Rural Americans make up an estimated 15% to 20% of the population, but the areas they live in often struggle to attract the necessary physicians and specialists to meet the health care needs of the community.1
As the only hematologist/oncologist in an approximately 200-mile radius, Divis Khaira, MD, of Aspirus Health, knows her patients depend on her. This can be a challenge in the Upper Peninsula of Michigan, where average annual snowfall reaches about 300 inches.
Last year, in what was considered a “relatively mild” winter, Dr. Khaira got stuck in the snow five times while driving and spent a lot of time “skidding on ice and bumping into animals” as she traveled to see patients at the four hospitals she serves.
“The good part is there’s no traffic here, so it’s great if you like roller coasters,” she said of the sometimes-adventurous rides through the snow, adding that she had watched “every YouTube video there was on driving on ice and snow” in preparation for the treks.
This year, Dr. Khaira bought a new Jeep Gladiator. “I’m dying to try it out,” she said.
The severe weather is just one challenge of serving rural areas, which often attract fewer physicians and specialists and have fewer resources – like regular access to PET scans, MRIs, or radiation services – than their urban counterparts.
“Because of the harsh weather and our location in the middle of nowhere, there are very few doctors available. We have mostly advanced practice providers (APs) available, but even if doctors do come, the attrition rate is very high,” Dr. Khaira said.
Patients in rural areas are also more likely to be on Medicaid compared to their urban counterparts, and in general tend to be older, poorer, and sicker, according to a 2018 issue brief from the Medicaid and CHIP (Children’s Health Insurance Program) Payment Access Commission.2
Racial inequities in health care also plague rural populations. Black people living in rural areas have higher rates of cancer morbidity and mortality than other rural patient populations, according to a 2017 report from the Association of American Medical Colleges (AAMC), while those living in the Navajo Nation may face language barriers that hinder their ability to get effective care and treatment.
To combat the challenges to care, health care providers in rural areas often rely on APs, specially designed health clinics, or telemedicine to try to improve patient care and outcomes.
Epidemic of Doctor Deserts
The federal government has designated nearly 80% of rural America as “medically underserved,” creating what have been termed “doctor deserts,” according to a 2019 Washington Post article.3
This shortage also extends to specialists including oncologists, hematologists, mental health providers, and OB/GYNs.
The epidemic of doctor shortages in rural areas has been well-documented. According to the National Rural Health Association, there are just 30 specialists per 100,000 people in rural areas, compared to 263 specialists per 100,000 people in urban settings.4
A recent study in JCO Oncology Practice found that in 2019, 64% of counties in the U.S. had no oncologists with a primary practice location within their county limits and 12% had no oncologists in adjacent counties.5 A 2021 snapshot of the state of the American oncology workforce found that just 11.2% of the 13,146 oncologists currently engaged in patient care practiced in rural areas.6
The problem is not unique to the U.S. The World Health Organization estimates that 70% of cancer deaths happen in resource-limited countries.7
As Satish Gopal, MD, MPH, director of the Center for Global Health (CGH) at the National Cancer Institute, told ASH Clinical News in 2017, “Blood cancers and hematologic disorders aren’t considered major public health issues [in limited-resource areas], in part because the surveillance data are not great. So, unless you’re really looking, these issues are sort of invisible.”8
The Laws of Attraction
From a physician’s standpoint, practitioners are often drawn to more urban areas because they can serve a greater number of patients, according to Marvella E. Ford, PhD. Dr. Ford is professor of public health sciences and associate director of population sciences and cancer disparities at the Medical University of South Carolina’s Hollings Cancer Center.
While there are federal programs that try to entice physicians to rural areas with incentives like loan forgiveness, Dr. Ford said it is too early to tell whether these programs have been effective. In all likelihood, she said, these programs will not be attractive enough to draw specialists to rural settings.
“For specialty care, incentivizing programs are not effective because there just isn’t the base of patients with that specific disease that specialists are focusing on,” she said. “A specialist with decades of experience wants to be able to treat patients with the disease they specialize in.”
Kevin Brigle, PhD, ANP, a hematology/oncology nurse practitioner who ran a rural outreach program at Virginia Commonwealth University (VCU’s) Massey Cancer Center for nearly 20 years, said many physicians also choose more urban or suburban settings for the quality of life they afford.
“I think individuals want to live in areas where they can do things – that’s probably the big thing,” he said.
While working at the rural outreach program, Dr. Brigle said most of the primary care physicians practicing in rural parts of the state had a personal connection to the area.
