Incentives for Recruitment of Physicians and Problems of Retention
In Rural South Carolina
Case in Point: Marlboro Park Hospital and Surrounding County, Bennettsville, SC
Sharon K. Saleeby, RRT
College of Health Professions
Medical University of South Carolina
Recruitment of physicians to rural areas is a difficult task. The federal government recognizes that rural health care recipients need physicians to serve in medically underserved areas; therefore they have devised monetary incentives to help accomplish the task of physician placement. The state government is involved with recruitment initiatives in a similar capacity. Rural hospitals, such as Marlboro Park Hospital in Bennettsville, SC are constantly seeking new physicians to expand their services and to replace those that have left or retired. The high physician attrition rate in the county is due to multiple factors. The inability to keep physicians in the county has multiple effects from community perceptions on the availability of health services to the long term viability of the hospital.
A persistent and pervasive problem facing small town community based hospital systems is the recruitment and retention of physicians. With the current downturn in the economy, the already arduous task of recruiting physicians has become even more difficult. While there are federal, state, and local initiatives to bring physicians into the community, retention of those physicians remains a constant problem, particularly to small community hospitals, like Marlboro Park, in Bennettsville, SC. The inability to keep doctors in the community effects the community’s perception of the hospital, causes rising visits to the Emergency Department for primary care issues, and will often force those same citizens to seek care outside of the county. Recruitment can be accomplished, but there are no easy answers and no quick fixes on how to keep these physicians in the county. The information in this paper is based on conversations held with the Director of Human Resources at Marlboro Park Hospital, the Director of Recruitment at the South Carolina Office of Rural Health, and through journal articles dealing with recruitment and retention of physicians to rural areas, not just in South Carolina, but nationwide.
Marlboro Park Hospital (MPH) is a private for profit hospital located in the town of Bennettsville, South Carolina. MPH has 102 beds, 18 active physicians, 28 physicians with courtesy privileges, 183 employees and 35 contracted employees. Dietary, Rehabilitation Services, and Biomedical are all contracted services. Additionally, the physicians staffing the Emergency Department are contracted. There are 12 specialty services (Family Practice, general surgery, Ob-Gyn, urology, radiology, pediatrics, internal medicine, nephrology, orthopedics, pathology, urology, and pulmonary medicine) and 2 consulting specialties (cardiology and gastroenterology). Some of the services that the hospital provide are: telemetry, cardiopulmonary, 24-hour Emergency Room, ICU, Imaging, Labor and Delivery, Laboratory, Pharmacy, and Surgical Services. They also have Post Anesthesia Care, EEG, Occupational Therapy and Physical Therapy Rehabilitation Care. Owned by Community Health Systems (CHS), which is based in Franklin, Tennessee, the company’s focus is on small rural hospitals. CHS provides recruitment services to these hospitals and management guidance. CHS’s mission, through MPH, is to build a strong community-hospital relationship. They currently own five rural hospitals located in the upstate region of SC. (C. Meggs, personal communication, October 4, 2009)
The Human Resource Department of MPH, as with many small rural hospitals, is staffed by one person. While Christi Meggs is responsible for overseeing the hiring of new employees, benefit packages and orientation of new employees, her main objective is recruitment of physicians and marketing for MPH. She is credentialed as a Senior Professional in Human Resources. It is through interviews with Mrs. Meggs that I am able to put the pieces of recruitment and retention into proper perspective and appreciate the difficulty involved.
The town of Bennettsville is located in Marlboro County, just north of Darlington, SC. The population of the county, based on 2008 census reports, is 28,021, of which 52.3% is black, 42.5% is white, and 3.7% is Native American. Sixty percent of the population has a high school education; 8.3% has a Bachelor’s Degree, and 8.9% have professional degrees. The school system in the county is ranked as one of the lowest in the state, based on Palmetto Achievement Challenge Testing results compared with state averages. (Great Schools, 2008) The median household income is $29,229 vs. $43,508 for the state and $42,000 US median. The unemployment rate is one of the highest in the state at 21.7%. (U.S. Census, 2008)
Nineteen percent of the population has no health insurance. Seventeen percent qualify for Medicare and 32% are Medicaid enrollees. (South Carolina Department of Health and Human Services, SFY 2008) While these are simply numbers on a census table, the stark reality is that 27.5% live below the poverty level in Marlboro County and these facts have a tremendous impact on the success of the hospital. (U.S. Census, 2008) Not only must MPH survive amid this, but they are faced with five competing hospitals within a 45-mile radius, and all with similar issues and competing for the same revenue base.
