DOCUMENT RE3UME
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TITLE Health Care in Rural America. INSTITUTION Congress of the U.S., Washington, D.C. Office of Technology Assessment. REPORT NO OTA-H-434 PUB DATE 90 NOTE 573p.; Some mall type may not reproduce well. AVAILABLE FROMSuperintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325 (Stock No. 052-003-01205-7, $22.00). PUB TYPE Reports - Evaluative/Feasibility (142) -- Statistical Data (110)
EDRS PRICE MF02/PC23 Plus Postage. DESCRIPTORS Community Health Services; Federal Legislation, *Federal Programs; Federal Regulation; Health Facilities; Health Personnels *Health Programs; *Health Services; *Medical Care Evaluation; Program Evaluations *Public Policy; *Rural Areas; Rural Population IDENTIFIERS Health Delivery Systems
ABSTRACT Haalth needs and health serv.ces in runal America are key issilas directly related to education as well as community well-being. This report examines rural America's access to basic health care services and discusses options for congressional consideration. The focus is on trends in availability of primary and acute rural healtn care and on factors affecting those trends. The report describes the characteristics of rural populations and health programs, the availability of rural health services and personnel, and delivery of rural maternal and infant health and mental health care services. Oa each subject, options for congressional action are examined. The federal government currently finances several different types of rural health care programs, and has a strong Interest in health care trends. Major declines in inpatient utilization, compounded by increasing amounts of uncompensated care, have undermined the financial health of many rural hospitals, which also are faced with tne outmigration of rural residents to urban areas for care. Policy reform option3 are presented in regard to: (1) improvement of rural health facilities: (2) availability and training of health professionals in rural areas; and (3) enhancing maternal and infant care programs and mental health care programs in rural areas. This document contains numerous charts, graphics, data tables, and appendices that present background in'ormation about the study. It also Includes a 745-item bibliography and a subject index. (Trs)
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CONGRESS OF THE UNITED STATES OFFICE OF TECHNOLOGY ASSESSMENT
2 _ 0,
Office of Technology Assessment
Congressional Board of the 101st Congress
EDWARD M. KENNEDY.Massachusetts. Chairman
CLARENCE E. MILLER.Ohio, Vice Chairman
Senste House
ERNEST F. HOLLINGS MORRIS K. UDALL South Carolina Arizona
CLAIBORNE PELL GEORGE E. BROWN, JR. Rhode island California
TED STEVENS JOHN D. OINGELL Alaska Michigan
ORRIN G. HATCH DON SUNDQUIST Utah Tennessee
CHARLES E. GRASS_EY AMO HOUGHTON Iowa NewYork
JOHN H. GIBBONS (Nonvoting)
Advisory Council
CHASE N. PETERSON.Chairman MICHEL T. HALBOUTY SALLY RIDE University of Utah Michel T. Haibouty Energy Co. California Space instituto
JOSHUA LEDERBERG.Vice Chairman NEIL E. HARL JOSEPH E. ROSS Rockefeller University IowaState University Congressional Research Service
CHARLES A. BOWSHER JAMES C. HUNT JOHN F.M. SIMS General Accounting Office University of Tennessee Usibeiii Coal Mine, inc.
LEWIS BRANSCOMB HENRY KOFFLER MARINA v.N. WHITMAN Harvard University University of Arizona General Motors CIO,
Director
JOHN N. GIBBONS
The Technology Assussment Board approves the release of this report.Theviews expressed In this report are not necessarily those of the Board, OTA Advisory Council, or individual members thereof.
ABOUT THE COVER: Population density map of the Unites States (one dot equals 1,000 people). Black areas represent areas of relatively low population density.
3 Health Care in Rural America
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CONGRESS OF THE UNITED STATES OFFICE OF TECHNOLOGY ASSESSMENT i 4 Recommended Citation: U.S. Congress, Office of Technology Assessment, rlealth Care in Rural America, OTA-H-434 (Weshington, DC: U.S. Government Printing Office, September 1990).
For sale by the Smerintendent of Documents U.S. Government Printing tai'fice, Washington, DC 20402-9325 (order form can be found in the back of this report)
5 il Foreword
Federal policies to advance the Nation . aeahh have often included provisions to mitigate the special problems in delivering health care in rural areas. Recently, however, these pclicies have received renewed scrutmy in the face of reported increases in rural hospital closures, ongoing problems in recruiting and retaining health personnel, and difficulty in providing medical technologies commonly available in urban areas. Mounting concerns related to rural residents' access to health care prompted the Senate Rural Health Caucus '....) request that OTA conduct an assessment of these and related issues. This report, Health Care in Rural Amerka, is the fmal product of that assessment. (Two other OTA papers, Rural Emergency Medkal Services and Defining "Rural" Areas. Impact on Health Care Poky and Research. have previously been published in connection with this assessment.) An advisory panel, chaired by Dr. James Bernstein of the North Carolina Office of Rural Health and Resource Development, provided guidance and assistance during the assessment. Also, three public meetings were held (in Scottsdale, Arizona, Bismarck. North Dakota, and Meridian, Mississippi) to provide OTA with the opportunity to discuss wlecific rural health topics with local and regional health practitioners, administrators, and officials. Site visits to local facilities were conducted in association with these activities. A number of individuals from both government and the private sector provided information and rev iewed drafts of the report. OTA gratefully acknowledges the contribution of each of thesc individuals. As with all OTA reports, the content of the assessment is the sole responsibility of OTA and does not necessarily constitute the consensus or endorsttment of the adv isory panel ot the Technology Assessment Board. Key staff responsible for the assessment were Elaine Power, Lawrence Miike, Maria Hewitt, Tim Henderson, Leah Wolfe, Mal C. Zimmerman, and Rita Hughes.
JOI-21 H. GIBBONS Director
ill Rural Health Care Advisory Panel
James Bernstein, Chairman Director, Office of Rural Health and Resource Development North Carolina Department of Human Resources
Robert Berg land T. Carter Melton, Jr. Executive Vice President and General Manager President National Rural Electric Cooperative Association Rockingham Memorial Hospital Washington, D.C. Harrisonburg, Virginia James Coleman Jeffrey Merrill Executive Director Vice President West Alabama Health Services, Inc. Robert Wood Johnson Foundation Princeton, New Jersey Sam Cordes Professor & Head Myrna Pickard Department of Agricultural Economics Dean University of Wyoming School of Nursing University of TexasArlington Elizabeth Dichter Senior Vice President for Corporate Strategies Carolyn Roberts Lutheran Health Systems President Denver, Colorado Copley Health Systems, Inc. Monisville, Vermont Mary Ellis Director Roger Rosenblatt Iowa Department of Public Health Professor & Vice Chairman Department of Family Medicine Kevin Fickenscher University of Washington Assistant Dean & Executive Director Center for Medical Studies Peter Sybinsky Michigan State University Deputy Director for Planning, Legislation, and Kalamazoo, Michigan Operations Hawaii Department of Health Roland Gardner President Fred Tinning Beaufort-Jasper (South Carolina) Comprehensive President Health Center Kirksville College of Osteopathic Medicine Kirksville, Missouri Robert Graham Executive Vice President Robert Vraciu American Academy of Family Physicians Vice President Kansas City, Missouri Marketing & Planning Health Trust, Inc. Alice Hersh Nashville, Tennessee Executive Director Foundation for Health Services Research Robert Walker Washington, D.C. Chairman Department of Family and Cc..ununity Health David Kindig Director Marshall University School of Medicine Huntington, West Virginia Programs in Health Management University of WisconsinMadison
NOTE' OTA appreciates and is grateful for the oaluabi.t assistance and thoughtful i.ritiques provided by the advismy panel members. The panel does not. however. necessarily approve. disapprove. or endorse this report OTA assumes full responschilny for the rePaa and the accuracy of its contents. iv 7 OTA Project StaffHealth Care in Rural America
Roger C. Herdman, Assistant Director, OTA Health and Life Sciences Division
Clyde J. Behney, Health Program Menager
Project Sterc' Elaine J. Power, P, Lawrence H. Miike, Projt
Tim Henderson, Analyst MariaHewitt, Analyst Leah Wolfe, Rese'h Analyst
Marc Zimmennan, Analyst3 Rita A. Hughes, Research Assistant4 Sharon Hamilton, Research Assistant5 Katherine Eddy Cox, Research Assistant°
Administrative Staff Virginia Cwalina, Office Administrator Carol A. Guntow, P.C. Specialist Carolyn D. Martin, Word Processor Specialist Eileen Murphy, P.C. Specialist
Contractors Jonathan Chin, Catonsville. MD Monty Dube, McDermott, Will, and Emery Tom Ricketts, University of North Carolina David Sheridan and Linda Kravitz, Chevy Chase, MD Don Stamper, Univeristy of MissouriColumbia Hospitals and Clinics Harvey Wolfe and Larry Shuman, Monroeville, PA National Rural Health Association
Iltrom May 1989. 24.1ntil May 1989. 3tIntil August 1989. 4Prom June 1989. *tom June 1990. 61Jnt0 June 1989.
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Contents
Page Part 1: Summary Chapter 1. Summary and Options 5 Part 11: An Overview of Rural Populations and Health Programs Chapter 2. Rural Populations 35 Chapter 3. Federal Prograr-is Affecting Rural Health Services 61 Chapter 4. The State Role in Rural Health 87 Part 111: Availability of Rural Health Services Chapter 5. Problems and Trends in Rural Health Services 111 Chapter 6. Short- and Long-Term Strategies for Effective Change by Rural Providers 157 Chapter 7. Regulatory and Legal Concerns foi Rural Health Facilities 181 Chapter 8. Collaborative Opportunities Between Rural Health Facilities and Government 197 Chapter 9. Conclusions: Availability of Rural Health Services 211 Part IV: Availability of Rural Health Personnel Chapter 10. The Supply of Health P,xsonnel in Rural Areas 219 Chapter 11. Identifying Underserved Populations 287 Chapter 12. Problems in the Recruitment and Retention of Rural Health Personnel 315 Chapter 13. Strategies To Recruit and Retain Rural Health Professionals 335 Chapter 14. Conclusions: The Availability of Health Personnel in Rural Areas 371 Part V: Two Examples of Specific Services Chapter 15. Maternal and Infant Health Services in Rural Areas 379 Chapter 16. Rural Mental Health Care 417
Appendixes Page Appendix A. Method of Study 437 Appendix B. Acknowledgments 439 Appendix C. Definitions of Hospitals in OTA Analyses of 1987 American Hospital Association Survey Data 442 Appendix D. Background Material for Two OTA Surveys 443 Appendix E. Rural Health Care Projects Funded by the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation 462 Appendix F. Census and DHHS Regions 465 Appendix G. Field Workshops 467 Appendix H. Summary of OTA Special Report on Rural Emergency Medical Services 475 Appendix I. Organizational Charts: U.S. Department of Health and Human Services and Health Resources and Services Administration 476 Appendix J. Glossary of Terms 478
References 487 Index 517
vi Glossary of Abbreviatiwis
AAFP American Academy of Family Physicians FTE full-time equivalent AANP American Academy of Nurse Practitioners FY Fedeial fiscal year AAPA American Academy of Physician Assistants GAO 0-Aietal Accounting Office (LI S Congreso ACNM American College of Nurse-Midwives G/FP general/family practitioner ACOG -i-American College of Obstetricians and GME graduate medicai education Gynecologists GMENAC Graduate Medical Education National AMNIA Alcohol, Drug Abuse, and Mental Health Advisoty Committee Administration (PHS) GP general practitioner ADMS Alcohol, Drug Abuse, and Mental Health GPCI Geographic Practice Cost Index Services Block Gram HCFA HealthCareFinancingAdministra.ion (DRIB) AFDC Aid to Families with Dependent Children HHI Herfindahl-Hirschman Index ABA American Hospital Association HMO health maintenance organization AlICPR Agency for Health Care Policy and HMSA --Health Manpower Shortage Area Research (PHS) HPOL HMSA Placement Opportunity List AHEC area health education center HRSA Health Resources and Services AHP allied health professional Administration (PHS) AMA American Medical Association BUD U.S. Department of Housing and Urban AOA American Optometric Association Development ASC ambulatory surgety center IMU Index of Medical Underservice BHCDA Bureau of Health Care Delivety and IOM Institute of Medicine Assistance (EISA, PHS) MS Internal Revenue Service BHPr Bureau of Health Professions (HRSA, PHS) JCA.140Joint Commission on the Accreditation of BLS Bureau of Labor Statistics (Department of Healthcare Organizations Labor) LHD local health department CCEC Community Clinic/Emergency Center LP/VN licensed practical/vocational nurse CDC Centers for Disease Control (PHS) MAF Medical Assistance Facility CFR Code of Federal Regulations MD medical doctor CHC community health center MHC migrant health center C-1114SA Cnucal Health Manpower Shonage Area MHREF-Montana Hospital Research and Education CLT clinical laboratoty technician/technologist Foundation CMHC community mental health center MHS muldhospital system C/MHC community/migrant health center MI, midlevel practitioner CNM certified nurse-midwife MPCA Michigan Primary Care Association COBRA Consolidated Omnibus Budget MR1 magnetic resonance imaging Reconciliation Act of 1985 MSA metropolitan statistical area COGME Council on thaduate Medical Education MUA Medically Underserved Area CON cenificate of need MUA/P Medically Underserved Area/Population CRNA --certified registered nurse anesthetist MUP Medically Underserved Population CT computed tomography NGA National Governors' Association DEFRA Deficit Reduction Act of 1984 NHSC National Healtn Service Corps (BHCDA, DHEW Department of Health, Education, and HRSA, PHS) Welfare (now DHHS) NIMH National Institute of Mental Health DHHS Department of Health and Human Services (ADAMHA, PHS) DO doctor of osteopathy NLM National Library of Medicine DRGs diagnosis-related groups NP nurse practitioner EACH Essential Access Communay Hospital NRHA National Rural Health Association ECH Emergency Care Hospkal OB/GYN obstetrician/gynecologist EMT emergency medical technician OBRA Omnibus Budget Reconciliation Act EPSDTEarly and Periodic Screening, Diagnosis. OMB U.S. Office of Management and Budget and Treatment (Medicaid) ORB office of rural health (State-level) ESWL --extracorporeal shock wave hthotripsy ORHP Office of Rural Health Policy (HRSA, PHS) FMG foreign medical graduate OT occupational therapist FmHA Farmers Home Administration (USDA) OTA Office of Technology Assessment (1.i S FNP family nurse practitioner Congress) FP family practitioner PA physician assistant PR Federal Register PCCA primary care cooperative agreement ETC Federal Trade Commission PHHS Preventive Health and Health Services Block Federal Ibri Claims Act Grant FrcA vii I (I PHS Public Health Service (DHHS) RRC rival referral center (Medicare-catified) PPA private practice assignment RT respiratory therapist PPO private practice option SCH Sole Community Hospital (Medicare- PPRC Physician Payment Review Commission certified) PPS prospective payment system (Medicare) SDMIX South Dakota Medical Information Ex- PRO peer review organization change ProPAC Prospective Payment Assessment Com- SIDS sudden infant death syndrome mission SNP skilled nursing facility PT physical therapist SOBRA Sixth Omnibus Budget Reconciliation RBRVS resource-based relative value scale (Med- Act of 1986 icare) SSI Supplemental Security Income RHC rural health clinic (Medicare/Medicaid- U.S.C. United States Cede certified) USDA United States Department of Agricul- RN registered nurse ture RPCH Rural Primaxy Care Hospital NAMI Washington, Alaska, Montana, and Idaho
1 1
OP Part I Summary
1 2 g,...,..i.,..iiiim..
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Chapter 1 Summary and Options
7 3 CONTENTS Page INTRODUCHON AND SCOPE 5 PROBLEMS AND CONSIDERATIONS IN RURAL HEALTH CARE 5 The Health and Health Care Access of Rural Residents 5 The Availability of Rural Health Care 7 The Federal Role in Rural Health 8 RURAL HEALTH SERVICES: ISSUES AND OPTIONS 10 Issues 10 Options for Convessional Action 13 RURAL HEALTH PERSONNEL: ISSUES AND OPTIONS 17 Issues 17 Options for Congressional Action 20 TWO SPECIFIC SERVICES 25 Issues and Options in Maternal and Infant Care 25 Issues and Options in Mental Health Care 27
Box Bcx Page 1-A. Federal Programs To Enhance Rural Health Resources 9
Figures Figure Page 1-1. U.S. Rural and Rural Farm Population, Selected Years, 1920-88 6 1-2. Trends in Hospital Utilization by Metropolitan and Nonmetropolitan Residents, Selected Years, 1964-88 7 1-3. Distribution of Community Hospitals in Metropolitan and Nonmetropolitan Areas, 1987 12
Tables Table Page 1-1. Characteristics of Metropolitan and Nonmetropolitan Community Hospitals, 1984-88 11 i-2. Physician-to-Population Ratios (MDs only) by County Type and Population, 1979 and 1988 18 1-3. Availability of Primary Care Physicians by County Type and Population, 198s 18
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Chapter 1 Summary and Options
INTRODUCTION AND SCOPE measures to overcome the special access problems of underserved areas and populations. Thus, the This report is about access of people in rural report does not discuss in depth either health America to basic health care service&. insurance coverage or health care fmancing. Instead, The 1980s witnessed rural economic decline and it considers these factors in terms of their influence instability, major changes in Federal health pro- on the availability and financial viability of providers. grams, and increasing concern about the long. term Two other important kse.; are also beyond the viability of the rural health care system. This scope of this report. First, the importance of rural concern prompted the Senate Rural Health Caucus health cite providers as sources of employment and and the Ranking Minority Member of the Senate mcome is not addressed here, although it is a vital Committee on I..abor and Human Resources to issue in many rural communities. Second, this report requer that OTA assess the availability of health does nen examine the quality ,.of rural health care in service., in rural communities, the problems rural any detail, although itis cleor that the quality provideis face, and the remedial stratebies that might implications of rural health interventions deserve be influenced by Federal policy.' scrutiny. But such ari examination would have to proceed with care. By necessity, an evaluation of the This report focuses on trends in the availability of quality of a service irov bled in rural areas must be primary and acute health care in rural areas and measured agamst tie implications of hav ing no factors affecting those trends.2 The rest of this locally available service at all. chapter summarizes OTA's findings and conclu- sions on rural health care availability and presents PROBLEMS AND options for congressional consideration. Many of these options bear some similarity to proposals by CONSIDERATIONS IN RURAL others to improve rural health care services, al- IlEALTII CARE though the details may differ considerably. The remainder of the report examines in detail the issues The Health and Health Care Access faced by rural facilities providing health services of Rural Residents and by physicians and other mai health personnel During this -entury, the rural population has To provide examples of how these issues may play become an increasingly smaller proportion of the out, it also discusses in more depth two specific total U.S. population (figure 14). As of 1988, about groups of services, maternal and infant health 23 percent of the 11.5. population lived in nonmetro- service . and mental health services. politan (nonmetro) counties (631). About 2 / percent Although the affordability of health care is an of the US. k.opulation lives in "rural" areas as defined by the Census Bureau (places of 2,500 or important factor in access to care by rural residents, fewer residents) (632), ane slightly more than 15 rbe fundamental issue of uninsured populations and icompensated care is beyond the scope of this percent of the population is rural by both defini- tions.3 Throughout tz,s report, "rural" refers to report, since it encompasses the urban as well as the nonmetro areas unless otherwise stated. rural health care system and has broad ramifications. Moreover, even if it were possible to enable all Rural residents are characterized by relatively patients to adequately compensate providers, policy - low mortality but rek,tively high rates of chronic makers would still fmd Jecessary to consider disease. After accowiting for expected differences
'Toro other renorts prepared in connecuon with this assessment have already been published Defining "Rural" Areas int*, ,iit Health Care pawl and Research (released July M9). and Rural Emergency Medical Services (released November 1980) nix report does not exam issues relating to the Indian Health Sexvice (1HS) or health-care t.xess for Native Americans who .eceive their care from the MIS. Previously published OTA reports examined these issues in detail (6161524 35ec the related OTA staff paper for a detailed discussion of the implications of different definitions of "rural" and the applications of these definitions (255). 5 I: 1 5 66Health Care in Rural America
Figure 1.1U.S. Rural and Rural Farm Population, Selected Years, 192048
141111ona to 2212 24 250 222
200 g
1980 1970 1980 1986 1987 1988 War
Oa Urban Et.3 Rat al non-farm Farm
?Based on the Census Suresats definition crf the nsral population. Wherural population figuresfrom 1950 on reflect detimbonalchanges, liad the previous definition been used. the 1950 rural popularion would have been 60,948.000, or 40 percent of the total U.S. population. SOURCE:Office of Technology Auessment, 1990. Data hum U.S. Dope:Ma:tot Commerce, Bureau& the Consus, jointly with the U.S. Departmentof Agriculture. "Rural and Rural Farm Popula- tion' 198S," Current Population Reports, Series P-20, No. 439 (Washtnglon, DC:U.S.Government Printing Mee. September 1989). due to age_ race. and sex distributions between urban and rural reas, mortality rates in rural areas axe4 pement lower thanin urban areas (626). Two notable exceptions exist: in rural areas, infant mortality is Photo awe Peter Beeson slightly higher (10.8 v. 10.4 per 1,000 infants), and injury-related mortality is dramatically higher (0.6 v. Farming communities were espedally hardbit by 0.4 per 1,000 residents). Chronic illness and disabil- economic slowdowns dunng the early 1980. s ity, on the other hand, affect a greater proportion of Economic barriers present many rural residents the tura' than the urban population (14 v. 12 percent) from receiving adequate health care and often (651).4 There is little overall difference between outweigh strictly physical barrien. Rural residents urban and rural residents in rates of acute illness. have lower average incomes and higher poverty rates than do urban residentb, and one out of e ery Rural populations are unique in the extent ot six rural families lived inpovertyin 1987 (629). physical barriers thcy may encounter when obtain- While some rural areas have prospered(e.g.,areas ing health care. Even in relatively well-populated that have become retirement havens), areas whose rural areas, the lack of a public transportation system economies are based on fa-ming and mining suffered and the existence of few local providers to choose real decreases in per capita income during the first from can make it difficult for many rural residents to half of the 1980s (106). Still other rural areas have reach facilities where they can receive care. And been pockets of poverty for decades. These areas of persons living in tow-density 'frontier- counties counties of six o- fewer persons per square mile persistent poverty are heavily concentrated in the South, where 25 million of the Nation's 57 million can have geographic access problems of immense rural residents live, and where 4 out of every 10 rural proportions. In these counties, predominantly lo- residents are poor, elderly, or both (633). cated in the West, there is insufficient population density in many areas to adequately support local Rural residents are much ttire likely than urban health services. residents to have no health insurance coverage (18.2
4These firms are age.adjukted end therefore cannot be captained by a greater proponion of 4-Maly residents in rural areas
1 6 Chapter 1Summary and Options 7
Figure 1-2Trends in Hospital Utilization by Metropolitan and Nonmetropolitan Residents, Selected Years, 1964-88
Hosfshal 41schaffros
e S4 12 10 -
4 NOM et.0 2 0 Mello 1984 1975 1980 , 1985 1987 198b
Nonmetro 11 3 13 8 I14 1I 117 1 10 9 11 4 I metro roeI, DI ic 9 8 7 Year (wo woo por wort
Averts* lamp of hoostal slay Tolal hospitalimmutertr di)*
taonmatro JLJLJgalv0m0 A JA.4)/=44. Moira 1964 1976 ETI luBs 1987 1988 121EIEMEMEI [tfoomotio 7.7 88 7 5 68 &WO L4 78 39 7 2 71 6 9 El650EH Idol) tew 100 peowsuara
NOTE. Numbers are adjusted for age 0.e., account for diterences in eve distributions between met(o and nonmetto areas) These data are based o n interviews and thus Include only patients who wore dscharged alive. SOURCE: Office ol TechnologyAssessment. 1990. Data from U.S. Department of Health and Huma,, Services, Centers for Disease COn1113( , NationalCenler for Health Stainer:is, Hoe" United Slates, 0982, 1988, and 1989 (Washington, DC. U & Government Prinbng Office, March 1983, March 1988. and March 1989). v.14.5 m 1986) (651).3 Among persons with inpatient utilizatior, by both urban and rural resi- incomes below the Federal poverty level, rural dents has declined (figure 1-2). Rural residents, residents are less likely than urban residents to be however, still report more admissions and shorter covered by Medicaid (35.5 v. 44.4 percent in 1987) hospital stays than do urban residents (651),6 (530). The Availability of Rural Health Care Health care utilization trends in rural areas have Rural health care availability in 1990 is better in paralleled those in urban areas. Iva time, people in many ways than that of 20 year- ago After years of both areas have increased the number of physician hospital construction, the rati,-, of community hospi- visits per person, although rural physician utilization tal beds to population is now about the same in rural remains below that for urban residents. Hospital as in urban areas (4.0 and 4.1 per 1,000 rvidents,
5tachatICSooly penoasunderatie 65. 'Information on average length Of hospital stay tALOSr is evadable both&umIn4pliat repoms oxhide patients discharged deadi and front patent inteiviews. Untilvery.moldy, both ALOS iniwal hospitals and A LOS reported by nind residents were towel than for dim urban counterpub Since 1987, rural hospitals haveactually reported shghtly higher ALOS thanurbanhospilals,4though rural few:lents swirevel lower AI OS on interview date. 7 .., Health Care in Rural America
Rural are is are finding it increasingly difficult to recruit and retain the variety of qualified health personnel they need. In some isolated and "unattrac- tive" areas, an absolute lack of providers may become a chronic situation. The number of areas designated by the Federal Government as primary care Health Manpower Shortage Areas (HMSAs) has not changed significantly since 1979. And in 1988, 111 counties in the United States, with a total .--1.--.-...... W..--- population of 325.100, had no phystcians at all _ (665; Half a million rural residents th e in counties to with no physician trained to provide obstetric care; , 49 million live in counties with no psychiatrist. States overwhelmingly rate health personnel short- Photo credd: Peter Beeson ages as a top problem area and a top focus of State Not all rural hospitals that have closed in recent years have rural health acuvities (627). been small Memorial General Hospital, a 256-bed facility in Elkins, West Virginia. dosed in the mid-1980s No single strategy is appropriate to all rural areas or all health care providers. Rural North respectively, in 1986). Federally funded community Dakota is not the same as rural Mississippi. Rural and migrant health centers (C/MHCs) provide subsi- health problems and issues vary dramatically by dized care to poor residents through nearly 800 region State, and locality. The success of strategies service sites in rural communities. Physician supply to address these problems will also vary, and some has been increasing for many years in both nwal and strategies that are vital to a few communities may urban areas; one out of every 440 people in the offer little to others. Furthermore, even in a single United States is now a physician? State or locality, multip8e approaches are more likely than single strategies to obtain results. Nonetheless, the future prospect for rural :iealth care in tue absence of intervention is grim. Rif al The Federal Government cannot fixall rural America cannot support its present complement ol health problems. It cannot force community t..ousen- hospitals, and the hospitals are going broke. By sus, or create new structures duectly adapted to local needs, or r -ercome all State-lev el b,uriers to change. 1987, rural hospitals as a group had higher expenses But ii can create an environment that facilitates these than patient care revenues, and small rural hospaals had higher expenses than revenues from all sources. activities, it can furnish t'e informition States and communities need to knou...fore undertaking them, Hospitals faced with continuing financial difficul- ties and no alternative forms of survived will and it can be the catalyst for great unprov ements in the rural health care system. continue to close, including some facihties that are the only reasonable source of care in their communi- ties. Rather than drawing local patients back to local The Federal Role in Rural Heald: care, many small community facilnies will contmue to lose wealthier patients to more distant urban The States are heai.ily dependent on the Federal hospitals and clinics. Local facilities will be left to Government for assistance m maintaining and en- contend with low occupancy rates and a high hancing rural health care resources; nearly one-half proportion of patients who cannot pay the full costs (44 percent) of their resources for rural health of their care. A lack of incentives and models for activities (e.g., personnel recruitment) come from developing appropriate networks of care may result Federal sources (4527). Federal health insurence in an increasingly fragmented health service deliv- programs such as Medicare are a large addinonal ery system. Federal investment in rural health care. -- ^ 71-bus number is calculated from tabte 1-2, winch Includes only NibsThe nun, uould he even gre4ter r1 Jut kas +1 ostenp.ohy uere 111(.104
1 8 ChapterISummory and Options 9
The bulk of the Federal role in rural health is carried out through four different types of pro- Box I-AFederal Programs To Enhance grams.8 First are health care financing programs Rural Health Resources most notably, Medicare and Medicaidwhich pay Federal rural health resource programs include: directly for health care services. Both programs the National Health Service Corps.which (in differentiate in a number of ways between rural and addition to having some commissioned mem- urban providers and payment to those providers. bers) provides placement services, scholar- Both programs also include special exemptions to ships, ard educational loan repayment for general payment rules for certain rural facilities and physicians and certain other health professionais services (e.g., physician services provided in certain willing to serve in certain designated 1LMSAs, HMSAs). programs that provide grants to schools edu- cating and training primary care providers Second is the health block grant, under which the (e.g., family practnioners, physician assis- Federal Government allocates funds to States to tants, and nurses); spend on any of a variety of programs in a general the Federal Area Health EducationCenters topic area. Three major block grants influence rural program, which links medical centers w lib health servi.-.-es: the Maternal and Child Health block rural practice snes to provide educatiowl grant; the Preventive Health and Health Services services and rural clinical experiences to block grant; and the Alcohol, Drug Abuse, and students, faculty, and practitioners in a variety Mental Health block rant. of health professions; the Community and Migrant Health Centers Third are F.:deral 1..._,;:arris for which enhancing grant programs, whkh Ire the Federal Gov- rural health resources is an explicit goal. Bex 1-A ernment's most prominent ativities to promote presents some major programs in this category. primary health care facilities in rural aieas, Primary Care Cooperative Agreements. A fourth critical Federal activityisthat of through which the Federal Government assists coordinating, undertaking, and funding research on States that are assessing needs for pnmary rural health topics. Major Federal agencies invohed health case and developing plans and informa- in this activity are the Office of Rural Health Policy tion to address those needs, and (ORHP) and the Agency for Health Care Policy and the Rural Health CareTransition Grant pro- Research. gram, established in 1988, which provides grains to small rural hospitals for strategic A major challenge in designing Federal rural planning md service enhancement. health policies is to identify those areas where residents' access to basic health care is sufficiently endangered to justify special protective measures. lems, and in still other areas health prov iders face Endangered areas those with chronic shortages of financial crises because they are losing their most health personnel, for examplerequire special at- lucra6ve patients to urban hospitals and physicians. tention and ongoing subsidies of providers in order liirural areasAurar ttkaland thrum problems to ensure a basic level of adequate health care to area of endangered access, Fedetal politlesale more residents. Although the present HMSA and Medi- appropriately oriented toKards measures to en- cally Underserved Area (MUA) design..a_ns have hance the (,apabilittes of pi ()Wen, encout age their shortcomings,the basic concept of designating adaptation to changes in the health careenviron- areas of personnel shortage and areas of poor ment, andensui e consistent and fatr payment health is sound. Extending this concept to encom- policies.Appropriate measures may include techni- pass rural hospitals and other facilities would :al assistant; e, occasional and temporary financial enable more appropriate targeting of Federal health a.v.:stance, targeted financial incentives, and indirect funds to needy rural areas. supports. Many rural areas are prospering and have suffi- A secondary problem for Federal ruLd health cient health resources, although these resources may policies has been how to idcnhfy areas that require not always be available or provided in an efficient special protection, whik accommodating the ue- manner. Others have temporary health care prol, mendous diversity in rulid health issues and [nob-
85ome otherPederal program also may play a :ognificant tok In promoting the health of rdrat mboluiis « 8 the Women. Intc ms. and 4..hilaten too(' distsibotion program of the Depattmatt of Agncultute). but Mose mogriatas ice not detailed here - I !-) 10 11.ra1th Care in Rural America
Photo mote: Gad Mooney
Eightbed Comtrey Hospital. Minnesota $ smallest hospital. includes an operating room, oulpabent clinic. and 24-hour emergency room.
lems in different areas of the country. Effa.mc and as remammg inpatient care became increasingly targeting of Federa; resuart.esu.)rur arta:: sophisticated. Both rural and urban hospitals wit- requires the intohement of the Sores. State ins oh e- nessed substantial declines in inpatient utilization ment mcludes notonlyenhsting tie assistance of (table 1-1). Changes in rural hospitals, however, State and local agencies m identify mg critical arel, were especially dramatic. Rural hospital occupancy but enabling State.) and localit..s to adopt and adapt .ates° in 1988 were only 56 percent, compared with programs tailored to their own needs. Nearly one- oser 68 percent for urban t..omrnunIty hospitals (35). half of States-21 of 44 States espondmg to an With lower inpatient adnassions, rural hospitals OTA surveyalready rely on their own designation has e become mere dependent on outpatient and cnteria instead of (or in addition to) Federal criteria lung-terri care revenue. By 1987, nearly one-half for identifying undersersed areas. (46 percent) of rural hospital surgery was performed on outpatients. One-fourth of rural hospitals have The enormous diversity across States in rural long-term care units, and in these hospitals long- health problems suggests that it is also appropriate term care beds make up nearly one-half of the total to maintain a strong State role m designing and beds (625). implementing solutions. But State capabilities to carout this role successfully vary considerably. These major declines in mpuent Federal coordination, technical assistance, and in- compounded by mcreasmg amo..ents of uncom- formation are crucial to States and communities pensated care, have undermined the financial health trying to address their rural health needs. of many rural hospitals From 1984 to 1987, the RURAL HEALTH SERVICES: amount of uncompensated care delivered by rural hospitals increased by over 26 percent. to an average ISSUES AND OPTIONS of more than $500,000 per hospital by ;987 (30). Nonpatient sources of revenuesin many cases, tax Issues subsidieshave become increasingly important to The 1980s brought niajrclianges to the Nation's hospitals' fmanual viabeity. By 1987, nearly all rural community hospitals. as medical practices. rural luispitals had higher costs than patient care technologies. and payment systems all acted to rev enues, the smallest hospitah had oasts higher replace inpatient procedures with outpatient t.are 0. tn revenues from all wurces (625).
Mese occupancy rates arc based on total hospital be& including long-Ictra ore beds
2(1 Chapter I-Summary and Options s I I
Table 1.1-Characteristics of Metropolitan and Nonrneiropolitan CornfliuMtyHospitals, 198448
Yeat Percent change Characteristic 1984 1985 1986 1987 1988 1984-88a illembor of hospitals Metro 3,063 3,058 3,040 3,012 2,984 -2.6% Nonmatro 2,698 2,874 2,638 2,599 2,549 -5.5
Average maims of beds/buspltal Metro 256 252 248 246 246 -3.9 Howlett* 85 86 85 8; 83 -3.5
Total weber of beds Metro 734,311 7/1,807 754,953 741.391 734,073 -6 4 Nonmetro 232.746 228.871 223.422 216.921 212.624 -8 6
Total admissions (million4) Metro 27.7 26.6 26.0 25.6 25 6 -7 7 Nonmatro 7.5 6.8 6.4 6.0 5.9 -21.0
Occupancy rate (percent) Metro 71.5 67.5 67.0 67 7 68.4 -4 3 Nonmetro 60.7 56.0 55 1 55.3 55.7 -8 2
Averagelength of hospital stay (days) Metro 7.4 7 1 7.1 7 2 7 2 -2.7 Nmunetro 6.9 6.8 7.1 7 3 7 4 7.2
Total weber of Inpatient days (millions) Metro 205.0 189.9 184 5 183 3 183 6 -10.4 Nonmetro 51.7 46.7 44 g 43 8 43 3 -16 1
Total outpatieet visits (millions) Metro 173.1 178.9 189.0 198.5 217.3 25.5 Nonmetro 38.8 39 8 42.9 47.0 51.8 33.5
Total enexgencyvisits (millions) Metro 57.3 58.4 59.9 61 2 63 6 10 9 Nommotro 15,7 16 1 16 7 17 1 17.7 12 8
Outpatient surgeries as a proportion of total urgeries Metro 28.1 34 5 39 9 43 4 46 2 644 Nommetro 263 34,7 42 1 45 9% 49 8 89 3
a Numbers in this table do not correspond exactly to the percentage change in evetY case duo to rounding of some table entries. Sae tables in ch. 5 for more detailed data SOURCE' American Hospital Association. Hospital Statistics (Chicago, IL. 1985-89 ads )
Nearly three-fourths of niral hospitals have fewer (382). Most rural hospitals are within a reasonable than 100 beds (figure 1-3). These small hospitals arc distance of another hospital (over 80 percent are hiparticular difficulty; they hove the fewest admi- within 30 miles), but extreme regional differences dons, the lowest occupancy, and the highest ex exist, for example, hospitals are much farther apart pulses per inpatient day of all rural hospitals (625). in the less densely populated West (589).1° Although Despite these trends, rural areas in general are still the mid-1980s wimesse.1 i 55 percent decline in the well-supplied with hospitals. In 1986, the ratio of number of rural hospitals (table 1-1). most hospitals community hospital beds to population was about that have closed irk recent years have been small the same in rural as in urban areas, in 14 States, facilities with low occupancy rates (692,693). Must bed-to-population ratios were higher in niral areas communities in which hospitals4-lvbedapp(ar to
vflevai percent of rural hospitals arc located in "frontier" counties (625)- 12 Health Care in Rural America
Figure 1.3Distribution of Community Hospitals' in Metropolitan and Nohmetropoidan Areas, 1987
4-49 beds 300* beds (300 110-199 beds (270 300* beds (2%) 8-49 beds 200-295 beds (7%) 50-99 beds (516) %) 200- 299 bed* 100-199 beds 60-99 bed4 1200 (18%) 121%) N on me tro Metro 2,694 hospitals 3,012 hospitals
aOTA's dellnibon of community hospital dir=slightly from the definition lased by the American Hospital Association tsesapp. ufor evanation ot differences.) SOURCE Otke of Technology Assessment. 1990 Data from the Amencan Hospital Association.* 1987 Annual Survey ol Hospitals.
continue to have reasonable access to emergency heavily ctependent on Federal grant funds, which ane, acute care. make up nearly one-half of total revenues. Despite their heavy Federal dependence, rural In fact, one af the greatest problems rural C/MHCs receive 15 percent less Federal funding per hospitals face Is the outmigrati^n of rural residents patient served than do their urban counterparts to urban areas for care. Studies suggest that rural (272). Factors such as differences in the complexity residents (especially young and affluent residents) of care patients require may explain ie of the have been increasingly seeking care outside their difference in funding but hay.ot been studied in own communities, either to obtain specialized care detail. not available locally or to obtain alternatives to locally available serv ices (102b,134,237,590). Rural health care facilities have a number of options in adjusting to recent changes in the health care and fiscal environment, ranging from short- Problems faced by publicly funded facilities that term options such as staff i:lonsolidation and reduc- provide primary care services are somewhat differ- tion to longer term strategies such as diversification ent from those faced by hospitals. From 1984 to and participation in multifacility alliances. But 1988 the number of rural C/MHC service sites many rural facilities have not successfully applied remained relatively constant, but patient visits to these strategies. rural C/MHCs rose nearly 19 percent during this period (658). Most of the increase in utilization One major barrier to the successful implementation appears to be by niral residents unable to pay the full of strategies is simple lack of .;ommunity and costs of their care. By 1987, nearly one-half of all provider will, particularly in cases where groups rural CIAIHC users received discounted care. More- e differing views on appropriate actions. But over, Medicaid-reimbursed visitc constitute an in . even when providers have a firm direction and creasing proportion of revenues, while the propor committment, they can be stymied by a lack of lion of revenues from private pay patients has information on the success uf alternativ e possible decreased (658). Consequently, C/MHCs remain strategies, and the lack of community and provuier 22 Chapter 1Summary and Options 13
that assumed an unrealistically low cost of providing such services, however, might dissuade these hospi- tals from making appropriate changes. Uninten- tional disincentives could be minimized by perform- ing a detailed analysis of the impact of any proposed new payment system on rural providers before adopting such a system. In addition to evaluating potential new health policies for their impact on rural facilities, the Federal Governtnent could take a number of specific steps to identify and protect essential rural health services, and to enhance the abilities of all rural providers to respond appropriately to changes in the health care and economic environment. Options for undertaking these steps are presented below.
Photo crolt: Tiro Henderson Options for Congressional Action Great distances in areas of sparse population can limit the availability ot even the most basic local rural health Identifying and Supporting Essential services. Rural Health Facilities technical expertise and fmancial resources to under- In some rural ATCAS, particularly those with high take suategic planning and other important steps. poverty or very low population density, a single Other especially important structural barriers can facility may be the only provider of some of the include: community's vital services. At a minimum, these vital services include basic emergency, primary, standards and requirements for Rural Health acute, and long-term care. Clinics (RHCs) and C1MHCs, including delays in the RHC certification process and C/MHC At present there are several programs aimed at efficiency standards that may be difncult for identify ing (and supporting) facilities providing one small or isolated C/MHCs to meet; or more of these services, specifically the C/MHC regulations to prevent fraud and abuse that grant programs and Medicare's payment exceptions may inhibit hospitals from engaging in somc for designated RHCs, Sole Conanunity Hospitals 'is that would encourage physicians to (SCHs), Essential Access Community Hospitals, practice in a rural aiea; and Rural Primary Care Hospitals. The assumption State licensure restrictions that prevent hospi- of each of these programs is that Federal subsidies or tals from reducing the scope of services (e.g., special exceptions to payment rules will enable -Inverting to a facility that offers only emer- kcs to be provided to populations whose health gency, subacute, and primary care); and care access might otherwise be severely anpaired. restrictions on public hospital actilities that Existing programs, howevermost notably the prevent the 42 percent of rural hospitals that are SCH programimperfectly identify these facilities. publicly owned from providing services not Furthermore, each program has its own unique expressly or implicitly permitted by their en- criteria that may not be relevant to other applica- abling statutes. tions. One potential direction for Federal policy is to undertake a more concerted effort to identify (option Federal intervention will have hi: led effect on 1) and protect (suboptions 1A-1C) a broad range of tome of these barriers. But the Federal Government essential facilities. can avoid policies that send contradktory messages *mai providers. For example, it may be appropn Option 1: Det.elop criteria to identify health ale for many rural hospitals with low occupancy facilities that prosi deessential emergency. rates to r- rient their services to place more empha primary, acute, and long-ter m catcin specified ston ctapatient care. Any changes in Federal rural areas, and det.elop programs to prmidc payment policies for ambulatory surgical services support for these facilities. r` 3 14 Health Care in Rural America
The Department of Health and Human Sell ices approving designations and affirming that the desig. (DHHS) could be directed, with assistance from the nated facilities were eligible for relevant Federal States, to make a comprehensive effon to develop programs. Facilities, once designated, 4;ou1d also be criteria that could be used to designate essential periodically "recertified" in order to remoe those facilities and services, which would then be eligible facilities no longer meeting the criteria. for a variety of Federal and State protections. Criteria could distinguish among facilities for which Option 1A. Protide direct grams and subsidies to no reasonable alternatives exist, facilities for which eligible facilities. alternatives exist but are more distant or otherwise less accessible, and all other facilities. Programs These corld include: using the facility designations thus might be applied Time-limited subsidies to maintain operations, to eithe the most narrowly or the more broadly and to plan and implement strategies to change defined group of "essential" facilities. the scope or delivery of services (e.g., I- to Designation aiteria for essential facilities might 3-year grants through an expanded Rural in clude: Health Care Tiansition Grant Program). distance/time to nearest comparable and near- Continued grant support andlor special altera- est higher level service or facility, considering tions in public sources of reimbursement to geographical and transponation limitations; maintain and enhance operations for facilities deemed unable to achieve self-sufficiency due level of medical underservice and indigence of to isolation or high levels of tlizeimbursed care. the area population; For example, designated hospitals could con- institution's area market share and measures of tinueto receive reimbursement exceptions community acceptance (e.g., utilization pat- under the Medicare program. Alternatively, the terns); SCH exception could be phased out altogether, evidence of plans or actions by the facility to and general subsidy grants analogous to those serve critical unmet needs of the local commu- provided to C/MliCs could be made available nity; and to all eligible hospitals, separating the subsidies other relevant factors (e.g., number of Medicare from the Medicare program. beneficiaries served). From the State perspective, Federal critern. often Option 1B: Require the Farmers Home Admin- seem inflexible and not adaptable to relevant local istration (FmHA), the Department of Housing conditions. To minimize this problem, the develop- and Urban Development (HLID), and other Fed- ment of designation criteria should Mclude the input eral agencies to give special attention to the and active involvement of Star' governments. State needs of essential rural health facilities when flexibility would be rather enhanced by the estab- making available loans to institutions for capital lishment of: improvement. minimum criteria to aid the Federal Gov - Many essential rural hospitals and clinics may ernment in basic and fair allocation of funds lack adequate access to capital for diversifying among States; and services and converting facilities to other functions. less restrictive crueria to enable States to use Many of these providers' basic facilities and equip- and modify the designations for then own ment also may need upgt ading to maintain quality of purposes, and to enable more flexibility in the care and conform to Federal and State regulations. application of Federal programs to variously Increased availability of capital through Fm.HA identified facilities. direct and guaranteed loans and RUD loan guarantee programs could help to ensure the financial stability Some of the difficulties of applying detailed and presence of these facilities. criteria from the perspective of the Federal Govern- ment could be avoick4 by requiring States to Option 1C. Protect essential facilitiez. from Federal actually apply the criteria and make the designations fraud Jnd abuse t egulanons that inhibit thar (see option 2). The Federal role could be restricted ability to lariat and retain physicians or to be to technical support and assistance, reviewing and acquired by physicians.
2 4 ..MEI...... ,
Chapter ISummary and Options 15
Close organizational association *vith physicians Option 2B. Prolide time-limited or ongoing grams may be the only financially feasible strategy for to States to help them undertake specifit attivtties long-term survival for some rural facilities, and for relating to essential and other rural health essential facilities the benefits of financial stability facilities. may sometimes outweigh the dangers of potential Such grants could enable States to: conflicts of interest. A specified " safe harbor" from fraud and abuse regulations, or a legislative exemp- identify 1.nd designate essential fauhties and tion to these laws, could provide for the arrange- services; ments these facilities might make to ermine the monitor the fmant ...undition of essential availability of a local physician (e.g., free onsite facilities and services, protect against un- office space). In addition, specified "safe harbor" desirable closure, and examine the compa- prac:ices could encompass the purchase of small, rability and acceptability of the nearest health failing hospitals by local physicians wishing to care facilities; ensure the availability of this resource. Whole or provide technical assistance to enhance leader- partial physician ownership of health care facilities ship and management skills, suppon strategic may be an especially attractive option in the case of planning, encourage reconfiguration of serv- small "alternative licensure" facilities that provide ices and cooperative affiliations with other mostly primary, emergency, and subacute care. institutions, and recruit critical staff, help subsidize existing statewide capital fi- To guard against abuse of this exemption, restric- nancing sources and/or uncompensated care tions could specify that incentives be independent of pools, making them more accessible to essen- the number of patients the physician refers to the tial facilities; facility, or that a faciP-. wishing to acquire a encourage special local tax initiatives and the physician practice coulu .iot exclude other local creation of health service districts, where ap- physicians from its staff. Also, facilities could be propriate, to maintain and expand services; precluded from listing recruitment and retention study the impact of Federal and State regula- costs on their Medicare cost reports. tions on essential facilities, disseminate infor- Option 2: Provide assistance to States to help mation clarifying State and Federal regulatory requirements, and develop model State legisla- them identify essential facilities, remove regu- latory barriers applying to these facilities, and tive and regulatory language; and offer State-based financial support to a more identify areas without access even to essential primary and other care facilities, and provide flexible set of designated facilities. funds to establish new facilities in these areas. Option 2A: Provide time-limited (I- to 3-year) grants for the development of State-designated Encouraging Comprehensive and offices of rural health to enable States tobetter Coordinated Rural Health Care support rural health efforts. Rural patients and providers are often both The Federal ORHP is an important part of the physically and professionally isolated. As a result they may be unable to obtain consultation and Federal effort to assess zural health program needs information and unaware of appropiate alternative and respond to information needs. Organizations sources of care. They may receive little feedback and that can cany out equivalent duties at the State level few resources from regional providers. are likewise important. As of February 1990, 19 States had instituted (and 5 more had plans for) Option 3: Award small Federal grants to projets State-designated offices of rural health(426,6:7). whose goal is the deelopment of model rural (Locations of existing offices were almost evenly health care networks. divided between State agencies and nonprofit organ- Short-term demonstration and development izations.) Thirty-four States reported the existence grants could be awarded by DHHS io States or of legislative gr executive task forces or committees nonprofit organizations to: to address State rural health issues(627).Thirteen States, however, have neither an office of rural identify special basic care need areas in geo- health nor a State rural health task force. graphicaIly remote and persistent poverty corn-
IN \ %. s) 16 Health Care in Rural America
munities, identify minimum service needs, and $)start 4 arrant a 4..omprehcnsite and ongoing anal- create and evaluate the effectiveness of service ysis to ease their incorporation into the system. networks in those areas; Adapting the system to accommodate these facilities identify regional needs and service resources introduces a myriad of questions. how to pay for the for comprebensive and integrated care in re- services they pros ;de, how to integrate them into a gions not designated as special basic care need comprehensive and coordinated system of care, an4i areas, and create and demonstrate integrated how to ensure that they cuntinue tc, provide services care networks in those regions; and vital to their communities. Answering these ques- develop regional referral networks for specific tions requires the input and s.00rdination a informa- services and population groups needing partic- tion from a ariery of Federal and State agencies. ular attention, using (and expanding) the peri- natal network model. The recently established ORHP and the National Advisory Committee on Rural Health wert created, Some aspects of this option are already in place; in part, to address such issues. At present, ORHP has for examp le, under Primary Care Cooperative Agree- a very small staff and a wide range of responsibility; ments, States can receive funds to help identify the Advisory COMMitie4 considers a similarly broad needs in underserved areas. Private organizations, range of issues and meets only four tunes each year. however, cannot receive funds directly at present :or These limitations at present prevent an immediate, this purpose. intense examination of the structure of the rural As an alternative to a new funding program, the health care system. Rural Health Care Transition Grant program could Option 4; Establish a short-term (18-24 month) be expanded. A proportion of these grant funds advisory task force whose purpose is to exam- could be directed specifically to funding for con- ine the future of rural health delivery systems sortia of hospitals and other providers wishing to and to provide guidance on the implementa- develop model arrangements for transfemng and tion of new service delivery structures. referring patients, and for enhancing local care through periodic specialty clinics and contiruing Ideally, the task force, comprising both public- education seminars. and private-sector experts in rural health and health care fmancing, would meet frequently and would Longer Term Assessment of the Future of the advise DHHS and Congross. It could be coordinated Rural Health (7are Delivery System with the current Advisory Committeefor example, Innovative rtsponses to existing barners to by having representatives from the Advisory Com- change include measures to modify State hospital mittee serve as part of the short-term task fs..ce. The licensure laws to permit the operation uf facilitie., task force could be staffed by an augmented ORHP that provide less than full-service hospital care. Two to eliminate duplication of effort. examples are Montana's Medical Assistance Facili- The immediate objectives of the task force could ties and California's proposal for basic facilities include: whose license category would depend on the extent of services they cffer. The Federal Government has 1. assisting DHHS 111 the developmeat of cntena taken similar steps with the enactment of the for identifying essential facilities (see option Omnibus Reconciliation Act of 1989 (Public Law 1); 101-239), which permits Medicare payment to small 2. developing guidelines under which projects rural facilities that are designated Rural Primary may demonstrate the feasibility of alternative Care Hospitals (RPCHs) in a limited number of facility and service delivery models and (if States. But the RPCH is not necessarily the only or necessary) obtain waivers from Medicare and the best model for all rural areas, and the ability of Medicaid certification requirements; other facility models to be eligible for Medicare and 3 expanding and coordinating discussion on Medicaid payment remains highly uncertain. potential methods of payment to these facili- The need for such "alternative licensure" facili- ties (e.g., prospective payment groups, inte- ties, the variety of proposals, and the potential grated payment for physician and hospital importance of these facilities to the rural health care services); and Chapter 1Summery and Options 17
4_ providing directions for research and dem- Option 6: Expand funding to the Office of Rural onstration efforts supporting the development Health Policy to administer an extended clear- of model service delivery networks in rural inghouse of information on innovations and areas (see option 6). successes in rural health delivery. Tb ensure that the recommendations of the task Many States and communities would like to force could be implemented, DHHS would nee to investigate and implement improved forms of health mahnain or develop complementary expenise. For service delivery but do not have, and are unable to example, DIMS staff might need to be able to: purchase, the necessary knowledge and expertise. The Federal Government has a unique capability to compile,analyze,andniake available infounation on existing efforts to develop model service act as a central point for information collection and dissemination. In aduition, the Federal Government structures and networks: has an interest.in providing assistance relating to help States and local communities to identify State and local implementation of current programs regional needs and determine standads for in order to enhance the effective ube of Federal acceptable acces to comprehensive services; and funds. participate in the development of both new ORHP's current eftoits to develop an information projects to demonstrate innovative service and clearinghouse cou'id receive supplemental suppon to: facility categories in rural areas (e.g., subacute contract researchers to develop extensive case care facilities) and networks involvmg such providers. studies of vartous naal service delivery innova- tions; work closely with private groups fividing Addressing Information Needs innovative rural health delivery demonstration Option 5: Expand basic research on access to projects to document and disseminate informa- health care in rural areas. tion on project activities and findings; and routinely analyze information collected on Specific topics that DHHS could be encouraged or innovative strategies, identify those that appear mandated to study include: to have the broadest benefit and transferability, Nationwide migration patterns of rural resi- and ;den* factors that will affect their appli- dents for health services outside their local cations in other areas. communities, why thev occur, and their impact on the economic viability of local health RURAL HEALTH PERSONNEL: services (particularly obstetrics services). ISSUES AND OPTIONS How travel distances and transportation limita- tions affect access to hospital care in rural /nuns areas. The costs to mral hospitals, under different Availability of Personnel" conditions, of restructuring their organization and services in various ways (e.g., capital, PhysiciansPhysicians have histoncally been operating, and regulatory costs of downsizing the cornerstone of the health care system, and hospitals to alternative delivery models). physician supply has been increasing for many years The availability, accessibility, and general op. in both rural and urban areas (table 1-2) (673). crating characteristics of rural C/MHCs, pprtic- Despite the overall increase, however, rural areas ularly those in persistent poverty and frontier have fewer than one-half as many physicians provid. regionv, special problems these centers face, ing patient care as urban areas (91 v. 216 per 100,000 whether these centers are abk to provide a residents in 1985) (table 1-2) (673). In the least sufficient scope of care, particularly obstetrics populated counties (those with fewer than 10,000 care; and how critic& they are as a source of residents), there are only 48 physicians for every primary care. 100,000 people- -about one physician for every
11Tbis report didDotexamine the availability of chiropractors or F.:hat:oats. 18 Health Care in Rural America
Table 1-2-Physlc lan-to-PopulatIon Ratios (Ms only) Table 14-Availability of Primary Care Physicians by by County Type and Population, 1979 and 19880 County Type and Population, 19880
Percent Primary care nhysielana change, Number Proportion of 1979 1988 1070,88 per 100.000 sll active residents phYsiciansc Total HU parusi,00eraaldantab Metro 219.3 262.6 19.7 Metro 86.8 381
Nonmetro 87.2 108.5 24.#. Nonmetro 55.3 57 50.000 and over 116.3 146.7 U., 50,000 and over 81.8 48 25.000-49,999 86.8 106.2 22 A 25,000 to 40.090 56.1 58 10.000-24,099 62.0 74.7 t0.5 10,000 to 24,999 48.5 71 0-0,009 48.6 58.r .a. 6 5.000 to 9,999 45.9 81 2.500 to 4,999 43.4 82 U.S. total 188.4 227.7 SO 0 Ftwer tam 2.500 25.6 78
Patient case NM per 108,808 residentmb U.S. total 79.7 40 Metro 174.3 215.6 23.7 °Includes Jon. 1. 1988 HD data and 1987 DO data. bPrimarycare physicians include profesaionally Nonmetro 73.3 00.5 23 .' active Ms in general/family practice. internal 50,000 and over 97.5 122.2 2f.3 medicine, pediatrics, and obstetrics/gynecologY; 25.000-49.000 73.3 89.9 4.26 and all doctors of osteopathy in patient care. 10,000-24,000 52.0 61.3 179. *Professionally active physicians include physicians 0-9.990 40,5 47.5 174 in research, administration, and teaching, end physicians in Federal service. U.S. total 150.7 187.2 24.3 SOURCE; U.S. Department of Health and Human Ser- 4 MD data for 1088 are as ofJan. I. Prior to 1988. vices, Health Resources and Services Ad- data are as of Dec. 31. ministration. Bureau of Health Professions, b 1087 population estimateswere used to calculate Office of Data Analysis end Managemant. 1988 MD ratios. Prior to1088. population esti- Rockville, MD. unpublished data from the metes used mere for the sameyear as ND data, Area Resource File ..ystem provided to DTA in 1989 and 1080. SOURCE: U.S. Department of Health and Human Ser- vices. Health Resources and Services Admin- istration, Bureau of Health Professions, Office of Data Analysis and Management. midwives (CNMs) have become important medical Rockville, MD. unp.bUshed data from the care providers in rural areas arm: are the only licensed Area Resource File system provided to OITA providers of primary health care in some areas with in 1989 and 1990. no physicians. Their small numbers are incitasing, although there appears to be a very 7adual treud 2,000 residents. Over 100 U.S. counties have no toward specialization and urban practice even for practicing physicians at all(665). these practitioners. The distribudcn of midlevel The availability of primar care physicians in practitioners varies enormously by State; these professionals are most likely to be found in States rural areas is of pardcular concern. Primary care physicians make up well over one-half of all with midlevel practitioner schools and in States that permit more independent practice. physicians who provide patient care in rural areas (table 1-3), but thesc areas are increasingly compet- Certified registered nurse anesthetists (CRNAs) ing with urban practices 4.uch as those associated are annther midlevel profession that is especially with health maintenance organizations) for pnmazy important to small rural hospitals that wish to care physicians. Osteopathic phybicians (DOS), who provide basic surgical services but car-mt support or constitute about 9 percent of the total U.S. physician population, make up a large proportion of rural attract physician anesthetists. The naticgal supply of CRNAs, however, appears to be in decline. primary care physicians. In small rural counties in some States, as many as three-fourths of the Nurses-Rural hospitals have markedly fewer physicians are DOs(318). registered nurses (RNs) and lower rati.4of RNs to Midlevel Practitioners-Nurse practitioners (NPs), licenced practkal/vocational nurses than do their physician assistants (PAs), and certified nurse- urban counterparts(671).The proportion of RNs 78 who work in =al areas has decreased in recent years, and rural areas will probably continue to be at a disadvantage when competing for the sbxinking national supply of nt, -402 On average, nurses in smaller mral counties ar° considerably older than other nurses and are less likely to have baccalaureate nursing degrees, making upgrading to midlevel degrees (e.g., NP) more difficult. Dentists.As with physicians, the number of dentists and the proportion of dentists entering specialty practice have increased considerably over the past two decades. However, =al areas have conskierably fewer dentists per capita than urban areas, and projected future shortages of dentists are likely to worsen the situation (673 ,686). Despite the large number of dentists in general at the present lime, there remains a small but constant demand for dentists in areas with chronic oroccesional difficulty reaniting these practitioners. PharmacistsThere has been no national census of pharmacists since the 1970s, and the number of phaimacists practicing in rural areas is unknown. The national supply of pharmacists is projected to Photo crock Peter Beeson increase (673). A handful of State studies suggest Some rural communities have fimited access to basic that urban/rural differences in distribution am less dental services. severe for pharmacists than for many other health tional therapists and some radiologic and laboratory professionals, but little is known about the existence personnel. of local areas of shortage. OptomentisOptometrists may be important Barriers to Rural Practice providers of vision care it. niral areas without Barriers to the availability and willingness of ophthalmologists. One-tlurd of all optometrists (and one-fifth of ophthalmologists) were practicing in health professionals to locate in rural areas intervene communities of 25,000 or fewer residents in 1983 at two levels. r a, because rural areas often have (42). As with pharmacists, the national supply of populations too sparse Lir dispersed to support many optometrists is increasing (673), although some subspecialty physicians, an inadequate supply of local shortages may exist. primary care physicians and midlevel practitioners is a bar rier to the availability of health care services Allied Health ProfessionalsThe allied health in rural areas even if there is an oversupply of professions include a wide variety of laboratory physicians overall. Although the supply of physi- personnel, therapists, technologists, emergency per- cians has grown dramatically inthe past two sonnel, dental hygienists, and other professionals. A decades, most of the increase has been among sMdy by the Institute of Medicine, which examined nonprimary care speeialists. The backbone of the 10 different allied health professions, predicted rural health care symem, however, is primary care serious impending shortages in the national supply physiciansthose who can provide a wide array of of physical and occupational therapists, radio:clic basic health services to small communities that technoiogists, and medical records specialists (288). cannot support a full complement of specialists. Tin available anecdotal evidence and small-area Recent Federal polkies have addressed this barrier studies suggest that some rural facilities are already by redesigning Medicare payment to enhance pay- suffeng critical shortages of physical and occupa- ment for many primary care services.Further
%rung school corollineht Actually Increased stightly In ai.ailenni. year 1987-15. bui long-ierm inci;eurorls arc still pessimism
7 20Health Care in Rural America
Options for Congressional Action
influencing the Supply of Primary Care Physicians Option 8: Reorient or augment existing Federal funding for graduate medical education to direct resources to primary care specialties (family practice, general internal medicine, general pediatrics, and obstetrics/gynecology). Option 8A: Expand Federal grant funding for -` primary care undergraduate and graduate medi- 1.6111V," cal education. - 154.7.7° 1.1 The Federal Government 1.-..ivides grants to fam- 4? ily practice, general interaal medicine, and general ,ecttlte-s7tg--51.;z. pediatric residency programs, but these grants de- Photo croolt: Peter Beeson clined substantially between 1980 and 1988. Grants Satellite clinics that are staffed part.time can be a for the development, improvement, and mainte- vital source of primary care servi:es In many rural nance of undergraduate departments of family medi- communities. cine have also decreased in recent years. Thrgeted funding for primary care education is one strategy Federal options discussed below include supporting for overcoming some of the disincenthes for spe- primary care physician and midlevel education cialty training in primary care. directly or through dui .ges in Medicare reimburse- Option 8H: Weight Medicare reimbursement for ment for direct medical education. direct medical education costs to give preference to primary care specialties. Second, within a given group of professionals (e.g,, primary case physicians), personal concerns, Medicare rcirnbursement to hospitals for direct perceived lower financial rzwards, professiuna; graduate medical eduaition expenses does not isolation, and lack of preparation for rural praLtice distinguish among specialties. By altering the pay. prevent many practitioners from locating and stay- mein formula to give greater weight, and thus ing in rural areas. Strategies to address these provide greater resources, to specified primary care barriers and concerns through rural-oriented training specialties, it ma) be possible to alter the mix of programs and direct fmancial incentives for nual physkian specialists without further increasing the practice have had some success in the past. Federal total number of physicians. A difficulty in imple . measures to addren disincentives to rural practice menting this option w ould be that of dev eloping an have been in piac i.. for two decades, out during the adecoate rationale for the specific weights to be 1980s their funding declinett Options for reinstating assigned to each specialty.An advantage, compared Fedual interventions include targeting funding to with option 8A, is that it could be adopted without rural-oriented health professions programs and q- increasing overall levels of funding. fering direct incentives to health professionals thrcugh scholarships, aucational loan repayment, Enhancing Training and Preparation and special payment or practice provisions that of Rural Health Personnel apply to health professionals in underserved rural Option 9: Within Federal grant programs for areas. The Federal Government could also choose to primary care medical education, target fund- enhance other resources available to rural practition- ing to rural-oriented programs. ers (e.g., technical assistance, continuing education, long-distance consultation resources). Combmanuns Option 9A. Target a fixed pen-enrage of grant funds of strategies. rather than any single strategy, are fur graduate medieal education specifkally to !ikely to be the most effeciive in improving the programs that emphasi2e preparation fur prac- lilability of health prifessionals in rural areas. tice in rural and underserved areas. 30
22 Health Care in Rural America expanded to enable nursing schooh to receiNe own loan programs, and it would atuact providers AHEC funds directly. interested in new locations. Offering Direct Incentives for Rural Practice Available data indicate that the original NHSC Option 13: Expand the National Health Service Scholarship Program, while expensive, was highly Corps (NHSC) by increasing fimding for both successful at placing providers in shortage areas. A the State and Federal components of the NHSC renewed scholarship program would be especially Loan Repayment Program and by reinstating appropriate for midlevel providers Their relatively a targeted Scholarship Program. low educational costs (compared with those for physicians) lead to correspondingly lower educa- In 1988, 29 pt.zent of all rural residents were tional indebtedness, making loan repayment a rela- living in federally designated HMSAs (665). This tively weaker policy tool, while making a scholar- number has not changed appreciably during the past ship program less expeusive for the Federal Govern- 5 years, indicating a need for ensuring the availabil ment. Scholarships for other health professions ity of health professionals who have at least a students could be targeted to those from low- short-term commitment to serving in these areas. income, minority, or nual backgrounds. These Federal investment in the NHSC declined dramati students are somewhat more likely than others to cally in the 1980s and is now embodied primarily in plactke in underserved areas after graduation, and Federal- and State-administered loan repayment they are less likely to be able to afford the economic programs. The Federal Loan Repayment Proram burden of a health profession education. was fended at $3.9 million in 1989 and that year recruited 112 professionals, mostly physicians. At Other measures could also be taken within both present, there are only seven State NHSC Loan the Loan and S.holarship programs to:-.hance the Repayment programs." rhilitie- of obligated professionals and to in- crease the likelihood that they would remain after The Loan Repayment program provides an incen- tive to recently graduated practitioners that is their obligation expires. For example: particularly appropriate for recruiting physicians Preference could be given to students who have and dentists, for three reasons. First, it does not enrolled in a program with a nual, primary -care- require any commitments until the practitioner has oriented curriculum. finished his or her education, leading to less Participants could be permitted to serve their likelihood of default. Second, recipients are availa- obligations at a single site regardless of any ble almost immediately. Third, the level of indebted- change in the area's designation status during ness among medical and dental students has in- their period of obligation. creased dramatically in recent years, and the pool of interested applicants to an expanded loan repayment The NHSC could actively coordinate with other program is likely to be large. programs (e.g., the AHEC program) to ensure support for scholarship recipients during their The State and Federal components of the loan education and periods of obligation. Support repayment program have complementary adv a ntageb. might mclude such features as rural preceptor- The State progrant efforts are more localized than ships, practice management training, ...chnical Federal efforts, and they attract providers who are assistance, and continuing education. willing to serve but want the assurance that they can carry out their seivice obligation within their State A renewed NHSC would be a major investment. of residence. In addition, the program requirement If this option were impkmented, the program would that States match Federal funds encourages greater warrant accompanying oversight (e_g., by the Gen- State participation in health personnel distribution eral Accounting Office) in its first years to ensure that funds were appropriately and efficiently admin- istered. Maintaining the Federal program would ensure that some obligated providers were available to Option 14. Encourage or require States to offer serve in underserved areas in States without their bonuses under Medicaid to physicians prov id-
IsThe seven States ate Mumesola. west Vanptua. Texas. Pionda. Nonh Carohoa, South Carohna. and New Mama Chapter 1Summary and Options 23
ing services in designated HMSAs, paralleling at the end of the 2-year period the ratio was still the current policy under Medicare. above the allowable limit, that HMSA could be dedesignated. Such a policy could be limited to This option would extend the benefits of in- primary care HMSAs or applied to all types of creased access to Medicaid as well as Medicare HMSAs. beneficiaries. It .. :aid also increase incentives for ptysicians Ir.: 1r...ely to provide services to Medi- Option 17: Authorize and implement a State care beneficiaries (e.g., pediatricians, obstetrician/ rurai health personnel grant. gynecologists). Medicaid bonuses might be espe- cially appropriate for physicians providing obstetric A drawback to all rural health personnel progr.-..-ns services in areas with shortages of obstetric tans. operated from the Federal level is the inability to adapt strategies to local concerns and conditions. A Option 15: Offer tax incentives to health provid- State with a school ro train physician assistants, for ers in specified rural and underserved areas. example, may most effectively address health per- Direct and tin.e-limited tax incentives for pnmaiy sonnel shortage problems by enhancing this school's care providers (physicians and midlevel profession- curricula and providing scholarships to its students. als) serving underserved populations might over- In another State, absolute heal th personnel shortages come perceived or real financial disincentives to might be less a problem than the provision of locating and practicing in rural areas. Tax incentives specific services, such as obstetrics; such a State could be offered to providers in all rural areas, but might fmd that paying malpractice premiums for this policy could be expensive without improvmg rural obstetrics providers was a more effective availability in the area.s of greatest need. li these strategy than direct recruitment of more physicians incentives are linked to federally designated short- to rural areas. A broadly defined grant to States age or underserved areas, however, their continua- would transfer responsibility to the individual States tion should not be dependent on the continued status to decide how they choose to alloc-?te the funds of the designation (i.e., if the area isdedesignateci among health professions programs and direct in- during the term of the incentive, the incentive should centive programs to enhance the supply of health not be removed). professionals in rural areas. Such a grant could either augment existing Federal programs or replace some Option 16: Allow a "grace period" before de- of them. designating HMSA areas, populations, and facilitie:. Under a rural health personnel grant program, States could be allocated grant funds based on a For HMSAs with small populations, the addition formula developed by DHHS (e.g., percentage of of a single physician (or the retention of rin NHSC population that is rural; number of rural residents physician past his or her period of obligated service) living in underserved or personnel shortage areas). can mean the loss of designated status. The sudden Within the grant, States could spend funds on any of loss of resources dependent on continued designa- a list of relevant specified activities such as: tion (e.g., Medicare physician bonus payments, placement of NHSC personnel, and qualification as grants to State health professions Jhools with a Rural Health Clinic under Medicare rules) may rural-criented curricula; produce unintentional negative consequences. Medicaid payment incentives fur services pro- A "grace period" could encourage existing vided in underserved areas; providers to stay while permitting the Federal Medicaid bonus payments for "dispropor- Government to direct new available personnel to tionate share" providers (those with unusually more needy areas. For example, if the addition of a high caseloads of Medicaid and uninsured provider in a designated HMSA raises the provider- patients); to-population ratio above the allowable limit and the scholarship and loan programs; HMSA is targeted for dedesignation during periodic other recruitment mechanisms (e.g., placement review, that HMSA could be placed on a provisional services, State tax incentives); list that received close monitoring. IIMSAs on the purchase of malpractice insurance premiums litr. might receive no new resources but could for rural obstetrics providers (obstetricians, continue existing :esources linked to designation. If family practitioners, CNMs, NPs);
-::3 24 Health Care ln Rural Amerka
innovative continuing education programs for might encourage their expanded use in urban as wc11 rural professionals; and as rural settings. development of appropriate curricula and es- This option carries weight only where State laws tablishment of community training programs permit midlevel practitioners to operate under off- (e.g., in local hospitals and community col- site supervision. The Federal Government has tradi- leges) for rural residents interested in one of the tionally not dictated the scope of practice that States allied health professions, and for current allied permit of their licensedhealth professionals. (Option health personnel wishing to extend their ac- 19 addresses a potential Federal role in the reexami- creditation to more than one area. nation of State licensure restrictions.) The e xpertise among State governmentsregarding Option 19. Encourage DHHS to spore or a confer- the administration of rural health programs vanes ence to discuss models and rtid dines for State considerably. Some States are capable of designing nurse and medical practice act revision that and administering a detailed array of incentive and would enhance the capabilities of midlevel grant programs, while others have much more practitioners to provide primary health care in limited capability at present. As a preirquisite to rural and underserved areas. receiving funds under such a grant, States could be required to provide a plan outlining the activiti:.s to Midlevel practitioners can provide a limited be funded and indicating that the State has ait number of basic health services in areas not ade- adequate administrative capatility (e.g., an Office of quately served by physicians. Then ability to do So, Rural Health or analogous body) to carry out the how ev er, is legally restricted in many States, partic- funding activities. In addition, States could be ularly for PAs. A conference, sponsored by DHHS, required to provide the Federal Government with would gib e representatives from different parts of basic information on the programs actually funded the gov ernment and health care an opportunity to over the preceding year as a prerequisite for renew- fees aluate the suitability of existing limas to midlevel ing the grant. This information would not only practice. Participants might int 'tide experts from the enable some oversight of expenditures but would medical, PA, and advanced nursing professions, provide the basis for the Federal Gov ernment to representatives from State and Federal agencies, and assist in information transfer among States regard representativ es from other sectors of the health care ing innovativepgrams. industry. Guidelines dev -loped by such a panel could help States evaluate a.al implement appropri- ate changes to their own regulations. Removing Barriers to Midlevel Practke Option 18: Require States to reimburse under Improving the Information Base Medicaid for the services of NPs and PAs in Option 20: Improve monitoriag of the Medicare rural areas, as long as these services arc Physician Bonus Payment Program to find out permitted by State practice acts. how well it works. Current Federal policy requires States to reim- The Medicare physiclua bonus program was burse under Medicaid for services provided by recently expanded to provide 4 10-peicent bonus for pediattic and family NPs (Pablic Law 101-269). it all physician services in all primary care HMSAs, in also allows States to exercise the option of reimburs- order to incre.se access to services for Medicare ing for other NP and PA services, and nearly beneficiaries. It is not clear whether a 10-percent one-half of all States now do so to some degree. The bonus on Medicare payment is sufficient to attract Federal policy requiring States to provide Medicrid physkians to areas where they would otherwise not reimbursement for CNM services provides a prece- choose to lucate, or whether it improves the retention dent for a more general policy. As with CNMs, of providers already in these areas. The Medicare Federal policy could prevent State Medicaid Pro- caseload varies gi eatly horn phy sician to physician, grams from requiring the direct personal supervision and the....agth of the bonus incentiv e probably of a physician during the delivery of atP and PA varies accordingly. To anprove DHHS's ability to services. Restricting the requirement to rural areas evaluate the program, ...criers could be required to might provide an additional incentiv e for NPs and submit to the Health Cart l inancing Admmistratron PAs to locate in these areas, while a broader policy data regarding the number of phy moans receiving
:4 4 Itill."=,...... 11100110S.Pla
Chapter 1Summary stnd Options 25
bonus payments and the distribution of services for Southare without any physicians who provide which bonus payments are made. obstetric care. In many mral areas, physicians Option 21: Establish a program, through the trained to provide obstetric services are not doing so. Unwillingness is often due to concerns about inade- Bureau of Health Professions, to provide small grants and technical assistance to States and quate sources of backup, consultation, and referral that are shared by mral physicians in all specialties. professional associations to establish and im- plement uniform data collection procedures In addition, however, many physicians are limiting or eliminating their obstetric practices as a direct among the health professions. consequence of the high cost of malpractice insur- Better data on the supply and distribution of ance and fears of lawsuits. Thece trends are particu- health professionals would improve the Federal larly disturbing in rural areas because alternative Government's abilityto monitor trends in the sources of obstetric care may be a considerable availability of these personnel in rural areas. Most distance away. professional associations collect data on the mem- bers oftheir profession, but these efforts are Where there am obstetric providers, they are sometimes very limited, and the data are nor usually general and family practitioners rather than compatible. States likewise collect data on licensed obstetricians. And although rural hospitals are much health professionals, and they may include some more likely than urban hospitals to offer obstetric professionals not represented in professional associ- :are, they are much less likely to offer specialized ation databases. To enhance these efforts with a care. Consequently, rural wonwn with complicated mininaim amount of Federal resources, the Bureau or high-risk pregnancies may have to travel consid- of Health Professions in the Health Resources and erable distances to rek.eise specialized care. Region- Services Administration could establish criteria for alized perinatal care, successfully promoted in the uniform data collecti in. The Bureau could then past by Federal programs, can enhance access to provide States and associations with technical assis- specialty services when obstetric or neonatal emer- tance on survey sample selection methods or on gencies arise, but regionalized sy stem b of care have census collection methods, make available startup deteriorated over the past several years. funds, and offer other appropriate assistance (e.g., for hardware, software, and other resources). In some rural areas, women who are able-- particularly those with higher ircomes and private insurance coverageare bypassing local facilities TWO SPECIFIC SERVICES to deliver in distant hospitals offering sophisticated services. One result may be to leave locLI phy sicians Issues and Options in Maternal and and hospitals with an increasingly higher proportion Infant Care14 of patients who cannot pay the fuli costs of their care. Fetal,infant, and maternal mortality are all Rural physicians under these circumstances may disproportionately high in rural areas (647,650).15 fmd itParticularly diffkult io afford obstetric These indicators of relatively poor rural maternal liabilityinsurance, possibly prompting them to and infant health persist despite priv ate and go v emment- reduce their obstetric practkes and furtherin- funded programs that have successfully reduced creasing the burden on remaimr.g ob.tetric provid- infant mortality in targetedareas. Two potential ers. contributors to the relatively poorer health of rural Federal maternal and infant health programs (e.g., mothers and infants are the limited availability of Medicaid, the Maternal and Child Health block obstetric provicbrs and access to specialized care grant, and C/MHC funds) are esp-cially important in for women with difficult pregnancies and deliveries. rural areas, where the inability to pay for obstetric The availability of rural obstetric providers has services is a serious problem. In 1982.1.aal deliver- declined sharply in recent years, and over 500,000 ies accounted for nearly one-half of all uncompen- residents of rural counties many of them in the sated deliveries 47MHCs are paaicularly important
145ee also option S and personnel options generally (opuoos 7 through 22) anis finding holds true after adjusting for race and sex Unitujusted rural torant mouldy rates arc .k.tually towe: than urban taws. ha aim ot tlw greater prevaknce of white infants to rural areas.
20-810 0 - 90 - 2 013 26 Health Care in Rural Americd
Whether the excess of rural fetal deaths is real or occurs because of differential reporting in rural and urban areas is unclear and deserves further investiga- tion. The underlying cause of the excess mortality in late infancy likewise deserves to be investigated. Clarification of perinatal health status in rural areas would be useful in targeting programs. Programs to improve care for pregnant women might curb excess fetal deaths, while improved pediatric care could potentially reduce high mortality rates among older infants. Congress could direct the National Center for Health Statistics or the Agency for Health Care Photo crecht.Thn Henderson Policy and Research to investigate these issues.
Many rural community health centen attract a large cross-sectIon of commumty residents and may be vital Option 238 Develop a database that H. ould allow sources of local obstetric care. Federal policymakers to target resources to States and to their rural areas with perinatal sources of prenatal care for many rural women, health problems. because they accept all Medicaid patients and provide discounted care for low-income uninsured k number of programs have shown suGeess in patients. But the expense of malpractice insurance improving access to prenatal care m the past.16 The has reduced the ability of some federally supported Federal Government could build on their success by CIMHCs to provide obstetric care (289). Ensuring targeting resourcei for such programs to areas with survival of essential rural C;MHCs (and their ability high-risk populations, high pennatal mortahty, and to provide obstetric services) is as important to a high proportion of women seeking late or no maternal and infant health as ensuring survivai of prenatal care. Such 4treasLouldbe identified in part essential rural hospitals. with information available on vital records (e.g., birth certificates). The National Center for Health Option 22: Extend liability coverage under the Statistics, in the Centers for Disease Control, could Federal Tort Claims Act to CIMIIC staff and undertake this activity. contract providers engaged in obstetric care. Option 24: Enhance the DHHS Office of Mater- The Federal Tort Claims Act currently insures nal and Child Health's (MCH's) ability to both commissioned officers of the NHSC and NHSC provide useful information and technical sup- scholarship graduates who work as civilian employ- port to rural maternal and infant care efforts. ees of the Public Health Service. Many C/MHC obstetric providers placed through the NHSC, how- Option 24A: Enable and encourage MCHsupport ever, have no federally provided insurance coverage addtuonal demonstration project.> on rival areas. because they are paid through the center. Providing Funded projects could evaluate the feasibility of insurance coverage might increase the willingness innovative approaches to improving access to of obstetric providers to join C/MHC staffs, to perinatal servwes in rural areas. remain at these locations, and to continue to provide a full range of obstetric seivices to C/MHC patients. Demonstration projects funded through MCH Option 23: Enhance the information base for could be used. for example. to compare the relative Federal rural maternal and infant health cost and effectiveness of bringing providers into policy. isokited rural areas with providing transportation services to the patients themselves. Among the Option 23A Investigate in more depth the urban and 4.urrent MCH-funded rural projects is an evaluation rival differences M perinatal health status indi- of the use of an outreach consultation team of cators. perinatal specialists to visit rural health districts
hsComponems orsuccessful proymms include plibhty supported ohstctri . pros tams. nudles ct pftt .. titionen, pertnatai ttansporiation systems. interagency coordination. and use of outreach workers to mi.nno patients and providefollowup drkdtransponanon Chapter ISummary and Options 27
(687). Demonstration project funding could be expanded to include more model projecia 'lat. employ nonphysician providers as rural out- reach workers, promote regional approaches to solve access problems, promote linkages of available perinatal re- sources, and thrlalia &Mal liedhCaner r's* .*T" incorporate home visits by rity.ses or para- professionals. Projects could be required not only to evaluate the effectiveness but the costs of these models. Option 24B: Provide additional funds (or earmark a proportion of future funds) to better allow MC H to offer technical assistance on request to States that are developing regionalized perinatal care services that include rural areas. A perinatal care network is an essential compo- nent of a functional network of comprehensive Phofo orodt Pah% Beeson health care services to rural residents. Resources A4:0336 tO toCal manta: health servtces s severmy kmded from various Federal sources are available to help in many rural areas. States develop regional and local networks and (e.g., from nonpiofioundations) are less available services. Greater availability of technical assistance from MCH might help States and communities use to fill the vacuum in rural than in urban areas. both Federal and local funds most effectively. Rural mental health professionals face problems similar to those of other rural health professionals. Issues and Options in Mental Health Care" They have fewer training opportunities, fewer col- The prevalence of mental disorders in rural leagues with whom to consult and to discuss Americans is similar to that of their urban counter- professional issues, and more diverse demands on parts. Despite the similarity in mental health prob- their time than do their urban counterparts. Primary lems, the little information that exists suggests that care physkians provide much of the mental health rural areas have substantially fewer mental health care in boih urban and rural areas, but they receive resources than urban areas. Furthermore, where relatively little training in mental health diaposis resources exist, they are likely to be narrower in and treatment. Master's level mental health profes- scope. sionals, paraprofessionals, allied professionals (e.g., the clergy), and volunteers are also vital providers of As with other health facilities, mental health rural health services. facilities face problems in serving populations spread over vast distances. In addition, they are The severe shortagef psy chiatrists and doctoral caught between competing needs for services for the le,cl psychologists in rural areas, the proportion of chronically mentally ill and services for acute and mental health care prov ided by nonpsyclikurit less serious conditions. Because recent Federal and physicians, and the types of services likely to be S ite policies have tended to emphasize the former, most acceptable to rural reside:Its all suggest that the ability of many rural mental health providers to integrating mi.ntal health and other health cJri. off.ff services such as suicide prevention, education, especially important in rural areas. Social worken, crisis intervention, support groups, and individual psy chologists, ctinial psy chiatric nurse apetialists, counseling for less severe mental health problems and paraprofessionals play an important iuIin has waned. Furthermore, other sources of services extending rural mental health serv ices to those in
175ce also option 12. 28 Health Care in Rural America
Option 26: Require States to reimburse under Medicaid for mental health services provided by midlevel mental health professionals to the extent that these services are permitted under State licensure law. Reimbursement could be limited to those services that were provided in HMSAs or MUM and would be covered if provided by a physician. It% rural communities without psychiatrists or doctoral psychologists, primary mental health care is provided by either nonpsychiatric physicians or by midlevel mental health professionals (master's level - clinical psychologists, clinical social workers, and clinical psychiatric nurse specialists). Current Fed- 411IE 1044,,T" eral policy covers reimbursement for the services of -1,16k.kteAr4 psychologists and social workers only in certified RHCs. Expanding the services for which midlevel .4 ..h mental health providers or their employers can receive reimbursement would probably increase Photo credit: Pete r Beeson access to these services in rural areas. Staffing crisis hoSines is a possible mental health rde for trained volunteers In rural areas. Option 27: Encourage the development of link- ages between rural health and mental health need, and in linking these services with physical services and professionals. health services. These linkages may include such features as health and mental health clinics sharing Greater enhancement of linkages might include a single service site, routine consultation between measures to encourage case management, share physicians and mental health center staff, or a building space, develop referral patterns, and make full-time social worker providing counseling and better informed decisions about patient care. "Link- educational services in a community health clinic or age workers" could be expanded to include master's physician's office. Recent legislation has expanded level nurse specialists. Federal initiatives of this the rehnbursement available for certain "linkage" kind are currently underway for health and substance services, namely the mental health services provided abuse treatment, but a more permanent and consis- by clinical social workers and psychologists in tent policy of linkages for substonce abuse, mental community health centers. Federal stimulation of health, and other health services could be adopted. linkage efforts themselves, however, has declined Specific Federal sirategies criuld include; since the implementation of the mental health block grant in 1981. reimbursement for 1in1;age workers' services (e.g., social workersservices provided in Option 25: Provide grants to mental health physicians' offices, mcludmg consultative serv- professions training programs that include ices provided to the physician); rural-oriented curricula and/or train pro- O funding for the salaries of clinicalsocial fess )nals most likely to locate in rural areas. workers and other meltal health providers in grants to federally funded C/MHCs; For example, the provisions of Public Law 100-607, which provided special project grants to funding for inserv ice traming, internships. and professional schools' training programs for clinical shared training sites; and psychologists, could be extended to include masters' rquiring States to demonstrate that a portion of programs for social workers and clinical psychiairic Federal mental health block grant funds is nurse specialists. Or, grants under this law could be being used to support linkage efforts in rural targeted or limited to projects emphasizing training areas as a prerequisite to continued block grant for rural practice. funding. Chapter 1SwnmarY and Options 29
Option 28: Inv est mor e resources in data collec- Option 29: Encourage or require ADAMHA to tion and analysis activity oriented at urt.an . fund projects intended to demonstrate the rural comparisons of mental health and sub. utilization of volunteers a nd paraprofessionals stance abuse epidemiology, and at the availa- in service delivery. bility of mental health services and personnel in rural areas. One way to help address mental health personnel The information available on rural mental health shortages is to include paraprofessionals and com- epidemiology and services is extremely thin and munity volunteers in service delivery. However, provides 2 poor basis for both monitoring mental little is known about effective ways to increase the health status and implementing Federal policies. use of these providers, their acceptance in the Even the most basic national data on community community, and the effectiveness of the seivices mental health centers have been virtually nonexist- they provide. Incentives to be tested in the demon- ent since 1981, and there are few reliable studies on mental health problems m rural areas. Congress stration projects could include training programs for could direct the Alcohol, Drug Abuse, and Mental paraprofessionals and clergy, reimbursement for Health Administration (ADAMHA) to place more professkinal activities to develop and train commu- emphasis on these research activities (e.g., through nity viorkers, and educational support for commu- the National Institute of Mental Health's recently nity workers in the form of tuition for college created Office of Rural Mental Health). training. Part II An Overview of Rural Populations and Health Programs
4 0 Chapter 2 Rural Populations
CONTENTS Page INTRODUCTION 35 WHO IS RURAL? 35 THE RURAL POPULATION 37 Size and Geographic Distribution 37 Demographic and Income Characteristics 38 THE RURAL ECONOMIC ENVIRONMENT 41 THE HEALTH OF RURAL POPULATIONS 43 Health Status 4:. Health Insurance 43 Health Care Utilization 47 TWO SPECIAL POPULATIONS: A CLOSER LOOK 50 The Rural E. 4 50 Migrant and Seasonal Farmworkers 52 SUMMARY AND CONCLUSIONS 53
Figures Figure Page 24. Metropolitan Statistical Areas 36 2-2. Frontier Counties: Population Density of Six or Fewer Persons Per &lore Mile 37 2-3. Inttstr) of 1:atployed Persons Over Age 16 in Metropolitan and Nonmetropolitan Areas, 1980 4i 2-4. Health Insurance Status of We king Adults and Their Families, by Type of Industry, 1987 49 2-5. Regional Distribution of Urban and Rural Elderly Residents, 1980 55
41 -
Tables Table Page 2-1. United States Rural.d Rural Farm Population, Selected Years, 1920-88 38 2-2. Size and Percentage of Population in Nonmetropolitan and Rual Areas, by State, 1987 39 2-3. Characteristics of Metropolitan and Nonmetropolitan Populations 40 2-4. Proportion of the 'LS:Population Age 65 and Older, by Metropolitan/Nonmetropolitan and Urban/Rural otatus, 1980 41 2-5 Age Distribution of the U.S. Population Across Metropolitan and Nonmetropolitan Areas, by Geographic Region, 1980 42 2-6. Meiropolitan/Nonmetropolitan Differences in Selected Health Indicators 44 2-7 Acute Conditions Involving Activity Limitation and/or Medical Attention in Metropolitan and Nonmetropolitan Populations, 1986 45 2-8. Selected Chronic Conditions Among Metropolitan and Nonmetropolitan Residents 45 2-9. Proportion of Metropolitan and Nonmetropolitan Residents Who Rated Their Hed.th as Fair or Poor, Selected Years, 1975-88 47 2-10, Selected Preventive Behaviors and Risk Exposure of Metropolitan and Nonmetropohtan Residents, 1985 47 2-11. Immunization Status of Children Aged 1-4, 1985 48 2-12. Percentage of Population With Health Insurance Coverage, by Age and Residence, 1984 48 2-13. Private Insurance Coverage of Metropolitan and Nonmetropolitan Residents, 1987 48 2-14. Insuranez ("overage of the Population Under Age 65, by Residence and Income, 1987 49 2-15. Interval Since Last Contact With Physician (1988) awl Centis (1986) for Metropolitan and Nonmetropolitan Residents 50 2-16. Percent of Metropolitan and Nonmetropolitan Residents Who Hese Had a Physician Visit Within the Past 2 Years, Selected Years, 1964-88 51 2-17. Distribution of Physician Visits in Metropolitan and Nonmetropolitan Areas, by Specialty, 1985 51 2-18. Hospital Utilization of Metropolitan and Nonmetropolitan Residents 52 2-19. Trends ::a Hospital Utilization by Metropolitan and Nonmetropolitan Residents, Selected Years, 1964-88 53 2-20. Age Distribution of Urban and Rural Elderly Residents, 1980 54 2-21. Percent of Urban and Rural Persons Who Are Elderly, tr, egion, 1980 56 2-22_ Income Characteristics of Elderly Urban and Rural Residents (age 65 and Wel). 1979 56 2-23. Living Characteristics of Elderly Urban and Rural Residents, 1980 56 2-24. Percent of Metropolitan and Nonmetropolitan Elderly Limited in &inlay Due to Chronic Conditions, By Age, 1987 57 2-25. Self-Assessed Health Status Among the Metropolitan and Nonmetropolitan Elderly, 1987 57 2 ^Rate of Restricted Activity Days Among the MetropoStan and Nomnetropolitan Elderly Due to Acute and Chronic Conditions, by Age, 1987 57 2-27. Utilization of Physician Services by Metropolitan and Nonmetropolaan Elderly Persons. Average Annual Number of Physician Visits Per Person, 1983 and 1987 58 2-28. Utilization of Physician Services by Metropolitan and Nonmetropolitan Elderly Persons, 1964, 1982, and 1987 58 2-29. Hospital Utilization by Elderly Metropolitan and Nonineiropolitan Persons, 1937 58 2-30. Most Fiquent Diagnoses Reported by 60 Federally Funded Migrant Health Centers, 1980 ,, 59 2-31. Major Illnesses Repotted by Migrant Farmworker Families, 1984 59 2-32. Utilization of Federally Funded Migrant Health Centers, 1984-88 59 2-33. State Distribution of Migrant and Seasonal Farmworkers (MSFWI and Federal Migrant Health Center (WIC) Funds, Fiscal Year 1988 60
4 2 WIN80~0/.117..=4.140IMMTatvi.....1.111.1"40eir.MINgiera
Chapter 2 Rural Populations
INTRODUCTION in places (towns, virsges, etc.) outside of urbanized areas with populations of at least "Rural" evokes images of wheat fields and dairy 2,500 (633). farms, long stretches of desert, and small Appala- chian communities. This chapter presents back- The nonmetropolitan (nonrnetro) population con- ground on the rural populatioe. who it includes, the sists of those people living oumide of metropolitan economic and demographic characteristics of rural statistical areas (MSAs), An MSA is a county,2 or residents, and some basic indicators of rural health group of countie., that includes either: status. a city of 50,000 or more residents. or an urbanized area with at least 50,000 people The adjectives "urban" and "rural" encompass that is itself part of a couay or counties with at enormously diverse populations. Urban people may least 100,000 total residents (634).3 be residents of large inner cities, suburbs, or smaller cities and towns, each with its own characteristics To be included in an MSA, a county that does not and cultures. Similarly, mral people may live in itself have a central city must have a specified level towns or open countryside; their nearest neighbors of commuting to the central county(ies) and must may be acmss the street or 10 miles down a dirt road. meet certain other standards reganling metropolitan Existing measures cannot convey the full diversity character, such es population density. Figure 2-1 of urban and rural populations, but they can provide shows the MSAs in the United States as of 1986. a starting place for examining the similarities end About one-fourth of the U.S. population is either differences between these groups. An overview "rural" by the Census definition or lives in non- contrasting these basic characteristics is the goal of metro areas, but these two groups of peopk are by no this chapter. Where possible, information summariz- 'nears identical. About 14 percent of the population ing aspects of rural diversity is also presented. living in MSAs is designated by the Census Bureau as rural, while about 38 percent of the population living outside of MSAs is designated as urban (633). WHO IS RURAL?' This OCCIlf s because, on the one hand, MSAs are county-based and may include large tracts of sparsely The term "rural" is inraitively associated with populated land in outly ing areas of the county. On areas of small and sparsely settled population. Two the other hand, the Census "urban" designation more specific definitions are commonly used for includes people in towns in otherwise sparsely statistical and health program purposes: the "rural populated areas. Roughly 15 percent of the U.S. population," as defmed by the Bureau of the Census, population is "rural" by both definitionsi.e., lhes and the "nonmetropolitan population," those peo- neither in places of 2,500 or more residents not ple living outside of metropolitan (metro) areas as metropolitan counties. defmed by the Office of Management and Budget. Each definition has its advantages. The Census The Census Bureau defmes the rural population as lesignations are more specific, because tbv are the population not categorized as urban, The urban based on smaller geographic units, such as census population, in turn, is defmed as those people living. tracts and towz.s. Census tract boundaries vary over time, however. In contrast, countiesthe basic units in an urbanized areaa central city (or cities) horn which MSA designations are made- -have and sts contiguous closely setded territory, with boundaries that are re1ath ely stable, a major advan- a combined population of at least 50,000, and tage for collecting and reporting st-istit al data that
ISee the related OTA Staff Paper for a snore detailed discussion (255). Ilnsix New England SunesMaine, New Hampshire, Vermont. Massaausens. nude Lbw. atidCucurAtac.ut MS& compn.a-. s tether than wbole counties. Standards for these MSAs are based pnraanly oa population Jew> and ,oruting patterns (04) 3Populanon is generally calculated based JO the mot recent dm-mania! einus, although some inten.ensus NISA desiguat, -"cs ain. oc, -35- 4 3 Figure 2-1Metropolitan Statistical Areas (June 30, 1986)
SOURCE. Adapted from U.S. Depalmeat of Commerce, Bureau 0 the Census. "Metropolitan Statistical Areas (CMSAL PMSAs. and MSAs) iGE-50. No 84) stock No. 003-02406508:1 (WaaNnolon, DC: U.S. Government Pdnting Office, 1986). 'N Chapter 2Rural Populations 37
Figure 2-2Frontier Counties: Population Density of Six or Fewer Persons Per Square Mile
Counties Other Selected
SOURCE.ILS. Department of Heann end Human Services, Health fiesoutoss erre Set vices Awanistation. Beleau of Health Profes.' AA. Offke of Data and Management Area Resource File, Juno 18, 1886. are comparable overtime. Data on "rural- resi . A paiticularly useful concept for the purpose of dents presented in this and later chapters are examining health care resources and access is that of actually data on nonmetro residents, unless a "frontier" areas, defmed as counties with popula different definition is specified. tion densities of six or fewer people per square mile (480).In such areas, physical access to health care is A problem of both definitions is that they are implicitly difficult for a substantial proportion of dichotomous; they permit classification into only residents. Frontier counties are concentrated in the two categories (urban/metro and rural/nonmetro). Great Plains and Western States and often extend Neither can descsibe the urban/rural continuum, nor over a large physical area(480)(see figure 2-2). can they dzscribe in any detail the range of variation that exists within rural areas. Some researchers have THE RURAL POPULATION developed more extensive typologies in an attempt Size and Geographic Distribution to overcome these disadvantages, relying on combi- nations of measures such as population size, popula- During Amerka's brief history as a nation, the flan density, adjacency to a metro area, and urbani- composition of the US. population hss changed zation. None of the available typologies has so fat from one that was merwbelmingly rural to one that found general application to health care prc grams, is predominantly urban. According to Census esti- although several of them are being used in reseach mates, 95 percent of the population was mral in efforts(255). 17%; about 60 percent was rural at the turn of the
4 6 38Health Care in Rural Amerke.
Table 2-iUniteu Mates Rural and Rural Farm Population, Selected Years, 192048
lturalrepaulationa Farm population Number (in Percent of total Number (in Percent of Percent Year thousands) U.S. population thousands) 'rural population of total
1920 51.553 49 31,359 60 30 1930 53.820 44 30,529 57 25 1940 57,246 44 30,547 53 23 19504 $4.230 %5 23,048 42 15 2960 54,054 30 13.475 24 9 1970 53,887 26 8,292 15 5 1980 . 59,445 26 6,051 10 3 1986 . 63,133 27 5.226 8 2 1987 . 63,889 27 4.986 a 2 1988 64.798 27 4,951 2
!Dosed on the Census-deiined rural pepula 'on. °The rural population figures from 1950 on reflect definitional changes. Rad the previous definition been used, the 1950 rural population would havebeen60,948,000, or 40 percent of the total U.S. population. SOURCE: U.S. Department of C--nerce. bureau of the Census, end U.S. Department of Agriculture,Rural and Rural Farm Populatioo 1988," Current_fopulation Reports. Series P-20, No. 439 (Washington, DC. U.S. Government Printing Office. September 1989).
20th century; and only 27 percent of the Nation's percent), followed by the West (16 percent) and, estimated 241 million people lived in rural areas by finally, by the Northeast (12 percent) (631). 1988 (table 2-1) (632). In 1988, an estimated 23 percent of the population-56,843,000 people States vary ixemendously in their degree of lived in nonnieto areas (631). "mralness" depending on the criterion used. Of the 10 States whose nonmetro populations are largest in absolute size, for example, only two (Mississippi The absolute size of the rural population has not and Kentucky) have more than 50 percent of their declined overall, but in recent years it has grown population residing in these areas (table 2-2) (631). much more slowly than the urban population. The Contrasts between States according to the definition nonmeto population grew at a rate of only 0.6 ei` rural" are stiking; less than one-half of Idaho's percent per year during the 1980s (after a mild boom population is rural according to the Census defili- in the 1970s, when the growth rate was twice as tion, but over 80 percent of this State's population high) (631). In contrast, the metro population has lives in nonmetro areas, the highest percentage in the continued to grow at rates of over 1 percent per year. United States (631). The rural fann population4 has undergone an Demographic and Income Characteristics absolute and marked decline during this century (table 2-1). In 1920, an estimated 31 million In general, mral residents are more likely than Americans lived on farms. In 1988, in contrast, the urban residents to be white, native-born, and living Census Bureau estimated the farm population to be in a family headed by a married couple (table 2-3) slightly fewer than 5 millionabout 8 percent of the (633). They are also more likely to be children Census-defined rural population, and about 2 per- (under age 18) or elderly (age 65 or older). They are cent of the total U.S. population (632). less likely to be employed and to have completed a high-school education (633). Of the four major regions of the country, the South Rtutal residents have relatively low incomes. The has both the highest proportion of its population (30 w,erage median family income in ruial areab in 1987 percent) and the highest number of people (25 was $24,397, about three-quarters of the average million) living in nonmetro areas. The next most urban family income of $33,131 (629). One out of rural region by this measure is the Midwest (29 eight urban families lived in poverty in 1987,
4The CensusBureau dermes the farm population aspeople living at meal areas properuel 4,1 At ieam 1 Acre ut Lad *fiat al ledNi$1.00U wonh of agricultural products was sold (or would have been said) during the previous 12 months (632) 311as ratiohas um changed since the 1980 census (633).
4 7 Chapter 2Rural Populations 39
Table 2-2Size and Percentage of Population in Nonmetropontan and Rural Areas, by State, 1987
Percent of Percent of total Size of nonmetro total popalation populalqop in Cenius- population in nonmetro areas defined rural areas State (in thousands) (1987) (1980)
Alabama 1.336 32.8 40.0 Alaskaa 303 57 6 35 7 Arizona 805 23.8 16.2 Arkansas 1,444 60 5 48.4 California 1,182 4.3 8 7 Colorado 603 18.3 19 4 Connecticut 238 7.4 21.2 Delaware 219 34 0 22 4
District of Columbia . 0 0.0 0.0 Florida 1,110 9.2 15.7 Georgia 2.204 35 4 37 6 Hawaii 252 23 3 13 5 Idaho 803 80.4 46.0 Illinois 2.022 17 5 16 7 Indiana 1.768 32.0 35,8 Iowa 1.612 56 9 41.4 Kanses 1.169 47.2 43 3
Kentucky 2.019 54.2 49 1 Louisiana 1.382 31.0 31 4 Maine 758 63 9 52.5 MMryland 322 7 1 19 7 Massachusetts 546 9 3 16.2 Michigan 1.820 19 8 29 3 Minnesota 1.435 33.6 33.1 Mississippi 2.829 69 7 52 7 Missouri 1.736 34 0 31 9 Montana 613 75 8 47 / Nebraska 842 52 8 37 1 Nevada . 175 17.4 147 New Hampshire 462 43.7 47 8 New Jersey 0 0 0 11 0 New Mexico 774 51.6 27 9 New York 1.696 9 5 15 4 North Carolina 2.868 44 7 52 0 North Dakota...... 417 62 0 51 2 Ohio 2.276 21 1 26 7 Oklahoma. 1.350 41 2 32 7 Oregon 083 32 4 22 1 Pennsylvania 1.828 15 3 30 7 Rhode Island 73 7 4 13 0 South Carolina 1.355 39 6 45 9 South Dakota 506 71,1 53 6 Tennessee 1.603 33 0 39 6 Texas 3.194 10 0 20 4 Utah 304 22 8 25.6 Vermont ...... 421 76 9 66 2
Virginia ...... 1.668 28 3 44 0 Washington 854 18 8 26 5 West Virginia... 1.209 63 7 63 8 Wiaconsin 1.610 33 5 35 8 Woming 348 71 0 37 3 aThe nonmetropolitan population in Alaska is determined using census tract and bo.ough boundaries rather than county boundar1Ls.
SOURCE. V.S. Bureau of the Census, Statistical Abstract of the United States 1469. 109th ed (Washington. DC: U.S. Government Printing Office. 1989) Table 2-3-Characteristics of Metropolitan and Nonmetropontan Populations
Metro Nonmetro
Gemara Characteristics (1987) Tote. population 187,072,000 56.324.000 Population density per sq ad 328 19 Social odd demographic Characteristics (1980) Median age 30.0 30.2 Percent of population under age 18 27.81 29.41
Percent of population age 65 and over...... 10.7% 13.02 Percent white 81.81 88.21 Percent Hispanic 7.61 3.22 Percent nom/hit* 18.21 11.81 Percent black 12.72 0.81 Percent American Indian 0 52 1.31 Percent Asian/Pacific Islander 2.02 0.62 Percent native-born 92.41 98.02 Birth rate (hirths/1,000 population/year, 1977-1980).... 1.5 1.6 Percent of households headed by women 28.31 23.92 Percent of children living with two parents 75.41 80.11 Education, employment. and income Characteristics MedianYearsof education completed (1980) 11 6 10.9 Percent high school graduates 85.01 83 11 Percent with college education (4 or more years).. .. 12 82 9.22 Unemployment rate (1985) 6.91 0.41 Median family income (1987) $33,131 $24.397 Percent with family incomes below poverty level(1987).. 12.51 16.91 White . 9 62 13.71 Black . 30.72 44.11 Hispanic 27.62 35.62 Percent of poor families with 2 or more workers(1083) 15.42 28.92
SOURCES: V S Department of Commerce. Bureau of the Census, Statisticel_Abstrart of the United States:1989 109th ed. (Washington. DC. U S. Government Printing Office, 1989), U.S. Denartment of Commerce. Bureau of tileCensus. 1960 Census General Social and Economic Characteristics, vol. 1 (Washington. DC: U SGovernment Pritting Office, SepteMber 1901), U.S. Department of Commerce, fito'eau of the Census, "Money Income and Puverty Status in the United States. 1987." Current, PoPulation Reports, Series P-60, No 161 (Washington. DC. U.S. Governmon. Printing Office. August 1988); D.1. Brown and K.LDeavers, "Rural Change and the Rural Economic Policy Agenda for the 1980s," D.L. Brown, J.N. Reid, R. Bluestone et al,(eds.), Rural Economic Development in the 198031 ProsPects for the 1t,:14.02 (Washington, DC U.S. Department of Agriculture. September 1988). compared with more than one out of every six rural oci-upation of over 7 percent of employed persons in families (table 2-3); the ratio approaches one out of nonmetro areas (v. 1.5 percent of employed metro two for black families in rural areas (629). The rural residents) (633). paor are much less evenly distributed throughout the United States than the urban poor; over one-half (53 A major caveat tothis picture of the rural percent) of poor rural people under age 65 live in the. population is that the definition of "rural" used can South (530). affect even some of the most basic conclusions regarding urhan/rura1 differences. For example, as The vast majority of employed people both within stated above, nonxnetro areas have a relatively high and outside of metro areas are employed in personal proportion of elderly res.dents. By the Census services, manufacturing, and retail trade (figure Bureau's defmition, however, urban areas have a 2-3).6The most striking employment difference, not higher proportion of elderly residents (633). This unexpectedly, is in agriculture, whichIsthe primary apparent discrepancy is resolved by 4.._oser examina-
*These OM occupational groups aeyount for 68 and 74 percent. respec.nvely, of employed ammo and mummy° mak ms
4 9 Chapter 2Rural Populations 41
Figure 2-3Industry of Employed Pe, eons Over Age Table 24Proportion of the U.S. Population Age 65 16 In Metropolitan and Nonmetropolitan Areas, end Older, by MetropolitanlIonmetropolitan and 1880 Urban/Sure Status, 1980
Serviceis Manufaoturing U.S. population Percent age Retail trade Ares (in thousands) 65 and over agriculture Construction Metro 169.430 10.7 Nonmetro 57,115 13.0 Transoloomm/utlf Public admin. Urban 167.055 11.4 Planneireal *Mats Rural 59.491 10.9 Wholesal trade Metro Mining Urban 145.451 10.9 Forestry a fisheries Rural 23,979 9.0 Nonmetro 0 5 10 15 20 25 30 35 Percent of soMployoct gamins Urban 21,603 14.3 Rural 35.512 12.2 CI Metro Nonmetro a"Urban" and -rural" as defined by the U.S. Census *Transportation. communications. and public utilities. bFinanco. Insurance. and real estate. Bureau. SOURCE: Office of Technology Auessawnt, 1996. Data from U.S. SOCRCE. U.S. Department of Commerce. Bureau f the PepadmentoiConurerce.BuresuoitheConsus. 1980Census. Census, 1980 Ceneus General Social and Genoasodaand &coon* Chatnetelistke,vol. 1 (Washing- Economic Chara_c ter is tt Co. vol. 1 (Washing- ton. DO: U.S. Government Pdritims Oleo. September 1991). ton.DC; U.S. Government Printing Office. September 1981). tion of the distribution of the elderly population, which shows it to be concentrated in small or 2. Manufacturing-dependenkounties-678 coun . medium-sized towns in both metro and nonmetro ties, concentrated in the Southeast, in which areas (table 2-4). manufacturing contributed 30 percent or more of total income. Within the nommen() population, the generalities 3. Mining-dependent counties200counties, con- regarding rural residents obscure substantial re- centrated in the West and in Appalachia, in gional differences. For example, nonmetro areas in which mining contributed 20 percent or more the West have a much higher proportion of children to total income. wan do metro areas (reflecting the profile for the 4. Specialized government counties-315 coun- Nation as a whole),butMidwestern nomnetro areas ties, scattered throughout the country, in which actually have proportionately fewer children than do government activities contributed 25 percent metro areas in that region (table 2-5) (447). or more of total income. 5. Persistent poverty counties-242 counties, THE RURAL ECONOMIC concentrated in the South, in which the per capita family income in the county was in the ENVIRONMENT lowest quintile in specified years between 1950 and 1979. The Nation's rural areas are economically as well as demographically diverse. The U.S. Department of 6. Federal lands counties-247 counfies, con- Agriculture (USDA) has identified seven groups of centrated in the West, in which Federal land nonmetro counties according to the principal eco- was 33 percent or more of the land area. nomic activity7 or other predominating characteris- 7. Destination retirement counties 515 coun tics:8 ties, concentrated in the South, Southwest, and northern Lake States, in which the net immi- 1. Farming-dependent counties-702 counties, gration rates of people aged 60 and over during concentrated in the Midwestern plains region, the 1970s were 15 percent or more of the in which farming contributed 20 percent or expected population in this age group in 1980 more of total income. (82).
