From revenue risk to resilience: A new financial model for rural physicians

Independent physicians in rural America are no strangers to adversity. An alarming 80% of rural America is medically underserved, and clinicians are feeling the pinch. In fact, between 2019 and 2024, the number of independent doctors in rural areas fell by 43%, and residents in rural areas had access to 11% fewer medical practices.

With many rural hospitals operating at a loss and at risk of closure, many small and medium-sized practices are now forced to shoulder a growing share of the patient care burden, without the financial infrastructure of larger systems. This financial strain is particularly acute in regions with older, diverse and low-income populations reliant on Medicare and Medicaid. Rural patients also have lower rates of employer-sponsored commercial insurance, resulting in higher out-of-pocket costs and greater financial pressure on physicians.


The proportion of U.S. adults classified as cost desperate, indicating an inability to afford necessary health care and medications, has reached a record high of 11%, with disparities emerging across demographic groups. Notably, Black and Hispanic adults, along with those from lower-income households, are disproportionately affected, exacerbating existing gaps in access to quality, affordable care.

The cost of traditional financial metrics

Historically, many health systems and private practices have used margin per patient as a benchmark of success. However, in rural care settings, that model can often fall short. Unlike urban, high-volume organizations that can prioritize profitable service lines, rural physicians must care for every patient who walks through the door, regardless of insurance status or income level.

When margins are thin and uncompensated care is on the rise, traditional financial models can push practices toward dangerous territory. Denying care isn’t an option, but delivering it without reimbursement isn’t sustainable. That disconnect isn’t just hurting the bottom line; it’s driving delayed care, skipped treatments and growing medical debt.

Medical debt is fueling the crisis

Unpaid medical bills are among the biggest threats to rural hospitals and their patients. Recent studies have found that a larger portion of adults in rural counties carry medical debt, higher than the national average and significantly higher than in urban areas. This debt doesn’t just sit on spreadsheets. It has real consequences: damaged credit, financial strain, skipped prescriptions and delayed treatment.

And it’s not just uninsured patients. High-deductible plans and rising out-of-pocket costs have made it harder for insured patients to manage their medical bills. In many cases, the bills they receive aren’t just unaffordable — they’re unpredictable.

This dynamic is especially harmful in rural areas, where many patients live on fixed incomes or don’t qualify for traditional credit. When affordability becomes a barrier to care, patients wait until it’s urgent. They often show up in the emergency room for a condition that could have been managed earlier and more affordably. These late-stage interventions cost more, strain the system and frequently go unpaid.

A shift in strategy: Financing with compassion

To survive, many forward-thinking rural physicians and other clinicians are adopting a different financial lens, one that prioritizes systemwide revenue margin and community economic health over per-patient profitability. One emerging solution is patient-first financing. Similar to retailers, this proactive approach introduces affordable payment options at the start, where the consumer, or in this case the patient, stands to gain 0% interest payment financing at the point of scheduling or care rather than months later when the bill arrives.

Instead of chasing payments after care is delivered or navigating an in-house system, physicians and their teams work with third-party partners to offer flexible payment plans based on a patient’s ability to pay. Providers are often paid within 48 hours of a procedure, even if the patient repays over time to the lender. That’s better not just for the books but for the patient. Studies show that when financing is discussed up front, patients are more likely to move forward with care and less likely to cancel or no-show due to cost. This approach also reduces the need to send unpaid balances to collections, protecting the patient-provider relationship.

Expanding the care model for long-term sustainability

Independent physicians are on the front lines of the rural health crisis and deserve financial models that reflect the realities they face, not just metrics designed for large, perfectly functioning systems. By rethinking success as “healthy patients, healthy practices,” small and rural practices can shift toward financial strategies supporting community well-being and long-term viability. This includes leveraging telehealth, expanding roles for advanced practice providers (APPs) and addressing critical gaps in physician availability.

Additionally, the American College of Physicians recently emphasized the need for policy makers to evaluate and implement investments to address rural health disparities and access challenges. Aligning clinical innovation with policy-level change can help ensure rural providers aren’t navigating this crisis alone. But as potential reimbursement cuts and regulatory rollbacks loom, health systems can’t afford to wait for policy change. They must focus on where they can take action internally, building financial resilience and expanding patient access through proactive care models.

Many practices are turning to advanced practice providers, including nurse practitioners and physician assistants, who can extend access and provide high-quality care, especially for routine or preventive services. At the same time, telehealth adoption, which surged during the pandemic, remains a powerful tool for maintaining access in hard-to-reach areas. However, broadband limitations, regulatory uncertainties and reimbursement inconsistencies still create barriers to broader use. Policy makers and health plans must continue supporting virtual care to ensure it remains viable for rural practices and their patients.

Patient-first financing is one of many steps toward that future, but it is a meaningful one. With the right tools, physicians do not have to choose between doing what is right for their patients and what is necessary for their practices.

