Independent primary care doctors see banding together as one way to remain solvent and keep their autonomy

Valley Medical Group joined an IPA to help regain its
financial footing. (New England Public Media photo)

As the number of primary care doctors in the U.S. continues to decrease, the number of independent primary care practices has also fallen. A practice in the Connecticut River Valley, Valley Medical Group, has sought to maintain its independence while boosting its bottom line by joining with other independent primary physicians, reports Karen Brown of New England Public Media.

Founded during the 1990s, Valley Medical Group has become one of the "largest independent practices in western Massachusetts," Brown writes. But the practice's patient volume and focus on quality family medical care haven't shielded it from the financial pitfalls of the American insurance payment system, which rewards specialists and physicians who perform procedures over primary care.

Valley Medical Group owners found themselves stuck in insurance contracts that didn't pay well or accurately. "In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions," Brown writes. "Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent."

VMG doctors also wanted to avoid selling their practice to a hospital, which would likely take away some of their clinical autonomy. Instead, the group opted to join an Independent Physician Association. Brown explains, "Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies."

While not all IPAs are equal -- some are owned by hospitals or private equity funds -- most help level the financial playing field for smaller practices. According to Brown, when independent practices band together, they can accept insurance contracts that pay them a per-patient allotment rather than billing for each visit or procedure.

Chris Kryder, CEO of Arches Medical IPA in Cambridge, Massachusetts, told Brown, "If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system. . . And we create more income for the primary care providers, which is dreadfully needed."

Waves of American doctors and nurses leave their practices and head to Canada to avoid U.S. political climate

Often born and trained in the U.S., many nurses and doctors are leaving the U.S. for Canada.
(Graphic by Oona Zenda, KFF Health News)

At a time when Americans can least afford to lose medical professionals, many are leaving the U.S., citing the country's current political climate as their reason for leaving. In rural parts of the U.S., already facing a chronic shortage of medical care providers, the loss of any medical professionals makes accessing care more difficult.

"American nurses, doctors, and other health care workers moving to Canada, and specifically British Columbia, where more than 1,000 U.S.-trained nurses have been approved to work since April 2025," Brett Kelman of KFF Health News reports. 

Justin and Amy Miller from Wisconsin serve as one example. They are both nurses who were born in the U.S. and trained at American schools, but didn't want to stay in the U.S. because of policies and cuts by the Trump administration, Kelman explains. They moved their family of five to Canada, where they found new nursing jobs.

As the Trump administration systematically slashed "funding for public health, insurance, and medical research, many nurses have felt the draw of Canada’s progressive politics, friendly reputation, and universal health care system," Kelman reports.

For U.S.-trained nurses, Canada is rolling out the welcome wagon. "Ontario and British Columbia have streamlined the licensing process for American nurses since Trump returned to the White House," Kelman writes. British Columbia also launched a $5 million advertising campaign last year to recruit nurses from California, Oregon, and Washington state."

Doctors are leaving as well. "Michael, an emergency room doctor who was born, raised, and trained in the United States, packed up his family and got out," Kelman reports. KFF did not use his last name because he expressed concerns about reprisals if he returned to the U.S. 

Rural Canadians, who also struggle with accessing medical care, are also hoping to attract some American medical professionals. Doctors Manitoba, which "represents physicians in the rural province that struggles with one of Canada’s worst doctor shortages, launched a recruiting campaign after the election to capitalize on Trump and the rise of far-right politics in the U.S," Kelman writes. 

Opinion: Rural Americans rely on immigrant physicians for care, but new restrictions will leave them with fewer doctors

Rural hospitals have relied on foreign-born doctors
to provide care for decades. (MedPage Today photo)

Rural communities already struggle to staff their hospitals and clinics with physicians of all types, from specialists to family practitioners. The Trump administration's failure to make progress on immigration changes and the newly established $100,000 fee for each new H-1B visa application, which has no exemption for health care workers, will leave rural Americans with far fewer doctors to treat them, writes Manav Midha in his opinion for MedPage Today.

The difference in the number of physicians and the availability of specialists between urban and rural locations is stark. Midha writes, "There are approximately 263 specialists for every 100,000 people in urban areas compared to 30 for every 100,000 people in rural areas, and 46% of counties (and 86% of rural counties) have not a single cardiologist."

For decades, rural communities have relied on immigrant doctors for their care. Midha explains, "Foreign-born physicians are uniquely willing to serve rural communities even when few others move there. Immigration restrictions risk cutting off one of the last remaining lifelines for rural healthcare access."

Immigrant doctors who came to the U.S. in the 1980s and 1990s were able to obtain J-1 visas, which "allow for a path to permanent residency if a doctor works for at least 3 years in an area with underserved healthcare needs," Midha adds. They cared for patients in "rural Indiana, deep Appalachia, coastal Louisiana, and parts of Texas, hours from the closest city," where few American graduates wanted to live.

