In parts of South Carolina, a doctor can be as elusive as a Bluetick Coonhound with insomnia.
Many counties and parts of many others are designated health care provider shortage areas.
And while there have been efforts to change that, progress is slow because it can take many years to produce a doctor, and there are only so many slots available in medical schools and hospital residencies needed to complete training.
Now the state Department of Health and Human Services is stepping in with a couple of ideas it hopes will blunt the impact of the shortage and improve access to health care in parts of the state where doctors are particularly hard to find.
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The physician shortage, which spans the country, has been exacerbated by an aging and growing population. And some specialists are in even shorter supply than much-needed primary care doctors.
Research published in the November issue of the journal Health Affairs projects the demand for primary care will grow about 14 percent from 2013 to 2015, while demand for vascular surgery, cardiology, neurosurgery, radiology and other specialties will grow 31 percent during that time.
More students have enrolled in medical school since 2006, when the Association of American Medical Schools called for a 30 percent increase to help stem the shortage. The number of first-year students has grown by 21.6 percent since 2002, and last year saw a record number of enrollees, according to AAMC.
New schools, like the University of South Carolina School of Medicine-Greenville, and increasing class sizes at other institutions are largely responsible for that growth, AAMC reports.
But at the same time, it takes at least seven years to become a doctor. And doctors are aging along with their patients. About 16 percent are 65 or older, and one in three expects to retire in the next 15 years, according to AAMC.
In 2012, there were an average of 260.5 active physicians per 100,000 population in the United States, ranging from a high of 421.5 in Massachusetts to a low of 180.8 in Mississippi, the group reports. South Carolina, with 10,250 active physicians, had 217 per 100,000 population, ranking 38th nationally.
There were 90.1 primary care physicians per 100,000 population in the United States in 2012, AAMC reports. The Palmetto State had 77.5 per 100,000, and ranked 40th.
“Almost every county in the state, at least part of it, is a primary care shortage area,” said Linda M. Lacey, director of the Office for Healthcare Workforce Analysis and Planning of the South Carolina Area Health Education Consortium.
AAMC estimates the country needs 91,500 new doctors by the end of this decade, and 136,000 by 2025.
The state is approaching the problem in two ways — by expanding telemedicine and making changes to graduate medical education.
Telemedicine uses technology to allow a doctor to “see” a patient at a remote location, thus stretching the reach of available physicians.
It’s been used successfully in treating stroke in South Carolina, where a third of the counties don’t have a neurologist, Dr. Mary Hughes, chief of Greenville Health System’s division of neurology, told The Greenville News.
A clot-busting drug known as tPA decreases the severity of a stroke, but needs to be given as quickly as possible, she said.
Using telemedicine, a stroke patient at a hospital with no neurologist is examined in real time via computer monitor by a neurologist at another location. That allows for quicker treatment, resulting in improved outcomes because “time is brain,” Hughes said.
“We live in the stroke belt and it’s an enormous challenge making sure that patients have access to the most aggressive and up-to-date interventions,” she said. “And when you look at the literature, the outcomes are the same as if I was standing in the ER with the patient.”
Moreover, she said, patients are comfortable with the technology.
The state began a telemedicine network for behavioral health in 2011 because psychiatrists are also in short supply, particularly in rural areas. So a patient at a hospital with no psychiatrist can be examined remotely by one elsewhere. In its first year, it saw a 300 percent increase in claims, from 236 prior to implementing the policy to 807, officials said.
Dr. Ken Rogers, chairman of the department of psychiatry at Greenville Health System, which operates its own telepsychiatry program between Greenville Memorial, Hillcrest Memorial, Greer Memorial and GHS Laurens County Memorial Hospital, said the need is tremendous.
“We probably get five consults or more a week from each hospital,” he said.
Using telemedicine, the patients get the care they need, he said, and it cuts the number of psychiatric patients waiting for care — sometimes for days — in ERs. And that frees up space for patients with chest pain or injuries, Rogers said.
Though GHS expanded its residency program to produce more psychiatrists, the first class doesn’t graduate until 2017, he said. And there are just four students each year, he said, so it will take several years before any impact is felt.
Beginning July 1, with funding from a legislative proviso for a pilot, DHHS is poised to expand telemedicine to Medicaid enrollees for pre-natal care in four particularly underserved counties, said BZ(cq) Giese, director of DHHS’s Birth Outcomes Initiatives, a program that reduced Medicaid costs and improved outcomes by enlisting hospitals to stop early unnecessary deliveries.
The counties — Allendale, Bamberg, Barnwell and Hampton - have no obstetrics practices or delivering hospitals, so women who live there must go to hospitals up to 37 miles away, she said. There were 876 births last fiscal year in those counties, and 70 percent of them were covered by Medicaid, she said. Generally, Medicaid covers 52 percent of all births in the state.
