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Doctor Shortages Distress Rural America, Where Few Residency Programs Exist

ReachMD Healthcare Image
04/19/2023
fredericksburg.com

ELKO, Nev. — Anger, devastation and concern for her patients washed over Dr. Bridget Martinez as she learned that her residency training program in rural northeastern Nevada would be shuttered.

The doctor in training remembered telling one of her patients that, come July of this year, she would no longer be her physician. Martinez had been treating the patient for months at a local health care center for a variety of physical and psychiatric health issues.

Dr. Bridget Martinez checks in with a patient and reminds him she will no longer be working at the Elko, Nev., clinic as of July 1.

Jazmin Orozco Rodriguez, Kaiser Health News

“She was like, ‘I don’t know what I’m going to do,’” Martinez said. “It almost set her back, I would say, to square one. That’s so distressing to a patient.”

Martinez and three other resident physicians make up more than a third of the family practice providers at a health clinic in Elko, a city of about 20,000 people in the largely rural 500-mile stretch between Reno, Nevada, and Salt Lake City. Another patient cried and said she was unsure who her provider would be once Martinez returned to Reno to finish training.

Established in 2017, the rural family medicine training program in Elko is shutting down for a variety of reasons, including financial struggles, lack of a united support system and a historical lack of health care investment in the area. Experts say systemic factors are common barriers to establishing and sustaining training programs for doctors throughout rural America.

Dr. Bridget Martinez, a resident physician, says she chose to pursue medicine to help people and chose rural family medicine because she knew the need for providers in rural areas was great. 

Jazmin Orozco Rodriguez, Kaiser Health News

More than 100 million people, or nearly one-third of the nation, have trouble accessing primary care, according to a recent study published by the National Association of Community Health Centers. This number has nearly doubled since 2014. The pandemic worsened provider shortages nationwide, but the problem is more acute in rural areas, which have long struggled to recruit and retain doctors and other medical professionals. Researchers say the relative lack of providers is one reason people living in rural areas experience worse health outcomes than people who live in urban areas.

Experts say expanding the number of medical residency training programs in rural areas is key to filling gaps in care because many doctors — including more than half of family medicine physicians — settle within 100 miles of where they train. And while the number of training programs has increased in rural areas during the past few years, research shows 98% of residencies nationwide are in urban areas.

Members of Congress have introduced several bills to address the health provider shortage, but they have not yet advanced.

Meanwhile, rural medical training programs need more state and federal investment to grow and remain sustainable, said Dr. Emily Hawes, associate professor at the University of North Carolina-Chapel Hill School of Medicine and deputy director with the federal Rural Residency Planning and Development Program.

There have been positive milestones, she said, including provisions in the Consolidated Appropriations Act of 2021 that created more flexibility in funding and accreditation for rural hospitals that want to establish residency programs.

Congress also created the Rural Residency Planning and Development Program, which Hawes helps lead. The initiative funded its first cohort in 2019. Since then, the program’s parent agency, the Health Resources and Services Administration, has given more than $43 million to 58 organizations in 32 states to launch rural medical residency programs. As of last fall, the recipients had created 32 accredited training programs in family medicine, internal medicine, psychiatry and general surgery, and received approval for more than 400 new residency positions in rural areas.

But it’s not enough, Hawes said.

For starters, the Centers for Medicare & Medicaid Services don’t reimburse rural hospitals for medical residency programs at the same rate they do urban hospitals, despite rural hospitals facing similar or higher costs. Rural hospitals’ lower patient volumes and higher rates of underinsured or uninsured patients affect how much the government pays to fund graduate medical education, or GME.

Hawes and other doctors argued in a research paper that rural hospitals participating in resident physician training should be paid the full cost of hosting residents, which amounts to at least $160,000 each annually.

The challenge of paying residents’ salaries proved to be part of the problem for the program in Elko.

Officials at Northeastern Nevada Regional Hospital decided, when they launched their residency program six years ago, not to use CMS funds to pay salaries and instead to pay those costs out-of-pocket. That amounted to about $500,000 a year, said Dr. Daniel Spogen, a professor in the Family and Community Medicine Department at the University of Nevada-Reno School of Medicine and director of the medical residency training program in Elko.

In retrospect, Spogen said, he wishes he and other faculty had pushed the hospital to pursue CMS funding, because it would have given the program a stronger financial foundation.

In a February press release, hospital officials said the decision to close the medical training program was difficult but necessary, because of rising costs and increased requirements.

In the end, the community and residents suffer the consequences, Spogen said.

Hawes said rural communities and their resident physicians often benefit mutually: Residents experience a more diverse and involved training than they would in a larger hospital, because having fewer residents and doctors means they can take on bigger tasks. Martinez recalled treating a gunshot wound in the emergency room, something she said she probably would not have gotten to do in a Reno hospital.

Closing any rural medical residency program ends a key opportunity to locate physicians in the areas where they’re most needed, said Hawes. Martinez and her husband, who is also finishing his medical training, had planned to stay in Elko. While that’s not off the table, she said, they’re keeping their options open now.

8 statistics that explain the rural doctor shortage

8 statistics that explain the rural doctor shortage

For Americans who live in cities or suburbs, going to the doctor is usually a simple errand. Even if they have trouble finding an appointment time that works for their schedule or getting their health insurance to cover it, their doctor's office or hospital is usually a manageable distance from their home or work.

