NC's rural provider shortage persists despite decades of efforts
For the last 40 years, state and federal agencies funneled millions to loan repayment initiatives with the goal of addressing medical provider shortages in rural parts of the state. But access-to-care gaps remain, particularly in the more remote areas.
by Liora Engel-Smith September 8, 2020 January 29, 2021
Location of placements in the NC loan repayment program for providers in FY2019. Source: NCDHHS Office of Rural Health
By Liora Engel-Smith
Camden County's health care workforce is as lean as it comes. There are no psychologists or nurse practitioners in the rural bedroom community in the far northeastern corner of the state. No podiatrists or nurse-midwives. No physician assistants either.
The county of roughly 10,000 has one dentist, one hygienist, one pharmacist and one primary care physician as of 2019, according to data from UNC Chapel Hill's Sheps Center for Health Services Research. The county also boasts 16 registered nurses and six licensed practical nurses.
It isn't that there are no health needs there. Residents say substance abuse is among the top concerns in the county, according to a health assessment Sentara Albemarle Medical Center in Elizabeth City conducted last year. The county's rates of heart disease, diabetes, breast cancer and obesity are also higher than the state average. Access to health care, the assessment found, is among the top concerns of residents in the county.
Camden's provider shortage is chronic. Since 2000, the number of providers in the Eastern North Carolina County fluctuated somewhat, Sheps data shows. The county gained a pharmacist but lost three physicians and six registered nurses. The number of dental professionals and licensed practical nurses remained roughly the same.
It's a problem that many rural counties in North Carolina face, despite decades of federal and state efforts to bolster the health care workforce in some of the state's most remote areas.
"I am a hopeful person, but when I look at the data I become cynical because we have been trying to address this for 40 years," said Erin Fraher, who studies the state's health care workforce at Sheps.
Among the state and federal government's oldest tools to combat the shortage is loan repayment. Both the North Carolina and federal programs began forgiving a portion of school loans of health professionals in the 1980s in exchange for service in areas of high need for a few years.
But assessing the success of this financial incentive approach in addressing North Carolina's rural provider shortage can be difficult.
The geography of choice
In theory, North Carolina's rural areas should have gained more than 250 new providers — doctors, nurses, dentists and nurse practitioners — in the last fiscal year. But the actual number is far lower in practice.
The federal government invested just under $10 million in loan repayments and scholarships for almost 200 providers in North Carolina in FY2019. Of these, 168 providers signed up for loan repayment. Exactly how many of them actually serve in rural areas is hard to ascertain. Cities such as Durham, Charlotte and Raleigh also have pockets of high need and providers can choose a placement there and still receive loan repayment; the federal database does not list service locations for loan repayments on its site.
That same year, the state of North Carolina invested roughly $2 million for 106 placements in underserved areas — both rural and urban. According to the Office of Rural Health, Pitt and Buncombe counties, both urban, attracted 25 placements between them. By comparison, many rural counties — including Camden — had no placements. Other remote locales, such as mountainous Clay and Macon counties, got one placement apiece.
Michelle Skipper has been thinking about that problem for much of her career. Skipper, who recruits nurses to East Carolina University's doctoral nursing program, said that loan repayment programs can encourage students from rural areas to attend school. She also noted that the more experience with a rural area a provider has, the more likely they are to practice there throughout their career. Yet clinics across eastern North Carolina continue to struggle with chronic shortages.
"If we've been doing this work for a long time, we've ought to be able to fill up those clinics," Skipper said. "And we're not. Certainly, you're getting some attrition there with age and retirement," but, she added, it's likely most who received loan forgiveness hit the road once their loans are paid.
These disparities in placements — and the potential turnover in more remote clinics — are in part a function of choice, Skipper said. Graduates themselves select the area they'd like to serve from a menu of clinics in need, and many providers prefer to live in a city or near one. The reasons for these preferences are complex, but Skipper said spouses of practitioners are more likely to find a job in a city.
