January 2006 | Back to Table of Contents
Pulse
Doctoring the Old-Fashioned Way
Susan Rutten, M.D., who practices out of her home in central Minnesota, makes house calls, shuns insurance, and recently found herself in the thick of a public health scare.
The snow-covered farm fields along Todd County Highway 11 near Clarissa, Minnesota, don’t look like the kind of place that would become the epicenter of an outbreak of poliovirus infection. But last September, that part of central Minnesota made headlines and created a stir in the public health community after a 7-month-old girl from one of the four Amish communities there was found to have the virus.
Public health officials knew that in order to prevent it from spreading they would have to make members of those communities aware of the importance of testing and vaccination. But how would they—strangers from the Twin Cities—approach a people who aren’t trusting of outsiders, much less convince them of how to protect themselves from a potentially crippling disease? And how could anyone prepare the communities for the onslaught of media attention that would no doubt encroach on their way of life?
Health officials needed someone who could connect them with the Amish. And that was how Susan Rutten, M.D., an internal medicine and pediatrics physician who practices in rural Osakis, became part of the story of the first reported outbreak of poliovirus infection in the United States since 2000.
Anatomy of the Polio Outbreak
On Sept. 27, a 7-month-old Amish girl from near Clarissa, Minnesota, was found to be infected with polio virus. It was the first case reported in the United States since 2000, and the first in Minnesota since 1992.
The infant, who had not been vaccinated against the disease, had been hospitalized for what was later diagnosed as severe combined immunodeficiency, according to the Centers for Disease Control and Prevention. The virus strain appeared to be a variant of that used in the oral vaccine, the use of which was discontinued in the United States in 2000.
How the infant contracted the virus remains a mystery. Health officials do know that the virus is spread through direct contact with the stool or saliva of a person who is infected.
After a door-to-door campaign by public health workers to inform residents—in particular, the 24 Amish families in the area—about the need for testing and inoculation, public health workers found the virus in four other Amish children. All were infected with the same strain as the first child.
Altogether, 32 people from five Amish families agreed to have stool samples tested for the virus. Fifty-three people from nine families had their first shot of polio vaccine, according to the Minnesota Department of Health.
“I think we achieved pretty good numbers under the circumstances,” says Susan Rutten, M.D., an internal medicine and pediatrics physician who treats patients from the four Amish communities and who helped health officials gain access to leaders of those communities.
Only one in 200 cases of polio result in paralysis. So far, none of the children have shown signs of paralysis, according to the Minnesota Department of Health.—K.K.
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Rutten, who opened her practice in the summer of 2002, has treated members of the four communities and agreed to speak with their leaders to apprise them of the situation before health officials came knocking on their doors. “I don’t know if you can adequately prepare anyone, but at least this way it wasn’t as if they hadn’t been warned,” she says.
Rutten, who wasn’t involved in the actual discovery of the virus, wasn’t surprised to learn of the outbreak. “We have a lot of people up here who don’t believe in vaccinations for one reason or another,” she says. “Any time you have people who don’t vaccinate, this sort of thing can crop up.”
Many Amish reject vaccination for religious or personal reasons. They’re also suspicious of modern medicine. “They don’t come to a traditional physician unless they’re quite desperate,” says Rutten, who explains that she often treats her Amish patients for lifestyle-related injuries. “Horse and buggy transportation is not safe. Neither is farming with horses,” she says.
Terms of Payment: Cash
For the 36-year-old Rutten, who was raised in Kalamazoo, Michigan, and returned to central Minnesota where her father grew up and where she still has relatives, treating the Amish is just one aspect of her unusual practice. Rutten also sees patients from a nearby Mennonite community and a number of Mexican patients who work in the nearby meat-packing plants (Rutten speaks Spanish).
What really sets her primary care practice apart from those of most physicians is her business model. On the door leading from the breezeway of the home she rents, which is also her office, is a price list for her services: $30 for a 30-minute exam—the minimum amount of time she’ll spend with a patient; $45 for a 45-minute exam; $45 for a physical (lab work is extra); $40 to $45 for a house call. Patients rarely have to wait to see her because she allots so much time for them, and they’re never asked for their insurance card.
