Rural health: Scope for improvement in return on investment

INTRODUCTION

A total of 46 million U.S. residents living in rural areas in 2020 made up 14% of the U.S. population, with a typical rural county containing 23,000 people as compared to 245,000 people in an urban county.^[1] Residents living in smaller and more isolated rural settings often face greater difficulties accessing provisions and services, including healthcare services. Trends in U.S. rural and urban populations over the past decade suggest more urban migration.^[1] Fifteen percent of rural residents are over age 65, compared to 12% in urban areas, suggesting that rural residents tend to be older and thus require more chronic disease management, specialist care, and nursing home care.^[2] According to 2018 data, there are approximately 2.9 doctors/1,000 inhabitants in the U.S.^[3] Furthermore, the generalist-to-population ratio is lower in rural regions: 1:1,282 in urban areas versus 1:1,754 in rural areas.^[2] More than 50% of non-metropolitan counties are consequently considered Primary Care Health Professional Shortage Areas (HPSAs), while parts of the rest of the non-metropolitan counties are HPSAs. ^[2]

NEED FOR ENHANCING RURAL TRACK IN MEDICAL EDUCATION AND FEDERALLY QUALIFIED HEALTH CENTERS

A measure taken to mitigate physician shortage in rural areas is the development of a rural track in medical education. Rural-based training is strongly associated with providers continuing in rural practice, with the additional benefit of preparing physicians for problems specific to the rural regions.^[2] In addition, Federally Qualified Health Centers (FQHCs) are Health Center Program Award Recipients providing primary care services in underserved areas.^[4] FQHCs play a major role in providing healthcare in underserved areas comprising certain rural regions. In 2019, there were 252,000 full-time FQHC providers and staff providing care to 30 million people, including 3.5 million low-income patients and 1 million agricultural workers.^[4] According to the 2018 Uniform Data Set, 56% of these health centers had operating margins of less than 2.5% and 43% had negative margins.^[5] A recent aggregate financial and operational profile of rural FQHCs clearly suggests that rural FQHCs generate less revenue for the number of centers, even with a comparatively better payer mix (i.e., less Medicaid, more private insurance). All types of patient visits (medical, mental, and dental) are lower for rural FQHC, in part due to low population density in rural areas. Rural FQHCs had a downward trend in operating margins from 2016 to 2019 because of an increased ratio of personnel-related expenses as a percentage of total operating revenue.^[6] The report indicated that personnel-related expenses are the primary component of the operating budget due to the high cost of recruitment and retention of providers.^[6]

POLICY CHANGE REQUIRED TO ATTRACT MORE PHYSICIANS TO RURAL AREAS

Physician shortage is increasing, and doctors have preferentially moved toward cities for better career opportunities, higher pay, and urban amenities. Only 10% of physicians now live in rural areas, compared to 20% of the overall U.S. population.^[7] Other contributing factors include urban versus rural education and class divide.^[7] Rural physicians tend to be older.^[8] Most younger physicians stay in rural areas to qualify for loan repayment from the federal or state government for a certain amount of time. In the context of these findings, policy change is required for better physician and non-physician provider staffing for a longer time in rural areas to maintain the continuity of care amidst decreased access to amenities, specialized health infrastructure, isolation, and low health literacy. The approach should be two-pronged: One to increase the out-migration to rural communities, either part-time or full-time, and another to increase telehealth access.

Practicing in a rural community could be incentivized. Although federal and state grants are provided for FQHC operations, organizational goals may not be the same as healthcare provider goals. FQHCs compete with for-profit or non-profit healthcare organizations for physician salaries while operating under a low profit margin. To decrease healthcare provider attrition, part of the funds may be directly invested at provider levels by providing tax credits for those who work in rural HPSAs, which would indirectly translate to better salaries. For example, if a provider covers an HPSA area for at least 10–20 h every week during the tax year, they may be eligible for $10,000–$20,000 in tax credits, depending upon the HPSA severity. This situation would only lead to revenue losses in the form of the income tax received from these providers. Certain providers may be willing to travel twice a week to an HPSA region to provide care on a regular basis without the additional stress of social isolation or access to amenities, which may support them to remain in the HPSA provider role for a longer period of time. This may also allow older physicians to remain in at least part-time practice during semi-retirement. Another policy to encourage more older physicians to consider moving to rural communities could be increasing the 401(k) limits for those who work in HPSA regions since physicians in rural communities tend to be older. Similar previous initiatives of loan repayment work obligations have been successful at improving health provider coverage in rural areas, with surveys suggesting that loan repayment is a motivator to stay in rural regions.^[9] Finally, providing telemedicine services to patients from rural HPSA regions could be incentivized by adding a modifier for rural regions that could bring the reimbursement to almost the cost of in-person visits. This strategy may allow the health centers to increase their rural coverage, especially specialty clinics based in non-metropolitan areas. National medical organizations (e.g., the American College of Physicians and the American Medical Association) could create a separate suborganization or a new organization with the goal of supporting and empowering rural providers providing care for rural populations. More Continuing Medical Education (CME) programs or webinars on rural health may be provided.

CONCLUSION

In summary rural residents have higher mortality, chronic disease morbidity, and lower access and use of preventive services. The physician shortage gap between rural and urban regions requires focus and policy changes. Policy changes to invest at the provider level by supporting more providers to remain part-time providers for rural communities for longer periods of time and increasing specialty telehealth access to the rural population should be adopted. In addition to supporting rural track residency, national medical organizations could provide training with a rural track focus or CME programs.