Providing Healthcare with Less Money and Less Physicians

Carrie Vaughan, for HealthLeaders Media, July 16, 2008

One healthcare trend that I hear repeatedly is that we need to do more with less—less money, less physicians, and less access to care. I doubt this trend will abate any time soon. First of all, there's not going to be a sudden influx of specialists choosing to practice in rural America. But an even greater concern may be primary care. If you live in a small town and your family physician has announced plans to retire, good luck finding a replacement. The number of U.S. medical graduates going into family medicine fell by more than 50% from 1997 to 2005. The fact that family docs earn on average about $170,000 annually while specialists earn on average about $322,000 annually isn't helping matters. Certified registered nurse anesthetists are earning more (on average about $185,000) than family practitioners, as well, according to a recent report by Merritt, Hawkins, and Associates. So unless family docs start getting paid more, I doubt we'll see more med students signing up for primary care—and who can blame them?

There are programs to entice primary care docs and specialists into rural practice like loan repayment, providing med students more experience in rural healthcare, and recruiting people from rural areas into the healthcare field. While these efforts may help increase the supply of physicians to rural areas, odds are there will still be major gaps in the rural healthcare delivery system.

One way to bridge these gaps is through telemedicine programs, which scored a big win yesterday when Congress voted to override President Bush's veto of HR 6331. The legislation, which stopped a Medicare physician pay reduction, also provides nearly $2 billion to rural healthcare including a provision that makes skilled nursing facilities, hospital-based dialysis centers, and community mental health centers eligible to participate in Medicare's telemedicine program. This is great news for people living in remote regions with little or no access to specialty care like mental health services.

While this legislation helps address some of the gaps in the rural healthcare delivery system, the full potential of telemedicine to help rural practitioners provide the high quality care that their communities not only expect but demand has yet to be realized. Hospitals and physicians have been using telemedicine to offset work force shortages, provide additional services, or improve access to specialty care for people in their communities—mostly through real-time videoconferencing consultations. But scheduling these consultations can be difficult given the high demand placed on some specialties in rural areas. In many nonemergent situations, store-and-forward telemedicine would be a more efficient model. Under this scenario, providers would capture the patient data and send it to the consulting physician, who can then review it at a time that is convenient. The problem? Currently, Medicare only reimburses for store-and-forward telemedicine in Alaska and Hawaii. (I'm not referring to teleradiology-type services for which Medicare does reimburse providers. Rather, I'm referring to consultations with specialists like dermatologists or ophthalmologists, which are not covered.)

Recently, I spoke with Stewart Ferguson, PhD, the director of telehealth for the Alaska Native Tribal Health Consortium, who is no stranger to the store-and-forward telehealth model. He heads the Alaska Federal Health Care Access Network, which is now in its ninth year and provides healthcare to federal beneficiaries in remote areas via telemedicine. Ferguson says that AFHCAN has found significant value in store-and-forward telemedicine and believes that the private sector could benefit from this model, as well. "Most of our healthcare delivery is not something that has to be dealt with immediately, but can be dealt within a 24-hour window. [Store-and-forward telehealth] is a really efficient use of our healthcare resources, which has got to be the focus of any solution at this point," he says.

Is telemedicine helping you improve access to care in your community, or are you struggling to afford or implement the technology? I would like to hear about your successes and headaches, please drop me a line at

Carrie Vaughan is editor of HealthLeaders Media Community and Rural Hospital Weekly. She can be reached at
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