Recruiting Rural Physicians; W. Pike

As the ranks of primary care physicians grew smaller, such doctors began to get lucrative offers from large urban managed care organizations. These trends left an obvi ous void-a shortage of rural primary care physicians. A survey of medical school seniors taken in 1979 showed that only 59 percent preferred a large or moderate city practice. By 1989 that number had grown to 80 percent.! William Pike is a fiscal analyst for the South Dakota Legislative Research Council. Government Response Local, state, and federal government agen cies moved to check this shortage by spend ing tax dollars and manipulating the market. Now most states maintain some sort of pro gram, at a cost of millions of dollars a year, to recruit and retain rural physicians. Politi cally, such programs are easily defended as absolutely necessary, in the words of Ten nessee's rural health office, "to improve and enhance the accessibility, availability, and affordability of quality health care." Few vot ers, and certainly few legislators, are willing to argue with such a mission. However, are such agencies really efficient in the face of freemarket alternatives?

How do government agencies recruit physi cians for rural communities? The foremost device is money. Many states lure doctors to rural practice by paying all or part of the cost of their medical education. In some cases the state contracts with new physicians to work in a rural area for a specific amount of time in return for payment of debts at the end of that service. In other, less effective programs, stu dents sign agreements promising to work in a rural area after completion of medical school, which the state pays for in the meantime. Obviously, this arrangement is prone to exploitation by students who, their education paid for and degrees in hand, decide not to practice rural medicine, or at least not to ful fill their entire obligation. In either case, citi zens pay heavily. 11 12 THE FREEMAN/IDEAS ON LIBERTY • JANUARY 1999 Other recruitment methods also exist. States have sponsored programs to interest rural high school students in medical careers.

They have also set up residency training pro grams in rural hospitals to give medical stu dents the chance to experience rurallife first hand. Some of these programs have succeed ed in bringing doctors to rural areas. In 1971 the University of Minnesota opened the Rural Physician Associate Program, a nine-month elective available to third-year medical stu dents. According to the university, "Students live and train in non-metropolitan communi ties under the supervision of family practice and other physicians called preceptors." Over 800 medical students have participated, and of those, 65 percent now practice in rural areas. Eighty-two percent of the participants chose primary care.2 In addition, state-sponsored recruitment agencies attempt to lure practicing physicians to rural hospitals and communities. For instance, Oregon sponsors the Healthcare Experts for Rural Oregon (HERO) program, which works with rural communities to attract compatible physicians, offering bonuses such as a state income tax credit of$5,000 for up to ten years.

Is State Recruitment Necessary? Government-sponsored recruitment is cer tainly a departure from freemarket- princi ples. However, it is not the kind of govern ment intervention that is likely to draw much criticism. The state would respond that it is fulfilling its proper role by helping rural com munities find the physicians they need for quality care. The subject isn't quite that sim ple, however, and the outcomes aren't always so rosy. The emphasis placed on recruiting physi cians helps contribute to a dangerous culture of dependence among residents of rural areas. Rural communities come to see themselves as "charity cases," unworthy of having a physi cian except at the start of his career and not able to support or attract a physician without state help. That culture subverts the free market principle of voluntary exchange for mutual benefit that rules other aspects of our economy, urban and rural. Consider the advice of one publication written as a guide for those working in the field of rural physi cian recruitment: Develop a recruitment fund with dona tions from the hospital, businesses, and community events, e.g., cake sales and high school car washes. Be prepared to spend several years of hard work develop ing the fund.

Considerdevelopinga communityfinance plan to help new doctors purchase equip ment or repay their educational debts.3 Imagine a community accepting such advice for the recruitment of bankers or lawyers. It wouldn't happen. We do not hear of severe shortages of bankers or lawyers in rural America, not because there are necessar ily too many of them, but because the free market offers a place for practitioners of these professions in small towns as well as in large cities. Advocates of state-sponsored rural physician recruitment are bound to argue that physicians cannot be compared to bankers or lawyers. But in fact, none can exist without the others. All three, along with grocers, cus todians, restaurateurs, teachers, carpenters, and a host of other workers and entrepreneurs are intertwined into any local economy, and none should be singled out for special treat ment. When special treatment is accorded to one occupation, the population is bound to suffer through both the cost and quality of the service offered. Lopsided dependence is no base on which to build any segment of an economy.

Just as government interference creates a culture of dependence among rural residents, it also creates a culture of transience in the rural health-care community. In the free mar ket, physicians take up practice in a commu nity because they want to live there and because they feel that good opportunities exist for them. Some are bound to move on, but many will stay and pursue their dreams. When physicians are lured to a community through state loan repayments, tax breaks, and other perks, a sense of transience is almost expected. One North Carolina study RECRUITING RURAL PHYSICIANS: SMALL-ToWN SOCIALISM 13 found that 19 percent of newly recruited rural physicians planned to leave, even when they first arrived. Fewer than half planned to stay.4 Though some physicians will remain in an area for a long time, others will move on to still greener pastures when their obligations are fulfilled or when they realize that their personalities and dreams do not fit the com munity in which they were placed. Such tran sience is detrimental to quality health care in small communities and merely perpetuates the recruitment problem by opening up a vacancy not long after it has been filled.

Market Alternatives Nevertheless, primary care physicians are few and far between in much of rural Ameri ca, and access to medical care there is often a real problem. But this situation must not drive us to conclude that freemarket solutions don't exist. Indeed, trends that have drawn so much discussion over the past decade may be reversing themselves. The growth of managed care organizations, which drew so many gen eral practitioners to urban areas over the last several years, is slowing. Profits are shrink ing. Consumers are clamoring for more choice.s The shortage of primary care physi cians nationwide may very well be turning into a surplus, as medical students realize where their best opportunities for work might be in the future.6 Some of these physicians will turn to rural communities on their own, realizing that markets there are open. In the meantime, rural hospitals and com munities should be encouraged to use private recruiting agents or cooperative recruiting efforts, rather than state-supported recruiting mechanisms. Such efforts are more realistic and efficient-and more satisfying in match ing a doctor to a community.

In short, we must be careful not to pass off any state-sponsored program as helpful or even as harmless without a full analysis of the freemarket alternatives. Though wide ranging government health-care initiatives, such as the 1993 Clinton plan, are likely to raise the eyebrows of voters, few people will even notice something as seemingly innocu ous as government-sponsored rural physician recruitment. On its surface that mission, like so many others, seems to be a proper use of tax dollars, a beneficial action on behalf of those with little political or economic power. Yet it is in exactly such cases that citizens lose freedom and independence to the state, a trend that is hard to reverse. D 1. Victoria D. Weisfeld, ed., Rural Health Challenges in the 1990s, (Princeton: Robert Wood Johnson Foundation, November 1993), p. 57. 2. University of Minnesota, Rural Physician Associate Program.

Http://www.rpap.umn.edu/. May 7, 1997. 3. Plugging the Leaks in Health Care: Harnessing Economic Opportunity in Rural America. Center for the New West. December 1992, p. K3. 4. Sari Teplin and Christine Kushner, Physician Life and Prac tice in Underserved Communities: Strategies for Recruitment and Retention, University of North Carolina Rural Health Research Pro gram, March 1994, p. 8. 5. Center for Studying Health System Change, Issue Brief, Wash ington, D.C., May 1998. 6. "Survey shows surplus of primary care physicians." CNN Interactive, U.S. News Story page, http://www.cnn.com/US/9804/ 13/doctor.shortage.ap/. April 13, 1998.