Disparities in Rural Health Care: A Look at the Field of Laboratory Medicine

Health care in rural areas has long been compromised by the uneven distribution and relative shortage of medical providers. Throughout the 1980s, the healthcare workforce dwindled as rural hospitals were shut down. This trend has continued; since 2010, 83 rural hospitals have been closed in 23 states.¹ Few rural towns have resurrected these dismantled healthcare systems, and despite attempts by policy makers and educational institutions to address rural provider shortages over the past several decades, the scarcities persist. While much research exists on the maldistribution of physicians across the United States, there is a lack of literature focusing on the challenges that impact the laboratory field in the same geographic areas. In fact, while the Bureau of Labor Statistics demonstrates that, across the nation, laboratories will require 80,000 new lab professionals (HT, HTL MT, CLS, MLT, PBT, PA) by 2026 to maintain optimal staffing, the National Accrediting Agency for Clinical Laboratory Science (NAACLS) reports that schools nationwide are only graduating 8,700 laboratory professionals per year.^2,3 Additionally, according to the American Society for Clinical Pathology’s vacancy survey of medical laboratories in the United States, retirement rates for laboratory professionals are at their highest since 2012.⁴ Understanding these challenges is an essential part of facilitating the recruitment and retention of qualified and certified laboratory professionals. By analyzing the obstacles faced by the laboratory field, it is possible to begin critically examining healthcare systems within a context that encompasses the complex intersections of socioeconomic, demographic, and healthcare infrastructure factors.

For laboratory professionals wanting to practice beyond major metropolitan areas, a rural community offers unique benefits. Initial benefits of rural professionals include loan forgiveness and sign-on bonuses.⁵ With work-life balance becoming increasingly important to laboratory professionals, rural areas are in a perfect position to provide it. The smaller populations of rural areas lend themselves to communal intimacy and stability as there are many longtime residents invested in the community’s well being. These close-knit, family-friendly environments are also a result of affordable housing, good school systems, and relatively lower crime rates. State- and community-specific programs have been enacted to enhance both provider and patient experiences. For example, rural communities in Nebraska benefit from the Medicare Rural Hospital Flexibility (FLEX) program and the Small Rural Hospital Improvement program (SHIP). The FLEX program grant provides for the financial and operational improvement of emergency medical services systems, supporting 64 critical access hospitals in Nebraska. SHIP, supported by a federal grant, enhances prospective payment system (PPS) activities, including staff training, activities that improve the quality of care, such as software to reduce medication errors, and data collection activities encompassing both inpatient and outpatient Hospital Compare data.⁶ In addition to the enhanced work-life balance provided by rural areas, professionals are more likely to have a broader medical experience. With less competition among laboratory services, rural professionals require an extensive skillset to provide quality care for all types of cases as they are more likely to encounter a wide scope of illnesses.

While acknowledging the above advantages, it is imperative to recognize that rural health care is, nevertheless, a double-edged sword. Rural Americans lack adequate healthcare access and quality. According to the Committee on the Future of Rural Health Care, more than 10% of Americans live in federally designated health professional shortage areas, where there are limited or nonexistent healthcare services.⁷ Compounding the healthcare shortage, rural populations are often older and poorer than their urban counterparts, and often have more limited insurance coverage. Rural communities routinely have difficulty creating, recruiting, and sustaining an adequate healthcare workforce as a result of factors such as geographic isolation, economic instability, resource limitations, provider shortages, ethical challenges, transportation problems, and funding disadvantages. States with many rural areas have less clinical laboratory technologists and technicians than states with fewer rural areas. For example, while the metropolitan area with the highest employment rate of clinical technologists and technicians is New York–Jersey City–White Plains, with 12,500 professionals, the corresponding nonmetropolitan area is northeastern Wisconsin, with 640 professionals.⁸ Although past strategies have focused on physicians in particular, rural healthcare needs are interdisciplinary and require the services of many laboratory professionals.

