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As a subscriber you can listen to articles at work, in the car, or while you work out. Subscribe NowFifty-three of Indiana’s 92 counties have a shortage of primary health care providers, federal data shows. And nearly all counties falling into that category are considered rural or partially rural.
Rural Hoosiers face a number of barriers to adequate health care, with many facing long drives to access care and lacking adequate internet service for online consultations. Cost and lack of insurance coverage also can be substantial hurdles.
Dr. Jesse Crane works 12-hour shifts as an emergency medicine doctor in rural Greene County. When he’s on duty, he’s the only doctor in the department to treat the 10,000 to 12,000 patients that come through his ER. Every shift, he sees patients suffering from lack of access to a primary care physician.
“They haven’t been able to get in with their primary doctor. They feel like it’s been too long or they need a … checkup,” he said. “We see this every day, but I think the ER becomes a safety net.”
A state health improvement plan issued in 2018 identified improving access to care as a top priority. “It is evident that not all Hoosiers have the same opportunities to be as healthy,” the report concluded.
When faced with persistent barriers, communities often find themselves comparatively in worse health with higher mortality rates and a lower quality of life.
“And despite the fact that health care providers, professionals, and individuals are motivated to address these health disparities and improve Hoosier health,” an Indiana University report said, “no treatment measure can be effective if the recipient cannot access the treatment itself.”
The pandemic made disparities in health-care access more apparent, especially when it comes to broadband access.
“It made people who weren’t used to facing health care access difficulties more aware of what it was like,” said Katherine Pope, IU School of Public Health-Bloomington project manager and researcher.
Myriad of difficulties
In a 2020 Indiana University Center for Rural Development study, researchers found barriers to receiving care included issues with health insurance, transportation, language barriers and a shortage of providers and clinics.
Pope, who complied that report, said the number one issue rural community members told her about when she was a health liaison was a lack of access.
One case Pope reflected on was a mother whose son needed care but had to rely on others for transportation. If their ride didn’t show up, they missed the appointment. Many times, Pope said, missed appointments meant months of setbacks that could be life-threatening and constitute living in pain or discomfort.
“Missing these critical appointments has a huge repercussion on people’s lives,” she said.
The most common barrier Pope found was geographic- and transportation-related. She mentions the Green County General Hospital on the west side of the county can be a 45-minute drive for those on the other side. For long trips like that one, she said it’s difficult to rely on friends and family to dedicate that time to drive them.
Crane, Greene County ER doctor, said he commonly sees patients with a lack of adequate health insurance coverage. They often don’t qualify for Medicaid and the insurance they can afford offers very little coverage. They are often elderly and live in less than ideal conditions, making their health worse than those of a similar age but with better means.
In other cases, Pope said language barriers mean patients are less inclined to seek care if there’s a chance their provider doesn’t look like them or understand them. That can be particularly true in rural counties like Dubois, which has a significant percentage of Spanish speakers.
Other hurdles include disabilities and the inability to take off work.
Compounding shortages
A provider shortage is a central reason for the health care access gaps, a worsening problem the industry has been sounding the alarm on for years.
According to the state health improvement plan, 87% of rural residents live in areas with a primary care shortage, compared to 62% in urban areas. Indiana has 230.8 active physicians per 100,000 people, the second lowest rate in the Midwest after Iowa.
Pope said the state is attempting to incentivize more physicians to practice in rural areas, but the arrangements don’t seem to last.
And when rural residents lack access to health care, the IU report said, they are less likely to receive preventative care, primary health checkups, dental care, behavioral health care and chronic disease management.
Indiana also suffers from a lack of mental health professionals. The state has 21 rural or partially rural areas that doesn’t have one psychiatrist per 30,0000 people. A fall 2022 estimate showed the state would have to add and strategically place 286 new psychiatrists to address shortage areas.
Looking forward
The money Indiana is investing in public health offers hope that the situation will improve or at least not get worse, Pope said.
Eighty-six counties joined a new state program that will spread up to $3.3 million to each county to better the state’s health outcomes. About 96% of Hoosiers live in a participating county. Funds will be disbursed to local health departments at the start of the year.
Other solutions Pope said would help include making it more difficult for people to lose Medicaid coverage, exploring creative transportation solutions, incentivizing rural medical residencies and making telehealth more accessible. Grants to help clinics upgrade and invest in such technology are also important, she said.
Another important factor, according to Crane, is educating Hoosiers about the importance of preventive care, health screenings and checkups.
One of the biggest improvements Crane has seen is the introduction of more social workers. They work with patients to connect them with proper care, create care plans and follow up afterward. They also help with people in need, he said, like assistance in getting transportation, home health visits or nursing home placement.
“It started out as kind of a bonus,” he said. “but it’s absolutely what every ER needs.”
Jon Agley, an IU public health professor and researcher, said the shortage of psychiatrists is being addressed by social workers, psychiatric nurses, psychologists, therapists and other professionals who have stepped in to work on closing this gap.
“While there is still a tremendous need, people have come together to foster access to care,” he said.
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When will everyone wake up!!!!!! Our State has the resources to do something about this shortage, but refused to spend any significant amount of money.
We have have a serious shortage of all types of health care workers. We need to train a lot more of everything including nurses, pharmacists, physicians, nurse practitioners, etc, etc., etc. Our state needs to support at least two more medical schools (both allopathic and osteopathic). I have always said that Purdue and Notre Dame would be the prime organizations to accomplish this. Both have plenty of money of its own. The State should support more residency programs for internal medicine, family practice and pediatrics. The current medical community should have a better relationship with nurse practitioners to share the load of primary care. Other States have figured this out. It is a turf war problem, plain and simple. Citizen of Indiana it is just going to get worse!!!!!!!!!!!!
A way to move forward in solving the rural health crisis would be to allow advanced providers (Nurse Practitioners, NP and Physician Assistants, PA) to move away from the shackles of practice agreements and practice freely in those rural communitees. A few doctors spew mis-information as to how medical doctors are perfect and advanced practitioners cannot diagnose a hangnail without an MD lording over their every move. My wife is an NP who has patients who never see an MD as they prefer to see her.
If the state wants to begin to resolve the shortage, all they have to do is start treating people who are trained in medicine to act as providers in those communitees in need.
Practice agreements are in place to keep patients safe and ensure they are receiving physician led healthcare. The training differences are vast. No one doubts an NP can dx a hangnail but it’s the recognition of complex pathology and how to best manage multiple medical comorbidities that requires 12000-16000 hours of high standardized training. Not 500 hours of loosely defined shadowing. The answer to a care shortage is not to reduce the standards of those providing it.