But using telemedicine, Giese said, women can be seen by a family doctor in their community, as well as an obstetrician at a remote location. This eliminates the need to travel so far to see a specialist, except for women with high-risk pregnancies, she said. And it can be used for any complications that might arise.
By increasing coordination of care and enhancing communication, outcomes should improve, she said. And that’s expected to translate into fewer early births, low-birthweight babies, and hospitalizations and thus, lower costs, though just how much isn’t known, she said.
The one-year program is expected to cost between $775,000 and $1.5 million, she said, but it’s hoped it will become sustainable for years to come.
“The importance of access for our Medicaid recipients is very big for us with this boost of telemedicine,” said Giese. “There are many areas of the state that don’t have this specialty care, and that’s something we’re looking to balance.”
Working off its other telemedicine programs, GHS plans to expand to other specialties, such as infectious disease, said Blix Rice, administrator for integrated health services.
Now, he said, infectious disease doctors from Greenville Memorial travel to Baptist Easley Hospital every other Thursday to see patients, he said. Under a pilot program, which would use the same equipment as the stroke program, infectious disease also would be covered by telemedicine.
“It’s not efficient for every small hospital in South Carolina to hire an infectious disease specialist, and they are in short supply anyway,” Rice said.
“This way we can leverage the technology so the physician can be in different places quickly and therefore virtually increase the supply of physicians.”
Dr. George Helmrich, chief medical officer at Baptist Easley, said the hours of infectious disease coverage rarely coincide with the need anyway. Telemedicine should bridge that gap.
“We may need a consultant two or three times in a week and then not need one for two weeks. This unpredictability has created challenges in providing this type of care consistently,” he said. “Once up and running, we will have real-time access to the specialists as we need them.”
And with patients managed more efficiently, it should mean less time in the hospital, he said.
Telemedicine enhances productivity and outreach while cutting costs, it improves diagnosis and care management in remote areas, and it reduces unnecessary care, such as unneeded transfers to other hospitals, according to GHS.
The technology also strengthens partnerships with community hospitals, which can retain more of their patients and revenue, while the tertiary care center becomes the provider of choice for transfers, GHS reports.
The University of Texas Medical Branch in Galveston reduced unnecessary ER visits by half and no-show rates by a third in its telepsychiatry program, according to GHS. And nine out of 10 patients said they would use the program again.
The state also plans to look at changes to graduate medical education, according to DHHS director Tony Keck.
South Carolina spends close to $200 million in Medicaid money each year on two programs that train physicians — one that pays hospitals for residency slots and another that makes supplemental payments to physicians at teaching hospitals involved in training, he said.
Yet almost all of South Carolina is classified as having a shortage of health professionals, he said.
The federal Centers for Medicare and Medicaid Services already plans changes to the supplemental teaching program because the state’s reimbursement methodology doesn’t meet their new definition, Keck said.
Meanwhile, DHHS has launched a review to see how South Carolina can produce more doctors, and keep them practicing here, particularly in high-need areas, so the state gets more of a return on its investment, he said.
One reason the state is short of doctors is that it hasn’t been training enough in medical schools, he said.
But in recent years, the USC SOM – Greenville, and the Edward Via College of Osteopathic Medicine in Spartanburg were added to USC and the Medical University of South Carolina, and that has significantly increased capacity, Keck said.
But the state also needs more residency slots for those who’ve graduated, and more in primary care and certain specialties, and ways to get them to practice in rural areas, he said.
“We have a great opportunity ... to tie a portion of (state money) to state policy goals that recognize if the state is going to spend this money on medical education it should encourage and/or require that we get more of the types of doctors we need in places we need them,” he said.
Some possible strategies include expanding existing residency programs, opening new programs at teaching hospital satellites, and recruiting the students most likely to practice in under-served areas and supporting them during medical school, he said.
“Doctors are most likely to locate practices close to where they went to medical school and trained,” he said.
“And if there are no training programs in ... those areas where have shortages, it’s harder to get folks to locate there. Also, people who grow up in rural areas or who are part of underserved populations are more likely to go back when they graduate.”
Other possibilities would be to create new residency programs in family medicine and primary care specialties, he said, or broadening the scope of existing GME funding to train nurse practitioners and physician assistants.
Tuition reimbursement and loan repayment programs are other possibilities, he said, as part of a comprehensive approach.
“You can give two physician graduates three years of loan repayment to go to a rural area, but who’s more likely to stay?” he asked. “The one who grew up in a rural area.”
Keck said there is enough money in the system to make it all work, and that he’s not interested in cutting funding, especially with a growing population.
According to the Health Affairs research, failing to address the problem here and across the nation will lead to longer waits, less access to care, and reduced quality of life.
About 45 percent of the doctors who did their residencies in South Carolina remained here to practice in 2012, according to Lacey.
That’s good news, Keck said. Now, he added, the state needs to take the next step.
“It’s not just about more medical students, but those who are likely to go where we need them,” he said. “It’s about making sure the money is spent on the things South Carolina and the taxpayers want to buy.”