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Texas hangs out shingle
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A Lonely Post
Challenges of a rural doc
Dr. William “Ben” Edwards has small-town doctoring in his blood. Both of his grandfathers were rural physicians, and he grew up hearing their stories of doing everything from treating strep throat to birthing babies.
He liked what he heard, and for that reason, the 2002 University of Texas-Houston Medical School graduate is Garza County’s only practicing physician.
“I looked at other counties and they all needed more doctors, but they at least had one,” the Belton native says. “My wife and I prayed about it and God led me here.”
Dr. William Edwards
“Here” is Post, a city of 4,000 about 40 miles southeast of Lubbock, which saw its only hospital shut down in 1996. Most of Edwards’ patients come from a 60-mile radius.
But there are challenges. Many rural patients qualify for Medicaid or Medicare. Edwards says the reimbursement rate – 50 to 60 cents on the dollar, respectively – isn’t much different than his 60-cent overhead. Edwards says he makes up for that tight margin by working extra – in the county jail, a hospice and nursing home.
The Texas Legislature has taken steps to encourage doctors to settle in rural areas, but Edwards says the best way to draw more physicians to underserved-areas is by increasing the Medicare and Medicaid reimbursement rates.
Rural counties generally have a lot in common: Wide open spaces, easy country living, and livestock.
But not nearly enough doctors. While one-fifth of the U.S. population lives outside metropolitan areas, only 11 percent of doctors practice there. The Texas Department of State Health Services identifies 118 counties (90 of them rural) as Health Professional Shortage Areas, which are regions, populations or facilities that have more than 2,000 people for every practitioner. About 1.8 million Texans live in the 118 underserved counties.
Dr. William F. Sorrels, chairman of the Texas Medical Association Committee on Rural Health, says the term “rural” doesn’t begin to describe some of those counties.
“There are some rural counties, particularly west of Interstate 35, where ‘rural’ is a generous term,” Sorrels says. “Down by Pecos County, west of Fort Davis, there are places where there is one doctor for a county or county and a half.”
Factors including compensation and social and lifestyle issues make it difficult to recruit physicians to those areas.
Rural Practice is Hard Business.
Taking time off is difficult and costly for rural doctors, particularly those in private practice. To avoid the risk of complaints, doctors must hire a substitute when they leave their coverage area. The cost for a substitute is often more than 50 percent higher than for the regular doctor, while income generated is only 40 to 50 percent of normal, Sorrels says.
Income guarantees, traditionally used to recruit rural doctors, often are not realistic. Although they usually exceed an urban physician’s compensation by 50 or more percent, they are usually only for one or two years. Sorrel says it takes a rural practice three to five years to become stable and self-sustaining.
“It’s hard for doctors in rural areas to make a living,” Sorrels says.
But that could be changing. In 2009, the Texas Legislature passed HB 2154, which could make it financially more attractive for 900 new doctors to locate in rural Texas areas during the next four years.
The bill revamps the 1985 Texas Physician Education Loan Repayment Program by vastly increasing the value of medical school loans that can be forgiven by practicing in an underserved area from $45,000 to $160,000. The amount escalates over four years, encouraging doctors to stay at least that long.
Stimulus Injects $20 Million
Federal stimulus money is also helpful. Texas community health centers were awarded 65 grants for operational costs totaling more than $20 million. The funding is projected to create or retain 461 jobs and treat an estimated 149,445 new patients – of which 93,021 are expected to be uninsured during the next two years. See separate story: “Stimulating Health Care.”
Around the state, cities and counties are taking different approaches to fill health care needs.
“Some doctors don’t like the big-city hustle and bustle, they like a smaller place to raise their children, they like to know all their neighbors.”
In Jim Hogg County, plans to build a local hospital fell through, so officials worked with local medical centers in nearby counties to expand. Laredo’s Gateway Community Health Center used a $342,000 U.S Department of Health and Human Services Health Resources and Services Administration grant to help fund new clinics in Jim Hogg and Zapata counties.
The East Texas Medical Center’s (ETMC) branch in Pittsburg obtained a $682,000 Texas Capital Fund grant for water and wastewater improvements to a new, 25-bed hospital. The bulk of the facility’s construction funds came from $30 million in bonds issued by ETMC in 2007. The 104,000-square foot, $38 million center is expected to create 45 medical jobs.
Mike Easley, incoming chairperson of the Texas Hospital Association Rural Hospital Constituency Council, says sparkling new facilities alone can’t be counted on to lure doctors.
“Rural counties have a cap on taxes,” Easley says. “They can’t raise them more than 75 cents for every $100 valuation. Sometimes they have to scale back, build smaller structures, or not at all.”
Sorrels says that the key – beyond financial incentives – to luring doctors to rural practices is finding physicians who want to be there.
“There’s a misconception that if a doctor practices in a rural county, he or she is not as good as those in a more highly populated area,” Sorrels says. “That’s not true. Some doctors don’t like the big-city hustle and bustle, they like a smaller place to raise their children, they like to know all their neighbors.” TR
To learn more about the state of rural health care in Texas, view the Texas Medical Association’s quarterly newsletter Rural Texas Physician. Find how federal stimulus funding is being spent in Texas at the Comptroller’s tracking Web site.