Primary care shortage has an outsized impact on rural Missouri

Communities across the country are suffering from a lack of primary care providers, and Missouri is no exception. In fact, it ranks fourth worst nationwide in terms of its primary care provider shortage.

All but seven Missouri counties have shortages of primary care providers. Those mostly rural counties that lack providers see higher rates of chronic diseases such as diabetes, cancer or kidney problems, as well as higher rates of tobacco usage.

And as those communities age and require more care, rural hospitals are closing. Eighteen hospitals have shut their doors in Missouri since 2014, and 12 of those were in rural areas.

Now, as Missouri looks to make inroads in recruiting and retaining primary care providers, those communities bear the brunt of the shortages. Southeast Missouri sees a higher rate of unmet needs when it comes to primary care. Having a regular primary care provider is associated with higher likelihood of appropriate care for a medical condition, and a regular source of care is linked with better health outcomes overall.

“For a person in a rural area without access to this primary care, it will hasten the impact of that disease process on them,” said Brock Slabach, the chief operating officer at the National Rural Health Association. “Now distance becomes a real variable in terms of care. So what we see is delayed care, then at that point, delayed care can be deadly.”

The growing shortage isn’t just a problem in Missouri. Nationwide, there is a projected shortage of 87,000 full-time primary care doctors by 2037, HRSA data show. Falling in line with trends, the shortage is predicted to be the worst in rural areas.

Like the rest of the U.S. population, primary care doctors are beginning to age out of the workforce, Slabach said. Figuring out how to replace those veteran doctors — who may have a different view of work-life balance and the demands of the workplace than the next generation — is a challenge.

“The cliff of those retiring is really just getting alarming,” Slabach said. “Rural communities have, on average, a much older cohort of physicians and advanced practice providers. In fact, they should be retiring. Many are not retiring because the need is so great.”

Hospitals, private practice clinics and health centers are also grappling with the changing expectations of a younger workforce.

“Going into a rural community and working 60, 80 hours a week like doctors did 30 or 40 years ago is not being replaced,” Slabach said. “People are wanting predictable patterns of work-life balance, and they’re insisting on that more and more.”

Primary care providers report higher rates of burnout and low satisfaction with work-life balance and a high load of patients. It’s also a less popular field for incoming medical students due to pay. The average salary for a primary care doctor in the U.S. in 2023 was about $272,000, compared to $558,000 for an orthopedic physician and $423,000 for a general surgeon.

But as the country’s population continues to age, the importance of a longstanding relationship with one’s primary care doctor is coming more into focus.

“We believe firmly in family medicine that continuity is protected and that it is worth striving for and attaining,” said Dr. Laura Morris, a family medicine physician at MU Health Care in Fulton.

For doctors who are getting familiar with a new patient’s medical history, it can be a complicated process.

“It makes it more challenging. It takes more time. It might make you overorder tests, or it might make you fail to recognize certain flags or conditions,” Morris said. “That knowledge and that awareness of the patient’s conditions is helpful from a medical and diagnostic sense.”

It’s a concerning trend as the nation’s population ages.

By 2030, one in five Missourians will be aged 65 or older, an increase of 29% from 2012. In 2020, 16.8% of the nationwide population was 65 or older. By 2040, it’s estimated that will increase to 21.6%.

“We know that in rural counties patients tend to be older. They tend to be sicker. And their outcomes in terms of even basic chronic conditions like heart disease and COPD do not look as good as patients that live in counties where they might have an oversupply of physician access,” Morris said.

A November 2024 study analyzed the national supply of primary care doctors focused on patients 65 and older. It found that while the number of geriatric-focused medical doctors is dropping, the supply of geriatric-focused nurse practitioners is on the rise.

The number of medical doctors per capita nationwide decreased by 12.7% from 2010 to 2020, the study found, while the rate of geriatric nurse practitioners increased by 125%. Over the 10 years of data the study analyzed, nearly 64% of small and rural counties had no geriatric physicians or nurse practitioners.

The state is also looking to amp up health care workforce recruitment and retention through training programs and loan repayment plans. One program sends physicians to practice in designated health care professional shortage areas across the state. During the 2022 fiscal year, 14 of the recipients were in rural areas and seven had a family medicine specialty.

That brings other medical professionals, like advanced practice nurses, behavioral health specialists and social workers into the mix.

“I think the solutions lie in team-based care and really pulling in all of the different resources we have available as a health care team,” Morris said. “It is not simply relying upon a doctor to hang out a shingle and provide all-encompassing care for an entire community. That’s not realistic.”

Nurse practitioners in Missouri have been pushing for more reliance on medical providers outside of medical doctors. Missouri is one of 11 states that require nurse practitioners to practice with a collaborating physician. It’s a requirement for nurse practitioners who want to prescribe medicines and treat patients.

Legislation has been introduced to eliminate some of those requirements after a certain number of hours worked alongside a collaborating physician, but so far it hasn’t gained much traction.

“Maximizing work from nurses, clinic pharmacists and partnering with other organizations to provide wraparound care … is the best way to most efficiently deliver care,” Morris said, “and then alleviate what looks and feels like an overwhelming workload on physician partners.”

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