Fewer doctors in Colorado’s rural communities — combined with increasing demand — creates a health care challenge of growing complexity and may mean reduced care for residents.
Rural areas have faced a dearth of health care professionals for decades. One in four people living in rural areas said they couldn’t get the health care they needed, and about a quarter of those said the reason was because their health care facility was too far or difficult to get to, according to a 2019 report, Living in Rural America (Part II) by National Public Radio (NPR), the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.
The Association of American Medical Colleges (AAMC) projects that the United States will face a shortage of between 54,100 and 139,000 physicians by 2033. The Robert Graham Center forecasts that by 2030, Colorado will need an additional 1,773 primary-care physicians (PCPs), a 49% increase since 2010.
The underlying reasons behind the nation’s current shortage of and increased demand for pri-mary care physicians are numerous and interconnected. Population growth and an aging popu-lation are the primary drivers of the increased demand. But other contributing factors include an aging healthcare workforce, rapid increases in chronic diseases and limited capacity of med-ical schools and health education programs.
In Colorado, the increased need for PCPs is primarily due to aging (19%, 338 PCPs), population growth across the state (72%, 1,283 PCPs) and a greater insured population growth, (8%, 152 PCPs), thanks to the Affordable Care Act. While Colorado’s increased physician demand is be-low other Western states, it is above the nation overall.
“Our patients are paying more of their income to housing and transportation, leaving less for other things that keep them healthy,” explains Mark Wallace ’79, M.D., M.P.H., chief clinical officer for Sunrise Community Health, executive officer for the North Colorado Health Alliance and a family physician who earned his undergraduate degree from the University of Northern Colorado. Wallace also serves on the Banner Health Board of Directors.
“The cost of health insurance is about $400 a month and if that buys a high-deductible plan where the first $5,000 is out of pocket, that adds a burden many cannot afford. [People are] likely to forego or decline health care when they don’t have the income or savings to cover high deductibles and copays. In general, Colorado is a state with high health care costs.”
Colorado is second in the nation for health care spending, with the average Coloradan spending $10,254, according to a 2022 state ranking by World Population Review.
“We also need to be better at assessing and collaborating to address the myriad social (non-medical) determinants of health,” said Wallace. “We need to talk about public health and community-based care to address social determinants…and focus on equity.”
Fewer physicians compounds problem of increased demand
While the lack of physicians is troubling communities across the country, it is particularly dev-astating to rural communities. Rural residents are more likely to die from health issues like cardiovascular disease, unintentional injury and chronic lung disease than people living in urban areas, according to a 2020 AAMC report.
“Fewer physicians are heading to rural areas, while the need is increasing due to the age de-mographics in these areas. The average age of rural populations is older and the need for healthcare services tends to be greater,” explains Brian Davidson ’99, M.D., M.B.A., a physician executive for the Western Region Banner Medical Group, who earned his B.S. in Chemistry from UNC.
As baby boomer doctors retire, independent family practices are closing, especially in small, rural towns. Only 1% of doctors in their final year of medical school said they wanted to live in communities under 10,000 and only 2% wanted to live in towns of 25,000 or fewer, reported NPR.
More than 180 rural hospitals have closed since 2005, and over 600 additional rural hospitals — more than 30% of all rural hospitals in the country — are at risk of closing in the near future, according to the Sheps Center for Health Services Research at the University of North Carolina. The closure risks are attributed to revenue loss from the cost of delivering services to patients. This makes rural hospitals less attractive to newly minted millennial doctors.
More doctors, but fewer hours
There are actually more doctors graduating now than in recent decades. But new doctors are seeking more work-life balance.
“The demographic and work-life balance of graduating physicians is very different than dec-ades ago. More physicians are looking for part-time practice or environments that offer more regular schedules and fewer on-call obligations. The physician of 30 years ago, who tended to work 65+ hours per week, is likely being replaced by a physician desiring better work-life bal-ance and substantially fewer hours,” said Davidson.
With many rural physicians nearing retirement, there will be nearly a quarter fewer practicing doctors by 2030. Even more worrisome, the number of medical students from rural areas — who are most likely to practice in those regions — declined 28% between 2002 and 2017, re-vealed a 2019 AAMC study. Students from rural backgrounds in 2017 comprised just 4.3% of the incoming medical student body at a time when the overall number of students in medical school increased by 30%.
