Rural doctors need to support recruitment of more colleagues, former Leitchfield hospital administrator writes

With Kentucky's doctor shortage about to be exacerbated by expansion of the Medicaid program and federally subsidized health insurance, there will be more competition than ever to recruit physicians, especially to rural communities. Some doctors resist such recruitment, but they are short-sighted, writes Stephen Meredith, former chief executive officer of Twin Lakes Regional Medical Center in Leitchfield.

Twin Lakes Regional Medical Center

"When I became CEO of TLRMC in 1983 our local hospital had seven doctors on its medical staff, so the first order of business was the recruitment of additional physicians, or so I thought. When this idea was presented to the collective medical staff it with was met with a resounding 'NO.' The medical staff’s concern was recruitment would hurt them financially by further 'dividing the pie' of a finite number of patients," Meredith writes for The Record in Leitchfield.

But many more doctors were recruited (now more than 30), and the old doctors realized it was a good thing, Meredith writes: "Two of the more vocal physicians against recruitment later acknowledged the addition of more physicians, especially specialists, made their own practices even busier than before. In defense of these men, they were so busy seeing patients in their practices, they had to believe they were seeing everyone who possibly needed medical care. However, they had no idea how many people were leaving our community for health care because of the shortage of physicians."

The phenomenon extends to other lines of work, Meredith notes: "What occurred within our medical community was recognized and theorized by John Nash as the theory of economic equilibrium for which he won the 1994 Nobel Prize in economics. His theory, in essence, is when we all work together for everyone’s mutual benefit rather than just our own, in the long-run, everyone benefits by expanding the 'size of the pie.' No one wins when it comes at the expense of others, but everyone wins when we take a broader view of our community and purposefully commit to pursuing initiatives which leave no one behind. After all, we are all in this together." (Read more)

As health care expands and more providers are needed, pressure grows to allow nurse practitioners more prescribing authority

By Molly Burchett
Kentucky Health News

As Kentucky expands Medicaid and implements the Affordable Care Act, more Kentuckians will have health coverage and access to care, worsening Kentucky's already existing shortage of physicians, particularly those providing primary care in rural areas. And, as the stakes get higher, so do tensions between physicians and nurse practitioners about how newly covered Kentuckians will receive their care.

Nurse practitioners say part of the solution involves removing their requirement to have a "collaborative agreement" with a doctor to write prescriptions. Nurse practitioners have been pushing for years to get rid of this requirement, saying they have the expertise to independently prescribe non-scheduled or routine drugs like cholesterol medications, reports Laura Ungar of The Courier-Journal in an article about the NPs' debate with physicians.

Doctors say collaborative agreements are necessary to protect patients, and call for a team-based approach to health care, writes Ungar. “My hope is the collaborative agreement will be strengthened,” Dr. Shawn Jones of Paducah, past president of the Kentucky Medical Association, told Ungar. “Certainly, physician manpower is an issue in Kentucky and in the U.S. ... but there’s not a great amount of evidence that collaborative agreements impair nurse practitioners from performing their duties.” But Ungar's story notes that NPs sometimes have trouble finding a collaborating physician.

Legislation to let NPs prescribe non-scheduled drugs without a doctor agreement passed the state House but failed in the Senate this year. The NPs aren't giving up, and many are working with state Sen. Paul Hornback, R-Shelbyville, on a similar bill for the next legislative session. Most agree that collaborative agreements are appropriate in the case of controlled substances, such as narcotic painkillers, but other wish to prescribe other drugs too, reports Ungar.

Seventeen states and the District of Columbia allow full prescribing authority for nonscheduled medications to nurse practitioners (see chart below), which means they do not require a signed agreement with a physician. Note that no Southern states allow nurse practitioners to work independently.

A recent report by Deloitte Consulting estimated that the state needs 3,790 more doctors just to meet current demand, which means this is what is needed even before considering the health law or Medicaid expansion. The report says that unlike the need for nurse practitioners, which is balanced between rural and urban populations, the state's doctor shortage occurs mostly in rural areas; the need was 61 percent rural in 2012 and is forecast to be 63 percent rural as Medicaid also expands.

The state needed 183 primary care physicians in 2012, and will need about 284 by 2017. The neediest counties are Bullitt and Spencer, which are close to Louisville. The need is heavily concentrated in the eight southwest border counties, and with Medicaid expansion, it will increase by 42 percent, says the report.

It's clear that large gaps appear in Kenucky's health-care workforce in Kentucky, particularly in rural areas, the Deloitte report says. A more detailed look at the county level is needed to determine the true workforce capacity issues, and can be done by provider type through an interactive tool the firm developed by clicking here.