Congress could expand the Conrad 30 program to add some physicians with J-1 waivers who can treat in rural communities. "The bipartisan Conrad State 30 and Physician Access Reauthorization Act would have expanded (albeit slightly) the number of spots and extended the program. It was initially introduced in Congress in 2023 and again in 2025 but has seen little movement," Midha writes.

In the face of the current shortage, some states are developing their own approaches to help rural communities secure access to doctors. Midha writes, "At least 18 states, led by Tennessee, have enacted laws permitting internationally-trained physicians with appropriate experience to practice medicine without having to repeat medical residency."

Meanwhile, some rural communities may face a more severe shortage of physicians, and residents will have to travel longer distances for care. Expanding and developing paths for immigrant physicians "is not merely a moral imperative -- it is an economic one," Midha adds. "And it is one that can address one of the greatest challenges to equitable care."

Report: Rural primary care physician shortages will persist for at least another 12 years

Graph by Celli Horstman and Arnav Shah, State of Rural Primary Care in the United States, Commonwealth Fund

Rural residents will continue to grapple with a shortage of primary care doctors for at least another 12 years, according to a report issued last week by the nonprofit Commonwealth Fund.

Using federal health workforce data, researchers concluded that "rural areas will continue to have only about two-thirds of the primary care physicians they need," reports Nada Hassanein for the Wisconsin Examiner. Report authors noted that the persistent shortage of primary care doctors leaves million of rural residents "with fewer options for routine and preventive care."

The report's release came just days after the window closed for hospitals to apply for a share of the $50 billion federal Rural Health Transformation Program administered by the Centers for Medicare & Medicaid Services. Hassanein writes, "Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one."

Nearly all of the more than 40 million rural Americans live in areas with primary care physician shortages, according to the report. "Forty-five percent of rural counties had five or fewer primary care doctors in 2023," Hassanein adds. "Roughly 200 rural counties lacked one altogether."

The report found that doctor shortages in rural areas vary by region. Hassanein writes, "States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician."

Although rural areas will continue to lack enough primary care physicians, some of the gap will be filled by rural nurse practitioners. Hassanein adds, "Nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the report authors wrote."

New doctors are avoiding abortion ban states, new analysis shows. Restrictions may add to mutiple-care shortages.

Fewer new doctors are applying for residency in
abortion ban states. (Hush Naidoo Jade photo, Unsplash)

States with significant restrictions or bans on  abortions may be inadvertently discouraging graduating medical students from applying for residency in their state, which could exacerbate regional physician shortages. Julie Rovner and Rachana Pradhan of KFF Health News report, "According to new statistics from the Association of American Medical Colleges, for the second year in a row, students graduating from U.S. medical schools were less likely to apply this year for residency positions in states with abortion bans and other significant abortion restrictions."

State battles over abortion aren't limited to uncertainties for doctors and pregnant patients; the tensions have "also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers," Rovner and Pradhan write. "Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. . . . A preliminary review of a new analysis by the AAMC found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2%, compared with a 0.6% drop in states where abortion remains legal."

The AAMC's analysis shows that when new doctors start avoiding certain states, those states gain fewer doctors, which adds to regional physician shortages in many specialties. KFF Health News reports, "The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties."

The number of new doctors applying for OB-GYN and internal medicine residency slots in those states "dropped 6.7%, compared with a 0.4% increase in states where abortion remains legal," Rovner and Pradhan explain. "For internal medicine, the drop observed in abortion ban states was over five times as much as in states where abortion is legal."

Incoming president of American Medical Association says AMA cares about getting more doctors in rural areas

With new research showing rural Americans are more likely to die early from the five leading causes of death than their urban counterparts, "the American Medical Association is sounding the alarm," reports Melissa Patrick of Kentucky Health News.

AMA President-elect Bruce Scott (AMA photo)

"Rural health is America's health," Dr. Bruce Scott, the AMA president-elect, told reporters in a May 9 press conference in conjunction with the National Rural Health Association annual conference in New Orleans. "We need policymakers to understand that the American Medical Association is deeply concerned about the ever-widening health disparities between urban and rural communities, disparities that are at the root of why rural Americans suffered disproportionately high rates of heart disease, cancer, stroke, respiratory illness, diabetes, and unintentional injuries." 

Scott, who is board-certified in both otolaryngology and facial plastic surgery, will become AMA president in June. He pointed to several environmental, economic and social factors factors that put people who live in rural communities at a higher risk of death from these often preventable conditions. But the AMA's focus, he said, is on the health-care worker and the physician shortage and how this affects rural people's health. 

He added that these shortages are hitting rural areas the largest and are "creating health-care trends that are simply unacceptable. We need to reverse these trends for all individuals to live a long, healthy and active life." Scott said rural areas have about 30 physician specialists for every 100,000 residents, compared to 236 per 100,000 in urban communities, and he noted that more than 130 rural hospitals closed from 2010 to 2021, with many more on the verge of closing today. 

