Back Going Where Physicians Are Needed Most - HPSAs

Going Where Physicians Are Needed Most - HPSAs

By Debra Wood, RN, contributor

For decades, rural America has struggled with recruiting and retaining physicians, but many enjoy it and are making a difference improving rural healthcare.

The problem

The Health Resources & Services Administration (HRSA) maintains a list of “health professionals shortage areas” (HPSAs) in primary care, dental services and mental health care. Those areas are eligible for some federal resources.

As of December 31, 2018, HRSA identified more than 7,000 primary medical HPSAs, 4,145 of those located in rural areas. More than 79 million people live in primary medical HPSAs, and rural healthcare suffers from shortages.

The National Rural Health Association reports “the patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas.”

California had the most HPSAs with 647, followed by Texas with 462, Michigan with 366, Florida with 275 and Georgia 235.

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One solution: training in rural areas

The University of Louisville started one of the country’s first rural medical-student education programs at the Trover Campus at Baptist Health Madisonville in Kentucky 20 years ago. A study conducted by William J. Crump MD, associate dean at the Trover Campus, and colleagues showed that physicians who spent the last two years of medical school at the rural location were more likely to practice in a rural setting, 45 percent compared to 7 percent of graduates from the university’s urban campus.

About 40 medical schools now have similar programs.

Affinity and geography

The University of Louisville program is built on the affinity model, Crump explained. He described two groups of people: those who like the hustle and bustle of the city and travel for the beauty and quiet of the country, and those who like living in the country and travel for cultural, sporting and other events.

“If you are in the second category, you have a natural affinity for small towns and rural areas,” Crump said. “The best way to get a doctor to a small town is to get a medical student from a small town. You get them from where they have an affinity, and you train them in a small town.”

When rural medical students attend an urban school, they often get used to the variety of restaurants and cultural events at the ready, and they learn to depend on consultants in subspecialties, rather than managing cases themselves, Crump said.

Physicians trained in the affinity model will likely stay in a similar environment, not necessarily the community in which they trained. Newly minted physicians also tend to stay geographically near where they train, perhaps because they become settled in and like the environment.

However, rural high students tend to have lower career expectations than their urban counterparts. The University of Louisville has high school and college rural scholars programs.

“You have to get more into medical school to begin with,” Crump said.

Family commitments

Physicians who begin practicing in a rural area often stay, unless family concerns interfere. A spouse or significant other who doesn’t like the lifestyle, or concern about their children’s education, may trigger a move to a larger community.

Douglas O. Staiger, PhD, of Dartmouth College in Hanover, New Hampshire, and colleagues found physicians with highly educated spouses and independent careers were less likely to practice in a rural HPSA, 4.2 percent for married physicians with highly educated spouses vs. 7.2 percent for married physicians without highly educated spouses.

Lifestyle issues

Physicians in a small rural practice may be on call many nights and weekends, leaving little time for family. But newer practice models, with hospitalists and emergency department physicians covering hospital patients, have made things easier for the rural family practitioner.

Rural physicians spend more hours per week in direct patient care, but commutes are shorter, Crump said. Physicians in a small town also have to set boundaries to avoid being asked about medical problems during off-work activities, such as at softball games or the movies.

Financial considerations

College loans create a barrier for physicians locating in a rural area. Physicians can earn more as a subspecialist in an urban area than in a rural practice, hence, they are able to pay their student loans off more quickly.

In medium-size towns, health systems will often offer loan repayment or a signing bonus, he said. Many locum tenens assignments in rural areas also pay a higher-than-average salary.

The National Health Service Corps and other scholarship and loan repayment programs exist to help rural physicians. Nurses and primary care nurse practitioners, certified nurse midwives and psychiatric nurse specialists also are eligible for loan repayment programs.

“That has revolutionized everything,” Crump said.

Additionally, the Centers for Medicare & Medicaid Services provides a 10 percent bonus to providers serving beneficiaries in a geographic HPSA. To fix the shortage problem now, Crump said it would require paying primary care physicians more.

RELATED: Top 5 States for Primary Care Pay

Nurse practitioners helping fill the void

Primary care physicians remain in short supply, especially in rural areas, but nurse practitioners are stepping in to fill some of the void, according to a new study led by Ying Xue, DNSc, RN, associate professor at the University of Rochester (NY) School of Nursing and reported in the Journal of the American Medical Association.

“Low-income and rural areas have higher demand and greater health disparities,” Xue said in a statement. “Increasing the number of primary care clinicians in those areas would help to increase access and help reduce health disparities. That’s the ultimate goal: To have sufficient clinicians to provide care in those areas.”

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