Rural Ohio facing doctor shortage

1274842811 34 Rural Ohio facing doctor shortage

In 2014, newly insured Ohioans may find what those living in rural areas already know: Having health coverage doesn’t guarantee quick, easy access to a family doctor.

Outside of Ohio’s biggest cities, doctors who represent the first point of contact for the insured are already spread thin. When health insurance reform is fully implemented, experts fear there could be a rocky period before medical school graduates meet statewide demand.

The Baby Boomer generation of doctors is nearing retirement. Meanwhile, the number of medical school students choosing primary care specialties, such as family medicine, has failed to keep pace with the growth in other fields of practice, according to the American Association of Medical Colleges.

In less than four years, there will be more than a million additional Ohioans who will have health insurance. They will be encouraged to use it for routine check-ups. These new patients, who previously turned to the emergency room instead of a doctor’s office, could worsen a shortage of primary care doctors — practitioners of family medicine, general medicine, internal medicine, pediatrics and obstetrics and gynecology — in underserved communities.

Still, the medical college association’s Center for Workforce Studies director Ed Salsberg is largely upbeat about the proposed plans in the Affordable Health Care Act to spur growth in primary care specialties. He also recognizes these next five years are “going to be a difficult time.”

“I do expect to see that growth, but I do want to be clear that it’s going to be a challenge,” he said, “and a greater challenge for rural and poorer communities.”

In 2008, there were almost 9,200 primary care doctors seeing patients in Ohio, according to the association. That’s a rate of 1.6 primary care doctors per 2,000 residents.

The U.S. Health Resources and Services Administration defines an underserved population as having more than 2,000 residents per one primary care doctor. So as a state, Ohio is comfortably above that line. However, when focused at the county level, real disparities appear between rural and urban areas.

The Ohio State Medical Board has 12,706 licensed primary care doctors in its public registry. The difference between that number and the association’s count is that an unknown number in the registry do not see patients because they are retired, are in academia or for some other reason, according to Joan Wehrle, the board’s executive staff coordinator.

Still, she said, because doctors submit a listed address — usually a business address — it can serve as a baseline to see how doctors are spread out geographically.

Richland County has a ratio of 1.6 primary care doctors per 2,000 residents, ranking it 28th out of the state’s 88 counties, according to the medical board’s registry. However, with 100 licensed primary care doctors in the county, the gap between that ratio and the federal guideline looks much slimmer if you assume one in four is not seeing patients — as the association’s statewide data indicates.

Only seven primary care doctors list a Morrow County address in the registry, putting the county among the state’s worst in that respect.

The registry shows one quarter of Ohio’s counties have more than 2,000 residents for each licensed primary care doctor. Those ratios are even more stark, given the inclusion of non-active physicians.

These 22 counties are sparsely populated — their median population is about 28,600 — and well removed from Ohio’s urban centers. Half of the underserved counties are south of Interstate 70 and east of Interstate 71.

“One of the main underserved area (types) are rural areas,” said Martin Kramer, a spokesman for the U.S. Health Resources and Services Administration. “People in rural areas have a harder time accessing health care because they have greater distances to cover.”

Today’s patient-doctor balances will be outdated when millions of people nationwide are enrolled in a health insurance plan by 2014.

In Massachusetts, which instituted its own health care reforms in 2006, there is one primary care doctor for every 927 residents, the association reports.

However, even with the abundance of primary care physicians, wait times in Boston were the longest of any of the 15 major markets surveyed in 2009 by medical staffing firm Merrit Hawkins. The average wait time for an appointment to see a family doctor in Boston was nine weeks. In Miami, it took seven days.

Since implementing statewide insurance reform, more than 400,000 people have enrolled in health insurance, according to the Massachusetts Division of Health Care Finance and Policy. Only one in 20 people younger than 65 in the state are without health insurance, four times lower than Florida, data from the Kaiser Family Foundation shows.

In Ohio the number of uninsured is higher than one in 10, or 1.3 million people.

Dr. Larry Leone’s days are long. The family medicine practitioner said he left his home at 6:30 a.m. Tuesday to make stops at nursing homes and hospice care facilities where he is a medical director. He arrived at Galion Community Hospital a couple of hours later, to see to 10 patients who are convalescing. His day ended at about 7:30 p.m. after performing sports physicals for area junior high and high school athletes.

