A Review of Physician Recruitment and Training in Rural America

By: Mollie Spire

 

American Medical Student Association

Washington Health Policy Fellowship Program

Washington D.C.

June 19 - August 4, 2000

Fellowship Site: National Rural Health Association

 

TABLE OF CONTENTS:

Introduction 3

The Current Status of Rural Health 4

Selected Federal Programs Aimed to Improve Rural Health 6

The Role of Medical School Curriculum in Rural Placement 8

GME Funding and Accreditation in Rural Health Centers 9

Assessing the Role of the Community in Rural Recruitment 11

Conclusion 12

Figure 1: National Primary Care Clinician Shortage 13

Figure 2: Family Practice Residency Programs with Rural Missions 14

Figure 3: Primary Care Health Professional Shortage Areas (HPSAs) 15

Bibliography 16

 

INTRODUCTION:

"We envision a rural America where all individuals have optimal health. Rural communities are models for achieving and maintaining this vision for our nation.

Rural America achieves optimal health through economic prosperity, essential health care resources, integrated systems of care, a safe environment, and an informed and educated public. In our communities individuals take responsibility for decisions that affect their health and society promotes wellness through action.

Our health system ensures a full continuum of care that is affordable, accessible and offers choices among plans and providers. Rural health systems are locally accountable, culturally competent, technologically advanced partnerships within and among communities.

Rural communities share in the responsibility for a healthy nation and the nation shares in responsibility for a healthy rural America (Rural Health: A Vision for 2010, 1998)."

This vision of ideal health in rural America was proposed by the Office of Rural Health Policy, the National Rural Health Association, and 17 rural health experts at an invitational workshop in 1998. Many barriers to this ideal exist, including location of medical training sites, physicians’ lifestyle preferences, rural community economies, and rural health care delivery systems (Barriers to Residency Training of Physicians in Rural Areas, 1998). It is the responsibility of heath policy makers, rural health practitioners, and the rural health population to preserve our rural heritage and ensure the best possible future for America’s rural health.

The workshop participants outlined six mission statements to achieve the vision of improving rural health:

1. Provide education, training, research and technical assistance
2. Educate and inform the public, providers and policy makers
3. Advocate for equitable resources, financing and reimbursement
4. Offer rural health services that are affordable, accessible and excellent in quality
5. Strengthen local delivery systems including involving the entire community
6. Promote health, wellness, legislation and policy

(Rural Health: A Vision for 2010, 1998).

CURRENT STATUS OF RURAL HEALTH:

The current status of rural health populations and rural physician providers must first be reviewed before addressing the specific concerns and barriers to health care in rural America. There are two definitions of rural that are used by the federal government in order to initiate federal rural health policy. The first definition is based on the Census Bureau and is designated by areas with small populations or unincorporated areas with a population density of less than 1,000 per square mile. The second definition is defined by the Office of Management and Budget (OMB). The OMB defines rural as nonmetropolitan counties. Nonmetropolitan counties are those outside the boundaries of metropolitan areas with no cities greater than 50,000 people. Metropolitan areas are defined by the OMB as cities with greater than 50,000 residents and fringe counties that are tied economically to the metropolitan cities (Definitions of Rural: A Handbook for Rural Health Polity Makers and Researchers, 1998).

As of 1998, more than 51 million Americans lived in areas classified as non-metropolitan by the U.S. Office of Management and Budget (OMB). It has also been found that a disproportionate percent of individuals in rural areas are living below the poverty level. The percent of Medicaid beneficiaries is disproportionately low in rural areas as well. Less than 11% of the nations’ physicians are practicing in non-metropolitan areas that are comprised of more that 20% of the nations’ population (Physician Recruitment and Retention, 1998). The National Health Service Corps estimates that nearly 3000 communities across the nation are considered underserved for primary health care (population to physician ratio of ³ 3500:1). Primary care includes family physicians, pediatricians, general internists, obstetrician/gynecologists, nurse practitioners, physician assistants, and certified nurse midwives. Twenty-seven million Americans lack access to a primary care clinician. As shown in Figure 1, more than 20,000 primary care clinicians are currently needed to remove all national areas from the health professional shortage area (HPSA) designation (The NHSC: An Investment in Health Professionals for Underserved Communities, 2000).

