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April 16, 2020  | Updated: May 13, 2020

Category: Rural Health


  • As older doctors retire, new generation hesitant to work in rural areas
  • Rural facilities face administrative challenges due to smaller budgets
  • Urban facilities offer providers more insurance options, patient demographics

A variety of issues contribute to health care complications in rural America, including a shortage of health care workers, continuing closures of hospitals, a high rate of elderly, poor, and underinsured residents, as well as a high frequency of chronic illness. In the final edition of our three-part series on the dilemmas faced by rural health care administrators, we examine the shortage of health care workers in rural America as well as the impact on facility operations and patient care.

Even if the difficulties surrounding patient access to health care are diminished and telehealth becomes a feasible reality in rural areas, a significant and continuous hurdle remains: a shortage of health care providers in rural areas of the country.

There is a faulty allocation of health care workers and licensed medical providers across the United States, with urban areas having the highest concentration of health care industry workers. As of March 2020, non-metropolitan areas accounted for 61 percent of Primary Medical Health Professional Shortage Areas, according to the Bureau of Health Workforce Health Resources and Services Administration (HRSA), which is part of U.S. Department of Health & Human Services.

The HRSA defines Health Professional Shortage Areas (HPSA) as designations that indicate health care provider shortages in primary care, dental health, or mental health. This high percentage of health care provider deficiencies across a wide range of medical practices causes rural populations to be at risk for limited access to care and thus results in poorer health outcomes (Mock et al.).

Provider Demographics: Changing Times=Change in Care

The question remains as to how rural health care facilities can not only enroll providers, but consequently retain them as well. There is a major shift taking place in the health care industry, and its effects are most notable in rural America.

As doctors from the Baby Boomer generation begin retiring, there is an increase of closures for independent family practices, most notably in small towns across the United States. According to the National Rural Health Association, the patient-to-primary care physician ratio in rural areas is approximately 40 physicians per 100,000 people. Whereas in urban areas, the patient-to-primary care physician ratio is approximately 53 physicians per 100,000 residents.

Merritt Hawkins conducted its 2019 Survey of Final-Year Medical Residents to showcase the “concerns and expectations of physicians who are about to complete their final year of training and enter the employment market.”

The results of the survey revealed a troubling reality for health care in rural America. According to the survey, only 1 percent of doctors in their final year of medical school said that they want to live in communities with a population under 10,000 and only 2 percent of doctors wanted to live in towns of less than 25,000 residents. There are a couple of substantial factors that play into this decision, including the high cost of taking over a small-town practice as well as the time intensive process that might be intimidating for younger physicians. Many of the doctors fresh out of medical training are choosing to work at urban hospitals, rather than opening their own practices. Offering a cost-effective solution that would permit more doctors to easily open and maintain a private practice, or enable existing rural medical facilities to entice this new generation of doctors to be part of a small community, may be the ultimate resolution to resolve the diminishing supply of doctors in rural America, and the increasing urban-rural divide (NPR 2019).

Health care compliance, credentialing, and enrolling providers are all essential procedures for medical facilities of any size that can be costly and time-consuming if not executed correctly.

Health Care Administration Requirements:

One of the largest hurdles facing the rural health care industry involving staffing is the complexity of the process a provider and health care worker must complete before patients can begin receiving treatment. Whether a provider wants to join an existing medical practice or start their own, they first need to get credentialed. Credentialing is a long, slow process that can take anywhere from a few weeks up to six months.

The credentialing process must be re-done every two years in addition to fulfilling continuing medical education (CME) requirements. In combination with other non-clinical paperwork, this administrative burden takes up nearly nine hours a week for the average doctor, according to a study published in the International Journal of Health Services (Woolhandler & Himmelstein 2014). On top of all the time spent, there are costs associated with losing out on potential patients and income. Failing to complete the credentialing process consequently delays the enrollment procedure. Enrollment refers to the process of a health care provider requesting participation in a health insurance plan network. It can also be the validation of a provider in a public health plan such as Medicare or Medicaid and the approval to bill the agency for services rendered.

Enrollment in Medicare and Medicaid is especially important for rural health care facilities, due to the larger percentage of elderly and low-income residents that live in rural areas compared to urban. Since rural hospitals do not have budgets anywhere near the size of their urban counterparts, much of the administrative work is conducted manually which results in income loss for the facility and the provider. Delays cost providers thousands of dollars in lost income—the exact amount of which depends on how much they earn and how long it takes to get credentialed. For a physician making the average income of nearly $300,000 a year, waiting a few weeks would cost the provider around $25,000 in lost income. The worst-case scenario of waiting six months would cost the provider around $150,000 in lost income. If rural medical facilities are not able to efficiently credential and enroll providers in government health plans or insurance networks that fit the needs of the patients, the provider is likely to transfer to an urban facility.


Rural health care currently needs more attention than ever, especially considering the devastation of the COVID-19 pandemic. Patients need improved access to medical facilities, the usage of telehealth and telemedicine needs to become more widespread and accepted by patients and providers alike, and medical facility administrators need to take the appropriate steps to ensure that health care providers are able and willing to become long-term members of their care team. If you have questions about credential management, automated enrollment, continuing medical education, or HIPAA-compliant messaging services, feel free to contact us. We’re always happy to help.

Related Posts:


  1. 2019 Survey of Final-Year Medical Residents. (n.d.)., Accessed April 15, 2020
  2. Bureau of Health Workforce Health Resources and Services Administration (HRSA). “Designated Health Professional Shortage Areas Statistics”. Accessed on: April 13, 2020.
  3. Cutler, D., Wikler, E., & Basch, P. (2012). Reducing Administrative Costs and Improving the Health Care System. New England Journal of Medicine, 367(20), 1875–1878. doi: 10.1056/nejmp1209711.
  4. David L. Paul and Reuben R. McDaniel. “Facilitating telemedicine project sustainability in medically underserved areas: a healthcare provider participant perspective”. BMC Health Services Research, 10.1186/s12913-016-1401-y, 16, 1, (2016).
  5. Groysberg B. The seven skills you need to thrive in the C-suite. Harvard Business Review Accessed April 8, 2020.
  6. Mock KD, Morton T, Quijada P, St. John J. Community health workers: recommendations for bridging healthcare gaps in rural America. Accessed April 8, 2020.
  7. National Rural Health Association. “About rural healthcare.”  Accessed April 8, 2020.
  8. Reimers-Hild C. (2018). Strategic foresight, leadership, and the future of rural healthcare staffing in the United States. JAAPA: Official journal of the American Academy of Physician Assistants31(5), 44–49.
  9. Rosenblatt RA, Andrilla CHA, Curtin T, Hart LG. Shortages of Medical Personnel at Community Health Centers: Implications for Planned Expansion. JAMA. 2006;295(9):1042–1049. doi:10.1001/jama.295.9.104.
  10. Siegler, K. (2019, May 21). The Struggle To Hire And Keep Doctors In Rural Areas Means Patients Go Without Care. Retrieved from
  11. Woolhandler, S., & Himmelstein, D. U. (2014). Administrative Work Consumes One-Sixth of U.S. Physicians Working Hours and Lowers their Career Satisfaction. International Journal of Health Services44(4), 635–642. doi: 10.2190/hs.44.4.a.