Stephen Feman
Most Missouri doctors work in densely populated communities, while areas needing physicians appear unable to attract them. Although health care issues fill our headlines, the problem of distribution receives little press coverage. Our state suffers from a unique health care disparity problem, one of geographic distribution. Elsewhere in America, it has been common for people to migrate to the cities and their suburbs, while in Missouri many prefer to live in rural areas. Today, about 27 percent of our state’s residents live in rural locations.

Previously, people thought the physician distribution problem would be resolved by economic factors alone, and suggested there would be a diffusion of doctors from urban to rural communities. But that did not occur. This may be attributable to the problem that most of the Missourians without health insurance live in rural areas. A 2004 state survey found that rural regions had the largest populations without health insurance, and few doctors choose to work where most people have no health insurance.

At one time, people thought the distribution disparity arose from physicians preferring to be near other doctors, in order to benefit from professional synergism, such as sharing emergency calls. However, another factor has been found: the risk of lower earnings in rural medical practices — a disincentive that keeps physicians from choosing those locations.

In response to this problem, the federal government started the National Health Service Corps (NHSC) to establish financial incentives that would bring doctors to areas with a physician shortage. Congress then established the Area Health Education Centers (AHEC) program, designed to retain health professionals in these locations.

Neither program, however, has satisfied Missouri’s needs. In spite of these government efforts, more than 18.6 percent of Missourians live in areas that are underserved by physicians, and more than 60 Missouri counties are identified as health care professional shortage areas. Last year, Missouri became the 10th-worst state in terms of the doctor/citizen ratio.

Why does this problem continue? In 1991, there were 10,095 physicians working in our state. Since then, the number has grown, and by 2001 there were 12,565. At the same time, however, the average physician age has increased. During that 10-year interval, the number of physicians under age 45 decreased by 25 percent, and now most rural Missouri surgeons are looking to retire. As a result, many Missourians do not have access to the health care they need.

How to respond remains uncertain, although a recent innovation addresses this issue. Missouri Southern University and the Kansas City University of Medicine have united to build a medical education program in Joplin. In an example of a group of citizens responding to their own needs, that community is developing a school to supply them with doctors. With this new program, another 100 physicians will graduate each year from the Joplin location. No one knows whether those graduates will remain in the area, but after four years, some will have local ties. Others, though, will look elsewhere. To keep them, incentives will be needed.

One approach might be to underwrite medical student loans that will connect the students to a local service obligation. Vermont initiated such a practice, and it has done well. There, new physicians that accept such loans have an obligation to practice in areas where there is a physician undersupply. A similar program already exists in Missouri, but it has had such limited publicity that most medical students and physicians are not aware of it.

There may be other and/or better incentive programs. It is up to your ingenuity, and that of your community, to develop them.

About the Author

Stephen Feman