Declining and Aging Rural Physician Workforce

A recent article (L Skinner et al NEJM 2019; 381: 299-301) provided data regarding the worsening disparity in physician availability in rural areas.

Key points:

  • “While the total number of rural physicians grew only 3% (from about 61,000 in 2000 to 62,700 in 2017), the number of physicians under age 50 years living in rural areas decreased by 25%.”
  • “By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60.” In urban areas, the numbers were 39% and 18% respectively.
  • It is projected that instead of the current 12 physicians per 10,000 population in 2017 there will be a drop of 23% (9.4 per 10,000) in 2030 in rural areas; in contrast, nonrural physicians supply will be essentially the same in 2030 (29.6 per 10,000) as current supply (30.7).
  • The fact that there will be one-third fewer physicians is coupled with the fact that rural areas have populations that are older, poorer, worse health, lower life expectancy, and less insurance coverage

My take: This report highlights the current disparity in rural health care and how this is worsening as the rural physician population ages.

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Immigrant Doctors Blocked by New Rules Too

With the U.S. government’s heightened emphasis on stopping immigration into the U.S., there have been noted declines in border crossings; however, it is anticipated that there will be billions in lost income in reduced tourism coincident with the implementation of these policies.

Along with the efforts to curb illegal immigration, new related policies may result in a significant decline in foreign medical graduates allowed to stay in the U.S. through expedited processing of H-1B visas.  This is likely to further strain the care available in rural communities.

From CNN Money: What Trump’s latest H-1B Move Means for Workers and Business

An excerpt:

Thousands of doctors from abroad need H-1B visas to continue working in the U.S. after the expiration of their J-1 visas — which permit them to complete a residency program…

Once they complete their residency, physicians can either return to their home country for two years before becoming eligible to reenter the U.S. through a different immigration pathway, such as an H-1B visa, or they can apply for a J-1 visa waiver.

In the last 15 years, H-1B visas have allowed 15,000 foreign doctors to come to American to work in underserved communities.

“The lack of premium processing would mean that there would be a delay for the doctors to start working in the communities they wish to serve, which have a lack of physicians in the first place,” said Ahsan Hafeez, a doctor who is in Pakistan awaiting approval of his H-1B so he can begin working in Arkansas.

From Internal Medicine News: Foreign doctors may lose US jobs after visa program suspension

An excerpt:

Starting April 3, U.S. Citizenship and Immigration Services (USCIS) is temporarily suspending its expedited processing of H-1B visas, a primary route used by highly skilled foreign physicians and students to practice and train in the United States…

In the meantime, many foreign medical students and physicians will lose top training spots and jobs as their H-1B applications linger in the system, said Jennifer A. Minear, a Richmond, Va.–based attorney and national treasurer for the American Immigration Lawyers Association.

“As a practical matter, the percentages of physicians coming into the U.S. who are accepted into residencies or fellowships, those are the top of the top for medical graduates around the world,” Ms. Minear said in an interview. “Most of them who stay afterward wind up working in underserved areas of the United States. It really doesn’t make much sense as a policy matter to create obstacles to attracting those people to the United States that would prevent them from getting here, obtaining U.S. education, and then remaining in the U.S. and providing urgently needed care to populations that would otherwise go without.”

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Rural Health: “And How Long Will You Be Staying, Doctor?”

A recent short commentary, (Full Text Link:“And How Long Will You Be Staying, Doctor?”) (H Kovich, NEJM 2017; 376: 1307-9), provides a great deal of insight into rural medicine.

  • “Twenty percent of the U.S. population is rural, but only 11% of physicians practice in rural settings, even though residents of rural areas are older and have worse health indicators.”
  • “Physician supply is driven by where physicians want to live, not by the health needs of the community.”
  • “The nearest tertiary care hospital is another 3 hours away. We don’t refer often.”
  • “Caring for entire families helps me understand my community.”
  • Physicians leaving:  “there is guilt for the person who left, insecurity for the one left behind…Should I leave too? It sounds nice to live in a neighborhood with Trader Joe’s, high-speed internet, and babysitting grandparents.”
  • Patients still ask me [after 7 years] “The Question at least twice a day. “You’re not leaving soon, are you?” …I tell them honestly, I have no plan. I don’t tell them that I’m undecided about buying a new dining-room table…I’m torn between buying a nice one that fits this space and getting a cheap one.  If I move, I might want something different in a new house….[my friend] “Buy a nice one for this space,” she says.”

My take: Currently there are not enough primary care physicians.  Rural settings suffer this deficit disproportionately and it increases inequities.

Related blog post: Zip Code vs. Genetic Code

Notre Dame

AAP -Behind the Scenes (Part 1)

Recently I was asked to become a board member for the Georgia Chapter of the American Academy of Pediatrics (AAP) in the role of chair of the section of nutrition.  My role at this meeting was limited.  I was impressed by the commitment of the participants and by the range of activities that the AAP chapter was working on –all in the efforts of improving the health of children in Georgia.

I only took a few notes but here are some of the details.  Dr. Evelyn Johnson (President) provided the president’s report and an overview of the chapter activities.

Dr. Anu Sheth provided an update on the Medicaid Task Force.  This issue was discussed in some detail.  The issue at stake is the low reimbursement for office visits for children with Medicaid coverage; the rate has not changed in 13 years with one notable exception.  In 2013-2014, the federal government provided a one-time boost in the rates of Medicaid reimbursement with the role out of the ACA (Obamacare) to encourage availability of primary care physicians to see the new enrollees.  There is preliminary evidence that this boost did improve access to care.

According to a recent study (NEJM 2015; January 21, 2015DOI: 10.1056/NEJMsa1413299), “Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times.”

Since 43.2% of all children in Georgia receive their health insurance through Medicaid this is a big issue.  It is also directly related to another topic of provider access.  61 counties in Georgia have a deficit of needed pediatricians and 23 counties have no pediatrician at all.  Currently, Medicaid rates to physician practices are only about 75% of Medicare rates and compared to commercial insurance plans, they pay only half.

Based on these considerations, the AAP is urging its members to contact their state legislators, particularly those more involved in the budget decision-making process.  While bumping Medicaid rates in the face of other budget constraints may be difficult, default limiting of access results in higher costs through emergency room visits and complications.

Georgia Politicians with Greatest Impact on Healthcare Decisions

Georgia Politicians with Greatest Impact on Healthcare Decisions

Rural communities are more affected by access issues than urban counties.  Dr. Angela Highbaugh-Battle provided an update on the Governor’s Rural Hospital Task Force.  There have been a number of hospital closures and more appear to be imminent.  Communities that are losing hospitals are losing important jobs, access to timely care, and will have difficulty attracting new businesses.

Another related topic was the issue of ‘retail-clinic’ healthcare.  While the ease of access is quite helpful for families, there are numerous concerns about the quality of care.  Several clinicians described their efforts to provide alternatives including extended hours in their practices and weekend hours as well.

Here’s a related article: “Retail clinics are in, traditional primary care practices are out”

One fascinating aspect about the discussion of retail clinics was its juxtaposition with efforts to improve the process of remaining board-certified (See related blog: Resistance to Maintenance of Certification | gutsandgrowth).  Given the increasing use of retail-clinics and midlevel providers, several clinicians emphasized that board-approval is not a strong consideration for families seeking healthcare.  The fact that the board approval process is not tied to a broad effort to show its impact on patient care and/or to market the efforts of pediatricians has led to widespread dissatisfaction.

Take-home message: The issue of adequate access to primary care physicians along with high quality care is important for everyone.  Make your voice heard!

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