7114., the industrythat contributed thc most tu Myr and proprietor income in tbose counhes in tbe 1970s. tin all. 370 counties did not meet the requirements for any of the7..oanty groups and am unclassified by tkus typology. 5 0 42 Health Care in Rural America
Table 25-Age Distribution of the U.S. Population Across Metropolitan and Nonmetropoldan Areas, by Geographic Region, 1980
Geosraphic region Population Under 17 17-44 45-64 65 years and residence (In thousands) Years Years years and over
United States Metro 150,836 25 6% 439E 19 9% 10 4% Nonmetro 70.650 27,5 40.7 19.6 12.3 Northeast Metro 38.061 24.9 420 21 .3 11.7 lionmetro 10.067 26.7 41.2 19.3 12 8 Midwest Metro 38,919 26 9 43.9 19 6 9.6 lionmetre 19.574 26.2 41 5 19 4 12 St South Metro 41.036 26.3 44.2 19 5 10 0 lionmetro 31,467 27 8 40.0 19 9 12.3 West Metro 32,021 25.1 45.6 19.0 10 3 Nonmetro 9,542 29.8 409 18.8 10 6
SOURCE: C.H. Norton and M A McManus, "Background Tables on Demographic Characteristics. Heaith Status and Health Services Utilization," Health Services Research 23(6) 725-756, FebruarY 1989
Rural America has undergone a major economic Individual rural communities are highly vulnera- restucturing over the past half century. In 1940, ble to economic shifts, because they are so often industries based on natural resources-agriculture, dependent on a single major industry (e.g., agricul- forestry, fishing, and mining-employed 40 percent ture). The slow employment growth m rural areas of the rural labor force (93). By 1980, these also means that worktrs who lose their jobs often industries accounted for fewer than 10 percent of cannot find alternative employment. Regional cluster- jobs, while service, manufacturing, and construction ing of particular industries and other characteristics industries had become as dominant as they were in of niral employment also amplify the effects of some urban areas (93). economic changes. Rural manufacturing employment, for example, is heavily concentrated in blue-collar The changes in the rural economy have not been occupations in low-wage industries. Thus, rapid job consistently accompanied by prosperity, Rural areas losses in the manufacturing sector are likely to have in the 1970s experienced both population growth a disproportionately negative effect on rural areas and economic prosperity. The disparity between (106). In addition, rural manufacturing is heavily rural and urban incomes narrowed during the early concentrated in the South, in large regions that may part of the decade, with rural per capita income thus experience simultaneous employment prob- reaching a high of 78 percent of urban income in lems. The agricultural sector experienced this situa- 1973 (253). During the 1980s, however, the rural tion in the early 1980s, leading to the "farm cnsis" economy slowed dramatically. The rural unemploy- that devastated much of the Midwest. ment rate skyrocketed from 5,7 percent in 1979 to 10.1 in 1982, and by 1985 it was still considerably Not all rural areasfaredbadly during the past higher than the urban rate (8.4 v. 6.9 percent). When decade. Rural areas with retirement- and gov ernment- the unemployment rate is adjusted to account for based economies experienced economic growth as discouraged workers (those no longer looking for high as that in urban areas, at least during the early jobs) and involuntary part-time workers, differences part of the 19806 (253). But counties dependent on were even more extreme (13.0 percent for rural farming, mining, and manufacturing suffered very workers v 9.9 percent for urban workers in 1985) slow economic growth. In farming and mining areas, (106). The rural poverty rate increased by nearly real per capita income (adjusted for inflation) one-third between 1973 and 1983 (106), despite actually decreased between 1979 and 1984 (253). improvements, it was still 35 percent higher than the Theeconomiupswing of the early 19801 for the urban poverty rate in 1987 (629). most part left rural areas behind; two-thirds of new 51 Chapter 2Rural Populations 43 jobs during this period were in senice industries, The proportion of people who consider themseh es and over 85 percent of those service jobs were in to bc ir, only fair or poor health has been declining urban areas (253). in both urban and rural areas (table 2-9). Nonethe- less, rural residents remain 20 percent more likely THE HEALTH OF RURAL than urban residents to consider themselves to be in POPULATIONS this category (651). Urban and rural residents differ in their practice of Health Status preventive behaviors. Rural residents are much less Table 2-6 presents some information on basic likely than urban residents to use seatbelts regularly (table 2-10), a characteristic that is consistent with health indicators for urban and rural populations. Compared with urban residents, rural residznts their higher motor vehicle accident fatality rates (649).9 Rural residents are also less likely to exercise overall have lower mortality rates, higher rates of regularly, and they are more likely to be obese. chronic disease, and comparable rates of acute Fewer rural residents smoke, but those who do health problems. smoke more heavily than their urban counterparts After accounting for differences in age, sex, and (649). racial distribution between urban and mral areas, In general, rural residents also appear to use mortality rates are lower in rural areas than in urban preventive screening services less often than do areas (table 2-6) (626). Two exceptions are notable. urban residents (table 2-10) (649). This difference First, infant mortality is slightly higher in rural areas. Second, deaths resulting from accidents are a may be attributable to differences in access to striking 40 percent higher in rural than in urban medical services, so it is difficult to interpret. In at least one area of preventive medical care, however, areas. rural residents participate on a greater level than U.S. The frequency of acute illness, and the ra.e of residents as a whole. Children in rural areas are more disability due to acute disease, is similar for mai and likely than urban children as a group, and inner city urban populations (table 2-7). Rural residents in children in particular, to be immunized against 1986 had a slightly higher incidence of acute childhood diseases (table 2-11) (651). conditions than did urban residents, and they had more days in which their activities were restricted Health insurance due to these conditions, but they were less frequently Rural residents are less likely than urban residents confmed to bed as a result of acute illness (648). An to be insured for their health care costs, particularly interesting and slightly different pattern is found for the subcategory of injury; rural residents have by private insurance (table 2-12). For children, differences in private insuredness among urban and relatively fewer injuries, but greater levels of injury disability (table 2-7) (648). rural residents isslight, but rural children are considerably less likely to be covered by Medicaid Chronic disease, on the other hand, is a significant (513). The opposite is true for nonelderly rural problem in rural areas. Some common chrone. adults. they are much less likely than urban adults to conditions (e.g., heart disease, hypertension, diabe- be prhately insured, but they have only slightly tes, arthritis, and certain vision and hearing impair. lower Medicaid coverage (5 13). In1987, 17.4 ments) are especially prevalent in rural populations percent of rural residents had no health insurance (table 2-8) (648). The high rates of chronic impair- (557).10 ment in rural areas result in slightly higher reported Differences in private coverage between urban overall days of activity limitation (including both and rural residents are strongly related to employ- acute and chronic conditions) among rural than ment. Rural residents are much less likely than urb an among urban residents (648). ones to have employment-related insurance (table High rates of chronic disease may explain the 2 13) (557). In fact, differences in pnvate coverage urban/rural differences in self-assessed health status. betw een urban and nu al populauons w ould probably
94oior vthkiciKtadcnis &tom own mote frcquatly in maiItail dkuibaci axed.. but whenAu...Kimdou..4....daldie iiivICitkily to tic Idol 02i, 11:Includes only civilian and noninstibnionalited person r:2 Table 24-MetropolitaniNonmatropolitan Differences in Selected Health indicators
Indicator Metro Nonmetro
Mortality" Infant mortality (deaths per 1 000 liveborn infants under age 1,1987) 9.88 10,07 Mortality from all causes (per 1,000 population, 1980)...... 9 21 8.87 Major cardiovascular disease 4.61 4,45 Malignant neoplasms 1.99 1.73 Chronic obstructive pulmonary disease .26 .25 Pneumonia and influenza .26 .24 Motor vehicle accidents .21 31 All other accidents 22 29 Diabetes mellitus .16 .16 Suicide .12 .11 Homicide and legal intervention 11 .07 Acute &some (per person per year, 1987) Number of conditions 1.73 1.73 Restricted activity days 6.72 7.07 Bed days 2.98 2.95 Work-loss days (employed adults) 3.13 3.00 School-loss days (Children) 3.36 3 48 Chronic diseaseb(percent of respondents with activity limitation, 1988) Total limited in activities due to chronic conditions 12.62 14.92 Limited in major activity 8 72 10.72 Unable to perform major activity 3.72 4.32 Limited in amount or scope of major activity...... 5 OX 6 42 Limited, but not in major activity 3 92 4 22 Overall 'malt'', Including both acute and thymic conditions Number of restricted days per person per year, 1987:
All types of restrictions . 14.1 14.7 Bed days 6.2 6 0 Work-loss days (employed persons) 5 2 4.9 Self-assessed health status, percent of respondents, 1988 b,c Fair or poor 9 02 Good 22.2% 2814.021 Very good or excellent ... . 69 02 64.32
'Mortality rates are adjusted to accommodate the different age, sex, and racial distributions of the urban and rural populations. bRates in these categories are age-adjusted. °Numbers do not add to 100 percent due to rounding SOURCES: Mortality rates from National Center for Health Statistics, unpublished and published data as adjusted by Office of Ticheology Assessment (oez, refs. 626 and 650). Restricted activity data from C.0Norton and M.A McManus, "Background Tables on Demographic CharacteristicsHealth Status and Health Services Utilization," Health Services Research 23(6).725-756, february 1989, and U.S. Deportment 41 Health and Human Services, Centers for Disease Control, National Center for Health Statistics, "Current Estimates From the National health Interview Survoy, 1987,' Vitil and Health Statistics Series 10, No 166, DHHS Pub. No. (PHS)88-1594 (Washington DC. U.S. Government Printing Off:ce, September, 1988). Activity limitation and se/f-assessed health status data from 1987 Nations/ Health Interview Survey data as published in U.S. Department of Hoalth and Human Services, Public Health Service, National Center for Health Statistics Health. United States. muand Bealth, United States. 1989 (Washington. DC U S. Government Printing Office, March 1989 and March 1990). be even greater except for the fact that rural residents Rural residents hoe lower average incomes .han are more likely than their urban counterparts to urban residents, and lower incomes ase associated in purchase non -employment-related private coverage both rural and urban areas with lower ran.- of pnvate (table 2-13). Employment-related insurance cover- insurance coverage (table 2-14) (530). At any given age is lower for agricultural, forestn, and fishery level of income, however, poor rural residents workers-occupations that are predominantly rural - (incomes below 200 percent of the Federal poverty than for workers in any other industries (figure 2-4) threshold) are more likely than urban residents to (557). have some private insurance. On the other hand, for Oupter 2-,Rural Popdations 45
Table 2-7-Acute Conditions Involving Activity Limitation and/or Medical Attention in Metropolitan and Nonmetropolitan Populations, 1986
Hurdler per 100 Persons per year4 Conditions Restricted activity days TYPs of acute condition Mauro Nonmetro Metro Nonmetro
All acute conditions 172.6 173.0 671.9 707.3 298 2 295.4 Infective/parasitic diseases 22.7 24.8 73.4 78,6 35.1 36.9 Respiratory conditions 80.0 80.2 263.9 265.8 131.0 136 5 Digestive system conditions 6.6 5.3 24.9 31.1 12.1 12.0 Urinary conditions 2.3 4.0 11.0 13.9 5.4 5.1 Mpaculoskeletal/skin conditions 5.0 2.7 29.0 28.3 10.5 6.2 Rar/eye conditions 10.7 11.1 25.5 20.4 11.0 7.7 Unspecified fever/headache (excluding migraine) 3.1 2.7 8.8 9.1 4.1 4.6 Injuries 27,6 24 9 158.6 180.2 52.4 568 Delivery/conditions of pregnancy 1.9 1.7 26.1 25.9 10.7 9.1 Disorders of the female genital tract 1.6 1.1 8.0 8.0 4.1 2.5 All other acute conditions 11.0 11 0 42.8 45.8 20.2 13.0
aThere estimates are based on a sample of fewer Chan l23.0a people. Estimates for low-incidence conditions thus have a high potential rate of error SOURCE. U.S. Department of Health and Human Services, National Center for Health Statistics. "Current Estimates From the National Health Interview Survey. United States, 1987," Vital and Health StatisticsSeries 10, No. 168. DHHS Pub. No (PHS) 88-1594 (Washington. DC. U.S. Government Prin
Table 241-Selected Chronic Conditions Among Metropolitan and Nonmetropolitan Residents (prevalence per 1,000 persons, 1987)'
Typo of chronic condition Metro Nonmetra
Selected ciroUL.tory conditions Rheumatic fever with or without heart disease.... 8.0 7.6 Heart disease 77.4 99.3 High blood pressure (hypertension) 113 6 135.7 Cerebrovascular disease 11.2 11 8 Hardening of the arteries 9.0 12 9 Varicose veins of 1.,4or extremities... 30.1 33 0 Hemorrhoids 41 7 51 6 Selected mapiratory conditions
Chronic bronchitis ...... 51,8 59.2 Asthma 39 9 40 9 Hay fever or allergic rhinitis without asthma 97.8 46 0 Chronic sinusitis 125 0 158 8 Deviated naoal septum 7.0 3 2 Chronic disease of tonsils or denolds .. 12 3 16 I. EbOhYsema 8 1 10 2 Selected Akin and musculoakolatal conditions Axthritis 123.8 158 9 Gout, including goutY arthritis 9 2 11 2 Intervertebrel disc disorders 16 9 16 0 lane spur or tendinitis, unspecified...... 8 7 11.5 Disorders of bone or cartilage.... 4 ? 5.1 Trouble with bunions 10 1 7 9 Bursitis. unclassified 19 0 20 9 Sebaceous skin Ost 5 9 5 8 Trouble with acne 19 4 18 8 Psoriasis .. 8 4 9.5
(continued on next page) r7, 4 46 Health Care in Rural America
Table 24 Selected Chronic Conditions Among Metropc,;.tan and Nonmetropohten Residents (prevalence per two personsow)' k Continued
Type of chronic condition Metro Nenmetro
Selected aktm end mummteekeletal conditionsCoetteued Dermatitis 35.8 38 9 Trouble with dry, itching skin (unclassified)... 16.8 22 1 Trouble with ingrown nails 19.9 37.1 Trouble with corns and calluses. 16.1 20 3 /10elements Visual impairment 31 9 37 9 11.0 Color blindness ...... 11.5 Cataracts 22.2 27 3 Glaucoma 8.2 10.8 Hearin& -.Marmot 82.0 108.5 Tinnitus 25 2 29 3 Speech impairment 9 8 10.9 Absencs of extremities 6 6 7.8 Paralysis of extremities, complete or partial 4 4 7 4 Deformity or orthopedic impairment 115.5 118.6 Badk C.5.4 63 3 Upper extremities 12.5 15 7 Loweextromiivi 50 4 55 2 Selected &emetic.. :-.deditices Vice: IP 1 23 1 Hernia of abdominal cavity.. 18 0 24.0 Gastritis or duedenitle .. 12 5 10 7
Frequent iadigestien .. . 22 6 35 2
Enteritisorcolitis.. . 7 9 9.9 Spastic colon 5 9 4 4 Diverticula of intestinee : 6 10 0 Frequent constipation 18 7 23 3 Other es'ected conditious Goiter or other disorda of the thyroid 11 4 11 7 Diabetes 26 7 31 6 Anemias 13 7 12 2 Erilepsy 4 1 4 9
Migraine headache... . 35 8 35 8 Neuralgia or neuritis, unspecified 3 3 5 1
Kidney trouble ...... 12 1 20 0
disorders .. . 1 3 18 4 Diseases of prostate 6 8 8 / Diseasnz of female genital organs 18 0 18 2
anew, estimates are based on a sample QA fewei than 123.000 people Estimates lot low preva/owce conditions thus have a high potential rate of error. SOMCE. U 8, Department of Health and Human Servxkou, Nat%o.1 Center for Health Statistics. 'Current Estimates From the Nationa) Health Interview Survey United States.1967,' Vital and Health Statistics, Series 10, H,. 166. NHS Pub No (PHS) 88-1594 (Washington, DC U SGovernment Printing Office, September 1988) any given income level, poor rural residents are States are required to provide Medicaid coveritgr, to much Less llely than poct urban residents to be all two parent families with incomes below State . covered by Medicaid. For farm residents, the lack of defumi poverty lev els. They must also cover all Medicaid coverage is siriking; fewer than 6 percent pregnant wumen and young luldren with 0.-Ornes of farm residents with incomes below thFederal up to 133 percent of the Federal poverty tlueshold, poverty threshold were covered by Medicaid in and they have the option of extendii.g coverage to 1987, compar ith over 44 percent of below- those with incomes up to 185 percent of the poverty poverty ints (and 38 percent of nonfarm threshold (Public Laws 99-509, 100-203,Other rural reside 0). A :lkely explanation is that poor indiv iduals howe% cr, still qualify for Medicaid poor farm tend tc. two-parent households onlyit theirinck,lesfall below State-defmecl who are often ineligible t...viedicaid. (As of 1990 eligibilit; levels). 5 Ciopter2--AuraiNpulatums e 47
Table 24Proportion of Metropolitan and Health Care Utilization INonntetropolltan ResidentsWheRated Their Health as Fair or Poor, Selected Years, 1975-88 Reral residents hate less contact with physicians than do people in urban aseas. Based on responses from the National Health Interview Survey, not quite Year Metro Nomnetro three-fon0s (74 percent) of the rural population
1975 11.2 14.2 have seen or telephoned a physician within the past 1980 11.0 14 0 year (table 2-15)." This proportion is slightly lower 1983 10.0 12 0 than that for the urban population (76 percent), 1985 9.0 12 0 1987 9.0 10 8 whose visits were also longer in duration (651). 1988 9.0 11 0 However, both urban and rural populations have increas -1 the number and frequency of physician NOTE: Numbers are adjusted for age (i a , account for differences in age distributions between contacts over the past two decades (table 2-16) metro end nonmetro areas). (651). SOURCES: U.S. Departmera of Health and Human Services, Centers for Disease Control. Compared with urban residents, rural residents National Center for Health statistics, are much more likely to visit a physician special-- Health, United States 1982, Health. Unit- ed States, 1986, ligalth. United States, in in family medicine end much less likely to van 198§, a n d Health. United States. 1989 one specializing in internal medicine (table 2-17) (Washington, DC U.SGovernment Priting (447). These differences are pr( oably largely due to Office, 1982; n- --her 1946, March 1989: and March 1990) the geographic distribution of the different special- ties (see ch. 10). Trends for visits to derlists prallel those for physician contacts. Rural residents average fewer visits per year and are less likely to have had a recent
Table 2-10Selected Preventive Behaviors and Risk Exposure of Metropolitan and Nonntetropolitan Residents, 1985
Percent of adult_noPulation with behavior Behavior Mout, Monmetro
Use seatbelts all or most of time . .... 38 9 25 5 Exercise regularlY 41 5 35 / Had Pap smear in past Year (women only)... ,,, 46 t 41 8 Had breast exam in past year (women only) 51 8 45 4 Had blood pressure check in past year 85 3 83 7 Have been told have high blood pressure at least 2 times le 8 19 4 Of those with high blood pressure. taking medication 64 9 67 9 20 percent or more above desirable body weight 23 1 76 9 CUrrently smoke cigarettes ZO 3 79 4 Of smokers, smoke 25 or more cigerettes per day. 26 0 28 ; Of women aged 18 to 44 giving birth n past 5 years Smokcd la 12 months before giving birth 31 7 31 9 Quit smoking when pregnant 22 0 18 A Reduced smoking when recnant 35 4 30 0 Of drinkers. in the past year: Consumed 5 or more drinks in nne day on at least 5 occasions 24 s 26 0 Have driven car when had too much to drink. 16 6 17 9 Exposed tc : least one job-related health hazard in current job 59 5 68 7
SOURCE. U.S. Department of Health and Human Services. Centers for Disease Control, Hyattsville. HD, Notional Center for Health Statistics, unpublished data from the 1985 National Health Interview rvey. Health Promotion end Disease Prevention componont.
Mine data are Opined for die differences in age distnbunons beisveri urban and nual populations.
0". el () Neatmrs.,!MtifirSWIgtz
48 Health Care in Rural America
Table 2-11Immunization Status of Children Aged 1-4, 19a5
fereent immunlz d Vaccination Iota! Central cities Other metro areco Nonmetio
Polio 55 3 47.1 56.4 50.0 Measles 60 8 55.5 63 3 !1.0 Mumlis 50.9 52 4 61.0 81 4 Rtihella 58.6 53.9 61.0 60.3 Diphtheria/pertusaia/tetanua 64.9 55 5 o8.4 67 9
NOTE: These rates are self-reportct ard based op resi.ondaut' memory. Rates reported by respondents whs1-. had consulted vaccination records were somewhat higher SOURCE: Data from the United States Immon.rets,:n Survey. as published in U S. Department of Health eud Human Services, Centers for flsease Control. National Center ivr Health Statistics. HealthUnited Stass. 1989 (Washington. DC: U.S. (overnment Printing Office, Mara 1990).
Tabie 2-12Percentage of Population W:tt. Health insUrancei Coverage. by Age and Residence, 19842
ALLssea .11:11.."N.rs 18-64 years Type of insurance Metro Notmetro Metro ttoneAtro Metro Nonmrtro Metre NAmetro
Private insurance. . . 77 2 74 7 72.6 72 3 '8 9 76.2 75 0 71 S b Medicare II 1 13 7 i lb 1 41' 1 1 4b SS A 96 i PUblic assistance (Medicaid, other) 61 53 )15 9 ; 6 3 9 5.6 76 Military/Veterans' Administration.. 3.2 3 9 2 7 2 9 3 1 3 6 i
No insurance. 12.3 145 )3 0 i6 2 13 8 16 1 9 9 0 9 atiumbere do not oddip to 100 percent, mince ind4..iduals may be coveted by more than me type of insure: e (e.g.. Medicare and private Insurance). Number applies to all persons under age 63 SOURCE. P. Ries, "Heafth Care Coverage by Stti4damographic and Health Chara.teris.ics. United States, 1984," Vital and HealthAllialiica, SPglos :). NO 162. D11HS Pub No (1716) 87-1590 (Washington. DC U S. Government Printing Office. NOvoi64,1- 1487)
Table 2-13Private Irsurance C. verrege of Metropolitan and Nonmetropontan Residents, ler
Percent et population with tire of health insurance Employmont-related Other private Public coverage Place o residence prisate covorage coverage only No ceverage
20 largest metre areas . 65 0 9 10 2 15 1
Other metru areas . 67 4 8.9 9 0 14 7
Nonmetro areas ... . . 57 4 13.4 11 8 17 4 _ SOURCE P F. Short. A Monheit. and K. &wires rdA PL_LLIe of Uninsured Americans. 011116 Pub No (PUS) 09- 3443 (Rockville. ) D U SDepruulent of Health and Human Services, September 1989) dental visit (table 2-15) (65 r, Eleven percent of residents ha only slightly more hospital days per raral residents have never visited a dentist(651). 100 residents in 1988 (table 2-18) (654 Rural Hospitalutilizationdifferences between rural and residents al:o have fewer emergency room visits urban populations are less consistent. Proportion- (447).As with phy',..,an contats, however,trends ately mere rural than urban people are hospitalized. in utilization are similar, tubanand rual grows but their hospital stays are shorter,l/ and rural have decreased both their rates of hospital &dads .
l2Data fromthe National HealthInterview 9-nvey showth;:.-uratre.sideats ostinnue to report skater huspoilstays than urban tesidents Steer 1987, bowrver. mai hospitals have acivally been eporting slightly longer average stays than urban hospdals ksee ..h s) lhe reason lof the discrepancy n uneleim r ) Chaptei 2Rural Populations 49
Figure 2.4Health insurance Status of Working Adults and Their Families, by Type of industry, 1987
Mloing .MMAW un,In0turIn0 n\\\ vrenzrob.1011.n. neransualeatloa -KIN\A\vm. ItIgaitetal 401, v10114, inekirbele* \\N \\\\ Pi018610fialeuveoes Public 24rdeli1lratIen, mleltary ltN\N _ 8a;eetrmsz fiancee aervioas
EntertMameat 1Alat MOSZSAtitiV
Coat:thee llot-imess,T,Nstmr-,-3 P4wecnai eery:rot A\VA 1VX.A\ft!Izmir Alorlaulture/lonoley/ --n Non 160117=1 0 i0 20 30 40 80 80 70 80 vo 100 Percent fmployment-rolated Unaneured hmvoance EQUHCE. Wesel ..zhnology Anseerrne01,109C4 Oft tram P.F. Short A. Morton!. and K. ifomeogard, A Pfofilo of frIguktradAntedttena, DPWpub. oo. (PK% at9-ts Toquilo, hift U.S DepaNYOW.1at Health and Human Ser.imaa,Septcrwer 1114).
Table 2-14---insureme Coverage of the Populaftn Un4-.1 Ago: 65, by Restdence and income, 198?
Dr.:we (percentof Federal Percent of population covv-ed poverty level) and residence bnInsuted Modllaid Private/other
Below pnwerty Metro.... 37 0 44 4 16 Nonmetro.. 38 3 35 5 26 2 Nonferra 38 9 4 22 7 Farm .. 32 4 5 8 61 8 100-1.414 Metro.. .. 4 13 5 50 1 Nomaetro. 31 59 3 nonfarm 32 ; o 7 58 farm .. :4 7 "1 9 71 4 158-199Z Metro 2t 6 1 67 8 13( turn ro., 1f3 8 5 3 74 9 Nonfarm 2t 7 5ir 74 7, Farm.. 15.1 1 3 133 288z a.? Nora Motro.. 10 5 1 1 88 4 Nonmetro 0 9 88 8 Nonfarm A, 0 1 0 890 Farm . 14 4 0 3 85 3
SOURCE Adapted f(om D Rowland and 8Lyons. -Trip1e JeopardyRural,Poor. and Unihsurod. Health Seri/Icon, Bes.arch 23(6)975-1004. february 1989 50 e Health Care in Rural America
Table 2-15interval Since Last Contact With Physician (1988) end Dentist ioob) for Metropolitan and Nonmetropolitan Residents
Interval since last visit Number of contacts per Residence person in Past Year* < 1 yr 1-2 yrs 2 or mo7e yrsb
Physician contacts Metro...... 5.5 77 8% 10 2% 120T Nonmetro...... 4 8 75 0% 11 5% 135% Dentist visits Metro 2 0 58 8% 7.1% 34 IX Nonnetro.... 1.7 51.8% 8 9% 393%
NOTE: Data are adjusted for differences in age distribution between metro and nonm .ro areas 'Physician contacts inclhde telephone. office visits, hospital visits, andother Dentist contacts inslude only visits. laIncludes those who have never visited a physician or dentist. SOURCE: U S DepArtment of Health and Human Services. Centers for DiseaseControl, National Center for Health Statistics. Health. United_States. 1289 (Washington. DC. U S Government Printing Office. March x2(20. sions and their average lengths of stay during the close second with 26 percent of the U.S. elderly. 1980s (table 2-19) ((551). over one-third of whom live in nonmerro areas. IL, contrast, the West and Northeast have a relatively TWO SPECIAL POPULATIONS: low rural elderly presence ((533). A CLOSER LOOK The rural elderly have incomes lower than those The rural population includes many subpopula- of the urban elderly (table 2-22). Based on the 1980 tions, each with its own characteristics. This section census, the median income is lower for nonmetro briefly examines two such subpoptdations IL greatet than metro elderly residents, and within both groups detail: the rural elderly and migrant and seasonal "mral" residents (by the Census definition) have iarmwolieers. lower median incomes than "urban" residents. In 1979. nearly one-third of nonmetro elderly persons The Rurat Elderly had incomes that were le:s than 125 percent or the Population Characteristics Federal pcwerty threshold ((533). The great majority of people age 65 and over in About 28 percent of both metro arid nonmetro the United States-71 percent--livt in metropohtan elderly residentslive alone (table 2-23) 033). counties (633). Nonetheless, elderly persons make Within nonmetro areas, howeser, thtte are subsran- up a greater proportion of the nonmaro than the tial differences in lis log arrangements. Only 16 metro population (13 v.1 ( percent) (table 2-20) percent of elderly persons on farms hve alone, for ((533). The elderly arc especially prevIlent intowns example, 75 percent live with their spouses. la of 2.500 to 10,000 resid-nts, where they make up contrast, only a little more than on,..-half ot elderly nearly 15 percent of tle population. Even the oldest individuals residing in smallCidcbandroVillblive ages are well-represented in these town,. the propor- ith their spouses. while u,er 30 percent live alone tion of the population that is age 85 awl over, for ((533). Thus, there is considerable vanation withia example, is higher in towns of this size than in any mral area- in the home-based faini4 and social other urban or rural categor, (table 2-20) ((533). resources Available to elderly people. Among geographic regions, the South has by far The gre,a. majority of amd elderly persons-96 the greatest number of rural elderly persons. One- percentare cover ed by Medicare (see table 2-12); third of the Nation's elderly live in this region less than 1 percent L ck any health insurance (5)3). (figure 2-5), and 38 percent of them Live in nonmetro Powever,the iuial elderly ate somewhat nore ktely arnas (633). Nearly 16 percent of farm residents in than the urban elderly to rely on Medicaid Jr other the South are elderly (table 2-21). The Midwest is a pubi:_. assistance, and they are less likely to have Chapter 2-Rural Populations 51
Table 2-16-Percent of Metropolitan and Table 2-17-Distribution of Physician Visits in Nonmetropoliten Residents Who Have Had a Metropolitan and Nonmetropolitan Areas, Physician Visit Within the Past 2 Years, by Specialty, 1985 Selected Years, 1964-88
Physician specialty Metro Nonmetro Year Metro Nonmetro General and family practice 11.91 52.61 1464 82.2 78.1 Internal medicine 51.7 10.0 1975 66.6 84.8 Pediatrics 6.0 7.1 1980 86.6 84.7 Obstetrics/gynecology 4.7 5.9 1982 37.5 85.2 General surgery 2.0 6.7 1985 85.9 84.0 Orlhopedic surgery 2.6 3 1 1987 87.6 85 6 Ophthalmology 3.4 3.6 1988 88.0 86.5 Other 17.4 11.1 Total IOC% 1001 NOTE: Numbers are ad4osted for ate (i.o ,account for differences in see distributions between SOURCE: 1985 National Ambulatory Medical Care Survey metro and nonmetro areas). data as cited in C.H. Norton and M.A. Mk- SOURCES. U.S. Department of Health and Human Manus. "Background Table_ on Demographic Services, Centers for Disease Contr4i, Characteristics, Health Status and Health Natlevial Center for Helth StatIstics, Services UtiLization," Health Services Hesich.,United States.,I982, Health, Unit-, Research 23(6):725-756. February 1989. ed Stftes, 148S, Health. United Statet, DIA an I HetalL_United States, 1989 (Washington, DC: U S. Ow/comment Printing urban elderly in nearly every category (645). This Office,1982., December 1386, March1985. lower utilization cannot be adequately explained by and March 1990). less illness and disability among the mral elderly. It is consistent, however, with relatively more difficult private insurance to supplemeLt their Medicare physical and economic access to physicians for policies (513). residents of mral areas. Hospital utilization patterns for rural elderly Health Status and Health Care Utilization persons, on the other hand, are not so easily Rural elderly residents are more likely than urban explained by leuened acccss to hospital facilities. elderly residents to have chronic health impairments Rural elderly individual., report more hospital dis (41 v. 36 percent) (table 2-24) (645), 5nd they are charges, but substantially shorter av,..age lengths of more likely to consider themselves iri oily fair or stay, than do +heir urban counterparts (table 2-29; poor health (table 2.25). Itapp....rsthat disability due (645). 'This pattern seemingly conflicts with the to acute illness is lower among rural than among image of hospital scarcity in rural areas, and it urban elderly residents, because when both chronic cannot be explained by a higher availability ilhome and acute causes of illness are considered, rural caregivers for the rural elderly (since just as many elderly residents actually report slightly fewer total lionmetro as metro residents live alone). days of disability (table 2-26) (645). A study of Medicare beneficiaries in five States Health care utilization trends for the rural elderly (Alabama, California, Minims, Montana, and Texas) parallel many of the trends for the urban elderly and lends some insight into the enigma. In this study, for the United States as a whole. For example, the Medicare hospital admissions decreased 18 percent number of physician visits rtr rural elderly person fin urban beneficianes and a dum.tic 22 percent for per year rose between 1983 and 1987, and within the rural beneficiaries between 1984 and 1986 (134 )." elderly group the frequency of visits rises with age Nut ,nly dui the rural trer-i follow the urban trend, (table 2-27) (645). Similarly, the proportion of the but thc greater declinc an admissions for rural rural elderly population who had seen a physician beneficiaL__ suggests the pos.,ibilitythat rural within the past year has risen over time (table 2-28). patients' hosj ital becoming more ble Nevertheless, physician utilization among the ruial that of urban patients. Furthermore, when admis- elderly continues to lag behind utilization by the sions were catgorized by type, by far thc greatest
WOOL nThen ripfeS NC for admissions adjusted for differences in 4c and r..adistabuticons Unadjusted tliflererkes *err.iiper.cra ha urban andi; pl:Seent for rural beatficales. C 52 Health Care in Rural America
Table 2-18Hospital Utilization of Metropolitan and Nonmetropolltan Residents
Measure Year Metro Nonmetro
Hospital discharges (number per 100 persons per year) 1966 8.7 11.4 Average length of hospital stay (days) 1960 6.9 6 0 Total hospital days per 100 population 1968 60.6 68.2 Average nuMber of des per person hospitalized per year 1967 8.3 0.0 Percentage of people hospitalised in past year 1987 0.22 9.22 1 episode 1967 6.72 7.32 2 episodes 1967 1.12 1.32 3 or more episodes 1987 0 42 0.62 Percentage of people with emergency visit in past Yelr 1066 18.22 16.92
SOURCES: 1986 date from Robert Wood Johnson Foundation, Access to Health_Care _In the United States;Reaults of a 1986 Survey (Princeton, N.J. Robert Wood Johnson Foundation, 1987). 1987 data from U.S. Department of 11c41th and Human Services, Centers for Disease Control, National Center for Health Statistics, "Current Estimates From the National Health Interview Survey. United States, 1987," Vital end Health Statistics Seees 10, No, 166. DHHS Pub. No. (MS) 88-1594 (Washington, DC. U.S. Goverment Printing Office, September 1988). 1980 data from U.S. Department of Health and Haman Services, Centers for Disease Control, National Center for Health Statistics. Health. United States. 1989 (Washington, DC: U.S. Golernment Printing Office, March 1990) difference in admission rates was for medical Migrant and Seasonal Farmworkers conditions treated in the "ocal hospitalparticularly "high-variation" conditions, for which there are Population Characteristics considerable differences in opinion among physi- cians regarding the appropriateness of nospitaliza- t!.S. agriculture is heavily dependent for farm don. In 1986, mral beneficiaries' admission rates for labor on the services of migrant and seasonal this group of conditions, which includes such farmworkers. The esernated 4 million such workers common diagnoses a.s pneumonia, bronchitis, an- are a culturally diverse group who have in common gina, and ga.stroenteritis, were 28 percent higher than a set of employ mentaelated health problems and admission rates for urban beaeficiaries34). who are characterized by low incomes, a lack of health insurance, a high proportion of individuals Thus, a plausible explanation for le aigher Ercni non-English-c eaking cultures, and (in the cise of migrant workers) high mobility. hospitalization rates and shorter stays of the rural elderly is that these individuals are more likely than Migrant and seasonal fannworkers are individuals their urban counterparts to be admitted to the "whose principal employment is in agriculture on a hospital for modest medical complaints. obsers a- seasonal basis [and who have] been so employed don, alai testing. If this explanation is valid it within the last 24 montns" Publit. Law 100-386). presents a perplexing policy issue, because many of Migratory w orlvers are those " who establish...for these conditions might, in an urban setting, be the purposes of suh employment a temporary censidered insufficient reasons for hospitalization abode," while seasonal w orkers are those who meet (rendering them unqualified for Medicare reim- the seasonal d.:fmition but are not nugrant workers bursement). In rural areas where access to urgent (Public Law 100-386). "Seasonal" is not defmed care is difficult, however, it may be that short explicitly in this law,,the Department of Agriculture hospital stays to ensure that a patient's condition is defines a "seasonal" farinworker as one who stable, or that the patient is available for tests, are performs 25 to l49 day s of farm wage work in l year looked upon as good care by the patient and (726). physician (albeit care that is costly to Medicare). It All estimates of the size of the migrant and is worth noting that, whatever the reason for the seasonal famiworker population are imprecise. State shorter stays, the effect is quite powerful; rural data and estimates suggest that there are approxi- elderly individuals, on average, spend 22 percent mately 4 million farrnworkers in the United States fewer days in the hospital during any one stay than and Puerto Rico, although this estunate includes do urban elderly persons (645). some duplicated counts of migrant farmworkers Chapter 2Rural Populations 53
Tabie2-1STrends in Hospital Utilization by Health Care Status and Utilization Metropolitan cid Nonmetropolitan Residents, Selected Years, 196448 There are few routinely collected national data on the health status of fannworkers; most that do exist are from farmworkers seen in federally funded Honmetro Year Metro migrant health centers (lvalCs). Although these Hospital dischargea (namileu per 100 Dotson: per peat) clinics serve only an estimated 523,000 persons per 1964. 20.8 11.3 yearabout 13 percent of the target population 1975 11.9 13.6 1980 11.0 14 1 (181)they are a vital source of health care services 1985 10 1 11 7 to migrant and seasonal farmworkers and the corner- 1987 9 3 10 9 stone of Federal policies to promote health services 1988 8.7 II 4 to this community. Average length of hospital. stay (days) 1964 9.4 7 7 A 1981 survey ,),f IVIIICs found that obstetrics and 1975 7.8 6.8 1980 8.3 7.5 hypertension were the most frequent reasons for 1985 7.2 6 8 visits to these clinics in 1979 and 1980 (table 2-30) 1987 7.1 5 8 (256). A 1984 survey of migrant farmw orker fami- 1988 6 9 6 0 Totalhospital inpatient days (per 100 population) lies identified some major health problems in the 1984 101.5 87 2 population (table 2-31), including: 1975 104 3 105 7 1980 91 1 105 8 ailments (e.g., urinary tract infections) associ- 1985 73 3 79 3 ated with poor sanitation and overcrowded 1987 65 6 63 4 living conditions (e.g., lack of toilets, hand- 1988 60 6 68 2 washing facilities, potable drinking water);
VOTE Numbers are adjusted f.n age vi.e . account a prevalence of parasitic infections that aver- for difrerences in age distributions between metro and nonmetro areas) These data are aged 20 times greater than in the general based on interviews and thus include only population; patients who were discharged alive acute and chronic illnesses related to pesticide SOURCES: U.S. Department of Health and Human poisoning; and Services. Centers for Disease Control, hazards affecting the health of pregnant women Rational Center for Health Statistics. Health, United States. 1982,HealthUnit- and children (605). ed States.,1986, bealth_United States. lam. a n d Health. United States. 1989 Most of the workers and their farnih sought (Washington, DC U.SGovernment Printing medical care mainly for acute illnesses. Mice, 1982. December 1986, March 1989, and March 1990) In 1988, 118 MHCs operated clinics in 33 States and Puerto Rico OM The number of MHCs and the (181). If ratios from the late I 970s still hold true. number of patient encounters (v is its)dithose centers apr:oximately 30 parcent of thesc farinworkers 1.2 have both incleased sligany in recent years,able million) are migrants (no. '2); in 1988, there were over 4.8 million encoun- s (about 41,000 per center) (181). Encounters Farmworkers are culturally diverse. In theEa.st. specifically from migrant and seasonal farmworkers many are from PuertoRico, Jamaica, and Haiti. In increased nearly threc times as fast as total patient the Midwest and West, the great majority of migrant encounters. In 1988, farmworker encounters repre- fannworkers are Hispanic. Native Amencans make sented about 35 percent of the total; the number of up a substantial proportion of the faxmworker cncountt .s per farmworker averaged 3.4. Among the population in the West and Southwest (726). States. California has both the largest total numbcr of migrant and seasonal farmworkers and the largest share of Federal MHC funds (table 2-33) (181). The living conditions of migrant and seasonal agricultural workers are typically poor. According to one source, the average annual family income in SUMMARY AND CONCLUSIONS 1983 for migrant workers was about $9,000,signal- Although rural" is a term uith considerable cantly below the Federal poverty threshold ($11,000 intuitive meaning, ty.conimonly used definitions for a family of four) (420). of the term describe somewhat different populations. 54 Health Care in Rural America
Table 2-20--Age Distribution of Urban and Rural Elderly Residents, 1980
Urban residents Rural residents Percett of total Ronurbanized area population in Alt United Urbanized 10,000 2,500- Farm Metro lionmetro area the. is: States All area and over 10,000 All residents areas areas
Age 65 or over 11.3 11 4 10.9 12 9 14.7 10.9 12.7 10 7 13 0 65-74 6.9 6 9 6,6 7 5 8,5 6.9 8.6 6.5 7.9 75-84 3.4 3.5 3 3 4,1 4.7 3.1 3 3 3,2 3.9 85 and over 1.0 1.0 0.9 13 1.5 0 . 9 0,8 0 9 1.1
SOURCE: U.S. Department of Commerce, Bureau of the Census, 1980 Census General Social and Economic Characteristics, vot 1 (Washington, DC U S. Government Printing Office, September 1081).
Most national statistical information is available by prevalence of cluonic disability and fatal injuries, the county-based metio/nonmelro designations, be- combined with a lower prevalence of some key cause county borders are relatively stable and enable preventive health behav iors (such as seatbelt use), consistent comparisons over time. Unfortunately, suggests that preventive and therapeutic health simple metro/nonmetro comparisons often blur im- programs addressing these areas might be particu- portant differences among populations that affect the larly appropriate to rural populations. perception of their health and other characteristics. Good information on health status and health Rural residents h7,te relatively low overall utiliza- programs is vital to the evaluation of programs, but tion rates for horitals and physicians, despite their when only metranonmeizo distinctions are ana- high number c . hospital admissions. Lower rural lyzed, information may he insufficient to a.sess incomes, combined with relatively low insurance health improvements adequately. coverage of nonelderly rural populations, suggest that these utilization patterns may be paroially In general, the picture of the rural population over attributable to financial access. The very low rates of the past decade has been one of sluggish and erratic Medicaid coverage among poor rural residents, economic and population growth. Improvements in especially farm residents, is of particular concern. the standard of living of rural residents have Interestingly, despite cortinued limitations in Rnan- generally lagged hphind thnse of urban residents, cial access to health care, trends in rural health care and rural povert.,las become a more pressing utilization over time have paralleled urban patterns. problem. These ger'fides obscure crucial regional albeit at a lower level. Physician visits have in- and local differences. The heavy dependence of creased, and inpatient hospital use has decreasw, for many regions and mral communities on single both groups. industries make them especially vulnerable to eco- nomic -flanges affecting those bidusuies. Counties The elderlyAttdispropottionaiely represented in economically dependent on agriculture fared badly nonmetro counties, w ith the South and Midwest during the early 1980s, for example, while rural having particularly high concentrations.of elderly counties that serve as retirement communities have rural residents. The broad brush of Medicare has been relatively successful at improving their eco- resulted in few elderly persons w about any health nonc well-being. The South l-ontinues to be 4 insurance, but rural elderly residents eye less likely reservoir of rural poverty. than their urban countcparts to hold prrv ate insur- ance supplements to their Medicare policies. The Despite persistent differences in important factors health care utilization patterns of the rural elderly such as income and education, mral residents exhibit parallel those of rural residents generally, with fewer fewer consistent indicators of poor health than might physician visits but mom hospitalizationsparticularly be expected. Mortality rates are lower in rural than short hospitalizationsthan characterize their urban in urban areas, the most spectacular exception being cou nterparts. for accidental deaths. However, rural populations are characterized by chronic impairments and poo. Although theu exact distribution 414.41.0s1, metro and self-perceptions of health to a substantially greater nonmetro areas is unknown, migrant and seasonal extent than urban populations. The relativ ely high farmworkas Are Another population of partici. la* (33 Chapter 2Rural Populations 55
Figure 2 5Regional Dlstribu:lon of Urban and Rural Elderly Residents, 1980
100 100 T 40 90I 61.3 80 oo 1
70 70 -I 82 SO 60 -
oo SO 40 40 36 30 90 I--
20 20
10 10 -I 3.3 I o 0 i =.7. Farm Metro Nonmetro SOUTH
100 t- 100 .
90-1 90 82.1 83 9 80 70.4 70 ! 70 1 83 8
80.1 t 00 1 50 1 50
1 40 I 40 I 36 2 29 6 30 1 30 1
20 ) 17.9 v8 1 20 ! le 10 s 0 6 0 ' - CM:3 Urban Rural Farm Metre Nonmetro Man Rural Farm Nonmetto NORTHEAST MIDWEST
SOURCE' Mat of TechnologyAssessmont, 1990 Data from U SDepartment of Commerce. Bureau of the Census, 1980 Census General Soaal and Economic Chataciensim vol. 1 (Washington, GG U 9 Government Pnnting Office, 1981) concern to rural health services. The health of thece Healt status and financial at.4..ess are only two of roughly 4 million farmworkers is greatly affected by the major contributors to health care utilization. A diseases related to their living and working condi- third potential contributoravadability of health tions. Federally funded MliCs appear to be a very resourcesis the topic of most of the remainder of important source of care to this population, even this report. though only a relatively small proportion of farm- workers seek care in these centers.
1.4 56 Health Care in Rural America
Table 221Percent of 1:-ban and Rural Persons Who Are Elderly, by Region, 1980
Entire Urban Rural resideLIA Metro Nonmetro .e.tirn residents All Farm areas areas
South 11,2 11.3 It 1 15.8 10.4 12.9 West 9..1 10.0 9.6 10 2 9.8 10,8 Northeast 12,3 12,8 10.6 9.8 12.2 13.2 Midwest 11,4 11,3 11 4 11.6 10.2 14.1
SOURCE: U.S. Department ot Commerce, Bureau of the Census 1980 Census General Social and Economic Characteristics. vol 1 (Washington. DC. U S Government Printing Office. September 1982).
Table 2-22Income Characteristics of Elderly Urban and Rural Residents (age 65 and olderi, 1979
Metro Nonmetro Total Urbana Rurala Total Urbana Rural*
Median income $13,'": 813.775 811.428 510,157 811,165 89,633 Percent of elderly with incomes
below Federal poverty level. . 12.f% 12 12 15 22 20 7% 18 4% 22 2% Percent of elderly with incomes below 125% of Federal poverty level 20 72 20.32 23 8% 30 9% 28 5% 32 6%
aAs defined by the Census Bureau, SOURCE. U S. Department of Commerce. Bureau of the Census. 1980 Census.General Social and Economic Charac-
teristics, vol.1 (Washington, DC U.SGovernment Printing Office. September 1981 )
Table 223Living Characteristics of Elderly Urban and Rural Residents, 1980
Urban residents Rural residents Nonurbanised area Living All United Urbanized 10,000 2.500- Farm Metro Ronmetro arrangement States All area and over 10.000 All residents areas areas
Living with others .. 665 648 659 602 606 TX 6 842 663 66 3 Head of household/
living with spouLe 556 533 535 52 I 533 624 746 546 58 3 'lying with other
reIouives ., . 88 92 100 61 59 7 7 86 9 ti 6 5 Living with non-
relatives. 2 1 23 24 1 8 16 1 '. 1 0 23 1 5
Living alone .. 277 288 283 31 1 396 244 1',8 276 2/ 9 Living in group .. quarters. ... 58 64 50 85 86 4 I 58 5 8
SOURCE. U S Department of Commerce. Bureau of the Census.1980 Census General Social and Economic Characteristics. vol 1 Was:iington, DC U SGovernment Pr,tritins Office. Septembei 1981) Chapter 2Rural Populations 57
Table 2-24Percent of Metropolitan and Nonmetropolitan Elderly Limited in Activity Due to Chronic Conditions, By Age, 1987
Metro Nonmetro >65 65-74 >75 >65 65-74 >75
Total with limitation of activity 36.2 33.5 40.7 41 0 38 2 45 3 Experienced limitation but not in major activity 13.6 11 9 16 5 17 4 15 3 20 7 Limited in amount or kind of major activity 12 7 11 2 15 1 13 2 11.5 15 9 Unable to carry out major activity 9 9 10.4 9.0 10.3 11.3 8 6
SOURCE! U.S. Department of Health and Human Services. Centers for Disease Control, National Center for Health Statistics. Hyattsville, MD, unpublished data from the National Health Interview Survey provided by D. Makuc. Oct. 4. 1989.
Table 2-25--Se if-Assessed Health Status Among the Metropolitan and Nonmetropoldan Elderly, 1981
Excellent Very good Good Fair or poor
Metro residents Age 65 and over...... 16 31 21.31 32.61 29 81 Age 65-74 17 7 22 2 32 8 27 2 Age 75 end over ..... 14 0 19 6 32 3 34 0 Nennetro residents Ase 65 and ove. 13 1 20 1 33 4 33 4 Age 65-74 13 9 19 8 35 3 31 0 Age 75 and over 11 8 20 5 30.6 37 2
SOURCE. U.S Department of Health at Human Services. Centers for Disease Control, National Center for Health Statistics, HyattsvilLe, MD, unpublished data from the National Health Interview Survey provided by D. Makuc. Oct 4, 1989.
Table 2-26--Rate of Restricted Activity Days Among the Metropolitan and Nonmetropolitan Emeny Due to Acute and Chronic Conditions, by Age, 1987 (number Of days per person)
Aite eroup 65 and over 65-69 70-74 75 and over
Restricted activitY All metro 30 4 25 1 11 3 34 6 Central city.... 33 8 28 3 16 0 36 7 Voncentral city. 27 7 22 9 27 6 32 7
All nonmetro. . . 30 2 24 1 10 7 35 1 Nonfarm. ... 30 7 24 3 32 2 35 0 Farm 24 4 21 8 13 3 36 9 Crnfined to bed All metro 14 1 It 8 13 6 16 9 Central city. 15 9 13 5 15 1 18 3
Noncentral city . 13 0 10 6 12 7 l5 6
All nonmetro.... . 13 2 10 4 12 / 15 9
Nonfarm... . 13 3 10 6 11 6 15 1 Farm 12 5 7 8 2 1 26 1
SOURCE. U.SDepartment of HaaLth and Human Services, Centers for Disease Control, National Center for Health Statistics, Ovattsville. MD, unpublished data fican the National Health luteiview SqrveY providprl G. Neadershot. November 1988
20-810 0 - 90 - 3 01 3 Table 2-27-Utilization of Physician Services by Metropolitan and Nonmetropolitan Elderly Persons: Average Annual Number of Physician Visits Per Person, 1093 and 1097
PhYsician visits per person 1983 1987 Age group Metro Nonmetro Metro Nonmetro
65 and over 7.9 7.1 9.1 8.2 65-74 7.5 6.8 8.8 7.3 75 and over.- 8.5 7.7 9.7 9.7
aData for 1983 include only visits tor which the location of visit is known. Visits in 1987 include those In unspecified places as well SOURCE: U.S. Department of Health and Human Ser- vices. Centers for Disease Control, Nation- al Center for Health Statistics, Hyatts- ville. MD, unpublished data from National Health Interview Survey provided by D. Makuc. Aug. 28, 1989.
Table 2-28-UUlization of Physician Services by Metropolitan and Nonmetropolitan Elderly Persons, 1964, 1082, and 1987
Percent of_sopulation with visits within oast Year 1964 1982 1987 Age Stoup Metro Nonmetro Metro Nonmetro Metro Nonmetro
65 And over 69 3 70.4 83.0 80.7 85 5 83 6 65-74 ,, 68,8 68.9 81.4 78.0 84 1 68 7 75 and over 70.4 73.2 85.7 85.1 87 7 88 1
SOURCE: U.S. Department of Health and Human Services, Centers for Disease Control, National Center for Health Statistics, Hyattaviile, MD, unpublished data from the Natlonal Health Interview Survey provided by D. Makuc, Aug. 28. 1989.
Table 2-29-Hospital Utilization by Elderly Metropolitan and Nonmeiropolhan Persons, 198P
Discharges Average Days of care (0er 100 population) lenitth of staY SII 100 population) Ago group Metro Nonmetro Metro Nonmetro Metro Monmetro
65 and over 25.4 26.2 8 8 6 9 221 0 181 0 65-74 22.4 23.6 8.7 6 9 194 8 162 2 75 and over 30.1 30.. 8 8 7 0 265 7 210 2
aData are based on interviews and thus do not include hospital staYs of persons who were not discharged alive Metro and nonmetro status refers to residence of respondent, not location of hospital used SOURCE: Unpublished data from the National Health Interview Survey. provtded by D Makuc. U $Depattment of Health and Human Services. Centers for Disease Control. National Center for Health Statistics, Hyattsville, MD, Aug. 28, 1909.
F7 Chapter 2Rural Populations 39
Table 2-30Most Frequent Diagnoses Reported by Table 2-31Major Illnesses Reported by Migrart 60 Federally Funded Migrant Health Centers, 19808 Farmworker Families, 1984
Number of Percent of families Diagnosis/reason for visit encounters renorting at least one member with specified Obstetrics 36.125 illness during Hypertension 32.067 Illness the past Year° Acute upper respiratory infection 30.364 Otitis media 17,931 Eye problems ,. 35 2 Anemia 17.889 Depreszion.. 23 1
Diabetes mellitus 17.266 Anemia... . 21 7
UrinarY tract infection 10,705 Arthritis.. . . 18 9 Family planning 6.827 High bLood pressure 16 8
Obesity 4,322 Stillbirth. . ... 16 2 Treuma 4,132 Kidney problems 14 8 Dermatitis 3.727 Obesity. 14 3 Heart disease 2.671 Problems during pregnanc, 13 4
Gastroenteritis 2,594 Asthma . . . .. 12 5 Intestinal parasites 11 3 °Not all of the 60 centers responding to the survey Deafness . 11 2 had complete data. Heart problems 11 2 Ulcers... 9 4 SOURCE: W. Hicks. "Migrant Health: An Analysis." Sunstroke.. 9 I. ErlingrY Care Focus, publication of the Diabetes Netional Association of Community Health 7 5 Cancer. 4 7 Centers, July/August 1982. as cited in V A. Epilepsy . 4,7 Wilk, The Ocouriational Health of Migrant and Pesticide poisoning 4 Ssasonal_Farmworkers in the United States Liver damage 3 Parmworker Justice Fund, (Washington, DC: 'Lazy eye, 3 8 Inc.. 1986). Tuherculobis 3 8 Infertility 3 2 Sickle cell anemia 4 9
Alcoh.ilism 1 9 Polio 0 9
aSurvey included 109 migrant farmworker families SOURCE R T. Trotter. -Project HAPPIER Final Report of Survey Results Migrant Family Survey." Sept 21,1984, as cited in V A Wilk. The Occupational Health of Migrant and Seasonal Farmworkers in the United States (Washing- ton, DC. Farmworker Jus(ire Fund. Inc i986)
Table 2-32Utilization of Fede Funded Migrant Health Centers, 198448
Percent change. 1084 1985 1986 1987 1988 1984-88
Number of centers° 114 120 1P, 119 1181) 33 Total center encounters (in millions) .. 4 !,2 4 08 4 C4 4 72 4 4,, 7 i Total farmworker encountersc (in millions) .. 1 42 1 43 i t4 1 6i 1 )0 ll ,1 Estimated total farmworker encounters per persond 3 36 3 35 1 41 3 ;0 3 40 1 2 _ °Number Of health centers receiving Federal fonds authorizi-cl under Sertiort 329 of the Pnbl;c HeAthtsivire ,Act, POf the Ile centers. 117 were reported cMigrant and seasonal farmworkers onll SOURCE U S. Department of lth and HUMAn Services. Health Rescmices And Sprvife: Aimin,stiat.oh. Health Care Delivety and Assistance, unpul,lithed 4,,A provIded by Jhgan, RorSville, MD Max0, 1990
essr , Table 2-33-State DiMribution of Migrant and Seasonal Farrnworkers (MSFW) and Federal Migrant Health Center (MHC) Funds. Fiscal Year 1988
MSFW 1.rcent MSFW MSFW user%.ofMflC Impact MHC funds, 1988 State population population Number Percent ratio Dollaraa Percent
Alabama. 6,483 0.2 0 0 0 0% 0 0 ..b Alaska... . 0 0 -- 0 0 0 0 -- 0 0
Arizona. . 31,795 0 8 9,310 1 8 29 5 650,011 1 6 Arkansas ..... -- 0 0 0 0 0 0 -- 0 0 California... 1.362,534 32 7 107.267 20 5 7 9 6,607.069 16 4 Colorado 49,347 1 2 26.37-4. 5 0 53 5 2.017,909 5 0 Connecti.mt 9,421 0 2 0 0 0 0 _ 0 0
Delaware.... 5,397 0 1 5,027 1 0 93 1 881,440 2 2 FINrida 435,373 10 4 77,113 :4 8 17 7
Georgia. 03,604 2 2 1.598 0 3 1 7 5.9144753.:538 "0: .. Hawaii,- -- 0 0 0 0 0 0 "- 0 0 Idaho . 119,968 2 9 12.935 2 5 10 8 465,026 1 2
Illinois. 20,840 0 5 5,894 1 1 28 3 454,985 11 indtana . 7.716 0 2 5.022 1 0 65 1 460.870 1 1
Iowa . 34.230 0 8 1,734 0 3 5 1 171,961 0 4 Kansti... 18,533 0 4 925 0 2 5 0 165.218 0 4 Kentucky. -- 0 0 0 0 0 0 _ 0 0 Louistana -- 0 0 0 0 0 0 0 0 Maine.. 8,6,4 0 2 .03 0 0 2 7 0 0
Maryland. 4.: r 0 1 0 0 ,:', 0 0 0
Massachusetts 7,111 0 2 100 u 0 1 3 78.000 0 2
Michigan . 67 227 1 6 26,676 5 1 34 7 2.535,192 6 3
Minnesota 13,344 0 3 9,254 I 8 69 4 t63 660 2 2 Mosissippi -- 0 0 0 0 0 0 -- 0 0 Missouri 20.324 0 5 0 0 0 0 130.346 0 3
Montana. 13,026 0 3 3,641 0 7 28 0 250 )72 0 6
Nebraska 18,756 0 5 1,421 0 3 7 0 224 475 0 6 Nevada -- 3 0 0 0 0 0 0 0
New Hampshire 726 0 0 'Y 0 0 J e0 New Jesey . 13,522 0 3 3.314 0 6 24 4 182,710 0 5 New Mexico 9,255 0 2 1,0A1 r) z 11 7 104,107 6 3
Me". York '0.811 0 1 1:' 0 7 11 7 i61,164 1 0 North Carolina 344.944 $ 3 2S 3!; 49 1 4 1 47 FPI 3 7
rr, - North Dakota 15.000 0 4 0 :! 0 0
... 8 Ohto . . 11.621 G 3 1 4ttk ;0 j 540,POO 1 1
Oklahoma. -- 0 i. $. 1 0 0 1, 0.6 0
Oregon 128,564 3 1 Z2,(01: 4 1 17 t. 1 444.900 3 A
Pennsylvania 24.711 0 6 5 I.q., 1 .. .'l ' COI lnr I '.
Puerto Rico 231,869 5 dp 71 211 14 r 11.. 1 .1... 12f. 9
Rhode Isla d 459 i',' q ', ,1 r 0 '
A. South Carolina 18,560 4 4 4,1.'0 .1 'i '',4"1:, 1 4 Sauth Dakota -- 0 0 0^ r.0 0 0
Tennessee 6,571 0 2 741 1 o 4 Texas 1;' 0 :$ $ P 1 ' :::::s. 500.138 t,' '( '4' -. cv. r Utah . 8,983 ,: 2 . .. ', i ' Vermont 178',1 06 1 '4 ' Virginia. 15,079 C' 4 , . .; 1
Washington 442.44, P ''. 't 24' r : f P. 441 . t.
.., West Virginia 2.700 F, 1 .% ' , 4 Wisconsin 3 194 0 1 c, 4 1...... o Wyoming s,100 0 2 4C', 0'1:"l. 0 4
1, 4., Totai 4,171.419 103 04 '.2,i,c4,4 .,. r4 .'r 4:' ,3,1 nt
aThe tc.tal funding shown dot's not refleut rroatvRtate tv..-401; ar..1 -) ' 11 i.0"", t- : t.4.i.:.11.1 57.215.080 The grand total for ftscal year 1468 w41;',;44 0,h,-,. bOashes indleate that none wet.. identifie4 Iv The Ste,0
SOTIRCE JFgan, U $ woar tment fH 1th ar.(1 H,uron . .1 . t' tor
Oifice of Migran.. Health rPrsovil (ommqvi. It 0. 1.1+,1 ' Chapter 3 Federal Programs Affecting Rural Health Services
70 CONTENTS Page INTRODUCIION 61 HEALTH CARE FINANCING PROGRAMS 61 Medicare 61 Medicaid 68 Exceptions to Medicare and Medkaid Rules for Rural Facilities 73 HEALTH BLOCK GRANT PROGRAMS 75 Maternal and Child Health Block Giant 75 Preventive Health and Health Services Block Grant 76 Alcohol, Drug Abuse, and Mental Health Services Block Grant 76 PROGRAMS TO AUGMENT RURAL HEALTH RESOURCES 77 Health Personnel Programs 77 Primary Care Facilities and Services 79 Acute-Care Facilities and Services 81 RURAL HEALTH POLICY AND RESEARCH 82 Agency for Health Care Policy and Research 82 Office of Rural Health Policy 82
Boxes Box Page 3-A. Summary of Formula for Medicare Payments to Hospitals for Inpatient Care, January 1990. 64 3-B. Qualifying Criteria for Rural Referral Centers and Sole Commimily Hospitals 66 3-C. Swing Bed Certification Reatiirements for Rural Hospitals 73 3-D. Rural Health Clinic Certification Requirements 74
Tables Tattle Page 3-1. Appropriatioos for Selected Federal Programs Affecting Rural Health Ser. Kes. Fi....al Years 1980. 1988, 1989, and 1990 62 3-2. Summary of Major Medicare Benefits, Copaymeir.s, and Coverage Lunitations, 199k.. 63 3-3. Some Basic Eligibility Characteristics of State 1 iedicaid Prow arris 69 3-4. Services Covered Under Medicaid 7 I 3-5 State Medicaid Hospital and I-hysician Reir:oursement Methuds. Fiscal Year1987 .. 72
71 Chapter 3 Federal Programs Affecting Rural Health Services ,II11/y. AWN/
INTRODUCTION HEALTH CARE FINANCING Federal programs affect the availability and provi- PROGRAMS sion of rural health services in a multio.ade of ways. Medicare This chapter presents n brief overview of major I health programs that fall into four categories. Medicare is a Federal health insurance program that serves approximately 34 million elderly and 1. Programs whose primary function is to pay for disabled persons and has an estimated 1990 outlay direct health servicesspecifically, Medicare of $108 billion (146.201). It is divided broadly into and Medicaid. These two programs fund a two parts, distinguished by their fmancing mecha- substantial amount of rural health care. and nisms. Part A (Hospital Pauran e) is financed consequently their policies can have a large through Social Sectnity taxes and covers hospital effect on the availability and provision of inpatient, skilled aursing facility, and home health services.1 services. Part B (Supplementary Medical Insurance) .,...'Federal block grant program that prowde is financed through a monthly premium and general States with resources to fund and prowtk revenues and covers outpatient and physician serv services. Three major programs that affect kr. andnonhospital medical equipment. Table 3 2 health care generallythe Maternal and Child surrmarizes Medicare 's bask medical care cov erage Health block grant, the Preventive Health dad and the ba....c limits and copayments it imposes. Health Services block grant, and the Alcchol. Because Medicare pays for the health care serv- Drug Abuse, and Mental Health block_int ices used by a large proportion of the population, and are described here. because its payment and regulatory policies are
3. Federal programs whose primary purpose is often used as models by other third-party payers, it 1 to augment the health resources avadable to can have a major effect on health care providers. In underserved areas and populations. Most of addition, Medicare explicitly distmguishes between these programs, which augment personnel, rural and uroan providers when paying for services. facility, and planning resources, are adminis The discussion below briefly describes some of tered through the U.S. Department of Health these payment policies. and Human Services' (DHHS's) Health Re- sources and Services Administration (HkSA). Hospital Inpatient Payment 4. Health policy and research. The Federal Basic Payment MahodsHospitaIs are reim- Governmem has recen ly undertaken to con- bursed for ill. atient :,ervices provided to Medicare solidate some health research and pc'ky beneficiaries according to a prospective payment efforts, including efforts focused on r....1 system TPS), under which a hospital is paid a fixi...1 health. Notable current efforts include those of amount for treating each patient (Public Law 98 the Agency for Health Care Policy and ke- 21).2 This payment amount is linked to the pnmary search and the Office c* Rural Healtn Pohcy. diagnosis of the patient and the diagnosts-related group (DRG) to which the patient is assigned. The Table 3-1.esenu recent appropri...... ,, figures fot system is based on averages and is attended to foster block grant and health resources prograras. effic lefty,,if a hospital is able to keep its own costs
- IA number of other Pede.s prograi is also finance or pro ide sines i health .are ke I.. she Deputin.ii ul t el oath Ara...Of.4sfiiall. i It ilkos litalaii1 And Medical Program of the thufolued Services) Ili:mow. their pohcic s have much ic,s onpa...t on rural licglei secs lc( s ..-to 4f1 thy. ti..I JC....fibta4. - i
Itelintliaa Health Service also proricks and funds sersiscs to the Agnificant plop/soon ot iliciota_I popn1 .4Ion4 oho it. Nally.. AIL14.1"0 .04 .140. ow,s1.4.4. Is tbe topic of a previous OTA report mid is not deseribed in this chapter (6/6) i 2Certain specialty hospitals ipsytiminc, Gamer. relubililation. and children s hosinkint arc , cc-rapt irorii dic frosiKui i -61- I 72 .._ aamillmfilM116=11111)jp OMMIMIN. trr...... ,wra.m.r.=Ammon. J 62 Health Care in Rural America
Table 3-1Appropriations for Selected rederal Programs Affecting Rurai Health Ser vices. Ftszal Years 1980, 1988, 1989, and 1990
Appropriation 1$ miriens 1980 1988 1989 1990
Block grant. programs Maternal and Child Health Services NA 528.57 554 27 553 63
Preventive Health and Health Servicese . NA 85 21 84 26 83 18 Alcohol. Drag Abuse. and Mental Hezith Services NA 643 20b 805 59b 1.192 85b Other pressers that affect health care facilities and services Community Health Centers 259 96 415 31c,'.4 435 36c 458 89c
Migrant Health Centers . 37 61 43 47 45 E5 47 37 Black Lung Clinics... 3 80 3 26 3 22 3 65 Rural Health Care Transition Grant Program NA N. 8 89 17 76 Progress that enact health personnal supply and distribution National Health Service Corpse 153 58 42 61 47 77 50 72 Area Health Education Centers 21 0 17 23 17 03 18 13 Border Health Education Centersf NA NA NA 3 93 Advanced Nurse Training Programs 12 0 16 76 17 29 12 77 /Advanced Nurse Tralweeships. 13 0 .2 45 12 84 13r4 Allied Health Grants and Contracts 5 14 0 Interdisciplinary Traineeships for Rural Areest NA NA 80 2 21 Nurse Anesthetist Iraineeships an0 Prcgrams NA 0 77 0 79 1 13 Nurse Practitioner and Nur,e Midwiiery Programs 13 4 11 49 11 85 13 43
Nursing Special Projects. . 15 0 11 68 12 85
Nurse Undergraduate Scholarshipst NA HA 11.1A05 2 95 Physician Assistant Training Programs 10 4 60 4 54 4 79 Family Medicine Residenciesg/General Dentist:fh. 16 51 35 41 14 3S 16 69 Family Medicine Departments (Undergraduate/ 9 50 6 70 6 62 6 68
KEY NA m not applicable a Excludesappropriation for program administrative supp(rt b The Alcohol and Drug AbuseTreatment and Renabilitation (40IR) b.ock grant Wet, CVMbInea with the Alcohol. Drug Abuse. ard Mental Health Services (ADM'S) block grant in 1989 Jublic Law /00-b09. as amended by Public Law 101-43) Fiscal year 1988 and 1989 figures in ths., table mclude appropriations for botb ADMS and ADill block grants, while tht 1990 appropriatior represents the new comLined appropriations clncludes Infant Mortality Initiative funds d.ncludes 812 25 millton roprogiammed from Vie National Health Service Corps (AIX> Field 1 rogram to Corr/trinity Health Centers (CHCs) to pay the salaries of NHSC assignees It CRCs Portion, of the original NHSC Fie:0 Program appropriations were reprog.ammed in tl,,s manner from 1983 through 1988 °Includes appospriations for National Health Seivic.e Corps Scholarship, Loan Repayment, u'i F.eid Programs ftlew program in 1994 The Interdistspiinart Trainenhik's foi Rural Arean Program was .lso apia.lr.at'd 80 million in fiscal year 1989 for a rtudy of rtral lie.'th manpower and edurItitn need., gincludes funds for :aculty devel41,ment, predoctoral trasni.g, and residency irainitg bUntil 1990, general dentistry tratning fund: were part of tbe appro)4.ation for larril ,11.umk
Fiscal Year 1990 arpropriltions In 014.1. tar' irclode i 1,wh rr SOURCE Office of 7..chro1ogv 19,10
lowerthantheaveragecostsrepresentedb,:beDRG ca.ies,and "outher"payments, payment, it may beep the differer.:e. additional payments for teaching and other The Wok PRG rams are adjusted according to a activities: lnd myriad offactors that depend on theh)cimoriofthe p iss-through mil-lents fin taplial,lirect medi- hospital, :mons otherthhip, to &gamine dic final cal edmation, and ,..ertain othet expense:. parnentamouna. Assummarizedinbox 3-ik,tc4al The components ot thebasicDR() payments Medicareinpatientpaymtnts recewld by ahospital ,:.ifferentiate explicaly between rural and urban over the course of a yea.e the sum of: hospitals. For each patieat treated by the hospital, total DRG payment', which are the sum of the the basicDR13 paymentis the prodikt of the basic basic DRG pnymeats, paymenfor transfer standardiLed pi., merit amount, the wage index, and
' 111115SHINNIUVIONINE-MINIINNIE
Chapter 3Federal ProgramsAffectingRural Health Services 63
Table 3-2- -Summary of Major Medicare Benefits, Copayments, and Coverage Linitabons, 1990
Benefit Copayments and coverage limitations
Pert A benefits Hospital acute inpatient care Coverage limited to 90 days per spell of illness.a plus 60-day 'lifetime reserve,- Coverage begins after patient pays $592 dedv-tible (pe- spell of illness). No coinsurance for days 1 through .3. PatiIt must pay coinsurance equal to 25% of deductible for days 61 through 90. Patient pays coinsurance equal to 50% of deductible for each of the 60 -lifetime reserve" days. After lifefune reserve is used up, patient is responsible f of the hospital bill Psychiatric inpatient care Same as acute inpatient but limited to 40 total days of coverage Skilled nursing Lacility care Limited to 100 days of care per spell of illness Patient must pay coinsurance equal to 1/8 of hospital deductible after day 20 ($74 in 1990). Does not cover custodial-only care in a nursing facility Patient must have been hospitalized for at Least 3 consecutive days within past 30 days for benefit to apply. Home health servicesb Patient must be homebound and in need of only part-time or intermittent nursing (no limit on other visits). Does not cover custodial services (e g., housekeeping, cooking, bathing) Servicas must be furnished under a physician's plan of care No coinsurance or deductible for most home health services, 20% coinsurance on new durable medical equipment. Hospice services Limited to 210 days of hospice care for terminally &ll patients Patient must pay coinsurance equal to 5% of drug costs or $5, whichever is less. Patient must also pay coinsurance equal to 5% of Medicare's cost for daily respite care services, up to a limit equal to the hospital inpatient leductibLo . atient must give up the right to most other Medicare benefits to receive hospice services (this election is revocable). Pert B benef its Physician and other medical Patient pays 20X coinsurance on allowed charges after initia' annual part services B 4eductible (deductible is t75 in 1990) Patient pays any part of bill that exceeds allowed cherge if physician does not accept assignme,,- Oh to a maximum) Benefit includes only dia6nostic and treaumnt services, most preventive services not covered c Hospital oinqsatient caje Patient pays 20X coinsurance on chw-ges after meetitg part B deductible AMbulatory surgical center Patient pays 20X coinsurance on applicable ASC payment amount after (ASC) care meeting part B deductible Mental health services Subject to $250 annual Medicare r.yment limit
aA "spell of illness" begins with the first day of hospitalization snd ends when the beneficiaiy "as hoi beeA an inpatient in a hospital or skilled nursing facility for 60 consecuttve days Nome health services are covered under both parts A and B CEXCepiOns Are vacine for pumenococcal pneumonia, vaccine or hepatitis B for high ru.) 11vdA. mutme Pap smears (as es July 1940), and preventive services provided to Medi,are hene(ik tuxes enrolled ih health maintenence org&nizations.
SOUKS. Office of Technology Assessment. 1994, Information from Commeto CiOarIng . Modicare and
Merifaid Guide (Chicago, IL, Commerce Clearinghouse. Inc , 1990)
the ORG weight. The DRG weight depends only on Addi:;onal payments arc also made to c.ertain the diagnosis of the patient, The standardized hospitals for other eUsts spectfk to the type of amount and the wage u dex, however, distmguish hospital and the population it seines. These include. among hospitals ot. the basis of whether or not the payments to acc.ount for the irukte4-t wsts to4 hospital is located in a mdrupolitan statistical area hospital of providing medical education to (Peftbox 3-A), physicians,
wy
I4 ..a.a.... .11==11 64 Health Care in Rueal Amen..a
Box 3-ASummary of Formula for Medicare Payment to Hospitals for Inpatient Care,January 1990
(1) (2) (3) Tori paymentstotal diagnosis-related group (DRG) payments + add.nonal payments + pass-through payments
(a) (b) (e) (1)T'sal ORG Paymentsregular DRG payments + payments for transfers 4- outlier payments (a)Regular DRG payment =standardized amount X wage index X DRG weight The standardizetl amount varies by location, with the difference between nonmetro and 'all other" metro areas scheduled to be gradually phased out. In 1989 these basic amounts were. $3,396.56 in metro areas of over 1 million population; $3,342.79 in all other metro areas; and $3,107.20 in nonmetro areas. The wage index applies only to die labor portion tit'the standardized amount uhelabor portion is 74.4 percent of that amount). The 324 metro areas each have a uniqee wage index. There are also 48 nonmetro wage indexes, one forall thenorimetm counties in each State (Rhode Island and New Jersey have only metro areas). The DRG weight depends on the diagnosis of the patient. There are 474 separate weights. (b) Payments for transfers: Hospitals recel, eapetdiem payment for each day before a patient is :ransferred(up to theDRG payment). Per diem rate Is regular DRO rate + the national average ';tigth of stay for that DRG (c) Outlier payments. Payments are the greater of day or cost payment. Day payments are 60 percent of the per diem rate for that DRO for each day abcve a set day outlier threshold. Cost outliers paymeots re 75 percentexcess cost of case over set cos.t outher threshold tor thatDRG in that hospitaL Outlier payments are financed with a Federal set-aside of 5 to 6 percent of I )ral DRG payments. Payments are fill:Aced fromseparate pooh foi metro and nonmro hospitals. (2) Additional payments go only to oualifyinghospitals. The teachimg adjustmentgoes to teaching hospitals to compensate fur the indirect costsof medical education. The payment is the totalDRG payment tunes an adjustment factor,the adjustment factor equals a1oxvrialely 7 7 percent ioi each 10 percent increase in the holmtah intern-and-residsnt-to- be4 ratio. The roportionate share adjustment goes to hospitalsserving high numbers of IOW-income patients. The factor for this adjustment is basednot onlyon the proportion of low-mcome patients but also on a formula that differs depending ona hospital's location and size. Adjustment !actorsfor small hospkalsare generally lower than those for large hospitals. The ESRD additional payment goes to hxpitals serving end-Aar renaldisea).epatients with ur-elatedillnesses The payment is a fixed amount per patientper vvezli t$335, for inpatient dial} sis SerViCes. (3)Pass-through paymentsgo to all hospitalsincurring relevant costs Capital costs (for rent, interest, depreciation) are paid at 85percent of Medware's shaie of actual costs. Direct costs of medieal education programs(e.g., for residents salaries) Arere antairsert m a paymant rate that equals ahospital-specitic fixed amoant per full-time equivalent t1-7TE, resideni. nines the current number ofFrE residents, times Medicare's share of inpatient days Direct r"sof other hospital-based eduealionprogram,' are reimbursed torreasonable costs actually incurred. ( 'her pass-througbpayments arc made for -asonable organ procuretnetu was And tor hat! debts of Medkare beneficiaries.
SOURCEAdapted from Pro4Pxtive Parnem 1w-esanent rumtupv un. A.thltongion, Iit t..)cpt..0 fo.s% mew t n.1,3 rjc( tiring too unpublorkA torsofing (Mammal.)xO Chapter 3Federal Programs Affecung Rural Health Servwes 65
payments to hospitals ben mg a disproportion- su... Jource uf lmalinpatient hospit.d care because ate share of low-irieome patients, and of the.. isohited hxation, Veather conditions, trav.4 payments for the costs of serv ing end-stage condinuns, o, the absence of other hospitals (see box renal disease patients with unrelated illnesses. 3 B). Because the closure of these hospitals would leave their Medicare patients without a local source Although a few rural hospitals are teaching hospi- of care, they qualify for special consideration. tals, and some are eligible for the disproportionate share payments, urban hospitals are more likely than Effective April 1. 1990 (Public Law 101-239). rural o nes to provide these services and to qualify fur hospitals that are designated SCHs receive Medkarm the additional payments or adjustments (491). PPS payments that are the highest of. Finally, hospitals are reimbursed for capital and the full Federal PPS rate, other "pass-through" expenses that are not affected 100 percent of a target amount based on the by the DRO rate. In the initial years of PPS, hospitals hospital's 1982 costs, or were reimbursed at cost for the Medicare share of 100 percent of a target amount based on the their capital expenses, but in the past few years hospital's 1987 costs.3 hospitals have not been able to recoup fully these An additional pyment may be provided if the SCH expenses due to congessionally mandated limits on experiences a deurease of more than 5 percent in its Medicare payment. In 1990, capital is reimbursed at total inpatient cischarges due to circumstances 85 percent of Medicare's share of the cost (140). beyond its contro'. Unlike other hospitals. SCHs are Payments fo Special Categories of Hospitals reimbursed for 100 percent of Medicare-related Four categories of rural hospitals qualify for special capitei costs. consideration under PPS: nral referral centers, sole A.. of Apnl 1990, 375 hospitals were designated community hospitals, Essential Access Community SCHs (448). Some hospitals that could qualify for Hospitals, and Rural Primary Care Hospitals. this designation have not sought it becaust. until the Rural referral centers (RRCs) are usually large. new SCH payment options were passed in late 1989. tertiary-care rural hospitals that serve a wide geo- their payments were higher under the usual PPS rates graphic alea. lb qualify for the designation, hospi- (488). These eligible but undesignated hospitals are tals must meet certain size and referral charactens- now also eligible to receive payment under SCH dcs (see box 3-B). RRCs are assumed to have cost rules, as are small (fewer than 100 beds) rural profiles more similar to urban facilities than to other hospitals for whom Medicare patients mak° up 60 rural hospitals. Thus, their DRG payments are based percent of the total caseload4 (Public Law 101-239). on the standardized amount applicable to metropoli EssentialAct.ess Cemmunity Hospitals lEACHS) tan areas of fewer than I million residents, rather and Rural Prtmar) Cal e HaspttaliCRPC Hs)are new than being based on the lower rural standardiLed designations. introduced in 1989 (Public Law 101. amount. 239). RPCHs will be small facilities providing emergency and very limited inpatient care that will The initial legislation stipulated that RRCs must initially be recertified every 3 years to continue to qualify for receive cost-based reimbursement. (An alternative payment system specific to these facili- higher payments. Subsequent legislation (Public Law 99-509, Public Law 101-239) made qualifica- ties is to be developed.) EACHs are envisioned as larger facilities that provide backup to primary care non automatic for all current RRCs until October 1. 1992. As of April 1990. 245 rural hospitals were hospitals: designated facilities will automaticall) qualify for SCH payment rules (as described above) designated RRCs (448). (Public Law 101-239). EACH and RPCH designa- Sole community hospitals (SCf1s) represent the nuns will be limited to hospitals in onlydfew States other end of the rural hospital spectrum. These are (see di. 8). No designations had been made as of hospitals, usually small, that are presumed to be the April 1990.
-- _------3Prior to April1990. SCHs were paid oo a prorated basis oi v./1441M1y25 per: col of il-c pci-...u.c paytaluto *.t, Lbc4101 Itgilfriiii DR(; I. 'IS,ik ramming 7$ percent was based on the hospital's actual costs 4Smafi rural hospitals in which Medicare patient thys sur 60 perkoat or rnorc of iota pa4,4 nt Javs .d,.) qu..A-lfy, 4 44.4 II lk it.441,641 plopoltion f Medicare patients is less than 60 percent (Public Law 101-239)
".. 1 4 0
=1.11, 66Health Care in Rural America
Box 3-BQualifying Criteria for Rural Referral Centers and Sole Community Hospitals A hospital qualifies as a rural referral center if it is located in a nonmetro area and meets any one of the following three specifications (42 CFR 412.96). 1. It has 275 or more beds. 2. It bas: a. at least 50 percent of its Medicare patients referred from other hospitals or from physicians not on the hospital's staff, b. at least 60 percent of its Medicare patients residing more than 15 miles from the hospital, and c. at least 60 percent of thc services it furnishes to Medicare t .i.neficories furnished to those who live more than 25 miles from the hospital. 3. It has: a. annual inpatient discharges equal to al least: 5,000 discharges (for nonosteopathic hospitals), 3,000 discharges (for osteopathic hospitals), or the median number of discharges for urban hospitals located in the same region; b. a case mix indexla measure of the medical complexity of patients treatedequal to at least: the national median case mix index for all urban hospitals, or the median case mix for urban hospitals located in the same region, excluding hospitals with approved teaching programs; and c. it meets at least one of the following thrce criteria: more than 50 percent of the hospital's medical staff are specialists, at least 60 percent of discharged inpatients reside more than 25 miles from the hospital, or at least 40 percent of inpatients have been referred either from physicians not on the hospital's staff or from other hospitals. To qualify as a sole community hospital (SCH), a hospital must meet onc of the following four sets of specificat:ons (42 CFR 412.92). I. The hospital is more than 35 miles from othei similar hospitals.2 2. The hospital is between 23 and 35 miles from other similar hospitals, and meets one of the following conditions: a. no more than 25 percent of the total residents or 'Medicare beneficianes in the hospital's service area are admitted to other similar hospitals; b. the hospital has fewer than 50 beds but (becaase it does not provide certain specialty services and consequently beneficiaries must seek care out:Ale the area for these serviceo is unable to meet the "25 percent" criterion above; or c. other similar hospitals are inaccessible for at least 1 mown of each year because of local topography or severe weather conditions. 3 The hospital is between 15 and 25 miles of other similar hospitals, but it is matcessible for at least 1 month of each year because of local topography or severe weather conditions. 4 The hospital was a Medicare-desIgnated SCH at the time that PPS was mpleiae-ated. (Because of this "grandfather" clause, many hospitals cuirendy designated as SCHs do not meet any of the first three criteria (739).)
1The case mix index is a measure of the coulmess of the casesatients) liv.led by a particular hospnal relative to the cost ol the national average of all Medicare hospital eases 2Congress in 1989 (Public Law 101-139) modified the eligibility requirements for SCHs to reduce the number of miles an $CH must be from another hospital from 50 to 35 aides (Tbe Secretary of the Department of Health and Human «ervires DHHS) may designate SCHs that are less than 15 miles from another hospital according to critena to be developed by DHHS i Ia addst on, under this law. the Secrewryof DHHS must develop and promulgate new distance entena based on travel ume Chapter 3Federal Programs Affecting Rural Health Services 67
Payment for Outpatient Care Four major factors may le id to urban/rural Medi- Payment to Ambulatory Surgical CentersAn care physician payment differences: ambulatory surgical center (AX) operates exclu 1. Physician specialty distribationHIbtorkally, sively for the purpose of providing surgical say ices for any givzn servke, general and family to patients not requiring hospitalization. lb recehc practitioners hav e had lowe- chines and Medicare payments, an ASC must be certified by the received lower Medicare reimbursements than program, and the services for which it bills Medicare practitioners in other specialties(475).Since must be approved for provision in that setting. ASC these rypes of physicians are disprown:m- services are reimbursed according to a fee schedule ately located in rural areas (see ch. 1)), iaral that categorizes each approved procedure into one of physicians' average charges and reimburs- six rate categories, depending on the complexity of ments are conebponding1) lower than those of the service (53 FR 3146). Only about 15 percent of urban physicians. ASCs are in rural areas (99), probaly because such 2. Type of phystcian servicesHistorically, surgi- facilities rely on high service volumes. cal services have yielded higher charges and Hospital Outpatieni PaymentUnlike ASCs, payments than counseling and other consulta- hospitals are not limited to any specific set of tive services(475).Since most physicians who procedures or services that can be provided to perform specialized surgical services are lo- outpatients.5 Nalsurgical hospital outpatient serv- cated in urban areas (see ch. 10), average ices (and some surgical ones) are reimbursed at the physician charges and payments may be corn lesser of either actual charges for the service or the spondingly lower ir rural tban in urban areas. hospital's reasonable costs of providmg the service 3Patients' ability to payRural residents have (as reported to Medicare on the hospital's annual lower average incomes than urban residents cost reports). Payment for most outpatient surgical (see ch. 2). lb the extent that rural physicians servkes (i.e., those that can also be performed by charge their patients correspondingly less than ASCs) is based on the lesser of two amounts. urban physicians do, these lower charges are reflected in lower "customary and prevailing" 1. reasonable costs or charges, whichever is charges and lower Medicare reimbursements. lower; or 4. Physician location in undersuffed areas 2. a 50/50 percent blend of the above rate and the Physicians practicing in federally designated ASC rate for that service (490). "high priority" rural Health Manpower Short- age Areas (HMSAs) are paid an additional 5 Payment to Physicians percent above the ac -roved charge for each Physicians are reimbursed for covered services servke reimbursedbyMedicaxe (Public 1.41% rendered to Medicare beneficiaries on a fee-for- 100-203). As of Januacy 1991, the bonus will service basis. At present, Medicare's "approv ed increase to 10 percent and will apply to all charge" for a service is set at the lowest of: rural HMSAs (Public Law 101-239) (see ch. 13). the actual billed charge; the physician's customary charge for die sen Beginningin1992. Medliare wall gradually ice, based on that physkian's pnor billings 'o switch from the c urrentreasonable chargepay the Medicare earner, or ment system to a fee schedule, in which payment for the prev ailing charge for chat sen ic, babed on bersice IS based on 4 nauonal rate (which lb then comparable physiciansprior htiling for the adjusted accordmg to geographic 1o4,4uon). Under same service in that region (bl5),6 thenossystem, Plc payment will be the lesser of the
411 is possible fothosptialro have us..topanerndepanmen, Latificel asanASC 4; IR 34082), but tin-oosr A du. tout.-NodPa Yment th6 thud dila restrictions on procedures that tun be perfonned under ASC ruks. rt 13 probable that few hospitals have done so 611a physician agrees to assertassrgnmene rambunemern from Mediare as paymentthfullhe. bOl .bc tmiscfp.s.aiy for ai.y amount over the 20 pen.ent voinsuraixe andany manauungdolut.oble. 11 the Oyu. andoes nos spi oththith h.i u Lu .ApCICd &the payment es not bound by the amount of the approved sane, aad the bencludary .s bathe any diflereoss or-euvcre d. 4.. I 441 Amt.. thal the allowed charge nip to a mtuumumh en addition io the. winsurame and deduoble Phy sr. sans may 'Ito& wurthei lu a.gurni.ra or. a ease-by.case basis Alternatively. A phy3s.sAA (An elesr to be a parauparing physkian by gift Ifiti h. 4vog1lor.A4 uri 41i Med4.41(Luw.. La the next 12 monlhS
- actual charge or the fee schedule amount. Once the families with dependent clukken, o first-time preg- new system is fully ;mplemented, payment amounts _ant women. These indiv iduaIgeneially become will not depend on the specialty of the physieian eligible for Medicaid through enrollment in another concerned (Public Law 101-23;). Urban/rural dif- public assistance program.' For example, all persons ferences in Medicare payments to physicians for a receiving payments under the Aid to Families with given service will still exist, however, for three Dependent Children program (AFDC) are automati- reasons. First, the new payment system includes an cally eligit for Medicaid. In addition, Medicaid explicit geographic adjustment factor, under which eligibility 'n most States is extended to all aged, services provided in an area with low physician blind, and disabled individuals (including children) practice costs will b.: paid at a lower rate than wito receive cash assistance under the Federal services in higher-cost areas (Public Law 101-239). Supplemental Secunty Income (SSI) program. (To Second, to the extent that rural physicians charbe be eligible for SSI, an individual must be disabled less than urban physicians and less than the fee and must have available meome and resources no schedule amounts, payments will also be less. Third, higher than established limns.) Fourteen States, the }NSA bonus will continue to apply under the however, exen. ise the so-called "209(b)'' option by new system. linking Medicaid eligibility for SSI beneficiaries to State standards that are more restrictive than Federal Medicaid standards (610).8 Medicaid is a federally aided, State-administered Congress has been expanding Medicaid eligibility program that provides medical assistance to a I since 1984 to include many individualsparticularly estimated 24 million low-income people (146). pregnant women and infantswho would not other- Operating within Federal guidelines, each State wise meet income and categorical standards. As of designs and administers its own Medicaid program. July 1990, all States are required to extend Medicaid Thus, although the Federal Government sets some eligibility to pregnant women and young children mimimum standards, Medicaid eligibility require- whose fan* incomes are within 133 percent of the ments, services offered, and methods and levels of Federal poverty level (Public Law 100-360). In payment to providers vary widely among the States. addition, 14 States have chosen the option, intro- The Federal Government pays 50 to 80 percent of duced in 1987 (Public Law 100-239), to make each State's Medicaid expenditures, based on State- eligible pregnant women and infants with incomes specific matching formulas (which are related to up to 185 per-Pnt of the Federal poverty level (table State per capita income) (199). Total Medicaid 3-3) (260.4140). outlays in 1990 are projected to be amroximately $71 billion, of which the Federal share wig be $40 Eligibility for Medieaid v anes a great deal among billion (199). the States, particularly for individuals whose Medi- caid eligibilityis based on their eligibility for Medicaid pohcies can have different effects on AFDC. In 1989, the State AFDC income eligibility urban and rural residents resulting from three levels for a family of three ranged from 14 to 77 factors: eligibility criteria, reimbursement methods, percent of ihe Federal poverty level (table 3-3) (260). and physician participation differences. There is no Thus, with the exception of pregnant women and direct way to measure urban/rural differences in infants, individuals in different States who are Medicaid status based on published data; virtually equally poor can differ enormously in their Medicaid all data on Medicaid are State-based. eligibility. Eligibility Until October 1990, when new Federal regime- Individuals are "categorically eligible for Medi- ments go into effect, famdy structure also affects caid if they have low incomes and fall into one of Medicaid ehgibility. . Pour two-parent families can- five categories- aged, blind, disabled, members uf not qualify for AFDC in many States, and thus in the
/Mates have Me option ro mac some orhei groups Guegoneally elrgibk well 4 g , dabiduaIN J1C Likiito!publu, J .iatanke bur nol receiving II. ao.tre individuals who lose p4.56, asaiciame chgtbdity due to ut,tealloJ dui dt41de4 ..hthtreti who would he hgu k ur 4.1SiMAJR,C insieruirOntlized.) 'The "209(b) opuon peramx stales t4, retain the mixt teSintInt 1ct1 ,1 110. ttiWti in 1k:sr IAte pfka (o UiFetkral Implemeomuon of Me SSI program VIVIOIMIMINOIMMNIV
Chapter 3Federal Pcograms Affecting Rural Health Servwes 69
Table 3-3Some Basic Eligibility Characteristics of State Medicaid Programs
Coverage for Pre 8flent AFDC-related income SSI-related women and infants (1990) eligibility cutoff eligibility Covers Income level (per month) (1989) more Has families eligibility Age In As percent restrictive medically with 2 level as cutoff dollars of Federal than Federal needy unemployed percent of for (family poverty requirements program parents Federal covered State of 3) level (1988) (1989) (1989 )a poverty level') infants
Alabama .118 14 100 1 Alaska.. ..809 77 100 3
Arizona ...... 293 35 100 3
Arkansas . . . .. 204 24 x 100 6 California .663 79 x 185 1 Colorado 421 50 75 1 Connecticut... 534 64 x x 185 6 Delaware .333 40 100 3 District of Columbia .393 47 x 100 3 Florida 287 34 x x 150 6
Georgia...... 376 45 x 100 4
Hawaii.. . .557 58 x x x 185 7
Idaho...... 304 36 75 1 Illinois.... .342 41 x x 100 1 Indiana.. .. 288 34 r 100 3 Iowa ...... 394 47 x 185 6
Kansas . 401 4, x 150 5 Kentucky 21$ 26 x x 125 2
Louisiana 190 23 x 100 is Maine 632 75 x 185 5
Maryland... 377 .5 x 185 2 Massachusetts 579 69 x 185 5 Michigan. .572 68 x 185 3 Minnesota ... 532 64 x x 185
Mississippi . .368 44 185 5
Missouri . 785 34 r 100 3
Montana... 359 43 x 100 1 Nebraska 364 43 x x 100 3
Nevada. . 330 39 75 7
NOW Hampshire 496 59 Y r 75 1
New Jersey ,. 424 51 , 100 5 New Mex:co 264 32 100 4
New York. . . 539 64 x 185 1 North Carolina 266 32 r x 150 6 North Dakota . 386 46 x x 75 1 Ohio.. 321 38 x 100 2 Oklahoma 471 56 x x 100 2 Oregon 412 49 x 85 4 PennsYlvania 384 46 x 100 3 Rhode Island 517 62 x 185 6
(continued on nexipage) past they have not been able to qualify for Medicaid would be 4. ategunt.41) eligible f4di iviedicaid except (table 3-3)(610),Since poor two-parent families arc that their income and resourt..esWVtoo high,and2) disproportionately located in rural areas (see t..h. 2), hav e high medit.4 expenses.. In the35 States(and the poor rural residents have been less likely thanpour District of Columbia) eaat have medically needy urban residents to be Medicaid-eligible, programs, these individuals become eligible for Medicaid once they have spent enough on medical States have the option to offet Medicaid to care to reduce their net resources to State-established "medically needy" individualsthose who,li limits. Each State may desigitate its own medicall) C (I 'Table 3-3--Some Basic Eligibility Characteristics ot State Medicaid ProgramsContinued
Coverage for pregnant
AFDC-relat . income SSI-related women end infants_11990) eligibilit itoff eligibility Covers Income level (Per month) (1989) more Has families eligibility A. In As percent restrictive medically with 2 level as cutoff dollars of Federal than Federal needy unemployed percent of for (family povertY requirementr program parents Federal covered State of 3) level (1088) (1989) (1989)4 poverty levelbinfants
South Carolina. . 403 48 185 6 South Dakota 366 44 100 2 Tennessee 365 44 100 6 Texas 184 22 130 4
Utah... . .502 60 100 Vermont .$29 75 185 6 Virginia.... 291 35 100 2
Washington.... . 492 59 185 7 West Virginia.. .249 30 150 7 ind Wiscoosin... .517 62 1
Waning. ... . 360 43 100
ABBREVIATIONS: AFDC . Aid to Families With Dependent Children 4As of October 1990, all States will be required to make eligible for AFDC (and Medicaid) all families who would be eligible tor AFDC under current rules except that the principle wage-earner is unemployed (Public Law 100-485), bAs of April 1990, all States must make eligible for Medicaict all pregnant women and infants up to age 1 whose incomes are no more then 133 percent of the Federal poverty level (Public Law 101-490) All children born after September 1990 whose family incomes are within this amount must also be made eligible through the age of 6 (Although this new standard is a Federal mandate, in fact it may take some time for many States to actually come into compliance with the new law )
SOURCES 1 Hill, National Governor's Association, Washington, DC, unpublished memorandum, MO 11.1939, U S Congress, Congressional Research Service. UMAjc.id Source Book Background Data arc] Analysis. House of Represencauves Committee Print No 100-AA (Washington. DC U S Cover ent Printing Of- fice. November 1988)
needy income and resource standards, but these although in :act almost none do so (475). Second, standards cannot exceed 133 percent of the State's under a part of Medicaid known as the Early and AFDC income and :esource standards (610). Thus, Periodic Saeening, Diagnosis, Treatment (EPSDT) even in the Statesthatoffer radically needy Program, children can receive a broad range of programs, Medic& eligibil'Pv under these programs screening and followup services not available to varies with AFDC standards. other Melicaid beneficiaries. And third, St-ttes In some cases may obtain waivers to the usual rules. Covered Services enabling them to offer certain services to a specified prpulation (e g., the elderly). tinder one Medicaid As a condition of matchuig funding, the Federal waiver program, for instance, States may provide a Government requires State Medicaid programs to wide range of community-based servkes necessary cover certain basic inpatient, outpatiern, and long- to keep people who would otherwise be institution- term care services for their categorically eligible alized in their homes. populations (table 3-4). States also have the option to cover additional services. Compared with Medicar..., Medicaid offers a in general, any services covered under the pm much inoader range of services, but it also places gram must be made available toall Medicaid much striae, lams on their use. Some unportant recipients, but several major exceptions to this rule types of limits' are: exist. First, States with medically needy programs may provide more limited coverage for these indi- Mechanisms to control the tae cf lumpitals viduals than for categorically eligible individuals, Particularly important are limas on the length
tome of these limus--e g . on ambulatory care outs to physk mos Jo nut apply lu 1.,tu1tiren moving Senn" onde: the EPM/T program
erit Chapter 3Federal Programs Affecting Rural Health Services 71
Table 3-4Services Co- red Under Medicaid Restrictions on physkian iisitsAs of 1986, 44 States and the District of Columbia limited Mandatory services the annual number of physician visits covered Inpatient hospital services by Medicaid(653).Six States limit the number Outpatient hospital services Physician services of reimbursable office visits (limits range from rarly and Periodic Screening, Diagnosis, and 12 to 48 visits a year); 3 States limit the number Treatment (EPSDT) for children* of home physician vicits;1 State limits the Family planning virvices and supplies Laboratory and X-ray procedures number of emergency room visits per yew: and Adult 041.1ed nursing facility care 6 other States limit the total number of physi- Home health care services for adults ciat visits provided for other than hospital Rural health clinic services Services of certified nurse-midwives inpatient care, with limits ranging trom 12 to 24 Optional _melees visits per year. In addition, 10 States limit Additional home health services physician visits in the hospital, and 11 limit Additional dental services visits in long-term care facilities(653). Services of chiropractors, optometrists, podiatrists, and other licensed practitioners Prior authorization and second opinion re- Clinic seivices strictionsMany States require recipients to Othe- diagnostic, screening. preventive, and receive permission from Medicaid before re- reha ilitative services Drugs ceiving certain servicese.g., elective surgery, Intermediate care facility services care provided in certain settings, or psychiatric Eyeglasses, prosthetic devices, and orthopedic shoes services. Stares may also require the opinion of Hone and skilled nursing facility care for a second physician before a paticnt may un- Children dergo certain procedures (15.53). Private duty nursing Inpatient psychiatric care for children Many other limits on specific services exist as Physical, occupational, and speech therapies Inpatient services to elderly persons in men' well. Some States limit the number of particular tal disease or tuberculosis facilities services provided (e.g., psychiatric visits, eye exams). Otaer unudical or remedial care recognized in States also impose limits on institutional and home- der State law, including transportation and emergency services based long-tem, care services, therapy services, home medical equipment, and the number and types *LPSDT is a program within Medicaid that iombines of prescription drugs that are covered(653). outreach, health screening, followup care for detected conditions, and case management Each Reimbursemen State is required to offer EPSDT services to all Meacaid-eligible children and youth under 21 Hospital CareMost States now pay for hospital SOURCE. U.S, Department of Health and Human Ser- care based on some kind of prospectively set rate per vices, Health Care Financing Administra- tion, Medicare and Medicaid Data Book, 1988 day, per discharge, or per admission (table 3-5). (Baltimore, MD. U S DHHS, April 1900 States use a wide variety of methods to set these rates, including selective cont.acting, hospital- of hospital sta) and total number of days qf care specific negotiated rates, DRG-based methods, anti covered annualy. in 1986,11 States hmued the past hospital costs (610). Only three States (Dela- number of days of hospital care for whichthey ware, West Virginia, and Wyoming) base their would pay (653). Restrictions ranged trot., Medicaid payment for inpatient care to a patient on limits of 12 to 60 days a year and 14 to 30 days that patient's actual incurred costs; one additional for each admission or spell of illness. In State (Utah) does so only for rural hospitals (343a). addition, .2 States restrict the ability of patients Medicaid payment methods for hospital outpa- to be admitted to the hospital on weekends or tient services are el en more %aried, ranging from fee on days preceding the day an operation is schedules and other forms of prospective rates to scheduled. Ten States limit the number of payments based on either costs or charges.'° Only hospital outpatient visits a year that will be Delaware and Wyoming pay for both ihpatient and reimbursed. outpatient services based on hospitals' actual costs
1113Asusall=4"osts refesaiacnudkomsotunangpeuamsog.onesalammsuppnckdcpro.gauvry ....hdigc, ea t. thy prh.c4that taquia.. Assign to services when billing patietts or mem. Charges are not recessanly directly related to costs.
. e 72 Health Care in Rural America
_- Table 3-5State Medicaid Hospital and Physician Reimbursement Methods, Fiscal Year 198? State° Hospital inpatieut Hospital outpatient Physiciansservices
Alabama Prospective rate Fee schedule Prevai' charges Alaska Prospective rate Frospective rate Prevailing charges Arkansas Prospective rat.e Fee schedule Fre schedule b California Prospective rate Fee schedule Relative value scale Colorado Prospective rated Percent of costsc Relative value stale Connecticut Prospective rats Prospective rate Fee schedule Delaware COst-bused rate Reasonable costs Fee schedule District of Columbia Prospective vete° Prospective rate Fee schedule Florida Prospective rate Prospective rate Fee schedule Georgia Prospective rate Cost-to-charge ratio Fee schedule Hawaii Prospective rate Negotiated rate Prevailing charges Idaho Prospective rats° Reasonable costs Relative value scale Illinois Prospective rate Fee schedule Fee schedule 'Miami Prospective rate° Reasonable costs Prevailinecharges d Iowa Prospective rate Reasonable costs Prevailing charges d Kansas PrOseective rete Fee Schedule Prevailing charges Kentucky Prospec .ve rate Percent of charges Prevailing charges Louisiana Prospective rate Reasonable coats Prevailing charges Maine Prospective rate Reasonable costs Pee schedule Maryland Prospective rate Prospective rate Fee scheduce Massachusetts Prospective ite Prospective rate Fee schedule Michiean Prospec.i. rated Provailing costs Fee schedule Minnesota Prosnecti.e rated Prevailing charges Provailing charges Mississippi Prospective rate Reasonable tests Fee schAule Missouri Prospective rate Percent of costsc Fee schedule d Montana Prospective rite Reasonable costs Fee schedule N4loreska Prospectivc rate Prevailing charrls Prevailing charges Nevada Prospective rats Fee sthedule Fee schedu.a New Hampshire Prospective rete d . e Reasonable costs Fee schedule d New Jersey Prospective rate rost-to-charge ratio Fee schedule New Mex.co prosim.tivis rate Reasonable costs Prevailing charges New York Prospective rate Fee sehedule 40 schedule North Carolina Protoective rate Percent of cost Prevailing charges North Dakota Pret active rated,* Reisonable costs Prevailing charges Ohio Prospective rated Reasonable costs Fee schedule Okithoma Prospective rete Percent of inpatient rate Prevailing charges d Geegon Prospective rate Percent of cost Fee schedule d Pennsylvania Prospective rate Fee schedule Fee schedule Rhode Island Prospect. rate Provrective rate Fee sthedule South Carolina Prospecti.a rated Percent of cost Relative value scale South Dakota Prospective reted Reasonable costs Prevailing charges Tennessee Prospective rate Reasonable costs Prevailing charges Texan Prospective rate d Reasoneble costs Prevailing Charges d f Utah Prospective rate of charges Fee schedule Vermont Prospective rate Reasonable costs Fee schedule Virginiu Prospective rate Peasonable costs vee schedule Washington Prospective reted Prospective ruts * schedule West Virginia Cost-based rate Fee schedule e schedule Wisconsin Prespectivo rate Prospective rata }revailing charees Wyoming Cost-based rats Reasonable costs Prevailing chi, ,.r
°Arizona does tot opera.e a fully fl.dgod Medicaid prog ram, its more limited medical assit ince program oper- ,ates PI a demenstration program undei waivers of certain Medicaid requirements u0i ne8..tiated rates cOr percent of Oarges dRates are weighted by diagnosis-ralated group 4)".:urrent as of 1989 fRural hospitals are paid 95 percent of r sonable costs SOURCES J Leuhrs, National Governor's Association, Washington, X. Summary of State Medicaid Inpatient Hospital Covera8e." memorandum to interested parties. Dec 18.1089. and U SCongr. s, Con8ress- ona 1 Research Se rv co. Medicaid Source Book Bac'lround Data and Analyses. House of Representatives Committee Print No 100-AA (Wsshington. DC U SOoverament Print.ng Office, November 1988)
en,3 Chapter 3Federal Pravams Affecung Rural Health Services 73
Physicians accepting Medicaid reimi-tentent Box 3-CSwing Bed Certification must agree to accept it as payment in full for covered Req.trensents for Rural Hospitak services. In general, Medicaid fees are well below To be eligible for the swing-bed program, a hospital those paid by Medicare, which ,i . e in turn lowei than must: those paid by the private sector." Recent legislation Be located in a rural area. In this program, requires the Federal Government to mole clo ely "rural" is defined according to the Census monitor State Medica... . rateslotobstetric and Bureau's del_ don (any 3eographic. area not pet'aatric services in order to ensure that rates for designated as urban in the most recent census). these serv ices are not so low as to restrict access Have fewer than 100 certified inpatient beds (Public Law 101-239). The impact of this mandate (exclusive of bassinet.: and intensive-care remains to be seen. bed-). Have ieceived a certificate or need for the provision of long-term care services from its Physician Participation State health planning and development agency Little is known about urban/rural differences in if the State is one that requires such aioroval Medicaid physician participation (i.e., physicians A hospit1.1 may not: who accept at least some Medicaid patients). There Have in effect a 24-hour nursing waiv er are draraatic differences in partipation across spe- granted wider the flt ubility ef personnel cialties, a 1984 surv ey found Medicaid participation standards. to range from 97 peroent among anesthesiologists to Have had a swing-bed approval terminated 60 percent among psychiatrists (394). Family prnti- within we 2 years prior to application (140) tioners had a relatively 'aigh participation rate in this A swing-bed hospital must meet certain stand- survey (87 percent). with rates for pedi &loans, a..ds for slotted nursing facility services in addition nter nista, and general practitioners somewhat lower to the standards it must meet as an acete-eare (80, 80, and 82 percent, respectively) (Y-stetrician/ general hospital. Accordingly, suchhospital must gynecologists had low rates (72 percel..) that were provide, or arrange to have provided by others. second only to those of psychiatrists. A study of rehabilitative services (including physical ther- pediatricians found that the proport-on who acceptee apy. oeoupational therapy. speech therapynd Medicaid patients declined from 85 te 77 percen. anthology); dental services; 'oetween 1978 and 1989. and only 56 percent of social services; pediatricians in 19f ) accepted new Medicaid pa- patient activities (provided by a qualified tients without regard to their payment status (743). activities coordinator): and -.lischarge planning Excepuons to Medicare and Medicaid Rules A swing-bed hospital must also meet res,wre- fo,* Rural Pactlitieg ments regarding patients' rights (140) The Swing-Red Program Physician ServicesAs of 1987. 30 States and ate care atid long-teim Lae hay e d if ferent the District of Columbia paid for physicians' serv goals and staffiti{, need., thus. the two generally ices to Medicaid beneficiaries according to a set fee hav e. c1iffei ent certific ation requirements undo th;.' schedule, 4 of these States derived the fee abet' Ile Medieare and Medieaid proglarns and must be from a relative value scale (a s...ale that assigns provided by different institutions (or distinct parts of weigins to the various proeedures) (table 3-5)(610), institutions). Under the swing-bed program. how The remaining 20 Staft.t.S based payments on actu.d ev er. sm.dlrar. ' hospitals that meet certain certifica- customary or prevailing charges, but since several of tion standaids L.ee box 3-Ct may use their beds those States no longer regularly update their eakula- interchangeably for acute and long-term Lae and tions of pre.,ailing charges, at.1 fees may be m.k.h receive reimbursement .n either case (Pub Ill Law lower than current charges MO). 96-499). Medicaid pcirnits sw ing beds to be used for
111n fact Med,caad as prohdmizd b Ian from paying mom ha Anitt Man 14.)11arc would pa) W. Nom dA14.1 iii a ft %).. hicakaid Tpareatly does kn mum pay more than Medicare doe).
4 ?