The need for nurse practitioners in 2012 is relatively low compared to other groups -- 148, or 5 percent of the current supply, says the report. However, "If 6 percent of the current [NP] population were added to the current PCP [primary care provider] supply, the entire PCP gap could be addressed," the Deloitte report says. (NPs are generally referred to as advance practice registered nurses, or APRNs, as indicated on this map.)

To help address this overall provider shortage, Deloitte made 11 recommendations to the state, one of which included authority for nurse practitioners to prescribe less risky drugs without an agreement with a physician. This has been the issue debated by NPs and doctors at the legislature. The report says loosening collaborative agreements could do a lot to address the need for primary care. Giving nurse practitioners more authority has many benefits, including the fact that nurse practitioners who would be able to work more independently may be more likely to set up practice in rural areas.

Some other recommendations in the report include creating support programs for small practices in rural and under-served areas; considering limits on medical malpractice awards; expanding regional rural health tracks to get more new doctors to rural areas and keep them there; and increasing health-care degree and residency capacity across the state.

Family physicians group objects to cuts to primary-care physician training programs; cites doctor shortage, which is worse in Ky.

Facing an already-existing shortage of primary care in the country and state, the American Academy of Family Physicians sent a letter to U.S. Rep. Harold Rogers, R-Ky., chairman of the House Appropriations Committee, saying the committee's 2014 funding allocations could damage the nation's primary-care infrastructure by cutting primary-care physician training and research programs.

In the June 18 letter, AAFP Board Chair Glen Stream wrote, "We are concerned that the House-proposed allocation will be inadequate to make the necessary investment in vital primary care research and physician workforce training." The proposed allocation would reduce funding for the only federal program that provides funds specifically to academic departments and programs that increase the number of primary-care health professionals, says an AAFP release.

There are not enough primary-care physicians being trained to meet the demand for services, and a recent study shows only a fourth of newly educated doctors actually go into this field. Even worse for Kentucky, which faces a critical doctor shortage amid Medicaid expansion, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services. The study's lead author wrote, "If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse."

How can Kentucky meet the critical demand for new doctors when Congress has proposed to make additional cuts to training programs?  Kentucky needed to increase its number of doctors and other medical professionals even before the state decided expand Medicaid, says a recent review by Deloitte Consulting.  The review found that the state needs 3,790 additional physicians, including primary-care doctors and specialists, and the doctor shortage is worse among rural communities.

Doctor shortage news: Residencies are filling the pond with primary care doctors, but U.S. and Ky. need an ocean of them

Despite a critical shortage of primary care in the country, only 25 percent of newly educated doctors go into this field, and even worse for the mostly-rural Kentucky, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services (SPHHS).

The report, which was just released in the “Published Ahead-of-Print” section in Academic Medicine,  suggests that not only are we facing a primary care shortage, but also that the problem is not likely to be solved soon. There's been a lot of talk about the need to get primary care doctors to practice in Kentucky, specifically in the state's rural areas, without mention of the underlying issue that the study makes clear: there are not even close to enough doctors being trained as primary care physicians in the first place.

In addition to finding that just 4.8 percent of the graduate medical education system practiced in rural areas, 198 institutions (26 percent) produced no rural physicians and 283 institutions (37 percent) produced no Federally Qualified Health Center or Rural Health Clinic physicians, which were created to enhance the provision of primary care services in underserved communities.

“If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse,” said lead study author Dr. Candice Chen, a professor at SPHHS. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”

Currently, the U.S. is producing primary care physicians at rates that are “abysmally low” and unless changes are made to the system, the nation will have an even greater shortfall of primary care doctors just as the Affordable Care Act ramps up demand for these services, said Chen in a Newswise release. And in Kentucky, the additional need for primary care doctors as a result Medicaid expansion is piled onto the heap of issues.

The study's authors said policymakers should take a hard look at the skewed incentives and other factors that have led to the current primary care crisis and develop a more accountable graduate medical education system. It is critical to find a better balance in medical specialties and more primary care physicians to build an effective, affordable health system.

Legislature eases physician assistant rules; nurse practitioners' prescription power, Medicaid prompt-payment bills, others linger

By Molly Burchett and Al Cross
Kentucky Health News

The Kentucky General Assembly has joined other states in easing the restrictions on physician assistants’ medical practice, but has held up a similar move for advanced registered nurse practitioners. Both issues relate to the shortage of medical practitioners in many Kentucky counties, and the quality of medical care.

The Senate added the physician assistant language of Senate Bill 43 to House Bill 104, an art-therapy bill, in order to preserve an agreement between the Kentucky Medical Association and the Kentucky Academy of Physician Assistants. It will repeal the law that bans PAs from practicing for their first 18 months unless a physician is on site; one will still have to be available by telephone. The amended bill has been sent to Gov. Steve Beshear for his signature or veto.