Also, he said that in 2023, 65% of rural communities had insufficient access to primary-care physicians, including pediatricians. And, he said there are not enough residency spots to train doctors in rural areas. "History has shown us that residents, 80% of the time, tend to wind up practicing within 80 miles of where they've done the residency," Scott said. "So residency location becomes very important. In addition, medical schools are receiving fewer and fewer applicants from individuals from rural areas."

Opinion: Why prescription drugs have little to do with the current illicit drug epidemic in the United States

The 1990s marked a time in U.S. medicine where doctors were taught to give narcotics.
(Graphic via Life and Limb blog, Edwin Leap)

Emergency physician Edwin Leap explains that U.S. doctors in training during the 1990s were instructed to treat pain with pills. He said a medical career taught him how misdirected those practices were. He adds that the nation's current addictions and overdoses aren't centered on prescription drugs anymore; they're all about super cheap, available and deadly fentanyl -- other opioids are almost an afterthought. An excerpted version of his commentary from MedPage Today is included below.

"When I was in my residency training, from 1990 to 1993. . . . We were told, over and over, that we should treat pain aggressively and should not be afraid to give narcotics to patients in pain. Who were we to judge someone's pain, after all? The young man who fell onto his knees at work, with a normal blood pressure and heart rate, looking about the room, might well categorize his pain a '10/10,' and we should honor that, respect it, and treat it."

Pain medicines such as hydrocodone and oxycodone (Oxycontin) were first marketed to doctors as a miracle for patients in pain. Given their addictive nature, it didn't take long for the drugs to take hold. Leap writes, "Much of our work as physicians was a balancing act between trying to show genuine compassion, mandated compassion, and appropriate skepticism about pain scales and the lies concocted in pursuit of drugs."

Given doctors' role as the prescription writers who "started" patients on the path to addiction, physicians are now forced to take additional narcotic treatment training. "I have to take a new 8-hour class on proper prescribing habits and pain management," Lead adds. "[But] nobody really argues with me about pain pills anymore. . . .We're only supposed to give a 3-day supply. We tell people that, and they shrug."

The likely reason a 3-day narcotic supply isn't a problem is the availability of fentanyl. "It's just so easy to get the stuff. It's inexpensive, and it's everywhere. It's in drug houses and gas station parking lots. It's in high schools and college campuses," Leap writes. "It's in prisons and homeless encampments. In fact, according to independent journalist Jonathan Choe, it can sometimes be found for 50 cents per dose in homeless camps."

U.S. physicians have little to do with fentanyl's street dominance. Leap writes, "The flood of illegal fentanyl precursors from China, which then become fentanyl and began flowing across the Southern border, continues unabated. . . . It's all rearranging the deck chairs of the Titanic until someone gets a handle on the crisis from a geopolitical standpoint. And yes, that means dealing with the border as well. . . . I'm not blaming one political side or another. I'm just saying that if it isn't taken seriously, then the deaths will keep skyrocketing."

This piece was originally published on Leap's blog, Life and Limb.

Rural areas desperately need more physicians, but even adding residency slots isn't a simple solution

Illustration by Shoshana Gordon, Axios

Rural areas don't have enough physicians because rural hospitals have not been able to add residency slots. Adding more slots may sound simple, but until the Covid-19 relief bill, slots, which are funded through Medicare, were capped. The relief bill added 1,000 residency slots and required 10% of those to be granted to rural hospitals, but few have applied. Maya Goldman of Axios Vitals reports, "Just seven of the 199 hospitals that have received federal dollars for new residency slots in initial funding rounds are in rural areas, federal health officials confirmed."

Because residents are more likely to stay where they completed their training, adding slots is considered the most reliable way for areas to "grow their own" doctors. However, hospitals must have the capacity to go through the slot application process and have the resources to train more physicians. Goldman explains, "A combination of limited infrastructure and staff to run residency programs, as well as a lack of awareness about the funding opportunity, has prevented more hospitals from applying, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association. . . ."

Part of the reason more funding has gone to more urban hospitals is because of a reclassification loophole. "The 2021 law requires that 10% of new Medicare-funded residency slots go to rural hospitals or hospitals that are 'treated as being located in a rural area," Goldman reports. "That wording is key: A 2016 court ruling allows urban hospitals meeting requirements to reclassify themselves as rural hospitals for certain financial purposes. Changing geographic classification can boost a hospital's Medicare payment and open them up to more residency funding."

The awards show how urban hospitals used reclassification to add slot funding. "In the first tranche of new residency slots awarded, about 6% went to geographically rural hospitals, while 42% went to geographically urban hospitals that reclassified as rural, according to NRHA data," Goldman adds. "NRHA wants the law changed so reclassified urban hospitals no longer qualify for the 10% rural residency slot allotment, said Cochran-McClain."

Fixing the rural physician shortage can begin with adding more federal and state funded residency slots

When residency slots increase, the number of
rural physicians can increase. (UICOMP photo)

By any measure, rural America is hurting for physicians, but more broadly, the nation doesn't have enough doctors. While U.S. medical schools have increased their enrollments, hospitals have yet to increase their number of residency slots, reports Brenna Miller of the Lown Institute, a nonpartisan health think tank.

