More rural hospitals are sharing specialists, for example, said Patricia Schou, executive director of the Illinois Critical Access Hospital Network.
Hospitals are also looking at wage scales and offering incentives, daycare and time off to workers, as well as relaxation rooms, Schou said. They’re also working to recruit students from rural areas to train as clinicians.
COVID-19 has driven home the underlying problems, Schou said. “We’d been dealing with shortages in our rural communities and all of these issues aggravated it. We don’t want to lose any more hospitals.”
Hospital leaders are especially concerned about nurses due to a long-running shortage that has become more severe during the pandemic.
“We were already faced with a nursing shortage in our nation before COVID. Especially if you’re in the (Texas) panhandle, it’s harder to recruit,” said Golden Plains Community Hospital’s Bates.
In rural areas, hospitals find it difficult to compete with wages offered by urban centers or traveling nurse agencies, which are offering higher pay as demand spikes. Nurses have also left to take early retirements, or because of burnout or concerns about safety.
“Since COVID, many nurses have left the profession because they simply can’t stand the loss anymore and then you’ve got many who leave to take the bucks. You can’t find staff,” Bates said.
Policymakers and health systems should focus more on retaining their current workers rather than looking for replacements when people leave, UNC’s Fraher said. For one thing, there aren’t enough educators to train new nurses or the capacity to churn out enough graduates to meet the growing need.
“We can no longer assume that nurses grow on trees or physicians grow on trees,” Fraher said.
In a McKinsey survey, nurses reported needing more support from their employers, including access to mental health resources, time off and more appreciation for their work. Among the 22% who said they might leave their jobs, more than half cited the insufficient staffing, workload and the emotional toll of the pandemic, and 43% said they would seek higher-paid positions.
Rethinking recruitment and residencies
One of the biggest ways to drive more clinicians to rural areas is to reform the $14 billion Medicare Graduate Medical Education program, which primarily benefits schools in the Northeast, experts say.
Some rural health advocates for years have sought changes to the program to make it more equitable for rural areas.
“While other smaller-scale programs like the new HRSA program are a good start, that doesn’t change the fact that we still invest about $14 billion nationally in GME and still only 1% goes to rural,” Fraher said. “Until we figure out how to change that system or at least reallocate some money to rural, we’re just going to be in this bind for a long time to come.”
Medical residents are disproportionately trained in Northeastern metro areas, which not only creates geographic disparities but inflates healthcare spending, according to a report issued last month by the Niskanen Center, a policy-focused think tank. For example, there are about 92 medical residents per 100,000 people in New York, compared with 32 per 100,000 people in Texas, a state with almost 10 million more residents and a high number of health professional shortage areas.
“That’s the worst possible system we could possibly construct,” the NRHA’s Morgan said.
Congress capped the number of Medicare-funded residency slots in 1997, essentially freezing the geographic distribution of residency slots for 20 years, according to the Niskanen Center.
“There has to be both an increase in funding, an increase in slots, and a focus on rural,” Morgan said. “Just adding to the current maldistribution of clinicians is not an acceptable path forward.”
That would take congressional action. A proposal from Sens. Jon Tester (D-Montana) and John Barrasso (R-Wyoming) would lift GME caps at rural hospitals, provide incentives for urban hospitals to increase the number of residents in rural tracks and help rural hospitals to start residency programs. The NRHA has asked Congress to include these providers in the Senate version of the domestic policy package Democrats are attempting to advance through Congress.
Currently, hospitals starting new GME programs don’t get funding from the program until residents start training, posing financial obstacles to under-resourced hospitals, according to a report the Government Accountability Office published in May.
Because of those obstacles, critical-access hospitals—most of which are in rural areas—are unlikely to participate in residency programs.
“We need more rural residencies for physicians, and it needs to be not just an elective, but a requirement,” said Pratt of St. James Parish Hospital.
Another proposal, included in the House version of the Democratic bill, would award 1,000 scholarships per year for students from underserved or rural areas to attend medical school if they agree to practice in those communities after graduating. It would also allocate an additional 1,000 residency slots per year for hospitals with a record of training medical students in medically underserved areas.
Anything that increases the number of clinicians in rural areas is good, said Topchik of the Chartis Center. Eventually, smaller rural providers are going to have to affiliate with larger health systems, he said.
About 56% of rural hospitals have these relationships and they tend to do better financially, and have better access to specialists. “I think independent hospitals operating as islands are the single greatest challenge. They just can’t compete,” he said.