Even if they place in rural areas first, some providers later choose to move closer to cities with better education options once they have children, she added.
The Office of Rural Health does not have accurate data on turnover as of yet, according to Stephanie Nantz, who works with the state's placement program. A data-gathering collaboration with the Sheps Center about turnover is underway, she added.
Though loan repayment can be a powerful incentive to serve in a rural area, it is just one piece of a much more complicated puzzle, said Office of Rural Health leader Maggie Sauer.
"If providers feel that they are accepted in the community, if they feel like their children can get a good education … those kinds of things, that in combination with loan repayment [can attract providers to rural areas]."
Sauer's observation is borne out in national research. While loan repayment can make practicing in a rural area more financially feasible, particularly for graduates with a high loan burden, other factors, such as having grown up or trained in a rural area play a much larger role.
"It's critical to devote more resources to that kind of training, that seems to be a more natural way to get people excited about [rural practice]," said Davis Patterson, who studies the healthcare workforce issue at the University of Washington. "Loan repayment [is] like the Band-Aid you put on after [the fact]."
A sense of mission
Anahita Shaya understands the financial calculus of working in a rural area. A dentist in the Pender County Health Department, Shaya said she knew she wanted to work in a public health clinic since she was a student.
"You kind of put a lot of your life on pause in dental school," she recalled. "So when you graduate, you've got everything waiting for you. Within those years, I got married, moved, bought a house and had kids. So it was a lot of cost of living accruing at once for me."
Balancing school loans and career aspirations, she said, would have been difficult without some kind of assistance, especially at that stage in her life. Loan forgiveness made practicing in the Pender clinic feasible, she said, but it was the sense of mission that first drew her to the work.
When Shaya applied for a job at the health department three or four years ago, the 63,000-person county had more than 20 dentists, Sheps Center data shows. Mission aside, the placement also had to work for Shaya's spouse. The couple settled in the nearby city of Wilmington, where her husband, a landscape architect, could find work too.
Dr. Anahita Shaya is a dentist at the Pender County Health Department. Photo credit: Pender County Health Department
It was only after Shaya applied for and got accepted to her role that she learned that she was eligible for an up to $100,000 payout over four years from the state.
"It definitely helped in terms of making a dent in some of [the loans] so that I could catch up," she said, though it did not cover the entire amount she borrowed.
Shaya recently got her last payment from the program but has no plans to change jobs anytime soon.
Practicing elsewhere, say in Camden County, where the nearest big city is roughly an hour away, would have been almost impossible, she said, because her husband would have struggled to find a job. These economic barriers make it harder to recruit providers in some of the state's most remote clinics.
An uphill battle
Hertford County has more than twice the population of Camden County, about an hour west, but it's no less remote or rural. The biggest town in the county, Ahoskie, has a population of just under 5,000. It is also home to the Roanoke Chowan Community Health Center, a federally funded provider that also has clinics in neighboring counties.
The clinic at Ahoskie is roughly an hour away from Norfolk, VA and Greenville and two hours from Raleigh, and Roanoke Chowan CEO Kim Schwartz knows she has to work extra hard to attract and retain quality medical staff.
Practicing in the middle of nowhere may not be a dream many providers have, but Schwartz has worked diligently to create a pipeline of providers. Having built relationships with medical schools all over the country, Schwartz said she does a fair bit of marketing in the recruitment process, highlighting some of the benefits of practicing in a rural setting, including a wide array of clinical experiences with a complex set of patients that providers in more populated areas often refer to specialists.
"You get to do everything, to try everything," she tells candidates. "What can you think of that you might want to try, because this is an open lab."
State and federal loan repayment is a benefit that may make Ahoskie more attractive financially, she said, but it is not the only factor. Schwartz knows, for instance, that strong community ties can help providers feel a sense of belonging, so she's dreamed up an initiative that would offer housing in the community to residents who choose to come to Roanoke Chowan. Even with perks such as work-life balance and a positive work environment, roughly half of the loan repayment recipients who come to work at the health center move on after a few years.
