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Report amplifies call for care in underserved areas

Primary care work force shortages are expected to worsen as medical students choose specialty fields.

By Marcia Frellick amednews correspondent — Posted Sept. 15, 2008

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A new report by the National Assn. of Community Health Centers shows a dire need for health care professionals in rural and low-income areas.

The report says about 56 million Americans lack adequate access to primary health care due to physician shortages in their communities. To reach these medically disenfranchised people and continue to serve current patients, health centers would need more than 51,000 more primary care professionals, including physicians, nurse practitioners and physician assistants.

The escalating need comes as career choices and location are turning many clinicians away from primary care and underserved areas.

"Coverage is not the only issue," said Jose Camacho, president of the Texas Assn. of Community Health Centers. The report ranked Texas among the top states needing the most primary care professionals. "We need infrastructure that's going to efficiently provide services."

Change will come only if more medical students choose primary care, more incentives are put in place to attract physicians to underserved areas and more attention is paid to the physician payment system, said Dan Hawkins, NACHC senior vice president of policy and programs and co-author of the report. The study was conducted with the Robert Graham Center and George Washington University, in Washington, D.C.

The AMA has encouraged development of incentives to make practicing in rural and urban underserved areas more attractive to primary care physicians.

An article in the March Academic Medicine said medical schools would more than double the number of new graduates going into rural practice if each added a rural training program. Researchers estimated that if each of the 125 allopathic medical schools committed 10 seats per class to a rural training track, the schools would produce 11,390 physicians over 10 years.

Currently, 3% of the 17,100 allopathic medical students who graduate each year plan to practice in a rural or small-town setting, according to the Assn. of American Medical Colleges.

Students choose specialties

Shortages are expected to worsen as medical school graduates increasingly choose specialty fields, experts said. Between 1998 and 2006, the number of graduates choosing anesthesiology residencies increased 150%, while the number choosing family practice decreased 51%, the report says.

Rick Love, CEO of Regence Health Network, which serves 12 counties in the Texas panhandle, knows well the problem of trying to attract primary care professionals to a small town.

One of his counties, Motley, with a population of about 1,500 and 60 miles from a sizeable city, recently lost its only clinician, a nurse practitioner who served 300 patients a month for nine years. Love has been filling the job with locum tenens three days a week but at twice the cost of having a full-time, mid-level professional.

He is considering telemedicine for the center, but that wouldn't help with emergency care.

"The people we are recruiting are the [international] medical graduates with J-1 visas," Love said. "They come for the three years they are under sponsorship and then they leave."

Nationwide, the pool of students on J-1 visas is declining -- from 11,471 in 1996-97 to 6,033 in 2006-07. That's partly because another type of visa, the H1-B, is less restrictive and thus, more attractive. A H1-B doesn't require students to serve in underserved areas if they stay in the U.S.

Among changes the NACHC report seeks is expanding the National Health Service Corps, which provides scholarships or other programs and loan repayment for students who choose primary care and serve in areas with a shortage of primary care physicians. But funding for that program has been decreasing steadily.

The report said policymakers must consider interventions to boost the primary care work force while ensuring that more practitioners practice in medically underserved areas.

In rural Yakima County, Wash., at Yakima Neighborhood Health Services, CEO Anita Monoian has witnessed the gradual erosion of the primary care candidate pool during her 30 years at the center founded to help the underserved.

"In the past, if we had an opening for a primary care physician, we would fill it in three or four months," she said. "Now we're looking at a year to 18 months. Particularly in the rural and frontier areas, it's gotten to be an almost insurmountable problem."

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