74 Health Care in Rural America
acute. skilled nursing, or intermediate care;12 Medi- care covers only acute and skillA nursing care. fox 3-DRural Health Clinic Ce-nficatian Requirements For swing-bed care equivalent to the care pro- vided in a skilled nursing facility (SNF), Medicare To become certified as a rural healei cPruc under pays the same average rate per patient day as would Medicare and Medicaid, a clinic must: be paid for routine SNF se-vices under the State's be located inCensusdefmed rural area that Medicaid program As of 1987, 983 hospitals were is aiso a federally designated primary care Medicare-certified to operate swing beds (625). Health Manpower Shortage Area or Medically Underserved Area.,1 Rural Health Clinics be engaged primarily in the prc..ision of outpatient primary rredical care; A facility certified by Medicare and Medicaid as employ at least one physician assistant or a rural health clinic (RHC) is eligible for exceptions nnrse puactitioner, to nbrmal pay_cer.t rules governing services pro- meet apphcable Federal, State. and local re- vided by midlevel practitionersphysician assistants quirements and Medicare arid Medit.aid health (PAs), nurse practitioners (NPs), and certified nurse- and safety requirements, midwives (CNMs). In most cases outside of RHCs, be wider the medival direction of a ph} sioan Medicare pay sfor services provided by these (who mutt be on site at least once every 2 practitioners only when they are "inr;,tent to" the weeks); services of a physician. This statutory restriction has have a midlevel Factitioner--a rase practi- tioner, physician assistant, or cenified nurse- meant that midlevel practitioners who were not midwifeavailable to provide patient care working under the direct supervision of a physician, services in the clinic at least 50 ptrcent of the or who were providing services normally provided tunic ihe clinic is open;2 by physicians (e.g., physical exams), could not provide routine diagnostic services iincluding receive Medicare reimbursement (617). Medicaid laboratory services). rules v .ry by State, but all States place some maintain health records on all patients. restriAions on midlevel practice. Under the Rural have written poilzies governing the serv Health Clinic Act (Public Law 95-210), however. that the clinic provida, the servit..es of these providersincluding swift es have available drugs, blood, and other supplies normally provided by physicianscan be reim- nxessary to treat medical emergencies; and bursed by Medicare and Medicaid if they are have arrangements with other i roviders and suppliers to ensure that clinic I), 'tents have provided in a certified RHC.13 aCCets to inpatient hocpital care and to other RHCs may be provider-basedior exampli ic phy skian and laboratory services not pros ided outratient deparnnent of a hospitalor freesia:- -g in the clinic (Public Law 95-210), clinics and physicians' offices. To be certified as an RHC, a facility must be located in an underserved son oag pupalanum who Ate undo-wood also rural area, meet certain standards for re.,3iclan qualify In addition. the Omnibus Recoia.ileation Act of 1989 (Pubhc Law 101-239) gives State governors the discretion 8, supervision ard mir:mum level of services offered, de.signate eligible sues he: rural health clinics that may not be and have a midlevci practitioner on duty at least 50 fzde-alldesignated as shortage areas p,...:ent of the nine the clinic L.. opcn (see box 3-D1. 2Tnisrequitanellt redth.ed froto i.: 51i pi neat a.. of The services of clinical psychologists and caaicai A.)c obcr 069 Pubhc Law 1101 219) social workers are now also reimbursable if piovicled in a certified RHC. although .hese pracdOners do '11-in lusive rate per vicit computed by Medicare not count towards certification requirements.14 (lAsed on past ec.: ts), with an end-of-year adjust- For freestanding RHCs. Melcue and MccILaid ment to reflei.4..tual costs. Total paymentE. bow make interim payments for covered services at an er.anr.,i exeed a Ipccifici,1 ceiling on average
inn contrast to skilled nurs.as care. intemiediaie uare pnmanly mquireapersonal ;Are ow ix.iuiig. raihci ithin inure medically intensive care (e.g giving injections) that requires a trained nurse 13Medieare eovaage for CHMs in RHCs was added in 1989 (Pubhe Law21Y r Waimeal psychologist services were added to the law 4 1987 iPublit. 100-2u3r.aud dintv.i! .uulct.p v.it II.C) wcit in 1989 iPublii. Law 101.239).
r- Chapter 3Federal Programs Affecting Rural Health as....res 75
payment per visit ($47.38 in 1990) (Public Law The legislation -reaung the block grant elimi- 100-203). For provider-6ased RIX& payment by nated most of the requirement, far provid_ng spe- bath Medicare and Medicaid is made according to a cific services. Fifteen peicern of the tetal funding Medicare cost-based rcimbursemerit formula with continued to be se: aside for speetal demonstration no ceillag on the reasonable costs (Fabric Law projects, Ica% ing 85 percent of appropnated fupds to 95-210). In either case, reinennsement is to the be allocated among the 3tatea. States were required clinic that employs ;he rractitioner rather than ta inatrl eve-y 4 Federal dollars received with 3 directly to the practitioner. f.:trtte &dare. An evaluation of the implementation of the block grant program by the General Account- mg Office (GAO) found that States ter Jed to spend HEALTH BLOCK GRANT their allotments m ways similar to prior patterns PROGRAMS (612). This section briefly describes three Federal block In 1986, Congtest t:hanged the -tind.ag formula to grant programs that affect health services in both earmark certain fun...6 for apecifit purposes. Under rural and urban areas. All were created by the 1981 current law, , a base amount ($478 million, an amount Omnibus Budget Reconciliation Act (Public Lau equal to the block grant 's fiscal year 1985 appropna- 97-35), which consolidated various sets of catego tion) is allocated accordinh to the ungina: formula, cal grant programs into block grants In each east. with 85 percent distr.buted to the Sia. and 15 the block grant increased State dircretion at the percent set aside f ar dem -.:-.tration grants 01/). ea; ase of Federal oirection and oversight. All three Amounts above that base, however, are allocated block gams have since been amended to cover under a new formula. In 1989, 9 percent of the additional services. (Individual programs and their amoant above the base was retained by DHHS to implicatiors for rural areas are disecased in mere fund genetic screening projects. Two-thuds of the detail in chs. l5 and 16.) remaining amount over the base was allocated cording to the 85 oereent/l5 percent formula The remainmg one-third wa3 also allocated according to Maternal and Chqd Health Block Grant the formula but was earmarked for programs to Authorized under Title V -if the Social Set unty develop primary health ..erv ices for children and Act and administered by HRSA, the Maternal and i:ommunity -based senice networks and ease man- Child Health (MCH) block grant program provides agement services for children with t.pecial health health services to mothers and children. Instead of care needs (611). operating as an insurance program, the Ftderal W;thin the non-earmarked portion of the MCH &anti ,. are awarded ta the States, which in turn fund grant, States retain tremendous latitude in the use of public and pn .ate providers of maternal and child funds. States determine both the distribation health care services (e.g., local health departments). funds among services and the eligibility criteria for The MCH block grant consolidated a series of indhidaals recenang those bell/ices. Staos may categorical Federal grants for: charge for the services prov ided. However, they may nat 76 Health rare in Rural America survey conducted by the Public Health For rridation. PHHS bIo. grant was $84.7 million. Of this, $3..! According to this source, most (69 percent) MCH million (the minimum speedier.: amount) was set block grant funds allocated to the States are spent on aside for rape crisis and preNenuon serf ice% and personal healea services, specifically for maternal allotted to the States on the baas of population size and child health ;ervices (496). Most of the remain- (320). der (19 percent) are spent on services to chiidren Compared with the MCH block grant, a .nuch with special health care needs. No information is greater proporticn of PHHS money is spen: on collected regardmg the residence (urban or rural) of individuals receiving services that are funded non-personal health servkes. In fiscal year 1987, 61 percent of PHHS block grant funds allocated to the threugh the MCF block grant. States were spent for personal health se:vices, 10 Preventive Health oud Health Services perceN for environmental health, and 16 percent for Block Grant health resources (496). Of the specific categories of services covered by the block grant, programs tor th4 The 1981 legislation creating the Pri.venrie detection and prevention of hypertension made up Health and Health Services (PHHS) blocl_ grant the single biggest expenditure category (19 percent). corsolidated funding for eight categorkal grants. Health edueation/risk reduetun; and emergency medical .services accounted for 17 and 15 percent of health education and nsk reduction, expenditures, respectively. In contrast, only three comprehensrve public health services. States funded home health agency demonstrations emergency medical services, with PHHS block grant funds, accounting for only home health demonstration services, 0.1 percent of expenditures under the grant (496). rodent control, fluoridation programs, detection and prevention of lin;enskin, and lcohol, Drug Abuse, and Mental Health rape Clisis and prevewion servi.. 5 Services Blect Grant Subsequent legislation add-cl several additional The Akohol, Drug Abuse, and Mental Health programs that could be funied under the PHHS Services (ADMS) block grantis administered, block grant: unsurOrisingly, by ;le Alcohol. Drug Abuse, ard Mental Health .roministiation (ADAMHA). This prevention of chronic diseases, prevention and control of uterine a.r6 breast block grant provides funds to States for prevention, treatment, and rehabilitation programs addressing cancers, immunization service- (wcluding immuniza- alcohol and drug abuse; and for grants to community mental health centers for health services, including tion of emergency workers agamst preventable services for the chronicalti mentally ill, severely occupational-exposure diseases, e.g., hepati. mentally disturbed children and adolescents, men- tis), and tally ill elderly individuals, and other special popula- serwn cholesterol control projects (Public Law tions. 100-607). The ADW block grant has a lively recent As with the MCH grant, each State retains tts own legislative histoiy. As with the other block ;punts, it decisionmakmg authority over how the funds are was created in 1981 to consolidate funding for distributed for the various services (with the excep- existing categorical programs (authorized by we tion of rape crisis and prey ent.on serqees, which are Community Menial Health Centers Act of 1963, the covered by setaside funds). The PHHS b:ock grant Mental Health System Act of 1980. and the Compre- is administere. by the Centers for Disease Control hens:-.. Alcohol Abuse and Alcoholism Prevention, (CDC). Treatment, and Rehabilitiaion Act of 1970). The PHHS grant allocations are based on the propor- bluek grant itself w as AMC nded in 1986 to inerease tion of funes each State received under the categori- its authon:Ation level, ihe same law also ereated a cal programs in the year before they were consoli- separate, new program of g ants to States to supple- dated ',Ito ihe block grant. In fiscal year 1989, the ment existing substan.e kw; treatment and reha- MR.:placed :a 1986by "victims of sex ()tenses ssnd tor prevention tit ceR offenses- tPubli. 11.1w 49-M4i /v INERIMMIlatr=7.27reMinvmmatc=r 111115111111111311=86131WWW 'r CJ apter 3Federal Programs Affe, tmg Rural Health Servwes 77 _ .. bilitation programs (Public Law 99-570i. The 1988 salaried employees of the Feder,u Goerrirnent and Anti Drug Abuse Act (Public Law 10 WO) then practice where they are sent by the Corps. The consolidated the nev, substance abuse grant into iie NI-PiC also includes a much larger group of health ADMS block grant. (This Act also authorized professionals who are placed in HMSio by the menteaealth set 'ces demonsh ation program, under NHSC but who are not aetuszlly comnssomed which 15 percer. of appropriated funds for the members. program mast te spent o projects in rural areas.) Originally limited to physicians, the NHSC place- Under the pre.ent block gran;., about two-thirds of ment program was expanded to include a broad the overall Fedend appropriation will be allocated range of other health piofessionals as well, including for substance abuse Programs and one-third for midlevel practitioners (462). The r iajority of NHSC mental health service argvities, although the propor- placements, however, are still physicians. tions allotted to individual States may differ. Th current forrnu:a for disnibutinh, funds to the States is The placement prJgram has three components. based on each State's populat .on of age voups at ie Volunteer Program, the Scholarship Program. greatest risk for substance abu,e and mencd and the Loan Repayment Program. Tlic Volunteer and on total taxable resource o each State. The Program consists of health professionals who are formula gives weight to Statcs w...11 urban, young recruited va, the NHSC to sec% e in HMSAs but who adult populations, who arpresumed to be at are unelcr no legal obligation to do so. These especially high risk of sutstance abuse (Public 144 N olurreers may either establish prh atc practiees or 100-690). recehe their salary from a variety of public and pi wale employers. They are not counted as NHSC The 1988 Act required each State to use at least 10 field personne1.17 percent of its hlock grant allocation for substance abuse programs, services, and demonstration proj- Under the Scholarship Progam. mdividuals en- vts for wo:nen, particularly those who are pregnant tering medical ior other health professional) schools or who have dependent children. At itast 5 percent are ..wardeci scholarships for their health professirms of the maim] health allotment must be used for new education. In exchange for each year of scholarship comme.nity menial health services not available received, the recipient is obligated to practice for before fiscal year 1988. year in a dcsigaated high-priority HMSA (689). The In fiscal year 1989, the approprzatica for the minimum service obligation is 2 years (662). Since ADM3 block grant was $805.6 million, of which 5 1987, NHSC scholarships have been awarded only percent were reserved for data collecuon and serv- to s few students w ith extreme financial need (43 in ices research. The remainder was allocated among 1989) (659). the States, with an estimated $247 million allocated The Federal NI-ISC Loan Repayment Program, for mental health services and $529 rnIIion for enactei in December 1987 (Public Law 100-177), suEstance abuse services (320). pays participants up to $20.000 a year toward their outstnnding health profession edueational loans. As PROGRAMS T( AUGMENT with the Scholarship Program, participants must RUR/ 1, HE LTH RESOURCES practice health care in a detagnated high .priority HMSA in order to meet the obligations of the Heed: Personhe! ProgramsI6 program. Obligations are from 2 to 4 years, with longer obligations receiving higher annual pay- National Health Service Corps ments. Applicants to the program must he in their The purpose of the National Health Si.7i ice Corps last year of education to beligith,r considera- (NHSC), established in 1972, ls tO .ricourage health tion, Priority is gnen tO aphc mis who arc about to professionals to practice in designs HMSAs. The graduate as medieal doe tor. NPs, or CNMs (eyei...) In NHS,:i. includes a small group of commissioned 1989, 112 placements were made through the officers of the Public Health Service, who are Federal Loan Repayment Prufsarn (6 591 . _ .4/early of these programs arc discussed In r.ore detail pro ch 11 "MI same prograis also recruits perlounel for the inthau Health Service A_Arj. 78 0 Health Care ia Rural America 1 A separate loan repayment program, administered include all. ?atm and osteopathic. metlicil schools 1 though the NHSC, operates through the States (see and groups of such institutions (677). ch. 13). States need not adhere directly to Federal The Federal "seed money" may not ..txceed 9 HMSA viidelines when designating divine areas to years for an individual AHEC, and Federal funding carry out the service obligation. Funds are Inmted. is decreased after the fourth year. Each project must however, f ad in 1989 only seven States received contribute at least 25 percent in rnatchmg funds from funds limier this program. State or other sources. Eighteen projects in 21 States Until 1979, when the first large group of obligated currently receive funding for planning, develop- NHSC scholarship recipients cline out of the ment, oi operation (677). Federal AHEC Program "pipeline." most field placements wem volunteers. awards in 1988 tomied $15.5 million. The NHSC field program (which pays for salaries, Since the program began. 23 AHECs have gradu- placement services, etc. for NHSC-placed person- ated from Federal funding. These AHECs are still nel) had its highest level of funding m 1983, but eligible for separate demonstration fun& for "spe- decreases in total field personnel were not seen until cial initiative projects." In fiscal year 1988, $1.7 years after funding was cut back, due to the long "pipeline" of the Scholarship Program. Field million was awarded to 28 such projects in 10 States (677). strength peaked in 1986 and has been declining since (659). The AHEC ....lucational mission is very broad; specific programs implemented depend on the deeds, The NHSC directly paid the saltmes of most field placements (both obbgated and volunteer health decires, and resources of the participants. Programs have included clinical training rotations in undersen- profesoionals) until 1979, whea it began to rely aiore ed rural areas, establhhing a Hispanic residency on other employers and self-employment of physi- cians to support placements. In 1988, odly 15 program in family medicine, training heath profes- percent of NHSC field positions were federally sionals to work with Native Americans from various cultures. and facilitating health professions educa- salaried, the remainder received their salaries nom community and migant health centers, private tional programs on such diverse subjects ab occupa- tional and agricultural health, primary care practices, and other organizations. t Southeast Asian refugees, and family and spousal Area Health Education Centers abuse (677). The purpose of the krea Health Education Centers Border HP4Ith Education Centers (AHEC) Program is to attac t and retain primary care The Border Health Education Centers program, professionals in shortage areas by linking academic authorized by the Omnibus Reconciliation Act of health sciences centets with clinical sites in under- 1989 (Public Law 1(i1-239), funds contracts with served urban and rural communities. Under this schools of albpathic and osteopathic medicine to program, the Federal Government enters into coop- create centers that will improve the supply and erative agieements with AHECs to establish net- quality of personnel providing health services along works of health-related institutions (e.g., academic the border betwc.-n the United States and Mexico. medical centers, hospitals, clinics, private medical Nonborder areas with large new immigrant popula- offices) to provide educational services to students, tions may also receive funds under the program. faculty, and prt...aitioners (Public Law 92-157) (677). Other Health Profes:;ions Education and Training Programs The original AHEC program began in 1972 and funded selected university medical c.chools under A number of other Federal programs. authorized 5-year. incremental cor tracts. in which funding under titles VU and VIII of tl4e Public Health Service increased during the fir-t 3 years and then decreased Act. pray ide support to institutions (through grants as programs became self-supporting (Public Lew and contacts) and to students (through loans, loan 92-157) (677). In 1981, the funding mechanism was guarantees, and s,:holarships) in the fields of medi. changed to a cooperative agreement that required a ,;.ine, osteopathy,, nursing, den tisu y. v^tennarymed- substantial F-deral role in the management of icine, optomeny. pocbatry, pharmacy, public health, AHEC projects Eligible recipients of AllEr. funds and graduate programs in health admintstration. ..,...-,.7..tH..7-7.:-.:,....._',Ye;17:'.:r.,-*:-.',...:-.i-1 Chapter 3Federal P. ograms Aff-etmg Rural Health Services 79 Health professions education piograms- -ecastruc- ILIUM. of the interdisciplinary programs that could lion grants to schocls and loans to studentswere devalop is unknown. initiated in 1963 (Pubhc Law 88-129) and 1964 nstitutional Assistance ProgramsThe Federal (Pubhc Law 88-581), in response to concerns that Government provides grants to family medicine. the United States faced a critical shortage of health pediatrics, general internal medicine, and general personnel (319). Over the next decade, the programs aentistry programs to support the planning, develop- expanded, becoming available to a greater number ment, maintenance, and improvement of pnmary of schools and students &id a broader range of health care undergraduate and graduate programs. Similar professionals. Grant prograns to encourage special general sapport programs exist for physician assis- projects at health professions schools were also tant programs, public health schools, and health added (319). aenunistration schools. Several institutional grants in 1976, Congress began t a refocus special projc.t are also available to support nursing school pro- grants to emphasize training i-or primar:" care provid- grams for NPs and nurse-nil& is es, other advanced er who would serve in anderserved areas, and it nursing training, and lursing facahy fctiossships bagan to replace broad scholarship programs with (319). more limited scholarship and k in programs. Legis- Two small institutional programs are targetet to lation in 1981 repealed all basic grants to hea..1) the health professions education of minority and professions schools except schools of public health, disadvantaged students. The Minot ty Education and 1985 legislation extended funding authcrity for Program provides grants to four health professions existing programs that address problems associatee schools for development of model education pro- with improving the geographic and specialty distri- grams for minority individuals. The Disadvantaged bution of professionals (319). 13nef descriptions of Assistance Prog XII provides gams and contracts to virrent Federal health professions edocation and health professions schools and other organizations training programs follow. to help them identify, recruit, and prepare minority and disadvantaged students for health professions StudentA ssistance ProgramsThe Federal Gov- ernment funds a number of trainee programs in careers (319). public health schools, pubhc administration schools. Special ProjecoSeLtion ;88 otdiePublic preventive medicine departments, nursing schouL. Health Act authorizes funding for Special Educ.ation aad hospitals. (These fun& reach students through Initiati es,turncu l um Des elopmenc, %hit. h includes the inatituti-ans rather than directly.) The gavern- grant.; arol zararacts to health professions institu ment also awards scholarships to some first-)car lions and other organizations for aanetsof health professions students through the Exceptional projects, including projects to pros ide sul port wrs - Financial Need Scholarship Program. Automation ices to health professionals pracucmg in HMSA,. exists for two student loan programs ani one loan Special project grants are also as ailable to nur,ing guarantee program, none of vauch have receised .chools and other organizations to support prop.ts appropriations in recent years (319) 18 to enhance nursing k Itsnd knoo. ledge 4)1 A new interdisciplmary naming program was Primary Care racititie and Service% authorized in late 4989 (Public Law 101-239) Its purpose is to prepare health piofessionals for prac- Community Health ( enters tice in rural areas where personnel are in short supply by training individu4s from different health profes- The Communit> H VI Center t( Protlf sions (e.g., pharmacists, physicians, aad NPs) to authorized in .ection 330 of the Publit Health Act work together in a rural setting. The program Is and administered ti) HRSA *s Bureau ot Health Cafe explicitly focused on nonphysician peisonnel, no Dehsery and Assistan..t.priii. ides grants toe,tahludi more than 10 percent of funds may be spent on and to operate Ci [Cs T1iec era,. rs pros ide primary training medical students (Public Lass 101-239). No exe servios to designated medicallyundersersed funds had been awarded as of April 1990, so the aux.and populations To re,..t orL Federal funding. Ink three proprams are net )Iealth Proies,Anni.Student loanProp An, And ihk Nursing Snuk ni Ian Pr, gram vh.h rot.,11,0, 1...k .10yr...114..1w, beaithrefesstons students, And the HeAult Anon A-sisiAns hian Proptal. Abu II pt.). plat Aid« 1,1 1.1i, A k 0,1ii uk. I Ali t I 80 Health Care in Rural America CHCs must pro-ide basic primary health services. systems for pregnant women and infant-i, enhancing including: the provision of primary and supplemental health services, and improving access to these services physician services (and, where feasible,-v- (320). ices of PAs and NPs); diagnostic laboratory and radiology services; DHHS also provides some CHCs with supple- preventive health services .(including family mental project grants and contracts to operate c Imes planning, prenatal, and well-child care); to treat black lung disease in coal miners. These emergency medical services; clinics operate at 58 CHC sites in 14 States and transportation services (as needed); provide for the analysis, examination, and treatment preventive dental care; and of breathing and lung impairments in active and where appropriate, pharnuceutical services. retired coal miners. In fiscal year 1988, the program provided services to an estimated 47,500 victims of In addition, CNC& may, where appropriate, providc black long disease (611). the following supplemental health semces: hospital services; Migrant Health Centers home health services: long-term care services; Like ales, migrant health centers (MHCs) are rehabilitative services; part of FIRSA's primary care program. The MHC mental health services; program closely parallels the CHC program. It dental services; provides grants both to establish and to ofm ate vision services; centers, which must provide the same basic primary therapeutic radiology services. care services provided by CliCs. In addition 4-, the allied health services; supplemental services that may be provided by public health services (inchie ..g counsehng. CHCs, M1-1Cs may also provide: referral, and followup for social and nonmedi- environmental health services (e.g., roden4 cal needs that affect health status); control field sanitation, sewage treatment); ambulatory surgical services; infectious and parasitic disease screening and health education services; and control; and services that promo:e the use of the above accident prevention programs (including pre- services, such as interpreters in CHCs that vention of excessive pesticide exposure). provtde semces to a large non-English- speaking population. The popul own that can recei% e MFIC services is limited to migratory and seasonal agncuhural work- In 1988, the Federal CFIC program supported 526 e . s and their families. In 1988. there were 118 MFIC CH Cs, of which 319 were in rural areas.19 On gram recipients operating clinics that served over average, each rural Cl IC provided nearly 35,000 500,000 people (see ch. 2) (181). Many MFICs also patient visits in that year (see ch. 5) (658). receive funds from the CHC program. As with CRCs are required to seek thud-party reimburse- CHCs, WIC sen ices are provided on a fee-for- ment (Medicaid, Medicare, private insurance) if service basis, with a :Aiding fee schedule applying to available. They provide services on a sliding fee those without insurance who cannot pay the full scale based on iicome and fanul)r size, farmhes with Lharge for thc SUN ices they recpeve. MHCs must incomes belly% the Federal poverty kvel receive free accept pinents co%cred h Medic.ue .ind Medicaid. care. Primary Care Cooperathe Agreement% Recent F ederal appropriations for CHCs have included supplemental funding for the Govern- Tic Public Health Service, under a program tnent's Infant Mortality Initiativel° Funds from this mithned in 1986, entels into primary care coopera- initiative "-1. to be spent on expanding health care tive agreements (PCCAsi wth individual State 1901C figures here refer 'o the number of cowls recemns Feder4 grant funds, lot the total nurntwr .11 4. hem sae. C 1kra.11, li, c Mon' than one Chille site MD 1990. [dull Mortality ImIntlee funds were tokkd imo the tool CNC pt.ol Gt diOnbunon lite.c ninth were .4..k.tok4 epatalety 9 7 Chapter3Federal Programs Afircur,g Rural Health Se, ru 41 __...__ . .. health departments and pnmary care ':«5souations.:1 Reconuhauon Act of 1487 (Public. Law 140-20). PCCA grants are intended to facilitate the develop- This program, adminizaered by the Health Care ment of primary care services in underserved areas Financing Administration 1HCFA), la intended to (both rural and urban). Recipients may use the grants help sma11,22 rural, nonprofit hospuals and their to determine the need for primary care services and Lummunities adapt to it,: following cat umstances. health professionals in underserved areas, and to assist in the recruitment and retention of health changes in clinical rractice natterns and servi,e personnel and development of service delivery populations: systems. As of 1989, 33 States had entered into .:: wessacute-Lare caNcity and declimr.g PCCAs (l15a). to provide appropnide inpatient care staffing: PCCA participants enter into a formal agreement increasing demand for ambulatory md emer- with the Federal Gov ernment based on a comprehen- gency services and the need for _integration of sive plan developed by the State agenues for community health services: and delivering primar)care services in undersened the need for adequate a ,ce..0, to emergency and arca:, (656). In one State, for examplc the activities inpatient care in areas where man), underu- funded under the State's 1988 PCCA included. ,ilized hospital beds axe being eliminated (Pub- lic Law 100-203/ a survey to determine die effect of malpractice liability costs on the delivery obstetric The program was stimulated by die Minnesota services in frontier areas; Rural Her.lth Transition Project isee ch. 6). which the establishment of a task force and work plan fo nd that successful hospital transitions depended to improve coordination between rHCs and as much on the ability to perform an effective local health departaients (e.g.in order to community needs assessment ,:s on financial support achieve more effective ouireach to low-income 1201). Transition Grant Pregram funds am treendcd pregnant women and improve medical record- to help rural hospitals examine the health needs of sharing); their service areas and plan and implement new support for various information projects (e.g.. services, coordinating servKes with other area helping a senior citizens group to develop and previders when necessary. Eligible hospitals can distribute health fact sheets statewide; apply for grants of up to $50.000 a year for up to 3 preparing a manual of available health data for years.23 Grant funds may not be spent on :Apitai- rural parts of the State; related costs or to retire existing debts developing a database on perinatal needs. explonng the feasibility of better coordination In 198S K TA rt., tic ed about 7(X) want applica- among rural CHCs; and tions, one-third of which were from hospitak providing technical assistance to CHCsur applying AS part of hospital con c.4,rtia (102) .24 HCFA physician recruitment, marketing of senites. awarded mc re than Ss million to 12 rural hospi- service linkage development. grant wriung. and ta1 SZ4 an 45 State:, and Puerto Rito. funding to dl board triining (701). grantees was for 1 year (102) Congress in late 1;89 appropriated additional monies for the second year Acute-Care Facilities and Servico of grants for which the initial grantees are eligible:, and also a ne v.amo.trit of grant funds for new hospital applicants (Pubhc Law IM -239) The Rural Health Care Transifion Grants Program agency is required :o evaluate the grant program's The Rural Transtuon Giants Program is a legi:da effecticeness and abilit1( io cirentzthen midi tive newcomer that was createt; Ornruhu. adrranis:ratice and triui ,. ial urinaryewe cooperan,e agreements arc fathomedundo. Scs non 33_11g1 iI di'. Puhk. 11c-ahn%CI ALI 221kwor than 100 bodS *Before Pubis, Law 101.239 was passcd m iatcI99. tiipspoak Aft('orels, Allowed to remit st h1.1ftWatle1111...1\ 11 . 24HCFAencouraged MONOr]ODC DospitalIMO)41 CAtiNqrtitlal toapplr in order u. promoic Low,i,e 'OF giu,11 If alert we: 155grantee hospdals. 11 of which werc ct Amnia cAntammg atmal ol 17 ho.pitals 26In 1990, HCFA expected to ma c new awarda appmtinattls, INS atMottonal si,Ispwak c't 4 82 Health Care in Rural America RURAL HEALTH POLICY AND m December of 1987, that sened as the foundation for a discussion of a rural health research agenda for RESEARCH the 1990s. A wide variety of Federal organizations with Funds allocated to A HCPR's rural health research disparate mandates carry out some rural health activities were $679,000 in fiscal year 1989 and $2.5 research. For instance, HCFA, the Prospective million in fiscal year 1990 (463). Activate funded Payment Assessment Commission, and the Physi- with 1989 funds included studies of: cian Payraent Review Commission have all under- taken studies of Medicare payment to rural physi- rates of hospitalization among CHC and non- cians and hospitals. Other Federal organizations CHC users in Maine; furid studies that are epidemiological or clinical in health care access for uninsured residents m nature (e.g., studies of interventions to ..ax.prove Nebraska; Infant mortality). Some agencies have consolidated use of ahernatives to traditional health care their rural research efforts; the National Institute of services by rural elderly, poor, and black Mental Health established an Office of Rural Mental populations; Health Research in early 19110, whose responsibili- urban/rural differences in the Ise of health and fies will include administration of a Rural Mental soma] services by elderly individuals; Health Research Centers program(640,641). the effectiveness and success of various rural Two Federal organizations have recently been -,ial managenicnt strategies, and established that have an especially strong and variation,. in resoc, use, costs and outcomes explicit link between rural health care policy and among obstetric pia.v1ders in Wa.hington. research. Descriptions of these two organizations follow. Office of Rural Health Policy Agency for Health Care Policy and Research The Office of Rural Health Policy (ORHP), The Agency for Health Care Policy and Research established in August 1987,2" is located within (AHCPR) is the successor the National Center for URSA and adv ises the Secretary of DHHS on a Health Services Research and Health Care Technol- sanely of rural health issues, particularly those ogy Assessment, a long-established Federal health regarding Medicare and Medicaid payment, avada- research organization. AHCPR was designated in hlay of health professionals. and access to care in 1989 to focus on the link between health research. rural areas (OSSi. ANAcomponent kif this Activity. the evaluations of tir: effectiveness of health care Office pros ides staff suppon to a committee, com- interventions, and health policy (PublicLink 101 posed of members of both the public and private 239). Its authorizing legislation specified that the sectors. This committee advisethe Secretary of agency should pay particular attentlon to research . DI-IHS on the priorities and :aratcetes that should be demonstration, and evaluation activities relatedho ccinsidered in iddres'f MS the pnbknis of financing the delivery of Lalth care services tn rural areas. and providing health tare in rural areas AHCPR has carriednit both intramural and In addition, the Offike administers the Rural extramural research on rwal health topics for the Health Research Center grant program, manages past two decadesStudies funded in the 1970s come rural health demonstration grants. and serves evaluated a variety of approaches for butlding and an informan)o hi Act forrural health Lee strengthening rural health care delivery systems. research findings and evaluation, ot innovative while in the 1980s projects concentrated on rural approaches to rural health tare delivery Under the hospital issues (e.g., costs and viabdity) and on 11w Rural Health Research Center grant program tau- health care needs of specific populanons Ic g thormed in Public Lau 100-203i, ORHP in Septem- minorities, migrants. Native Americans) (463). In ber 198$ awarded grants to five university-hased response to a congressional mandate. AHCPR sup- research t enters to koIk.I and nalymformat poned a number of studies. presented al a contemn. e conduct applied rewarch orru.il health, and dis- - 27Rburby afier /IP was established, t ' digress Obltpl.ilctt uts e C 0 kraNI,01..0 ,POW0 I I :S:CI tat Chapter 3Federal Programs Affectmg Rural Health Serlees seminate the re.inits.28 The acth ities being con- examining patterns of change in rur.d residents' ducted by these .;caters include: use of hospital services; describing the condition and roles of rural establishing a clearinghouse for Staw-level hospitals; information on rural health initiatives and State examining the availability of obstetric care in laws affecting rural health; rural areas; and documenting the distribution of registered nurses surveying rural migrants and Mexican nation- in nral areas and issues relating to rural nursing al near the southwest border to determine their practices; health care utilization patterns and financial tracking the geographic variation in per capita accessibility to care. expenses of Medicare beneficiaries in rural areas: The Omnibus Budget R4. zoncihation Act of 1989 compiling a national rural health atlas reflect- (Public Law 101-239) appIpnated funds for up to ing the health status and health sen iLes aNaila- ft:a research centers in addition im ale fhe Jready ble to rural resider ts; receiving funding. - _ _ ------__ - _ .- -,_ - - - _ - 28The frit centers let coring gedni.s.ne The Center for Raul 1 ItAltri !verso.% at do, 1 Po. (As ol \ 4111 I mk. I.i ir.tild I o.i., M.,1,hit.1.1 %.14,1o..11 Research Foundation. Marshfield. W1%(.41.slil. lif.41411 Scrvices Ro.sc.u.li ( vniti .(I the I iio,.rsir;..1 \ .di iJ.F.4.11.1( kit.% I Milt tusttsio. ot Wa,thogion School of Medicine. Scat.k. and the t.niversiis of Ariloo,, St ho()I tlt maiktric, -01,..4.0 1,) 9 .6. CONTENTS Page INTRODUCTION 87 OVERVIEW OF STATE RURAL HEALTH ACTIVITIES: RESULTS OF AN OTA SURVEY 87 Creaeral Description of Responding Organizations 89 Rural Health Activities 41 Ranking of Selected Rural Health Issues )7 Cunent and Future State Activities in Rural Health 98 A CLOSER LOOK AT STATE RURAL HEALTH ACTIVITIES 100 State Offices of Rural Health 100 Selected Examples of State Legislative and Administrative Activity ...... 101 SUMMARY AND CONCLUSIONS 106 Box Box Page 4-A. Recently Created State Offic% of Rural Heahh: Two Examples . . 103 Figures Figure Page 4-1. State Use of Provider Recruitment and Placement Methods . 93 4-2. State Involvement in Rural Health Research Activities 95 4-3. Stated Involvement in Rural Health Systems Coordination and Implementation Activities 96 4-4. State Involvement in Rural Health Educational Activities 97 4-5. State Prionties.for Rural Health Activities...... 98 Tables Table Page 4-1. Potential State Roles for Improving Rural Health Services 87 4-2. List of Respondents to MA's 1988 Survey of State Rural Health Act:. tiles 4-3. Changes in State Rural Htalth Budgets, 1987-89 4-4. Funding Sources of Organizations Responding to OTA'sirvey of state Rural Health Activities, 1989 oo 4-5. Overall Activity E :ength of State.; Responding to OTA's .F9 rvey of State Rural Health Activities 91 4-6. State Provider Recruitment and Placement Activity 92 4-7. State involvement in Rural Health Technical Assistance Activities . . 94 4-8. Selected State Rural Health Activities From OTA's Survey of State Rural Health Activities 99 4-9. Selecttd Rural Health Activities: Comparison of "More Rural" and "Less Rural" State.. and States With and Without Identifiable Offices of Rural Health (ORM; 10() 4-10. State Ranking of Six Major Rural Health Care Delivery Issues. 1989 101 4-11. Relationship Between States' Perception of Major Rural Hcahh Issuo and Spo.ifi Rural Health Activities 102 4-12. States With Offices of Rural Health, 1990 133 4-13 Four Examples of State Task Forces and Committees Created To Address Rura' Hcalth Issues 104 96 .../1.1 Chapter 4 The State Role in Rural Health INTRODUCTION OVERVIEW OF STATE RURAL Faced with dwindling Federal resources, States HEALTH ACTIVITIES: RESULTS have assumed more responsibility for defming and OF AN OTA SURVEY addressing their health care needs. The potential role for States in improving rural health services is laige OTA conducted a suney of States in fall 1988 to and diverse (table 4-1). To carry out this role, several identify. I) those nual health issues Sta:es perteive States have created State offices of rural health, and to be most critical, and 2) specific activities ar.d many have developed specific let,islathe and ad- piograms that States had undertaken during the past ministrative initiatives. In some States, sweepmg 3 years to address uiese issaes. The sun, ey targeted changes in rural health care policy and delivery h.ve organizations that w ere either State-based or State- developed quickly. In others, policymakers and su7ported and that were invohed in rural health planners are only just beginning to address rural planning, development, research, or polio.All 50 health issues. States responded to the survey. This chapter presents an cverview of State rural The survey defmed a State acth ity as anyai.LiNity health activities, discusses these actk ides, and in which the State was involved directly tthrough profiles selected recent State rural health legislathe regular paid staff time or State budget authority) or initiatives.' indirectly (e.g., through contract to an outside Tabie 4-1Potential State Roles for Improving Rural Health Services Developing rural health policy Provide grant funds to promote linkages between Establish special office, task force, or commis- facilities and to stimulate the development of sion new modeis and approaches Conduct special studies Create special capital equipment funds to alsist Providing technical assistance and information to hospitals needing access to low-interest capital rural providers and community groups loans Provide technical assistance to promote regionalization and integratior of services Increasing the availability of health professionals Provide information to providers and community Establish scholarship programs for rural pro- groups viders Assessing and changing State laws and regulations Fund rural preceptoiship programs a Assess impact of regulatory requirements for Permit and encourage the cross-training and mul- small and rural hospitals tiple certification of allied health profes- Change State licensure laws and regulations to sionals promote greater flexibility it the staffing. and configuration of rural medical facilities Change certificate-of-need requirements or Increasing payment or financing create special exemptions for rural medical a Expand Medicaid eligibility for the poor facilities Increase Medicaid reimbursement to reflect 'true Change State scope-of-practice laws to permit costs" of providing services in rural area., greater use of midlevel practitioners in -ural m Stimulate private sector funding through sub- areas sidies for health Insurance for low-income rural Create more flexibility in the definition of workers "continuous Service- foi emergency medical Change re mbursement to provide more in,entives facilities for providers practicing in rural areas Maintaining weeded services Incresse .eimbursement to rural clinics provid- Establish criteria for designating "essential' ing Medicaid-covered ambulatory services rural providers or for intervening in possible Increase reimbursement for rural emers, .y meth closure of ruial hospital cal services and transportation services SOURCE. D Helms, "The Role of the State Ir. Improving Rural Health Cate,' paper presented at arural health care workshop sponsored by the National Center fox Health Services Research, RockvilleKD Nov 7,1 1980 10Iher State rural health activities arc discussedno chs 7. S. 13. and 1$ of this report 87 20-810 0 - 90 - 4 01.3 88 Health Care in Rm.& America Table 42List of Respondents to OTA's 1988 Survey of State Rurai Health Activities Number of Statt respondents Entities whose activities were reporteda Alabama 1 * Department of %bile Health Alaska 1 * Division of %bile Health, Department of Health and Social Services Arizona * Rural Health Office, University of Arizona Arkansas 2 * Section of Health Facilities, Services &Systeme, Department of Health * kkkammam Area Health Education Centers Program California 2 * Office of State Health Planning &Development *Rural and CommonitY Health Division, Department of Health Services Colorado 1 * Departmeal of Health Connecticut 1 * State of Ceenecticut Delaware 1 * Division of %bile Health. Department of Health and Social Services Florida 1 * State of Florida Georgia 2 * Center for Rural Health, Georgia Southern College Primary Health care Section, Division of Public Health, Department of Human Resources * Department of Health Idaho 1 * State of Idaho Illinois * State of Illinois Indiana 1 * State of Indiana Iowa 1 * State of Iowa Kansas 1 * State of Kansas Kentucky 1 * State of Santa:dry Louisiana 1 * State of Louisiana Maine I * State of Maine Maryland 2 * Primary Care Cooperative Agreement Unit. Department of Health and Mental Hygie-* Maryland HeaiLh Resource Planning Commission Massachusetts I Department of Peblic Health Michigan 1 * Diviaioo of Health Facility Planning & Policy Development. Bureau of Health Facilities, Department of Public Health Minne 1 * Department of Health Mississ 1 * Office of Primary Care Liaison, Department of Health Missouri 2 * Bureau of Primmry Care, Division of Local Health & Institutional Services. Department of Health * Certificate of Need Program. Department of Health Montana 1 * Bureau of Health Planning. Department of Health & Environmental Sci. ices Nebraska 1 * State of Nebraska Nevada 2 * Nevada Office of Rural Health. University of Nevada * Division of Health. Department of Human Resources New Hampshire 1 * Division of %bile Reath Services. Department of Health and Nsman Services New Jersey 1 * State of Eaw jersey New Mexico 2 * Primary Care Section, PUblic Health Division. Department of Health and Environment * Nom Mexico Health Resources New York 1 * State of New Yokk North Carolina 2 * Office of Health Resources Development, Division of Facility Services Department of Human Resources * Dorth Carolina Area Health Education Canters Program North Dakota 2 * Department of Health * Center for Rural Health Services', Policy & Research, University of North Dakota Ohio 1 * Primary Case Section, Office of Health Resources. Deparailent of Health Oklahoma 3 * Oklahoma Health Planning Commission * Oklahoma Physician Manpover Training Commdssion * Departemnt of Health Oregon 1 * State of Oregon Pennsylvania 2 a Division of Hospitals. Department of Healttb * Bureau of Health Financing & Program Development. Department of Health Rhode Island 1 * State of Rhode Island South Carolina 1 * Office of Primary Care, Department of Health And Environmental Control South Dakota 2 a Department of Health * Rural Health Program. University of South Dakota School of Medicine 98 Chapter 4The State Role in Rural Health 89 Table 4.2Listof Respondents to MA's 1988 Survey of State Rural Health ActivitiesContinued Number of State respondents Entities whose activities were reporteda Tennessee 1 * State of Tennessee Texas 3 * Departmentea Roalth * Departaleatof Agricultnre * Texas Higher Education Coordinating Board Utah 1 * State of Utah Vermont 1 * State of Vernet Virginia 1 * State of Virginia Washington 1 * Department of Health West Virginia 1 * Department of Health Wisconsin 1 * State of Wasoonsim Wooing 1 Health Deparbeent *Boldface typo indicates the entity fox which the respondent reported activities Normal type indiates the location of tnat entity within the State government or other organization. SOURCE: Office of Technology Assessment. 1990. organization). no.: survey asked centralState health Table4-1Changes in State Rural Heilth Budgets*, administrative officers in the targeted organizations 198749 about State activities in areas such as technical assistance, special rural health initiatives, personnel percent change in rura: issues, and research. It did not explicitly attempt to health budgeta, 1987-89 8,,mber of Statesb obtain information about programs not formally -41 or less 2 linked to the State, although some respondents used -21 through -40 .. 3 open-ended questions to describe such programs. A -1 through -20 . 3 description of the survey methods, a copy of the 0 through +20 13 +22 through +40 . survey instrument, and a list of addresses of survey +41 or greater a respondents are included in appendix D of the report. Total number of States reporting 33 General Description of Responding aResponden.s were asked to provide figures reflecting their total budget for rural health activittes for Organizations 1987, 1988, and 1989, Methods of budget calcula- tion varied condiderably Fox multiple respondent Table 4-2 shows the entities whose activities are States. budget figures for all respondents were to- reflected in the survey. taled and the percent change was calculated from the total. Organizational Base and Authority bResponses from only 33 States were used in this analysis because some Statss were unable to provide Of the 65 responding organizations in 50 States, comparison data for 1987 57 were State-based, 7 were university-based, and 1 SOURCE Office of Technology Assessment, 1990 was a private nonprofit organization created through Governor's action tha ler gained legislative author funding soun.es for 1989 for 42 States and tord rural ity. Most of the organizations (62 percent) had been health budget slange., from 1987 to 1989 for 33 established through State legislativ.: authority, with States.1 Although the majority of States reponed a substan:ial minority (35 percent) established modest increases in their total rural health budgets through administrative authority. from 1987 to 1989, the budgets oi nearly one-fourth of the States (8 of 33) had decreased (table 4-3). Funding States' dependence on Federal, State, and other States inconsistently reported fmanual data,'' but funding sources v aried widely. The proportionof OTA %a., able to analyze State rural health activity fundmgdendfiom FederalJourebranged from 0 2Seeapp.D. 3For Stateswith more than one respondent wetghted pementage) wive do:named ttvutaktabhad ptu4idt4 fuutik.,41 daw If ga iuvundcow bad not provided data, data from that Slate were regarded as missing. 90 Health Care in Rural America Table 44Fundin9 Sources of Organizations Responding to OTA s Surveyof State Rural Hearth Activities, 1989 Haan percent of 1989 fundinge,bderived from. Federal sources State souices Other sourcese All States (42)d...... 44 42 12 Region:e Northeast (5), 51 35 15 South (l5) . 40 48 12 Midwest (12) 44 31 17 West (l0) 47 49 5 "More rural" States (14)f 38 55 'Less rural" States (28)f 47 32 States with an ORB (11)8 47 42 11 States without an ORM (31)8 43 42 12 eOf the 42 States providing financial data, 4l rrovided 1989 budget est.mates and 1 provided 1988 budget estimates. The l988 budget estimate was averaged in with those for 1989. leMeans were calculated by averaging the individual percentages for each State within given source category. This explains why the rows do not add up to 100, e"Other" sources can include private funding, local funding, and fee-for-service revenues. dNumbers in parentheses denote nuther of States in each category for which financial informationwas available for this analysis. eSee app. F for a list of States in each region fStates were classified as "more rural" o. "less rural" depending on the percentage of their population resid- ing in nonmetro areas in 1986 ("more rural" . over C3 percent. "Iess rural" m 0-50 percent (See app. D for a list of States.) 8An "office of rural health" (ORH) was either identified aJ such by a respondent or was knownto be an office uhose primary responsibility was to administer to the health needs of rural areas of the State (Seeapp. D for a list of CRI1 States and an explanation of how these States we_e identified.) SOURCE: Office of Technology Assessment. 1990. percent in one State to 100 percent in 6 States. Federal sources than did States without anORH.6A Eighteen States (42 percent) derived more than 50 possible explanation is that ORH States have a more percent of their funding from Federal sources. State centralized focus for rural health efforts and have funding likewise ranged from 0 percent in 8 States been more successful in obtaining Fekieral funding. to 100 percent in 5 States. Twenty-five States (59 percent) received more than 50 percent of their Mean proportions of State and Federal funding did not differ greatly among regions,7 but States in funding from State sources.4 the South and West reported somewhat greater dependence on State funding source than did States In general, "more rural" States received a higher percentage of funding h om State sources and a in the Northeast and Midwest. States in the West reported much lower dependence on "other" fund- lower percentage of funding from Federal sources than did "less rural" States (table 4-4).5 One ing sources (e.g., local and private funding and revenues). explanation may be that "more rural" States are appropriating more State funds for tural health Conversations wish several respondents revealed activities; alternatively, the Federal Government that, in a number of Sutes, the major source of may be directing its rural health funding to "las funding was a Primary Cal:. Cooperative Agreement rural" States. States with an office ..f rural health w ith the U.S. Department of Health and Human (ORH) had a higher percentage of funding from Servkes(see ch.3). OtherFederalfunding sources Me proportion of funding kom solutes other than Federal nod State government ranged from 0 mums in 2Z ;tales to over 70 patent us 3States. IStates were :twilled AS 1901 War. 01leaS nfrarSCPC96198 09I&pi optative of thee ptipulauon restdieg in Bowsaw =AS i.080 k MOTC 11111d" overSO potent. less near z 0 to SO percent) ,See app. D (01 aint OfSOWS., Selrea1y-919C pen.Cla vi WC. Mat now 51.11W prOVIding fiaanciat dida receivedmore than 30 percimt of then holding from State sounes. oompared with 4 pert.emofless ruralStates. 4An"offict of mat health"' was tithes tdcatificd as seal* &respondent ot *as known to be anofFm. whose primary resposOul try was to mixtures= to the health needs antral areas of the State (See app. D fou a Int of ORH States and an eapianation of bow Ibex Siamwere gloated £4hry-two percent of ORH States received more 44.4i 30 penem of then funding from Sane sourt.es. wmpared with SO peo.cat ot non-URH Siam 'States weredivided into fourstandud regions. Northeast. South, Midwest.eild VcCSL SOC,app. F for the Stares intdoded in tsar region 1 O() Cr 4--The State Role in Rural Health 91 Table 4-5Overall Activity Strength of States Respondin s Sot vey of State Rom Health Achvittee 'Less active' "More aetive" (0-15 activities. (16-30 sc.ivitvas) (31-54 activities) U.S. total (5014 ...... 11 18(362) 21 (422) Within regions: Northeast (9) 3(33%) 5(56%) 1 (11%) South (161... . . 3 (19%) 3 (19%) 10 (63%) Midwest 1121...... 3 (25%) 5(42%) 4 (33%) West (131 2(15%) 5(38%) 6 (46%) -More rural" States (151. 3 (20%) 6 (40%) 6 (40%) "Less rural" States (351 8 (23%) 12(34%) 15 (43%) States with ORR (12) 0 (0%) 5(42%) 7 (58%) States without ORH (381 1) (29%) 13(34%) 14 (37%) IsActivity strength measures only number of reported activities, not level of effort expended in these ac- tivities. bRespondents reported activities they had been directly involved in at any time during the past3years The end date of this period was late 1988 or early 1:769, depending on the State eltuabers in brackets denote nuMber of States in each category for which data were analyzed dNuMbers in parenOeses indicate the percentage of States within that region or catcgory that weru less ac- tive," "active,' or "more active." SOURCE: Office of Technolo6y Assessment, 1990 included block grant funding to State health depart- Rural Health 4ctivities ments, special research or program grants, and Federal funding to health professions schools. Specific Activities Rural Health Objectives The survey asked whether responding organiza- tions had been directly involved during the past 3 Organizational objectives cited by respondents years in specific rural health activities within the ranged from the very broad (e.g., providing informa- following categories:8 tion to increase awareness of rural health issues) to the very specific (e.g., providing mcbile dental provider recruitment and placement, health services). Some of le more frequently fmancial assistance to local organizations. mentioned objectives concerned: technical assistance to rural communities, health facilities, and health providers; improving access to primary health care serv- rural health research; ices, either throughout the State (13 States) or rural health systems coordination and imple- specifically in rural areas (12 States); mentation; provider recruitment and retention (22 States); rural health care systems development and education; legislative affairs relating to rural haalth; ana network coordination (21 States); technical assistance to health care providers rural health-related publications. and communities (12 States); The survey form suggested 54 specific acticities needs of underser. ed and at risk population within these 4-ategones, on the average, respondents (11 S tates); identified 25.5 that were conducted in their State. resource identification and procurement (7 Total number of activities ranged from I to 44. The States); number of activities reported tended to be greater in support of emergency medkal su-vices ata the South and West than in the Northeast and ties such as plar.oarg, training, and technical Midwest (tabli. 4-5). No notable differences were assistance (6 States). and found between "less rural" and "more rural" development of rural health polu;), plans, and States, howevef, States with ORHs tended to engage standards (5 Staies). in more activities than did other States. *As noted in app. D. the survey 1114 AU. attempt tv dettnatee tht. levet a effurt tespundems [hell egcnt.tc:. %vac &vow% tv mty go et.laity 1 92 Health Care in Rural America Tabie 4-6State Provk,Recruitment and Placement ActivRya Range of number Nuaber of Number of States that recruited providers of placements in States that Recruited Recruited but States that placed at did not Total 6 placed did not place° least one provider recruit Physician (MD/DO)a ...... 35 33 2 1 602 14 Registered nurse° 16 11 5 1 - 520 33 Nurse practitioner.... 10 7 12 1 - 10 31 Physician assistant 17 7 10 1 - 12 33 Mental health professional.. 15 8 7 2 - 17 35 Dentist 8 8 0 1 - 8 42 Pharmacist 3 3 0 1 - 27 47 Physical therapist 4 4 0 1 - 12 46 Paramedic 1 1 t 19 - 10 49 Other providersd 10 10 0 1 - 104 40 aStates were asked to report the number of pr,viders recruited and placed d ring the past 3 years. The end date of this period was late 1988 or early 1989, depending on the State. Numbers reflect only recruitment and placement activity carried on by the responding State organizations, which may only be a small proportion of all such activity in the State. bThis indicates the number ot States that recruited a particular type of provider but did not place any during the past 3 years. For example, if a State recruited 9 physicians and only placed 3, it would not '..us counteo in this column but rather in the second column of this tableIn this sense, it is an underestimation of th., number of States that had difficulty filling all of the positions for which they were actively recruiting. apata not available for one State. °Other providers recruited include nutritionists, licensed practical nurses, occupational therapists, speech therapists, dental hygienists. SOURCE: Office of Technology Assessment. 1990. Provider Recruitment and PlacementThirty- were States in the Northeast 22 percent), West (50 eight of the 50 States (76 percent) reported that they percent), and Midwest (42percent).10Southern had engaged in provider recruitment and placement States weie also more than twice as likely as States activities.9Of these, more reported recruitment and in other regions to recruit through State loan placement of physicians than of other health profes- forgiveness/repayment and scholarship programs. sionals (table 4-6). The number of providers placed Other recruitment methods used by States included: varied widely. One State had placed only a single physician during the past 3 years, while another had a program that provided travel allowances to placed 602. A considerable number of States re- prospect've physicians for visits to practice sites (North Carolina). ported unsuccessful ttempts to recruit nurse practi- tioners and physician assistants. States most fre- a bonus of $20,000 to any physician willing to quently recruited through the National Health Serv- locate in a designated shortage area (Olda- ice Corps (NHSC), service-contingent State scholar- homa), sh4State loan forgiveness/repayment programs, a loan fund to help physicians and communities and placement services (figure 4-1). Nine States establish rural pnmary care clinics (Arkansas), reported using other types of financial incentives a program to provide equipment and startup (e.g., recruitment travel assistance) to attract and funds for physicians locatmg in areas eligible place health personnel. for the State's loan forgiveness program (New York), Regional comparisons showed the South to be establishment of rural placement offices in particularly active in pros ider rectuitment and place- State medical schools (Oklahoma), ment. More States in the South (63 percent) were a ioition reimbursement program for physicians likely to use the NHSC as a recruitment source than locating in communities of 2,500 or fewer Mese numbers reflect only retnutment and placement achsity LAmed vo bydiCre.sponding State orgameanons, which may only be a small percentage of all such acuvrty in the state tollismay be areilectIon of the retanvely high oticenttation of potenhally tru.difying NH .4pl.v. ement sues in thc South t ompred with othertegions (see di I I) 1 1 )2 Chapter 4The State Rale in Rural Health 93 Elgure4-1State Use ot Provider Recruitment and Placement Methodso Method National Health Service Corps 23 State scholarships in exchange tor service 15 in rural areas State loan torgivenese/ repayment programs 16 Other financial incentives Placement service 29 Other recruitment methods 14 0 10 20 30 40 50 Number of States usingmethod aStates were moved to report methods used to mutat persunam dun% me put 3 years. The eno date ot the ptiu4 vrau late 1338 uearly IMO. deperldiN, on the State. SOURCE: Mee of Technology Assessment. 1990. residents (South Dakota), matched subsidies. Fifteen States were providing payment of malpractice insuratiepremiums other tyrs of financial assistance. States in the for obstetricians (Tennessee), Northeast and South were more likely to have requirements that State medical residency pro- provided local financial assistance than were those grams actively recruit physicians to undei - in the Midwest and West. Some examples of State saved areas (Texas), financial assistance include: newsletters advertising available positions, low-interest loans in exchange for service in provision of living allowances to nursing and rural areas, and medical students while they are in clinical a locum tenens" program for nurse practition- training at rural practice sites (Arimna), as and physician assistants. loan fund to support the development of local services and improve access to services (Az- In telephone conversations and in open-endee re- kansas), sponses, some respondents indicated that reductiou a Mortgage Li...an Insurano Program to help of the Federal NHSC program had had a negative health facilities finance capital expenditures at impact onphysician availability in underservedrural leasonable cost (California), communities. matching funds for local transport systems for FkanziabissWancetolocalOrganizationsThirty- newborn infants (Delaware), five States (70 percent) were offering 30= forn of rural medical school demonstration projects financial assistance to local organizations and indi- (Florida), and viduals. Only 3 were providing loans to local finAs for recruitment and retention of primary organizations, while 9 were providing fimal on a care providers in community health centers matching basis, and 31 were providing direct un- (Tennessee). UV= ts a program that providea personael to eaves for prat....Moners during v &Aaiun, educational, or other leave periods 1 3 94 Iha ith Care in Rural America Table 4-7State involvement in Rural Health lbchnical Assistance Activities, States reporting Activity involvement (N=50) Technical assistance to rural commonalties: HMSA/MUA/MUO designations 41 (82%) Statewide rural health needs asses'. ,,,,,,,,,, 29(58%) Other needs assesemente 34 (68%) Cammunitylboard training . 24 (48%) Grant application assistance. 39(78%) Program planning 37 (74%) Resource identification 45(90%) Other types of cmehnical assistance 16 (32%) Technical assistance to rural health facilities/providers. Facility developmemt/constructi,, consultation 26 (52%) Grant application assistance...... 40(801) Management assistance 31 (621) Other types of technical assistance ...... 18 (36%) *Respondents reported activities they had been directly imoived in at any time during the past 3 years The and date of this period was late 1988 or early 1989, depending on the State. bOMSA = Health Manpower Shortage Area; MUA Medically Underserved Area; MUP = Medically Underserved Popula- tion. These are Federal designations used for the allocation of Federal health resources. and they require substantial involvement of State and local officials in the designation process (see ch. 11). eIncludes assessments of needs of particular areas, populati.ln. and health facilities and services SOURCE: Office of Technology Assessment, 1990 Technkal AssistanceStates were very active in market research and education, providing technical assistance to rural communities, analysis of trends in rural hospital utilization health facilities, and health providers (table 4-7). and financirg, and Out of 12 listed on the survey, the mean number of expansion of Rural Health Clinic certification. technical assistance activities reported by States was ResearchNearly three-fourths of all States 7.6. Only one State reported no involvement in such reported that they had conducted research on the activities. The types of technical assistance most heal& status of mral populations or on rural health frequently provided by States were resource identifi- personnel Over one-half had conducted research on cation, Federal shortage area designation application mral lealth services utilization, rural health systems 2grant application assistance, and pro- assistance,' coordination, or insurance coverage in the rural gram planning assistance. Other techmc al assistance population (figure 4-2)." activities included: Rural Health Systems Coordination and imple- accreditation workshops for rural health facih- mentationMostStates had undertaken activities to ties, promote the coordination of rural heath services and technical assistance to rural facilities for cernficate- facilities through the development of networks and of-need (CON) and licensure application, systems of facilities and providers (figure 4-3). Only physician recruitment assistance, three States (6 percent) reported no such involve- health provider contract negotiation, ment. Participauts in State-promoted health system rural socioeconomic assessments and raral "alliances"14included, but were not limited to: survey assistance, hospitals, primary care providers, health depart- assistance to small hospitals restructuring their ments, mental health 4-enttrs, health professions service and governing structures, education institutions, Slate primary care associa- 12Pederal shortage area designadons include Health Manpower Sbonage Areas and Medically Vaderserved Areas/Populations. Sec oh. 11 (or discussion of Federal and State shortage area designations. 13Raponsm reflect research efforts onavariety of kvelsprnmity and secondary. formal and informal. pine tam "alliance" was not defined in the questionnaire It may include arrangcnienta ranging from maw= to aimed purchase or star hag arrangements to informal Wml networks between medical and other humanrvice providets in rata! and urban areas 1 1) 4 Chapter 4The Stare Rale in Rural Health 95 Figure 4-2--State Involvement in Rural Health Research Activities° Research topic Health personnel in rural arse* 37 Rural Malt:. services utilization 27 Health status of rural populations \ A. 37 Rural health syuiems coordinationL\ \ \\\\\ \ 128 Insurance coverage in rural population \\\ 30 Medical liability insur- ance costa/availability \ \ 23 New health technology in rural areas \ 14 Quality of care in rural areas\avallability 16 Rural hospitals SMIMS1 30 Other rural health related research topics° O 10 20 30 40 50 Numberof States thatconducted research on tonics° aReociondentS ieporled afIi1ies they had peen dm Oct* girolrea 0 el any 1.1115duringtree past 4 yeal S The ere3t.itile el this penun vrastetedititan Shiny teat., k_depsocring on the State. °Other rural health-related topica included. border Mann ueszauun panel ns VC), alsed bean pessentiel on ASA re.*pitais einersent4 iriedua. sor.Les (GA), perinatal care acr..ess (GA), lamdy piannbig t."sk, av...ess tu prun dee., sw ve.es IC2A). muwiedge 404 pi ve..tiees in uuidul served ovpuemens &Muffed immunodeficiency syndrome (Gk. genaire. tale Mb. iont. tMCn, uavel erne bees/eel, neat hospitals tilLy. !rumen bosun eel (ws Ma. SD), Federal And Stats--AA-. mad pninary ewe venters iTb1). site speute. epicermeviiivu swan j1X,, trausporitalun systems Ai shortage asses AA). CVagd responses ware received from all 50 States. SouRcE:Office of Technology Assessment, 1990 lions,nursing homes, laboratories, and pharmacies. in contiguous counties (Texas), and Over one-half of States had promoted alliances grant programs to encourage formation of between hospitals and other health providers, while alliances between health sen ice facilities kNew nearly four-fifths of States had promoted alliances York). that involved only nonhospital providers. Educational ActivitiesForty-five States were Nine States reported involvement in other ty pesa ...onducting rural health-related educational activ rural health systems coordination and implementa- ties, with fiv e States reporting no such activ ales. tion activities, including: Over two-thirds were involved in health professions education for rural providers, and well over one-half the development of adolescent health services were involved in providing continuing education for and prehospital emergency medical services rural health professionals. Over one-half had organ- (Hawaii); ized Statewide rural health conferences (figure 4-4). the Iowa Rural Work Group, which provided a forum for discussion of a vanety of rural Legislative AffairsForty.four States reported concerns among representatives of Federal and involvement in legislative affairs. Thirty -fou, had State agencies; developed task forces or committees to address rural defining "rational service areas" for primary health issues. Thirty -nine of the responding organi care to assist in State and local planning efforts zauons hadworkedw ith State legislatures and/or (Nevada); legislative committees on rural health issues. Six development of multicounty health districts to reported other types of involvement in legislative help consolidate and integrate health resources affairs related torualhealth. States in the Northeast . 5 96 Health Care in Rural America Figure 4-3Stated Involvement in Rural Rea Ka Systems Coordination and implementation Activitle34 Type of activite Developing alliances between hospitals 27 Developing alliances between hospitals and other medical 34 service facilities Developing alliances not involving hospitals 42 Development of special health service districts or 14 other financial options Other hesith systems coordination and implementation activities 0 10 20 30 40 50 Number of States involved in activity e actespendents reported activities the)ihad been directly involved in at any time during the past 3 years The end date of this penedwaslise1988 or early 1989. depending on the Stele. tribe lerm "alliance" was not defined for respondents. and may include a variety of formal arid informal arrangements Walid responses were received from all SO States SOuRCE: Offacis ol Technology Assessment, 1990. were considerably less likely to report involvement See table 4-8 for the distribution of selected rural in legislative affairs (56 percent) than were States in health activities by State. the South (100 percent), Midwest (92 percent), and Comparative Characteristics of Active States West (92 percent). No notable differcnces in overall activity strength PublicationsRural health-related publications emerged between "more rural" and "less rural" had been produced by respondents in 40States.1 States (see tabie 4-5). Concerning specific activity The most common were policy recommendations categories (table 4-9). "more filial" States were (21 States), newspaper articles (20), research reports slightly less likelyto have engaged in NHSC (18), newsletters (18), and information packets (17). recruittnent activity, &axial assistance to local Other publications included annual reports and organizations, and rural health systems coordination evaluation reports. and implementation activities, but they were slightly more likely to indicate involvement in legislative affairs than were "less rural" States. Priori0 Areas for Rural Health ActivitiesThe sumy asked respondents to choose three top States with identifiable offices of rural health priority areas from among the nine broader activity weremore likely tobe "active" or "very active" categories. As figure 4-5 shows, States most fre- than werenon-ORH States(seg table 4-5). ORH quently ranked rural health systems coordination and States were slightly more likely to have engaged in implementation,provider recruitment/placement, and general provider recruitment and placement activi- technical assistance as high priorities. ties, NHSC activity, and educational activities, and 1514ine states mooed no publications. aod one Statt did not provide information regarding pubhcations 106 Chapter 4The State Role in Rural Health97 Figure 4-4State involvement in Rural Health Educational Activities° Activity Medical and other health professionals education for 34 rural providers Rural consumer health education 23 Continuing education programs for rural 31 health personnel Statewide rural health conference 27 Other educational activities° 21 0 10 20 30 40 SO Statesreporting involvementc aRaspondents reportedactivities they had pew, ditectly ww4ved wly urnecumg the paw 3 yawTue enowne u evhuo was iftut eany _depending on the State. °Other mai health-related educational whrities reponed by Sidoeb noo,le etwevnue emelilwit4 wedi..a4 Del oyes o:mtemokos, mwelopu Ii Insowsouru alliances, load beard training, management assatenue workshops to row ouviders. assistalweAi ea nem' E...s...ation :Ail net pound pg cAl mutton adivitios; and grant writing seminars. Weld responses ware received from all 50 States. SOURCE: Office of Technology Assessment, 1990. they were much more likely to have conducted wrwernmore frequently in the Northeast than in reseatth activities or to have developed special task other regions, whereas Southern States were more forces or committees to address rural health issues. likely tu emphasize .ervices issues. ORH States were less hiely, however, to have senrice-contingent Statg loan furgiveness/repayment While "less rural" States were much more likely or scholarship programs. to rank medical liability insurance costs/availability highly, "more rural" States were more likely to Ranking of Selected Rural Health Issues identify payment issues and meeting the needs of special populations as major problems. ORH States OTA asked respondents to rank six general health were more likely to stress medical liability insurance care delivery issues for the extent to which they costs/availability and less likely to identify quality posed problems for iural areas (table 4-10). Health of care asamajor problem than were non-ORH personnel problems were the most pervasive. They States. were more hiely than any other issue to be ranked highly, regardless of region, degree of rurality, ur States actic Ines w ere nut consistently linked te presence of an ORH. Payment issues were also their perceptions of key issue:, (table 4-11). In frequently ranked among the top three problems. general, States that ranked a given issue among the Every issue was considered most important (ranked top three were either slightly mute likely than Us first) by at least one State. States in the Northeast and equally as likely as other States tu be involved in South more frequently ranked meeting the needs uf relateda...ayities. Activities that did nut fit this special populations highly, while States in the pattern included use uf NHSC as a recmitment Midwest and West more frequently stressed pay method, State sehuhu ship program, medical and ment issues. Quality of care emerged as amayor other health prufc&&ions edul.ativn, watinwng edu ." 98 Health Care in Rural America Figure 4-5State Priorities for Rural Health Activities' Activity category° Rural health systems coordination and implementation 35 Provider recruitment/ placement 33 Technical assistance 28 Financial assistance to local organizations 14 Legislative affairs 14 Education Research 84 Publications0 0 10 20 30 40 50 80 70 80 Number of States listing activity as one of their top three priority area: ifor mull* respondent States. results are based on the response of a single resp:indent in each State identified as most knowledgeable about and central to State rUflki health aothnlies. Data were missing for one Stale. Mose cslegodos correspond to activity categodes on the surrey instrument Some respondents may h. se Onswered this queutron based on their current prionlles rather Irian on plonk* that guided their salmis during the previous 3 years. SOURCE: Office of Technology Assessment, 1990. cation for rural health professionals, and targetin f Finally, the survey asked respondents to describe uninsured populations in rural health programs and activities they would most like to see in their State activities. In these cases, States that had not ranked to .iddress rural health issues in the future. Among the related issue in the top three were mare likely the wide variety of activities described, those most than other States to be involved in the activity. frequently mentioned included: Currert and Future State Activities in improving theavailability of primary care Rural Health services in rural areas: creation of a State ORII; The survey asked respondents to briefly describe three current activities or programs in their State that development of rural health paicy, plan, and had been effective in addressing rural health is- standards; sues.° Examples ranged from creating an OM to facility planning and developmeat, providing services to mral people with acquired improvement of health insurance coverage; immunodeficiency syndrome (AIDS). Some of the Medicaid expansion/reform; more frequently cited effective activities included: provider recruitment and placement (loan re- provider recruitment and retentionactivities paymentiforgiv eness program, scholarship pro- (both educational and rmancAlincentives), gram, clevelopment of rural-orientpAicurricula technical assistance activities, in health professional schools); and Medicaid expansion or reform, and building stronger statewide rural health coali- primary care systems and facility development tions oi consortia. Ordy one respondem indicated DO current rural health activities Chapter 4The State Role in Rural Health 99 Table 44Selected State Rural Health Act lvdles From OTA's Survey of State Rural Health AcIlvltles° Provider reaultmenVrelention Technical assiehvice :.I II il ;i 1 i iI, Is il li111 I State M i Ig!I&]II111II iiIii cli 1 il11 H" Afemma x x x x x x x .. x x x x x x Moshe x x x x x x x x x x x Adzata X X X X X X X X X X X X X Arkansas X X X X X x X x X X X x X X X X California 0 0 Ok X X X X X X X X X X X0 X X X X X X X X Connecticut X X X X X X X X X X X X X Hod& X x x x x x x x x x x x x Gmbh X X X X A X X X X X Head X X X X X X X X Y X X X X Idaho X X X X x X X X X X Minob X X X X X X X X X Indiana X X X X X X X X X X X X iOVA1 0 0 0 X X X X X 0 X X X X Kansas . 0 0 0 x X x x x x x x x x x x x x x x x x x x x x Weans X x x x x x x X x x x x itsylux1 x x x x x x x x x x X x x x Massaciametts X X x X x X X X X X Michigan . 0 X X X X X X X X Minnesota 0 0 0 X X X X X X X X X X X Mississippi X X X X X X X X kikeoud X X X X X X X X X X X X X Nevada x x x x x x x X x x x x Nen Hampahlre X X NewJersey 0 0 o x x x x x x 0 0 x x *xi Wok° x x x x x x x x x x x x x x x Nen York X X X X X X X X X X X X X X X Math Carolina X X X X X x X x X X X x X X X X Math Dakota . . . X X X X X X X X X X X X X Ohlo X 0 X X X X X Oklahoma X X X X X X X X X X X X X X X Oregon X X X X X X X X X X X X X X X X X k X Rhode bland X 0 X X X X South Gwen x X X x x x x x South Dakota ... OX X X X X X X X X X X x Tennessee X X X X X X X X X X X X X X X Texas X X X X X X X X X X X X X X X Uteh X X X X X X x x x x x x Wimont 0 0 ) x x x x x x x Irlrybla x x x x x x A x x x x x X X X X X x X x X X X X X x =kr*.. x x X X k X x X X X X X x Wleuxuln x X X X X X X X X X X VisliwillM 0 0 0 0 0 0 0 X do Respondng orgentzauons Nom ens State mcircoaen two iney ilea seen 'Amoy invutved 'Ohm ponowlattwity Jtoi sst :.yeal e LOKof Ate aii. of years: 1986 through 19811). Responding organizations mamma mel, aaaougn may aaa MA been aim" olvoiven ir, trols actu iiity din o. iy) J.. i.klat 3 ythki a. /he. vf9111AatiUrieIi. Slate may have been involvcd. Noted In reviewer's commentsdoes not reflect original survey response, saes table 4-2 tar a Rat al the ogyanizattonal entities whose actiVilles wets reported in this survey See mj.. C kuii .Atry _4 :he her., Resoondentsreponed activates they Inn been directly involve* el many ememilli ne pest 3 yewThe end Jaw 4,1,, mei 1..A1.0o intel989 co early 1989 depending on tho State. SOURCE:0111os et Technology Assessment, 1990. 100 Health Care in Rural America Table 4-9Selected Rural Health Activities. Comparison of "More Rural'. and Less Rural States and States With and Without identifiable Offices of Rural Health (ORHs) Percent of States involvedin activity 6 "more rural."4"less rural"4 ORH non-Ofdi (0=15) (0=35) (11=12) (1fr38) Provider recrwiteent/pLacoment 73.3 77.1 91,7 71 1 National Health Service Corps ... . 40 0 48,6 58.3 42 1 State loan forgiveness/repaYment program 33,3 31 4 25 0 34 2 Service-contingent State scholarships.. 33.3 28 6 16.7 34 2 Financial assistance to local organisations 60.0 74,3 75 0 68.4 Technical essistance 100 0 07.1 100 0 974 Research 80 0 85 7 100.0 78 9 Research on health personnel... . 73 3 73.5 91 i 18.4 Vnicallbealth ayetese coordination and implementation...... 86 7 97 1 100 0 92 1 Education 86 7 91 4 100.0 86 8 legillativo affairs 93 3 85,7 91.7 86.8 Development of task force/committee to address rural health issues. .. 68 7 67 6 83 3 632 45tates were classified as "more rural" or "less rural" depending on the percentage of their popalation resid- ing in aonmetrc areas in 1986 ("more rural" = over 50 percent, 'less rural' = 0-50 percent (See app D for a lx. o( States.) bAnoffice of rural health" was either identified as such by a respondent or was known to be an office whose primary responsibility was to administer to the Lealth needs of rural areas of the state. (see appD for a list or ORH States and an explanation of how these States were identified ) SOURCE:Office of Technolog/ Assessment, 1990 A CLOSER LOOK AT STATE likely to have established a StateORH. Third,States with ORI-Is may have been in a better position than RURAL HEALTH ACTIVITIES other States to respond to questions regarding specific rural health activities and problems in the State Offices of Rural Health survey. ORH States reported larger proportions of Anumber of States have attempted to give their State funding (table 4-3), suggesting that more rural health efforts a more central focus by creating targeted State funding is aailable in States that have a formal ORI-1 to coordinate, advocate, plan, admin- taken steps to centralize efforts. istrate, and evaluate various rural health activities at the State level. ORI-Is may be located within the The 19ORHsidentified by OTA m 1990, based State government, within a separate State-funded both on OTA's survey and on a survey conducted in organization (e.g., a university), or in an organiza- 1988 by the National Rural Health Association tion that is entirely independent of the State govern- (NRHA) (426), were located m State agencies, ment. In OTA's survey, most "ORI-1 States" have universities, Alta Health Education Centers (AHEC5), State-based ORHs." The survey found"OHR and other organizations (table 4-12).18 At least six States" to be more active than others in rural health offices had been established since 1986, and an activities. There are several possible explanations additional six States were interested in or planning for this fmding. First, the existence of a centralized to establish ORHs. The range and extent of ORI-I entity whose primary purpose is to addiess rural functions varies greatly and may include health health care issues may enhance the State's level of personnel recruitment and retention. health person- effort. Second, States that place a higher priority on nel and consumer education.tedmical assistance rural health issues may be more active and more and consultation, research and evaluation, informa- 17See app.D for Ihe defunuOn of "office antral health" used in the survey. 15'Ibe number of ORHs in table 4-12 differs from the number identified to PTA s 1488 Sur. 4:y ot Sue Rural ticAlth ALtivaues be, auscnot .dl ORM were 0t extstence in 1988 and some were not identified as appropriate iespondents 1 0 Chapter 4The State Role in Rural Health 101 Table 4-10StateConking ofSix Major Rural Health Care Delivery Issues, 19890 Number of States b c giving the issue a ratikiag.J11_ Issue (1) (2) (3) (4) (5) (6) (7) A. Health provider issues (e.g .shortages. recruitment/retention) 22 13 10 4 1 0 0 B. Meeting the needs of special populations 10 10 8 14 5 3 0 C. Payment issues (e.g., Medicare, insuratva 7 coverage of rural populations) .... . 10 14 13 6 0 D. Medical liability insurance Costs/ availability...... 4 7 6 5 9 16 1 E. Services issues (e.g., hospital closures/ restructuring, system* planning and development). 3 5 15 5 14 8 0 F. Quality of care. . 2 1 5 9 13 20 O. Other issuesd. 2 Number and Percent of all States ranking issue among the top 3 (A) (B) (C) (D) (E) (F) U.S total 15010.. . 45(903) 28 (56%) 31 (62%) 17 (34%) 23 (46%) 8 (15%) Northeast 191. 9(100%) 6(673) 3 (33%) 2 (:23) 4 (44%) 3 (33%) South 1161. . 12 (75%) 11 (69%) 9(56%) 5 (3,1) 9t56%) 2 (13%) Midwest 1121.. 11 (92%) 5 (42%) 9(75%) 5 (42%3 1 (8%) West (13). 13(100%) 6(46%) IC(77%) ,' (38%) Z ((13.281%) 2 (15%) "More rural" States 1151i 13 (87%) 10 (67%) 12(80%) 2 (13X) 6 (40%) 2 (13%) "Less rural" States 1351t 32(91%) 18 (51%) 19 (54%) 15 (43%) 17 (49%) 6 (17%) States w/ an ORH 112)6... 11 (92%) 7 (58%) 8(67%) 6 (50%) 5 (42%) 1 (8%) Status w/o an ORH 1381g. 34 (90%) 21 (55%) 23(61%) 11 (29X) 18 (47%) 7 (18X) aDate of ranking may be late 1988 or early 1989, depending on the State bValid responses were received from all 50 States aFor multiple respondent States, results *re based on the "sponse of a single respondent in each :tate who was identified as most knowledgeable about and central to State rural health activities dA blank line was provided on Which respondents could list an additiolal general issue and incorpera0 it inuo tho ranking scale accordingly The three "other" issues listed by tespondents were alterna ive delivery models; availability of obstetrics services, unspecified °Numbers in brackets denott number of States within each region or category tStates were classified as "more tutal" ot 'le,s rural- depending on the percentage of their population residing in nonmetro areas in 1986 (-more rural" = over 50 percent. 'less rural m 0-50 percent (See app D for a list of States ) gAn "office of rural health" (ORR) was either identified as such by a respondent ot was known to be an offlue whose primary responsibility was to administer to the health neels of rural areas of the state tSes dpp D for4list of ORR States and an explanation of how these States wer, identified ) SOURCE. Office of Technology Assessment. 1990 tion dissemination, advocaq, health systems dev el these levels. Respordents also felt that the Federal 3pment and integration, and diret-t serv (424 offiv.et.ould assbt 111 ne development of nevv State ORHs by helping State governments Identify poten- State ORHs may also be of value in i-oordinating tial resoun-es and othel State models. Examples of and implementing Federal rural health initiatives. In twu States that have ret-ently teated ORM ate the 1988 NRHA survey of State ORHs, respondents presented in box 4-A. saw the Federal Office Rural Health Policy as playing a central role in dissemination of informa- Selected Examples of State 1 Pgimafive and tion regarding funding sources for =al health programs and aettvPies, while State ORHs were Administrative Activity seen as playing a cr..ical role in determining State The reatiai of spet-ial task forki:s or Lollainitic.:4 and regional rural health needs and guiding a more is a 4,ummon step toward.,kompr4hensive cx.uni- rational allocation and coordination of resources at nation of State rtital health issues. Thirty foul Slaws Table 4-11--Re lotion:No Between States' Pere, doof Major Rural Health issues and Specific Rural Heaith Activities States ranking issue States HOT ranking Ranked issue 1-3 1-3 and involved issue 1-3 and Involved !number of Statell in the activity in the activity Issue Yes Ho Related activity buster Percenta Humber Percent? Provider issues 45 5 Had actively placed ;,iroviders during past 3 years 34 (75Zt 4 (80Z) Had used HHSC as a recruitment method 20 (44%) 3 (600 State loan forgivenesstrepayment program 15 (33Z) (20Z) State scholarship program 13 (28%) 2 (40%) Placement service 26 (57z) 3 (60%) Research on health personnel in rural areas 33 (73Z) 4 (80Z) Medical and other health professions education 29 (64Z) 5 (100z) Continuing education for rural health professionals 27 (60x) 4 (80Z) --- Medical liability 17 33 insurtnce costs/ Rural health-relate-.1 research on avaalebillty medical liability insurance costs/availability 9 (53Z) 14 (42%) Meeting the needs 28 22 of special Had targeted some their rural populations health activities to special populations 26 (93%) 20 (91%) Research on health status f rural populations 20 (71Z) 17 (77Z) Payment issues 31 19 Research an insurance ,.overage in rural populations 20 (64Z) 10 (53Z) Research on rural hospitals 20 (64%) 10 (53Z) Development of health service districts or other financial options 10 (32Z) 5 (260 Had targeted uninsured populations in some of their rural health activities 22 (70x) 16 (84%) Had targeted low-ancomo populations in some of their rural health activities 27 (87Z) 16 (84Z) Quality of care 42 Research or quality of care in rural areas/facilities 4 (50%) 12 (29%) Research on new technology in rural areas 3 (38Z) 11 (26%) Services issues 23 27 Hed provided some form of technical assistance to rural communities 21 (100Z) 26 (96%) Had proviatd some form of technical assistance to rural health facillties/provider$ 22 (96%) 21 (78%) Rural health systems coordiaation/implementation activities 22 (96%) 2S (93Z) Research on rural health services util'zation 14 (61%) 13 (48Z) Itesearch on health systems coordination 1: (6.4) 13 (48Z) Research on rural hospitals 18 (78z) (44z) aPercentage of States who ranked the related issue 1-3 and were involved in the activity bPercenttee of States who did not rank the issue 1-3 and were anvolved in the activity SOURCE: Office of Technology Assessment. 1990 Chapter 4The State Role In Rural Health 103 Table 4-12States With Mos of Rural Health, 1990 Box .1-ARecenfly Created State Offices of States withOffices of Rural Health: Rural Health: Two Examples ElLekt Location of OM lowaCreated in 1989, the Iowa Office of Rural Arizona University Health is located within the Department of Public Arkansas State agency California State agency Health (302),It is required by law to submit a report Connecticutb State agency and recommendations to the State kgislature on the Georgia' State agencY & university impact of current Medicare reimbursement policy Illinois' State agency on rural hospitals and other providers; to provide Iowaa State agency Kansas' State agency assistance to nual communities to improve reim- Nebraskaa State agencY burseinent through p-rticipation in the Rural Health Nevada University Clinics program (see ch. 3) and establishment of New Mexico Not-for-profit. organization skilled nursing facility beds, and to coordinate North Carolina State agency research on health status and morbidity. It was also North Dakota University Oregon State agency required to make recommendations to the legisla- South Dakota' State agency & university ture by February 1990 on the development of a new Texas University alternative licensure category for rural medical Utah State agency facilities (302). Washington Area Health Education Center Wisconsin University South DakotaThe South Dakota Office of Rural Health, established in 1988, has two offices: States interested iu or planninlito establish one within the State Department of Health, and the Offices of quralilealth. other within the University of South Dakota School Alabama Minnesota of Medicine (627). The Office was created by a Alaska Mississippid memorandum of agreement between the medical Michigan MoLtana school and the Department of Health, and it receives 8Established since 1986, funding through a State legislative appropriation. bOffice of rural and urban health. Mditional funding is ganed through the School of ',Established since 1988. Medicine. Activities of the ORH include: °A 1890 bill (S.B.2:38) pending in the MissibIippi State Let.slature would create an office of rraL recruitment and retention of rtual health pro- health within the State Department of Health. Thvre fessionals; is an existing Rural Health Researcb Program in the technical assistance to help rural provider University of Mississippi School of Pharmaceutical establish and maintain rural practices, and to Sciences, but it i% not involved in rural health help rural facilities apply for Rural Health policy or planning. Clinic certification under Medicare and Medi- SOURCE: Office of Technology Assessment, 1090. Based on data from lirtional Rural Health Associ- caid; ation. "Report of the Task Force on Offices health care needs asse mous for rural areas; of Rural Health and State Rural Health and Associations," Hatieual Rural Health Asso dissemination of rural health information to elation. Kansas City, MO, Aug. 12. 1988, as medical students and medical residents (627). updated by OTA. reported that they had developed task forces, most egis . c Commission en Rural Resources held a commonly through administrative action of the bylllpubiu111 to d.55C6bth_ xuiali.ealth tare system and Governor's office. Table 4-13 provides some exam- to design a framewoik to ensure access to rural ples of State task forces and committees and their health for the next 20 years. The symposium responsibilities. The experiences of New York and identified three major area.s legislath c and Texas, ,,escribed below, illustrate the role of task administrative attention: forces in catalyzing legislative and administrative action on nsral health issues. need for regulatory flexibility (e.g., granting New York rural hospitals a waiver from the CON process). Both the State legislature and the State Depart- ieed for reimbursement and Naming metta ment of Health haw recently examined rural health nisms that more acurately reflect costs 4., ,d care issues in New York. In spring 1987, the improve access to capital, and ./ J. 104 Hee, ith Care in Rural America Table 4-13Four Examples of State Task Forces and Committees Created To Address Rural Heaith Issues State Name of task force/committee Autho,ity Responsibilities New York Task Force on Rural Health Administrative e Examine rural health care issues and prob- Strategies (1987) Lams statewide Develop stratceies and recommendations for administrative or legislative action Washington Washington Rural Health Legislative Review existing laws and regulations Care Commission (1988) gcuJrning rural health services and identify barriers they create to efficient and effective delivery Review issues that affect the current delivery of rural health care Establish operational standards for a model alternative rural health facility end review the impact of existing government payment policies on such facilities Alabama Alabama Rural Health Legislative Study and recommend to the legislature ways Task Force (1989) to address the problem of declini:g availability of obstetrical servic..e in rurrl areas of the State Recommend ways to Improve the financial health of rural hospitals delivering obstetrical care through better management practices. modified scopes of services, and other mechanisms Texas Special. Tail- Force on Rurat Legislat.ve Define minimally acceptable levels of Health Care Delivery (1987) medical care for t State's rural areas. focusing on specific issues in emergency medical transportation, huspital care, emergency and outpatient care, and ancillary services SOURCE Office of Technology Assessment. 1990 Data fromNew York State Department of Health, Toward Improving Rural Health CareA Report of the Task Force on Rural Health strategies tAlbany, New York State Department of Health, November 1987/, State of Texas. Special Task Force on Rural Health Care Delivery. Final Resort and Recommendations to the Governor (Austin. TX State of Teyas, Feb- rua,y 1989). JColeman, West Alabama Health Services, E.Aaw, AL, personal communication, July 1989, Washington Rural Health Care Commission, A keport to the Leaislature on Rural Health Care in the Stata of Waihington (Olympia, WA Washington Rural Health Ca-e Commission. January 19891 need for coordination and community planning improving migrant health services. among State and local rural programs. promoting rural health networks, impm-ing the supply and distribution of health Other recommendations included increased State- personnel, and level technical assistance to local providers in grant establishing a rural nealth council (434 writing and services coordination. The findings and recommendations of these groups led to direct legislative and administrative A subsequent legislative commisn found that many of New York's rural hospitals and nursing action, including the establishment of two new ctatewide rural health entities. The Rural Health homes suffered from inadequate access to financing Council, which includes providers, consumers and for major project& The Commission recommended elected officials who act as advisers, now oversees that information resources be enhanced, the CON State-funded rural health programs and offers ideas review process for capital purchases be modified, on possible new initiatives, The Office of Rural and State-level capital financing programs be made Affairs works with State agencies to monitor new more accessible to rural providers(439.440). legislative programs affecting rural areas (394 The State has recently authorized appropriattons for. A State Department of Health task force created specifically to examine State rural health cart issues small grants to providers in underserved areas and problems issued a report in 1987. Its recommen- who toordinate with other facilities to combine dations included: needed services and procedures: 1 5 Chapter 4The State Rale in Rural Health 105 grants to iural hospitals for service diversifica- insurance premium discount for such phy si- tion, expansion, conversion, or the develop- cians (597). ment of various affiliations and alliances; a development program that helps rural provid- ers plan and implement projects to improve Other State Initiatives existing primary care services or develop other Initiatives in other States include a wide s ariety of essential services such as emergency medical programs aimed at coordinating and augmenting care, rehabilitation, and long-term care, rural health care services. For example, some States a program to expand prhnary care services in are consideiiig creating new health facility catego- underserved rural areas and to make primary ries to enable small, struggling rural hospitals to care accessible to medically indigent popula- resmicture and narrow their scope of serv ices (see tions; and ch. 8). Other examples are: a swing-bed demonstration program for rural conununity hospitals (438). In Arkansas, the State legislature recently appropriated new funds ($225,000) to an exist- ing rural medical clinic loan fund for small Texas conomnities that lack adequate medical serv- In 1987, the Texas Legislature created a special ices (54)- task force to define minimally acceptable levels of In Illinois, the Department of Public Health rural medical care. Work groups addressed specific recently issued a report on participation in the issues of emergency medical mar .1rtation, hospital Rural Health Clinics program (see ch. 3). The care, emergency and outpatient Lire, and ancillary report provided *.ackgrounti on this program, services. The task force's fmal report (issued in identified areas where clinics would qualify for February 1989) descnbed a crists m thc State's rural participation, discussed clinic certification pro- health delivery system, citing several hospital clo- cedures and reimbursement, examined the im- sures, a curtailment of obstetric services, and short- pact of certification, and outlined a plan for ages of health personnel, The report's reconunenda- disseminating information on the program to lions addressed trauma care, Medicaid reimburse- rural providers (28(5). ment, capital finance progiams for rural hospitals, in Iowa, provisions of an extensive law passed and hospital diversification. The report also recom- in 1989 include: mended creating a statewide center for rural health creation of State Office of Rural Health (see initiatives to promote integration of rural health box 4-A); programs and services into an overaii system of care technical usistance by the Department of (574). Public Health to help coordinate develop- ment of outreach centers for pregnant women In 1989, the State legislature authorized the and infants and children; creation of a Center for Rur! Health Initiatives pilot programs in rural hospitals to provide within the State Department of Health to cooidinate prunary and preventive health services to the and ...evelop rural health services in the State. The medically indigent; legislation also: expansion of agricultural health and safety established a Medicaid swing-bed program; programs; allowed full implementation of the Federal expansion of mental health outreach serv Rural Health Clinics Act (Public Law 95-210) ices, homemakerlhealth aide programs, and in the State; public health nursing progranr; and directed expansion of rural hedical student and authorization of the use of an eiusting tax residency training programs; levy for rural hospital operation and mainte- required hospitals to implement patient transfer nance (302). agreements to preveni 'reverse dumping of In Tennessee, the Cohununity Health Agency indigent patients; and Act of 1989 authorized and appropriated $6 indemnified physicians at least 10 percent of million for eight rural and four urban cummu- whose patients were on Federal or State medi- nit) health planning agendes. Each planning cal assistance and mandated a malpractice agency muss define and help develop a regional 11 6 106 Health Care in Rural America system of coordinated primary care servkes nificant capital if they were to have a pronounced accessible to all area residents (594). and prolonged impact. SUMMARY AND CONCLUSIONS When asked what activities or programs they States have both a high level of involvement in would like to see in the future to address rural he. 1th rural health activities and a significant degreetA issues, respondents to this survey often suggested an dependence on Federal funding for thoss v ales active Federal role. Activities such as the creation of (table 4-3). The level of effort States are deb, oung to State ORHs, development of rural health policies, mg health issues varies dramatically and does not plans, and standards, improvement of health insur- necessarily correspond with States' degree of nual- ance .:overage, Medicaid expansion or refoam, rural ness or perceived level of need. Differences between health systems coordination and network develop- "more rural" and "less rural" States emerged ment, loan repayment or forgiseness and scholarship primarily in the States' perceptions of major rural programs, and as ailabiity of rural-oriented health health care problems (table 4-10) rather than in their professions education were frequently mentioned. A level of rural health-related activity. While some Federal role is possible, if not implicit, in all of these States boast a variety of successful initiatives and initiatives. programs, other Statesand, notably, some States in which a large proportion of the population is Recent State legislative activ ity on rural health nualhave not mobilized to adckess their particular issues has ranged from energetic to nonexistent. rural health problems. These States might especially Active States c.an prov ide valuable models for less benefit from Federal guidance, encouragement, and at tis e States, and certain State programs could serve continued support. as models for broader Federal initiatives. OTA 's survey of State rural health activities reveals some Because the OTA survey did not attempt to significant regional and State differences that may describe the degree to which reported activities were be useful in targeting Federal resources. felt to have been successful by the States, or the sources of funding for specific activities,itis impossible to distinguish clearly between the Fed- State ORHs provide focal points for State rural era] and the State roles. A study conducted by the health activities and programs and can improve the Federal Bureau of Health Professions in 1986 found development and coordination of local, State, and Federal efforts. The degree to which State agencies that State support for health professions disinbution can effectively direct suai offices, however, will programs increased significantly during the first nalf of the 1980s (685).19 However, OTA' s survey found vary depending on fmancial and organizational that States still rely heavily on Federal funds to factors. The distribution and organization of current State ORHs suggests that aay Federal support for the support a variety of existing rural health activities. creation or operation of State ORHs should be Most States identified provider recruitment and flexible with regard to location of the ORH within placement issues as high priorities, but most did aot the State. Some States currently without ORHs have programs (e.g., service-contingent loan forgiv e- might consider alternatives to the State agency- ness/repayment and scholarship programs) com- based model (e.g., university-based ORHs like those monly believed to be most effective in addressmg in Arizona and North Dakota). South Dakota and these issues. Because scholarships and loans are Georgia are examples of States whose ORHs are costly, such programs would probably require sig- based both within a State agency and a university. *Ibis study. as vee11 aS state efforts in health pess.mne1 recruitment and mientrun. are discussed in greater dei: in uti 13 i 1 7 Part III Availability of Rural Health Services 11 el pi e5 Chapter 5 Problems and Trends in Rural Health Services CONTENTS Page INIRODUCTION 111 HOSPTTAL CHARACTERISTICS 111 Number of Community Hospitals 111 Hospital Ownership 111 Hospital Scope of Services 113 Size of Hospital Medical Staffs 116 HOSPTTAL UTILIZATION AND COMPETITION 117 Hospital Inpatient Utilization 117 Hospital Outpatient Utilization and Ambulatory Surgery 122 Competition for Patients 123 PRIMAnY CARE FACILITY CHARACTERISTICS AND UTILIZATION 124 Number of Community Health Centers 124 Community Health Center Servicas 126 Community Health Center Utilization 126 Number of Certified Rural Health Clinics 126 HEALTH MAINTENANCE ORGANIZATIONS 129 HOSPffAL FINANCIAL VIABILITY 130 Revenue Issues 130 Costs and Operating Margins 135 Access to Capital 137 FINANCIAL VIABILITY OF COMMUNITY HEALTH CENTERS 140 Revenue Issues 140 Costs and Operating Margins 141 FACILITY CLOSURES 142 Number of Hospital Closures 142 Characteristics of Closed Hospitals 143 Impact of Hospital Closures on Acctss to Cam 144 Efficiency of Hospital Closures 145 Closure of Primary Care Facilities 145 POPULATION MOBILTTY AND ACCESS TO CARE 146 Patient Outmigration 146 Geographic Limitations to Access to Care ...... 147 SUMMARY OF FINDINGS ...... 151 RUrai Community Hospitals 151 Rural Community Health Centers ...... 152 Access to Care . 153 1 1 9 Boxes Box Page 5-A. The Hill-Burton Program 119 5-B. The Hill-Burton Uncompensated Care Obligation 132 Figures Figure Page 5-1. Nonmetropolitan Hospitals by Census Region, 1986 113 5-2. Ownership of Nonmetropolitan Community Hospitals, 1987 113 5-3. Short-Term Hospital Beds to Population Ratio, 1986 121 5-4. Certified Rural Health Clinics, 1988 129 5-5. Sources of Payment for Services in Rural Federally Funded Community Health Centers, 1984, 1986, and 1988 142 5-6. Closure of U.S. Community Hospitals by MetropolitatilNonmetropolitan Status, 1981-89 143 Tables Table Page 5-1. Community Hospital Size and Utilization, by Metropolitan/Nonmetropolitan Status, 1984-88 112 5-2. Number of Community Hospitals by Metropohtan/Nonmetropolitan Status and Bed r ze, 1984-87 112 5-3. Most Cognmon Selected Services Available in Nonmetropolitan Community Hospn ... With Fewer Than 300 Beds, by Bed Size, 1987 115 5-4. Intensive Care Capability and Selected Diagnoitic and Treatment Services Available in Community Hospitals, by Hospital Location and Bed Size, 1987 115 5-5. Long-Term Care Services Provided in Nonmetropolitan Community Hospitals, 1987 116 5-6. Total Medkal Staff ID Community Hospitals With Fewer Than 300 Beds, by Hospital Location, Type, and Bed Size, 1987 117 5-7. Changes in Utilization of Community Hospitals by Hospital Location and Bed Size, 1984-87 117 5-8. Utilization of Nonmetropolitan Community Hospitals by Hospital Type and Bed Size. 1987 118 5-9. Distribution of Hilt-Burton Short-Term Hospital Projects and Population, by Community Size, 1948-71 120 5-10. Community Hospital Beds per 1,000 Population and Occupancy by Hospital Location, 1986 120 5-11. Community Hospital Outpatient Utilization by Hospital Location. 1984-88 123 5-12. Select Ambulatory Care Services Provided in Nonmetropolitan Community HospiLds by Bed Size and Hospital Type, 1987 123 5-13. Nig nber of Federally Rmded Community Health Center (CHO Grantees and Serv ice Sites by Rural/Urban Status and Region, 1984-88 125 5-14. Utilization of Rural Federally Funded Community Health Center Grantees and Sep. ice Site:, 1984-88 127 5-15. Primary Care Physician Utilization in Rural Federally Funded Community Health Centers by Region, 1984-88 . 127 5-16. Number of Certified Rural Health Clinics, and Nonmetropobtan Counties in Which Clinks Could Qualify for Certification, by State, 1989 128 5-17. Average Days in Patient Accounts Recetvablt for Community Hospitals. by Hospital Location and Bed Size, 1984 and 1987 . 110 5-18. Aggregate Uncompensated Cue in Community Hospitals by Hospital Lootion and Bed Size, 1984-87 131 5-19. Sources of Net Patient Revenue of Community Hospitals, byHospit,t1LA awn. 198h I Al 5-20. Distribution of Hospitals by Medicare Percentage of Net Patient Revenue, 1906 132 5-21. Community Hospitals Retoivinf, Tax Appropriations From State and Local Governments by Hospital Location and Bed Size, 1984 and 1987 133 5-22. Average PPS Operating Costs Per Case of Hospitals in the Fifth Year of PPS, by Hospitcl Location and Type 133 5-23. Hospital PPS Operating Margins for the HIV 5 Years of PPS, by Hospital Location and Type 134 5-24. Fiftb-Year Hozpital PPS Operating Margins: Means and Percentiles by Hospital Location and Type 134 5-25. Community Hospitals: Gross Outpatient Revenue From Outpatienti .. Percent of Total Grog Patient Revenue, by Hospital Location and Bed Size, 1984 and 1987 135 5-26. Mean Hospital Costs Per Case Compared With Mean Proposed ASC Payments Per Case and Blended Rate Payments Per Case, by Hospital Location and Bed Size 136 5-27 Changes in Total Revenue and Expenses for Community Hospitals by Hospital Location and Bed Size, 1984 and 1987 137 5-28. Tctal Mean Expenses Per Inpatient Day for Nonmetropolitan Community Hospitals by Bed Size, 1987 138 5-29. Total Expenses Per Nonmetropolitan Community Hospitals by Ownership and Bei& Size, 1987 138 5-30 Community Hospital Net Patient Margins and Net Total Margins, by Hospital Location and Bed Size, 1984 and 1987 139 5-31. Comparison of Nonmetropolitan Hospitals Having Positive and Negative Medicare PPS Operating Margins, PPS Years 2 Through 4 139 5-32. Community Hospitals Acquiring New Capital Debts, by Hospital Location and Be0 Size, 1984 ^-4 1987 140 5-33 Aggi Ate Funds Given to Endowments or Available for Plant Replaceinent/Expansion and Other Restricted Purposes in Community Hospitals, by Hospital Location and Bed Size, 1984-87 141 5-34 Patients Requiring Sutsidies in Rural Federally Funded Community Health Centers o CHCs) by Region, 1987 141 5-35. Community Health Center (CHC) Revenue and Expenses, 1986 and 1988 142 5-36 Geographic Distribution of Community Health Centers and Federal Funding, 1983-86 143 5-37. Characteristics of Community Hospital Closures in 1987, by Hospital Location 144 5-38. Factors Related to Hospital Closure in 1987 as Reported by Nonmetropolitan Hospital Mministrators 144 5-39. Cbanges in Rural Community Health Center Granteeb. Mergers, Closures, and New Staits, 1984-88 146 5-40. Sources of Inpatient Care for Rural Residents in New York State, 1983 147 5-41. Household Characteristics for "Community C" by Hospital Utilization Experience, 1984-85 148 5-42 Regional Differences in Distances From Nonmetropolitan Hospitals to the Nearest Hospital 148 5-43 Travel Time to Nearest Hospital for Nonmetropolitan Hospitals That Are More Than 15 "Crow Fly" Miles From the Nearest Hospital, 1984 149 5-44. Travel Time and Distance to Nearest Hospital for Nonmebopolitan Hospitals More Than Twenty-Five Miles Front the Nearest Hospital, 1984 149 5-45. Regional Distribution of Nonmetropolitan Hospitals by Sole Conununity Hospital (SCH) Status, 1984 150 5-46. Characteristics of Four Frontier Hospitals 151 5-47. Federally Funded Community Health Center Service Sites Located in Frontier Areas by State, 1989 152 1 2 .1 Chapter 5 Problems and Trends in Rural Health Services INTRODUCTION HOSPITAL CHARACTERISTICS Recent changes in the delivery of ruralt health services have created both problems and opportum Number of Community Hospitals ties for rural communities and their health cam In recent years, the number of community hospi- facilities. In particular, significant changes in the demand for the services of rural hospitals and tals in boa rural and urban areas has decreased slightly. M shown in table 5-1, the number of rural primary care centers threaten their operational sta- hospitals &dined 5.5 percent from 1984 to 1988, or bility and thus the ability of some rural residents to about twice as much as did the number of urban obtain basic health care. hospitals. Over 70,000 hospital beds were elimi- nated during this period through the downsizing or This chapter begins by describing trends In closure of hospitals. Only 29 percent of the elimi- operating and service characteristics of rural acute nated beds were in rural hospitals, but because rural and primary-care facilities, particularly mgarding hospitals are bmaller in size (i.e., have fewer beds) utilization and competition for patients. It then than urban ones, the proporuoa of beds eliminated examines trends affecting the financial condition was actually higlier in rural than in urban areas.1 (In and viability of rural hospitals and community 1988, rural hospitals made up about 46 percent of the health centers (CHCs)2, and the impact of the 5,533 community hospitals, but they housed only 22 growing number of health care facility closures in percent of the total licensed beds (35).) rural areas. Finally, it examines what is known about In 1987, nearly three-fourths of rural hospitals had the nature of travel by rural residents outside their fewer than 100 beds (and about one-third housed communities for health care and the geographical fewer than 50 beds)(table 5-2). By comparison, only limitations to accessible care in rural areas. 23 percent of urban hospitals had fewer than 100 beds. From 1984 to 1987, the number of large rural Most of the data documenting changes in hospizal hobpitalb declined, while the number of rural hospi- operations are from 1934 through 1987 and were tals with fewer than 50 t Ids actually increased OM. supplied by the American Hospital Association Hospitals are not evenly distributed throughout (AHA). Additional AHA data also enabled a more rural areas of the country. Nearly two-thirciP of rural in-depth analysis of hospital orerations in 1987. bospitals are located in the four central Census Most data on CHCs cover trends from 1984 through regions of the United Stater,4 over 20 percent are 1938, and most were obtained from the Bureau of located in six Midwestern States (figure 5-1) (382). Health Care Delivery and Assistance of the U.S. About 11 percent of rural hospitals are in frontier Public Health Service. areas (counties with six or fewer persons per square mile). In 1987, there were 277 hospitals located in Local health departments (LHD5) and private 387 frontier counties (see app. C). group practices are also important sources of basic rural health services. No infoimation on these facilities is presented in this chapter, however, Hospital Ownership because no national data are available on their Nearly one-half (48 percent) of all rural commu- numbers, scope of services, or other Ns ;.ii; operating nity hospitals in 1987 were privately owned, non- characteristics. profit facilities (figure 5-2). State and local govern- Valens otberwis., noted, "rural" orresponds to nonmetropohian areas all areas uutbidc of &agitated metropolitan ...ouruies, i4e. J.. 2., 2"CliCs" in this chapter includes migrant health centers. nbc number of hospital beds refers to total fauhty beds tboth &toe ..are and other) set up awl biall.,4 rot uu, A hubpotel a milittxiad biatica ta.1,4 Is tYPically fewer Wail the total amber of beds the hospital is licensed to operate by the State. 45ee app. F for a description of Census regions. .-111 112 Health Care in Rural America Table 5.1 -Community Hospital' Size and Utilization, by Metropohlan,Nonmotropontan Status, 198448 Percent change 1984 1985 1906 1987 1988 1984-88 Number a hospitals Monmetro 2,696 2,674 2,638 2,599 2,549 -5.5 Metro 3,063 3,058 3,040 3.012 2,984 -2.6 Nosbet ot beds Nannette 232,746 228,871 223,422 216,921 212,624 -8 6 Metro 784,311 771.807 754,453 741,391 734,073 -6.4 Average aueber a beds/hospital Yonmetro 86 86 85 83 83 -3 5 Metro 256 252 248 246 246 -3.9 Admissions (Lm thousands) Yonmetto 7,450 6,826 6,360 6,000 5,882 -21.0 Metro .. 27,706 26,622 26.019 25,601 25,571 -7.7 Inpatient days (In tisousends) Sennett* 51,651 46,746 44,920 43754 43,313 -16 1 Metro 204,952 189.873 184,527 1b3.761 183.562 -10.4 Occupancy rate (percept) Yonmetro 60.7 56.0 55.1 55,3 35,7 -8 2 tro 71,5 67.5 67.0 67.7 68.4 -0.3 Averege length a stay (days) Yonmetro 6.9 6.8 7.1 7.3 7 4 7 2 Metro 7.4 7.1 7.1 7.2 7.2 -2.7 4CommunitY hospitals defined here ar all non-Federal, short-tern general and other special service hospitala. bOocupancY rates are based on the hospital's botal number of beds (both acute core and other). SOURCE: American Hospital gssocietIon, Hosnital_Statistics (Chicago, IL: AHA, 1985-89 eds.). Table 5-2-Number of Community Hospitals by Metrepollten,Nonmetropobtan Status and Bed Size, 1984.87 Percent change Bed size 1984 1985 1986 1987 1984,87 Monnetro hospitals 2.696 2,674 2.638 2.599 -3.6 6-24 beds 182 177 175 192 5 5 25-49 799 600 sog 605 0 8 50-99 932 919 908 893 -4.2 100-199 606 610 576 536 -11.5 200-299 131 125 130 135 3 0 300-399 34 31 30 28 -17.6 400-599 6 0 5 5 -16,7 500 or more beds. 6 6 5 5 -16.7 Metro hospitals 3,063 3,058 3,040 3,012 -1.7 6-24 beds 33 31 36 38 15.1 25-49 us 182 184 174 -7 4 50-90 476 480 468 471 -1.0 100-199 772 797 806 811 5.0 200-299 603 614 622 618 2 5 300-399 402 408 407 397 -1.3 400-499 263 233 211 211 -19 8 500 or note beds 326 313 306 292 -10.4 4Commurity hospitals defined het'is all non-Federal. short-term general and other special service hospitals. SOURCE: American HIspital Association, Chicago, IL. unpublished data from the Annual Survey of Hospitals. 1984-87. 3 Chapter 5Problems and Trends in Rural Health Servica 113 Figure 5.-1 --Nonmetropolltan Hospitals by Census Figure 5-2Ownership of Nonmetropolftan Region,51986 Community Ho s pitals,* 1987 City/county Or both West $0ettl Central 10.6% 24.8% HosPital chstrict atountem or authority 9.7% 18.6% Wool North Central 22 1% Patutoo State 6.0% 0.7% For-prof it Now Eno:and tOs 3 2% Church-operated Mai Atlantic (nonprofit) 3 S. 7.8% East South Control 9.6% 'South Jsactfic 14 East North Control 13 as Rural hospitals Other nonprofit (2,638) 40.2% aAs defined by tho U.S . Census Bureau. Sas app. F lot geograpric drool ommunity hospitals de led hers as aN non Federal, short atay, nonspo of regions. clay hospitals (see app. 0). SOURCE. Olika of Technology Assessment, 1990. Data hr ,n H. hisrlir , SOURCE Oflice of Todutology Assessment, 1990 Data trom American "Rum! Hospitals," U.S. Congmss. Comma* sal Roses 4h Hospital Assodation's 1987 Annual Survey of Hospitals. Service, Washington. DC: no. 89-298 EPW May.4. IVO:. In 1987, about 19 percent of rural hospitals were ment authorities owned another 42 percent, and contract-managed (see ch. 6), compared with 8 for-profit investors the remaining 10 percent (625). percent of u:ban hospitals. The number of rural facilities under contract management increased 15 A rural hospital's type of ownership is related to percent from 1984 to 1987, suggesting a change in its size. Hospitals with 100 or more beds were traditional forms of governance for many hospitals predominantly private nonprofit facilities, whereas (e g., greater involvement in hr.spital operations by over one-half of hospitals with fewer than 50 beds interests outside the community) (30). were owned by State and local governments (625). The large number of rural community hospitals under local government authoriprobably indicates Hospital Scope of Services the importance of community-subsidized support for There are few in-depth analyses of the nature of these facilities. medical services offered by rural community hospi- tals, or their dependence on hospital size, location, Type of ownership also varies by the location and and other factors, Shortell, in a national study of type of rural hospital. A majority of hospitals in hospitals in muhihospital systems6 from 1984 to frontier areas (56 percent) were 6overnment-owned 1987, found that rural hospitals offered fewer in 1987, but just 21 percent of rural referral centers services (average 17) than urban hospitals (average (RRC8)5 were government-ewned. Conversely, 71 22). However, rural hospitals were found to provide percent of referral centers v. only 42 percent of a variety of services (particularly outside the host .- frontier hospitals were privately owned, nonprofit tal) targeted to the elderly (418). Much of the facilities. The ownership profile of Medicare- difference in the scope of servi..es of Aural and urban designated sole community hospitals (SCRs) (see hospitals appears to be due to s.nallei rural hospital ch. 3) was comparable to that for rural hospitals in size. A study of hospitals in 13 geographically general. Just 3 percent of both frontkr hospitals and diverse States found that nual hospitals a&a group SCHs had for-profit owners, RRCs had a slightly offered 30 percent fewer services than did urban higher proportion (7 percent) (625). hospitals, However, no significant differences were 5ltural referral centers arc described in ch. 3. 6An in-depth discussion of multiltospital systems in nualareas ispresented in ch. 6. 