Contending with a new provider every few years can be difficult for patients, she said. Here too, the center adapted, by making sure patients connect with a team, rather than one provider, so even when a provider leaves, there's still continuity. It isn't ideal, Schwartz said, but it's the reality of rural care.
Fraher, of UNC's Sheps Center, said loan repayment alone likely won't resolve some of the interlocking issues that Roanoke Chowan and other rural clinics in the state are up against.
"We have taken too much of a siloed approach," she said. "We've got to be strategic. Yes, let's invest in loan repayment, but let's also tweak graduate medical education.
"We could, I would argue, make a much bigger difference with a strategic plan for rural health that involves coordinating those efforts, yes, then you could solve the problem."
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by Liora Engel-Smith, North Carolina Health News
<h1>NC's rural provider shortage persists despite decades of efforts</h1> <p class="byline">by Liora Engel-Smith, North Carolina Health News <br />September 8, 2020</p> <h4><b>By Liora Engel-Smith</b></h4> <p>Camden County's health care workforce is as lean as it comes. There are no psychologists or nurse practitioners in the rural bedroom community in the far northeastern corner of the state. No podiatrists or nurse-midwives. No physician assistants either.</p> <p>The county <a href="https://www.census.gov/quickfacts/fact/table/NC,camdencountynorthcarolina/PST045219">of roughly 10,000</a> has one dentist, one hygienist, one pharmacist and one primary care physician as of 2019, according to data from <a href="https://nchealthworkforce.unc.edu/interactive/supply/">UNC Chapel Hill's Sheps Center for Health Services Research</a>. The county also boasts 16 registered nurses and six licensed practical nurses.</p> <p><a href="https://www.northcarolinahealthnews.org/donations/give-to-nchn/"><img class="aligncenter size-full wp-image-27373" src="https://www.northcarolinahealthnews.org/wp-content/uploads/2020/04/Covid-Donate-Ad-SMALL.jpg" alt="ad reminding readers to support our COVID coverage" width="650" height="149" /></a></p> <p>It isn't that there are no health needs there. Residents say substance abuse is among the top concerns in the county, according to a <a href="https://www.sentara.com/Assets/Pdf/About-Us/Community-Health-Needs-Assessments/2019-SAMC-Community-Health-Needs-Assessment.pdf">health assessment </a>Sentara Albemarle Medical Center in Elizabeth City conducted last year. The county's rates of heart disease, diabetes, breast cancer and obesity are also higher than the state average. Access to health care, the assessment found, is among the top concerns of residents in the county.</p> <p>Camden's provider shortage is chronic. Since 2000, the number of providers in the Eastern North Carolina County fluctuated somewhat, Sheps data shows. The county gained a pharmacist but lost three physicians and six registered nurses. The number of dental professionals and licensed practical nurses remained roughly the same.</p> <div class="flourish-embed flourish-chart" data-src="visualisation/3646600" data-url="https://flo.uri.sh/visualisation/3646600/embed" aria-label=""><a href="https://public.flourish.studio/resources/embed.js">https://public.flourish.studio/resources/embed.js</a></div> <p>It's a problem that many rural counties in North Carolina face, despite decades of federal and state efforts to bolster the health care workforce in some of the state's most remote areas.</p> <p>"I am a hopeful person, but when I look at the data I become cynical because we have been trying to address this for 40 years," said Erin Fraher, who studies the state's health care workforce at Sheps.</p> <p>Among the state and federal government's oldest tools to combat the shortage is loan repayment. Both the North Carolina and federal programs began forgiving a portion of school loans of health professionals in the 1980s in exchange for service in areas of high need for a few years.</p> <p>But assessing the success of this financial incentive approach in addressing North Carolina's rural provider shortage can be difficult.</p> <h4><b>The geography of choice</b></h4> <p>In theory, North Carolina's rural areas should have gained more than 250 new providers -- doctors, nurses, dentists and nurse practitioners -- in the last fiscal year. But the actual number is far lower in practice.