A HPSA is defined as population groups and facilities with a shortage of health professionals according to rural and urban geographic areas. The HPSA designation allows public and non-profit organizations to apply for National Health Service Corps personnel as well as other federally funded programs. Three criteria must be met in order for an area to be designated as a HPSA: (1) The area is a rational area for the delivery of primary medical services; (2) There is a ratio of population to primary care physicians of at least 3500 to 1; (3) Primary care in the contiguous area is overtaxed, excessively distant or inaccessible to the population of the area under consideration (Rural Health Dictionary of Terms, Acronyms and Organizations, 1997). A distribution of national HPSAs by state can be seen in figure 3 (The NHSC: An Investment in Health Professionals for Underserved Communities, 2000).

SELECTED FEDERAL PROGRAMS AIMED TO IMPROVE RURAL HEALTH:

Several programs aimed at recruitment of primary health care practitioners to rural areas include the National Health Service Corps (NHSC), Interdisciplinary Rural Training Grants, Health Professions Education Programs, Area Health Education Centers (AHECs), and The Rural Recruitment and Retention Network (3-R Net) (Selected Federal Programs: Meeting the Health Care Needs of Rural Americans, 2000).

The NHSC is a federally funded program that offers a total of $116.9 million in scholarships and loan repayments in exchange for service in HPSAs as well as appropriation for site development and support. Since 1972, the NHSC has placed over 20,000 primary care clinicians in federally designated HPSAs. Approximately 12% of the need in underserved areas is met by the NHSC placements. Sixty percent of the NHSC placements are in rural areas (Selected Federal Programs: Meeting the Health Care Needs of Rural Americans, 2000). The NHSC promotes interdisciplinary primary care, an ethnically diverse clinician population, culturally competent and community responsive clinicians. The NHSC also promotes dedication and recruits clinicians who are committed to remaining in underserved areas once their service is fulfilled. Currently, 50% of NHSC clinicians remain in HPSAs once there commitment is fulfilled (NHSC: An Investment in Health Professionals for Underserved Communities, 2000).

The Interdisciplinary Rural Training Grant program was authorized in 1998 with an aim at recruiting rural clinicians via giving students an opportunity to rotate through a rural health care center during their training period. Colleges, universities, and other health professional training institutions are appropriated grants of up to $190,000 per institution. The program encourages interdisciplinary study of rural health care by those clinicians specializing in areas outside of primary care. It has been reported that 54% of the grant recipients choose to work in rural or frontier areas following completion of their degree program (Selected Federal Programs: Meeting the Health Care Needs of Rural Americans, 2000).

Physician training programs that have a rural component and a history of placing graduates in underserved rural areas are preferred for the Health Professions Education Programs. These programs are allocated a total of $300 million per year for health care training institutes by the Health Resources and Service Administration (HRSA) Bureau of Health Professions. It has been reported that graduates of institutions supported by the bureau and include rural rotations are four times as likely to practice in underserved rural areas (Selected Federal Programs: Meeting the Health Care Needs of Rural Americans, 2000).

The Area Health Education Centers (AHEC) program financially supports medical schools, health science centers, and nursing schools in rural areas in order to increase the availability of health related training and continuing medical education (CME). One AHEC program center has a standard of three affiliated AHEC training/education centers. Currently, 40 AHEC program centers with 170 affiliated AHEC centers are operational in 40 states. The AHEC centers provide CME courses, access to health science libraries, access to colleagues in medical specialties, and telecommunication links to rural health care institutions. The AHEC program is funded by HRSA Bureau of Health Professions (Selected Federal Programs: Meeting the Health Care Needs of Rural Americans, 2000).

Forty-six state recruitment programs aimed at recruiting health care providers to rural areas make up the Rural Recruitment and Retention Network (3-R Net). 3-R Networks consist of nonprofit organizations, state primary care associations, state offices of rural health, and AHECs which assist health professionals in locating suitable rural practice sites. 3-R Net is funded by federal and private grant support. It also collaborates with the NHSC and the Indian Health Services (Selected Federal Programs: Meeting the Health Care Needs of Rural Americans, 2000).

