By Rose Hoban
For years, rural hospitals, clinics and towns have been struggling to recruit physicians, and now, that lack of doctors in some of North Carolina’s more far-flung burgs is showing.
“On almost any measures when you look at rural health, rural areas are doing poorer,” health economist Mark Holmes told lawmakers on the legislative Committee on Access to Rural Healthcare in North Carolina in January.
Holmes, who leads the Sheps Center for Health Services Research at UNC Chapel Hill, noted that rates of diabetes, opioid use and overdose deaths, heart disease, and other problems are higher in rural areas. And rural people in North Carolina die younger than people in urban areas. For the past three years, life expectancy in rural areas has actually decreased.
Recent presentations to lawmakers at the General Assembly have highlighted the holes in the state’s health care provider networks. Holmes told lawmakers that 20 counties have relatively few primary care doctors, and three have none.
“In Harnett County, there are two practicing OB-GYNs. We just received notice that one of them is going to retire in October,” Michael Nagowski, the CEO of the Cape Fear Valley Health System, said during a presentation this week to members of a different committee, which was formed to look at issues of graduate medical education.
Nagowski detailed the needs of just his region: 145 additional family practice doctors, 23 pediatricians, 15 general surgeons, 42 psychiatrists and 33 more OB-GYNs. He described how the emergency department at his hospital in Fayetteville gets more than 130,000 patient visits a year, making it one of the 20 busiest EDs in the country, largely because there are few other places to receive care.
“For those of us who have boots on the ground in that region, what we see is the development of a doctor desert,” he said.
Wanted: The basics
Holmes pointed out that North Carolina has plenty of doctors, but “they tend to cluster in affluent urban areas.”
For example, last week, his co-worker Erin Fraher explained to lawmakers the importance of general surgeons, who are lacking in 26 counties.
“General surgery and surgery procedures can keep a rural county hospital alive in terms of financial viability,” she said. “Often in many rural counties you have internists who can’t do scoping or family physicians who can’t do C-sections and you need that backup. You’ve got to have that general surgery backup.”
She also noted the rural physician workforce is aging, with the average age for non-metropolitan physicians being 52.6 years, compared to urban doctors, who are 48.4 years old on average.
[sponsor]“If you only have a few physicians and they’re going to retire, that puts your county at risk pretty quickly for gaps in access to care,” she said.
In recent years, North Carolina has put up to $30 million every year in Medicaid supplemental payments towards paying medical “residents,” those doctors who are newly graduated from medical school and receiving hands-on training, usually in hospitals. The federal government kicks in an additional $60 million annually to match the state Medicaid dollars.
Some of the money goes to training people in new residency settings, such as clinics run by the Mountain Area Health Education Center in Asheville or the Southeast AHEC, which places people in rural practices.
But the vast majority of residents train in hospitals. And although the state is in desperate need of those generalists a minority of the state’s residents decide to become family docs or OB-GYNs.
Fraher and her colleagues at the Sheps Center studied four years’ worth of medical residents, from 2008-2011 and tracked their specialties and where they were practicing five years later. Their research showed that out of 2,009 physicians who graduated from North Carolina-based residency programs, fewer than half stayed in the state, and only 65 of them (3 percent) were practicing in rural areas.
“This is a legislature that wants to know the return on investment, and the data show it’s really low,” Fraher said.
Not just money
Lawmakers focused on what incentives could draw new doctors to rural practices, and they heard multiple presentations on loan repayment programs meant to induce people to move to rural areas.
“We know that debt makes a difference,” AHEC director Warren Newton told lawmakers in February. “If people have high levels of debt, they’re much more likely to go (to rural areas), if we give loan repayment that can help.”
Maggie Sauer, who heads the state’s Office of Rural Health, said she has staff who go out into communities to meet medical students and work with residency programs of all types to get people into rural residencies. And her office also administers a plethora of state and federal loan repayment programs and helps place foreign medical graduates in about 30 residency slots per year around the state.
“The folks who are here and show up because they want to be there,” Sauer said. “I will tell you there’s no dedicated group of folks. You will have some who are there because they want the loan repayment and they may choose to leave, but a lot of times… it tends to be something around the community that causes them to leave.”
She – and others – talked about the need for decent schools for doctors to send their children to, places for their spouses to work and social and recreational opportunities in the small towns that are desperate for doctors.
Other presenters described the challenges of professional isolation for newly minted physicians who need a community of other practitioners to bounce ideas and issues off of. Without those supports, the doctors are likely to move on.
“The places where communities are connected to this issue have a much better rate of retention,” Sauer said.
That can include rolling out the red carpet, something Nagowski is used to doing.
“We fly them in, we meet them at the airport, we have a sign welcoming them and their spouse at the airport, we have dedicated drivers who take them to the hotels that we’ve selected for them to go to,” he said. “When they come into our facility, there’s a sign welcoming them and their spouse. They’re very well coordinated visits.
“And we’ve had some success, but it’s limited at best.”
In the end, what works best is to recruit students who actually grew up in rural areas, preferably in North Carolina, and who have family ties to draw them back home. And lacking that, training people closer to rural areas, at what Newton called “attractive practices,” can keep them there.
“We know that if you do training in community settings in the medium sized hospitals, you’re much more likely to get docs in the right place,” Newton said.
He, Fraher, Holmes and others all noted that the solution to the state’s rural health needs would not be an easy – or quick – fix.
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Are you considering advanced practice providers? I have practiced as a P.A. for sixteen years, but primarily in dermatology.
FYI: There’s been very little discussion of advanced practice providers during this committee process. It’s been very physician-focused.