</p> <p>The federal government invested just under $10 million in loan repayments and scholarships for almost <a href="https://data.hrsa.gov/maps/fact-sheet-maps/">200 providers</a> in North Carolina in FY2019. Of these, 168 providers signed up for loan repayment. Exactly how many of them actually serve in rural areas is hard to ascertain. <a href="https://data.hrsa.gov/tools/shortage-area/hpsa-find">Cities </a>such as Durham, Charlotte and Raleigh also have pockets of high need and providers can choose a placement there and still receive loan repayment; the federal database does not list service locations for loan repayments on its site.</p> <p>That same year, the state of North Carolina invested roughly <a href="https://files.nc.gov/ncdhhs/2019%20NC%20DHHS%20ORH%20Medical%20Placements%20One%20Pager.pdf">$2 million for 106 placements </a>in underserved areas -- both rural and urban. According to the Office of Rural Health, Pitt and Buncombe counties, both urban, attracted 25 placements between them. By comparison, many rural counties -- including Camden -- had no placements. Other remote locales, such as mountainous Clay and Macon counties, got one placement apiece.</p> <p>Michelle Skipper has been thinking about that problem for much of her career. Skipper, who recruits nurses to East Carolina University's doctoral nursing program, said that loan repayment programs can encourage students from rural areas to attend school. She also noted that the more experience with a rural area a provider has, the more likely they are to practice there throughout their career. Yet clinics across eastern North Carolina continue to struggle with chronic shortages.</p> <p>"If we've been doing this work for a long time, we've ought to be able to fill up those clinics," Skipper said. "And we're not. Certainly, you're getting some attrition there with age and retirement," but, she added, it's likely most who received loan forgiveness hit the road once their loans are paid.</p> <p>These disparities in placements -- and the potential turnover in more remote clinics -- are in part a function of choice, Skipper said. Graduates themselves select the area they'd like to serve from a menu of clinics in need, and many providers prefer to live in a city or near one. The reasons for these preferences are complex, but Skipper said spouses of practitioners are more likely to find a job in a city.</p> <p>Even if they place in rural areas first, some providers later choose to move closer to cities with better education options once they have children, she added.</p> <p>The Office of Rural Health does not have accurate data on turnover as of yet, according to Stephanie Nantz, who works with the state's placement program. A data-gathering collaboration with the Sheps Center about turnover is underway, she added.</p> <p>Though loan repayment can be a powerful incentive to serve in a rural area, it is just one piece of a much more complicated puzzle, said Office of Rural Health leader Maggie Sauer.</p> <p>"If providers feel that they are accepted in the community, if they feel like their children can get a good education … those kinds of things, that in combination with loan repayment [can attract providers to rural areas]."</p> <p>Sauer's observation is borne out in national research. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5789104/">While loan repayment</a> can make practicing in a rural area more financially feasible, particularly for graduates with a high loan burden, other factors, such as having grown up or trained in a rural area play a much larger role.</p> <p>"It's critical to devote more resources to that kind of training, that seems to be a more natural way to get people excited about [rural practice]," said Davis Patterson, <a href="https://depts.washington.edu/fammed/chws/team/davis-patterson/">who studies the healthcare workforce issue </a>at the University of Washington. "Loan repayment [is] like the Band-Aid you put on after [the fact]."</p> <h4><b>A sense of mission</b></h4> <p>Anahita Shaya understands the financial calculus of working in a rural area. A dentist in the Pender County Health Department, Shaya said she knew she wanted to work in a public health clinic since she was a student.</p> <p>"You kind of put a lot of your life on pause in dental school," she recalled. "So when you graduate, you've got everything waiting for you. Within those years, I got married, moved, bought a house and had kids. So it was a lot of cost of living accruing at once for me."