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Missouri Physician Shortage: Why?

Missouri is ranked second in the nation for exporting the doctors it trains, causing primary physician shortages particularly in rural areas, according to a recent report released by the Missouri Hospital Association.

The two largest contributors to the state’s exporting of doctors is its production of physicians and, more importantly, its inability to keep them.

“We have six medical schools here, which is a very large number of schools for a state our size,” said Tom Holloway, executive vice president of the Missouri State Medical Association.

In 2011, the state had 489 graduates from its various medical colleges, according to statistics from the Henry J. Kaiser Family Foundation and the Association of American Medical Colleges.

The University of Missouri School of Medicine in Columbia recently expanded its class size to 104 students from 96 and have a graduation rate of nearly 99 percent, according to the school’s Office of Medical Education. They have yet to graduate a class of more than 100 since the expansion is fairly recent, but the school still provides roughly 19 percent of the state’s medical school graduates.

Of the university’s most recent class, which graduated in May, 46 percent stayed in Missouri, said Stephanie Baehman, of the school of medicine’s public relations department. Also 25 percent stayed at the university hospital for their residency and 40 percent of them went into a primary care field.

A main reason for the problem is a lack of residency positions for graduating medical students, according to the Missouri Hospital Association (MHA) and the Missouri Medical Association (MMA).

“There simply are not enough slots for residency, and that is not just a state thing. There are not enough slots nationwide for medical school graduates,” Holloway said. “Every year you have a several, like 400 to 500, students graduate medical school, but they do not get in a residency because there are not enough slots. … And there are not enough teaching institutions that have the funding to keep the residency slots available.”

The funding for these teaching institutions is provided by the federal government, and the lack of funding is the main reason for the lack of residencies, Holloway said.

Another reason Missouri can’t keep its doctors is expensive malpractice insurance.

Two years ago the Missouri Supreme Court made a ruling in the case Watts verses Cox that reversed one of its previous rulings and removed the cap on non-economic damages. This means whatever the court wanted to award someone for pain and suffering had to be paid by physicians or healthcare providers, whether it be $1 or $1 billion. Before the cap was completely removed the limit on damage payments fluctuated with an inverse relationship to the number of physicians in the state.

“We saw this 10 years ago, when we got that higher cap on the books we had a large amount of physicians leave the state,” Holloway said about the relationship between the damages cap and doctor population. “And then when we got the cap down to $350,000 we saw a large influx in medical positions being filled.”

The third reason many doctors move away after graduating is the large amount of the uninsured people in the state. Private primary care physicians have to limit the amount of care they give to the uninsured, unlike hospitals, because they are running a business and they cannot operate at a loss, Holloway said.

Missouri has roughly 843,000 uninsured residents, meaning more than 14 percent of the population is uninsured, according to the Census Bureau’s March 2012-2013 Current Population Survey.

However, approximately 150,000 people participated in the federal market place for insurance through the Affordable Care Act so the number of uninsured is probably closer to 650,000 people, said Dave Dillion of MHA.

“The policy environment has not been attractive enough, compared to other states, to attract and maintain physicians and that is how come we produce more than we can keep,” Dillion said. “The state lawmakers have put several items on the ballot that have kept the state from being engaged in the federally facilitated market place.”

The Affordable Care Act did not cause the problem of fleeing physicians, but it is exacerbating it, Dillion said. Providing insurance to 100,000 plus people has put more strain on already stressed system, he continued. He added that expanding Medicaid and actually taking part in the Affordable Care Act could alleviate some of the problems of the state’s healthcare climate.

“More than 50 percent of doctors practice at hospitals,” Dillion said. “The hospitals will accept all comers so the Medicaid expansion would make a big difference for doctors that practice at hospitals. If your hospitals in the community are not strong, then they cannot recruit doctors to practice there. Or at least it puts those hospitals in a poorer competitive position.”

He explained that the hospitals absorb the cost of treating uninsured patients, but if the state were to opt into the expansion of Medicaid then the hoards of the uninsured would decrease and the hospitals would be paid more from Medicaid.

Also because hospitals accept everyone who needs medical attention there is an unfair and unneeded stress put on emergency rooms, Dillion said. He said when people are uninsured they are not able to see a primary care physician for their needed, regular treatment of chronic illnesses and other non emergency medical conditions, such as the flu. This means they have to delay seeing the doctor until it is too late and they need emergency treatment, rather than being able to stay on top of their medical issues.

The primary care physician is the front line of medicine that would treat these people if they were insured and relieve emergency rooms, which are notoriously the most expensive and less efficient way to treat chronic illnesses or other non-emergent conditions, Dillion said.

To make matters worse, the number of people who need to see a primary care physician but can’t is growing, while the number of primary care physicians is shrinking. One of the reasons for this are the incentives provided by medical schools to go into a specialty, such as specialist are paid more on average than primary care physicians. The increase in pay allows specialist to pay off the high cost of medical school sooner.

Nearly all of the growth in the number of doctors per capita in the last several decades was because of specialists. Between 1965 and 1992, the primary care physician-to-population ratio grew by only 14 percent, while the specialist-to-population ratio exploded by 120 percent, according to the Missouri Hospital Association’s report “Primary Care Physicians: Rural and Urban Disparities in Missouri.”

The report also states that the number of practicing physicians in the state has slightly increased, but rural Missouri areas have been losing physicians since 2011. Also, approximately 80 percent of the state is classified as a “health professional shortage area” and one in five Missourians have no access to primary care, according to information provided by the Missouri Foundation for Health.

Missouri State Medical Association is trying to alleviate some of these problems by pursuing legislation to restore the cap on non-economic damages, thus lowering malpractice insurance. And they are trying to secure more money from the federal government to increase the number of residency slots available to medical school graduates, Holloway said.

There is still a problem with the few doctors that the state is able to keep, and it is the same problem the population of the state is facing: time. Around 40 percent of practicing physicians in the state are older than 55 and rural physicians are usually at least two years older than their urban counterparts, according to the MHA report. Also more than one-third of the nursing workforce is older than 50.

As for the population, approximately 19 percent rural Missourians are more than 65 years old, while around 14 percent of the urban population in that old, the report states. As the population of physicians and residents get closer to retirement the need for the state to retain the young doctors it produces is growing.

“Missouri’s primary care system is at a crossroads,” according to the report’s overview. “The nexus of an aging primary care workforce, an aging population with increased healthcare needs and extended health insurance coverage through the Affordable Care Act have placed demands on the system that have stretched it past its capacity. Moreover, these factors and others portent a primary care shortage that will increase through time.”