Access to primary care doctors is about to go from bad to worse for South Carolina's rural residents.
Already 45 of the state's 46 counties have doctor shortages, according to a July report compiled by the state.
What experts have called a "perfect storm" of complicating factors -- from health care reform to steep cuts in incentives designed to lure doctors to rural areas -- means that more patients soon will be lining up to see even fewer doctors.
Pete Tucker, who has worked as a physician recruiter in Hampton County for more than a decade, said that county has seven primary care physicians to serve a population of more than 22,000 people.
The county needs at least five more primary care doctors to handle the patients there, Tucker said. But for more than a year, it has not found one to hire.
"The good doctors in areas like ours aren't accepting new patients or they are doing it on a very limited basis," he said.
"It is definitely bad enough now and it's getting worse. Patients are leaving town, lining up, waiting for days to be seen or hours even if they have an appointment. Now, more than ever, they're using the emergency room for non-emergencies because it takes too long to be seen by a primary care physician."
Dr. Beth Gordineer, who has her own practice in Edgefield County, an area with four primary care doctors for about 24,000 residents, said she also has had difficulty hiring a new doctor.
"The young guys were trained in the city and they want to work in the city, or on the coast, or in the mountains," Gordineer said. "No one wants to come to small, rural, poor South Carolina."
Gordineer said the situation is "becoming a crisis."
"The other three doctors here are about 60 (years old)," the 50-year-old physician said. "No young doctors are coming here to take our places."
And some other rural counties face similar crises.
In Williamsburg County, the patient to primary care doctor ratio is 3,300-to-1, three times the rate in the more urban Charleston County, said Mark Jordan, director of the S.C. Department of Health and Environmental Control office of primary care.
"There's way too many doctors in Columbia, Greenville and Charleston and not enough in the rest of the state," Jordan said. "There are simply not enough providers per capita in the rural parts of the state."
National health care reform means that in the coming years everyone will have insurance, and many more people will begin demanding regular doctor visits, experts said.
"With new laws, more and more people will suddenly want to have a physician they can call their medical home," Tucker said.
The South Carolina Area Health Education Consortium, a state group that works with health care professionals, tracks trends in health care supply and demand.
Ragan DuBose-Morris, the group's spokeswoman, pointed to Massachusetts as an example of the challenges South Carolina soon will face. Massachusetts, which passed a state law in 2006 requiring residents to have insurance, had more physicians per capita than any other state in the country, she said.
Still, the state experienced primary care physician shortages once residents began demanding doctors.
Only seven states in the country have fewer actively practicing primary care physicians -- those who practice family medicine, general pediatrics or general internal medicine -- than South Carolina, according to state data.
The primary care shortages that already exist in most of the state will become more pronounced in the coming years, DuBose-Morris said.
The problem probably will be exacerbated further because statistics show that rural areas are home to the sickest residents. Compared with the suburban and urban parts of the state, rural areas show the highest rates of hypertension, diabetes, smoking and obesity, according to state data.
Local observers, including Dr. Peter Carek, a professor of family medicine at the Medical University of South Carolina, described an already dire scenario.
"Patients now find it difficult to find a primary care physician," Carek said. "They must travel to get the primary care they need. Or in many cases, they don't go for preventative care. If they have a chronic disease, they don't go for treatment as often as they should or they wait longer than they should to seek help. They wait until they're very sick."
A combination of all those factors drives up costs in the long run, he said. "With more doctors, that could be avoided," he said.
Becky Seignious, the state health education group's director or recruitment and retention, said luring primary care physicians to rural South Carolina has been an uphill battle and is only becoming more challenging.
A state grant that provided doctors with $10,000 a year for a four-year commitment to practicing in under-served rural areas was cut this year, giving recruiters one less tool to entice doctors to practice in what can be a personally and financially challenging environment.
Rural physicians treat more patients on Medicare and Medicaid, meaning they are reimbursed at lower rates, Seignious said. With fewer nearby colleagues, they often have more patients, work longer hours and spend more time on-call than their urban counterparts, she said.
Lifestyle also plays a large role, as many young doctors are educated in urban areas with big-city amenities, in and out of the health care arena.
"We need doctors desperately in Allendale, but who wants to go there?" Seignious said. "Their spouses won't want to go because it's not near anything else. They don't want to raise a family there because the schools are bad. Who can blame them?"
Meanwhile, many doctors who already work in rural areas are approaching retirement. Statewide, the average age of actively licensed primary care physicians is 49 years old; 30 percent of them are more than 55 years old, according to a recent state workforce analysis.
