Phil Haire and Ray Rapp.

Perdue remarked that the 150-foot tall and 200- to 300-foot wide rockslide looked much bigger in person.

“Those boulders are enormous,” said Perdue.

The N.C. Department of Transportation estimates that it will take about four months to open the 20-mile section of I-40 now closed to thru-traffic.

The department has hired Phillips & Jordan of Knoxville, and rock stabilization specialist Jonad Contractors of Champion, N.Y., to perform the work.

So far, contractors have installed a pulley system and moved two drills into place on the face of the mountain slope. They have drilled holes in the rock to set explosives and planned to begin blasting on Tuesday afternoon.

While the biggest challenge lies in stabilizing the precarious rock precipice still looming over the highway, crews will also continue to break up the largest boulders lying in the road for a couple of weeks. At that point, they will have a much better estimate of when I-40 will be able to reopen.

The N.C. DOT has set up a Web site dedicated to updates on the cleanup efforts with a map of alternate routes, all directly accessible off the home page. The agency will also post daily updates to its Twitter account.

Ted Phillips, owner of Phillips & Jordan, emphasized the need to work safely and steadily using a top-down approach to clear the rocks.

“You can’t work down below and undermine yourself,” said Phillips. “You can’t remove it until you get it in the condition to remove it.”

While Phillips said it would take a small crew a “real long time” to clean up the rockslide, Phillips said his company has previously handled a lot worse.

“In my scope, it’s not a big job,” Phillips said.

Measuring perceptions

Local and state officials have begun working on a marketing campaign that will publicize the fact that much of WNC is still accessible.

Starting this week, the state Department of Commerce will survey 1,000 prospective travelers in Atlanta, Charlotte, Columbia, S.C., Knoxville, Raleigh, Winston-Salem and Greensboro to determine awareness of the rockslide, ask about impact on travel plans and test marketing strategies.

Smoky Mountain Host, a tourism organization the represents seven counties west of Asheville, will utilize its hefty database, with 40,000 e-mail addresses of past visitors to the area, to do similar target research.

David Huskins, managing director of Smoky Mountain Host, said N.C. DOT needs to make sure to market alternate routes and let the public know they can still reach points west of Asheville.

Ron Leatherwood, a board member of the Haywood County Chamber of Commerce and former DOT board member, encourages locals to patronize the businesses that are most likely to be affected by the I-40 closure, especially the gas stations, motels and restaurants clustered at exits 20 and 24.

Local and state authorities who were around for the last major rockslide on I-40 in 1997 said they were better trained to handle the crisis this time around. Lynn Minges with the State Department of Commerce said as soon as the agency found out about the rockslide, it got on the phone to rally its troops.

The completion of I-26 also helped route trucks away from the two-lane roads they had to resort to during the last rockslide. In addition, the advent of the Internet, with its perpetually updated social media sites, has made connecting with prospective travelers much easier.

Minges estimates that about $150,000 was spent on advertising alternate routes and promoting travel to Western North Carolina last time around.