Desperate to persuade young doctors to settle in rural areas — or just keep them from leaving the state — medical schools, hospitals, and state legislators are getting creative. They’re forgiving tens of thousands of dollars in loans, setting up mentorships, and recruiting med school grads with local ties in an effort to hold on to providers.
Convince a 30-year-old doctor fresh out of her residency to stay put, after all, and she could easily wind up delivering four decades of care in a needy community.
But on this crucial metric, some states are faring far worse than others. California, with an abundance of space and jobs for doctors, retains 70 percent of residents and fellows trained in-state — compared to just 28 percent in tiny New Hampshire, where full-time physician jobs are few and leaving the state may only mean moving a short distance.
There are stark contrasts even between states with similar demographics: Montana has a retention rate of 62 percent, compared to Wyoming’s 30 percent.
The data come from a new report from the Association of American Medical Colleges, which each year tracks America’s doctors and doctors-in-training, state by state.
Talia Bronshtein/STAT
Reversing physician shortages is a lot more complicated than simply “putting docs out in lonely frontiers,” said Dr. Janis Orlowski, a nephrologist who serves as the AAMC’s chief health care officer. States seeking to retain more of the young doctors who train there must focus on “making not only the environment a place where a physician wants to live, but also making the professional environment something that they are attracted to,” she said.
Here, some of the top strategies states are trying:
Wiping out student debt
One of the most popular tacks: agreeing to pay young doctors’ medical school debt or tuition costs if they agree to practice in underserved areas in the state.
Kansas’s program, funded by the state, draws about 30 students per class at the University of Kansas School of Medicine, according to university spokeswoman Natalie Lutz. For each year that they receive funding to cover tuition and living expenses, they agree to spend a year after their residency practicing primary care in Kansas, either in underserved areas, at a free clinic, or by serving veterans.
In Alaska, local governments foot the bill. Such programs often cover about $50,000 to $80,000 a year of debt on top of the young doctor’s salary, in exchange for three years of service in a region where physicians are scarce. The town of Valdez, which has four doctors for 4,000 people, is working to get the newest such program off the ground, according to Dr. John Cullen, a Valdez local who’s also president-elect of the American Academy of Family Physicians.
But these programs don’t always work: Lawmakers two years ago halted the state-funded program for students at the University of Mississippi Medical Center. It turned out that 40 percent of the 93 students who had signed up since 1999 didn’t end up practicing in Mississippi’s needy areas. Instead, they either paid back their loans, are still in the process of paying them back, or defaulted on them, according to Jennifer Rogers, the director of a state agency devoted to student financial aid.
Opening up new medical schools
One common obstacle to retention in underserved areas is the fact that there are often no medical schools pumping out doctors for hundreds of miles. So states are trying lure providers to these places at the very start of their medical training.
That’s why the Medical College of Wisconsin in 2015 opened a campus in northerly Green Bay and then last year opened another campus in the central part of the state.
And in Texas, similar efforts are underway far away from the metropolises of Houston, Dallas, and Austin. Texas Tech University in 2009 converted a satellite campus in El Paso to a full four-year medical school, while the University of Texas last year admitted its first students to a new medical school in Rio Grande Valley.
Giving students an early taste of life as an in-state doc
Medical school students get the summer off between their first and second year. In Ohio, that period becomes a chance to show off the charms of the Buckeye State.
Since 1990, nearly 1,000 Ohio medical students have participated in a program that allows them to spend four weeks shadowing a veteran doctor who practices family medicine in the state. They get a stipend and often get placed in rural areas. One of the goals: “Letting them know that those opportunities are available in Ohio,” said Ann Spicer, vice president of the Ohio Academy of Family Physicians, which funds the program through its foundation.
Funding more slots for medical residents
Another common barrier to retaining young doctors: too few residency slots — in some cases not even enough to accommodate many who went to medical school in-state.