1 ;' 4 114 Health Care in Rural America found in the number of services between rural and hav e an ultrasound unit, compared with 77 percent urban hospitals of the same size (590). of rural hospitals in this group). In a recent study of the service mix of both rural and urban hospitals in 1985, the provision of specific Complex Acute-Care Services services was linked to local demand, provider capabilities, and mission or strategy of the hospital. The proportion of hospitals offering intensive care For example: services differs by location and decreases by bed size (table 5-4). Although 62 percen t of all rural hospitals Rural hospitals provided more long-term care with fewer than 300 beds have medical/surgical servkes than did urban hospitals. intensive care units (compared with 88 percent of Emergency and obstetric services were present urban hospitals of the same size), just 19 percent of in nearly every rural hospital. mral. hospitals with fewer than 25 beds have this Occupational therapy was most likely to be service. Only a small percentage of ali hospitals with delivered by smaller urban hospitals that could fewer than 300 beds offer cardiac oi neonatal target specific needs of the market. intensive careservices commonly reserved for Most hospitals with fewer than 50 beds did not larger urban refenal centers (625). provide cardiac intensive care, an expensive specialty service. Other new and complex services are also found less often in small than in large hospitals and in rural Long-rem care services were particularly prominent than in urban hospitals of a given size. In 1987, for in smaller rural hospitals, where the hospital-based example, rural hospitals were generally less likely to nursing home often had three to five times as many provide in-house computed tomography (CT) scan- patients as the acute-care part of the hospital (236). ning, nuclear magnetic resonance imaging (MR.1), Rural hospitals generally provide less highly cardiac catheterization laboratory services, organ specialized care and perform fewer complex proce- transplants, open heart surgery,,and extracorporeal dures than do urban hospitals. Number of hospital shock wave lithotripsy (ESWL) for kidney stones beds and the ability to obtain a regular surgeon (table 5-4) (625). appear to be critical factors in whether rural hospitals Mobile settings may make some expensive tech- provide inpatient surgery. Hart et al. found that nology more accessible to small and isolated hospi- procedttes in hospitals with fewer than 100 beds tals. These facilities can then have periodic access to were generally common ones of relatively low risk on-site technology without needing to generite the and complexity. Rural hosVtals with fewer than 25 patient volume for its full-time support. MR.1 and beds provided very little inpadent surgery; 79 ESWL are particularly attractive candidates for percent of these hospitals performed fewer than 100 shared use among small hospitals. An estimated 28 annual inpatient operating room surgeries. By com- percent of MRI scanms in 1987 were mobile units, parison, over two-thirds of all rural hospitals with at and manufacturers estimate that in 1990 approxi- least 50 beds performed more than 100 surgeries a mately one-third of ESWL equipment operate in year (236). mobile settings (489542). Common Acute-Care Services No studies have directly compared rates of Thble 5-3 lists the most common services of technology adoption in urban and rural hospitals, but community hospitals with fewer than 300 beds in small and nonteaching hospitals have been shown to 1987 (625). The likelihood that such hospitals adopt specific expensive and complex nes .. technol- provide any of these services increases as the ogies less rapidly than do other hospitals. One study, number of beds in the hospital (bed size) increases. for example, found that large hospitals i250 or more Nearly all niral and urban hospitals (over 90 percent) beds) were much more likely than smaller hospitals of this size provide an emergency depanment, to have adopted certain sophistkated laboratory diagnostic x -ray facility, and ambulatory surgery. equipment by 1980 (707). The study also found that The remaining common services, however, are as the inerea.se between 1975 and 1980 in the adoption much as 40 percent more likely to be provided in of endoscopes was higher for small nonteaching urban than in rural hospitals of a given size (e.g., 93 hospitals, suggesting that these hospitals adopted the percent of urban hospitals with fewer than 300 be& teshnology later than did other huipirdis (which e Chapter 5-Problems and Trends in Rural Health Services 115 Table 5-3- Most Common Selected Services' Avalle in Nonmetropolitan Community Hospitais'' With Fewer Than 300 Beds, by Bed Size, 1987 Percent of hosPitals offering. Metro Nonmetro hospitals hospitals 6-24 25-49 50-92 100-199 200-299 All < 300 Ali < 300 Services beds beds beds beds beds beds beds Emergency depart_tot 95 98 99 98 98 28 96 Diagnostic X-ray facility 95 96 97 98 100 97 99 Ambulatory surgery 77 91 95 97 99 93 98 Respiratory therapy 67 84 91 96 100 89 96 Physical therapy 50 70 67 93 98 81 92 Ultrasound facility 39 6: 83 93 99 77 93 Blood bank 45 50 67 70 87 63 76 Patient education 47 49 63 75 83 61 79 Organized outpatient service....55 53 60 64 76 59 73 Comvvuity health Promotion 39 39 54 66 78 52 73 Chroait obetructive PmlwenarY services 39 43 51 62 77 51 72 Birthing roan. 28 33 52 70 75 49 54 !Services are those hospital-based only. qCommunity hospitals defined here as ail non-Federal, short-stay, nonspecialty hospitals (see app C) SOURCE. Office of Technology Assessment, 1990. Data from American Hospital Association's 1987 Annual Survey of Respite-4. Table 5-4-- Intensive Care Capability and Selected Diagnostic and Treatment Ssi vK.es Availabie in '.ommunity Hospitalsb, by Hospital Location and Bed Size, 19e7 Percent Af hospitals offering. Nonmetro Metro 6-24 25-4950-99100-199200-299 6-24 25-49 50-99 100-199206-292 Service beds beds beds beds beds beds beds beds beds beds Intensive care (lC) capabiLity Medical/surgical IC beds 18.6 43.6 69.1 83.8 93.9 4.5 56.6 83.7 91.1 95.8 Cardiac IC beds 3.3 4.1 6.3 7.4 34.1 0.0 3.3 3.3 14.6 39.2 Neonatal IC beds 0.0 0.0 0 7 4.4 12.1 0 0 0 0 1.1 5 1 15 1 Selected technologies Computed tomography scanner 7.1 14.1 41.3 69.6 90 2 0 0 24.6 52 6 79 2 93 2 Nuclear magnetic resonance imaaing... 1 6 U 7 1.6 3.8 7.0 0.0 2 5 4.1 6 5 12 6 Cardiac catheterization laboratory 0.0 0.3 0 8 6 8 18 2 0 0 0.8 1 9 16 2 42 2 Organ transplant capability .. 0.0 0.1 0.6 1.0 1 5 4 5 0.8 0 3 1 6 6 0 Open heart surgory 0.0 0.0 0.1 1 1 4 5 0 0 0.8 0 8 5 5 22 4 Extracorporeal shock- wave lithotripter. . 0.0 0.0 0.7 2.1 1 5 0 0 0 8 0.6 3 2 5 3 *Includes hospital-based services only. bCommunity hospitals defined here as aIl non-Federal, than-stay, nonspecialtY hospitals (see app C) SOURCE. Office of Technology Assessment, 1990. Data from American Hospital Associa.iun's 1907 Annual ZurveY of Hospitals. 116 Health Care in Rural America Table 5-5Long-1brm Care Services Provided in Nonmetropolitan Community Hospitalsa, i987 Hosuitals having. Separate long-term Skilled nursing care unit facility unit Portent Percent Bed size NuMber of total NuMber of total 6-24 beds 6 3 4 2 25-49 7* 10 5$ 50-99 268 32 211 25 100-199 211 40 196 37 200-299 45 34 42 32 300 or more ...... 11 30 8 22 Total 615 25 519 21 Sole community hospitalab... $5 30 73 25 Frontier hospitals 103 40 77 30 Rural referral centerab 32 15 34 16 NOTE. Numbers of hospitals with skilled nursing facility units are Probably included in the nuMbers of hospitals with separate long-term care units. 8Community hospitals defined here as all non-Federal, short-stay, nonspecialty hospitals (see app C). bAs defined for Medicare purposes (see apP. C) SOURCE: Office of Technology Assessment, 1990 Data from American Hospital Association's 1987 Annual SurveY of Hospitals. presumably were closer to market saturation in The most common type of long-term care unit m 1975) (707). rural hospitals appears to be the separate skilled Long-term Care Services nursing facility (SNF). About 21 percent of all rural hospitals have "distinct part" SNFs (table 5-5) For many rural hospitals, involvement in long- (6251. Swing bed carewhereby a certain propor- term care has become as crucial to their livelihood as tion of hospital beds may "swing" between acute the more traditional acute inpatient services. As and skilled nursing or intermediate long-term care as shown in table 5-5,25 percent of all rural community neededis another common form of long-term care hospitals in 1987 had some form of a separate provided in rural hospitals (see ch. 6). long-term care unit. Rural hospitals are much more likely to have separate long-term care units if they are relatively large. Size is not the only important factor, however. Only about 15 percent of the larger Size of Hospital Medical Staffs rural refenal centers have separate long-term care units, while 40 percent of the typically smaller Rural hospitals have substantially fewer medical hospitals in frontier areas have such a unit (625). staff physicians than urban community hospitals of These figures suFsest that hospitals with highly comparable size (table 5-6). As expected, among utilized and profitable acute-care Jervices have a rural hospitals, larger hospitals have considerably lower tendency to provide long-term care services. more staffphysicians.1However, not allstaff Long-term care is a major service of those differences can be explained by hospitalsize. hospitals providing it. In the 25 percent of rural Hospitals in frontier areas, for example, have sub- hospitals that have a separate long-tenn care unit, stantially fewer phy sician staff than all comparably beds in that unit make up, on average, nearly sized rural hospitals. This may reflect differences in one-half of the total hospital beds. Althoue, only 6 the range of services and technology evadable, percent of all admissions to these hospitals were of lower admissions, and gleater difficulty attracung a iong-tenr nature, nearly two-thirds of inpatieut and retaining physkians in more isolated areas days were long-term care related (625). (625). 1sec ch. 10 for differences in the number of staff physicians by 'CCU* Chapter 5-Problems andTrendc in Rural Health Services 117 Table 5-6-Total Medical Staff in Community P. spitalso With Fewer Than 300 Beds, by Hospital Location, Type, and Bed Size, 1987 Mean number of tot,1 hospital medical staff by bed sizecatennm All hospitals -Hospital type 6-24 25-49 50-99 100-199 200-299 under 300 beds Metro 17.7 32.8 56.7 115.0 184,5 116.0 Nonmetro 6 4 10.9 21.2 42 5 77.6 24,2 Sole community hospitalsb 6 2 10.1 20.4 45.3 80.2 21 5 Frontier hospitals 4.3 6.3 11.9 22.1 9.0c 83 !Community hospitals ("lined here as all non-rederal short-stay, nonspecialty hospitals (see app. C) °As defined for Medicare purposes (see app. C). cRepresents only one hospital. COURCE. Office of TechnologF Assessment, 1990 Date from the American Hospital Associetion's 1987 Annual Survey of Hospitals. Table 5-7-Changes in Utilization of Community HOSPITAL UTILIZATION AND Hospitals° by Hospital Location and Bed Size, 198447 COMPETITION Hospital Inpatient Utilization Percent change. 1984-87: Bed size Admissions Inpatient days Inpatient service utilization in both rural and urban community hospitals has been in steady Nonmetro -19.5 -15.3 decline since the early 1980s (see table 5-1), but 6-24 -17.9 -13.1 25-49 -16 1 -12.0 declines have been greater in rural hospitals. From 50-4 -18 2 -13.6 1984 to 1988, adm:ssions to rural hospitals dropped 100-140 -24 4 -18 1 about two and one-half times as much as admissions 200-299 -9.7 -8.1 -23.8 to urban hospitals. While urbiLl hospital occupancy 300 or more -20.1 rates dropped to about 68 percent in 1988, occu- Metro -7 6 -10 6 pancy levels for rural hospitals declined nearly twiw 6-24 -9 9 -8.2 as much to a low of 55 percent,3 despite their 25-49 -14.9 -14.8 relatively greater rate of bed elimination and a 7 50-99 -13 3 -13.1 100-199 -1 6 -3.1 percent increase in the average length of stay (to 7.4 200-299 -2 3 -3.9 days) in rural hospitals. (Longer lengths of stay 300 or more -10.2 -13.8 enhance average occupancy but not necessarily the *Community hospitals defined here as all non-Faderal. hospital's fmancial condition. Medicare, for exam- short-term general ano ocner special service hospi- ple, usually pays a fixed rate per pativt discharged, tals. regardless of the patient's length of stay.) Although OURCE American Hospital Assoctatloa. Chicago. IL, they made up 46 percent of community hospitals in unpublished data from the Annual Survey of Hospitals. 1984-87 1988, rural hospitals accounted for only about 19 percent of all hospital admissions and inpatient days rural hospitals (table 5-8). Compared with Anal (35). hospitals in general, for example, hospitals in Within rural hospitals, declin:_in admissions and frontier are...5 (two-thirds ofwhkbhave fewer than inpatient days were somewhat greater among larl,e 50 bed.$) had less than one-third as wally admission, than among small hospitals (table 5 .7). This tend is per hospital. Frontier hospitals also had lower the reverse of that for urban hospitals (where average occupancy lutes, a lower proportion of declines were generally greatest among those hospi Medicare inpatient days, and a higher proportion of tals -vith fewer than 100 beds) (30). Medicaid days. SCris had similar but less pro- By 1987, these tends had resulted in substantial nounced characteristics. RRCs, on the other hand, differences in iapatient utilization among types of were not only lager but had higher oLcupancy 'Occupancy num here are based on Me hospital's total number of beds (both acute care and other) L, rre.bon...1,../APIANIAMINWMPPWWW40.61114110086.Per 118 Health Care in Rural America Table 5-2Utilization of Nonmetropolitan Con.munity Hospitelso by Hospital Type and Bed Size, 128, Inpatient daYs_211r_hospital Occupancy Humber of Pimissions Percent Percent rate Hospital type hospitals per hospital Total Medicare Medicaid (percent))) Total umpietem 6-24 bejs 200 418 2,265 45 11 31 25-49 817 918 5,241 47 12 38 50-99 893 1,854 13,520 41 18 SI 100-199 539 3,842 29.749 39 20 59 200-299 135 7,325 54.518 43 15 64 3,0 or more 37 12.603 97,143 41 14 70 Total 2.621 2,295 16,710 43 16 48 Sole commmate 6-24 beds 36 390 2.174 38 15 31 25-49 111 692 5,616 40 11 42 50-99 97 1,935 13,881 38 19 53 100-199 SO 4,311 30,015 39 20 60 200-299 13 7.144 55.048 42 17 85 300 or more 4 11,600 85.878 47 17 65 Total 3)3 2.097 14,736 39 18 48 Frontier 6-24 beds 55 333 2.010 39 13 29 25-49 127 641 4,827 38 16 38 50-99 81 980 14,918 24 28 62 100-'99 13 1,572 31,803 18 37 70 200-299 1 1.270 76,727 8 49 90 300 or more 0 0 0 0 0 0 Total 277 725 8,744 33 20 45 Ruralreferral centime.. 217 7,545 48,151 48 9 61 *Community hospitals defined here as an non-Federal, short-stay, nonspeciaIty hospitals (see app. C). bOccupancy ratesare based on the hospital's total number of bed*. (both acute care and other). eAs defined for Medicare purposes (see app. C). SOURCE. Office of Technology Assessment, 1290 Data from American Hospital Association's 1987 Annual Survey of Hospitals. levelg, a higher proportion of Medicare days, and a both urban and rural areas (table 5-10) (figure 5-3), lower proportion of Medicaid days than did other and in 14 States, ratios were actually higher in rural rural hospitals. Occupancy rates for all rural hospi areas(382).As a legacy of the massive hospital tals declined as bed size decreased, ranging from 70 constriction resulting from the Hill-Burton era, percent for hospitals with 300 or more beds to only many small rural hospitals lie within reasonable 31 percent for hospitals with fewer than 25 beds driving distance of other hospitals. One study, for (625).9 example, found that 84 percent of all rural hospitals Excessive bed supply is one potential reason fur were less than 30 road miles from another hospital the recent decline in hospital inpatient utilizauon. As (539)A relatively high bed- to-population ratio in noted in box 5-A, the Hill-Burton program (Pubia. -.;ral areas of sparse population may sometimes be Law 79-725) successfully increased the supply.4 justified by tLe need for remote hospitals to staff hospital beds, particularly in low income rural areas. enough beds to handle unexpected fluctuations in By 1986, the ratio of conununity hospital beds to inpatient demand caused by disasters and major population was about 4 beds per 1,000 persons in accidents. However, this rationale cannot explain ola general, occupancy rates for acute-cam beds in rural hospitals eat smalla than total bed km-upamy levels Acute Lam bed occupancy also declined as bcd size deceased (623). ./A- Chapter 5Problems and Trends in Rural Health Services 119 Box 54The Hill-Burton Program Use and Distribution of Funds Congress enacted the Hospital Sun ey AndConstruction ("Hill-Burton'.)Ao (Public Laa 79-725) in 1946 in response to a widely perceived shortage of hospnal beds, pahicularly in rural areas. States were ehgibl'e to recen e Federal matching grants Li assist in fancying State needs, dev eloping statewide plans 'or construcung nonprofit, nongovernmental hospitals, andconsmicting thefat..ilata. A.mendments to the Act in 1964 (Public Laa 88-443) made constniction fimds available fot the modernization or replacement of facilities, set minimum staictural and design standards affecting safety and efficiency of operations, required funded hospitals and other facilities to provide free care to Persons unable to pay, , and authorized studies to demonsuate the coordinated use of hospital and other health .are facilities. In 1970, a loan guarantee component was added tu Hill-Burtun whereby the Federal Government would cov er a portkm of the interest cost and guarantee payment of thepnnopal fba Lk. funk.: facilities (335). The legislation required State plans to abide by Federal standards of adequacy in defining bed need. Until 1965, such standards were simpl) defined as the ratio of beds to populationthenumber of generalbeds should equal but not exceed 43 beds for every 1,000 residents, except in sparsely populated areas. Criticsargued that such a standard was arbitrary, as demand for hospital care could vary in areas of similar populatioa (334 Hill-Burton sought to equalize the distribution of hospital facilities between rural and urban areas. Above a minimum amount alloted W every State, the program alucated funds basedLon Suitepopulation UMand per capita income. Per capita income entemd the formula twice (both as a measure of a States bed arid financial need) to go e less affluent as well as more rural States an advantage. Within States, rural areas again were to be gn etpnonty for funds (thisprovision was eliminated in 1970)(131,335). By 1974, when the Hill Burton program was abolished, Liv et 10,700 projects had been funded, about one-third were for new facilities a nd the remainder for modernization. The iutalcostof the projeas was $12.8 billion, ufwhKh the Federal Government contributed over $3.7 billion. Over one-half of the funded projects werefeu new or modernized short-tenn hospitals (5,787), representing 71 percent of thetotal amount of Hill-Bunon funds. About 30 percent of all hospitals built between 1949 and 1962 used Hill-Buiton monies (335). impactonRural Areas As intended, "ill Simon funds for short-term hospital projects were concentrated in les . populated areas (table 5-9). About 75 pc_A of all projects ahd 67 percent of total Hill-Burton fands between 1948 <0.41971 were devoted to communities with few er than 50,000 residents. Nearly 44 percent of the projects w ere in com.i.i.ni ties cif less than 10,000 residents. Little is known about tla! impavt of the program in rural areas of panicular States. One study in Mmnesota found substantial differences in the allocation of Hill Burton funds between urban and rural areas of the State from 1950 to 1973. Merage per capita funds for hospitals innual wunneswere une- third greato than funds for hospitals in urban counties, rural counties received almostt% ke clbmany general hospital beds per 100,000 residents mulct the program as did urban counties. However, 13 of the 78 rural counties received no Hill-Burtonsupport.Also, of those mral counties obtaining su2port, the most rural and economically disadvantaged did receive the expected higher proportion of program funds. Some a these areas may have had insufficient resources tosupportAMA, 01 modernized facility (264). The Hill-Burton program did substantully increase the number of shon-terni hospital beds. From 1947 to 1970, short-term hospital beds per 1,000 people increased frLan 3.3 to 4.3 in thc United States 335). By 1)86, the ratio of community hospital beds in both rural and urban areas was about 4 beds per 1,000 people, ahhuagh vanaticai among and within individual States was substantial oee iable 5 10 and figure 5-3). In 14 Slates, bed-tu-population ratios were actually higher in rural than in urban areas 0454 The Hill Burk.'" program had no authonty to lima bed supply. By the 1970s, it was w idely percerved that II4I Burke had acrually contnbuted to au Qv crsupply of genera: hospital beds in many areas of the country. Although it had a substantial effect on bed ..upply, the Hill Burton program did not significantly affect the redistribution of physicians (264). Also, there is little indication thar Bunce's attempt tu demonstrate the coordinated use of hospital and other health care facilities fosteredthe iniegrauonand itponalizatum uf health services in mai communities. "i 20-010 0 - 90 - 5 013 .; 120 Health Care in Rural America Table 5-0-Distribution of Hill-Burton Short-Term Hospital Projects and Population,byCommunity Size, 1948-71 CommnitY size Total Percent Percent of total Percent of 1980 (1960) of projects Hill-Burton funds U.S. population Fewer than 10,000 43.4 28.9 4!.7 10,000-24,999 19.8 22.0 9.8 25,000-49,999 11.6 16.3 8,3 50.000 and more 25.1 32.8 36.2 Total 100.0 100.0 100.0 NOTE: Totals may not add to 100 percent due to rounding. SOURCE: J. Lave and L. Lave.The Hospital Construction Act An Evaluation of the Hill-Burton Proxram. 1948- .1273 (Washington, DC; The American Enterprise institute, 1974). Table 5-10-Community Hospital Beds per 1,000 Population and Occupaicy by Hospital Location, 1986 Beds per Occupancy ratea Beds per Occupancy ratea 1 000 emulation (Percent) 1,000 population (percent) NonmetroMetro NonmetroMetro NonmetroMetro NonmetroMetro Alabama 4.4 5.3 54 65 Kontana 5.7 5.9 57 62 Alaska 1.7 2.8 55 59 Nebraska 5.6 8.2 51 61 Arizona 2.4 3.3 53 65 Nevada 2.8 3.6 44 49 Arkansas . 4.1 5.3 49 67 Naw Hampshire 4.0 2.6 65 66 California 2.7 3.1 49 63 New Jersey 0.0 3.9 0 75 Colorado . 4.4 3.2 54 61 New Mexico 2.5 3.1 58 61 Connecticut 2.8 3.2 56 74 New York 4.3 4.4 75 82 Delaware . 2.8 3.8 69 67 North Carolina 3.3 3.7 59 69 Dist. of ColuMbia.. 0.0 7.5 0 78 North Dakota 6.9 7.7 59 63 Florida 3.6 4.4 53 63 Ohio 3.4 4,7 50 66 Georgia 4.3 4.1 61 S6 Oklahoma 3.8 4.1 46 63 Hawaii 3.2 2.2 66 78 Oregcm 3 2 3.1 47 59 Idaho 3.6 2.9 53 67 Pennsylvania 4.0 4.7 66 71 Illinois . 4.3 4.6 54 86 Rhode Island 3.0 3.6 63 76 Indiana 3.2 4.6 49 61 South Carolina 3.1 3.6 66 71 Iowa . 4.4 6.2 53 63 South Dakota.. 6.4 6.6 54 63 Xansas 8.0 4.0 47 63 Tennessee.... 4.2 5 7 55 66 Xentucky 3.7 5.2 61 65 Texas...... 4.6 3.8 40 59 Louisiana 3.5 4.9 46 61 Utah...... 2.4 2 7 42 62 Maine 3.6 5.2 62 73 Vermont 3.7 4 7 63 81 Maryland 3.4 3 2 73 73 Virginia 3.7 3.5 62 70 Massachusetts 3.7 4.3 65 69 Washington 3 2 2 8 44 61 MidbiBan 3.6 4 1 54 67 West Virginia.. 4 3 6 4 57 63 Minnesota 6.1 4.5 61 65 Wisconsin 4 7 4.4 61 60 Mississippi 5.1 4.7 54 67 Wyoming 4.6 3 8 51 49 Misat,uri 3 6 5 7 51 67 Total U.S 4,0 4 1 55 67 aOccupancy rates are based on the hospital's total nuMber of beds (both acute care an.; other) SOURCE: M. Merlis, "Rural Hospitals," U.S. Congress,Congressional Research Service, Washington, DC, no. 89- 296 EPW, May 2, 1989. the high bee:to-population ratios in more densely nonhospital settings. As simple low-nsk cases (e.g., populated rural areas. cataract surgery) are increasingly cared for outside Other poteLtial factors affecting changes in mpa- the hospital, the remaining inpatiers are likely, on average, to have more serious medical problems tient utilization include changes in medical practice, requiring twvre intensive cart and longer lengths of urban competition, and p.yment incentives. stay. This is probably a contributing factor in the Changes in MedicalPractice-Changes in medi- trends toward both lower admissions and longer cal technology have enabled physicians ard other lengths of stay. In a recent study of hospital use by providers to care for many patients in outpatient and Medicare oeneficiaries in five States from 1984 to 131 Chapter 5Problems and Trends in Rural Health Services 121 Figure 54Short4erm Hospital Reds to Population Ratio, 1986 (bynorimetropolltan co...rity) !I a .."1,1,:aaL WO at IP PICt 1,, MI 411 6. a V ;r4".,"±APe 114117,NV;Istnv V11OA t au a IA 0 a TP. 411..4 3.ig, p Iii41jr le;er.".'1°..±-" tr t ":":4,4i:4.. "la. 0111106,041.' !NM 11141Zt:o 11%, lir°41r Ill= Vr L., #b14 et. rIL=1 Pr *it 41:-k4. 44.ale Hospital beds per 1.000 population IMIMI No hospital beds MEE Less than 3 II=MI 3 to 4.2 CI Greater than 4.2 CI Metropolitan counties SOURCE. T.0 RIcketts, 1161411 Hetet Reseanil tionlei Univeisity oi North C4tro44oa at Chattet MI. NC Anatysts ul wipubashed Aoki Resotave File data wtooded by the U.S. Health Resoumed and Set vmapAdrnInlettabonj conducted Wain wratact mut are alfwe of Technology Assesement. lass and 1990. 1986, the largest declines in hospital admission rates locally a% ailable. A recent study found this ou.ur, were for conditions that many physicians believe du rence to be increasing. From 1984 to '186, the not usually require hospitalization (e.g., simple v olume of " teclmology inte nsiv e ad- pneumonia). On the other hand, rates of admissions missions in a five-State sample of rural hospitals involving some degree of subspecialty care and high either declined or rose at a much slower rate than the technology (e.g., heart transplants) rose slightly uluiae of such admissions to urban hospitals (134). during this period. The impact of these trends is significant for small rural hospitals. Those cases Pressures of PayersDwing the l980s, Medi winning legs cona..nsus on the need for hospitaliza 6are and other health care payers implemented ust tion typically represent the largest proportion of containment measures that increased incentives fur admissions to these hospitals (134). hospitals to discharge patients quickly. Medicare also intensified sanctions by Peer Review Organiza- Attractiveness and Utility of Urban Resources tions (PROs) for admissions deemed unnecess,uy The more rapid adoption of new, sophisticated t4S6). PRO efforts and other factors (e.g., changes in technologies by urban hospitals may lure MIA medical practice) am thought to hay:. restricted residents whu perceive then hospitals to be provid- "social adniissions" of patients admitted to or ing superior care. Also, many rural residents navel allowed to stay in An aute-aie setting w ho do not to large urban hospitals to obtain specialized care not require an acute les el of care. The effect of sudi 1 ;42 122 Health Care in Rural America having available some care of questionable quality and having no caie available at all. Possible reme- dies for this predicamc.., include:1) volt.ntary regionalization of services to consolidate lower volume services and improve quality, and 2) selec- tive contracting whereby payars stipulate that 'oene- ficiaries use only certain facilities for specific kinds of care. Hospital Outpatient Utilization and Ambulatory Surgery The number and volume of hospital services provided in outpatient settings increased rapidly in the 1980s, and the growth of outpatient visits was f actually greater for rural than urban hospitals (table 5-11). From 1984 to 1988, total outpatient visits to rural hospitals increased by over one-third, and outpatient visits to the emergency room rose nearly Photo credit: Got Mooney 13 percent (35). Small rural hospitals unable to support funlime physician specialists must often rely on Itinerant physicians. The increasUig demand for outpatient care is Dr. Littleton, a radologist, travels as needed to reflected in the growth of new outpatient depart- hospitals in 12 States. ments in many rural hospitals. From 1982 to 1985, the number of rural hospital outpatient departments rose 48 percent (31). By 1987, 60 percent of rural community hospitals had outpatient departments factors on rural hospital utilization has not been (625). As table 5-12 shows, the likelihood that rural studied. hospitals have outpatient departments increases with the size of the hospital. Frontier hospitals are less Lower utilization is believed to affect the quality likely and rural referral centers are more likely to of certain inpatient services. Studies of various have outpatient departments.10 surgical procedures (e.g., total hip replacement) have found that worse outcomes tend to occur at The amount of surgery performed on hospital lower volumes (495 420). Referral of patients need- outpatients has increased dramatically in recent ing such procedures to larger hospitals may be both years In 1984, about 28 percent of all aurgeries in economical and quality-enhancing. urban hospitals and 26 percent of rural hospital surgeries were performed on an ambulatory basis Many small rural hospitals, unable to provide a (table 5-11). By 1988, outpatient surgery accounted sufficient volume of surgery to support a reguiar for one-half of total surgeries in rural hospitals and physician, employ itinerant surgeons (surgeons who over 46 percent in urban hospitals (35 ). The number travel to hospitals to operate on scheduled elective of hospitals pros iding ambulatory surgery has also patients and typically are unavailable for followup grown rapidly. In 1980, only 65 percent of all care). A recent study of such hospitals found that the community hospitals (rural and urban) performed use of itinerant surgery may contribute to higher ambulatory surgery (490). By 1987, 93 percent of rates of poor quality care. In the 28 percent of small rural hospitals provided ambulatory surgery (table rural hospitals sampled that used itinerant surgeons, 5-12). Larger hospitals are more likely to offer 16 percent of the cases ireated by these surgeons had ambulatory surgery, nearly all rural hospitals with adverse outcomes (60g). In such situations, mere 200 or more beds provided this service, compared appears to be a tradeoff for the patient between with only 77 percent of hospitals with fewer than 25 *The patentor of hospitals with outpatient departments underrepreseuts the total number of borplals actually deliventig outpal...nt scrVMS Most bospitals typecally provide a substantial portion of nonurgent care In their emergency rooms, 1' Chapter 5Problems and Trends in Rural Health Services 123 Table 5-11Community Hospital* Outpatient Utilization by Hospital Location, 1984 80 Percent change 1984 1985 1986 1987 1988 1984-88 Total mnbpatimitvisits (thousands) Ponmetro 38.819 39,810 42,899 46,996 51,823 33.5 Metro 173 242 178,907 189,013 198,528 217,306 25 5 amergeney room visits4 (tbousamds) Honmetro 15,654 16,139 16,674 17,068 17,665 12.8 Metro 57,326 58,408 59,928 61,219 63,595 10.9 reseamt of hotel surgeries doss as cutpatient basis Honmetro 26.3 34 7 45.9 49.8 89.3 Metro 28.1 34.5 39.9 43 4 48.2 64.4 *Community hospitals defined as all non-Federal, short-term general and other special servie h,spitals bOutpatient visits prbnarily for true emergencies. SOURCE: American Hospital Association,HosPital Statistics (Chicago, IL. ARA, 1985-89 eds.). Table 5-12Select Ambulatory Care Services tASCs). The number of ASCs tripled from 1983 to Provided in Nonmetropolitan Community Hospitals* 1988, increasing from 239 to 983, the number of by Bed Size and Hospital Type, 1987 surgical operations performed by ASCs grew by 368 percent during this time (489). Little information Humber/percent having exists on the nature of ASCs in rural areas. Only Cutpatient Aribulatry departmentb surAcrY about 15 percent of ASCs are located in rural Hospital HumberPercent Humber Percent communities (99), presumably because centers rely on large volumes of service to cover fixed costs and 6-24 beds 100 55 141 77 25-49 402 53 682 91 sustain a profit. 50-99 498 60 785 95 100-139 337 64 509 97 200-299 100 76 131 99 Competition for Patients 300 or ogre beds 29 78 37 100 Total nonmetro....1,466 60 2,285 93 Competition From Urban Providers Sole community hospitals* 173 60 254 89 Anecdotal information suggests that some urban Frontier hospitals 137 53 299 77 hospitals and physicians are expanding their service Rurel referral areas Lao rural communities in order to increase centers* 157 73 213 99 their patient base. Expansion tactics may include: *Community hospitals defined here as all non Were!, advertisements stressing the quality of care and short-stay, nonspecialty hospitals (see app C) bPercent with organized, distinct outpatient depart- leading-edge technology available in the city; ments. The percent of hospitals actually providing rural-based outpatient cAinks, from which pa- outpatient services is higher. tients are referred to urban hospitals for diagno- *As defined ferMedicare purposes (see app. C). sis and treatment; and SOURCE: Office of TechnologY Assessment, 1990 Data from American Hospital Association's 1987 urban facilities such as ASCs and urgent care Annual Survey of Hospitals. centers that target rural communities in order to capture their mobile anr! better-paying patients beds (625). These smaller hospitals (many of them (leaving rural providers to provide less lucra- frontier hospitals) may have difficulty attracting tive emergency care and care for more disabled and nonpaying patients). surgeons and the necessary volume of surgical cases. Whether based on real or perceived better-quality Although most ambulatory surgery is performed 4-are in urban hospitals, a trend toward urban based in hospital outpatient departments, there has been 43an be self sustaining, re42u..ing the ,:onfidence dramatic growth in the number and activity of that rural physivians and their patientshavein rhe separate, freestanding ambulatory surgery centers local hospital. Competition with urban-based managed care Third, urban hospitals and phy sicians may estab- plans (e.g., health maintenance organizations) may lish affdiated networks of loyal hospitals arid be especially troublesome for some rural hospitals. physicians in rural areas. In these situations, rural The selective contracting process between hospitals physicians may be given incentives to admit patients and managed care plans emphasizes price discounts to affiliated rural or urban hospnals rather than to in exchange for an assured patient volume. A rural local unaffiliated facilities. hospital may have to reduce its patient fees in order to compete for patients covered by the plans (157). PRIMARY CARE FACILITY Patients in these plans may be required or encour- CHARACTERISTICS AND aged to use nearby urban hospitals rather than their local facilities. Also, since many of the utilization UTILIZATION" and cost control measures imposed by managed care plans are inte nded to limit hospitalization, participa- Number of Community Health Centen tion by rural hospitals in these plans may further Federally funded CHCs are important rural pri- erode inpatient volume and revenues. mary care prov iders. The number of CHCs receiving Local Competition Federal grants has diminished in the 1980s, and the rate of decline has been much greater for rural CHC Competition among neighboring communities is grantees than for urban grantees. Table 5-13 shows inherent in rural life. For example, community pride that while the number of urban CHCs decreased by in local school athletic teams may be evident in the just 1 percent from 1984 to 1988, the number of competition and rivalry among small tawns only a CHCs in rural areas dropped 20 percent, from 399 to short distance apart. Competitive actions among 319 centers (658). Variations among regions are rural health care providers commonly take three enomious. The number of grantees in 3 of the 10 forms. First, competition may increase among rural U.S. Department of Health and Human Services hospitals operating in overlapping or adjacent mar (DIMS) administrative regtaansi2ramained unchanged ket areas. One target for competition is physicians, or increased, while in 1 Midwestern region the who in turn may "play the hospitals off against each number of rural grantees was reduced by one-half. other" in order to have the hospitals add more Part of the decline was due to CHC mergers in the services, equipment, or other new technologies that mid-1980s as part of an initiative by the U.S. Public directly benefit the physicians. In some cases, two Health Service. In 1988, 61 percent of all CHC local hospitals that engage actively in competition grantees were in rural communities. Isleafiy one- may not realize that both facilities are losing patients third of these were located in the Southeast. to larger urban hospitals. The decline in nral CHC grantees does not Second, rural hospitals may compete with their necasarily mean there are fewer delivery settings, own physicians for patients and revenues. Physi. since many centers have more than one service site. cians can now provide many surgical and ancillary From 1984 to 1988, the total number of rural CHC services (e.g., laboratory tests) in their offices that service sites appears to have remained relatively previously were offered in the hospital. The ability constant, although defmitional and data collection of a physician to provide certain services at lower changes made by DIMS in 1986 make comparisons cost and with fewer regulatory restrictions than the difficult." From 1986 to 1988, the total number of local hospital may help to increase the physician's rural CHC serv ice sites decreased, but at one-third office-based revenues and profits. Consequently, the rate of decline of rural grantees itable 5-13). The some well-established physicians may become less opposite was true of urban CHCsthe number of dependent on the local hospital for income and may total service sites dropped nearly twice as fast 4S the begin to reduce their hospital practice. number of grantees. In 1988, there were a total of Milking's no nationwide (1ata are available on local health departments. many nual LNDs am known lo offer pnmiuy clic services (see cli. b tor examples). 12The DUBS regions arc shown in app. F. one first year CHCs began using standard definitions to repon their number of service sites *as 1980 lbe totak number ot service sites is acount of die number of Federal gramees and permanent satellite clinics It is uot intended to include administrative sues where no ciinic scrvices are provided or specialty clinics operating under the same goof as other chives (585). 1fies Table 5-13Humber of Federally Funded Community Health Center (CM) Grantees and Service Sites by Rural! Urban Status and Region, 19134-8136 Percent change 1984 1985 1986 1987 1988 1984-88 Centers RuralUrban RuralUrban RuraL4i\an RuralUrban RuralUrban Rural Urban Grentwas RegionbI 16 22 15 22 13 24 12 24 12 24 -25 9 II 24 43 24 43 23 44 22 40 20 35 -17 -19 III 65 25 63 24 62 23 54 23 52 22 -20 -12 IV 140 31 141 31 127 34 110 33 104 33 -26 6 V 39 26 37 27 35 28 33 27 31 27 -21 4 VI 37 15 34 16 40 17 37 17 38 1' 3 12 VII .. 12 1: 10 IL 9 11 6 12 6 12 -50 9 11//1 24 7 25 7 26 8 21 7 20 7 -17 0 IX 26 22 25 21 29 22 30 24 30 23 15 5 X 16 7 16 7 18 7 16 7 16 7 0 0 Total 399 209 391 209 382 218 329 214 319 207 -20 -1 Total service sites° 763 433 791 402 838 464 821 428 793 17 4 -4 NOTE: Definitions used by U S. Department of Health and Human Services regional offices to identify CHCs as rural and urban approximate a center's location in either a nonmetropolitan or metropolitan area. aFederal Fiscal Years. bFederal Department of Health and Human Services regions. See app. F for geographic display of regions. aTotal number of Community Health Center (CHC) service sites includes the number of Fdora'. grantees and permanent federally supported satellite clinics. They are not intended to include administrative sites whole no clinic servicss are provi..ed or specialty clinics operating under the same roof as other cLinics. Grenteirs may have more than one servkce site. TotaL service site data for 1984 and 1985 may be inaccurate; reporting hy grantees improved beginning in 1986 with the use of standard definitions (see text). SOURCE- U S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Care Delivery and Assistance, Rockville, MD, unpublished data for ruraL +unity health centers 1984-88 from the BCRR file, provided by E Sullivan, 1989. ESu'livan, Bureau of Health Care Jeliv , and Assistance, Health Rescraces and Services Administ.ation, U S. Department of Health and Human Services, Rock4ille, MD, DTA pernal. communication, April 1990 0.1 MEW11=11 126 Health Care in Aural America 793 rural CHC service sites, or an average of 2.5 of patient encounters per primary care physician sites per rural CHC grantee (585). eclined slightly (by 2 percent) (658). Community Health Center Services There was considerable variation among DHHS regions in annual encounters per primary care Little documentation is available on the range of physician from 1984 to 1988 (table 5-15).15 Change services provided in rural CHCs. Tradidonally, in encounters per physician ranged from a drop of 12 CHCs were intended to serve as sources of inte percent in Regina VIII to an increase of 14 percent grated and comprehensive primary care and preven in Region IX. Three of the 10 regions ni 1988 had live services, which would pay particular attention to average annual encounters per physician that were needs of the poor (sze ch. 3). %bootees were required below 4,200, the minimum level of productivity to form a broad array of referral and ce..,peradve usually consid-red acceptable by DHHS, which linkages with other area providers that could deliver administers the grant program (65S). those services CHCs did not provide themselves. Early studies of rural CHCs and primary care One po.,3ible explanation for the sharp rise in programs often did not focus on their specific aux of demand in rural CHCs is rising rates of uninsured- services, but rather on the effectiveness of center ness. CHCs and other publicly funded health centers organizational forms and operating efficiencies and (c g., county health denartments) are commonly their impact on patient health status and clinic viewed as sources of basic health care open to self-sufficiency. everyone, regardless of one's ability to pay. A survey of rural CHC operations from 1986 to 1987 It may be difficult for small rural CHCs to provide found that most of the new patient users could nix a range of services comparable to that of larger Pay the full cosis of their care. Of the new users of centers, especially if the rural centers serve small rural CHCs, 83 percent were reported to have no populations. Many rural CHCs have apparently public or private insurance or lacked the income reduced the scope of services that supplement their necessary to pay the medical care fees (307). delivery of basic primary medical care. In a survey of rural CHCs in 1986 and 1987, many centers Number of Certified Rural Health Clinics reported having to reduce or eliminate services such Many rural CHCs and other primary care provid- as nutrition education that often are not covered by ers are eligible to become certified rural health insurance. Also, according to the survey, worsening clinics (RHC5). RHCs receive cost-based rates of of the local economy was a factor in the increase in payment from Medicare and Medicaid if they offer the proportion of CHCs (from 31 to 34 percent) that the services of a midlevel practitioner at least 50 were unable to deliver some mandated basic primary percent of the time16, and if they are located in a care services (307). nonurbanized Medically Underserved Area (MUA) Community Health Center Utilization or Health Manpower Shortage Area (HMSA).17 When the RHC program was established in 1977 by Federally funded CHCs in rural areas haw Public Law 95-210, some health care experts esti- experienced a surge in demand for primary care mated there would be nearly 2,000 rural chnics services. From 1984 to 1988, the number of visits to kertified by Medicare as RHCs by 1990 (588). As of rural CHCs increased 18.5 percent, or 14 percent per April 1989, there were 470 certified RHCs in 37 CHC service site14 (table 5-14) (585,658). Encoun States, about one-half were in just 8 States (table ters with CHC-based primary care physicians ac, 5.16) (653a). Even though ovei 2,000 nonmetro counted for most of this rise in demand, ina-ea.sing counties are designated as MUAs or HMSAs, few 34 percent. Because the number of physicians rose actually have RHCs (figure 5-4) (5 11). The Federal at a faster rate than visits fur the period, the number Go vernment is reported to have akioally certified 14service sites of CHCs include Federal grantees and any permanent federally supported satellite Itny.s isSee app. P for geographic display of regions. "In 1989, Congress (Public Law 101-239) redwed from ei0 1050 pereeoi Mc mui,mum soi,,uu, ., lane.4fin4i0o...1 iiin.libui,41 iliu.4 tic un.iit. during RHC operations. 17 gee ch. 11 for a di-eussion of MUM and HMSM- Chapter 5Problems and Trends in Rural Health Services 127 Table 5-14Uttlizattor, ot Rural Federally Funded Community Health Center Grantees and Set vice V*es, 188418 Percent change Utilization 1984 1085 1986 1987 1088 1984-88 Total patient encounters°. 9,315,177 9,484,803 10,056.534 10.798,460 11,041,636 18.5 Number of rural CBC grantees . 309 391 382 329 319 -20.0 Average patient encounters per rural CRC emote* 23,346 24,258 26.326 32,822 34.613 48.3 Number of rural . CDC service sites° 763 791 838 821 793 3.9 Average patient encounters per rural CNC service site 12,209 11,191 12.001 13.153 13.924 14.0 NOTE: Deftnitions used by U.S. Department of Health end Human Survices regional offices to identify CHCa as rural apprortaate a center's location In a nonmetropollten area. a Includes encounters bothon and off the center site. b The totalnumber of rural CHC service sites includes Federal grantees and pormanent federally supported satellite clinics. They are not Intended to laclude administrative sites where no clinic services 4re provided, or speciality clinics operating under the same roof as other clinics.Grantees may have more than one service site. Total service site data for 1984 and 1985 may be Inaccurate, reporting by grantees immovedbeginning In 1986 with the use of standard definitions (see tort). SOUECE. U.S. Department of Health and Human Services, Health Resources and Servites Administration. Bureau of Health Care Delivery and Assistance, Rockville. MD, unpublished 1984-88 oata for rural community health centers from the BCRR file, provided by E. Sullivan. 1989, E. Sullivan, Bureau of Health Care Delivery and Assistance, U.S. Department of Health and Human Services, personal communication. April 1990 Table 5-15Primary Care Physician Utilization In Rural Federally Funded Community HealthCanters by Region,1984-88 Percent Patient encounters per primary cora physician chew RAgion° 1964 1985 1986 1987 1988 1984'88 I 3.880 3,733 3.857 3,951 3.829 -1.3 II 5,479 5,537 5.582 5,189 4,905 -10.5 III 4,270 4.361 4,352 4.345 4,534 6 2 IV . 4,486 4,308 4.153 4.012 4,227 -5 8 V 4,531 4,406 4,273 4.338 4.490 -0 1 VI 4,540 4,566 4,396 4.262 4,412 -2.8 VII. 4.281 4.486 4,155 3.967 4.280 0 VIII . :.,378 3,599 3.1379 3,982 3.866 -11 7 IX . 4.1)8 4.083 4.193 4,408 4.774 14.0 X -.0:65 3,716 3.648 3.241 3.810 4 2 total 4.532 4.456 4,384 4.283 4,431 -2.2 NOM DeLnitions used by U.S. P4partment of licelth and Human Services regional offites to identify CRCs as rural approximate a center's location In a nonmotropolitan area. °Federal Departs nu of 1441th -.ad Human Services regions.See app. F for geographic display of regions. soma U.S. Jo-srtment of Health and Hume., Services. Health Cosources und Services Administration. Bureau of Health Care Delivery and Assistalce. Rockville. MD. unpublished 1984-86 data for rural community tuut:th centers from the BCRR file, provided by ESullivan, 1989. over 800 rural health clinics since 1978, but nearl) Independent or freestanding clin.ks account for one-half have withdrawn from the program for about 95 percent of all RHCs. Only 25 RHCs are various reason, inch.ding concarns over RHC provider-based cLnics (i.e., sponsored by a hospital, regulations (e,te ch. 7) (588). nursing home, or home health agency) (653a). 1 ;-) 128 Health Care in Rural America Table 5.16Number of Certified Rural Health Clinics*, and Nonmetropelitan Counties in Which Clinics Could Qualify for Certification, by State, 1989 Certified rupI healthslinics Number of nonmetro Provider- counties)) designated as Stat,e Total Independent based either a HMSAc or an Mlie California 52 49 3 21 North Carolina.. 38 35 3 73 West Virginia, 28 28 0 45 Panneylvania 28 28 0 31 Tsunamis 26 26 0 68 Mine 25 25 0 13 New York 24 24 0 26 New Mexico 22 16 6 29 South Dakota 22 21 1 57 Georgia 21 21 0 116 Florida 18 18 0 35 Ohio 17 17 0 37 Alaska 16 16 0 0* Oregon 13 13 0 25 Colorado 13 13 0 36 Washington 13 12 1 24 /owe 13 12 1 66 Litho 8 8 0 30 Mississippi 8 8 0 75 Utah 8 6 2 16 Vermont. ... . 6 6 0 12 Kentucky. 6 1 5 89 Nevada 5 5 4 13 Alabama ... 5 5 0 Arizona .... 5 4 1 12 Kansas 5 3 2 69 Illinois.... . 4 4 0 65 Minnesota... . 4 4 0 61 Wisconsin... . 3 3 0 48 Rhode Island . 3 3 0 0* Montana 2 2 0 40 New Hamnshire.. 2 2 0 4 Virginia 2 2 0 61 South Carolina . 2 2 0 34 Maryland 1 1 0 8 Texas 1 1 0 166 Wyoming.... 1 1 0 20 Arkansas. . 0 0 0 65 Connecticut 0 0 0 1 Delaware... 0 0 0 1 Hawaii 0 0 0 0 Indiana 0 0 0 41 Louisiana 0 0 0 45 Massachusetts 0 0 0 2 Miehigan.. ... 0 0 0 49 Missouri.... . 0 0 0 87 North Dakota .. 0 0 0 44 New Jersey. 0 0 0 0* Nebraska... 78 . 0 0 0 Oklahoma 0 0 0 51 Total U.S . 470 445 25 mod *These States have no nonmetro counties Alaska was considered a single metro county in this analysis *Clinics certified under tha Rural Health Clinics Act (Public Law 95-210) as of April, 1989 bThis is an underestimate of the number of counties that qualify under Public taw 95-210, since it only includes nonmetro counties. Nonurbanized metro counties may also qualify cPrimary care Health Manpower Shortage Areas, 1986. Medically Underserved Areas as of 1981 Includes whole end partial-county designations. dIbis may be a slight overestimate since MUA designations can cross State boundaries SOURCES. U.S Department of Health and Human Services, Health Care Financing Administration, Baltimore. MD, unpublished data on certified rural health clinics, provided to OTA in 1989 T CRicketts. Rural Health Research Center, University of North garolina. Chapel Hill, NC Analyst, of unpublished data (provided by the U.S Health Resources and Services Administration) conducted under contract to Office of Technology Assessment, 1989 40 Chapter SProblems and Trends in Rural Health Services 129 Figure 54Certified Rural Health Clinics, 1988 iby nonmetropolaanPAUA or HMSA county status) Pri 'Nice of certified rural health clinics =MI loninetropolitan Medically Underserved Area iMilA1 or Health Manpower Shonage As ea i II MSAi without i.er tilled rural health MationmettopostanMedically Undorsenied Area al WI) or Health Manpower Shortage Area ltild Silo with certifies I vial health sitno. MEM NoninetrepOlitan Nun Medically Underserved Area MA and Non Health Manpower Shortage Area IHM SAl 1== Metropolitan county SOURCE. T.C. Ricketts, Rural Heath lir/search Center. University el North Calourie el Chapel mill, NC Anarysis el unpublished A.44 Rostrum. File date (provided ay the U.S. Health RebOUMOS and Set ,n,..Nts Adaunisnatorq cow . undei contract wIth Me Office ot tedmology Assessment. 1989 and 1990. HEALTH MAINTENANCE existed in 1988 than in 1987 (491). No information is available on recent trends for HMOs serving rural ORGANIZATIONS areas, but it is unlilrely that the overall presence of HMOs in rural areas has increased. Possible reasons Health maintenance organizations (HMOs) pro- for the small rural HMO presence include. vide a specified, often comprehensive set of services to an enrolled population on a prepaid basis. HMOs limital prospets fur enrollment due to the in rural areas showed substantial growth in the earls relatively low number uf large emplo)ers in 1980s. Ar of June 1984, there were 118 HMOs many rural areas, serving rural areas in 34 States, and 19 of these were continued resistance of some rural physicians based in rural areas. This was a substantial increase to participation in HMOs, over the 79 HMOs serving rural areas in 1981. The number of rural residents estimated to be served by lack of available capital for development (Fed HMOs in 1984 was approx.mmely 500,000, or about eral funds for HMO development have ceased). 1.7 percent of the total rural population (127). and concerns of rural HMOs serving Medicare More recently, the number of HMOs nations* ide patients about the adetida44 of Medicare pa) has declined slightly; 6.6 percent fewer HMOs ments and how they are calculated. 130 Health Care in Rural Ame Ica HOSPITAL FINANCIAL labia 5-17Average Days in Patient Accounts Receivable° Mr Community Hospitals°, by Hospital VIABILITY Location and Bed Size, 1984 and 1987 Revenue Issues Hospital 1984 1987 Demand for Uncompensated Care Matzo 62.0 76.0 Nonmetro 70.0 75 ^ An increasing number of persons seeking care are 6-24 beds 81.4 81.2 unable to pay for it (see ch. 2). Most uninsured 25^in 75.8 81.3 persons are employed. In rural areas residents are 50-99 71.3 74.8 100-199 68.7 74.8 often self-employed; they work in agriculture or 200-299 73.5 73.1 small businesses without insurance benefits. 300 or more 65.5 71.2 Hospitals are providing increasing amounts of 8Defined as net pationt receivables multiplied by 365 care for which it takes longer to Deceive ;nyment, or daYs divided by net patient revenue. Yet patient revenue consist, of gross patient revenue less care for which they will receive little or no payment deductions tot contractual adjustments, bad debts, at all. As table 5-17 shows, the average number of and charity. days it takes rural hospitals to.Ilect the full amount bCOunmnity hospitals defined here es all non-Federal. short-term general and other special service of a bill rose 7 percent from 1984 to 1987, to 75 days. hospitals. In 1987, the average period an account was outstand- SOURCE. American Hospital Association, Chicago. IL. ing was highest for rural hospitals with under 50 unpublialied date from the Annual Survey of beds (30).lt is unclear how much of the increase Hospitals, 1984-1987. between 1984 and 1987 may be attributed to problems with patient collections, payment delays bearing the heaviest social burden are placed at a from third party insurers, or hospital billing errors competitive disadvantage that may ultimately threaten that delay payment. Regardless of the cause, this their survival. All States provide fmancial assistance overall increase in the time it takes hospitals to to hospitals to cover some of the costs of such care, collect payments suggests a decrease iavailable either as adjustments under the Medicaid hospital cash to cover expenses. payment system m through direct subsidies (494 The amount of uncompensated care provided in "ricwever, these subsidies do not necessarily cover rural hospitals increased over 26 percent from 1984 the full costs of such care, and some hospitals are to 1987, to nearly $1.5 billion (about $565,000 per concerned that these programs will be unable to hospital) (table 5-18). The largest propomonal support the future indigent service loads. increases were in the smallest facilities. The amount of uncompensated care increased by 59 percent in Reliance on Public Payment hospitals with fewer than 25 beds, and it grew over and Funding Sources 35 percent in facilities of 25 to 49 beds. (The amount Most rural community hospitals depend to a of uncompensated care in urban hospitals also significant degret on publiz. Jourc.ts of payment. As increased during the period, rising 33 percent to over shown in table 5-19, 52 percent of all rural hospital $11 billion or over $3.7 million per hospital (30).) A net patient revenue in 1986 came from government study of rural hospitals in Florida found that 13 sources. Medicare revenues play a particularly large percent of their patients in 1985 did not pay the full role. In 1986, nearly 42 percent of all patient revenue bill, compared with 10 percent for the State's urban of raral hospitals was derived from serving Medicare hospitals. The average rural hospital provided inpa- patients (30). (For urban hospitals, the figure was 39 tient care to about one charity patient for each day of percent.) While three-fourths of hospitals with 25 to the year (194). 99 beds received more than 42 percent of their patient revenue from Medicare, hospitals with fewer Uncompensated care has always existin hospi- tals; in fact, hospitals receiving Hill-Burton funds than 25 beds and hospitals with at least 100 beds were required to provide a certam amount of relied much less on Medicare revenues (table 5-20) (32). uncompensated care (box 5-11). When the distribu- tion of uncompensated care becomes uneven, how- The greater dependency on Medicare revenues m ever, hospitals providing the most such care and rural than in urban hospitals may be a result of the 14+ii/ Chapter 5Problems and Trends in Rural Health Services 131 Table 5-18Aggregat e uncompensatedCate on Communkty Hospdals,by Hospital Locationand Bed Stze, 1984437 Percent Lincomnensated_eare (millions of dollars) change 1984 1985 1986 1967 1984-67 Metro 86,377 86,301 810,320 811,174 33.4 Nonmetro 1,162 1.225 1,344 1,468 26.3 6-24 beds 8 9 11 13 59.0 25-49 107 116 141 145 35 5 50-99 294 314 353 376 27.9 100-199 425 454 465 507 19.3 200-290 185 196 223 255 37.6 300 or more 143 135 131 171 19.6 NOTE: Uncompensated care costs include deductions from hospital revenue attributable to bad debt and charity tar.. °Community hospitals defined as ell non-Federal, short-term general and othir special service hospitals. SOURCE. American Hospital Association. Chicago. IL, unpublished data from the Annual Survey of Hospitals, 1964-67. high rural concentration of elderly residents, who thz three communities was just under $31 million, typically are less mobile and may be more likely the revenues needet1 to support the communities' than other rural residents to receive care at the local local healthI,areservices was approximately $143 hospital. Medicaid revenues, on the other hand, are million, of which 6. percent was for the ho-pital a slightly lower percentage of total patient revenues (46). in rural than in urban hospitals (8.7 percent v. 9.6 percent in 1986) (table 5-19). This is not necessarily Difficulties in Shifting Costs a positive factor for rural hospitals however; poor Faced with providing uncompensated care, a rural residents are less likely than poor urban ones to be eligible for Medicaid (see ch. 2), and fewer health facility has three options to covertheloss: Medicaid patients may mean more charity pa- private or public subAdy (e.g., chmitable dona- tients." (ions), recouping sufficient extra revenue from paying Rural hospitals increasingly depend on State and patients, or local tax subsidies. Table 5-21 shows that in 1987, internal cross-subsid) from other profitable 69 percent of rural community hospitals received non-Federal tax appropriations worth over $216 activities and investments. million. The average tax appropriation pet hospital Rural hospitals are at a particular d.badvantage in doubled from 1984 to 1987. Very large n..al trying to realize additional reimbursement, because hospitals receive the largest State and local si. their small size makes it difficult to spread costs to dies, with the smallest hospitals a somewhat distant large numbers of paying pail,mts. 1.,..spita1s with a second (30). high proportion of Medicare tad Medicaid patients have additional problems with cost-shifting, since Many of the health care dollars that might help these sources of payment are relatively inflexible. support rural hospitals are spent outside the commu- nity. A study of 3 rural communities in Washington, A recent study in Wisconsin found that 18 to 35 each with a hospital of SO or fewer beds, found that percent of charges by rural Wisconsin hospitals to about one-half the residents expenditures for care private-pay patients were required to cover revenue were not spent in those communities. In 1985, the shortfalls from Medicare. Medicaid, and charity total expenditures for health services by residents in care. The smaller hospitals (with an average daily dismay Mates. Medicaid parneat loots for hoz, . ndhyst ulao %am Emma stgairro.antly below pros mkt 4.hargea for midi are (sec di 3), 1'IL") Table 5-19Sources of Net Patient Revenue, of Box 54The Hill-Burton Uncompensated Community Hospitals," by Hospitai Location, 1986 Care Obligation A crucial continuing element of the Hill-Burton Honmetro Metro AIL program (see box 5-A) is the "free-care" obligation hospitals hospitals hospitals of hospitals and other health facilities that received its construction funds to provide a reasonable Percent Medicare.. 41.9 38 6 39.1 volume of services to persons unalge to pay. In Percent Medicaid 8.7 9 6 9.5 addition, health facilities agreed to "community Percent other Government 1 0 1 8 1.7 service" (i.e., to make their services availzbi to an Percent total persons residing in their geographic areas). non-Oovernment 48.4 50.0 49.7 The free-care obligation is a time-limited am- Total 100.0 100.0 100.0 mitment, usually for 20 years from the date the assisted project opened for service. The amount of Iliet patient revenue consists of gross patient service each facility is committed to provide is revenue i ss deductions for %-ontractual adjust- ments, bad debys. and charity care. determined thmugh a formula based on the facil- bCommunity hospitals defined as all non-Federal, ity's operating Litiget and the amount of assistance short-term general and other special service hospi- received. Persons whose incomes fall below die tals. Federal poverty guidelines are eligible for free care SOURCE. American Hospital Association. Chicon*, IL, at facilities that am still under the free-care obliga- unpublished date from the Annual Survey of tion (320). Hospitals, 1984-87, The community service obligation is not time- limited; it applies as long as the facility is in Table 5-20--Distribution of Hospitals by Medicare operation. lt does not require the facility to provide Percentage of Net Patient Revenue*, 1986 general services at ne charge, as long as the facility has fulfilled its free-care obligation. However, the Medicare Percentage of net Patient revenge. community service obligatioa does prohibit a 0-42 43-52 53+ hospital from denying emergency services to par- sons because they me Enablo to pay (320). percent diatribution or hospitals: Total hospitals 53 38 9 Honmetro hospitals 6-24 beds 75 12 13 census of 35 patients) had the largest average cost 25-49 23 61 16 shift, equal to 35 percent of charges (563). 50-99 26 64 10 100-199 74 21 s Medicare's Impact on Hospital Operating 200 or more 6' 31 3 Margins Total nonmetro 41 48 11 This section briefly examines the conaibution of °Het patient revenue consists of grog& patient rev- enue Iesa deduction& for contracival adjustments, Medicare's prospective payment sygem (PPS) to the bad dbts, and charity care. revenue and fiscal health of rural hospitals. In the SOURCE American Hospital Association. Profile of fifth year under PPS (roughly 1988), average Medi- Small or Rural Hospitals 1980.86 (Chicano, care payments per case to rural hospitals were 43 IL: ABA, 1988). percent19 lower than those to taban hospitals (494). This difference in payment roughly parallels that in average operating costs per case (table 5-22). With :n Through the first 5 years of PPS, Medic.are payments rural hospitals, the smallest hospitals have the per case rose an average of 7.4 percent a yeas while lowest per-case costs (93a). The gap between operating costs per Medicare case increased 8 payments and costs has worsened over time. percent annually (495)." 1/Preliminary esdmate. 30PP5 years 1 through 5 correspond roughly to Federal fiscal years 1984 to 1988 butte first year of PPS. average increases m pa-casc payments were noticeably higher than in later years AlthoughPPS had intended to restrict payments in its first years to be no hibber or lower than would haveoccurred under cod-based reimbursement, Medicare revenues for hospitals icidally increased much faster than hospital costs. 1 4.4 Chapter 5Problems and Trends in Rural Health Senices 133 Table 5-21Community Hosptalso Receiving 1bx Appropriations From State and Local Governments, by Hospital Location and Bed Size, 1984 and 1987 1984 1987 Tax appropriations Tax appropriations Hospital RuMber Percent Pes hospital RuMber Percent per hospital Metro 2,468 81 $881.104 2,441 81 $1,230,534 Ronmetro 1,762 65 79,556 1,791 69 120.680 8-24 beds 77 42 130,153 97 51 170.118 25-49 410 52 105,889 514 64 102,309 50-90 635 68 75,904 583 65 103,045 100-199 480 79 67,480 441 82 138,474 200-299 118 90 28,892 123 91 14,586 300 or more 42 92 65,297 33 87 730,703 'Community hospitals defined here es ellnon-Federal. short-term general and other special service hospitais. SOURCE. American Hospital Association,Chicago, IL, unpublished data from the Annual Survey of Hospitals, 1984-2987. Table 5-22Average PPS Operating Costs Per Case of margins for 4 of the first 5 PPS years, and by year 5, Hoseitais in the Fifth Year of PPS, by Hospital Location over one-half of rural hospitals had negative margins and Type (table 5-24). The smallest rural hospitals (with under 50 beds) fared the worst; 10 percent of hospitals in Percentage difference this group had margins lower than minus 49 percent Average from average costs (495). costs per case for 30spital typea per Calm all hospitals Designated SCHs receive special treatment under Metro $4,746 10.4 PPS (see ch. 3), but at least until recent changes in Ronmetro 2,899 -32.5 Afthisspecial treatment has not Under 50 beds 2,494 -42.0 the payment la 50-99 2.624 -40.0 actually translatvl into financial protection. In PPS 100-169 2.983 -30.6 year 5, the average Medicare operating margin of 170 beds and over 3,410 -20.7 SCHs was minus 4.2 percent, and the bottom 10 Rural referral 3.455 -19.6 percent of SCHs had margins averaging minus 45 Sole community 2.938 -31.7 Other nonmetro 2.633 -38.7 percent (table 5-24). In fact, depending on their costs, some SCHs would have received higher NO/E: PPS stands for Medicare's prospective paYment Medicare payments under national ratesone rea- system. Hospitals s.n MarYland and New Jersey are excluded. Pith-yeas rPs roughly cor- son why some sole providers have not sought the responds to Pedeval fiscal y.2s 1988. SCH designation (487). New payment rules may aAll PPS hospitals. enhance SCH opetrating margins, at least for Medicare- SOURCE: J. Boulanger. Prospective Payment Assessment related services (see ch.3).22 Commission Washington, DC, personal commu- nication, April 1994. The poor operating performance of rural hospitals As a consequence of the trends in Medicare under Medicare is not explained by the high percentage of Medicare patients saved. In PPS year payments and costs, Medicare PPS operating mar- 4, rural hospitals with few Medicare days had larger gins21declined substantially for both rural and urban negative Medicare margins than did those with hospitals after the first 2 years of PPS (table 5-23), moderate shares of Medicare days. Furthermore, Eleven percent of rural hospitals had negative those rural hospitals with the smallest proportion of 21The hdPdicare operating margin bdicates how a hosr 'oatfiniag linanually on tbc smuts it provides to hieduare patients, It is Nun to revenues received ander PPS less ihe operathig costs co-ered by PPS payments divided by PPS revenues andthen tnuluphod by tdi-hiedlcam men= and (Mb forsenkcs nOt coveted under PPS, slid' as capital expeaditates and direct medical cdukanonsts, atecaludedt.S62).A surplus ormunemargin occurs when IMMO exceed costs, and a IOU x negadve margin follows when die opposde is Mae. 22Chaages made by Congress hi 1989 (Public Law 101 -239) are intended to mom eftet,tively znati.h Meds.are payments tu unts ol btlis and num hoophallvedth fewer duut 100 beds and ad ks$160 pcmrant AlcOricare patients es dlays of case (sre ch. 3). t " 134 Health Care in Rural America Table 5-23-Hospital PPS Operating Margins for the First 5 Years of PPS, by Hospital LocationandType Pereentage of hospitals Annual oturatIng_Mgrgins (percent)* with 4 years of PPS PPS PPS PPS 1.4 negative margins in Hospital typeh 1 2 3 4 $ first 5 years Metro 15.8 15.5 11.3 6 8 3.8 3,2 Nonmetro 8.4 8.8 3.1 -0.3 -2.3 10.7 Under 50 beds 6,4 6.0 -0.9 -2.3 -3.5 11.9 50-99 6.4 7.4 1.4 -1.6 -4.0 11.3 100-169 8.8 8.1 3.0 -0.7 -0.5 7.5 170 beds end over 9.4 12.4 6.9 2.4 -1.8 6.9 Rural referral 9.5 13.4 8.2 4.3 -0.1 3.5 Sole community 6.9 8.2 1.2 -2.7 -4.2 13.2 Other nonmstro $.0 6.5 0.3 -2.8 -3.4 11.1 MOTE: PPS stands for Medicare's prospective payment system. Hospitals in Maryland and New Jersey ere excluded; hospitals in Massachusetts and New York arc included beginning in PPS 3. *PPS 1-118 5 roughly corresponds to Fderal fiscal years 1984-88. bAll PP$ hospitals. SOURCE. Prospective Payment Assessment Commission, Medicare ProaPective Payment and the American health Care Sntemt_Raport to Congress (Washington. DC. U.S. Government Printing Office, June 1990). Table 5-24-Fifth-Year Hospital PPS Operating Margins. Means end Percentiles by Hospital Location end Type Moan 10th 50th 90th Hospital typea percent percentile percentile percentile All hospitals 2.6 -28.3 -0.5 18.6 Metro 3.6 -22 2 1 2 19.7 Nonnotro -2.3 -33.9 -2.6 17 2 Under 50 beds -3.5 -48 5 -2 4 20 4 50-99 -4,0 -28 2 -3.2 14 0 100-169 -0 5 -28 2 -1.8 13 3 170 bee. and over.. -1 8 -16.8 -1.7 14 8 Rural referral... . -0.1 -14.8 1 1 1$ 5 Sole conwunity -4.2 -45.0 -6 3 14 5 Other nonmetro...... -3.4 -35.2 -2 6 18 0 NOTE: PPS stands for Medicare's prospective payment system Hospitals in Maryland and New Jersey aAa ex- cluded. The fifth year PPS roughly corresponds to Federal fiscal Year 1989 aAll PPS hospitals. SOURCE: Prospective Payment Assessment Commission, Medicare Prospective Payment and the American health Care System. Report to Congress (Washington. DC U S. Government Printing Office, Juno 1990). Medicare days have shown poorer Medicare mar- percent of patient revenue in urban hospitals was gins since the beginning of PPS (492). irom outpatient sources (30). Ambulatory Surgery and Medicare Payment Medicare payment for ambulatory surgery can be Rural hospitals have found revenue from outpa- a major source of outpatient revenue. Current tient services increasingly important to their sur. Medicare payment for hospital outpatient surgery is vival. In 1987, over 23 percent of all gross patient based on the lesser of reasonable costs or a blend of revenue in rural hospitals was f--.rn outpatient 'Aospital costs and freestanding ambulatory surgery services; this proportion represents an increase of center (ASC) rates. Freestanding ASCs currently more than 50 percent since 1984 (table 5-25). receive lower payment rates from Medicare, and Smaller rural hospitals had the greatest dependence they reportedly have lower fixed costs than do on outpatient revenue. By comparison, less than 19 hospitals. A recent analysis found that hospital 146 Chapter 5Problems and Trends in Rural Health Services .135 Table 5-25Community Hospitals.* Gross Outpatient ASCs may " skire the least complicated cases Revenue From Outpatients as a Percent of lbtal Gross and better-paying patients, lea,,,ing competing Patient Revenue, by Hospital Location and Bed Size, hospitals with dm mom complex and uncom- 1984 and 1987 pensated cases. At least 85 percent of AS Cs are located in urban 1984 1907 areas (99). ASCs can generate low costs Metro hospitals 14.1 18.5 through specializing in high-volume services. Ronmetro hospitals 15.3 23.5 Rural hospitals, on the other hand, generally 6-24 beds 20.7 34.3 have low surgical volumes due to low popula- 25-49 17.2 27.6 tion density in their service areas. 50-99 16.1 25 5 100-199 15.2 23.5 Hospitals generally provide a wider range of 200-299 14,3 20 7 needed services than do ASCs, including more 300-399 14.1 18 5 nonroutine ctr..e and standby capacity for emer- 400-499 12.8 18.1 500 or more 9.1 13.9 gencies that rosult in higher fixed costs. Other requirements associated with the need to ac- ROTE. Gross patient revenue consists of reveoue commodate intens;ve care in hospitals (higher based on full established rates from services rendered to patients, including payments costs of skilled staff and supplies) may also add received from or on behalf of individual to cost differences between hospitals and ASCs. patients. !Community hospitals defined here as all non-Federal. Incentives for rural hospitals to provide more short-term general and other spe6ial iser..160 hz.spi efficient outpatient care may well be appropriate, A tals. payment system that assumes that mral hospitals can SOURCE. American Hospital Association, Chicago, IL, achieve the high-volume efficiencies of AS Cs, unpublished data from Annual Survey of Hos- pitals, 1684-87. however, will probably be insufficient to cover costs and may further threaten hospital survival. outpatient surgerycosts are significantly greater than die current blended payment rate (table 5-26) Costs and Operating Margins (490), Hospitals reimbursed under the blended rate Fed by rising amounts of uncompensated care and receive payments that are 19percent lower than their mflexible or inadequate reimbursement from public per-,:ase Costs.23 payers, total expenditures of rural hospitals have been growing faster than total revenues. From 1984 Medicare expenses for outpatient care have in- to 1987, total expenses for mral hospitals rose by creased dramatically in recent years, and Congress 15.8 percent, while revenues increased by only 14.4 has directed that a prospective payment sy stem be percent (table 5-27',. Th.: smallest rural hospitals developed for such care (see ch. 3). A danger exists experienced the largest shortfalls, total expenses for that more stringent catpatient payment controls hospitals with fewer than 25 beds increased by 28.5 could further increase the risk of survival for many percent, while total revenues lose by only 21.9 rural hospitals. A 1989 study found that if proposed percent (30). per-case payment rates to ASCs were applied to rural By 1987, the smallest mral hospitals also had the hospitals, they would be 38 percent less than highest total expenses per inpatient day-4724 for hospital costs (table 5-26) (00). Outpatient surgery hospitals with fewer than 25 beds, compared with costs for a hospital service may be greater than ASC $534 for all rural hospitals (table 5-28) (625). Small costs for that service for a number of reasons: SCHs and frontier hospitals had especially high expenses per day, suggesting that the very smallest Most hospitals,in an effort to lower inpatient and most isolated rural hospitals ha,,,e the greatest COM under PPS, have allocated portions of difficulty providing a sufficient volume of services inpatient care and overhead expenses to outpa to cover their fixed expenses. Expenses also in- dent services, whose 4nt thus becomes over- aeased with size for very large hospitals, possibly state& reflecting the delivery of more complex care. For 231bc analysis did col amount for say unpitiveinenu int&vpiui cirtium.)brought about byrclunnsursici 4 ponicn. " Table 5-26Mean Hospital Costs Per Case Compared With Mean Proposed ASC Payments Per Case and Blended Rate Payments Per Case, by Hospital Location and Bed Size Percent (A) (11) (C) Difference between Difference between of total Facility Proposed Blended colvnns (A) and (B) columns (A) and (C) Hospital ASC-approved costs ASC payment rate payment costa per case costs per cams tY104) surgical cases per case per mask° per casec dollars percent dollars percent All 300 $640 $394 $517 -$246 -38 -$123 -19 Metro 81 675 414 545 -261 -39 -130 -19 Nonmetro 19 580 361 471 -219 -38 -110 -19 Under 50 beds 2 551 338 445 -213 .39 -107 -19 50-99 5 592 360 476 -232 -39 -116 -20 100-169 6 411 379 495 -231 -38 -116 -19 170 beds and over 6 563 386 474 -176 -31 -88 -16 HOTE. ASC stands for albulatory surgerY center.Cost and payment estimates based on outpatient department surgical bills from October 1, 1987 through June 30, 1988. aThe U.S. Health Care Financing Administration estimated costs for each hill by appl/Ang hospital-specific departmental cost-to-charge ratios from the Medicare Cost Report to charges on the outpatient department bill. bASC payment per case is adjusted to reflect area wage indices. cThe blended rate pigment equals 50 percent facility costs plus 50 percent proposed ASC paYnant. SOURCE: Prospective Payment Assessment Commission. Medicare Payment for Hospital OutPatient SuraerY The Views of the Prosoective foment Assessment Omission (Washington. DC: U.S. Government Printing Office, April 1989). 1 2, Chapter 5Problems and Trends in Rural Health Services 137 Table S-27Channes in Tvtat Ftevanue and Expenses managed to avoid a negative matgin in a given yew. for Community HospitaL.5 by Hospital Location and The presencc of negativ e margins ov er a long period Bed Size,1984 and 191:17 of time, however, suggests deteriorating fmancial health (690). Percentclithitt 1{034 to rata Total Total A study of the financial condition of rural revenues expenses hospitals during the secoud, third, and fourth years Hzumetro hospitals 14.4 15.8 of PPS (roughly 1985 through 1987) compared rural 6-24 beds 21.9 28.5 hospitals with positive Medicare operating margins 25-40 21.0 23.7 ("winners") with ones with negative Medicare 5O-^9 16.9 18.7 operating marg'-is ("losers") (table 5-31). "Win- 100-199 6.3 7.8 200-299 25.9 27 4 ners" were larger in size, had higher occupancy 300 or more 10.5 10.0 rates, had more discharges per hospital, and had Metro hospitals 23.9 25.0 substantially lower costs per patient than "losers." Also, "winner" hospitals in the fourth year of PPS *Community hospitals defined here as all nor-Federal. short-term general and other special servic4 hospi- were paid by Medicare sligIaly less per discharge tals. than "losers," leading the study to conclude that SOURCE. American Hospital Association, Chicago, IL, cost per patient, not Medica_..: payments, was the unpublished data f:7/0 Minuet Suzvey of "primary (4.q.enninont- of whether a rural hospital Hospitals, 1984-1967. was profitable (690. rural hospitals of a gi ;ea T.:Le, total expenses were About 44 percent of all "loser" hospitals wchillu highest in nonprofit hospitals and lowest in govermnent have "broker' even" 1 Medicare patients (Medi- owned facilities (table 5-29) (625). care revenues at least equal costs) in PPS year 4 if they had: 1) received up to 10 percent more revenue Since expenses were increasing faster than reve- per Medicare discharge, or 2) lowered their cost per nues from 1984 to 1987, patient and total hospital discharge an equal proportion. Another 25 percent of margins declined in both rural and urban hospitals "kser" hospitals would have achieved break-even for the period24 (table 5-30). In 1987, urban hospitals status if they had obtained up to 29 percent experiemed the poc.est pati--it margins (minus 31 additional Medicire revenue (696). These estimates percent), while nusl hospitils bad the worst total only apply to additional revenues needed for rural margins (plus 3.2 percent). Nearly all rural hospitals hospitals to break even serving Medicare patients; It had mgative patient margins by 1987 (as low as is not clear what impact the added Medicare mina; 21.5 percent for hospiials with fewer than 25 revenues would have had on the overall operating beds); most rural hospitals (except f with under margins and profitability of these hospitals. 50 beds) were able to achieve positive total margins. Larger rural hospitals generally had better patient and total margins than smaller rural hospitals. Small Access to Capital rural hospitals were more dependent on nonpatient revenues (e.g, tax appropriations) than were larger Many rural hospitals' physical plants and equip- hosp;tals, but even these revenues were not suffi- ment, funde.:. with Federal assistance under the cient to result in positive total margins (SO). Hill-Burton program in the 1950s and 1960s, may be in need of replacement, renovation, or moderniza- Operating with a negative margin in any single tion (363), although little 4 known about tire extent year does not necessarily mean financial distress. und nature of what is :equired. Needed changes may Negative margins may be present in fmancially include c.onversion of some of the facility from sound hospitals in a year when the hospital is faced inpatient to other kinds of scr% kes and investment 'a with paying for large or unexpected faciluy reneva- diagnostic, theiapeuti,.n4administrative resell! Les. lions or major equipment. Conversely, hospitals Hospitals that have had to use their cail reser% cs to plagued with seriarnancial problems may have maintain operations have fewer resources availablc ATI= prim -am, wlai pa maAt rovenues payments frum all pauems vl insurers) *Eh Iutal rital huspital mergra k onlpate5 *avenue, from all so. Ana; pre cocantelsons, 'mai government slubSitiles, ffiC.ImcIt1 111tiu tolih tutoi 1)4,spetidmaugia provides a clearer inucata4 a hospital mall financial condition than paeeu warm. 138 Health Care in Rural Arnerka Table 518Total Mean Expenses Per Inpatient Day for Nonmetropollt an Community Hospitals*by Bed Size, 1987 HonmetropoLitan Hospitals at Bed size hospitals frontier areas 6-24 $724 $948 $903 NA 25-49 585 686 535 $221 50-99 494 572 277 681 100-199 466 560 260 633 200-299 482 473 87 551 300-399 517 5'a NA 513 400-499 519 NA 495 500 or more 566 NA NA 584 Total $534 $651 $518 $588 NOTE: NA not applicable. eCommunitv hospitals defined here as all non-Federal, short-staY, nonspecialty hospitals (see app. C). bAs defined for Medicare purposes (see app. C). SOURCE: Office of Technology Assessment, 1990 Data from the American Hospital Association's 1987 AnnuaL Survey of Hospitals. Table 5-20Total Expenses Per Nonmetropoliten Community Hospital* by Ownership and Sed Size, 1987 Type of Ounershio Government How:Tait For-profit Mean expense Mean expense Mean expense Bed size Humber per hospitalb Number per hospitalb Humber per hospitalb 6-24 118 $1.262 66 $1.478 16 $1.556 25-49 423 2,474 324 3.087 70 2.825 50-99 362 5.164 432 6.448 99 6,258 100-199 165 10,787 305 14,087 69 21.080 200-299 23 25.113 102 25,874 10 22,932 300 or more ...... 7 47,847 30 $51,378 NA NA Total .1,098 $5,243 1,259 $9.818 264 57.216 NOTE: NA = not applicable 4Community hospitals defined hereas all non-Federal,short-stay, nonspecialty hospitals (see appC) bin thousands of dollars SOURCE: Office of Technology Assessment. 1990 Data from the American Hospital Association's 1987Annual Survey of Hospitals to help fund such projects. Therefore, outside capital loan programs under Section 242 of the Federal is often needed. Housing Act developed inthe 1970s, enabling nonprofit hospitals to dramatically improve their The sources of outside funding for capital projects c....cess to capital financing for construction and in rural hospitals have changed over the years. Until the early 1970s, hospitals derived most of their renovatinn projects. The creation of the Medicare capital for major purposes &lin Hill-Burton con- and Medicaid payment programs in the 1960s also struction wants and charitaole contributions. The allowed hospitals to be reir Amused a share of Hill-Burt grant program ended at a time when reasonable capital costs (primarily interest and charitable contributions as a proportio.1 of capital depreciation) related to the institutions' Medicare funds were also decLiing. However, commercial and Medicaid patient1oad.25Since 1986, however, 231a Some State.. Medicaid Qom oot pay bospitals for capital inIkegame way as Medicare (474) 1 51 Chapter 5--Problents Ind Trends in Rural Health Serykes 139 Table 5-31Comparison of Nonmetropolitan Hospitals Having Positive and Negative Medicare PPS Operating Margins, PPS Years 2 Through 4 --vastINNI Hospitals during Hospitals, PPS 2-0 during ffS 40 PositiveNegative Positive Negative margins Margins margins margins ?FS revenue per .444.^hirge.S2.674 42,634 b2,721 62.770 Cost per disaharge $2.414 62.909 62.468 $3,111 Average hondtal sixe (beds,. .. 70 63 NA NA Photomat: Potot 13oeson 7otal discherges per hospital . 2,069 1,601 1.902 1.678 Some small rural hospitals built with HillBurton funds 1 during the 1950$ and 1960$ are now In need of Staff prr major renovation. occupted bed , 4 95 5 29 5.14 5 5/ :leasers latgin Table 5-30Community Hospital° Net Patient Margins of stay (days,. 6 54 7.08 6 42 7 1) and Net Total Margins, by Hospital Location and Bed Size, 1984 and 1987 NOTE PPS stands for Medicare's prospective psymort system. Table excludes rural referral cen- ters. hospitals in States exempt from ?PS. thneo with cost report periods of less then Net patient Total net hospital 10 months 4r am that 14 months, those with marlinh (percgraki marsinc (perceall no Medicare lischargss or mors than 20,000 1984 1987 1984 1987 Medicare discherges, aria t'ose with a ratio of medicare pps costa-to-dischergsa of less Metro hospitals.... -1.9 -3.7 5 2 44 than 100 or moi than 15.000 NA not avail- Nonmetro hospitals. -0.9 -2.7 4 3 32 able. 6-24 beds -13 9 -21.5 0 9 -45 alloughly corresponds t, Federal fiscal Years 1965-87. 25-49 -6.5 1 5 -9 "i0 1 bRoughly corrflpotds to Federal fiscal year 1967 50-99 -1 9 "3.8 3 5 29 100-199 C.5 -1.0 4 9 4 1 SOURCE U.S. Department of Health and Human Serv- 200-799 ...... 1.2 -0.3 5 5 4 ices, Office of Inspector General, Status 300-399... 17 -0 3 5 8 5 of Rural NosPitals Under the Medicare Part A 400-499 ...... 0 8 0.4 5 4 - Prospective Payment System (Washington, DC 500 or more -4.9 -0.5 4.8 OIG, July 1988). tommunity hospitals defined here ali tan-Federal. the Is short-term general and other spec *1 service to borrowers because interest income not hospitals. subject to Federal tax, and thus interest rates are bThe net patient margin is equal to patient revon.es substanually below those of the taxable market. minus total costs, divided by patient. ,evenaes, Such finary og may be less profitable for lenders, multiplied by 100 cThe net total hospital margin is equal to tote; however. ...id the potential for loan repayment revenues (Including those from sotkes ,ttivx tnan bet-ornes amoie important consideration068,694 patients and insurers) minus total costs. .1,vided by total revenues, multiplied by 100 Borrowing hospitals may be subject to greate: scrutiny by these lenders, possibly adding to their SOURCE: American Hospital Association, Chicago, IL. unpublished data from Annual Surv..y ot difficulties in obtaining capital. Recently, smaller Hospitals, 1984-1907 and declining operating margins of hospitals may have weakened their creditworthiness with lenders. hospitals have not been reimbursed for Medicare's full share (PublicLaw 99.509).(In 1989, Medka:e Al ancty of public and priv atefulanansmethods paid 85 percent of capital costs (Public Law 101- have been used by rural facilities to provide the 239).) capital to fund major projects. Donations aid local fund drives remain an important source of capital The largest single mechanism of debt financmg funding in many rural communities. Hospitals may for nonprofit hospitals is now tax-exempt rev.t.....e lease expensise equipment to avoid Lige Lapital bonds. Tax-exempt financing is inherently attractive outlays. The Faimers Horn.: Adminisation 140 $ kleedsCameinitunlitincrica ban a popular source of low-cost funds for non Table 5-32Community Hospitals* Acquiring New profit ntral hospitals, CHCs, and other health cane Capital Debts, by Hospital Location and Bed Size, facilides, although its application review process is 1984 and 1987 often criticize i as being slow and cumbersome I (25)). Rural hospitals have relied heavily on local 984 1981 banks for capita funding, bur their often highez Percent Perceut interest rates and dghtening credit restrictions have Hopitals NuMber of to'.,a1 Humber of totol made many less competitive with urban banks. Also, Metro 56 18.,4 /29 24.Z according to a 1989 survey, 18 States have estab- Nonetrom 1542 12.7 503 /9 4 lbhed fume* programs to make capital funds 6-24 bc:e ... . 11 6 0 23 12 0 I available to nomofit hoopla's and C4'i faciiities; 25-49...... 84 10.f, 13! 10 9 at least 2 State programs Nils on the pardculae '14 12 2 15.5 122 22.8 capital needs of rural facilines. These programs' 200-sue 14 36 26.7 fonds, however. are oftee nerron 'y restricted, and 300 or maze .... 15 32 6 18 47.4 I hospiads with poor crerLa ratings may have diffi- tommlett..1 hospitels defined hero es all non-Federal. culty qualifying (474 short-term isfteral and other special service hospi- tals The proportion of rural hospitals obtaieing new 1! SO4RCE. American Hospital Asauciauion. Ch.tego. I' capital debt is small but growing (table 5-32). Fewer unpublished data from Annual :;urvey of =all than 'tinge rural hospitals obtained uew capital Hoapitala 1984-1887 debt from 1984 to 1987, perhaps because of the inability of tenall rtirai heapiteds v3 acquire capnal The inability of Tyra CHCs to recoup the full financing (30). This tra-o4 might also be explained by charge is also reflected in the ce dere overall the increasing amounts of unborrowed fundire collection rateIn 1988, just 48 percent of all available to small hosoitris for capital peojents. the cav -:s--whether full or disccuntedwere lect amount of funds given to hospital endowmenta dad Regionally, rural CF,C collection rates restricted for facility coastmnon/renevation and ranged from 82 percent of chatgc s in Region Ito just 26 percent of charges in Regbn II (658). othen purpodes inereasod signiflcan ly fox smelter nut hospitals. From 1984 to 1987, such funds rose nearly 59 percent for hospitals with 2$ to 50 beds Reliance on Public Paynaatt while declining 15 percent for hosphals with 100 to and Funding Sources 199 beds (table 5-33) (30). The proportion of mral CHC revertues that derive FINANCIAL VIARILITY OF from public payrnern sources has increased noticea- bly in recern years. In 1984, Medicaid revenues were COMMUNITY HEALTH CENTERS about 19 percent of total patient revenue; by 1988, Revenue Imes the proportion had risen te nearly 25 peiceut (figue 5-5). During the same period, the proportion of total Demand for Uncompensated Care avenues caccted directly from patients fell from 44 to 38 percent (658). These tends offer additional The number of persons receiving discounted or evidence tints rural CHCs are serving increasing unpaid care in rural CHCs is also growing. A recent numbers of patients who are unable to pay for basic survey of rural CHCs reported that many CHC user s health care were paying for services under a slicVng fee scale, permitting patients with incomes up to 200 percera DeTite overall increases in patient revenues, of poverty level to pay less than full cbarge (IN ('eiCs remain heavily dependent on government exact amount paid is based on income ani family grant funding to cover expenses. Rural CHCs rely size). In 1987, nearly one-half of a asers of more heavily than oti- ers on Federal grants as a surveyed CHCs pvid for services according to a proportion of total revenue, even though the propor- sliding fee scale (table 5-34). The number of patients tion has declined slightly in recent years (table 5-35) rquirting subsidaeed service in mral CHCs in 1)87 (585). Amorrural CHCs. frontier CtiCs are range from 82 percent of users in Regice Vi to enly especially deaandent on Federal funds. For the years 7 percent in Regkat 1(307). 1985 through 1987, 30 frontier centers surveyed in 1 .-13 Chapter 5-Pr3blems andrrends in Rural Health Services 141 Table 5-33-Aggregate Fundsb Given to Endowments ot Available for Plant Replacemei,:. and Other Restricted Purposes in Community Hospitalsb, by Hospital Location and Bed Size, 1984-87 Percent chs-ra Hospital 1984 1985 1986 1987 1984-87 Metro 85.175.3 85.231.0 85.736.0 06.021.2 16.3 Nonmetro 848.5 915.9 903.7 879.0 3.6 6-24 beds 8.3 4.5 8.1 9.1 44.4 25-49 58.0 79.7 98.4 92.0 58 6 50-99 191.5 218.6 247.9 260.7 34.7 100-199 :010.7 389.6 346.6 305.0 -15.4 200-299 160.8 259 3 143.6 153.8 -4.4 300 or more 69.1 64.1 59.1 58.4 -15.5 aln millions of dollars. Only fund balances (balance remaining after subtracting hospital liabilities from es- sets) aro report:d. bCommmnity hospitals defined hero as all non-Federal. short-term general 4.13 other special service hospitals SOURCE. Annual S..rvey of Hospitals, Chicago, IL, unpublished data from Annual Survey of Hospitals, 1984-1987. Table :-34--Paxtients Requiring Subsidies in the amount of funds received by urban CHCs.26 Rune narlemily Funded Community Health Centers (CHCs), Accordmg to a recent analysis, rural CHCs in 1986 by Region, 1987 received nearly 60 percent fewer Federr...1 grant Total clinic All sliding Percent of dollars per center and 15 percent fewer grant dollars Regions users fe users tota users perpatientthan did urban CHCs (table 5-36)? From 1983 to 1986, the average amount of grant funds rer I 9,480 640 7 patient in rural CHCs declined slightly, compared /I 9,010 1,480 16 III 8.545 3,662 25 with an increase of 27 percent in per-patient funds to IV 8,811 5,541 63 urban CHCs (272). It is difficult, however, to know V ...... 9,045 3,117 34 whether rural CHCs receive inappropriately less VI 9,455 7,732 82 VII 5,0C4 1,504 30 Federal funding than urban CHCs without analyzing VIII 4,855 3,068 82 in more detail differences among centers in such Tx 18,300 6,975 38 factors as: X ... 6,522 4,861 75 Total 8,7io 4,312 49 patients' abilities to pay full charges; dependency on direot padent mvenues ( leve. NOTE: Users aro averages per canter. Rural aCs are those identified by the U.S. Deportment of nues from nongant sources); Health and Human Service4 regional offices scope and costs of center services and opera- that approximate a center's location in a tions (e.g., extent of on-site ancillary service:4. nonmetropolitan r-ea. Lnd 4Federal Department of Health and Human Services regions (see app. F). severity of health problems in patients served SOURCE: Joint Rural Hvalth Task Force of the Nation- al Associatian of Comammity itsalth Centers, Costs and Operating Margins Washington, DC, and the Lational Rural Health Association, Kanssa tity. MD, Eommu-, As with 1.spitals, total expenses for rural CHCs pity HeaItti "enters fad the Rute Econow have been rising faster thanotal revenue. Total Dacember 1988 The StrultaktiaLlurvivaI expenses increased 19 percent between 1986 and 5States needed Federal grants to cover about 65 1988, compared with about 16 percent ftotal percent of their operating expenses(204). operating revenue (see table 5-35). In 1986, totai revenue occeeded expenses in rural CflCs by $8 The amount of Federal dollars granted to rttrIl million -about $21,000 per center, by 1988, the CliCs has been significant-I less in recent years than margin was nealy eliminated. The proporbon vf 36Differenecsinthecomputtonotbastglantino,mstlisusbutedtururatsadubanwannurutpaugrant Altlis.enks:puoesiuwlyle.A:Leds.o,Ast mid49808 (660). Mural CNCmincesrepresent over 60 percent of the total MC grantees, bt. they serve about AL. MITIC twain vi usen aIti ban CNC vantees 6560). 1 I. Figure 5-5--Sources of Payment for Services in Table 6-35Community Health Center (CtiC) Revenue Rural Federally Funded Community Health Centers, and Expenses, 1986 and 1988 1984, 1986,and 1988$ Percent se P4:cont 436 change 1986 1988 1906-88 401 Belaborof Men 30 Rural 382 319 -16.5 Total 600 526 -12.3 Total operetimg revenue(' (in millions of do/lairs) Rural $356 $415 16.5 Total $877 8917 13.7 Percent Federal grantt WWW4m Minleeld Othei lantana* Direct *404ar of total revenue Poen* Of Payment eolNietlea4 Rural 521 471 -9.6 Mine CO ems1_ Ross Total 482 431 -10,4 NOTE Wmsynot equal 100 potent due it. .nundinc Total expanses notelpayme..«....re 1109 Wilton in 1984.1;128million 1111986. and $161 tim 1LU of dollars) ninon In 1988. Rural ...... $348 $414 19 0 SOURCE:Office di Technsiogy Asseeemsot. 1990. Data from 11 S. Total.... . $066 $598 15.2 Department c4 Health and Human ..1en4cas, Health Resources and Swims Administration, Bureau ot 1-laulth Care Delivery NOTE Definitions used by U.S. Department -4 Health and Assistance, flodtvile. MD. unpvellshed 198448 data for mat commurily health centers froin the SCAR File. provided by and %Wan Services regional offices to E. Sullivan. 1989. identify CHCs as rural or urban approximate center's location in either a nonmetropolitan or metropolitan area. revenue derived from Federal grant funds dropped aTotal operating revenue includes both reverue from by nearly 10 percent from 1986 to 198'4 and the drAp patient charges and nonpatient revenue such as was barely balanced by the 26 pcicei... ..ncrease Federal ii:ant funds. patient revenue for the period (see figure 5-5 and SOURCE. f: Sullivan, Bureau of Health Ciro Delivery and Asslitance, Health Resources snd table 5-35) (585 ,65 Services Administration, U.S. Department of Health and Human Services Rockville, MD, FACILHY CLOSURES perslnal communication,Januery 1999. Facilities that cannot gene lte sufficient revenue in ll4, rural hospitaiclosures represented over to maintain their financial viability eventually close.14 two-thirds of all community hospital closures (328). Where alternative sources of care are not easily A recent report pretacts that, if these trends were to available, facility closure could severely limit access continue. 40 percent (about 2,700) of all U.S. to critical services by people living in the commu- hospitals would close or convert to other health care nity. Where services are duplicative, on the other purposes by the year 2000 (415). Only three States hand, facility closure may actually allow local health (Rhode Island, Vermont and Wyoming) and the care resources to be allocated for better use. The District of Columbia had no hospitals dose between following section describes the trends in rural 1980 and 1989 (33,116). facility closures and their potential consequences for access to care and general efficiency of the health Available figures on hospital closures are not delivery system. alwrys complete and useil measures of changes in Number of Thspital Closures access .o basic health sei .ices. Ar,.ival AHA num- bers on community hospital closures include as Rural community hospital closures totalled 237 "closed" all tiospitals that no longer provide acute from 1981 through 1989, with annual numbers rising inpatient care (as of the end of the yea). Some of steadily for most of that time (figure 5-6) Since these hospitals may still have an acute-care license. 1986. more rural than urban hospitals have closed: or they ma; 'lave remained in operation as a Ant:re may be moms other than financial hardship for the closure of health care facilities leg.. goveniment regulatiot.. (sedgy mergers) t-') Chapter 5Problems and Trends in Rural Health Services 143 Table 546--Geographie Distribution of Community Figure 5-6--Closure of U.S. Community Hospitals Health Centers and Federal Funding, 1983-86 by Mettopolitan;Honmettopolitan Status, 1981-89 Numberof closures Tear 100 Location 1983 1984 1985 1986 85 80 A 77. Lumber of comminitv health centers° 65 Rural . 366 396 390 385 80 Urban 2.01 210 212 215 39 !I 37 ; 21 40 I I 1 1 pundinc (in milltmns of doliara, 46 Rural . S14 $135 $149 $162 I 27 24 25 40 ' Urban 148 213 227 234 ;tr ! I 20 16 ! 0 ; iis ; / Avrag funding per center I 14 11---1 _ . . (in thousands of dollars) 0 It1-U,--/- A Rural $402 $34l $303 8044 1981 S982 1983 19214 1985 1988 1987 1986 1989 7-1-on 736 1014 1071 1088 Ft.:] Noeseetro Metro Average funding per patieLt (in dollars) SOURCE: Office oflheimolopy Assessment, 1990. Data from P. Kraloyek Rural $69 $60 $65 $60 Hospital Data Center. Ameffean Hospital Associatien, ChkagO, Urvari 55 77 81 80 IL, personal communication, April 1990. NOTE. Definitions used by U.S. Department of Health South Central, and West South Central census and Human Services reoional offices to iden- regions accounted for 70 percent of all rural closures. tify CEOs as rural or urban approximate a center's location in either a nonmetropoii - Texas led all States with nine rural hospital closures tan or metropolitan area . (382). °Number varies s 1 ightly from reported figures of the U.S. Publi c Health Service . Rural hospitals that closed in 1987 had signifi- SOURCE . R. Berner, ,rmpatt of Federal Ewalt° Cei e cantly lower occupancy rries than both dosed urban :olicy in Rural Areas Empirical Evidence hospitals and all open facilities (table 5-37).29 In Prom the Literature" The _Journal of Rural Health 4 (2) :13-27, July 1988. interviews with State and local officials familiar with the closed facilities, factors most often related specialized hospital (e.g., a psycluatra. fainiity)or to closure for both rural and urban hospitals were converted to another type of health care facib..y (e.g.. declidng occupancy a, d the esuking deein es in nursing home or ambulatory care clinic) (178). revenue and increases in per-case costs (692).30 One-half of all rural hospitals that dosed in 1987 had Receiving urban PPS payment raks would have reopened as some kind of health care fat-day by May increased revenue and Lelped some of the closed 1989 (see table 5-37) (692). At least one new rural hospitals, but the closed hospitals as a group would hospital opened in 1988 (178). still ha, e had negative total ho pital and Medicare operating margins (694). Characteristics of Closed Hospitals In a survey of 29 administrators of rural hospitals The typical recently closed rural hospital is small, that dosed in 1987, competition from other hospitals for-profit, and located in the South. All of the 40 was cited as a key factor in closure by nearly 70 rural hospitals that closed in 1987, for example, had percent (table 5-38) (33). A study of rural hospitals fewer than 200 beds; 65 percent of them had fewer for the period 1980 through 1987 found that dosed than 50 beds. For-profit hospitals accounted for 40 rural hospitals were more often located in counties percent of closed facilities in that year, compared with many other hospitals and high ratios of hospital with 35 percent for private nonprofit hospitals and beds to population 009). Closed hospitals had also 25 percent for government-owned hospitals (33). In offered fewer servii.es, had had proportionately 1988, rural hospitals in the South Atlantic, East more long-term care units, and were more likely to vats report defined closed facilities as those ao loops prmilaggeneial, Aun-terrao..eta iopeuent vivre Hu5pliala and ravening. and those mug* or sold to other hospitals in which the hospital remained open rip iwitte inpauem %.au *Om sadj.judcd. immeing in kweivaysturathan implied frorn ARA data. sSimilar characteristics were present for rwal hospitals closing in 1988 (693). 144 Health Care in Rural America Table 5-37Characteristics of Community Hospital Table 5-38Factors Related to Hospital Closure in Closures in 1987, by Hospital Location 1987as Reported by Nonmetropolitan Hospital Administrators', HonmetroMetro *Whet Percent reporting reporting Total hospitals closed° 37 32 Percent of all hospitals 1.5 1.2 Fewer admissions 28 96.6 Percent closed with under 50 beds... 76 47 Fewer days of care... 28 96.6 Occupancy rate (percent): Closed hospitals 21 30 Annual operating losses.. 25 86 2 All hospitals . 32 56 Competition from Average daily patient census other hospitals ..... 20 69.0 of closures 9.1 24.6 Reduced Lire of Percent of communities with medical staff...... IS 65.5 closed hospitals having: Lack of gen4rosity of Genera/ hospital within Medicaid program 13 44.8 20 miles 75 100 Lack o: competency of Emergency services within top management ..... 12 41 4 20 miles 78 100 Service cutbacks arising Current use of closed hospitalsb from Medicare PPSb.. 11 37 9 Humber reopened as hospital 4 4 Humber reopened as Employee cutbacks arising from Medicare PPO 10 34,5 lone-term cars facility 7 1 Humber reopened as Unprofitable ancillary out-patient services/clinic.... 4 12 services 10 34 5 Humber reopened as specialty Loss of key staff 10 34.5 treatment facility 3 3 Humber vacant 20 14 High numbers ot uninsured patients 9 31.0 aHospitals that stopped providing general, short- Total respondents.. 29 term, acute inpatient services in 1987. Hospitals closing and reopening, or merging or sold to other NOTE. Reasons reported by less than 30 percent of hospitals in 1987 are not Included. administrators are not listed. b AS of Nay 1909. Summ are greater than total number °Includes responses by 29 administrators closed duo to 8 of the 89 hospitals providing more bPPS 0 Prospective Payment System. than ono service as another healthcare facility. SOURCE. America, Hospital Association, Rural. Hostel.- SOURCE: U.S. Department of Health Jona Human tal Closure- Msnoement and (2.--mmunitv Im- Services, Office of Inspector General, plications (Chicago, IL: ADA. 198)) Hospital Closurel 1987, (Washington, DC: COG, May 1989). 25 of the 156 rural community hospitals closing be under for-profit ownership. Memberuhip inA from 1980 to 1987 were the only general hospitals m multihospital system was alsociated with a de- their respective countieJ.11 All so-calledmonop- creased risk of rural hospital closure (409). oly " closures were of hospitals with fewer than 100 eeds. Most of the hospitals were for-profit owned Impact of Hospsal Closures on Access to Care and had experienced marked declines in admissions Few generalizations can be made about the impact before they closed (252). of rural hospital closure on access to care by local residents. Although in most cases the counties of A study of hospital closures in 1987 found that the closed hospitals contain other alternative hospitals, nearest general hospital for one-fourth of the rural in some cases the closed hospital may have been the communities with closures was more than 20 miles only source of care for a large area. away, and residents in three of the communities with A study of hospital closures between 1980 and closures had to travc1 more than 30 miles for 1985 found that of the 85 rural counties with a inpatient care. However, even before the hospitals community hospital closing, 6 were left without a closed, many residents were already bypassmg their hospital of any kind (408). A recent study founu that local hospitals to use tither facihnes fur (Are 092). 310nly closures iLL tbe 48 contiguous States were included. Chapter 5Problems and Trends in Rural Health Services 145 A recent study of rural hospitals in Minnesota the closure of the hospital would hay .:. an overall judged 12 of the State's 95 small rural hospitals to positive benefit to the community. The) believ.-4 be "fmancially vulnerable," most had negative closure would reduce the ovenapply of 1.-4-ripital operating margins in each year from 1984 to 1987. be4is and the community 's reliance on outdated Five were held to be in imminent danger of closing. facilities (33). If all 12 hospitals were to close, the number of rural residents located more than 30 minutes from a Most small rural hospitals have low occupancy rates. Where more than one such hospital exists in a hospital would nearly double; about 5,800 residents community, closing one hospital may strengthen the would be more than 45 minutes from a hospital. position of the other(s). Closure can benefit the (Currently, about 19,000 rural Minnesota residents community as a whole by lowering costs at the in 14 counties must travel more than 30 minutes to remaining hospital(s) (through increased utiliza- reach the nearest hospital; fewer than 500 residents tion), and by enabling a sufficient patient base to must travel more than 45 minutes (391).) justify a more extensive array of services. Although In addition to longer distances to receivc aute studies of hospital use in the 1970s found minimal care, hospital closures often lead to concerns regaid cost savings resulting from hospital consolidation, ing: average hospital occupancy rates were higher at the time of these studies, and savings may be more likely Rapid access to critical emergency and obstetric careThirteen of twenty-nine administrators today (382). of closed hospitals believed that community In some cases, howe' er, use of aaother hospital by residents needing trauma cate would have residents pre% iously .en ed by a closed hospital may greater problems receiving this service (33). not lower health ca.e costs. if the alternative hospital Residents in eight of the rural communities provides more costly care than the :losed hospital with hospitals closing in 1987 had to trar el (e.g., if it is an urban hospital with high inpatient mole than 20 miles for emergency care, al- costs and receiving high payment rates), system though all had available emergency transport costs may not decrease (382). services. In only one of the eight towns was ambulance travel time more than 30 minutes Even where hospitals have low utilization, there (692). is a trade-off between health system cost savings * Maintaining access fer the low-income and less through service consolidation and cost increases mobqe elder.-Nearly three-fourths of sur- associated with reduced access to care. The trade-off becomes more critical as the distance of alternative veyed admuusors felt that closure would hospitals from closing hospitals increases. If pa- increase probleii.if access to hospital care for elderly patients; 35 percent believed that access tients forego vital care because the source of acute care is inconveniently located, if they postpone care would be impaired for many low-income per- until their health problems are more expensive to sors (33). The ability of communities to attract and treat, and if transportation and opportunity costs of reaching the new source of care are high, neither maintain physicians and other providersForty- system costs nor community health may benefit one percent of the administrators believed that some community physicians would relocate from hospital closure. due to closure (33). Unfamiliarity with quality of care at remaining Closure of Primary Care Fecilities or alternative facilities. Little is known about closures of primary care facilities, although some data for the 1980s are Efficiency of Hospital Closures available. The number of federally supported CHCs in rural areas has declined in recent years. From It is by no means clear that hospital closures are 1984 to 1988. 75 CHC grantees closed and 51 always undesirable. Hospitals may be in fmancial opened (table 5 39). Most closures ot-t-urred in 1985 distress because they provide poor quality care, or and 1986 during an acthe time foi mergers of because there are more hospitals than a community centers. Both acth ities may hare bc.en affluent.ed by needs or can support. Thirty-one percent of surveyed Federal policies that w ere Intended to enhanc.- administrators of rural hospitals closing in 1987 felt affiliatauns among CHCs and other pry% Wets a.id /' n Table 5-39Changes In Rural Z.'ommunity Health 4ii9, and no new providers were expected to locate Center Grantszs: Mergers, Closures, and in these towns soon (103). New Starts, ;984-88 POPULATION MOBILITY AND Hew Wont Yeara Mergers4 Closuresa startsd private° Total ACCESS TO CARE 1984 1 14 12 0 27 Patient Outmigraaon ioes 12 15 7 0 34 I986 21 31 18 0 70 Regardless of whether local hospitals or clinics 1987 8 11 11 0 30 1988 2 4 f 3 2 11 have closed, many rural residents have already TOTAL 44 75 51 2 172 decided to leave their local communities to obtain some or all needed services. Such action may be NOTE: Definitions used by U.S Department of Health either for the purpose of receiving care locally and Human Services regional offices to identify CHCs as rural approximate a center s unavailable (e.g., highly sophisticated tertiary care), location in a nonmetropolitan Aires. or because residents choose not to use local services. aFederal fiscal year. A few studies have attempted to document this bYhose merging with another CRC. !Those closing or phasing out operations. "outmigration" for hospital services in ntral areas. 'Hew CHCs beginning operations that year. A 1988 study examining the patient travel pat- °Those choosing to relinquish Federal suppnrt and be- come private. terns of Medicare beneficiaries in rural areas sug- fIncluding i that phased out to become part of a hos- gests that a significant number of patients relied on pital. out-of-area institutions for inpatient care. The study SOURCE: E. Sullivan. Bureau of Health Care Deliver/ and Assistance, Health Resources and Ser- compared rural hospitals' actual share of the number vices Administration, U S. Department of of Medicare residents in their maiket area who Health and Human Services, Rockville, MD, obtained care at any hospital. Whea a very nurow personal coemunication, January 1989. defmition of a hospital's market area was used,32 64 percent of all Tara hospitals provided at least improve center efficiency (585). No information is one-half of the total mpatient discharges of Medicare available on the areas where xural CHCs closed, or patients residing in their market area. Just 7 percent the reasons for closure. of ntral hospitals (195) provided as much as 75 A study of nurse practitioner and phys,"lan percent of the inpatient care used by Medicare patients from their narrow markei area. When the assistant (NP/PA) satellite centers established m the widest market area definition was used, turd hospi- 1970s suggests that some of the reasons for closure tals' market shares were smaller; only 46 percent of of primary care facilities may have changed over rural hospitals provided at least one-half of the time. In a national sample of 44 rural NP/PA satellite inpatient discharge.; of area Mediare patients, For centers surveyed between 1975 and 1985, 12 had the most isolated hospitalsthose that were 50 ceased to function, leaving their communities with- miles or more from the nearest hospital or were often out immediate sources of primary care. Of the eight inaccessible due to seasonal weather conditions centers that closed before 1979, reasons given for market shares were still surprisi-';mall. Using closure included poor fmancial management, death the widest market defmition, fey ..,an 6 percent of of the backup physician, relocation of the town's these hospitals delivered as much as 75 percent of major employer, the center's purchase by a physi- the inpatient care of area Medicare beneficiaries cian who later left the area, and establishment of a (589). new, physician-staffed clinic nearby. The average population of these communities (in 1980) was A New York study of travel patterns for inpatient 1,960, yet by 1984, physician practices had located care by rural res,dents dunng 1983 found that 71 in all of them. For the four centeis that closed after percent of all hospitalizations of ruraliesidents were 1979, however, the Major reason given was low in the patients' own county (table 5-40). The oldest service utilization. The average local population w as rural residents were the least likely to travel for care. nThe narrowest definition of a hospites market arca inaattod only the Zr ..odcs am -cat the ho5paa6 aad hum Mash thc haanscs drew at least 50pmeent oftheir Medicare patients The widest definition included ZIP ..odes from alma Me huspiud drew at kast ;5 percent ot as Medic= paacati. P Chapter 5Problems and Trends m Rural Health Services 147 Table 5-40Sources of Inpatient tare for Rural Residents in New York State, 1983 noumetro hospitals Nonmetro MC.ro out of hospitals, hospitals county in county Ail nonmetro patients: Percent of discharges...19.3 9.7 70.9 Percent of days 22.3 9.1 68.7 Nonmetro patients over age 75: Percent of discharges 10.2 8.0 81.7 SOURCES M. Merits, "Rural Hospitals, U.S. Congress, Congressional Research Service, Washington, DC, no. 89-296 EFR, May 1989, and C. Hogan, -Patterns of Travel for Rural Individuals Hospitalized in New Yo State. Relationship Between Distance, ,s- tination and Case Mix.' Journal of Rural Health 4(14 29-41, Julyisee 10' 82 percent received care in their home county. PhotooraltAturemmon Nearly two-thirds of all those who left their own Poorroad °amnions in rural areas eon lengthen travei county for inpatient care traveled to urban hospitals limes to health care facilities. (265). Rural hospitals in New York have an abnor- mally high occupancy rate (84 percent in 1983, arm, but 90 percent would migrate elsewhere for compared with 66 percent for rural hospitals naCon - cancer care (237). Similar usage patterns were ally), so these outmigration rates are probably lower observed in a recent five-State study that found thai than would be found in other States (382). most rural Medicare beneficiaries needing special- ized "high-tech" care traveled to urban hospitals Results of a survey of households in the service (134). areas of f;ix niral Washington hospitals likewise suggest that there are different outmigration patterns Geographi... Limitation3 to AcceA3 to Care for different segments of the population. In this stu-i!', higher income households with private inbur- Time and Distance Between Hospitals ance we, e more likely than other households to leave their local community fcr hospitalization (table Geographical accev* to health care remains a critical issue in many rural areas. In one study that 5-41) (237). examined distances and travel times between rural hospitals, 84 percent of all rural hospitals were Of those surveyed that had used a hospital outside wilin 30 road miles of a ne;ghboring hospital (table their rural community, a large proportion (ranging 5-42). Only 86 rural hospitals (3 percent) were more from 41 to 63 percent) stated that the service they than 50 road miles from the nearest hospital. The needed was unavailable in their local hospital. A Mountain region, with its rugged terrain and low simihr proporeon of respondents stated that they population density, was a clear exception to national had been referred to the nonlocal hospital either by averages; fewer than one-half of rural hospitals in a local or nonlocal physician. Resident? use of a that region were within "a0 road miles of therearest local physician was also associated with increased alternative hospital. Of the 39 percent of all iural likelihood of using a local facility. When asked hospitals that were thc sole hospitalsin their whether they would use the local hospital for counties, nearly 70 percent were less than 30 road spiNific medical conditions, respondents indicated miles from the nearest hospital (589). less willingness to use the local hospital for more apparently complex services. Only one-fourth would Travel time is often ..unsidered WI= indKatur not use the local hospital for the care of a broken of distance between hospitals than road mileage, ti UM, 541-Household Characteristics for "Community C'' by HospitalUtilization Experience, 1984145 BOtOttal Ulilizatinn Local Local and Nonlocal Househed hospital nonlocal hospital Not characteristics only hospital only hospitalized Overall Income $25,000 or more (percept) 21.6 28 2 35.9 24.4 26.3 All meMbers 60 years old or older (percent) 26.1 26.5 20.7 24.7 24.5 Private insurance is xpected principal hospital peyer (percent)11 44.3 44 9 55.0 45.4 46.8 Less then 30 minutes from local hospital (percent)b 87.9 91.0 70.5 80.1 80.0 More then 10 years living in community (percent) 58.8 57.1 62.2 57 2 58.4 Personal physician status (percent): Local personal physitien 79.9 74.3 34.3 56.8 59.5 Nonlocal Personal physician 11.6 6,6 11.1 22.4 16.4 No personal physician 8.5 19.1 54 5 20.8 24.1 NuMber of respondents 228 136 203 596 1,139 (percent of households) 20.0 11.9 17.8 52.3 100.0 NOTE: "Community C" refcrs to one of the rural communities in Washington included in a study of rural hospital utilization. !Response is for the respondent but is utilized as a proxy tor the household, 'Tata are from "Community E.These data are typical of all the communities except "Community C where there were no meaningful differences. SOURCE: G. Hart et el., Rurat_Toarital Utilization. Who StaYs end Who Goes' Rural Health Working Paper Series. 1(2), WART Rural Health Research Center, University of Washington School of Medicine (Seattle, WA: March 1989). Table 542-Regional Differences in Distances From Nonmatropolitan Hospitals to theNearest Hospital Road miles to nearest hosoital Total Less than 20-29 30-39 40-49 50 or more nonmetro Census region 20 miles° miles mites miles miles hospitals New England 49 21 8 4 3 85 Mid Atlantic 69 30 5 2 0 106 South Atlantic 225 98 25 12 1 361 East North Central 263 78 18 4 2 365 East South Central 233 74 20 2 0 329 West North Central 300 211 64 14 9 598 Weat South Central 261 1..8 35 11 4 459 Mountain 68 47 62 33 50 260 Pacific 86 21 15 8 t7 147 Total 1,554 728 252 90 86 2,710 NOTE: Distances are approximately those from one hospital to the nearest hospital Hospitals aro those included in the 1984 American Hospital Association's Annual Survey of Hospitals °Includes all hospitals less than 15 "crow-fly" miles t.o the nearest hospital These hospitals are all assumed to be less than 20 road miles from the nearest hospital SOURCE: Systemetrics/McGraw Hill, "Small Isolated Rural Hospitals Alternative Criteria for Identification in Comparison with Current Sole Community Hospitals," contract reo6rt prepared for the Prospective Payment Assessment Commission, Washington. DC, June 1988. Chapter 5Problems and Trends in Rural Health Services 149 Table 5-43Travel Time to Nearest Hospital for Table 544Travel Time and Distance to Nearest NOnmetropolitan Hospitals That Are More Than 15 Hospital for Nonmetropolitan Hospitals More Than "Crow Fly" Miles From the Nearest Hospital, 1984* Twenty-Five Miles From the Nearest Hospital, 19840 Travel time to Number of hospitals more Mean Mean Mean nearest hospital than 15 "erow-fly" miles (minutes) from nearest hospital distance travel time Census resion (miles)speed (mph) (minutes) Less than 30 848 30-39 402 New England 38 42 55 Mid Atlantic 30 42 43 40-44 90 45-49 52 South Atlantic 32 43 45 48 50-54 45 East North Central....33 41 55-59 31 West Worth Central...,30 49 36 East South Central....32 52 37 60-09 87 90 or more 17 West South Central....32 51 37 Mountain 45 49 56 Total 1.572 14,ifie 44 47 57 National average 49 45 °Excludes three hospitals on islands. 36 SOURCE: prospective Payment Assessment Co:mission. °includes an estimated 700 hospitals. Taehnieal Appendices totheCaunission*s SOURCE' Prospective Payment Assessment Commission, March 1988 Report (Washington. DC: U.S. Technical Appendicesto the Commission's Government Printing Office. 1988), March 1988 Report (Washington. DC: U.S. Government Printing Office. 1988), because it may more accurately reflect actual trave: conditions and is a more relevant indicator of access Antisome have elected to drop their designaon (e.g., elapsed time en route in emergency situations). because the) have not found it financially advanta- In the above study, of the 42 percent of hospitals geous. There is little evidence that the criteria for more than 15 "crow fly" miles from the nearest pa) ing isolated rural hospitals have been sufikient hospital(589),over one-half were less than 30 to stabilize then fmancial condition (see p. 23), nor minutes from that hospital (table 5-43). Over 85 do the criteria appeir satisfactory in ensuring percent were less than 45 minutes from the closest accessibility to inpatient care and othersentices.34 hospital. For rural hospitals more than 25 road miles from the nearest hospital, there are extreme regional A 1988 study found that, by current SCH designa- differences in travel time to the closest hospital. tion criteria, most eligible hospitals were not desig- Rural hospitals in this category that were located in nated and most designated hospitals did not meet the the Mountain and Pacific regions had average travel times of about 56 minutes, whie travel times criteria. Using 1984 hospital data, the study found between rural hospitals in the West North Central that 211 rural hospitals were eligible for SCH status within thc continental United States based on the region averaged 36 minutes (table 5-44)(488). criteria (table 5-45). Of the 308 rural hospitals actually designated as SCHs, only 92 met the Sole Community Providers designation criteria, suggesting that most designated In some rural communities, a single facilityisthe hospitals may actually be within reasonable proxim sole source of locally available, hospital-level health it) of other hospitals (488). The current numbez of care. As of 1987, there were 367 Medicare- SCHs amounts to about 14 percent of rural h. pitals designated SCHs (see app. C), and the vast nlAiority (625)" If ail eligibles were designated, the numter were located in rural areas." Not ail rural hospitals of rural SCHs would expand from 308 tc or that qualify for SCH designation have applied for it, about 16 percent of all rural hospitals in 198 r k488). l'Some urban hospnals wee-gmadfathered inas sole utomanay lemma's at Mc ham thc at* pe) went system was arapicmcmcd. lain 1989. Coagross mama for quauftatum and paymcmt f SCHs Piibi Lie 101 :39met. kit. 3) It iowercd ape Onadrium444111064 thAt a SCH must be from anothet hospital ocrtainelleepUOIMwould bc woselemd), setpured that Ove.ciitkanui) zii.tia totLmAl iaaa.czfabCbe aud required Medicare payments to be more effectively matched to SCH costs 33Th1s percentage is based on the assumpuon that all of the 367 SCHs m 1987 were rural 150 Itsahh Care in Rural America Table 545Regional Distribution of Nonmetropolitan Hospitals by Sole Community hospital tSChi &anis, 1984 Elisible Eligible current not current All nonmetro SCR ellebles Current $CR SCR --150. hospitals Census region Nu:Aber Percent Number Percent NuMber Nweber Number Not England 29 13.2 22 7.1 14 15 85 Mid Atlantic . 17 7.3 I 0.3 NA 17 106 South Atlantic 9 3.6 19 6.2 2 7 361 East North Central 31 15.5 13 4.2 5 26 365 East South Central 3 1.8 i i 3.6 1 2 329 Vest North Contral 19 10.0 60 19.5 12 7 598 West South Central 10 5.0 24 7.8 3 7 459 Mountain 71 33.6 110 35.7 43 28 260 Pacific . 22 10.0 48 15.6 12 10 147 Total . 