Over the past three years, MPH has been unable to hire a psychiatrist and therefore have had to close their Adult Mental Health facility. They have lost a gastroenterologist and had to close their GI suite. Two family medicine physicians employed by the hospital have relocated, which resulted in the reconfiguring of the hospital based Rural Health Clinic. The hospital has had a turnover of five CEOS and three Directors of Nursing. Though these problems seem insurmountable, Christi Meggs, prods forward and is enthusiastic in her endeavors to restore a semblance of stability within the hospital. These issues are not unique to Marlboro County; they are pervasive throughout the country.
When we speak of “rural”, we are referring to counties in which there is no metropolitan area with more than 50,000 residents. Fifty-three percent of SC is considered rural and only 9% of physicians practice within this rural area. Here we find our most susceptible and underserved populations. (Hancock, 2009) Statistics reported by the Center for Disease Control (CDC), state that those living in rural areas have “higher death rates from unintentional injuries, higher incidences of chronic obstructive pulmonary disease, and higher rates of suicide.” (Escarce, 2009, p.625) Heart disease, obesity, tobacco, alcohol and drug abuse are also higher than non-rural areas. Unfortunately, this vulnerable population is least likely to seek care, thus contributing to the high mortality rate.
In response to the need for rural health care access, the Federal Government has tried to set in place initiatives to aid in the recruitment of physicians to rural areas. In 1987, the Medicare Payment Incentive Program was initiated in the attempt to retain existing physicians in rural areas and to provide funding to offset the cost of relocation and costs associated with opening new practices. In that same year, the Omnibus Budget Reconciliation Act was passed. (U.S. Department of Health and Human Services,[DHHS] Office of Inspector General, 1994) This provided for bonus payments to physicians for a five percent increase (now a ten percent increase) to the amount paid by Medicare for their services. This bonus was allocated providing they worked in areas designated as medically underserved. To establish guidelines in defining what regions actually qualified for funding, the Department of Health and Human Resources Service Administration, under the Public Service Act 1976, ( Sec. 215 of the Public Health Service Act, 58 Stat. 690 (42 U.S.C. 216); sec. 332 of the Public Health Service Act, 90 Stat. 2270 - 2272 (42 U.S.C. 254e) categorized areas as Health Professional Shortage Areas (HPSA). There are three subcategories of HPSA. Geographic HPSA must have a physician patient ratio of greater that 3,000:1. Low income HPSA is an area living below the poverty level. Facilities HPSA are non-profit medical facilities such as Community Health Centers, Rural Health Centers, and correctional institutions. The designation of these areas is determined by the states.(South Carolina Department of Health and Environmental Control, [SCDHEC]) In SC, it is determined by the SC Department of Health and Environmental Control’s Office of Primary Care after a Health Care Access Analysis is done. To achieve a designation of a Medically Underserved Area (MUA) or Medically Underserved Population (MUP), the U.S. Department of Health and Human Services will analyze the ratio of primary care physicians per 1,000 populations, the infant mortality rates, percentage of those living under the poverty level, and percentage of those over the age of sixty five. (U.S. Health Resources and Services Administration, [HRSA]) These designations make it possible to establish federally qualified Health Care Centers, rural health care clinics, and HPSA Medicare programs (due to the complexity of Medicare and Medicaid reimbursements to physicians, I have opted to only make mention of their existence.)
Recruitment of physicians is directly affected by HPSA or MUA/P designations in that it will determine federal funding. Thirty state and federal programs use the HPSA/MUA designations to establish eligibility for loan repayment programs, scholarships programs for medical students, and J-1 visa programs for international students. (SCDHEC) There are three specific federal programs available whose focus is rural area recruitment. The Health Resources and Service Administration Loan Repayment Program is funded through the National Health Service Corp. The program is aimed at primary care physicians that are U.S. citizens or naturalized citizens and requires the recipient to work in HPSAs that accept Medicare and Medicaid. Usual sites for placement of recipients are rural health clinics, public health departments, hospital-affiliated primary care offices, managed care offices, and prisons. Compensation varies by state. Presently, the limit is set at $35,000 for a two year commitment, but can be extended beyond the two year period with added compensation. All funds are tax exempt and medical malpractice is covered. Applications go through the DHEC Office of Primary Care. (DHHS,National Health Service Corp, [NHSC])
The National Health Service Corp provides both a loan repayment program and a scholarship program. The loan program is available for physicians whose specialties are Family Practice, Internal Medicine, Ob-GYN, Pediatrics or General Practice. This program also requires that the recipient make a commitment of at least two years to practice in a HPSA. The amount of repayment is up to $25,000 and up to $35,000 for third and successive years. Furthermore, physicians are given additional income (39% of the amount) to offset the tax liabilities of the funding. (American Association of Medical Colleges, 2009) The scholarship program requires the recipient to be a U.S. citizen attending an accredited medical school in this country. A future residency in a primary care field is required and a one year commitment for every year of aid is expected.
