Editor’s Note: Colorado’s healthcare system is entering a period of accelerating instability — a “tsunami,” as multiple leaders describe it — driven by collapsing hospital finances, shrinking Medicaid reimbursements, disappearing services and a political fight over who is responsible for this unraveling. Healthcare Freefall is a multipart series examining how Colorado arrived at this moment, what H.R. 1 will do next and why communities across the state are bracing for deeper shocks.

Dr. Beth Longenecker still vividly recalls her childhood holidays growing up in rural Pennsylvania.

Be it Thanksgiving, Christmas or the Fourth of July, Longenecker could always bank on someone arriving at her family’s doorstep in Limeport, Penn. 

More often than not, those visitors would be locals from the area with no family ties — other than the fact that they were often in need of seeing her father, who happened to be the only doctor in the then-rural community of 2,000.

“There wasn’t a holiday that went by that someone wasn’t knocking on our door,” Longenecker said. “He would always see them and treat them. I understand what rural communities are like, and also the challenges of attracting a physician in those communities.”

Longenecker is now far removed from rural Pennsylvania, but she hasn’t lost her rural bearings.

She lives in Greeley and serves as dean of the University of Northern Colorado’s College of Osteopathic Medicine, which opened in July with its first class of 81 students as the state’s third medical school.

The University of Colorado Anschutz School of Medicine and Rocky Vista University College of Osteopathic Medicine house the state’s two other medical schools. 

Like many other states, Colorado needs more physicians, particularly in rural areas east of Denver, where ratios are as high as 5,635 residents per primary care provider.

The U.S. Health Resources and Services Administration noted that only 35% of Colorado’s physician needs are being met. 

The Cicero Institute — a Texas-based think tank — highlighted that 54 of Colorado’s 64 counties have professional shortage areas in primary care, and that 31.2% of Colorado physicians are in the retirement range. 

Equally alarming is that by 2030, nearly 40% of American physicians will reach retirement age.

Creating a pipeline

Longenecker said UNC’s medical school will help address the shortage. After the initial class of 81 students arrived on campus in July, medical school class sizes in subsequent years will range from 150 to 162. 

As UNC’s cohorts grow, Longenecker is optimistic that more students will be open to practicing in rural areas.

“There’s a real need here in Colorado for more physicians, particularly in rural areas,” Longenecker said. “I reached out my first year here (2022) and started talking to rural hospitals, and I toured the whole eastern part of the state. Their biggest concern is how to grow a pipeline because it can be hard to recruit to those areas.”

Dr. Kelli Glaser, too, has high hopes of addressing worries and emerging trends as UNC’s chair of primary care in the medical school. 

She said a major selling point of coming to UNC from Rocky Vista University in Parker was that the school could help address the need for more physicians in Colorado’s rural communities.

“There’s a constant turnover of physicians in a lot of these rural communities,” Glaser said. “I knew that with the positioning of UNC in Greeley, it would probably more directly meet the need and recruit students who came from areas nearby, especially the rural areas, and that they might be more likely to return to those rural areas to practice. I wanted to help foster that taking place.” 

One of the ways Glaser is trying to develop a pipeline is by reaching out to the youth in rural communities early. 

She said one of the first things she did at UNC, with some colleagues in the medical school, was volunteer at career health fairs organized by school districts. 

“A lot of medical schools talk about creating a rural pipeline, but that doesn’t happen overnight,” she said. “It really might be a 12-plus year process. You really have to start targeting students who live in rural areas when they are young. You try to inspire them as early as elementary school. It is like planting an early seed and showing them a little bit about it to get them excited. Then you help inspire them again in middle school and high school.”

Another way UNC hopes to prioritize rural healthcare is by admitting applicants from rural areas in and outside of Colorado. 

Longenecker and Glaser both believe that if a student comes from a rural area, they are far more likely to return to practice medicine there. 

Longenecker added that the class composite of UNC’s first medical school cohort includes 8% of students from rural areas and that she would like to see 10%, if not more, in the years to come.  

