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For Darlene Nelson, going to the doctor is an all-day affair.

Nelson’s drive from Moab to Price and back is close to two hours each way, and touches three counties. The appointment itself takes about an hour.

“It’s a day trip, always,” Nelson said. “When you live in a rural area, you just kind of get used to that.”

Utah’s rural counties generally have fewer than one medical doctor per 1,000 people, and some have none at all.

Those numbers improve some when you add osteopathic doctors, physician assistants and advanced-level nurses, but nearly all of Utah’s rural counties have a dearth of health care providers.

That makes people less likely to go to the doctor for routine care, said Brady Bradford, health officer for the Southeast Utah Health Department.

“We end up with people not as ready and able to visit a doctor for a physical, a checkup to get symptoms when it’s early,” Bradford said.

By the time they get to a doctor, they’re dealing with emergencies and later stages of diseases, he said.

Danielle Pendergrass, who started Eastern Utah Women’s Health in Price a little more than a decade ago, said there was a high rate of breast cancer among her patients because women weren’t getting mammograms.

Pendergrass — a board-certified, doctorate-prepared women’s health nurse practitioner originally from Carbon County — also saw a “huge gap in contraceptive care” along with undiagnosed diabetes, high blood pressure, smoking and substance use disorder.

The problem isn’t unique to Utah, said Marc Watterson, or even to rural areas. Watterson, who directs the state’s Office of Primary Care and Rural Health, said there’s a nationwide shortage of physicians.

All but five of Utah’s 29 counties have a geographic shortage of primary care physicians for at least part of the county, according to the U.S. Health Resources and Services Administration.

Bradford stressed the doctors who practice in rural Utah are “dealing with a huge array of issues and they do a really good job of it.”

But a lack of health care access does lead to worse outcomes, he said.

Utah has several different grants and programs that work together to attract more providers to rural areas and the state as a whole, Watterson said, and they’re helping in rural communities.

Utah averages 3 providers per 1,000 residents

In 2021, the number of doctors and advanced nurses per 1,000 people ranged from none in Piute County to 8.8 in Summit County, and averaged three providers for 1,000 residents, based on data from the U.S. Health Resources and Services Administration.

For Nelson and others, that means driving hours to see even a primary care physician.

Pendergrass has patients who drive about 2½ hours to see her.

Gina Gagon, who helped her husband run his medical practice in Price for more than two decades, said they have people who drive from Roosevelt, Vernal, St. George and Mesquite, Nev.

Many of those patients lived in the area when they established care with Gagon Family Medicine, Gagon said — and kept coming after they moved elsewhere. (The practice also runs a clinic in Huntington, in neighboring Emery County.)

Because of that long drive, said Shlisa Hughes, people often don’t get medical care. Hughes, who lives in Green River and works for the Association for Utah Community Health, said that’s even true for her.

“It’s hard to take an extra day to go drive,” she said.

From her home, it’s a three-hour trip to get a mammogram — an hour to the nearest facility that can do one, an hour for the appointment, and an hour home.

Green River Medical Center is the only medical facility near Hughes’s home, and she said the next closest is more than 60 miles away.

Emery County, in which Green River is located, had seven physicians and mid-level providers combined in 2021, according to federal data.

That’s 0.7 providers per 1,000 people, the lowest rate other than Piute County, which has no providers.

Emery County is one of 18 Utah counties below the state average of three providers per 1,000 residents. Most of the counties below that average are rural, though some have smaller cities and two — Iron and Wasatch — are considered metropolitan because they have at least one city of 50,000 people or more.

Only two rural counties have more providers per 1,000 residents than the state average.

Even when a county has providers, it can take time to get an appointment.

Nelson said even if you’re sick, it can take six weeks to get an appointment — and you “rarely” see your provider unless you’ve scheduled it in advance.

Pendergrass, whom Nelson has now seen for more than a decade, is an exception to that.

Nelson said the Price doctor will go “out of her way” to accommodate and has gotten her in the next day when needed.

Gagon said the family’s clinic has done things to help with long wait times, including hiring a second physician. Currently, there’s a three-week wait time to establish care with a physician, she said, but someone can get in the same day with a nurse practitioner.

