The ru­ral route

Hos­pi­tals in un­der­served ar­eas tak­ing dif­fer­ent roads to re­cruit, re­tain physi­cians

Modern Healthcare - - SPECIAL REPORT - Beth Kutscher

Bis­bee, Ariz., is a for­mer min­ing town of about 6,700 peo­ple, some 12 miles north of the Mex­i­can bor­der and nearly two hours south­east of Tuc­son. Built in the hills of the red-rock Mule Moun­tains, it’s now known as an en­clave of sorts for artists and hip­pies and was even a one-time run­ner-up as the “quirki­est” town in Amer­ica. But while it has at­tracted gal­leries and cof­fee­houses, it has strug­gled to find health­care providers.

“We’re hav­ing a harder time this year than last year,” says Jim Dick­son, CEO of 14-bed Cop­per Queen Com­mu­nity Hos­pi­tal in Bis­bee. “I think there’s a bid­ding war go­ing on for physi­cians.”

The height­ened de­mand means Cop­per Queen’s start­ing salary for pri­mary-care doc­tors has in­creased to $225,000, up from first $150,000, then $175,000, and it may need to rise to $250,000 to keep up with lo­cal com­peti­tors, Dick­son says. But be­cause the hos­pi­tal can’t bill enough to jus­tify lu­cra­tive pay pack­ages, it re­lies on as­sis­tance from National Health Ser­vice Corps, an HHS agency that pro­vides in­cen­tives in­clud­ing loan re­pay­ment for doc­tors will­ing to prac­tice in un­der­served re­gions.

It also spon­sors for­eign doc­tors with J1 visas, though Dick­son notes that they tend to have higher turnover rates.

The in­vest­ments are crit­i­cal to Cop­per Queen’s sur­vival. Less than a decade ago, “We had no pri­vate doc­tors left in town,” says Dick­son, who since 2007 has grown the med­i­cal prac­tice from four physi­cians to 11, as well as four mid-level providers. “The hos­pi­tal would have im­ploded with­out th­ese doc­tors.”

Cop­per Queen’s chal­lenges are not unique. The doc­tor short­age in ru­ral Amer­ica is wide­spread and pro­jected to get worse. Med­i­caid ex­pan­sion and in­sur­ance ex­changes are ex­pected to pro­vide cov­er­age to about 30 mil­lion Amer­i­cans—but many in ru­ral and un­der- served com­mu­ni­ties may have to drive hun­dreds of miles for care if it isn’t avail­able lo­cally.

A 2009 pol­icy brief from the fed­eral Of­fice of Ru­ral Health Pol­icy high­lighted that 77% of ru­ral coun­ties are fac­ing a short­age of pri­ma­rycare providers, and 8% don’t even have a sin­gle pri­mary-care physi­cian.

“It’s per­va­sive,” says Brock Slabach, se­nior vice pres­i­dent for mem­ber ser­vices at the National Ru­ral Health As­so­ci­a­tion. “There’s just a sig­nif­i­cant need for work­force.”

The num­ber of gen­eral sur­geons prac­tic­ing in ru­ral com­mu­ni­ties de­creased 21% be­tween 1981 and 2005, ac­cord­ing to a study from the depart­ment of fam­ily medicine at the Univer­sity of Wash­ing­ton. In ad­di­tion, more than half (52%) of sur­geons were ap­proach­ing re­tire­ment age, be­tween 50 and 62 years old.

The Pa­tient Pro­tec­tion and Af­ford­able Care Act does try to ad­dress those is­sues by pro­vid­ing more re­sources to med­i­cal schools and the National Health Ser­vice Corps to help with train­ing and re­cruit­ment.

Some ar­eas of the coun­try—those close to moun­tains or beaches—may be able to draw on their idyl­lic sur­round­ings to at­tract physi­cians, es­pe­cially those look­ing for a qui­eter life­style. Oth­ers, not so much.

Neil MacKin­non, di­rec­tor of the Cen­ter for Ru­ral Health at the Univer­sity of Arizona, re­calls how not once, but twice, physi­cians land­ing in the desert town of Yuma—which has a pop­u­la­tion of 93,000 and aver­age July tem­per­a­tures of 106 de­grees—re­fused to even get off the plane. Re­cruiters now fly in physi­cians at night. “Some places in this coun­try have unique chal­lenges,” MacKin­non says. “We try to look at what is the best fit. The real key is know­ing your state and the at­tributes of the com­mu­ni­ties.”

In Arizona, smaller towns and iso­lated ar­eas aver­age only 70 physi­cians per 100,000 res­i­dents, com­pared with 270 per 100,000 in ur­ban ar­eas, and 250 per 100,000 statewide. “That’s cer­tainly a large, large gap,” MacKin­non says. “In some cases, it does mean scal­ing back ser­vices.”