"Medical school enrollment has been consistently growing, but funding for residency slots hasn't caught up. For every medical school graduate looking for a resident position, there have been between 0.8 and 0.85 slots available in recent years. This a problem as states require at least one year of hospital residency as a licensing requirement."

Without intervention, rural physicians will become increasingly scarce. "Rural areas face the brunt of this shortage as urban areas have higher densities of primary care physicians and specialists," Miller writes. "Patients in rural areas tend to be older, poorer, and sicker, especially with chronic conditions. With fewer doctors around, they have to travel further for both preventative and emergency care, putting them at greater risk for poor health outcomes and mortality."

If rural areas want more doctors in the future, there must be fundamental changes to residency funding and slot offerings. Miller explains, "The mismatch between medical school enrollment, residency slots, and the need for physicians in the workforce has resulted in a lose-lose situation where perfectly competent physicians face barriers to working while simultaneously, entire regions of the country are without sufficient access to physicians."

Some changes need to begin at the federal level. Residency slots are primarily funded by the Centers for Medicare & Medicaid Services, meaning that "they need action by the federal government for expansion. This also means that no significant action had been taken for over 20 years (Congress had actually capped the number of residents) until the Covid-19 relief bill was passed," Miller reports. "The  bill opened the door for 1,000 new residency slots, 10% of which must be in rural areas. Another similar bill has been introduced in Congress that would allocate funding for an additional 2,000 residency slots every year for seven years starting in 2025."

State funding is an additional option. Miller reports, "The majority of doctors stay in the states where they completed their residency. Both California and Texas – where the shortage is predicted to be the worst – approved multimillion-dollar expansions in funding, resulting in increased retention of physicians in underserved, local areas."

Today is Rural Health Day -- a focus on the many people and organizations addressing unique healthcare needs

Today is the 13th annual National Rural Health Day, an opportunity to bring an increased awareness of rural health-related issues and to recognize "the incredible efforts of rural healthcare providers, communities, organizations, State Offices of Rural Health, and other stakeholders dedicated to addressing the unique healthcare needs of rural America," according to the Power of Rural website. 

Since 2011, Rural Health Day has been set aside as a special focus for the country to observe. In his Presidential Proclamation, President Joe Biden said, "America’s rural communities are indispensable to who we are as a nation, where over 60 million people who live in rural America fuel our economy and help forge our future.  On National Rural Health Day, we recommit to investing in rural communities and delivering affordable, quality health care so that generations of rural Americans can thrive."

The day's celebration includes the unveiling of the "2023 Community of Stars," a recognition program designed to honor extraordinary efforts by individuals and organizations who exemplify the "Power of Rural." A navigational map includes 39 stars chosen by their respective State Office of Rural Health that all have an inspirational story and ideas to share. 

The Power of Rural website is chockablock full of free resources and ideas to support rural health communities including promotional kits and ways to celebrate. 

U.S. physician shortages expected to increase dramatically as older doctors retire or quit because of heavy workloads

Lack of doctors will mean a sicker population.
(Photo by J.C. Gellidon, Unsplash)

U.S. physician shortages are expected to increase substantially as aging doctors retire or extreme workloads push them out. "As the aging population's need for care grows, retirement and burnout are both driving swaths of health care workers out of the field, fueling a crisis that shows no signs of stopping,"  reports Alejandra O'Connell-Domenech of The Hill. "The country is expected to suffer a shortage of up to 124,000 physicians in the next 12 years, according to a 2019 report from the Association of American Medical Colleges." American Medical Association President Jesse Ehrenfeld told O'Connell-Domenech: "When people don't have access to routine primary care and preventative services [due to no physician access], they live sicker and die younger. . . . These are things that are only going to get worse as we put more pressure on the physician workforce." In many rural areas, the lack of doctors is already a stark reality.

If there aren't enough physicians, those who are working will have to work longer hours with sicker patients, which leads to burnout and more doctors deciding to retire or leave medicine altogether. "A 2022 study found that nearly 63 percent of physicians experienced symptoms of burnout by the end of 2021, representing a 19 percent increase from 2017," O'Connell-Domenech reports. "Another 2022 study determined that one out of five doctors said they were likely to leave their current practice within two years, citing burnout and workload as two major reasons."

The numbers explain another reason for the shortage. "There are about 55.8 million people aged 65 and older in the United States, according to Census Bureau," O'Connell-Domenech explains. "Their numbers are growing and will continue to do so. . . . Almost half of working physicians in the United States are 55 and older, according to the AMA. Thirty-five percent of the physician workforce will reach retirement age within the next five years."

