Doctors are becoming a scarce commodity in rural Arizona, and despite recent legislation, it seems like money isn’t the real answer.

In February, Governor Doug Ducey signed a bill which enhances the Arizona State Loan Repayment Program. The program is set in place to entice healthcare professionals, including physicians, general dentists, nurse practitioners, physician assistants and certified nurse midwives, to underserved areas by paying back their student loans.

The bill gets rid of the 4-year service cap on the program, as well as increasing the reward for physicians and dentists to $65,000 for a 2-year commitment and a continued award of $35,000 past those two years in a qualifying health professional shortage area. The bill will become effective 91 days after the legislative session ends.

According to Arizona Health Services, there are an estimated 400 designated health professional shortage areas in Arizona. Out of those, 153 are primary care HPSAs. A primary care shortage area meets qualification by having 3,500 or more people to every one primary care provider or a high need population of about 3,000. This means that Arizona has a primary care shortage that requires 442 new primary care providers to fill.

Ana Roscetti, a workforce section manger and overseer of the loan repayment program for Arizona Health Services, thinks the money will definitely help reduce those numbers.

“Salary is extremely important when you’re looking at a job, that’s just basic,” said Roscetti.

According to the Arizona Academy of Family Physicians, graduating physicians have an average debt of $170,000.

“That means if they commit for four years to this program, they can have most, if not all, of their student loans paid off. That’s a huge relief,” said Roscetti.

“We’ve already seen an increase in participants, just this year,” she said. “We had only 17 participants last year, and we have 34 this year. That’s a 100 percent increase, even before this legislation.”

Roscetti accounts this increase to a doubling in funding from the federal government, allowing them to take in more participants. Without the 4-year cap, and the additional bump in payouts she believes the number will keep rising.

She’s also hopeful about retaining these providers. “Only about 19 percent of our participants do not renew,” she said. “Fifty percent have maxxed out their commitment according to the 4-year cap but still stayed, and 31 percent are in their third or fourth year.”

She expects that without this cap, many of those providers will now reapply for funding or stay for a longer contract.

But money isn’t the only thing keeping these physicians away, says Joyce Hospodar. Hospodar is the senior program coordinator of the Medicare Rural Hospital Flexibility program. This is a state run program that is funded by the U.S. Department of Health and Human Services. She helps gather data for rural Arizona hospitals seeking to be designated as a Critical Access Hospital, under which they can receive funding and support. The Flex program provides reimbursement for Medicare inpatient and outpatient services and offers specific grants for broader initiatives meant to improve rural health care infrastructure. CAH have less than 25 inpatient beds and are usually at least 35 miles from another facility.

According to the U.S. Department of Health and Human Services there are more than 1,300 hospitals that have converted to CAH status across the country, but they’re still struggling. The National Rural Health Association has recorded 48 rural hospital closures since 2010, and more than 200 are in danger of following.

Hospodar says that the money from programs like the Loan Repayment and Flex program will entice some doctors, but it isn’t a long-term solution.

“It’s not just one thing,” Hospodar said, “It’s an environment…It’s an excellent incentive. But there’s a lot more factors involved.”

Dr. Carlos Gonzalez is the director of the Rural Health Professions Program & Commitment to Underserved People Program at the University of Arizona. This program places medical students in rural areas for brief training and then later long-term clinical rotations. It was designed in 1997 to try and combat the already growing shortage of primary care physicians in rural Arizona. Since then, the program has grown and sends students to train in over 40 communities across the state. Twenty-two medical students are taken in each year and Gonzalez says they see a very high retention rate with those doctors going on to practice in rural areas.

“A lot of our preceptors now were actually participants in the program years ago,” said Gonzalez.

But he says that it wasn’t money that brought them there.

“I did the loan-repayment program myself, years ago when I started practicing. But that’s not why I went to a rural area,” he said.

Gonzalez grew up in Tucson but after getting his degree and working for several years at El Rio Community Health Center he wanted to do something different. He moved to Patagonia where he worked for 13 years as the only doctor within 1,600 square miles.

“I still live down there actually,” Gonzalez said, “I love living out in the rural areas. I love the lifestyle.”

Gonzalez says most physicians who go to rural areas have usually grown up in one and gaining an affinity for the area like he did is what programs like the RHPP are trying to encourage. Getting students from metropolitan areas to move to rural communities is a struggle, as well as making sure students want to practice primary care instead of specialize.

“There needs to be more emphasis on becoming a primary care physician,” said Gonzalez, “When you practice in rural areas, it’s all about practicing primary care. Trying to prevent problems instead of treat the complications of the problems, which is what specialists do.”

Rural hospitals all over the country are struggling to stay open, and it seems like money isn’t the real answer.

“The income to becoming a primary care doctor needs to increase,” said Gonzalez, “But we also need to continue to move towards repaying quality of care, not quantity.”

 Mary Rinker is a reporter for the Arizona Sonora News, a service from the School of Journalism at the University of Arizona. Contact her at [email protected].