As America’s population ages at an unprecedented pace, the demand for geriatric care is surging. By 2030, one in five Americans will be 65 or older. Yet even as the healthcare system scrambles to meet the needs of this demographic shift, one specialty remains chronically under-recognized and under-resourced: Geriatric Medicine. The problem becomes even more pronounced when we zoom in on rural America, where the pay gap between rural and urban geriatricians mirrors a deeper divide in healthcare equity, workforce distribution, and systemic priorities.
This blog explores the rural vs. urban pay gap for geriatricians, the critical shortage of specialists in underserved areas, and why it’s time for policymakers, hospital systems, and payers to elevate the role of geriatricians in our healthcare infrastructure — especially outside the metro bubble.
The Invisible Backbone of Aging America
Geriatricians are medical doctors who specialize in caring for older adults, particularly those with complex, chronic conditions, cognitive decline, polypharmacy challenges, and functional limitations. Unlike other specialties, geriatrics takes a holistic approach that values quality of life, patient goals, and interprofessional care planning.
But despite its importance:
- Geriatrics is one of the lowest-paid medical specialties.
- Only ~7,500 certified geriatricians are practicing in the U.S. — far below what’s needed.
- Many counties — especially rural ones — have zero access to a board-certified geriatrician.
Pay Disparities: Rural vs. Urban
Unlike surgical or procedural specialties that flourish in high-income metro areas, geriatric care is overwhelmingly funded through Medicare, a program with rigid fee schedules and little room for negotiation.
Urban Areas:
Urban-based geriatricians may benefit from:
- Academic hospital affiliations.
- Higher volume of Medicare Advantage plans with bonus incentives.
- Greater access to interdisciplinary teams and resources.
- Opportunities for teaching, research, or administrative roles.
Average salary in metro areas: $220,000–$250,000 (varies by region and experience).
Rural Areas:
In contrast, rural geriatricians often face:
- Isolation and lack of specialist support.
- Higher patient loads with more social complexity.
- Greater travel demands, especially with home visits or SNF care.
- Fewer institutional supports or care management teams.
Yet surprisingly, rural pay for geriatricians is not significantly higher, and in some cases may be lower — especially if bonuses and call pay are limited. Average salary: $200,000–$230,000, with many seeing no geographic bonus despite higher need.
Why the Gap Exists
- Medicare-Dominated Reimbursement
- Unlike plastic surgery or cardiology, geriatrics is not procedure-heavy.
- The majority of revenue comes from Evaluation & Management (E/M) codes.
- Rural providers often rely solely on Medicare, while urban centers may diversify with private payers, concierge models, or grants.
- Undervaluation of Cognitive Care
- CMS reimbursement models continue to favor volume and procedures over cognitive, longitudinal care — precisely what geriatrics excels in.
- This biases the system against time-intensive, relationship-driven care.
- Lack of Institutional Support in Rural Areas
- Many rural hospitals can’t support a full-time geriatric program.
- Geriatricians may be absorbed into internal medicine departments with no distinction in pay.
- Burnout and Professional Isolation
- In rural settings, geriatricians often manage everything from end-of-life care to dementia to elder abuse risk — with little peer support.
- Without adequate compensation or support, many leave for better urban opportunities.
The Workforce Crisis in Rural Geriatrics
The data is grim:
- Over 50% of U.S. counties don’t have a single practicing geriatrician.
- The National Center for Health Workforce Analysis estimates a need for 33,000 geriatricians by 2025. We’re nowhere near that number.
- Rural counties — particularly in the Midwest, Appalachia, and the South — are aging faster than urban counterparts.
This means rural elders are more likely to:
- Be seen by providers unfamiliar with geriatric syndromes.
- Be overmedicated or misdiagnosed.
- Lack access to advance care planning or home health coordination.
Why Prioritizing Geriatricians in Rural America Matters
- Demographic Reality
- Rural populations are older, sicker, and poorer.
- Without trained geriatricians, rural elders face greater risks of hospitalization, institutionalization, and premature death.
- Value-Based Care Needs Geriatrics
- Geriatricians help reduce hospital admissions, improve medication management, and align care with patient goals — all key metrics in value-based models.
- Yet they are not being properly incentivized to work where they are most needed.
- Community Anchors
- In rural communities, geriatricians often serve as more than physicians — they are advocates, educators, and liaisons to social services.
- Investing in them pays dividends far beyond the clinic walls.
- Equity and Justice
- Health equity demands we stop ignoring rural elders and the clinicians who care for them.
- A pay gap sends a clear message: this work is less valued. That must change.
What Can Be Done?
1. Federal Incentives and Loan Forgiveness
- Expand NHSC and similar programs to include geriatricians, not just primary care.
- Offer rural geriatric bonuses similar to rural OB/GYN or psychiatry incentives.
2. Medicare Reimbursement Reform
- Advocate for higher rates for cognitive, longitudinal care.
- Expand CPT codes that reflect the true complexity of geriatric care.
- Reward care coordination, home visits, and polypharmacy management.
3. State and Hospital-Level Incentives
- Offer relocation bonuses, housing stipends, and CME funding for rural geriatricians.
- Create hybrid roles that combine clinical care, teaching, and telehealth outreach to reduce burnout.
4. Raise Awareness
- Geriatrics needs a rebrand: it’s not “just primary care for old people.”
- It’s a complex, vital specialty that improves quality of life and system sustainability.
Final Thoughts: Time to Close the Gap
Rural geriatricians are unsung heroes holding together fraying safety nets across the country. Yet they’re often paid less, supported less, and valued less than their urban or procedural peers. As a nation, we must shift how we view — and pay — those who care for our most vulnerable.
The rural vs. urban pay gap is not just a number. It’s a reflection of our healthcare system’s priorities. And right now, those priorities need to change.
Coming Soon: A breakdown of how much revenue geriatricians actually save the healthcare system — and why investing in them is a win for patients, payers, and policy.