Wyo Hospital Assoc. President: Federal changes makes it almost impossible for us to be competitive and for us to recruit especially family practice physicians in these rural areas where they’re needed the most.
By James Chilton, Cowboy State Daily
CHEYENNE – When it comes to sheer numbers, Wyoming’s doctor shortage isn’t all that bad, on paper at least. Just two dozen additional full-time outpatient physicians would be enough to meet the primary care needs of the nearly 188,000 Wyomingites living in federally-designated Health Professional Shortage Areas, or HPSAs.
“The population of designated HPSAs in Wyoming for primary care is 187,903, and only 53.81 percent of that population’s need is met,” said Keri Wagner, of the Wyoming Health Department’s Office of Rural Health. “The practitioners needed to remove that designation is 24 for the entire state.”
While it might not sound like much, getting those 24 full-time doctors into the state, getting them to the communities where they’re needed most, and offering them the compensation and quality of life needed to keep them here have proven uniquely difficult in the Cowboy State. Federal and state programs have made some headway in the effort to bring more doctors, dentists and psychiatrists to all corners of Wyoming. But while the state’s reputation for wide-open natural splendor brings in the tourists and outdoorsmen, it’s not necessarily what most doctors are seeking when looking to relocate.
“It really takes a specific type of person, someone who grew up in these frontier communities that really wants to get back to practicing someplace where they’re relatively isolated. If they’re outdoorsmen or like cross-country skiing or hunting, sure; but there are long distances to get to any other type of entertainment,” Wagner said. “We’re surrounded by states with larger population centers, more enrichment opportunities and educational opportunities, so it can be a really tough sell for some communities that don’t even have a supermarket.”
The HPSA designation seeks to help with this by grading facilities, geographic regions and specific populations on criteria like patient-to-provider ratio, percentage of the population living below the federal poverty level and travel time to the nearest source of care. From this, hospitals, clinics and geographic areas are scored, with higher scores getting the most attention from the U.S. Health Resources and Services Administration.
“If they have the HPSA designation for any of the three disciplines (primary care, dental or mental health services) it opens up the opportunity to participate in the National Health Service Corps,” Wagner said. “We have roughly 30 corps participants every year.”
The National Health Service Corps tries to get practitioners to where the need is by offering scholarships and loan repayment programs to fledgling doctors in exchange for an agreement to work in a designated HPSA for at least two years. Physicians working in geographic HPSAs can also obtain additional bonus quarterly payments from the Centers for Medicare and Medicaid Services.
For HPSA designation and related support, practitioners must submit reports updating the state on statistics such as doctor-to-patient ratios.
“It’s important enough they’ll return their surveys if they’re afraid they’ll lose their designation,” Wagner said. “I’ve seen people where they receive the bonus payment, but there was some cutoff or something wrong with the timing, where the HPSA designation goes away and they have to return it. I think one of the big things that’s happened is the population is so small that just the loss of a quarter of an FTE (full-time equivalent, i.e. 40 hours of work per week) can make or break a designation.”
That’s been a continuing cause for concern for Eric Boley, president of the Wyoming Hospital Association. Boley agreed with Wagner’s assessment that, for whatever reason, the HPSA system seems weighted to apply to more densely-populated areas, where small changes in population don’t move the needle as much.
“The feds have changed the way the HPSA scoring is calculated based on service areas, so areas I and my members would designate as shortage areas no longer meet their criteria,” Boley said. “For example, south Lincoln County used to easily qualify for HPSA funding, where northern Lincoln County, the Star Valley area, didn’t have some of the challenges. But now because of criteria changes, the whole area is lumped into one.”
As a result, Boley said some of the state’s most vulnerable rural communities are left with few resources to attract medical talent from larger hospital systems, and even those that do have the resources have to make steep offers to even stand a chance.
“My facilities are having to pay, in some cases, the 95th percentile for salaries, with sign-on bonuses and really lucrative living expense packages,” Boley said. “It makes it almost impossible for us to be competitive and for us to recruit especially family practice physicians in these rural areas where they’re needed the most.”
Wagner noted the state has led its own effort to try to provide a little more financial leverage to small communities through the Wyoming Provider Recruitment Grant Program, which provides up to $50,000 to a hospital, clinic or community organization attempting to recruit a healthcare provider. Initially funded for the 2009-10 biennium, the program doesn’t level the playing field, Wagner said, but it has helped to recruit more than a dozen physicians, psychiatrists and, following a 2015 legislative change, other health professionals like registered nurses or occupational therapists.
Like most programs, Wyoming’s provider recruitment program has some strings attached that have kept it from being fully utilized. One big problem is that the grants are meant for reimbursement, meaning whoever’s doing the hiring needs to have the money up front and has to have someone recruited within one year for the payments to come through.
“If they don’t recruit within that one year, they don’t get any money. If they do recruit, the provider has to start within six months of the date they sign them,” Wagner said. “So, is this entity able to fund all of this up front and wait for the reimbursement? Our neediest have applied, but they couldn’t go anywhere without money to front it.”
As such, Wagner said applications made through the program dropped from 45 in the 2009-10 biennium to just nine in the following biennium, and they have remained low ever since. But for those hospitals able to navigate the process and pay for the initial recruitment process, the program has proven a useful tool.
“I think it’s successful in that it provides funding to help recruitment at safety-net facilities. These are organizations that don’t have a ton of funding; they have a hard time competing with larger hospital systems in surrounding states,” she said. “So when a provider is contacted and they’re mulling over whether they should go to a rural health clinic in Colorado that’s offering an $80,000 loan repayment on top of a $40,000 sign-on bonus, versus this hospital in Wyoming … this program improves Wyoming’s negotiating position. It provides them with a little bit more clout.”