As the COVID-19 pandemic starts to wane and Americans start to see semblance of normalcy, doctors and healthcare systems are left picking up the pieces of the events of the last 18 months or so. The pandemic has clearly magnified and worsened many pre-existing healthcare problems, most notably physician shortage.
The COVID-19-related retirements and death/disability of physicians, sadly in many cases, is already having devastating impacts, but the effects are being felt much stronger in areas which have had pre-existing shortages of doctors. Small and mid-sized communities which assume doctors will automatically get replenished are doing so at their own peril. The days of physicians who returned to their hometown no matter where it was located has been severely upended by several market forces and governmental policies. The financial risk, while dealing with the barrage of administrative burdens associated with patient care, is turning off young physicians from owning their own medical practice. The consolidation of care into larger organizations which can withstand risk due to their size and lobby the legislature with their deep pockets are hastening this trend. Additionally, younger physicians are preferring urban and suburban areas which have enticing turnkey employed positions as they graduate with larger and larger student debts.
The American Associations of Medical Colleges (AAMC) predicts a shortage of up to 122,000 physicians by 2032, with rural and historically underserved areas experiencing those shortages most acutely. Only 11% of doctors practice in rural communities, and as of 2019 over 62% of all federally designated primary care Health Professional Shortage Areas (HPSA) were in rural areas according to one study.
The number of physicians per 10,000 people is 13 in a rural area versus 31 in a urban location, according to the National Rural Health Association. What’s astounding is the shortage of specialists when comparing rural to urban communities. The discrepancy is a shocking 30 specialists in remote areas to 263 available to metropolitan areas per 100,000 people.
As it has in the past, the AAMC has supported passing legislation that would increase federal support for an additional 3,000 new residency positions each year over the next five years. But you need many doctors to train a doctor, and the complexity of increasing training program slots without compromising quality is a discussion in itself.
In a physician-owned cancer clinic, patients walk in through the front door because of the physician’s reputation and the results that he or she provides. The conversations with your personal hometown physician over sickness or about general wellbeing have deep impacts on a person as the message is being delivered by person who knows a good bit of your life story as the doctor is a part of the same community. I have personally seen how a simple and focused conversation about kicking a habit like smoking has had on a person’s life.
Additionally, a physicians clinic has an outsized impact on the local economy in terms of well-paying jobs and people migrating into the community for short-term needs and long-term retirement. Besides, study after study has shown that your local cancer doctor’s office is a significantly cheaper site of care compared to a hospital system.
The effects will be quickly felt when one must drive 50 miles for basic acute and preventative care that used to be available in under a 10-minute drive. Imagine the impact on your work and family life if you must be away from family and friends for chemotherapy or radiation which could last 7 or 8 weeks in a city where you do not know anyone.
Lamenting about the situation without solutions is ineffective. These are complex forces that drive this trend and hence any attempt to provide bumper sticker solutions may be frustrating to a policy guru, but change must start somewhere. In fact, every major piece of legislation started off as an idea somewhere from someone. In my opinion, we can change the trajectory of this issue by changing the incentives that drive this perverse concentration of medical resources through legislation and through local community action, the latter being a more achievable task in the highly partisan political era in which we find ourselves.
Concerned citizens need to talk and write to their elected representatives, both at the state and federal level about their ideas on legislation that will increase incentives for practitioners to move to smaller communities. This can be done at the medical student level by forgiving student debt, by increasing reimbursement for practicing in these areas and decreasing administrative burdens. Misguided mandatory risk sharing demonstration models from the government stand to do nothing other than push younger cancer doctors to work for a hospital and hence must be nipped at the bud. There are a lot of smart folks who can propose legislation, but a majority of citizens must notice what is going on and demand bold action. Policy follows people’s appetite for action in any democracy, and your elected representatives will listen if enough people make those calls.
At the community level, the local chamber of commerce (COC) needs to collect data on healthcare practitioner trends over time and come up with a plan in conjunction with the physicians on how to make the community attractive for future recruitment and prevent early retirement and closures. The local COC needs to view a doctor’s office as a ‘small business of special significance’ and look into projected 5- and 10-year future trends for coming up with an action plan. Local citizens can do their part by creating not-for-profit charities to support patient’s skyrocketing out-of-pocket costs for healthcare. Additionally, larger healthcare systems with community presence need to find innovative ways to invest in the long-term viability of their local physicians. It would also help if certain well-meaning but misguided legislations (certain provisions of stark/anti-kickback laws) are amended to collaborate with cancer clinics in underserved areas instead of trying to swallow them.
The bottom line is that small and mid-sized communities can no longer take local cancer care for granted. Local citizens and groups that take innovative and proactive steps to retain and support reputed local doctors and their clinics in their communities like any other small business, will reap its significant benefits both in the short and long term.
Dr. Harsha Vyas MD FACP, is a practicing Medical Oncologist and Hematologist in Dublin, Georgia. He is an Assistant Professor of Medicine at Augusta University. He along with his partner founded the Cancer Center of Middle Georgia, a private practice community cancer center providing Hematology and Oncology care in Dublin, Georgia. His mission is to deliver quality, comprehensive, compassionate care to cancer patients in and around Laurens County in Central Georgia.
Dr. Vyas is a member of American Society of Oncology (ASCO), Community Oncology Alliance (COA), American Society of Hematology (ASH), and the American College of Physicians (ACP). He is an active member of the governmental affairs board of the community oncology alliance which advocates for the community cancer patient.
Dr. Vyas has also been involved in various advocacy activities including communicating the importance of preserving community oncology as the best way to deliver personalized, high quality, affordable, accessible cancer care.