The state of nursing post pandemic
Set against the backdrop of the COVID-19 pandemic, this makes for a particularly challenging situation. All health professionals, including nursing, medicine and related fields, are facing a higher rate of burnout, according to the Agency for Healthcare Research and Quality (AHRQ). They are feeling emotional exhaustion, depersonalization and a lack of sense of personal ac-complishment.
Melissa Henry, Ph.D., R.N., F.N.P.-C, director of UNC’s School of Nursing, sees the issues sur-rounding the nursing shortage and staffing as one of the most significant healthcare challenges facing rural Northern Colorado.
“Nurses are fatigued. The past two years have been incredibly challenging and many [nurses] are changing their positions,” said Henry. “Nurses’ roles are more complex than at any time in my nursing career of over 25 years — with sicker patients and higher complexity of care. This, and the long hours of physically and emotionally demanding work, is leading to a cycle of nurse fatigue and burnout.”
Similar to the shortage of doctors, the demand for nurses is higher than the supply.
“Northern Colorado is facing the same challenges we see nationwide, including nursing short-ages, nursing faculty shortages, nursing fatigue and burnout, difficulty in increasing nursing student enrollments, etc.,” said Henry. “However, one of the highlights of this region is the number of regional nursing leaders who are dedicated to addressing these issues.”
Together with Dr. Carrie Brunson from Banner Health, Henry co-chairs a consortium of nursing leaders from industry, education and the regional workforce to address these larger issues. She calls this model “a bright star for the region,” noting the many positive, forward-thinking nurs-ing leaders across Northern Colorado dedicated to making change.
Training future nurses alongside physicians and other health professionals is the type of inter-professional education that the National Academies of Sciences, Engineering and Medicine fer-vently recommends in its report The Future of Nursing: Leading Change, Advancing Health.
A new way of thinking about health care
The University of Northern Colorado is responding to the region’s health care challenges in a big way.
Similar to how UNC was founded in 1889 in direct response to the need for teacher preparation in Colorado, the university is again responding to community needs to train more physicians and alleviate the state’s shortage of physicians, particularly in rural and underserved communi-ties. UNC is in the process of developing an osteopathic medical college to not only help miti-gate physician shortages, but also to improve access to healthcare and enhance the quality of care available across the region and the state. The goal is for the first cohort to enter the Col-lege of Osteopathic Medicine at UNC as early as 2025.
The legislature passed Senate Bill 56 in March of this year granting the university permission to create a college and award degrees in osteopathic medicine.
The ambitious initiative builds on UNC’s strength and depth in its sciences and health sciences programs, which includes nursing, public health, behavioral sciences, biology, chemistry, audi-ology, speech-language pathology and others. The university will leverage synergies among programs to enhance the osteopathic medicine curriculum and students’ academic experience in related fields.
In April, UNC hired Dr. Beth Longenecker as the founding dean of UNC’s College of Osteopathic Medicine. She will lead the college through accreditation and help position it as a world-class center of medical education to support the health of communities across Colorado.
“The osteopathic medical school at UNC will help treat the undersupply of physicians in Colora-do and the region,” offers Davidson. “UNC has a history of adapting with the needs of the communities it serves, and this time in history is no different. The university is rising to the challenge by adding a medical school alongside multiple programs of excellence in education, business, humanities, science, arts and others.”
Osteopathic medicine is one of the fastest-growing health-care professions in the country. The number of osteopathic physicians in the United States climbed to nearly 135,000, an 80% in-crease over the past decade as reported by the American Osteopathic Association’s Osteo-pathic Medical Education Report. The osteopathic medical profession has a long tradition of providing care where patients lack doctors, often in rural or underserved areas. More aspiring physicians than ever are choosing osteopathic medicine, leading to a growing, youthful profession.
“We [in the School of Nursing] are excited to partner with our physician colleagues at the new College of Osteopathic Medicine to help meet the needs of our community and ensure that there are adequate health care providers in all settings, particularly in rural areas,” adds Henry.
The key to the future of health care is innovation and collaboration. Colorado’s health care needs are daunting, with a need to expand health-care access for underserved and aging popu-lations, increase the number of primary care doctors in the state and improve the health-care delivery system for underserved populations.
UNC is well positioned to launch the College of Osteopathic Medicine and once again rise to meet the need of Northern Colorado communities just like it did in 1889. This health care initi-ative has the potential to transform the region while meeting the needs of future generations of learners, teachers, health-care delivery systems and patients and improving the health and well-being of future generations across Colorado. UNC