“A couple of the doctors’ fathers are physicians down there, so they are continuing in that vein,” he said. Without those connections, “I think it’s really hard to attract somebody to an economically depressed area.”
Dr. Khaira decided to make the move to the Upper Peninsula after retiring from her own 3,000-patient practice and spending several years working as a locum tenens physician, most recently in Guam. She was drawn to the rural area of Michigan because she was ready for a slower-paced life in a peaceful setting.
“It’s absolutely breathtakingly beautiful up here,” she said. “My friends ask me all the time, ‘Don’t you miss shopping at Macy’s and Nordstrom?’ I tell them, ‘The best part of being up here is you can go to a store, pile your cart up, and it will only cost you $65.’”
Impact on Patient Population Health
Patients living in resource-limited settings not only face a lack of providers, but also often have higher incidences of disease and worse health outcomes than those living in urban areas.
According to the Centers for Disease Control and Prevention (CDC), the number of people who die from the top five leading causes of death (including heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke) is higher in rural areas than urban ones.9
“The biggest challenge in caring for patients [in areas] with shortages of physicians and resources is just the fact that people in those areas tend to be less healthy to begin with,” Dr. Ford said. “If there’s less access to primary care physicians and specialists, then people in the area tend to have higher rates of cardiovascular disease, diabetes, and stroke.”
This can mean that patients are often dealing with comorbid conditions, further complicating their care.
“Oncologists working in medically underserved areas often have patients coming in for chemotherapy who have had undiagnosed diabetes for years,” Dr. Ford offered as an example. “They are getting diagnosed at the start of their cancer treatment because it may be the first time someone has drawn their blood and checked their glucose levels or their A1C levels.” In these scenarios, “oncologists then have to adjust their chemotherapy dosage levels because they have to get the patients’ diabetes under control first,” she said.
Dr. Khaira said rural hematologists and oncologists also have to battle outdated equipment, limited access to tertiary centers, and “almost nonexistent subspecialities back-ups.”
“For example, if I want to obtain an MRI of a patient’s liver for iron deposition, I may not be able to do it on the MRI machine available,” she said of the tools at her disposal. “That can be an issue, especially when the people I am treating are too poor to afford to travel long distances where those services are available.”
In the Upper Peninsula of Michigan, there are only two PET scanners available in the area once a week, leading to a backlog of up to six weeks, Dr. Khaira said.
Although most laboratory tests can be conducted at the rural hospitals in her area, she said others are unavailable and patients are forced to drive two to three hours to get the lab work completed.
“All patients with leukemia, for example, get transferred out because the local clinics do not have the ability to provide that kind of acute care. Plus, there’s no blood bank around, so getting blood products for on-treatment leukemia patients can be an issue,” she said.
The nearest radiation services are also about two hours away, which means that patients have to rely on sequential radiation rather than concomitant radiation and chemotherapy.
“Here in the rural area, you are looking at two to four weeks before you can start a patient on treatment because everything is so fractured,” she said.
According to Dr. Khaira, the scarcity of health care resources also limits the drugs that she can offer her patients. For example, the recently approved belantamab mafodotin-blmf would typically be offered to patients with relapsed multiple myeloma, but has a black boxed warning for ocular toxicity. With no subspecialists available to conduct the recommended ophthalmic exams, prescribing the drug is too risky.
Access to specialists is equally difficult for those living in the Navajo Nation, a Native American territory encompassing 27,000 square miles that includes parts of Arizona, Utah, and New Mexico, according to Gayle Chacon, MD, professor emerita at the University of New Mexico School of Medicine.
She said residents of the mostly rural area may have to travel 100 to 200 miles to get to the nearest oncologist. Although some specialists make monthly visits to local clinics, those patients who need more extensive services face significant transportation challenges. “It’s a huge burden,” she stated.
The significant language barrier between oncologists and those who primarily speak the Navajo language can also present obstacles to care.
“There’s no word for ‘cancer’ in the Navajo language and other native languages because it was not original to them,” Dr. Chacon said. “It was originally translated to ‘the sore that does not heal.’ That creates fear in patients – just to think that you have something in your body that just doesn’t heal.”
She added that some patients have even refused radiation due to communication difficulties. During translation, patients were told they would be getting burned. For these reasons, she said it is important to have someone in a local clinic who can effectively translate and communicate with patients about their treatment protocol, upcoming appointments, and any other medical information.
