Rural medicine won’t be helped by health reform

by Rick Bendinger, MD

I am a rural health provider in Abbeville, Alabama and have been here almost 30 years. I originally went to school on a public health scholarship and took the private practice option. This was a program that existed in the 1980s that paid for tuition and a stipend with the obligation to go either to a prison, rural area, or Indian reservation.

Sadly the program no longer exists. Both myself and my partner went to school on this program. The thought was that once you paid off a 4 year obligation working in a rural area you would stay and for me it worked.

Currently we provide care to the county and surrounding counties but with the 21% Medicare cuts, rising costs and requirements it is going to make our job even more difficult. I have reassured my patients that in spite of the current cuts I will still be here for them but I really worry about affording to continue to care for them and what will happen when I retire.

Most primary care providers in Alabama are in their mid-fifties and we are getting little help from new students who, owing $250,000-$300,000, opt for more lucrative specialties. Many will retire with the advent of this bill and make things more difficult. Furthermore, poor counties provide poor schools and not many young professionals with children want to practice in rural areas of this state.

We treat the poor and indigent each and every day but have a hard time with their care when we want to refer for specialty care as many of the internists and specialists in the nearby “big town” are not taking new Medicare patients and won’t take indigent care. Not because they are greedy but because they are not paid enough to operate a business.

I practice in a different environment than the big city doctors. Patients are friends and like family. I have coached their children in baseball and basketball helped them with some of their homework, and been a part of the community. I see them in the grocery store and at ballgames they are friends. I have stitched them up on my kitchen table, made house calls and cried with them when they have lost a loved one. They are like family in a small town practice and that is a big difference between what I do and a big city doctor.

With that said, the new health care bill gives patients a shiny new card that is supposed to keep them out of the ER, but in reality, if they have no provider to go to that is where they will end up. You can’t just dump another 30 million folks into this system without more doctors. The requirements for their care built in this bill will require us to do more work and outcomes data without paying for the cost of doing this. Frankly, it is an impossible task.

I really noticed the uptick in non-productive work with the advent of the Medicare Part D program. Although I still fully don’t understand the rationality of things like the doughnut hole provision, we spent many visits trying to explain to patients what the program was about and many hours on the phone with their pharmacy benefit managers trying to get their medicine they had been on for years approved.

This was the tip of the iceberg because many private insurers followed suit with the prior authorizations for drugs and MRIs as well. I have one employee who does nothing but these issues. This is an example of what drives up our overhead. Medicare has not raised our rates in 10 years. Medicare monies are taken out of one big finite pot. So if we get a raise, another provider gets a cut. Promises of higher primary care payments have been empty.

Will I retire because of health reform? No, I can’t afford to leave patients without a stable provider. But this new bill will make my work even harder. My hope is that there is an effort to train and increase primary care providers. It addresses student loans, restaurant calorie counts and numerous other superfluous things that won’t bring new rural doctors.

I would like to see a Manhattan-type program, like what the government did with the bomb, that would train primary care doctors and pay them on a better scale. Medical students who come out with $300,000 in student loans can’t go into primary care for $170,000 per year. Surely, within the trillions that are being proposed for health care there could be an effort to incentivize some of the best and brightest students to go into primary care.

Nurse practitioners and physician assistants are being hired by many of the specialists to work for them — they too are often shunning primary care. We need to capture some of them, but they need to be paid as well. Currently, private insurers only pay them 80% of what they pay me to do the same thing.

Hopefully this gives some insight into what I do and how rural medicine will be affected by health care reform.

Richard Bendinger is a family physician.

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  • jsmith

    Well said, Dr. Bendinger. I too practice in a rural setting but not in private practice, so my life is easier financially. Unfortunately, this bill was never meant to help rural docs much. Not many votes in the hinterland or much lobbying money therefrom.

  • R Watkins

    Excellent post.

    And the amazing thing (actually, not amazing) is that the AAFP aggressively lobbied for this bill, that does NOTHING for the docs they claim to represent, in return for a few photo ops with President Obama.

  • Paula

    Actually, public health corps grants and scholarships still exist, and were increased by $500 million last year as part of the 2009 American Recovery and Reinvestment Act, in anticipation of workforce shortages. Funds to train new primary care physicians for underserved areas were supplemented by the new health care reform law, and will be available later this year. Obviously, it will take time to ramp up the program, but the expansion of benefits spelled out in the new law will take place gradually over four years.
    For an overview of US public health corps programs, see a story I wrote for a publication for minority research scientists:
    Or, go to these sources directly:

  • BladeDoc

    Haven’t you all figured out that the goal is the collapse of the current system to be replaced by a NHS/Canadian system? These people aren’t stupid. You are not pointing out anything they don’t know. It’s the point.

  • Dr. Mary Johnson

    Paula, I was in the Public Health Service – the National Health Service Corps, to be exact (loan repayment for service). I was recruited back to my own hometown. And let’s just say that mine is NOT a “success story” that the NHSC will be posting on its website:




    And I would tell any young physician considering “enlisting” for the government’s curious brand of indentured servitude, that they would be MUCH better off going into private pracice in a larger city and budgeting their loan repayment as just another living expense/loan to pay off.

    These programs turn rural communities into revolving doors for doctors. Yet everyone from Clinton to Edwards to Obama has recommended more of the same!?!

    Oh, and what BladeDoc said.

  • ninguem

    I’ve heard more than one NHSC doc mention very matter-of-factly, that the NHSC system deliberately antagonizes their doctors.

