The Doctor Shortage In Rural Missouri: Are Advanced Practice Nurses A Solution?
Part two of a three-part series.
Lisa Schofield regards her business as an example of the future of health care in rural Missouri.
She owns the Theodosia Family Medical Clinic in south central Missouri, a region with a big demand for medical care and too few doctors to meet it. Theodosia is situated in Ozark County near the Arkansas border. The clinic serves about 900 patients, all of whom are treated by a nurse practitioner, or an N.P.
That’s the title reserved for nurses who have completed graduate-level study and have undergone hundreds of extra hours of supervised clinical work. Schofield argues that N.P.s, also called advanced practice registered nurses, are the best antidote for curing the acute doctor shortage in rural communities.
“Access to health care is terrible in these little towns,” she says. “I want to see people taken care of because I’m from this area and my heart is here.”
In addition to having the second highest percentage of uninsured residents among all counties in the state, Ozark faces the usual problem of doctor access. Rural Missouri in general has only one primary care doctor for every 1,776 residents, compared to one for every 962 residents in urban areas.
But the disparity is actually more pronounced in places like Ozark County, which has no full-time primary care doctors for its 9,600 residents. More generally, Ozark is among 25 counties in rural Missouri with a population-to-primary-care-provider ratio exceeding 3,500:1, according to a report by the Missouri Foundation for Health.
Where are all the doctors?
The problem isn't that Missouri doesn’t train many doctors. The problem is, in part, that few doctors are willing to practice in underserved areas of Missouri and that others are choosing not to remain in the state once they've completed their medical training.
While Missouri makes up 1.9 percent of the nation's population, it produces 2.7 percent of the nation's medical school graduates, according to a paper released in 2011 by the Missouri Foundation for Health and the Healthcare Foundation of Greater Kansas City.
The report added that Missouri ranked second nationally in exporting physicians it trains to other states or countries.
There have been attempts to ease the shortage by relying on the large numbers of physicians from other countries who want to work in the U.S. Nearly a quarter of all U.S. primary care doctors attended medical school in other countries. But they come to the U.S. to practice by getting special visas that oblige them to work in underserved areas, including rural ones. However, after they repay that obligation, these doctors tend to leave the underserved communities, according to a study published in the journal Academic Medicine.
Another complication is that only about one-fourth of doctors practicing in the state choose a primary care specialty. This is due in part to a doctor’s wish to make more money to pay off medical school debt in excess of $145,000.
That may explain why many decide to turn to more lucrative specialties, such as orthopedic surgery or radiology. Those specialties can see incomes three times higher than the median salary of $184,000 for primary care doctors.
Are nurse practitioners a possible solution?
The doctor shortage is one reason nurse practitioners have become the fastest growing segment of the primary care workforce. Their numbers have grown an average of 9 percent annually, compared to 1 percent for primary care physicians, according to a Missouri Hospital Association report.
Along with about 5,000 practicing primary care doctors, Missouri has more than 4,000 N.P.s. Some clinic owners, like Schofield in Ozark County, feel N.P.s are in a position to help address the doctor shortage and should be given more freedom to take on even more medical responsibilities without the guidance of collaborating physicians.
That is the heart of a growing debate. The Missouri Medical Association says patient safety should be the prime consideration. It says N.P.s are not capable of practicing without supervision because they have no more than 1,500 hours of clinical training, compared to 15,000 hours of such training for primary care doctors.
Missouri law requires that a supervising doctor be no more than 50 miles from the location where an N.P. provides services. The law also requires a doctor to review the nurse practitioner's major clinical work every two weeks
Schofield said the 50-mile rule is one of the biggest stumbling blocks to bringing care to many rural communities because a doctor isn’t always located within a 50-mile radius of where an N.P. might work. She said that’s one reason her own clinic almost didn’t get off the ground. The closest doctor willing to collaborate with her N.P. was situated two or three miles beyond the 50-mile radius, Schofield said. She sought a waiver from the 50-mile rule but was turned down.
“A family friend had to come out of retirement and collaborate with us. One day I will face this issue again," Schofield said. "What are these people going to do? Already I have to give free treatment to some who otherwise wouldn’t get medical care.”
Rebecca McClannahan, a former state lawmaker and current president of the Missouri Nurses Association, said Missouri has among the most restrictive rules governing N.P.s. At least 17 states and the District of Columbia have already eliminated many restrictions governing N.P.s, giving them more freedom to practice without a doctor’s supervision.
McClannahan said Missouri’s restrictions “prevent advanced practice nurses from practicing in a way they are able to and have been trained to do.” Relaxing the rules, she argued, would make it more likely for N.P.s to step in and care for patients in Missouri counties with few or no doctors.
Weighing in on the side of Schofield and McClannahan is state Rep. Lyle Rowland, R-Cedar Creek. He has introduced HB 1481 to allow a doctor and nurse practitioner to collaborate through “effective electronic communication.” One option, he said, could be to allow the collaborating physician to rely on electronic health records for reviewing the nurse practitioner's work, which would eliminate the 50-mile rule.
Rowland's action is bolstered by the Institute of Medicine's recommendation for removing barriers to the range of work N.P.'s can do. But nobody seems ready to bet those barriers will fall in Missouri this legislative session.
The only certainty seems to be a prediction made in the Missouri Hospital Association two-year-old report. It says policy implication of the barriers “will be debated during the next several years as the primary care physician supply continues to deteriorate.”