For international medical graduates, recruitment to HPSA is achieved through J-1 Visa programs. The minimum commitment time is three-years. For these graduates, they must first apply through the U.S. Department of State, then through the DHEC Office of Primary Care. Here in Marlboro County, J-1 Visa applicants work either at a local rural health office, also known as CareSouth, Inc. or at Evans Correctional Center (state penitentiary) or the Federal Corrections Institute (federal penitentiary). These same graduates will qualify for permanent residency status with an additional two year commitment to continue their work in underserved areas. (Pennsylvania Department of Health, 2009)
State incentives for recruitment are accomplished through a state incentive grant. This grant is sponsored through the SC Area Health Education Consortium (AHEC) and is co-sponsored by the Medical University of SC, and is managed by the Rural Physician Incentive Board. The purpose of this grant is to provide assistance to new physicians setting up practices or joining existing rural practices in the hopes that they will maintain a viable practice and commit to the area. Depending on state budget allowances, a maximum of $40,000 is awarded over a four-year period. First priority candidates of grant distribution would be SC natives that have attended medical school in SC. Recipients must agree to accept Medicare patients, Medicaid patients, and any other patient regardless of their ability to pay for services. The SC Office of Rural Health tracks the number of patients seen by the practice to ensure compliance with grant requirements. If default of the grant occurs, all funds must be returned. Additionally, there is a State matching Incentive program that was developed to help physicians start up a primary care office in an area designated at medically underserved. (SC Area Health Education Consortium, Recruitment and Retention Programs) This is both a federal and state plan in that funds from the federal government are matched equally by state funding. (Texas Medical Association, 2008)
Marlboro Park Hospital has its own incentives for recruitment. If the recipients of any of the loan repayment programs or J-1 Visa programs wish to continue service in the county after their commitment is over, MPH will often help them establish a hospital affiliated practice. This sets up a win-win situation in that it takes care of the physician, yet provides a revenue source for referrals to the hospital. (Norbut, 2004) As an added incentive, these physicians are given positions on hospital committees, such as the Hospital Utilization Board, Medical Executive Committee, and the Credentialing Committee. Studies have shown that physicians look favorably on being given leadership positions or expanding their administrative or clinical positions. (Deprez, 2004) Physicians are also offered commitment bonuses, varying from 10 to 30K, funds for Continuing Medical Education Credits (CME), and relocation packages. If there is no available physician to fill an opening, MPH can obtain help from the Department of Rural Health through membership services. The cost of membership is $3,000 yearly and the hospital is able to have access to their physician databases and recruitment services. (Stacey Day, Director of Recruitment, Office of Rural Health, personal communication, Oct 20, 2009) The corporate office of CHS also deals with recruitment by attending national conferences, direct mailings to physicians, accessing national databases, visiting medical schools, and referrals from other physicians. (C, Meggs, personal communication, Oct 4, 2009) While all of these programs exist to bring doctors into this community, it is quite another issue having them stay.
Once physicians are recruited to rural areas, there are problems inherit is continuing to live in small communities. Chief complaints for doctors usually revolve around educational isolation and long hours and frequent on call schedules. (Deprez, 2004) For instance, in Marlboro County there were six physicians sharing call for medicine patients, which means that the call schedule was rotated every six days; not necessarily different from an urban area. However, there is only one surgeon, so he is on call every day. There are three Ob-Gyn physicians, which necessitates a rotation schedule every three days. All three Ob-Gyns service the neighboring county, which is likewise a rural agricultural area. Attaining continuing medical education credits (CMEs), as required by the State Board of Medical Examiners, is difficult here as well. The hospital will periodically sponsor in-services and will reimburse for travel to programs, however, most rely on on-line programs. The South Carolina Area Health Education Consortium will frequently offer classes to ensure the attainment of required CMEs.