ROLE OF MEDICAL SCHOOL CURRICULUM IN RURAL PLACEMENT:

The curriculum of medical schools is a strong predictor of placement of graduates in rural training sites. A recent study showed that 151 medical training programs claimed to have a rural mission. There are 25 additional programs that have a Rural Training Track (RTT) program, rural clinic, or rural fellowship but no specific rural mission. The existence of a rural mission and probability of graduating physicians dedicated to rural practice varies with location of the program as seen in Figure 2. The programs located in the south, southeast, and west United States are more likely to place residents in rural sites than other areas of the country. Several characteristics of medical school programs were related to the probability of placing graduates in rural practice sites. These include the following: (1) Increased number of required rural and obstetrical training months, (2) Rural mission, (3) Located in a rural state, (4) Program director with rural experience, (5) Procedural emphasis, (6) Higher percentage of male, Caucasian residents (Physician Education and Rural Location, 1999).

The Rural Training Track (RTT) is a program that was developed by family practice residency programs in order to address the problem of rural GME. The RTT program is based on a strong relationship between an urban teaching center and a small rural family practice group. The first year of residency is completed in the urban teaching center while the second and third years are completed in the small rural family practice. Residents remain associated with and in contact with the urban teaching center during their second and third years. Successful RTT programs exhibit five main qualities: (1) Academically sound and easily accessible urban teaching component, (2) Supportive urban medical center, (3) Financially viable rural hospital, (4) Modern rural practice center, (5) Robust rural community. The RTT is a promising idea, but problems with recruitment, funding, and rural economies pose barriers to the program . As of 1998, there were 31 RTT sites in 26 programs nationally (Physician Education and Rural Location, 1999).

GME FUNDING AND ACCREDITATION IN RURAL HEALTH CENTERS:

One of the major barriers that exists in recruiting health care providers to HPSAs is the financial barrier related to Medicare Graduate Medical Education (GME) funding. Two major Medicare GME funding problems exist that disproportionately select against GME training in rural areas. The first is that Medicare GME funding is paid to hospitals rather than residency programs. The second is that GME funding is determined by hospital volume of Medicare patients. Small rural hospitals cannot compete with larger urban hospitals even though they may have a larger percentage of Medicare patients. Small rural hospitals are also less likely to be able to withstand the financial stress placed on them by Medicare delays in GME payments. Rural residency programs are largely based on family medicine in an outpatient setting. It is obvious that this factor poses a barrier because Medicare GME funding is linked to the inpatient volume of hospital systems rather than the volume of outpatient general care (Barriers to Residency Training of Physicians in Rural Areas, 1998). The Balanced Budget Act of 1997 (BBA97) made several changes that would potentially allow for increased rural residency programs. The BBA97 allowed for GME payments to nonhospital sites including Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and Medicare+Choice organizations (Physician Education and Rural Location, 1999).

The funding problem of rural health hospitals can be approached in several ways. The University of Washington WWAMI Rural Health Research Center makes several suggestions to increase the budget of rural hospitals and support rural health training and practice. The Medicare Incentive Program, which pays a bonus for physician services to residents of designated shortage areas, can be expanded to include practices in remote rural towns. A Medicaid program could be installed similar to that of the Medicare Incentive program. States should take advantage of implementing the Critical Access Hospital Program in order to stabilize hospitals in small towns. Telehealth programs should be encouraged and developed to link urban teaching centers to rural practice sites in order to support resident education and physician consultation. Also, rural areas should take advantage of the NHSC scholarship and loan repayment programs as well as state funded loan repayment programs which require a service obligation (Physician Education and Rural Location, 1999).

In addition to GME funding, accreditation of rural residency programs by the Family Practice Residency Review Committee (RRC) is a problem. The RRC limits rotations outside the Family Practice Center to two months per year. In RTT programs, the Family Practice Center is typically the urban teaching site associated with the small rural group practice. As a solution, the RRC should tailor it’s requirements to encourage quality GME training in rural locations. This can be done by increasing the amount of time that residents can spend in rural rotation sites. The Family Practice Center definition can be expanded to include RTT sites as long as a close relationship and easy access is maintained between the rural site and the urban teaching site. Also, by only allowing one resident at a time into each RTT, the quality of education and experience can be maximized (Physician Education and Rural Location, 1999).

