In Depth

Helping the Underserved

Panelists to Discuss Identifying, Addressing Areas Without Doctors

The popular conception of medically underserved areas is a remote rural locale—the hollows of Appalachia or South Dakota’s plains, say—where residents must travel many miles to be seen by a physician or wait for the medical practitioners to come to them via traveling clinic.

There are plenty of those areas nationwide, including about 200 U.S. counties with no doctor in residence, said Dr. Mark Doescher, director of the WWAMI Rural Health Research Center at the University of Washington. (WWAMI stands for the five states covered: Washington, Wyoming, Alaska, Montana and Idaho.) But densely populated inner-city areas with hundreds of doctors can qualify as well, he says: “‘Underserved’ implies a lot of things.”

Dr. Doescher, who is also a family physician, is one of three panelists who will discuss “Identifying and Addressing Underserved Medical Areas” at a Friday morning AHCJ session moderated by Leah Beth Ward, a Yakima (Wash.) Herald-Republic reporter. The other panelists are Anita Monoian, chairwoman of the National Association of Community Health Centers and CEO of Yakima Neighborhood Health Services, and Kris Sparks, manager of rural health programs in Washington state’s Office of Community Health Systems.

Multiple Factors

For Dr. Doescher, “underserved” implies “some sort of disconnect between the level of the patient and their access to the health care system and level of care.” In addition to distance, he said, disconnect factors can include cultural and language barriers, which affect immigrants in both inner-city and rural locations, and lack of health insurance or under-insurance, which is largely related to employment and income and affects minority groups disproportionately.

In addition to the 200 U.S. counties without physicians, about the same number are classified as thinly populated with doctors, many of them aging, and several hundred more have only a minimal number, he said. Meanwhile, he noted, a large city such as Tulsa, Okla., can have “bazillions of physicians” who remain out of reach of some groups of residents.

Short-term remedies for getting more doctors to underserved areas center on federal HPSA (Health Professional Shortage Areas) designations. Medical professionals who practice in HPSA-designated areas, which can be ranked by geographic and demographic factors, often qualify for financial incentives.

Set up in the 1970s, the system is considered by many to be out of date, but there is little consensus on how to change formulas for designating HPSAs, said Ms. Sparks, whose office gathers data to get such areas designated and tries to attract health care providers to the areas.

Built into the system, she noted, is a contradiction. “On the face of it, it’s a good thing to get rid of shortage areas,” she said. But because HPSA designation means raising the level of health care for residents, “I always say I’ve never seen a shortage area I didn’t like. I’m trying to be sure as many places qualify as possible.”

The issue of medically underserved populations has grown in the last two decades as the U.S. has produced a constant number of physicians, even as the population has jumped by a third. Foreign-born doctors made up some of the shortage.

The problems are compounded by financial incentives for doctors to go into certain specialties at the expense of primary care. Inner-city areas, Dr. Doescher noted, are lacking in general, internal and geriatric specialists, while some rural areas have a shortage of surgeons, obstetricians and pediatric specialists.

Starting Early

Dr. Doescher is focused on longer-term remedies that start as far down as elementary school. Doctors are more likely to practice in a rural area if they grew up in such an area, he notes, which means improving the quality of math and science education so residents from those areas can excel in college pre-med classes.

“Undergraduate institutions need to be attuned to the background people come from,” he said, to boost rural students’ chances of success, while state-funded medical schools could, within legal boundaries, look at admissions criteria to make sure students reflect their state’s rural or inner-city or low-income populations. At the residency level, he said, funding incentives could be changed to lure doctors back to rural areas.

“If one wants to address some of these shortage areas, a more coordinated approach to workforce planning would make a lot of sense,” he said. While what he’s proposing is a long-term plan, “I think it can be done,” he said.