Rural Challenges & Recommendations

Education & Recruitment

While rural healthcare requires diverse and specialized skills from laboratory professionals who work with fewer diagnostic and treatment resources than those in urban areas, educational opportunities to become laboratory professionals and to upgrade skills while pursuing professional development are also more limited in rural than in urban areas. Practicing laboratory professionals lament that there are “no nearby schools of medical technology” and that several “community college[s] dropped the program several years ago,” while others proclaim that “rural areas are hurting badly for qualified laboratory professionals as pay does not compete with nurses having an equivalent education.”⁴ In fact, the Bureau of Labor Statistics reports that the median salary of medical laboratory technologists (MLTs) is $51,770 annually, while registered nurses (RNs) earn a median salary of $70,000 per year.⁹ In addition to the pay deficit, school closings in rural areas have reduced the number of medical laboratory scientists and MLTs being trained annually. Since 1990, the number of rural laboratory training programs has dropped from 720 to 608, a decrease of more than 15%.¹⁰

It is necessary to establish outreach programs in rural communities to attract qualified applicants to professional laboratory training programs. Establishing significant educational training programs in rural areas as well as developing rural-specific training opportunities with financial incentives for rural practice is imperative. According to Slagle, there is strong evidence that “rural origin” (or background) is associated with rural practice.¹¹ Known as the affinity model, this theory states that students who have lived or trained in rural towns are more likely to choose rural practice. The establishment of outreach programs in rural communities with the goal of attracting qualified applicants to health professional programs is essential. A Kentucky study demonstrated the strength of the affinity model as 75% of the 151 participants pursued a health career and 10% entered medical school.¹² The affinity model eliminates the notion that it is necessary to move to large cities to have a significant impact in healthcare spheres. Additionally, funding should be invested in training programs with explicit rural missions, allotted to employees for travel to professional meetings and continuing education, and utilized for the reimbursement of relevant graduate coursework. Tuition payment programs and other financial incentives, telemedicine initiatives, and rural clinical rotations will aid in significantly increasing the recruitment of lab professionals.

Retention

Laboratory professionals, like other healthcare providers, leave rural practice for a variety of reasons, including a lack of feedback during initial work months, issues with family relocation and personal transportation, difficulty joining the community or having an outsider role, and poor access to funding and resources. A Tennessee study recorded that 53.4% of rural laboratory directors, compared to only 22.6% of their urban counterparts, cited difficulties with family relocation programs as a factor in their decision to leave.¹¹ Rural laboratory professionals also have access to limited funding. For example, under the American Recovery and Reinvestment Act of 2009, little or none of the $200 million designated for the Health Professions Training Programs Implementation Plan was allocated to recruit, train, or retain laboratory professionals.¹³Limited access to professional development opportunities, frustrations regarding facilities, and an abbreviated list of services provided to patients impact the retention of laboratory professionals.

By enhancing rural laboratory professionals’ desire to work in smaller communities or emphasizing commitment to their hometowns, it is possible to improve retention rates across the healthcare workforce. According to Daniels et al, 76% of health professionals cited “enough work to support self/family” and “opportunity for professional experiences” as essential for retention, while 69% of respondents considered “income potential” and “serving health needs in the community” to be pertinent factors.⁵ Communities must prioritize the allocation of financial incentives for laboratory professionals, increase professional development and educational opportunities, heighten awareness of community-specific health needs, and improve the attractiveness of their community as a place to both reside and work by making family relocation and transportation services available. According to Bamberg et al, laboratories with strong organizational support and supervisors who demonstrate transformational leadership behaviors, such as including employees in problem solving, treating employees as individuals, supporting unique characteristics and strengths of each employee, and developing a collective organizational mission, are positive indicators of retention as each strengthens the commitment to serving the rural community.¹⁴ These recommendations are meant to highlight the value of offering ample and well-paid employment as well as opportunities for rural laboratory professionals’ growth.

Resource Limitations

Continued school closings have left some states, such as Nevada, Vermont, and Wyoming, with only one NAACLS-accredited laboratory educational program, forcing labs in those states to recruit from other states. Despite the decline of these programs, many have the potential to train additional students. According to Scott, the difficulty comes in finding clinical placements where the students can complete their training.¹⁰ Even more apparent than the limited training available to rural laboratory professionals is the smaller rural workforce itself. Rural laboratory professionals have extremely limited access to colleagues for consultations, referrals, and expertise. Since there are fewer providers in rural areas, most providers have generalist training, meaning that specialists are more difficult to access. Funding is a continuous and permeating issue in rural communities as fiscal barriers halt or complicate most aspects of healthcare.

