Health in the Heartland: Where Will The Doctors Come From?

Cheryl Clark, for HealthLeaders Media , May 6, 2009

At the fourth in a series of stakeholder discussions in Washington after the report's release, ranchers, farmers, and fishermen from the nation's heartland gathered with Nancy-Ann DeParle, President Obama's new director of the White House Office for Health Reform, to discuss the root of the physician shortages in their communities.

A key point was the need for health reform to create insurance programs–perhaps cooperative group health plans–that can provide health coverage for adults before they are eligible for Medicare.

"There needs to be more choices in the insurance market for affordable health coverage," she said. "The call was very clear; we need more choices for affordable options."

Many panelists told of their personal experiences in trying to access affordable healthcare even after they got sick.

"My father is recovering from colon cancer surgery, but he put off getting his port removed until he turned 65," said a man from Holton, Kansas. He hopes the reform package includes incentives for rural areas to find innovative ways to help people get affordable coverage.

One Nebraska resident told DeParle that he pays $1,000 a month for a health plan with a $10,000 annual deductible. "My mother, who just turned 90, never had health insurance until she became eligible for Medicare."

One of the panel members was Congressman Mike Ross, D-AR, who was born in Texarkana. He said that in his home town, "we used to have a hospital, but now we don't. We had six doctors, now only two. We had two dentists, and now one, and the number of pharmacists is down as well," he said. "We need country doctors," especially pediatricians. "That keeps everyone from having to take the whole day off."

Rhonda Perry, a livestock and grain farmer who directs the Missouri Rural Crisis Center Program, noted that farmers spend 15% of their income on catastrophic health policy premiums.

Ambulatory care centers may be part of the solution. A multitude of research papers issued recently point to how such care settings can, with relatively minimal expense, thwart the need for more acute and expensive hospitalizations months or years down the road.

According to a White Paper released last fall by the American College of Physicians, a group representing the nation's internists, rural areas that have more primary care physicians have lower rates of all-cause mortality, and specifically deaths from cancer and heart disease.

"Nonurban counties with a greater number of primary care physicians had 2% lower all-cause mortality, 4% lower heart disease mortality, and 3% lower cancer mortality than nonurban counties with a smaller number of primary care physicians."

The American College of Physicians advocates a number of measures to continue to attract foreign medical school graduates to practice in the U.S., a source of physicians it called extremely important for rural and underserved areas.

If all international medical graduates in primary care practice were removed, one out of every five non-metropolitan areas in the U.S. that now have an adequate supply of physicians would be reclassified as having a physician shortage, the ACP paper said.

Perhaps through a combination of more incentives for physicians and more financial support for hospitals, some of the severe gaps in healthcare to the heartland may be filled. There is potential for better use of providers other than physicians, such nursing or other types of health professionals to fill the needs in these areas. And there's a potential to build and support new models of clinics or urgent care centers that don't necessarily have to be staffed at all times by doctors.

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