Possible solutions include lessening student loan debt and increasing the number of physicians allowed to train. "The Resident Physician Shortage Reduction Act of 2023 could help by lifting the cap on residency programs," O'Connell-Domenech adds. "The bill. . . would expand the number of Medicare-supported medical residency positions by 14,000 over seven years. . . . Another piece of legislation that could help stem the shortage is the Conrad State 30 and Physician Access Reauthorization Act, according to Ehrenfeld. Under the bill, international doctors could stay in the U.S. after their residency programs as long as they committed to practicing medicine in parts of the country with physician shortages. . . . Easing medical student debt could also potentially increase the amount of doctors willing to work in underserved areas, Ehrenfeld said."

New, lifesaving antibiotics don't make it to patients. Researchers say a different business model is needed.

Antibiotics have played a major role in helping to extend the average life expectancy across the world by fighting infectious diseases. But the companies that develop and produce antibiotics are struggling to make profits on the antibiotics they produce, causing severe problems in efforts to fight newer disease strains and keep patients alive. "The Treasure Called Antibiotics" explains the drugs' impact: "Prior to the beginning of the 20th Century, infectious diseases accounted for high morbidity and mortality worldwide. The average life expectancy at birth was 47 years. . . . The antibiotic era revolutionized the treatment of infectious diseases worldwide, although with much success in developed countries. . . . In the U.S., the average life expectancy at birth rose to 78.8 years."

Stock prices slide on new antibiotic companies.
(Graph by Josh Ulick,WSJ, from Dow Jones data)

But those once powerful drugs are no longer always effective. Antibiotic-resistant bacteria require new antibiotics; however, the companies that create new strains don't make money, reports Dominique Mosbergen of The Wall Street Journal. "The push for antibiotics to fight fast-evolving superbugs is snagging on a broken business model. Six startups have won Food and Drug Administration approval for new antibiotics since 2017. All have filed for bankruptcy, been acquired or are shutting down. About 80% of the 300 scientists who worked at the companies have abandoned antibiotic development, according to Kevin Outterson, executive director of CARB-X, a government-funded group promoting research in the field."


The crux of the problem is the current model for drug company profits, "which counts on companies selling enough of a new treatment or charging a high enough price to reward investors and make a profit — isn't working for antibiotics," Mosbergen explains. "New antibiotics are meant to be used rarely and briefly to defeat the most pernicious infections so bacteria don't develop resistance to them too quickly. Companies have priced them at 100 times as much as the generic antibiotics doctors have prescribed for decades, costing a few dollars per dose. Most have sold poorly."

Infectious disease specialist Dr. John. H. Rex told Mosbergen, "Antibiotics are like fire extinguishers. You really want these drugs available, but you mostly don't want to use them. That's the paradox." Mosbergen reports, "New antibiotics should get support similar to treatments for rare diseases, said Ryan Cirz, a co-founder of Achaogen, which filed for bankruptcy in 2019 less than a year after the FDA approved its drug Zemdri for complicated urinary tract infections. . . . The Orphan Drug Act of 1983 provides subsidies, tax breaks and additional years of market exclusivity to drugmakers that develop treatments for diseases affecting fewer than 200,000 people in the U.S."

"About 13,000 people in the U.S. each year develop a severe type of drug-resistant infection that Achaogen's drug Zemdri was developed to defeat," Mosenberg reports. "Up to half of people hospitalized with such infections die. They are among the more than 35,000 people in the U.S. who die annually from drug-resistant bacterial or fungal infections, a toll that has risen in recent years."

In 2019, the United Kingdom started a "subscription-style model to pay drugmakers for new antibiotics based on their potential public-health value," Mosbergen adds. "U.S. lawmakers have considered similar legislation. Bipartisan bills reintroduced in the House and Senate in April committed $6 billion to purchase new antibiotics to treat drug-resistant infections. They haven't received a vote." Dr. David Hyun, director of the Antibiotic Resistance Project at Pew Charitable Trusts, told Mosbergen: "It sounds like the intent is to save companies, but we're really talking about trying to fix the antibiotic pipeline itself."

Rural doctors have to do it all, from snake bites to meat-stuck-in-throat; video looks at challenges of rural medicine

Amid a national physician shortage, getting a doctor to practice in a rural place has never been more challenging, and as rural hospitals close, the lack of providers is predicted to worsen, reports Hyacinth Empinado of STAT. "In 2023, 65% of rural areas had a shortage of primary care physicians, according to a report published by the Health Resources and Services Administration. More than 15% of Americans — about 46 million — live in rural areas, but only 10% of doctors practice in these communities, many of whom are primary care and family physicians."

Meeting the medical needs of 46 million Americans is a big undertaking. And because there are so few doctors, each has to work harder to tackle vastly different medical illnesses and accidents with limited resources. In this short documentary, STAT explores why the shortage exists and "shows what life is like for a doctor in Kansas who wears many hats and a physician in Illinois pondering retirement."

