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Commentary: It’s Time Governments Consider Paying Doctors to Practice in Rural Areas [1]
['Thomas Gruca', 'University Of Iowa']
Date: 2024-03-01
This opinion column was originally published in the Cedar Rapids (Iowa) Gazette. You can learn more about this independent, employee-owned news organization here.
Rural health care is in crisis and while many solutions have been offered to encourage specialist physicians to practice in small towns, the fact that rural health care still is in crisis suggests that none have been successful.
New ideas are needed, and an Australian government program that provides cash subsidies to specialists to regularly offer clinical care in rural parts of the country could be a viable model for rural states in the U.S.
I was part of a research team that looked at the potential effectiveness of giving government subsidies to doctors to practice at least part-time in rural parts of Iowa, the heavily-rural state where I live. We looked at cardiologists, which are an especially critical need in rural areas, where residents are more apt to suffer from heart disease, high blood pressure, and stroke. Studies have shown that just a single annual visit with a cardiologist can have significant health impacts.
However, Iowa has fewer than 200 cardiologists, almost all of whom live in urban areas, and their numbers are expected to drop even further as many retire and aren’t replaced. The equivalent of 2,000 cardiologists leave practice every year in the United States, while fellowship programs graduate only about 1,500, a net loss of about 500 annually. In Iowa, the number of cardiologists is expected to drop by 10 percent in the coming years.
To make up for that lack of rural presence, many Iowa physician group practices have developed a strong network of visiting consultant clinics where urban physicians in many specialties, including cardiology, make periodic visits to rural areas to see patients. The networks provide reasonable access and effective care to most people who live in communities too small to support a full-time cardiologist.
Other options have been considered. One suggestion, recruiting foreign doctors to practice in rural areas, has met with some success for primary care physicians, where the bulk of the funding is targeted. Increased use of telehealth also has been proposed, but patients have proved reluctant to use it for complicated health concerns.
While the outreach clinic model has been the most successful in plugging holes in rural cardiology access, it still has weaknesses. Physicians who participate in the program are unable to see patients while they’re driving to the outreach clinic. This “windshield time” can last as long as 2 to 3 hours in Iowa and includes not just lost opportunities to see patients but also mileage and other vehicle expenses. The opportunity costs are significant enough that only about half of Iowa’s cardiologists participate in an outreach clinic.
Our research team wanted to find out how to mitigate the potential loss of cardiologists and encourage more to participate in these visiting clinics. We looked at a program in Australia, which has an even greater rural health care crisis than the United States. There, the Australian government’s Rural Health Outreach Fund subsidizes qualifying specialists to motivate them to practice in rural areas. Our study found that if a payment program were adopted in Iowa to subsidize physicians for their windshield time, the payments would cost about $430,000 a year to maintain the current level of cardiology care in rural areas, even after the anticipated decline in numbers.
We also looked at the costs of recruiting and training foreign-educated doctors to practice in rural areas. For such a program to be more cost effective than the public subsidy, it would have to attract five cardiologists who would work for $81,000 or less a year, a highly unlikely outcome. They would also provide far less coverage than the network of outreach clinics for the same amount of money.
While our study looked only at cardiology, the findings suggest similar public subsidies would be an effective way to at least maintain health care coverage in rural areas in other specialties. While we’ve generally been reluctant to suggest the government pay providers to practice in certain locations, we may have few other feasible options to provide equitable access to necessary health care to some 60 million rural Americans.
Thomas Gruca is professor of marketing at the University of Iowa’s Tippie College of Business.
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