Many med­i­cal cen­ters are staffing their clin­ics with mid-level providers such as nurse prac­ti­tion­ers and physi­cian as­sis­tants, but while they can re­lieve some of the bur­den, state rules vary when it comes to how much physi­cian over­sight is still re­quired.

With the need so dire, new physi­cians are be­ing re­cruited as early as their sec­ond year of res­i­dency, of­ten re­ceiv­ing dozens of glossy brochures ad­ver­tis­ing a town’s na­ture trails, fes­ti­vals and short flights to ma­jor metropoli­tan ar­eas. Start­ing salaries can seem tan­ta­liz­ingly high com­pared with spe­cialty av­er­ages.

While Slabach con­cedes that in­comes can reach into the top quar­tile for a given spe­cialty, he notes that those high salaries of­ten come with sig­nif­i­cantly more work. “They’re very, very busy,”

he says about ru­ral physi­cians. In a short­age sit­u­a­tion, “you have higher vol­umes typ­i­cally.”

But he adds that ru­ral fa­cil­i­ties may also ben­e­fit from the CMS’ re­im­burse­ment as­sis­tance for sole com­mu­nity or crit­i­cal-ac­cess hos­pi­tals.

A 2012 sur­vey from Med­scape, a med­i­cal in­for­ma­tion provider, found that physi­cians in the North Cen­tral part of the U.S.—Iowa, Kansas, Mis­souri, Ne­braska and North and South Dakota—earned the high­est aver­age salaries in the coun­try.

In con­trast, physi­cians in the more-densely pop­u­lated North­east—from Maine to New York—earned the low­est. “Some­times it does end up be­ing a bit of a bid­ding war,” MacKin­non says. “It comes down to sup­ply and de­mand.”

The daunt­ing propo­si­tion of be­ing a sole prac­ti­tioner in an un­der­served area is com­pounded by chang­ing ex­pec­ta­tions from med­i­cal school grad­u­ates, who no longer want to be teth­ered to their pagers around the clock. Work-life bal­ance tends to be es­pe­cially top-of­mind for women, who now ac­count for about half of med­i­cal school grad­u­ates.

“A lot of providers aren’t in­ter­ested in be­ing the 24/7 kind of docs,” says Robert Duehmig, di­rec­tor of com­mu­ni­ca­tions at the Ore­gon Of­fice of Ru­ral Health at Ore­gon Health & Science Univer­sity.

More­over, mov­ing to a ru­ral com­mu­nity is of­ten a fam­ily de­ci­sion—with spouses’ ca­reers and chil­dren’s ed­u­ca­tions to be con­sid­ered. “When you’re re­cruit­ing a provider, you’re re­cruit­ing more than one per­son,” Duehmig says.

So hos­pi­tals are work­ing to smooth the tran­si­tion. Slabach notes that ru­ral hos­pi­tals are in­creas­ingly em­ploy­ing doc­tors di­rectly, which al­lows clin­i­cians to fo­cus on prac­tic­ing medicine while hos­pi­tal ad­min­is­tra­tors han­dle ad­min­is­tra­tive tasks such as billing and li­cens­ing.

He also points to two pri­mary in­di­ca­tors of whether some­one will prac­tice in a ru­ral area: be­ing born and raised in a ru­ral com­mu­nity and be­ing trained there. “Those two ar­eas alone can have very big pre­dic­tive value,” he says.

With that in mind, some med­i­cal schools are giv­ing pref­er­ence to ru­ral ap­pli­cants. The Schol­ars in Ru­ral Health pro­gram at the Kansas Univer­sity School of Medicine even re­cruits col­lege sopho­mores in­ter­ested in serv­ing ru­ral com­mu­ni­ties, and of­fers them guar­an­teed ad­mis­sion if they com­plete pro­gram re­quire­ments. The ap­pli­cants must have ex­pe­ri­ence liv­ing in a ru­ral area and in­tend to prac­tice medicine in ru­ral Kansas.

More com­mu­ni­ties are also par­tic­i­pat­ing in physi­cian shares—where joint con­tracts be­tween hos­pi­tals not only pro­vide ex­tra cov­er­age but also help physi­cians feel less iso­lated. “I think that’s prob­a­bly go­ing to in­crease,” says Joyce Grayson, di­rec­tor of Ru­ral Health Ed­u­ca­tion and Ser­vices at Kansas Univer­sity Med­i­cal Cen­ter. “What we don’t know is what that’s go­ing to look like on the back end if that physi­cian leaves.”

Physi­cian re­ten­tion has been just as much an is­sue as get­ting physi­cians to make an ini­tial com­mit­ment to ru­ral life. Grayson says that, na­tion­ally, physi­cians stay in their first jobs for only about three years, and the chal­lenge be­comes find­ing those doc­tors who are will­ing to stay for five or more years. “We can cer­tainly help with re­cruit­ing, but we’re re­ally in­ter­ested in help­ing those who we want to keep too,” she says.

