Doctor shortage takes toll in rural areas

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Doctor shortage takes toll in rural areas

Declining Medicaid payments, long hours and rising costs are part of the problem.

by Andrew Kramer, The Associated Press via Statesman Journal
September 28, 2003

Rick Bowmer / Associated Press

Internist Roger Piepenbrink adjusts the lights of an examination room at his office at the Pioneer Memorial Hospital in Prineville. Piepenbrink is the only internist for the town of 7,400. Hurt by rising costs and dropping reimbursement rates, physicians are reluctant to take positions for country doctors open in Oregon and across the country.

Nestled in a valley below ridges of exposed rock, Prineville is favored by

fly fishermen, elk hunters and horseback riders.

But the city of 7,400 is a hard sell for doctors graduating from medical schools in larger cities. A position for an internist at Prineville’s Pioneer Memorial Hospital has not been filled for more than one year.

Buffeted by rising costs and declining Medicare and Medicaid reimbursement rates, rural physicians say that practicing medicine in the countryside is increasingly a money-losing proposition. Many doctors are avoiding rural areas and working in cities, where their hours typically are shorter and their costs lower.

In Oregon , 14 hospitals, four clinics and two health departments in rural areas are short a total of 70 physicians, according to the Office of Rural Health at Oregon Health & Science University.

Throughout the country, at least 1,500 positions for rural doctors are vacant, according to the Madison, Wis.-based Rural Recruitment and Retention Network.

“The people that have insurance live in cities,” said Roger Piepenbrink, a Navy-trained internist at Pioneer Memorial, who now is the town’s only such doctor.

“It’s hard to make a living off subsidized medicine,” he said. “You can make your overhead, but you can’t pay yourself.”

Piepenbrink, a specialist in osteoporosis, said he is on call more often than an urban counterpart, earns less, and has no colleagues to consult.

The other internist left in 2002, moving to Bend for personal reasons, Piepenbrink said.

Three candidates for the second internist position have visited, said Don Wee, the hospital director. The last, a graduate of a New York medical school, came 10 months ago.

“It just wasn’t a good fit,” he said about the candidates.

All were treated to dinners, introduced to the local medical community of about a dozen doctors and shown real estate. But none wanted to move to Prineville.

The shortage of doctors and specialists has a significant impact on a community’s residents. They often have to travel long distances for care or wait weeks or months for appointments. Because of a shortage of obstetricians in Prineville, some women choose to have their babies in Bend , 34 miles away, Piepenbrink said.

The dwindling pool of rural physicians drew the attention of the state Legislature this summer. It passed a law subsidizing malpractice insurance for rural physicians with a $10 million fund. Oregon already offers $5,000 state tax credits to rural doctors and pays rural hospitals more for Medicaid patients.

At the same time, however, faced with a state budget crunch, the Legislature cut rates for the Oregon Health Plan, the state’s version of Medicaid assistance for the poor. It also stripped Rural Health Association grants.

Nationwide, states raised Medicaid rates this year on average 9 percent, lagging behind inflation in private medical insurance premiums of about 14 percent.

Also, the Northwest’s payments to doctors for Medicare, the federal insurance for the elderly, are among the lowest in the country, said Paul McGinnis, director of field services for the Office of Rural Health at Oregon Health & Science University.

Lower Medicaid and Medicare rates affect country doctors more than urban and suburban doctors, because the percentage of public health recipients is greater in rural areas.

In Prineville, between 50 percent and 60 percent of the patients at Pioneer Memorial are on Medicare, and 12 percent to 15 percent are on Medicaid, Wee said.

Both compensate at about 60 percent of market rates.

Other problems for doctors include a low volume of patients, and the cost of equipment and malpractice insurance are the same as in a city.

A survey by the Oregon Medical Association this summer showed that rural doctors are on call more hours than their nonrural counterparts. The state average was 40 hours per week but doctors in Central Oregon averaged 46, and in rural Eastern Oregon 61 hours.

The survey also showed doctor’s practices closing at a greater rate in rural areas than in the state as a whole.

Statewide, 4 percent of doctors recently closed or plan to close their practice because of rising costs, according to the survey. In some rural areas, such as Eastern Oregon , the rate was more than 10 percent.

The rapidly changing, high-priced world of modern medicine is colliding with the traditions of a country doctor, said Piepenbrink, who moved to his job three years ago from Pensacola, Fla.

“Hopefully, you had your friendly family doctor all through your life, but how he runs his practice has changed completely,” Piepenbrink said.

“The face stays the same, but the guts of it are changing. The industry is changing, and the rural community has not answered,” with more incentives for doctors, he said.