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ER Staffing Split Along Urban-Rural Divide

Analysis  |  By Christopher Cheney  
   June 18, 2018

Nearly two-thirds of emergency medicine physicians work in urban communities, and the staffing mix in rural counties reflects an emergency physician shortage in those areas of the country.

Emergency department staffing patterns have a gaping urban-rural divide, new research shows.

In 2014 Medicare data, the distribution of emergency medicine physicians is strongly skewed toward urban areas. The researchers found urban counties had a much higher proportion of emergency physicians—63.9% compared to 44.8% in rural counties.

The shortage of emergency physicians in rural areas is severe, says M. Kennedy Hall, MD, MHS, lead author of the research and an emergency department physician at Harborview Medical Center in Seattle.

"Rural area patients are now considered a disparity population, and rural areas are faced with an ongoing problem of insufficient numbers of emergency medicine-specialty physicians to staff their emergency departments," Hall told HealthLeaders last week.

Hall says earlier research has shown that rural areas have fewer incentives and more barriers compared to urban areas for ER physicians seeking employment. That research found several factors influence job location choice:

  • Lifestyle
  • Access to amenities and recreation
  • ER volume and acuity
  • Family and spouse considerations
  • Access to specialists
  • Location of residency programs, which are mostly set in urban locations

In rural areas, research published in 2013 indicates there also are budgetary and strategic factors at play in the employment of ER physicians. Some hospital executives reported that low ER patient volume and acuity did not justify hiring emergency medicine specialists. The executives also reported satisfaction with the care provided by their non-emergency medicine physicians and advanced practice providers.

In rural areas, cost considerations discourage the hiring of emergency medicine physicians, Hall says.

"A provider mix with preferential hiring of non-emergency medicine physicians and advance practice providers at lower salaries can form a larger staff than a few highly paid emergency medicine-specialty physicians, which can in turn provide care to larger rural areas."

ER Staffing Mix Reflection of Urban-Rural Gap

Hall and his team found that rural areas have a much larger proportion of nonemergency physicians and advanced practice providers than urban areas.

In the study, which was published by Annals of Emergency Medicine, urban counties accounted for 50,157 emergency medicine clinicians, with ER physicians dominating the mix:

  • Emergency physicians, 63.9%
  • Non-emergency physicians such as family practice doctors, 12.0%
  • Advanced practice providers such as nurse practitioners and physician assistants, 24.1%

Rural counties accounted for 8,408 emergency medicine clinicians, with non-emergency physicians and advanced practice providers outnumbering emergency medicine physicians:

  • Emergency physicians, 44.8%
  • Non-emergency physicians, 28.3%
  • Advanced practice providers, 26.8%

In addition to lower staffing costs and easing the ER physician shortage, Hall says non-emergency physicians and advanced practice providers are a good fit at rural ERs with expanded care models.

He says non-ER physician providers can be essential caregivers in an integrated emergency medicine and primary care model.

"As emergency departments increasingly serve as health safety nets in rural areas—becoming both primary sources for hospital admission and hubs for unplanned acute care—a mixed ER staff of emergency physicians, non-emergency physicians, and advanced practice providers may be able to better collaborate on care coordination."

Under this model, non-emergency physicians and advanced practice providers give more comprehensive care than traditional ER models, says Hall, an assistant professor at the University of Washington School of Medicine in Seattle.

"The varied and usually primary care-centered training and skills of non-emergency medicine physicians and advanced practice providers serve as a valuable asset in addressing patients' health over a longer term than typically considered in traditional ER models."

Hall says hospital executives should consider four factors when deciding ER staffing targets:

  • Whether patient volume is large enough to generate a cost-neutral or cost-saving employment of emergency medicine physicians
  • Whether budget considerations dictate the hiring of non-emergency physician staff to serve a coverage area adequately
  • Whether the care model favors emergency physicians or a more balanced mix of healthcare providers
  • Whether there is the capability to provide training and experience for non-ER physicians who lack emergency medicine board certification

Christopher Cheney is the CMO editor at HealthLeaders.


63.9% of emergency medicine physicians work in urban areas

Cost factors depress hiring of emergency physicians in rural areas

Shortage of emergency physicians in rural areas is severe

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