There are issues with medical insurance reimbursements, keeping in mind, there are high levels of uninsured patients, and those on Medicare and Medicaid. While there are government programs in place that aid in Medicaid payments, such as the Physician Incentive Bonus Payments, reimbursements tend to be low (mentioned previously, gives a 10% bonus to those treating Medicaid patients.) (Phillips, 1998) Specialty physicians are often concerned about the number of patients to support their practices. Financial viability is an extremely important consideration. (Deprez, 2004)
Issues with spouses and children, seems to be the largest disincentive to stay in the county. (O’Shaughnessy, 1997) This is especially true in cases where the spouse has left behind a successful career, described in HR and management literature as the “Trailing Spouse Syndrome”. (Phillips, 1998) Spouses often leave behind careers and/or take substantial pay cuts, or else face extensive travel to other areas to retain their jobs. They often must take a back seat in their career plans. Regarding the family, the children are often placed in school systems that may be inadequate. Such is the case in Marlboro County schools where scores remain some of the lowest in the state based on Palmetto Achievement Tests. An alternative to the public school system is a private school; however, enrollment is currently very limited. Travel to the neighboring county of Chesterfield or Scotland County, North Carolina are other choices that some parents consider, due to higher ranking test scores. Ultimately, issues with the spouses and children significantly undermine the retention rate. Not everyone is cut out for the bucolic lifestyle, and many families of these physicians opt to live outside of the county. In fact, some of these families live as far away as Columbia, SC and their spouses commute over an hour and a half to get back into the county. (personal observation)
Of those physicians that opt to stay, studies have shown that many have backgrounds growing up in small town atmospheres. (Rabinowitz, 1999) They were looking for comfortable environments that offered a slower pace of life and the chance to get to know their patients. In short, they wanted to feel a community connection. Other factors that have a positive effect on their decision to stay, revolve around the types of rural care programs accessible in their medical school training. Some medical schools offer in their curriculum rotations through rural practices, rural health centers or health departments. (Hancock, 2009) Others believe that if medical schools encouraged students to follow in primary care studies, then more would be inclined to practice in rural areas. (Phillips, 1998) Their involvement with this type of curriculum tends to be a positive affirmation to pursue rural care. It has also been shown that when physicians buy practices they are more likely to be committed to their community and are more likely to stay. (Pathham, 2004)
A negative community perception of their hospital is directly affected by the inability to recruit and retain physicians. Citizens want to have a continuity of care and with a steady stream of changing physicians it is difficult to establish trust. This is especially true if the same physicians that work in the community do not live, nor do their children attend schools in the county. (O’Shaughnessy, 1997) The same citizens may feel that the rural hospital may not be as up to date as larger more urban hospitals and therefore will leave the county for their care. Interestingly, the Northeastern Rural Health Network keeps statistical information of those that use MPH emergency room and those that seek the same care outside of the county. Of the total number of cases seen by MPH and other ER facilities by the residents of Marlboro County, 57% of those cases remained in the county and sought care, while 43% went to other emergency rooms outside of the county. Of this 43%, most residents sought care in the neighboring county of Chesterfield, followed by Florence and Dillon counties. (South Carolina Budget and Control Board [SCBCB], 2009) These facts account for a tremendous amount of revenue lost by MPH. Studies have also shown that one-half of pregnant women in rural areas bypass their local practitioners and hospitals and opt for more urban centers. The same is true of those with private insurance, except the percentage is lower at 30%, and those seeking treatment for more complex illness. (Escarce, 2009) While hospitals may have these services, some people are just resistant to using these rural facilities. When informally questioning neighbors and asking them why they did not use the local hospital, the overwhelming response was that they felt services were lacking. The second most frequent response was that their primary care physician had moved and they were forced to see a physician in another county.
Lack of primary care physicians also account for frequent visits to the Emergency Department. Data attained from the Northeastern Rural Health Network show that MPH had 13,567 ER visits. They also listed the top fifty reasons for these visits. While they did not categorize these into what constituted simple primary care issues, we know that there is a 10% admission rate from the ER at MPH. (SCBCB, 2009) National averages of admission rates are 12.8%. MPH reports that ER visits have shown a yearly increase, while admissions have basically not changed. The same is reported by the Center for Disease Control (CDC) in their National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. From these reports, we can determine that most visits involved non-emergent issues, thus probably primary care issues. Under Emergency Medical Treatment and Active Labor Act, or EMTALA, these patients cannot be turned away, however, if they do not have a primary care practitioner, where are they to go? Those without resources or transportation are limited to their county emergency departments and unfortunately drive the cost of care up and play havoc with the revenue of the hospital. Again, the answer to this problem is the availability of primary care physicians and a community commitment to utilize what is available in the county.
The incentives given by federal, state, and the local hospital for physician recruitment are entirely monetary. The retention involves more than just a monetary fulfillment, but rather a family and personal commitment to a community. If that commitment cannot be attained, then the attrition rate will remain high for rural areas. Again, there is no simple solution to keeping physicians. The community must support their hospitals. MPH is convenient, there are services available, and there are doctors that are giving their time and dedication to serving the county. The more the community gives to the hospital, the more the hospital can give to the community. It falls on the lap of the human resource department at MPH to remain on the front line of physician recruitment and retention, not only relying on what the state and federal government provide, but becoming creative in developing solutions to overcome some of the counties short comings.
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