Health in the Heartland: Where Will The Doctors Come From?

The task of persuading physicians to set up a practice is a daunting one for rural areas across the country.

And the vast acres of California's Central Valley, where town signs boast claims such as "The World's Fruit Basket" and "The Raisin Capital of the World," are no exception.

"Physicians don't want to come to Kaweah in large part because of the payer mix," says Steve Jacobs, physician recruiter for the Kaweah Delta Health Care District. Centered in the city of Visalia, Kaweah Delta serves a population spanning three geographically large agrarian counties.

Here, the population receiving Medicaid (Medi-Cal) is more than one in three. But of dozens of primary care physicians in the region, only 10 are willing to accept it, Jacobs says.

"Reedley, (pop. 22,000) has a beautiful new community clinic, but can't get a physician to come to a rural town. The town of Porterville (population 39,000) has been looking for an orthopedic surgeon for at least two years," he says. "The area surrounding us is very rural, and there's not a lot of infrastructure."

Jacobs said the district finally found a gastroenterologist after a five year search, "but he's 58, and in a few more years he'll retire and we'll have to start looking again. We tend to find physicians who are later on in their career. But the job of looking for any specialist for the area can take up to three years."

Kaweah Delta's challenge was clearly documented this week by a federal report entitled "Hard times in the Heartland," which noted that while urban areas across the country have, on average, 72 physicians per 100,000 population, rural areas have 55 and small rural areas have only 36.

"Rural areas continue to suffer from a lack of diverse providers for their communities' healthcare needs," the report said. There are half as many specialists in rural areas compared with urban ones, and a third as many psychiatrists. The situation is only going to get worse, because rural areas have a higher percentage than urban areas of physicians nearing retirement. "Recruitment and retention continue to be a challenge."

According to a multitude of studies, the lack of rural physicians translates into a lack of healthcare, and that means more disease and premature death in rural areas compared with urban parts of the nation.

The shortage of physicians is largely blamed on the fact that one in five of the nation's uninsured, or 8.5 million people, live in rural areas, which have a larger number of residents classified as unemployed and poor than urban areas. Those who lack health insurance or have large deductibles are more likely to avoid or defer care, as the report, issued by the U.S. Department of Health and Human Services, noted.

And if the number of patients willing to seek care isn't enough, the doctors just can't afford to come.

For these residents, many of whom have worked their entire lives in small businesses or for themselves, their only guarantee of healthcare comes only after they turn 65.

At the fourth in a series of stakeholder discussions in Washington after the report's release, ranchers, farmers, and fishermen from the nation's heartland gathered with Nancy-Ann DeParle, President Obama's new director of the White House Office for Health Reform, to discuss the root of the physician shortages in their communities.

A key point was the need for health reform to create insurance programs–perhaps cooperative group health plans–that can provide health coverage for adults before they are eligible for Medicare.

"There needs to be more choices in the insurance market for affordable health coverage," she said. "The call was very clear; we need more choices for affordable options."

Many panelists told of their personal experiences in trying to access affordable healthcare even after they got sick.

"My father is recovering from colon cancer surgery, but he put off getting his port removed until he turned 65," said a man from Holton, Kansas. He hopes the reform package includes incentives for rural areas to find innovative ways to help people get affordable coverage.

One Nebraska resident told DeParle that he pays $1,000 a month for a health plan with a $10,000 annual deductible. "My mother, who just turned 90, never had health insurance until she became eligible for Medicare."

One of the panel members was Congressman Mike Ross, D-AR, who was born in Texarkana. He said that in his home town, "we used to have a hospital, but now we don't. We had six doctors, now only two. We had two dentists, and now one, and the number of pharmacists is down as well," he said. "We need country doctors," especially pediatricians. "That keeps everyone from having to take the whole day off."

Rhonda Perry, a livestock and grain farmer who directs the Missouri Rural Crisis Center Program, noted that farmers spend 15% of their income on catastrophic health policy premiums.

Ambulatory care centers may be part of the solution. A multitude of research papers issued recently point to how such care settings can, with relatively minimal expense, thwart the need for more acute and expensive hospitalizations months or years down the road.

According to a White Paper released last fall by the American College of Physicians, a group representing the nation's internists, rural areas that have more primary care physicians have lower rates of all-cause mortality, and specifically deaths from cancer and heart disease.

"Nonurban counties with a greater number of primary care physicians had 2% lower all-cause mortality, 4% lower heart disease mortality, and 3% lower cancer mortality than nonurban counties with a smaller number of primary care physicians."

The American College of Physicians advocates a number of measures to continue to attract foreign medical school graduates to practice in the U.S., a source of physicians it called extremely important for rural and underserved areas.

If all international medical graduates in primary care practice were removed, one out of every five non-metropolitan areas in the U.S. that now have an adequate supply of physicians would be reclassified as having a physician shortage, the ACP paper said.

Perhaps through a combination of more incentives for physicians and more financial support for hospitals, some of the severe gaps in healthcare to the heartland may be filled. There is potential for better use of providers other than physicians, such nursing or other types of health professionals to fill the needs in these areas. And there's a potential to build and support new models of clinics or urgent care centers that don't necessarily have to be staffed at all times by doctors.