“Twelve- or 14-hour days are not unusual,” he said.

Leone said he loves the variety his job affords him. “You know a little bit about everything, but not a whole lot of one thing.”

He admits there are times when the stress can be overwhelming.

“I try to get out of town every two months or so for three or seven days just to keep my sanity,” he said.

For someone who enjoys sitting down with patients, getting to know them and treating them over a long period, family medicine can be a rewarding career, Leone said.

He would encourage medical students not to come to school with blinders. Leone said improving Medicare and Medicaid reimbursements for primary care doctors would go a long way toward making these first-contact specialties more lucrative, and thus more attractive to students.

“We’re going to need a huge amount of people in family practice and internal medicine and pediatrics,” he said.

Formerly a nurse at Children’s Hospital in Columbus, Amee Bigelow is enrolled in the American University of the Caribbean School of Medicine in St. Maarten, Netherlands Antilles.

The 2003 Lexington High School graduate likes working with children and is fairly certain pediatrics is her calling.

“I love their energy, their resilience and their youthful outlook and interpretations of situations,” she wrote in an e-mail. “I feel I could work a lifetime with this population and in this environment without getting burned out because I would love what I do.”

Bigelow said doctors choose a specialty path because of their passions — obstetricians love working with the miracle of life, neurologists are fascinated by connections in the brain — not for financial reasons.

Still, she believes medical students who have not been grabbed by any certain specialty could be persuaded to pursue family medicine or primary care through incentives such as loan forgiveness “because of the amount of debt most medical students are faced with once they graduate.”

Primary care specialties are on the lower end of the physician pay scale. Pediatricians and family doctors make about $170,000 annually, according to a 2009 report by Merrit Hawkins. In comparison, some cardiologists make almost three times as much on average, the report shows.

At The Ohio State University College of Medicine, students already are spending about half a year under the tutelage of a primary care doctor as part of their education, said Dr. Catherine Lucey, vice dean of education.

“Every one of our 200 students work at some time, for some time, with an extremely competent community physician … and I think that’s really critical,” Lucey said.

The college also has been targeting students from underserved areas, including rural communities, for admission because research shows those future doctors are more likely to return to that type of setting to practice their craft.

Since adopting this approach, Lucey said the number of family medicine-bound students has increased by 40 percent.

One definite bright spot for Ohio is the age of the state’s doctor population. One in five active physicians is younger than 40, the third-highest rank in the nation. The group of doctors in the state age 60 or older is in the bottom 25 percent. Salsberg said this should stem some of the fear in Ohio about the retirement losses that many other parts of the country will experience in the next few years.

Salsberg said an expansion of the National Health Service Corps could potentially address reservations about pursing a career in primary care while also stationing doctors in areas where they are sorely needed.

The corps offers loan repayment for primary care graduates who practice in underserved areas.

Another possible program would involve the establishment of primary care extension programs. Much like agriculture extensions, these regional offices would support primary care physicians through training and guidance, Salsberg said.

Perhaps the most immediate need, Salsberg said, is the standardization of insurance paperwork.

“When we survey physicians, particularly primary care physicians, they have been very clear that the time spent on paperwork for insurance is a concern,” he said.

Salsberg said there are provisions in the health care act to simplify insurance claims by making these documents follow standard formats that require the same information. This is to be combined with a push toward the electronic transfer of medical records, he added.

Part of the solution to the impending doctor shortage might already be in the workplace: advance practice nurses.

Keely Harding, legislative co-chairwoman for the Ohio Association of Advance Practice Nurses, said nurses with master’s degrees or higher are entering primary care work at nine times the rate of physicians.

In Ohio, Harding said, advance practice nurses can see patients like any physician, but they must have a collaboration agreement, meaning a doctor must be continuously available to provide guidance.

The nurses’ association said advance practice nurses began practicing in the 1960s in response to a national physician shortage. Harding, a pediatric nurse practitioner in Cincinnati, said advance practice nurses will play a large role in allaying any future shortage.

“I think there are going to be plenty of patients to go around for physicians and advanced practice nurses,” she said.

razimmer@nncogannett.com 740-328-8830