I will never forget one of my patients from residency training who drove an hour and a half to visit our clinic. She did this because there was no physician in her rural town, and there was no clinic in the 100 miles between her house and Denver that would accept her insurance.
She was medically complex, and distance and financial barriers seemed to multiply the complexity of caring for her by at least threefold. Multiple times I spent hours on the phone with her trying to diagnose and manage likely heart failure exacerbations because she couldn't afford gas money and time off work to drive the three hours roundtrip to see me in clinic. At least once, that delay in diagnosis and management turned what could have been an office visit with close follow-up into a three-week hospital stay and two weeks of post-hospital rehabilitation.
She needed a family physician closer to home -- and she's not alone.
Rural Americans face greater socioeconomic barriers (income inequality, transportation, internet access, etc.) than their average urban counterparts. In addition, rural communities have higher incidence of poor health outcomes, including higher rates of all five leading causes of death in the United States (heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke), along with mental health disparities.
It should come as no surprise that residents in these communities face significant barriers in accessing affordable health care. Rural patients are seven times as likely as urban patients to report difficulty obtaining needed health care.
Given the health disparities, it would make sense to prioritize the allocation of resources to rural communities. Unfortunately, the exact opposite is happening. Part of the problem is the lack of physicians in our rural communities. According to the 2016 Census Bureau report, 20% of the U.S. population lives in rural areas, but only 12% of primary care physicians and 8% of subspecialists practice in these areas. The sharp contrast between physicians practicing in urban and rural communities remains true across numerous specialties, including psychiatry, general surgery and oncology.
From 2013 to 2015, the total number of physicians in the United States grew by 16,000, but the number of physicians practicing in rural areas fell by 1,400. Attempts to attract physicians to rural areas, including loan repayment programs, have been inadequate to meet the health care needs of rural Americans.
Growing a rural physician workforce that is foundationally strong in primary care is not going to be an easy task. The solutions will have to be multifaceted and address physician training, payment reform, insurance reform and more.
One place to start is physician training, knowing that we also need to address the sustainability of paying physicians and improving patient access to care.
Where you train matters -- and we aren't training enough physicians in rural communities. The current geographic maldistribution of the physician workforce reflects the highly urbanized graduate medical education system because most family medicine graduates will practice near their residency training programs. Currently, only 414 family medicine residents and four general surgery residents are in rural residency programs.
The Teaching Health Center Graduate Medical Education program is an important part of the solution. This program helps train physicians in community-based centers away from traditional, large urban academic centers. But THCGME funding has been erratic and more rural sites are needed.
So how do we train family physicians in rural communities? Rural training tracks, which train resident physicians in high-need areas with critical physician shortages, represent one successful example. RTTs are often structured with the first year of training at a sponsoring institution, usually an urban academic hospital, with the following two years based in rural community training sites. Multiples studies have demonstrated that at least half of RTT graduates will practice in rural areas, and they are more likely to practice in health professional shortage areas and safety net hospitals -- exactly the places we need them.
So, if RTTs are so great, why don't we have more of them? Too many rules and regulations. GME financing is complicated, especially in rural areas. CMS funding, responsible for more than 90% of GME, disadvantages RTTs by using regulations and funding formulas that do not account for the diversity of care provided in rural settings. For example, approximately one-third of GME funding is based on the "per resident amount," a historical monetary value set in 1983. The PRA funding a hospital receives is directly related to how many Medicare patients it sees. As rural hospitals often have smaller Medicare populations relative to urban hospitals, the PRA does not cover costs for smaller rural training sites.
In addition to getting less money than urban hospitals, RTTs face numerous regulations that restrict access to funding, especially in areas of high need. Until recently, sole community hospitals and critical access hospitals were not eligible for a large portion of GME funding from CMS. Thanks in part to continued efforts from the AAFP, CMS changed its rules to allow CAHs to receive GME funding that they previously couldn't. Both CAHs and SCHs could provide training sites for resident physicians in rural communities with high medical need and low access to care if they had sustainable sources of residency funding.
Rural Americans lack access to affordable health care in part due to the inadequate number of rural physicians. Growing the rural physician workforce is going to require multifaceted solutions that address training, payment and insurance. We know that where you train matters and RTTs represent one evidence-based way to train physicians in rural communities. For RTTs to flourish, we need to fundamentally change the way we pay for them.
Some policymakers and health policy groups are working on this issue, including through a Senate bill that aims to address some of the barriers to starting and maintaining RTTs.
We need to turn our attention to rural health care and begin to produce a physician workforce that meets the needs of our population.
Kyle Leggott, M.D., is a family physician doing a fellowship in health politics and policy at the University of Colorado. You can follow him on Twitter @KyleLeggott. He thanks Sarah Hemeida, M.D., and the Eugene S. Farley Center for their contributions to this post.