Enticing doctors to rural practices

Last month, New York became the latest state to confront a problem that other states have been wrestling with for some time-increasing the supply of physicians in their underserved areas.

New York, like other states with large swatches of rural land, has reason to act. One-quarter of the state's population-roughly 4.9 million people-lives in areas with more than 3,500 people per physician. According to the state Department of Health, it would require an additional 300 primary care physicians or more in each of these Health Professional Shortage Areas to begin to right the imbalance. Many of these same areas are also short of specialists. Eight New York counties, for instance, have no gynecologists practicing obstetrics. And Western New York is hemorrhaging surgeons at an alarming rate.

The proposed initiative-Doctors Across New York, the brainchild of Gov. Eliot Spitzer-is aimed at reversing these trends. In return for a five-year sign on, the state would help newly minted physicians pay up to $150,000 of their medical school loans. The program would also boost Medicaid pay for doctors who elect to practice in smaller communities and other areas of need.

States fill the vacuum

States have stepped in because "there's a vacuum" at the federal level, says Joel S. Levine, chair of the Board of Regents of the American College of Physicians and senior associate dean for clinical affairs at the University of Colorado School of Medicine, in Denver.

ACP would prefer to see a more coordinated federal effort, which is why it supported workforce legislation introduced in Congress last year. If passed, the bill would have offered scholarships and/or debt relief to new PCPs willing to practice in critical shortage areas.

The extra scholarship component, says Levine, is critical. "Debt from medical school is a mountain most doctors can't look past," he says. Making scholarships available to students who qualify for them keeps that mountain from forming in the first place. And that, he says, makes it easier for doctors to remain in underserved areas instead of bolting to higher-paying ones.

The bill-or something like it-may be reintroduced this session. Meanwhile, state-based actions are likely to continue. If Levine were designing them, they'd include scholarship grants for some students, sufficient debt relief for others, and universal coverage for every state citizen. "If 20 percent of the patients who come in to see a rural physician are uninsured, it's going to be that much harder for him to take care of people on state assistance or Medicare."

However they're constituted, high-need physician programs may always be a tough slog financially. Levine, for one, finds that curious: "As a society, we've accepted the fact that it costs more money to deliver mail to remote places because we believe it's important that everybody gets mail. Well, isn't it just as important to pay a little extra for high-need doctors so everyone gets healthcare?"