Rural Doctors Exit as Health Declines

LINCOLN, Neb. (DTN) -- On average, rural Americans are sicker, live shorter lives and -- to complicate matters -- are seeing the number of available doctors continue to fall compared to their urban counterparts.

In other words, rural America is losing doctors as it becomes less healthy.

The fixes aren't simple but they are possible, according the president of the American Medical Association during a press conference last week.

"More than 15% of the U.S. population -- 46 million people -- live in rural areas," said Dr. Bruce A. Scott, a Louisville, Kentucky, otolaryngologist and newly elected AMA president.

"That means that when you add it all up, the people and the families living in those small towns, farms and ranches across the country, you're talking about a population that exceeds the people living in America's largest 20 cities combined. So rural health is America's health and we need policymakers to understand that."

Scott said it's not a stretch to say if rural America can attract more doctors, many of the health problems would begin to resolve.

Rural Americans experience disproportionately higher rates of cancer, stroke, heart disease, diabetes, respiratory illness and unintentional injuries than do urban residents.

Several factors are driving the disparity, Scott said, including economic pressures and lack of job security, sometimes limited access to healthy food and good living conditions.

"My focus -- and the focus of the American Medical Association -- is on the worsening healthcare worker and physician shortage of primary care and specialists, particularly in the rural areas that are exacerbating these concerns and creating healthcare trends that are simply unacceptable," Scott said.

"We need to reverse these trends for all individuals to live a long, healthy and active life. Compounding these healthcare woes is a national and worsening physician shortage that is hitting rural areas."

MORE DOCTORS PER PATIENT IN URBAN AREAS

A study by the National Rural Health Association found there are about 30 physician specialists for every 100,000 residents in rural areas, compared to 263 specialists per 100,000 people in urban communities.

Not only are medical specialists in short supply, Scott said, but more than 130 rural hospitals closed between 2010 and 2021, and "many more are on the verge of closure."

In 2023, about 65% of rural communities had insufficient access to primary care physicians, including pediatricians.

"There are insufficient residency spots for training doctors in rural areas to make up and take off some of the pressure of the physician shortages," Scott said.

"History has shown us that residents 80% of the time tend to wind up practicing within 80 miles of where they've done their residency. So, residency location becomes very important. In addition, medical schools are receiving fewer and fewer applicants from individuals from rural areas. These are the individuals who are most likely to return to practice in rural areas. Even those who consider practicing in rural areas, because of the large student debt that exists, ... many of them are choosing not to return to rural areas to practice where the wages tend to be lower."

Scott said the AMA continues to advocate for changes to the Medicare physician payment system.

Because of "administrative burdens," Scott said doctors are spending increasing time away from patient care.

"Both of these issues lead to physician burnout and they're emblematic of a broken and unsustainable healthcare system that we currently have," he said.

"Physicians have known for some time that our Medicare payment system that reimburses physicians for care for Medicare patients was falling behind, but this was creating severe financial stress for physicians, particularly those in private practice like me, who are also the backbone of the healthcare safety net.

MEDICARE PAYMENT RATES TO DOCTORS FALL

When adjusted for inflation, the payment rate to physicians who care for Medicare patients has dropped 29% since 2001, Scott said.

"Physician practices like my six-physician private practice in Louisville, Kentucky, are struggling in large part because the Medicare rate has remained stagnant or declined over the last two decades," he said.

"Last year, facing once again inflation, and this year inflation-position reimbursement by Medicare was cut, the AMA went to work to try to reduce the cuts and we were successful in reducing the cuts. But we still faced over a 2% cut in those years."

At the same time, Scott said practice costs have risen "substantially."

That means "small businesses like ours have employees who are feeling the sting of inflation, and understandably, they are asking for increased wages."

In addition, he said private payers and other insurers who are "well aware of the downward spiral of Medicare payment system" have linked their payment to the Medicare payment structure.

"In our case, a major insurance company that controls over 60% of the private payer market in Louisville, Kentucky, offered us rates that were linked to Medicare and were surgical rates less than they paid us six years ago," Scott said.

"This is obviously a problem for us, but when doctors lack the resources to take care of our patients, we're potentially going to have to make difficult choices."

DOCTORS FACE TOUGH DECISIONS

That includes deciding whether to invest in the latest equipment, reducing the number of employees and deciding whether to accept new Medicare patients, Scott said.

One of the administrative burdens doctors face, he said, is getting authorization for procedures from third-party payers such as insurers.

"On average, physicians complete 45 prior authorizations per week and it's even worse in primary care," Scott said. "The prior authorization process is overused, overly burdensome and wastes physicians' time."

A survey of physicians, he said, found about one-third of doctors reported that prior authorization led to "serious adverse events" for their patients because of delays or abandonment of care. About 80% of physicians said prior authorization often leads to patients abandoning treatment altogether.

To address the doctor shortage and faltering rural health issues, Scott said the AMA continues to push for several reforms to the U.S. healthcare system. That includes overhauling the Medicare physician payment system; allowing for the continued use of telehealth flexibilities established during the COVID-19 pandemic; expanding the number of doctor residencies and graduate medical education positions; developing more incentives to attract more doctors to rural areas; and addressing stresses on the medical workforce that are leading to burnout and retirement.

Todd Neeley can be reached at todd.neeley@dtn.com

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