As rural communities lose physicians, a creative "patchwork" of care can emerge

An OnMed health kiosk uses high tech, remote care.
(Photo by Arielle Zionts, KFF Health News)

Rural patients are more likely to face medical provider shortages, and these communities have to find new ways to provide care. In LaFayette, Alabama, "Terry Vester and her husband, Al, are the only primary care doctors in the town of 2,700 residents, surrounded by farms and other small communities," reports Arielle Zionts of KFF Health News. "The Vesters are in their late 60s and would like to retire soon. Terry Vester wants to spend more time with her grandson and aging parents. But she can't imagine abandoning her patients, some of whom she has cared for since they were born."

Attracting new physicians is challenging for LaFayette, which is not a wealthy town with the amenities many doctors seek. Residents have a median income of $39,077, compared to the state's $59,910. "Black residents — who make up 70% of the population — are much more likely to live in poverty than white residents," Zionts writes. "The Vesters have worked in LaFayette since the early 1980s and saw the local hospital close in 1988. The nearest emergency room is now in another town 20 minutes away along a rolling road. So are the nearest urgent care clinic and pediatrician's office."

With those barriers in mind, town residents who need medical advice have turned to "the city fire department, staffed with full-time firefighters and emergency medics," Zionts reports. "People from LaFayette regularly walk or drive themselves to the fire station to ask for help, said Fire Chief Jim Doody. He added that the station has a makeshift exam area within its small entryway, containing a bench, defibrillator machine, and cabinet filled with medical supplies. . . .This de facto walk-in clinic option isn't available in most other rural areas, where emergency medical services are often run by volunteers who aren't posted at a station all day, Doody said. But he's noticed fewer LaFayette residents relying on the fire department since a new telehealth service arrived in town."

OnMed telehealth kiosk service opened in LaFayette to meet basic medical needs. Patients can head into a computerized booth, press a button and see "a nurse practitioner appear on a large vertical video screen positioned at eye level," Zionts explains. "OnMed patients use an automated blood pressure cuff and other devices to collect their vital signs, and the data is sent to the provider treating them from a distance. Patients can also hold a stethoscope to their chest to transmit the sounds of their heart and lungs. A special camera captures internal temperatures, which can be used to diagnose infections. A hand-held camera lets providers examine problems such as rashes, irritated eyes, and swollen throats. In some states, the stations can dispense medications."

While Vester spoke positively about OnMed services, she feels "It's still important to have doctors in town," Zionts reports. "Vester plans to reach out to Alabama medical schools to let them know she's looking for doctors to take over for her and her husband."

Finding more physicians for rural America: Appalachian doctor looks for students with a 'passion for healing'

Anya Cope, D.O., believes career options ought to be offered to rural
students before high school. (Courtesy photo via The Yonder)

What's the best way to attract physicians to practice in rural America? Find ways to plant the idea in rural youth and then nurture them. That's what Anya Cope, a doctor of osteopathy from Dryden, Va. (pop. 878), does at Lincoln Memorial University in Harrogate, Tenn., reports Taylor Sisk of The Daily Yonder. "Cope is an associate dean of clinical affairs and an assistant professor of internal medicine at LMU's DeBusk College of Osteopathic Medicine. . . . Described by a colleague as 'a fixer; a doer,'[Cope is] a living example; through her instruction, she demonstrates how to excel in a demanding field when the odds appear to be against you."

Cope's father was a coal miner, and her mother a power-company employee, Sisk writes: "She graduated from high school in 2000. It was, she says, a 'weird time' in the mountains of rural Southwest Virginia: The over-prescription of opioids had taken deep root across generations. . . . She considers her education. . . to have been sufficient; she was prepared to be successful at college. But the family had no real knowledge of or resources for board prep courses. Her Medical College Admission Test score, she says, wouldn't get her into med school today. . . . Cope believes schools too often put too much emphasis on standardized testing. . . . She urges administrators to look beyond that number. It tells you nothing about a potential student's determination, their passion for healing."

Cope spends time doing outreach in the region's undergraduate colleges, Sisk writes, but "the outreach, she believes, must start early." Cope told her, "Too many kids in this region think their only options are coal mining, teaching, and nursing – all of which are commendable careers – or illegal drug dealing. You can't be it if you don't see it. We need to show them there are other options – that there are people from here who are succeeding in all kinds of fields. And it has to be before high school." Sisk reports, "Toward that end, the college is setting up camps for pre-K through eighth-grade students that will offer opportunities to study Science, Technology, Engineering and Math topics, explore career choices, and gain skills necessary to be successful in those fields."

Cope's other role includes forging connections with hospital staffs, high schoolers and undergraduate students. Cope told Sisk, "My job is all about relationships. . . . [she is looking for] someone who is adaptable. Someone who, despite facing adversity, has been able to keep going. Someone who has shown a commitment to medicine and a passion for medicine. . . . Of course, we want someone who is drawn to Appalachia and to rural medicine. But I think that even those who have not had the experience of rural medicine, once they get here, we can convince them."

