Rural Health - The Foundation of the

CommunityPam Danner, MBA

Director, Rural Health

F. Marie Hall Institute for Rural and Community Health

Complex Health Issues Providing access to care for the large and

growing number of uninsured persons Caring for the aging population Aligning financial incentives for payers,

providers and patients Integrating population-based services with

personal care services

These problems are made worse in rural areas: Geographic isolation/Transportation barriers Growing minority populations with increased

health risks Populations that are generally older and less

affluent Shortages of financial, human and capital

resources High poverty rates Lower educational levels Lack of healthcare specialists

Objectives Assess how geographic isolation, low

population density and other “rural” factors contribute to and exacerbate already complex health problems

Understand problems related to supply and demand of health personnel in rural areas

What is Rural? It’s not urban…for real For our purposes, a county is designated

as rural if it’s population is less than 50,000

The Rural “Picture of Health” Rural Americans:

are less likely to have employer-provided insurance tend to get less preventive care and medical treatment

than urban people exercise and play sports less die from accidents at higher rates are more likely to die after breast cancer diagnosis are more likely to have lost all their teeth by age 64 are more likely to have untreated dental decay are less likely to have fluoridated water supply

According to the Center for Disease Control

Rural health issues cont. on average, income is $7,417 lower than in

urban areas 40% of rural 12th graders reported using alcohol

vs. 25% of urban counterparts up to 90% of rural first responders are volunteer have higher mortality rates

40% higher for children and teens than in urban areas

Federal Interagency Forum on Child and Family Stats

Barriers to Health in Rural Areas

Transportation Seeking help when you’re not anonymous Language Educational level Resources

Facilities Hospitals Community Health Centers

Comprehensive healthcare Primary patient population - underserved

Rural Health Clinics Non urbanized area MUA or HPSA

Rural Hospitals: Some of the Issues Uninsured/underinsured Physician recruitment Medicaid/CHIP funding Medicaid Managed Care CHIP Eligibility Tort Reform Worker’s Compensation Physician Self Referral Workforce

Critical Access Designation Rural public, non-profit or for-profit hospital Located more than 35 miles from any other

hospital Makes available 24-hour emergency care

services Provides not more than 15 beds for acute

care Annual average length of stay < 96 hrs.

Uninsured/Underinsured Improved access to equitable and high

quality healthcare Expand essential services to the vulnerable

uninsured

Texas has the highest rate of uninsured people in the nation. 24.6% in 2005

Physician Recruitment Allow rural hospitals to offer employment

contracts Exempt small hospitals from Corporate

Practice Act

Medicaid/CHIP funding Preservation of access to services for low-

income Texans Oppose any further reduction in

reimbursement to rural providers

Tort Reform Continuation of liability reform measures

passed in 2003 Currently total liability for non-economic

damages (pain and suffering) cannot exceed $750,000

Worker’s Compensation Allow rural hospitals to “opt-out” and

strengthen healthcare networks

Only large employers are allowed to self-insure

Self-Referral Limit the practice of self-referral and do

away with duplication of services in rural areas

Workforce Nursing shortage and other skilled

professionals

Why don’t they choose Rural? Professional isolation Stigma, “rural is for underachievers” Seeing patients around town..”never off” Community leader

Provider Shortages

Ratio of Primary

Care Doctors

Ratio of PAs

Ratio of NPs

Ratio of Pharmacists

Ratio of RNs

Ratio of

LVNs

U.S.,

2000

69 14.4 33.7 71.2 780.2 240.8

Texas, 2005

68.5 14.7 17.7 73.7 628.6 269

West Texas,

2005

41.7 16 13.4 50.9 364.5 424

Ratio of providers per 100,000 population. Source: HRSA Bureau of Health Professions and Texas Department of State Health Services

What did that table mean? West Texas has far fewer health care

professionals than the state and national averages, except for PAs and LVNs.

PAs – about par with the state and national average. Many communities are using these mid-level providers as physician extenders

For LVNs, which is the lower level of nursing licensure, West Texas has almost double the number of the state and nation.

Perceptions/Reality of Rural Practice and Living Lower reimbursement and higher overhead Longer hours Lack of relief coverage Lower quality education for children Limited cultural activities Limited availability of quality housing

Historical approaches/ short-term fixes

National Health Services Corp

J-1 visa programs

Loan forgiveness

Community collaborations

Bonuses

Problem with these “fixes” These programs don’t foster long-term

relationships between participants and communities

Participants in these programs “do their time” and leave, creating a rotating cycle of need in the community

What can be done? Recruitment and Retention Programs Pipeline Programs

West Texas AHEC Patient Care Programs

Mobile Clinics Rural Health Clinics/Community Health Centers

Health Education Programs Department of State Health Services West Texas AHEC

Telemedicine

Hypothesis

People from rural communities are most likely to pursue a health care

career in a rural community.

People from West Texas are most likely to pursue a health care

career in West Texas.

Rural Health Support and Education Initiative

Implement a longitudinal, comprehensive program to Support practitioners in rural West Texas Expand the educational pipeline to supply new

practitioners Focus research on improving rural health Area Health Education Centers to provide

infrastructure for regional outreach

Spring 2007: Dental Outreach event in Hereford, Texas. Almost 900 rural residents from surrounding communities received free dental care.

Telemedicine TTUHSC started utilizing telemedicine in 1990 Primarily used in correctional settings Also used to increase access to health care for rural

communities Primary care (Hart School Based Clinic) Specialty care (Childress Oncology and El Paso Burn

Follow-up) Supportive services (Turkey, Earth, and

Plains/Brownfield telepharmacy)

Earth, TX

Turkey, TX

Patients from Turkey and Earth that see a doctor from Plainview via telemedicine, and then receive pharmacy services via telemedicine from the TTUHSC Pharmacy in Lubbock.

Nelson Pharmacy in Brownfield has partnered with Yoakum County Hospital (Denver City) to use telemedicine for providing pharmacy services to residents of Plains, Texas.

Telemedicine is used to provide follow-up care to burn patients in the El Paso and Eastern New Mexico areas so that they don’t have to travel 600+ miles roundtrip to be seen by the burn specialist and care team.

Hart, Texas is a community of 1,200 people that has no local health care professionals except for the school nurse. The school has developed a school-based health clinic, where students can be seen by a doctor through a weekly visit or through telemedicine. The clinic also has a Class D Pharmacy, dental services (visiting dentist) and nutritional services.

Telemedicine as a tool Telemedicine can enhance access, but

challenges Equipment and connectivity costs have decreased

but still a challenge for some communities Reimbursement for providers is improving but still

limited Referral patterns and private insurance issues for

network versus non-network Licensure issues HIPAA compliance and patient privacy

Questions?