Local, state officials grapple with current, projected primary care shortages
October 29, 2011
At a glance …
• Moffat and Rio Blanco counties designated as primary care health professional shortage areas.
• Federal designation flags areas where residents have limited access to primary care providers like pediatricians, internal medicine physicians and family practitioners.
• Colorado Health Institute: Colorado will need about 1,000 more primary care physicians by the year 2025.
• Shortages projected to increase as rural primary care providers retire, medical students opt for specialty medicine and health care reform gives more patients access to health care.
• Organizations and state agencies seeking to attract more medical students to primary care through programs and incentives.
From broken bones to heart attacks, Dr. Jon Ossen treated just about anything that came through the door during his seven years as family practitioner in Craig.
"You do everything," he said. "You take care of your patients from the cradle to the grave."
Ossen, who still practices in Craig, left family medicine in November 2005 to pursue his longtime interest in emergency medicine.
Yet, he still recalls the reaction he got from his urban colleagues when he would describe what his duties as a rural family doctor entailed.
"They look at you like, 'I would never do that. Why do you do it?'
"Well, because somebody has to."
Family physicians and other primary care providers can have a profound impact on a community's overall physical and economic health. But in most of Colorado, and in rural areas in particular, officials said roadblocks prevent residents from getting this crucial care.
Moffat and Rio Blanco counties are no exception. They, along with all but a handful of counties in the state, are considered primary care health professional shortage areas.
The Colorado Department of Health and organizations across the state are trying to ensure there are enough primary care providers to serve Coloradoans, both now and in the future.
But, if current trends continue, the prognosis could be poor, especially for Colorado's rural communities.
'The working poor'
Health professional shortage areas, which are federally designated, are regions where people don't have enough access to primary care doctors, like pediatricians, internal medicine physicians and family practitioners.
The designation is designed to "help us decide what areas of the state—or the country, for that matter—have the highest need so that we allocate those limited resources to those communities that have the highest need," said Stephen Holloway, director of the Colorado Department of Health's primary care office.
A county can be flagged as a shortage area for several reasons, said Fabian Valle, director of workforce programs for the Colorado Rural Health Center.
In some cases, residents have to travel long distances to get to a physician. In other cases, there just aren't enough doctors to go around. Regions can get designated as a shortage area if there's only one doctor per 3,500 people or more, Valle said.
Moffat and Rio Blanco counties fall into the low-income qualifier, which is based on the percentage of the population living below the current federal poverty guideline, he said. More simply put, some residents can't afford health care.
"That's the real unfortunate situation that rural communities face," said Jennifer Riley, chief of organizational excellence for The Memorial Hospital. "They don't have access to some of the other reduced cost medical services that maybe a larger urban area would be able to provide."
TMH's clinic works with patients on Medicaid and offers services on a sliding fee scale, "but for some people, even that is not enough," she said.
For those residents, there is the Northwest Colorado Visiting Nurse Association's Community Health Center, which is intended to "serve people who traditionally face barriers to health care," said Lisa Brown, Northwest Colorado VNA chief executive officer, "and that tends to be based on transportation and language and, most specifically, income."
Community health centers, are awarded to medically underserved regions and cannot turn away patients based on their inability to pay.
About 60 percent of the health center's patients have no insurance, Brown said, adding that they make too much money to qualify for government benefits but don't make enough to pay for commercial insurance.
"They are essentially the working poor," she added.
Good access to primary care providers can have far-reaching benefits.
"We know that as communities improve their access to primary care, overall healthcare spending goes down in a community and overall health status improves," Holloway said.
Communities where residents can get primary care often have fewer deaths related to cardiovascular and pulmonary diseases than one without it, according to a 2010 report from the Colorado Health Professions Workforce Policy Collaborative. Their residents visit the emergency room less, use fewer medications and generally spend less on medical care.
Attracting doctors to primary care and keeping them there, though, isn't easy, particularly in regions miles removed from the urban landscape.
"It is challenging to recruit a physician to come to a small town," Riley said, adding these communities don't offer the same amenities a physician could find in the city.
The nature of primary care in a rural area also comes into play.
"A lot of times in rural (settings), you're the only provider out there," Valle said. "And with whatever comes up … your training (has) to be up to par, and you have to make decisions without having a second opinion to get some support."
That puts a lot of responsibility on rural primary care doctors, he said, adding that physician burnout and turnover is always a risk.
"If you burn providers out in some of these communities, it's hard to replace them," Valle said.
If current trends continue, the primary care shortage in Colorado could get worse. The Colorado Health Institute projects that the state will need about 1,000 more primary care physicians by the year 2025.
An aging workforce is part of the issue.
"We know that the primary care physician workforce is older than physicians in general, and in rural communities, it's even older still," Holloway said. "We know that we're, over the next decade, going to experience a lot of retirements in primary care physicians that will be disproportionately happening in rural communities."
Training their replacements, he added, takes years.
At the same time, many medical students are shying away from fields like family practice, opting instead for specialty medicine, where the hours and type of work are more predictable, Valle said.
Specialty medicine also pays significantly more than primary care, making it more appealing to newly-graduated medical students, who, on average, leave school with about $150,000 in student loans, according to the American Medical Association's website.
"If you have many hundreds of thousands of dollars of school debt at the end of medical school, it's easier to see yourself becoming, say, a dermatologist versus a family medicine (physician) because the pay is almost double," Holloway said.
There's one final factor to consider that could exacerbate a physician shortage. Health care reform could give more people access to healthcare, putting an additional strain on an already understaffed health care workforce.
"That's part of the problem," Valle said. "We don't have enough health workforce providers, period. And if you expand coverage, it doesn't necessarily expand access to providers."
One solution to the projected physician shortage might be found in medical students like Nathaniel Chappelle.
The 26-year-old native of Pierre, S.D., is a third-year medical student at the University of Colorado. At a time when many of his peers are setting down roots in urban areas or gravitating toward a medical specialty, Chappelle is seriously considering practicing family medicine in a rural area, maybe even a place like Craig, where he's now doing some of his training under the tutelage of local family practitioner Dr. Larry Kipe.
The setting suits him.
"I'm originally from a small town, so it's something I'm comfortable with," Chappelle said.
During his training at Moffat Family Clinic, Chappelle has seen everything from the common cold to congestive heart failure and diabetes. But, he's OK with handling a wide range of cases during the day.
"I'm more of a generalist than a specialist," he said. "I like the idea of doing lots of different things and knowing about lots of different things, which is increasingly rare in the way that medical students are trained."
Health care organizations in the state are looking for these kinds of students, and they're willing to offer them incentives to come to Colorado.
The Colorado Health Service Corps—a state, federal and private partnership—can help physicians pay off their student loans if they agree to provide primary care full-time in a health professional shortage area, according to the Health Department's website.
Medical schools like Chappelle's offer programs specifically tailored for rural practice, which can be crucial for physician recruitment and retention. A student who trains in a small town is more likely to go back to one when he or she graduates, Valle said.
"They can see the impact they're making in those communities and feel the satisfaction that that will have into their future career," he added.
This may be the key to staving off a future physician shortage, because as difficult as primary care in a small town can be, it has its rewards.
Just ask Ossen.
It's a challenge, he said, but that challenge is part of the appeal.