Daily Montanan: New legislation aims to boost number of rural, ‘frontier’ doctors

by Darrell Ehrlick

Montana’s shortage of doctors and nurses has been well documented and almost as constant as the unpredictable weather in the state. However, U.S. Sen. Jon Tester has introduced legislation that could make a substantial difference in the number of doctors being trained in Montana’s frontier medical centers.

The problem is simply stated: Montana needs more doctors. Some counties don’t have a single physician living in them, creating a critical care shortage.

The solution would seem equally simple – get more doctors. However, the obstacles don’t budge easily. What is often characterized as a “doctor shortage” might be better described as a “training shortage.” For example, hundreds of people graduate from medical schools each year, but they are not matched with clinical training sites. Without that supervised training, doctors cannot get the experience they need to be licensed.

Training is often tied to whether sites can be reimbursed for those services and doctor visits done by the residents. That reimbursement is dictated by Medicare, which puts a cap on the number of graduate medical training sites and has remained largely unchanged since 1996.

Tester’s bill would create a new, different route to pay for rural residency training. Any hospital can choose between the standard graduate medical reimbursement currently offered or the new track outlined by Tester, which would allow full-time training for any medical specialty for any duration longer than eight weeks. Another key feature is that the payments to these rural training sites are not discounted based on Medicare patient load, meaning they are specifically calculated to enhance payment to hospitals for rural training positions.

The law would also allow urban medical centers to send residents to more rural, critical-access hospitals and be reimbursed, something that is currently not allowed.

“The shortage of doctors in rural America threatens the future of our frontier communities,” Tester said. “Folks in every corner of our state deserve access to high-quality care, no matter where they live. This bill works to cut the burdensome red tape that prevents rural hospitals from bringing in more residents, and ensures those facilities have the resources they need to recruit and retain doctors for the long haul.”

The measure has already garnered a wide swath of support among Montana medical leaders as one solution to help the doctor shortage. They point out that nationally, about 80 percent of residents wind up practicing in the same place where they started, meaning the program could be a key recruiting and retention tool.

“These barriers keep residents from going to the rural and frontier areas,” said Jean Branscum, executive director of the Montana Medical Organization, which represents the doctors of Montana. “This opens the door for critical access hospitals and helps the pipeline. We’re getting beyond the cap of Medicare, and this has been an ongoing challenge for years.”

More doctors would also relieve the pressure on current doctors with high demands and few back-ups.

“It’s going to help with physician burn-out,” she said.

Rich Rasmussen, the chief executive of the Montana Hospitals Association, said that while medical care has continued to make leaps and bounds, the system is stuck in the past.

“This model has not been updated in decades,” Rasmussen said. “This creates enough financial support so that our members can host medical residencies and clinical rotations. More important, it lets them practice medicine close to the patients.”

Rasmussen points out that Montana is the most “frontier” state of any – even more so than Alaska – at fewer than six people per square mile in most places.

“We will do what we can in Sen. Tester’s home state and encourage other state hospital associations,” Rasmussen said. “This doesn’t just help Montana, it would help all rural America. When they come to Montana, they fall in love with the community and people – and each place is so unique. Our residents in this state still respect the doctors and appreciate the physicians who come to work there.”

Billings Clinic, the largest healthcare system in the state, is supportive of the measure, and it has residents at its location. It has long advocated for changes that allow residents practitioners to fan out into rural settings.

“Creating more opportunities to train residents in rural settings is an important part of addressing the need for more doctors in rural states like Montana and Wyoming. Medical education is a cornerstone of Billings Clinic’s mission and we support this effort to increase funding for more graduate medical education in the rural areas we serve. Billings Clinic has a strong commitment to our own Internal Medicine Residency program, a partnership with the University of Washington for our Psychiatry Residency and we partner with other local health care organizations on the Montana Family Medicine Residency in Billings,” said clinic spokesman Zach Benoit. “We know that, after graduating, resident physicians are more likely to practice near where they finish their residency versus medical school. This bill would help to ensure that physician education is community grown, maximize the use of rural facilities in that education and do so at a scope and scale that is appropriate for our region. Investing in the training of resident physicians is investing in the sustainability of rural health care.”

Because of a different reimbursement model, Tester’s office said the legislation is budget neutral.