“I’ve got 12 little babies that I delivered their mothers 18 or 20 years ago, so I’m kind of on my second generation,” he said. But Dr. Alling no longer has a place to deliver babies in the county. The community hospital in Bridgeport that he helped found in 2008 merged its obstetrics unit with the Wise Regional Health System in Decatur in March. That hospital, where Dr. Alling delivered babies before he left for Bridgeport, instituted a policy in 2009 that allowed physicians to deliver babies only if they had undergone a three-year residency program specializing in obstetrics and gynecology. “The purpose of that was looking ahead to the potential in the growth of our market,” said Steve Summers, the chief executive of Wise Regional. For more than a decade, Mr. Summers has worked to shift Wise Regional toward a “specialist model.” He said it was an effort to meet the quality-of-care standards set by its urban affiliate, the Baylor Health Care System, which operates hospitals nearby that also allow only qualified obstetricians to deliver babies. Although he acknowledged that family physicians usually receive a rotation of obstetrics training during their residency, Mr. Summers said the hospital board decided not to allow exceptions to its policy. As a result, Dr. Alling and three other family physicians were denied obstetrics privileges at Wise Regional and are in legal mediation with the hospital. They estimate that 50 to 100 pregnant patients, the majority of whom live in rural areas and are covered by Medicaid, have been affected by Wise Regional’s refusal to grant them obstetrics privileges. Those patients now have three options: they could transfer their care to one of three doctors with obstetrics privileges at Wise Regional; continue to see their current doctor and go to the emergency room when they are in labor; or travel roughly 30 miles to Jacksboro, where a community hospital has granted those family doctors obstetrics privileges. The situation in Wise County illustrates how many family physicians are caught in a growing divide between rural and urban health care markets. With a shortage of medical providers nationwide, one that is particularly acute in remote corners of Texas,? rural regions continue to rely on family physicians to provide an array of services. While some urban hospitals allow qualified family doctors to deliver babies, the practice has become less common, in part because patients with more provider options often choose medical specialists. “You can’t chalk it up to any one thing, but the underlying reason — it’s money,” said Dr. Brad Faglie, one of the family physicians denied obstetrics privileges at Wise Regional. Specialists “make more money on these bills.” Moreover, he said, “Maybe rural life is losing out to urban life.” A 2012 study by the Journal of the American Board of Family Medicine found that the number of family physicians providing maternity care declined to 9.7 percent in 2010, from 23.3 percent in 2000. The study attributed the decline to “malpractice costs, lifestyle concerns, lack of institutional and community support of family physicians delivering babies” and changes to family medicine residency requirements. In a written response to that study, Dr. Howard Blanchette, the chairman of the obstetrics and gynecology department at New York Medical College, suggested that there was “growing evidence that the adequacy of prenatal care for women in rural and medically underserved areas is deteriorating.” Dr. Faglie said that nearly 90 percent of his obstetric patients, whom he sees at a rural health clinic in Alvord, northwest of Decatur, are on Medicaid. He continues to receive new obstetric patients, he said, many of whom do not want to change doctors before delivery, or who have difficulty transferring to Wise Regional because those doctors are booked. He said the situation had endangered some patients, especially those with high-risk pregnancies, because it had been difficult for him to coordinate patient care with a specialist. “I have patients that I’m seeing to term, and when they go into labor, they go to the E.R.,” Dr. Faglie said. “That is a poor standard of care.”
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