Friday, September 4, 2015

The Aging of Rural Primary Care Physicians


EDITOR’S NOTE: A study supported by the federal Office of Rural Health Policy and other federal agencies shows that rural communities are at greater risk of losing primary care physicians through retirement. The study was released by the University of Washington School of Medicine’s Department of Family Medicine. Below are excerpts from the report. The full study is available here.

The study looked at the number of primary care providers who were approaching retirement (aged 56 and older). It found that 1) rural areas had a greater percentage of such physicians than urban areas and 2) the percentage was highest among remote, rural counties.  

Primary care is the foundation of the rural health care workforce. However, a substantial percentage of primary care providers (PCPs) in the United States are approaching retirement age at the same time that fewer new U.S. medical graduates (USMGs) are opting for primary care specialties. Shortages related to retirement will coincide with accelerating demand for health care as the number of Americans aged 65 and older doubles between 2000 and 2030 and additional millions receive health insurance coverage through provisions in the Patient Protection and Affordable Care Act (ACA).

This study describes how an aging workforce may exacerbate the problem of rural PCP shortages by identifying rural locations with high proportions of PCPs nearing retirement age. Knowing where near-retirement PCPs work as well as the location of rural populations in greatest need of access to primary care services may help workforce planners avert impending shortages. …

Rural Has Greater Percent of Doctors Nearing Retirement

Near-retirement primary care providers (PCPs) constituted 25.5% of PCPs practicing in urban areas compared to 27.5% in rural places (Figure 1). As degree of rurality increased, so did the percentage of PCPs nearing retirement, reaching 28.9% in remote non-core locations. The same trend held true when family physicians/general practitioners were analyzed. For this group, the percentage of near-retirement physicians overall was higher in rural areas than urban ones, 28.3% versus 27.0% respectively, and was highest in remote non-core locations (31.0%).

Darker states have a greater percentage of primary care providers in their non-metro counties. (Click map to enlarge.)At the state level, high proportions of rural, near-retirement PCPs were located in all four census regions, and this was particularly true in New England, the lower Midwest, the South, and along the West Coast (Figure 2). Eleven states had 30% or greater of their rural PCP workforce near retirement age: North Dakota and Arkansas (30.3%), Vermont and Nevada (30.4%), Oregon (30.8%), Oklahoma (32.3%), Florida (32.6%), Connecticut (33.2%), California (34.2%), West Virginia (36.1%), and Massachusetts (42.1%). …

Compared to all other rural counties, rural counties in the top decile [the top 10%] of near-retirement physicians were characterized by lower population density and lower socioeconomic status as measured by persistent poverty, lower education, and lower employment (Table 3). They also had the lowest median household income. Of all rural counties that had PCPs, rural counties in the top decile of near-retirement PCPs also had fewer PCPs per 100,000 population. These counties tended to be located in the mid-section and western portions of the country (Figure 3). In 72 rural counties, all PCPs were aged 56 or older. There were 166 rural counties with no PCPs. These counties were concentrated in the mid-section of the country (Figure 3), and almost 60% of them were categorized as remote non-core areas.

Bright green counties are in the top 10% of nonmetro counties with the highest percentage of primary care providers approaching retirement age. Gray counties are nonmetro counties that have no primary care providers. (Click map to enlarge.)

Retirement May Worsen Primary-Care Shortgages

This national study reveals that PCP retirement over the coming years may exacerbate PCP shortages. Many of the locations with high proportions of near-retirement PCPs had low overall PCP supply, and in many better-supplied locations, impending PCP retirement will likely create new locations with low PCPs supply. Furthermore, the impact of PCPs retirement is likely to come just as demand for primary care services in rural areas spikes due to overall population growth, the “graying” of rural America, and expanded insurance uptake through ACA provisions. Compounding this situation is the fact that compared to the 1990s, fewer medical students have chosen family medicine, the largest contributor to rural PCP supply, for residency training. For example, the number of first-year family medicine residency slots declined from 3,293 positions nationally in 199812 to 2,730 in 2011. Furthermore, on an annual basis, rural PCPs see more patients than do urban ones, but as physicians approach retirement they tend to work part time and see fewer patients. Given these factors, understanding the additional impact of physician age distribution on the rural PCPs workforce becomes especially important, so research factoring in provider age, productivity, and practice location is warranted.

The problem of PCP loss through retirement will affect both urban and rural areas, but rural locations will be at the greatest disadvantage.

