How Rural Rheumatologists Are Coping with Passage of Affordable Care Act, Changes in Reimbursement, Payment Systems

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Four years ago, a series of articles in The Rheumatologist talked about the practice of rheumatology in rural settings. Since then, changes have occurred, with the passage of the Affordable Care Act (ACA), differences in reimbursement and the trek toward value-based payment systems.

One major concern expressed in the original article was the fact that many of those practicing outside the urban areas were reaching retirement age. Of the six people interviewed, only three are still practicing.

Difficult to Find Associates

Another worry, especially for those in solo or small group practices, was an inability to recruit physicians to help relieve some of the burden or, perhaps more importantly to many of these doctors, to take over care of their patients when they retired.

“The trials and tribulations are about the same as four years ago, only magnified,” says Karen S. Kolba, MD, a rheumatologist in solo practice in Santa Maria, Calif. “I am still unable to find an associate to bring in.”

She notes that doctors now graduate with huge debts, limiting their ability to undertake the business risks inherent in rural, solo practice. She isn’t in a position to guarantee them a salary, and they aren’t in a position to risk defaulting on their loans.

“Many newer graduates are not willing to take on a small practice workload,” she continues. “Many want 40-hour weeks, and honestly so do I, but that isn’t the way you run this kind of business.”

Selling the Practice?

Another way other specialties have coped with changes is by selling the practice to an area hospital. This makes the physician an employee of the facility, easing many administrative and financial burdens. Especially in rural areas, the local healthcare system may be the only buyer.

So far, most practice purchases have been to control primary care networks or those specialties that are frequent admitters. Rheumatology does not send many of their patients to the inpatient side and may not be an enticing takeover target.

Robert Jackson, DO, is president of Premier Specialty Network (PSN) and a rheumatologist at rural hospitals in multiple states. PSN partners with local hospitals to establish satellite clinics. The physicians work for PSN and have control over their time while being sheltered from some of the financial aspects.

Too Few Practicing in Rural Areas

“The ACR notes that currently less than 10% of rheumatologists practice in rural locations,” says Dr. Jackson.¹ “The College is concerned, because if you don’t live in an urban area it can be a 200 or more mile journey to get needed care.”