</p> <p>Balancing school loans and career aspirations, she said, would have been difficult without some kind of assistance, especially at that stage in her life. Loan forgiveness made practicing in the Pender clinic feasible, she said, but it was the sense of mission that first drew her to the work.</p> <p>When Shaya applied for a job at the health department three or four years ago, the 63,000-person county had more than 20 dentists, Sheps Center data shows. Mission aside, the placement also had to work for Shaya's spouse. The couple settled in the nearby city of Wilmington, where her husband, a landscape architect, could find work too.</p> <p>It was only after Shaya applied for and got accepted to her role that she learned that she was eligible for an up to $100,000 payout over four years from the state.</p> <p>"It definitely helped in terms of making a dent in some of [the loans] so that I could catch up," she said, though it did not cover the entire amount she borrowed.</p> <p>Shaya recently got her last payment from the program but has no plans to change jobs anytime soon.</p> <p>Practicing elsewhere, say in Camden County, where the nearest big city is roughly an hour away, would have been almost impossible, she said, because her husband would have struggled to find a job. These economic barriers make it harder to recruit providers in some of the state's most remote clinics.</p> <h4><b>An uphill battle</b></h4> <p>Hertford County has more than twice the population of Camden County, about an hour west, but it's no less remote or rural. The biggest town in the county, Ahoskie, has a population of just under 5,000. It is also home to the <a href="https://www.rcchc.org/">Roanoke Chowan Community Health Center</a>, a federally funded provider that also has clinics in neighboring counties.</p> <p>The clinic at Ahoskie is roughly an hour away from Norfolk, VA and Greenville and two hours from Raleigh, and Roanoke Chowan CEO Kim Schwartz knows she has to work extra hard to attract and retain quality medical staff.</p> <p>Practicing in the middle of nowhere may not be a dream many providers have, but Schwartz has worked diligently to create a pipeline of providers. Having built relationships with medical schools all over the country, Schwartz said she does a fair bit of marketing in the recruitment process, highlighting some of the benefits of practicing in a rural setting, including a wide array of clinical experiences with a complex set of patients that providers in more populated areas often refer to specialists.</p> <p>"You get to do everything, to try everything," she tells candidates. "What can you think of that you might want to try, because this is an open lab."</p> <p>State and federal loan repayment is a benefit that may make Ahoskie more attractive financially, she said, but it is not the only factor. Schwartz knows, for instance, that strong community ties can help providers feel a sense of belonging, so she's dreamed up an initiative that would offer housing in the community to residents who choose to come to Roanoke Chowan. Even with perks such as work-life balance and a positive work environment, roughly half of the loan repayment recipients who come to work at the health center move on after a few years.</p> <p>Contending with a new provider every few years can be difficult for patients, she said. Here too, the center adapted, by making sure patients connect with a team, rather than one provider, so even when a provider leaves, there's still continuity. It isn't ideal, Schwartz said, but it's the reality of rural care.</p> <p>Fraher, of UNC's Sheps Center, said loan repayment alone likely won't resolve some of the interlocking issues that Roanoke Chowan and other rural clinics in the state are up against.</p> <p>"We have taken too much of a siloed approach," she said. "We've got to be strategic. Yes, let's invest in loan repayment, but let's also tweak graduate medical education.</p> <p>"We could, I would argue, make a much bigger difference with a strategic plan for rural health that involves coordinating those efforts, yes, then you could solve the problem."</p>
