Physician shortages, particularly primary care shortages in rural areas of Arkansas far from metro areas, are acute and there is a looming imperative to address the issue not just for the present, but for the next ten to 20 years when many older family doctors will be retiring.

“We have a number of counties that are considered to be primary care professional shortage areas,” said Charles W. Smith, MD, a family physician and professor at the University of Arkansas for Medical Sciences (UAMS) who heads the UAMS primary care service line. “Those shortages can be found in all corners of the state except central and northwest Arkansas.”

Solving the problem has been hampered by residency caps from the federal government.

“The Centers for Medicaid and Medicare Services (CMS) have limited expenditures for training,” Smith said. “They have been reluctant to expand that funding. That has put a damper on expanding residency slots because they are very expensive to develop without CMS funding. One of the things that needs to happen nationally is that CMS needs to expand its funding for residency positions. Then you would rapidly see existing programs growing and new programs starting.”

In 2007 the Arkansas Legislature created the Community Match Physician Recruitment Program that targets state residents and “new” physicians – not medical students.

“The community provides $10,000 per year for four years and this is matched by state funds for a grand total of $80,000 over a four-year period,” Smith said. “Funds are paid to the physician practicing in the medical underserved community ‘after the fact’ on a quarterly basis – therefore assuring 100 percent compliance before funds are paid to the physician.”

Tracy Bradford, section chief of the Arkansas Department of Health (ADH) Office of Rural Health & Primary Care, said the farther away a community is from a metro area, the harder it is to attract doctors.

“A large part of the state is considered rural and there is a lack of services and providers,” she said. “There is a great need. What our office does is focus specifically on recruitment for primary care, dental and mental health providers.”

Bradford said the shortages in the Delta are the most acute in the state. Success can be achieved by letting physicians know how rewarding it can be to work in these communities.

“Surprisingly, a lot of medical students are not aware of the loan repayment program,” Bradford said. “In the big scheme of things, it is a limited commitment of two years.”

Joy Gray, an ADH program specialist who works on recruitment and retention of physicians, said the student loan repayment gives physicians $50,000 a year for a two-year commitment, and then $20,000 per year if the physician stays after that.

“It is tax free and goes directly to student loans for healthcare professionals who agree to serve in a health shortage professional area,” Gray said. “That same program is applicable for dental hygienists, dentists, nurses, advanced practical nurses (APNs), and nurse midwives. Another program called Nurse Corps is just for nurses with different scholarship and loan requirements.”

The umbrella of general practitioners covered includes internal medicine, OB/GYN, general pediatrics, general psychiatry, and geriatrics.

“Psychiatry is a big one we don’t have enough of in the rural areas,” she said. “Some psychiatrists who are based in Little Rock travel monthly to see clients in outlying clinics.”

Another program, the Arkansas Rural Medical Practice Student Loan and Scholarship Program, provides for medical students (and applicants on the alternate list) to contractually agree to practice primary care in a medically underserved community in Arkansas. Funds are provided by the state to medical students to help pay for tuition, fees and living expenses. Typically, the obligation is for four years. Each year of full-time service will cancel one year of assistance.

Since the inception of the program in 1995, all alternates approved and advanced on the Rural Practice program have subsequently been admitted to medical school.

“I am pleased to report that a study conducted by Tammy Henson, administrator of the Rural Practice Program, shows a 96 percent success rate,” Smith said. “We have placed quite a few physicians around the state in shortage areas with that program.”

The challenges of attracting and retaining physicians isn’t limited to rural areas or to primary care. Many younger physicians don’t want to work 60 hours a week. They highly value quality of life and having time for family and hobbies.

“We regularly interview physicians who are as interested in hearing about their potential lifestyle as they are about their salary,” said David P. Foster, MD, FAAFP, president of St. Vincent Medical Group in Little Rock. “We are intentional in building practices which support physicians. In a private practice, the physician is the lead clinician as well as the business owner (or partner). Therefore, most every decision is made by the physician. This can become overwhelming.”

Foster said in a high-performing, multi-specialty clinic, they use team-based care where everyone is encouraged to practice at the top of his or her respective license. “This allows the physician to focus her time on what she was trained for: taking care of patients,” Foster said.

Solving the physician shortage problem is an issue critically important not just to health, but to the economic survival of rural areas of the state. Smith said it is important enough that the public as a whole should get behind the notion of expanding the primary care workforce.

“I think although APNs and physician assistant providers are going to be helpful because those professions don’t require the same length and complexity of training as primary care physician training programs, it isn’t correct to assume one will substitute for the other,” Smith said. “It works best when they work as a team.”

Smith said healthcare reform is setting up the environment to support and encourage the movement from more specialty care to more primary care. Cost effective care is often basic care, coordination of care and preventive care as opposed to doing more procedures and seeing more specialists.

“Everyone is going to have to buy into a slightly different way of looking at healthcare in order for this to be solved,” Smith said. “It would be nice to see some of the best students aspiring to be the best primary care physicians seeking to serve the population. That hasn’t been the case for some time, and we really need to return to a philosophy along those lines.”

Smith said part of the solution is moving from fee-for-service to outcome-based payments and population based models. “Get paid for good outcomes,” he said. “As insurance companies and the government pay in a different way, it will reward primary care more than it has been rewarded in past.”