That’s because Rutten doesn’t take insurance. And starting Jan. 1, she won’t accept Medicare, either. “Medicare never paid me $30 for an office visit, anyway; I was lucky if I got $12 to $20. It’s even worse when they deny your claims, which is why I’m getting out. I don’t have time to resubmit those claims over and over. I’d have to raise my rates and pay someone else to do it, and that’s not fair to everyone else.” Rutten says she sent a letter to her Medicare patients explaining the situation and letting them know that they can pay whatever they can afford if they still want to see her. “I’d never turn anyone away if they couldn’t pay me, and I’m not going to start now,” she says.
Rutten says she hasn’t had a problem with patients not paying. “Right now, I just have one outstanding bill for the last two quarters,” she says. And sometimes in addition to her payment her patients stop by and leave tokens of gratitude—fresh eggs, produce, venison—which was not something she experienced while working for Allina’s Woodlake clinic in Richfield, where she practiced for three years.
There, Rutten became disenchanted with corporate medicine and the health care system in general. During her first year practicing at the clinic, she was shocked to see a statement showing how much revenue she had generated versus what she was paid. “I only had to see that once to realize that the overhead is a lot of administration, and they didn’t do anything to help my patients most of the time. In my estimation, they made my job harder, and they made it harder for patients to get what they wanted,” she explains.
She also found it troubling that insurance companies reimbursed the clinic for 60 to 70 percent of her fees on a good day, yet when a patient had no insurance, she was required to bill for the entire amount. “And that person’s supposed to pay the whole thing? I thought that was really lousy, and I wanted to do something about it.”
Greater Rewards
A strong believer in letting the market dictate the price of medical services, Rutten fast-forwarded her plans to open a practice in an area that needed affordable health care. She chose Todd County because it had neither an internist nor a pediatrician. And, according to Minnesota Department of Health figures from 2001, 7.5 percent of its population along with more than 10 percent of the population in neighboring Cass and Otter Tail counties were uninsured. Many more were what Rutten describes as “functionally uninsured,” meaning that they have insurance but with deductibles as high as $2,000 to $7,000 per person.
Slowly, patients started following the wooden signs along County Highway 11 that lead to Rutten’s office. But it wasn’t until last summer—three years after opening—that she started seeing an exponential growth in demand for her services. Rutten says she doesn’t know how many patients she has cared for over the years. Some have a primary care physician and come to her for a second opinion, and others only call on her when they’re ill or injured. In addition to serving those patients and her regulars, she also is medical director for the Todd County Detention Center in Long Prairie and Mother of Mercy Nursing Home in Albany.
Rutten admits that the price of providing affordable care has been doing without the luxuries of a larger clinic. Her kitchen doubles as a reception area, with filing cabinets sharing space with the refrigerator and stove. A tiny room next to the kitchen, where an antique chaise lounge she uses as an exam table sits across from a desk with a computer and fax machine, is her exam room. She relies on agreements with Long Prairie and Douglas County hospitals for getting blood tests and X-rays done inexpensively. For example, Rutten says a complete blood count costs her $4—an amount she passes on to the patient without markup. Until recently, she relied on a donated Jeep Cherokee for transportation, and her plans for renovating an old farm house and building an office along side it are coming along slowly with the help of friends.
“She is not in it for the money,” says Cheryl Kennison, a registered nurse whom Rutten hired last year and who happened to grow up in the house in which Rutten lives and practices. The two had worked together at the University of Minnesota, where Rutten did her residency. “She just wants to make sure people are taken care of.”
And that might mean sewing up a wound on one day or helping prevent the spread of what can be a devastating virus the next. For Rutten, her patients’ appreciation is the currency she most values. “I have never felt so appreciated in my whole life,” she says. “I’m meeting a need, and it’s a profound need at times … and that’s the thing that makes it worthwhile.”
—Kim Kiser