Finding Solutions to Improving Care
To serve patients in these so-called doctor deserts, providers have embraced a variety of unique solutions, including adopting new delivery models, partnering with larger systems or networks, working with APs, and implementing telehealth services, according to the Rural Health Information Hub, a resource supported by the U.S. Department of Health and Human Services’ Health Resources and Services Administration.10
Realizing the potential of telemedicine to reach rural patients, hematologist Steven Fein, MD, MPH, started Heme Onc Call, a telemedicine hematology practice. The service improves access for medically underserved patients, relying on blood tests, imaging, and video consults with patients.
Dr. Fein provides hematology services to rural hospitals and underserved suburban hospitals without a hematologist on staff, often focusing on treating patients with blood clotting issues, idiopathic thrombocytopenic purpura, deep vein thrombosis, sickle cell disease, and acute promyelocytic leukemia (APL).
The importance of intervening early in the diagnosis of APL prompted Dr. Fein’s shift from hospital-based hematology in Miami to more rural areas.
“The patients who are dying of this disease are located mostly in rural or possibly just underserved suburban areas – any hospital that has no hematologist,” he said. “If their disease is not caught within the first few days, they die. These are often young people with children. It’s a tragedy.”
Through telemedicine services, Dr. Fein has been able to help patients like Jim Corbin, who presented to Southwestern Regional Medical Center in Riverdale, Georgia, after falling and hitting his head.
The hospital ran some blood work then consulted with Dr. Fein, who was able to quickly identify Mr. Corbin as having APL. He was rushed to Emory University for further treatment.
According to Dr. Fein, telehealth hematology services can help save lives, help rural hospitals keep patients within their walls who may otherwise be transferred out, and ensure a smoother transfer process for those who do need care at a larger facility. He admits, though, that starting the service has not been easy.
To provide telehealth services, Dr. Fein must become a full-fledged member of each hospital’s staff and be licensed in most of the states where he sees patients. He said getting through all the red tape has been a costly and time-consuming process, yet he believes providing hematology services through telehealth is a worthwhile endeavor.
“The biggest challenge in caring for patients [in areas] with shortages of physicians and resources is just the fact that people in those areas tend to be less healthy to begin with.”
—Marvella E. Ford, PhD
Providing care virtually is also a relatively new practice that patients and providers are becoming more comfortable with in the aftermath of the COVID-19 pandemic.
“Everybody in and out of the hospital has a higher comfort level with telemedicine now,” he said. “The stars aligned to enable us to actually recreate the inpatient setting online. Now every single hospital has telemedicine carts.”
In a recent survey of American Society of Hematology members who are practitioners, the ability to connect with patients in underserved areas and to consult with hospitals without in-house hematologists were listed as key advantages of the telehealth flexibilities implemented by the U.S. Department of Health and Human Services during the COVID-19 public health emergency.
Yet, for telemedicine to be effective, rural hospitals need high-speed internet access – something that may not be available in all areas, Dr. Ford cautioned.
In the rural outreach program at VCU’s Massey Cancer Center, Dr. Brigle – who spoke in-depth about the program with ASH Clinical News in 201912 – said that the center partnered with four smaller, local hospitals to set up oncology clinics there. Nurses stationed at these hospitals received specialized chemotherapy education and training at VCU, then returned to their hospitals to run the daily operations of the clinic, while Massey providers traveled to the regional, rural clinics one day per week to see patients.
To accommodate the patient population on that one day per week, Dr. Brigle said the clinic opened at 7 a.m. so that patients could make early appointments without fear of docked pay or worrying that the person who provided their transportation would miss work.
When Virginia practice laws changed to allow nurse practitioners to enter collaborative practice agreements, Dr. Brigle said the clinics ran even more smoothly. He and other APs were allowed to act as the sole provider at the clinics when the Massey provider was unable to.
Financial Struggles Facing Rural Hospitals
The VCU program ran for two decades but was recently shut down after the hospital was sold to another not-for-profit and the new owner decided to discontinue the clinics.
The elimination of the program coincides with financial challenges faced by many rural hospitals. Since 2005, more than 180 rural hospitals have closed their doors, according to a 2021 report by CNN. The picture only got bleaker when the COVID-19 pandemic hit.13
Rural hospitals were already serving higher rates of uninsured patients and those on Medicaid, whose cases bring less money into the facilities, but the COVID-19 pandemic caused many rural hospitals to lose out on outpatient services due to canceled appointments.
In 2020, 19 rural hospitals across the country shuttered their doors.