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If doctors were trained in leadership, the entire health care system would benefit

If we can agree that leadership means influencing behavior to achieve a desired result, then it becomes obvious that all doctors are acting as leaders in many different health care environments.

But as I see it doctors aren’t formerly trained as leaders or even taught about the importance of leadership—i.e. Influencing behavior to achieve a desired result— in their daily work. Leadership training is not a standard part of medical school curricula.

This gives us an opportunity to change that paradigm. Medical education can absolutely prepare doctors for the challenges of being a leader—starting on the first day of medical school. Additionally, leadership development can be a cornerstone of each physician’s professional development throughout their career. In a future state where every physician is educated and trained in fundamental leadership skills, the entire health care system would reap the benefits—nurses, technicians, administrators, finance departments, HR professionals, and doctors themselves. But the chief beneficiary would be patients.

Leadership is a core competency – and should be taught as such

As a core competency for physicians, leadership is just as critical as clinical skills. Influencing thought and behavior is essential to achieving desired results in patient care. Leadership connects directly with the Accreditation Council for Graduate Medical Education’s (ACGME) six core competencies, encompassing all of them, either directly or indirectly​.

Therefore, we have an opportunity to teach leadership as a core competency for all physicians. Leadership involves a complex interplay of professionalism, communication skills (especially listening skills), cultural sensitivities, etc. And we are not necessarily born knowing these things. Fortunately, leadership is a learned skill. It can be improved through study of the theory and practice of leadership and through practical exercises and feedback.

We owe it to our medical students and residents to: 1)be explicit that they have a role as leaders in the healthcare environment, and 2) prepare them to lead in various environments as members of multidisciplinary teams under high levels of stress, including the responsibility for people’s lives and well-being.

But medical students and residents typically acquire leadership skills only in an ad hoc, inconsistent way. Students may gain some leadership experience through observation and even extracurricular activities, but this is largely unstructured and varies widely between institutions and individuals. The lack of intentional, cohesive, progressive leadership development leads to gaps in physicians' ability to lead effectively within health care systems.

Setting standards and getting oversight bodies on board

In visualizing how leadership should be taught in medical school, consider presenting it as foundational, much in the same way we teach physiology, pharmacology, or how to tie a surgical knot. I believe we should recognize that influencing thought and behavior to achieve desired results is a critical enabler of physician success numerous times each day, and we should build a foundation in how to accomplish that.

A physician who is a less effective leader is a less effective doctor. If you don’t start thinking about leadership until you’re 50, you’ve lost a huge opportunity to gain that mastery.

My personal vision is that we develop a set of standards for the leadership aspects of a physician’s training. Eventually, this set of standards would be adopted and refined by the oversight bodies that guide physicians’ careers, such as the Liaison Committee on Medical Education (LCME), the American Council on Graduate Medical Education (ACGME), and the American Board of Medical Specialties (ABMS).

These bodies have prescriptive authority. They can say to medical schools and training programs, “This is what you need to be teaching and practicing,” and can work with these entities over time to ensure that all doctors have a common training in a fundamental leadership skillset.

Standardization would benefit healthcare system leaders, as they would know that newly hired doctors possess a base level of leadership competency, much as they now know that all doctors possess a base level of clinical competency. Every physician will have been thinking about leadership, doing self-assessments, undergoing 360-degree assessments, and refining his or her leadership skills for years. The organization can then build on that base set of competencies to further develop the physician leader.

Advancing the leadership conversation

That is the vision. But we are a long way from seeing that as a reality. I have no illusions that such a change will happen overnight. The medical establishment changes slowly. Incorporating structured leadership training into every medical school and GME program can take decades.

Implementation should aim at codifying a set of base-level skills that can be generally agreed upon as a good leadership foundation for all doctors. In the meantime, let’s advance the conversation. Let’s start addressing leadership topics at conferences and symposia. Let’s get to work within our own organizations to develop in-house standards for physician leadership. Let’s start creating leadership curricula and sharing it with other institutions and organizations. Let’s start developing courses, implementing them, and measuring results. Let’s start assigning leadership coaches and mentors to doctors in our system.

Doctors should be trained in how to lead themselves, other individuals, and teams. Those who show interest and potential should be further trained in organizational leadership. Medical schools can lead the way in establishing the conviction in young physicians that they are leaders—that they have influence and impact every day—and igniting the desire to be trained as such. By linking leadership skills to the improved performance of health care teams and better patient outcomes, schools can change the current culture in which student doctors relegate “soft skills” to the back burner as they focus on clinical training.

Realistically, we can’t take hours of instruction away from core clinical courses. Nor would we want to. So, the trick is to find places in the curriculum where we’re already teaching “leadership-like” topics and to organize and revamp that material in a more cohesive and powerful way.