In Texas, the legislature has tried to address that problem over the past few years by pumping millions of dollars into efforts to increase the number of residency slots in the state. In the most recent grant cycle, that meant creating or maintaining 680 slots for medical residents.
Recruiting doctors with local ties
It can be hard for states in flyover country to compete with places like California for doctors fresh out of their residency. But otherwise overlooked states can get an upper hand if a potential recruit has a personal connection to the state. Maybe they grew up there. Or got their undergraduate degree there. Or they might have family nearby.
The Iowa Medical Society is building a database of residents and doctors all over the country who have local ties to Iowa, in the hope that in the future it could aid in recruitment, said Dr. Joyce Vista-Wayne, a psychiatrist who serves as the group’s president.
Cullen — the family medicine doctor in Alaska — said that local ties can be a crucial factor in convincing young doctors to settle down.
“We’re all competing for the same physicians,” Cullen said. And, he predicted, “states and communities are going to be ending up competing even more.”
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Pure and simple is best. The shortages exist where the financial design is worst. The financial design is so bad for office, cognitive, basic services where most needed such that no training intervention can fix the shortages. It does not seem logical that the nation can have massive deficits of training while training far too many MD DO NP and PA graduates – but it does. Workforce can only go where the dollars flow – and the health care dollars are concentrated more and more in fewer places away from most Americans.
The US has now tolerated massive overexpansions of NP PA DO and MD and new sources of health professionals are still being proposed. Until the dollars are specific to building primary care, womens health, mental health, basic surgical services – especially where most Americans most need care – the shortages will continue to worsen.
Our national designs concentrate training, training dollars, and practice dollars in 1% of the land area with 10% of the population in 1100 zip codes with 45% of the health care workforce and well over 50% of health spending.
Why do residents leave states or fail to be found in some states?
1. States that have too many GME positions (about 6 – 10 states in a few dozen counties mostly in 1% of the land area) produce the most workforce. This is more than their state can support. These states also have the highest concentrations of workforce. The residents are forced to leave their state of training. They also have previous origins that are different than their residency training states.
2. States that have insufficient workforce (and counties, and cities) have a financial design that is insufficient to support generalists and general specialists. States tolerate insurance that fails to be accountable to the state or to local health care needs for most in the state. The states could also force greater levels of spending. A few are trying to double primary care spending because they realize that 5% of health spending is ridiculously low for 50% of services, but more than primary care needs help.
The primary care, mental health, women’s health, and basic surgical services are 70% of services overall, but are 90% of such services where half of the American population has half enough basic workforce – and far less of everything else.
3. No training design can overcome the overwhelming power of the financial design. Multiple new sources created with massive expansions of annual graduates have failed.
This failure is about insufficient revenue such as paid less where shortages exist and in the specialty areas most needed – such as primary care.
This is also about forced higher costs of delivering care due to usual costs increasing more rapidly than revenue and due to the focus on measurement. Micromanagements of cost and of quality are specifically more disabling to health access where most needed.
A better financial design supports more and better team members as seen in more specialized care. They now have substantial (and increasing) NP and PA contributions as they also concentrate where workforce is concentrated – due to the higher revenue for procedural, technical, hospital, and subspecialized care.
The salaries are also higher along with benefits when there is a better financial design. In my opinion the focus on salary differences hides the real reason for the problem – the financial design.
Residents in training fail to depart residencies after graduation to become general specialists (surgery, ortho, ENT, ob-gyn) – they continue to one or more fellowships. The academic and largest hospitals would like them to continue in training in fellowships because they are low cost high yield sources of revenue. The fellows also level up to a better financial design with more and better team members.
Shortage situations continue to worsen. The most rapid growth of population, demand, and complexity is specific to the 2621 counties lowest in health care workforce with 40% of the population
1. And only 22 – 26% of generalists and general specialists
2. 42 – 45% of elderly, poor, high deductible, Medicare, Dual, and Medicaid along with Food Stamp dollars, disability dollars, Social Security dollars (all on the chopping table).
