It’s getting harder to find a pediatrician in rural Alabama, as over a third of the state’s counties don’t have a single pediatric practice.
That’s despite Alabama adding nearly 150 pediatricians since 2022. Most of those physicians are flocking to the state’s largest metropolitan areas in Baldwin, Madison and Jefferson counties.
“These numbers mean we have more pediatricians overall per patient population, which is great.” said Dr. Nola Ernest, president of the Alabama chapter of the American Academy of Pediatrics. “But unless we can get primary care doctors to where the patients are, it doesn’t really matter that there’s more of them.”
Pediatricians in rural communities have struggled to keep their doors open. The price of rent, utilities and supplies have gone up, while the rate they’re paid by Alabama Medicaid has remained the same for decades.
A bill to increase a tax credit for rural doctors from $5,000 to $10,000 died in the House during this year’s legislative session after failing to advance through committee for a vote.
In the last two years, rural areas including Blount, Coosa, Cleburne and Barbour counties have lost their pediatricians, according to data from the American Board of Pediatrics. A total of 25 counties in Alabama, all in rural communities, do not have pediatric practices, up from 23 in 2022.
Many of the counties in the coverage gap are in the Black Belt region.
There are currently 696 pediatricians in the state — about 1,625 children for every pediatrician, according to the pediatric board data.
The data, which tracks the number of physicians certified by the board, is not perfect. “But overall, the trend is correct,” Ernest said.
Linda Lee, executive director of the Alabama chapter of the Academy of Pediatrics, said the data may have discrepancies because some of the doctors are registered by their home address instead of where they practice.
Ernest sees about 40 patients a day at her practice in Enterprise, a town of just under 30,000 people in the Wiregrass region. Many come from the surrounding areas where there are no pediatricians, including Andalusia, Opp and Slocomb.
“I say frequently to legislators or anyone who will listen, I cannot be the pediatrician for every child in the state of Alabama,” Ernest said.
Her practice has been able to stay afloat because she shares resources, like billing, human resources and coding services, across a network of pediatricians based in Dothan.
Otherwise it would be too expensive for one practice to take on all those costs alone.
Primary care physicians in Alabama have seen the cost of running their practice go up by as much as 35% since the pandemic, according to a recent survey done by the Alabama chapter of the American Academy of Pediatrics.
“And yet Alabama Medicaid is paying us the same for a well-child checkup that we were paid 20 years ago,” she said.
Doctors in rural areas predominantly see patients on Medicaid. And Ernest said the low rate of reimbursement “is just not sustainable.”
“There’s less money to run your practice,” she added.
Over 50% of children in Alabama — nearly 645,000 — are enrolled in Medicaid.
In rural areas, hospitals once helped smaller practices with shared resources, similar to the model that Ernest and her partners use. Since 2005, seven rural hospitals have closed in Alabama. A 2023 report warned that more than a dozen more rural hospitals in the state are at risk of closing.
“Hospitals were the anchor for these smaller practices and they are disappearing,” Ernest said.
Alabama is one of 10 states that have not expanded Medicaid for people with low incomes.
Officials with the Alabama Hospital Association have said that expanding Medicaid could boost the finances of rural hospitals and those that serve people with low incomes.
But even doctors in urban and suburban areas say they face some of the same issues as rural physicians.
“The same thing that’s driving pediatricians out of rural counties is also impacting pediatricians in more urban counties — and that is really horrendous Medicaid payments and really horrendous support from our Medicaid agency,” said Katrina Skinner, founder and CEO of Fairhope Pediatrics in Baldwin County.
Baldwin County is the seventh fastest growing metro region in the country, but the rate of pediatricians to children is comparatively low, with over 1,700 children for every doctor.
With rural practices closing, patients travel long distances for primary care visits. According to Skinner, patients travel up to two hours to her practice.
About 40% of Skinner’s patients are currently covered by Medicaid, but she said she’s “having a harder time continuing to accept Medicaid patients.”
Last year alone, Skinner said she paid upwards of $4,000 out of pocket for translation services for her Medicaid patients who do not speak English.
Alabama Medicaid is supposed to pay for translation services for patients who need it, Skinner said, but the agency’s local coordinated health network told her they haven’t had a translator service in years.
Skinner said the state Medicaid agency also doesn’t reimburse her for after hours calls.
“We’re obligated, by our contract with Medicaid, to provide 24-hour service for their recipients,” Skinner said. She uses a call service at Children’s of Alabama, which costs her about $15 a call.
“When you look at the rates of usage, Medicaid patients use a disproportionately higher percentage of those calls compared to commercial patients… and [Medicaid] is not paying us back for it,” she said. “So there’s a higher cost to provide care for these patients and it’s unsustainable.”
Even Ernest in Enterprise has had as many as 10 patients from 300 miles away in Madison County in the north of the state — all of them on Medicaid and unable to find a doctor near home who will take their insurance. She typically does telehealth appointments for those patients, but they have to make the four hour drive at least once a year for annual checkups.
“Madison is not an underserved community, but they have very few doctors that will take Medicaid because it doesn’t pay well and they can’t keep their businesses open if they take Medicaid,” Ernest said.” They can keep their business open on Blue Cross, Blue Shield, because almost everyone in the Huntsville-Madison Area has private insurance.”
Ernest has done work with the American Academy of Pediatrics and the Medical Association of the State of Alabama to attract more doctors into pediatrics, “and we’ve seen some improvement,” she said.
“But now we have to make sure those doctors can stay in business.”
