Doctor shortages in rural America reduce access to care, and lack of rural residency programs adds to the problem

Dr. Bridget Martinez visits a patient in Elko, Nevada.
(Photo by Jazmin Orozco Rodriguez, KFF Health News)

One of the best ways to encourage doctors to practice in rural areas is to get them to do their residencies at rural hospitals or clinics, but such residency programs are in short supply and some are closing, Jazmin Orozco Rodriguez reports for KFF Health News (formerly Kaiser Health News; KFF stands for Kaiser Family Foundation, which wants to seperate the news service from Kaiser Permanente, a health insurer).

In Elko, Nevada, a young resident physician, Bridget Martinez, has to leave June 30 because the program in the city of about 20,000 between Reno and Salt Lake City is ending for a variety of reasons, including financial struggles, lack of a united support system, and a historical lack of health-care investment in the area, Rodriguez reports.

That will reduce the number of doctors at the clinic to three from four, making it more difficult for residents to get primary care -- shortages of which affect more than 100 million people in the U.S., a number that has nearly doubled since 2014, Rodriguez reports, noting that rural health-care provider shortages only got worse during the pandemic.

"Researchers say the relative lack of providers is one reason people living in rural areas experience worse health outcomes than people who live in urban areas," Rodriguez writes. "Experts say expanding the number of medical residency training programs in rural areas is key to filling gaps in care because many doctors — including more than half of family medicine physicians — settle within 100 miles of where they train. And while the number of training programs has increased in rural areas during the past few years, research shows 98% of residencies nationwide are in urban areas."

Members of Congress have introduced bills to address the health care provider shortage, but to no avail. Meanwhile,  rural medical training programs need more state and federal investment to grow and remain sustainable, Dr. Emily Hawes, associate professor at the University of North Carolina-Chapel Hill School of Medicine, told Rodriguez. 

Hawes said there has been some progress, including a law that created more flexibility in funding and accreditation for rural hospitals wanting establish residency programs. Since 2019, the program "has given more than $43 million to 58 organizations in 32 states to launch rural medical residency programs, reports Rodriguez. 

But it’s still not enough, Hawes said. She said one of the main challenges is that the Centers for Medicare & Medicaid Services don't reimburse rural hospitals for medical residency programs at the same rate they do urban hospitals, despite facing similar or higher costs. Hawes told Rodriguez that  rural medical training programs don’t have to end in struggle and that "part of her job with the Rural Residency Planning and Development Program is to ensure faculty, residents, and hospital leaders have the resources, support, and knowledge they need to sustain their programs."

Opinion: Senator and med-school professor say allowing physicians to own hospitals again would help rural areas

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"What if lawyers weren’t allowed to own law firms or chefs weren’t allowed to own restaurants? Sounds absurd, but it’s a reality for one profession: doctors," opine U.S. Sen. James Lankford of Oklahoma and Brian J. Miller, an assistant professor at Johns Hopkins University, for The Wall Street Journal. "A tiny paragraph in the enormous Affordable Care Act prohibits physicians from building or owning hospitals. Any existing physician-owned hospital built before 2010 is prohibited from growing beyond the size it was when the bill passed. This law limits competition, defies common sense and is likely contributing to higher prices for Medicare and reduced access to treatment for millions of Americans."

Noting projections that the trust fund for Medicare’s hospital financing will be unable to pay full benefits in six years, and arguing that costs have risen 5.9% a year despite "government price controls," they say "Political leaders overlook the most obvious way to increase health-care options: letting doctor-owned and -managed facilities grow as they did before 2010."

Physician-owned hospitals could help rural areas, they argue that the Centers for Medicare & Medicaid Services "sees the value in physician ownership, particularly in high-need areas, as shown through its recent proposed rule on Conditions of Participation for Rural Emergency Hospitals. But the clause relaxing ownership restrictions wasn’t finalized, owing to vague, unsubstantiated staff unease regarding 'program or patient concerns.' If it had been, it would have permitted physician ownership of new rural emergency hospitals, which would benefit rural America. . . .These small hospitals struggle under today’s healthcare complexity and costs. . . . Allowing doctors to own and run hospitals would give rural communities another option to maintain local high-quality care and encourage local investment in existing hospitals." 

What do hospitals have to say about it? They write, "The hospital industry has long argued that physicians cherry-picked healthy patients and preferred those with private insurance as a rationale for supporting the ban on physician-owned hospitals. . . . Specialty physician-owned hospitals focused on cardiology and cardiac surgery were found to deliver higher-quality care than nonprofit hospitals, with lower rates of hospital readmission or mortality for high-risk surgery. Physician-owned specialty hospitals for orthopedic procedures, such as hip and knee replacements, offered lower costs and higher quality than nonprofit counterparts."

They offer a possible solution: "Existing laws prohibit new physician-owned hospitals from billing Medicare. One of us (Lankford) is introducing the Patient Access to Higher Quality Health Care Act to solve this problem. . . . The federal government doesn’t prohibit plumbers from owning plumbing companies, radio hosts from owning radio stations or farmers from owning farmers markets. It’s time to reopen the free market in health care and let the power of competition do its work."