Credit: Courtesy of Beartooth Billings Clinic

State lawmakers spent the better part of last winter and spring discussing how to improve rural health care in Montana. Now, U.S. Sen. Jon Tester is keeping the debate alive in Congress, having introduced a bill earlier this month aimed at addressing a shortage of physicians at Montana’s frontier hospitals.

The Rural Physician Workforce Production Act would increase the amount of federal Medicare funding rural hospitals can tap into to cover the costs of hosting medical residencies — the final step a medical school graduate has to complete before becoming a practicing physician. Tester’s bill would also allow Medicare to reimburse urban hospitals that send residents to rural facilities for a portion of their training.

“Folks in every corner of our state deserve access to high-quality care, no matter where they live,” Tester said in a statement announcing the proposal. “This bill works to cut the burdensome red tape that prevents rural hospitals from bringing in more residents, and ensures those facilities have the resources they need to recruit and retain doctors for the long haul.”

Montana Hospital Association President Rich Rasmussen characterizes Tester’s bill as a grow-your-own approach to workforce development. New doctors have a tendency to stick around the communities and hospitals where they completed their residency, Rasmussen said. Data from the Association of American Medical Colleges bears that out at the state level, demonstrating that Montana retained 63% of medical residents trained in the state between 2010 and 2019 — 10% above the national average. But according to the Montana Office of Rural Health and Area Health Education Center, about 76% of Montana physicians are concentrated in the state’s seven largest communities, where only 35% of the state’s population resides.

“When folks come here, they fall in love with the people and the community and certainly the beautiful environment we have,” Rasmussen said. “But we’ve got to look at ways in which the payment policy really incentivizes growing residency programs in small facilities.”

Montana currently has four residency programs centered in Billings, Missoula and Kalispell, which do send residents into rural health care facilities for short periods known as “rotations.” According to Barry Kenfield, chair of Montana’s Graduate Medical Education Council, no rural hospitals in the state are currently hosting residents full-time. Kenfield said Tester’s bill addresses the first of two obstacles in establishing such residencies: money. He estimated the average cost of hosting a resident at $240,000 a year, a burden that Tester’s proposed Medicare reimbursement increase would help alleviate.

“In almost every community in Montana, if not every community, the hospitals and clinics are the largest employers. If the supply chain of physicians gets interrupted, it puts the whole picture at risk.”

Kelley Evans, CEO of Beartooth Billings Clinic in Red Lodge

While Kenfield believes Tester’s bill is on the right track, he said the second obstacle is one that politicians are powerless to change. Residency programs have specific requirements for aspiring physicians, set by the national Accreditation Council for Graduate Medical Education, that are difficult to meet exclusively in rural settings. Residents in Missoula and Kalispell, for example, spend a portion of their residencies shadowing medical specialists such as cardiologists and neurosurgeons. Kenfield said Tester’s bill will give rural hospitals greater financial opportunity to host residents for longer periods of time, but those residents would still need to do rotations at larger urban facilities to meet program requirements.

“Even if a rural facility initiated a residency or partnered with someone to initiate a residency in their community,” Kenfield said, “they still would have to send those residents into Missoula, Billings, Helena, Bozeman, Kalispell, Great Falls, to get more of those experiences that they need to meet the accreditation standards.”

Kelley Evans, CEO of Beartooth Billings Clinic in Red Lodge, agreed that improving rural training opportunities for medical residents will translate to an expanded pool of new frontier doctors. Montana’s struggles with a rural physician shortage are nothing new, Evans said, and the situation has only been exacerbated by what she calls “COVID burnout” among existing hospital staff. Though rural, Beartooth Billings has benefited from being part of the Billings Clinic system, with residents from Billings-based residency programs doing rotations in Red Lodge. Evans said the funding made available by Tester’s bill would help her facility offer more structure and depth for residents and motivate them to stay on in a rural setting.

“In almost every community in Montana, if not every community, the hospitals and clinics are the largest employers,” Evans said. “If the supply chain of physicians gets interrupted, it puts the whole picture at risk.”

The economic role played by health care facilities in Montana communities, and especially rural ones, was the focus of a study this month from the University of Montana-based Bureau of Business and Economic Research. The study showed that health care accounts for nearly 83,900 permanent jobs statewide — the largest employing industry in the state — and generates more than $6.3 billion in annual income. Economic vitality has served as a powerful argument for advocates pushing improvements to Montana’s health care system.

The loudest argument, though, continues to be about patient access to health care given the provider shortage. Legislators passed a raft of laws this session to improve access and beef up the labor pool, including enhancements to community college funding designed to incentivize career and technical education programs such as nursing, which is also experiencing a workforce shortage. Federal funding allocated by state lawmakers from the American Rescue Plan Act was also flagged to maintain and expand Montana’s health care workforce, a program that Tester’s office indicated could, if successful, help recruit more professionals to rural locations. 

Tester’s proposal may not be new — he introduced a similar measure in 2019 without success — but for Evans, it continues a critical dialogue about how to resolve one of Montana’s biggest health care challenges.

“The increased dialogue is bringing more solutions to the table over issues that haven’t been funded in the past,” Evans said. “Frankly, I don’t know what’s going to stick and evolve from it, but at least the dialogue is on the table, which is a huge improvement from where we were five years ago.”

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Staff reporter Alex Sakariassen covers the education beat and the state Legislature for Montana Free Press. Alex spent the past decade writing long-form narrative stories that spotlight the people, the politics, and the wilds of Montana. A North Dakota native, he splits his free time between Missoula’s ski slopes and the quiet trout water of the Rocky Mountain Front. Contact Alex by email at asakariassen@montanafreepress.org.