Research supports her approach: "A 2021 Journal of Graduate Medical Education study found that 'Physicians often practice within 100 miles of where they completed residency' and 'Training residents where they are needed in practice is one promising strategy to increase the supply of rural physicians," Siskk reports. "Personally, she's driven to underscore for those from rural communities that 'you can be just as good as any others – and maybe better because of the resistance you've had to fight against. It's like cross-training: fighting against resistance makes you stronger.'"

Different initials, but education and care are the same; osteopaths, or D.O.s, are filling a rural void with 'their thing'

Kevin De Regnier, an osteopathic physician in Winterset, Iowa,
examines Alice Collins. (KFF Health News photo by Tony Leys)

In rural America, you may be more likely to be treated by a "Doctor of Osteopathic Medicine," or D.O., instead of an M.D., but their schooling and boarding tests are alike," reports Tony Leys of KFF Health News. "Osteopathic physicians go to separate medical schools from medical doctors. . . . Their courses include lessons on how to physically manipulate the body to ease discomfort. But their training is otherwise comparable, leaders in both wings of the profession say. . . . Both types of doctors are licensed to practice the full range of medicine, and many patients would find little difference between them aside from the initials listed after their names."

Although currently not as common, D.O. numbers are increasing, especially in rural areas, partly because new osteopathic medical schools have located in places like Pikeville, Ky., and Harrogate, Tenn. "School leaders say their locations and teaching methods help explain why many graduates wind up filling primary care jobs in smaller towns," Leys reports. "U.S. News & World Report ranks medical schools based on the percentage of graduates working in rural areas. Osteopathic schools hold three of the top four spots on the 2023 edition of that list."

"The very nature of osteopathic training emphasizes primary care. That's kind of their thing," Michael Dill, director of workforce studies at the Association of American Medical Colleges, told Leys.

Leys reports, "Data from the University of Iowa shows osteopathic physicians have been filling rural roles previously filled by medical doctors. The university's Office of Statewide Clinical Education Programs tracks the state's health care workforce, and its staff analyzed the data for KFF Health News. The analysis found that, from 2008 to 2022, the number of D.O.s based outside those urban areas [previously filled by M.D.s] increased by 29%. Because of the shift, D.O.s now make up more than a third of rural Iowa physicians, and that proportion is expected to grow."

From 1990 to 2022, "the number of osteopathic doctors more than quadrupled, from fewer than 25,000 to over 110,000, according to the Federation of State Medical Boards. Over half of D.O.s work in primary care, which includes family medicine, internal medicine, and pediatrics. By contrast, more than two-thirds of M.D.s work in other medical specialties," Leys reports.

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."

First tribally affiliated medical school in the U.S. creates a life-changing partnership for under-served communities

Medical students stand outside the College of Osteopathic Medicine
at the Cherokee Nation. (Photo by Oklahoma State University)

Nearly a decade in the making, Oklahoma State University and the Cherokee Nation have opened the country’s first tribally affiliated medical school. "The 84,000 square foot facility in Tahlequah officially opened its doors in early 2021, following half a year of virtual classes for the college’s first cohort of students," reports Gretel Kauffman for Rural Health Information Hub. "The facility itself was paid for by the Cherokee Nation, while OSU staffed the college and provided the educational technology. The school had been nearly a decade in the making, with conversations between OSU and the Cherokee Nation starting in 2012."

Amid a national physician shortage, "Oklahoma has one of the most severe doctor shortages in the nation, ranking 48th for number of active physicians per capita in 2022," Kauffman writes, "In rural parts of the state, it isn’t uncommon for a county to have one primary care provider, said Natasha Bray, dean of the College of Osteopathic Medicine at the Cherokee Nation. While telehealth has proven to be a helpful tool for some communities, it isn’t a reliable alternative for patients who lack access to high-speed internet, Bray said — and isn’t a direct substitute for in-person care."

Bray told Kauffman, "All people deserve a health-care provider who’s going to be able to be their partner and be present with them. The development of that relationship is so critical to building trust and improving care in our rural communities." Physicians who are "homegrown" are more likely to embrace rural life. Bray said, "They understand all that is amazing about living in a rural community, and they understand what the challenges are. They’re able to successfully build a practice and care for their community because they have an understanding of what’s involved in it.”

Only one in five of the students are Native American, Kauffman reports: "Roughly half hail from rural Oklahoma. Those percentages are in stark contrast to other medical schools across the U.S., where less than 5 percent of students come from rural backgrounds; that percentage drops to less than 0.5 percent for rural students from under-represented racial or ethnic minority groups. Meanwhile, American Indian and Alaska Native students account for less than 1 percent of medical students nationwide."

Bray explained the spirit of the school to Kaufmann: “When we look at success in medical education, one of the important components for avoiding burnout is your sense of belonging within a community. Having people who share your mission, your values, and your goals is extremely important — and that translates not only to individual well-being, but also to academic success.” Cassie McCoy, a second-year student, told Kauffman, “There is just this natural sense of family, and I think OSU does a really good job of promoting that and creating a culture where we can ask each other for help. You just feel that community, that sense of pride and belonging.”

