Rural medicine: The GP problem


First Posted: 12/30/2014

Just a few years ago, a visit to a small town doctor’s office involved filling forms with a receptionist, a vitals check with a nurse, and a chat, examination, diagnosis and treatment plan from a doctor. Waiting times varied, but the pattern had remained largely unchanged for decades.

Now the same visit is increasingly likely to involve the doctor only near the very end, if at all.

What happened?

For starters, the country faces a shortage of general practice doctors as many medical students look at the high cost of their student loans and the relatively low pay for a GP.

The average debt nationally of a graduating medical student is $175,000, while one in five owe more than $250,000, according to The Commonwealth Medical College in Scranton, Pennsylvania, established in 2008 with the express mission of relieving the doctor shortage in that region.

Federal data for 2013 lists family/GP average annual salary at $183,940. Compare that to $235,070 for anesthesiologists. Drill into the data to the elite specialties like neuro- or spinal surgery and the pay can double or nearly triple.

Technological and pharmaceutical advances that prolong life and manage chronic conditions compound the shortage. The longer people live, the more people requiring care. And older patients cost more. According to the Henry J. Kaiser Family Foundation, the average cost per person for ages 25 to 44 is $2,739. That doubles to $5,511 for ages 45 to 64, to , and rises another 77 percent to $9,744 for those 65 or older.

But other, less obvious forces are driving rural costs up. National Rural Health Association Senior Vice President for Membership Services Brock Slabach notes an often overlooked factor: Rural areas get shortchanged in “social services that are part of a network of care you take for granted in urban communities.”

Such care can include everything from a prenatal support group for expectant mothers to meal delivery for housebound elderly.

The lack of social services bodes ill for rural hospitals as the “Hospital Re-admissions Reduction Rate” program created by the Affordable Care Act kicks in. The program punishes hospitals that have high readmission rates by reducing Medicare reimbursement, and Slabach said more than 2,000 hospitals are expected to take a hit in 2015.

“When a patient is discharged in a rural setting there is not a network of services for post-acute care,” Slabach said, “and often patients will come back to hospitals because there were no other services to go to.”

Medicare cuts during the last few years have also hit rural providers harder than urban counterparts, including the nearly-forgotten “sequestration cuts” negotiated during a budget impasse in 2011. The threat of indiscriminate cuts was designed to force the two sides to compromise. They didn’t, and Slabach notes the economies of scale inevitably mean equal cuts to rural and urban providers have unequal results.

Getting doctors to practice in rural areas is hard to begin with. Getting them to do so with competition rising and reimbursement dropping becomes a losing formula. “When you have to hire them at a higher rate than the reimbursement can sustain, those dollars have to come from someplace,” Slabach said. Urban systems with large patient counts have more financial options in swallowing the sequestration — or any other economic — pill.

One answer has been to increase the use of physician assistants and nurse practitioners. The two occupations require different training paths, but in the end they serve similar purposes: Taking on duties once the exclusive domain of doctors, including diagnoses and prescribing medication, leaving the doctor to enter the picture when his or her specialized training is most needed.

Roughly one third of PAs nationwide work in primary care, according to the American Academy of Physician Assistants, and 37 percent work in medically under-served counties. The American Association of Nurse Practitioners notes 49 percent practice in family medicine.

The demand has increased pay for the professions, but they remain lower than doctors: Federal data lists a national average of $94,350 for PAs and $95,070 for nurse practitioners. The theory is that medical care can be expanded while costs contained by switching to a team approach, embodied in “Patient-Centered Medical Homes” within neighborhoods.

“It uses the team-based approach for primary care, and we think rural communities are uniquely situated to take advantage of this notion,” Slabach said. “Our challenge as we move into health care delivery transformation is to figure out how we provide team-based care that actually improves health status and treats a disease before hospitalization becomes necessary.”

What happened to bring such big changes to small-town America? No single thing, Slabach believes.

“The culmination of all these factors is kind of like the straw that broke the camel’s back, except you don’t know which straw.”

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