Rural Medicine at a Crossroads

Editor’s Note: This article was originally published in the Fall 2015 issue of Alabama Medicine magazine

Part 1 – Feeling the Physician Shortage Pinch

Living in a small town means everyone knows everyone, a tip of the hat speaks volumes, and the nearest neighbor may be a mile down the road. Physicians in these communities are often called upon for a variety of reasons from treating flu and pneumonia, to setting broken bones, to delivering babies. Oftentimes, today’s rural physician is a jack of all trades.

There are many challenges to living in an area that may only have one grocery store or gas station. But, when it comes to the health of Alabama’s residents, many rural counties are further struggling with access to proper health care. As older physicians retire, they leave behind shoes that are tough to fill as fewer young doctors are willing to practice medicine in rural areas.

With Alabama’s rural health care at a crossroads, where do we go next?

Alabama’s 5 million residents routinely struggle with some form of access to health care. Whether it’s finding a specialist or one in primary care, there simply are not enough physicians in Alabama, especially in rural areas…and the shortage is projected to only get worse.

“Already having a relative shortage of physicians compared to urban areas, the trend, which is more pronounced in rural areas, of an increasing proportion of the population who are elderly, has increased the need for rural physicians,” said John Wheat, M.D., professor of community and rural medicine at the University of Alabama’s College of Community Health Sciences and School of Medicine and director of the Rural Medical Scholars Program at the University of Alabama School of Medicine.

Sixty-two of Alabama’s 67 counties have been designated as whole or partial health professions shortage areas, or HPSAs, in which there are not enough physicians to meet the needs of the population. Eight counties have seen their hospitals close, and others are fighting to keep their doors open.

In addition to an older population as compared to urban areas, Medicaid is the primary source of insurance in these rural areas. One-in-four rural residents is eligible for Medicaid benefits, about 10 percent higher than in urban areas. There are many uninsured Alabamians in rural areas who, despite their lack of insurance, still have health care needs.

The shortage of physicians is compounded by the number of older doctors who will retire in the next few years with relatively few young physicians in the pipeline to take their place. This was one of the main reasons the Medical Association worked to pass the Interstate Medical Licensure Compact earlier this year.

“The Compact will allow board-certified doctors with clean records a much faster path to medical licensure in Alabama,” said Buddy Smith, M.D., president of the Medical Association, and a family physician from Lineville. “We want to be able to recruit and attract quality physicians and have them begin treating patients immediately.”

Part 2 – Life in a Small Town

The waiting rooms were packed with nearly every seat occupied on this day as most days for David Arnold, M.D., and Dale Mitchum, M.D. Dr. Arnold, a family physician, and Dr. Mitchum, a general surgeon, work in Geneva County where the population is around 27,000. Dr. Arnold is one of a handful of family physicians in the county, but Dr. Mitchum is the only general surgeon.

Life here moves at a slower pace, with shopping and dining opportunities limited. The challenges of a rural lifestyle require Drs. Arnold and Mitchum to approach their patients and practices in unique ways.

As a family physician of more than 30 years, there’s not much Dr. Arnold hasn’t seen, so he and his staff make sure there is time in their busy schedule during the day for unexpected events that “pop up,” such as cases of sick children or elderly patients or even broken bones.

“Most of my staff have been with me for at least 15 years. We’ve learned to anticipate each other, so our teamwork is exceptional. We wouldn’t be able to see as many patients as we do if we didn’t work so well together,” Dr. Arnold said.

For Dr. Mitchum as the county’s only surgeon, the physician shortage isn’t unique to Alabama. He also treats patients in nearby Bonifay, Fla., and sees how a shortage of physicians anywhere can strain a community’s health care system. As many physicians that have come from his home county of Geneva, he’s seen them leave for a host of reasons to practice elsewhere. Those who stay tend to do so because of family connections.

“It’s hard work,” Dr. Mitchum said. “If you have a relative who is going into medicine who can look to you as a mentor, they can acclimate to the situation. It’s really a nice place to live, but you have to acclimate to the day-to-day slower style of living. It can be culture shock if you’re not used to it.”