This <a target="_blank" href="https://www.northcarolinahealthnews.org/2020/09/08/ncs-rural-provider-shortage-persists-despite-decades-of-efforts/">article</a> first appeared on <a target="_blank" href="https://www.northcarolinahealthnews.org">North Carolina Health News</a> and is republished here under a Creative Commons license.<img src="https://i0.wp.com/www.northcarolinahealthnews.org/wp-content/uploads/2021/10/cropped-favicon02.jpg?fit=150%2C150&amp;ssl=1" style="width:1em;height:1em;margin-left:10px;"><img id="republication-tracker-tool-source" src="https://www.northcarolinahealthnews.org/?republication-pixel=true&post=31749&ga=UA-28368570-1" style="width:1px;height:1px;">
Tagged: Ahoskie, breast cancer, Camden County, Clay County, diabetes, East Carolina University, heart disease, Hertford, loan repayment, Macon County, N.C. Office of Rural Health, obesity, Roanoke Chowan Community Health Center, rural health, Sentara Albemarle Medical Center, Sheps Center for Health Services Research at UNC Chapel Hill., substance abuse
Liora Engel-Smith
Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...	More by Liora Engel-Smith
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6 replies on "NC's rural provider shortage persists despite decades of efforts"
Allen Smart says:
Some of the smartest people in the country on rural provider supply are quoted in the piece. What a comprehensive approach would look like would be deep work with communities, economic developers and healthcare employers on how to make those willing to go to rural areas (loan forgiveness or not) feel they and their families are valued and welcome. Its a business and community development approach. The viability of rural healthcare is often the lynchpin for rural community survival and its definitely as much relational as tactical.
Liora Engel-Smith says:Article author
Thank you for reading the story, Allen. Yes, it seems that experts are leaning toward a comprehensive approach.
Mary Helen Johnson, MD says:
I was recruited home to Asheboro by the National Health Services Corps AND the NC Office of Rural Health back in 1995. I completed my service obligations (in 1998) and was promptly thrown out on the street by Randolph Hospital executives – just two weeks after intervening in (and reporting) a "bad baby" case. That (now bankrupt) hospital pulled every dirty trick you could think of. I pleaded for help from the state and Federal governments. They FAILED UTTERLY to enforce the terms of their own agreements.
I sounded the alarm about the hospital's fiscal shenanigans two decades ago. No one would listen when it might have made a difference. I still own a home in Asheboro. I NEVER wanted to leave. But I could not come home.
These public service programs form a line and a revolving door – for young, naive, newly-minted physicians to be used/abuse/thrown away. It's been twenty-two years since that nightmare irrevocably changed my life. Nothing has changed.
I worked in Ahoskie for four years – as the only Pediatrician admitting patients to the hospital for four counties. They did not have to "work" to retain me – I LOVED the work and sense of mission and wanted to stay. The more I gave, the more the hospital took. I worked like a dog and was not paid nearly what my time was worth. In my end, shortly after Vidant became Vidant, I was thrown out on the street for daring to challenge the Draconian/abusive terms of my contract. Once again, no one helped.
Right now, I am embroiled in a whistle-blower situation with another small NC hospital – enduring brazen in-your-face retaliation for reporting a lack of resources and poor (nursing staffing) that affected the care I could provide. The state conducted a site visit and found deficits – it's public record. The hospital was in the wrong. But somehow, I am still out of a job.
NORTH CAROLINA HAS NOT DONE ANYTHING IN A QUARTER-CENTURY TO PROTECT EMPLOYED/CONTRACTED DOCTORS FROM CORPORATIONS. NOTHING.
Rose Hoban says:
Editor's note: this comment has been shortened to conform to our comments standards that allow for a 350 word maximum comment. For more information, see our comments policy: https://www.northcarolinahealthnews.org/about/comments-policy/
I did not realize – the comment was not cut off (as usually happens when one is too verbose). The full comment is posted publicly on my Facebook page: Mary Johnson, Asheboro. Pediatrician. Look for a skeleton holding his aching head – and a Cheshire Cat.
Melissa P Martin says:
I'm sorry to hear this. Your situation is messed up on so many levels. Unfortunately, I don't find this hard to believe for North Carolina. I'm located in rural area, Rockingham County. It's always been terrible! It's so hard mentally.