Seeking the Rural Health Workforce
Summary of the 4/15/99 Forum

April 1999

An effort to dislodge the blindfold and see the proverbial elephant – in this case, the real dimensions of the rural health workforce – brought together a researcher, a recruiter, a legislator and two federal managers, April 15th.

The Capital Area Rural Health Roundtable’s forum on the rural health workforce and workforce programs, "Separating Myths From Realities," drew more than 90 organizational representatives to learn more about the relative undersupply of health care services and professionals in rural areas.

Guest speakers were Senator Kent Conrad (D-ND); Health Resources and Services Administration bureau chief Vincent Rogers, DDS; University of North Carolina Rural Health Research Center Director Tom Ricketts, Ph.D.; national rural physician recruiter Fred Moskol of the University of Wisconsin and director of the Wisconsin State Office of Rural Health; and National Health Service Corps director, Don Weaver, MD.

An immediate rural concern is the upcoming reauthorization of one of the oldest federal workforce safety net programs, the National Health Service Corps. Another is the actual prospect of elimination for one of the newer programs, the J-1 visa waiver for international medical graduates (IMGs).

The latter, which was expanded in 1995, allows medical exchange graduates in U.S. residency training to extend their stay for three years, provided they practice in an underserved community. For certain rural as well as urban areas of the United States, the "J-1 docs," as they are popularly called, have been key providers.

"Forty states participate in this program and it has made a real difference in extending health care to people who desperately need it," said Senator Conrad, who initiated the State-20 legislation in 1995 that allows states, not just federal agencies, to request up to 20 waivers a year. Eighty-five percent of North Dakota suffers a shortage of health professionals, said Conrad. [See Conrad Pledges J-1 ‘Fight’]

But deciding on the most effective combination of public interventions is a national puzzle that defies simple answers, if the Roundtable discussion was any testimony. First, the health care workforce is difficult to track. Second, the workforce is changing functionally as managed care reorganizes the market and as non-physician professionals acquire skills and expanded licensure for primary care. Noting that "roles are changing," Ricketts said Mississippi, in fact, "just passed a bill allowing pharmacists to counsel in a much more PA-like [physician assistant] way."

While across disciplines the "pull of specialization and urban practice," continues to undercut prospects for expanding rural practice, according to the speakers. Safety-net programs designed to resist that trend still feel the impact on their ranks, according to Dr. Rogers.

Even the international medical graduates, said Ricketts, "are like any other health professional across the United States." Although they practice "slightly more often in underserved areas," he said they "still tend toward specialization and urban practice."

Priming the Pipeline

Under Title VII of the Public Health Service Act, Dr. Rogers’ Bureau of Health Professions administers almost $300 million in annual grant dollars for health professions education. This sum amounts to a thumbnail of influence on the scale of national spending for professional education - less than a tenth of a percent.

The bureau’s programs, he said, are not so much designed to affect the overall supply of practitioners as to influence their direction. Various grants for medicine, dentistry, nurse education, and allied health training have funding priorities that emphasize generalist training, community-based training, and practitioners from under-represented rural and minority communities. Generalist and community-based training tends to yield more graduates who take up practice in underserved areas. About $73 million of those programs also have a specifically rural component.

Rogers did not extrapolate his program data for rural areas, but he made the case that while only 10 percent of the graduates of all U.S. health care programs work in medically underserved communities, "bureau-funded programs on average do much better" - by a factor of nearly four. Furthermore, bureau-funded minority graduates are more than double the U.S. average, he said. (Minorities comprise 30 percent of the rural poor.)

High Demand, Active Recruitment

We’re learning more about how to get people out in rural areas," said Wisconsin’s Moskol, "but there’s still a lot more to be done. We can’t rely on the training programs entirely to get people out there."

A pioneer of Wisconsin’s non-profit, rural physician head-hunting program, Moskol has used federal and private grant support over the last four years to organize a now 46-state national recruitment network of not-for-profit organizations called the "Triple-R Net, or rural recruitment and retention network. Mirroring commercial recruitment strategy, the network, said Moskol, witnesses a pervasive demand from rural communities.

"In these [46] states the demand for physicians and non-physician primary care providers is well in excess of 5,000," said Moskol. "It’s not a number that’s fluctuating very much." Even in Wisconsin, which has a well-developed rural delivery system, there is a strong demand, he said.

Moskol said the Triple-R Net came about because "there was a recognition that to get people to go and stay in rural communities took some talent." The most important facet of the network, aside from the clearinghouse function, he said, is the emphasis on community development. Recruiters have to know the community.

A potential threat to rural and other underserved communities, however, is the perceived national need to reduce the absolute number of physicians being trained in the United States, particularly specialists. That oversupply has been associated with a doubling of IMGs in the last decade, because they use their visa waivers as a bridge for establishing permanent residency, once they have fulfilled their obligation in an underserved site. Rrecommendations have come from the Institute of Medicine, the Council on Graduate Medical Education (COGME), and may soon come from the Medicare Payment Advisory Commission to reduce advanced training subsidies for IMGs. In 1998 the COGME called the J-1 program a "suboptimal" solution for rural shortages.

Yet rural demand "has not gone South," said Moskol. "Even with the J-1 program and the National Health Service Corps, we still don’t meet the needs for rural communities."

Data Myths and Realities

Finding the optimal approach to the workforce elephant, however, is further obstructed by the real blindfold of incomplete data. One of the reasons the picture is not connected is that states are the licensors of practitioners and few have in-depth information on numbers and practice locations, said Ricketts.

