The rural route

Bisbee, Ariz., is a former mining town of about 6,700 people, some 12 miles north of the Mexican border and nearly two hours southeast of Tucson. Built in the hills of the red-rock Mule Mountains, it's now known as an enclave of sorts for artists and hippies and was even a one-time runner-up as the “quirkiest” town in America. But while it has attracted galleries and coffeehouses, it has struggled to find healthcare providers.

“We're having a harder time this year than last year,” says Jim Dickson, CEO of 14-bed Copper Queen Community Hospital in Bisbee. “I think there's a bidding war going on for physicians.”

The heightened demand means Copper Queen's starting salary for primary-care doctors has increased to $225,000, up from first $150,000, then $175,000, and it may need to rise to $250,000 to keep up with local competitors, Dickson says. But because the hospital can't bill enough to justify lucrative pay packages, it relies on assistance from National Health Service Corps, an HHS agency that provides incentives including loan repayment for doctors willing to practice in underserved regions.

It also sponsors foreign doctors with J1 visas, though Dickson notes that they tend to have higher turnover rates.

The investments are critical to Copper Queen's survival. Less than a decade ago, “We had no private doctors left in town,” says Dickson, who since 2007 has grown the medical practice from four physicians to 11, as well as four mid-level providers. “The hospital would have imploded without these doctors.”

Copper Queen's challenges are not unique. The doctor shortage in rural America is widespread and projected to get worse. Medicaid expansion and insurance exchanges are

expected to provide coverage to about 30 million Americans—but many in rural and underserved communities may have to drive hundreds of miles for care if it isn't available locally.

A 2009 policy brief from the federal Office of Rural Health Policy highlighted that 77% of rural counties are facing a shortage of primary-care providers, and 8% don't even have a single primary-care physician.

“It's pervasive,” says Brock Slabach, senior vice president for member services at the National Rural Health Association. “There's just a significant need for workforce.”

The number of general surgeons practicing in rural communities decreased 21% between 1981 and 2005, according to a study from the department of family medicine at the University of Washington. In addition, more than half (52%) of surgeons were approaching retirement age, between 50 and 62 years old.

The Patient Protection and Affordable Care Act does try to address those issues by providing more resources to medical schools and the National Health Service Corps to help with training and recruitment.

Some areas of the country—those close to mountains or beaches—may be able to draw on their idyllic surroundings to attract physicians, especially those looking for a quieter lifestyle. Others, not so much.

Neil MacKinnon, director of the Center for Rural Health at the University of Arizona, recalls how not once, but twice, physicians landing in the desert town of Yuma—which has a population of 93,000 and average July temperatures of 106 degrees—refused to even get off the plane.

Recruiters now fly in physicians at night.

“Some places in this country have unique challenges,” MacKinnon says. “We try to look at what is the best fit. The real key is knowing your state and the attributes of the communities.”

In Arizona, smaller towns and isolated areas average only 70 physicians per 100,000 residents, compared with 270 per 100,000 in urban areas, and 250 per 100,000 statewide. “That's certainly a large, large gap,” MacKinnon says. “In some cases, it does mean scaling back services.”

Many medical centers are staffing their clinics with mid-level providers such as nurse practitioners and physician assistants, but while they can relieve some of the burden, state rules vary when it comes to how much physician oversight is still required.

With the need so dire, new physicians are being recruited as early as their second year of residency, often receiving dozens of glossy brochures advertising a town's nature trails, festivals and short flights to major metropolitan areas. Starting salaries can seem tantalizingly high compared with specialty averages.

While Slabach concedes that incomes can reach into the top quartile for a given specialty, he notes that those high salaries often come with significantly more work. “They're very, very busy,” he says about rural physicians. In a shortage situation, “you have higher volumes typically.”

But he adds that rural facilities may also benefit from the CMS' reimbursement assistance for sole community or critical-access hospitals.

A 2012 survey from Medscape, a medical information provider, found that physicians in the North Central part of the U.S.—Iowa, Kansas, Missouri, Nebraska and North and South Dakota—earned the highest average salaries in the country.

In contrast, physicians in the more-densely populated Northeast—from Maine to New York—earned the lowest. “Sometimes it does end up being a bit of a bidding war,” MacKinnon says. “It comes down to supply and demand.”

The daunting proposition of being a sole practitioner in an underserved area is compounded by changing expectations from medical school graduates, who no longer want to be tethered to their pagers around the clock. Work-life balance tends to be especially top-of-mind for women, who now account for about half of medical school graduates.

“A lot of providers aren't interested in being the 24/7 kind of docs,” says Robert Duehmig, director of communications at the Oregon Office of Rural Health at Oregon Health & Science University.

