Attracting Doctors to Rural Areas

Commentary by State Senator Roy Dyson (D-29th)

Most of us can remember our family doctor. My family doctor was Philip J. Bean, M.D., of Great Mills. He charged $2.00 for an office visit and that included medicine. Today the "practice of medicine" is very different, house calls are almost unheard of and can you imagine delivering a baby at home? According to the National Rural Health Association, while 25% of the population lives in rural areas, only about 10% of the nation's physicians practice there.

According to the Maryland Hospital Association and Med Chi, which represents 7,200 of the state's doctors, Maryland's doctor shortage is 16% below the national average. It is far worse in the state's rural areas of Southern and Western Maryland and the Eastern Shore. The Eastern Shore shortage is 60% below the national average. The Western Maryland shortage is 66.7% below the national average. And worst of all, the Southern Maryland shortage is 83.3% below the national average.

Along with Senator "Mac" Middleton of Charles County, I sponsored SB 495 to establish a Task Forced to Review Physician Shortages in Rural Areas. On January 2009, the Task Force reported its findings and recommendations, which included expansion of the Physician Loan Assistance Repayment Program and increasing physician reimbursement disparities in shortage areas. Similar recommendations were made by the Task Force on Health Access and Reimbursement. Both recommendations were approved by the General Assembly and signed into law by Governor O'Malley on May 19.

The doctor shortage in Maryland is no mystery. The average medical school graduate is $147,000 in debt. The debt level coupled with Maryland's low reimbursement rates and high cost of living creates a formidable disincentive for doctors to locate in and serve rural residents and other underserved individuals. The Maryland Health Care Commission reports that the state's physicians are in the lowest 25 percentile of the nation in terms of reimbursement.

One of the bills signed into law creates a loan forgiveness program to assist in repaying loans owed by a physician who practices primary care for a nonprofit organization or government entity in an area of the state that has been federally designated as having a shortage of primary care or mental health providers. In addition, financial aid awards will be made to assist in repaying loans owed by a medical resident specializing in primary care who agrees to practice for at least two years as a primary care physician for a nonprofit organization or government agency in a geographic area of the state that has been federally designated as a shortage area.

The second bill signed into law establishes a floor on payments for non-contracting providers treating HMO patients would be pegged to the greater of 140% of the Medicare fee and 125% of the average in-network rate for evaluation and management services.

This bill was recommended by the Task Force on Health Care Access and Reimbursement in its final report in December 2008. Providers told the Task Force that:

-- Fees paid to non-contracting providers are too low.

-- Some HMOs do not pay what is required under law.

-- Statutorily established fees serve as the ceiling on reimbursement rather than the floor.

-- Enforcement of existing law is difficult due to lack of clarity.

The Task Force also found that the payment formula for non-contracting providers is susceptible to gaming by plans, not transparent to providers and difficult to enforce. Current fee schedules were found to be particularly inadequate for provider evaluation and management services.

At a recent "primary care summit," hosted by Howard County health officer Dr. Peter C. Beilenson and County Executive Ken Ulman, the dire shortage of primary care physicians was stressed. For every 1,000 new doctors who enter the primary care field each year in the U.S., 3,000 to 4,000 leave it. With staggering tuition loans often doubled by interest, high office administrative costs and low insurance reimbursement, medical students are choosing better paid specialties.

The primary care physician is the main link between the patient and medical care. The Obama Administration's effort to provide health insurance for all Americans will be of diminished good if the insured cannot get in to see a family doctor.

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