Federal government agencies and the health policy sector have become increasingly aware that reimbursement strategies are a critical element in resolving rural physician shortages. It is imperative that this awareness begins to extend to incorporate laboratory professionals as well. Comprehensive strategies could be implemented within government through coordinated policy changes in Medicare and Medicaid reimbursement or in the funding of educational programs with a rural-specific mission. The flow of Title VII funds for rural hospitals as well as for professional programs with rural missions must increase. This expansion of funds will also make the process of applying for grants to benefit rural areas less burdensome and costly.

Advances in medical informatics and telemedicine have the potential to remove communication and knowledge barriers between rural and urban areas, but have not yet been widely applied in rural practice. Funding the development of telehealth programs that link academic health centers and teaching units with the mission of continuing rural education to rural practices will facilitate learning and communication. For example, the National Institutes of Health–funded eClinic, a 30-module computer-based laboratory educational tool complete with virtual wet labs and advanced learning strategies, to better prepare students for professional practice, from 2012 through 2017. The program provided training where clinical rotations sites were unavailable. Currently, four modules are available online: Body Fluid Dilution, Gram Staining, Mass Spectroscopy, and Platelets.¹⁵ In order to achieve widespread adoption of the product, eClinic will be licensed to publishers, dealers, retailers, and distributors with established marketing channels.¹⁶ Similarly, rural laboratory professionals must be creative and flexible, capable of collaborating across disciplines, and sufficiently aware of when to seek external resources in order to overcome the inherent resource limitations of rural life and health care.

Service Access

Unreliable transportation, extensive travel distances, and elevated healthcare costs disproportionately affect rural healthcare professionals. Rural providers and residents are faced with difficult weather conditions, geographic isolation, terrain challenges, high transportation costs, and long distances between facilities. These long distances between residential communities, primary care facilities, and specialization offices result in fragmented or discontinuous care.

In addition to physical barriers to healthcare facilities, other barriers to healthcare access stem from issues with the education and recruitment of laboratory professionals. Rural communities have insufficient access to training due to time and staffing limitations. As rural providers tend to be geographically isolated, there is little opportunity to venture beyond their practices to pursue professional development opportunities, due to a lack of coverage. Since travel is required for most training, rural laboratory professionals, who have been overburdened and underpaid, experience the additional obstacle of restricted training.

Much literature has begun to recommend the integration of physical health, mental health, and substance abuse treatment in a single facility to ameliorate burdens of travel and fragmentation of care.¹⁷ This, however, raises the issue of increased travel distance for both patients and healthcare professionals to this singular service center. While travel remains an issue, it is possible that increasing the use of electronic medical records may reduce the fragmentation of care by building a system capable of storing a patient’s entire health history across primary and specialty care facilities, compiling a comprehensive patient chart. This will allow professionals to make appropriate decisions, improving overall health outcomes. The training of laboratory professionals must be carefully structured to prepare professionals for rural practice.

Moving Forward

The National Center for Health Workforce Analysis has estimated a 24% increase in the demand for laboratory professionals by the year 2025.¹⁸ With population growth and aging, increased coverage of screening tests resulting from federal healthcare reform, and the development of new tests, the volume of laboratory work is expected to increase. However, an increase in the vacancy rates of laboratory professions can be attributed mainly to the retirement of current professionals and a slow replenishment of vacancies by graduating laboratory professionals as a result of diminished educational programs and clinical rotation sites. As noted by James Wisecarver, MD, PhD, FASCP, providing sustained exposure and increasing awareness by educating both students and the general public about the roles of laboratory professionals are critical to our nation’s healthcare system.¹⁹ The application of these recommendations will serve to directly address vacancy issues facing many laboratory facilities by improving education, recruitment, and retention across the United States, especially in rural areas.

Rural healthcare is not a one-size-fits-all model. The establishment of community-specific outreach programs is an important factor in the attenuation of rural healthcare disparities across the United States. Effective strategies must be as multifaceted as the barriers themselves. Rural lab professionals have the difficult task of supplying a diverse range of healthcare services in settings that, in many ways, limit their effectiveness and success. Although the barriers to rural health care are persistent and pervasive, embedding these recommendations in community-specific healthcare plans, focused on partnership building and supportive of creative and sustainable alliances, will mitigate disparities between urban and rural areas.

References

Author notes