However, for 46 million Americans living in rural areas, accessing healthcare isn't as easy.  According to a 2018 survey by the Pew Research Center, nearly a quarter of rural Americans say access to good-quality hospitals and doctors is a challenge for their community. Making things worse, these rural residents tend to be older, less wealthy, and less likely to have health insurance than their urban and suburban counterparts.

The challenges preventing rural Americans from accessing medical care will likely worsen. The Association of American Medical Colleges projects a shortage of 54,100 to 139,000 doctors in the United States by 2033. Residents of rural communities will see their travel times to doctors and hospitals increase even more.

Of course, not every doctor's visit requires in-person care: Telehealth is becoming more popular, thanks in part to government agencies offering grants and training programs promoting telehealth and the uptick in virtual visits during the COVID-19 pandemic in 2020 and 2021. However, many people in rural areas also lack access to a stable broadband internet connection—which renders telehealth visits nearly impossible.

To understand the effects of the rural doctor shortage in the United States, Incredible Health compiled data from government entities and research institutions. Here's what you need to know about the current lack of medical care in rural communities, the effects the shortage has on patients, and the outlook for health care in rural areas.

Nick Otto for the Washington Post // Getty Images

There are fewer health care providers per capita in nonmetropolitan areas

Although nearly 20% of the U.S. population lives in rural areas, less than 10% of U.S. doctors practice in rural areas. According to data from 2018 and 2019 that was released in 2021 by the Department of Health and Human Services, nonmetropolitan areas have fewer than half as many physicians per 10,000 people as metropolitan areas. Primary care providers and behavioral health care providers are in particularly short supply. For nursing shortages, the gap is slightly better, but there are still only seven nurse practitioners per 10,000 people in rural areas.

Incredible Health

1 in 4 rural teens—and 1 in 5 rural adults—don't have a primary care doctor who they see regularly

The lack of primary care physicians in rural populations is particularly troubling. Patients who regularly see a primary care physician tend to spend less time in the hospital and have lower health care costs over their lifetimes. Additionally, many Americans consider a primary care doctor a trusted source of advice: A 2022 survey reported that rural adults said that their health care provider was the most trustworthy source of information about the COVID-19 vaccine. Four percent of unvaccinated adults said that the reason they weren't vaccinated is that they didn't have a primary care provider.

Canva

Compared to metropolitan areas, there are more than twice as many rural counties in health professional shortage areas

Data released in 2022 by the Department of Agriculture shows that rural counties are more likely to face shortages of primary care doctors, dentists, mental health care providers, and even hospitals.

Rural residents are also more likely to have to travel farther to access medical care. A 2018 report from the Pew Research Center found that rural residents drive 17 minutes on average to the nearest hospital—more than five minutes longer than the average driving times for suburban and urban residents. An extra five minutes might not sound like much, but it can make a big difference in a medical emergency.

Incredible Health

Medical practices in the most rural locations treat four times as many Medicare patients as metropolitan practices

When a community has only a few health care providers, those practices end up with a much heavier workload. Research released in 2022 found that more isolated practices with fewer physicians cared for greater numbers of patients on Medicare. Practices in urban and suburban settings typically offer more flexible schedules, lighter workloads, and shorter shifts—an attractive proposition for new doctors.

Michael S. Williamson/The Washington Post // Getty Images

142 rural hospitals have closed since 2010

Out of 185 rural hospitals that have closed since 2005, 76% closed after 2010. A 2022 study found that lower profits, shrinking patient volume, and staffing challenges contributed to most of these closures. Because rural hospitals typically treat more patients on Medicare and Medicaid, they often receive lower reimbursements than they would for patients with private insurance.

The patient mix in rural hospitals is also frequently older, poorer, and sicker than hospitals in urban or suburban settings.  Making matters worse, when a rural hospital closes, it doesn't just make it more difficult for residents of that community to get medical care—it can also harm the local economy by cutting physician and nursing jobs, as well as dozens of related jobs in the community ranging from food services to cleaning and transportation.

Lauren A. Little/MediaNews Group/Reading Eagle // Getty Images

1 in 5 medical schools ran a formal rural program in 2019

Attracting recent medical school graduates to rural areas is crucial to reducing the rural doctor shortage. However, although most medical schools offered some rural clinical experience, only 21% of medical schools operated a formal rural program in 2019.

Rural training programs offer medical students hands-on experience in communities where a primary care doctor might be the only physician for miles, forcing them to expand their scope of practice to cover specialties like obstetrics. That expanded workload doesn't translate into additional stress: One 2019 study found that rural physicians in South Dakota experienced lower rates of burnout than their peers in cities or suburbs.

Anthony Souffle/Star Tribune // Getty Images

Hundreds of millions of dollars are going toward mitigation efforts and solutions for this shortage

Addressing the rural doctor shortage will likely require a combination of several different approaches. Building on the existing rural training programs, the Department of Health and Human Services announced it would award more than $155 million to teaching health centers that focus on providing primary care and mental health care to underserved rural communities.

Creating pre-medical pipeline programs in rural communities can also help high school and college students see themselves entering medicine, which could bolster the rural applicant pool. The Office for the Advancement of Telehealth within the HRSA also runs several projects aimed at providing better access to telehealth services for rural communities.

This story originally appeared on Incredible Health and was produced and distributed in partnership with Stacker Studio.

010110010101101 // Shutterstock

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