Rural health care falling behind nationally, and action is needed now, AMA president-elect says

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Rural health is America’s health, but the U.S. health care system is leaving behind residents of rural parts of the country, said the president-elect of the American Medical Association (AMA).

Bruce A. Scott, MD, a Kentucky otolaryngologist, next month will assume the formal role of AMA president. This month, he is a guest speaker at the National Rural Health Association’s (NRHA) annual conference in New Orleans. Scott also met online with news media on May 9 to discuss “the ever-widening health disparities between urban and rural communities.”

Those are at the root of why rural Americans suffer disproportionately high rates of heart disease, cancer, stroke, respiratory illness, diabetes, and unintentional injuries, he said.

“Let's look into what are the common health disparities that are driving such poor outcomes in these rural communities,” Scott said. “Of course, they include economic pressures and the lack of job security. Sometimes there's limited access to healthy food and good living conditions. Many of these individuals live below are at the poverty level.

“But my focus, and the focus of the American Medical Association, is on the worsening health care worker and physician shortage of primary care and specialists, particularly in the rural areas, that are exacerbating these concerns and creating health care trends that are simply unacceptable,” he said. “We need to reverse these trends for all individuals who live a long, healthy and active life.”

Possible solutions

While the AMA president is changing, the organization is keeping its priorities for reform in the U.S. health care system, Scott said. Needed improvements are:

• Fix the Medicare physician payment system.
• Address workforce burdens that are spurring early retirements and burnout.
• Expand residency and Graduate Medical Education slots.
• Create incentives for physicians to work in rural communities.
• Expand and change J-1 visa rules to allow qualified international medical graduates to stay and practice in the United States.
• Allow COVID-19 pandemic telehealth flexibilities to continue. Telehealth and remote patient monitoring are essential in rural areas where transportation may be a challenge.

Finally, chronic disease is disproportionately affecting rural populations. AMA, lawmakers and regulatory agencies need to bolster health outreach and education to rebuild trust in science and medical institutions.

Primary care needed

The NRHA notes family physicians make up 15% of the U.S. outpatient physician workforce nationwide, but they provide 42% of the care in rural areas.

“We believe that primary care is essential because that's where care begins,” Scott said. “We are strong believers in the medical home format, that if patients go to their primary care or early and get preventive care, then we know that that reduces chronic disease and reduces expense overall.”

But they are saddled with the most challenges – being on the lower scale of reimbursement, stuck with more prior authorizations but lower pay than other medical specialties, Scott said.

Not enough doctors

While small towns and farmlands individually have small populations, collectively they add up to 46 million people more than 15% of the American population, and more people than the nation’s 20 largest cities combined, Scott said.

For those seeking health care, the situation is growing bleak. Studies show there are about 30 specialist physicians for every 100,000 residents in rural areas, compared with 263 specialists per 100,000 people in cities.

From 2010 to 2021, more than 130 rural hospitals closed their doors, and many more are on the verge of closure now, Scott said.

A full 65% of communities don’t have enough primary care physicians, including pediatricians. Residents 80% of the time will practice within 80 miles of where they do their residency, but there aren’t enough training slots, and new physicians saddled with medical school debt end up practicing where wages are higher.

Not enough money

Meanwhile, Medicare physician payment is shrinking, dropping 29% since 2001, when adjusted for inflation, as practice costs have gone up by 54% in the same time.

“Physician practices like my six-physician private practice in Louisville, Kentucky, are struggling in large part because the Medicare rate has remained stagnant or declined over the last two decades,” Scott said.

“Making matters worse, is that the private payers, the other insurers, are well aware of the downward spiral of Medicare payment system,” he said. “And as a result, what they've done is linked their payment to the Medicare payment structure.”

In an example from his practice, a major insurance company that controls 60% of the private payer market in Louisville, Kentucky, offer rates linked to Medicare, with surgical rates lower than what they paid six years ago, Scott said.

Meanwhile, employees also feel the sting of inflation and are asking for raises. Physicians have difficult choices – invest in the latest equipment, or not, or reduce staff, or limit new Medicare patients he said.

“We need a system that is sustainable, predictable, and provides at least an annual inflation update that encourages patients choice rather than consolidation,” Scott said.

Too much burnout

Scott also described the administrative burdens plaguing physicians who now spend two hours on administrative work for every hour of patient care. Physicians complete an average of 45 prior authorizations a week, more in primary care, contending with insurance company staff who do not know the patients and may not have gone to medical school.

“And heck, in my case, sometimes they can't even say otolaryngology, much less telling me what the appropriate care is for my patients,” Scott said. In another anecdote from his own practice, he described a patient who needed an aggressive surgery to remove a maxillary sinus tumor. The insurance company rejected the prior authorization because she had not been on antibiotics, which would not have cured the tumor anyway.

Scott convinced the insurance company and that patient is recovering, but the stress on her “was just unacceptable.” It’s a situation replicated across the country every day, he said.