Dr. Mitchum understands firsthand about coming back home to take over the family practice. His father, O.D. Mitchum, M.D., was a long-time family physician in Geneva when his son worked as an orderly in the local hospital. After medical school and residency, he came home to stay and eventually practiced with his father for about 20 years before the elder Mitchum retired.

For Dr. Arnold, it was his intention all along to practice rural medicine. The pull of small-town life and the close relationships that often develop between rural physicians and their patients was enough to bring Dr. Arnold to the City of Geneva.

“Now I’m seeing the children I delivered back in the day that have grown up and have children of their own,” Dr. Arnold said. “In these rural counties, the patients are so spread out. Staying in touch with our patients presents its own challenges. I can’t say that we don’t have our own special challenges.”

It’s those “special challenges” and a shrinking number of physicians dealing with them that makes provision of rural health care so different. This is especially true in primary care, where there are fewer students in medical schools across the country choosing primary care as a focus or willing to practice in areas that are designated health profession shortage areas, or HPSAs.

Another challenge for the rural physician, Dr. Mitchum said, comes when a patient needs a specialist. According to him, rural physicians have to deal with all types of problems out of necessity.

“I’m not saying rural physicians are any better at those jobs than physicians in other places, but we deal with those types of things every day. A family physician in a rural setting requires more expertise than one that might practice in an urban setting because we have to be a little bit of all things at all times and do more with less.”

As Dr. Arnold explained, one of his biggest concerns may be access to care, but that’s just the tip of the iceberg. Geneva County has a hospital that’s connected to a nursing home, and he and Dr. Mitchum see patients at both facilities. In addition to the special challenges rural medicine faces, these physicians also have the same burdens of federal regulations to deal with, such as ICD-10, electronic health records, Meaningful Use, etc.

“After seeing patients all day, the next biggest challenge for me is keeping the chart gods happy,” Dr. Arnold said. “Making sure the charting is complete is a huge part of my time when the software required by government regulations will only do so much. The rest is up to me to make sure what goes into the chart is correct.”

Both Drs. Arnold and Mitchum own their practices, and they bear the burden of financing these federal mandates on their own. While these are certainly not easily absorbed by any practice, solo practitioners have an even more difficult time with such expenses. With the current transition to ICD-10, questions remain about reimbursement, delays in payment, and other mandates yet to come.

All three physicians agreed the outlook for rural medicine could be and needs to be improved. The belief that it’s cheaper to practice in a small town is a misconception, they said.

Steven P. Furr, M.D., former president of the Medical Association, and a family practitioner from Jackson, Ala., agreed the regulatory burdens on rural physicians make it more difficult to sustain a medical practice. In fact, Dr. Furr argues the time physicians take to satisfy these federal regulations from Meaningful Use to maintenance of certification to ICD-10, as well as the quality initiatives by insurance companies, negatively affect patient care by overwhelming the physician and staff.

“All physicians are facing these problems, but in rural areas there’s often the lack of staff and training resources to help them migrate through these minefields,” Dr. Furr said.

Physicians enduring the “normal” challenges of practicing medicine and also the special challenges of providing rural care are tremendous assets to the communities they serve.

Dr. Smith stressed that physicians are uniquely situated to help improve both health and the economy, but for rural communities in particular, attracting and keeping them is key.

“When you realize the economic footprint of just one physician is more than $1 million, that’s huge for a small town,” Dr. Smith said. “If you can attract one or two doctors to a rural area, the health and financial benefits to the surrounding area are tremendous.”

Part 3 – From School to Practice…The Making of a Rural Physician

The shortage of physicians is a national problem, and Alabama’s rural communities are certainly feeling the pinch.

According to Allen Perkins, M.D., MPH, professor and chair, Department of Family Medicine, University of South Alabama, one contributing factor for the physician shortage in Alabama could be that medical schools cannot keep up with the health care needs of the state.

“It is clear the overwhelming majority of the medical students come from the urban counties yet the average age of our rural physicians is over age 55. We have an acute lack of mental health services in rural Alabama and yet not training professionals in rural settings,” Dr. Perkins explained.

