Density of US primary care clinicians increases, particularly in urban counties

Gary Price, MD

The Physicians Foundation has not drilled the data from its surveys down to the county level as Zhang and colleagues did. However, the overall message of their findings — that rural areas do not have as many physicians as urban areas — mirrors those of the Foundation’s surveys conducted at state, regional and national levels.

To reverse the trends that we and Zhang and colleagues identified, we need to incentivize rural physicians, as well as account for the challenges of their practice settings in payment schemes. Current federal quality measures penalize physicians who treat large numbers of patients with conditions exacerbated by social determinants of health, a common scenario in rural practice. Consolidation of health systems, encouraged by the payment environment, has led to rural hospital closures, increasing costs and decreasing access to care, frustrating physicians and patients alike. The adoption of telemedicine can be more difficult and expensive in rural areas for both physicians and patients. There are currently relatively few opportunities for medical students and physicians in residency training to work in rural settings.

I do not want to make it sound as if everything about practicing medicine in a rural area is bad. It can be a rewarding lifestyle for many, especially when a physician becomes connected to the community that he or she practices in. But it will take more than that to encourage more physicians to practice in rural areas. We need more rural frontline physicians to step forward and be heard on professional issues that trouble them, so that lawmakers and educators understand the unique aspects of this important segment of health care.

Reference:

The Physicians Foundation. Taking the pulse on how physicians and patients feel. https://physiciansfoundation.org/physician-leadership/physician-and-patient-surveys/. Accessed November 10, 2020.

Carrie Henning-Smith, PhD, MPH, MSW

This new study by Zhang and colleagues adds additional evidence to what we already know to be true: Rural areas have disparities in access to care relative to urban areas. The authors find that “the density of primary care clinicians increased overall, yet rural-urban disparities in the primary care workforce are increasing in the U.S.” The former is a largely good news story about general increases in the availability of primary care, with especially notable increases in the supply of nurse practitioners and physician assistants. However, the latter part of their finding signals pervasive geographic inequities in the availability of health care workforce.

Notably, Zhang and colleagues looked at rural-urban differences on average across the U.S. but included maps that indicate heterogeneity in primary care workforce availability within rural areas. Rural areas are not monolithic, nor are the residents that live within them. For example, rural hospital closures are disproportionately located in Southeastern states, and structural racism contributes to within-rural disparities in health outcomes by race and region. Extension of Zhang and colleagues’ research should explore ways that the availability of primary care varies across rural areas.

Primary care is often the first stop for care and is critical to providing routine preventive services, as well as to diagnosing and treating chronic illness. Reducing health inequities between rural and urban populations needs to include a focus on access to care, starting with primary care. Programs exist to encourage health care providers to practice in rural areas, including rural training and residency, loan repayment, increasing the number of graduates and removing barriers to practice. However, this study by Zhang and colleagues shows, once again, that there is still more work to do.

References:

Henning-Smith CE, et al. Health Aff. 2019;doi:10.1377/hlthaff.2019.00847.

Rural health information hub. https://www.ruralhealthinfo.org/topics/health-care-workforce. Rural Healthcare Workforce. Accessed November 10, 2020.

Rural hospital closures. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/. Cecil G. Sheps Center for Health Services Research. The University of North Carolina. Accessed November 10, 2020.