Even before the COVID-19 pandemic, many rural hospitals were facing their own financial hardships. The University of North Carolina’s NC Rural Health Research Program found that, in 2018, approximately 30% of rural hospitals reported negative total margins in 2018.14 A February 2021 survey of Critical Access Hospital (CAH) executives identified three major threats to the long-term viability of many rural hospitals: uncompensated care and affordability of health insurance; patient and ambulance bypass that reduces hospital reimbursement and influences patient perceptions of quality; and uncertainty about the 340B drug pricing program and declining access to medications.15
CAH designation is given to eligible rural hospitals by the Centers for Medicare and Medicaid Services (CMS) and is intended to reduce the financial vulnerability of rural hospitals and improve access to health care by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services, including outpatient, inpatient, laboratory, acute care, and therapy services. Unfortunately, the current reimbursement rate was reduced from 101% to 99% as a result of the 2013 budget sequestration.15
When a rural health care system closes, its negative impact reverberates across the area, increasing the distance its residents have to travel for preventive and treatment services, adding transportation costs, and eliminating access to emergency services.10
To avoid a complete closure, the CAH executives surveyed suggested that viable options for struggling rural hospitals include restructuring to become rural health clinics, emergency, or urgent care centers. Federally Qualified Health Center designation is another option. These community-based clinics receive funds from the Health Resources and Services Administration’s Health Center Program to provide primary care services in underserved areas.
While rural hospitals still face several significant challenges, hematologists and oncologists are working diligently to bridge treatment gaps and bring better care to patients – regardless of where they live.
“It’s become like a labor of love,” Dr. Fein said. —By Jill Sederstrom
References
- AAMC. Health Disparities Effect Millions in Rural U.S. Communities. October 2017. Accessed October 29, 2021. https://www.aamc.org/news-insights/health-disparities-affect-millions-rural-us-communities.
- Medicaid and CHIP Payment and Access Commission. Access in Brief: Rural and Urban Healthcare. March 2018. Accessed October 29, 2021. https://www.macpac.gov/wp-content/uploads/2018/10/Rural-Access-In-Brief.pdf.
- The Washington Post. ‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles. September 28, 2019. Accessed October 29, 2021, from https://www.washingtonpost.com/national/out-here-its-just-me/2019/09/28/fa1df9b6-deef-11e9-be96-6adb81821e90_story.html.
- National Rural Health Association. About Rural Healthcare. Accessed October 29, 2021. https://www.ruralhealth.us/about-nrha/about-rural-health-care.
- Shih YT, Kim B, Halpern MT. State of physician and pharmacist oncology workforce in the United States in 2019. JCO Oncol Pract. 2021;17(1):e1-e10.
- 2021 Snapshot: State of the Oncology Workforce in America. JCO Oncol Pract. 2021;17(5):249-249.
- World Health Organization. Cancer fact sheet, February 2017. Accessed October 29, 2021. http://www.who.int/mediacentre/factsheets/fs297/en/.
- ASH Clinical News. A World of Difference. December 1, 2017. Accessed October 29, 2021. https://www.ashclinicalnews.org/spotlight/a-world-of-difference/.
- Garcia MC, Faul M, Massetti G, et al. Reducing potentially excess deaths from the five leading causes of death in the rural United States. MMWR Surveill Summ. 2017;66(2):1
- Rural Health Information Hub. Healthcare Access in Rural Communities. Accessed October 29, 2021. https://www.ruralhealthinfo.org/topics/healthcare-access.
- National Cancer Institute. Unique Trial Aims to Decrease Early Deaths in Patients with Rare Leukemia. January 3, 2018. Accessed October 29, 2021. https://www.cancer.gov/news-events/cancer-currents-blog/2018/apl-trial-preventing-early-death.
- ASH Clinical News. Bringing Cancer Center Expertise to Rural Hospitals. August 1, 2019. Accessed October 29, 2021. https://www.ashclinicalnews.org/viewpoints/advanced-practice-voices/bringing-cancer-center-expertise-rural-hospitals/.
- CNN Health. How the pandemic killed a record number of rural hospitals. July 31, 2021. Accessed October 29, 2021. https://www.cnn.com/2021/07/31/health/rural-hospital-closures-pandemic/index.html.
- NC Rural Health Research Program. Geographic variation in uncompensated care between rural hospitals and urban hospitals. June 2018. Accessed November 3, 2021. https://www.shepscenter.unc.edu/download/16789/.
- Rural Health Information Hub. Critical Access Hospitals (CAHs). Accessed November 3, 2021. https://www.ruralhealthinfo.org/topics/critical-access-hospitals.