21 100.0 308 100.0 92 110 2,710 NOTE: EA v not applicable. SOURCE Prospective Payment Assessment Commission. Technical Appendices to the Commission's March 1988-ReR2rt (Washington. DC: U.S. Government Printing Office, 1988). Most currently designated SCHs are located in the social needs for hospital serv ices. It was iested West.36The South has relatively few, probably in only four States. because its rural hospitals are closex together (see The study concluded that relatively few rural facili- table 5-44) and are less affected by extreme weathex ties are physically remoie from other hospitals, conditions. As a result, neither eligible nor current SCHs appear to serve a significant number of although for other reasons (e.g., differences in low-income rural areas (which are predominant in community need and hospital services) other hospi- tals may also be irreplaceable health care facilities the South Atlantic and Central regions) (739). (739). This study also simulated the impact of four major Some rural conununity clinics are the sole provid- alternative eligibility criteria. These included: ers of primary care services to their communities; however, such status has not allowed them any Substituting travel time for road mileageA special protection by the Federal Government, 40-minute minimum travel time would add 197 Federally supported CHCs, and some rural clinks hospitals unable to meet the current 50-mile that receive State support in such States as North requimment, bringing the total designated SCHs Carolina and Chegoit, often serve remote communi- to 408. ties unable to atiraci and support full-time physician Using sole-county provider status as e measure practices or other health care providers. Little is of isolationIncluding so con= hospi- known about the extent and nature of these soie tals that are the sole providex in the county or community primary care facilities, or how critical are located 25 miles or40 minutes from another their presence is to preserving access in areas hospital would make a total of 1,224 rural afkcted by geographic isolation. hospitals eligible to be SCHs. Being located in a low-density frontier county Frontier Areas with 6 or fewer persons per square miie would People living in frontier areas, where the nearest qualify only 4 hospitals." health care facility may be a great distance away, are Serving Medicare beneficiaries in medically faced by special problems of physical access to underserved areasThis criterion is intended health care. Hospitals in frontier areas tend to be to measure mobility of the population and other small in number and apai-ity, and the supporting 1987.102 SCHs were locatedin howler areas, all in Ihewestern bdtf of die'Anion, Nearly 37Pm= of all lroatiot hospitals wore dont:lamed SOU(62$). ollio wither of hospitals ide_lcdb Ibis analysis .re c.onsalerablyfewerthan the number of Lspitais J. hAMIA iu by t,) lAanalyses onkeno areas (277 hospitals in areas with 6 or fewer persons per %pare mile) unoted.terltet. Chapter 5Proi Trends in Rural Health Services 151 Table 5-46 ':haracteristics of Four Frontier Hospitals Distance to nearest hospital next Level t care by sire 100 or Population Humber of Ownership and 50-100 100-200 more of county and Hospital licensed beds management beds beds beds density (1980 Allen Hemostat 38 County 108 miles 120 miles 210 miles 8,241 Hospital acute-careb Hospital 2,2 persons per Moab. UT District square mile Garfield Memorisi 20 Intermountain 0 110 miles 200 ml s 3.873 Hospitei acute-careb Health Care 7 persons per Panguitch, UT (nonprofit multi- square mil.* hospital system) Hy* General 21 acute-care; County 120 miles 210 miles 210 miles 9,048 Hospital 24 lon8-term Hospital 5 persons per Tonopith, KV care District square mile William Bee Rirto 43 County 189 miles 250 miLos 250 miles 8,167 Hospital acute-carob Hospital .9 persons per ELY. OV District square mile *Those Located in counties with Less than six persons per square mile bParticipates in swing-bedrigram. SOURCE: D. BerrY et al. "Foutier Hospitals Endangered Species and Public Colicy Issue. Hospital anll fiealth Services Aministration 33(4) 481-498, Wintel. 1988 population is sparse and sometimes widespread. 5-47), about 7 percent of al rut al CHIC service sites Berry et al, exAmined characteristics of four frontizr (585).10No data are avaiLble un the population base hospitals in two States, including distances to the of these centers or alternative sources of primary nearest hospita1.38 Fot three of the four facilities (all ;re in the areas they sene. As noteti eer her, some with fewer than 50 bed:), the nearest hospital of zny CHCs serving v ery sparse, is ulated populations need size was 108 miles away (table 5-46). Larger substantial ongoing subsidies tobUITIVC.However, hospitals (with 200 or more beds), likely to provide many of the operating requirements important to more secondary and tertiary kvels of inpatient care, receiving vital Federal funding (e.g., minimum were at least 200 miles from any of the four frontra phy sician productiv ity stanJards) are difficult to hospitals. The authors noted that, giv en the facih- meet fcr some frontier centers, possibly limiting ties' frontier location, travel to the nearest hospital gant support And their ove-all development (see 4.11. may be affect'd by poor road conditions and natural 7). (In 1988, congressiunal reauthurizition of le barriers as well as by distance. The three county- CHC program re4uired that special consideration be affdiateti hospitaisall sole providers of hospital given to supporting CHCs in fr. -diet oreas (Public care and two located in counties with population Law 100-386)) densities of less than one person per square mile-- were all experiencing fmancial problems and low SUMMARY OF FINDINGS occupancy (89). Rural Commuuity Hospitals As with hospitals, C Cs require a sufficient Most rural hospitals are small ( nearly three- population to support therna problem in many fourths have ..sv..r than 100 beds) and nonpr Rt. frontier areas. In 1989, there were 59 federally In 1988, they rcti...sented 16 percent cf all commu- supported CHC delivery sites in frontier areas (table nity hospitals. About 14 percent of annual huspitals %%The cLarsetenstics of these bospuab, itisluding their &manse frur.. odes hospitals.Aft oul typivgi uftrouper hospitals in gam ai wIlus figure represents the nutnicr of federally funde C1:C sets h,e di ery s les In frontier areas. nut the 20-61d 0 - - 6 01.3 1 c 152 Health Care in Rural America Table 5-47Federally Funded Community Health By1988, one-half of all hospital surgery was done Center Service Sites Located In Frontier Areas' on an outpatient basis; over 90 percent of all by State, 1989 hospitals in 1987 performed ambulatory surgery. Also in 1987, of the 25 percent of hospitals that bad Number of frontier States health cen a separate long-term care unit, long-term care beds constituted nearly one-half of total hospital beds. Colorado. 8 Frontier hospitals as a group had more long-term Idaho 8 care units (40 percent) and less ambulatory surgery Nevada.... 6 (77 per.ent) than other rural hospitals. Anecdotal texas ...... 6 South Dakota. b infomiation indicates that competition is increasing Montana, 4 between rural and urban providers and locally New Mexico .. 4 Utah 4 among hospitals, physicians, and other providers. Oregon 3 Washington 3 As inpatient demand has declined, the receipt of Minn* -ca... 2 revenue has become more of a problem. From 1984 Wyoming.. 2 to 1987, uncompensated care delivered by mral Arizona.. .. 1 hospitals rose over 26 percent (increasing faster for California . . 1 North Dakota 1 smaller facilities), averaging over $0.5 million per New York 1 hospital in 1987. Average Medicare payments, Total... 59 which make up over 40 percent of patient revenue, NOTE Number of community health centers indicate were actually slightly lower than average costs in the total number of eruct,: service sites. in- 19874° in rural hospitals. Although they represent cluding federally funded grentals only about 9 percent of patient revenue, Medicaid &Frontier Ls defined as counties with six or fewer payments are often significantly below related costs. persons per square mile bIncluding 1 site transferred to the Indian Heaith In addition, as outpatient services (e.g., ambulatory Service in December 1989 surgery)have increased, hospitals (especially smaller SOURCE E Sullivan, Bureau of Health Care Delive.y facilities) have become more dependent on outpa- and Assistance, Health Resoorces and Ser- tient revenue, leading to concern over proposed vices Administration. U S Department of Health and Human Services. Rockville. MD, future changes in payments for these services. personal communication. April 1989 Total expenses have risen faster than total reve- aues (the smallest hospitals show the largest g were designated SCHs in 1987; hoppitals located in leading to the decline in both patient and total frontier areas represented 11 percent" of 211 rural hospital operating margins. By 1987, nearly all hospitals and were smaller than other..ural hospitals rural hospitals had negative patient margins; those (two-thirds had fewer than 50 beds). with under 50 beds also suffered negative total margins. From 1984 to 1988, inpatient admissions in rurl hospitals dropped 21 percent (compared with less Rural Community Health Centers than 8 percent for urban hospital:). By 1987, The number of CHC grantees fell 20 percent from inpatient occupancy levels were around 50 percent 1984 to 1%8, varying widely across :egions, al- for all rural hospitals, becoming smaller zs hospi- tal size decreased (31 percent for hospitals with though the number of total CHC service sites under 25 beds). Hospitals in tronuer areas had remained relatively unchanged In 1988, rural grant- ees made up 61 percent of all CHCs. From 1984 to significantly fewer admissions and numbers of staff 1988. patient visas to rural CHCs rose nearly 19 physicians than other similar-sized rural hospitals. percent, again showing significant regional differ- ences. Rural hospitals are providing increased amouli:. of outpatient and long.term rare services. From Most of the increase in CHC utilization appears 1984 to 1988, outpatient visits increased about 34 to be for under. and uncompensa:ed care. In 1987, percent (compared to 26 percent for urban hospitals). one-half of all CHC users reLeived disteunted one actual penod of Om° is bospnals' fourth year under Medicare's prospective payment systau Chapter ,5Problems and Trends in Rural Health Services 153 care. Increasingly, CHCs are deriving more e their "Outinigrationfor hospital cLre appears to be revenue from Medicaid patients and less from increasing among rural residents (even in isolated private pay patients. They also remain heavily communities with local hospitals), although the full dependent on Federal grant funds (which make up extent and nature of this trend is not well understood. nearly one-half of total revenue). Total expenses Outmigration is occurring because either specialized have also increased faster than total revenue, nearly care is unavailable locally or :esidents choose not to eliminating by 1988 any positive total operating use locally available services. margins for the average center. Local health departments (LHDs) in rural areas Most rural hospitals are within close physical are thought to be a valuable source of basic health proximity (in terms of road miles and travel time) of services for many residents. However, little; s another hospital, but extreme regional differences known about the numbers and operating charactens . tics of rural LHDs. exist. Hospitals are much farther apart in less densely populated areas of the western part of the Access to Care country. Most of the 367 designated SCHs are By 1986, the ratio of community hospital beds to located L- the estern half of the Nation (102 are in popula.tion was about the same overall in ural and frontier areas there). Only about 30 percent of all urban aie .In 14 States, bed-to-population rhtios design. ^ed hospitals meet current SCH criteria. were highel in rural areas. Closures of financially tmubled rural hospitals In summary, major changes in the volume of have increased; over twice as many closed m 1989 services provided, coupled with substantial in- as in 1985. Most of the recent closures have been of creases in the delivery of uncompensated care, have small facilities with low icpatien, utilization and been contributors to the rising fmancial vulnerability occupancy, and most communities of closed hosp, of many rural hospitals and CHCs. Physical access tals appear to have reasonable access to emergeny to bask primary and nospital aie remains a problem and acute care. A few closures, however, ha% e been in mar.y nealareas,particularly in less dens.ely in communities with no local alternatives. populated communities. (i Chapter 6 Short- and Long-Term Strategies for Effective Change by Rural Providers 1 CONTENTS 1 Page INTRODUCTION 157 SHORT-TERM STRATEGIES 157 Local Flindiaising 157 Cost Containment 158 1 Ibugher Billing and Collection Practices 159 Strategic Planning 159 Marketing and Public Relations 161) Improved Leadership and Management 160 LONGER TERM APPROACHES 161 Hospital Conversion 162 Hospital Diversification 162 Primary Care Facility Diversification 168 Hospital Cooperatives 169 Alliances Between Primary Care Providers 172 Mull 'hospital Systems 173 Local Hospital Mergets and Agreements 175 Hospital-Physician Agreements 176 SUMMARY OF FINDIMS 177 Boxes Box Page 6-A. Example of Local Fundraising 157 6-B. Three Examples of Marketing/Public Relations Efforts 160 6-C. Example of Successful Short-Term Management 161 6-D. Two Examples of Hospital Conversions 163 6a. Example of Hospital Diversificatica. 16.4 6-F. Example of Hospital Diversification Into Primary Care 167 6-G. Four Examples of Rural Primary Care Networks 168 6-H. Three Examples of Hospital Cooperatives 170 6-L An Example of a Rural-Urban Hospital Alliance 171 6-J. Seven Examples of Primary Care Alliances 174 6-K. Two Examples of Muldhospital Systems 175 6-L. Example of a Local Hospital Merger 176 Figure Figure ?age 6-1. Nunter of Medicare-Certified Swing Bed Hospitals. by Census Region and State. 1987... 166 Tables Table Page 6-1. Community Hospitals With Medicare-Cenified Swing Beds, 1987 . 165 6-2. Descriptive Characteristics of Rural 14ospital Consortia 171 6 3. Nonmersopolitan Hospitals Under 300 Beds in Alliances by Bcd Size and Ownership. 1987 172 6-4. Ibtal Expenses.... per Hospital by Nonmet i.eolnan Hospitals in Multiho..pital Systems and Alliarees, 1987. 172 6-5. Nonmeut,.itan Hospitals Under 300 Beds in Mulutospital Systems by Bed Size and Ownership, 1987 176 1 "'Fi Chapter 6 Short- and Long-Term Strategies for Effective Change by Rural Providers INTRODUCTION Establishing endowments is another strategy to raise ongoing funds. F^r example, Copley Hospital, The current problems for rural health care facili a 50-bed nonprofit fJity in Morrisville, Vermont, ties and services are varied and complex, and the in 1988 resolved to raise a $5 million endowment for prognosis for rural health care delivery seems maintaining the provision of adequate indigent care uncertain at best. The difficulties rural hospitals and helping with its capital needs (186). In addition face, for example, are not limited to immediate to providing some financial benefits to local donors, concerns such as declining inpatient demand and endowments and other planned giving arrangements increases in uncompensated care. Rural hospitals may enhance the hospital's reputation in the com- must also find ways to redirect their services to meet munity. evolving community needs and changing environ- mental realities. This chapter will discuss ap- proaches mral hospitals and primary care facilities Hospitals are not the only focus of fundraising have taken to altering or expanding their missions, efforts in rural communities. South Gilliam County, both in the short term to strengthen operations and Oregon, for example, has created a health district community support, and inthe longer term to fund in cooperation with a local foundation to accept restructure the organization and delivery of services. private donations for primary health care projects in the district. Donations may also be earmarked for SHORT-TERM STRATEGIES specific health needs (e.g., ambulances) (314). Local Fundraising' Box 64Example of Local Fundraising Local fundraising has historically been a major source of capital to fmance construction and renova- Hall County Hospital, a 42-bed facility in the tion of rural health facilities. By one estimate, 40 small town of Memphis, Texas, nearly closed in 1988. Two of the thre physicians on me hospital percent of cash donations garnered throagh fundrais- staff had receney ceased practicing, and patients ing by rural and urban hospitals in 1988 were -.gan migrating 90 miles north to Amanllo for earmarked for construction, renovation and equip- most of their care. Sigaificant declines en patients ment purchases (80). A 1989 national survey found and revenues could not he offset through loal tax that more than 30 percent cf responding individuals increases because the 4-emmuntty WAS already eaxed had contributed to hospitals or other health :are at the full legal levy to support the hospital. Instead, organizatioas (mud and tuban) within the preuuus the town uf 3,000 raised aboat $400,000 to maintain 2 years, and the great majonty uf these were 1gu1ar hospital :rations. Memphis' residents had differ donors (566). ing opinions on how to address the hospital's problem, and many were weary of spending large For some hospitals, fundraising is an important tams of money on the hospital. The fund drive to source of capital for longe r. term investments. For save the hospital appeared to re%e and reunite the others, however, al donations and philanthrop) ummunny. Local school rallies ar,d suppon from are needed simply to sustain immediate operattons. passing trekkers helped to Luse ihe money er 3 There is considerable uncertainty whether hospitals months, kaving the hospital about $100,000 short in severe fmancial crises have all the necessary of the $500.000 needed and the necessity of still elements to survive effectively beyond the receipt r :tailing two physicians Local officials acknowl- eaged that unlegs the town could find the two and use of such .4 'bail-out" funds (see box 6-A). phycicians, the hospital's survival remains in doubt Success may be contingent on bow well these (79). resources arc spent on ->lanning for and ensuring future needs. 'Local Lax support ts another major source of nonp mem revenue for !Kalil) tare facilmes (see ell 8) -457 payment system, the number of FTE employees in rural hospitals dropped by 7.7 percent between 1983 and 1985 alone (31). Rural hospitals also increased their use of part-time staff to enhance their staffing flexibility. In recent yearS, the numbers of FTE staff per hospital have actually increased. Possible rea- sons for the increase include more severely ill patients, the growth in outpatient care and swing bed services, and longer lengths of stay (31,462). A few rural hospitals, however, have continued to improve staff efficiencies. Some successful strate- gies include: planning staff size and workloads according to expected daily work volume. emphasizing cross-training and cross-utilization of employees to do nondinical tasks, combining departments (e.g., housekeeping and engineering) tofacilitate flexibilityin staffing, and iderl.ifying appropnate uses of outside contract services for both clinical and administrative functions (203). In 1988, for example. the new administrator of a 75-bed hospital in Columbus, North Carolina ap- plied some of these strategies to lay off 10 full-time employees (a 6 percent rzduction in staff). Other expenses were rcduced and patient fees increased, ..reaing a net intotoe of $735.000 for the hospital in 1988. compared to a net loss in 1987 of $358.000 k3o1) Pho0 croc* tlari Mooney Many community health centers (CHCs) have ako had to find ways to further reduce costs. As Even the .Tmaticst doriabons can 'ielp mai hospitals struggling to survive, and tundraise s ca: rehect a strong noted in chapter 5. increased use by patients who desire by the connnunity to keep their hcspital open casinot pay for care has lowered collections in many rural CHCs. A recent survey of these centers found Cost Containment that most reported loteering operating costs through imposing personnel hiruig freezes and layoffs, Excess capacity. small size, and unexpected eliminating staff education programs. and reducing variations in utilization cal make cost reduction; supply order.,. Some said they were forced to difficult to achieve in many rural hospitals. One eliminate t ert am .serv ices 4ltocther it. r.denn.1 and common strategy for lowering costs has been ta pUrinacy services} (304 reduce staff. From 1980 to 1987. rural hospitals reduced the number .ull-tirne eqiuvalent (FTE) The cuts made by some CHCs te ensure survival staff by 9 per;ent. while urban hospital staffing have becn drastitt . A CHC in rural Maryland, for actually increased 14 percent. Both rural and urban example. viras forced into bankruptcy in the early hospitals had a decline in labor costs as a percentage 1980s. Facing pre-tnes from 'some 906 creditors, a of total costs (382). new adnunisi;r closed three lamilite clinics, reduced staft irom 100 to 25, and kmeted sahries. Much of the staff reduttion took plat t: umnedi- The 4.entcr has rem.uned ink pet cition. rlytt.on ately after the inception of the Meditate pro,fettA State and lot .d giants in ,leadot redera:fantline. and 7i) Chapter 6Short- and Long-Term Strategies for Effective Change by Rural Providers 159 was due to make its final payment on the $1.4 untici the scale, and enforcing stronger collection million bankruptcy decision in 1989 (108). procedures on self-pay balances (307). Tougher Billing and Collection Practices Strategic Planning Hospitals appear to be increasingly aware of how Rural hospitals, particularly small hospitals, may improved billing and collection activity can enhance often view planning either as a luxury or a burden. critical cash flow. Hospitals and clinics can affect It is clear now to many rural providers, however, that delays in billing and payment by methods such as: they must find the means to reexamine their mis- sions and roles and improve their capacity to solve submitting correct or "clean" claims to third- problems. party payers in a timely manner, reducing the number of improperly submitted claims re- One example of efforts to improve the ability of turned to the hospital for reprocessing; rura hospitals to engage in such planning is the WAM9 Rural Hospital Project at the University of reducing the delay in assigning fmal diagnoses Washington. With funds from the Kellogg Founda- and completing patient charts; tion, WAMI recently assisted several rural commu- increasing the number of patients paying their runes and their owspitals to develop and implement bill at the time of service; and a range of strategic planning activities. In Tonasket, reducing the number of patients who incor- Washmgton, foi example, the Project worked in rectly do not receive a bill. partnership with the community and its 22-bed In order to streamline the billing and collection hospital to determine the area's major health care process, one rural hospital put a single individual in sys' -m problems by doing area demographic pro- charge of registration, billing, discharge, and medi- files, community need assessments, and reviews of cal records. Another hospital assigned a star mem- hospital operations. Tonasket was experiencing a ber to the task of ensuring that nurse and physician depressed economy, substantial patient outmigra- notes are properly recorded in advance of patient non. and persistent physician shortages. The hospi- discharge. A third hospital trained staff to encourage tal suffered from negative operating margins, the payment before patients leave the hospital, resulting highest percentage of uncompensated care of any in 12 percent of collections made before the patients ' hospital in Washington, weak management exper- discharge (431). tise, and patient dissatisfaction. The projeftt facili- tated the development of community teams to clarify Some hospitals are establishing inhouse goals and establish trust through open communkation tion agencies in order io colket a higher proportion and conflict resolution, and to initiate community of bills, eliminate commission costs, and improve leadership and slull buildmi, efforts to plan w ays to access to account information. A rural South Caro- soh e identified problem& Specifii. plans were made lina hospital's inhouse agency has collected 22 for the It tspital to lower costs. increase revenues. percent of its bad debt (about $200,000 a year) that recruit physicians, market and diversify its serv ices. otherwise was uncollectible. When the hospital used and restructure its board. Within 3 y ears. North All outside firm, it recovered only about 10 percent Valley Hospital began show ins income from opera, annually, and 40 percent of this amount was lost in lions (45). commission costs (432). Some hospital associations have ako been eir Some CHCs have also changed their collection phasizing support for stratega i.planning among practices in response to the grow mg demand for care small and rnal hospitals. In North Carolina. the by the medically indigent. About 42 percent of hospital association, w ith support from A piiv ate recently surveyed centers reported that they were foundation, recently opted to make planning grants making changes designed to lower sliding fee use available to such facilitie& Of the 67 hospitals and improve collections. These changes included eligibleforparticipation. 55 were expected 10 increasing sliding fee scale eligibility and documenta- receive planning grams by the end of the projeu tion requirements, increasing the minimum fees paid 2Washingcon, Alaska, Montana, and Idaho ...... www.....PC,Mmeu....ny. 160 Health Care in Rural America Box 6-0Three Examples of Marketing/Public Relations Efforts Central Plains Regional HospitalFor hospitals in small towns, "word-of-mouth" and improved visibility can play aitical marketing roles. Central Plains, a 151-bed hosiiital in Plainview, Texas, -ecogntzed that a significarn number of its local residems were migrating w Lubbock, 45 miles away, for hospital services. Central Plains administrator decided to promote the institution's quality and convenience, espectally to senior citizens unwilling to travel frequently To do this, he joined local chapters of service orgaruzations and provided space at the hospital for their regular meetings, started an annual health fak, and provided health programs at senior cItizen centers. He also encouraged the local newspaper w print a regular colut..1 on hospstal services and activities, and he personally followed up with discharged patients to ask how they enjoyeti their hospital stay. He noted that these more personalized efforts appeared to have increased the local appeal of Central Plains over the last 3 years (17"). Mercy Medical CenterOther marketing efforts have attempted to expand .he awareness of a facdity's capability to a larger geographical area. Mercy Medical Center, in the isolated mountam community of Durango, Colorado (population 15,000), decided in 1987 to become more of a regional hospiul. Impetus came from its need to compete with the other hospital in town, a publk facility, for patients in an overbedded market. The 100-bed facility began to promote its 85-mysician medical staff, $1.7 million outpatient center, magnetic resonance imager, trauma center, and high-technology emergency aircraft to 120,000 residents living over 7,500 square miles in 4 States. The hospital used advertising to promote the hospital's expanded services and its picturesque mountain environment (243). Harts Health ClinicCHCs have also used marketing to successfidly improve community awareness and increase access to care A cerner in the small remote town of Harts, West Virginia, successfully used feature articles and announcements in the local weekly newspaper, open houses, speaking engagements at area civic clubs, and colorM brochures and banners to communicate the presence of new prov tders, equipment, and services. Clinic service utilization noticeably increased, apparently cournermg earlier community concerns about the lack of personal physician care and the lack of available needed services in the area (251). Rural CHCs can also benefit from strategic administrator was most commonly charged with the planning. The Public Health Service provided cate- marketing function, m contrast to urban hospitals gorical grants to many rural centers in the mid-1980s where such responsibilities are typically handled by to develop and implement plans to adapt to local a marketing director. The study also found a lack of changes 'and reduced Federal funding (585). No understandmg of markettng. and its importance. by known evaluation of the success of these planning trustee.; and management (MM. efforts has been performed to date. Marketing and Public Relations improved Leadership and Management Rural hospnals often ;offer from inexpencnced Many rural hospitals have tradmonally encoun- tered little compention by other facilittes and administrators and high management turnov er. Ac- cording to one report, the adminiMrawr turnover rate providers. These hospitals now mcreasingly face yeached 24 percent m 1986-87 among urban and declining inpatient demand, competition for patients rura' hospitals combined The hospitals w ith the from more aggressive rural and urban providers, and highest turnover have generally been small, and they poor community perceptions o. the extent and are more likely tc have experienced higher costs and quality of their services (see ch. 5). The consequence lower profits and admission rates thaa other hospi- is a renewed emphasis on marketing and public tals (607) Yet e cpertenced admtnistrators may be relations by many rural facilities (see box 6-13). unattracted to rtral hospitals because of lower A 1987 study of 476 small or rural hospitals by the salaries, and thus many rural institutions may have American Hospital Association (AHA) found that to accept untested or mediocre administrators UN). about 60 percent of the institutions were actively CHCs can also suffer if their admmtstrators are engaged . in marketing, with a heavy reliance on inexperienced. such Jdministiators may lack the image advertisements in newspapers (244). A re- time or sophistication to prepare Federal grant lated Audy in 1985 found that the rural hospital's applications and operations reports in a 4 attsfactory I. -1t 41 Chapter 6Shcrt- and Long-Term Strategies for Effective Change by Rural Providers 161 manner, potentially jeopardizing receipt of funds and center solvency. Box6-CExample of Succes$fal Short-Tern, Management Rural managers with small operating budgets and limited specialty staff may need to acquire for Trigg MeillOPial Hospi;a1.a 30-bed facility in themselves the skills needed for recruiting and lucumcari, New Mexico, was in critical financial condition in the mid-1980s. Demand for inpatient trimming staff, writing eervice plans, creating adver- care had dropped 16 percent a year for the 4 tising copy, and completing cost reports. Itis previous years and the hospital had accumulate4 a possible that more extensive management training $1 million deb,.. Staff morale was low and pahent enhances the ability of administrators to carry out dissatisfaction was high as a result of some budget such diverse tasks. One survey found that 53 percent cuts, for example, the management had discontin- of rural hospital administratois with bachelor's ued lmen service, and patients began k.anplaining degrees stated their hospital; were sound financially,, of having to dry themselves with paper towels. A compared with about 62 percent of those with new administrator, hired in 1985, found ways to master's degrees (361).3 reduce expenses without sacrificing patient satis- faction, made other operational improvements, and Governing boards also play a critical part in increased collections. He invested considerable hospital :lability, a factor recognized in seeral time in increasing community ack.eptance and communities. For example, with assistance from the support by attending chic ilub meetings, schedul- WAMI Rural Hospital Project, several rural mstim- ing hospital open hot ses, and speaking on local tions in Washington have implemented plans for radio talk shows By 1987, the hospiudWaS trustee education and development in order to showing a small profit. Some major capital im- increase thr; quality of leadership and teamwork provements, including replacing a boiler and water pipes, however, were still unrealized (258). (45). In the early 1980s, the Association of Western Hospitals Educational and Research Foundation. with support from the Kellogg Foundation, created 1. The reconfiguration of a facility's own serv- a 6-year program to improve management and ices, through: leadership skills in rural hospitals (see app. E). hospital con% ersion to some firm of non- Projects included a fellowship program to place acute care; recent graduates in health management into rural hospital diversification into new products or institutions, the use of retired healthcare executives services; and as consu'tants, an educational and development program for trustees, and a program to help form service expansion ..nd practice enhancement alliances between rural hospitals and local busi- by primary care centers. nesses. Evaluation of the experimental program The establishment of intennatituuonal rela- among participating rural hospitals found enthusias- tions and partnerships through. tic support (188). formation of consortia and alliances, main- An example of successful short-term management taming autonomy of the individual allied is shown in box 6C. institutions; and affiliations with other facilities, or a system LONGER TERM APPROACHES of facillies. that limit the control indiv idual institutions have over their operations. lb maintain or irviove their financial position. and to better sent lieir communities. rural health Lunited specific information exn.ts on these ap- care facilities may take actions that Inv ohe some proaches. and wh.0 does exist is larsely anei.dotal. change in their mission or the extent of their The following sections disuss some of the consider- autonomy. These actions fall into two general ations and risks of ea4. h approaa. and v.amples of categories: how they have been applied. nberebutonsinp between anainutustratot &Mononai tram:1g aaa ta.rspous operatiag pcittomea t.c.aki) al1l$ totJ., L., 4. V-"afkl boepitals may be more able to offer salines Mai attract admuustrators with higher degteeb 1t 162 lfealth Care in Rural America Hospital Conversion released to home or transferred to a hospital. However, current Federal and State regulationn still Low occupancy and shrinking markets halm usually iequire these facilities to be licensed as caused many rural hospitals to consider converting full-service acute-care hospitals and bear basic costs all or part of their service capacity to something associated with this designation (74). other than inpatient care. The additional threat of fmancial insolvency and closure may have forced Conveision does not necessarily eliminate the many hospitals to coasider conversion as a last problems faced by rural hospitals. State limits on the resort The final decision to convert, however, may addition of certain services and beds may prevent often be difficult mid very risky for rural hospitals. conversionitself. For example, Minnesota has Conversion may be an appropriate option when. recently had a statewide nursing home bed morato- rium (391).4 Also, State facility licensure laws the hospital core business has declined, and typically prevent the conversion of hospitals to additional markets caimot be found; "lower level" emergency treatment and stabiliza- certain resources (e.g., adequacy of the facility, tion facilities unprepared to abide by regular hospital ability to attract appropriate staff or physicians) licensure requirements. are limited; reimbursement for existing services is made- Obtaining the car/ital to cover the planning and quate, and reimbursement for new services constniction costs 'if converting an existing facility through cocversion appear to be more acct tad- may be difficult aud expensive. Legal fees, unem- ble; ployment compensation to displaced staff, and the the hospital is having trouble c.ovenng exisung payment of existing debts and obligations typically debts: must also be covered. The facility may need to the coaversion is targeted to a specific market recruit new staff or operational expertise (e.g., nurse population; thd aides for a long-term care unit who must undergo the hospital has a (..ontingency plan and avoids additional training and certification) (187). unnecessary risks (373). There is no information on the number and scope Common types of hospital conversions are trom of rural hospital conversions nationwide, but case exImples describing some of the range of experi- acute-6are inpatient to ambulatory care or long-term care facilities. For example, some rural hospitals ences are available (see box 6-D). have converted to comprehensive ambulatory care centers with capability to deliver some level of Hospital Diversification emergency care. Services might includt1 primary care, emergency care, basic laboratory and radiology Unlike conversion, in which part or 41 of a service, and outpatient surgery. Existing hospital hospital actually changes its mission and service structure, diversification involv es expanding into beds might support surgical recovery, emergency new services Diversification is commonly intended waiting, or adult day care services. Other hospitals may convert more simply to nonsurgical, diagnostic, to: or urgent care outpatient centers. Conversion to incrase the institution's revenue base, some form of long-term care facility may be a strengthen referral sources, especially attractive to some rural hospitals with enhance community image, excess acute care capacity and large elderly service develop more comprehensive services, and populations. limit excess capacity. Some small rural hospitals have already in effect Diversification, like conversion, carries many risks converted to short duration, medical observation and requires careful research and planning to avoid facilities or infmnaries. In these facilities, patients overexteadmg resources. Undersiandmg the market typically are held 24 to 48 hours for stabilization and demand for the proposed service, havir g a favorable observation by a physician or nurse, and then either reimbursement and regulatory env inment, know. 4Morrdotia on nursing home services by States may, m addition to inu1t.4.ing that then s yunently a suftment supply of such services. reflect the fact that state Medicaid budgets (the major payer of nuning home (Mel are already severel) yoristrained. and the Sums tom atford holm requests for nursing home Me payments. 1-11 2. Chapter 6Short- and Long-Terin Strategies for Effecnve Change I:, Rural Providers 163 Box 6-0Two Examples of Hovilal Conversions Warren General Hospital, a 37-bed public hospital in rural North Carolina plagued by debt, low occupancy rates, and an impev ensiled Patient base, decided to close in 1985. The corrununity feared that if sers ices ceased they would lose theu remaining phystc tan s and then km1) locahource of emergency care. In 1988, the community pa sed a bond referendum to raise the capital for the i-..onventon a the hosk:tal to a primary care center. They did so, nowevei, at the expense of other vital comniunity services, such as schools, that w ese also dependent on support from the county's eroding tax base. With coordinated suppon from the State and Federal Gov ernments, the community nas able to recnAt duet new physicians. The clinic currently is delivering primary care under the Joint direction of the county 's health department and a federally supported community health center (86,87). McGinnis Hospual, a 17-bed hospital in rural Pennsylvania, was struggling with declining inpatient utilization and ensuing operating losses in die early 1980s. The hospital was pievtously privately owned, but it had recently been purchased by a nearby hospital group, Vv'estmoreland Health System. Because of the hospital's aging facility, eroding financial condom, and small size, Westmoreland management explored a number of facility corn ersion options, includmg ambulatory surgery. substance abuse, wellness sen ices, hospice, andNaxiom types of long-term care. In 1984, Westmoreland decided to (..onvert the hospital to an ambulatory care facility , specializing in same-day ophthalmologic and reconstructive surgery. The center now has a medical staff a 21 performing over 2,000 outpatient surgenes a Yeat, drawing from a large geographic area, and it is reahzing a profit from operations However, Westmoreland has had to overcome some difficulties, includIng resistance to change by the facility board and community residents and lack. of enthusiastic support from employees and medical staff. The center decided to retain os acute-care hcense In order to remain eligible for maximum reimbursement rates, but in otder to comply with hospital licensure requirercents it has had to maintain certain expencoe faulity and staffing standards. Proposed changes in Medicare reimbursement for outpatient surgery t see ch 3) may limo the facility 's profits (374) ing the competition's capabihty as well one's own, moil. lab etielpment in their own offices), and and being willing to nsk failure by providing reduced need to transfer or refer patients to nontraditional services are all critical elements of other health service providers (109.387). this process (214). Common candidates for diversification include: Diversification can take many forms, although in long-term care units (see ch. 5); most cases hospitals probably diversify within the psycluatnc and substance abuse treatment- health care industry.s It is often a form of vertical rehabilitation services; letegration, where the hospital expands its service ambulatory care (e.g., outpatient surgery, diag- base to encompass a more comprehensive level of nostic imaging, wellness and health promotion care. Examples are hospital sponsorship of a primary services): care group practice or home health agency. This occupational medicine; and strategy has several advantages for the hospital. women's medicine and birthing services. including: An example of how these services might be used is greater control over referrals, presented in box 6-E. The use of swmg beds for increased access to reimbursement at different long-term care and diversification intovarit;ii, levels ef patient care; ambulatory care services are particularly common an attraction for consumers who would have a ior ntral hospitals. variety of their needs met at one location or by one system of care; t'se of Swing Beds the possible forestalling of competitive prac- Swing beds are hosp,,a1 beds that may be used to tices of physicians (e.g., housing certain diag- provide either ditAne.4.longer term care The teim 5Some nonprofit hospitals may undergo smpurate restnietwine)%leant* parern holding eomparue s aridehanging 1h ur Lisq 6Por most hospitals, swing bed revenues exceed swing bed costs it low volumes of swing bed cam However, at btal-_ -.wag bcd volumes labout 2.000 patient days). one study found that costs began exceeding revenues (54 1) 1$4 a Chapter 6-4hort- and Long-Term Strategies for EffectiveChange by Rural Providers 165 Table 64Community Hospitals With Medicare-Certified Swing Beds, 1987 Swing bed hospitals Total Modicero-certified swing bed hospitalsa 983 Percent of bospitals in frontier areas that ire Medicare-certified swing bed hospitals 80 Percent of sole community hospitalsb that are Medicare-certified swing bed hospitals.... 38 Charseterintics(parMing bed bosspita0 Mean number of acute care beds designated as swing beds.... 17.3 Mean percent of swings beds to total facility beds° 39.6 Mean swing bed admissions: number (porcent) of total admissions 47 (6) Mean 'n8 bed inpatient days: number (Percent) of total inpatient days 888 (13) NOTE. Community hospitals are defined here as all non-Federal, short-stay, nonspecialty hospitals (see app C) aNumber doesnotincluio 19 hospitals that had swing beds but were not. Medicare-testified swing bed hospitals. UuMbor includus only hospitals in nonmetto ores. Federal Law de:Aping semaphical eligibility for Meditate swing bee certification uses the U.S. Bureau of the Cerisus dainition of a rural area. bAs defin 1 for Medicare purposei. c Total facility beds include *It bedshospital and long-torm care beds. SOURCE: Office of Tochnolo gy Asseasment 1990. Data f.om AmeriAan Hospital. Association s 1987 Annual Survey of 3ospitals. Hospitals converting acute-care beds U.' sw mg fmd swing beds especially attractive. Swing bed beds may face problems such as: hospitals are most prevalent in the central and staff reluctance to accept new responsibilities; western parts of the United States; the West North Central region contains 42 percent of all swing bed = staff recruitment difficulties imposed by Medi- facilities (figure 6-1). care's conditions of participation that require the provision of certain services (e.g., reaea- The growth of swing bed use in some States may tional therapy); be hampered by certain Federal and State regulations unfamiliarity with regulations that were de- (see ch.7),however, some States have eased signed for skilled nursing facilities, and restrictions or. swing bed de4elopment. North Caro- inadequate third-party reimbursement. lina now exeilpts swing beds from certificate-of- Most of these problems diminish with hospital need review unl:ms e.penditures related to swing beds are $2 Mifflin or mcwhich is unlikely given experienre as a swing bed provider (700). the small capital costs required for such diversifica- Recent legislative changes (Public Law 100-2011 tion (474). Montana, which prev iously had allowed enable all rural hospitals with under 100 beds to Medicaid payment for swing beds only when there participate in the Medicare swing bed program', 'furs was no available nursing home bed wi,11.:1a expanding the pool of eligible hospitals to about 100-mile radius of the swing bed hospital, reduced 2,800(555). Hospitals with more than49beds must its I;mit in1989to a 25-mile radius (452). Also, meet conditi..ns intended to miaimize comr -Aron several States recently have passed laws authorizing with nursing homes. These conditions include mi. s- Medicaid to pay for sw ing bed services. A1989 ferring extended-care patients within 5 days to a survey found that 31 States were presently providing skilled nursing bed in the hospital's region unless the Medicaid coverage of sw ing bed care (474). transfer is not deemed medically appropriate by a physician or there is no such bed available. Ambulatory Care In 1987, 983hospitals were reported to bc Although nearly all rural hospitals provide some certified by Medicare as swing bed providers (table outpatient ben ices ksee ch. 5), ambulatory care 6-1). In these hospitals, swing beds accounted for continues to be an attiactive area of hospital nearly 40percent of total beds and 13 percent of total ersification. In 1987, obout 80 percent of ad inpatient days. Hospitals ..ocated in frontier areas hospitals (both rural and urban) suneycd by 'he 'Mates alsoMayextend Medicaid coverage to all rural hospltals tinder 100 beds. 166 Health Care in Rural America Figura 8-1Number of Medicare-Certified Swing Bed Hospitals, by Census Region and State, 1987 Pacific Mountain West I East Middle NW North Central North Central Atlantic England 1 I i \ MT VT 4 WI MA Fil ID lalWI '-'er ---1-. --i NJ MD OE WashingteeEl C 10 10 ' Tx 76 ,,-( ...co -..--' ( East West 1 South 1 South Central Central South Atlantic Regional totals West North Central 415 South Atlantic 68 West South Central 133 Pacific 42 t Mou,rtaiii 124 New En, "nd 13 East South Central 98 Mul-Atlablic 3 East North Central 87 SOURCE- Office of Technology Assessment, 1990 Data from Amencan Hospital Association $ 1987 Anr imf Survey of Hospitals AHA said they planned to diversify f-rther into community. However, many hospitals ,.ire concerned ambulatory care. iney perceived the advantages to about their profitability because of low ratient be increased revenues, larger market shr...e, greater volumes and changes in reimbursement (see ch. 5). impatient occupancy, and the improved ability to Another ambulatory care option for rural hospitals compete with area providers (275 1. is the sponsorship of primary or urgent care clinics Hospital-based ambulatory surgery facilities can and group practice centers. Physicians may some- be pardeularly attrartive in rural areas. They require times fmd these arrangements attractive because limited capita:, are convenient for physicians, and they ensure back-up ...ssistance and remove many are a major source of surgical emergenc y c are for the adminisrative responsibihkes from the physman. 1 7,3 ;001ENIMPOINWasties. AIIM0.1... Chapter 6Short- and Long-Term Strategies for Effeatve Change by Rural Providers 161 For hospitals, the benefits include working more closely with pl',.sicians to capture and retain pa- Box 6-F--Example of Hospital tients, stabilizing the physician ractice, and im- Diversificatior. Into Primary Care proving the delivery of primary care services. In the mid-1970s, Roanoke-Cho..an Hospual in However, obstacles to rural hospital dk ersAation Hertford County, North Carolina, opened a primary into primary care 1nay include: care t.enter Gatesville (25 miles away in Gates County) to make health . a there mote accessible difficulty recraiti 'g and retaining physicians; and comprehensive. (Gates County is predomi- hospitals' lack ot ,nowiedge and experience in nantly poor and has one of the highest infant primary care delivery; mortality rates in the State.) The hospital's outreach opposition by the local medical community, effort was unusual in that. was believed to be the competition from primary care physicians and first case of a Non), karolina public hospital hospital emergency moms; providing such services beyond its county borders. unstable fmancial condition of the hospital or Development of the satellite program involved primary care practice; and initial foundation support and the cooperation and lack of patient awareness or acceptance due to assistance of the Gates County commissic hers and poor mr-keting and quality assurance. a nearby State-supported rural health clinic. The center was to be staffed full-time by a family nurse Nationwide, the numbei of hospital-operattd free- practitionerith onsite supervision from a hospital standing centers providing primary or urrnt care emergency room physician 20 hour a week. Center services had risen to 1,003 in 1988 (362). No data services were to Mei Hie a pharmacy, diagnosuc specifically exis for rural hospitals. care, and transportation services for patients to and from the hospital and are.: specialists (45). Hospital-affiliated primary care in niral areas talv-s iarious forms, including: 1. Hospual-based and sponsorea prima. ) care chmcs may provide community '.tcation, clinicsIn this model (used by many Indian screening services, other priniary -are serv- Health Service hospitals), the hospital deleio ices, and diagnosis and treatment for essential the primary care. In one example, an 80, 'ted erneigency care. They can also ,a.ovide a more rural hospital in North Carolina piovi..4 accessible anc: less costly source of primary onsite facility and operating subshiies to sit- care for poor patients who previously may tract a primary care group practice to the 1. Ave used the ho.pital's emergency room (see hospital campus (485). box 6-F) (190). 2, Hospite-based certified rural heale; clinics (RHCs)Becoming a Medicare-certified RHC Corporate. itestructuring may help a rural hospital's ambulatory care Hospitals may restructure their corporate or or- diversification efforts. As noted in chapter 3, ganizational identity hespital-base4 primary care clinics under this in order to diveisify. For example, they may transfer certain hospital assets or program are paid a rate covering all reasonable costs for serving Medicare and Medicaid functions to a separate corporation, such as a parent holding company of which the hospital becomes a patients if they offer the use of midlevel subsidiary. This arrangemc A may be attractive to practgioners at least 50 percent of the time. private, nonprofit hospitals wishing to protect their However, many rural hospitals remain un; tax-exempt status while diversifying into unrelated ware of this opportunity, find Lidlevel practi- and often for-profit businesses (31). tioners unavaila'ole, are in States that limit Medicaid reimbursement for their savices, or Hospital icstnhauring throuBh the formation of face other discouraging factors (bee ch. 7). Ab parent hold ink, cot ipanies and subsidiaries 5as not of 1989, no more than 25 hospitak had been become common. A 1987 national survey of hospi- certified as RHCs (see ch j. tals interested in diversification found that only 3. liospital.sponsored, satellite primary Lare t en- one-fourth had creatcd a subsidiary to operate ursSatellite clinics extend the hospital's dk ersification activities (275). Corporate restruc lur- referral base aad piovide pnmary care to a ing is particularly uncommon in rural hospitals. geographically broad service area, Satellite About 11 percent of rural community hospitals were 168 Health Care in Rural America Box 6-GFour Examples of Rural Primaty Care Networks Marshfield Clink ,located in Marshfield, Wisconsin, a a large pnv ate, muhispec laity group praence dux otrei: a variety of outreach pi .rams to a larg e. rural region of the State. Created by 6 physicians in 1916, it not: has over 250 physicians representing some 60 medical specialties. Since 1976, Marshfield has established 17 regional dm ics, most located in small town'. 10 to 100 miles from the main clinic. A regional semees program provides advanced diagnostic testing and medi*.al educatutn and consultation services to over 370 hospiuls and health care facilities serving a populatbn of 3.5 million. The prcgram provides various mobile diagnostic eriices echocardioIogy;, and a regional reference laboratory performs about 250,000 tests annually. The Clinic has also formed the Marshfield Medical Research Foundation to provide support in such areas as physician recrunrnei. , clinical research, and administration of a federally funded clinic serving low-incom.- patients t449i. The Southern Ohio Hp alth Sem. is Nem ork, a private, nonprofit system of primary care centers, was oi %many creaNd to attract physicians to a poor and medically underserved AppaIacht0n region The number of pnmary eare centers opera by the network has grown from 1 in i976 to 12 in 1988, ci-ivenng 4 counties and serving 30,000 patients In addition, the network manages a Center that provides State-supported comprehensive prenatal care and supplemental nutrition services Federal funds now provide 32 percent of ihe network's budget, compared with 52 pereuit when the network began operations The centers share the serv lc, of some spe..ialty physicians. They also share central office financial and personnel management and centrally organued staff education (724). West Alabama health Services (WAi), opened in 1973, operates 5 pranar> care chafes, a 20-bed hospital, and a 52-bed nursing home md serv.., 0 counties in rural Alabama. Greene County, site of the central office and main medical center, is one of the five poorest counties .n the Nation. In response to a high incidence of infant mortality and teen pregnancy in the area, WAHS began the Rural Alabama Pregnancy and Infant Health Project, providing preventive care with the support of a pnvate foundation and participation by the district health department, an urban community Sea!th center, and university medical center WAHS also employs dentists and specialists in mental health, nutrition, hypertension, and prevent-, e health, and it has lint.ages with area Head Start and eld.-rly meal programs WAHS now provides more than 100,000 panent visits a year, nearly one-fifth of its patier .s :ely on transportation services provided by WAHS The central office handles all purchasmg, billing and othi: adrninistrative support requirements for the centers (135) United ClinicsSome rural private practices have also used satellitelimes to cxpand seeviees. In i 965. two private physicians (a family pro 'lice physician and a radiologist} inmed United Chnics.prvate multispecialty group practice in rural North Dakota The group expanded mto internal medic me, obstetries, pediamcs. and general surgery, and now has 17 physicians. Over a penod of 20 years, United Clinics established six satellite cs. ics serv ing nine counties in North and South Dakota Each clinic maintains x-ray. laboratory, and mtnor surgery capability to suppoil the delivery of basic primary can; tilid sow speciairy services pars of a holding company in 1987, and just 6 percent networks thu permit both operational efficiencies operated a Subsidiary (625),8 For publicly .wned and service expansion (see box 6-GL hospitals, the:e are several legal restraints tt torpo- Satellite clinics staffed by midlevel practmoners rate restructuij:.g (st : ch 7). can be.:sedto expand primary care..er-iices, partrularly in sparsely populated areas where there Primary Care Facility Direr.sificati,m n local ph; Klan. Such midlevel j. ractition- .:rs 4--an opermc. with ^ot.siderable auton my, re- Like hospitals, some primt...y care centers hat e -Avili?.routine chroca; ,,upervision and support sought to diversify thr services in order to provide ionn foty..ii-Lants M other '..:ominuaittes.In one clinic a fuller arra),f health care while maintaining or in a small isolioro South Dakota communny. for improving their financial standing. These ,:enteis example, a pill Klan asistant (PA) isthe sole may depend on goveinment funding (e.g as com- prov ider tpf tale. The Limi . is located fictween two munity health centers (CECs)) or operate as private Indian reservations and serves three ot the area's i...actices. One emerging "diversification" strategy poorest counties. The PA can 4. all in prescnptions to is the development of satellite clinics or multicenter the n- .test pharmacy 55 n. away, and orders IlInctudes only rural hospitals with fewer than MX) beds Chapter 6Short: and I 'ing-Term Strategtes for Effecnve Change by Rural Prm. ii 169 usually arrive in the conanunity within a d..y. The to eligibility for tit-fAce anch provam. PA is also allowed to have predispensed starter About half of du...Waren exanuned in the fi s st year doses of drugs Gal site for common needs (354). of the project were found :o nk:ed min ..diate dental Some communities have resorted to anusual treatment (485). arrangement.: to obtain urgent primary care. A small rural community near the Colot ado/Kansas border Hospital CoopvetliQS lost all essential primary care services in late 1935 Filar)aI problems and increased competition for when its small hospital cloeed and was convened to slurnknig resources 'e.g., capital financing) have a nursing home, and the local physicians closed their compelled many rural hospeals to seek assistance practices and moved a. y. ln 1986, investors from from or cooperation with other providers. Such the community asreed to become partners with a alliances may be sought in order to it:crease opera- private urgent care medical group in Denver, in on.ter tional efficiencies. obtain management expertise, for the group to reopen the community clinic next to af.d enhance access to other resou yes. %le musing home as an urgent care center. Three physiciat. from the medical group were flown in to Cooperative effo:ts have a solid he,' -.Ty in the staff the eihric. None of the physicians lixl in the delivery of esseatial rural services eteetrkity, community on a regular basis and none offered credit unions). Cooperath e venttues to auract and extended hours, but they were on call for emerget,- provide health servrces bloomed in the 19 +Os, only cies around the clock. To ensure some continuity of re fade withm a deca.:'? as comrnumty a ....overn- care. the group also planned to negotiate contracts ment support dec.Imed ;300,ilie cooperative con- with regional ho)pitals to arrange secondary and cept appears to hat e expenenced a resurzenee tertiary care for patients seen at the clinic. Commu- recent years, due toits promise of enhancing nity support h: the early stages of a"ntwe waa resources while preserving the independence of reported to be excellent (723). individual pioviders. The nature of the relationshi? among cooperating facilities may t ary considerably Where no sraditional primary care prtenders are (see box 6-H for exa np es). available, some local health departments have begun providing primary can,often to poor patients or Some of the potential.enefit f cooperativ e residents of sparsely populated areas. For example. relationships are: the health department in Price. Utah c.ontracts with more efficient operations from reducing dupli- a physician to deliver primary care and case manage- ment services to Medicaid recipient and those cation and sharing equipment. racihnes, staff and benefit plans, admmistrative services, rac- without insurance in a four-county frontier area The health department also has become a Medicare- keting and man agemem talent, and other re- certified home 'realth agency (622). sources: unprovemen: of market strength through cost in 1986, rural Marion County, Florida opened a sat. args (e.g., horn volume purchase discounts). primary care center, funded through the county znt: ceased produz tivity. and anproved a-cess to health department, in order to reduce mappropriate capital estabhshment of beneficial use of the county hospiial'a emergency loom factb panera reienal arrangements and participation ties by indigent patients. The primary care dati. ine..:utef suchprcfened prov ider gam& furnished nearly 3,700 patient visits in its first 5 tions and regional reference laboratories. months of operatioa (222). providing a forum for information sharing and polical advocacy of eommon causes; and Local health departmer.is sometimes target a very strengil.oung qualu :. of care measures specific setvice and population. With pit ate foun- dation and State support, the disuict health depart . There are ob:.taLles to taese potentially ad ania ment in Elizabeth City, North Carolina tiegan in the geous ietationsiops. nmt. lack of trust awing mid-1970s providlngniobikentJincrviceto 4-orripetno,b may be hxd to o.eikomc Second, the needy ehildren living in a four-county region. rigocle,of ,ome alhatices ina",not sua some Services inctude screening, education, treatment, members' nezdh. un. a:i...nces ma) limit the choice and referral. The mobile unit serves children onsite of Awed ;.ervices. or they may not he flexible at area public schools, eligibility for services is tied ernt.gn to adapt go tn the market f . I 170 Health C-re in Rural America Box 6-HThre.. Examp. es of Hospital Cooperatiees The Rural Wisconsin Hospitd Cooperative (RWHC)isa network ucorporated in 1979 th:.; itow includesig smal; hpspitals (average 50 beds) located in southern Wistonsin, and an urban university hospital. Tile purpc.se of RWI-IC is to piovide a base of support and a catalysi for the development a joint ventures. Modeled after the traditional (and familiar) dairy cooperative, member paitiopation in particular 4iared servites is voluntary and is contracted on a fee-for-service basis. RWHC's projects include: she.ring such diverse services as rehabilitation therapy and physician cos erage of emergency rooms, development and early administration of MP Health Maintenance Organization (IMO) of Wisconsin, one of the first rural-based HMOs in the country; developmmt and admmistrati.m of the RWHCT t.providing health and dental insurance for staff of member LozphaIs; a mobilo -ornr_'..!te.i tomography scinner and nuclear meditine services program for RWHC members and other area hospitals. In 1988, with support from the Robert V xxi Johnson Foundation, RWHC implemented a regional approach to improve hospital quality assurance programs and physician eredentiahng, enhance hospital fmancial management capabilities, and improve hospital trustee governance (624 Northern Lakes Health Care Consortium (NLHCC), founded in 1985, is a nonp;ofit cooperative n, twork of 21 hospitals, 50 medical chnics. and'? medical schools located in northern Minnesota. The consort :In, which grew out of r. series of worl&aopt and studies in 1984, quickly became an arena for area rural hospitals and physicians to erplore solutions to common problems_ NLHCC roles include legislative advoeacy, technical assistance, shared services (e g , diszounted joint purchasing), ongoing educational sessions to the tommunity and consortium, and multifaceted research on issues such as health promotior. and disease prevention. With rivate foundation support', NLHCC has also instituted several oemonstration nrojects aimed at assisting member hospitals adapt to change: The Rural Health i''ransition i ecr, under which NLHCC provides matching g 'ants and technical assistance to consortium hospitals to assess tiler internal operation and service area needs, and to plan any necessary restmeturing. A quality assivance nen4m.k, In develop comprehensive quality standards and help hospitals implement quality assurate programs. A physician reel ailment progren,,;inat..!' medical students graduating iron; the Uawersity of Minnesota with NLHCC's inember hospitais A regional long-term care nenvork. which helps iong-ierm care prot.iders integrate existing services, assess local long-term care needs, and establish new services. The network provides shared technical services such as physical therapy; ia" lervit'e education, community-based outreach services for me elderly (e.g., home health care, case management. transportation ^ers ices), marketing support, personnel recruitment, and quality assurance (261.391). The CARES Project (Coordinated Ambulatory Rehabilitation Evaluation Sersices) %kat reated in 1979 by the Medical Center Rehabilitatlon Hospital at the University of North Dakota in cooperation with two rural community hospitals. The U S Public He 1th Service provided hiitial funding. Fhe goal was to provide coordinated, multidisciplinary services for mral euldren with multiple disabilities CARES serves children in Kr sparsely ;opulated counties covering nearly one-fifth of the State, In the first phase of the proj.ct, a core team of visiting specialists from the rehabilitatiori hosotal traveled bimonthly over 300 miles to each rural hospital to provide treatment and cormihation to otients referred by arta pnysicians. These physicians recewed written reports ancontinued to be responsible for overall patient caie management In the second phasc, local Imoviders (e g , ph, .ical therapists) were trained by rehabilitation hospital staff to act as g at of the core staff at tbe clinics Specialty rehabilitation teams now are compnsed pnnianly of local hospital personnel, with ownership and program responsibility shiftmg Li the rural hospital and a few local physicians that have reeewed special training. Because of the projee, kl.sabled children are now more likely to receive rapid evaluation and comprehensive care (459) 1Sources of suppon includethe Blanch')Foundation and the Retu outfit Rose 4r, II.ourni.thon m &v.... tom .nitii the I 'taiversies North Dakota Affil..9011MgENIMMEInt. Chapter 6Short- and Lor glen,: Strategies for Effective Change by Rural Providers 171 services. Third, alliances c.in be time-co.i.:aming to Table 6-2Descriptive CharectertstIcs ot deveJop and maintain because of the loos .y coupled Rural Hospital Consortia' nature of the cooperative relationship and the distances betweer. participating institutions. Odrei Characteristics Mean obstacks may ly. legal OT regulatory in nature (see Age (years) ..... 6 ch. 7). Total number of members,. . . 15 Percentage with rural hospital Table 6-2 dercribes characteristics of 120 rural having 100 or more beds.. 51 hospital consortia or alliances e4lsting in 1989.9 The Percentage with urban hospital 55 Percentage with nonhospstal member 30 average rural consonium had thout 15 members. Humber of meetings past year., . 9 One-half of the alliances included at least 1 rural Percentage with beard of directors 60 hospital with 100 or wore Nxis, and over one-half Size of board of directors. .. 10 Percentage with paid director . 44 had at leas:urban hospital. The most commov Percentage with budget 63 consortia activ4ies were physician or staff education Size of budget ..... S231,693 programs and shared services (103). $Jurces of funding. Percentage with member dues . 33 Rural hospitals are less likely tklan urban ones to Percentage with grants.... 26 belong to an alliance. In 98;of community Percentage with revemais from activities 26 hospitals with fewer than 300 beds, 19 percent of Force- go with other sources vf revenues. 23 urban and 12 percent of rural hospitals belonged to Number sf activities/frograms offered by corsortia 6 alliances (625). One-beli of the niral members had Types of activities (1 consortia offerin8 fewer than 100 bcds, and nearly two-thirds had a civ: ty) nonprofit owners (table 6-3). Rural hospitals in PhY.sciati or staff educe....ion programs 81 Shared services. 80 alliances had slightly higher expenses than did all Legislative iiaison 70 rural hospitab (table 6-4). Marketing or community relations 62 Regional planning. 58 Pkvsician or staff recruitment 55 Cooperative Opportunities With Shared staff . 47 Urba n Referral Cen ter s Management or financial services 47 Primary or specialty clinics 43 Some rural hospitals formalize their patient refer- Quality sreurance. 42 ral relationships with urban tertiary centers and Acute-care bed conversions 22 specialists (see box 6-1). Cooperative referral net- aBased on the American Hospital 4ssociation dot- works with urban providers may help rural hospitals ir.cson, 12C rural. hospitai 40hUntia were ident- and physician s stem the outward flow of patients and ified (see Not ln.lvdeu ace ivial hosplLals working only wish nonhosp'tal organizations, meat- revenues to urban farilities. Conversely, referrals of irg only for discesion purposes or to pursue a complex cases from rural providers can bring single activity pertaining o polity or planning substantial revenue to urban tertiary hospitals and Issues, and those working together mainly because of metlhospital system ownership or management spe.iafists. arranhements (403). One report found that referrals from rural areas in SOURCE I Moscovice et al , The Development and Characteristics of Rural Hospital Consor- Utah account for percent of an urban tertiary tia." contract Paper Prepared for the Rob- center's pan...nt days ;..ut up to 20 percent of its rt Wood Johnson Foundation Hospital-based revenues (76). A study of referrals from rural family Rural Health Care Program, Now York, NY, 1989 practice physioians to universit:-based physicians in mid-Missouri from 1982-85 found that the averar Rural hospitals and phy cleans benefit from such referral generated nearly $3 000 ir hospital and professional revenues within 6 months Nearly referral arrangements by: one-half of the referrals (110 of 7'15) resulted in developing ;lose relatamllps between iefer- admissicos to tne university teaching hospital, ring and referral cent ,r physielans that lead to representirg 72 percent of all referral revenue for die sIde ber efits (e.g., oceasional prai.u...c ...overage hospittl for referring physicians); 1)4hosposlallianceirithisudAradefinedh_IA As a funimit) orpinaztIgivul, vf huspitilsor huspiuti s.)twos that hay< %oUn: together he ptiirsts and have specific membership cistern. 3 172 Health Care in Rural America Table 64Nonnietropolltan Hospltale Under 300 Table k. ITotal expenses per licspitat tor Beds In Milanese by Bed Size and Ownership, 1987 Nonmetropohtan Hospitals* in Mutimospitai Systems and Alliances, 1987 Onnershiq__ - Bed sir* Government Nonprofit Total In 6-24 5 7 12 Total multihoapital In 25-49... 27 28 55 Red size rural systoms atlieneez 50-99 29 50 79 400-199 27 66 93 6-24 81,357 $1,881 81,454 200-29S 10 as 49 25-49.... 2.747 2,987 3,039 51-99.. ... 5,t107 6,352 7,628 Iota 96 Ice 288° 100-199.. . 12.820 13./10 15,306 200-299.. 25.526 24,395 27.934 *Community hospitals defined here as all noreTederal, 300-319 44,881 49,683 45,000 short-stey. nonspocialty hospitals (see app. C). 400-499...... 46,264 27,09 42,625 bAlliances are defined by the American Hospital 500 or more.... 05,712 06,129 77,9011 Association as a formally organized group of hospitals or hosp.tal sYstems that come together Total 87.639 87,830 87,642 for specific purposes and have specific membership criteria. *Community hospitals deSloed here as all non-Federai, *For-profit hospitals in alliances numbered 3 41 short-stay, nonspecielty hospitals, (see app. CI. percent of total). SOURCE Office of Technology Assessment, 1990 Data SOURCE.Office of 7echnology Assessment, 090 pate from ew.;ican Hospital Association's 1987 from American Hospital Association's 1937 Annual Survey of Hospitals Annual Survey of Hospitals. providing local followup care for patients nining and dev elopment, and prider recrintment. treated at urban facilities; Box 6-J gives some examples of primaiy care receiving periodic support of urban spec:alists aiances that hav e apparently been successful. to perform certain procedures (e.g., uncompli- cated surgeries), to gain access to sophisticated CNC alliances with area agencies on aging technologies, and to offer clinical training ant; (AAAs) are a specific. response to a need for greater expertise; and linkage between health care and other services for enhancing the overall image of the local kospi- the elderly. AAAs werc created to provide., t?' comprehensive and coordinated set of services for the elderly (e.g., home-delivered meals, information However, efforts to formali2e referral relationships and referral, transportation) (Public Law 93-29). (e.g via contacts) may encounter drawbacks. Rural AA.As appear to have smaller budgets and These may include legal problems associated with more limited ranges of services than do their urban self-interest in making referrals (see ch. 7) and limits counterparts (287). on the use of alternative referral options. In 1987, tl a U.S. Public Health Service and Alliances Between Primary Care Providers Administration on Aging undertook a joint initial:ire to increase coopration between CHCs and AAAs. Some rural primary care providers have also Cooperation moy for example, involve the use of developed cooperative arrangements. The Federal AAA senior centers as satellite clinics for CHCs, and Government has recently encouraged CHCs to the provision of dental services to the elderly by establish coopera ie relationships with each other CHCs. CHCs can provide many of the basic health, and with other health and social agencies.10 Cooper- nutrition, and preventive care services that AAAs ative activities have included recruiting physicians, may be unable to offer (box 6-J) (460). establishing computerized information networks, channeling low income patients to prepaid services, The mandates of both CHCs and Iocal health providing sources for continuing education, and departments (LHDs) to pr,...tv.de basic health services sharing staff, equipmer:, and other resources (585). to the poor and disathantaged may lead to duphca- Some CHCs have linked management services to tion of services. With the recent mvolvement of improve activities such as grantsmanship, board many LHDs in rxirnary care. CHCs an') LHDs ni 411oFtiblic He Itb Service provacd special funds to about 120 CHCs between 1984 and 1988 to suppon o.onsenta activities, hoping u demonstrate Moir dfcesiveneas and encourage their development cis...woken without funher funds A formal evahusilon of kbese effons is planned tor :9904585). 1 P%." .4 Chapter GShort and Long-Terin Strategies fo, Effective Change hi. Rwal Providers 173 probaUy be unable to reverse its lease or sale to the Box baAn E.kanspk of a Rural-Urban MHS. Contract unagement by an MHS is also Hospital Alliance relathely irreversible. It appears to have improved Mercy Hospital Medical Center, a nonprofit the management of many hospitala (315), but it may 535-bed tertiary care facility m Des Moines. Iowa, be pereeived b) some hospitals as a means by an has established a cooperative network linkmg MHS to eventually gain more control. Mercy and 38 oral ilospda:4 within a 100-mile radius. The tit twork attempts to improve and Many of the conditions that lead hospitals ta expand services of panicipatng rural hospiuls and di% etsify or participate in cooperatives also apply to nicrease patient referrals to Mercy from rural joining MHSs. In addition, hospitals may turn to piysicians. Witnessing guitar competition among MHSs because of immediate financial eriats Spe- Les Moines hospitals, Mercy in 1985 surveyed area cific factors might include: nral hospital needs and sub; equently organried a network of outpatient .pectaay clina.a. By 1989. physical plant deficienues that the hospdal physicians from 20 specialttes were providing over does not have the capital to reried),, 30 clinics in 28 mral hospiods. Urban consulting the petceived opponunity fot the hospaal te specialists are now encouraged lc use local hospital improve accessto capital and specially ti resources (e.g., laboratory and x-ray facilities) that management expertise through an MHS; and generate added revenue for the rural hospital. To assist the specialists and keep local physicians yessure from local community LI. Jars who axe familiar with new medical technology, Mercy also anxious to stabilize the hospital's operatmg provides certain clinical technology services and environment (282). equipment (e.g., compumixed EKG machme) at minimal cost to the local facility For the MHS. advantages of recruiting rural hospi- tals may include eliminating competition. enabling The Mercy Hospital Network has formal affilia- more control over regional markets to gain patient tion agreements with 11 rural hospitals, 7 of which have requested Mercy for an administrator. To share and profits, and improving the delivery and maintain U. local hospital's autonomy, the admin- access of certain health Fen' we s. Box 6-K provides istrator is accountable to that hospital's board of two examples or MHSs. directors. All rural hospital affiliates may obtain Rural participation in MYSt: has waxed 4nd low-cost management and clinical consultation services, staff education programs. and assistance waned. From 1950 to 1983, the number of small in recruiting physicians and allied health protas- rural hospitals (with fewer than 100 beds) that joined sionals. Network hospitals without formal affilia- sy stems increased from 32 to 490 facilities. Most tions may purchase similar services at :somewhat hospitals in MHSs (46 percent) were under comract higher prices (81). management (345). By 1985. more than one-third of rural commimny hospitals were in MHSs (31). By 197, however, the number of rural community rural areas may fulditadvantageous to share hospitals in multihospital systems appears to have services and resources (box 6-i ) declined to about 25 percent of rural community hospitals with kwer than 300 beds (table 6-5) Multi! uspital Systems The rezent decline in MHS participation by rural A multihospital system (MH3 ) is broadly defined hospitals is probably indieative of their fears that by the American Hospital Association as two or more hospitals that are owned, leased, sponsored, or their autonomy An 1 fa exibihty w ill be Limon contract-managed by a central organization (1 on. ished; MHSs may be either nonprofit or investo:townto MHS management will ntElet los al intertsts Nonprofit systems ale tax-excmpt organizations. and needs (e.g.. staff will be repite ed v. ith usually regional in scope. Investor-owned systems corporate-designated personnel). and are for-profit, sharehoider-based m st it utions usually loeal res elute may be loss from the eontrounay controlled by a cenVal management. (345). Affiliation with an MHS requires yielding some On their pan. many Mils., ate MI au dly foaling or all of a hospital's autonomy. A hospital w ill rural hospitals to be less Atha...the as in, i-aments. 1 5 174 Health Care in Rural America Box 6-JSeven Examples of Primary Care Alliances Eastern Shore Rural Health Systems, a nerirk of three Virginia CHCs, needed additional physician services in the rnid-1980s but could not justify the use oftull-nme provider. With aderal support, the network negotiated with Dehnarva Ministries, a regional migrant service program that needed a physician dunng the nugrant worker season The subsequent agreement to jointly recruit and share another physician also allowed the jomt purchase of a new van needed to serve people with inadequate transponation (585). Aroostoock County Action Program, a consortium of five CHCs in northern Maine, was forma' to improve access to obstetrical services for women in a 900-square-mile area. Consortium plans included recmitIng and sharing a physician to provide obstetric care, 2nd later expanding obstetrical services to include a multidisciplinary team of professionals (e g , nutritionist, outreach worker) to be shared through cooperative agreements with area agencies These efforts would coincide with the consortium's development of a perinatal care plan for the area, linking needy and high-risk patients to a compreheasive array of services (585). Three small CHCs ftxfronner Utah agreed in 1988 to establish an intormal consortium. Major distances from other health care resources limited thee ability to obtain regular coverage for their solo-practice physician assistants (no physicians were on site). Early efforts by the CHCs to develop a consortium have centered on applying for a foundation grant to support a preventive care program foi the elderly at each of the centers, and jomtly recruiting and sharing the costs and services of an additional midlevel provider (600). Valley Health Systems, a group of southern West Virginia CHCs, affiliated in the late 1970s to share administrative and clinical services Initially under a contract wi.h a separate management group, the centers received support for grant writing, daily operations management, board training, provider recruitment, and other needs In recent years, with encouragement from the Federal Government, the management group has assumed greater control over the centers to furthet consolidate grant activity and center operations (551). The Mance for Sensors is a cooperative effort begun in 1982 bet amen area nual CHCs and the Egyptian Area Agency on Aging serving elderly ;(sons in a 13-county area in southern Illinois The alliance was in response to an Illinois requirement for a statewide case management system to serve as "gatekeepers" for elderly persons needing long-term care. Activities include: hiring a nursing home ombudsman, undertaking a 3-year elderly abuse prevention demonstration project, placing nurse educators in senior centers and encouraging local health departments to become mvolved in providing health promotion to seniors, and training homemakers and chore workers in oral screenmg and dental i..are, and purchating equipment enabling area dentists to serve the homebound (287) Wayne Health Service, a CHC in West Virginia lacking its own radiology equipment. had many patients in 1981 with no regular transportation but who often needed x-ray services. The only commonly available x-ray unit was about 40 minutes away. and the county health depanrneat's anit nearby was used infrequently The CHC initiated an agreemeat with the health department to lease use of as x-ray unit at no charge, stipulatmg the ClIC woald cover all related operating costs. The CHC hired a pan-time technician,set up a regular schedule for testing nonemergent referrals, arranged for an area radiologist to read films, and promoted the new service t251). The Shenandoah Community Health Center in western Virginia, which serves a large migrant farmworker population at renain times of the year, rehes on the local health department to contact migrants who have been exposed to in'ectious diseases The CHC and health department jointly mrease staffing and (ollowup care during the harvest season to minimize delay in tracking exposed mdivaluals To address deniaad for more extensive laboratory tests, the health department is also helping tram CHC staff to plrform some of the laboratory work {501). Some M143s have divested themselves of rural which once managed 20 rural hospitals. was in 1988 hospitals. in 1985, fot example, Republic Health operaang only 3 moil hospttals that it had been Corp. SCA five of its rural hospitals, while American unable to sell (360)Westworld Community Healthca,e Management Inc,planned to sell Ave of Healthcare, which operated 40 rural hospitals at its its eight remaining rural hospitals that same year peik m 1986. declared bankruptcy :n 1987 while (559). Other MI-16, opefating rural hospitals hare running 14 hospitals and reporteoly incurnng a $135 suffered financial harm. Bask American MedicaL midion debt (709) Chapter 6Short- and Long-Term Strategies for Effe,e C ;eM kural Pr nider 175 _ Box 64--Two Examples of Multihospital Systems Memonal Hospital and Home, a29-bed hospital and 102-bed nursing home in rural Mmnesout. u, 1984 tcas suffering from dechiang utilization, suff turmoil, a negative community image. and a $25C,300 operating deficit In 1985, Memcrial's board of directors signed a 2 year agreement oath Saint Luke Hpt4b Ment(are. 4 Luse teniary hospital located 7e miles west in Fargo, North Dakota, to Lontract-manage Memonal. Neither hospita! had previous experience with such a n arrangement. The 4., ontra. requited Saint L kc s to hoe an administrator and in the first year develop new operating procedures, strategic p:tirts, and marketing programs. conduct board training, evaluate and revise administrativ e and nursing polietes te.1,., a new wage svon), and review quality assurance activities. By the second year, new purchasing and computer services contracts were established, and outside speeiahsis from Saint Lukes were brought in as needed to run clinks and pros tele staff education. By 1986. the hospital showed a profit of $97,000. ln 1987. remaining problems includedaiingenng low patient census, some negative community feelings. and the return of unexpected oixrational losses, -however. most board members agreed to a new contract for .an additional 19 months, allowing Memorial to participate U. J joint purchasing agreement with Saint Luke's and Voluntary Hospitals ofAmenca (246) Intermountain Health Care. Inc..a nonprofit NIBS, was rounded in 1975 in Salt Lakt City. Utah to assume ownership of 15 hospitals in the regwn divested by the Mormon church. IHC now alanages. leaseor owns 23 community hospitals (i4 of which are rural) in 3 Shoes It also operates 4 freestandint., ambulaP ry surgical centers and 25 rural primary care clinics that serve as outreach facihties to the mrai hospitals. Sent:es pros, itIcti to its member facilities inclr:!e: a cardiac emezgency care network linking rural hospitals and physicians with area tentary care centers, access to high-risk perinatal care, lithotripsy, and central lab yavices, crosstraining and continuing education to retain nurses: sharing of medical directors between some hospitals, he !rig smaller fat. dams ti s rctkrit whew and 4ualit assurance activities; and group pen:hasing for supplies, data processing services, msurance, and employee heatdi benefits intermountain has recently faced excess eapacrty and hicreasing losses in its ruwal hoTilak. toron. ttt(. consider liquidating hospitals or converting them to other use (115) Overall, the effectiveness of MHSs in helping Commls on on Accreditation ttf Healthcare Organs- rural hospitals to survwe is uncertam. A national .d they had a higher average expense per study of MHSs from 1984 to 1987 found little patiPnt clay, but they thd not provide more service:, difference in the profitability and scope of serviees iNS). Neither study examinedhcther rural hospitals between autonomous rural hospitals and those in N1HSs tiad Improc ed aeeess to capitalthe most MHSs. However, rural hospitals in MHSs had lower commonly perceiv ed advantage of MHS partic !pa- costs per admission, were twice as hkely !c enter into wn. economic joint ventures with physicians, and pro- ; less uncompensated care than did independent lAcal Hospital IV:very and Agreements rural hospitals. Among rural hospitals in MHSs. nonprofit systems offered a greater number of Where iommunity has two or more hospitals out-of-hospital services, engaged in more economic pros iding duplieative sers icesandsuffenng ex...ess joint venture and managed care detit it). and had less 4..spac1ty,o n so !dation of theta serv kes may be a uncompensated care and lower eosts per admissloo suecessful strategy isee box 6-Li. If hkaf hospitals than investor-owned systems, but they were less mergt. ther organuations and assets, or enter into A profitable and had higher room charges OM. An formal agreement regarthng the ths Ism' of sers PAN. earlier study found similar results, there were few they van each provide only those specialized serv differences in performance between hospitals ow lied ices fur which they are best suited te.g.. One th,pital by or leased to MHSs and MHS-managed or pro% Wes obstetrical :,eRkeN. another deliver,long- independent hospitals. Owned or leased hospitals (OM care). These tiangements Malythey, help were more likely to by accredited by the Joint subsidize the corn owed pros t.sion a; each hospital of 1 176 Health Care in Rural Amerka Table 6-5--Nonmetropolltan Hospitals,' Under 300 Beds In Muttihospital Systems by adir! Size Box 6-LExample of a Local and Ownership, 1987 Hospital Merger In the 1970s, two 150-bed hospitals in a commu- )arnershin nity of 50,000 residents On Michigan's remote Bed size GovernmentNonprofit Profit Total upper peninsula decided to merge to improve the 6-24 8 23 6 37 provision of acute care in the region. They hoped to 25-49 26 05 25 146 create a more favorable image among area physi- 50-99 24 129 64 217 cians, who were then referring patients to hospitals 100-199 13 88 53 154 200 or more miles away. After the merger, a new 200-299 3 25 a 36 144-bed facility was built adjacent to the old Total 74 360 156 590 building of one hospital (Saint Luke's). The second aCommunity hospitals defincd here as ail non-Federai. hospital was sold to the State and later converted to short-stay. monspecia1ty hospitals (see app. C). a veterans' hospital. In 1984, a new outpatient SOURCE Office of Technology Assessment, 1990. Data cancer treatment facility was opened at Saint from Amerlcan Hospital Association's 1907 Luke's, and an extended care center whit a magneti-: Annual Survey of Pospitals resonance imaging scanner was planned for com- pletion in 1987. 11etween 1984-85, hospital admis- essential Services, such as emergency care, that it sions increased 11) percent while other area hospi- may be inappropriate to centralize. tals were noticing declines (274). Success of these arrangements is affected by: traditions of institutional independence and joint ventures or other dfdiations. Tie joint venture pride and the present extent of interinstitutional is a legally enforceable azueement involvmg finan- relationships, leadership, and community sup- cial speculation and risk Cm two or more parties in port; order to conduct a new business, most often out-of- differences in ownership ttnd corporate operat- hospital services. Like diversificni In, joint ventures ing cultures of the institutions; with physicians may help the hospital strengthen its the proximity and similarity of hospital service referral base for inpatient admissions and outpatient areas; specialty care. Common ventures are diagnostic area overbedding, service duplication and other imaging centers, laboratories, ambulatory surgery operating inefficiencies in each hospital, and centers, and leasing facility space. Some hospitals the resulting economic pressures; have also suld physicians a stake of minority competition among hospitals for gaining arca ownership in their facilities, intending to strengthen physician loyalty and support; and physician referral loyalties and encourage maximi- the growing threats of antitrust investigation zation of hospital resources (4>. Joint ventures are and litigation. often corporations or parnerships in which the hospital assumes the greater risk as general partner, Littleis known about how common and how while the physicians are limited partners. These successful local mergers and service agreements agreements may encounter some legal obstacles (see between rural hospital: are. ch. 7). Hospital-Physician Agreements Hospital-physician joint ventures are relatively new and few. A 1984 survey by AHA found fewer Hospital and physician services increasingly over- than 12 percent of hospitals &both urban and rural) lap. Hospitals may compete with the private practice reporting such arrangements, and these were pre- of their medical staffs by opening and staffmg their dominately ventures creating prepaid medical care own ambulatory care centers; physicians may com- plans. Cities with populations of 250,000 or more pete by offering ancillary and high-technology were most likely to have hospitals with established services in their private offices or in freestanding joint ventures (401). facilities. Hospitals also attempt to bond physicians by In some cases, hospitals and physicians have offering incentives that capture most of their mpa- decided to cooperate rather than compete, through tient admiss1ons and referials to outpatient services, 1 6 wawmommowl Chaprer 6Shorr- and Long-Term Straregtes for Effecnve Change by Rural Protuiers in and reduce competition from urban hospitals. Ty pi address changing utilization and revenue patterns, cal incentives are: and joining alliances or multihospital systems to share resources and lower fmanciai risks. office space and equipment; subsidized malpractice insurance, Some strategies hate been used widely and patient referrals from hospital satellite enters successfully. The number of rural hospitals, for or through managed care conmicts, example, that have become sw ing bed providers has management services (patient billing, market- grown to about half of those elitoble, allowing these ing support, financial counseling), facilities to diversify away from dechning acute care continuing education; and utilization and meet growing post-acute care de- guaranteed income or cash incentive compen- mands. sation. Other strategies have been tried n i1h more A recent study asked physicians in nine rural t;mited success. For example, wu hospital mem- midwestern communities which factors were impor- bership in multihospital systems appears to be tant ill selecting a hospital for practice. Support declining. It is not cleat whether certain types of services of highest interest included accredited rural hospitals are more likelyto benefn from continuing education, hospital liaisons to case com . inclusion in multihospital systems. munications with administration, medical staff of- fices with effective support and communications, Littleis known about the success of many and assistance in developing patient information and efforts, and no effective way now exists to predict satisfacfion surveys. Services noted of least interest and communkate th,:r success. Also, little oppor- were billing services and opportunities to participate tunity is available for communities to compare and in managed care arrangements and joint ventures exchange ideas. Examples of apparently succcssful (534). strategies include improvements in leadership and management, hospital conversions to alternative SUMMARY OF FINDINGS heath facilities, local hospital mergers, hospital- physician arrangements, and CHC consortia and Many rural providers have found effective means categorical care initiatives. of adapting to changes in their environment. There are numerous examples of efforts by rural hospitals, 01:ter rural protiders hate not atailed them- CHCs, catd other facilities to support effectire selves of Lelpful methods and strategies, in part change. Many have found ways to strengthen facility because it appears they have been slow to accept solvency and stabilize operations in the short term necessary change. For example, despite significant (e.g., renewed fundraising, tougher t-ollection pub declines in inpatient uuluauon tsee ch. 5), many cies). Also, many rural facilities hare instituted rural hospitals remam full.sen ice acute 4, dre facib strategies that reconfigure their organizational and ties, apparently, without the will lg rewurt,es to service stmcture for the longer term. These efforts thoroughly examine their roles and capabilities and include cony erting or diversifying service bases to make significant structural changes. Chapter 7 Regulatory and Legal Concerns for Rural Health Facilities 1 :in CONTENTS Page INTRODUCTION 181 FEDERAL ISSUES 181 Medicare Conditions of Participation 181 Raral Health Clinic Certification 182 Pedonnance Standards for Community Health Centers 183 Tax Laws Affecting Health Facilities 183 Fraud and Abuse Regulations 184 Antitrust Issues 185 STATE ISSUES 188 Facility Licensure 188 Certificate-of-Need Requirements 188 Property Tax Laws 189 Public Hospital Issues 190 SUMMARY OF FINDINGS 192 191 i>o tVib) Association for information and image Management `iv k $100 Wayne kdenue, Suite 1100 N Sayer Spring, Maryiand 20910 301687.8202 Centimeter 11 12 13 14 15 mm 1 2 3 10 Inches 4\ A (N.\ NEP MANUFACTURED TO PIIM STANDARDS 4c1C4;:kits BY APPLIED IMAGE.INC. Chapter 7 Regulatory and Legal Concerns for Rural Health Facilifies INTRODUCTION burdensome, vague, irrelevant to their settings, or limiting to the effectiveness of certain services. Rural facilities wishing to improve their effi- ciency and financial condition, and enhance their Staffing RequirementsMedicare requires that ability to deliver more appropriate and accessible hospitals provide 24-hour nursing service furnished services, cannot always pursue the strategies they or supervised by a regis &red nurse (RN) in each prefer. This chapter discusses some of the Federal department Or unit of the facility, including the and State laws and regulations that may impede emergency room. Hospitals must also use licensed diem. laboiatory arid radiology technicians, and they must have a full-time director of food and dietary services. FEDERAL ISSUES Small rural hospitals may have difficulty recruiting Or affording such skilled staff, or they may not have Medicare Conditions of Participation enough patients to justify the presence of so many staff.3 Moreover, complex requirements for assuring In order to participate in the Medicare program, quality of cam (51 FR 22042) require several hospitals and other health care facilities must meet administrative committees that small medkal staffs certain "conditions of participation," intended to may find excessively burdensome. ensure that facilities serving Medicare patients meet minim= standards of quality, regardless of where Facility RequirementsMedicare requires hos- they are located.' Medicare conditions for hospitals pitals to meet standards for architectural configu- define what provisions must exist with regard to ration and physical environment, many of which governance, quality assurance, utilization review, were developed by the National Fire Protection medical and nurse staffmg, clinical and support Association (51 FR 22042). Meeting these building services, and the physical environment (e.g., facility standards (e.g., having emergency power and water specifications). The standards also describe what supplies and building con-idors of a minimum width) services a hospital participating in Medicare may can add significantly to rural hospital renovation deliver. The participating hospital must comply with costs. applicable Federal health and safety laws, and its facility and perconnel must be licensed or meet other Administrative RequirementsRequirements for standards set by the State. In most States a hospital's quality assurance, utilization review, and medical accreditation by die Joint Commission on Accredita- record services (51 FR 22042)intensified by tion of Healthcare Organizations (JCAHO) is ac- payer-induced incentives to monitor quality and ceptable for meeting conditions of participation. However, many small rural hospitals are not JCAF10- utilizationhave resulted in increased need for documentation, leading to longer work hours for aceredited;2 these facilities must be approved to adrnmistrative staff in many health care facilities participate in Medicare by State government agen- (3 78). Paperwork is generally not reimbursable by cies (51 FR 22042). payers, so facilities must absorb the related increase Some requirements set by the I;onditions of in staff costs. Many small rural facilities may lack participation (or resulting from their interpretation) the administrative depth and financial stability to are viewed by many rural facilities as partkularly adequately meet these requirements. if:edifies receiving Medicaid payments must mcel similar conditions of participation 21n 19r 7,38 percent of all rutathospivals tcompared with 11 patent ut urban hospitals, were notg4.1.1t444,1 u y/CAHO proportion rises iv Deafly 60 percent et rend hospitals with 2$ to 49 beds and 80 pemem of those fauhtra with fewer that, Z.bcti4 Of wban tiosp,m6,30 pch.cni *A Z5 tv 49 beds and 84patent with fcwo than 25 bcds were net ICAHOaccmditcd (625). 3"11=0 staffing rapine/was may bc misunderstood by some hospitals, and Dui .ai4iimai rurd hospital4 (nay bc aw arc vf 41tiart fiCAittilitICS uilua gm commons for participation that may be gramol under these situations Fut example, under ..enain L.moinstaac,.rnp.rary w 16 en a .!x.:4- boa =mg staff requirement may be granted Po nual hospitakwith $0 us fewerbeds foundtu bc.:uoof ..umphatmc wal, .oralu,_.es of partmepatson (42 CTR 1988 ed. 488.54). -181- I 12 182 Health Care in Rural Americl Home Health ServicesHospital-based home cash flow problems for smaller providers heav- health programs in some rural areas have difficulty ily dependent on such sources of payment. complying with Medicare regalations because they (Once certification is received, RHCs are enti- lack a full-time RN director (219). Some mral local tled to retroactive reimbursement under the health departments with home health agencies have new fonn of payment.) also had difficulty justifying and affording a full- time RN who is responsible solely for the home Administrative requirementsThe paperwork health service (519). Other =al home health agen- burden necessary to complete extensive cost cies have expressed concern about their ability to reports and other requirements may be over- obtain the required qualified instructors to conduct whelmingly complex for small ansophisticated classroom teaching for home health aides (279). RHCs with few administrative staff. Such centers may have to obtain costly outside Swing BedsSome rural hospitals believe that accounfing and financial assistance. RHCs can Federal regulations on swing beds are too stringent also encounter operational difficulties when or unclear. To qualify for swing bed reimbursement, States conduct annual recertification surveys palients must meet the sune standards of medical without prior notice. Small centers where staff need as patients who qualify for reimbursement in handle both adminisuative and cbmcal duties skilled nursing facilities. Hospital patients dis- may be unable to fulfill all of their clinical charged from acute care who need transitional care obligations during unannounced recernfication less intense than skilled nursing care are thus visits (713). ineligible for Mvdicare swing-bed reimbursement (194). This creates a gap in health care coverage, Requirements for midletel practitionersA palicularly in areas with no easily avadable home midlevel practitioner must be on site at an RHC health services. Hospitals .t.,,o complain that Medi- at least 50 percent of the time the facility is care intennediaries4 inconsistently interpret billing ;pen (Congress reduced this requirement from instruction manuals when classifying swing-bed 60 percent in 1989 (Public Law 101-239).) This patients as recei$ ing skilled or intermediate c.are, requirement may be difficult for some clinics to creating confusion and limiting swing-bed use meet. First, some RfiCs have problems recruit- (732). ing and retaining midlevel practitioners due to supply shortages, or due to restrictEons in some States that affect the ability of midlevel provid- Rural Health Clinic Cerfification ers to practice medi.-ine (see ch. 12). Second, tura] providers with several clinic sites that Faced by increased financial pressures, rural share midlevel practitioners on a part-time health facilities are seeking ways to enhance reim- basis may be unable to qualify each site as an bursement under Medicare and Medicaid. Recent RHC, because the midlevel practitioners may congressional actions to improve reimbursement for not always be available at each sae at least 50 certified rural health clinics (RHCs) (see ch. 3) have percent of the time the center operates. renewed provider interest in becoming or remaining certified as RHCs. However, providers often lack Limited guidarki for 1,.4,ider-based clinks knowledge about the program or are concerned Health Care Financing Administration (fICFA, about Mr regulations. Major concerns include. regulations for RHCs have focused on free- standing clinics (the vast majority of RHCs). Delays in certificationMany providers seek- Some observers report that the regulations lack ing RHC certification report that the applica- sufficient guidance for provider-based sites tion process is burdensome and lengthy, ofte .1 (e.g., in hospitals or skilled nursing facilities) lasting 6 or more months (87,713). on acceptable methods of determining reasona- Divontinuance of billingsProviders must ble costs fot reunbursement 023). Provide:- stop billing Medicare and Medicaid while based clinicsare supposed :o receive full &waiting RHC certification, creating possible cost-based reimbursement (see ca. 3). 4MedicArc intemietharics arc listal aguits aypitAlly illus. Crus., plab vt ,untaicrml 60Milalk.0 fonot untia 4.tAutat.t iv ibu fic4ith Lac 1- inanung Administration for administration of specific Nicdia.rc task., tc. g , dciamintog rcasunabk wsts fur items. making payrrienbt )'3 Citapter 7Regulatory and Legal Concerns for Rural Health Facilities 183 Pesformance Standards for Community munications, record center, personnel, and Health Centers clinical services; it may provide such services only to two or Allornrnunity health centers (CHCs) are ex more exempt hospitals or to government owned pected to meet certain administrative and clinical and operated hospitals ("permissible recipi- standards of performance set by the Bureau of ents"); and Health Care Delivery and Assistance (BHCDA) of it mug be organized and operated on a I..uupera- the U.S. Public Health Service. Such measures five basis, it must have as members or share- include minimum productivity 1.'vels (e.g., numbers holders only permissible recipients, and it must of patient encounters per physician, physician- to- allocate or pay all net earnings to its patron patient ratios) and maximum ratios of administrative hospitals on the basis of services performed for costs as a percent of total costs. the patron hospitals (Internal Revenue Code Small rural CHCs, particularly those in frontier Section 501 (e)). areas, may fmd it difficult to meet these standards The list of permissible services is narrow and omits In a survey of frontier centers in five States covering many services that rural hospitals in cooperatives the years 1985-87, CHCs had higher proportions of and other main gements nught efficiently share (e.g., administrative costs, higher medical costs per visit, management, laundry, and housekeeping services). and lower proportions of charges to costs than The penalty for providing nonpermissible services is BHCDA considers acceptable. However, the centers stiff. If a shared service organization (e.g., a cooper- on average met the standard for provider pro ductiv ative) provides any unlisted services, or if it provides ity(204,350).Recently, BHCDA has considered services to any institution that is not a hospital, the suggestions for changes in CHC performance meas- organization williuse exemption for all of its ures that are more sensitive to the diverse popula services. Unlike other exempt institutions, shared lions served by centers(477). service organizations are not simply subject to tax on such unrelated activities. Tax Laws Affecting Health Facilities Efforts to recruit and retain well-qualified medical Essentially A of die Federal tax laws affecting the staff can also endanger exempt status. To attract delivery of health care concern the acthities of physicians, a hospital may wish to offer loans, tax .exempt organizations and their affiliates. Exclu income guarantees, p. actice facilities, and other sions, deductions, and credits are not generally benefits. Offering incenthes may endanger a hospi- available under Federal tax laws for the :3 peicent tals tax exemption by implying that the hospital is of rural hospitals that are proprietary. This section unduly furthering the interests of private indiv iduals. discusses how such tax provisions affect the survh al Under Treasury regulations, a tax-exempt health and expansion strategies of nonprofit rural hospitals. provider mug meet the following tests. Tax-Exempt Organization Status it must be organized and operated exclusively for exempt purposes; Because the promotion of health is considered A no part of its net earnings may inure to the charit -t- le purpose, nonprofit hospitals and other benefit of persons having a personal and priv ate health care providers generally have no difficulty interest in the organization, and obtaining tax-exempt organization statt.s. However, it must demonstrate that it is nut organized or a hospital providing services to uther hospitals can operated to benefit private interests U.S. Treas. endanger its exempt status. For example, in order for Reg. sec. 1.501). a hospital cooperative to retain its tax-exempt status The Office of the General Counsel of the Internal while providing and receiving shared services: Revenue Service (IRS) h as indicated that physicians it may provide only the following "permissi . recruited as employees, ur as indiv iduals with a doe ble" services, data processing, purchasing, professional relationship with a hospital, are ,,ubject warehousing, billing and collection, food, in to review under the inurement proscription(300 g.' dustrial engineering, laboratory, printing, corn- Hospitals also mast demorsti ate that their opera- sGeottal Counsel Memoranda am not bonding but indicate how Mc IRS is likely to rulc on an isuc 20-810 0 - 90 -7 OL3 184 Health Care in Rural America lions do not benefit private interests more than Although in considering these issues the IRS has incidentally. In theory, this standaid may not be indicated no "across- the-board" recognition of a difficult to meet. For example, the IRShas ruieti that rural hospital's role, courts ha% e been 4ympathetic to a rural area with a significant need to attraa rural hospitals. For example, inH. irauts Hospual physicians could use community funds to construct N . United States,the court held that a , .zal hospital's a medical office complex, because any personal pharmacy sales to private phy sicians patients were benefits physicians might derive w ould be incidental not taxable income because the pharmacy's aNail- to the community benefit(298).However, the ability was an inducement to practice medicine in analysis that must be done to demonstrate this the hospital, and thus it contributed to the goal of condition can be difficult. It reqaires that benef:ts making medical services available(257).Income providei by the physician to the hospital and the from rent of office space to physicians has not been community be quantified and compared to the considered taxable because locating physicians on recruitment or retention benefits provided to the thz hospital campus is, in the 1RS's view, substan- physician. This is not an easy task, since community tially related to the hospital's pros ision of medkal benefits are often subjective and not easily quantal care, whether the hospital is urban or rural 097). ble. Uncertainty about what hospitals may offer to attract and retain physkians is exacerbated by the Ta x-Exempt Fin a ncing recent MS announcement that exempt hospital- As noted in chapter 5, access to tax-exempt physician relationships will be subject to heightencd financing is crucial for many nonprofit rural hospi- scrutiny. tals. Under the IRS Code, interest income from new bonds issued after August 1986 to fmance tax- exempt health facilities is exempt from Federal tax Unrelated Business Income if: Tax-exempt organizations are subject to Federal all of the properly obtained with the proceeds of tax on income from any regular business that is not the bonds is owned by the tax-exempt provider, substantially related to the organization's charitable and purpose (MS Code Sections 511(a), 512(a)(1), no more than 5 percent of the facihties financed 513(a)). These activities may be restricted not only by bond proceeds are used by a nonexempt by imposing tax, but also by concerns that status of person or in an unrelated trade or business (IRs the facility (or of bonds fmancing it) may ly... Code Sections 103, 141, 145).6 endangered. Recent proposals by Congress broaden the types of income classified as unrelated and limit Fraud and Abuse Regulations the deductions permitted in computing taxable income (e.g., from hospital gift shops, myalties, and The Antikickback Provisions rent from organizations hospitals control). The Medicare arid Medicaid antikickback provi- In general, sesvices provided by hospitals to sions (42 U.S.C. § 1320a-7b) were first adopted by physicians in private practice or to their patients Congress in 1972. The provisions were intended to generate taxable income. Such services include provide penalties for certain practices that have been long considered unethical by professional groups reference laboratory, adrunistrative, and pharmacy and that contribute significandy to the cost of the services(294,295,290,299).However, the IRS has recognized to a limited extent that rural hospitals Medicare and Medicaid programs. The regulations prohibit offering, soliciting, paying, or receiving meet unique community needs that justify tax "any remuneration (including any kickback, biibe, exemption of such activities. For example, a hospi- or rebate) directly or indirectly, overtly or covertly, tal's reference laboratory service may be exempt if in cash or in kind" in exchange for or to induce any the hospind is geographically isolated and the of the following actions: services are not reasonably available from commer- cial sources(299).This test is fact-specific, how- referring an individual to a pros ider for the ever, and does not provide general guidance for r aral receipt of an item or service thatIS %AAe.ed by hospitals. Medicare or Madicaid; or 'Rector proposals by Cuogress hac Aix,...ille4 itn lauktut a ta6plialievCi ut grabgern ',Arc 4k...wail:sued tlitubady ko tas-cacmpt Loara.m8. 17 1 ) Chapter ; .gu:aiory and Legal Concerns for Rural Health Facilities 185 purchasing, leasing, or ordering aiiy item or Services (DHHS) to deN clop regulations specifying service that is covered b, Medicare or M 01- "safe harbor" practices that would not be consid- caid. ered violations of the statute (Public Law 100-93). The proposed regulations were issued in January If read literally, these regulath as can he viewed as prohibiting a number of relatively ccmmon 1989 (54 FR 3088), but they have not resolved the Llasawt.Piy. . For example, one of the proposed "safe activities. The provision of free coffee by a hospital harbors" would permit a physician to receive to memberc of its medical staff could bc interpreted dividends from investments in large, publicly traded as an inducement to the physicians to admit their patients to the hospital. Although this particular companies that operate entitics to which the physi- cian refers patients.7 The legality of this practice, common practice is unlikely to warrant prosecution, however, was never seriously i,uestioned. What had health care providets may fmd it difficult to clearly been (and remains) uncenain v, as the permissibility distinguish between pennitted and prohibited con- of physician investment in hospital-physician joint duct. ventures, or physician ownership of community Many hospital strategies to recruit or retain hospitals. Sunilarly, the proposed regulations would physicians (e.g., offering physkians financial assis- protect the purchase by a physkian of the practice of tance in establishi^g a practice) can trigger aritikik . another phy sician who is retiring or is 1cm ing the back provisions. Such arrangements might be area. However, the regulations say nothing about viewed as the furnishing of compensation to a whether a hospital may purchase a physician's physician by an entity to which the physician refers practicea question that is likely to be far more patients. important for the rural hospital trying to maintain its The ownership of hospitals by physicians may patient b-se. Final "safe harbor" regulations are expected to be published in 1990. also be viewed as a violation of antikickback laws if these physicians tend to refer patients to the hospi- Antitrust Issues tals they own. These "self-referrals" by physicians may be especially prevalent in rural areas where the Mergers and Acquisitions physician-owned hospital is the only local hospital. Some rural hospitals may find it increasingly In othu rural communities, some fol-profit multi- desirable :43 combine their assets and operations. hospital chains (e.g.. Hospital corp. of America and However, recent increases in goveri..ien oversight American Medical International) have explored the and enforcement of hospital consolidation activity possibility of selling unprofitable facilities to mem. by the U.S. Justice Department and by the Federal bers of the hospitals' medical staffs (584). Where a Trade Commission (FTC) raise important antitrust rural hospital is unprofitable, the members of its issues for these rural hospitals. Section 7 of the medical staff may be the only persons w ith sufficient Clayton Act (15 U.S.C. 12-27) prohibits mergers or capital to take over the facility and prevent its acquisitions that may substantially lessen competi- closure. Also, physician ownership may mean diere tion or tend to i... eate a monopoly. The Clayton A .A.S is sufficient interest by local physicians in maintain application requires r predicticof the like!, effect ing a practice at a nearby. hospit...nd that at least of the merger Cir acquisnion on consumer welfare. some of the income from the hospital's operatiohs Guidelines for el. aluating this effect w ere issued in will remain invested in the commuruty. 1984 by the Antitrust Div osion of the Department of Justice. "Safe Harbor" Regulations The principles and standards contained in these '... an attempt to resolve some of the 4., unfusion merger guidelines have recently been applied in two surrountang the meaning and scope of the anukick cases lin oh mg mergers of nonprofit hospitalsone bzk statute, Congres.. recently directed the Secre- in Roanoke, Vugmia. the other in Rockford, Illi- tary of the Department of Health and Human nois! In each case, the Federal GoNernment sought 'Rural towlines ate exempted Irom kgislauun piusticl by Cungrei4 in 1'089 an denim Medo..0 . mmi_rit lot .linii..11 Liborator> vs/ v iw...s it tlo. rcfcmag physician has a financial inieresu in, ot rokeoc; comperts.ttion twin. the awl) thdi priAides thc say i.c. tPtiblik. Law 101 2361 Vnor to 1988. Me Fedaal agcnoes iesponnoic no entoti,ing (he dittainwha% had V.kiaillawc4mil, (6, all-egtn IA alw4111VIteld1.1 1(1%01V/he 40-11Chit medical and surgical hospitals 1 N t ) 186 Health Care in Rural America to prevent the consolidation ota nonprofit hospi- Virginia, and 3 comities of West Virginia. This tals in suburban communities with few acute-care conclusion was based IA the court's finding that the facilities. Both cases were decided in early 1989. In hospitals involved drew a "substantial"' number of the Rockford case, the court found that the merger patients from outside the immediate vicinity. In the violated the antitrust laws; in the Roanoke case, the Rocicford case, the court defined the geographic court held that it did not. Both decisions have since market as the area representing about 90 percent of been upheld by courts of appea1.9 The legal stan- the admissions of the defendant hospitals. Factors dards arising from these conflicting decisions are involved in this decision included: outlined below. the extent to which physicians admitted pa- 1. Product Market DefinitionThe first step in dents to nearby hospitals, merger analysis is the defmition of the relevant usage of the hospitals by non-Rockford patients product markets. In the two recent hospital merger needing specialized care, cases, the relevant product market alleged by the the number of hospitals where individual physi- government was acute inpatient hospital care. Both :fans had admitting privileges, hospital defendants, however, argued that the appro- priate market included both inpatient and outpatient data on patient residence and destination for receiving services, and care provided by all health care providers. The court in the Rockford case adopted the government's the physical geography of the area. narrower market; the court in the Roanoke case 3. Market StructureA third important compo- adopted the defendants' broader market.10 The nent of merger analysis is an assessment of the product market definition was critical to the out- competitive structure of the market and the way the come of both cases. The court's adoption of the merger will alter that structure. This is done by Roanoke hospitals' broad market defmition meant identifying the competitorsinthe market and that more providers (such as outpatient climes, estimatiig the market share of each before and after urgent centers, and even doctors' offices) would be the merger According to the merger guidelines, a viewed as competitors to the merging hospitals, and postmerger projected market share over a threshold that the eliminAion of one of the hospitals would amount" implies concern that the merger may have less competitive impact. The opposite was true violate the antitrust statute. The merger guidelines in Rockford; the court found that beca ise there were used by the courts in the Rockford case. would be fewer hospitals if the merger took place, the loss of even one could have significant anticom- Most of the hospital markets in rural areas are petitive effects. The decision by other courts in the considered to be highly concentrated. This is be- future regarding the appropriate product market cause most rural communities cannot support the definition may have a significant impact on the minimum number of independent hospitals that viability of consolidation as an option for rural must be in a market to keep the market share of hospitals. combined hospitals below the threshold amount.12 Consequently, mergers or acquisitions involving 2. Relevant Geographic MarketThe definition competing hospitals in nonmetropolitan areas will of geographic markets of hospitals is the second often create an apparent violation of the merger element in a nrrger case. The courts in the Rockford guidelines. and Roanoke cases used similar evidence to defme the geographic market, but the results were remarka- 4. Other Factors Affecting Concentration bly different. In the Roanoke case, the court con- Other factors commonly considered by the courts in cluded that the relevant geographic market com- assessing the competitive effeos and the legality of prised 16 counties and 3 iadependent cities of a hospital merger include: tubsequeatlY, in IR* Roanoke case, ike gOvcramcat decided to drop in opposition to the hospital magcr . ifteellaired.Sexes v Health Systeat.1989-1 Trade Cas 68451 (WI) W 1989) ("Roanoke"), United States v Rockford lifentonal ( orp . 089.1 Trade Case 68.462 (N.D.III. 1989) ("Rockford"). line Herr:Maki-Hirschman Index (11111) sums the squares of ea..h competitor's market share A maga may viutaw the antamst statute it the postnIeTgeWfl eceeds 1,800. and if the merger increases the HID t7 SO points 12par extraiple, to keep the postmerger Hill below 1,800. a market would have to have at kast six equally sized hospitals 1 "'s Chapter 7Regulatory and kgalConcerns ft.,- Rural Health Facilities 1e7 Barriers to entryBan lers to entry make acqairing another entity to pay a $20,000 filing fee merger approval less likely. If there are few as part of FTC's premerger notification require- bathers to entry, it is less likely that incumbent ments. For hospital mergers, the filing fee is required hospitals could exercise control of the market. if: State certificate-of-need (CON) regulations and 1. the acquiring entity has at least $100 million in insufficient demand for services render entry by new hospitals unlikely in many rural mar- total assets or net patient revenue, and the other entity has at least $10 million in assets or net kets. patient revenue; and Nature of competition in the marketThe 2. the total value of the assets actually bought in courts in Rockford and Roanoke recognized the acquisition will be at least $15 million. that hospitals generally have been forced to become more competitive; the court concluded in the Rockford case that hospitals in the Medical Staff Credentialing market could benefit by engaging in anticom- Antitrust cases brought against hospitals and their petitive activities (e.g., price fixing) at the medical staffs by physicians who have been denied expense of consumer welfare. medical staff privileges are perhaps the single Financial condition of the merging hospitals largest categor) of antitrust cases involving health If one of the merging hospitals in a market is care providers. In these cases, the issue is whether likely to fail in the near future and is unlikely the hospital and its medical staff conspired to to successfully reorganize under the Bank prevent the excluded physician from competing for ruptcy Act, and there are no less anticompeti- patients needing hospital care. In areas with many tive alternative purchasers, courts may fmd the physicians, the exclusion of a single physician is merger more acceptable (the so-called "failing unlikely to result in an antitrust judgment.13 CaSes 111 company defense"). which the hospital board unilaterally decides for Likelihood that the merger ivtll allot the ,-alid reasons that a pl:y sician should be denied hospitals to achieve efficiencies that could not privileges also generally do nct incur antitrust be obtained individuallyThe procompetitive liability. benefits of certain otherwise unattainable effi- More Usual antitrust cases involve hospitals that ciencies may outweigh the potential anticom- have entered into exclusive contracts with a physi- petidve effects of a merger. The savings from cian or physician group (most commonly for such such efficiencies will vary in eacn case; courts services as anesthesiology, emergency medicine, reviewing mergers have balanced claims for pathology, and radiology). Where the hospital bends efficiencies against the anticipated anticom- to pressure from the medtcal staff to insulate certain petitive effects. practitioners from competition by giving them an Although the legal issues and factual settings in exclusive contract, and where the hospital has a the recent Rockford and Roanoke cases were re- dominant share of the market, it may invite an markably similar, the courts decisions are diametri- andmist action. Rural hospitals are especially sus cally opposed on virtually every major issue. The ceptible to this threat because of their large market legality of any hospital merger inevitably will share. In a Montana case, for example, anesthesiolo- depend on the competitive environment in which the gists on the staff of a hospital that had 84 percent of merging hospitals exist, and at present there are kw the market share for general surgical services had consistent legal guidelines to help hospitals assess threatened to lee e the hospital unless they got an the legality in their specific situations. exclusive contract. The contract resulted in the exclusion of a nurse anesthetist, and the anesthesiol- Recent action by the FTC may inake mole 4.4.