Protect, grow or cover differently — getting ahead of physician vacancies in rural settings

Most rural health care administrators can see the next physician departure coming. Few start recruiting in time to replace that physician.

A full 64% of rural administrators expect at least one physician to retire or substantially reduce hours within five years, according to "Rural Healthcare Specialty Priorities," a report by Jackson Physician Search, LocumTenens.com and the Medical Group Management Association (MGMA). Yet only 12% of administrators' most consequential physician vacancies were anticipated more than a year ahead, and 57% were anticipated less than six months before they occurred or not at all.

The three organizations released the report during MGMA's 2026 Annual Conference this fall. It is drawn from responses by 59 administrators and 168 clinicians with rural experience, surveyed online in August 2026.

At the conference, Helen Falkner, president of Jackson Physician Search, and Pamela Ograbisz, DNP, FNP-BC, FAANP, vice president of clinical operations at LocumTenens.com and LT Telehealth, discussed the findings with MGMA Senior Editor Chris Harrop in the session "Build, Borrow, or Bridge: Choosing the Right Coverage Model for Rural Specialties."

The report organizes rural staffing decisions into three actions:

• Protect existing physician capacity before it becomes a vacancy.
• Grow capacity.
• Cover vacancies differently through locum tenens, care teams, telehealth, visiting specialists or partnerships.

Why do administrators wait?

Falkner said the warning signs are often visible, from physicians' ages to call burden to "prevalence of an unhappy spouse."

"They don't start recruiting until they have a resignation letter in hand, and succession conversations get delayed," she said. "I believe it's because no one wants to look like they're pushing anybody out the door."

Physician contracts compound the problem, she said. Out clauses often run 90 to 180 days, while rural recruiting takes much longer, both to sign a candidate and to get that physician to the bedside.

Succession planning is uneven. Among administrators answering the question, 26% had a formal plan for all or most expected departures and 15% had a formal plan for some. One-third had only informal plans.

Starting earlier gives an organization access to residents and fellows, who often make decisions 12 to 24 months out, and time for a three- to six-month overlap that allows a warm handoff, Falkner said.

"But the real cost is the empty seat," Falkner said. "It is going to be the lost professional fees, the referrals, and the downstream volume, and that doesn't even account for the locums spend."

What does a vacancy cost?

Most organizations don't know. Only 25% of administrators had formally estimated the financial effect of their most consequential vacancy, and 43% made no estimate. Administrators rated their interim coverage highly for patient access (52% good or excellent) but not for finances. Only 19% rated it that well on sustainability beyond 12 months.

The report includes a worksheet for pricing a vacancy, which combines direct revenue, downstream revenue, interim coverage costs and recruiting costs into a monthly estimate. It also cites American College of Surgeons estimates that a rural surgeon can contribute $1.05 million to $2.7 million a year to a small hospital.

In an interview with Physicians Practice after the session, Ograbisz said practices that use locum tenens clinicians can enroll them with their payers, so the work they do is billed rather than treated as a cost the practice can't recover.

Why do similar searches end differently?

Falkner described two family medicine searches in Nebraska that came in about four months apart with similar scope, compensation, bed count and communities. In the first, the hospital CEO called a candidate within 48 hours, and the hospital brought the physician and his family on site on the physician's timeline. That search was filled in just under seven months.

In the second, the CEO and medical director failed to move on candidates in the pipeline. That search, she said, was still open.

Another mistake is to stop recruiting once a promising candidate appears, she said.

"That administrator put all their eggs in one physician's basket, abandons the pipeline, and then it turns out that that provider takes another job, and you're back to square one after six months of recruiting," Falkner said.

Administrators should also be clear about why they are recruiting. Falkner described an Oklahoma hospital that sought a third family physician with obstetrics. The search looked like growth, but deliveries had been flat at about 90 a year, and the real goal was to cut call from one in two to one in three.

"Recruiting into a practice where the volume is flat or shrinking is fundamentally a different recruitment than recruiting into a practice where there is true volume growth," she said. "It's very important to be honest and address the gap upfront."

What can administrators control?

The average time to fill a physician position is seven months, Falkner said, and it can be much longer in rural settings. Time to the bedside is often 12 to 24 months. She pointed to three levers administrators can control: urgency, flexibility and engagement.

"Flexibility means accepting 70% of your ideal candidate profile as a strong outcome," she said.

Engagement should be strong enough that a physician's site visit confirms what the candidate already knows, she said. That includes the physician's family. "We all know if you can recruit a spouse, you can recruit the physician," Falkner said.

When a permanent search stalls, the position itself may need to change. She described an ob-gyn search in Montana that was open for three years. After physicians said they would work shifts but not relocate, the hospital redesigned the role to have three ob-gyns share one full-time position at 10 shifts a month each. It now has two of the three and has kept its labor and delivery unit open.

How should locum tenens fit in?

Respondents rated locum tenens the strongest short-term option: 47% of specialty assessments called it viable for up to 12 months. Yet when vacancies opened, administrators most often relied on physician-plus-advanced practice provider (APP) models (21%) and internal cross-coverage (18%). Locums were fourth at 12%, and 16% of administrators said no interim approach was used.

Ograbisz said the difference often comes down to whether an organization plans ahead. "Are you a reactive organization or are you a proactive organization?" she said.

She urged administrators to stop treating contract clinicians as a last resort.

"I think that there needs to be a new understanding of the fact that 1099 providers ... need to be an actual primary solution and need to be factored in as part of your staffing plan," she said.

How locums are introduced matters to the clinicians already there, she said.

"Being on the medical staff side, I can tell you that when someone just shows up and no one told me they were coming, I feel very differently rather than when we had a staff meeting," Ograbisz said.

How can administrators spot a departure early?

Ograbisz listed behavioral red flags, including:

• Rising callouts among physicians and APPs
• Declining participation in things like grand rounds and committee meetings
• Lower productivity and patient satisfaction scores
• Growing peer conflict

"If your callouts are going up, something's going wrong," she said. "When people ... stop showing up for things, they're checking out, and a decrease in engagement is always significant."

She recommended what she calls "transparent chats" in which physicians feel safe saying how they really feel. For practices already down a physician, Falkner said, recruiters must be specific about panel size, ramp-up and a realistic call schedule, because physicians who hear vague answers "read that as a red flag." Nearly one in four administrators (23%) said their open vacancy made it harder to recruit anyone else.

Falkner said leaders who keep a finger on the pulse can plan from a position of strength.

"In today's market, you have to be the administrator that says, we saw it coming," she said. "Not the administrator who says, hey, we didn't see that coming and we were totally caught off guard."