"We know that there is a variable distribution of health professionals in the nation," said Ricketts, who projected several maps, one of which showed the national range in physician-to-population density by county.* "We also know that a little more than 10 percent of the docs are serving 20 percent of the U.S. population." But exact data on who is practicing and in what capacity is still sketchy. To the extent that shortage areas must document their thin supply of practitioners, there is a better grasp of the elephant’s tail, so-to-speak. But the big picture using national data, said Ricketts, is based on estimates from sample surveys rather than inventories, especially for nurse practitioners, physician assistants and certified nurse midwives.

"We know even less about the minimum mix of health professionals" a community might need, said added Ricketts. That formulation could be changed, also, by ongoing systemic pressures from managed care, Medicare reimbursement, and graduate medical funding.

Nor have analysts looked at the combined effect in one county of several safety-net programs - such as rural health clinics, the National Health Service Corps, or Community Health Centers - in affecting demand for health professionals.

Questioning the Surplus

Ricketts saved his biggest surprise for what he called "the fundamental thing we don’t really know." He suggested that the prevailing assumption of a 20 percent global oversupply of doctors in the United States may be over-estimated by 13 percent or more. Calling North Carolina’s annual physician registration system "one of the few data sets that can verify the issue," Ricketts said his research center began assembling information three years ago - not on the number of heads or licenses, but on the actual number of hours physicians in that state practice medicine. Using the American Medical Association’s standard full-time-equivalent of 43.7 hours, Ricketts’ team produced an effective count of 12,134 active patient care physicians. Yet the North Carolina Medical Board’s head count was 18 percent higher at 14,366, and the AMA masterfile on the state was 13 percent higher at 13,670.

"We may find that the oversupply of physicians will actually disappear if we count them this way,’ Ricketts told the forum. He said North Carolina researchers and the University of Washington Rural Research Center have submitted for publication a joint paper with findings in both states that further corroborates the North Carolina work.

Analysts studying the nursing supply often refer to the numbers of people out of the full-time workforce, but the concept of actual clinical practice hours has been only minimally considered for physicians, said Ricketts: "This has huge implications for the effort to starve graduate medical education [funding] or cut off the J-1 visa program on the basis that there is an overwhelming supply of physicians."

Learning What It Takes

Meanwhile, panelists said there are definite gains in what is being learned about getting physicians, nurses, and others to go into rural areas, about training people adequately for broad practice demands, how to select candidates for rural practice and how to support them adequately when they get there.

Both Moskol and the NHSC’s Weaver, said placing rural clinicians is a deliberate matchmaking process. And where it’s a marriage, there’s an ongoing effort on both sides.

"Successful communities know what their needs are," said Dr. Weaver. Similarly, successful clinicians are those who understand the local culture – and "rural Appalachia is not the same as rural Alabama, Mississippi or Washington," he said.

Weaver said the Corps is ready to go beyond what may have been "the easy communities" to communities where the effort will be "labor intensive. Ships are safe in the harbor but that’s not what ships are built for," he said of the celebrated program. A reauthorized NHSC should be held "accountable" for its performance, he said, in terms of new clinical sites, rates of retention, and reduction in health disparities.

The Corps Versus the J-1

While the April 15^th forum underscored the need for more specific and comprehensive methods for tracking the health care workforce, it also highlighted the importance of the local conditions, traditions, and state proclivities.

An informal survey of state recruiters by Moskol’s Triple-R Net revealed a dramatic variation in observations about state use of and success with the NHSC and the J-1 programs. In Utah, for example, the J-1 option was called "a god-send" for its rural hospitals, because it "goes beyond primary care and helps sites not qualified for NHSC and state loan repayment programs." In Kansas, "only the real problem sites will hire" J-1s, it was said, while experience with the NHSC "has been excellent," although "more restrictive site qualification has cut potential [placements] in half."

Where indices of health are not as severe, such as in the West, said Moskol, communities have had more difficulty qualifying for NHSC practitioners. The Corps must fill sites of greatest national need, according to a four-criteria profile. For example, there are communities throughout parts of the Midwest, explained Weaver, that don’t quite make the cut because they don’t meet criteria for high poverty levels, minority populations, low birthweight or infant mortality, even though they are short of practitioners.

In contrast, the J-1 waiver and State–20 program gives states site discretion and allows them to tap even specialists. Yet a state like North Carolina, said Ricketts, deliberately decided not to use the State-20 program because state leaders wanted to keep pressure on local medical schools to meet state needs with domestic students. And the Corp’s scholarships helped bring those students to the schools.

Perhaps a "state-10" allotment for NHSC placements might give states more options, suggested Weaver, adding that this was a "variation on a theme that has been going around the table."

Panel moderator, Dr. Wayne Myers of the HRSA Office of Rural Health Policy had asked panelists to explain states differences in their dependence on the NHSC and the J-1 program. "I’m concerned we’ll get in the position of playing off the J-1 program against the Corps," he said. "I think that would be a terrible mistake."

Indeed, there were many suggestions in the Triple-R Net survey for refinements to each program. And the commentary made for subtle but, perhaps, significant distinctions in the elephant’s anatomy. The tail is, afterall, not the trunk.

*North Carolina Rural Health Research Center Maps on health professions and program distribution are on the Internet at http://www.shepscenter.unc.edu/research_programs/Rural_Programs/
maps/maps.html