$.5tIy ogists subsequently mcreased their annual earnings the mergers and acquisitions of many larger rural by 40 to 50 percent. Given these circumstances, the health care facilities. In late 1989, the FTC began court found that the exclusive t;ontract unreasonably requiring entities (including hospitals) interested in restraine.d dade in;elation of the antitrust laws." 135ocapelaa v. Sisters of Mercy Health Cotp. 621 F. Supp. 1262 (ND. Ind198S). afrd. 800 F 2d 119 t7th Or. 1986) 145 ec 0112 v. St. Peter's Cootomnity Hospital. 1988.2 Trade Ot.s. (C CH ) 68.34S (9th Or 1988) 1 a 188 Health Care in Rural America The argument that a competing physician was may require SNFs to have their own nurses' excluded based on review of that physician's record station apart from the hospital's acute-care by the hospital medical staff is not always a nurses'station. Medicare certification also successful defense, even in a State with a statute generally requires hospital SNFs to remain encouraging such peer review. In an Oregon case distinct units with sc irate b eds and staff. involving this issue (see Patrick v. Burget, 108 S.Ct. Complying with such standards may result in 1658 (1988)), the Supreme Court b.."it the State both SNF and acute-care nursing staff being of Oregon did not actively supe evi underused, especially in small rural hospitals activities, nor did it have a mechati, .- whose acute-care census is low. ing inappropriate peer review decisio. .nerefore, Personnel trainin8 requirementsSome the Court concluded, such activities were not States Limit the use of multiskilled allied health immune from antitrust challenge. care personnel. Many rural hospitals incur higher costs because they must, according to Joint Ventures State &ensure laws (and Medicare conditions Hospitals that have a very large market share for of participation), employ several full-tirne mdi- hospital services in a particular area may be in joint viduals to perform tasks that a single profes- ventures (e.g., for provision of home medical sional could do if appropriately trained and equipment) that effectively limit competition by licensed. suppliers not included in the ventures. Likewise, a Higher license feesCertain States reportedly group of rural physicians who account for a majority have instituted significant increases in fees for of the physicians in a particular community may face facility licenses, CON apphcations, and other antitrust risks associated with joint ventures. Agree- business requirements for health care facilities. ments with joint venture partners to refer all patients These fees are proportionately more difficult for durable medical equipment or home health to the for small providers than for large providers to venture, for example, may have antitrust implica- pay. tions. 11W.; is known about the costs these regulations entail, and what impact they have on rural hospital STATE ISSUES efforts to preserve quality of care, maintain opera- Facility Licensure tions, and adapt to environmental changes. Where States have made substantial changes in State licensure standards are intended to ensure response to rural hospital concerns, hospitals may that patients using licensed facilities will be pro- still be faced with incompatible Federal certification vided care of at least a minimum level of safety and regulationsThe State of Montana recently re- quality. (In addition to receiving State hcensure, quested a waiver of Medicave conditions of i artici- facilities wishing to be certified by Medicare and pation and certain reimbursement policies from Medicaid, as noted earlier, must meet standards set HCFA that would permit the State to create a new by JCABO or State licensing agencies mandated class of rural facilities (medical assistance facilities) under Medicare conditions of participation.) These as an alternative to a rural hospital (see ch. 8). standards, however, may sometimes mhibn rural Changes in State licensure laws are sufficient to hospitals from undertaking some activities to en- permit such facilities to function, but changes in hance their snrvival. Melicare certification requirements are probably Operating room requirementsStates gener- necessary to make them financially viable. ally require all licensed hospitals to have fully equipped operating rooms. Even if a small rural Certificate-of-Need Requirements hospital no longer performs surgeries due to declines in demand and availability of sur- la 1972, the Federal Government required States geons, it must continue to maintain surgical to begin instituting CON progams to more effec- facilities and staff. tively control health care capital expenditures and Hospital-based SNF requirememsSome State other medical costs. In general, CON was seen as a licensure laws pertaining to hospital-based way of limiting unnecessary investment by hospitals skilled nursing facilities ("distinct part S:4Fs") an6 other health facilities in new beds, plant, and I ')9 Chapter 7Regulatory and Legal Concerns for Rural Health Facilities 189 equipment. States were required to establish health petition suppo:t CON efforts and other restrictions planning agencies to conduct CON reviews ofhealdi that prevent other facilities from expanding. facility capital projects, and develop regional plans A few States have amended (or are currently for rationally allocating and distributing limited considering amending) their CON laws to enable resources and ser 'ices (Public Law 93-641). In rural hospitals to more easily diversify into new 1987, Federal reqwements for State health planning services or to convert to alternatively lictnsed health and CON review were repealed. care facilities. For example, some States have raised With the el i of Fzderal oversight, many States the CON review thresholds for certain capital have modified or eliminated their CON laws. A 1989 expenditures. Others have exempted certain projects survey found that 11 States have eliminated their or facilities from CON review altogether. Other CON programs. In addition, some States have (or are States now allow qualified niral hospitals to convert considering) CON laws that exempt certain facilities up to a certain number of acute-care beds to and services from review (.'I). A number of States swing-bed status without CON review (see ch. 6) without CON laws are limiting expansion in other (440,450). ways (e.g., through moratoria) on certain new services. Only seven States have no limits at all on Property Tax Laws the numbers of skilled nursing, swing, rehabilitation, Requuements for exemption from State and local psychiatric, and alcohol/drug treat meat beds in property tax law s generally are more restrictive than general acute-care hospitals (474). conditions for exemption from Federal income tax. Only 17 States and the District of Columbia have State mechanisms to limit expansion may conflict enacted laws that expressly recognize the delivery of with survival strategies of rural hospitals. For hospital care by a nonprofit entity as sufficient for example, a State with a moratorium on new SNF property tax exemption. State and local laws typi- beds might not permit a mral hospital to convert cally require a property to be owned by a charitable unused acute-care beds to long-term beds if the organization and to be used exclusively for charita- statewide supply of SNF beds is already at the ble purposes. Under States having "all-or-nothing" regulatory limit.15 Many health facilities view CON requi.ements, use of any part of a property for thresholds for capital expenditures (the minimum nonexempt purposes or on behalf of nonexempt expenditure levels at which the CON review and persons renders the entire property subject to tax. approval process is invoked) as too low and the Many States, however, permit proration of a prop- related application process too burdensome and erty between exempt and nonexempt portions for tax lengthy, threatening their access to capital. purposes. Also, some States make swing-bed conversions In addition, many State and local legislative, contingent on a hospital's acute-bed '..apacity or the administrative, and judicialinitiatives have re- availability of nursing home beds in the area. sponded to needs for increased revenues, and Kentucky, for instance, places linuts on hospital complaints by small businesses of =fair competi- Medicaid participation by restricting the number of tion from the nonprofit sector, by proposing to swing-beds in a hospital to 25 beds or 1) percent of revoke tax exemptions. Recent challenges tt plop- the hospital's acute-bed came* (whichever is erty tax exemption have been mounted in California, greatest), but not to exceed 40 percent of acute-bed Missouri, Pennsyh Tennessee, lexas, Utah, capacity (474). and Vermont (202,271). Charitable organizations have been challenged to justify their exemption by On the other hand, CON in some States may sene showing public benefits piov ided, such a.sthe to maintath the continued existence of some rural amount and availability of uncompensated 4_,tie '6 facilities and seivices by giving them special consid- Following et recent Utah dewsits, local tax. g eration. Many rural facilities concerned about com. authoritiesin several States have attempted to uMoratonaon addmonal 5NF peof, m many Statftoften atinbtacd. fapan.to diunaby fauna%lekanc.) to pu_vent ,umpo.utiva humjAtit. %Alt hospitals providisqc iong-tam csreservices (474) i65 ee UtahCounty V. Intermountain Heakhore In... 709 P d 2ss(UtahI9e5 0.AndMedkul Center Hospita of I ernlom Cay of Burlington.No. 87-801: Oct 13. 1989. t) 190Health Care in Rural America revoke property tax exemptions held by sc...e nonprofit hospitals within their jurisdictions. In some States, hospitals have agreed to donate cash and services in lieu of paying property taxes (397). Proposals have also been made that would require r payments to local governments to cover costs for nty ' NO TSCou municipal services (467). inS AINHealth Services Ib date, such actions have been primarily in urban HOSPITAL araas. This may be because the community benefits provided by a rural hospital are more readily apparent to local trxing authorities. But loss of exemption from property tax is nonetheless an ominous spectre for rural hospitals, particularly those with a shaky financial foundation. Photo crodt: Po* Beeson Public Hospital Issues Clue tostateenabling statutes, most publicly owned hospitals face strict limits on III& :Ability to diversify Rural government-owned hospitals, whether enti- services and opmpeto for patients. ties of a county, district, township, or other munici- pal authority, are confronted by State statutory, general (see Ala. AGO 82-00510) provides that a judicial, and constitutional impediments to their public hospital has no clear authority to pay a ability to diversify and engage in joint ventures. physician interest-free loans or income guarantees. Statutory Restraints on Diversification A 1985 Georgia court decision concluded that a county hospital did not have the power to operate a Rural public hospitals, like public hospitals gen- durable medical equipment business (406). erally, are creatures of their enabling statutes. Public hospital enabling acts are, almost without excepdon, strictly construed by State courts and attorneys Statutory Restraints on Competition general. The single most important restriction on the ability of public hospitals to diversify and to provide Rural public hospitals are also confronted by the a full range of health care and nonhealth related following statutory barriers to competition arising services is based on State court interpretations of out of their restrictive enabling acts. "Dillon's Rule," which reads as follows: Local goveraments have only those powers spe- ExtraletritorialityAlmost without exception, cifically panted by eonstitution or statute or neces- publk hospital enabling acts prohibit mumcipal sarily arising by implications from the expretsed corporations or political subdivisions from exercis- powers (177). ing any authority, or owning or operating any The impact of this restrictive rule on pubhc property or business, outside of the geographical territory in which they are empowered to operate. hospitals is considerable. As a result of this rule, a public hospital may engage in a specified activity For example, a hospital district wishing to establish only if its enabling act expressly empowers it to do a physician satellite clinic outside the boundaries of the district would probably lose a court challenge to so. But, because most public hospital enabling acts this action. This effective4 precludes the h .1 were drafted decades ago (often before the 1940s), the services empowered by their statutes are very from capturing primaty and secondary t..are pdnents limited. Thus, for example, many public hospitals outside of the limiled service area. are unable to own or operate a durable medical Board CompositionMoat public hospital ena- equipment company or provide nonacute care serv- bling acis expressly limit the number and types of ices. individuals who may serve on the board of the public State courts typically resolve any doubts about hospital. They often prohibit medical staff members, whether such powers exist against the hospital. For persons who do not reside withinthebounwries of example, a 1982 opinion of the Alabama attorney the municipality vi political subdivision, and public rs 4, t Chapter 7Regulatory and legal Conceras for Rural Health Facilities 191 hospital employees from serv ing on the board." Public Bidding Lap,sAlmobt every State has a Such resttictions may make it difficult for some mai competitive bidding process that is applicable to public hospitalsto fmd trustees know ledgeable public hospitals. The considerable delay and ex about hospital and health care issues. pense generated by these statutes may impede or prevent rural public hospital administrators from Public Disclosure LawsMost States have pub- reacting to changing market conditions in their lic disclosure laws that require public bodies, purchase of property and services. including government-owned hospitals,to hold Judicial Restraints open meetings and provide the public access to numerous records of the public body. Although Decisions by public hospitals concerning the these laws serve this purpose well, they als I may credentials of medical staff are reviewed by State place public hospitalsat a severe competitive courts, both to review the hospital's compliance with disadvantage. In a rural area with more than one the bylaws procedures and to affirm the underlying hospital, a public hospital is disadvantafied by merits of the decision. In contrast, so long as a having sensitive business plans reported on the private hospital follows the procedural guidelines evening news or heralded on the front page of the set forth in its medical staff bylaws, courts in most local newspaper. In 1986, the California Legislature States will not step in to second-guess the substan . addressed this problem by amending the State's tive decision of those hospitals. Hospital District Law to enable a i:istrict I ospital Constitutio nal Restraints board to order a closed session to discuss or deliberate on hospital "trade secrets" where neces- Almosi overy State constimtion prohibits munici- sary to initiate a new hospital service or program that pal corporations, including public hospitals, from would, if prematurely disclosed, create a "substan- owning stock or serving as a parmer with a private tial probability of depriving the hospital of a entity. This prohibition arises out of States' concerns substantial economic benefit." 8 about the commingling of public with private funds, and the potential "gift" of tax dollars that would enrich private individuals. Such absolute prohibition Certificate-of-Need LawsPublic hospitals typi- from equity ownership precludes almost all types of cally are not empowered by their enabling acts to joint ventures between public hospitals and physi- engage in the corporate restructurings that might be cians or private hospitals. Thus, a method used used to circumvent CON review of a major project successfully by private hospitals to encourage closer in many States. The ability of private hospital relations between hospitals and physicians and to competitors to do so thus may give them an access additional sources of capitalisusually important competitive advantage over public hospi- unavailable to public hospitals. tals. Possible Solutions Investment RestrictiansMany State enabling Amendments of State public hospital enabling acts place severe limitations on the types of inv est acts and whet statutes may .ud public hospital efforts ments in which public hospitals may place their to expand their scope and array of dal% Hies to funds. For example, the Illinois Inv estment of Public .nhance their surviv al. Also, borne public hospitals Funds Act prohibits public entities from owning have created "parent subsidiary" or "brother stock for investment purposes." In Alabama, publk. aisle.multicorporate structures to avoid statutory hospitals may only invest in "direct obligations of and constitutional ,.onstraints. These panial wiz, the United States."2° Restrictions of this kind lions. however..ue not without their own problems. protect the public purse but also prevent pubIi First, it may be unclear w hether the newly created hospitals from placing hospital funds in higher affiliate can be capitalized by the governmental interest-yielding investments. body without violating the State constitutional 175ee, e.g.. Mkhigan Op. Atty. Gen No. 6067. p 646 0982/ °See California Health and Safety Code. Secdon 32106 Ince Illinois, Rev. Stat. eh. 85 § 2401 el seq (1983) 21)See Alabama Code § 22.21.77(15) (1989). 4" N t - 1 192 Health Care in Rural America prohibition on "public gifts." Second, the greater interests; or if it receives substantial income from the control by the governmental body over the any business not related in a major way to the affiliate, the greater the likelihood that (for regula- hospital's charitable activities (e.g., sharing man- tory puiposes) such transactions will be considered agement s...rvices). In a time when many hospitals improper. The adoption of these structures is clearly are con.3idering participating in shared service coop- not without legal risk. eratives and diversifying into new services, the similar limits that apply to these ventures may A third issue involvmg public hospitals has been inhibit hospitals from carrying out such strategies. a national movement toward allowing public hospi- Nearly one-half of rural hospitals are private non- tals, through State enabling azt amendments, to profit institutions, and loss of tax exemption for "convert" to private, nonprofit status by selling or many would further weaken their financial condi- teasing all of the public hospitalsassets and tion. operations to newly created nonprofit corporations. Once legal authority to "convert" exists, the me- Some referral practitcs that rural hospitals chanics of conversion must be investigated. One of might undertake to maintain their panent base and the major concerns in any public hospital conversion retain physicians may be subject to Federal anti- is the degree to which the nonprofit entity that kickback regulations.Because many providers operates the hospital will be accountable to the consider the scope of antikickback rules to be vague, public after the conversion. Public concerns may certain practices deemed to be "safe harbors" under include potential reduction of services, reduction or the law have been proposed by DHHS. Uncertainty elimination of uncompensated care, and unreasona- remains, however, over the legality of many prac- ble "inside deals" between the public body and the tices such as physician investment in hospital- new nonprofit hospital board, These concerns must physician joint ventures, physician ownership of be addressed expressly in either the lease or sales hospitals, and hospital purchase of physician prac- agreement between the public body and the new tices. hospital corporation, or in the new hospital corpora. Hospitalmergers and physician relations are non's articles and bylaws. now facing greater scrutiny under Federal anti- trust laws.The legality o f any merger depends on the SUMMARY OF FINDINGS specific competitive environment of the merging Federal and State laws and reguk,ns governing hospitals. Legal decisions regarding Federal efforts delivery of services have created a number of to regulate hospital mergers, however, have brought concerns for rural providers. opposing results even in factually similar cases, perpetuating the uncertainty in many hospital mar- Some State licensure rules and Medicare partici- kets. pation requirements tire seen as in'ibiting opera- 'ions and strategies for effectivechange. Many Federal performance and certification Van- rural hospitals, especially smaller ones in more dards for some rural clinics are seen as inappropri- remote settings, argue that standards for minimum ate or overly burdensome.Some small federally staffmg and service requirements are impractical to funded CHCs, especially in remote areas, believe follow, because staff are unavailable, too costly, or Federal performance standards governing adminis- cannot be justified due to insufficient patient de- trative and clinical operations of allCHCsare mand Some recent State efforts (e.g., in Montana) to :ifelevant or too inflexible for their environments. alter licensure rulesfor struggling hospitalsin Rural centers wishing to become certified rural isolated rural areas may face Medicare certification health clinics believe the process of certification is requirements that cannot accommodate anything unduly long, complex, and sometimes impractical. less than a full-service, acute-care facility. State CON rule.s and other lews that place limits Eligibility requirewnts for Federal tax exemp- on the number of new long-term care beds are tion are seen as endangering some surival strate- sometimes seen as preventing rural hospitals from gies of rural hospitals.A rural nonpr '.it hospital's converting away from acute care.Such restncuons exemption from Federal income tax is "- atenci if in all but a few States are believed by some rural it offers incentives to auract physicians that mt.,' be hospitals to restrict conversions of excess acute care seen as unduly furthering the physician 0,ate beds to nonacute or other spet.aalty cam beds. Some 2.13 Chapter 7Regulatory and Legal Concerns for Rural Health Facilities 193 States, howevet, have changed their CON laws to prohibit A public hvspital's operation of related allow hospitals to more easily convert beds or businesses; diversify into new servicois. limit operations to r Ted& service area; State anr1 local property tax exemptions for limit tiustees to residence in a specific area hospitals and other providers are facing greater (possibly restricting the hospital's ability to ccrutiny. At least seven States recently have chal- fmd qualified governance); lenged property tax exemptions oi hospitals and require public disclosure of sensitive business other providers. Loss of tax exemption might further and marketing strategies; and endanger the fmancial v lability of some small rural place other restrictions on investments, medical ft .:lities. staff credentialing, and joint ventures. Rural public hospitals face strkt limits on their Solutions being t-onsidered byStates to these ability to diversify and compete. Strict State ena, restraints on public hospital acti4, it) .1.7t not without bling acts and constitutional provisions are seen .is ritk. For example, States that allow publil. hospitals inhibiting survival efforts of rural publk hospitals to restnicture L.) private, nonprofit corporation status when they: may lessen the hospital's public accountability. r ); 4.:t -2 Chapter 8 Collaborative Opportunities Between Rural Health Facilities and Government 205 CONTENTS Page INTRODUCTION 197 DETERMINING A STANDARD OF SERVICES FOR RURAL COMMUNITIES 197 Washington: Five Health Service Groups 197 Utah: Basic Needs 198 CREATION OF ALTERNATIVELY LICENSED FACILITIES IN RURAL AREAS 199 Montana 200 California 201 Colorado 202 Initiatives in Other States 202 Comparison of State Efforts 203 Recent National Developments 204 STATE-PROMOTED INTEGRATION OF SER VICES 204 LOCAL TAX INITIATIVES 205 SUMMARY OF FINDINGS 206 Tables Table Page 8-1. Bask Health Services for Rural Areas (Washington State) 198 8-2. Recommended Health Services by Size of Community (Utah) 199 2 :18 Chapter 8 Collaborative Opportunities Between Rural Health Facilities and Government 11==.1 111111 INTRODUCTION At least two States have developed conceptual frameworks of basic services and delivery models In recent years, many rural health care facilities that should exist in rural communities. THese have found that their prospects ..or survival are frameworks, described below, address such funda- enhanced by working with Federal, State, and local mental questions as: governments interested in developing new ap- proachea to improve facilities and services. This Current scopeWhatare the scope, volume, chapter will first discuss efforts by some States to purpose, and effectiveness of services now conceptualize an appropriate or minimally accepta- being delivered? Who is delivering them? ble array of services for rural communities. Second, AppropriatenessAre the servicesappropriate the chapter examines work by some States, and more for the current and expected level of demand recently die Federal Government, to develop alter- and community capability to support them? native delivery models for rural facilities. These Are they meeting basic health needs? Have the efforts focus mostly on redefining what is meant by community's perceptions and feelings been a "hospital" and rearranging the existing regulatory adequately understood and addressed? framework to enable rural hospitalsespecially Facilitylconununity cooperationArelocal fa- those that are financially troubled or are the only cilities doing enough to deliver appropriate local facilityto have a structure more appropriate services, assure their accessibllity and quality, to local needs and capabilities. Next, it offe:s some and control costs? Would the community be unique examples by States to support the integration willing to accept the loss of certain services it of health services by rual facilities. Finally, the could no longer support? chapter examines how some local governments in Maintaining accessCanlocal facilities con- rural areas are finding ways to provide sorely needed tinue to meet their traditional obligations to the tax support to area facilities. poor and underserved? If so, how? If not, who will? DETERMINING A STANDARD Changing missionShocldthe hospital or OF SERVICES FOR RURAL other local health care facility shift some or all of its resources to other services or business COMMUNITIES activities? Ideally, the development of services and facihties Facility organizationShould areafacilities that reflect local needs and conditions begins by continue to operate independently or should determining the essential service requirements of a they engage in cooperative arrangements with community. This task is not an easy one. Each rural other providers? Is the community willing to community has its unique set of service delivery relinquish any or all control over the delivery of problems, resources, and priorifies. Some small local services? hospitals, struggling with declining utilization and Washington: Five Health Service Groups poor operating margins, have considered severely limiting their scope of serv ices. But for sole commu The Washington Ruial Healtls Care Commission, irty providers serving wide and sparsely settled as part of a 1989 report to the State legislature that geographic areas with few health care alternatives, examined way s of maintaining and imps's. isig ac determining what services can be eliminated is cm to care for rural residents, identified five levels difficult. Community health centers (CHC) have of bask health services to reflect the range of servke traditionally been a major source of comprehensive resources that should be available in most rural primaty care for the poor, but many CHCs fas..e areas. Basic ,,ci vices are divided into five priority iris7reasing demands for uncompensated care (see ch. groupings ("bands") that repre.ient levels of patient 5) that may require them, too, to rethink. the stope of immediacy or use and complei,ity of patient ..ondi- services they can afford to provide. dons and care (table 8-1). The five bands are- -197- ) I.-,i 198 Health Care in Rural America Table 8-1Basic Health Services tor Rural Areas (Washington State) Bend 1-1prevent death, disability, serious illness Band 3-11mM-toms Lapetient madhouse health 24-hour emergency medical services (first Home health services responder/emergency medical technician) Visiting nurse Stabilization Medical services Communications Selected Ocute short-term hospital services Air to ground anbulance transport Acute conditions (e.g.. pneumonia, gastroenteritis, and certain accidents) Essential pant health services Childbirth services (level 1) Environmental services monitoring and Selected acute alternative facility trvicesa response Perrona1 health services monitoring and Bend 4--cammemity-besee care for Chronic conditions response Mental health services Evaluation Primary care (e.g., provided by a physician or s Mental health consultation midlevel practitioner) including: Psychological therapy Routine health maintenance tong-term care services Prevention Communit7-based care (e.g.. et-re services. Care for acute conditions home meals, adult day health) s Prenatal care 9 Supervised Living. boarding housing, respite care Mental health Skilled and intermediate nursing far lties s Crisis intervention Substance abuse and chemical dependency Counseling Bend 2.-nesessamy support services for band 1 Treatment referral Diegnostic services Bend 5--other services X.-ray: extremities, chest; fluoroscopy; Dental care ultrasound Routine examination, mechanical cleaning. Laboratory: chemistries. urines, blood, fluoridation bacteeology Vlsion and hearing care Other. %wises at same level of complexity Hospice care and aemand Other treatment modalities NOTE: The first band of services contains the most emergent services as well as those services of greatest. Use. 2Would be developed thtlugh changes in State Licensure starlards. SOURCE. Washington Rural Health Care Commission, A Report to the Legislature on Rural Health Care in the State of Washington (Olympia. WA: January 1989). 1. those services most critical to survival or most the primacy of prevent: .g death, disability, or often utilized (e.g., emergency and primary serious injury; care services); the need for immediate diagnosis or treatment 2. basic diagnostic support services, to prevent illness or injury from becoming more 3. an essential core of basic acnte care and home serious and more costly or difficult to treat; health services; the need for medical monitoring to prevent disability or injury; 4. community-based care for chronic conditions; and the need to prevent conditions from occurring that would threaten the health of the general 5. services that help residents in larger populated population; rural areas stay within the community for care. the length of time a health condition can exist This model acsumes that, for certain levels of care, before irtaiment is needed; and providers must use referral arrangements and coop- the physical, psychological, emcional, fman- erative agreements to ensure continued access to cial, and time advantages to community and needed services. Only larger rural communities providers of having certain services locally could afford to provide services in all five bands. available(714). Utah: Basic Needs When assigning services to the bands, the Com- mission applied certain criteria to determine the The Utah Department of Health has outlined a :4 degree of urgency and appropriateness for the of minimum health sen,kes that should be available service. These included: to small communities in sparsely populated or A anali. ' .)*" Chapter 8Collaborans,. Opportunities Between Rural Health Faalities and Government 199 Table 0-2Recommended Health Se. vices by Size of Community (Utah) Population/ Emergency med.-el SpscialtY service area services Primary erre Ca7.0 Hospitalization Fewer than 500 First responder Intermittent MLP or MD by Referral Referral persons EMT appointment Sateliite/part-time clinic: EMT supervision vi* tele- communication and written protocol 500-900 EMT Full-time MLp or port-tis.e MD Referral or Referral persons first responder Arrangement for emergency periodic network in coverage and EMT supervision arrangement in outlying areas the community 900-1,500 EMT Full-time MD or M1,12, or Referral or Referral and persons first responder combination full and part-time periodic infirmary network group practice arrangement in model Emergency coverage and EMT the community supervision 1,500-4,000+ EMT Small group practice: 0n-site full-time Small community persons first responder combination of MD and/or MLP, regularly hospital or network medical specialists (MD/MLP); scheduled clinic infirmary IM,PED or OD, CNM es determined within primary referral by community need; care prectice Emergency coverage and EMT Referral supervision ADERFVIATIONS. CHM certified nurse midwife. EMTemergency medical technician, IM Internist, MO moditoi doctor; MLP tAdlevel practitioner; OB obstetrician: PED pediatrician. SOURCE. G. Elision, "Frontier A,eas. Problems for Delivery of Health Care Services, Rural Health Care 1, September/October 1986 (newsletter of the National Rural Health Association. Kansas City. MO) frontier areas (table8-2). Its recommendation* by experimenting with the development of new specify that emergency medical personnel would be models of health care facilities that require .hanges the first responders in all small communities, with in State 1i...ensure rules. Must of these ilteniati% e regular primary care by a midlevel practitioner or modelsfk., on strengthening underutilized and physician made available in communities of at least financially unstable small, isolated rural hospitals 500 persons. Specialty care in most small commum, Implementation of these models (typkally by "dow-n ties would be available only through our-of-area sizing" existing hospital ,:apacity and services) is referral or through arrangements under whkh out . intended to ensure access to basic acute and emer- side providers periodically conduct local clinks. In gency care without burdening the facility with the some cases, hospital care could be provided in requirements of a full-service hospital. communities of 1,500 to 4,000 or more persons (183). Efforts to develop alternative delivery models for niral hospitals have a relatively brief history. In the CREATION OF ALTERNATWELY early 1970s, the U.S. Department of Health, Educa- LICENSED FACILITIES IN tion and Welfare (DHEW)now the Department of Health and Human Services (DHHS)perini- RURAL AREAS about 150 hospitals to waive the Medicare require- Desinte their conceptual importanct, State at- ment that a registered nurse supervisor must be at the tempts to define minimum service g for rural hospital 24 hours a day..Most of these hospitals were health care have not directly affected rural a. as. A in remote areas and served as sole local health care few States have recently begun to intervene more providers. In 1973, DHEW stud; ki the feasibility of directly m the structure of basic rural health serv ices establishing a new category cf "limited seri, ice " . , ' 200 Health Care in Rural America rural hospitals that would be small, isolated, and reapply for it. (Other Montana hospitals are no limit their services to the capabilities of the staff and longer subject to CON regulation (377)4 facility. The study concluded that implementation of The new category of health facility la as de.signed the classification would be difficult on a national primarily to give underutilized small rural hospitals scale, as some States might be unwilling or unable the 02tion of reducing the scope of their operations to make the licensure and other regulatchry changes to provide only low-intensity, short-stay acute care. necessary to adapt to the new Medicare participation Hospitals currently targeted for MAP status appear requirements (352). to be no longer viable as full-service acute-care Ibday, the Opposite situation exists Some States facilities. (The majority have closed their acute-care have been considering redefining rural facilities, but units and provide mostly long-term care services they have no assurance of any parallel change in (377)). Interviews with residents in counties of Federal regulations. Many current State efforts to prospective MAFs found widespread support for the develop alternative facility models would require idea (377,399). However, as of lune 1990,ho Federal permission to waive certain Medicare and hospitals had converted to MAFs, in part because of Medicaid participation requirements in order to the uncertainty of obtain ng the Federal waiver that receive payment from these sources. Described would enable them to receive Medicare and Medi- below are activities underway in Montana, Califor- caid payments (377). nia, and Colorado, followed by brief mention of new In 1988, the Montana Hospital Research and 1 censure laws in Florida and Wyommg that have not Education Foundation (MHREF) sought coopera- 'leen fully implemented. tion and support from the Health Care Financing Administration (HCFA) to further develop the MAF Montana idea. HCFA initially awarded MI-IREF a 1-year planning grant and evaluative support to enhance the In 1987, the Montana Legislature, with support MAF design and refine ideas for its demonstration. from the Montana Hospital Association, created a However, HCFA made no assurances about whether new licensure category of health facility called a it would eventually approve the waivers of Medicare Medical Assistance Facility (MAP). An MAF, as conditions of participation that would make the new defmed by State law, is a health care institution that facilities eligible for payment. Under a demonstra- provides inpatient care to persons needing care for tion project, as proposed by MHREF, three hospitals no longer than 96 hours, or to those requiring cart (two that already have closed acute-cxe units) prior to transportation to a hospital. Such a facility would i)articipate as MAFs, and six hospitals would must be located either in a county with six or fewer serve as comparison sites (377).1 To evaluate the persons per square mile ("frontier" area) or more potential success of MAFs, MHREF contracted with than 35 miles from the nearest hospital. At least oct various parties to examine: physician must staff the facility with assistance from one or more physician assistants or nurse practition- licensure and certification standaids for facili- ers, and the physician must be phy sically present in ties and professionals, including ehgibility for the MAF at leastice every 30 days. Proposed participation (e.g., whether providers other administrative ruk state that each MAF must than rural hospitals should also be eligible), provide a minimum set of nursing, pharmaceutical, staffing requirements (what types of staff laboratory, food, dietary, and emergency semices. should be required on-site for what time The MAP is also required to have equality assurance schedule); program that includes routine re ,. iew of pat:ent beneficiary acueptame of the new service utilization and the facility's health care policies. model; Under the above guidelines, 17 of the State's 56 model acceptance by eligible facilities, and the hospitals would be eligible to become MAFs. In fmancial implications of facilities becoming order to convert to MAF status, a facility must MAFs; receive certificate-of-need (CON) approval, and it ciseurvaliiceoscfocareacnodpe must surrender its hospital livmse with the option to nucern;s; I ITU six companson sites may convert to MAF statuS dorms the tune of the demonsuatton only of thesr dome is imminent L 2 1 0 Chapter 8Collaborative Oppornmates Between Rural Health Fat limes and Government 201 institutional liability issues; and ing care for up to 96 hours, and patient transfer possible Medicare and Medicaid reimburse- to a hospital if necessary; ment schemes and their impact on facility basic ambulatory care, limited to nonemergent profitability(377 ,524). diagnosis and treatment, minor surgeries re- quiring local anesthesia, and obstetric care for In 1989, ivIHREF, as part of its request fur 4 y ear prenatal and postpartum conditions (these serv - funding of a full MAF demonstration, asked HCFA ices may be provided through the emergency to waive. 1) Medicare's conditions of participation service component if they will replicate similar and requirements for prospective reimbursement, soy ices already available in the area), and 2) conflict of interest iules that would prohibit basic lab and radiology serv ices, kncluding Peer Review Organizations (PROs) from helping simple urinalyses, blood c..ounts, and bask MAFs to develop quality assurance programs.2 In x-rays; and September 1989, HCFA approved continuation appropriate suppurt sy stems suchASdietary and funding of the MAF project for1 year (377). pharmaceutical serv ice s, an d protocols for qual- MHREF expected to receive approv al of its waiver ity assurance and utilization review. requests in mid-1990, allowing all MAFs to begin operating by fall of the year(377). Model hospitals choosing to provide only the core services would face the most lenient facility, staff- ing, and peer review requirements, and they would California be expected to show the greatest savings in fixed costs. As an opOon, model facilities could supple- In 1988, the ....ifornia Legislature passed a law ment we requiret; core services with additional, (117) panting broad authority to the State Depart- more specialized services to meet the specific needs ment of Health Services to study ways to facilitate of their communities. These might include expanded the development of new delivery models for rural inpatient services (for acute care longer than 96 hospitals. The Departrieat was given three rharges hours), expanded obstetric and radiology services, First,it was to undertake a comprehensive as- and selected inpatient and outpatient surgical sen- sessment of reetatory requirements applizable to ices027).The level of regulatory oversight would small and rural hospitals (up to 76 acute-care beds increase with the service scope of the facility. and located in areas with 15,000 or fewer residents3). Second, it was to institute emergency regulations Guidelines for eligibility currently being consid- that waive or modify existing regulations found to be ered allow only certain mral acute-care hospitals to unreasonably burdepsome or inapplicable to rural participate as new model facilitks. Eligible hospi- hospitals, including licensure requirements. And tals would be small (e.g., have an average daily third, a was to conduct pilot projects in small and census of 10 or fewer acute-care patients) and rural hospitals using alternative rural hospital stand- typically would be the sole acute-care providers in ards and models. their communities. They would maintain their li- censes as hospitals and be encouraged to provide In accordance with the law, the health department subacute skilled nursing care (with swing beds or a is creating a new model design that pros ides distinct-part skilled nursing facilit)). Hospitals also regulatory relief for mral hospitals and is based on would have to have the support of their board and local needs foi an essential, core group of services medical staff to participate as a demonstration site, These core services include. and they would be required to develop a quality standby emergency medical services, with 24- assurance plan(427). hour coven4e by a physician or midlevel In 1989, three hospitals %%ere initially proposed by practitioner; the California Department of Health for designation basic patitat holding and stabilization capacity and demonstration as alternative model facilities offering short-term inpatient medical and nurs- (An estimatxl 25 sites have been targeted ) Two of *I:MEP has requested that MAFs be paid initially on the basis of reasonable costs 000 Conflivt of merest rak s do not allow PRch tocontract sepandely weth hospitals to provide support cc g., assistance *.di preadmission review) if they arc already requind K conduo peer rev Pew Ind nionnor the facility's quality of cart. MIIREP has requeated that PROs be allowed to enter into such contracts 30ther conditions of eligibihty also exist (117) 202 Health Care in Rural America the three agreed to participate and reduce their referrals and other service needs. Tb ensure availa- services to a level comparable to the model's core bility of inpatient accommodations for emergency and expanded service restrictions. Hypothetical care, the facilities must have no more than six beds financial analyses indicated that both hospitals to stabilize and hold patients for un to 72 hours. A would be fiscally solvent under the alternative physician is required to be availatde by telephone model. Because the hospitals would not imme- and to reside within 15 minutes travel time, and diately be expected to ma'-ignificant staffing 24-hour skilled nursing coverage must be available changes (in order to limit locai economic upheaval) on-site. Minimal laboratory and dietary services are or to make physical changes in the facility, the also required. CCEC regulations waive many hospi- Department believed it would not be necessaiy tor tal facility standards, requiring facilities to operate them to obtain waivers of Medicare's conditions of much like small clinics and making them an participation (427). attractive form of service provisior for providers other than hospitals (391,524). However, a Federal waiver would still be required if the 96-hour length-of-stay limit was applied. To Much of the effort to promote provider interest resolve this situation, the Department decided to use and participation in the CCEC model appears to a facility's admissions criteria (i.e., the type of have been futile because of the lack of any involve- patients seen as (*tilted by the facility's licensed ment or support by HCFA. Thus far, the agency has mix of services) as a de facto measure of service shown no interest in certifying CCECs for Medicare intensity (285). Initial analyses suggested that use of and Medicaid participation and reimbursement, the length-of-stay limitation may not have been limiting the usefulness of this designation. As of necessary in most cases. For those targeted hoLpitals 1989, only five CCECs had been certified, four of that already had "downsized" operations and were which were CHCs or nursing homes (which must concentrating on providing essential services, about rely on private insurance for reimbursement). NJ 85 percent of all patients wcre discharged within 96 hospitals have become CCECs (524). Little informa- hours (427). tion is available on the performance of CCECs, or on whether the State plans to make any changes to In late 1989, the health department recommended that the State create a pilot project to test the encourage greater involveincnt from rural facilities and the Federal Government. alternative rural hospital model, providing regula- tory relief and technical assistance to participating Initiatives in Other Slates facilities (427). A fmal report, stating whether modified regulations and the alternative models Florida should become permanent, is due to the State Based on recrmmendations of a 1987 study of the legislature in 1993 (/17). problems facing rural hospitals in the State, the Colorado Florida Legislature in 1988 designated 27 small rural hospitals4 to receive special consideration In 1986, the State of Colorado developed a new under State regulations (e.g., receipt of Medicaid licensure category for rural providers calik,d Com- reimbursement for swing-bed care, exemption from munity Clinic/Emergency Centers (CCECs). CCECs budget review by the State's Hospital Cost Contain- are defmed by regulation as health care institutions ment Board) (478). in 1989, State lawmakers, "planned, organized, operated and maintained to intending to further help these hospitals, created an provide basic community facilNes and services for alternative licensure category for rural facilities the diagnosis and treatment of individuals requiring called Emergency Care Hospitals (ECHs) (195). The outpatient service and inpatient care, including ECH, modeled after Montana's MAFs, would pro- inpatient accommodations for emergency care" vide emergency care and routine inpatient services (Code of Colorado regulations 6 CCR 1011.1). for up to 96 hours under the care of a physician or CCECs provide only emergency and outpatient midlevel practitioner. In addition, basic diagnostic services, but they must have a written affdiation with services, primary and obstetric care, and various a nearby general hospital te coordinate patient long-term caw services (e.g., skilled nursing and 4Each of these hospitals (fewer than one.half of the States rural hospital owl) has 85 or fewer beds and an emergency room. and all arceither the sole mpaticat facilities in their counties or serve MIS with no more than 100 persons per square mile 2 ; 2 Chapter 8Collaborative Oppornantas Between Rural Health Facihties and Government 203 home health) are authorized to be provided. Hospi- establish alternathe licen sure laws before develop- tals applying for ECH status will receive expedited ing ideas for new delivery models. review under Florida's CON process and may retain Ehgibility criteria vary for rural providers seeking their hospital license Regardless of whether they to participate as alternative facilities (e.g., they may become ECHs, the 27 hospitals are also exempted from CON review of home health, hospice, and be restricted to hospitals or to facilities meeting only certain size and location cnteria). For example, swing-bed services under the 1989 law. Plans to Montana's MAFs must be the only local inpatient pursue Medicare waivers and implement the ECH care providers in remote areas. Four of the facilities legislation are being delayed until the State decides operating as CCECs in Colorado are CHCs or whether to apply for participation in the new Federal nursing homes, and all are the sole providers in their alternative niral hospital program discussed below. communities. Wyoming States have different ideas on whether a hospital In 1989, the Wyoming Legislature established becoming an alternative facility should be allowed new licensure and operation regulations for health to keep its existing license to protect against the risk care facilities (741). The law introduces the new that its participation as a new facility is unsuccess- licensure category of medical assistance facilities, ful. Regulations in Montana require a hospital modeled after Montana's MAFs, which would becoming a MAF to give up its acute-care license. In provide limited acute care to patients for a period of California, alternvive model hospitals would retain no more than 60 hours prior to their transfer to a their acute-care license. Hospitals in Florida that hospital (if transfer is necessary). The medical become ECHs but later decide to seek full acute-care assistance facilities must be located more than 30 relicensure would receive expedited review and miles from the 1201u-est Wyoming hospital. As in reclassification. Florida, regulations that would govern the specifi c Differences exist among States on the scope of operation of these facilities have not been estab services to be provided m aliernathely licensed lished; the period for making these regulator) facilites, and the tok rural providers and communi- changes ends in 1993. ties have in making these decisions. Most of the new models allow for use of both physicians and Contpariwn of State Efforts midlevel practitioneis, and most proposals would Efforts by the above States to develop alterna- require facilities* ensure-.propriate transfer and referral of patients to other tively licensed facilities in rural areas have impor- widers. Only minimal tant similaities and differences. attention appears klave been given by most States (except Montana) to the effects of new models on To date, only Montana has obtained direct interest quality of care and patient satisfaction. and support by HCFA that might lead to waivers of Most models that provide for limited inpatient Federal conditions of participation, allowing the services in the form of holding and observation care model facilities to receive Medicare and Medicaid reimbursement. However, as noted by differences units use a maximum time standard of 96 hours (Colorado and Wyoming use shorter periods). Exist- between the Montana and California projects, there may be ways to minimize HCFA 's role in such ing data suggest that the average acute-care length of stay m a small rural hospital may already closely matters. The need for waivers will depend in part on match these proposed limits.s The maximum length the spucific needs and objectives for developing new models and the extent of regulatory changes in- of stay is intended to act as a proxy for service volved. intensity and severity of illness. However, some States (e.g., California) have suggested other meas- The amount of effort that has been invested by ures (e.g., lists of approved admitting diaposes or States in developing alternative facility modeh, as senices, composition and skill mix of medical well as the specificity and flexibility of the laws personnel) that might be more appropriate indicators defining and regulating them, varies considerably. of low -intensity care, while giv ing model facilities Except for Califorwa, most States have chosen to more flexibility to hold patients for different periods 5In 1983, the average length of stay for a noel hospital with fewer than 2$ beds was 4 9 days. or about 118 hours (236) 2 ; j 204 Health Care in Rural America of time (398,478). Length-of-stay restrictions may (which does not include physician charges) or a be the most problematic in very remote areas where t;omprehensive cost-based rate (combuung facility alternative sources of care are far away. and professional services). A prospective payment system must be developed by 1993 for both inpatient Recent National Developments and outpatient RPCH services. States will be responsible for designating and In 1989, Congress required DHHS (Public Law supporting the development of EACH networks. 101-239) to establish a progsam to provide grants for When designating RPCHs, States that have EACHs up to seven States to designate and develop two new must give preference to hospitals participating in types of rural hospitals: Essential Access Commu- rural health networks. Grants for up to 3 years from nity Hospitals (EACHs) and Rural Primary Care the Rural Health Care Transition Grants Program Hospitals (RPCIls). In addition, up to 15 RPCHs (see ch. 3) and the Medicare trust fund will be may be designated ix. States without EACH pro- available to help States and hospitals to plan and grams. EACHs and RPCHs are to form a network of implement the EACH/RPCH designations and rural rural health facilities designed to ensure the regional health networks. accessibility and continuity of emergency, primary, acute, and long-term care services. Eligible hospitals The EACH program posestkdilemma for States must be located in States that have oi are developing that are developing theirOW11alternative models for a plan calling for the creation of rural health care mral facilities. On the one hand, the State-developed networks. models can be adapted to the needs of those States. For example, States may wish to: To be designated as an EACH facility, a rural hospital must be more than 35 miles from another establish their own minimum mileage lunits designated EACH or rural referral center, and it must between designated facilities; have at least 75 beds or be located more than 35 establish their own limits on the number of miles from any other hospita1.6EACH5 will provide acute-care beds and the allowed levels of emergency and medical backup services to desig- service intensity in model facilities; and nated RPCHs in the network; they must agree to consider criteria for essential access facilities acc,...pt patients transferred from mral physicians and other than distance and facility size (e.g., RPCHs, receive and transmit data to RPCHs, and community income or poverty levels). provide staff piviieges to RPCH physicians. EACHs will be considered "sole community hospitals" for On the other hand, States may also fmd the Federal the purpose of Medicare reimbursement. program attactive because it enables RPCHs to receive Medicare paymenta valuable incentive for RPCHs are smaller facilities that will be requhed hospitals to shift their emphasis from acute care to to provide 24-hour emergency care, to cease offering emergency and primary care (87). inpatient care except through using a maximum of 6 holding beds to stabilize patients for up to 72 hours; and to have patient transfer arrangements with the STATE-PROMOTED nearest hospital(s). Rural hospitals becoming RPC1-is INTEGRATION OF SERVICES will be allowed ro provide skilled nursing services, Rather than (or in addition to) adopting a more and they may use midlevel practitioners with physi- sweeping approach, some States have focused their cian oversight. These facilities will not have to meet support (e g , technical assistance, regulatory relief' existing hospital requirements for 24-hour operation on a few targeted facilities to improve the integration (except emergency care), and the services of dieti- and accessibility of local health services in specific cians, phatmactsts, and certain laboratory and radi- ology technicians need only be available on a rural communities. Below are three examples of such initiatives. part-time, off-site basis. Inpafient acute-care serv- ices will iMtially be reimbursed by Medicare at cost. North CaralinaThe Roanoke Amaranth Com- For outpatient services, RPCHs will at first have the munity Health Group, a private, nonprofit primary option of receiving either a cost-based facility fee care practice in rural North Carolina, was estab- (These requirements may be waived by the secretary of DIMS. Chapter 8Collaboranve Opportunities Between Rural Health Facilities and Government 205 lished in 1976 with technical assistance from the State in 1986 appropriated funds to maintain hospi- State and funding from the U.S. Public Health tal operations for 1 year. Service. The State recently supported research that found that the area's elderly were using post-acute A study of the facility recommended a plan to care resources in distant places near where they had convert 10 of the 29 beds from acute care to skilled been hospitalized, forcing many to relocate in order nursing care and improve outpatient services. The to obtain needed rehabilitation and support services. plan would allow the county to operate the facility "lb address the need for accessible and comprehen- on a "breakeven" basis (in which revenues would at sive long-term care, the Roanoke Group decided to least equal expenses). Despite pressure from the sponsor the development of a long-term care campus county's other hospital, the county eventually agreed adjacent to the practice. to accept the State's restructuring plan. To assist the restructuring process, the State altered California Development of the long-term care complex regulations (i.e., approved use of a joint nursing began with construction of a 60-bed nursing home station for the acute-care and skilled-nursing units, and an 18-be4 board-and-care facility, which opened and hospital-based skilled nursing beds for Medi- in early 1990. Other facilities that have begun caid patients). Provisions were made also to cross- operations are a senior center (supported by a State train and certify staff lab and x-ray technicians to grant) and 20 elderly housing units subsidized by a reduce standby costs (4 18). loan from the U.S. Department of Housing and FloridaThe North Central Florida Health Plan- Urban Development (HUD). Additional plans call ning Council, a Star -funded district health planning for opening 30 market-rate rental units and an agency covering 16 rural counties, assisted in the outpatient rehabilitation clinic. recent expansion of State-supported primary care services to indigent populations. The Council real- The State has helped the Roanoke Group over- ized that the increased delivery of such services by come several regulatory obstacles during the course area county health departments Wag insufficient to of the project. Technical assistance from the State meet many indigent patients' needs for followup helped Roanoke receive a CON to build the nursing care. The Council worked with local health depart- home and gain loan approval from HUD to develop ments participating in the State program to establish the subsidized rental apartments. Efforts by a referral network of specialists and hospitals, and to Roanoke to secure a Farmers Home Administration set up a centralized Medicaid billing system to be (FmHA) loan to build the 30 market-rate apartments used by participating physicians (222). have been delayed, however, because of FmliA claims that no comparable market rate exists from which to make lending decisions. The State is also LOCAL TAX INITIATIVES providing assistr.nce to help the proposed outpatient clinic become certified as a provider-based rural In order to maintain health serv ices, local govern- health clinic (see ch. 3), enhancing ihe facility ments in many rural areas have increas' their tax Medicare and Medicaid relmbursement (418,479). support for public hospitals and c.I.er facJities (see ch. 5). (In Montana, for example, nearly 60 percent CaliforniaThe Mono (Count)) General Hospi, of the nonoperating revenue of the Sate 's small rural tal, a 29 bed public Lcility in rural northern hospitals in 1985 came from tax funds of local California, had been sufferinb, annual operating counties and hospital districts.' (73).) Rural commu- deficits of over $300,000 since 1984. After an nities in States with enabling laws r;an create tax unsuccessful attempt to have the hospital managed support through the establishment of health care by a multihospital system based 2 hours away, the distrkts. In addition, some rural facilities may seek county considered closing the facility. In response to local approval of special, temporary tax levies to concerns that closure would severely limit access to alleviate immediate fmancial problems. Tw o exam basic health services for area highway travelers, the pies of local tax initiatives are described below. Vospnal distmts arc one type uf 4Fek.sal distrm that CAM tv supptat 41 singk pauli. fun...ttun ur purpoat Spcktal Jutik.ts ate to&paakat governmental ands that hoe. among edam things, the aatortomuas puaer tu ow The Idea of spp.lai &tutu., is nut nen b> 1982 thete were 28.000 nattonvente maudy serving total requiremenb tor st.bouls, water. fire pima-avg. healtht.ate. ut uthet neoled cj 44, Mult ipet..d &Ara ia arc lc:mated m Mal areaS t63 percent ilk 1971. eftes they are 'he only mcana by *beat smali 4.013imellitle& 4.4k11 tiblAsee ...411y needed pubheriJi/fl 2 '7) 206 Health Care in Rural America the hospital district and a special 1.year tax levy. Levies fcr the hospital, to be collected about 8 months following the election, were estimated to be $100,000 (379). OregonIn 1980, the rural community of Con- don, Oregon, having been without a ph) sician for 2 years, sought assistance from the State Office of Rural I-71th to establish a health service district for south Gilliam County. The State granted Condon $20,000 to develop primary care services and assist the county in the formation of the health service district. After a brief campaign, voters approved the creation of the district and a property tax rate expected to yield 50 percent of che budget of a new OTC AGAIN': primary care clinic in the first year. Future tax OSP1TAL TAX subsidies were lowered as the clinic began showing rca an a profit (441). SUMMARY OF FINDINGS Photo credit: Peter Beeson Federal, State, and local governments have under- Rural communities 63 not always agree on the best taken some extraordinary efforts to enable rural I Ion for their ailing hospitals. In Gldcfngs, Texas, facilities and communities to preserve or enhance a r., .mt referendum was passed, despite constderabte local opposition, that createdatax district to fund basic services. At least two States have developed the county hospital. conceptual frameworks for determining an appropri- ate or minimal set of services and providers for rural WashingtonAbont 75 percent of Washington's co.nmunities, although thus far these efforts have rural hospitals are part of public hospital districts found little practical application. Sew I rural com- (714). Some of the State's rural hospitals have munities have enacted new mechanism., for improv- sought local tax support both thrqugh the establish- ing local tax support for area health facilities and ment of hospital districts and the creation of special services. Some States are offering targeted financial tax levies. support or regulatory relief to a handful of rural facilities for improving the local integration of Whitman Community Hospital, a county-funded service s. facility, had been losing money for several years, Increasing numbers of States, however, are and in 1986 it requested the county to create a special tax district to support the facility. The county 's taking a broader approach. the development of alternative &ensure and delivery models for rural commissioners turned down the request, because facilitiesNo collaborative effort between govern. property tax rates were already at their limit man- ment and rural facility has been mute dramatic than dated by the State, and a new hospital dutrict would activities by a few States to change regulations and reduce amounts for existing special districts (e.g., design rew models intended to alter and improve the fire protectio1fl4raries). A 1987 State law, how- deliveiy of health services in rural areas. These ever, allowed loal voters to increase their property efforts reflect differences (and similarities) among tax rates, fueling again the hospitafs mterest to propose the new tax district. In 1988, to ease States in the need for siructured change in rural concerns from existing districts, the hospital decided fac ilitie s. to propose a new district under which ;t would agree Montana and California have the most developed only to seek special, temporary tax levies. These models thus far. Montana's new MAF licen sure levies would not be affected by State limits on category alters regulations to allow small, underused current property taxes or require existing districts to acute-care hospitals to become providers of low- share tax monies. In September 1989, following a intensity, short-stay acute care. Federal support has major campaign. voters approved the formation of helped develop ideas for demonstrating MAFs. 2 6 Chapter 8Col1:wrative Opportunities Between Rural Health Facilities and t;overnment r 207 Waivers of Federal conditions of participation for of Federal ,:onditions of participation to be neces- the new facilities are now necessary in order for sal), for the rural hospitals initiallytargeted to MAFs to receive Medicare payments and begin participate in a demonstration Foject. effective operations as part of a demonstration project; however, the Federal Government had not National legislation passed in late 1989 created a yet approved the State's waiver requests as of June program in up to seven States to develop EACHs 1990. California is designing a mew delivery model and RPCHs. Up to 15 RPCHs may be developed in that would allow rural hospitals, through proposed States without EACHs. Eligible EACHs and RPCHs changes in State licensure standards, to operatz and will bc designated by participating States and are provide services under conditions more appropriate intended to operate as part of a rural health network, to local needs arid capabilities. These conditiorh reducing excess capacity of acute-care beds and permit underutilized rural hospitals that For ide ensuring regional accessibility of services. As of only a core group of basic services to function under June 1990, regulations had yet to be developed and more lenient State regulations and w ith lower fixed ma ny questions remain about die plogram's benefits costs. At present, the State does not consider waivers and feasibility. 1'1 -, et, Chapter 9 Conclusions: Availability of Rural Health Services 2 ; 8 CONTENTS Page WABILTTY OF MCILITIES AND SERVICES 211 FACILITY ADAPTATION TO CHANGES 211 AVAILABILITY OF SERVICES 213 COORDINATION AM) INTEGRATION OF SERVICES 213 2 1 9 Chapter 9 Conclusions: Availability of Rural Health Services '.IMI VIABILITY OF FACILITIES to counter the general decline in demand for acute care, stimulate involvement in other ventures and AND SERVICES services, and improve total hospital operating mar- Rural health care facilities face ominous changes gins. in their operating environment. Major declines in Community health centers (CHCs), a primary the number of inpatients have made it difficult for source of nonuegent care for rural poor and many rural hospitals to function under stable uninsured residents, are providing ever greater circumstances. Inpatient volume and occupancy amounts of under- and uncompensated service and levels often are insufficient to support the basic fixed remain heavily dependent on government grants costs of treatment, especially for the smallest and payers (e.g., Medicaid). Small and isolated facilities. But the strategies that such facilities might CHCs, which are less able than others to cut use to lower these fixed expenses are limited. Some expenses or collect additional patient revenues, are basic services and staff must be maintained to especially dependent on Federa; pants for their address unexpected variations in utilization and survival. As with hospitals, costs are rising faster meet Federal and State regulations. Small isolated than total revenues in nee CHCs. hospitals serving sparse populations lack the econo- mies of scale gained from providing high-volume services, and they are often unable to share resources FACILITY ADAPTATION TO with other facilities to help lower their fixed costs. CHANGES Growing numbers of rural re.sidents appear to be Many rural health facilities hate inadequately leaving their communities to obtain hospital care detekped nek Jenice missiom and structures in in urban areas, either to receive specialized care response to these health sy stem changes, in part unavailable locally or because they choose not to because they faix several obstacles to doing so. use local services. The migrating patients tend to be those who are best able o pay for care, leaving local Information on strategies is lacking. Although hospitals more dependent on the lesser paying numerous short- and long-term strategies exist that might enable rural health facilities to adapt to patients and 2.trther weakening the hospitals' finan- cial condition. The results of this trend for rural changes, evidence of their existence and effective- ness is limited and comes largely from anecdotal hospitals are significant increases in the proportion of care that is uncompensated and a heavy depend- sources. Few mechanisms exist through which ence on inflexible public payers (e.g., Medicaid and information on prospects and efforts might be disseminated to rural facilities or to government Medicare) that have not kept payments at pace with policymakers who might wish to support such rising costs. Such revctnue constraints have further efforts on a larger scale. pressured these facilities to reduce inpatient costs and to rely more heavily on local tax subsidies ,uid The meam for accomplishing thange can be fundraising. However, efforts to lower costs and extraordinary and quite risky. Strategies by a few improve revenues have had only limited success. States to develop Alternative delivery models foi Positive operating margins are now minimal Lit rural hospitals typkall) require major restructuring nonexistent for most rural hospitals. of facilityservices and operations. Most such models address the faltering condition of small, The costs to rural hospitals of uncompensated underutilized hospitals by limiting their scope of care we probably much greater for uninsured and services to essential levels of emergency, subacute, Medicaid patients than for Medicare patients. En- and primaty care. Patients needing other services hancements to inpatient Medicare payments may would be stabilized and transferred under these help in the short-term to increase coverage of acute models. care costs and subsidize some nonacute care services in smaller hospitals. Over the long term, howevet, Adopting well measures is risky fin both facilities increased inpatient Medicate payments will do little And their i-unununkies. There are few precedents, 211 2 ,.."(t) and there are no assutances of support from govern- regulatory requirements associated,.th pro- ment or other sources. For example, hospitals in viding hospital-based post- acute and long . wan Montana that agreed to become medical assistance care (e.g., the requirement that a skilled nursing facilities would: 1) serve remote rural communities facility have its own nursing station). with limited accesr to care, 2) have to surrender their acute-care license, and 3) need a waiver of Federal Hospitals operating 4 a loss develop poor credit iegulations in order to receive Medicare and Medi- ratings, forcing lenders to deny these hospitals caid payments. capital to invest in new equipment and facilities for diversified services. Some providers applying for One barrier that must be overcome for these certification as rural health clinics have difficulty alternative facilities to become viable are inflexible complying with certain regulations (e.g., midlevel regulations that affect scope of services, staffmg, staffmg). Others experience lengthy waits frior to facility specifications, and other factors. Existing approval of participation, delay ing their receipt of laws and reimbursement policies now prevent many Medicare and Medicaid payments. facilities from redesigning their structures and services to fit local needs and capabilities. The new Parcchialism, inertia, or lack of planning re- Federal initiative creating e.ssential access commit- sources may prel.ent some facilities from effec- -J*1y hospitals (EACHs) and rural primary care tively exploring prospects for change. Anecdotal hospitals (RPCHs) is designed to provide an alterna- reports suggest th.t some nual hospital executives tive to some of these regulatory linuts on hospltals. have been slow to accekt and address rapid changes Some States, however, may find EACHs!RPClis in thcir financial condition, market, and regulatory less appropriate than State-designed models ILA arc environment. Trustees and management often are more attuned to local needs. mindful of community pride in past accomplish- ments and desires to maintain the status quo and are Other barriersthat may influence the development oriented more to service delivery than business ef akernative facilities include: management. In certain cases, this situation may be indefinite support from Federal and State exacerbated by the lack of dynamic leadership and governments for planning and technical assis- access to specialized management and legal counsel. tance, improved access to capital, and other It appears that rural facilities are either skeptical forms of financial assistance; of the benefits of interinstitutional affiliauons or opposition by health ,,are professionals 4: o n simply lack die opportunity to participate. Less than cerned about quality of care and protecting 15 percent of rural hospitals have joined .nopera- traditional roles and authority; and fives, and the number in multihospital gy stems questionable acceptance and support from the appears to be declining. community, which may believe that inferior quality care will be provided. To help rural facilities overcome their problems and implement strategies to adapt to changes, Effective change is stifled by facilitj financial Federal and State gocernments can mtenen. in two problems and shortsighted government policies. broad areas: For example, the increase in outpatient and post- acute care services in most rural hospitals has assessing Federal and Slate regulations and brought these facilities a new source of cost-based removing those that pre $ e nt useful approache s revenue. However, these new revenue sources are to change, and endangered by: providing incentives to Slates and local com- munities to help restructure facilities and increased efforts of hospitals to have these services. services absorb losses accruing from inpatient care; Changes in regulation, however, must assure patient current plans by Medicare to pay for ambula safety and quality of care. Assessing the impact of tory surgery and other outpatient services or4 a new facility models and other strategies on the prospective basis, which could potentislly dis quality of care should bc an explicit 4.ompurient of advantage many rural hospitals; and evaluation efforts. 2,. Chapter 9Conclusions: Availability nf Rural Health Services 213 AVAILABILITY OF SERVICES hospital care in rural area_ In fact, only abolt 30 percent of Medicare-designated SCHs meet cuneig Most rural hospitals are within reasonable eligibility criteria. Furthermore, under past payment travel time or distance to another hospital. How- rules many SCHs were in poor financial condition, ever, rural hospitals lo.:ated in more rugged terrain and the alue of SCH designatioi.1..«.. been question and in kss densely populated regions of the able to most rural hospitals until recently. Changes Western 'Jnited States are farther apart. Not much in SCH reimbursement (Public Law 101-239) may is known about the characteristics and accessibility improve the financial solvency uf many SCHs, but of hospitals nearest these facilities. Hospitals in smaller SCHs (like many small rural hospitals in isolated areas are often the only providers uf general) will probably remain financially vulnerable accessible emergency and acute care for widely despite higher Medicare payments. Classification of dispersed populationsyet this role may be im sole -ommunity hospitals in geographically iso- peded by a lack of physicians and patients. Fut lated rural areas should more accurately designate example, frontier hospitals have significantly few et and protect critically needed facilities. Also, be- staff physi,-ians and acute-care admissions than du yond Medicare's prospective payment 0,, stem, new other similarly sized mral facilities. sole community provider criteria might, 1) give special attention to hospitals in mral areas that have Some financially troubled rural hospitals can no a large proportion of low-income or uninsured longer survive as hospitals, due mainly to declining residents, and 2) be expanded to include nonhospital inpatient volume and rising costs of maintaining prov iders (e.g., primary care centers, long-term care underused acute-care capacity. The excessive sup- facilities). ply of hospital beds in many rural areas has been created by a combination of the prolific hospital Travel time to services is an importart potential construction of the Hill-Burton era, health system criterion for, determining when a provider is an changes pioducing more outpatient care, and greater essential sole source of local care. But determining use of sophisticated technology that cannot be an acceptable standard of travel time or distance to provided economically in small hospitals. health care for residents in remote areas is difficult and controversial. Travel guidelines being debated Thosc rural hospitals that have closed an for application to hospital care in rural areas are relatively near other hospitals, small in size, and overly simplified (e.g., apply to all rural areas and few in proportion to the number of open hospitals. all levels of treatment).t Most recent studies exam- The effects of hospital closures are felt most keenly ining travel distances ha% e riot considered important where the hospitals are the only providers of acute at.Gebb issues such as zhe urgency of the care care over large areas But apparently, few closed required, the mobilit,of the patient, and the hospitals thus far have significantly affected access variability among facilities in the scope a..d quality to care for local residents. Litt!: is known about the uf bervices and policies fur care to indigent patients. comparability of open hospitals neatest these closed facilities in terms of soope and quality of services, COORDINATION AND geographic and financial accessibility, or opera- INTEGRATION OF SERVICES tional stability. Health services have developed in response to There are no well-defined criteria or designa- myriad factors (including vanous government pult- dons for rural health facilities that. 1) are essential cies, programs, and reimbursement mechanisms). sources of emergency, primary, and acute-care Consequently, many serv ices might appear frit& services for residents geographically isolated or mented and uncoordinateit particulatly foi the pour unable to pay; and 2) may need special protection and elder') indhiduals commonly thought to have to maintain the provision of essential services. The the greatest difficulty in gaining access to health Medicare sole community hospital (SCH) designa ser4,...ea. Hospitals in rural communities generally don was intended to serve this purpose, but as a hai4 deseloped and operated independently of group, SCHs no longer represent critkal souices of other hospitals and area health services. Their lack Vet example. Ihe 1978 Natscatal Guidelines lot Health Masa% kw* icpeakir iuggcsial that Emu:4 WIA. tud hoSplial 1111.1pgliy ut nanicui4 of anal seas should be no meta dna 30 =antes (43 PR 3056). 2 )4 214 Health Care In Rural America ef coordination between services can have serious given scant attention to the development of facility consequences. For example, some rural county networks. Examples include: health departments in Florida providing primary care to the indigent have until recently lacked the New deliver) models in areas with limited funds and r!anning assistance to arrange necessary accessIngeneral, State efforts to create rural followup ire with area hospitals andecialists alternative delivery models have only involved (322). individual hospitals. No States have considered developing networks of different types of In other situations, one may fmd: facilities that improve access to and continuity Ruralfacilitiesdelivering duplicathe or under- within a more comprehensive set of services. utilized servicesFor example, some transpor The recent Federal initiative that allows the tation services to primaiy care clinics are creation of EACHs and RPOis addresses the available from various local agenc:es; how- importance cf rural health care networks; ever, there may be little coordination or infor- however, it is not clear to what extent nonhospi- mation on how to obtain these services. Conse- tal facilities and provideis will be encouraged quently, some residents may forego importx.. to have a role in the networks (e.g., only care or be prematurely instimtionalized be- hospitah are now eligible to become RPC}15). cause they are unaware of vital services. Also, few State models address problems of Rural facilities endangering continuityof care mral areas with large proportions of low- when referring patientsto distant provkkrs income or uninsured persons. For rural hospitals and physicians not engaged The Federal Rural Health Care Trensition in cooperative transfer and referral arrange- Grants Program (seech. 3) is laudable in its ments with distant providers, ensuring bp)pro- intent to encourage rural hospitals to adapt to plate and coordinated care for referred patients changes and promote cooperative activity among is difficult. Also, because of the lack of locally available care, some rural elderly persons must facilities. However, the program lacks the be referred to distant communities for both resources to offer hospitals incentives that me appropriate and adequate for major structural hospitalization and post-acute suppoft services. change and long-tenn solutions. The program Thus, some residents relocate and fragment the would also be more effective if grant funds relationship with their local primary provider. were better prioritized and targeted (e.g., to Rural hospitals having difficulty discharging facilities and networks in areas with critical patients ernctivelyNearly all rural (and urban) hospitals have difficulty fmding appropriate access problems). post-acute care for discharged patients (613). Many rural facilities are either unaccustomed to This is a pmblem in rural communities where cooperative delivery networks or may be less no skilled nursing facility beds or full-service inclined to participate in networks because of home health agencies are conveniently availa- possible government resections (e.g., antimist, ble. antikickback, and tax-exemption rules). Anappro- The lack of effectively coordinated and inte- priate Federal role would oe to provide gui(1-lines grated health services in many rura: cmnmunitics and incentives for Stales and localfacilities to plan underscores the need for creating new or betier and demonstrate networks.Networks developed in delivery networks of various providers.Current areas with critical act-ess problems may need special efforts to improve rural health service delivery have treatment to ensure their existence. Part IV Availability of Rural Health Personnel 2 :' 4 Chapter 10 The Supply of Health Personnel in Rural Areas CONTENTS Page INMODUCTION 219 PHYSICIANS 219 National Supply 219 Rural Supply 232 MIDLEVEL. PRALi I tIONERS 249 Nurse Practitioners 250 Physician Assistants 252 Certified Nurse-Midwives 256 Certified Registered Nurse Anesthetists (CRNAs) 257 NURSES 259 National Supply 259 Rural Supply 265 OTHER HEALTH PROFESSIONALS 268 Dentists 268 Phamiacists 272 Optometrists 274 Allied Health Professionals 275 SUMMARY OF FINDINGS 282 Physicians 282 Midlevel Practitioners 282 Nurses 283 Other Health Professionals 283 Boxes Box Page 10-A. Provider Profile: Physicians 220 10-B. Provider Profiles: Midlevel Practitioners 250 10-C. Provider Profiles: Nunes 259 10-D. Provider Profile: Dentists 269 10-E. Provider Profile: Pharmacists 272 10-P. Provider Profile: Optometrists 274 10-0. Provider Profiles: Allied Health Professionals 279 2 -1-o Figures Figure Page 10-1. Supply of Physicians (MD and DO) by Sex: Estimated 1980 and 1986, Projected 1990 and 2000 231 10-2. Number of Counties Without Selected MD Speci4hies by Metropolitan/Nonmeiropolitan Status, 1988 245 10-3. Distaution of Nurse Practitioners by Community Size, 1988 251 104. Distribution of Physician Assistants by Community Size, 1989 256 10-5. Employment Status of Registered Nurses in the United States, Selected Years, 1977-1988 260 10-6. Employed Registered Nurses (RNs) Per 103,000 Residents in the United Staks by State, March 1988 263 10-7. Registered Nurses (RNs) and Licenst4 Practical/Vocational Nurses (12/VN5) in U.S. Comm:inky Hospitals: Total FrEs and FTEs per 100 Patients, 1981-88 266 10-8. First Year Enrollment in U.S. Schools of Pharmacy, Academic Yeats 1969-70 Through 1985-86 273 Tables Table Page 10-1. Supply of Physicians (MDs) in the United States, Selected Years, 1963-88 219 10-2. Supply of Professionally Active Physicians (MDs and DOs) in the United States. Estimated 1986 and Projected 1990, 2000, 2030 221 10-3. Estimates of Physician Supply, Requirements, and Surplus, 1990 and 2000 221 10-4. Supply of Non-Federal MDs by State, 1980, 1985, 1988 222 10-5. Number of Professionally Active MDs Per 100,000 Residents by Region and State, Estimated 1986 and Projected 1990 and 2000 224 10-6. Enrollments and Graduates of Allopathic (MD) and Osteopathic (DO) Medical Schools. 1981-82, 1986-87, and Projected 1991-92 225 10-7. Supply of Active MDs in the United States by Speciaity 1970, 1980, and 1988 227 10-8. Professionally Active MDs in Primary Cate: Rate Per 100,000 Relidents and Distribution by Specialty, 1981 and 1938 229 10-9. Number of Professionally Active MDs in Primary Cate and Nonprimaiy Care. Estimated 1986 and Projected 2000 and 2020 230 10-10, American Medical Association (AMA) Projected Changes in Physician Supply and Utilization by Specialty, 1985-2000 230 I0-11. Comparison of Canadian and American Physician Supply for Selected Speialties, 1985 231 10-12. Distribution of MDs by Major Professional Activity, Sdected Years, 1970-88 "32 10-13. Board-Certified Osteopathic Physicians (D0s)11 Specialty, 1986 233 10-14. Distribution of Osteopathic Physicians (DOs) by Geographic Ret,:en and State, 1986...234 10-15. Supply of Professionally Active Physicians in Primary Care and Nonprimary Care by Type of County, 1979 and 1988 235 10-16. Supply of Primary Cate MDs by Specialty and Type of County, 1975 and 1988 236 10-17. Professionally Active MDs, Primary Care MDs, and DOs per 100,000 Residents in Metropolitan and Nonmetropolitan Areas by Region and State, 1937/1988 237 10-18. Physician-To-Population Ratios (1985), Percentage of DOs (1985), and Percent Change in Ratios (1975-85) in Saa Nonmetropolitan Counties, by Region and State 239 10-19. Average Number of Hospital Medical Staff in Selected Specialties by Hospiul Bed Sue and Metrepolitan/Nonmetopolitan Status, 1987 240 10-20. Average Travel Time to Physicians for Metropolitan and Nonmetropolitan Residents, 1983 242 10-21. Average Travel Time to Physicians for Nonmetropolitan Residents by Imomes Abuveui Below the Federal Poverty Level, 1983 243 10-22. Number and Resident Population of Nonmetropolitan Counties Without a Professionally Active Physician (MD or DO), 1988 244 10-23. Number and Resident Population of Counties Without a Primary Cue MD by Type of County, 1988 244 10-24. '11=1 MDs, Patient Care MDs, and .,..ace-Based MDs Per 100,000 Residents by Type of County, 1979 and 1988 246 10-25. Supply of Primary Care Physicians in Metropolitan, Nonmetropolitan, and Sai...:1 Nonmetropolitan Counties, 1975 and 1985 247 10-26. Foreign Medical Graduate (FMG) Physician Supply in Small U.S. Nonmetropolitan Counties, 1975 and 1985 248 10-27. Distribution of Primary Care MDs by Age in Metropolitan and Nonmetropolitan Counties, 1975 and 1985 248 10-28. Practice Location Preferences of Allopathic Medical School Seniors, 1979 and 1989 249 10-29. Characteristics of Practicing Nurses Practitioners (NPs) by Community Population Size, 1988 252 10-30. Ninnber of Physician Assistants (PAs), 1987, and Number of PA Training Programs, 1989, by Region and State 253 10-31. Distribution of Physician Assistants by Specialty, 1978 and 1986 254 10-32. Characteristics of Practicing Physician Assistants by Community Population Size, 1989 255 10-33. Distribution of Practicing Certified Nurse-Midwives (CNMs) by Community Population Size, 1982 and 1987 257 10-34. Number of Nurse Anesthetist Training Programs and Graduates, 1976-90 257 10-35. Supply of Certified Registered Nurse Anesthetists (CRNAs) and MD Anesthesiologists by State, 1986, Ranked by CRNAs and MD Anesthesiologists Per 100,000 Residents 258 10-36. Estimated Supply of Registered Nurses (RNs) Employed in Nursing by Regioa and State, 1980, 1984, and 1988 261 10-37. Registered Nurse (RN) and Licensed Practical/Vocational Nurse (LP/VP) Supply in U.S. Community Hsopitals, 1981-88 263 10-2?. Estimated Supply of Licensed Practical/Vocational Nurses (LP/VNs) by Region, 1983 264 10-39. Registered Nurses (RNs) Employed in Nursing, 1988, and Employed Licensed Practical,' Vocational Nurses (LPIVNs), 1983, by Primary Employment Setting 264 10-40. Number of Programs Preparing Registered Nurses (RNs) and Licensed Practical/ Vocational Nurses (LPIVNs) and Number of Graduates: 1976-77 and 1981-82 through 1988-89 265 10-41. Metropolitan/Nonmetropolitan Distribution of Registered Nurses (RNs) Employed in Nursing in the United States by Region, 1980 and 1988 266 10-42. Estimated Number and Distribution of Registered Nurses Employed in Nursing by County Population Size, 1988 267 10-43. Characteristics of Registered Nurses (RNs) Employed in Nursing by County Population Size, 1988 268 10-44. Estimated Supply of Registered Nurses (RNs) and Licensed Practical Vocational Nurses (1P/VNs) in U.S. Registered Community Hospitals by Metropolitan/Nonmetropolitan, Frontier, and Sole Community Hospital Status, 1987 270 10-45. Supply and Distribution of Active Dentists by General and Specialty Prau ice, 1970, 1980, and 1986 271 10-46. Number of General Practice and Pediatric Dentists and Other Specialty Dentists Per 100.000 Residents by Type of County, 1981 and 1987 271 10-47. Supply of Active Dentists in the United States: Estimated 1988 and Projected 1990-2020 272 10-48. Number of Dentists Per 100.000 Residents and Number of Counties Without General Practice or Pediatric Dentists by Type of County, 1987 272 10-49. Supply of Professionally Active Pharmacists, Selekled Years, Estimated 1970-1988. and Projected 1990-2020 273 10-50. Supply of Professionally Active Optometrists, Selected Years. Estimated 1970-1988. and Projected 1990-2020 274 10-51. Number of Cities With Optometrists and Ophthalmologists by State, 1983 276 10-52. Distribution of Optometrists by Community Population Size. 1989 277 le-53. Estimated Supply of Selected Allied Health Personnel Employed in the United States. 1970, 1975, 1980, and 1986, and Percent Change, 1975-86 278 10-54. Provider-to-Population Ratios for Selected Allied Health Professionals by Metropohtan/ Nonmetropolitan Area, 1980 281 2 N7 Chapter 10 The Supply of Health Personnel in Rural Areas INTRODUCTION health professionals nationwide and in rural areas.' Although there are no uniformly accepted standards The health care services in rural areas' depend on of adequacy against which to compare these supply the presence and skills of the professionals who figures, this chapter presents trends over thne and provide them. contrasts availability across urban and rural areas to The rural supply of health professionals is de- lend some insight into relative adequacy. pendent on both the size of the national pool of PHYSICIANS5 professionals and the distribution of that pool between urban and rural areas. Reduction in the size National Supply of the national pool of health professionals may have a greater impact on rural than on urban areas. Over the last two decades, physician supply Conversely, incteases in the national pool may not relative to the U.S. population has greatly increased. be reflected uniformly across all areas. From 1563 to 1988, the total number of physicians (MDs only) in the United States more than doubled This chapter describes the supply of physicians,' (table 10-1), w hile thc U.S. population increased by midlevel practitioners,1 nurses, and selected other only 31 percent(39,671).6The total physician-to- Table 101Supply ot Physicians (MDs) in the United States, Selected Years, 1963-880 Mare/sate supply Percent change, 1963 1973 1978 1283 1985 1988 1963-88 Total physiciansb 276,475° 366,379 437,486 519.546 552.716 585,597 111 8 Physicians per 100,000 population° 146 i74 196 218 228 237 62 3 Total U.S. population (In thousands) 189.242 210,908 223.400 238.189 242,046 247,508d 30 8 * Data for 1988as of Jan. 1. Data prior to 1988 as of Dec. 31. b Includes MDsin patient care, research. administration, and teaching. MDs in Federal service. and inactive MDs. Includes 1.335 phYsicLans. addresses unknown, who are not distributed according to sources of medical education. °1987 population estimates were used to calculate 1988 MD ratios. Prior to 1988, population estimates used were for the same yoar as HD data. dloS7 population estimate. SOURCES. U.S. Department of Health and Human Services. Health Resouices and Services Administration, Sixtb Report to the President & Conaress on the Status of Health Personnelinthe United States 0 H H Pub. Ho. MRS-P-01)-88-1 (Rockville. MD. HRSA, June 1988). table 3-1. American Medical Association, unpublished data. provided bY staff at the U.S. Department of Hea10 and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Rockville, MD. 1990. 4ink4sothavimmdicAmd, rurjamAw nidhsaaptalormslouvuumoupviumt,vi.nues.ded eitanah.a ram to mestopolitat 2AHopmhicpbrsidans(Nt4)amloMeopadicphysichns(DCM). 1/4ursepractitiouers,physicanassistants,cerufiedrintsc-oudwries.andcatifiedreguteredhursedric:,thrtots 4Thissmdydiduotexamirmihesupplyofpodiatrinsorebitopractorsinruralareas. tome of um,datapreseated in this repon do out include osteopathic EDOr physicians doe iv thcidru,t4 tnlcgiauvu vi dead tentWsand LrGa This may lead to an modercsumatton of phy stwan-urpopatatwu rativ.S. particularly n1501*, rural arcio *bac bus on hMi g,.v,viadia,..diC Maiptuatv,Alt population. 4Iu 1988, the American Medical Assouation 4-han8ed as annual repurtmg date for ph) ucchr J.u4 hong Do. 31 io ktiof Mc teportmg y Lai rot Moscato's,tabks indus mon showmg AMA treed data throuti 1988 reflect chaNges ova a pcnod Mat we y644 Mono g , 1980 88 repic.buso a 7. rather than au 8.ycar pcnod. Whac 1988 MDto-populahoo ratios are Mown. 1987 rather Mari 1988 popilatun cblinaJW.4 uScd 215 2 " physicians by the year 1990 (654). Since the Box 10-AProvider Profile: Physicians GMENAC report, supply forecasting methodology Both allopathic (MD) and osteopathic (DO) and results have been extensively debated and physicians undergo 4 years of undergraduate me& revised. Table 10-3 compares three alternative sets cal training (671). In 1989 there were 126 colleges of projections for the years 1990 and 2000. Recently, of allopathic medicine and 15 colleges of osteo- the Council on Graduate Medical Education (COGME) pathic medicine in the United States (673). Allo- reviewed and critiqued various projections and pathic schools teach traditional medicine, while concluded that, in the aggregate, there is now or soon osteopathic schools take a more holistic approach will be an oversupply of physicians in the United and emphasize the importance of the musculosicel- States, but that the extent of the oversupply is etal system in the overall health of an individual (148). The curricula in allopathic and osteopathic impossible to quantify at present (672). It also schools, however, have become more similar over concluded that the supply of primary care physicians the years, and the quality of osteopathic physicians is in jeopardy, and that expansions in tralning has been increasingly recognized by Federal an pregrams will be needed to prevent future shortages other groups (148). (672). Aftergraduating,allopathic and osteopathic physi- cians can begin general practice or enter a residency Despite considerable growth in aggregate physi- program in their chosen specialty. Residency pro- cian supply, there were still!,944 designated grams last from 3 to 7 years, depending on the primary care Health Manpower Shortage Areas specialty (673). Ginduates of osteopathic schools (HMSAs) in 1988, with a resident population of can enter either allopathic or osteopathic residency almost 34 million (see table 11-5). Art estimated programs, although the vast majority spend their 4,104 primary care physicians would have been first postgraduate year in an osteopathic internship required to remove these designations. Twenty-nme as required by the American Osteopathic Associa- percent of all rural residents lived in primary care tion (673). HMSAs in 1988, compared with 9.2 percent of urban On completion of residency training, physicians residents (see table 11-5).10 can take a certification examination in their medical specialty. Compared with approximately one- National figures obscure considerable State and fourth of osteopathic physicians, most allopathic regional variations in physician supply. In 1988, physicians today are board-certified specialists when the national ratio was 229 non-Federal" MDs (671). per 100,000 residents, ratios in the States ranged from a low of 135 in Mississippi to a high of 349 in Maryland (table 10-4) (39). Not all of these physi- population ratio7 increased by 62 percent over this period, and it is projected to continue to mcrease cians provided patient care; the number of MDs in further through the year 2020 (table 10-2) (673).89 direct patient care per 100,000 reside nts ranged from This growth was largely due to Federal and State 115 in Idaho to 270 in Massachusetts (table 104) (39). efforts in the 1960s and early 1970s to combat a perceived physician shortage (129). Table IC -5 shows projections of the number of active MDs per 100,000 residents in eich State, In the early 1980s, Federal efforts leveled off after geographic region, and div mon for 1990 and 2000. the Graduate Medical Education National Advisory In 1986, when the national taut) tivaa 216 per Committee (GMENAC) predicted an oversupply of 100,000, the East South Cential dnusion had the 71411% only. tProjections in table 10-2 include MDs and DOs. *.klltables in this chapter that present Bureau of Heahh Professions supply project,..., rellet.4 thc medout 01bank. seticsprop:knolls, whtl,ftsume that ucent trends in emollmeats and graduations will continue. For *more detailed dcsamtiou viBlIP, s ule44Stinis sheihuthottogy, see thebui4itepoet to the President and Congress on the Status of Health Personnel in the Unaed States (671). laSee ch. 11 (or a detailed discussion of Federal HMSA designations. II "Non, Federalphysicians" excludesall physicianualaried dueetly by the Federal Gotttiontent It 0 , ph) ,,,i4as int& military or m the Nem. Heath doyley) it itsCiudes National Hcalth Service Corps physiciam who am nut salaned by the Federal Go. ematent Ahhuulth the supply ut fedenti physicians is important, it makes sense 10 exclude them from the overall vomit when lulAting Al availability of physiciois to the ....titian population. Although at one time most National Health Service Corps physicians were Federal employees, most today are not 2 Chapter 10The Supply of Health Personnel in Rural Areas 221 Table 10-2Supply of Professionally Active Physicians (MOs and DOs) in the tinned States. Estimated 1986 and Projected 1990, 2000, and 2020 KEUDIWtet Proiected 1866 1880 2000 2020 Number of active_PhYsicions AIL 50tive* 544,830 (1001) 601,060 (1001) 721.600 (1001) 848,620(100%) MDs 522.020 (95.61) 573.310 (95.41) 682,120 (94.5%) 789,560(93.0%) DOsb 22.810 (4.21) 27,750 (4.61) 39,480 (5.5%) $9,060 (7.01) Number per 100,000 residents All active* 224.9 240.0 269,0 288.3 MDs 215.5 226.9 259.3 268.2 posb 9.4 11.1 14.7 20.1 *Professionally active MDs include MDs in patient care, research, administration, and teaching. MDs professionally active in 106 include approximately 90 percent of the physicians who are not classified according to activity status by the American Medical Association and whose addresses are unknown. b Doctors of Osteopathy. SOURCE. U.S. Department of Health And Human Services, Health Resources and Services Administration, Bureau of Health Professions Seventh Report to the President and Congress on The Status of Health Personnel in The United States. DIRIS PubNo. HRS-P-00-90-1 (Rockville, MD. URSA, June 1990), table VI-A-12. Table 10-3Estimates of Physician Supply, Requirements, and Surplus, 1990 and 2000* 1990 Data source Supply Requirements Surplus Supply RequireCi0ments Surplus BHPrb 597,040 570,500 26,540 708,600 637,000 71,600 Original GMENACC 535,750 466.000 69,750 642,950 498,250 144.700 Revised GMENACd...... 535,750 473,000 62,750 642,950 505.750 137,200 AMA° 592,000 NA NA 693,000 NA NA NOTE; NA = not available. *Includes osteopathic physicians. bThe Bureau of Health Professions (Blift) model assutes that residents . 1 00 full-time equivalent (FTE) !The Graduate Medical Education National Advisory Committee (GMENAC) model assumes that residents . 35 FIE 'This model also assumed that residents . .35 PTE. *The American Medical Association (AMA) model assumes that residents 1 00 FTE. SOURCES U S Department of Health & Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine. Council on Graduate Medical Education First Report of the Council, vol II (Rockville, MD July I, 1988), Weiner, J P., "Forecasting Physician Supply Recent Developments " Health Affairs vol. 8, No. 4, pp. 173-179, winter 1989, Exhibit 1 Based on data from W D. Harder. P.R. netke. A.B. Silberger, et al , physician Supply and Utilization by SpecialtyTrends and Pro1251ions !Chicago, IIAmerican Medical Association, 1980, M A Bowman, J.M. Ketzoff, Garrison,I. P., et a' "Estimates of Physician Requirements for 1990 for the Specialties of Neurology, Anesthesiology, Nuclear Medici...le, Pathology, Physical Medicine and Rehabilitation, and Radiology," Journal of the Americ n Medical Association vol250. No 10. PP 2623-2627, Novemter 1983, U S. Department of Health & Human Services, Health Resocrces Administration, Office of Graduate Medical Education, Report of the Graduate Medical Education National AdvisorV_Committee (GMENAC) to the SerretatTLof the penartment ef Res-an and Human Services., vol I; SummarY Resort, DHHS Pub. No. (HRA) 81.651 (Washington, DC. U.S. Government Printing Office, April 1961), U S. Department of Health & Human Services, Health Resources and Services Administration, Bureau of Health Professions, Siglh_Report the President & Congress on the Status of Health Personnel in the United States, NHS Pub. NoMS-P-0E0-88-1 (Rockville, MD HRSA, June 1988). J Totalnon- Table 10-4-Supply of Non-Federal"1980 MDs by State, 1980, 1985, andRate 1988b per100.000 Totalnon- 1985 Rate 100,000per Totalnon- 1988 Rate par100,000 Percentchange Non-Federal patient care MDs per AlibitmaState . Federal5,039 Mils residents°civilian 130 Federal6,000 MDs residents°civilian 152 Federal6,580 MDs residents°civilian 182 1980-19881n rata, 24.6 100.000residents. civilian 1988 140 CaliforniaArkansasArizonaAlaska 58,3682,9395,535 509 248205128134 69 2086,9423,532 680 268220150137 73,832 3,747,63/ 729 269157227145 22.710.7 8.58.2 217135178127 DistrictDelawareConnecticutColorado of Columbia 3.6261,0018.1775.999 576169264210 2.54460.743,7551,252 607203302216 10.150 3,8691.3487.214 629210317221 24.320 1 95.2 2 475177257182 HawaiiGeorgiaFloridaIdaho 20,374 1,0892,0208,060 116222208149 10,14226,5662,3881,331 239236133172 10,98629.0872,5931,358 136253178244 17.214.019.517.3 207115154187 KansasIowaIndianaIllinois 21,740 3,8933,8477,415 132191166135 24.9004,3504,0058.542 217179140156 25,0714.5754.4749,029 186157163224 20.717.312.018.9 157131140189 MarylandMaineLouisianaKentucky . 11,7456,7521.8855,059 281169161139 14,4912,2328,3125,982 334123187162 15.6438,6026,3682.367 201194172 49 24.220.523,718.9 267160168150 MississippiMinnesotaMichiganMassachusetts 15,34716,342 2,7978,150 112200188285 17,20519,2423,2799.326 126223'31190 17,97220,2243,5229,849 135232195346 20.516.017.521,4 270110193164 MontanaMissouri....Nebraska.... 2.4421.1008,301 157140170 9,7502.7071.276 170155495 10.290 2.8341,059 174'168202 20.01418.8 0 155144171 NewNevada.. HampshireJersay . 14,799 1,8551,171 201180147 18,313 2.0801.604 243207173 19,410 2.2411.726 253213173 25.918.017 7 211172147 NorthKwNew YorkMexico CarolinaDakota 49,105 9.3542,143 419 2801431(2166 1134756,392 1.1412,830 318168185184 12,33058.916 1.1842.869 179195331193 25.22C.418.216.3 158161269155 OregonOklahoma...OhioPennsylvania.. 23,04718.342 5,1194,031 19719410417) 27,72721,0194,8665,764 234215149199 29,0122.2126.0495.055 246222156206 2421 141692 4 204181104175 RhodeTennesseeSouth Island DakotaCarolina 7,4804,3622,102 809 143223163118 8,9825,3032,3851.003 248189143161 9.8341,0665,7362,602 190151170265 22.128.018 18.98 218173130145 VirginiaVermontUtahTexas 22,571 2.4929,6821,185 186231170159 28,25411,8753.0251.436 214268185174 12,74430,0523.2071.512 22205?J1180 19.419.012.413.2 186215161153 Table 10-4Supply of Non-Federal° MDs by State, 1980, 1985, and 1988°Continued 1980 1985 1288 Total Rate per Total Rate per Total Rate per Percent Non-Federal patient non- 100,000 11013- 100,006 non- 100,000 change care MDs per State Federal civilian Federal civilian Federal civilian in rote, 100.000 civilian MDs residentsc MDs residentsc MDs residentsc 1980-1988 residents, 1988 Went Virginia 2,745 141 3,319 171 3,396 179 27.0 152 Wisconsin 7,859 166 8,969 188 197 18.7 167 wash% 567 120 140 147 22.5 126 Totald 439.301 195 522.1 220 554,155 229 17,4 /89 a"Federal" and "non-Federal" statue are self-reported. Physacians are asked to list their status as "Federal" if they are military, Public Health Service, Veterans Admtnistration, or other. IND data for 1988 as of Jan. 1. Prior MD data as of Dec. 31. c1987 population estimates were used to calculate 1988 MD ratios. Prior to 1988, population estimates used were for the same year as MD data. dExcludes physicians and residents in the U.S. possessions. SOURCE: American Medical Association, unpubLished data, provided by staff at the J.S. Department of h and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Rockvilie, MD, 1990 23 224 Health Care in Rural America Table 10-5-Number of Professionally Active Ms Per 100,000 Residents by Region and State. Estimated 1986 and Projected 1990 and 2000 Mps Mar 100.000 residentsa 1966 1990 2000 1986-Ire"90 81:911Z2000 Mined Steteeb 216.4 223.4 247.8 6.2 17.6 Northeast. 270.2 303.0 372.7 11.8 37.7 New England 283.3 314.2 387.2 10.6 36.4 Connecticut 294.1 327.0 402.1 10.9 36.7 Maine 165.6 176.5 207.7 6.0 25.4 Massachusetts 330.7 378.4 496.2 14.2 49 9 Mow Hampshire ...... 175.6 174.5 172.3 -0.5 -1.6 Rhode Islend 236.1 259.7 317.0 9.7 33.9 Vermont 254.5 269.2 305.4 5.5 19.6 Middle Atlantic 265.7 299.0 367.1 12.4 36 0 New Jersey 223.4 444.4 282.5 9.4 26.4 New York 308.1 354.9 444.8 14.9 44.1 Pennsylvcnia 229.4 255.6 319 4 11.3 39 2 NUAlost 194.5 207.3 243.2 6.2 24.7 East North Central... 195.8 208.1 244.4 6.1 24.5 Illinois 225.5 245.5 295.5 8.9 31.0 Indiana 152.1 159,2 184.2 4 6 21.0 Michigan 188.4 195.7 224 4 3.7 19.1 Ohio ...... 195 6 210 4 253.6 7 2 29.7 Wisconsin 188.8 195 8 217 2 3.7 14.8 West North Central., ...... 191 4 205 4 240.4 7 3 25.6 low4 156.4 160.6 186.0 2 6 18.5 Kansas 188 3 202.4 234.0 7 4 24,4 Minnesota 232 5 251.1 298.6 7 7 28 4 Missouri 193.7 211.2 249.3 8.8 26.4 Nebraska 179.0 189.2 210.2 5.6 17,3 North Dakota...... 162.7 172.3 193.7 5.5 19 1 South Dakota ...... 138.3 149.2 171 5 7.2 23.9 South 182.7 164.9 194.5 4.0 9 6 South Atlantic 206.0 198.0 206.8 4.2 9 0 Delaware 161.4 201.0 232.7 10 5 28.1 District of Columbia 731.3 998.8 587.8 36.5 117 1 Florida 181.0 173.4 153 0 -3.6 -15.4 Georgia ...... 163 7 177 3 191.8 7 9 17.1 Maryland. 358 7 396 0 465 0 )0 3 29.6 North Carolina.... 174.4 187 6 208 9 7 5 19 5 South Carolina. ... . 148.2 150,9 154 3 1 3 4.0 Virginia 210 2 227 0 257.7 8 1 22 4 West Virginia. . . ,. 169.3 173.5 201 1 2 4 18 3 East South Central .... 161.2 167.5 186 6 3 7 15 5 Alabama 147 5 154.8 170.7 4 7 15.6 Kentucky.... . 106.5 170.8 192.5 2 4 15 0 Mississippi... 132.3 136 3 154 0 4 5 15 9 Tennessee.... . 184.6 191.4 212.4 7. 3 14.6 West South Central 165 3 173 1 176.6 4 2 7 9 Arkansas ...... 146 6 149.3 158.6 1 4 7 5 Louisiana.. ... 176 7 183.4 196 1 3 4 10 8 Oklahoma...... 149 0 158.1 378 3 0 0 19 5 Texas 168 2 176.9 177 1 4 8 4 8 Wait 226.1 235 6 245.3 3 1 7 5 Mountain 188,2 180 2 171.2 -4,2 -8 9 Arizona.. 187.3 173.7 149 7 -6 8 -19 7 Colotado... 230.7 227.7 224 5 -1 2 -2.5 Idaho ...... 134 1 127.0 132.5 -5 1 -0 6 Montana . 161 3 163 0 162 8 C.6 13 0 Nevada 158.5 141.1 119 9 -10 6 -23 9 NOW Mexico 186.5 208 4 243.0 11 3 39 0 Utah 185.6 170.1 156.6 -8 0 -15 5 *coming 141 2 115 6 104.9 -17 6 -25.4 2 '! Chapter 10-The Supply of Health Personnel in Rural Areas * 225 Table 10-5-Number of Professionally Active MDs Per 100,000 Residents by Region and State. Estimated 1986 and Projected 1990 and 2000-Continued MDs per 100-000 residents& Percent change 1986 1990 2000 1988-1990 1986-2000 Pacific 242.7 258.4 280.5 6.2 15.2 Alaska 180.5 203.0 244.6 26.2 12.3 California 250.9 273.8 300.5 8.8 19.5 Hawaii 239.9 250.8 270.0 4 . 2 12 5 Meson 222.3 204.1 209.3 -8.0 -5 7 Washimiton 215.7 217.1 231.0 0.5 7.0 U.S. possessions 185.2 216.8 275.3 16.7 48.6 aIncludes MDs in patient cate, research, administration, and teaching, and MDs in Federal service 1986 figures include approximately 90 percent of those MDa not classified according to activity statue by the American Medical Association. hIncludes MDs in the U.S. possessions. SCCRCE. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions Seventl Report to the President and Congress or the Status of Health Personnel in the United States, DHUS PUb. No. HRS-P-OD-90-1, (Rockville MD. HRSA, June 1990), table VI-A-16. Table 10-6-Enrollments and Graduates of Allopathic (MD) and Ostoopathic ma, Medical Schools. 1981-82, 198647, and Projected 1991-92 Percent chanRe 1981-82 1986-87 to to 1981-82 1986-87 1991-92 1986-07 1991-92 HD First-Year enrollments 17,871 17,136 16,677 -4 0 -2.8 Graduates 15,985 15.836 18,169 0 9 2 I DO First-year enrollments 1,582 1,724 1,692 9 0 -1.9 Graduates 1,017 1,587 1,512 C 0 -4 7 Total First-year enrollments... 19,453 18,880 18,389 -2.9 -2 7 Graduates 17,002 17,481 17,681 2.8 1.1 NC/E. For allopathic and osteopathic schools, first-year enrollments are actual for 1981-82 and 1986-8? and are projected for 1991-92, graduates are actual for 1981-82 and 1986-87 and are projected for 1991-92. MD first-year enrollments include students transferring from 2-year schools, other degree programs, and foreign medical schools. DO first-yeas enrollments and grnduates for 1986-87 are preliminary estimates. SOURCE U S. Department of Health & Human Services, Health Resources and Services Administration, Bureau of Health Professions Seventh Report to the President & ConAress on the Status of Health Porlogael IR the United States, DHHS PUb. Ho. HRS-P-00-90-1 (Rockville, MD. URSA, June 1990), table VI-A-11. lowest ratio(161) and New England bad the highest the United States (table 10 2) (673). Their growth in (283) (673).12 Although most States may expect an importance is expected to continue nito the next increase in coming years, substantial decreases are %..entury, even though enrollments in bothosteo- projected for some (e.g., Colorado, Nevada, and pathicand allopathic schools are projected to Wyoming) (673). decrease (table 10-6) (673). The number of osteo- Doctors I:: lsteopathy (D0s) represent a small but pathic medical schools increased from 5 in 1968 increasing proportion of total active physicians in to 15 in 1989 (148)." As of September 1, 1989, USWmpp.1/1FacalblofStMcSindadedhseachcommusreghwianddivIsion. "Thcessesse in the aumba of osteopaubiumedkai si.buois i. meat jrc.an. and die 4.4011101.piCrit darulac th uurdtria$ cl404.4041WA.Lusilui totra ibalhvi byan increase in die number of osteopathic residency naming prugrams. As icsuil. APpli4igaluy uUC :kW vi v)tOrpaduk. giaktudtva )eck.mg scstdcm., ttaining are now entering allopathic residency graining programs (148). 2 f; k....II 226 Health Care in Rural A-v.erica there were 27,627 active DOs in the UnitedStates medicine (65). Specialties showing the greatest (711). increases among male seniors included the pediatric and internal medicine subspecialties, rehabilitation Distribution by Specialty: medicine, and public health(65). Primary v. Nonprimary Care Primary care physicians are almost twice as likely Growth in physician supply has been accompa- as nonprimary care physicians to practice in rural nied by a fiend towards more specialized practice. areas. In 1988, 15.9 percent of all professionally The period 1970 to 1988 saw a 68 percent increase active primary care physicians (MDs and DOs) were in die total number of professionally active MDs, but in rural areas, compared with 8.0 percent of aoive the number of MDs in general/family practice nonprimary care physicians (MDs only) (086).16 The increased by way 20 percent during this time (table trend towards nonprimary care onil ibus have a 10-7) (39.671). Specialties experiencing the greatest disproportionately negative effect on muareas. increases in absolute ..umber during this period included radiology,14 plastic surgezy, gasiroenterol- The proportion of primary care MDs who are ogy, neurology, pulmonary and cardiovascular spe- office-based has declined as more of these physi- cialties, and ...... sthesiology (39471). cians enter research, administration, teaching, and hospital-based positions(68).Rural areas have This (rend towards spe6alization has widened the suffered more than urban areas from this tend. From gap between supplies of primary and nonprimary 1963 to 1986, the ratio of office-based primary care care physicians.15 Between 1981 and 1988, MD-to- MDs to area residents increased by 2 percent in population ratios increased more quickly for nonpri- urban areas but decreased by 8 percent in rural areas mary care specialists than for primary care physi- (68). cians (table 10-8)(39,672).Furthermore, ratios for family/general practitioners showed the smallest increase (8 percent) of the three primary care Trends in the Supply of General and specialties for which information is available (table Family Practitioners 10-8). The slower rates of increase for primary care The "classic" primary care physician is the MDs in general, and for family and general Nactition- ers in particular, are projected to continue through family practitioner (FP) This specialty was first recognized in 1969 with the establishment of the the year 2020 (table 10-9) (673). The AMA predicts American Board of Family Practice(11).The that, unlike the supply of other physicians, the supply of general and family practitioners and predecessors of board-certified FPs were general practitioners (GPs), who received no specialty general surgeons will not keep pace with growth in training and typically went into practice after 1 year the demand for their services gable 10-10) (369). of graduate internship. GPs still make a significant A recent study examined data from the 1983 and contribution to the primary care work force, but their 1987 Association of American Medical Colleges numbers have been decreasing. In 1963 there were Graduation Questionnaire to determine trends in over 73,000 G Ps in the United States. By 1986, there evolution of specialty choice among allopathic were only slightly more than 25,000 GPs, and most medical school seniors. During this period, the (60percent) were over the age of 55(11,68).In 1940, number of seniors indicating a choice for any app.oximately 75 percent of physicians in patient primary care specialty decreased, with the most care were GPs (37). By 1970, general and family dramatic decrease occuning in general internal practitioners (ombined) represented only 19 per- KInctudes diagnosde radiology theapeulk radiology. radiation oncology, and nuclear medicine. inhere Is some debate over which specialdes should be included aspnmary cart specalues. Wilde all internats and pesharomans were once considered primary care speciarsts, increasing subspecialiradon in both fields has led rescan.hers and polikymakers to exi-lude subspecialnis hom the definition of "primary care " Some definitions of primary care physicians include obstamshtynowlogy and general salsa,. since these spectahsts often provide substantial amounts of primary care, especially when there is a lack of other primary ene providers. Me Bureau of Health Professions and the Bureau of Health Care Delivery and Assistance currently include faaubar Nal pratsice. general internal mediune, general pethatnes. and obsteniestrecology in their definition of pritnary Care physicians for purposes of shorugc arca designation We us. I i p. rhc definition of pnmary care specialties used in this mon varies depending on the sour. e of information. I6Primary care here includes &Ms in wend/family panice. general internal medicine. general pediatncs. and utaictrpSigyuCcOlOgy, and ail 001 in patient care. 21 ;"I Table 10-7-Supply of Active MDs in the United States by Specialty, 1970, 1980, and 19813A Active MDs 1970 1980 1988 Rate per Rate per Rate per Percent change in 100,000 100,000 100,000 in number, Number resideutsc Number residentsc Number residente 1970-1988 Estimated active:I 314,106 150.0 440,357 190.4 536,185 216 6 70 7 Prole:mil:sally active 310,845 149.4 414,916 179.4 521,328 210.6 67.7 General and family practice 57,948 27.8 60,049 26.0 69,339 28 0 19 7 Medical Specialties 77,214 37.1 125,755 54 4 170,502 68.9 120.8 Allergy 1,719 0,8 1,518 0.7 1,471 0.6 -14.4 Cardiovascular disease 6,476 3 1 9,823 4 2 15,132 6.1 133.7 Dermatology 4,003 1.9 5,660 2.4 7,041 2.8 75.9 Gestroenterology 2,010 1 0 4,046 1.7 6,868 2.8 241.7 Internal medicine 41,872 20.1 71,531 30.it 94,674 38 3 126.1 Pediatrics allergy ...... 391 0.2 461 0 2 378 0 2 -3.3 Pediatric cardiology.. 487 0.2 659 0.3 931 0.4 91.2 Pediatrics 17,041 8.6 28,342 12 3 38,231 15 4 113.1 Pulmonary diseases 2,315 1,1 3,715 1.6 5,776 2 3 149.5 Surgical specialties ...... 86,042 41 3 110,778 47.9 132,409 53 5 53.9 General surgery 29,761 14.3 34,034 14.7 37,792 15 3 27.0 Neurological surgery.... 2,578 1 2 3,341 1 4 4,217 1 7 63.6 Obstetrics and gynecology 18,876 9 1 26.305 11.4 32,278 13 0 71.0 Ophthalmology 9.927 4.8 12,974 5 6 15,581 6 57 0 Orthopedic surgery 9,620 4 6 13,996 6 1 18,234 7 4 89 5 Otolerynology 5,409 2 6 6,553 2 8 7,182 3.2 44.4 Plastic surgery ...... 1,600 0.8 2,980 1 3 4,356 1 8 172 3 Colon and rectal surgery 667 0.3 719 0.3 860 0 3 28.9 Thoracic surgerY...... 1,809 0.9 2,133 0 2 2.124 0.9 17 4 Urology 5,795 2 8 7,743 3 3 9,155 3 7 58.0 Other specialties ...... 89,641 43 1 118,334 51 2 149.078 60.2 66 3 Aerospace medicine 1,188 0 6 587 0 3 605 0 3 .42 3 Anesthesiology...... 10.800 5 2 15,958 6 0 24.258 9 8 123.4 Child psychiatrY... 2.090 1 0 3,271 1 4 4.107 17 96 5 Neurology 3,074 1.5 5.685 2 5 e.663 3 5 181.8 Oscrpational medicine 2,713 1 3 2,358 1 0 2.701 1.1 -04 Pathologyi 10.483 5 0 13,842 5 9 16,504 6 7 58 3 (cont(nuee on next page) 2 Table 10-7Supply of Active Ws In the United States by Specialty, 1970, 1980, and 19806 bContinued Active &Os 1970 1980 1988 Rate per Rate per tate per Percent change in 100,000 100,000 100,000 in number, Number residentsc Number residentsc Humber residentsc 1970-1988 Physical medicine and rehabilitation 1,479 0.7 2,146 0.9 3,729 1 5 152.1 PsychiatrY 21,148 10.2 27,481 11.9 33,679 13.6 59.3 Public health$ 3,833 1.8 3,126 1.4 3,050 1 2 -20.4 Radiologyh 3.360 6.4 20,282 8.8 26.833 10.8 698.6 Other and unspeoifiedi 19.415 9.3 23,798 10.3 24,779 10.0 27.6 °Includes Federal MDa and MDs in U.S. possessions. Data for 1988 ere as of Jan. 1. Data for 1970 and 1980 are as of Dec. 31. bIn its publlcatiom of 1981 data, the American Medical Association (AMA) began differentiating additional subspecialists in internal medicine, pediatrics and surgery. Separate estimates were made available for internal medicine subspecialties of allergy and immunology, diabetes. endocrinology, geriatrics, hematology. immunology, infectious diseases, nephsology, nutrition. oncology and rheumetology. Separate estimates in pediatrics wore provided for the subspecialties of adolescent medicine, neonatal-perinatal medicine, pe..atric endocrinology, pediatric hematology/oncology, and pediatric nephrology. Separate estimates for surgical subspecial"es were made available for abdominal surgery, cardiovascular surgery, hand surgery, head and neck surgery, pediatric surgery and traumatic surgery. In this table, these subspecialties were formerly included in AMA published data under internal medicine, pediatrics snd general surgery. When excluded from these categories, the total number of general internists, general pediatricians, and general urgeons presented for 1988 decrease to 72,038. 34,689, and 32,339, respectively. cRetios aro based on total population plus civilian population in U.S. possessions. 1987 population estimates were used to calculate 1988 MD ratios. dAdjusted to include MDs whose addresses were unknown or who were not classified according to sptcialty °Excludes MDs who were inactive, not classified according to specialty, or whose addresses were unknown. fIncludes foiensic patbolnY. !Includes general preventive medicine. °I1cludes diagnostic and therapeutic radiology, radiation oncology, and nuclear medicine lIncludes emergency medicine. SOURCES; U.S. Department of Health and Human Services. Health Resources and Services Administration, Bure.0 of Health Professions. Sixth Report to the President &Congress on_the Status of Health Pereonnel in the United States, DRHS PubMu HRS-P-00-88-4 (Rockville, MD: EISA. June 1988), table 3-3; American Medical Association, unpublished data, provided by staff at the U S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Frofessions. Rockville, MD, in 1990, 240 Chapter 10-The Supply of Health Personnel in Rural Areas 229 Table 10-8--Professionally Active MDs In Primary tently been greater than 80percent, fell to 73 percent Care: Rate Per 100,000 Residents and Distribution in 1988 (94). Similar declines were seen in the fill by Specialty, 1981 and 19886 rates for other primary care fields, including general internal medicine and pediatrics (94). Percent Urban areas compete heavily with rural areas for change 1981 1981 1908 to 1988 FPs. A recent survey of hospitals (both rural and urban) in five geographic regions showed that FPs Rate per 100.000 residents.b are in the greatest demand (514). The American All activec 184.5 210.6 14 11 Academy of Family Physicians (AAFP) anticipates PrimarY care 63.7 71.1 11 6 that the continued growth of managed care systems Family/general practice . 