Possible Solutions

… This observation underscores the importance of supporting programs that place newly trained PCPs in rural shortage locations, such as the National Health Service Corps (NHSC) and the J-1 visa waiver program.

Other potential solutions include:

• Bolstering the overall number of graduates entering rural primary care programs in schools of medicine. In particular, medical schools that focus on admitting students from rural backgrounds and providing longitudinal experiences in rural community settings have proven effective.

• Parallel efforts within nurse practitioner and physician assistant programs to train students for rural primary care careers could help alleviate physician shortages.

• To be effective, such strategies would benefit from pre-health professions matriculation programs to bolster the rural pipeline, such as better K-12 and college student preparation for rural health care careers, promotion of admissions policies that serve rural health, expansion of rural health care training opportunities as part of core educational curricula, and the availability of financial and lifestyle support for providers in rural primary care practice.

Local, targeted efforts can also be implemented to help rural communities manage PCP retirement. [Other researchers] have recommended various strategies to better prepare rural communities for local physician attrition, such as the following scenarios:

• Recruiting a new physician, [nurse practitioner], or [physician assistant] before the retirement of an existing provider occurs will prevent gaps in service delivery.

• Supporting transitional work arrangements for near-retirement PCPs could help postpone full retirement. Examples of this approach could include locum tenens arrangements (i.e., temporary physician coverage), after-hours call coverage, and shared practice arrangements.

• Determining the future primary care needs of the community and prioritizing options for addressing those needs would allow effective proactive planning to be implemented. For example, younger PCPs, all of whom have completed residency training in the current era of work hour restrictions and many of whom have spouses or partners with career obligations, may work fewer hours and take less after-hours and weekend call than their predecessors. Thus, replacing a retiring PCP may require hiring more than one new PCPs, an interprofessional team, or individual nurse practitioners or physician assistants.


Meredith A. Fordyce, Ph.D., was a Research Scientist at the WWAMI Rural Health Research Center, University of Washington School of Medicine, at the time of this study. 

Mark P. Doescher, M.D., MSPH, was the director of the WWAMI Rural Health Research Center and an associate professor in the Department of Family Medicine, University of Washington School of Medicine, at the time of this study. 

Susan M. Skillman, M.S., is the deputy director of the WWAMI Rural Health Research Center, Department of Family Medicine, University of Washington School of Medicine.



Designs Still Fail Ten Years Later

Non-primary care physicians are older than primary care physicians across rural settings and practice sites with lower physician concentrations. Only the sites most urban, highest income, and most concentrated in training have younger workforce - by design.

Current medical education design prevents careers specific to rural practice - general surgery, general obstetrics-gynecology, general orthopedics. Rural hospitals will be impacted by these declines. This is one of many current threats to rural hospital funding all set in motion - by design.

Declines in internal medicine primary care output plus stagnant family medicine and pediatrics will result in declines in rural primary care physicians. Internal medicine has only generated about 1400 a year for primary care since the 2000 class year and will be less than 45,000 by 2030 or half of the level experienced in 2000. Thirty years of 1400 per year determines the workforce in 2030. Rural populations and elderly populations are losing a major source of workforce. Pediatric expansions from 2200 to 3000 have not increased primary care result because only about 1400 remain in primary care. Less than 10% of this primary care component is found in rural distribution. Limited primary care result and limited distribution is shaped - by design.

Legislative efforts to increase primary care, graduate medical education in 30 states in need of workforce, and rural training have failed as indicated by Chen and others. Thirty years of failed designs are long enough. The only design changes that have mattered have been about expansions of workforce specific to family practice positions filled, but these increases are now limited - by design.

There are specific solutions for rural generalists and for rural general types of specialties known for 40 years but these solutions have been avoided by all but a few MD, DO, NP, and PA schools and programs. These solutions have been avoided by state and federal government for 30 years. These require a change in the design.

The solutions for rural workforce are the same solutions needed by the populations growing faster, by Medicare populations, by Medicaid populations, and by populations gaining health insurance. Instate, primary care visits, where needed are solved by more family physicians or by NP or PA training made permanent to family practice. Rural primary care and non-primary care workforce is the result of Rural Medical Schools or longitudinal integrated curricula in rural sites such as built in rural Minnesota by the Rural Physician Associates Program. These changes in design have been turned down by states and the federal government.

Robert C. Bowman, M.D.

Basic Health Access - requires specific design