    If a NHSC doc decides he/she actually likes an area, and chooses to set-up privately, it puts the NHSC out of business in that area.

    Almost certainly, a private doc setting-up there, will not need anywhere near the administrative staff needed by a NHSC site.

    Government bureaucrats do not put themselves out of business. So, deliberately make life miserable for the new doc. Go out of your way to antagonize the doc. Then doc gets disgusted, counts the days ’till departure day.

    Bureaucrat gets to crow about how they’re so needed there, “no one wants to work here”, and government is the savior.

  • rezmed09

    Having done NHSC and Loan Repayment and worked in a rural environment let me add my two cents.

    Loan Repayment is a great idea that has been allowed to wither. It gets docs who freely chose their specialty and who freely wish to help the under-served. But…the amount per year of repayment (from the feds) has been stuck at $20-25K for the last 10 years. Furthermore, the people managing the system are difficult to get info from and inflexible with start dates. They are not helpful to docs finishing residency. They expect all sorts of contract work to be completed by administrators at disorganized rural job sites and busy residents. In short Loan Repayment is a great idea that has been underfunded (to the docs) and mismanaged by the office people who, as far as I can tell, could not care less.

    NHSC sounds great but in reality, it does nothing to fix many of the problems with under-served locations which are: poor pay and poor management. All that NHSC does is ensure a steady stream of young docs that can be mistreated, overworked, and underpaid by bad management. NHSC creates animosity between providers and patients because of rapid turnover at locations that remain undesirable locations to work. “Finish your commitment and move on and get out of this hell-hole.” Many administrators of these poor locations often treat providers as replaceable FTE’s and make little effort to make them happy, i.e, to keep them there for the benefit of the community.

    Loan Repayment needs to be fixed. But NHSC (scholarships forcing people into primary care) is only a bandage on the problems of rural medicine: poor pay, poor administration, and the problems of living in a rural community. Rural medicine can be wonderful, but that’s not what’s driving political change and it is certainly not where the money is.

  • Dr. Mary Johnson

    “NHSC sounds great but in reality, it does nothing to fix many of the problems with under-served locations which are: poor pay and poor management. All that NHSC does is ensure a steady stream of young docs that can be mistreated, overworked, and underpaid by bad management. NHSC creates animosity between providers and patients because of rapid turnover at locations that remain undesirable locations to work . . . Many administrators of these poor locations often treat providers as replaceable FTE’s and make little effort to make them happy . . . i.e, to keep them there for the benefit of the community.”

    EXACTLY, Rezmed!!! The young & indentured are a “dime a dozen” (a direct quote from a mill-town hospital executive).

    But wait! The solution of Obama/the Congress is to throw 300-600 million MORE tax-payer dollars at a program that can barely be called a bad BandAid.

    What KILLS me is that the AMA and DHHS/other powers-that-be are now obviously reading some of the higher-profile blogs like Kevin’s (even contributing to them) . . . in the process hearing more and more angry dissent from doctors who have been-there-and-gotten-the-big-SCREW-YOU!!! in public service (with some of us still waiting for the Feds to ride in on that white horse) . . . yet they continue to pretend that we/our problems never happened, and we do not exist.

    The NHSC’s mission is not just about recruitment to an under-served community. It is about RETENTION as well. At least that’s what they told me BEFORE they totally let me swing in the wind.

    There are things the powers-that-be could address NOW . . . situations they flubbed-then-but-could-still-remedy NOW . . . that would go a long way towards restoring credibility in their program, fixing what doesn’t work for the doctors laboring in it, AND preventing problems for the newbies down the road.

    I’m still waiting for that invitation to testify before Congress. I’m also waiting for the USAG in Greensboro, N.C. to deal as harshly with two “non-profit” hospital executives (for multiple felonies) as those executives dealt with me (for ignoring their threats and saving a baby’s life).

    But the Dr. Rohacks of this world cannot understand why the AMA’s influence & membership is dropping like a stone . . . and doctors are turning to tea parties to be heard.

  • Theo

    Well, I don’t mean to get partisan here, but I have noticed in regular news comboxes that people leaning liberal hold us folks out in the hinterlands in great disdain. It’s all about the cities to them. Yes, the politicians look to the high concentrations of people for votes, but the animosity of the regular liberal citizens is just plain scary. They truly think of us as uncultured, uneducated, unintelligent enemies of progress, when all we really want is a nice quiet life without other people interfering. We gotta be stupid if we didn’t vote for Obama, right? That proves it.

    Now they’re taking away the doctors. Diverting resources to themselves. Forcing the rural people into the cities to get healthcare, where they’ll become good little voters.

    Lots of things need to be fixed in the healthcare system, but the reforms didn’t fix those things. It just made it more of the same, so the problems that have been lurking will only get bigger.

  • rezmed09

    This really isn’t partisan.

    Let me say that no administration in the last 25 years did anything to fix NHSC or Loan Repayment or to help rural medicine. Only Clinton cut the pork out with Re-Inventing Govt. and help clean out some dead weight.
    Reagan talked about “getting government off the backs of the people” and “the problem is govt.” but only increased the size of the govt. I know, I was watching the budgets swell and decrease.

    NHSC will get more money. More indentured servants will be sent forth for servitude – at least the ones not rich enough or lucky enough to get money elsewhere. The revolving door will spin faster. Only because it is the simpler fix and it is the way Washington and Hospital Administrators think.

  • DT

    Who is John Galt?

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