While not a cure-all for Alabama’s rural health crisis, more physicians is a good thing, and programs to increase the number of physicians in rural areas like the Rural Medical Scholars Program (RMSP) at the University of Alabama’s College of Community Health Sciences and the Board of Medical Scholarship Awards (BMSA) are part of the solution.

RMSP is a highly selective pre-med and medical education program allowing 10 qualified students annually to take graduate level courses, participate in farm field trips, shadow rural physicians, conduct or assist with health fairs and screenings or other community service projects and attend lectures and workshops pertaining to rural community health topics. RMSP is one of several rural health care pipelines in Alabama working to put family physicians into rural areas.

Of the nearly 200 rural Alabama students that entered the RMSP during the past 20 years, about 70 percent entered family medicine and almost 60 percent went on to practice in a rural area. More than 90 percent of RMSP graduates remain in Alabama, yet not all remain in primary care, Dr. Wheat said, as some have gone on to other medical specialties.

Drs. Wheat and Perkins also agree the need for greater funding of the BMSA is key to not only attracting young medical students to the field but keeping them on track for a career in family medicine in Alabama.

The BMSA began in the 1960s as a state-funded incentive program to increase the supply of family practice, internal medicine, and pediatric physicians, and encourages practice in Alabama’s rural medically underserved communities. Several hundred loans have been awarded since the BMSA was created. Students who receive the loans agree to return to a pre-approved medically, underserved community to practice primary care.

“The scholarship board needs to be fully funded,” Dr. Perkins said. “Support for the scholarships that place physicians in rural communities is necessary here.”

Dr. Wheat said he feels the medical schools do their part to train the students, but the scholarships also go a long way to getting the students into the schools. He said the Medical Association’s work to keep and increase the amount of scholarship money available each year helps students decide to stay and practice in rural Alabama.

“More than 90 percent of the first 30 RMSs who chose rural practice were recipients of this [BMSA] award,” Dr. Wheat said. “We see this playing out to the benefit of communities. With a bit more effort on the parts of each of our partners, even the most persistently underserved rural areas of the state will see positive results.”

Family physician Terry James, M.D., said the RMS program was invaluable to him. “I might have had to make different arrangements early on in my career,” Dr. James said. “If not for the RMS, I don’t know if we would be addressing the health care shortage in rural areas at all. I think it goes a long way to fill that void.”

Outside of the state’s two allopathic schools – The University of Alabama School of Medicine and The University of South Alabama College of Medicine – the state has two new osteopathic schools, the Alabama College of Osteopathic Medicine (ACOM) in Dothan, and the Edward Via College of Osteopathic Medicine (VCOM) in Auburn.

“For a state the size of Alabama to have four medical schools is a very big deal,” Dr. Smith said. “Graduating more medical students is a piece of the puzzle and we are very glad to have these two new osteopathic schools here in Alabama.”

Osteopathic medicine is fast-growing with the number of D.O.s having increased more than 200 percent in the past 25 years. Estimates indicate there are more than 92,000 D.O.s practicing in the United States and 540 are in Alabama.

ACOM’s first graduating class will be May 2017, and according to Dean and Senior Vice President Craig J. Lenz, D.O., FAODME, expectations are high for these third-year students who are just now finishing their clinical experiences. According to Dr. Lenz, the real test will be to see how many ACOM graduates come back to their rural beginnings.

“Dothan may not seem like a rural area, but from a medical care point of view, we are. It’s primary care; it’s family medicine; it’s general internal medicine…those are the defined specialties where the need here is the greatest,” Dr. Lenz said.

VCOM-Auburn is also getting its footing and hopes are equally high for the school’s first crop of students. VCOM is a private college that is part of the Edward Via College of Osteopathic Medicine system of campuses across the South.

Gary Hill, D.O., VCOM-Auburn’s Associate Dean for Clinical Affairs, believes more D.O.s entering rural medicine can help solve Alabama’s physician shortage.

“Much misconception about osteopathic medicine is a result of lack of exposure to the osteopathic profession and physicians,” Dr. Hill said. “Many of the old arguments have vanished as osteopathic physicians now have complete practice rights in every state and are fully recognized and accepted in the U.S. armed forces.”

Dr. Mitchum said while the need for more physicians in rural areas is immediate, the solutions may take more time.