“We’ve tried to be proactive for our specific practice,” she said, adding that being in private practice lets them be more nimble than clinics that are part of a health care system.

Nearly half of counties had no specialist in 2021

While providers are rare, specialists are rarer.

Eleven Utah counties had no specialists in 2021, based on federal data, and the most any county had was 1.6 specialists per 1,000 people.

Only two counties — Salt Lake and Summit — had more than one specialist per 1,000 residents in 2021.

Nelson said seeing a specialist has always been a bigger challenge.

When she was diagnosed with breast cancer, it took weeks, she said, because she had to wait two weeks for someone to read a mammogram, then another week for the biopsy, and a week for someone to read the biopsy. Five or six weeks passed between her mammogram and her diagnosis, she said, but that was just the process.

General providers have expertise, Gagon said, but it caps out. Once patients need to see a specialist like a neurologist or a urologist, she said, it could take six months.

‘Really hard to recruit’ to rural Utah

Increasing the number of providers in rural Utah isn’t easy.

“It is really hard to recruit physicians to rural areas,” Gagon said. The second physician that Gagon Family Medicine hired rotated with the practice as a medical student, she said.

Utah is doing things to help, Watterson said, such as using state and federal funds for various grants and programs.

A lot of the funding goes to loan repayment, he said, which helps rural hospitals and clinics recruit because providers can get help paying off their student loans for each year they live and work in rural areas.

Hospitals sometimes provide matching funds, Watterson said, and “everybody has skin in the game” to try to bring more medical providers into rural areas.

The state also works with the U.S. State Department through a visa program that allows people who weren’t born in the United States but did train here to continue working in the country, he said.

Those people with J-1 visa waivers typically are specialists, Watterson said, and the state works with those visa applicants to fill in gaps in coverage.

Another grant helps cover costs as providers care for underinsured and uninsured patients, he said, specifically to cover the gap between those payments and what private insurance would reimburse them.

It’s sometimes harder for rural hospitals and clinics to keep things together financially because they see so many patients who are on Medicaid or Medicare or who are uninsured, he said, and that helps offset some costs.

Watterson compared the state programs to a band. “You’ve got different instruments that are playing. There are some that maybe they’re featured at different times so you can really tell that they’re playing,” he said. “If one or two is missing, it just doesn’t sound quite right.”

Telehealth — the ability for patients to see providers virtually — can help, Watterson said, but it only solves part of the problem because there’s a “finite amount of providers.”

There’s a lot of stress on getting more people to choose medicine as a profession, he said, and state lawmakers have given more money to graduate programs in medical education and removed potential barriers to getting a license.

Physicians need policies to support rural health

Pendergrass said she would also like to see policies to address transportation, fair compensation for telehealth, broadband access and affordable health insurance.

Transportation is a big issue, Gagon said, because there isn’t any public transit in rural Utah. Some patients will call an ambulance and go to the emergency room, she said, because that’s their only way to get to a provider.

Policy needs to support efforts physicians are making in rural areas, Pendergrass said, such as utilizing telehealth and nurses to fill gaps.

“I can live this unicorns-and-rainbows dream, but if we don’t have policy to support that, it’s more difficult,” she said.

Bradford, the health officer for the Southeast Utah Health Department, said his agency tries to head off the effects of the shortage differently — by stressing preventive care. The department covers Emery, Carbon and Grand counties, which rank in the bottom half of Utah’s counties for health outcomes.

“We feel on our end that it’s that much more important that we are impactful on a public health side, on a prevention side,” he said.

The department, Bradford said, stresses healthy behaviors such as eating right, eating with family, getting outside and exercising, as well as getting to the doctor for checkups.

The department feels those efforts help “reduce the burden that’s placed upon our acute health care system,” he said, and improve health outcomes.

There are risks to living in rural Utah, Bradford said, including less access to health care — but there are also “tremendous benefits.”

No one in rural Utah hangs their heads about health outcomes, he said. Instead, they band together to work for a better solution.

Megan Banta is The Salt Lake Tribune’s data enterprise reporter, a philanthropically supported position. The Tribune retains control over all editorial decisions.