A mentoring program for physicians in rural areas is being tapped by the federal government to expand access to specialized care
ESPANOLA, N.M. — The heart of an unborn child beat strong and steady through an amplified monitor, as physician Leslie Hayes examined a pregnant 40-year-old who recently was weaned from heroin with help from anti-craving medication.
Hayes and her colleagues treat more than 200 patients for drug-use disorders involving heroin and prescription opioid pain medication at a rural clinic in New Mexico's Espanola Valley, where rates of opioid addiction and mortality are among the nation's highest.
Hayes' ability to effectively treat opioid addiction with the medication buprenorphine, which blocks cravings and withdrawal symptoms, would not be possible without years of regular videoconferences with specialists at a major medical center in Albuquerque under a program known as Project ECHO.
The model is being tapped by federal officials now that President Barack Obama has signed legislation aimed at improving patient access to specialized treatments for a variety of diseases and complex conditions, from HIV and diabetes to bone ailments associated with osteoporosis.
Project ECHO's long-distance training for physicians, their assistants and nurse practitioners mimics the mentoring that interns and residents receive at elite urban hospitals.
Sanjeev Arora, Project ECHO's founder, came up with the concept in 2003 when he realized most New Mexicans with hepatitis C were being left without proven treatments, often leading to liver failure and premature death.
His training model has expanded to 57 medical conditions, while Arora sees a unique opportunity to contain the nation's epidemic of opioid addiction. In 2015, more than 15,000 people died from overdoses involving prescription opioids, while many prescription addicts have transitioned to cheaper heroin.
"There are very few doctors in the country right now to match the scale of the problem," Arora said.
Under the ECHO Act, the U.S. Health and Human Services Department — which oversees Medicare and Medicaid — will review the mentoring programs and look at ways they could be integrated into one of the world's largest health care systems. The study also is expected to produce suggestions for continued funding.
The outcome will fall largely to the administration of President-elect Donald Trump, who has vowed to replace portions of Medicaid and Medicare that are the bedrock of funding for federally qualified health centers that serve impoverished rural communities in New Mexico and beyond.
Bipartisan support for the ECHO legislation came from Republicans including Sen. Orin Hatch of Utah and Democrats such as Sen. Tom Udall of New Mexico.
Proponents believe the training can result in dramatic cost savings, especially if the health care industry embraces reforms that place a value on treatment outcomes rather than fees for each medical service.
Borrowing military terminology, Arora describes ECHO as a "force multiplier" for attacking rural America's most pressing ailments.
With guidance from the Project ECHO Institute at the University of New Mexico Health Sciences Center, the effort has been expanded or replicated in 30 states and other countries including India, Brazil, Namibia and Northern Ireland.
"I think the opportunity is, if they are looking for innovation to improve access and improve quality and lower cost at the same time, and create a workforce that stays in the rural areas by producing joy of work for them, then we would like to share" our project, Arora said.
New Mexico, with its grinding rural poverty and patients who are cut off from overbooked specialists hundreds of miles away, provided an ideal laboratory for ECHO — short for Extension for Community Healthcare Outcomes.
A peer-reviewed study published in the New England Journal of Medicine in 2011 showed primary care physicians paired with mentors in New Mexico were just as effective in treating hepatitis C as established specialists at the University of New Mexico.
The model defers to local physicians who are in tune with local cultural nuances.
At El Centro Family Health in Espanola, Hayes attends mostly to Hispanic patients in a community that grew over centuries out of a patchwork of Native American and Spanish-colonial settlements.
Hayes believes the valley's high incidence of heroin addiction dates to the 1960s, when veterans returned from Vietnam with a drug habit linked to pain treatment.
"It became intergenerational," she said. "I would say half of my patients who use drugs had it in their household growing up."
On a recent December morning, she met with two patients who are being treated for opioid addiction with Suboxone and Subutex, brand name drugs containing buprenorphine. One woman arrived with her 9-month-old son; the other was several months pregnant.
Taken at home, Suboxone provides a more practical alternative to daily visits to methadone dispensaries.
Hayes' questions for her patients extend beyond drug cravings. They talk about family relations, nutrition, exercise routines, daily anxiety and even nighttime dreams during pregnancy.
With training at no direct cost from Project ECHO, Hayes began prescribing Suboxone in 2006 — before the nation's opioid epidemic came into prominent view.
"I always felt like it was an issue here," said the physician from nearby Pojoaque, whose work was lauded this year with an award from the White House. "Once it hit the middle class, suddenly, it became important."
Once a trainee, Hayes now mentors others. New Mexico has more physicians per capita with licenses to prescribe buprenorphine than all but two states.
Miriam Komaromy, associate director of the ECHO Institute, is busy turning all that experience into a playbook for other medical centers — in Washington state, Montana, Boston and New York state. The federally funded initiative launches in January with more than 400 front-line medical practitioners.
"We have a whopping big problem with opiates," Komaromy said of New Mexico. "So it's been a very rich opportunity for us to try to intervene and help because so much help is needed."