As they age, some doctors have cut back their hours even as patients continue to demand service, Seignious said.
Experts said an overall shortage of primary care physicians is one that has plagued the country for years. Observers attribute the nationwide dearth of primary care doctors to a lack of both prestige and money.
Doctors in specialized fields, such as dermatology or cardiology, can earn triple what they could earn in family medicine, according to national data.
"When you come out of school $200,000 in debt, money can make a difference," said Dr. Lori Heim, president of the American Academy of Family Physicians, a national family medicine advocacy group.
About 20 percent of medical school graduates choose to go into primary care, far fewer than the 50 percent Heim's group said is needed to cope with patient demand. A national dearth of primary care doctors means even fewer of them are trickling to rural areas, Heim said.
"Even if you have means to pay now, you may not be able to find a practice accepting new patients," she said.
Luring them here
The $40,000 grant awarded to doctors who gave a four-year commitment to practicing in the state's under-served areas was cut this spring as part of the S.C. Legislature's sweeping budget cuts.
Health officials, including Tucker of Hampton Regional Medical Center, said losing the grant crippled recruitment efforts.
"It helped us recruit mid-career doctors that already had their loans paid," Tucker said.
Student loan reimbursement through the federal government still is available for some physicians entering under-served areas.
Doctors can get $50,000 in tax-free tuition reimbursement for a two-year obligation to a rural area, and up to $35,000 for a third year. More than 30 South Carolina doctors from various fields applied for and received the reimbursement last year.
Another program grants foreign medical school graduates residence training in America in exchange for a three-year commitment to an under-served rural area.
But all the incentive programs guarantee doctors for a limited time only.
Jordan, of the state primary care office, acknowledged that retention numbers are low for all three programs.
For example, 19 doctors have practiced in Allendale County to receive tuition reimbursement since the federal government began the program in 1990, he said. Of those 19, only two remain -- and both of them started last year, meaning they still are under their obligated contracts.
None of the three doctors placed in Allendale through the visa program remain, he said.
"They're in areas that are rural and poor and isolated," Jordan said. "They go. They serve. They leave."
Although the incentives have some inherent flaws, they get the job done, officials said.
"Even if they're only there three or four years, at least you have somebody for those three or four years," said Heim of the national family medicine group.
Jordan said the incentives are necessary to get doctors to the dozen least-served counties in the state.
"What else have you got?" Jordan asked. "If it weren't for those incentives, you wouldn't get them at all."
S.C. legislators say the grant money probably is not coming back any time soon.
"I'd like to say it is, but I know it's an even tighter budget in 2011 than in 2010," said state Rep. Anne Hutto, D-Charleston, who serves on the House Medical, Military, Public and Municipal Affairs Committee.
"We need to find a way of making it more attractive to go to rural areas that won't cost the state money."
Rep. Leon Howard, D-Columbia, chairman of the House committee on medical affairs, said state leaders are "very aware" of the doctor shortage problem.
"The resources are just not there to deal with it," he said. "Unfortunately some people will suffer because of this. It's not going unnoticed."
Rep. Wendell Gilliard, D-Charleston, who also serves on the committee, said the state's medical schools should target rural high school students.
"We need to sit down with deans of medical schools to come up with a plan to address rural shortages," Gilliard said. "They're in a position that they can guide us to come up with a plan that would really work long term. We're going to have to have doctors to serve the masses because even our rural areas are not so small anymore."
Local and national health experts affirmed Gilliard's proposal, saying data shows rural recruitment has eased shortages in other states. Carek, the MUSC professor, said Pennsylvania has successfully retained doctors in rural areas by actively recruiting from those same areas.
"They feel close to the patients and have strong ties to the communities," he said.
Dr. John Creel, a family medicine doctor who grew up in Cottageville, and for the past five years has operated his own practice in nearby Walterboro, said he's an example of that tactic's success.
Creel, who has 8,000 patients, said he earned his medical degree at MUSC but always intended to return closer to his hometown.
"The key is finding rural high school students who have strong science and math backgrounds and an interest in medicine," said Creel, who received $40,000 in state grant money while it was still available. "It's hard to keep a physician out in a rural area unless you grew up there."
Dr. Neal Goodbar, a 27-year-old MUSC graduate from Rock Hill, said the strategy made sense to him too.
Goodbar, who is in the first year of his family medicine residency in Greenwood County, said he wanted to train there in part because it is where his extended family lives. After his residency is complete, Goodbar said he will "at least stay in a similar-sized location."
"I got tired of living in city," he said. "I like the smaller cities. I like going out to Walmart and seeing a patient or someone I know from church. It's a comfort."