The amendment was used because the House had tacked onto SB 43 an amendment from advance practice registered nurses that would have repealed the need for them to have a collaborative agreement with a physicians to prescribe non-narcotic drugs. The KMA opposes that idea.

"It's looking like the doctors win," said Sen. Julie Denton, R-Louisville, who favors the repeal. "I'm not hopeful" it can pass, she said, but added that some physicians also favor it: "With Obamacare coming in, we're going to need all the front-line physicians we can get." Leading opponents of the measure, Republicans Katie Stine of Fort Thomas and Carroll Gibson of Leitchfield, didn't return a call seeking comment.

Nurse practitioners say that SB 43 is necessary to allow them to fill health-care gaps in rural Kentucky and address the state's shortage of primary-care providers. The Kentucky Coalition of Nurse Practitioners and Nurse Midwives says in an article prepared for Kentucky newspapers that NPs have never been required to practice under physician supervision and 17 states allow full prescribing authority for non-scheduled medications.

The Medicaid prompt-payment bill, HB 5, went to a conference committee after the House refused to go along with Senate changes, and may be considered when the legislature returns later this month, ostensibly to consider any bills Beshear vetoes. The bill would apply prompt-payment laws to managed-care organizations and would move Medicaid late-payment complaints to the insurance department; those are now handled by the Cabinet for Health and Family Services, which administers Medicaid.

In the final crunch to pass legislation before the veto recess, lawmakers attached seven health care-related bills to HB 366, which had focused on identifying congenital heart disease in newborns. It had 10 additional measures "hung on it like a Christmas tree before the free conference committee of House and Senate members," reports Ryan Alessi of cn|2's "Pure Politics."

The bills still hanging on the measure, dubbed the "healthy Christmas tree," are:

• HB 187, addressing a free prescription-drug program for under-insured Kentuckians.
• HB 79, which would exempt licensed health care providers from being disciplined for prescribing naloxone in the event of an overdose.
• HB 387, which aims to provide nutritional supplements for low-birth-weight newborns.
• SB 201, which addresses licensed diabetes educators.
• SB 38, to require Medicaid to accept provider credentialing by a Medicaid managed-care organization.
• SB 108, relating to managed-care contracts with the IMPACT Plus program, a behavioral health program for children.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Health reform expected to hurt recruitment of rural doctors

Recruiting doctors to rural hospitals will get harder in the next few years as the Patient Protection and Affordable Care Act reaches full implementation and the demand for healthcare services increases, a new report suggests. An Association of Staff Physician Recruiters report, "In-House Physician Recruitment Benchmarking," says interview-to-hire ratios in rural areas are much higher than in urban, and rural recruiting officers are often responsible for several things, not just hiring new doctors, making them overworked. Both factors make it harder for rural hospitals to recruit, the authors concluded.

ASPR Benchmarking Committee Chair Shelly Tudor told John Commins of HealthLeaders Media that the cost of recruitment is rising, making it hard for rural hospitals to compete with their urban counterparts. "In lots of respects, the process favors urban providers. Physicians are coming to urban areas and they are looking for jobs, whereas rural providers have to go out and target physicians that are likely to come to their area," Tudor said. Rural recruiters have to "filter through a lot of people to find the right one who is willing to come in and even look at the opportunity," she said. (Read more)

New health law and aging baby boomers' anticipated strain on the system is about to make chronic doctor shortage worse

Kentucky's persistent physician shortage is hardly new. Almost a century ago, the Frontier Nursing Service came to Hyden on the presumption that doctors wouldn't. A report from the Health Resources and Services Administration in 2005 found that 81 of 120 of the commonwealth's counties were officially health professional shortage areas. Now comes news that areas in the United States with growing and dense urban populations are feeling the considerable pinch of also not having enough doctors to provide care.

New York Times reporters Annie Lowrey and Robert Pear report that with the expansion of insurance coverage and aging baby boomers driving up demand, we shouldn't expect the shortage to get better anywhere before it gets worse everywhere. (NYT chart)


"The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. That number will more than double by 2025," report Lowrey and Pear. "Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000." In addition, Medicare officials predict their enrollment will surge to 73.2 million in 2025, up 44 percent from 50.7 million this year because of the baby boomer demographic hitting their golden years. “Older Americans require significantly more health care,” said Dr. Darrell G. Kirch, the president of the Association of American Medical Colleges. “Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.”

Medical school enrollment is increasing, but not as fast as the population. The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement. (Read more)