3. 75% of the rural population (rural is not specific to underserved)
4. 32% of the urban population
5. 45 – 50% of diabetics, premature death, obesity, smoking, Veterans
6. Highest readmission penalties and likely other penalties because local providers care for populations with inherently lesser outcomes due to situations, conditions, environments, and other determinants of health outcomes.
7. Worst increases in the costs of delivering care because of the focus on metrics, measurements, micromanagement, reorganization, consultants, software, and corporations that do not deliver care and impair the team members that do deliver the care (for even less revenue)
These counties did not lack for health insurance more than the others as they had 40.2% of the population in 2010 and 40.6% of the uninsured. Before, during, and after ACA and proposed health insurance reforms, they will still have the worst financial designs specific to the services they need most. Expansions of plans that do not pay for basic services or that do not pay enough to cover the costs of delivering care – kill local workforce.
Only 6% of residents in training, faculty, researchers, and others most associated with major medical centers are found in these 2621 counties with 40% of the population.
The designers have created the most lines of revenue and the highest payments that benefit places of highest concentrations of workforce most.
The designers have neglected the one or two lines of revenue paid lowest where most Americans most need access, health care dollars, health care workforce, and economics.
When the diagnosis is insufficient finances, the solution is to address finances. But our designers went the opposite way.
1. They have not increased payments where shortages exist and they have not addressed 15% lower payments by design (15 – 30% lower when considering hospitals and other facilities).
2. They have increased the costs of delivering primary care in lowest concentration counties by about 8 billion dollars for MACRA, Primary Care Medical Home, and HITECH changes in the past decade, leaving only about 30 billion to invest in primary care delivery where there was once 38 billion.
The costs of each of these changes are greater for the smaller practices in these counties as measured per primary care physician.
3. CMS has no plans to invest more in generalists or general specialists in these counties most behind and crushes those who remain by penalties and much higher costs of delivering care.
The physicians in these counties have tired of working part time jobs so that their failing practices can continue. They will continue to exit to better financial design areas such as ER, hospitalist, urgent care, specialized care, and opportunities outside of most needed care.
The nurse practitioners and physician assistants share the same problems as MD and DO – as shaped by the financial design.
And to make matters worse, we have massive overexpansions in four sources of health care workforce. The diploma mills use the excuse that the nation has shortages – so we need to expand MD DO NP PA and GME. It will not work because of the financial design. And as bad as health care spending increases have been at 2% a year, the expansions of workforce are far greater.
Workforce should increase with population growth which has slowed to 0.6% a year – or 1.2% if allowing for aging changes. NP graduates have a 6% – 7% growth rate – from 10,000 to 35,000 and beyond since 1995. Other sources have 4 – 5% growth rates. Four sources all expanding way too fast – will be hurt all who are not near retirement. And the shortages will remain.
There is another consequence of massive expansion. The NP workforce has grown so fast that the majority have zero to five years of experience as an NP. This may been an even less experienced workforce in areas such as primary care, retail care, and urgent care which has higher turnover. There are also reductions of experience due to more who are part time, inactive, returning for other training, between jobs, or seeking to leave primary care.
A great job board no Physician knows about is from Kaiser in SoCal-http://scpmgphysiciancareers.com/
Take a look at public medical schools and the glaring percentage of in-state residents that are rejected in favor of out-of-state residents with higher grades and MCAT scores. Or the number of family medicine/internal medicine/pediatric residencies that prefer to take graduates from more prestigious Ivy League-type medical schools rather than graduates from local DO and MD schools. As medical school and residency becomes more and more competitive each year, it is no surprise that states have a hard time retaining local students – they don’t stand a chance in their own state.
This tells me that medical schools and residency programs care more about increasing their prestige rather than producing local doctors that are willing to practice in local underserved communities.
