August 22nd, 2018
The shortage of physicians in rural America is getting worse. According to an analysis by 24/7 Wall Street, every state in America – even states with a high doctor-to-patient ratio – has at least one county in which there is no doctor. These counties are overwhelmingly rural, most with declining populations and rates of poverty higher than the state average.
According to Dr. Vikas Saini, president of the Lown Institute, the physician shortage has a lot to do with medical education and training infrastructure. “Our training systems are biased towards cities and big urban centers,” said Saini, quoted in 24/7 Wall Street. Urban areas have larger populations with generally higher education rates, making it easier to attract medical students and trainees.
That’s crucial because “where people train tend to be where people practice,” Saini said.
Salary and lifestyle considerations also play a large role in determining where doctors practice. Residents of rural counties are generally older, lower-income, and in worse health than people who live in urban areas. Therefore doctors in rural areas are more likely to be reimbursed through Medicare or Medicaid, which pays less than private insurance, and could be punished financially for having a sicker and poorer patient pool. Also, counties that have difficulty attracting residents have difficulty bringing in doctors, many of whom are young and may be looking for a more fast-paced lifestyle.
Although the doctor shortage is most acute in rural areas, the effects of this shortage ripple throughout the country. A rapidly aging population, coupled with high costs to entry for medical school and increased barriers to immigration for foreign-born doctors, means that we will soon face a shortage of doctors everywhere; rural counties are just the canary in the coal mine.
“The doctor shortage is the tip of a broader iceberg,” said Saini, in an Atlanta Journal-Constitution piece about the physician shortage in rural Georgia. Having fewer doctors in rural areas also puts a strain on urban health centers. “When people who don’t have good access to care come to the cities for health care, they’re sicker, they come there later, and their use of resources is higher,” said Saini.
There have been some promising initiatives to bring needed health care to rural areas. In Webster County, GA, some health providers drive patients twenty miles to their appointments, or deliver medication to patient’s homes.
In rural Maine, Dr. John Lowery and Dr. John Gunel of Central Maine Medical Center Family Medicine Residency conduct home visits to bring primary care to where patients are.
“With home visits we can see and treat the whole family at once,” says Lowery, in an interview with the Lown Institute, “We also eliminate no-shows and can get over potential language barriers by having an interpreter in person.”
However, these are difficult to implement at scale, and don’t solve the underlying issue of not enough health providers. Doctors who practiced in underserved areas need to be better compensated for their work, not punished financially with lower reimbursements. One way to do that would be having Medicare and Medicaid base their risk adjustments not only on medical risk but measures of social risk, such as disability, poverty, and homelessness.
Another way would be to offer more incentives to young doctors to practice in rural areas, or for underserved populations. New York University Medical School also made waves with their announcement to eliminate tuition costs for medical students, but as Elisabeth Rosenthal writes in The New York Times, this policy could have been better targeted to encourage doctors to fill in the gaps in care to reduce these inequalities.