KANSAS CITY, Kan. — Almost four years ago, a task force of Kansas doctors, educators and rural health experts prepared a report with 24
recommendations for expanding the state’s primary-care workforce.

Since then, progress has been made on several fronts identified by the team.

“It wasn’t an exercise in futility. And overall, it’s been one of those documents we refer back to on a periodic basis,” said Dr. Michael Kennedy, assistant dean of rural health education at the University of Kansas medical school and one of the task force members.

Aging doctor workforce
But even with that, concerns remain that Kansas will lack enough medical professionals of all sorts to meet growing needs as a current generation of doctors retires, the Baby Boomers continue to age, and federal reforms extend health coverage to thousands of additional Kansans. The shortages are expected to be particularly acute in rural Kansas, where doctors have always been too scarce.

“There have never been enough physicians in the rural areas,” said Roger John, president of Great Plains Health Alliance, a nonprofit health care management firm headquartered in Phillipsburg. “The med center is doing everything it can and we appreciate that, but there still aren’t going to be enough physicians.”

“We still need more family docs,” said Carolyn Gaughan, executive director with the Kansas Academy of Family Physicians. “If we had 200 or 250 more family docs, we still wouldn’t be oversaturated. The state can’t snap its fingers and all of a sudden have a bunch of doctors appear.”

And things are likely to get worse before they get better.

According to a 2009 report from the American Association of Medical Colleges, nearly a fourth of working doctors in Kansas and nationwide were ages 60 or older, which means they are ripe for retirement. Almost 40 percent were age 55 or older.

Too few replacements
Meanwhile, the same study found that the number of students enrolled in medical or osteopathic schools in Kansas had increased only 1.5 percent between 1999 (when there were 715 enrollees) and 2008 (when there were 727 enrolled.)

The Affordable Care Act is expected to mean more than 100,000 additional Kansans will have some form of health insurance beginning Jan. 1, 2014, creating even greater demand for medical services.

The reform law also put some emphasis on beefing up primary care, which is seen as one of the ways to help curb health care costs by catching illnesses earlier or preventing them altogether. Several of the reform provisions were included with the goal of encouraging growth of the primary-care workforce, including Medicare and Medicaid payment incentives for primary-care providers. But it remains to be seen what those provisions will accomplish or whether they will remain fully funded given ongoing contention in Congress over health reform and federal spending.

Kansas medical educators are well aware of the pressing need for more primary-care doctors and nurses and have made some strides since the 2007 recommendations were issued. Several programs have been started or strengthened and the word is being passed to students.

"That's what we need"
"We do encourage people to go into primary care. Some students complain we apply too much pressure," said Dr. Joshua Freeman, chairman of the KU family medicine department. "That's tough. In my opinion, that's what we need."

But it can be difficult to convince medical school students that they should focus on primary care or family medicine, since those types of doctors, despite the new law's incentives, can still expect to earn about a third of what some high-paid specialists make. Finding students willing to become a primary-care doctor and then live in a small town, is even more challenging.

Freeman said doctor salaries are driven by federal policies, particularly in the Medicare program, which tends to set the pace for all medical payments, even those from private health insurers.

"If Medicare said we're going to pay family doctors more than radiologists," Freeman said, offering an example, "that's the kind of policy change that would eventually eliminate money concerns as a reason for not going into primary care."

Freeman in a recent blog posting also called for government to pay off or forgive student loans for all who agree to practice primary care.

HERO
But dramatic changes in loan forgiveness or Medicare payment policies are not likely to happen quickly, if at all, despite the Affordable Care Act incentives.

So, Freeman, Kennedy and other like-minded Kansas medical educators continue to work on other ways to increase the likelihood of more graduates going into primary care.

For example, KU Medical Center is developing plans to collaborate with the University of New Mexico on a federal grant that would allow creation of rural health extension services, modeled more or less on the agricultural extension services offered through Kansas State University and other land-grant colleges.

Freeman said New Mexico already has experience with a health extension program, which was created there with the goal of reversing some of the worst health outcomes in the country. Two other rural states, Oregon and Kentucky, also would partner on the federal grant.

"We're thinking of taking a page from New Mexico's playbook," Freeman said. "They have a (Health Extension Regional Office) program they call HERO. We think that's a real good idea."

Among other things, the program would offer current primary care doctors help in improve their practices, provide local programs intended to make communities healthier and develop recruitment programs to encourage local kids to prepare for health careers in their hometowns.

Other steps
And of the 24 recommendations made in 2007, several have been neglected or only partially acted upon, in part because of state government's fiscal woes since the report came out.

