According to the National Rural Health Association, 25 percent of Americans live in rural areas, but only about 10 percent of physicians practice there. On top of this already alarming statistic, more than 470 rural hospitals have closed in the past 25 years, and Medicare payments to rural hospitals and physicians have been significantly lower than their urban equivalents. Thus, rural America has fewer healthcare providers per capita, fewer healthcare facilities to treat illnesses and injuries, and fewer incentives to bring providers to their communities.
The scarcity of healthcare providers and facilities in rural areas is compounded by economic and societal trends that result in increased challenges for individuals in obtaining healthcare services. Such challenges include longer travel distances to healthcare facilities, lack of transportation, inability to finance care, lack of healthcare insurance, and/or limited access to physicians due to the physician shortage. The combination of aging physicians, increased specialization, and a lack of medical schools in rural areas has exacerbated this issue by making it extremely difficult to attract and retain physicians at rural healthcare facilities.
An Aging Physician Population
The rural healthcare system is inherently different than other healthcare settings. Rural communities often rely on traditional family practice physicians who see patients at the office, in the hospital, or in the nursing home. In many cases, these physicians have been working in the community for years without much turnover, providing a breadth of services, and often serving as a one stop shop for rural patients.
Unfortunately, many of these physicians are reaching retirement age. In fact, one in three practicing physicians in the United States is over the age of 55, and many expect to retire in the next 10 to 15 years. When physicians who serve as the sole primary care provider for their community retire, patients often find it difficult to find a new provider, incurring additional travel time, cost, and inconvenience.
Few Young Physicians Choosing to Practice in Rural Areas
The next generation of physicians is hesitant to fill the rural healthcare void for a variety of reasons.
Work-Life Balance
Rural healthcare providers often work longer hours and handle higher patient volume than their urban counterparts, which creates poor work life balance. This exacerbates the issue of rural physician recruitment and retention, especially among younger physicians who value work-life balance more than their predecessors.
Increased Interest in Specialization
Primary care providers remain the backbone of the rural healthcare system. However, in recent years medical students have been choosing specialties outside of the primary care field. There has been an emphasis and increased value placed on specialized skills in the medical community, and an increase in instability in the traditional family practice settings. Medical students are further discouraged from choosing to practice in rural areas due to “low compensation, rising malpractice premiums, professional isolation, limited time off, and scarcity of jobs for spouses.”
Stability of Employment
With the unsettling reimbursement picture and a growing number of regulations, young physicians prefer the stability of working in a hospital as a hospitalist, emergency department physician, or as a specialist. Yet, rural hospitals often do not have the patient volume to support such specialization. For example, there are hospitals in Mississippi that have an average daily census of 10, which is not enough to support even one hospitalist position.
Few Rural Medical Schools and Residency Positions
Most physicians wind up practicing within 100 miles of where they attended medical school or completed their residency. However, rural areas have fewer medical schools and residency programs on average. For example, Mississippi has only one medical school in the state. Thomas Jefferson University states, “The shortage of physicians, especially primary care physicians, in rural areas of the US represents one of the most intractable health policy problems of the past century.”
It is difficult for small rural hospitals to make residency positions available to attract residents and also to be financially solvent. Starting a family practice residency position could end up netting a $3 million loss over the first three years. That money is hard to come by with Medicare and Medicaid reimbursement declining, commercial payers tightening up, and hospitals providing more charity care.
Exacerbating this issue, for the second year in a row the number of medical school graduates has exceeded the number of residency slots available. Residency programs are primarily funded through Medicare, which contributes approximately $9.5 billion to fund a share of costs of 100,000 positions in teaching hospitals across the United States. In 1997, Congress enacted the Balanced Budget Act which capped the funding for General Medical Education (GME), effectively freezing the number of medical residency slots available. Even if a rural hospital wanted to increase the number of residency slots, they would be unable to do so.
Current and Future Solutions
There are a number of educational, technological, and staffing solutions to address the shortage of primary care providers in rural areas.
Educational Solutions
Thomas Jefferson University Sidney Kimmel Medical Center has created the Physician Shortage Area Program (PSAP). This program is designed to increase the supply and retention of physicians in rural areas. The program recruits medical students who grew up in a rural area or small town, and who intend to ultimately practice in a rural area or small town. Such programs add incentives and opportunities for medical students to return to rural healthcare practice upon completion of their education.
Technological Solutions
There are a number of technological solutions to take into consideration, primarily telemedicine. Telehealth technology expands access to healthcare services for people living in rural and medically underserved areas, cutting down on the need for travel and minimizing the cost of care.
John Gill, president of Big Timber, Montana’s Pioneer Medical Center and a member of the National Association of Rural Health Clinics’ 2014 Board of Directors, supports the expansion of telehealth, stating, “I think telehealth is really going to be important … because of the lack of providers, and I think we’re going to go through another crisis here with provider access and issues and distribution … and now that we have the technology to utilize telehealth and telemedicine services, we really ought to get aggressive with it.”
In 2013, nearly 900,000 American households used video conferencing technology to facilitate a consultation with a healthcare professional. According to a report from Parks Associates, that number will jump to 22.6 million in 2018. Programs such as these could go a long way towards addressing the shortage in the long term.
Staffing Solutions
In the short term, many rural and underserved communities rely on a steady stream of locum tenens physicians to meet their needs. Locum tenens physicians provide high quality patient care to rural communities across the nation. Here at Barton Associates, a significant percentage of our client base is located in rural areas, and our locum tenens providers find working in rural communities rewarding and challenging. In fact, many say that working in rural areas is a great way to gain valuable experience, as being the only provider for miles means that they see a greater variety of medical conditions and situations.
As the composition of healthcare in the United States continues to evolve, new methods for addressing the rural healthcare provider shortage must be considered, including expanding the role of advance practice providers and the use of telemedicine. In the meantime, companies like Barton Associates are taking on the challenge to provide practical solutions for healthcare organizations that are struggling with the physician shortage. For more information on Barton Associates and the benefits of locum tenens, please visit bartonassociates.com.