2e0 28 0 7 7 such as health maintena nce organizations (HM0s)- General internal medicine. 25.8 29.1 12.8 General pediatrics 12.0 14.0 16.7 whIch are disproportionately located in urban areas- HonprimarY care 120.8 139.5 15.5 will result in a strong demand for FPs (11). Such systems seek FPs and other primary care providers Percent Distribution because they offer a broad range of services, can act All activec 100,0 100,0 as "gatekeepers" and thereby control referrals to Primary care 34.5 33.0 more expensive specialists, and are generally seen as Family/general practice 14.1 13.3 efficient utilizers of resources. At present, of the 94 General internal medicine. 14.0 13.0 percent of FPs in patient care, an estimated 23 General pediatrics.... , 6 5 6.7 percent were employed by HMOs, 12 percent were Bonprimary care 65 5 66.2 in independent practice associations, and 15 percent aData for 1988 are as of Jan. 1. Data for 1986 are as were in preferred provider organizations (11). of Dec. 31. b1987 population estimates were used to calculate In contrast to the United States, Canada has 1988 MD ratios. Prior to 1900. population resisted the trend towards specialized medical prac- estimates used were for the some year as MD data. tice. Although it has 19 percent fewer MDs per cIncludes MDs in patient care, research, administra- tion, and teaching. Excludes inactive, not clas- capita than does the United States, Canada, in 1985> sified, and address unknown categories had a general/family practitioner-to-population ratio SOURCE. U.S. Department oi Health & Human Services, of 89 compared with the U.S. ratio of 28 (table Health Resources and Services Administra- 10-11) (129). Apprnximately 50 percent of all tion, Bureau of Health Professions, Divi- sion of Medicine, Council on Graduate Medi- practieing physicians in Canada are in general or cal Education. First Report of the Cuuncil, family practice (3a), compared with 13 percent of vol. 2 (Rockville, MD: July 1, 1900), table 6; American Medical Association, un- physicians" in the United States (table 10-8) (39). published data, provided by staff at the U.S. Department of Health and Human Ser- Other Characteristics of the MD Population viced, Health Resources and Services Admin- istration. Bureau of Health Professions, Female physicians are an increasing proportion of Rockville. MD, 1990. all physicians. Between 1980 and 2000, the percent- age of physicians who are female is projected to cent of all professionally aetive physicians; by 1988, more than double, from 11 percent to 23 percent they represented only 13.3 percent (39). (figure 10-1) (671). The implications of this trend for health personnel policy may be significant, since The continuing attrition of GPs, and the fact that studies have shown that women physicians see there has not been a significant increase in recent fewer patients and work fewer hours than their male years in the number of FPs, raises concern about the counterparts (95,308481). Female physicians are adequacy of the future supply of these key primary more likely than their male counterparts to choose care providers. One indicator of declining interest in salaried positions (378) and are less likely to practice family practice is the 1988 decrease in the pereent of in mai areas (184). available first-year family practice residency posi- tions in the National Residency Match Program that Tlx proportion of MDs who are graduates of had been filled. The "fill rate," which had consis- foreign medical schoola (FMGs) nearly doubled 17MscoWy. 242 230 Health Care in Rural America Table 10-9-Number of Professionally Active MDs in Primary Care and Nonprimary Care; Estimated 1986 and Projected 2000 and 2020* Percent change Specialty 1986 2000 2020 1986-2020 Primary care 102,110 223,920 282,010 43.9 General/family practice 71,320 82,780 97,520 38.7 General internal medicine. 76,260 94,280 111,130 45.7 General pediatrics 34,530 46,860 53,360 54.5 Primary care with obstetrics/gynecology 215,540 268,040 314,530 45.9 Other medical specialties 80,700 99,170 115,820 90.8 Surgical specialties 134,440 165,550 182,770 35.9 Other specialties 144,530 193,240 228,710 $8.2 Totalb 521,700 681,890 789,300 51.31 NOTE: Figures gay not add to totals due to rounding. aIncludes MDs in patient care, research, administration, and teaching, and MDs in Fecliral service 1986 figures include approximately 90 percent of the Physicians who are not classified according to activity status by the American Medical Associationandwhose addresses are unknown. brigures may not add to totais due to rounding. SOURCE: U_SDepartment of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. Seventh Report to the President& Congress on the Status of Health Personnel in the United States, DHOS Pub. NoHRS-P-OD-90-1 (Rockville, MD. HRSA, June 1990), table VI-A-14. Table 10-10--American Medical Association (AMA) Projected Changes in Physician Supply and Utilization by Specialty, 1985-2000 Difference between Percent gzowth, 1985-2003 growth in utilization Supplya Utilizationa and supplyb All MDsc , 23.81 34.51 931 General/family practice 9.9 13.0 -3.1 Internal medicine 36.6 24.0 12.6 General luternal medicine .. 27.0 24 6 2 4 Medical subspecialties. 51 8 23.4 28 4 Ail surgical specialties.... 13.1 17 0 -3.9 General surgery 0 $ IS $ -16 0 Surgical subspecialties... 19.9 17 1 2.8 Pediatrics . 38.8 ' 0 31 8 Obstetrics/gynecology. . 24 3 2.8 21 $ Psychiatry ...... 14.0 19.4 -54 Emergency nuwlicine... 69.4 6 2 63 2 cSupply growth estimates baaed on the projected number of active physicians.Utilization growth estimates based on the number of of physician contacts (excluding telephone contacts) as rept ted in the National Health Interview Survey and the National Medical Care Ut!lization and Expenditure Survet, bThis represents the percent growth in utilization (column 2) subtracted from the the percent growth in supply (column 1). cThe AMA predicts a 81 0 percent increase in the supply of osteopathic physicians 4.0s) between 1986 and 2000. In 1986, DOs represented 4.2 percent of all physicians--the proportion is expected to increase to 5.5 percent by the year 2000 (table 10-2). SOURCE. W.D. Harder, P.R. Kletke, A.D. Silberger, et ai. Physician Supply and Utilization by Specialty. Trends and Projections (Chicago, ILAmerican Medica). Association, 1988), table 8-2. Chapter 10The Supply of Health Pet wane! in Rural Areas 231 Table 10-11Comnanson of Canadian and American Physician Supply for Selected Speciarties, 1985 kit Canada United States Active Federal Active civilian Physicians and non-FederaI Physicians physicians, per 100,000 physicians per 100.000 Dec. 31, 1985 residents Dec, 31, 1985 residents PrimarY care (including subspecialties) 28.538 111 220.036 92 PrimarY care with obstetrics/gynecology 30.007 11. 250.903 104 General/family practice . 22,789 89 67,051 28 Internal medicine and subspecialtiesa.. ,. 4.14i 16 116,146 48 Pediatrics and subspecialtiesb 1,608 6 36,839 15 Obstetrics/gYnecologY 1,469 6 30,867 13 NonprImary case 15,692 61 291,054 121 Total 44,230 173 511,090 213 NOTE: As of Jan. 1, 1986, the Canadian population was 25,625,000, and the U.S. population was 240,468.000 Canadian and American population data are from the Bureau of the Census Werld Population ProLte. 1986. aCanadian data ftor the category'internal medicine and subspecialties" are directly from their category of the same name. American data forthis category are the sum of the American Medical Association's (AMA's) category for internal medicine,allergy, cardiovascular disease, gastroenterology, and pulmonary disLase b Canadiandata for the category pediatrics and subspecialtiesare from their category "pediatrics " American data for this category are thesum of the AMA's categories for pediatrics, pediatric allergy, and pediatric cardiology. SOURCE.Adapted from F.L. Clare. E. SpratleY, P. Schwab, et af "Trends in Health Personnel," Health Affairs vol. 6, No. 4, winter 1987, pp 90-103. Figure 10-1Supply of Physicians (MD and DO) between 1963 1983, increasing from 13 to 23 bY Sex: Estimated 1980 and 1986, Proiected 1990 percent of all U.S. physicians, but it has since and 2000$ declined slightly (to 21.7 percent in 1988)(39,671). This proportion may decrease further if Federal policies restricting the number of FMGs allowed to practice in the United States are implemented (388). Table 10-12 shows changes in the distribution of MDs across various professional activities over the past two decades. Fluctuations from year to year in the proportion of MDs who were not classified according to activity status or whose addresses were unknown prevent determination of any consistent trends. Nevertheless, a slow but steady increase in the proportion of MDs who are in research, a recent decrease in the proportion who are in office-based C.r.l shoe DFmat patient care, and an increase in the proportion who eincludoa all prolessiwally active physicians. Estimates of MDs adosted are inactive (i.e., retired) can be detected (39.67 1). to indude oppitcdmately 90 percent of physicians who are not classified actordlne to activity statusbythe American Medical Association and whose addresses ore unknown. SOURCE:Office of Technology Assessment. 1990. Data from U.S Department of Health and Human Services, Health Resources Doctors of Osteopathy end Services AdafinIstration, Bureau of Health Professions, Sixth Reportto the President anct Congress on the Steers of DOs are considerably more likely than are MDsto Health Personneffn the United States.1)1414S Pub. No. HSB-P 0048-1 (Rockville. MO: HRSA. June 1088), tame 3-48. be primary care physicians. Of board-certified DOs 232 Health Care in Rural America Table 10-12-Distribution of MDs by Matsor Professional Activity, Selected Years, 19?0-880b Activity 1970 1975 1980 1983 1985 1088 Percent distribution Patient care ...... 83.4 79.2 80.5 81.5 81.2 81 7 Office-based. 57.6 54.7 58.2 59 7 59.7 57 8 Hospital.based.... 25 8 24.5 22.3 21 8 21 5 23 9 Residents.... 15,3 14 7 13 3 14.1 12.6 15 4 Staff 10.4 8 9.1 7 7 7.8 8 4 Nonpatient care.. ., 9.7 7.2 8.2 8 8. 7 7 3 Medical teaching 1.7 1 6 1.7 1.5 1 4 1 4 Administration 3 6 2.8 2.6 2 7 2 5 2 5 Research 3 6 2.0 3.3 3 6 4.2 2.8 Other 0 8 0.7 0 6 0 6 0 6 0 6 Not classified or address unknown... 1 1 8.1 5.8 J 0 3 0 2 8 Inactive ...... ,. . 5.9 5 4 5 - 7.1 7.0 8.2 100 0 100 0 100.0 100 0 100 0 100 0 1.':ftel for 1988 are as of Jan. 1 Priov: data are as cf Dec, 31, bIrcluods MDs in Federal service. '..centages may not add to 100 due to rounding SOURCE U.SDepartment of Health and Human Services. Health Resources and Servp-es Administration, Bureau of Heal:h Professions, Sixth Report to the P-esident and Congress on the Status pf Health Personnel in The United StatesDHHS Pub No MRS-P-OD-88-1 (Rockville, MD. HRSA, June 1988), table 3-5. Ammrscan Medical Association, unpublished data, provided by staff at the U.S Department of Health and Human Services Health Resources and Services Administration, Bureau of Health Professions, Rockville, MD, 1990. in1986.339 percent were in general uctictice," and Rural Supply an adifts,al 21 percent were in internal medicine, obstetrics/gynecology, or pediatrics (table 10-13) (671). However, the percentage of DOs in general Prevalence of Ru ral Physicians practice decreased slightly from 1982 to 1986, from 41 to 39 pern- (671), raising the qutstion of The number of profession. Jy active physicians whether osteopathic graduates are R llowing allopa- (aviDs and DOs) per 100,00u residents was more than ths' trends in preferring specialized to general twice as high in urban as in rural areas in 1988 (table practice.24The distribution of DOs by State is rather 10-15)21(686).For primarycare physicians, urban- uneven, with the highest concentrations in States rural differences are less dramatic but still pro- where osteopathic schools are located (table 10-14) nounced (table 40-1S). Within rural counnesi- (e,g., Michigan, Pennsylvania, and Ohio) (671). physician-to-population ratios are related to county 18Only 27 percent of all DOs are board-certified specialists (711). one American Osteopathic /Association dots not recogisize die term "foul. practice We osteopathic physician comrnuwey, 'general pracnce " describes physkims who have completed a residency i general practice or whosa practice is of a general rather than a specials:et. nature(7 1 1). 2sFor purposes of dataa nalysis. the Federal Bureau of Ha lth Professions regards all DOs wo prov ide patient care as primary care poysicauts,-. diess of board certification and specialty (570). 21In table 10-14 and other aubseqvut tables. physician distabuion and suppb re shown by county size and clasrdicanon. In 1987, the total sJ S. porlatian (ae estimated for the purr aes of' the Area Resource File database) was 243.398,300. Dismbution 01 dial population vms as follows. metro-188,261.600(77%); nonmetro-55.136,703 (23%), nominal) counties with 50,000 or more residents -18,937,200 (7.7%). nonmeac Olinfles wit* 25,000-a9999 tendons-17,930,700 (/ 3%). nonmetro counties with 10,000-24999 residents-14;94900 0.8%), nonmetro counties with 9999 reskichts-3.132.500 (1 3%). nonmetro cowstics with 2.500-4.999 residents-681,400 nonmetre counties with fewer than500 ats-1e0.000 (<05%)within nomnetro counties of fewerthan 10.000 residems, the total population an counties with 6 or fewer persons per spiare was 1,4100 (0 5% of die total U S population) aid the total population f all other counties was2,695,(i00tJ 1% of the torahS population) ). 22Here ma wbrre in this chapter, "mral countles" and "tuba .ounnes" refer to nonractro and Mtn() counties, respectively Chapter 10The Supply of Health Personnel in Rural Areas 233 Table 10-13Board-Certified Osteopathic Physicians (Ws) by Specialty,19864 Percent of ooard- Number of certified Certification board DOs. 1286 DOs Anesthesiology.. ... 227 3.5 Dermatology 58 0 9 Emergency medicine.... 108 1 6 General practice 2.582 39 3 Internal medicine.. . 1.020 15.5 Keurology/psychiatry..., 139 2.1 Nuclear medicine 80 1.2 Obstetrics/gynecology. . 180 2 7 Opthamology/otorhinotaryngology. 330 5.0 Pathology 226 3.6 Pediatrics 170 2.6 Proctology 72 1.1 Pnblic health/preventive medicine 64 1,0 _44 4a)iim Radiology ...... 452 6 9 , 4.8wAzze Rehabilitation medicine 82 1 2 General ',-tery.... . 398 6 1 -:pmsatice:=45 Neurologic surgery. . .. 17 0 3 .110046;itollik .*, Orthopedic surgery. 193 2 9 Plastic & reconstructive surgery 3 0 0 Thoracic surgery ...... 32 0 5 Urologic surgery . 59 0 9 Other 85 1 3 Total 6,566 100.0 aOnly 26 percent of all DOs were board-cortified in N. I k 1986. * o. 4, 4.4 SOURCE U.S. Department of Health & Hummn Services. Photo crodlt: Pot*, &soon Health Resources and Services Administration, Bureau of Health Professions, Sixth Report Pnmary care physicians make up the majority of physicians to The President & Connress on The Status of in rural areas. Health Personnel in the United States.Wills Pub. No. HRS-P-OD-88-1 (Rockville, MD' HRSA. June 1988). table 3-13 than one-third as many general internists, approxi- mately one-fourth as many general pediatricians, and slightly more th an one-fifth as many obstetrician/ size," with the smallest rural counties haiang fewer gynecologists per Lapita as urban counties have than one-half as many primary cue physicians and (686). approximately c 1-ninth as many nonprimary care physicians per capita as the largest rural counties. Wide variations in rural phy sic ian supply exist among States and regions (table 10-17) (511). The Thc supply of diffeient types of primary care South consistently has mral physician-to -population specialists (MDs only) likewise varies consideratly ratios below the national rural average for all MDs, by countySi2.e(table 10-16) (686). General/family DOs, and primary care MDs. Numbers of primary practinoners are by far the most evenly distributed re MDs per '00,000 resioents in mral areas range across all county types and sizes, although even from 41.7inAlabama to 99.1 in New Hampshire these physicians are much less common in very (table 10.17) (511). An in-depth study of physician small counties. Met prumuy care specialists are supply in small (fewer than 10,000 residents) rural less evenly distributed. Rural counties have fewer counties also found considerable regional and State 23Unlass othemise Indicated, county size in thts chapter refers to population rather than geographic sat of county 2 " 234 Health Care in Rural America Table 10-14Dietribution of Osteopathic Physicians (DOs) by Geographic Region and States 19b0° Number of DOs Perssett of VO6b 114mtbesst 6.104 24 3 Cennecticut 58 0 Name . 309 $ 2 Massachusetts.. . 172 0 / licw Hampshire...... 19 0 1 Now a%traeyt. .. 1,444 5 7 NeurYoskt 799 3 i Penosyllninle 3.k:12 12 $ Rhoda IxIstel 130 0 Vermont 32 4 Midwest 9,752 54 Z 802 3 I Indian* 3A0 1 2 Kowa° 0:/ 2 6 Kansas... )20 1 3 Madame 3.555 )4 0 Mlnnesota 0 3 Illmeauce...... 1.521 6 0 Nebraska 27 0 1 North Dakota...... 10 Ohle 2,141 8 4 South Dakota.. . :4 0 1 Wfaconaln 1 1 South 5,275 :0 7 Alabama Si 0 2 Arkansas 48 0 2 Dal 9: 0 4 District of CoIunkfa 19 0 1 Floridec... . 1, 638 b 4 Georgia. . . . 222 0 Kentucky ...... IS 0 2 Louisiana. 28 0 1 Maryland ...... 58 0 5 Mississippi... 50 0 2 North Carotins 07 0 3 078 3 4 South Caro1ino 34 0 2 Tenn 102 0 4 . 1.508 6 2 Virginia... 104 0 I. VJA71101e . 216 6 A 2.791 11 1 Alaska . 25 0 1 Arirona 2 8 Catlforss4 727 2 9 Colorado 396 1 6 Bewsli. . 42 0 2 Idaho... . . 40 0 7 Montana 34 0 1 Nevada . 63 0 2 Sew Mexico. . 154 0 6 Dragon.. . 254 1 0 Utah 22 0 1 Reshington... 298 1 2 *owing._ , 15 0 1 Saetth Service, 0 4 U.S. Total ..... 24.128 100 0 NOTE: Lass then 0.5 pexc of the total number of Oft, alncludes residents nd intrns (12.0 percent of total.), retired and inactive DOs (5 7 percent), DOs in research, ducation. adminiotratien, end other nonpatient care fields (2 0 percent), end DOs whose profasslunsl activity was unknown (20.3 percent). Excludes DOs in U S possessions aro: in Matti,/ service bParcentages may not edd to totals due to rounding, cStatas eith colleges of osteopathic medlcine. SOURCE' U.S. Department of Health end Rumen ServIcas, Health Resources end Services Administration, Bureau of Bealth Professions Sixth Annual Report to The President & Conxrels on Tho Status of Health 1-ison net in The United S..ates, DONS Pub Ho ORS-P-00-88-1 (Rockville. MD OSA Juoe 158A1. table 3 16 2 Table 10-15--Supply of Professionally Active Physicians° in Primary Care and Nonorimary Care by Type oi CowZy, 1979 and 1 geeb all active -iIITILS.P.LSL- moegaimary ca ed ,i2v 1979 1988 Percent 1070 1960 94ested 1979 Percent tovIty '.ate per tote per than)/ Nate ptr tate pvr change Rate pet Rote pet change clattificatlion 163,000 100,000 in rite 100,000 100,000 in tato, 100,600 100,000 in rste, cod comnty eta avaiber population *este population 1979.40 Numberpopulation Nurtor pocularico 1979or Motor copulation Owlet population 1079-08 ,..M.M Petro... 312,5'6' 141.7 424 192 223.3 24,0 123,42C 7.7 161,349 864 6.1 184,009 107,0 "42,043 138,5 29.5 toosetris 41,082 74.0 53,333 ID.; 24,1 24,04 .f.,8 10,461 55.3 2).8 16,932 12,2 22,817 41.4 28.7 54.40 end o 17,930 101,8 24,249 '28.0 2S4 8,987 51.0 1%691 6o.8 21.4 8,963 50.8 12,558 66.2 30,3 23,..w to 44,9.9 11,241 72.* tr,113 9,.7 23.4 7,846 45.9 10,051 56.1 24.4 5,415 31,7 7,0 39.5 24.9 smog to 24,951,,, 7,924 o7 2 1,766 45.3 19.3 5,691 41.1 6,936 48.5 18.1 t.233 16.1 2,830 19.8 22.6 :,001 to 9,999.... 1.310 47.9 s,739 S6.I 17.1 1,244 39.5 1.438 45.0 ".s.2 266 0.4 321 10.2 21.3 2,932 to 4.999 .. 31; 44.5 159 52.7 15 i 264 '1.5 210 41.4 15.0 47 6 7 63 0.2 37.5 flotr tban 2,500 46 21.2 54 32.3 15.2 38 23.3 41 25 : 9 $ ..0 II 6.9 40.1 rewtetton A 10,0001 4, 6 mom*/ ;7.4 zawro wale 620 47 0 7" 39.9 495 37.5 623 47.4 26 4 124 9 5 163 12.5 31.5 rp persons/ Sambre A 1,237 46.2 i,08 52,2 13.0 1,05' )8 9 ' '67 43.3 11 4 200 2.4 241 8.9 21.6 U.S Tote.' 33.531 1°7.4 477,530 196.2 24.3 152,500 67.9 '91 810 79 7 '7.2 200,941 89 S 285,720 11C S 30.2 41acludoe aperPan Nedicel kiid1.tIOfl . 4ToPicen OsutopatSie lianciatior data phw.4.vios tn reseech, administratIo.%, ono tochIng,eft* Physiosos in folerei emit*. b198: ND 441a it of 46A. I. Vet. ..e 19,9 s of 0 31. eio .udes pooratrram,ty poectwe. Paternal ra"dici pedirstr'cs. *tatetr'es/tinecotoei, ono i93 " DO patient eve. diets only 41987 cmpulotico estimates rye urea to calesilege 1488 NO end 1987 Of ratios, 1079 ao94toti1n eetootes were 0s66 to calculate 1020 PO end 00 raoos 14%.0C:: 0.5 Deportment of eeell* and tumors 5e.vites. Itealt4 ItelOofro ant/ Set', tec AchlriattsOn. Bureau ot 6&6101 Profeation4. -flit. of Cm* *nitro% ems manes:moot, 04etitiefed. "Ualithed do:* *ram ihe tree Resourer i'le syeter.. vow' ea go 014 in 1980 ena 1900 2-e Table 10-16-Supply of Primary Care Ws by Specialty and Type Of Cnunfy, 1975 and 1913115 General/family practice General internal medicine 1975 1988 Percent 1975 19e8 Pe. int Rate per Rate per change Rate per Rate per change 100,000 100,000 in rato 100,000 100,000 in rate b Number residentsb Numberresidents 1975-86 Number residentsbNumber residents b 1975-88 Metro 37,916 22.5 47,771 25.4 12.9 45,157 24.7 74,624 30.6 60 3 Nonmetro...... 13,595 27.0 16.251 29.5 9.1 2,855 5 5 6,207 11 3 104 5 50,000 and over...... 3,981 23.8 5,021 26.5 11.6 1,546 8 9 3.147 16 6 86 7 25,000 to 49,999 4,495 27.4 5,304 29.6 7.8 906 5.4 2,020 11 3 107 1 10,000 to 24,999 3,934 29.7 4,591 32.1 8.2 35 2 6 914 6 A 144 3 41 5,000 to 9,909. . . 931 30.3 1,070 34.2 12.7 1.2 108 3 4 177 9 2,500 to 4,999 218 31.0 235 34.5 11.4 7 1 0 14 2 1 105 7 Fewer than 2,500 36 22.0 30 18 8 -14 7 0 0 0 4 2 5 0.0 Population 10,000 U S. total 51,511 23.5 64,022 26.3 11 8 48.012 20 3 80.831 33 2 63 9 General Pediatrics Obstetrice/gynecology 1975 1988 Percent 1975 1988 Percent Rate per Rate por Change Rate per Rate per chanse 100,000 100,000 in rate 100,000 100,000 in rate b Number residentsbAlperresidentsb 1975-88 Number residents Number resi.dentsb 1975-88 metro... 18.651 10 3 30.615 16.3 58.5 18,654 10 8 26.999 14 3 32 6 Nonmetro. 1,351 2 6 2,646 4 8 81.7 1,653 3 2 2,908 5 3 62 4 50,000 and over. . 783 4.6 1,446 7 6 65 6 949 5 6 1,581 8 3 48 4 25.000 to 49,999. 436 2 6 893 5 0 89 4 554 3 4 993 5 5 64 8 10,000 to 24.999 . 123 0 9 278 1 9 117 9 139 1 0 303 2 1 110 7 5.000 to 17%5 7 0 2 23 0 7 221 2 11 0 4 20 0 6 77 0 2.500 tc 4,999.. 2 0 3 6 0 9 208 6 0 0 9 1 3 0 0 ?ewer than 2,500 . 0 0.0 0 0 0 0 0 0 0 0 2 1 3 Population < 11,000 6 persons/sq mile 3 0 2 36 1 1 3639 0 2 18 16 7947 6+ perso...:fsq tele . 6 0 2 15 0 6 .459 9 0 3 14 0 5 53 0 U S total .. . 20,002 8 5 33,261 13 7 61 0 20.307 9 1 29.901 12 3 35 7 a1988 MD data as of Jan. 1. Data for 1979 as of Dec 31 b 1987 populatiorestimates were used to calculate 1988 MD ratios. Prior to 108, population estimates used were for the same Year as MD data. 2 5 0 SOURCE. U.SDepartment of Health and Human Serv.ices. Health Resources and Services Administrat. Aureau of Health Professions. Office of Date Analysts and Management, unpublished data from the Area Resource File System pruelo. ..)1A in 1989 and 1990 Chapter 10-The Supply of Health Personnel in Rural Areas 237 labia 10.37-Professuona4 Active MDs, Pnmary Cam MDs, and DOs par 10C,300 Reskients in MetropoPan and Nonmetropoliten Areas by Region and State,1987/1988* Total active MDsb per Total active DOsc per Primary care MDsd per 100 000 residents. 1988 100 000 residents. 1987 100.000 residents. 1988 Metro Non:metro Metro Nonmetro Metro Nonmetro United States., 243 1 IA 7 10 3 6 6 98 5 56 2 Northeast ...... 254.1 137 0 12.2 7.8 112.9 67 3 New England 201.8 182 0 4.4 8.6 102 7 85 1 Connecticute... 291.3 0 0 1.8 0 0 102 4 0.0 Maine...... 195 9 140.1 26.5 16.7 101 9 84 5 Massachusetts. 328 2 171.5 2.6 2.3 106 8 73 9 New Hampshire . 151 0 274.3 1 7 2 7 64.7 90.1 Rhode Island° 242 7 NA 10.3 NA 104 4 NA Vermont 196 1 174.4 2 9 6 1 138.9 82.7 Middle Atlantic. . 281.6 118 5 14.8 7 4 116 3 59 9 New Jersey* 233 3 NA 18.0 NA 107 1 NA New York 326.6 122.0 4.5 2 0 120 (., 56 7 Pennsylvania.. .. 246.4 115 2 28.6 12.5 117 4 63 0 Nicheast 226 6 82.5 17.1 10 7 102 1 57.4 East North Central 217 0 85 2 18.0 8 8 100 3 54 3 Illinois . . 234 3 88.8 7 4 3 5 99 5 53 t Ind-ina. . . 184 1 78 8 5.6 3 9 78 1 47 5 Michigan.... 204 7 81 2 39 6 20 2 114 2 60.0 Ohio 220 6 80 4 20 7 12 2 103 0 52 5 Wisconsin . 222 8 98 9 6.2 2 9 89 7 58 6 West North Central 258 2 79 1 14 3 13 1 108 i 61 1 Iowa... . 233 6 77 0 34 4 11 6 115 6 56.4 Kansas. . 237 0 93 3 13 9 10 0 97 1 65 1 Minnesota . 278 3 82 7 15 2 2 106 5 58 3 Missouri 257 7 58 1 22 0 36 3 113.3 68 6 Nebraska ... 258 6 84 1 2 1 0 8 97 6 54 5 North Dakota 274 9 95 9 3 1 2 4 105 9 59 7 South Dakota 249 3 92 2 2 5 5 9 102 3 61 1 230 2 88 7 7 4 3 9 89 9 50 8 South Atlantic. 251 3 105 2 6 7 3 2 95 6 54 0 Delaware 226 2 122 3 16 9 5 5 101 2 51 6 District of Columbia 583 1 HA 5 1 HA 191 8 HA Florida. ... 211 4 104.5 12 8 5 9 87 6 50 9 Georgia 205 9 91 7 5 0 2 6 78 5 48 8 Maryland 391 5 147 3 2 6 1 6 134 1 65 1 North Carolina. 235 0 102 8 1 8 0 8 86 5 52 8 South Carolina 197 ,.: 86 5 1 3 1 5 78 8 50 0 Virginia . 233 5 208 5 2 8 1 3 89 5 56 1 West Virginia 210 3 138 2 9 6 it 8 88 8 68 7 East South Central 225 6 79 2 2 0 2 4 86 0 47 1 Alabama 197 5 66 3 2 0 1 6 79 3 41 7 Kentucky 244 2 88 3 2 3 2 1 83 5 50 8 Mississippi. 205 4 88 3 2 3 2 4 79 7 49 5 Tennessee . 243 3 69 3 1 8 1 6 91 1 44 5 West South Central 198 4 73 1 !O 7 6 4 82 5 49 5 Arkansas. 229 2 86 5 1 6 2 3 84 3 53 5 Louisiana 233 3 68 2 0 9 0 7 80 8 42 3 Oklahoma 191 8 74 3 11 5 16 1 104 6 57 7 Texas 189 3 68 6 10 6 6 5 79 6 47 2 (continuer, on next page) 2'4. Table 10 17-Professionally Active MOS, Primary Care Mpe, and DOs per 100,000 hasidents in Metropolitan and Nonmenopolitan Areas by 'legion and State, 1987119880-Continued Total active MDs b per Total active DOsc per Primary c..re MDsd per 100 000)reaulenta. 1988 100 000 rksidents 1987 100.000 residents, 1988 Metro Nonmetro Metro Nonmetro Metro Nonmetro Nest 233.5 114.0 5.8 5.6 91.6 63 9 Mountain . 213.1 104.8 12,5 6 6 88 1 61.6 Arisona. 220.7 93 1 22,6 9.1 101 6 59 0 Colorado ...... 219.0 112.1 11.8 13.4 91 2 72.0 Idaho... .. 172.7 106 4 4.1 4 0 66.9 56,3 Montana...... 202.9 131 9 2 0 4.6 60 1 71 1 Nevada 169.2 107,7 7.5 4 7 67 8 61 3 NowMexico 250.8 94.6 12.3 7.6 96 1 59 2 Utah 203 2 86.4 1 4 1 6 70.9 49 5 Wyoming ...... 189.2 108 9 0 7 3.2 87 9 64.1 Pacific 238,8 128 7 4 1 4 2 92.5 67 2 Alaske.. .. 131 0 NA 7.0 NA 69.5 NA California... 244.2 129 5 3 1 2 8 o3 0 64 8 Hawaii 226 1 169.1 6.7 4 0 99.2 88 5 Oregon . 229 4 124.8 10 2 4 9 94 4 66.3 Washington... 223,1 119 9 7 4 5 5 90.0 65 2 NOTE: NA not applicable (see footnote e) !Population estimates are for 1987. °Includes MDs of all specialties in patientcare. researe., administration. and teachingAmerican Medical Association data as of Jan. 1,1988. clncludes DOs of all specialties in patientCare,research, administration.andteaching American Osteopathic Association data as of 1987 dIncludes MD family practitioners,general practitioners, general pediatricians, general internists, and obstetrician/gynecologists. °For the purposesifthis analysis, Rhode Island and New Jersey were considered to have nononmetro counties, and Alaska was considered all ono "county" (so the entire population is listed under the "metro'column) SOURCE T C Ricketts, Rural Health Research Center, University of North Carolina. Chapel Hill, NC Analysis of unpublished data (provided by the Health Resources and Services Administration) conducted under contract with the Office of Technology Assessment, 1989 varinns(table10-18)(318).The number of parts. In a 1985 survey, 22 percent of rural residents phy ins (MDs and DOs) per 100,000 residents in reported that they had to iravel outside of their small rural counties ranged from 39 in the East South community to receive any kind of medical care Central Region to 751n the Pacific region, and from (303).Rural residents have longer average travel 31 in Georgia to 86 in California(318). times to every type of physician (table 10-20)(644). Rural hospitals have fewer than one-hall the Differences are least for travel to primary care physicians, especially general practitioners, and medical staff of urban hospitals with a comparable greatest for secondary care physician specialists. On number of beds (see table 5-7)(625).'Rural hospitals with fewer than 50 beds have roughly average, for example, a rural resident must travel twice as long as does an urban resident to visit a one-third the medical staff of their urban counter- riturologis° (644). parts. Among rural hospitals, frontier hospitals have particularly small medical staffs (625). Table 10-19 Among rural residents, those living on farms presents rural-urban differences by hospital size generally have relatively greater travel times to category for each physician specialty.25 physicians (table 10-20)(644).With few exceptions, poor rural residents also have slightly longer travel Travel Times to Physicians in Rural Areas times to physicians than do residents with higher Rural residents travel for longer periods of time to mcomes (table 10-21)(644).The exceptions may be receive medical care than do their arban counter- due to physical orfinancialconstraints upon poor 1Includes both board-ccruficd and nonboard-ccnified medical staff (MDs and DOs) 2sPhysician specially as reported by each bospdal. 2"1'') Chapter 10-The Supply of Health Personnel in Rural Areas 239 Table 10-18-Physician-To-Population Ratios (1985), Percentage of DO3 (1985), and Percent Change in Ratios (1975-85) in Small NonmetropeMen Counties, by Region and State Percent change in Number of Physicians per physician-to- smell nonmetro 100,000 Percent DOs population ratio, Region and State° countiesb residents (1985) (1985)c 1975-85 Sortheast 0 0.0 0.01 0 OX Midwest 291 58.4 21 7 16 5 East North Central ..... 33 47.2 7.2 14 0 Illinois 13 33.3 6 7 -11 4 Indiana 5 31.5 16.7 10 5 Michigan 10 70 5 5 6 36 9 Wisconsin 5 49.2 6.7 20 0 West North Central 258 60.2 23.5 17 9 Iowa 15 53.3 45.5 -4 3 Kansas . 61 76 ? 24.7 28.7 Minnesota 12 56 6 18.2 7 0 Missouri 2b 58.1 73 7 -0.3 Nebraska 61 51.5 1 3 15.8 North Dakota 36 52.8 6 5 39 3 South Dakota...... 47 61.0 7 3 39 3 South 244 43.1 11 2 16 0 East South Central.. 46 38 7 5 9 9 2 Kentucky 24 40.5 2 7 17 7 Mississippi s 35 6 11 1 1 4 Tennessee 14 35.6 11 1 1 4 West South Central.... 110 49.1 18 1 5.1 Arkansas 8 34.6 4 3 18 9 Oklahoma 15 56.3 36.4 -0.3 Texas 87 49.7 14 8 -3 3 South Atlantic ...... 88 40,0 6 3 26 6 Florida 8 41 9 12 0 41 1 Georgia 47 31 3 10 0 11 4 North Carolina... 8 45 8 0 0 24 5 Virginie 16 53 6 1 7 52 3 West Virginia 9 49 3 4 g 3 8 West 140 63 9 7 5 25 9 Mountain 110 60 8 8 7 14 9 Colorado 31 53 2 3 9 -9 8 Idaho 20 52 0 10 5 30 3 Montana.. 34 SA 7 12 0 33 9 New Mexico 9 56.1 12 0 10 4 Nevada 7 56 6 18 2 7 0 Utah 11 65 3 0 0 20 3 Wyoming.. . 8 77 5 11 6 26 6 Pacific 20 75 0 3 4 36 7 California... 4 86 2 5 3 85 0 Oregon a 68 0 3 3 17 4 Washington.... a 76 0 2 6 7 6 All nonmetro counties with fewer than 10,000 residents 53 0 15 3 14 2 Entire United Statesd .. 164 8 5 1 33 6 °Only includes the 32 States with nonmetro coanties having fewer than 10,000 residents bNumber of palmetto courties with fewer than 10,000 tesidents in ea,h State No ;.tates in the Nurfh.-1,t Legion had nonmetto counties with few,: than 10.000 residents cDoctors of osteopathy. dIncludes all metro and nonmetro counties SOURCE. D.A. Kindig rnd 8. Movassaghi, "The Adequacy of Physi(lan Supply in Sma:1 Rural Cnonties, Health Af WEI vol8, No. 2. 1989, pp 63-76, exhibits 4 and 5 Table 10-19-Average Number of Hospital Medical Staffs In Selected Specialties by Hospital Bed Size and Metropolitan/Nonmetropolltan Status, 1987 Hospital bed size 6-24 25-_49 50-99 100-199 200-299-. Percent Mean Percent Mean Percent Mean PercentMean PercentMean Medical with number per with nuMber per with number per with number per with number per b specialty DODOb hospital noneb hospital noneb hospital noneb hospital none hospital Gener2l/famtlY practice Nomotro 3.0 2.7 21,6 4.21 1.2 6.36 0.7 9.29 2.2 12.53 Metro 12.9 3 96 3.5 6.57 1 6 10.31 2.4 17.69 3.2 22.45 General internal medicine Nonmetro...... 83,0 1 47 59.4 1.73 27.1 2.96 $ 1 5.65 1.5 10.14 Metro.. ,. . . 83.9 11 60* 25.2 4 92 4.1 7.00 2.1 14.60 .1 26.16 Pediatricsc Nonmetro 97 0 1.17* 85.7 1.30 50,3 1 70 21.9 3.01 5.2 4.96 Metro 93 5 6 00* 62 9 2 57 30 4 3.27 12.4 6.44 6.8 11.83 Oth.t.: medical sPecie1t1084 Nonmetro . 95 0 1.90 84 5 1 89 12.1 2.80 49.7 4.44 19.3 7.54 90 3 1.67* 60.1 7.14 37.P 7.59 13.4 14.59 7.0 25.30 Obstetrics/gynecology Nonmetro 89.5 1.38 81 5 1.39 46.4 1.96 18.2 3.32 4.4 5.42 Metro . 90 3 4 00* 51.0 3 00 17.8 4 09 3.6 7.76 1.5 12.63 Ophthalmology Nonmetro 90 5 2 3- 91.1 1 47 64.8 1.41 26.7 2.21 8.1 3.26 Metro .. 74 2 9 3,* 67 8 3.22 34 9 2 52 8,1 4.44 1.3 6,94 Orthopedic sargery Nonmetro 91 0 1 41 82.6 1.59 54 5 1.79 23.0 2 73 4.4 3.91 Metro . 74 2 2 63* 54 5 2.80 19.9 3.66 3.* 6.22 1.3 9.42 Plastic surgery Nonmetro 99 5 1 00* 98 8 1 20 94 7 1.11 81.7 1.40 60.7 1.55 Metro 83 ? 1 80* 79 7 2 93 61.7 2.26 30.3 2.18 13.5 3.75 General surgery Nonmetro 65 5 1 52 36 4 1 55 15 6 2 18 6.1 3.46 0.7 5.43 Metro 58 L 2 31 20 3 3.34 3.7 4.50 1._ 8,01 0.7 12.59 :horac_c surgery Nonmetro 98 5 1 00* 97 3 I 14 94.5 1 29 80,5 1.50 54.1 1.82 Metro. . . . 91 5 2 50* 85.3 2.62 75.4 2.41 34.8 2.87 15.5 3 75 Other surgical uFPcialtiesc Nonmetrc 84 5 1 29 80 4 1 96 55 0 2.39 26,9 4.19 5.9 6_88 Metro. 64 5 2.00 56 6 6.74 19 4 6.42 6.5 12,12 3.7 18.34 2 Table 10-19Average Number of Hospital Medical Stafl° in Selected Specialties by ilospital Bed Size and Melropolitan/Nonmetropolitan Status, 1987Continued Hospital bed sire 6-24 NOIAMM..M 25-49 50-99 100-199 200-299 Percent Mean Percent Mean Percent Mean Percent Mean Percent Mean Medical with number per with number per with number perwith number per with number per b b la specialty none hospital noneb hospital noneb hospital none hospital none hosmital Anesthesiology Nonmetro. 92.0 2 13 80 A I 39 87 7 1.56 30 6 2 35 8 9 3.63 Metro ...... 71 0 5.33* 54 m 3.05 26 5 3 12 3 8 474 1 5 6 92 Dermatology Nonmetro 100 0 98 5 1.33 95 4 1 10 77.0 1 25 47 4 1 69 Metro...... 93.5 1 50* 86 7 1.42 81 3 1 84 47 0 1 99 22 5 2 77 Emergency medicine Nonmetro...... 97.5 2 60* 91 1 3.86 69 4 2 97 43 8 3 51 16 3 4 32 Metro 93 5 4.50* 74 8 4.08 40 5 3 55 18 9 5 11 10 8 5 84 Nuclear medicine Nonmetro. 100 0 99 3 1 67* 97 5 1 82 91.7 A 73 78 5 1 66 Metro . 100.0 93 7 1 78* 89 7 2 07 76 2 2 17 81 5 2 82 PathoIogyc Nonmetro.. ... 79 0 1 98 71 7 2 07 47 7 1 56 19 7 1 74 3 7 2 37 Metro 71 0 2 00* 49 0 1 97 20 6 2 05 4 0 2 46 1 0 3 44 Psychiatry Nonmetro, 99.0 1 00* 96 3 1 37 84 5 1 38 57 9 1 88 24 4 3 00 Metro 90 3 2 67* 84 6 3 55 63 7 2,74 29 9 4 27 13 2 7 28 Radiologyc Nonm.:tro. 75 0 2 06 59 7 1 74 28 2 1 75 , 12 6 2 58 1 0 4 13 Metro 71 0 2 44* 35 7 2 46 11 0 2 66 2 9 4 51 0 8 6 40 Other specieltiesc Nonmetro.. ... 70.5 3 49 71 0 5 49 67 1 5 81 67 7 5 65 57 0 6 03 Metro .. . 48 4 5 25 63 6 7 56 54 3 8 99 50 5 9 07 49 0 11 26 NOTE. "*" .ndicates mean is based on fewer than 10 cases aIncludes all active on essOCiate medical staff. board-certified and nonboard-certified Excludes courtesy. consulting, hon rary. provisional, or other medical staff bPercentage of hospitals within each bed size category reporting no medical staff in that pa. clar specialty c"Pediatrics" includes pediatrics, pediatric allergy. and pediatric cardiology. 'Other medi,..al specialties' includes allergy, physical medicine and rt.habilitation, cardiovascular diseases, gastroenterologY, pulmonary diseases, nephrology, neurology, and child psychiatry; "Other surslcal specialties" includes neurolot.ical surgery otolaryngology. colon and rectal surgery, urology, oral and maxiI1ofaciaI surgery: -Pathology- includes pathology and forensic pathology. "Radiology includes radiology. diagnostic radiology, and therapeutic radiology; "Other specialties" include aerospace medicine, occupational medicine. general preventive medicine, and public health. SOURCL. U SCongress, Office of Technology Assessment, analysis of data irom American Hospital AssociatIon 1987 Survey of Hospitals. performed for Rural Health Ca e report (see app C) 2-" 2 .) 31,..11Milt-M.C.20. mem. 242 Health Care in Rural America Table 10-20Average Travel Time to Physicians for than 25,000 tesidents, 1.56 woe counties with Metropolitan and Nonmetropatan Residents, 1983 fewer than 10,000 tesm;ents. Well over one-half v ere frontier counties. Among MDs, general/family Mean travel time (minutes) practitioners are the :nost ubiquitous specialists; TYpe of Nonmetro they were present in all but 205 rural counties and all physician Metro All Nonfarm Farm but 2 urban counties (figure 10-2) (685). AEI physicians. 20 25 24 35 All primary care Changes in Rural and Urban Physician Supply physicians 18 20 20 26 General practitioners 17 18 18 23 Federal policies regarding health personnel have Internists, 21 32 32 36 Pediatricians 17 23 23 31 been influenced not only by GMENAC's ptojections Obstetrician/ of increases in supply but atlo by three RAND Corp. gynecologists. ... 19 24 23 36 studies conducted in the early 1980s which sug- Family practitioners 18 20 20 Osteopaths. 14 16 16 17 gested tl at overall &row& in physician supply would All secondary care in timc solve the problem of geographic maldistribu- specialists 24 37 36 57 tion of physicians. Surgeons ..... 23 25 25 22 Orthopedists 24 36 33 46 All three studies examined changes in the supply Ophthalmologists 25 41 39 70 of physicians in towns with populations of 2,500 and Neurologists.... 26 58 58 Radiologists/oncologists 30 58 48 86 more during the 1960s and 1970s. The first study Urologists. 23 38 36 53 (550) found that the number of board-certitied Dermatologists . 20 34 34 27 specialists per capita increased more in smaller Proctologists. 22 54 54 C..olaryngologists 24 3/ 37 3; towns than in larger towns. The second (436) found Psychiatrists.. 24 33 33 that by 1979, nearly every town of more than 2,500 Ammsthesiologists/ residents had ready ace.ss to a physician. The third pathologists .. 20 73 73 Other specialists 29 40 40 60 (727) found that 96 percent of towns with a population of at least 2,500 were fewer than 10 miles NOTE Not all metro areas are included Sample siz- away from a physician and that 98 percent of the es in some cases maY be verY small Statis- ticd1 significance of differences in times U.S. population lived within 25 miles of a general or cannot be calculated Asterisks t * ) family practitioner. These three studies, however, indicste that no one in the sample met the had some limitations: they excluded towns with specifications for that entry fewer than 2,500 residents, the results were domi- SOURCE U.S. Department of Health and Hummn Ser- vices. Centers for Disease Control, Nat- nated by findings in towns with more than 10,000 ional Center for Health Statist,cs, Hyatt- residents, and they excluded DOs and Federal sville, MD, unpublished travel time data physicians (,318). from the 1983 Nar',nal Health Interview Survey provided in )arsons, May 1989 From these three studies policyma'...ets conciuded that market forces play a significant role in the rural residents toisit the ph> skian dosesi to their distribution pattet n of physicians, and that a greater homes. supply of physicians in a particular specialty will lead to a greater diffusion of those specialists into Counties With No Physicia ns rural areas. In the wake of RAND and GMENAC studies, Federal efforts to improve the geographic In 1988, 111 rural counties (with an aggregate distribution of health personnel decreased signifi- resident population of 325,100) had no physician at cantly (68.318.462). However, more recent State all (table 10-22) (511). These counties are concen- and national studies have found that increases in trated in the West North Central, South Atlantic, national supply have not consistently produ.::ed West South Central, and Mountain census divisions. corresponding increases in rural supply. particularly More detailed data are isVailable for MDs alone. In in small or Isolated ru.al areas, and that rural/urban 1988, 17f -lunties (with a total resident population dbpar:ties in 0,,eta1l ph) skian supply have atually of 713,7t,had no primary care MD (table 10-23) idened during the past two dec.aths. Summaries of (686). All of these were mral counties wita fewer the studies follow. e yogniswannielimummENNI1111111111minimminaNammrallmmillEgliMilli Chapter IOThe Supply of Heakh Personnel in Rural Areas 243 Table 10-21-Average Travel Time to Physicians for lionmetropolitan Residents by Incomes Above or Below the federal Poverty Level, 1983 Mean travel time (minutes) Above Below Intone Type of physician All nonmetro Poverty Level Poverty Level Unknown All physicians 25 24 25 29 All primary care physicians 20 20 22 21 General practitioners 18 17 22 18 Internists 32 31 35 42 Pediatricians 23 22 26 26 Obstetrician/gynecologists 24 25 15 33 Family practitioners. . . 20 20 * 20 Osteopaths IS 17 15 2 All secondary care specialists... 37 36 39 46 Surgeons 25 24 32 10 Orthopedists ...... 36 36 38 26 Ophthalmologists 41 38 53 70 Neurologists 58 65 46 27 Radiologists/oncologists . 56 57 2s t.4 Urologists 38 35 45 62 Dermatologists ..... 34 33 30 40 Procte 54 54 Otolaryngologists . . 37 35 51 44 Psychiatrists 33 35 43 14 Anesthesiologists/pathologists 71 25 120 Other specialists 40 41 13 47 NOTE. Sample aizes in some cases may be very small.Statistical significante of tlifferences in times cannot be calculated. Asterisks ("*") indicate that no ono in the sample met the specifications for that entry. SOURCE. U.S. Department of Health and Human Services. Centers fox Disease Contro'. National Cantor for Health Statistics. Hyattsville. MD. unpublished travel time data from the 1983 N.tional Health Inteiview Survey provided by E Parsons. May 1989 National Studies Examining Change in Rural young phy si6ans or had lost some. The Northern Physician SupplyA Bureau o: Health Piofessions and Western regions had the most success attracting (BHPr) study found that during the 1970s, the young physicians, while the Central region had the greatest improvement in the number of patient ...are least suc..ess. A later study found that in 1983, 31 and office-based primary care physicians per capita percent of the least populated as compared with 92 occurred in large (more than 25,000 residents) rural percent of th c. most populaieO rural counties had counties and small urban counties, with the smalitl gained at least ..ne young graduate (334). This study rural counties experiencing comparatively small concluded that physicians tend to locate in larger, increases (683), A study of pi-, sician distribution more attractiv: rural communities, and that less trends between 1950 and 1978 singled out those attractive communities haydifficulty atua,-ting counties with the smallest populatior., and the physicians withe..0 special targeted efforts. poorest physician-to-population ratios as those with the leas" improvement in supply (205). study cf More recent BHPr data indicate that relatively changes in physician supply in individual rural low increases in physician supply in small rural communities between 1971 and 1981 found that a ounties have continued throgh the 1980s. From large number of these communities did not cxperi 1979 to 1988, the number of office based MDs per ence increases in physician supply, and that som.; 100,000 resident.; n 8 percent in nual counties of even experienced decreases (738). fewer than 10,000 residents compared with 23 percent in all rural counties and 25 percent in urban A studyf young physicians settling in rural areas counties, the corresponding increases for all patient between 19i5 and 1979 (332) found that 60 percent care IsolDs were 17, 24, and 24 percent (table 10-24) of all rural counties had either not attracted any ne (686).In lco8, the int:dence of patient.citteMDs in eb (1 () . Table 10-22Number and Resident Population of Table 10-23Number and Resident Population of Nonmetropolitana Counties Without a Professionally Counties Without a ?rimary Care MDCbby Type Active Physician (MD or DO), 1980*b of County, 19880 NuMber Resident Humber of Resident of nonmetroa ympulation counties population counties of countiesd Metro 0 0 United States. 111 325.100 Honmetro 176 713,700 Northeast 1 4.900 50.000 and over.. 0 0 Hew England 0 0 25,000 to 49,999. . 0 0 Middle Atlantic. ... 1 4.900 10,000 to 24,999. 10 119.500 New York .. 1 4.900 5.000 to 9,999.... 47 327.800 Midwest 49 138.600 2,500 to 4,999.... 45 160.300 East North Central,. 2 7.300 Fewer than 2,500... 74 106.100 Indiana 1 5.400 Population <10.000. Michigan ..... 1 1,900 Pacific.. . 2 3.700 Oregon. 2 3,700 A characteristic of these trend data (and most detailed trend data on rural health personnel in this eThere were no metro countve without an acttve MD or DO in 1988. chapter) is that the unenlying counties in each bIncludes physicians of all specialti in patient category ca.. change dramatically over time as care, research, administration, and teaching This counties gain or lose population. As a result, cha.46zs iS a listing of counties that have no professional- in practitioner-to-pJpulation ratiosparticularly ih ly active MDmano rrofessionally active DO °Data from the American Medical. Association as of categories vith only a small number of counties Jan. lv 1988. Data from the American Osteopathic can be abrupt, making trends more difficult to ,Association as of 1987. interpret. °Resident population is only for those counties in- cluded in the listing. Residynt kopulation estimates aro for 1987. As the RAND studies predicted, specia:ties with SOURCE: r.c.Ricketts, Rura''ealth Research Center, the greatest growth rates (i.e., the nonprimary care University of North Carol't. Chapel Hill. specialties) appear to be diffusing to small rural Pq. Analysis of unpublishor.. data (provided by the Health Rosources and Services Admin- counties at a faster rate than that for primary care istration) conducted under contract with physicians. For primary care physicians (MDs and the Office of Technology Assessment, 1989 DOs), increases in supply were actually grea!er in the larger rural counties than in urban counties (table !0-15) (686). Within rural counties, however, in- 2f;1 Chapter 10The Supply of Health Personnel in Rural Areas 245 Figure 10-2Number of COunties Without Selected MD Specialties by Metropolitan/NonmetrOpolitan Status, 1981:10 soe General \family practice 2 1 Gneral surgery 994 General Internal medial ten 4 f Obstetrics/gynecology 1.473 98 General pediatricsFoTmzmmmom222,1.488 RadiologyX2iffmml' Aneethesiology Psychiatry I 798 I I I I 0 L 10 1.000 1,600 2,000 2.600 Number of counties without MD specialist 0.3 NOnmetto DESMetro aExdudes Federal physicians ang physicians in the U.S. possessions SOURCE. Officeof Technology Assessment, 1990. Data frolr. U.S. Department of Health and Human Services. Health Resources and Services Administraiost, Bureau of Health Professions, Office of Data Anidysis and Management, unpublished 1988 data from the num Resource Pile data system. creases in primary care ),,liisician supplywert. than in urban counties (12.9 percent), and actually directly proporlional to county size, with the small- decreased in rural counties with fewer than 2,500 est counties (fewer than 2,500 residents) expeii- residents ( 14.7 peicentl (table 10-16) (680. In encing less than half the Mcrease of the largest contrast,ht. supply of general internists, Leneral counties (25.000 ormonresiderg41. nor:primary pediatncians, aud obstetncian/gyneoologist mcreased care physicians, the pattern was essentially the more in rural than in urban counties during this reverse: large rural counties had slightly greater period (table 10-16) (686). increases than did urban counties, but increaseb in nonprimary 'care physician supplywithin rural Kiadig and MuNa.ssaghi undertookst detailed counties were inversely proportional to coluty size -itantinatior. of phy sician a adabihty in the 684 (table 10-15). Within countit s of fewer then 10,000 rural counties having fewer than 10,00.0 residents in residents, counties with 6 or fewer yrsons per blth 1975 and 1985 (318,. This st6dy included all square mite had substantially greater it,creaLes uf active Federal and non Federcl MDs and DOs, but primary care and nonprimary care phy6icians than e7.4..1uded interns and resider is.) They found that counties with higher population densities (table from 11,)75 to 1985, the mean ,.vel of physician 10-15)(686). 'Some of these data may be misleadinz. Aailability increased by 34 percent in the United in lVf. att.: '.47914!.treere so few nonprimary care States as a whole but by oidy 14 percent in small physicians irk the sm.:rest rural counties that their rural counties (table1).18). Percent change in ratios were remarkably sensitive tu die addition of a p'ay sician,to-populatiou ratios tiurinthe per:od small number of physicians (table 10-16) (636). Langed from 5 percent in the West :iouth Central region to 37 percent in the Pacific region, and from Within the primary care specialties, the supply uf 85 percent in California to -11 percent in 711i/ins general/family practitioners intreased more slowly ttan'e 10-18). Primary t.4ue76 phy sician from 1975 to 1988 in rural counties (9.1 percent) inertased more rapidly in all iural counties (42 26"Primary are" physicians bac Hide& MDs a. gcacial,Tanuly genaal Ames rid mintaine. scacratpediail RS ,AsICIA-000gPiC4A4,40 2,,4 246 Health Care in Rural America Table 10-24--Total MDs, Patient Care MDs. and Office-Based MDs Per 100,000 Residents by Type of County, 1979 and 1988* County classifica'ton Percent change, and countY populatio-i 1979 1988 1975-88 /21§1ARA_ger 100.000 residentsb MMtro 21i.3 262 6 19.7 Nonmetro 87.2 108.5 24 4 50,000 and over 116.3 146.' 26 1 25,000-49,999 86.8 1es.2 72 4 10,000-24,999 62.0 74 7 20 5 0-4,999 48.6 58.2 19.6 U.S. total 188.4 227 7 209 Patient care MDs _Pax 1043,000 residentsb Metro 174.3 215.6 23.7 Nonmetro 73.3 90,5 23 5 50,000 and over 97,5 25.3 25,000-49,999...... 73.3 1::.: 22.6 10.000-24,999...... 52.0 61.3 17 9 0-9,999 ...... 40.5 47 5 17 4 U.S. total...... 150.7 187.2 24.3 Offio,-based MDs vet 100,000 rgskikultsb Metro 123 5 153.8 24.5 Nonmetro 65.6 80 6 22 9 50.000 and over.. .. 85 9 107 0 24 6 25,000-49,993 66.4 81 3 22 3 10.000-24.999... 46 7 54.9 17 ' 0-9,999 37,4 44 1 17 7 U.S. total ...... 110 0 137 2 24 8 411, D data for 1988 are as of Jan. 1. Prior to 1988, data are as of Dec, 31. b1987 population estimates mere used to calculate 1988 MD ratios Prior to 1983. Population as-imates used were for the same Year as MD data. SOURCE: U.S. Department of Health and Human Services. Health Resourcei and Services Administration. Bureau of Health Professions. Office of Data Analysis and Management, Rockville. MD. unpublished data from the Area Resource File system provided to OTA in 2989 and 1990 percent) than in all urban counties (27 percent), hut actually dropped during this periodfor rural increased very little (9 percent)" in small rural and urban counties alike(i45).2 counties (table 10-25) (318). In Minnesota, the primarycare30physician-to- population ratio increesed by 63 percent in State Studies Exam:nit ,7 Changes in Rural urban counties from 1965 to 1985, but actually Physician Supply-Several State studies lend sup- decreased by 2 percent in rural counties. The port to the findings of the natkbnal studies mentioned rat;os of other specialists increased m smaller above: communities, however, and these physicians may actually be providing a substantial amount In Pennsyli,-.!:, overall physician-to-population of primary care (M). ratios increased by 25 percent in rural and 32 Io Georgia, physician-to-population ratios in- percentHIurban counties fro in 1970 to1980.28 creased slightly more in null areas (28 percent) Ratios for general and family practitioners than in urban areas t24percent) bLiween 1968 VIncrease wa.1 8.7 parent with MD$ only, and 9.4 percent what DC's were mcludcd ATMs analysis included MDs and DOs. Z9Thi5 nnalysis did not include DOI. Ma this Indy, -prizary ,are inchted gencral/famtly procure. pethamc(uu.luding u,i#rual mcdirtm totcluding subspecialties). , AgEilhadnaZIESSIValaWarailirmommossomarloznamm.. Chapter 10The Supply of Health Personnel in Rural Areas 247 Tabto IG-25Suppy oi Primary Care PhyslCianSiflMetropolitan, Nonmetropolit. n, and Small Norimeiropolitan Counties, 1975 and 19956 1975 1985 Percent change in Primary care Percent Primary care Percent number of primarY physicians of all physicians of all care physicians per 100,000 patient care per 100,000 patien... care per 100,000 residents physicians residents physicians residents. 1975-98 Metro counties (MDs only) 59.5 43.8 75.5 43.2 27 Ronmetro counties (MDa only).... 38.1 58 4 53.9 55.0 41 Ronmetro counties with fewer tAan 10,000 residents: MDs only 32.2 81 0 35 3 77.9 9 MDs and DOs. 80 7 40.8 770 U.S. total (MDs only) ..... 53.9 48.0 70.4 44.9 31 *Excludes medical residents and feilovs. includes general practice. familypractice.general internal medicine, general pediatrics. and obstetrics/SYnecology. SOURCE. D.A. Tindig end R. Movasseght, 'The Adequacy of Physician Supply in Smell Rural Counties. Health vol. 8, No. 2.1989, pp. 63-76, exhibit 3. and 1983, but whie variation in percent change Foreign Medical Graduates Although they are existed within both mina and rural areas. In disproportionately located in urban areas, FMOs 1983, physician-to-plpulation ratios in Geor . nonetheless play a significant role in health care in gia were still twice as high in urbaii as in rural some rural areas. In Georgia in 1986, 1_, example, areas (740). FMGs were actually more common 'n rural areas: Who Are Rural Physicians? they accounted.for 17 percent of physicians in rural counties but only 13 percent in urban counties (167). Rural areas rely much more heavily Itm" urban In 1985, FMGs accounted for '12 percent of patient areas on primary care physicians and DOs. Some rural areas also rely heavily on EMOs. Rural care physicians in the United States as a whole, compared with 15 percent in rural counties with Physicians are also older tkan their urban counter- partt fewer than 10,000 residents (table 10-26)(316). The proportion of patient care physicians who were Primary Care PhysiciansIn 1988, primary care FMGs, nywever increaseal much more quickly from physicians accounted for 81 percent of all profes- 1975 to 1985 in small rural comties than in the sionally active physicians in rural counties with country as a whole (table 10-26) (316), indicating fewer than 10,000 residents and 57 percent in all that FMGs play an increasingly important role in rural counties, compared with 38 percent in all urban counties and 40 percent in the United States as a neahh care in small rural counties. whole (686).31 The Age Distribution of Rueal PhysiciansThe Doctors of OsteopathyJn 1985, DOs made up proportion of physicians who are Jung (under age 15.3 percent of all patient care physicians in small rural counties compared with 5.1 percent far the 35) increaged substantially ;+. both urban and rural United States as a whole (table .10-.16) (318). The areas from 1975 to 1985, but rural physicians on the distribution of DOs by State is highly uneven. DOs merage are still older than their urban counterparts constituted as much as 74 percent of all patient care (table 10-27) (686). Physians age 65 and over physicians in Missouri's small rural cowaies, but r 1 13 percent of the rural physHan popula were entirely absent in small rural counues in Utah tian, compared with 9 perccnt in urban areas (table and Nor.:Itrolina (table 10-18) (..:18). l0-27) (686). Elderly physicians make up an even Placeide. MDs and DOs Primary ease here exhales Mm n gencrei/famsiy praecox. scrarai .eitrual tnetheinc.5cncral oboorics/gynecology. andalb :.0a in patient cate. 20 810 0 - 90 - 9 61.3 2*' Table 10-26Fooe1gn Medical Graduate (FMG) Physician Supply in Small U.S. Nonmettopolitan Counties, 1975 and 1985 Percent change 1985 in proportion of As a percent As a percent all patient care Number of all Nurober of all physicians who of patient cal 01 patient care were FMGO, FMOs physicians physicians 1975-85 All nonmetro counties with fewer than 10,000 residents . 174 10 325 15 SO $.000-10.000 13$ 10 251 15 50 2.500-4.999 35 12 68 20 67 Fewer than 2.500. . 4 10 6 14 40 Population < 10.000. 4m, 6 peisons/square mils 71 12 119 17 42 76 persons/square mile 103 9 206 15 67 b U.S. total 46.165c 18 6 82.525 22 1 19 alncludes MDs and DOs bIncludes all metro and nonmetro counties c1978 figure. SOURCE. D.A. Kindig and H. Movassaghl. "Trends in Physician Supply and Characteristics Small Rural Counties of the United States 1975-1985." National Aural Health Acsociation. Kansas City. MO. July 1987, Table 10-27Distributicn of Primary Care MDs by Age larger percentage (16 percent) of patient care physi- in MetropolitPn and Nonmetropolitan Counties cians in small (fewer than 10,000 residents) =al 1975 and 1985 counties (316). 1975 198: Future Supply of Rural Physicians Age Me1ro Nonmetro Metro Nonmetro SMbility f Rural Physician hucticesMany 425 271 II% 33. 21% physicians practicing in small rural counties report- 35-44 22 23 27 30 edly view their counties as lacking sufficient health 45-54 23 29 16 18 personnel. In a 1988 survey of physicians in these 55-64,.. 16 22 14 19 areas,32 32 percent of the respondents indicated that 654- 11 15 9 13 there were too few physicians in their counties. Totalb. 100 100 100 100 Based on these responses, researchers estimated a aExcludes federal physicians and phfsicians in the need for a 50 percent increase relative to the current U S. possessions Includes physicians in supply o f physicians in these counties (405). Twenty- generel/femily practice, general internal medicine. six percent indicated that they would be leaving their general pediatrics, and obstetrics/gynecoiogy bPercentages may not sdd to 100 due to roundint. respective communities within 5 years; of this SOURCE U S. Department of Health and Human Ser- group, about one-half were under agq45 (405).33 Of vices, Health Resources and Services Ad- the 510 respondents, 53 penent were in solo ministration. Bunion of Health Professions. practice. Although this particular study offered no Office of Data Analysis and Management. Rockville. MD. unpublished da from the comparable data for urban physicians, a recent Area Resource File system provs ed to OTA survey of' Minnesota physicians found differences in 1989 and 1990 between rural and urban practitioners. Only 64 percent of rural physicians surveyed eepotted that it was "very likely" they would continue to practice 32Data based on a 50 percent random sample mail survey of all MDs and DOs pracucmg in small rural counties in l91111 The survey responserate was SO pescent. 33Physicians were uot asked whether they planwl to relocate to an urban re to another real community 2# 5 Chapter 10The Supply of Health Personnel in Rural Areas 249 Table 10-28Practice Location Preferences of Allopathic Medical School Seniors, 1979 and 1989' Setting where student would most like Percent of seniors practice upon completion of medical training') 1979 1909 Large anc moderate sized 4itie0 and suburbs. 59.1 79.5 Large citY (more than 500.000 residents) 17.2 23 7 Suburb of large city . 10.1 17.4 City ot moesrmte siza (50,000 to 500,000 residents) 2-..4 29 9 Suburb of moderate size city 6.4 8.5 Small city or town (not a suburb) 26 6 12.0 Small citY (10,000 to 50,000 residents--other than suburb) 18 5 9 1 Town (2.500 to 10.000 residents--other than sOurb) 8.1 2 9 Smell town or rural. area 3 2 1.5 Small town (fewer than 2,500 cesidents)... 1 8 0 7 Rural/unincorporated area . .... 1.4 0.8 Undecided or no preference 8.6 6.5 Other 1.0 RA No response 1 5 0.4 lotale ...... 100 0 100.0 NOTE: '1w not applicable. alleflects preferencet 1 Aiceted by allopathic Radical school seniors on a graduation questionnaire In 199. 8,382 seniors (or 55 percent of al). final year -Ludents) completed the questionnaire In 1989. 11.175 students (or 72 percent of all final year students) completed the questionnaire hoes not reflect metrn or nonmetro status of area cpercentages may not add to 100 due to rounding SOURCES. Association of American Medical Colleges, ig79Medical.Student GraduationAhiestionnaire Survey Summary Report for All SOPILL (Washington, X Association of American Muclical Colleges, 1979). Associaticn of America, Medical Colleges 1989 0.-roduate Ousationnairejltesults All School Summery ('michinrsq, DC: Association cf American Medical Colleges. 1989). medicine in their current geographic area during the ee box 1043) have played valuable roles in next few years, compared with 74 percent of providing primary health care services traditionally physicians Statewide and 79 percern of phy skians in provided by physicians. Often referred to collec- the Twin Cities metro area (173). tively as "midlevel practitioners" (141-Ps), these r4eation Chokes of New Medical Graduates three professional groups have developed rapidly Allot uhie medical school graduates are mcrem- siuce the 1960s in response to .concerns over ingly expressing a reluctance to choose rural prac- geographic maldistributionf primary care provid- tice, in 1979,27 percent of allopathic medical schoul ers. Although MIls can substitute for physicians in seniors preferred to practice in a small city or larger maay instance; in the delivery of primary medical town, and 3 percent preferred small towns or rural care, theil scupe of practice is more limited. State areas (table 10-28) (58). By 1989, these proportions niedi._41 and nurse practice laws that regulate these had dropped to 12 percent and 1.5 percent, respec. professions requre some degree of physician super- fively (table 1(-28) (61). Osteopathic physicians 161011 or collaboration. Within their areas of compe seem to have a markedly greater inclination towatds Lace, MI.Ps provide .41e whuse quality is equiv a- rural practice than do allopaths. in 1988, 21 percent lent to that of care provided by physielans, and they of senior osteopathic medical students reported thai often do so at a eomparanv ely low ost (617). NT'. they Wed to practice in communities of 10,000 and, to a lesser extent. PAs see fewer patieots and to 50,000 people, and 9 percent int.nded to practice spend more tune wIth each patient than do physi ut communities of fewer than 10,000 people (21) clans, presumably hecao.,e NPs provide tionmedi,11 :or-vices such as counseling and health eduer ion MIDLEVEL PRACT ITIONERS dering a patient visit (617). Notwithstanding the Nurse practitioners (NPs),cern.' ied nurse- quality and cost-effectiveness of lviLP :are, lack of midwives (CNT4s), and physician ass stants (PAs) ditect thi;c1-pacty coveiagv for MU' seri iees haL. 250Health Care in Rural Amerira Box 10-BProvider Profiles: Midlevel Practitioners Nurse Practitioners (NPs) The NP profession developed during the 1960s in resronse to concerns over a shortage of physicians (617). NPs are registered nurses who have completed advanced training programs in primary health care delivery. These programs grant either certificates or master's degrees and involve from 9 months to 2 years of full-time study. Functions performed by NPs include health assessment, physical examinations, management of minor acute and chronic illnesses, development of plans of care, patient edu.ation and counseling, health promotion and disease prevention activities, and coordination of health care services. In some States they have the authority to prescribe medication. NPs can manage patients independently of physicians, but they do so within the context of a system that allows for professional consultation, collaborative management, and, when appropriate, referral (617). Physician Assistants (PA s) The PA profession also developed during the 19663 In response to concerns over a shortage of physicians (617,671). PAs work with or under the supervision of physicians, providing diagnostic and therapeutic patient care. They take patient histories. perfo:rn physical examim.,..ons and basic diagnostic tests, develop treatment plans, counsel patients on preventiie health behavior, and facintate refenals to other health or social service facihues (671). In some States, they have the audiority to prescribe -:eriain medications (192). PA training programs provide an average of 50 weeks education in the basic medical sciences and another 52 weeks in various clinical disciphnes, including approximately 34 weeks of supervised primary care clinical experience and approximately 19 weeks in the nonprimary care specialties. Most PA programs grant either bachelor's or associate degrees, depending on the program structure and the educational background of the student (192). A small but increasing number of PA programs are now granting master's degrees ((673). While NPs and CNMs perform both nursing and primary medial care tasks. PAs perform medical tas,,i exclusively (192). Certified Nurse-Midwives (CNMs) Trained nurse-midwives were introduced into the United States with the establishment of the Frontier Nursing Service in rural Kentucky in 1925. Thc first formal training program opened in 1931 (24). A CNM is educated in the two disciplines of nursing and midwifery. CNMs provide gynecological care, family planning, an d prenatal care. They also deliver babies, co-manage high-risk pregnancies with physicians, and care for mothers and infants after pregnancy (24.617) Programs preparing CNMs offer either cenificates or master's degrees (24). Like NPs. CNMs can practice independently of p:rysicians, but only within a context that provides for c,nsultation, collaborative management. awl referral (24). Certified Registered Nurse Anesthetists (CR1VA s) CRNAs are baccalaureate-prepared registered nurses who have completed an additional 24 to 36 months training in anesthesiology in an accredited program and have passed a national certification exanunation in the specialty (522). CRNAs substitute for anesthesiologists across States and across a wide range of procedures. Licensure and certification laws require that CRis I t s work under physician supervision, but direct supervision by an anesthesiologist is generally not required (522). resulted in these practitioners' not being used to their Nurse Practitioners fullest potential (617). National Supply This section examines the supply and geographic 4 distribution of each type of MLP. Also included are In 1988, there were in the United States an supply and distributional data for certified registered estimated 56,043 RNs who had completed formal nurse anesthetists (CRNAs), who o ften substitute for training as N Ps (511). Only 20,649 RW, however, anesthesiologists in rural facilities (see box 10-B). were employed with thc position title of nurse Studies comparing anesthesia outcomes by provider practitioner, including 2,318 who had not completed type have found no significant differences between formal training (511). NPs are employed primarily CRNA and MD anesthesiologist-administered serv- in ambulatory care settings (about 33 percent) and ices (75 ,200,211). community and public health settings (about 30 Chapter 10The Supply of Health Personnel in Rural Areas 251 percent) (673). Another 27 percent are in hospitals Figure 10.3Distribution of Nurse Practitioners (673).34 by Community Size, 1988* The future supply of NPs is influenced by the availability of eligible applicants as well as by the availability of slots in training programs. Most programs preparing NPs today are master's level (86 percent of federally funded programs in 1986), in contrast to 1973 when most programs were at the certificate level (671). Many NP training program.1 require a baccalaureate degree in nursing. This may affect the ability of rural RNs, who are less likely to have a baccalaureate degree (317), to obtain ad- vanced degrees. In 1984, there were 208 NP training programs in the United States, and almost one-half Mote than 60,009 (91) received some degree of Federal support (671). Anecdotal reports suggest that there are roughly four eComr talky size does not reflect rnebo.nortmeirv status Data based on 5.987 responses to a national random sample survey of nurse practitio. jobs available for every new NP gruduate (603). The nem. &dudes 210 respondents who did not indirme the size of their geographic &Caution of TVs is directly related to community. SOURCE Office of Technology Assessment, 1990 Data front American the geographic distribution of NP training programs Academy of Nurses Praellfloners, LoweP, MA. unpublished data (586). from th4 1988 National Nurse Practitioner Survey. Rural Supply In Georgia, in 1983, 32 percent of NPs were The proportion of NPs in rural areas decreased working in rural areas (535). slightly between 1984 and 1988. Of the 20,649 RNs In Utah, in 1986, slightly more than 10 percent employed as NPs in 1988, 15.8 percent were in rural of the State's 252 licensed NPs were practicing areas (511). In 1984, appr oximately 18 percent were in rural areas (67/ ).36 Preliminary data from the in rural counties (158). American Academy of Nurse Practitioners' (AANPs') In the 1960s, many NPs practiced independertly 1988 National Nurse Practitioner Survey indicate in rural satellite clinics under supervision of physi- that 30 percent of all NPs are practicing in .winnuni ians in neighboring communities, but this mode f ties of 1,000 to 50,000 residents, and 2 percent are NP practice has become less common as denia..- ror practicing in communities of fewer than 1,0C3 NPs in a variety of other nonrural settings haa grown residents (figure 10-3) (13).36 (617). Table 10-29 examines selected characteristics of NPs practicing in communities of fewer than Some State data on the rural-urban distribution of' NPs are available. For example: 1,000 residents, communities of 1,000 to 50,000 residents, and communities of 50,000 or more In Texas, in 1986, approximately 12 percent of residents (13)18 Compared Mb' NPs in the largest the State's 1,046 board-approv ed NPs were communities, NPs in smaller communities are more practicing in rural counties (708). likely to specialize in family health and to have In Arizona, in 1987, the NP- to-100,000 popu- hospital and nursing ham privileges. NPs in the lation ratio was 12 in rural counties a:. som smallest communities are most likely to be em- pared with 1; in urban counties." Among ployed in freestanding primary care clinks, NPs in Arizona's 13 rural counties, NP.to-100,000 communities of 1,000 to 50,000 residents are found population ratios ranged from 0 to 26 (220). mr.stly in priv ate practice s or in public healtl. "Data on employmeta unias include approximately 2.900 RNs employed woo the positive tide of nurse-midwife {67Ji. "Because 1984 ditstribudosal data included RNs employed *nth the position adz of rease-midwtk. i44 and AB Jac& we um dame.), .....a.paiebit. However, nume-mldwives were only a small proponion {12 perrmni of RNs employed as nunc-malwoes or NPs in 1984. "Community size deo not :Ow (Ave et rural staies.,Sutallet weimuniues may tic at urban areas. mid largerlAnturnaliuwad, Iffae dhC4b "These ratiOs He based on the total 488 board certified NF$ Raiding Anivea di 137 and May be. to4CieSiuhak3utrm.rual auppl, bak.5 die a..4t4ity status of these Ws was not examined. 38590 footnote 36. 2.1.8 252 Health Care in Rural America Table 10-29--Characteristcs of Practicing Nurses Practitioners (Nes) by Community Population Size, 1988* CoarnunnY Mosoulat J,on8 Fewer than 1,000 1.000 t4 50.000 More than residents residents 50.000 residents (N 1,22) IN = 1,7711 (N 3.884) Percent of UPS' Specialty: FamiLy health. . 59 8 32.8 10.1 Aduit health 3 3 IO 6 17 4 Pediatric heaLth . 1.2 3 16.8 18 1 OprontoLogic heaLth.. . 3 3 1.9 3 3 School/college health. .. 2 5 4 4 4 3 Viomen's health. .. 5.7 19 3 16 0 Psychiatric/mantel heeith . 0 0 1.9 2 9 Other 13 1 10 1 15 9 Total. 100 0 100,0 100 0 Rdneation: Masters degree or greater 33 8 33 2 52 4 Other 66 2 66.6 47 6 . I00 0 100 0 100 0 Employment setting: Private practice (with & without a physician) 9 2 20 14 5 0 8 3 0 104 Fraestanchng primary care clinic 47 5 16 117 Hospital outpatient clinic 3 3 4 S 7 Public health clinic 7 5 19 1 7 9 Hospital. inpatient unit 25 6 5 Extended :are facility 2 5 1 5 1 7 Schooldcoliege S 0 11 7 11 7 Occupational health 2 5 2 9 2 8 Otber . . 18 3 13 6 le 2 Total 100 0 100 0 100 0 Other characteristics: Percent of NE's having hospital priviLeges 27 S 26 1 26 0 Percent of NPs having nursing home privileges 9 8 8 6 3 9 Percent of NPs caring for patients over age 6S 769 56 4 SO 1 kommunity population 41se was self-reported and self-definedIt does not reflect metro or nonmetro location SOURCE. American Academy of Nu:se Practitioners. Lowell MA. unpubhed data from the 1988 Nurse Prac- titioner SurveY and NPs in the largest communities are more likely Approximately SO percent of these PAs were m- to be ,:ound cn private practices or hospital outpatient volved M patient care (071). The distribution of PAs clinics. Approximately one-third of NPs in the by State is closely linked to the presence of PA smaller communities have a master's or doctoral training programs (table 10-30) (62,671). Dramatic degree, compared with over one-half of those in the differences in estimated PA population exist among lar:st communities (13). States, ranging from 2,508 PAs in California to only Physician Assistants 35 in Delaware. The East South Central had the lowest regional PA popu'ation (648 PAs) in 1987, National Supply while the Middle A tlantic had the highest (3,793 In 1987, there were an estimated 19,446 PAs PAO (62.671), PA distribution may also be influ- licensed to practice in the United States, an mcreabe cnced b Stdte lau s And regulauons regarding PM' of 15 percent over only 2 years ember (671). scope of practice. In some States, PAs are ref:pared 2r!9 Chapter 10The Supply of Health Personnel in Rural Areas 253 Table 10.30Number of Physician Ass,atants (PAs), 1987, and Number of PA TrainingPrograms,1989, by Region and State Number of Estimuted Number of Estimated PA training number of PAs, PA training nunber of PAs, programa, 10894 19071) programs, 19894 1987b Mated States 51 19,449 Florida 1 846 2 688 Nnathewst. 14 5,082 Georgia Maryland 1 751 New England 2 1,289 North Carolina 2 905 Comucticut 408 South Carolina 0 202 Wane 192 VirAinia 0 348 Massachusetts 1 455 West Virginia 1 203 New Hampshire 105 East South Central 3 648 Rhode Island 69 Altbame 1 169 Vermont 60 KentuckY 1 209 Middle Atlantic 12 3,793 Mississippi 0 32 New JerseY 1 232 Tennessee 1 238 New' York 7 2.465 West South Central 5 1,524 Pennsylvania 4 1,096 Arkansas 0 48 Midwest , 13 3,367 Louialena...... 0 105 7 East North Centrel 2.129 Oklabxma 1 335 Illinois 1 229 TIMM 4 1,036 Indiana 0 147 West 7 4,o40 MiChigan 2 700 Mountain 2 1,255 Ohio , 3 698 Arizona. 0 277 Wisconsin 1 355 Colorado 1 392 West North Central, 6 1,238 Idaho 0 54 Iowa 2 236 Montana 0 41 Kansas 1 228 Nevada 0 02 Minnesota 0 177 New Mexico ..... 0 247 Missouri 1 178 Utah 1 120 Nebraska 1 175 Wyoming...... 0 42 North Dakota 1 127 Pacific ...... 5 3,385 South Dakota 0 117 Alaska 0 169 South 17 6.23# California. 4 2,508 South Atlantic 9 4,042 Hawaii... 0 70 Delaware 0 35 Oregon.. ... 0 146 District of ColuMbia 2 106 Washington 1 492 aPrograms must be accreo.tad in order to graduate PAsAs of November 1989. four additional PA training programs were areiting accreditation, bfncludes PAs not involved in patient care. SOURCES. U.S. Department of Health and Human Services. Health Resources and Seroices Administrativn. Bureau of Health Pro-fessions, Sixth Report to The President & Congress on The Statue of Health Persemnel in The United States DHHS Pub. No. HRS-P-OD-88-1 (Rockville. MD. HRSA, June 1908), tal,le 4-3. Association of Physician Assis-tant Programs. Physician Assistant Progrems National Directur 1909- 99. (Alexandria, VA: APAP, 1989) to practice under the direct personal superv isicnof Pronounced changes in the distribution of PAs by a physician (16) (see ch. 12). practice setting have also been occurring. From 1981 to 1984, the proportion of patient care PAs in solo The percentage of PAs in primary care practice is office-based practice decreased from 18 to15 percent, while the proportion of PAs practicing in large but decreasing. In 1986, only 65 percent of all hospitals, HMOs, office-based group practice, and PM were in family practice, compared with 74 prisons increased (671). The increase in hospital- percent in 1978 (table 10-31) (671). Conversely, the based PAs is likely to be further influenced by the percentage of PAs in the medical and surgical recent broadening in 19R6 (Public Liw 99-509) of subspecialties has increased significantly (671) Medicare reunburseme it policies for PA serv ices This trend parallels that in the physician population, prov it:ed in hospitals, sKilled nursing facilities, and possibly becaust of the close relationsiiik. between intermediate care facilities. Ai:cording tdie Ameri PA and physician practice. can Academy of Physician Assistants (AAPA) and 254 Health Care in Raral America Table 1041-Distribution ot Physician Assistants Rural Supply by Spiciaity,1978 and 1986* Little is known about the rural supply of PAs. PAs 1978 1986 are slightly more likely (39 percent-figure 10-4) to SpecialtY (Nw3.416) (14.8.330) practice in communities with fewer than 50,000 residents than are NPs (32 percent-figure 10-3) PrimerY care specialties 7442 65.12 (13,17). Recent evidence suggests that the propor- Family practice 52,0 37.3 tion of PAs practicing in very small communities has General internal medicine 12.0 13 5 Enemata medicine 4.9 4.3 decreased and will continue to do so. In 1981, 27 General pediatrics.. 3.3 5.8 percent of all professionally active PAs were practic- Obstetrics/gynecology.. 2.0 4.2 ing in communities of fewer than 10,000 residents Medical. sUbspeaialties 6.3 5.4 (671). la 1989, only 20 percent were practicing in Surgical specialties 11.7 19.2 Other specialties 7.8 10.3b communities of this size; an additional 19 percent Total° 100.0 100.0 were in communities of 10,000 to 49,999 residents, and the remainder (61 percent) were in larger °Data are based on two nationel. sample surveys of communities (figure 10-4) (17).40 The 36 PA train- PAs. bIncludes 1.9 percent industrial medicine and 1.3 ing programs that received Federal funds in 1986 percent psychiatry. reported (iat approximately one-third of their gradu- °Percentages may not add to 100 due to rounding. ates were prazticing in primary care HMSAs (671), SOURCE: U.S. Department of Heoith 6 Human Services. with recent data indicating a trend toward PAs Heaith Resources and Services Administra- tion. Bureau of Health Professions. Sixth practicing in the urban as opposed to the rural Report_to the President 6, Congress on the shortage areas (72 1). Status of Health 1,garimok_in the United, States, DMUS PubHo HRS-P-OD-88-1 (Rock- Data from selected States indicate a substantial ville. MD: HRSA. June 1988). table 4-6. proportion of PAs in rural practice. others, there has recently been an increased demand In Arizona, in 1987, approximately 30 percent for PAs to fill hospital surgical resident house staff of the State's licensed PAs were located in rural positions, where they are believed to improve counties, making their PA-to-population ratio quality of care as well as to help minimize costs higher than that of urban counties (8 v. 6 per (470,671). A threefold increase in the demand for 100,000 residents) (220). PAs in Federal prisons is anticipated as the size and In Texas, in 1986, 66 percent of the State's 412 PAs were practicing in rural counties (708). number of prisons expand (192). Increased demand In Utah, in 1986, 37 percent of the 75 PAs were for PAs in these settings, along with the trend away practicing in =al counties (158). from primary care specialty practice, is likely to In OkIrisoma, in 1987, the distribution of PAs have a significant impact on the future supply of PAs showed a somewhat different pattern. Twenty- in rural areas. eight percent of all PAs were located in rural counties, but the M-to-100,000 population Approximately 1,200 new graduates are added ratio was almost twice as high in urban counties annually to the PA pool, and approximately 90 (7.4) as in rural counties (4.0) (451). percent of these enter active clinical practice (671). Table 10-32 describes selected characteristics of The BHPr projects that the total number of Ms PAs by size of community in 1989. The specialty could more than double by the year 2020 (671). distribution of PA I' differed greatly by community Nonetheless, PA programs reported an average of size, with PAs in small communities (fewer than more than seven available jobs per graduate for the 10,000 residents) and small cities (10,000-250,000 1988 class (18).39 residents) employed mostly in family practice, and 3911asulon a susvcy of PA program directors conducted in February 1988 Direciors ',ere &Act 1) of how many PA "Sb posmons they had became& swam over the post 12 months and 2) how many new PA graduates they had in 1985. Prom these dam. AAPA calculated for coca programthe rano of available positions to PA graduates The =weighted avenge of ali ratios was 7_5.1. All pmgrams reported a ratio squat to or greater than 2 1.When asked the subjective question. "Do you feel there is a shortage of PAO." all programs respondsd "yes" (18,192). glee footnote 36. Communities with fewer than 50,000 residents May be in either rural or urban areas 2;/1 ...,.....mrsnwrota Chapter 10The Supply of Health Personnel ir Rural Areas 255 Table 1042Chalactenstics of Practicing Physician Assistants by Community Population Size, 19816 CommunitY_Penulation Fewer than 10,000 10,000 to 250,000 More than 250,000 residents residents resident4 Percent of PAs. Primary specialty: FamilY/general practice 67 36 24 EmergencY medicine 8 6 5 Internal medicine 5 9 11 General pediatrics 3 4 3 Orthopedics 3 7 6 Industrlal/occupational medicine 2 3 5 Geriatrics 2 1 3 General surgery 2 5 6 Obstetrics/gynecology 1 5 6 Other 8 24 31 Total° 100 100 100 Practice Setting: Group office 17 27 19 Zolo office 20 13 9 Nursing home 1 1 2 PUbiic hospitai 7 13 12 Private hospital ...... 4 10 17 PUhiic clinic 4 8 6 Private clinic 7 9 9 Rural clinic 21 1 Inner city clinic 0 1 4 Other ciinic 14 12 7 HMO 1 7 14 Prison/jail.... 4 2 1 Other normitnic 1 1 1 Total° 100 100 100 Number of years in current practice setting: Less than 1 year 19 r4 23 1 to 3 years...... 26 30 37 4 to 6 years 21 18 21 7 to 9 Years.. 15 12 13 i0 years or more.. 20 15 7 Unknown ...... 0 * 0 Total^ ..... 100 100 100 Academic Degree: Certificate ... 14 9 4 Bachelor's .. 66 88 74 Master's 7 12 13 Associate 14 10 8 Doctorate... ) 1 1 None stated 1 0 * Total°. 100 100 100 Sem: M le. 71 63 55 Female.... 29 37 45 Total° 100 100 100 Macaw, Age (in Years) 407 485 374 NOTE; * * less than 0.5 percent of total 4This information is derived from the Amcrican Acaden7 of Physician Assistants1989 Presk.riptide Pratio Survey and is statistically representative of member and nonmember physician assistant; in communities of all sizes. Community population size was self-reported and self definedIt does not reflect metro or nonmetro location °Percentages maY too add to 100 due to rounding SOURCE. Amer6csn Academy of Physician Assistants. Alexandria. VA, unpublished data firm Cho 198o rA PrOtcriptive PraOtico Survey provided Lo OTA in 1989 (k)- 1 4 Figur.-10-4Distribution of Physician Assistants who were not (.t81). Almost one-fourth of CNMs hy Community Size, 1989* responding to the 1988 ACNM survey were em- 10.000-49.999 ployed by hospitals (342). Seventeen percent were 19% employed by physicians, and 9 percent were em- Fewer than 10.000 ployed by other CNMs or were in private practice \ 20% (342). Twenty-five nurse-midwifery education pro- grams were in operation it-I the United States at the end of 1987 (24). 50,000-249.999 24%1, Studies have sltuwn that CNMs can manage normal pregnancies at least as well as physicians (169,359,502 500,000 or more MS). Numerous factors, includ- ing lack of physician acceptance, liability coverage 250,000-499,999 26% 11% costs and availability, and reimbursement coverage, *Represents location of Pike" major practke miring Based on 1.588 have influenced the characteristics and location of responses to a 1989 sample urvey of PAs. Community size was self-darted end sett-reported. and does not reflect metio'nonmspo CNM practice. _location. *The actual percents9s (2442) was rounded to 24 percent for the purpose of thlsfigure. Rural Supply SOURCE: Office of Technology Assessment. 1990 Data from American Academy of Physician Assistants, Alexandola, VA. unpublished Although r o in foimation regarding the national data born the 1989 PA Prescriptive Pracbce Survey mral/urban distribution of CNMs is available, sur- PAs in large cities (more than 250,000 residents) vey data show that the proportion of CNMs in employed mostly in other medical and surgical smaller communities has decreased in recent years. subspecialties (17). Mere small community and The proportion of active CINMs practicing in com . small city PAs than large city PAs were in solo munities of fewer than 50,000 residents decreased practice settings, and fewer were in group practice, by over 10 percentage points in both small (fewt.1 hospital, and HMO settings. PAs in small communi- than 10,000 residents) and tmd-sized (10.000 to ties were considerably older, were more likely to be 49,999 residents) communities between 1982 and male, had lower salaries, and tended to have been in 1987 (table 10-33) (23a,26).42 their current employment setting much longer than State data indicate that thedi...-..tribution and PAs in small and large cities. Small community PAs :ctivit) of CNMs vary considerably between rural were also less likely than PAs in small and large and urbat areas. cities to have at least a bachelor's degree (17). ln Arizona, in 1987, although only one-half of Certified Nurse-Mid.ives CNMs in urban counties were practicing mid- wifery, all of the 21 CNMs in rural counties National Supply were deliveringbabies.CNMs attended 4 As of January 1990, 4,260 nurse-midwives had percent of all deliveries in Arizona in 1985, and been certified bythe American Collegeof Nurse. in Lome rural counties they delivered more than Midwives (ACNM) (27), a 67 percent increase over 50 percent of the total county births (220).43 the number in 1982 (2,550) (23a).41 Seventy-one ln Texas, in 1986, 22 percent of the 79 CNMs percent of all CNMs responding to a 1988 ACNM practicingnurse-midwifery were practicing in survey. were practicing nurse-midwifery (342). The rural counties (708). Division of Nursing estimates that there were some ln Utah, in 1986, only 1 of the 42 known 2,886 practicing nurse.midwives in the United employed CNMs was practicing in a rural States in 1988, but it does not distinguish between county. Only one rural hospital in Utah granted those who were certified by the ACNM and those delivery privileges to nurse-midwives in 1987, 4lDals on the geogniplucdistribunOn and characicnsticsof CNMs were av adabk for 1982. 195aia: 1988. based on surveys conclucood by the ACNM Tbe ACNM is Only national certifying body for ourse-midwwes 425ce footnOte 36 43Most CNMs delivering babies in rund Arizona counties work on Indian men. in.. and arc empinyed by the Indian I kalsh Service (2.:1) 2 73 Chapter 10The Supply of Health Personnel in Rural Areas 257 Tabla10-33-3intnbution of Practicing Certified Nul se- Table 10-34Number et Nui se Anesthet,st Traming (CNMs) by Community Population Size, Programs and Graduates, 1976-90 1982 and 1987° Total ,.er Total number Year of graduates of programs 1982 1987 (N.1,065) (11.1,526) Community populationc 1976 1,094 194 1977 1,029 166 Fewer than10,000 8 71 7.91 1978 1.063 172 10,n00 to 140,000 . 13 7 14.5 1979 1,078 163 50,000 to 100,009 ..... 17.4 20.0 1980 1,023 161 '00 to 409,609. 10 6 13 2 1981 1.055 148 ot more 40 '6 39 0 1982 1. 107 142 d Total...... 100.0 100 0 1983 985 137 1984... 953 127 1985., 722 112 *Represents community population sire of ClItis' 1986 722 104 Primary work site, 1987., 720 99 bfiata are based on the 1982 and 1987 Americar. College 1988... 574 84 of Nurse-Midwives11M) Surveys and only reflect 1989 636 characterastlis of uurse-midwives who are certified 199C 693c :10)b according to the requirements of the AICHM. Data for 1982 are based on responses from 1,684 CH Ms (661 of 4Pro cted. al). CNMs in 1982) D for 1981 are based on responses from 2 8 Cgt-is (571 of all. CNMs in Number of programs as of Apr 1, 1990. 1987). CNMs who we. residing outside of the Unite., SOURCEAmerican Association of Nurse Anesthetists. States, were not pract1c4u3 curas-midwifery. or did Chicago, IL, unpublished data providedto not indicate the sire of their p-imary worksite are OTA in April1090 excluded. cDoes not reflect metto or nometro location dpercen.ages maynot aoc to 100 due to rounding withdrawal of anesthesiolob:st support ?nd concerns SOURCE American College of Nurse-Midwives. Nurse Midwifery I-, the United States 1902 (Wash- within hospitals over program costs (522). The ington, ACNM. 1984). Mericai College number of graduates has increased since 1988, of Nurs.,-Midwives, Washing Lyn, DC. unpub- reaching a projected 693 in 1990 but it is still far lished data from the 1c87 five-Y,Iar survey below the pm. level of 1i482 (table 10-34) (22). provideto OTA in 1990 The distribution of CRNAs mid anesthesiologists and CNMs in the State do not participate in by State is shown in table 10-33, which ranks the home deliveries (c8). States by their CRNA-to-population ratio. The seven States with average rates at or above the natior_d CerhfiedRegisteredIst arse Anesthetists (CRNAV median for both p:oviders all have both large anesthesiology residency programs and nurse anes- In 1986, there were 22,500 CRNAs and 19,000 thetist training programs(522).The eight Soles with anesthesiologists in the United States, bu, the rates below the national median for boih pros iders number of anesthesiologists has increased mu, h all have largt rural areab and belu% a% erage hospital more quickly than that of CRNAs over the past two bed-to-ppt In ratios (522). decades (116 v. 68 percent) (522).44 The number of graduates from nurse anesthetist training programs Hospitals that lack the se of MD a:testhesi dropped by a precipitous 44 percent from 1980 to ologists may rely on CRNAs as the sole pr oviders of 1988, due to a 48 perc.nt reduction in the number of anesthesia during ...irgical procedures. CRNAs s. MUM anesthedst train'ag programs (table 10 34) minister nearly 70 percent .4 all ancstheti.s gi% n in (2.'"). Reasons for 2rogram closure may Include the United Strees (/22).45 In 1982, 3 vent of *these figurcutprescat the nundof =tubers in the Amcman AssoAtuttn of Num Ant.e.lictoti.utti male Arrierit,to.'avt..ely Alicmhe,,olotoik.,, but they exclude nutse anesthesia stmts and anesthesiology fendeMs (522). 45ALconimg to an anesthesia pramive minty imiduLted by the Canto for Health Eortwoos Itt icardi tn.:), 19 pta..eut uf anc.sdicsia scs .6.44 nationwide are provided by CRNAs alone, 48 part,eni by aoestbestologots and CRNA s t.,gethet, and 33 peo...ot ti otothe.aolos.A. di,oe Mot anesthesiologists and CRNAs work together. it is usually thc CRNA who at.tualt 4jministers the anesthesia (MI) 46Rxcluded from dm &palms mete hospitals in tbc LIS (=runes. long term are and FolculborpthiLs. 41n4.1414 bu.yitaL .ut 4th.t Care Fintuv-intt :dministration's definition of i.ommunity uospitil. and hospitals not providing surgu.at scrum* 2 VIId=r1IlmaiNks 258 Health Care in Rural America Table 10-35-Supply of Certified Registered Nurse Anesthetists (CRNAs) and MD Anesthesiologtsts by State, 1986, Ranked by CRNAs and MO Anasthesiologists Per 100,000 Residents Ansthesia proviers ClthAs _411211,11L11.9.12 t:g-- (CRHAs plus MD lesthessolousts) P. 100,000 Per 100,000 par 100.000 State Number° resident? Rankc N.mber6 residentsb Rank. restclents Alabama 562 ;4.0 7 175 4 4 46 16 4 Alaska .... . 34 6 5 41.5 21 4.0 48 10 5 Arirona 140 4.4 47 263 II 3 7 12 7 Arkaises 243 10 3 16 105 4 5 44 14 8 Califurr.a 957 3,6 50 2,025 77 10 11 3 Colorado 181 5 6 44 2 J 7 ':' 12 5 12 a ConnactIcut 287 9.0 24 280 8 8 5 17 8 Delaware 78 12.5 11 37 5 9 3C 5 10 4 District of Columbia 61 0 7 21' 48 7.7 10 11 4 Florida... .. 860 7.6 33 822 7 2 12 5 14 8 Georgia 546 9.1 23 367 6.1 27 15 2 Hawaii 104 9 2 19 61 5 8 32 5 15 7 Idaho 09 9 9 19 31 3 1 50 13 0 Illinois.... 816 7 0 39 700 6 1 27 13 1 Indiana 11? 2 2 51 374 6 8 17 9 0 Iowa.. 208 7 2 36 16t 5 5 34 5 12 7 Kansas...... 326 13 3 9 126 5 1 39 18 4 KentuckY... 301 8 1 29.5 199 5 3 36 5 13 4 Louisiana 723 16.1 4 216 4 8 42 20 9 Maim 125 10.' 15 69 5 9 JO 16 6 MarYland 310 7 2 37 5 404 9 2 2 5 16 3 Massachusetts., ..456 7 8 31 582 10 1 1 17 8 Michigan...... 992 10.9 14 502 5 5 - 5 16 4 Minnesota.. . 774 18 , 3 267 6 4 24 9 MisstissipPi... 263 10.1 17 87 3 3 40 13 4 Missouri... ,. .. 611 12 I 12 291 5 8 32 5 17 9 Montana 59 7 1 37 5 51 6 4 24 13 3 Nebraska 193 12 1 11 61 5 2 16 17 2 Nevada.... 35 4 1 49 81 8 7 6 12 8 Now Hampshire. 44 8 4 27 53 5 3 36 5 13 7 New Jersey 347 4 6 45 51. 6 8 17 LI 4 New I./wilco- 117 8.1 .;9 5 87 6 0 29 14 1 Hew York 80C 4 5 46 1,461 e 2 8 12 7 1 North Carolina... 883 13 8 0 283 4 5 44 10 3 North ('dote- la 18 6 2 31 4 5 44 23 3 Ohio 946 8 8 25 765 7 1 14 15 9 Oklahoma . . 244 7 4 34 164 5 u 40 32 4 Oragen...... 168 6.3 43 208 77 10 14 1 Pennsylvania, .1.772 14.9 5 824 7 0 15 21 9 Rhode Island. . 61 8.4 27 60 6 2 24 14 6 South Carolina.., 337 0.9 19 140 4 2 47 14 1 South Dakota .... 1#1 19.9 I 10 2 7 51 2' 6 Tenn ...... , 625 13 1 10 100 6 5 Is 5 19 6 Texas .. .. .1.382 8 4 27 1.1:65 6 5 19 5 14 9 Utah. 71 A 3 48 152 9 2 2 5 13 5 Vermont ...... 41 7.7 32 33 6 2 24 13 9 Virglnia . .. 525 9 2 22 358 6 3 22 15 5 ifashingtOn... . . 286 6.5 41 5 394 8 9 4 15 4 West Vir3in14... 279 14.4 6 95 4 9 41 19 3 41sconsin 350 7.3 35 326 f A 17 14 1 HYOming :4 6 7 40 31 6 1 27 12 4 U.S. tot's/ 8,4 6 1 14 5 °Active members in tro American Association of Nurse Anmithetiats, as of August 1906 Nosed on 'as population. citee4ed by CRNAs par rapita, dActive members in the American Sociaty of AnasthwilolOgiste. as of Dec 31. 1986 °Ramked by H) anestheolologists po- cap.ta. SOURCE: Adelitini from M.L. Rosaftbach and J. Cromwell, 'A Profile ofAnesthessa Practtce Patterns.Health Affairs, vol. 7. No. 4, Fall 1988, pp, 118-131. exhibit 3. 2 wasilaseme.la Chapter 10The Supply of Health Per:: nnel in Ri.ral Areas 259 Box 10-CProvider Profiles: Nurses Registered Nurses (RNs) Although all RNs take the same lis.ensure examination, bask nursing educati.in as pros ided in a Pumber of different settings (673). Programs vary in length andtype of degree pros ided. Diploma programs. itAia/t) losated in hospitah. are typically 3 years in length. Assosiate Jegree programs, typically losated in eummunny are generally 2 years long. Bachelor's degree programs me located rb ;colleges and universities and requue a total af 4 years of undergraduate edusation for degree completion. In reeeni years, there has been a trend away hum the diploma and toward the bat.helor's degree or assoiaate degree as the route of entry into die RN wolk Assoeiate degree programs are still prodn..ing the majority of RN., (673). Many ads anced nursing &grit gograms, such as those preparing NPs. CNMs, and CRNAs. require a prev ious bachelor's e gree (673), and some Steshai, e initiated plans to r...quire a bachelor 's degree for RN professional praetice 0574 The total emplos eu RN population ineludes RNs with advanced training (e.g., NPs, CNMs,CRNAs, chria.al nurse speelahstsi who are eub:r in elinicaI pat lee or are employed in research, teaching, or administration (673). Licensed Practical/Vocational Nurses (LPIVNs) LP1VNs must complete a training program in prastical nursing (typiall) 12 months lung) before raking a national hcensure examinaticn (Ca In Califorrna and rexa.., the lisensiug laws refer to voeational nuries rather than practical nurses fr.', 1.2/VN... are not considered pro(essio..al muses beeause their stalls and training me nut equivalent t') those ..Ns (9). 1..FIVI4s are responsible to RN supervisors under St..e nurse praetiee acts 09). hospitals° relied sold) on CRNAs for anesthesia tl) on registered nurses (RNs) employed in hospi- service provision (123),4' 85 percent of these tals. The impact of the national nursing shortage in hospitals were located in raral areas (123). In rural areas is difficult to determine due to the isolated areas, a single CRNA may prov ide senii limitations oi those studies and their data F,Ourt.es. in as many af four hospitals (699). but avzilable data suggest that rural ares are suffering e least as much as urban areas. Smiler The high proportion of rural anesthesia services rural facilities are more sensitive to the lots of a provided by CIINAs suggests a concentration of these professionals in rural areas, but recent de- single nurse, because such a loss can critically affect their ability to delive health services. creases in the number of programs and graduates may disproportionately affect rural areas. A surv This section describes the nattonal and rural. of rural and urban hospitals in as found that the supply of registered nurses (RNs) aud heensed vacancy rate for CRNAs wa.s percent in r. ral practical/v ocational n urses (1. P/VNs ) (see box IO- hospitals, compared w'ith 2 percent in urban hospi- C). tals (595). National Suppe NURSES The U.S. health care system employs over J Current Supply million nursing personle! at a wide raaj,e of Aa of March 1988, the -e were jus:er 2 million professional levels and in w rang o settins,:. RN_ 1icer6ed to practiein the United States, (671). Reports from nur..e emp:-,yers st.t,,,est represi....*:ag an increase approximately 45 per- recent serious national shut age of nurse 1598). The t ent or the 1977 RN populanon (figure 10-5) nature and extent of this shortage have :nen the (V.?). "tom 1984 to1986, bowever, total RN subject of numeroes studies at the national, State. yolation increased by only 8 perceti, The esti- and local levels. These studies Lave fix used prima bated total number o( RNs emploeJ m nuisi in 05ever .een percent used anesthesiologist, owl,. and 4.: poll IA-411 tact] bltdb ACKSihtblViugbi4 41md CRNA, TN. tot tadoict u,od oho pru,idas ,e RNs other physician specialists). 48A substantial number of muses Oh main of T.Nt tr, 19 41 c employed port tam i* HP. adjusted lye tto. pucesuage of RN, employed pan-ume 1988 to produce esumates of full unit ...rttrakti. gi.) RN and LINN supply t%88. when the tutet empluya./d supply atts million, the estimated FrE supply was only 83 pement o. that, oi I .to .ndltott teo,rt in 1463. FLPAN vt,ts 87 peo-cro ul ale 0.. ...wild 0.4a1 numbet of LP/VNs 0.71;, The percentage of both RNs ald I.PNNs Are Ghipiuyed full time tants somewhat by regain AA Suite to. 260 Health Care in Rural America Figure 10-5Emp1oymem Status of Registered residents as the West South Ceaull legion (table Nurses In the United States, Selected Years, 10-361 (673). ka6os in the Stares ranged from a low 1977-1988 of 442 in Louisiana to a Itigk of 1,167 in Massacnu- tl.b1.4Ilton setts Employed-RN-to-population ratios increased in all States between 1980 and 1988, although the 2.03:032 2 0 t 1.887.697 rate of increase varied considerably, and a few States 1,882 382 : experienced decreases during the latter part of that 5 ; ,,401,833 period. Regions with the lowest ratios experienced 17:15:1377e 22% the highest rates of inerease (table 10-36) (404,673). 1 0 1:11 Regional variations are less pronounced for LP/ .1 VNs (table 10-3S). The national ratio of LP/VN5 per 1111111;)II 5 1 LILL; 100.000 residents was 231 in 1983. The only regions 30% 23% 21% :041 0 vith ratios Yell below this average were the 1977 1980 1984 1988 Mountain (173) and Pacific (176) regions (671). Year Interestingly, the two regions veal:the lowest relative 1LN-to-population ratios in 1984 (East South Not in nursing C..r.:3 Part-time Central and %Vest South Central) (table 10. 36) hal SOURCE* Orrice of Technology AssesernoAl, 1990. Data from U hig't relative LP:Vt population ratios in 193 Department of : lealfh and Human Semoda. Health Resources and Serf/roes Administrabon. Bureau of Healthrmfessoone. (218 am. 274, respectively) (404,671). Seventh Repoli to the President and Congress cn Me Status et Health Personnolin thy Unite d Stales. DHHS Pub No HRS,D- Over two-thirds of KNs employed in nursing (in OD-90-1 fRockvila. MD: HASA. June 1990). taNe V111-2 1988) and over one-half of employed LPriNs (in 1983) worked in hospitals (table 10-39) (671,681). 1988 was approximately 1.6 million, or roughly 80 Other major employment setungs for RNs were percent of all licensed RNs 073). Both the propor- aursing homes, ambulatory care settings, and public tion of licensed RNs whri are practicing aid the heal h settings. Other major employment settings for proportion employed full-time have increased in LP/VNs were nursing homes and physicians' or recent years (fgure 10-5) (673). There were 668 dentimoffices. RN employment in ambalatory employed reNs par 100,00C residents in the United care set Lags (e.g., group practice physician affices, States as a whole in 1988a 19 percent increase HMOs, freestanding cluucs) increased by 29 percent over the 1980 ratio (table 10-36) (404,673). The from 1984 to 198. hut it changed little in public number of RaNs employed in hospital settings has health settings (073). increased dramatically in recent years (table 10-37) 071,6961. iuture Supply In 1983, the most recent year for which data are The main cause for conce; a regarding future available, there wPre inthe United States an supply of nurses is the recent downward trend in estimated 781,506 LP/VNs. with 69 percent of these ea. ollments in and graduations from nurstag pre aerially employed in practica! nursing. Approxi- grams. Total enrollmentsinbasic RN nursing mately 5 percent of all 12/ Ns wera also heenral to ea'acation programs deci eased in all but three years practice as RNs, and almost 12 percent of the between academic years 1975-76 and 1987, then LP/X/1\1s who were not employed in practical nursing increased shghtly in 1988(077.674ln 1989-90, 083 wei .. employed as R.Ns (678). -1 e nunber first-time student enrollments in 4-year RN pro- of 1.2,NNs employed in hospitals dee-masa:1 sut grams increased by 6 percent over the previous stantially between 1581 and 1988 (table 10-37) yearthe first increase in 5 years (20). Enrollments (671,698). in practical aursing progxams peaked in 1982-83, and they have since declined significantly (671). Considerable State and regional variatiore in estimated RN supply e ist (figure 10-6, table 10 35) The number of graduales from RN programs, after 004,673). in 1988, for example, New England had nezela a deaaide of increaae, dropped significantly in more than twice as many employed RNs per 100,000 1985-86 and haa aontinued to decline (table 10-40) 0 1 L I -fable 1046Estimated Supply ofRegistered Nurses (liNs) Employed In N.asing by Region and State,.1900,1984,and 19MP 1980 1984 1986 rercent change Rate per Rate per Rate per in rate per Number 100,000 liumbe* 100.000 Number 100.000 of Ms residents 100 000 residents, of ilils teuidents of.RNs residents 1980-84 19e4-88 Milted States. ., .... 1.272.851 560 1.485,725 629 1,627,035 Nortbeast 668 12 6 New England . . 119,116 882 119,914 953 130.915 1,020 8 7 Connecticut .. . 26,083 838 26.40/ 837 Maihe /,583 29,357 916 >-0 5 9 673 8.453 731 Massachusetts... 9,639 839 g $7.052 993 63,540 11 1.096 68,255 1,1's7 Oew Hampshire, .. 7.368 798 10 6 8.024 621 10,015 Rhode Island. 7,025 740 96 15 8,851 920 9.149 933 Vermont...... 4.005 24 1 782 4.639 875 4,490 Middle Atlantic 821 12 252 51 666 277,040 -6 746 293,96! 785 New Jewsey . 46,768 9 634 52,493 699 New York. 53.239 693 . 12,184 695 10 -1 133.310 752 142,899 PennsylvaniA, 802 a 7 83,769 705 91,238 767 9: 823 819 Midwest ci 7 East North Centre. . 231,557 555 277,260 667 295.202 705 Illinois. ... . 20 66.997 586 60.564 C 700 84.7,0 734 Indiana . . 25.379 462 19 5 32.240 586 35,527 612 Michigan.. 48,427 523 27 10 56,449 622 60,463 658 Ohio , , 61.841 573 19 6 Wilconsin. 75.676 70e JC.095 743 . . 28,913 612 23 6 32,351 679 34,3-4 014 lest North Certral 111.206 646 11 1 125.639 117 135,464 768 10W1. .. . . Il / 19.600 6)3 23.704 815 Kansas, 22,770 805 14.574 616 21 - 1 15,943 664 16,863 683 Minnesota 32.184 788 A 3 32.229 774 33.911 79e Missouri 25,635 -2 3 521 31,866 636 Nebraska.. 10.325 65: 36,2?? 751 22 18 11.094 691 11.627 North Dakota, 728 5 5 4.264 652 ',,617 822 6.239 923 South. D- -,ta 4,623 670 26 12 5 It' 731 5.777 818 South 9 12 South Atlantic .. 186,486 502 227,724 DAaware 57' 259,671 F23 . 3,832 643 15 8 4 423 722 5.661 sei Diana of Columbia 8.462 1,328 12 23 S,465 1.519 10.279 Flolida . . 1.656 49 245 499 67,722 14 g 617 '0,319 66e Oeorg:a 24.756 452 24 8 29.65 503 33,660 445 Marylati . .. 24.639 11 e 583 31,565 726 North Ca.-n1Ina 32,207 710 25 27,536 468 32,460 L 527 37,568 586 South Carolina 12.537 401 11 1, 11.761 4i7 15.180 444 Virginia' 26,138 407 4 6 28,477 505 33,500 West Virginia 567 4 12 9,336 479 10.485 537 11.097 585 12 g (continued on next paw) -4,;) .1 A. Table 10-36--Estimated Supply of Registered Nurses (RNs) Employed in Nursing by Region end State, 198O t984, and tveile- Centinuod 1980 1964 1988 Petcent change Rate per Rate per Rate per in rate per NuMber 100,000 NI:giber 100.000 Number 100.000 100.000 residents of RNs residents of Ms residents of RNs residents 1960-64 1904-08 South (continued): East South Central 62.411 425 72..29 482 82.644 $40 13 12 Alabama 16.026 411 19.i50 495 22,113 541 2 9 paLuoky... .. 16,972 463 16.799 451 19.495 523 -3 16 Mississippi 9,052 359 10,537 407 12.147 461 13 13 Tennessee.. . 20,350 443 25,302 516 28.889 595 21 11 West South Central 87,476 366 113,518 435 125,470 466 19 7 Arkansas 8 405 366 10,258 07 11.292 173 19 a Louisiana 14.556 345 17.372 389 19.685 442 13 14 Oklahoma 10,509 346 13.50 411 15,036 458 19 11 Texas ..... 54.006 377 72,320 452 79,457 474 20 5 West Mountain...... 61.214 536 72,446 577 81.038 623 8 8 Arrona, .. 16,665 611 19,01J 623 23.191 585 2 10 Colo:ado 17.820 614 21,212 667 23.459 713 9 7 Idaho... 4.062 429 5.039 50: 4.063 501 17 <0 5 Montana 4,824 612 5,260 638 5.275 655 4 3 11evada... ,. 3.950 489 4,849 532 6.367 636 9 20 Now Mex:co . 5.478 120 7,255 509 7,489 500 21 -2 Utah.... . 6.045 411 7.151. 433 0.397 500 15 Wyoming . 2.350 495 2,667 522 2,697 551 6 Pacifi.... 170,672 535 199,734 584 221,869 507 9 4 Alaska. .. . 1.948 483 3.256 651 3.351 648 35 (0 5 California . 122,176 514 141.834 554 159,008 575 8 4 Hawaii .. 4,763 492 6,462 622 5.923 545 26 -12 Oregon 17,208 652 18.081 676 20.466 753 4 11 Washington ... 24,576 592 30.100 692 33.121 729 17 5 aData for 1980 and 1984 as of November. data for 1988 as of March bPopulation data basid on provislonal stimates of rosiasnt population as of Ju. 1984 in the publication of 0 S Department of Commerce. Bureau of the Census. State PoPolatiOn Estimates. by Aise and ComMenents of (...anite 1980 to 1984. Series P-25. No970. issued June 1985. 40orAlation pews Dosed on provisional estimatos of resident population as of July 1,1904 tn the publication of U.S Department o/ Commerce. Bureau of the Census. Stattlopiousehold Estimates. with AA*, Sex and Commnnents of Chrite1,92,82. Series P 25, No. 1024. Issued Ma) 1988. SOURCES F B Moses. The Pestistered Nurse Population FindinAs frnm the National Sample Survey pf Pegistered Nurses. November 1984 DHHS Pub. No. HRP-0906938 (Rockville. MD HRSA. 1906). end U.S Depattment pf Health and Human Services. Health Resources and Services Administration. Bureau of Health Professions. Seventh Report to the President and ConAress on the Status of Healtn Personnel in the United states. (huts Pub. No. HRS-P-CD-90-1 (Rockville. MD: URSA. June 1090). table VIII-A 3. )1 Chapter 10--The Supply of Health Personne: in Rural Areas 263 Table 10-37Registered Nurse (RN) and Licensed Practi4a1Vocational Nurse (LPVP) Supply in U.S. Community Hospitals,* 1981-88 1 . 1982 1983 1984 1985 1986 1987 1988 Ills: Total. F1T8b (1.0000 629 672 698 698 709 736 759 771 PTEs per 100 patients° .... 72.1 76.5 80.8 85 1 91.3 95 6 9/8 9/9 Vacancy rate 7.3 5.3 4.4 4 .6 6.3 11.0 11.3 NA LP/Vis: Total FIT? (1,000s) 234 238 230 205 187 174 170 171 PTEs per 100 patients° 26.8 27.1 26 6 25.0 24 1 22 6 21 9 21 7 Vacancy rate 5.5 3.4 2 .8 3.3 NA NA NA 114 NOTE; NA = not available. !Asi defined by the American Hospital Association. urtill-time equivalent. cIncludes !npatients plus outpatient visits converted to inpat.ent. equivalents SOURCE. AltletiCall Hospital Association, Hospital Statistics, 1982-1990 eds (Chicago, IL, AHA. 1982-1990), U.S. Department of Health and Human Services, Secretary's Commission or Nursing,SrolemL.s Commission on Nursing. Final Report.. Volume I (Washington. DC. December 1988), figure 1,, U.S Department. of Health and Human Services. Health Resources and Services Aduinistration, Bureau of Health Professions. Sixth Report to the President and Congress on the Status of Health Personnelin the UM ted Stek.es, DIMS Pub. No. HRS-P-OD-813-1 (kockvillo, MOHRSA, June 1988), table 10-12. Figure 104Employed Registered Nur ses (RNs) Per 100,000 Residents in the United States by State, March 1988 RNs per 100,000 residents: ,440 -549 4.\\I550-653 860-79S 800 and over SOURCF. Office et Technology Aseessmert 1990, Based on datafrom US Deparlment of Wealth end Wumen Services. Heellh Resources and Services AdmInutration, Bureau of Herdit Professions, Seventh Report to the President and Congress on the SU** of Hain Personnel In the Weed States. OWNS Pub No MRS+ OD-961 (Reckville.101):1IPSA, June 1990). figure V1114 2Y; 2 264 Health Care in Rural America Thb le 10-38Esilmated Supply of Licensed Practical, Table 10-39Registeted Nuisi pis) Employed in Vocational Nurses (LPVNs) by Region, 19830 Nursing, 1988, and Employed Licensed Practicalt Vocational Nurses (LPNNs), 1983, by Primary Employment Sailing Rate per 100.000 Number residents Employment setting NuMber Percent United States 539.463 231 EstimmtadUm employed in nursing, 2988 New England 33,0C.4 164 Middle Atlantic... 82,885 24 Hospital 1.104.978 679 South Atlantic 86.872 224 Nursing home/extended East Souch Central. 41,598 278 care facility... 107.80$ 66 West South Central 70.671 274 Nursing education 30.005 18 East North Central 94.979 229 Community/public health. . 110.886 68 West North Central 48,729 280 Student health service 47,792 29 Occupational health 21.857 Mountain ...... 21.386 173 13 Pacific 59.330 176 Ambulacory care. . 125.813 77 Private duty nursing 19.988 12 a Includes onlynurses actually employed ap LPPR1s. Self-employed . 13,203 08 Other .. 43,321 27 SOURCE: U.S. Department of Health and human Ser- Unknown.. 1,386 0.1 vices. health Resources and Services Ad- Totala.. 1,627.035 1000 ministration. Bureau of Health Professions. Sixth Report to the President end Congress Estimeted LP/Vga employed on the Status of Health Personnel in t:ie as LPIJs, 1943 United States DEHS Pub. No. P1S-P-OD-88-1 Hospital 310,842 576 (Rockville. MD: HRSA. June 1988). table 10- Nursing home. 121.398 225 7. Public/community heeth 13.574 25 Student. nealth 4,200 0 Occupational health. 5,056 11 (421)." Similarly, the number of gradua:es from Physielmis ordentists LP/VN programs increased until 1984-85 but has office, . 48,969 91 ewe dramatically declined, dropping by almost Private duty 19.959 37 20,000 between 1984-85 and 1987-88 (table 10-40). Other... . 6.13) 12 Not known.. 6.129 15 While the number of programs preparing RNs has Totala 530.465 1000 increased slightly in recent years, the number of LP/VN programs has .4ecreased (table 10-40) (421)). "eicentages may not add 100 due to rounding SoUCES U SDepartment of Hea1tb and 11Aman Ser- BHPr projects a continuing decline in graduates vices, Health Resources and Services Ad- from all basic nursing education programs throt h ministration. Butsou of Health Profess- the year 2020 (673). Between 1990 and 2020,e ions, Division of Nursing. Rockville, MD, unrublished date from the 1988 National total supply of employed RNs is projected to Sample Survey of Registered Nurses pro- decrease by 2.6 percent (from 1,687,100 to 1442,900), vided to OTA in 1989, U S. Department of while the supply of employed RNs relative to Health and Human Services. health Resour- ces and Services Administration. Bureau of population is projected to decrease Sy 17 percent Health Professioas. Sixth Report to the (from 674 to 558 per 100,000 residents) (673). The President and Conareas on the Status of total number of LP/VNs per 100,000 residents is Health Perso.nel in the United Stales. DHNS PubNo.HRS-P-OD-68-1 (Rockville. MD HRSA, prclected to peak in 2004 and to subsequently June 1988). table 10-11 experience a slow but steady decline (671). The pool of potential nursing students also seems to be shrinking. Ai* ongoing study of career mterests The 198(h Nursing ShortageAlthough in the of first-time freshmen college students c onducted by future there is likely to te a shortAge of nurses due the University of California (Los Angeles) shows 4 to lack of nursing graduates. the shortage of Rtis an marked decrease in the numbers indkating an the 1980s was primarily due tu an int-Tease m interest in nursing (63). demand (698). Demand factors included: °Mese figura include gmduates of all RN prognms Rekost data from --- Amemau Ass:xi:mon of Colimso of Naming iAnsais indruite thai mc dumber of first time student gmduates from 4 year programa teslisding atadons eho wat aiitad RNa bin wcts eP6'6040/3 toe baw-mmucate deflieet condnues t demeansby 16 percept l.etwiteu 1987 and 1)88. and by 11 percent t.stwiten 1988 as ' 1989 bowmen is ai ow.vstawmte progtams also continue to deao.se. although more slowly during the past 2 yews when vompared with previous yearS 2 Chapter 10The Supply of Health Peru/nu:I in Rural Areas 265 Table 10-40--Number of Programs Preparing full-time equivalent (FTE) RNs per 100 patients in Registered Nurses (RNs, ....: Licensed Practicer vmmunity hospitalb increased by 21 pen-ent from Vocational Nurses (LPIVNs) and Number of Graduates i983 to 1987 (from 80.0 to 9/.8)kfigure10-7), RN 1976-77 and 1981-82 through 1988-89 vacancy rates in these hospitals increased from 4.4 percfsut to 11.3 percent during the same period (table Number of Number of Year programs araduates 10-37)(69450As the number of RNs in hospitals 1 has increased, both the number of LP/VNs and Oa: reported LP/VN vacancy rates have decreased (fig- 77.955 1976-77. 1,358 ure 10-7, table 10-37) (671,698). Nursing homes, 1981-82.. . 1.401 74,052 1982-83 1.432 71,408 which employed almost 7 percent of RNs in 1988 1983-84 1.466 80,312 (673), reported an RN vacancy rate of 8 percent in 1984-85. 1,40, 82,075 1987 (462). The number of Riers employed in 1285-86 . . 1,473 77,027 1986-87 1,46f.. 70.561 nursing homes may increase in the near future due to 1987-88 1,65 64,839 new requirements for weater RN staffing in Medicare- 1988-89,. 1,442 NA and Medicaid-certified nursing homes ;Public Law 1.1P/VIsi 1976-77 1,318 46.614 100-203) (462,6 /:*1. 1981-82... 1,309 43,299 1982-83. 1,295 45.174 Rural Supply 1983-84 1.297 44,654 1984-05. 1.254 36.554 The proportion of RNs who work in rural areas 1985-86 1,165 29,599 1986-87. 1.087 27.285 has dek-reased in recent years, but it is not clear 1987-88... 1,068 26.912 whether this is the result of decreased demand in 1988-89 1,095 NA rural settLigs or decreased supply of nurses willing 2,161E NA not available to locate Ilme. In 1988. 17 percent of ail RNs SOURCENational League for Norsing. New York. NY. employed in nursing in the United States were unpublished data provided by staff at the employed in rural areas, compared with 20 percent U S Department of Health and Human Zer in 1980 (table 10-4. )081). The rural/urban disaibu- vices, Health Resources and Services Admi- nistration. Bureau of Health Professions. norr of RNs varies considerably by region. The West Rockville. MD, 1990 North Central and East South Central regions had the highest proportions of their nurses in mai areas increasing demand for RNs in hospitals due to in 1988 (31 percent and 30 percent, respectively) advances in medical technology, shorter hospi- (681). The distribution o:RNs across rural and urban tal stays, and increased severity of illness of areas in 1988 cannot be fully explained by the hospital patients, which results in intensifica- distribution of U.S. registered hospital beds, 21 tion of required RN services, and reduction in percent of wire -were located in rural areas in 1988 hospitals' ancillary nursing staff, which in- creases the range of tasks that must be per- (178).51 formed by RNs: Rural RNs are concentrated in the most populated incrPasing demand for RNs in nonhovital counties. According to a recent analysis of i988 setungs (e.g., ambulatory care and home health data, only 8.7 percent of all RNs employed in care); ar.i nursing were itA:ated in counties of fewer than 50,000 residents (table 10-42) (317). Most of these increasing opportunities for RN employment were in counties of more than 25,000 residents (table outside of traditional medical settings (628). 1042) (317).52 Increase in demand for RNs in the hospital seaur Compared %kith RNb in larger 4,ounties, RNs in is evidenced by increases in both RN employment small counties (50,000 or fewer residents) aae older. and vacancy rates. Although the average number of more likely to uork foll-time, more likely to vok 5°Evidenceot the nursing shortage is typioity expressed in ICITAS ot budgeted staff 4a Figure 10-7Registered Nurses (RNs) and Licensed PracticaiNocational Nurses (I.PNNs) in U.S. Community Hospitals:a Total FTEsb and FTEs par 100 Patients; 198148 ..,Thouunda , 400 4 .5..s,- n 5,..,.,-, 200 ,,,--' .7- 7..., n: '.,';'' ..,,,,,,,:, ..,- -7.-'-- % "'" -7, ,--. ..,,,,p: ..,.r, 7-,:-'. ...,:, .7, ---- ,..:', ....., -,,,,7;1 ,,,- %"-=' .:', 7. ... _ 102 gos 1986 4:47 1988 Mit tee2 '993 198 tees teee fest toss FTfis ETEsD...lOciintl*Ms MIII44MaLP /VN4 IinN.tZg Livvro Asdefined by the Amman Hospital Assodation. Wull-Imeequtvatent. "Wien inpatients plus outpatient visits converted to inpatient equivalents. SOURCE: Once of Technology Assessment. 1990 Data from American Hospital Assoctatlon.Nospdal Stabsba(Chicago, H.. AHA, 1982-1989 Ws). Table 10-41MetropolitanINonmetropolitan Distribution of Fidilistered Nurses (RNs) Employed in Nursing in the United States by Region, 1980 and 1988a Total Metro Nonmetro United States 1,268.870 1,010,934(802) 257,936(202) 1.626.026 1,344,143(832) 281.883(17%) Now England. 106.027 80.297(761) 25,730(241) 130.838 106,908(821) 23,930(181) Middle Atlantic 252.435 220.639(871) 31.796(131) 293.961 31,487(111) East North Central 231.324 2$6,240(801) 45,276(20%) 294,850 ,i(1:1;73: (:941) 46,120(161) West North Central 111,206 71,463(641) 39.743(36%) 135,362 93,432(691) 41,960(31%: South Atlantic 186,355 141,746(761) 44,609(241) 259,502 207,568(802) 51,934(201) East South Central, 62.382 44,854(72%) 17.528(28%) $2,594 58,182(702) 24,412(302) West South Central., 87.375 71.199(611) 16.176(192) 125.307 104.866(84%) 20,44)(igg) Mountain . 61,154 42,744(702) 18.410(301) 81,828 61,403(75%) 20,425(252) Pacific 170,612 151,844(891) 18.768(111) 221.765 200,581(901) 21,184(101) '1980 data as of November; 1988 data as of March. bTotal excludes RNs whose metro or nonmetro location was not known SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. Division of Nursing, Rockville. MD. unpublishe. 'a from the 1980 and 198$ National Sampie Surveys of Registered Nurs4s. nursing home or public health settings, less likely to as their highest degree in nursing is highest in the work in hospitals, and less likely to have a baccalau- smallest counties (tablt 1043) (317). This %ding reate degree (table 1043) (317). RNs in small may be indicative of a more pressing need for counties are also more likely to work in administra- well-trained RNs in the smallest, most remote tive or supervisory positions. Most of these charac- facilities. teristics are most pronounced in the smallest coun- ties; for example, RNs in the smallest counties are Rural RNs are less likely than urban RNs to be more than three times as likely as RNs in the largest employed in nursing (77 v. 81 percent in 1988) counties to work in a nursing home or extended care (681). Analysis of 1984 national survey data re- facility. Oddly enough, within the smaller counties, vealed that 14 percent of RNs who resided in rural the percentage of RNs with a baccalaureate degree areas commuted to urban areas to work, while only 25 Chapter 10The Supply of Health Personnel in Rural Areas 267 Table 10-42Estimated Number and Distribution of LP/VNs, and critical care RiNs in air> State were only Registered Nurses Employed in Nursing by County slightly higher in rural than in urban hospitals (595). Population Size, 1988 County Estimated Percent Nurse Supply In Rural antl Urban Hospitals population size number of RPs disributionb Rural hospitals have markedly fewer RNs and All U S. counties 627,035 100 0 distinctly lower RN-to-LP/VN ratios than their Mere than 50,000 1,485,999 91.3 urban counterparts (table 10-44) (625). Among rural 50,000 or fewer 140,057 8 7 hospitals, hospitals in frontier areas have especially 25,001 to 50,000. .. 79,117 4 8 few FTE RNs---as little as one-fifth as many FTE 10.001 to 25.000.... 46,955 2 9 10.000 or fewer 13,986 0.9 RNs as nonfrontier rural hospitals of comparable size. Medicare-certified sole community hospitals 4County population size does not necessarily reflect tend to have slightly larger FTE RN staffs than those metro or notmetro status. b Percentages may not add to 10. due to rounding. of other rural hospitals (625). SOURCE: D.A. Kindig, University of Wisconsin. In contrast, rural hospitals of any given size Madison, WI, and H. Novassashi. Ithaca generally have slightly more FTE LP/SiNs than their College. Ithaca, NY, unpublishxd analysis of data from the 1988 National Sample urban counterparts (table 10-44). Again, however, Survey of Registered Nurses (provided by frontier hospitals have :h e fewest FTE LP/VNs the Division of Nursing, BureauofHealth (625)- Professions) conducted under contract with the University of North Dakota Rural Health Research Center, Grand Forks, ND, 1989 Urban hospitals have up to two times as many FTE RNs per FTE LP/VN as do rural hospitals of comparable size (table 10-44) (625), vAlecting a 2 percent of RNs residing in urban area.s comm.ted greater reliance on nurses with less training and to rural practice sites (699). lower salaries in rural hospitals. It is unclear whether the greate: representation of LP/N/Ns in Anal hospi- Data from selected States indicate substantial tals is due to the hospitals' inability to pay the higher rural/urban differences in RN and LP/VN distribu- RN salaries, their inability to recruit qualified RNs tion. For example: from the larger national pool, or a lower demand to InTexas, in 1986, the number of employed RNs RNs in these hospitals. per 100,000 residents was 228 in rural counties, Eighteen percent of large urban hospitals and 9.5 compared wilt 460 in urban counties (708). percent of rural hospitals reported closing beds in In Arizona, in 1987, the total number of RNs 1987 due to shortage of nursi g staff (699). Al- per 100,000 residen'ic was also much lower in though a larger proportion of rural than urban rural than in urban counties (477 v. 850). hospitals report no vac nt RN positions, high RN LP/VN availability was also lower in rural than vacancy rates (over 15 percent) are more common in in urban counties (186 v. 238 per 100,000) rural than in ur an hospitals (699). Because most (220). rural hospitals are small and employ relatively few In Oklahoma, in 1987, the total number of RNs RNs, they may be subject to extieme shiftsin per 100,000 residents was again much lower in vacancy rates, and they may be more sensitive to the rural than in urban counties (397 v. 686), but the oss of a single nursing employee. ratio of LP/VNs to 100,000 residents was Data are scarce regarding the extent of the nursing actually higher in rural than in urban counSS (387 v. 286) (451). shortage in ambulatory and other nonhospital, non- nursing home health care settings, which employ These differences may be explained to some extent approximately 25 percent of all RNs and 22 percent by rural/urban distribution of hospitals, where most of all LP/VN5 (table 1039) (ô71,681). Lack of such RNs and LP/Ms an employed. In Texas, in 1986, data hinders accurate assessment of the extent of the for example, only 19 per ent of the State's hospital nursing shortage. This limitationis particularly beds were located in rural counties, and 42 of the 43 troubliiiit; given the recent inaease ift 1 N employ- Texas counties without a hospital were rural (708). ment in ambulatory care settings (673) anu given the A recent stu y found that vacancy rates for Risis, relatively large proportion of RNs ins.s..11 rural 4 0 268 Health Ca:.e in Rural America Tab la 1043- -Characteristics ot Registered Nos ses ;FINs) Employed in Nto sing ty :,ounty Popuiaton Spie,' tow County_ponulation size more than 50,000 25.001 to 10,001 to 10.000 All U S 50,000 or fewer 50,000 25,000 or fewer counties residents residents residents residents residents Percent of Rtls. Basic nursing education: Diploma 446 44 5 45 6 43 8 47 1 $0 9 Associate degree .. 31.5 30 9 38 6 40 5 37 2 32 4 Baccalaureate. masters or doctoral degree. , 23.5 24 2 15 5 15 4 15 5 16 7 Unknown, .. 0.4 0 ' 0 2 0 3 0 2 b Total . . . 100 0 100 0 100 0 100 0 100 0 100 0 Highest nursing degree: Diploma . 36 5 36 1 41 1 19 5 42 ' 44 5 Asiociate degree...... 28 0 27.2 36 2 18 5 34 2 29 1 Baccaluareate degree. .28 7 29 5 20 1 18 8 21 1 24 3 Masters or doctoral degree . 6 3 6 7 2.5 2 9 1 8 2 1 Unknown ...... 0 4 0 4 0 2 0 3 0 2 b Total 100 0 100 0 100 0 100 0 100 0 100 0 Roodivod degree/certificate from curse practitioner/Midwife program: Yes 1 4 3 5 2 3 2_ 8 1 6 1 9 96 1 96 0 97 4 96 98 2 S8 Unknown 0 5 0 5 0 2 0 3 0 1 Totalb 100 0 :00 0 100 0 100 0 lel 0 Age: <2$ 4 7 4 6 34 1 7 2 7 . 0 25-34 33 3 33 6 30 4 31, 4 31 1 27 1 35-44 31 7 31 6 31 2 11 8 31 .b 8 45-54 19 2 10 0 21 4 :=0 4 71 2 27 5 >55 10 7 10 4 13 6 13c 13 2 14 Unknown 0 5 0 5 0 2 0 0 2 0 2 Total!' 100 0 100 0 100 0 10A 1 6^ 100 0 EinaLoYmang status: Full-time 67 67 4 84 c 71 1 ) 1 AA 0 Part-time .. 