Once medical schools are doing this, residency training programs, physician practices, and healthcare systems can build from there. The leadership curriculum should never end. Everyone in medicine should ideally continue to seek and receive leadership training and feedback throughout their careers.

Doctors who know how to truly lead make a difference

Doctors are leaders, whether we recognize it or not. Our only real choice is whether to embrace our leadership role and commit to doing it to the very best of our ability. Or not.

Great physician leaders exude a presence. They bear themselves with confidence, but not cockiness. They look people in the eye. They listen to their patients, absorbing everything they’re saying—and not saying. They treat colleagues warmly and respectfully. They speak with directness but also with compassion and sensitivity. They welcome questions, invite feedback, and are always trying to improve. They address doubts and uncertainties. They strive for consensus.

That kind of leadership presence has a direct bearing on the way patients commit to treatment and the way colleagues rally together as a team. Don’t doubt for a second that it affects patient outcomes. It does.

If you are a physician, you should want to be the kind of leader who inspires people through your words, your actions, and your presence. And if you are in health care management, you should want to have a staff full of physicians who possess this kind of leadership ability.

My hope is that medical school deans, residency and fellowship program directors, health care administrators, and leaders of physicians’ societies feel inspired to work together and take up the cause of teaching better leadership skills to physicians. In doing this, we will enrich the future of medicine, create higher-performing health care teams, and improve patient outcomes.

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Two simple workflow tools cut physician message load by 16%

A new study from the University of Michigan shows that rethinking how patient portal messages are routed, and by whom, can significantly reduce the inbox load on primary care physicians, without additional tech or spending.

The study, published in the Journal of General Internal Medicine, tested a pair of workflow tools at a single academic internal medicine clinic. Compared with two control clinics, the intervention site saw a 16% reduction in monthly messages per full-time physician and a 65% drop in “carbon copy” messages that often flood physician inboxes.

The key change: assigning message responsibilities more clearly across the care team.

“We were able to significantly reduce the volume of messages by simply outlining roles and routing guidance for common issues,” said the study’s lead author and clinical assistant professor, Nicole Hadeed, M.D., in a university news release. “Focusing on getting the right message to the right place the first time was a simple and powerful intervention.”

A pandemic-era problem that never left

The volume of patient messages through electronic health record (EHR) portals surged during the COVID-19 pandemic — and has remained elevated ever since. That shift has increased administrative strain across primary care, where time spent managing inboxes is now a major source of burnout.

Researchers analyzed more than 340,000 messages across 31,000 patients over a one-year period. They found that a significant portion of message volume came not from patients but from internal routing inefficiencies, including duplicate messages sent to multiple staff or bounced among team members.

To address this, the clinic developed and implemented two simple tools:

• A set of “best practice standards” for managing and routing common messages.
• A “routing guide” clarifying which roles should handle what types of messages.

These tools were rolled out during meetings and huddles, and one staff member per week was temporarily assigned to manage the inbox on high-volume days.

Clearer roles and fewer clicks

Following the intervention, monthly messages per physician fell from 1,342 to 954. Messages sent directly to physicians dropped by 26%, and carbon copy messages declined from 4.4% of all messages to just 1.5%.

The percentage of portal message encounters involving physicians held steady, indicating the care team’s broader role in handling lower-acuity issues.

Survey data also pointed to improved team dynamics. Scores for clarity of expectations in portal messaging rose from 2.7 to 3.5 on a 6-point Likert scale. Staff reported that the routing guide, in particular, helped new team members get up to speed and made workflows more consistent.

“I like this document,” one medical assistant said in a post-intervention interview. “I feel like this document helps when you are orienting a new staff member to know the roles. It also says to you who gets what, where does this go.”

Staffing and sustainability challenges

The intervention did not come without complications, though. During the rollout period, the clinic faced a significant staffing shortage, which required physicians to take on more triage duties than anticipated. While the intervention still led to reduced message volume, the staff shortage may have skewed the degree of physician involvement.

“It’s pretty tough to route things to a team that is composed of one person who doesn’t have enough time to do their job,” one physician said.

Still, the study authors emphasized that the intervention’s success hinged not on added resources, but on clarifying how the existing team functions.

“While many clinician and staff reactions to the patient portal emphasize drowning under the brunt of clinical care happening over in-basket messages, it was evident that a significant proportion of messages are created by inefficient routing practices within the clinic itself, driven by a lack of transparency of each person’s role within the multidisciplinary team,” Hadeed said.

A model for inbox management?

The University of Michigan team believes their approach is both replicable and scalable. Unlike many tech-driven solutions, these tools require no EHR customization or new hires, just a clinic’s willingness to map its workflows and act on gaps.

The team plans to explore long-term sustainability next. While the initial intervention period lasted just four months, maintaining those gains as staff changes and workloads evolve will be key.

Ultimately, the authors suggest that other health systems take a similar approach to identifying local gaps in training and role clarification to enhance in-basket management, decrease volume and bolster well-being.

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