Just look at the number of urban medical schools that boast that they care about producing physicians that are dedicated towards serving the underserved, yet most of their graduates go on to specialize in lucrative fields.
There is clearly a pecking order. And in states such as Nebraska, those who used to get into more exclusive schools do not, this displaces other Nebraskans more likely to remain instate or choose FM. And yes, schools do recruit out of state origin students for research careers and for academic reasons. Some parents move to a state to get instate opportunities. Those with means can send students to Caribbean or international schools.
Exclusive origin students have many opportunities. More average students have one or none.
But all of this has little to do with primary care or serving where needed which is limited mostly by revenue too low, costs of delivery accelerating along with complexity.
Rural areas could benefit from the thousands of IMG who would love the opportunity to serve the community.
The studies about IMGs have been flawed up to the recent Graham Center article that include entire database contributions. The flaws include
1. Cherry picking of graduates that have only been out of residency for a few years when obligations and first career choices are maximal for primary care and underserved
2. About 20 – 30% of IMG graduates go back to home or other nations. These are excluded from analysis – also resulting in inflated claims
Studies using the entire AMA Masterfile demonstrate a cross section of career contributions and comparisons over two different years of Masterfile data confirm the lack of contributions to primary care, rural health, or counties lowest in physician concentrations.
The IMG outcomes are what you would expect from origins associated with top concentrations of people and advantages who have life experiences in the US in highest concentration settings.
Exclusive origins, training, and career choices limit distribution and health access contributions for all types of schools.
Graduates from countries such as Pakistan make significant mental health contributions and those from The Philippines and some Central and South American nations also have good contributions, but often in just a few states (ND, WV).
Distributions for International Graduates are similar to those of the top third of US MD schools in terms of exclusivity – about half the national average or less.
Choice of internal medicine for 45% results in a small portion in primary care and even lower in distribution. Family medicine is the only marker of distribution at 2 to 3 times greater. Internal medicine choice shrinks distributions of graduates.
Yes there are many graduates from exclusive schools or international schools that make outstanding contributions – but the cross sections do not indicate anything beyond low average levels.
Simple percentages do not take into account state geography (large state, multiple states bordering, coastal state, island, state financial designs specific to physicians, training in a city on the border of two states, multiple residencies/fellowships, and maldistributions of GME with so much in 6 states and so little in 30 states.
Regression studies indicate that 6 states with top concentrations of GME have difficulty retaining graduates in state – not just first choice but entire cross sections of currently practicing physicians. These states also tend to have top concentrations of physicians.
For 30 states lowest in concentrations of physicians, instate residency grads were about 20 times more likely to be found in the state using the AMA Masterfile with over 800,000 active physicians.
Instate birth and instate medical school were each about 3 to 5 times multipliers. More variables would help as these are only convenience data. Better data would be high school of origin, spouse and family influences, and specialty choice impacts. When variables are missing, those that are loaded take on increased contributions.
Sometimes career choice has a big impact. University of Nebraska med students choosing FM had 16 times greater location instate in Nebraska in one of 75 counties lowest in physician concentrations compared to UNMC grads not choosing FM (who had different origins, residencies, other state location of residency). U of KS had about 12 times multiplier for instate where most needed with FM choice. This is great for stats, but it has not increased health access. The FM increases just replaced internal medicine primary care and without a gain from the 50 primary care physicians per 100,000.
The financial design limitations result in a rearrangement of the deck chairs rather than needed improvement.
Rural locations and 2621 counties lowest in physician concentrations with 40% of the US population (50% by 2040) have half enough local primary care, women’s health, mental health, and basic surgical workforce (90% of local services where needed) because they have patients with the worst public and private insurance plans that pay less for basic services and 15% less for these services in these counties. No training intervention is capable of overcoming the ultimate power of the Triple Threat – payments too low and costs of delivery accelerating with complexity of care. Expansion of loser plans do not help. Innovation and regulation make matters worse.