News From Terre Haute, Indiana

June 29, 2014

Doctor shortage looms in rural counties

Health insurance expands pool of patients; Indiana near bottom in ability to handle new load

Maureen Hayden

WASHINGTON, Ind. — It didn’t take long for Dr. Rex Stroud to feel that he had more patients than time to see them.

Two years ago, after working in emergency medicine, Stroud opened a primary care practice in this small southwestern Indiana town of 10,500 people. He was soon hit with a wave of people calling for appointments.

Many were older with chronic health problems that required more of his time. So Stroud brought in two part-time nurse practitioners and a physician’s assistant to help manage the caseload.

Still, he routinely runs behind schedule.

 “I make my office manager anxious,” Stroud said during a hurried conversation in his modest office near the local hospital.

“Spending longer time with patients isn’t good from a business standpoint, but from a patient relationship standpoint it is a good thing,” Stroud said. “I can’t do it any other way.”

He’s not the only busy doctor. Some of his colleagues in neighboring towns are turning away new patients or making appointments several months out. Daviess County — of which Washington is the county seat — is among Indiana’s least-served by primary care providers.

Stroud and others believe the strain is likely to get worse as Indiana increases access to health insurance through the Affordable Care Act.

After initially resisting the federal government’s call to expand the traditional Medicaid program, Gov. Mike Pence has proposed using the state’s Healthy Indiana Plan to expand coverage by early next year. If approved, it would add more than 400,000 low-income Hoosiers to the rolls of the newly insured. Many, having put off seeing a doctor they couldn’t afford, are expected to come in with chronic — and time-consuming — health problems.

“We’re quickly going to be saturated with more patients than we can handle,” said Stroud.

Growing demand for care, not enough doctors

Dr. Richard Feldman, Indiana’s former health commissioner, has warned about the national shortage of primary care physicians. The dwindling supply of doctors who provide preventive care is what he calls a “looming crisis that’s been smoldering for years.”

Estimates vary, but Feldman cites national studies that show a shortage of 20,000 primary doctors in the United States. And that is projected to more than double by the end of the decade.

Population growth is one reason. So is the aging of the nation. But the most pressing reason is the millions of newly insured people that the Affordable Care Act is bringing into a health care system with little capacity to handle them.

Indiana, which ranks 39th for its ratio of physicians to population, needs at least 2,000 new primary care physicians by the end of the decade to handle all who then will be newly insured.

Demand is uneven throughout the state. A 2012 inventory of the state’s health care workforce found a disparity, with more than enough primary care providers in more affluent communities but a dearth in rural areas — which would include many counties in the Wabash Valley.

The report, by the Indiana Center for Health Workforce Studies and the Bowen Research Center at Indiana University School of Medicine, found only 11 of 92 counties meet a commonly accepted standard of 10 primary care doctors for every 10,000 people.  

The report noted another age-related concern: More than one-third of primary care doctors in rural counties are within a decade of retirement.

In response to the shortage, Indiana University’s School of Medicine is increasing admissions by 30 percent and expanding classes on nine campuses around the state. But health experts say there’s no quick way to close the gap since it typically takes a decade to train a doctor.

“If you only look to physicians for the answer, it’s not going to be there,” said Dr. Richard Kiovsky, director of the Indiana Area Health Education Centers, a statewide network of hospitals working to boost the number of health care workers in Indiana.

 “We can’t produce enough physicians now to fill the need that is so great in our state and elsewhere.”

Hard to recruit for rural areas

Dr. Stroud’s decision to set up practice in a small community is unusual.

Researchers at George Washington University’s School of Public Health and Health Services have found that only 1 of 10 new doctors enters the primary care field. Even fewer choose to practice in rural areas.

There are myriad reasons, said Don Kelso, executive director of the Indiana Rural Health Association. Despite agreement about the value of primary care, the system rewards specialized and procedural services. Medical students, carrying an average debt of $170,000, are lured by specialties that pay them two to three times more.

“Just as we’re needing more primary care doctors in underserved areas, it’s getting harder to recruit and keep them,” said Kelso. Among the initiatives he’s helped launch is one that enlists rural hospitals to help pay for medical school for local students who agree to come home to practice.

For Stroud, the decision to return home seemed natural. He grew up in the area and went to medical school at Indiana University on a Navy scholarship. After a six-month tour as an infantry battalion surgeon in Iraq, he spent the remainder of his service at Crane Warfare Naval Base, the majority of which sits in Martin County, less than an hour from his hometown.

He’s since returned to the family farm, where he raises cattle. Few of his medical school friends took a similar route.

“If you don’t grow up in a rural area and understand rural life, it can be very hard,” said Stroud. “You have to love it to want to be here.”

More recruiting, more support

Health care educators are trying to recruit and train doctors in areas — including rural communities — where physician shortages are most acute.

The IU School of Medicine in Terre Haute  created a curriculum focused on rural medicine. Hospitals that serve rural communities are working with IU’s medical school and local doctors to set up clinical rotations for students.

More young doctors are doing residencies in community-based health centers, instead of big city hospitals. And schools and hospitals are recruiting high school students who show an interest in medicine, offering to guide them through medical school.

Kiovsky, of the Indiana Area Health Education Centers, said there’s also increased emphasis on recruiting and training nurse practitioners and physician’s assistants who can alleviate some of the increased demand for preventive care in areas that sorely need it.

Stroud is convinced that kind of intervention works.

The first in his family to go to college, he never dreamed of becoming a doctor. “I thought, ‘My family can’t afford that,’” he said. “Really, my first response was, ‘Only doctors’ kids become doctors.’”

A college counselor told him otherwise, pushed him to take the medical school entrance exam, then helped him figure out a way to pay for medical school.  

“Letting people know, ‘We need physicians here and we’re going to support you if you want to go into the medical field and we want you back here,’ is important,” he said. “It’s not a life for everyone, but if you do it for the right reasons, it’s rewarding.”

Maureen Hayden covers the Statehouse for CNHI, the Tribune-Star’s parent company. Reach her at Follow her on Twitter @MaureenHayden.