“We have a real need here,” Dr. Mitchum said. “More funding for scholarships and gearing residency programs for rural health care should be a priority. We require more expertise than one that might practice in an urban setting because we have to be a little bit of all things at all times. To do that properly, young physicians need extra training, which means we need better funding for scholarships and opportunities. That begins in the schools.”

Part 4 – Rural Medicine…Medical Association Seeks Solutions

Not just sustaining rural medicine in Alabama but actually moving it forward will require the support and buy-in of multiple entities, including the state’s medical schools, state lawmakers and even the communities where the need for medical care is greatest. Training and residency programs must encourage and prepare those willing to serve rural patients to do so, and state-sponsored scholarship programs that help defray the expense of a medical education are a significant part of that. But there’s another very big piece to the rural medical puzzle.

In many counties lacking significant industry or large employers, Medicaid is the most common form of insurance. As Medicaid reimbursements barely cover or don’t at all cover the cost of providing that care, rural practices’ ability to keep their doors open seems under constant threat. just sustaining rural medicine in Alabama but actually moving it forward will require the support and buy-in of multiple entities, including the state’s medical schools, state lawmakers and even the communities where the need for medical care is greatest. Training and residency programs must encourage and prepare those willing to serve rural patients to do so, and state-sponsored scholarship programs that help defray the expense of a medical education are a significant part of that. But there’s another very big piece to the rural medical puzzle.

Alabama has historically offered some of the most meager benefits yet highest qualification thresholds in the nation for its Medicaid program. This leaves many individuals who would otherwise qualify for Medicaid in another state unable to under Alabama’s plan, driving up the rate of uninsured residents, estimated to be close to 750,000 people statewide. But lack of insurance doesn’t stop many rural physicians like Dr. Mitchum from treating a patient even though he must absorb the cost of that treatment entirely, further burdening his practice.

“Every time I hear where we have people without health care, I cringe,” he said. “We do a lot of charity care because we don’t turn away someone in need.”

With higher numbers of uninsured and Medicaid patients in rural areas and with practice visits increasing, Dr. Smith said as far as the Medical Association is concerned, two things the Governor and Legislature could do to improve the outlook for rural medicine are increasing all physicians’ Medicaid payments to Medicare levels and providing Medicaid coverage to the working poor.

“Raising payments rates for Medicaid will cost the state some funds in the short term but should save considerably more over the long term as the anticipated increased access to medical care allows patients’ health to be better managed,” Dr. Smith said. “Untold Medicaid dollars could be saved by preventing costly hospitalizations and long-term care stays whenever possible, in fact that is one of the chief goals of Alabama’s fledgling Regional Care Organization program. The RCOs need enough doctors of all specialties participating so the frequency of those types of costly stays can be mitigated.”

Dr. Smith said the sooner state officials act to address the issue of insurance coverage for the working poor the better.

“Without health insurance, not only are some of these individuals who would qualify for Medicaid suffering but the cost of care provided is borne by the entire health care community,” Dr. Smith said. “It is my hope the Governor and Legislature would work swiftly to tackle this issue.”

While additional funding for scholarships and training, recruiting and attracting more physicians willing to locate in rural areas can go a long way, these alone cannot solve Alabama’s rural health challenges. Dr. Furr said he still believes other incentives are needed to retain physicians in rural areas.

“Whether that is debt service, some type of reduction in income taxes, not just for those who initially come out to practice, but also for those who continue to stay, or perhaps some kind of protection against medical liability for those who practice in underserved areas,” he said.

Delivery of rural medicine is about the ensuring the viability of the people who make up rural communities, Dr. Smith says, mentioning that large employers and economic developers often review an area’s education and health care systems in determining where to next locate a project.

The physicians who call these communities home are vital to rural Alabama’s future, he believes.

“Rural medicine is indeed at a crossroads, but rural communities themselves are as well,” Dr. Smith said.

“What happens in the next several years will determine the fate of ‘country doctors’ and – I think you can say – their patients, too. It’s my sincere hope that we’ll look back in a decade and see the present as just another mile marker, not the end of the road.”

Article by Lori M. Quiller, APR, director of communications and social media