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.