Kansas pro­grams such as stu­dent-loan for- give­ness have had an 80% re­ten­tion rate dur­ing the past 23 years, Grayson says. The state also funds a pro­gram that pro­vides tem­po­rary clin­i­cian cov­er­age to un­der­served ar­eas so that solo providers can have time off.

“You absolutely can have work-life bal­ance out in the ru­ral ar­eas,” she says. “There has been a big change over the last few years.”

In Ore­gon, state se­na­tors have in­tro­duced a bill that would re­cre­ate a pri­mary-care loan re­pay­ment pro­gram and es­tab­lish a loan re­pay­ment fund—some­thing the state dis­con­tin­ued in 2009. It would build upon Ore­gon’s other in­cen­tive pro­grams, such as its par­tic­i­pa­tion in the fed­er­ally ad­min­is­tered state loan re­pay­ment pro­gram, a match-grant pro­gram in­tended for pri­mary-care providers will­ing to spend at least two years prac­tic­ing in an un­der­served area.

On the national level, two bills in­tro­duced this year in the Se­nate aim to help re­tain in­ter­na­tional med­i­cal grad­u­ates.

The Con­rad State 30 and Physi­cian Ac­cess Act, in­tro­duced in March by Sens. Jerry Mo­ran (R-Kan.), Amy Klobuchar (D-Minn.), Su­san Collins (R-Maine) and Heidi Heitkamp (D-N.D.), elim­i­nates the sun­set on the 1994 pro­gram of the same name that al­lows states to waive visa re­quire­ments for ru­ral physi­cians.

And last month’s Bor­der Se­cu­rity, Eco­nomic Op­por­tu­nity and Im­mi­gra­tion Mod­ern­iza­tion Act has a num­ber of pro­vi­sions that could di­rectly or in­di­rectly boost physi­cian im­mi­gra­tion, such as do­ing away with per-coun­try lim­its on green card hold­ers and in­creas­ing the num­ber of physi­cian im­mi­grants who stay af­ter com­plet­ing train­ing here. Then there are the hy­per-lo­cal ef­forts. In 2009, Dou­glas, Ariz., an­other town on the U.S.-Mex­ico bor­der, re­ceived a visit from thenAmer­i­can Idol judge Si­mon Cow­ell as part of “Idol Gives Back.” Be­cause of a do­na­tion from the show, the town was able to con­vert a for­mer school into a pe­di­a­tri­cian’s of­fice.

“It re­ally united the whole com­mu­nity,” MacKin­non says. “Some­times it comes to think­ing out­side of the box.”

Ashland (Kan.) Health Cen­ter, a pub­lic hos­pi­tal in a town of only 900 peo­ple, was an­other “pretty ex­treme case” when Ben­jamin An­der­son ar­rived as CEO in 2009.

Dur­ing the past 18 years, 11 physi­cians had come and gone. The 24-bed hos­pi­tal was op­er­at­ing with only one physi­cian as­sis­tant who was work­ing around the clock and was over­seen by a physi­cian 30 miles away who came in for a half day a week. “That’s all that was keep­ing this place open,” An­der­son says.

An­der­son ap­proached two fac­ulty mem­bers in the ru­ral health pro­gram at Via Christi Health in Wi­chita, Kan., which has a part­ner­ship with Ashland, to ask for their help.

He was given a list of di­rec­tives. He was told to of­fer physi­cian re­cruits four days of clinic with one day a week on-call, one week­end on call a month, a salary that met the national aver­age, and eight weeks of paid time off for in­ter­na­tional mis­sion­ary work.

“You show them they can be a mis­sion­ary here for 44 weeks,” An­der­son re­calls. “The physi­cian who’s will­ing to prac­tice medicine in a mud hut in Africa—they don’t need a Nord­strom’s or restau­rants.”

An­der­son was then asked if he’d be will­ing to go to Africa to see for him­self, and ul­ti­mately trav­eled to Zimbabwe to build screens around mis­sion­ary hous­ing to pre­vent malaria. “It was a game-changer for me. And I’ve been back ev­ery year since,” he says. “I was sur­prised by the sim­i­lar­i­ties be­tween ru­ral Amer­ica and over­seas.”

Ashland now has two fam­ily medicine physi­cians, two physi­cian as­sis­tants and one nurse prac­ti­tioner. “We’ve be­come a lit­tle med­i­cal hub,” An­der­son says, not­ing that six com­mu­ni­ties now ben­e­fit from the ad­di­tional cov­er­age. “We share those providers with the sur­round­ing ar­eas.”

Since 2007, Cop­per Queen’s med­i­cal staff has grown from four physi­cians to 11.

Ashland Health CEO An­der­son in Zimbabwe. “I was sur­prised by the sim­i­lar­i­ties be­tween ru­ral Amer­ica and over­seas,” he says.

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