LETTER The vanishing doctors of Missouri: How Medicare cuts are fueling a health care desert

Missouri’s doctors are disappearing. Here’s why.

Rural Americans are facing a harsh reality: they may soon join the millions Americans living in a health care desert, an area with limited to no access to medical services.

Missouri is no exception. Today, nearly every county in the Show-Me State is experiencing a shortage of primary care providers. In total, our state has over 900 federally-designated Health Professional Shortage Areas, meaning that residents in those communities are struggling to access care close to home.

The shortage is made worse by a wave of physician retirements and high rates of burnout that is pushing many physicians to leave the workforce early. Unfortunately, there aren’t enough physicians to replace them, as merely half (54%) of practicing physicians who completed residency in Missouri from 2014 through 2023 have stayed in the state, according to the Association of American Medical Colleges.

Missourians are feeling the effects. Patients who are desperate to develop meaningful, long-term relationships with physicians are now increasingly being turned away or told they have to wait months for an appointment because offices don’t have the capacity to accept new patients. Some practices are deciding it doesn’t make sense for them to see Medicare patients at all, while others are considering shutting down because sinking reimbursement is not sustainable in the face of surging costs.

A major driver of this trend is our country’s broken Medicare system. Over the past 20 years, the American Medical Association estimates physician payment under the Medicare Physician Fee Schedule has fallen by 33% when adjusted for inflation. Yet, at the same time, the cost of running a practice rose 60%, leaving physicians struggling to keep up with the rising cost of medical supplies, equipment, and overhead.

With increasing administrative burdens, burnout, limited time with patients, and above all, declining Medicare payments, many rural doctors are deciding it isn’t feasible to remain in private practice. In fact, a study conducted by the American Medical Association found that between 2012 and 2022 the share of physicians working in private practices fell from 60.1% to 46.7%. In contrast, the share of physicians working in hospitals as direct employees or contractors increased from 5.6% to 9.6% during that same period. Meanwhile, the percentage of doctors employed by practices that were at least partially owned by a hospital or health system increased from 23.4% to 31.3%.

What does this mean for patients? As doctors’ offices (which are typically small businesses) close or get absorbed by larger systems, patient choice and access could be compromised, especially in areas that are already health care deserts.

With less access to trusted local doctors, the chronic disease epidemic we are already facing could get even worse in rural areas. Compared to urban populations, Missouri’s rural residents have higher rates of heart disease, cancer, diabetes, and kidney disease – all leading causes of death in our state. What’s more, the government will shoulder the ballooning cost of treating these conditions, as those aged 60 to 64 make up the highest share of Missouri’s rural population, meaning millions of Missourians will soon rely on Medicare to cover their health care.

To improve healthcare outcomes in a cost-effective way, we must act now to tackle these trends head on. As a start, Congress must reverse the latest 2.8% payment cut that went into effect at the beginning of this year, which is already straining doctors nationwide and pushing them out of private practice.

Thankfully, lawmakers have introduced the Medicare Patient Access and Practice Stabilization Act (H.R. 879), which would reverse this cut and provide a 2% payment update. This bipartisan bill will help to stop the bleeding for rural independent practices, helping to strengthen the stability of Medicare, and most importantly boost health care access in remote communities.

The well-being of America’s rural older adults hinges on timely access to care. If we want to Make America — and Missouri — Healthy Again, Congress has an obligation to support our doctors. I urge Rep. Jason Smith to support HR 879, which will make a meaningful difference for all constituents in need of care.

David L. Pohl, MD, FACR is the President of the Missouri State Medical Association.