Officials, advocates push more rural health-care providers to prescribe Suboxone (buprenorphine) for drug addiction

Bonnie Purk, left, meets with nurse practitioner Andrea Storjohann at the
Primary Health Care clinic in Marshalltown, Iowa. (Photo by Tony Leys, KHN)

More than 150 people a day die of overdoses related to synthetic opioids such as fentanyl, and disproportionate share of the dead will be from rural areas, according to the Centers for Disease Control and Prevention. Given the magnitude of loss and the prevalence of fentanyl in most illicit drugs, more rural medical providers are prescribing buprenorphine for patients struggling to end their addictions, and treatment advocates are pushing them to do more, Tony Leys reports for Kaiser Health News: "The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years. Treatment advocates hope to see that trend continue."

Buprenorphine, best known by the brand Suboxone, "does not cause the same kind of high as other opioid drugs do, but it can prevent the debilitating withdrawal effects experienced with those drugs," Leys notes. "Without that help, many people relapse into risky drug use.

Such “maintenance treatment” has been done mainly with methadone, but it "is tightly regulated, due to concerns that it can be abused," Leys explains. "Only specialized clinics offer methadone maintenance treatment, and most of them are in cities. Many patients starting methadone treatment are required to travel daily to the clinics, where staffers watch them swallow their medicine."

Federal approval of Suboxone in 2002 helped smaller towns, but physicians have been slow to get certified to prescribe it. Recently, "Federal regulators have made it easier for doctors, nurse practitioners, and physician assistants to become certified," and "have encouraged more front-line health care professionals to prescribe Suboxone and other medications containing buprenorphine." Congress could relax the rules even further in must-pass legislation next week.

The spread of fentanyl has complicated the effort to expand the treatment. Patients "can suffer severe withdrawal symptoms when they begin taking buprenorphine, so health practitioners must be careful when starting the treatment," Leys reports. "In Iowa, officials designated $3.8 million from the state’s initial share of opioid lawsuit settlement money for a University of Iowa program that helps health care providers understand how to use the medications.

Andrea Storjohann, a nurse practitioner in Marshalltown, Iowa, a town of 27,000, works in a repurposed grocery building, with "no signs designating it as a place for people to seek treatment for drug addiction, which is how Storjohann wants it," Leys writes. Until recently, “We were kind of a unicorn in this part of the state, but that is changing,” Storjohann told Leys.

Still, treatment may be hard to find. The public database of providers certified to prescribe buprenorphine treatment "lists only providers who agree to include their names," Leys reports. "Many do not do so. In Iowa, only about a third of providers with the certification have agreed to be listed on the public registry, according to the Iowa Department of Health and Human Services."

Federally qualified health centers, rurally important, are insulated from lawsuits; here's a list of what taxpayers paid

Screenshot of top of KHN list, adapted by The Rural Blog; the whole list, which is searchable by state, is here.

Federally qualified health centers, or FQHCs, are very important parts of the health-care delivery system for the poor in rural areas. They must not turn anyone away, and charge patients based on their income. In return, they get an annual grant and higher reimbursements from Medicaid and Medicare — and, for the vast majority of clinics, financial immunity from malpractice lawsuits.

The centers can still be sued for malpractice, but the federal government pays the settlements or judgments. That little-known aspect of FQHCs is examined in a story by Phil Galweitz and Bram Sable-Smith of Kaiser Health News, along with a list of the 485 payouts made on the centers' behalf from 2018 through 2021, totaling $410 million. "Nearly half of the centers’ patients are covered by Medicaid, and 20 percent are uninsured," Galewitz and Sable-Smith report.

To win congressional protection in the 1990s, the clinics "argued their revenues were limited and malpractice insurance would divert money that could better be used for patient care," KHN reports. About 86% of the 1,375 clinics have protection; to get it, a clinic "must have quality- improvement and risk-management programs and must show regulators that they’ve reviewed the professional credentials, malpractice claims, and license status of their physicians and other clinicians. . . . Ben Money, a senior vice president for the National Association of Community Health Centers, said the process improves care and directs scarce operating dollars toward the needs of patients, versus costly malpractice coverage." Attorney fees are limited to 25 percent of awards.

"A patient alleging medical malpractice by a health center must first submit claims to the U.S. Department of Health and Human Services for review. The government can make a settlement offer or deny the claim. If the claim is denied or not settled, or a six-month review period expires, the patient may sue in federal court under the Federal Tort Claims Act," KHN reports.

"Malpractice lawsuits are a risk for all health-care providers and are just one barometer of quality of care. The settlements and court judgments against the health centers don’t measure the clinics’ overall performance. Even lawyers who have sued on behalf of health center patients acknowledge the importance of the facilities. Rhode Island plaintiff attorney Amato DeLuca said that the health centers serve a vital role in the health industry and that he had found “a lot of really wonderful, extraordinarily capable people that do a really good job” at the centers. Yet everyone must be held accountable for mistakes, DeLuca said."