She also noted that UNC already has an affiliation agreement in place for 500 rural rotations. The rotation breakdown is as follows:

• Family medicine: 190
• Internal medicine: 100
• Medical specialists: 44
• General Surgery: 64
• OB-GYN: 53
• Emergency medicine: 50 

Breaking barriers

Nick Arvanitis is, in many ways, the kind of student UNC’s College of Osteopathic Medicine hopes to attract.

He will join UNC’s inaugural medical school class.

Arvanitis lives in Fort Collins now, but he grew up in Currituck County, a rural stretch of northeastern North Carolina with just over 28,000 residents. He said the county had no Walmart, no McDonald’s — and only two physicians.

He was the first in his family to go to college, a decision shaped largely by a traumatic event. His grandfather was shot in the head while working at a convenience store. He survived but had to be airlifted to the nearest trauma center in Norfolk, Va., over two hours away.

“I didn’t come from a successful family,” Arvanitis said. “My grandfather getting shot was a big reason why I went to college. I just wanted to get out from where I had grown up.”

Arvanitis doesn’t expect to return to rural North Carolina to practice, but he said he understands the barriers rural communities face in accessing care.

“I think one of the areas that UNC has a real opportunity to shine is in putting a light on rural access,” he said. “Healthcare is just a small part of what these people deal with all day, every day. They often have limited access to food, water and clothing. It is all part of a much bigger issue which needs attention.”

‘An uphill battle’

Zachary D’Argonne is well aware of what Arvanitis is referring to directly and indirectly. 

As the president and chief executive officer of the Eastern Plains Healthcare Consortium, D’Argonne often serves as the voice at the legislative table for the 15-member hospitals in the EPHC. 

“I split my time between the Eastern Plains, visiting our hospitals and meeting with our hospital board of directors,” D’Argonne said. “I also spend a fair amount of time on Capitol Hill in Denver, meeting with legislators and working with large healthcare systems in metropolitan areas to make sure that they’re aligned with our goals.”

D’Argonne said that rural hospitals and clinics face built-in challenges that larger metropolitan hospitals or areas typically don’t face.

“One of the top three bullet points of imminent risk of rural healthcare is just the lack of the provider pipeline,” he said. “I’m painting with a broad brush here, but we commonly see providers that are either brand new to the field, but they don’t necessarily have ties to rural medicine. We’re grateful to have them, but once their loans are paid off, they often move on.”

D’Argonne, Longenecker and others said that some rural areas are considering incentive packages to attract healthcare providers, but that, ultimately, the best-case scenario would be to create a pipeline. 

The hope is that UNC can deliver more and more doctors to rural areas who want to serve those communities for the long term. 

“We’ve been working with UNC for the past 18 months,” D’Argonne said. “We know the best way for us to actually recruit somebody is if they grew up in the community or have a rural interest.”

D’Argonne said there is significant uncertainty facing rural healthcare and hospitals.     

He is not sure that some legislators and larger healthcare systems have rural providers or residents in mind when writing healthcare policy. He even recalled a doctor at a conference saying that one day rural healthcare should be provided by AI avatars.

“To me, that was such an indictment of understanding that rural healthcare is not lesser healthcare and the people that live in rural communities are not lesser,” D’Argonne said. “What happens when that baby comes on the side of the road, or when you’re having a heart attack or a brain bleed and you’re snowed in?” 

“Our hospitals were never going to be elite neurosurgery centers or orthopedic trauma centers, but by golly, you’re going to really be happy when you need us,” the health executive added.

For her part, Longenecker knows all too well the importance of rural healthcare providers growing up in rural Pennsylvania and in her present role as the dean of the University of Northern Colorado’s College of Osteopathic Medicine — even on the holidays.

“We know there is a need and a shortage, and a lot of these communities are facing an uphill battle,” Longenecker said. “We’re in the process of trying to develop a rural residency track program, which we hope will attract more physicians to rural communities.”