ASSESSING THE ROLE OF THE COMMUNITY IN RURAL PHYSICIAN RECRUITMENT:

The economies of rural communities and the lifestyle associated with rural communities are strong barriers to recruiting and retaining physicians. Rural health care practices are dependent on Medicare and Medicaid for their gross revenue. These federal programs reimburse at a lower rate than private insurance agencies. Another barrier to high revenue is that rural physicians are limited in the extent of procedures in which they can perform. Rural health clinics cannot typically afford to support technologically advanced equipment and procedures (Physician Recruitment and Retention, 1998).

Rural physicians typically work longer hours than urban physicians because of a shortage in co-workers. Rural hospitals and health clinics cannot economically support increasing physician employees. Rural health depends heavily on non-physician providers for this reason. Non-physician providers can be utilized to decrease the workload of physicians. Careful selection of these providers is important to insure adequate knowledge and ability of the non-physician providers (Physician Recruitment and Retention, 1998).

Many physicians avoid rural practices because of the lifestyle changes it would entail. There is a smaller employment opportunity for the spouse as well as limited educational opportunity for children. Professional isolation for the physician also poses a barrier. These issues can be approached by careful selection and recruitment. Physicians who grew up in rural areas or participated in rural rotations are more likely to be aware of social and lifestyle issues of rural communities. With the advent and implementation of telemedicine, physicians can be linked to larger urban facilities to relieve the feeling of isolation (Physician Recruitment and Retention, 1998).

CONCLUSION:

Less than 11% of the nations’ physicians are providing health care to more than 20% of the nations’ population which live in non-metropolitan, rural areas. In order to remove the 3000 communities nationwide from shortage of primary care, barriers to physician recruitment and retention in rural areas must be overcome. The barriers discussed include location and funding of rural medical training sites, rural community economies, rural community lifestyle, and rural health care funding and delivery systems. Several governmental initiatives have already been installed to help overcome these barriers. The National Health Service Corps, Area Health Education Centers, Health Professionals Education Programs, Rural Recruitment and Retention Network, and Interdisciplinary Rural Training grants are aimed at offering incentives and adequate training to rural physicians. GME funding and accreditation of rural residency sites need to be addressed by federal health policy in order to support rural training and recruitment. Many medical schools across the nation are addressing the rural underserved population by implementing Rural Training Tract programs and declaring rural missions. A healthy rural America can be obtained by the cooperation of health policy makers, rural health practitioners, health educators and the rural communities.

Bibliography

Bowman, R.C.; Penrod, J.D. Family Practice Residency Programs and the Graduation of Rural Family Physicians. Family Medicine, 30(4), 288-292.

Bowman, Robert; Crittenden, Robert; Hart, Gary; Maudlin, Robert and Barry Saver. Barriers to Residency Training of Physicians in Rural Areas. Working Paper of WWAMI Rural Health Research Center, University of Washington School of Medicine, 1998.

Capital Area Rural Health Roundtable. Selected Federal Programs: Meeting the Health Care Needs of Rural Americans. Center for Health Policy Research and Ethics, George Mason University, 2000.

Coombs, John; Geyman, John; Hart, Gary; Lishner, Denise; and Thomas Norris. Physician Education and Rural Location: A Critical Review. Working Paper of WWAMI Rural Health Research Center, University of Washington School of Medicine, 1999.

Federal Office of Rural Health Policy, National Rural Health Association. Rural Health: A Vision for 2010. Report from an Invitational Workshop, January 22-23, 1998.

National Association of Community Health Centers, National Rural Health Association. The National Health Service Corps: An Investment in Health Professionals for Underserved Communities, 2000.

National Rural Health Association, Office of Rural Health Policy. Rural Health Dictionary of Terms, Acronyms and Organizations, 1997.

National Rural Health Association. Physician Recruitment and Retention, 1998.

Ricketts, Thomas; Taylor, Patricia; and Karen Johnson-Webb. Definitions of Rural: A Handbook for Health Policy Makers and Researchers, 1998.