Moreover, moving to a rural community is often a family decision—with spouses' careers and children's educations to be considered. “When you're recruiting a provider, you're recruiting more than one person,” Duehmig says.

So hospitals are working to smooth the transition. Slabach notes that rural hospitals are increasingly employing doctors directly, which allows clinicians to focus on practicing medicine while hospital administrators handle administrative tasks such as billing and licensing.

He also points to two primary indicators of whether someone will practice in a rural area: being born and raised in a rural community and being trained there. “Those two areas alone can have very big predictive value,” he says.

With that in mind, some medical schools are giving preference to rural applicants. The Scholars in Rural Health program at the University of Kansas School of Medicine even recruits college sophomores interested in serving rural communities, and offers them guaranteed admission if they complete program requirements. The applicants must have experience living in a rural area and intend to practice medicine in rural Kansas.

More communities are also participating in physician shares—where joint contracts between hospitals not only provide extra coverage but also help physicians feel less isolated. “I think that's probably going to increase,” says Joyce Grayson, director of Rural Health Education and Services at the University of Kansas Medical Center, Kansas City. “What we don't know is what that's going to look like on the back end if that physician leaves.”

Physician retention has been just as much an issue as getting physicians to make an initial commitment to rural life. Grayson says that, nationally, physicians stay in their first jobs for only about three years, and the challenge becomes finding those doctors who are willing to stay for five or more years. “We can certainly help with recruiting, but we're really interested in helping those who we want to keep too,” she says.

Kansas programs such as student-loan forgiveness have had an 80% retention rate during the past 23 years, Grayson says. The state also funds a program that provides temporary clinician coverage to underserved areas so that solo providers can have time off.

“You absolutely can have work-life balance out in the rural areas,” she says. “There has been a big change over the last few years.”

In Oregon, state senators have introduced a bill that would recreate a primary-care loan repayment program and establish a loan repayment fund—something the state discontinued in 2009. It would build upon Oregon's other incentive programs, such as its participation in the federally administered state loan repayment program, a match-grant program intended for primary-care providers willing to spend at least two years practicing in an underserved area.

On the national level, two bills introduced this year in the Senate aim to help retain international medical graduates.

The Conrad State 30 and Physician Access Act, introduced in March by Sens. Jerry Moran (R-Kan.), Amy Klobuchar (D-Minn.), Susan Collins (R-Maine) and Heidi Heitkamp (D-N.D.), eliminates the sunset on the 1994 program of the same name that allows states to waive visa requirements for rural physicians.

And last month's Border Security, Economic Opportunity and Immigration Modernization Act has a number of provisions that could directly or indirectly boost physician immigration, such as doing away with per-country limits on green card holders and increasing the number of physician immigrants who stay after completing training here.

Then there are the hyper-local efforts.

In 2009, Douglas, Ariz., another town on the U.S.-Mexico border, received a visit from then-American Idol judge Simon Cowell as part of “Idol Gives Back.” Because of a donation from the show, the town was able to convert a former school into a pediatrician's office.

“It really united the whole community,” MacKinnon says. “Sometimes it comes to thinking outside of the box.”

Ashland (Kan.) Health Center, a public hospital in a town of only 900 people, was another “pretty extreme case” when Benjamin Anderson arrived as CEO in 2009.

During the past 18 years, 11 physicians had come and gone. The 24-bed hospital was operating with only one physician assistant who was working around the clock and was overseen by a physician 30 miles away who came in for a half day a week. “That's all that was keeping this place open,” Anderson says.

Anderson approached two faculty members in the rural health program at Via Christi Health in Wichita, Kan., which has a partnership with Ashland, to ask for their help.

He was given a list of directives. He was told to offer physician recruits four days of clinic with one day a week on-call, one weekend on call a month, a salary that met the national average, and eight weeks of paid time off for international missionary work.

“You show them they can be a missionary here for 44 weeks,” Anderson recalls. “The physician who's willing to practice medicine in a mud hut in Africa—they don't need a Nordstrom's or restaurants.”

Anderson was then asked if he'd be willing to go to Africa to see for himself, and ultimately traveled to Zimbabwe to build screens around missionary housing to prevent malaria. “It was a game-changer for me. And I've been back every year since,” he says. “I was surprised by the similarities between rural America and overseas.”

Ashland now has two family medicine physicians, two physician assistants and one nurse practitioner. “We've become a little medical hub,” Anderson says, noting that six communities now benefit from the additional coverage. “We share those providers with the surrounding areas.”

Follow Beth Kutscher on Twitter: @MHbkutscher