One of the recommendations was that salaries for primary care residents be increased to at least match regional averages. First-year salaries were increased from about $43,000 to about $45,000 but that is still $5,000 or more below the regional average, Kennedy said.

Despite that gap, the salary increase appeared to help somewhat, he said.
"It's not an enticement," he said. "But it kind of removes it (resident compensation) as a barrier."

Also, a $10,000 bonus is added for rural residencies done at KU's Salina program or in Junction City. There are 12 residencies in Salina and one in Junction City, where training is done at the local hospitals.

KU Medical Center also has expanded the Scholars in Rural Health program, which allows participating undergraduates automatic admission to the medical school and priority for student loans, if they meet a number of conditions that include interest in practicing medicine in a rural area. Most who practice in rural areas train in primary care or family medicine.

When the report was written there were six participants in the program. This year, Kennedy said, there are 16 slots and there have been 36 applicants.

Also, the monthly stipend for the Kansas Medical Student Loan program has been increased from $1,500 to $2,000. Those who get the loans, which are limited to 30 students a year, can work them off by agreeing to go to rural or other underserved areas once they become doctors.
Kennedy said KU Medical Center officials also are in "the very early stages" of considering the start of rural residencies in places like Garden City or Pittsburg.

Campus expansions
The biggest development since the report was published was the expansion of doctor training at KU Medical Center's Wichita and Salina campuses.

Starting this month, training on both campuses will be for four years. Previously, the first two years of training came at the medical center's Kansas City campus. The expansions also will allow for training more doctors.

Each year's graduating class in Wichita is expected to increase from about 55 to 75.

The Salina campus is expected to graduate eight students per year. And KU already has the Smoky Hill Residency Program in Salina, which allows for 12 residents.

But even with the expansions, KU will only produce about 36 more doctors per year starting in 2012, far fewer than are needed and there is no way of assuring even a majority of them will focus on primary care or choose to practice in Kansas.

The medical school is already operating at full capacity in Kansas City, where it graduates about 175 people a year, and could not add more students without building new facilities, officials said.

"No earthly way to know"
Whether the recent expansions will be enough to meet the state's needs remains to be seen.

“There’s no earthly way to know,” said Kansas Medicial Society Executive Director Jerry Slaughter. “It’s true that we have a lot of docs who are getting to the age where they’re pretty seriously thinking about retiring, but that’s not the only trend that’s going on."

Slaughter said he’s heard several physicians in their late 50s and early 60s say they may retire by 2014, allowing them to avoid the record-keeping and increase-in-demand headaches that are expected to accompany federal health reform.

He also echoed Freeman's point about too little pay from government health programs even as more Kansans come to rely upon them.
“Medicaid and Medicare have a history of not covering costs,” Slaughter said. “At the same time, as our rural counties continue to lose population, as their populations continue to age in place and as their economies continue to decline, more and more of their care is being picked up by Medicaid and Medicare. If this trend continues, it’s going to be extremely difficult to attract and retain docs - no matter how many more we’re training. They’re not going to be able to cover their costs."

He also said more small-town physicians are going to work for a regional clinic or for their local hospital.

Hospitals buying out doctors
That trend, also noted by Kansas Hospital Association President Tom Bell, might make it easier to recruit doctors to small towns.
Bell said that in many cases hospitals are buying the local physician's clinic and hiring the physicians who welcome the change of working regular hours.

“It’s sort of a package deal,” he said. “The hospital takes on the hassle factor, you (the physician) get to practice medicine without having to worry about all the other stuff. You improve your chances for recruiting another doctor because the people coming out of med school today are looking at things a whole lot different than they were 30 years ago.”

A.J. Strickland, 25 is a fourth-year student at the KU medical school’s Wichita campus. He grew up on a family farm outside of Washington, Kan.

“I’m an outdoorsman,” he said. “I love living in a small town. There’s nothing better than the county fair, going to the rodeo, and being able to walk out your back door and be fishing in 10 minutes. I want to the be guy who gets his picture in the newspaper for having the best buck (deer) of the year.”

Strickland, who is single, said he’s plans to do his residency in Salina.
“My biggest concern at the moment is that I don’t want to move to a small town if I’m not married. That, I think, would be difficult,” he said. “But at the same time, I don’t want to end up with someone who’s accustomed to the city lifestyle and doesn’t want to move to a small town.

“A lot of times, that’s what happens,” Stickland said. “Someone like me is ready to move to a small town. It’s the spouse who doesn’t want to go.”