32 4 32 5 30 Ii 47 9 32 0 Full-time/part-time 0 1 0 1 Totalb 100 0 100 0 100 0 10.0 0 100 0 Field of employmeog: Hospital 5"/ 9 68 9 57 60 4 0,, 7 sa 7 Nursing home/extendec care 6 6 6 0 13 5 11 6 ,, 19 A Nursing education 1 8 1 8 1 2 4 9 9 1 2 Public/community 6 8 6 3 11 8 105 I, 4 14 4 > 8 Ambulatory care 7 7 77 7 1 1 I 5 7 Otherc 8 9 9 2 7 3 / 1 0 2 5 4 Unknown 0 1 0 1 0 0 0 1 * b Total 10., 0 100 0 100 0 100 0 100 0 100 0 countiesk work in these settings (tai--le 1043) attne dentist- to- populatioli ratio (table 10-15 ) (t '1). (317), Of these dentists, 85 percent were in general practice, bm this pro,- ation is declining (671). From OTHER HEALTH PROFESSIONALS 1981 to 1987, th.: general and pediatric dentist-to- population ratio increased by only 1.4 percent, v '"le Dentists the denial specialist-to-population ratio increaseu ...y 35 percent (table 10-46) (686). The trend towards National Supply specialty practice in demist-v is slight compared In 1986, theie were 143,000 practicing denfisis on ith that sten in med:cine, but At may be L.ause fur the United States--a 40 percent increase in abbolute 4-uncern the future if Anuall auppi) deLreawb numbers since 1970, and a 20 percent increase in the (table 10-47) (673' 2 Chapter 10-The Supply of Health Personnel in Rural Areas 269 Table 10-43-Charac1eristics ol Registered Nurses iRNs) Employed in Nursing by County Population Size,' 1988-Continued CountY PoPulation size more than 50,000 25,001 to 10,001 to 10,000 All U.S. 50,000 or fewer 50,000 25,000 or fewer counties residents residents residents residents residents Percent of Title of position: Administrabor/Assistant administrator 6.0 5.6 10.5 8.4 11.4 19.6 Supervisor 5.6 5.2 9.9 10.1 10.0 8 3 Instructor 3.8 3.6 4.0 4.7 3 3 2.6 Staff/general duty nurse 66.9 67.3 62.5 62.6 63.2 50.6 Practitioner/midwife 1.4 1.4 1 4 1.7 1.1 1.2 Clinical specialist 1.8 1.9 0.7 0.7 0.7 0.4 Certified nurse anesthetist 1.0 1.0 1.4 1.3 1.5 1.5 Otherd 13.0 13.2 9.3 10.2 8.7 6.9 UnIcnown, 0.4 0 4 0.2 0.3 0.1 * Total' 100.0 100.0 100.0 100.0 100.0 100.0 NOTE: * li.ss than 0.05 percent of total. 4County population size does not necessarilY reflectmetro or nonmetro status bPercentagos maY not add to 100 due to rounding. c"Other" includes the following, student health.occupational health, private duty, self-employment, and other. d'Other" includes the folizming consultant, head nurse,assistant head nurse, nurseclinician, research, private dAty, and other. SOURCE. D.A. Kindig. University of Wisconsin, Madison, WI, and H. Movassaghi, Ithaca College, Ithaca, NY, unpublished analysis of data from the 1968 National Sample Survey of Registered Nurses (provided by the Division of Nursing, Bureau of Health Professions) conducted under contract with the University of North Dakota Rural Health Research Centor, Grand Forks, ND. 1989 creased national supply has had little effect on State Box 10-D-Provider Profile: Dentists and regional distribution. Dentists undergo 4 years of post-baccalaureate In 1988, there were 793 designated dental IIMSAs undergraduate training in general and some spe- in the United States, with a resident population of cialty dentistry (671). Graduates of these programs may erne: dental residency programs to receive almost 16 million, An estimated 1,729 dentists training in orthodontics, oral and maxillofacial would be needed to remove these designations. Over surgery, periodontics, pedodontics, endodonucs, 70 pe:cent of all dental HMSAs are in mai areas.53 prosthodontics, public health dentistry, of oral Trends in the number of dental students suggest a pathology (671). leveling off in future supply. For example: the number of applicants to dental schools Variations in active dentist supply among geo- decreased by nearly two-thirds between 1975 and 1986, from 15,734 to 5,724; graphic regions and States are as great as for other health professions. In 1986, the ratio of dentists to the number of first-year enrollments decreased 100,000 residents in the United States was 57.3. by 27 percent from 1978-79 to 1986-87; and katios in the States ranged from a high of 76.2 in the number of graduates decreased by 14 percent from 1982-83 to 1985-86 (671). Connecticut to a low of 35.2 in Mississippi (671). Regionally, ratios in the Northeast were well above Rural Supply the national average, while the South fell well below (671). These patterns show little difference from The distribution of dentists 44.4 t/S urban and rural those existing in 1970 (671), suggesting that in areas is very similar to that of physicians. for all asce ch. II. table 11-5. 2 270 Health Care in Rural America Table 10-44-Estimated Supply of Registered Nurses (RNO and Licensed Practical Vocationai Nuises(1.12,VN5) In US_ Registered Community Hospitals by Metropolitan;Nonmcbopoliten, Frontier, and Sole Community Hospital Status, 1987 Mean numberof estimated FTE8 RNs, by hospital bed size: 6-24 25-49 50-99 100-199 200-299 All U.S. community hospitolsb 7,6 15.4 37.3 90.5 188,8 Metro 9.5 22.6 48 8 105.2 Nonmetro 7.3 14.2 31.8 69.9 Within nonmetro: Frontier 8.7 9,0 16 3 32.5* 26 0* Not frontier 7.5 15.0 33,4 70.8 139.8 Sole community hospitald 8.1 15.4 36.2 SI 7 332.9* Not sole community hospital.... . 7 1 14.0 31.3 68.7 139.6 Mean numberof estimated FTE8 LP/VNs, by hospital bed size: 8-24 2549 50-99 100-199 200-299 All U.S. community hospitalsb.... . 3 5 7.4 15.2 27.8 45.3 Metro 2.6 7,5 15.7 27 0 43.0 Nonmetro 3.6 7 4 14 9 28.9 55 5 Within nonmetro. Frontier 3 0 43 6 9 6 9* 18 0* NOt frontier. 3 9 8.0 15 7 29 5 55.8 Sole community hospitald . 2 6 4 13 3 29 5 45 5* Not sole community hospital 3 7 6 15 1 28 9 56 5 Estunated FTE8 RN-to-LP/VNratiot, by hospital bed size categorY ---§al- 25-49 50-90 ISO 199 200-299 All U.S. c, 'lit), hospitals" 2.88 3.11 3 81 5.70 8 74 Metro. 3 82* 4 25 4.57 6 69 0 Nonmetro 2 75 2 91 345 4 33 4 28 NOTE: indicates thai the figure is based on fewer than 30 cases 8Full-time equivalent. bThe definition of "community hospital" used by OTA in this ahalysisdiffers slightly from that used by the American Hospital Association (see app C) %atlas were calculated using nonrounded figures. d130 hospitals without any LP/VNs, were dropped from the enalysis SOURCE U.S. Congress. Office of Technology Assessment, analysisof data from American Hospital Association 1947 Survey of Hospitals. performed for WALIIALIWALSAL1report (see appC) dentists, office-based dentists, and general practice (686).All but two of these counties were rural and pediatric dentists, rat.-per 100,000 residents counties of fewer than 25,000 residents, and most of were much lower in rural wan in urban counties in these were counties of low population density. 1987 (table 10-48)(686).Within rural counties, ratios were directly related to county size, with the Data or. the '4;edistribution of dentists show no smallest counties (fewer than 2,500 residents) hav- ing fewer than one-half as many dentists per capita notable rrral/urban differences, but the proportion of as the largest counties. Interestingly, the greatest dentists who are young decreased substantially in all increases in both general and specialist dentist areas between 1981 and 1987(686).This trend supply between 1981 and 1987 occurred in the reflects the decreasing number of new graduates in smaller rural counties (table 10-46)(686).Howe-4er, recent years. As oldei dentists retire, ruial areas ..11 in 1987, 183 counties in :he United States still had have toompete with urban areas for an mcuasingly no general practice or pediatric dentist (table 10-48) limited supply of new dentists. 2 Chapter 10-The Supply of Health Personnel in Rural Areas 271 Table 10-45- -Supply and Distribulion of Active Dentists by General 8nd Spec.any Practice, i .70, 1980, and 1986* ° 1970 1980 1966 Dentists Dentists Dentists per per per 100,000 100,000 100.000 Specialty HuMber Percentapeopleb Humber Percenta peopleb Hunber Percentapeopleb All active 102,200 100 0 49.5 126,200 100.0 55.2 143.008 100.0 58,9 General practice 92,880 90.9 45.0 109,050 86.4 47.7 121,700 05.1 50.2 All speclalties 0,320 9.1 4.5 17,150 13.6 7.5 22.300 14.9 8 8 Orthodontics 3,900 3.8 1.9 6.560 5 2 2 9 7,150 5.0 2.9 Oral& maxilla- faclal surgery... 2,190 2.1 1.1 3,960 3 1 1.7 4,730 3.3 1.9 Perlodontics 930 0.9 0.5 2.240 1.8 1.0 3,030 2.1 1 2 Pedodontics 1,070 1.0 0.5 2,060 1.6 0.9 2,600 1.8 1 1 Endodontics 460 0 5 04 2,170 0.9 0.5 1,900 1 3 0 8 Prosthodontics 590 0.6 0.3 950 0.8 0.4 1,560 1.1 0 6 Public health dentistry 90 0.1 * 110 0.1 0.1 170 0.1 0 1 Oral pathology 90 0.1 * 100 0.2 * 160 0.1 0 1 NOTE: "*" fewer than 0.05 dentists per 100.000 people aIncludes dentists in Federal service. bAll ratios are based on total population. °Percentages may not add to 100 due to rounding. SOURCE. U.S. Department of aealth & Human Services, Health Resources and Services Administration, Bureau of Health Professions. Sixth RePert to The President & Conaress on The Status of Hea1-J1 Personnel in The United States, DRHS Pub. No. HRS-P-0D-88-1 (Rockville, MD MRSA, June 1988). tabl_ 5-4 Table 10-46-Plumber of General Practi.. and Pediatric Dentists and Other Speciany Dentists Per 100,000 Residents by Typa of County, 1981 and 1987 General practice and nediatric dentistsa Other snecialtiesa Rate per Rate per 100.000 residents Percent 100.000 residents Percent change, change, 1981 1987 1982-87 1981 1987 1961-87 Metro 45.7 46.2 1 2 7 0 9.3 32 6 Honmetro 31.2 31.6 1 2 2 0 3 0 49 9 50,000 or more 34.2 34 0 -0.7 3 8 5,5 43.5 25,000 to 49,999.... 31.8 32.2 1 2 1 7 2 7 52 6 10,000 to 24,999.. 28.2 29 1 3 0 0 5 0 8 67.6 5,000 to 9,999... .. 25.8 27,1 5 1 0,2 0 4 103.5 2,500 to 4,999 ..... 25 5 25 5 0 1 0.1 0 7 420 5 fewer than 2,500. ... 13.2 24 4 8 7 0 0 0.0 0 0 Population < 10,000: ce6 persons/square mile.... 27 7 28.7 3.7 0 1 0.5 520 $ >8persons/squere mile.... 23.9 25.0 4.7 0 2 0 4 66 3 U.S. total 42.3 42.9 1 4 5 8 7 9 34 7 alncludes both full-time and part-time dentists Part-time don.ists are counted as full-time dentists SOURCE. U.S. Department of Health and Human Services. Health Resources and Services Administration. Bureau oi Health Professions, Office of Data Analysis and Management. Rockville. MD, unpublished data from the Area Resource Flle ayatem provided to OTA in 1989 and 1990 272 Health Care in Rural America Table 10-47Supply of Active Dentists in the United States. Estimated 1988 and Projected 1990-2020 Box 10-EProsider Profile; Pharmacists In orderto obtain a license, pharmacists must Number of Active dontists complete either a 5-year baccalaureate education active per 100.000 program or a 6-year doctoral program (671). The Year dentists people. amount of preprofessional college study required 1988 146.800 59.4 by these programs varies from 0 to 2 years. The 1990 149,700 59.8 number of envy-level doctoral pharmacy programs 2000 154,600 57.6 and degrees awarded has increased in recent years, 2010 151.200 53.5 and this increase is projected to continue. TheITIcijOr 2020 140,700 47.8 dimensions of pharmacy practice include: general aRatios are based on total population, including management and administration of the pharmacy, Armed Forces overseas, as of July 1 for 1990 and activities related to processing the prescription; succeeding years. drug-related decisionmaking and patient care func- SOURCE: U.S. Department of Health and Human St: tions; drug preparation, distribution, and control; vices. Health Resources and Services Admin- istration, Bureau of Health Professions, and education of health care professionals and Seventh Report to the President and Cons- patients (671). resa_an_tb0 Statue otiloalth Personnel In the United States, DHHS Pub. No. HRS-P-OD- 90-1 (RoAville, MD: HRSA, Juno 1990), table WI-A-5. Table 10-46Numberot Dentists Per100,000 Residents and Number of Counties Without Generat Practice or Pediatric Dentists by Typeot County, 1987 Counties without general practice Number of dentistsa_per 100.000 residents or pediatric dentists 1987 General practice Number of Resident Total Office-based and pediatric counties population Metro. 57,7 55 5 46 2 2 15.400 Nonmetro 35 3 34 6 3! 6 181 731,500 50,000 or more 40 4 39 5 34 0 0 0 25,000 td '9.999 35.5 34.8 32 2 0 0 10.000 to 24,999 30 4 29 8 29 1 11 141,200 5,000 to 9,999 28 1 27 5 27 1 41 291,789 2,500 4,999._ . 26 6 26 3 25 5 4$ 178,30V fewer than 2.500. 15 0 14 4 14 4 81 : 1,300 Population < 10,000: <=6 persons/square mile. 29,7 29 2 28 1 115 272,600 >6persons/square mile 26.0 25 4 25 0 57 333,100 U.S. total. . . 52 7 51 8 42 9 183 746,900 alncludes both fu'l-t1me and part-Lime denAsts SOURCE. U S. Department of Health and Human Services, Health Resources and .Services Adorntstratrun. Bureau of Health Professions. Office of Data Analysis and Management. Rockville. MD, unpublished data from the Area Resource File system provided to OTA in 1989 and 1990 Pharmacists percent from 1970 to 1988 (table 10-49) (673). Signif.cant trends in the pharmacy profession in- Nationa! Supply clude: There were an estimated 157,80() practicing an increase in the proportion of pharmacists phasmacists m the United States in 1988 (673). viao are female (from 4 percent of the active Paralleling the pattern in dent a.st Supply, the absolute work force in 1950 to 26 percen.in 1988) (673); number of pharmacists increased by 40 percent and an increase in the percentage of minority the pharmacist-to-population ratio increased by 17 pharmacists (horn 8.9 percent in 1980 to 10.5 2 d 1 Chapter 10The Si of Health Personnel in Rural Areas 273 Table 10-49Supply of Professionally Active .gorei0-8First Year Enrollment in U.S. Schools Pharmacists, Selected Years: Estimated 19704988, ofPharr 4cy, Academic Years 1969-70 Through and Projected 19904020* 1988-860 Puroament 10.000 HuMber of active Active pharmacists Year pharmacists' per 100,000 peopleb 8.000 1970 112.600 54.5 1980 142.400 62.2 6.000' 1988 .. 157.800 63.8 1990 161,600 84.5 2000 181.400 67.6 4.000 2010 200,500 71.0 2020 .. 213,800 72 6 2.000 Percent change. 1970-1988...... 40.1 '7.1 1969-70 1074-76 1979430 MOBS Percent change, Academie yaw 1988-2020 35.5 13 8 Nndudes students in the first of 3 years of protestor-lel pharmacy 'Includes pharmac.sts in Federal service education. Excludes students In pm-pharmacy education. bRatios based on total populatiou. including Armed SOURCE.OHIce of Twhnoiogy Assessmenl, 1990. Data from U.S. Forces overseas, as of July I. Department of Health and Human Services. Health Resources SOURCE: U.S. Department of Health and Human Ser- and SorileasAdministraton. Bureau of Health Professions, vices, Health Resources and Services Admin- Sxth Report to Ma Pfasidsnt and Cangross on no Status of Health Panama,' in TN Ulted Stafas,OHNS Pub. No. istration, Bureau of Health Professions. HRS-P-OD-88-1 (Rodmille. MD:HRSA. Juno19138). table 84. Seventh Report to The President & Congress on The Status of Health Personnel in The United States. DOHS Pub. Ho. HRS-P-OD-90-1 (Rockville. HDHRSA. June 1990). table ernment agencies, and other areas (671). The Pedaal XII-1. Government at one time designated pharmacy HMSAs but no longer does so (see ch. 11). percent in 1988) (673); end MIR projects continuing increases in both the a change in professional focus from men...y number of active pharmacists and the pharmacist-to- distributing drugs to providing a wider range of population ratio over the next three decades (table services, including quality assurance, patient 10-49) (673). The increasing number of female education paaent care aztivities, and monitor pharmacists in the work force may lower the overall ing in order to reduce adverse drug effects number of PTE pharmacists, since female pharma- (671). cists tend to work fewer hours than their male After decreasing for a number of years, enroll- counterparts (673). Despite recent increasesin ments in U.S. schools of pharmacy have recently supply, however, demand is outpacing supply, and increased slightly, although they are still well below many employers have reported difficulty in recrui the peak level reached in 1974-75 (figure 10-8) ing for vacant pharmacist positions (673). Taking (671). As of 1988, there were 74 colleges of into account recent trends in the output of the pharmacy in the United States (466). phannareutical industry, as well as the expanded clinical role played by pharmacists, future require- The National Association of Boards of Pharmacy ments may continue to exceed supply. reported that 68 percent of all active pharmacists in 1986 were in community pharmacies, with the great Rural Supply majority in chain store pharmacies (671). Only E Current information on the national rural/urban percent were in independent establishments. Just distribution of pharmacistsa bcace.No national over 20 percent were working :n hospital settings, census of pharmAcists has been conducted since the and the remaining 12 percent were employed in 1970s, and no information on the rural/urban distn- manufacturing, wholesale practice, teaching, gov bution of pharmacists iav &liable from that census 2 12 274 Health Care in Rural America (46454 State studies that examined the rural/urc .n distribution of phannacists during the 1980s suggest Box 20TProvider Profile. Optometrists there are a few areas with shortages but little overall Optometrists examine, diagnose, and treat prob . reason for concern. lems of the eyes and vision system (673). Optome- In Georgia, in 1983, only one county lacked a try students must complete from 2 to 3 years of preoptometry higher education before entering a licensed phannacist, and the phannamst-to- 4-year program in optometry. On completion of 100,000 populadon ratio was only slightly undergraduate training, some optometrists enter lower in rural than in urban counties (81 v. 88) specialized residency programs in fields such as (740). family practice, primary care, geriatric, pediatric, In Texas, in 1988, 14 rural counties had no and rehabilitative optometry (671). pharmacist (575). In Arizona, in 1987, the average phannacist-to- 100,000 population ratio in the 13 mral cow- Table 1040Supply of Professionally Active ti4s was 47 (range 18-58) as compared with 78 Optometrists, Selecte Years: Estimated 1970-1988, in the 2 urban counties (220). and Projected 1990-2020P In Oklahoma, in1987, the pharmacist-to- 100,000 population ratio in rural counties was Active optometrists 67 compared with 72 in urban counties (451). Humber of active per 100,000 In Nebraska, in 1981, 52 percent of all active Year optometristsa peopleb pharmacists were located in the State's 4 urban 1970... 18,400 8 9 counties (429). This distribution closely paral- 1980 22.200 9.7 lels that of Nebraska's resident population, 53 1988.. . . ,, 26.100 10 6 1990...... 27,100 10 8 percent of whom resided in urban counties in 2000.... 33.100 12.3 1986 (631). 2010 38.000 13.7 2020 41.700 14.2 Optometrists aInclades optometrists in Federal service National Supply bRatios based on total population, including Armed Forces overseas. as of July I. The active optometrist-to-100,000 population ratio SOURCE U.S. Department of Health & Mmen Services. increased from 8.9 in 1970 to 10.6 in 1988. BHPr Health Resourtes end Services Administra- tion, Bureau of Herat') Professions Seventh, projects that the ratio will increase to 14.2 active Report to The President & Congress on The optometrists per 100,000 residents by 2020 (table Status of Health Pe...onnel in The United 10-50) (673). States NHS Pub, U. HRS-P OD-90-1 (Rock- ville. MD: HRSA. .h.ne 19903. table XI-A-I The number of applicants to schools and colleges of optometry peaked in 1975-1976 and has declined 1980 to 1988, the median age fell from 49 to 41 years continuously since then (671). Enrollments in- (673). The proportion of all optometrists who are creased until 1985-86 but have since leveled off women is expected to increase from 11.5 percent in (671 ,673); the nwnber of graduates increased until 1988 to 28.4 percent in the year 2000 (673). As for 1983-84, declined slightly in 1984-85, and has pharmacists, the Federal Government has ceased to remained relatively stable since etat tune (071 473). designate HMSAs for vision care providers (see ch. The American Optometric Association (AOA) 11). estimates that nearly three-fourths of the 25,400 practicing optometrists in the United States in 1989 Rural Supply were in independent practice, with the remainder Optometrists are important providers of pnmary employed by HMOs, ophthalmologists, optical eye and ision care in areas that lack ophthalmolo- chains, the Armed Forces, and other employers (56). gists. An analysis of 1983 registnes of optometrists The a-, ..rage age of optometrists is decreasing; from and ophthalmologists Londui,tcd by the AOA found Mibe American Association of Colleges of Phaimacy. m cooperatiou with the Natiooal PL...4.tution of Boards et Pharmacy. Is currently prepanng to conduct anodic:caws Rural/urban distributional mformadon will be toadable from lus .--eusus, but not for another 2 years t000r 2.)1 Chapter 10The Supply of Health Personnel in Rural Areas275 that optometrists were practicing in 6,612 communi- settings. Table 10-53 lists some of the many floss in the United States and in 4,153 were the only professions in this category. providers of primary eye/vision care (table 10-51) (56). It is not known whether optometrists are more National Supply or less likely than ophthalmologists to practice in Between 1970 and 1986, the total estimated rural areas, because available data are neither number of AHPs employed in the United States comparable nor consistent. Over one-third of optom- almost doubled, reaching 1.3 million" in 1986 etrists practice in communities of fewer than 25,000 (table 10-53) (671). This rapid growth is largely residents (table 10-52) (42).56 Twenty-one percent attributable to increasing need to delegate tasks of ophthalmologists" surveyed in 1988 were prac- formerly performed by other health professionals, ticing in large (more than I0,000residents) "rtiral"58 and the rapid evolution of medical technologies that areas, and 2 percent in small (fewer than 10,000 require skilled personnel (288). Occupations with residents) "rural" areas (49). However, data from the greatest rates of growth between 1975 and 1986 the AMA show only 4.7 percent of all ophthalmolo- were dietetic technicians, medical technologist& and gists practicing in rural counties in 1988 (686). medical laboratory technicians (table 10-53) (671). Data from two States suggest that the urban/rural Despite this growth, concerns have mounted in distribution of optometrists is more even than that of recent years over a shortage of certain AHPs. The many other health professionals. paucity of information regarding the demand for and In Arizona, in 1987, the optomenist-t9-100,000 supply of AHPs prevents an accurate determination population ratio was 8 in rural counties com- of the degree of shortage.° However, available data pared with 10 in urban counties (220). and anecdotal evidence suggest that shortages may In Oklahoma, in 1987, the optometrist-to- reach critical proportions during the next two 100,000 population ratio was higher in rural decades if current downward trends in enrollment in than in urban counties (13.6 v. 9.8) (451). AHP training programs continue. Characteristics of the AHP Labor MarketIn a Allkd Health Professionals 1989 report on allied health services, the Institute of The term "allied health" has no set definition. Medicine (10M) found that the AHP labor market is The vagueness of the term is due in part to the characterized by: continuing and rapid evolution of the numerous a predominantly female work force, health fields it includes, and the lack of a set technically competent workers; definition may be cne reason why the allied health highly regulated professions and woik env non- professions have historically received relatively ments ; little attention from researchers and policymakers. educational programs that have difficulty cap- Allied health professionals (AHPs) are a diverse turing limited resources and recniiting enough group of practitioners who make up the majority of students; and the health care work force, have educatbn varying 4 rapidly changing work environment where from on-the-job training to advanced college de employers must make decisions as to the hiring grees, and are employed in all types of health care and compensation of it wide range of health Commtmities include cities and towns ir the United States. :Aid; are lima by State in duo-tones pubhsbed by the Amencati optometric Association(41)and the American Academy of Ophthaknology(14). $6Data do not distinguish between nual and urban location. 57Includes only ophthalmologists belonging to the American Academy of Ophthalmology. ssDoes not reflect metrchionmetro location. Some smaller commumues may be m metro amas. &se of community cvm demoniacal oy survey analysts. who looked up the name of each community and placed it in one of four size ategones, the two smallest of which were teamedruralOur. "ibis somewhat restrictive estimate. which recognizes only speafi, groups of AHFs who uave metved professional munwg at the postseondary level, is las than one-half Of a recent estimate made by the American Sower, of Allied Health Professionals tASAMP). Using a brunda deftunion. ASAIW estimates a supply of over 3 millionAHPs (462). eolbeBoreau of Labor Statistics(13LS)collectsinformahonon 4.ettain cute/pale-sof licensed. employ edAles.but these data are unwed beiatise nand ATMs lack formal training Or !karate For example. the BLS estimated that there were $7.0)3 emPiuyod sPeci-h language imfbniugbia and audninigim In 1986 (table 10. 53) 'Ilse American Speed- Language Hearing Assotastion tASHAr. how ev et. emanated that approximately so. ha) spee0i-ranguage pathologists and audiologists (both licensed and nonlicased) were active ia the work force in1987 (288). 9 4 4- 't 276 Health Care in Rural America Table 10-51Number of Cities With Optometrists and Ophthalmologists by State, 1983 Cities with Cities with State optometrists olfthalmologishs Differencea Alabama 101 27 74 Alaaka 14 5 9 Arizona 55 ,1 32 Arkansas 92 /4 68 Claifornia 505 54 251 Colorado 73 27 46 Connecticut 104 5$ 49 Delaware 11 7 4 District of Columbia 1 1 0 Florida 207 116 91 Georgia 146 $0 96 Hawaii 24 8 16 Idaho 49 13 36 Illinois 326 117 209 Indiana 176 $1 12$ Iowa 145 30 115 Kansas 119 27 92 Kentucky 116 32 84 Louisiana 88 34 54 Haino 67 23 44 Maryland 103 52 51 Massachusetts 218 97 121 Michigan 253 94 159 Minnesota 166 49 117 Mississippi 81 26 55 Hisaouri 152 35 117 Montana... . 49 11 38 Nehraska 74 13 61 Nevada 16 6 10 How Hampshire ...... 38 22 16 New Jersey. 292 148 144 New Mexico . .... 39 26 23 New York 400 222 188 North Carolina 176 59 117 North Dakota.... 42 7 35 Ohio 313 92 222 Oklahoma 105 24 81 Oregon 95 29 66 Pennsylvania. 407 162 245 Rhode Island 30 12 18 South Carolina 91 27 64 South Dakota 48 8 40 Tennessee.. ... 124 36 88 Texas 273 95 178 Utah 37 11 26 Vermont 28 26 12 Virginia...... 119 52 67 Washington ...... 117 43 74 West Virginia CO 22 58 Wisconsin 202 52 150 Wyoodng...... 25 8 17 Total cities in O.S. . 6,612 2.459 4,153 NOTE.Only communities with either an optometrist or an opthaLmologist are included in tbe count atunimum number of cities whereono or more optometrists were practicing in 1983, but whore no ophthalmologista were practicing in 1983. SOURCE. P. Aron. Manager of Information and Data, American Optometric ASsociation, St Louis. MO. personal communication. 1989. Data were collected by hand counts of optometrists from Amorican Optometric Association. The nue Book of Optometrists. 1884 37th ed (Chicago, IL Ptofeseional Press. Inc., 1983) and of ophthalmologists from American Academy of Ophthalmoltogy. The Red Book tC OphthaLmotegm. 1983. 35th cd. (Chicago, IL: Professional Pross, tic , 1983) Chapter 10The Supply of Health Personnel in Rural Areas 277 Table 10-52Distribution of Optometrists by In most other allied health fic.Idsclinical labora- Community Population Size, 198, tory technology, dental hygiene, speech-language pathology and audiology, respiratory therapy, and Canmunitlt Percent of population sireb optometrists° dietetic technologysupply and demand were ex- pected to remain fairly well balanced through the "Urban" (total) 40.7 year 2000, provided that downward trends in the 500,000 or more 13.2 number of graduates in certain professions are halted 100,000-500,000 12.9 25,000-100,000 14.6 and that improvements are made in salary and working conditions (288). "Sdburban" (total) 24.8 500,000 or more 2.9 Recent and projected trends in allied health fields 100,000-500,000 6.0 25,000-100,000 15.9 include: Under 25,000 34.4 A 35 percent decrease in the number of Total° 100.0 - graduates from clinical laboratory technologist °beta based on approximately 1,100 replies to the programs from 1982 to 1988, and a 25 percent 1989 American Optometric Association (A0A) Economik. decrease in the number of graduates from Survey, which was sent to a random sample of AOA clinical laboratory technician programs from members. The AOA menbership represents approximate- ly 75 percent of all practicing optometrists in the 1982 to 1987 (673). A recent national survey United States. indicated a 54 percent undersupply of technolo- btommmnity population sire was selt-reported, It does gists and a 38 percent undersupply of techni- not necessarily reflect metro or nonmetro location. °Percentages may not add to 100 due to rounding. cians.61 Other reports also indicate a marked SOURCE. American Optometric Association, St. Louis, undersupply of these professionals in most MO, unpublished data Prom the 1989 AOA employment settings (288). Economic Survey provided to OTA in 1989 Increased demand for occupational therapists (0Ts) during the past several decades (288,673), professionals in the absence of adequate infor. and a projected 52 percent increase in the motion (288). number of OT jobs from 1986 to 2000 (288). Short supply is liaked to the limited number of Selected information on the educational preparation, training programs and the mobility of those employment, role, and regulatory en% honment of programs to recruit faculty (288). IOM predigs practitioners in selected ARP fields is summarized a future shortage of OTs unless these condi- in box 10-0. tions change (288). The number of OT gradu- ates did increase by 18 percent from 1982 to Trends in the Supply of AliPsAn adequate 1988 (673). future supply of AIIPs will depend on changes in A projected 87 percent increase in the numter health care financing policies, technology, educa- of jobs for physical therapists (Fro from 1986 tional programs, and the regulatory environments to 2000 (288). Although the numbur of new PT that affect each type of ARP. Of the 10 professions graduates has increased substantially during studied by IOM, physical therapists were most often the 1980s (673), supply may still not be able to reported as being in short supply (288). The IOM keep pace with demand. concluded that, "barring major economic or health A 24 percent decline in the number of dental care fmancing contractions, the growth of the hygiene graduates from 194 to 1985 (be number of jobs for allied health workers will number increased slightlyin1986) (288). substantially exceed the nation's average rate of Strengthening entry requirements and increas- growth for all jobs". The growth rate is expected to ing the length of training required may place be hibhest for physical therapists and medical further limits on the pool of interested students. records specialists. In the fields of physical therapy,, Some areas have reported acute shonages of radiologic technology, occupational therapy, and dental hygienists (288). medical record services, IOM indicated a potential A projected 45 percent increase in the numbta for serious future imbalances in supply and demand. vf jobs for radiologic personnel from 1986 iu MileSed on an informal survey of constituent societies conduted by thc /Unman Society for Mcddai Tehnologyt2813) 2.4; 278 Health Care in Rural America Table 10-53-EstImated Supply of Selected Allied Health Personnel Employed inMOUnited States. 197009750960, and 1986, and Percent uhange, 1975-866 Percent change, Occupation 1970 1975 1980 1986 197S-85 Total allied health personnel 673,000 899,000 1,100,000 1,330,000 47 Dental hygienist , 15,000 27,000 38,000 48,000 77 Dental assistant 112,000 134,000 155,000 175,000 31 Dental laboratory technician 31,000 42,000 53,000 63,000 50 Dietitian 17,000 23,000 32,000 41,000 78 Dietetic technician 2,000 3,000 4,000 7,000 133 Medical record administrator 10,000 12,000 13,000 16,000 33 Medical record technician.... 42,000 53,000 64,000 76,000 43 Medical laboratorY personnel:- 135,000 191,000 249,000 293,000 53 Medical technologist 57,000 93,000 138,000 174,000 87 Cytotechnologist 3,000 6,000 7,000 9,000 50 Medical laboratory technician. ... 1,000 8,000 13,000 18,000 100 Other laboratory personnel 74,000 84,000 91,000 94,000 11 Occupational therapist 5,000 21,000 25,000 32,000 52 Physical therapist 30,000 38,000 50,0nrs 63,000 65 Radiologic service worker 87,000 97,000 116,00v 143,000 47 Respiratory therspist 30,000 43,000 56,C00 65,000 51 Speech pathologist/audiologist 10,000 32,000 42,000 57,000 78 Other allied health personnelc 135.000 183,000 212,000 251,000 37 aAll numbers are rounded to the nearest thousand. Some numbers may differ from those that appear elsewhere due to revisions and independent estimations. 61ncludes only those personnel who haw received certification/formal training in their parttcuiar allied health field. Does not inclua4 0o-the-job trained, noncertified personnel who may be employed in nonregulated health care settings. *includes, but is not limited to. dietetic assistants, general assistants, operating room technicians, ophthalmic medical assistants, optometric essistants 4nd technicians, orthopedic and prosthetic technologists, pharmacy assistants, pediatric assistants, vocational rehabilitation counselors, other rehabilitation services personnel, and other social and mental health services personnel. SOURCE, U.S. Department of Health and Human Services, Health Resources and Services Administration, bureau of Realth Professions Sirth Re1ert to the President and Conaress on the Statue ef Health Personnel in the United States. DHHS Pub No.HRS-P-00-88-1 (Rockville, MDHRSA, June 1980. table 12-1. 1990(288).Severe shortages are likely to occur A projected 75 percent increase in demand for if the current downward trend in graduates it certified medical record technicians from 1986 not reversed. The number of graduates from to 2000, due to ule increasing complexity of the radiography programs decreased by 24 percent tasks these personnel must perform(288).After from 1981 to 1988, and the number of graduates changes in Medicare hospital payment methods in nuclear medicine technology decreased by in 1983, hospitals reported substantially higher 44 percent from 1984 to 1988 (673). growth rates in employment of medical record technicians and administrators than had been An increased dem. nd for emergency medical seen in previous years. Demand for medical technician (EMT) paramedics in hospital emer- records personnel in nonhospital settingt is gency departments due to the recent nursing expected to increase as well(288). shortage(288).Estimating current supply and A nationalsurvey of hospitals conducted by the ;redicting future supply of EMTs of all levels American Hospital Association found that personnel of training are difficult, since most EMTs are vacancy rates were highest for Prs (16 percent) and volunteers and no national data on the number OTs (15 percent)(673). A 1986survey of 167 of graduates of training programs arc availa Veterans' Administration facilitiet found high va- ble,62 cancy rates for Prs (23 percent), respiratory thera- Oro! more inforinalion on rural cmcrgcm.y medu,a1 personnel, 4ce OTA s Speual Rcpuri un %maiErnagertuy Mcdowu Scrvmes n A. Chapter 10The Supply of Health Personnel in Rural Areas 279 Box 10-6Provider Profiles: Allied Health Professionals (AHPs) Clinical Laboratory Technologists/Technicians (Ws) CLI fields include generalist medical technology, blood bank technology, eytoteehnoIogy, hematology, histology, microbiology, and clinical chemistry(288).CLTs perform a wide array of tests used to help prevent, detect diagnose, and treat diseases (673). Technologists are baecalau.eate-prepared, teehnkians aae assouate- degree or certificate prepared (288). Six States require teehnologists to be licensed (673), remaining States require only registration (288). Many CLT tasks are performed hy nonlicensed, nonregistered individuals in unregulated environments (e.g., private physician offices)(288).The Bureau of Labor Statisties estimates that, in 1988, 71 percent of CLTs were employed in hospitals(673). Physical Therapists (PTs) Pl's must graduate from an accredited program before talung thea hcensure examination (288). Three types of programs exist. baccalaureate programs, certificate pruglams for those with baccalaureate degrees in another field, and 2 year master's degree programs (288). Pl's plan and administer treatment to relieve pain, improve functional mobility, maintain cardiopulmonary functioning, .nd limit the disability of people suffering from disabling injuries or diseases(673).All States require lkensure for TT nraetiee (673). In 1986, 38 States allowed Pl's to evaluate patients without physkian referral, and 14 States allowed Prs to treat patients without physie Ian referral(288).In 1986, 40 percent of PTs worked in hospitals and 15 percent in nidependent or group practieet288). Occupational Therapists (OTs) OTs are trained through baccalaureate programs, post -baecalaureate eertifitate programs, or masters' programs (673).OTs work with disabled individuals to help them learn the skills necessary to pe:.orm daily tasks, diminish or correct problems, and promote and maintain health. In 1989,25States and the Distnet of Columbia required ficensure, 3 States required registration and had eompeteney standards, and 4 States required eerufication for OT practice(673).In 1986, 35 percent of OTs worked in hospitals, 17 patent in schools, 10 percent in rehabilitative facilities, andtheremainder in long-tenn care and home health settings(288). Respiratory Therapists (RTs) Accredited RT programs, whieh hav e grown in number in reeent years, provide 2 years of training and grant either associate or baccalaureate degrees, depending on the student's prey ious educational baekgruund 0:3). RTs provide services ranging from emergency care for stroke, drowning, heart failure, and shoek to temporary relief tor respiratory disorders. They also treat patients after surgery to prevent respiratory illness (288.673). Cernficauon is voluntary(673).In 1987, 18 States licensed respiratory care personnel, and lieensure balls had been introduced in 10 others(288).In 1986, almost 90 percent of RTs worked in hospital settings, ai.e the remainder were employed in nursing and home health facilities. Forty percent of RTs are mena larger proportion than in many other allied health fields(288). Dental Hygienists Accredited hygienist programs include associate degree programs requiring 2 or more )ears of training and baccalaureate degree programs requiring 4 years of training(288).Dental hygknists remove stains and deposits from patients' teeth, take and develop x-ray films, apply fluoride, and make impressions vf teeth. In some States, they may apply sealants to teeth, administer local anesthesia, and perform periodontal therapy. Lieensure is required in all States. In most States, hygienists are required to work under the supei ion of a dentist. The profession has been striving for greater autonomy, and legislation reeently passed in Colorado allows dental hygienists to praetice independently(288)In 1986, 99 percent of dental hygienists were women and oc. )0 percent were under age 44 (673). Ninety-five percent were employed in private dentists' offices(673). Dietitians Dietitians are '....accalaureate prepared professionals who have eumpleted special courses in nutritioa and hav e completed the praetical training required by the American Dietetic. Assouatiun Cut iegistration (288). Dieatians assess the nutritional needs of hospital patients and implement special diets. They also prov ide dienuy k.uurbehrag I to groups and individuals. All certified dietitians must pass a national registration exam and pan icipa(c. in ..untinumg I education programs in order to maintain cenifiLationt288).Light States require la ensure, 5 require eemfieation, continued on next page_1 20-810 0 - 90 - 10 013 2 '; 280 Health Care in Rural America Box 10-6Provider Profiles: Allied Health Professionals (AHPs)Continued and 3 require registration for the practice of dietetics (673). Most dietkians are employed in hospitals and nursing and personal care facilities (288). Radiologic Technicians The field of radiologic technology includes three distinct types of personnel. Radiographers receive 2 to 3 years of training in operation of x ray equipment. They are licensed in 18 States (288). Radiatwn therapists receive 2 to 4 years of training and work primani in oncology, , preparing patients and administenng ionizing radiation therapy Fifteen States licensed these personnel in 1987, and another 10 States had enabling legislation but no licensure requirement. Nuclear medicine technelogists receive 1 year of technical training in the use of radiopharmaceuticals in diagnosis and treatment Seven States litcnsed these professionals in 1987, and another 10 had enabling lezislation but no licensure requirement. in 1986, 60 percent of all radiology personnel worked in hospitals, but employment in freestanding diagnostic centers is expected to increase III the camihg years (284 Emergency Medical Technicians (EMTs) There are three levels of EMTs, distinguished from one another by the extent of training anohed (288). All programs are certificate granting, and they are offered by police, fire, and health departments as well as by medical schools, colleges, and universities. All 50 States hav e some ty pe tAcertification procedure for EMTs, and 24 require national registration for one or more of the 3 levels of EMT practice (288). There were ari estimated 65,200 paid EMTs in 1986, working in private ambulance senices, hospitals, and police and fire departments (288). Hawever, roughly two-thirds of EMTs are volunteers who work for rescue sq.uuls and local fire departments (268). In rural areas, an even larger proportion of EMTs are volunteers (623). Medical Records Personnel Medical records administrator programs are bachelor degree-granting and are based ri colleges and universates (288) Medical records technicians typically hold associate degrees from commanitytollege-based programs. Many lower level medical records personnel are trained on the job. No mandatory registration exists, although medical records administrators may choose to take a national registry exam. Three-fourth s. f all medical records personnel are employed by hospitals, others work in HMOs, nursing homes, and medical group practices (288). Speech.Language Pathology and Audiology Personnel To be certified, speech-language pathologist& and a liologists must have completed a master', degrees in their field, although many States permit non-certified, ba..;aureate-prepared practitioners to work in pubirc school settings (288) Speet h language pathologists diagnose and treat speech or language disorders, and audiologists diagnose and correct hearing disorders. Increasing numbers of nractiuoners ate entenng independent private practice (288) Thirty seven States require licensure for private practice in thrics or other nonschool settings i4573), Over one-half of employed speech language pathologists aad audiologists in 1986 worked in schools, colleges, and universities, with the remainder in healin care setting: ;288). pists (16 percent) and radiation therapy technolo- phlebotomists, and laboratory assistants) was 16.5 gists and technicians (15 percent) (673). percent, an increase over 4.6 percent in 1981. Ninety-four percent of all medical teel4nology staff Surveys of AHP supplyin a wider range of vacancies reported were in hospitals. The vacancy settings were conducted in North Carolina in 1986 rate for medical records personnel was 11.9 percent (445), The highest vacancy rate reported was for and the lowest reported vacancy rate 8 percent) was OTs (21.5 percent). The vacancy rate for PTs for radiologic pen:camel (445). increased from 8.7 percent in 1981 to 19 percent in 1986, and tends away from hospital employment AHPsAHPs became increasingly and towards self-employment were noted. The specialized during the 1960s and 1970s due to rapid vacancy rate for respiratory care 1...r.onne1, 98 technological ajoancements in the health ctse field, percent of whom were employed by hospitals in During the 1970s, however, concern about the 1986, doubled from 1981 to 1936, from 9 to 18 .-apply of health professionals in rural areas led to an percent. The vacancy rate for medical technology acrea ed emphasis on the need for AHF's w itb NUL staff (medical technologists, medic-al tecluacians. in nore than one field. Surveys have found that 2 ARIMMROSIMI.M.P.VICERtlf.V.T.TRY11 mum or s NI Pm I I I 11 Chapter 10The Supply of Health Personnel in Rural Areas 281 Table 10-54ProvIder-to-Population Ratios tor Selected Med Health Professions by Metropolltan/tionmetropolitan Area, 1980 Ouniher per 100.000 residaats tionmetro ratio as a percentage of Occupation Vonmetro metro ratio Dietitian 30 9 26 0 842 Speech therapist 19.5 14.4 74 Health aide (excludes nursing cues) 138 5 99 9 72 Inhalstion therapist 23 1 16 6 72 Dental assistant 75.2 53 2 71 Health record technic. 7,2 5,0 69 Radiologic technician 46.3 31 0 67 Phy ical therapist 21 1 12.7 60 Clinical laboratsry technician 120.5 68.9 57 Dental hygienist ...... 23.1 12.3 53 Occupational therapist 9.3 3.5 38 SOURCE. Adapted from Institute of Medicine, alLicd Health Servic&s_1122,5(Washington. DC Natiunal AcadmmY Press, 1989), table 6.4. many hospitals use multishiled AHPs (130,358a.424), technicians, and dental hygienists t288). The greatet and that many more would do so if the) were oncentration of health care facilities in urban areas available (424). Training for raultiskilled AHPs may explain some of the differences, but some ranges from formal training programs that offer dual disparities- -e.g., those amonz OTsare too great to certification eligibility to informal on-the-job train- be explained so simply. The reportedly wide use of ing. The range of skill combinations reported by nuncenified personnel to perform AHP tasks in hospitals that use multiskilled workers i., great, but non: egulated env ironments (e.g.. private physi- the three most common combinations are. cians' offices) further confuses assessment of true 1. Respiratory therapist or technician and electro- AHP availability and distribution. Anecdotal evi- encephalography or electrocardiography tech- dence suggests that the most severe shortages of nician; AHPs in rural health care facilities nationally are for 2. Radiologic technologist and ultrasound tech F1's and OTs (162,461473), although individual nician; and rural facilities report shortages for a wide array of 3. Laboratory technologist ot technician and ARPs. radiographer (424). A 1989 survey of small rural hospitals in Florida No national data on the supply of multiskilled AHPs k572) found high v aancy rates fur geneial radiogra- are available. Survey data inch...ite that most multi- phers (20 percent), laboratory supervisors (16 per- skilled AHPs are employed in small not- for-profit 4.ent), laboratory technokigists kl3 percent), and and small non-Federal government hospitals (424). 14...Oratory therapists t8.6 percon). A huge propoi- A recent study identified only 75 programs in the tion of hospitals reported diff ulties recruiung these United States offering fort,. .1 cross training, but personnel, PTs and physicai therapy tedinmans informal training for multiskilleu AHrs has most were also often difficult to recruit. Rural hospitals likely been occuring for some time (4:4). had sharply higher vacancy rates than did thtir urban counterparts for laboratory and radiology personnel, Rural Supply but they had slightly lower rates for respiratory therapists (572). Information regarding the national rural/urban distribution of MIN is similatly scarce, and the Rural facilities oftei, cannot support lughiy spe available national data are not current. Table 10 54 AHPs on a full-time basis due to small shows the raral/urban di5.tribution of selected AIIPs population bases and low patient v olume ksee4-ha.7 in 1980. Personnelto population tatios were lower and 12). Preanous fuiarkial 4.onditions make it in rural areas in every AHP categor; and were difficult for some rural health fatalities to 4..ompete especia11,.low for PTs, OT clinical laboratory for .`.HPs in the national labor market by raising 30o 282 Health Care in Rural America salaries and offering other incentives. Strategies that time than do their urban counterparts to obtain have been suggested to overcome some of these medical care from physicians. bafflers and ensure the adequate supply of AHPs in 1n 1988, all of the 111 counties (with a total rural areas include: resident population of 325,100) with no MD or DO encouraging the development of multiskilled were rural. In 1988, 29 percent of all rural AliPs through training and increased flexibility residents were Hang in federally designated pri- of licensure laws for rural facilities, mary care HAISAs, compared with only 9.2 percent increased recruitment of students from rural of urban reside nts (see eh. 11). Ova 4,000 primary areas who may be more likely to return to those care physicians would be needed to eliminate areas to practice, shortages in these urban and rural HMSAs. increased opportunities for training at rural Despite increases in the proportion of physicians sites, and employer-initiated cooperative hiring of AHP who are young (under age 35) in both rural and urban areas, rural physicians are still older than their urban staff by several health care facilities (288). counterparts. Most physicians in small rural counties are in solo practice. SUMMARY OF FINDINGS Some rural areas rely heavily on DOs. Although they made up only 9.4 percent of the total U.S. Physicians physician population in 1986, DOs make up as much °vault physician supply has increased substan- as 74 percent of total physician supply in some States' small niral counties. tially over the past two decades. The number of MIL relative to the U.S. population more than doubled Evidence suggests if itthe current supply of between 1963 and 1988from 146 to 237 per physicians in small rural counties is unstable. New 100,000 residents. The primary are specialties medicai graduates are increasingly indicating a (particularly general a nd family practice) hare preference for practice in large cities and suburbs, seen the lowest increases. From 1979 to 1988, the with fewer indicating a preference for small town number of primary care physicians per capita and rural practice sites. increased by 17.2 percent, compared with 30.2 percent for nonprimary care physicians. Midlevel Practitioners Prima:y care tliysicians are twice as likely as Midlel, el practitioners can prov ide pnmary medi- nonprimary car. .1 .sicians to practice in rural areas, cal care sers ices in areas where no physician is but this may change due to recent increases in available. NPs are about as likely as primary care demand for primary care physicians in urban set physicians to practice in rural are as. The proportion tings. Rural areas rely heavily on primary care (ANN who are ta rural dteas seems to be decreasing. physicians. In rural counties with fewer than 10,000 residents, for example, primary care physicians The belief that PAs are more likely than physi- cians to locate in rural areas cennot be confirmed constitute 81 percent of all professionally active physicians Future national shortages of primary because data on the rural/urban distribution of PAs care specialists are therefore likely to have a are not available. The limited data available, how- ever, suggest that the proportion of PAs practicing in disproportionately negative effect on rural areas. small communities (under 10,000 residents)is The increasing supply of physicians has resulted decreasing. This is also true for CNMs. This shift in greater physician availability in counties of all may be due to an increased demand for these sizes. However, overall increases in physician-to- prov.ders in urban settings. population ratios have been lowest in the least On the national level, evidence suggests that populated counties. In 1988, rural counties still had current demand for NPs and ?As exceeds current fewer than one-half as many patient care MDs per supply. capita as had urban counties. Rural counties with fewer than 10,000 residents had fewer than one CRNAs, who pro% ide nearly 70 percent of anes- fourth as many patient care MDs per capita as urban thesia ben it..cs in rural areas, are crucial members of counties. rairal residents travel for longer periods of die rural health6arc teani in many hospital settings, 4. N.1 I) ';i Chapter 10The Supply of Health Personnel in Rural Areas 283 but their supply is in danger. Prewitous decrease.s rural counties (fewer than 2,500 residents) hay ing in the number of programs preparing CRNAs a nd the imily 15 office.based &mists per 100,000 residents. number of new CRNA graduates will adversely The relative supply of general and pediatric affect the future supply of CRNAs both nationally dentists increased more in rural than in urban areas and in rural areas. during the 1980s. However, future constraints on national supply due to recent and continuing de- Nurses creases in the number of dental graduates may RN- and LP/VN-to-population ratios are pro- change this trend. Mere is a slight trend away from jected to decrease in coming years. The number of generalist and towards specialist practice among graduates from nursing programs has already begun dentists; however, most der"cts are still generalists. to decrease, and this trend is expected to continue. In 1987, 85 percent of dentists were in general RN-to-population ratios are the lowest in the South, practice, compared with 91 percent in 1970. Mountain, and Pacific regions. Furthermore, the In 1988, 183 counties had no general or pediatric proportion of employed RNs working in rural areas dentist. Of these, 181 were rural counties of fewer has decreased in recent years, and rural health care than 25,000 residents. An estimated 1,729 dentists facilit- may have increasing difficulty competing are needed to eliminate shortages in almost 800 with urban facilities in RN recruitment. designated dental HMSAs, 72 percent of which are While the number of RNs employed m hospitals in rural areas. Over 8 million people resided in rural has been increasing, the number of LP/VN5 has been dental IIMSAs in 1988. decreasing. Rural hospitals have markedly fewer Ph armacists RNs and higher RN-to-LP/VN ratios tban do their urban counterparts. Analysis of regional nurse-to- Time are no data on U.S. rural pharmacist supply.. population ratios shows that the regions with lowest State studies suggest that although some rural areas RN availability are those with highest LP/VN have few pharmacists, rural/urban differences in availability, indicating that LP/VNs may be substi- pharmacist distribution may not be as drxnatic as tuting for nurse positions that would otherwise be those for other health professionals. An increase in filled by RN. the number of pharmacists relative to population is expected over the next three decades, but growth in Data on RN shortages (e.g., vacancy rates) are demand for pharmacists may exceed growtn in the limited to the hospital and nursing home sector. RNs national supply. in smaller counties are more likely than RNs in large counties to be employed in nunhospital settings, yet Optomet rists little is known about the adequacy of RN supply in In many communities, optometrists are the only such settings. providers of primary vision/eye care. Their rural/ urban distribution is not known, but a substantial Other Health Professionals proportion (31 percent) practice in communities of Numbers of practitioners in all other health 25,000 or fewer residents_ Although the number of professions examined in this report have increased applicants to schools of optometry has declined in c _; the past two decades. Recent data on rural/ recent years, enrollments have remained stable. The %moan distribution are unavailable for most of these supply of optometrist relative to population is pro&ssions. For some professions, even national projected to increase over the next two decades. supply estimates are difficult or impossible to obtain Allied Health Professionals due to lack of data collection. Physical therapists Jre in short supply nation- ally, and the potential for serious future shortages Den lists exists in the fields of physical therapy, radiologic The distribution of dentists parallels that of technology, occarational theruo, and medical physicians. Rural courKes have substantially fewer record services. 'An most othei Abed health fields dentists per capita than Arban counties (35 t. 58 per studied, downv,ard trends in th number of training 10000 resideats in 1987). Within rural counties. programs and graduates vi ili need to be reverbed to ratios decreased with county size, with the smallest avoid future shortages. rl1 -I 284 Ileahlt Care in Rural America Although no recent national data are a% ailable on and laboratory personnel are also in 1 ery short the rural/urban disiribution of AHPs, selected State supply in some rural areas. data and anecdotal evidence suggest that rural Multiskilled AHPs may be especially appropri- settings currently have a disproportionately small ate for small rural facilities. Although a small share of AHPs, and they are likely to suffer more than urban settings in the face of future shortages. number of formal training programs exist, no national data on the supply of multiskilled AHPs are Evidence from these sources further suggests that available. some rural facilities are facing critical shortages of physical and occupational therapists. Radio logic Chapter 11 Identifying Underserved Populations CONTENTS Page INTRODUCTION 287 DESCRIPTION OF FEDFRAL DESIGNATIONS 287 Health Manpower Shortage Areas 287 Medically Underserved Areas/Populations 291 Currat Status of Federal Designations 293 USES OF DESIGNATIONS 296 Federal Uses 296 State Uses 301 FEDERAL DESIGNATIONS: STATE ACTIVITY AND SATISFACTION 301 TIMSAs 301 MUM 304 State Designation Capability 306 STAIE SHORTAGE DESIGNATIONS: PREVALENCE AND USES 306 HMSAs AND MUM: PROBLEMS AND ALTERNATIVES 308 Shortage Area Designations 309 Underserved Area Designations 310 SUMMA.RY OF FINDINGS 310 Boxes Box Page il-A. HMSA Designation Process 288 11-B. MUA/P Designation Process 293 Figures Figure Page 11-1. Health Manpower Shortage Areas (ETHSAs), 1987 296 11-2. Medically Underserved Areas (MUAO, 1981 299 Tables Table Page 11-1. High Needs and Insufficient Capacity Criteria for Primary Care, Dental, and Psychiatric Health Manpower Short Areas (HMSAs) 290 11-2. Ci.,:ria for Primary Care Health Manpower Shortage Area (HMSA) Priority Groups 291 11-3. Basic Designation Criteria for Primary Care, Dental, and Psychiatric Health Manpower Shortage Areas (HMSAs) 292 114. Application of the Index of Medical Underservice (IMU): Two Hypothetical Examples 294 11-5. Primary Care, Dental, and Psychiatric Health Manpower Shortage Areas (HMSAs). Numhor, Population, and Number of Providers Needed To Remove Designations, 1979, 1985, and 1988 295 11-6. Characteristics of Metropolitan and Nonmetropolitan Primary Care Health Manpower Shortage Areas (HMSAs), by Region and State, Sept. 30, 1988 297 11-7. Medically Underserved Areas (MUAs) With Federally Supported Health Centers, by Region, 1989 300 11-8. State Service and Shortage Criteria, 1986 301 11-9. Presence of State Health Personnel Distribution Programs That Use Shortage Area Designations, 1989 302 11-10. Changes in Designation Activity for Metropolitan and Nonmetropolitan Primary Care IIMSAs &ace 1985 302 11-11. Factors Affecting the Demand for Federal Primary Care HINSA Designations Since 1985 303 11-12. State Satisfaction With the Federal Primary Care Health Manpower Shutage Area (HMSA) Designation Process, 1989 303 1-13. Changes in De.N:gnation Activity far Federal Medically Underserved Areas (MUAs) Since 1985 305 11-14. Factors Affecting the Demand for Federal MUA Designations Since 1985 305 11-15. State Satisfaction With the Federal Medically Underserved Area (MUA) Designation Process, 1989 305 11-16. Comparison of the Federal Index of Medical Undezservice (IMU) and the Michigan Primary Care Association (MPCA) Model 307 11 17. State Opinions on How Accurately Federal HMSAs and MUM Reflect St...c Health Personnel Shortages, 1989 307 11-18. Shortage Area Designation Activity, by State, 1989 308 - ...... ,....www.,...... pr...... -.1a- ..=W....,=..1 Chapter 11 Identifying Underserved Populations INTRODUCTION ment programs. Students in schools of medicine, osteopathy, dentistry, and optometry who served in That rural areas have a relative lack of health designated shortage areas could have all or pact of personnel is indisputable. Whether this difference their educational loans forgiven. Shortage areas results in inadequate access to health care is more were designated oy State health authorities accord- difficult to determine. ing to population-to-practitioner ratio criteria estab- The Federal Government uses two composite lished by the Secretary of the Department of Health, measures for defining areas in which the population Education, and Welfare (DHEW).2 Most of the has inadequate access to health services. Areas, designations were at the county level (i.e., for whole population groups, and facilities that lack sufficient counties) and were in rural areas. health personnel, as measured by population-to- Legislation enacted in 1971 (Public Law 92-157, practitioner ratios, are termed "Health Manpower Section 332) extended the loan repayment projam Shortage Areas" (HMSAs). Areas and population to cover non-Federal as well as Federal loans arid groups that have inadequate access to heath care, as shifted die responsibility for designating HMSAs measured by an index of four weighted indicators of from the States to the Secretary of DHEW The 1971 health needs', are ki. ,wn as "Medically Under legislation added podiatrists, pharmacists, and veter- served Areat:Popu1at:" (MUA/Ps). Although it inarians to the list of eligible practitioners. The value is possible for an area to be designated both as an of the shortage ratio for each of the professional HMSA and as an MUA, the two Federal designa . groups was established at approximately 150 per- lions are independently determined and must be cent of the national mean population-to-active applied for separately. practitioner ratio for that group (except for physi- This chapter summarizes the development and cians, v *here 200 percent of the national mean was uses of the Federal HMSA and MUA designations used). Using these cut-off points, about two-thirds of and presents the results of an OTA survey exanuning all U.S. counties were designated physician shortage State activity and satisfaction with HMSAs and areas and about one-half were designated dentist MUAs. (See app. D for a descriptioa of the survey.) shortage areas. In addition, the chapter examines the prevalence and A list of "Critical Health Manpower Shortage ases of State shortage area designations. It concludes Areas" (CI-ilvISAs) was c =piled following the with a discussion of the concepts a"shortage" ni passage of the Emergency Health Personnel Amend- "medical underservice" and a review of the litera- ments of 1972 (Public Law 92-585). A populauon-to- ture on alternative designation criteria. primary care physician ratio of 4,000,1 was used to identify either county or subcounty areas as DESCRIPTION OF FEDERAL CHMSAs. The list was used to place National DESIGNATIONS Health Service Corps (NHSC) personnel from 1974 to 1978.3 Health Manpower Shortage Areas In 1976, Congress directed the DHEW (Public History Law 94-484) to establish new criteria for designating HMSAs that would: The first Federal shortage area designations were mandated in 1965 (Public Law 89-290) for the permit designation of urban4tb NNell4tbrural implementation of health professional loan repay- areas; Me four unbutton used lo detUMIlle MUAS are the ditall IFICatality Mit, UM. vt..14AAll .4 ific itupulahuii t...'; and iiiiici. ilk lick.cira vl itii .pupulaiiiin livill$ inprim.and the population-io-pnmary care physician ratio. Me populanoirto-ptactitianci mum 4hasca as shortage levels foi purpusea .4 Ivan 4,111.411am), *ere 1,300 i lot pk,R.,Aii. 3.000 I ful JerniAs. and 0,000.1 for optometrists. Speual imnitlesalicaWIS St v eII 104iii..-ity4.0Iaubi.uunty aicas with iii.a.u.saibil. ni.ii...4 4c, a.i.a. Lido ki ui inapai.a.mixt practitioners, and paticulat local holt problems. 35ee ch. t3 for a dcsaiplion of the NHSC program. -28 ;- a '() 288 Health Care in Rural Amenca Box H-AHMSA Designation Process Requests for HMSA designation may be submitted to DRHS's Office of Shortage Designanon by any individual, project, or agency. Copies of the request, tor designation are then forwarded to 10-al and State health rlanning agencies, State Govern.. rs, State health departments, and appropriate professional abbot-milks, fiat review and comment. Following the comment period, the Office of Shortage Dezagnation complete, its evaluation oi the request to detemiine if it satisfies the criteria for designation. Applii,ants ar..: informed of the re,ult, of the evaluation hy letter. A record of all the designations made :arm 1978 h contained in a coniputenzed file, the Shortage Area Data Base. This file is updated regularly to account for new desigLations, dedesignations, and changes in degree of shortage By law, the lig of 1-LMSAs must be roiewed annoally. Each year, DHHS send, the States the data it has on every county in the State and aver) designated pnrnar) care HMSA for the States to review. The States are notified that all primary care HMSAs that are 3 years old or older will he dedesignated unless the States supply updated information that warrants their Lonuraied designation (341). The mo,i reent comprehensive rev few was the 1988 89 annual review, which emphasized the assessment of those primary i.are HMSA designations made or most recemly updated during 1985 Bet.ause v ery few resoun..es are ,uteently tied to dental and psychiatric 1-LMSAs, these designations are updated less frequently than pnniary Lare HMSAsusually on a case-by-case basis when a dentist or a psychiatrist is being placed (341). DHHS periodically publishes lists of primary care HMSAs by State in the Federal Register. The most recent list was published in November 1987 (52 FR 43992). broaden the concept of shortage to include groups, or 3) public or nonprofit private facilities. indicators of a nc,....1 for health sen ices such a, The primary criterion for HMSA designation is still infant mortality, health status, and access to the popuhtion -to-practitioner ratio. The responsibil- health services; ity for designations rests in the Health Resources and permit population groups and facilities expen- Seri) ices Administration's ( HRSA 's) Office of Short- encing health personnel lAiortages to be desig- age Designation, within the Department of Health nated; and and Human Services (DHHS).5 Box 11-A describes establish priorities for assigaing personnel to the HMSA designation process. areas, population groups, and facilities with Current Designation Criteria high needs (682). Primary Care HMSAsPrimary care physicians The new criteria and designation, which replaced are defined for designation purposes to include CHMSAs, were published as final regulations in family and general practitioners, general pediatri- November 1980 (45 FR 75996-76010). They in- cians, obstetricians and gynecologists, and general cluded separate criteria for each of seven types of internists. A geographic area may be designated as health manpower primary care physicians, dentists, hay ing 4 shortage of pnmary medical care personncl psy-niatrists, vision care providers, podiatrists, phar- if it meets the following criteria; macists, and veterinarians. HMSAs were further categorized according to them degree of powder itis a "rational" area for the dehvery of shortage. primary medical care services; it has a population-to-primary care physician The 1980 HMSA designation criteria are still ratio of at least 3,500:1 (3,000.1 if the area ha.s used, but HMSAs are currently being designated for " unusually high need for primal) care serv- only three types of health professionals. pnmary ices or "msuffiuent capacity" of existing care physicians, dentists, and psychiatrists.' Under primary care providers), and the current regulations, HMSAs can be defined as. 1) primary medical i...are manpowei in Luntiguous urban or rural geographic areas, 2) population areas are overutihzed, excessive;y distant, or 4Bctause of the lack of resources and recultitig low designation ai,li vity, HMSA , fu, Liston L oc providers, podiatrists, phartnai.ists, and vetenn.inans are no longer routinely designated or updated Designation of nursing dionato. ari..w is 4....omplisbed unda a sep,umc legislative authority 1 1 ale %.111 of the Public Health Service Ad) nhe Department of Health. EduLation. and %gait was renamed the Depanmeni of Health and Human Sen k es in May 1980 Chapter IIIdentifying Underserved Populations 289 otherwise inaccessible to the population of the oped to prioritize IIMSAs so that scarce resources area under consideration (45 FR 76001). could be targeted to areas of highest need. Qualify- ing HMSAs are separated into four groups according An area qualifying as "rational" for the delivery to population-to-primary care physician ratios and of primary medical care services need not conform indicators of high needs or insufficient capacity to county boundaries; it may be part or all of a single (table 11-2). The most critical shortage areas (group county, two or more counties, or an urban neighbor- 1 HMSAs) are those areas that have no physicians or hood. In some cases a rational service area t have a population-to-physician ratio greater than extend across State as well as county boundaries. 5,000:1 and an indication of high needs or msuffi- Although service area size may vary due to differ- cient capacity. ences in population densities, HMSA criteria gener- ally require the population centers of counties or Sped* population groups w Ain geographic contiguous counties seeking designation to be within areas may be designated as pnmary 1..are HMSAs if 30 minutes travel time of each other. Although the they meet the following criteria. specific definition of a rational service area is left up to the local applicant, Federal officials consider such the area in which the population resides is factors as compactness, roads, natural barriers, rational for the delivery of primary medical care services; sociodemographic and language barriers, and other isolating features when reviewing applications for access barriers (e.g., language differences) designation (682). prevent the population group from using the area's existing primary medical care providers; Prhnaxy care practitioner counts include all non- and Federal doctors of medicine (MDs) and doctors of the ratio of the number of persons in the osteopathy (D0s)6 providing primary care in a population group to the number of primary care service area and contiguous areas. The number of physicians serving the group is at least 3,000.1 full-time-equivalent (FTE) primary care providers is (45 FR 76002). computed to take into consideration the amount of time that is spent providing direct patient care ras Eligible populatior groups might include those with opposed to administration, research and teaching incomes below the poverty level, those eligible for duties) and to weight the care provided by interns, Medicaid, medically indigent populations (defined residents, graduates with foreign medical degrees, as poverty population minus Medicaid eligibles), and practitioners who are semi-retired 05 FR migrant workers and their families, native Amen. 76001). cans, homeless populations, and other populations isolated as a result of language, cultural barriers, or An area with a population-to-prhnary care phy si- handicaps. Population group designations differ cian ratio greater than 3,500.11 automatically quali- from geographic area designations in that phybicians fies for HMSA designation, au area with a ratio 'les.; aot serving the specifit.. population group are ex- than 3,000:1 is automatically disqualified. Within cluded from physician counts phy sicians not that range, the area may qualifyif unusually sering Medkaid patients are not counted in the high-needs criteria (e.g., infant mortality and Pov- designations of Medicaid eligibles). Population erty rates) or insufficient-capacity crituia (e.g., group designations are made fot partial-county average waiting times for appointment and average areas, but not for whole countic.. waiting times at site of care) are sufficiently great to warrant the designation. (See table 11-1 for a list of Public or nonprofit private medicalfactlities may the high-needs and insufficient-capacity criteria.) be designated as primary care HMSAs if they serve designated areas or population groups and have Primary care HMSA priority groupings (also insufficient capacity :Jo so. Separate criteria are called "degree of shortage groupings) were devel- used for designation of Federal ot State correctional (National Health Scrvwe Corps t1,4115C).Athunisswoed wips and obligated persoonet arc rwt awitidt.o tri poysu ton wurus MSC providers arc counted f theydeeule to continue praytweng in the arca fol1owing4a,mpletaa. A their obhgated pertod4:4 servu.c This pics ...4.44)vukl .atis. iti .uya to be dcdesignated. Inc current cal.:non of a 3.500.1 populauoti4o-physietan ratio was ..hoscn based tat i974 data bu.aust, .1 tepicseated u 1e..4..1appnotattately percent worse than the median wanly level and identified those ,ouaties that tell into the tativat gigantic of poputation 1.- ntoysiom raw, i66.-.1 Table 11-1High Needs and Insufficient Capacity Criteria for Primary Care, Dental, and Psychiatric Health Manpower Shortage Areas (HMSAs) Type of criteria Primary care HMSAs Dental HMSAs Psychiatric HMISAs Unusually high Must meet at least Mist meet at least Must meet at least needs criteria one of the following: one of the following: two of the following: 1. Fertility rat. more tl-an 1. Poverty rate more than 201 1. Poverty rate more than 201 100 births/year per 1,000 2. Majority of the population 2. Youth dependency ratio (ratio women aged 15-44 does not have a fluoridated of population under 18 to 2. Infant mortality rate more water supply 18-64) greator than 601 than 20 infant deaths per 3. Aged dependency ratio (ratio 1,000 live births of population 65+ to 18-64) 3. Poverty rate more than 201 greater than 602 4. High prevalence of alcoholism Insufficient Must meet at least Mist meet at least capacity criteria two of the following: two of the following. 1. More than 8,000 visits/yr 1. More than 5,000 visits/year per Physician per FTE dentist serving 2. Unusually long waits for the area appointments 2. Unusually long waits for 3. Excessive average waiting appointments times at primary care 3. Two-thirds or more of area's providers dentists do not accept 4, Excessive use of emergency new patients facilities for routine care 5 Two-thirds or more of area's physicians not accepting new patients 6. Low annual office visit rate SOURCE' Federal Refti,...er, vol. 45. pp. 75996-76010 :3 6 Chapter 11-1dentifying Underserred Populafions 291 Table 11-2Criteria for Primary Care Health Manpower Shortage Area (HMSA) Priority Groups Group Criteria if high needs Criteria if high needs are not indicated are indicateda 1 No phYsicians No physicians or population greater than 5.000 per physician 2 Population greater than Population between 4.000 and 5.000 5,000 per physician per physician 3 Population between 4,000 and Population between 3,500 and 4,000 5,000 per physician per physi.:ian 4 Population between 3,500 and Population between 3,000 and 3.500 4,000 per physician per physician aAreas are considered as having "high needs" for primary health care urvices if they meet at least one of the "unusually high needs" indicators a at least two of the "insufficient capacity" indicators. SOURCE: Endaral Register, vol. 45, p. 76002. facifities. Like population group designations, facil- tion, infant mortality, and health personnel were ity designations are made only for partial counties. selected because data for these factas were nation- ally available and reliable (329). MIS published Dental and Psychiatric HMSAsCriteria for the the IMU criteria for use in designating and prioritiz- designation of geographic areas, population groups, ing MUM in 1975 and 1976 (40 FR 40315 and 41 and facilities as dental and psychiatric 111VISAs FR 45718). resemble those for primary care HMSAs, with a few important differences (see table 11-3). The mini- Public Law 94-63 authorized grants to be made to mum population-to-practitioner ratios, for example, proje...ts to plan, develop, or operate community are 5,000:1 and 30,000:1 fordentists8and psychia- health centers (CHCs) that serve in designated trists, respectively. Unusually high-needs and insuffi- MUAs. In 1978, to eliminate the need to apply for cient-capacity criteria for these types of lilvISAs also two separate designations pertaining to medical differ from the primary care HMSA criteria (see underservice, areas designated as primary care table 11-1). Psychiatric facility designations may be HMSAs were granted MUA designation status for made for State and county mental hospitals as well the puipose of meeting CHC funding criteria. In as for Federal and State correctional facilities. 1980, these policies were repealed because HMSA designations were considered to be unstable and Medically Undersened Areas/Populations overly dependent on small changes in numbers of History physicians or local population characteristics (46 FR 23817). However, the assumed greater "stability" MUAs were authorized in 1973 by the Health of MUA designations cannot be assessed, since Maintenance Organization (HMO) Act (Public Law these designations have never been reviewed on a 93-222). HMOs drawing 30 percent or more of their regular basis. membership from MUAs were to receive preference for loans for initial operational costs" The Ifiv10 Federal legislation passed in Public Law 99-280 legislation required th..Secretary of DHEW to enabled State gov ernors to request designation for develop explicit criteria for the designation of Medically Underserved Populations (MUPs) that medical underservice. To do so, DHEW funded a did not meet MUA criteria. The fust two State study that developed the Index of Medical Under- requests for MUP designations wet e published m the service (MU) as the mechanism for determining Federal Register in March 1987 t52 FR 7215). The MUA status. Of the various indices of underservice extension of the designation to specific population considered by the study panel for inclusion in the goups was prompted by situations such a., that IMU, measures of poverty, agedness of the popula- desaibed by the Gov ernoi of Oregon in 1988, in sUnlikethe calculattonof FTE pnmary care physicians, the ..alculatton of FIE datums reflecb prudtit.tr,dtltescacc, dam% demAips4oa.us Paled on the age of the dentist, the number of awahanes employed, and the number of hours worked per week. °No new loans have been made or gumanteed under this provesion mace September 1986 (42 U.S.C. MOW) 2 Table 11-3Basic Designation Criteria for Primary Care, Dental, and Psychiatric Health Manpowei Shortage Areas (11MSAs)' Type of designation/criteria PrimarY care HMSAs Dental HESAs Psychiatric HMSAs Geographic area Rational area for service Within 30 minutes travel Within 40 minutes travel 4ithin 40 minutes traml delivery time and not part of another time and not part of another time and not part of another service area service area service area Minimum population-to- Minimum 3,500:1 (3,000:1 with omum 5,000:1 (4.000:1 if Minimum 30,000:1 (20,000.1 practitioner ratio unusually high needs or unusually high needs or if unusually high needs) insufficient capacity) insufficient capacity) Health personnel in contiguous Mace Chan 30 minutes travel More than 40 minutes travel More than 40 minutes travel areas are inaccessible time away or ratio greater time away or ratio greater time away or ratio greater than 2.000:1 than 3,000:1 than 20,000:1 Population group Rational area for service Within 30 minutes travel Within 40 minutes travel (not requ'red) delivery time time Access barriers prevent group Poverty. language/culture. Povurty, language/culture, Poverty, language/culture, from using area's existing Lack of physicians accepting Lack of dentists accepting luck of psychiatrists providers Medicaid Medicaid accepting Medicaid Minimum ratio of population Minimum 3,000 1 Minimum 4,0001 Minimum 30.000:1 (20,000:1 group-to-practitioners unusuaLL) high needs) serving the population group Facility Public or -profit private Facility serves designated Same as primary core HMSA Same as prima,y care HMSA, but facilities areas or population groups separate criteria for designation and has insufficient capacity also exist for State and county to do so. Separate criteria mental hospitals are defined for Federal or State correctional facilities 8Information on criter4a specific to the type of practitioner designation is presented under tile appropriate column SOURCE:Federal Reeister. vol. 45, PP. 75996-76010 312 4....111/11..M...... ,...., Chapter 11-4denlying Underserved Populations 293 which a community's health access problems had been exacerbated by an economic depression fol- Box 113MUAIP Designation Process lowing a decline in the timber and wood products The original set of MUA designations was made industry (53 FR 10435). by HRSA in 1976, based on a list of all US. In August 1989, the responsibility for MUAR counties and subcounty areas (including individual census tracts) that met the designation criteria (see designations was moved within the Bureau of Health text). States did not have to request designations. Care Delivery and Assistance from the Division of The original list did not consider whether desig- Primary Care Services, where grants to CHCs are nated areas were actually rational service areas made, to the Office of Shortage Designation, so that (728). HMSA and MUA designations would be handled in The current MUA designation process requires the same office. Box 11-B describes the MUAR that State agencies provide the Office of Shonage designation process. Designation with data on the four IMU compo- nents. Where exact data are unavailable for small Current Designation Criteria geogaphic areas and population gx-ips, extrapola- MUA Designafi.ins--MUAs are identified based tion me.%ods may be used. MUPs may be requested on their lMU score, Alaieh considers the following by State gover:ers or local officials who submit four factors: data on the IMU indicatorc Is well as a description of the unusual local conditions that affect the 1. infant mortality rate, ppulation group. After undergoing an initial staff 2. proportion of the population over 65, review, MUA and MUP re.aiests are listed in the 3. proportion of the populavion with incomes Federal Register to provide interested parties with below the poverty level, and an opportunity to comment. DIMS then makes a 4. ratio of population-to-primary care providers. fmal decision of whether to designate or deny the request and informs the applicant of the results by The MU score for an area is the sum of weighted letter. values for each indicator (41 FR 45718). (See table 11-4 for two hypothetical examples.) Value of the index range from 0 to 100, with lower scores 12-year period. These predictions were based on the indicating increasing medical underservice. The assumption that an increased supply of physicians 1975 median lMU score of all U.S. counties was 62, would result in corresponding increases in under- and that value was used as the cut-off point for served areas. underserved areas. Tile geographic boundaries of MUAs may be county lines, or they may be subcounty boundaries such as townships and census Despite the predictions, thetotal number of tracts. designated HMSAs has actually increased since 1982. As of December 31, 1988, there wcre 1,944 Aftm DesignationsMUP criteria have not yet primary can HMSAs 10 percent more than the been publisged. In general, MUP designations are 1982 figure), 793 dental HMSAs, and 592 psychiat- based on the application of the IMU and an ric HMSAs (table 11-5) (665). Of the primary care evaluation of the unusual local conditions and access HMSAs, 67 percent (1,307) were located in rural barriers that led to the recommendation for designa- (nonmenopolitan) areas. Of these rural HMSAs, 63 tion in spite of failure to meet the IMU cutoff (728). percent (821) were group 1 or 2 IIMSAs and 37 Current Status of Federal Designations percent (486) were group 3 or 4 HMSAs (665). HMS As Although the number of people living in rural In 198..,, HRSA projected tb: t the number of primary care HMSAs is slightly smaller than the counties that were wholly or putially designated as number lis 'mg in urban primary care HMSAs (16.5 primary care HMSAs would decline from 1,501 in million v. 17.4 million), this population is a dispro 1982 to 810 in 1994 (633). It also predicted that the portionateb large percentage of all rural residents. munber of primary care physicians needed to bring In 1988, 29 p. centof ihe U.S. rural population lived areas below the level of 3,500 residents per physi in designated primary v,are HMSAs, compared with cian would decrease from 5,076 to 3,204 during the 9 peicent of the urban population (table 11-5). 0 i 4 294 Health Care in Rural America Table 114-Application of the Index of Medical Underset vice (lMU). Two Hypothetical Examples Count County 2 IMU criteria percent/ratio weighta percent/ratio weighta Infant mortality 11.40 24.8 17.30 19.5 Population 65+ 8.60 19.9 14.10 18.7 Population below poverty 7.30 21.9 37.50 3.4 Primer), care physicians per 1,000 population .85 .7 .15 2.8 MIU score 87.3 44.4 Qualifies as an MUA (IMU 640re <62) No Yes aWeights that apply to the associated pers,ov. u, ratio. r: listed in the Federal Register (41 FR 45718). SOURCE: Office of Technology Assessment, el90 Both the number of dental and psychiani: . :AS/ , :signation requests, especially forMedicaid eligi- and the population living in those areas were higTia iltes and the medi.ally indigent (340). for rural than for urban HMSAs. The disrmity is lb the extent that factors such as the lack of especially apparent for psychiatric HI+ISAs; incentives and the lack of funds discourage areas December 1988, 61 percent of the rural population from applying for Federal designations that would lived in designated psychiatric HMSAs (table 11-5). otherwise qualify, the number of designated HMS As Both the total number of primary care I1MSAs and MUAs underestimates the actual level of and the percentage of primary care ILMSAs that are shortage. In 1986, for example, there were 95 in rural areas have been quite stable during the past nonmetro counties with a physician shortage (popula- decade (table 11-5). However, there has been some tion-to-physician ratio greater than 3500:1)m Qat instability among indi vidually designated areas (i.e., were not designated as HMSAs, even though they some areas have been newly designated and otheis wouid presumably qualify (5'1). These counties dedesignated). Figure 11-1 illustrates the whole and were concentrated in the South and North Central partial counties that qualified as rural pnmary care regions. Also, since this analysis used county.based I1MSAs in 1987. data, it did not capture partial-county areas that may have qualified for designation." Table 11-6 shows the numbe- of urban and rural primary care HMSAs, the total population in pri- MUA/Ps mary care HMSAs, and the number of physicians In 1981, the most recent year for whil compre- needed to remove designations, by region and State, hensive ticIt4 are available, there were 2,440 desig- as of September 1988. The South led the four regions nated MUAs (both whole- and partial-c ounty ) (5 11). with both the largest total number of primary care Of these, 1,328 whole-county MUAs and 567 HMSA designations (849) and the largest number of partial-county MUAs were in rural areas (511) (see nenmetropolitan primary care HMSA designations figure 11-2). The highest proportion of whole- (623) (666). One-half of the U.S. population in rural county MUAs were located in the South, and the HMSAs were living ir the South. highest proportion of partial-county MUAs .e located in the North Central region (511). Population group designations accounted for 12 percent of primary cam HMSAs as of December 31, These %Ala MUAs are not only outdated but are 1988 (665), 22 percent of the urban primary care probably inaccurate, due to the fact that the initial I1MSAs and 8 percent of the rural primary care MUA designations did not assess whethidentified HMSAs were for population groups (667). In the subcounty areas inet the "rational service area" future, the Office of Shortage Designations expects criterion (see box1 B). Thus, some designated to see an increasing number of population group areas may not actually be underserv ed. Updated 0llmscummpuMUoLoarchasedontbcpnmen6cofductgnsofnudxAnconiyamldooutwawJathcpmscm.441 40LhAsausmopado lila1988. 49 percent of all mai 1110As ware partial-county desisaatioas(667). 3 0.0 Table 11-5Primary Care, Dental, and Psychiatric Health Manpower Shortage Areas (HMSAs). Number, Population, and Number of Providers Needed lb Remove Designations, 1979, 1985, and 19884 Oscoveer 31.1979 Juno 30_ 1995 --. Docombor 31. 1960 gumbo, or Nukbor of nab: of Populotlan Providtre Population providers Populetion providers Number of In needed to Number of 10 00000 d to Number of in Po:amass. neede to dealonotod00000 plied remove dealensted dealensted :move dealsnatoddeeignated of V S. fOCOOVO NMSA typo areas :040 oe,ilinetione' doeisssiieme4 i00 4x04. 90Pulotionc des4noti4ne4 hickory CO:0 (total) 1,921 41,004,430 5,635 1,043 33,600,635 4,331 1,944 33,658,014 13 0 4.104 Nonsetro 1,350 19,010,058 2,587 1,314 17,661,218 2,044 1,307 16,477,146 29 0 1.794 Metro, 571 22,674.372 3,248 529 16,029,417 2,20Y 631 17.361,868 9 2 2,314 Dental (tool) 916 20,952.631 2,442 777 16,d14.930 1.715 793 15,632,532 6 5 1,729 MAIM:0 735 11./11,440 1,450 581 8,075,971 635 574 8,898,800 15 7 BOO Metro 161 9,241,151 965 196 7,838.959 sae lie 7,141.332 3 8 650 Psychiatry (total) 218 19,224.01Y .d 473 42,473.600 2,314 20 1 1,410 __d ..r *maestro 160 ..d 317 ::: 1::::::::: 61 0 1,137 Metro . 58 --4 --4 156 --t 196 15,124,443 e 0 03 'Mese figures include all [NSA* (priority groups 1-4), including EMSAs In the U.S. possessions. bThe number of additional providers needed to dedosignato all HMSAs. as follows. For primary care HMSAs, the number of odditionai primary care physicians (general/tamily practice, general internal medicine, general pediatrics, obstetrics/gynocology) require,' to achieve 4 population-to-primary care physician ratio of 3,500.1 (3,000.1 where high needs aro indicatoC; for dental IIMSs, the number of additional dontiats required to achieve a populatlon-to-dentlet sotto of 5,000.1 (4,000.1 where high needs are indicated), for psychiatry HMSAs, the number of additional ps)rchiatrists required to achieve a population-to-psychiatrist ratio of 30,000 1 (20,0v0 1 where high needs are indicated). cBaSod on 1987 population estimates "'nate not available. SOURCES U S Department of Health, Education and Welfare, Health Resources Administration. Bureau ot Health Professions, Division of Heolth Professions Analysis, "Selected Statistics on Health Manpower Shortage Areas es of December 31, 1980," Report No. 81- 11, Rockville, MD, Feb 26, 1981, U.S. Department of Health and Human Services, Health Resources and Sor.iceir Administration, Bureau of Health Profesaions, Office of Data Analysis and Management, "Selected Statistics on Health Manpower Shortage Areas es of June 30,1985," Rockville, MD. U.S. Department of Health and Human Services, Hoelth Resources and Sorvicrs Administration, Bureau of Health Care Delivery and Assistance, Office of Shortage Designation, "Soletod Statistics on Health Manpower Shortage Areas as of December 31, 1988," Rockville, MD, U.S. Deportment of Health and Human Services, hellish Resources and Services Administration, Bureau of Health Profession*, Office of Date Anolyols and Manogement, Rockville, MD, unpublished data from the Ares Resource Filo provided in 1989 and 1990. 3 296 Health Care in Rural America Figure 11-1Health Manpower Shortage Areas (HMSA5), 1987(by no...aetropolitan county, ido6i HMSA Classificatton flonmetropolitan HMSA Whole County WICHM HOrimetropelitan IIMSA Partial County ==Iflonmetropelitan flon-HMSA = Metropolitan County SOURCE T c. Ricketts. Rural Health Reseest.h Centel, University ot North Catokna. Chapel Hai, NC, unow x.riaact to me Offiueot Teo iiiulugy A4sessment. 1989 Data from the Area Rew,urce File, Bureau of Health cale Dei.reiy dild AbS*1411,0f. I4s41th RusuU14.4.! 414 5 I vIl.eb AMrlirolatratION U.S. Department of Health and Human Services. figures cannot be determined ill any case, because HMSAs (see 4.1.13).Abtherearemany more the existing MUA database is configured ir such a HMSAs than NHSC Jcholarship obligated provid- way that subcounty MUAs may be double-counted. ers. loan repayment partmpants, and nonobligated As ofJune 1990, a total of 13 MUP Oesignations had providers (i.e., volunteers), a rational vacancy list is been made (728). prepared by the Federal Division of NHSC12 that includes the most needy of the desigiated shortage USES OF DESIGNATIONS areas. Federal Uses To be included on this vacancy list, a site must be National Health Service Corps part of a system of care, be located in a currently The principal Federal program using HMSA designated HMSA, and need atleast one FTE designations is the National Health Service Corps practitioner before it would be dcdesignated (664)." (NHSC), which places both volunteer and obligated The degree of shortage (priority grouping) of the health care practitioners (mostly physicians) in HMSA is one of sev encriteriathat are used to 12TheFederal Division of NHSC is located in IHRSA's Bureau of Health CareDeliver) And Assinam.e isee app I) "Rutalprui.dry4.1110HMSAs needing lessthat one FTLpraouunct befuredalcoignauun v. uull kos...4.1 may tic ,ului.ki4.1 LA dm. 41..4biui ttt l vi ilul4L practitioners,other midlevel practioners, and in some cases fordie placemeM of a physician(664) 3 ; 3 MMOIVECWIP...... 110MO.MMM Chapter .1 1-Identifying Undersmed Populations 297 Table 11-6-Charamenstics of Metropolitan and Nonmetropolitan Primary Care Health Manpower Shortage Areas (HMSA,$), by Region and State, Sept. 30, 1988 limber of physicians needed NuMber of orimarY_care HMSase Atte, oonulation in FIMSAs to remove desianation? Geographic area Metro Nonmetro Metro Nonmatro Metro Nonmetro United Statue6 635 1,280 17,173,563 14.183.882 2305 1570 Eorthaast 147 84 4,509,819 741,387 412 77 New England 52 24 951,162 100,789 120 14 Connecticut 10 0 100,424 0 22 0 Maine 6 17 40,178 62,446 5 9 Massachusetts 24 1 583,847 5,306 73 0 Now Hampshire 2 1 33,618 2.616 5 1 Rhode Island 8 0 146,095 0 14 0 Vermont 2 5 27,000 30,421 1 4 Middla Atlantic 95 60 3,558,657 640,596 292 63 New Jersey 12 0 736,677 0 36 0 New York 46 31 1,766,304 325,671 163 31 Pennsylvania 37 29 1,055,676 314.927 93 32 Midwest 122 319 3,907,546 3,730,108 577 454 East North Centrai 91 139 3,387,761 2.110,938 527 297 Illinois 27 24 1.634.575 342.253 268 25 Indiana 10 27 249,650 392,380 40 42 Michigan 14 34 057,229 471,648 101 44 Ohio 29 27 :92,254 610,626 60 44 Wisconsin ...... 11 27 254,053 302,031 38 31 West North Central 31 180 519,785 1,611.170 50 157 Iowa 6 17 76 7111 218 n". 7 16 Kansas 2 14 44,409 4sz,I93 0 7 Minnesota 8 17 113,329 129,870 9 7 Missouri 10 49 258,750 628,049 30 66 Nebraska 2 21 23,449 149.437 2 13 North Dakota... .. 2 26 31,006 171,254 2 24 South Dakota 1 36 4,90 182,346 0 24 South 226 623 6.228,126 7,036.045 864 771 South Atlantic 107 219 2,995,959 3.335.279 449 344 Delaware ...... 2 1 49,626 31,700 5 1 Porida 35 32 1,027,093 392,995 180 55 Georgia ..... 21 53 731,901 628.434 109 66 Maryland 8 5 274,757 72,169 37 5 North Carolina. . . . 8 37 426,406 775,496 37 93 South Carolina.. 15 29 264,723 465,648 43 34 Virginia ID 27 112,372 469,809 14 38 West Virginia.... . 8 35 100,281 499,026 24 52 East South Central 49 162 1,318,070 2,492,083 168 237 Alabama . 20 28 550,529 528,470 61 46 Kentucky 5 43 131,501 517,723 23 70 Mississippi, 7 48 260,413 808,425 35 60 Tennessoe 17 43 375,627 637,457 49 61 West South Central.... 70 242 1,914,097 2,009,483 247 190 Arkansas 10 37 96.601 306,452 23 25 Louisiana 19 31 405,468 713,318 55 61 Ok1ahoma., 8 16 170,813 92,673 25 11 Texas 33 88 1,241,215 697,040 144 93 (contsnuodon next page) 298 Health Care in Rural America Table 11-6--Characteristics of Met Opolitan aid Nonmetropolitan Primary Care Health Manpower Shortage Areas (HMSAs), by Region and State, Sept. 30,1988Condnued Hunber of physicians needed HHMINIr of_primarY care OSA? Total ventilation in RHEA* to remove designation') Geographic ar.a Metro Nonmetro Metro Nonmetro Metro Nonmetro Mast 140 254 2,528,072 1,875,542 452 268 Mountain 40 167 350.25$ 1,283.060 87 190 Arizona 10 23 109,532 193.923 26 28 Colorado 8 10 67,767 83.410 9 12 Dish° 1 32 1,450 239.144 .i 42 Montana 0 .3 0 141.366 0 20 Nevada 12 8 50.069 30.159 10 6 Rew Mexico 6 27 96,352 351.362 29 57 Utah 2 15 14.680 130.705 3 13 Wyoming I 14 1.385 103.991 0 12 Pacific 100 87 2,177,817 592.482 365 78 Alaalta 3 11 42,855 61,914 0 15 California 65 27 2.800,804 230.455 284 16 Hawaii 2 0 18.760 0 13 o Oregon 20 31 161,303 113.379 31 23 Washington 10 18 148.095 186.734 35 24 aIncludes geographic. Population, and facility designations. bThis is the number of additional primary care phYsicians needed to bring the population-to-primarY care physician ratio beiow 3.500:1 (3,0001 where high needs are indicated). °These flames do not include HMSAs in the District of Columbia or in the U.S. possessions. SOURCE: U. Department of Health and Human Services. Health Resources and Services Administration. Bureau of Health Care Delivery end Assistance. Office of Shortage Designation, Rockville. MD, unpublished statistics on Health Manpower Shortages as of September 1088. provided to OTA in 1989. determine a site's ranking on the vacancy list. The There is a separate vacancy list for each primary seven criteria are: care specialty and for emergency medicine (270). The opportunities vary by specialty. Family practi- 1. infant mortality rate, tioners, br example, may get lists of relatively 2. percent of population with Incomes below 200 isolated rural sites, while other primary care special- percent of poverty level, ists may get lists of placements in more populated 3. HI4SA degree-of-shortage grouping, areas (716). Placements of obstetricians are made 4. percent minority population served by the site only in areas where an "established and well- or residing in the county where the site is functioning system of care with appiopriate cross- located, coverage" exists (716). 5. percent special population (including home- less, migrant and seasonal farmworkers, peri- The highest priority sites on each of the vacancy natal, persons with human immunodeficiency virus and acquired immunodeficiency syn- lists become the "HMSA Placement Opportunity diome (AIDS), substance abusers, and elderly List" (HPOL)" for that specialty. The number of persons) served by the site, sites on each specialty HPOL corresponds exactly to the number of graduating scholarship recipients 6. vacancies as a percent of total budgeted gaff, and available for placement in a given year. In 1991, there will be 74 obligated professionals available for 7. degree of rurality (664). placement (716). The obligated NHSC participants A point system (0-4, with 4 indicating greatest need) select placements from the List and arrange inter- is applied to each of the seven criteria, with the total views. Negotiation for a placement occurs between points indicating a site's relative need and determin- the NHSC participant and the community or orgam- ing its ranking on the vacancy list (664). zation that has the vacancy. 14The IIPOL Wasfart used in 1983 followingcongressional hearings suggestingthatDHHS target NHSC resources to areas of greatest need l270). 3 Chapter 11Identting Underserved Populations299 Figure 11-2Medically Undorserved Areas (MUAs), 1981(by nontnotropolltan cOunty, 1986) ab.) -%*? a 11, 4. 1 As . I..) ,0 -o asimgoII !;i1 1111 ,,. 111 'ti 4,1'A 4111 146. .11k, col igrv MUA Classification Nonmetropolitan MUA Whole County 11=1 Nonmetropolitan MUA Partial County Nonmetropolitan Non.MUA = Metropolitan '1unty SOURCE. T.C.Ricketts, Riser Heaith Researm Comer, University of Noah Camaro, Chaper HA, 116..indel uenthkt te the Oftk ..'Tschnvivtry Assessment. 1989. Data frcfn the Area ReaftrOD File. Bureau ol mos C.sie Delivery end AfaatanG0, Health Resuuk.os ,iG11111AcIrranistraton, U.S. Department of Health and Human Service& Following the determination of the HPOL, a loan that only one -fourth of nonmetro whole.county repayment list is created from the sites remaining on MUAs have a federally supported CHC or MHC, the vacancy list. The number of sites on the loan and the great majority of these are in the South (table repayment list is based cn estimates of the number 11.7) (511). Only 17 percent of nonmeto partial of providers the Division of NHSC hopes to recruit county MUAs have a CHC MHC. under the loan repayment program (the goal for 1991 is 900 providers) (716). Fisally, a volunteer vacancy Althougl. HMSA and MUA designations were list is determined that includes all the sites on the designed to meek le needs of the NHSC and CHC vacancy lists that are not included on the HPOL or programs, they have since been used to implement loan repayment lists. (Volunteers may, of course, number of other Federal programs as well. Those practice at a higher-priority site if they choose., linked to HMSA designations include th: provision Other Programs of funds for health professions training, the Area Health Education Center (AHEC) program, and the MUA/P designations have primarily been used tu Medicare physician bonus payment program (see eh target Federal resources to CHCs and related pro- 13 for prk ,..vm descriptions). Both HEMSAs and grams (e.g., Migrant Health Centers (MHC5)) (Pub- MUAs are used to target lesources under die Rural lic Law 94-63). However, existing data" suggest Health Clinics Act (Publik. Law 95-210) Providers ISBasedont981 MUAdata end 1989 CHC/MHC data. 3..`j Table 11-7Med Wally Underserved Areas (MUAs) With Federally Supported Health Centers, by Region, 19890 Mettonolitan Nonmetronolitan Type of health Whole-countyPartial-countY Whole-countyPartial-county Region Facility center in MUA Region Non-MUA MUA HUA Non-MUA MUA MUA totals tote.. Community Northeast 4 1 39 0 9 19 72 Heatth Center South 6 16 40 4 166 9 241 (CHC) only Midwest 3 1 27 4 37 23 95 West 0 o 18 8 28 s 60 468 Migrant Health Northeast 5 o 3 1 0 1 10 Center (MHC) South 1 6 5 1 28 6 47 only Midwest 2 o 7 9 1 7 26 West 2 0 4 a 6 4 25 108 Both CHC Northeast 2 o 10 o 1 o 13 and MHC South 1 7 15 1 47 2 73 Midwest 2 o 10 4 3 8 25 Wort 2 0 27 6 5 9 49 160 None Northeast 26 1 26 : ), 5 42 122 South 34 82 116 68 654 76 1,030 Midwest 88 5 70 193 257 316 909 West 13 0 11 139 81 39 203 2.344 Totals 171 119 426 469 1,328 587 'Canters data as of 1989; population as of 1986; MUAs as of 1981. SOURCE: T C. Ricketts, Rural Health Research Center. University of North Carolina, Chapel Hill. NC. Analysis of unpublished data (provided by the Health Resources and Services Adminiatration) conducted under contract to the Office of Technolo8y Assessment. 1989 end 1990. 3 '3 372 Chapter 11Identifying Underserved Populations 301 Table 11-8--Siate Service and Shortage Areas Criteria, 1986 Criteria programs Statesa HealthManpowerShortage Area (BMSA) 16 14 ERMA and/or Medically Underserved Area (MUA) 2 2 Madified HMSO 5 4 Population-to-physician ratios° 3 3 Community sineu s 8 Anywhere in State. 10 s State criteriaf s 4 Other 9 A Total 61 51 'States do not total to 50 because multiple programs in the State use tho same criteria. Eight States with programs have no critria. Naryland. Maine, Hew Mexico, and North Carolina add their state and Local heeith, mental health, and corrections institutions to a list of acceptable practice sites. cCounty-wide population-to-physician ratios are used by three States, Kansas (3,000.1), Kentucky (4.500 1), ,and South Carolina (2,000:1). °The States with programs with placements according to ..ommunity size are Alabama (5,000 population maximum), Arkansas (8.000). Georgia (15.000). Illinois (35.000). Missouri (6.500), Mississippi (10.000), Oklahoma (7.500), and Texas; (30,000). *Alai:kb. Arizona. Kansas (primary care specialistsi, Massachusctts, Maryland (except Montgomery County), Washington. West Virginia. and Wisconsin. 4California, Illinois, New York, and Oregon. SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Mimi.. of Health Professions, Office of Data Analysis and Management, Compendium of State Health Professions OistributipLaloggams: 1986, OHMS Pub. No. HRP-0906864 (Washington, DC. U.S. Government Printing Offic, 1986). must be located in clinics in rural HMSAs or MUM shortage area designation (either an HMSA, MUA, to qualify to receive cost-based reimbursement for or State designation) (table 11 9).16HMS A designa- Medicare and Medicaid services (see oh. 3). Most tions were most frequently used to implement 'NSA-linked resources are tied to the primary oare AHEC programs, service-contingent loans and schol- HMSA designation. arships, health professions school loan repayment programs, and preceptorships. State designations State Uses were most frequently used for service-contingent Many States have adopted programs to promote loans and scholarships, placement programs, and the placement of health professionals in underserved targeted primary care trairing opportunities. areas (see ch.12). Although some States have developed their own shortage area designation FEDERAL DESIGNATIONS: STATE criteria, many States rely on Federal designations to ACTIVITY AND SATISFACTION identify areas and populations in need. HMSAs Of 113 State health professions distribution pro- grams identified by the Federal Bureau of Health Activity Professions in 1986, 61 used some type of shortage Interest in obtaining HMSA designations has not area criteria. About one-third of programs and S tates declined substantially despite a decline in die used the Federal HMSA criteria or slight modifica- number of available NI-ISC personnel. In fact, in tions of them (table 11-8). OTA's survey the percentages of States indicating Three-fourths of the 45 respondents to a 1989 that the demand for Federal primal, care HMSA OTA survey of State HMSAMTUA activity (34 designations had increased or remained the same States) indicated that their State had health person- since 1985 were 71 and 82 percent for urban and nel distribution programs that used some type a rural areas, respectively (table 11.10) States indicat- *To respondents indicated thatibex Mains did not have anyhealth personnel distribution programs using shortage area do-.4snations arid nite respondent aoswered "don't know." 3 ,".4 302 Health Care in Rural America Table 11-9Presence of State Health Personnel Distribution Programs That Use Shot lege Area Designations, 198r Program present Shortage desisnation used, In state)) State State dietribution programs NR HMSe MUA designation Itansationat provers Are. Neelth Education Centers 21 15 9 II 2 3 Targeted primary care treining opportunities (e.g., residencies) 20 15 10 6 0 7 Seat purchases 5 20 20 I 0 0 Preceptorehipe 20 15 10 9 2 3 Other educational program 2 15 28 I 0 0 Ilagneial. Incentives daring traniag Service-contingent loans end schoLarships 27 II ) 10 3 i6 Other Loans 4 20 22 I 0 2 Other schoLerships I 20 24 0 0 I Other financial incentive I 15 29 I 0 0 Add im practice Placement 16 15 14 6 2 9 Oueranteed income 2 21 22 0 0 0 Loess 6 27 22 I 0 4 Health professions school LOIA repayment 13 19 13 10 i 4 Malpractice subsidy 5 20 20 i I 2 Other aid in practice 3 14 28 I I 2 Otbm programs 4 13 28 2 2 2 ABBREVIATIONS: Y yes; N w no; MR no response. ceased on 45 States responding to OTA's survey of shortage end underserved areas (see app. D). bTen States reporting no State health personnel distribution programs, and one responding "don't know." were included as "no" for each specific program. Where States answered "yes" to some prograge but left others blank, the blank responses were included in the "no response" column. cHMSA, MUA, and State designations used for a particular program do not always add up to the number of States indicating that the program was present in their State. Some States use more than one designation criteria to implement programs, while other States did not indicate that any of the three criteria were used. SOURCE.. Office of Techuology Assessment, 1990. Table 11-10Changes In Designation Activity for Metropolitan and Nonmetropolitan Primary Care HMSAs Since 1985 (as of 1989) Number (percent) of States that had: Increased No Decreased Don't know/ activity change activity doas not apply Totut =Ober of Otataa: Metro A. , 22 (271) 20 (441) II (252) 2 ( 41) Nonmetro EMSAs 26 (581) II (241) 7 (I61) 1( 21) Nithha resigns: Northeest (7 States) Metro NMSAI , 0 ( 01) 4 (571) 2 (um 1 (141) Nonrstro MA' 2 (291) 2 (291) 3 (431) 0 ( 0%) South ,16 Stem() Metro NMSAs 6 (38%) 5 (311) 4 (251) 2 ( 61) Nonmetro NMSAs 11 (691) I ( 61) 3 (IC%) I( 61) Midweet (II State.) Metro IIMSAs.. I ( 91) 8 (73%) 2 (181) 0 ( 0%) Nonmetro 11MSAs 5 (46%) 5 (461) 1 ( 92) 0 ( On West (11 States) Metro SMSAs 5 (46%) 3 (271) 3 (271) 0 ( 01) Nonmetro EMSAs A (731) 3 (271) 0 ( 01) 0 ( 01) ceased on 45 States responding to OTA's survey of shortage and underservod areas (see app. D). SWIM Office of Technology Assessment, 1990. N 41 ;) Chapter 11Identifying Underserved Populations 303 Table 11-11Factors Affecting the Demand lot Federal PrimalyCare HMSA Designations Since ! 985 (es of 1989)a Number (mertent) of States that had! Increased Decreased Rad no Don't No Pastor demand demand effect know response Need for NSSC personnel 31(691) 5 (II%) 6(13%) 3( 71) 0 ( 0%) Availability of NBSC personnel 15(331) 23 (51%) 5(11%) 2( 4%) 0 ( 0%) Rural Beath Clinics Program 19(42%) I ( 2%) 11(24%) 13(291) 1 ( 2%) Medicare physician bonus payment 28(581) 0 ( 01) 7(16%) 12(27X) 0 (0%) State programs linked to *ISM 18(401) 0 ( 0%) lo (42%) 5(111) 3 ( 7%) Other 10(221) 0 ( 0%) I( 2%) 2( 4%) 32 (71%) ABBREVIATIONS: RMSA Health Manpower Shortage Atom. NRSO . National Health Service Corps. eBessod 0111 45 Stetes responding to OTA's survey of shortage and underoerved areas (see app. D). SOURCE: Office of Technology Assessment, 1990. Table 11.12State Satisfaction With the Federal Primary Care Health Manpower Shortage Area (HMSA) Designation Process, 1989* Number (vercent) of States that wage. Setisfied Dissatisfied Don't know/no opinion No response Criteria 28(62%) 16(36%) I(21) 0 (0%) Application process 32(741) II(26%) 0 (0%) 0 (0%) Review process 30(67%) 13(29%) 0 (0%) 2 (4%) !Used on 45 Stetes responding to OTA's survey of shortage end underserved areas (see app. D). gThe two States that have not filed an RMSA application since 1985 were not asked to valuate the applicetion process. Thus the total number of States motoring this question was 43. SOURCE: Office of Technology Assessment. 1990. ing an increasein designation activity were most workable. Aspects of HMSA criteria that respon- likely to be located in the South or the West. del& thought were good and should be retained Forty-three of 45 responding States had filed at least included: 1 HMSA application since 1985, but treads ir designation activity varied considerably among high needs criteria (9 States), population-to-physician ratio (7 States), States. consideration of distance and travel conditions Factors cited most often as contributing to in- (6 States), creased demand for HMSAs since 1985 were. the "rational service area"' concept (4 States), consideration of contiguous area resources in need for NHSC personnel (31 States); assessment of the availability of physicians (3 Medicare physician bonus payment (26 States); Rural Health Clinics program (19 States); and States), and State programs linked to HMSA designations focus on special population groups (2 States). (18 States) (table 11-11). For the substantial minority of States (36 percent) that were dissatisfied with the criteria, the most Ironically, the factor cited most often as decreasing HMSA demand activity was the availability of common criticism was that the present cut-off point of 3,500:1 for the population-to-primary care physi- NHSC personnel (23 States). cian ratio is too high (13 States). Suggested cut-off Satisfaction With HMSA Designations points ranged from 2,000:1 to 3,000:1. Related suggestions to Improve the identification of primary CriteriaIn OTA's survey, most States (62 care personnel shortageareas concernedthe produc. percent) were satisfied with the criteria used to tivity and actual availability of phy sicians counted. designate Federal primary care HMSAs (table 11 Three respondentssuggested discountingelderly 12). Overall, respondents indicated that HMSA physicians before they retire. Several respondents criteria were generally relevant, welt-dermed, and suggested excluding phy sieians whose hen it.es are 43 0 304 Health Care in Rural America not available to the general public (e.g., physicians HMSA criteria (e.g., if ...-riteria were more sensitive located in mental hospitals or on military bases). to specialty shortage areas, or if changes were made Other areas of dissatisfaction with Federal HMSA in the high needs categories). Foil' respondents designations that were listed by respondents in- noted that HMSAs with CHCs usually were as- cluded: signed higher priority than 1.12VISA5 without Federal centers." lack of specialty shortage area designations, especially for obstetrkians (12 States), Application and Review ProcessesMost re- lack of discriiination in the cakulation of spondents indicated that they were satisfied oath the physician counts between physicians vho sery e HMSA application and rev iew o4..ess (table 11- Medicaid patier a... and phy sician, who do not (6 12). Federal staff were generally reported to be States), helpful, but one-third of respondents found long ambiguity of the rational service area critena processing times to be a problem, especially for rural States), and areas. problems designating special population groups (e.g., the indigent, the homeless, AIDS patients, MtlAs and mhiority groups) (4 States). Ac tivity While nine respondents specifically mentioned the Although 43 of 45 States responding to the OTA high-needs indicators as a very positive aspect of the survey 1Ad filed an HMSA designation application HMSA criteria, some suggested improvements such since 1985, only 18 States indicated that they had as eliminating the fertility criterion, substituting filed an MUA application since 1985." Most States unemployment rates or per capita income for pov- reported that MUA application activity in both rural esty level, and changing the weighting of the infant and urban areas has remained the same or decreased mortality criterion. since 1985 (table 11-13). The need for CHCs was Difficulty designating fronfier areas was the most listed most frequently as having increased demand commonly listed problem associated with health for MUA designation, .vhile the akailabittry of CHC personnel shortages in rural areas of the States. funds was listed most frequently as having de- Other problems characteristic of rural areas mduded creased demand for MUA designations (table 11- the application of the "rational service area" 14). criterion, inadequacies of distance and travel time criteria, and severity of specialty shortages in rural Satisfaction With MLA Designations areas. CriteriaMany Sta-s in OTA's survey reported HMSA Priority GroupsThere was considera- that they were unfamiliar with MUA designation criteria Of respondents exr fess* an opinion about ble disagreement among survey respondents regard- ing the usefulness of the pnmazy care HMSA their satisfaction with the criteria used to designate Federal MtJAs, slightly more were dissatisfied (16 priority groupings. Over one-half of the respondents agreed that they are a good measure of HMSAs' States) than were satisfied (12 States) (table 11-15). relative degrees of shortage, while one-third disa- Over one-third of repondents answered "don't know," "no opiri;?n," or left this question blank. greed. Over 40 percent of States did not believe that Several States suggested that Federal staff clarify the Federal lesource allocation was correlated with the current relevance and utility of MUA designation& priority groups." Several respondents felt strongly that the priority groupings did not reflect the States' Mustrespondents commented favorably on at primary care personnel needs and should be elimi- least a few of the indicators of need. Changes nated. Others commented that groupings would be suggested to improve the MUA designation cntena more meaningful if other changes were made in included: "Twenty nine percent of the respondents thought resource agecauon*As vunejalgti withHIYISApnoltry sumps nod 29 pemem responded don 1 blOw.""no opinion," or leftthequestion Mank . anis is probably *reflection of ao NNW POlicy that gi*cs PrkairY to roderally &laded cHC4 krthe placement 431 omegated personnel ksee ch. 1.3). "Mealy-font States indkatedthat the) had not filed aa applicauva 1 MUAdesignation unce 19£35. vac State mspunded don tsnow. and nvo States left ens question blank. 3 ,,7 Chapter 11Identifying Underseryed Populations 305 Table 11-13Changes in Designation Activity for Federal Medically Underserved Areas (MUAs) Since 1985 (as of 1989)" Number_(2agtent) of States that had: IncAeased No Decreased Don't know/ No activity change activity does not apply response Metro MUAs 4(92) 12(272) 12(272) 10.22%) 7(16%) Nonmstro MUAs 3(72) 14(312) 11(242) 10(222) 7(162) aBased on 45 States responding to MA's survey of shortage and underserved areas (see app. D) SOURCE: Office of Technology Assessment. 1990. Table 11-14Factors Affecting the Dernond for Federal MUA Designations Since 1985 tas of 1989) Number (percent) of States that ad. Increased Decreeeed Had no Don't No Factor demand demand effect know response Need for CPCs 14 (312) 0 ( 02) 15 (332) 5 OM 11 (242) Avilability of CSC funds 7 (16%) 11 (242) 12 (272) 5 012) 10 (222) Rural Ilealth Clinics Program 9 (20%) 0 ( 02) 16 (36%) 9 (202) 11 (24%) State programs linked to MUA deeignetion 3(7%) 0 ( 02) 22 (492) 5 (112) 15 (332) Other 0(02) 2( 2%) 0 ( 02) 0 ( 02) 44 (962) ABBREVIATIONS: CBCs Community Beath Centers; MUA w Medically Dnderserved Area. 4Based on 45 States responding to OTA's survey of ehortage and underserved areas (sae app. ,). SOURCE: Office of Technology Assesement. 1990. Table 11.15State Satisfaction With the Federal Medically Undemerved (Mk Designabon Pr ocess, 1989" Number (Percent) of States tbAt were: Satisfied Dissatisfied Lon't know/no opinion No response Criteria 12(272) 16(361) 15(332) 2( 42) Application processb 2(112) 9(502) 6(332) 1( 62) Review process 2( 42) 20(442) 16(362) 7(162) !Booed on 45 States responding to OTA's survey of shortage and underserved erase (see app D) °The 27 State* that had not filed an MUA application since 1985 were not asked to eval..ete the appliatton procees. The total number of States responding to thie question was 18. SOURCE: Office of Technology Assessment. 1990. updating the weik, nig factors attached to the reexamining the current applicability of the four indicators of need (8 States), IMU cut-off score used to distinguish an MUA considering combining HMSA and MUA des- from a non-MUA (2 States). ignations into one measure (7 States), Two States mentioned that the weighting factors incorporating factors that might be affecting associated with th: proportion of the population that access to care (e.g., the percentage of the is elderly and the infant mortality rate tend to cancel population that is uninsured, on Medicaid, or a each other out. Designating frontier areas was member of a minority) (6 States), reported by five States to be a problem. nplacing sonn criteria with other measures (e.g., lov, birt.isv-ight percentage instead of Application and Review ProcessesOf the 18 infant mortality, unemployment rates or p:r States that had filed an MUA application since 1985, sonal income instead of poverty rates, and rates 9 repot,cddimatisfactlonwith the application proc of chronic disease instead of percentage of ess (whit 1115). Four respondents noted that they elderly) (4 States), and had recc.7ed no reponse to designation requests and 3,1R 306 Heahis Care in Rural America cited poor communication with Federal staff as a States (22 of 45), either alone or in -onjunction with problem. HMSA or MUA criteria, to implement State health personnel distribution programs. In describing crite- Must respondents who expressed an opinion were ria, two States reported that they used modified dissatisfied with the frequency of review (table HMSA designadoncriteria, four States used specialty- 11-15), with suggested frequencies ranging from specific population-w-provider ratios, and two annually to every 3 to 5 years. Thre. States believed States used a population-to-primary care physician the optima! frevera4 would depena on the specifics ratio that was lower than the HMSA cut-off of of new modified MITA designation criteria and how 3,500:1. Another criterion used by two States was resources were tied to MUA status. community size (e.g., an area could qualify if it had Thirteen States suggested that criteria used for fewer than 15,000 or 10,000 residents). reviewing MUM that have CHCs or other federally funded services should differ from criteria used for A few States have developed more elaborate other MUM. Several States raised the concern that indicators of medical underservice. Michigan, for when CFICs have a favorable impact (e.g., reduce example, has expanded on the IMU to develop a new infant mortality), this jeopardizes their MITA desig- model designed to be more responsive to State nation status. One respondent suggested that differ- economic conditions (386). The Mi.higan Primary ent MUA criteria be developed for initial designa- Care Association (MPCA) model added two new tions and for those areas seeking redesignation. variables (percentage of persons eligible for Medi- caid and the aggregate unemployment rate) to the State Designation Capability IMU and has a revised system of weights (table 11-16). The MPCA model puts the greatest empha- OTA's survey also examined the opinions of the sis on poverty and Medicaid eligibles, while the respondents regarding how well-equipped they were 1MU emphasizes population-to-primmy care physi- to conduct shortage designation activity in their cian ratio: and infant mortality. The MPCA intends States. Nearly three-fourths of respondents (33 of to use its model as one of the criteria in a State 45) reported that the withdrawal of Federal planning program to place physicians, nurse practitioners, and resources had a negative effect on the States' ability nurse-midwives in areas of need (323). to prepare requests for HMSA/MUA designation. Respondents overwhelmingly linked the lack of Over 40 percent (19) of States responding to the staff available to prepare requests for designations to survey were defining shortage areas for physician the withdrawal of Federal funds. The majority of specialties or for nonphysician health personnel. respondents (35 States) reported that State and Eight respondents indicated that they were identify- Federal resources were not adequate for maintaining ing shortage---.ms for all physician specialties, most an accurate and up-to-date list of health personnel using population-to-provider ratios specific to each shortage areas and medically underserved areas. specialty. Shortage designations for obstetricians were the most common designation described (eight STATE SHORTAGE States). Several States were either currently defining DESIGNATIONS: PRENALENCE or were planning to defme shortage areas for nurses. Other specialties for which States were designating AND USES shortage areas include psychiatrists, pediatricians, Federal HMSA and MUA designations prov ide 4 family practitioners, aiternists, and general practi- centralized and relatively uniform designation sys- tioners. tem, but they do so at the cost of being inflexible to State-specific priorities and needs. To fill m the When asked why States used their own criteria instead of Federal IIMSA or MUA designations, gaps, some States have expanded on Federal desig- respondents said they viewed their State criteria as nation criteria or created their own criteria to address a more accurate measure of need. Some respondenta particular problems. States that have developed their slated that their State designation criteria were own criteria generally apply more lenient or more addressing areas of specialty shortage, were more specific criteria in defining shortage areas. sensitive to needs of frontier and other rural areas, In the OTA survey, State designation criteria were weie more lenient than HMSA iziteria, or were more being used in almost one-half of the responding timely. Chapter 11Men:Vying Underserved Populations 307 Table 11-16----Comperison of the Federal Index of Medical Uoderservice OM% and the Michigan Prima;yCare Association (MPCA) Jodele IMU weight MPCA weight Federal variable (percent) (percent) Percentage of persons below 1001 of Federal poverty level 25.1 20.7 Plye year infant mortality rate 26.0 17.2 Percentage of persons age 65 and over 20.2 17.2 Primary cars physician to population ratio 26.7 13.8 Percentage of persons Medicaid eligible . NA 20.7 Unemployment rate. --IS 10 a 100.0 100.0 MOTE: MA 1. not eppliclble. albe weights that appeer in this table ere those associated with least-naedy extreme for eech criterion (e.g., the IMU weight of 25.1 for percentage of population below the Federal poverty level is associated with 01 below poverty). (See 41 FR 45718-45723 for the complete weighting tables used for IMU computation.) Lower weights are saociated with more critical need. SOURCE. Michigan Primary Care Asaocietion, 8_111ueDrInt far Primary Wealth Care. Communities Ouildima a §,±111, executive summary (Lansing, MI: Movelitar 1987). Table 11-17gfato Opinions on How Accurately Federal HMSAs and MIAs Reflect State Health Personnel Shortages, 1989° Don' t know/ Po Yes No no opinion Response State hes ress/populations that hove heelth peraonnel shortages or are medically 38(841) 3( 7!) 3( 7%) 1 ( 2%) underserved but are na designated es EMSAs or MUAs Stets has areas/populations jusimaropriatety designated 8(16%) 29(84%) 8(181) 0 (01) Federal EMSAa/MUAs 4 Used on 45 States responding to OTA's survey of shortage shd underseryed areas (see app. 8). SOURCE: Office of Technology Assessment, 1990. Testifying to the limitations of the Federal desig- lacked financial resourees and staff to nominate nation criteria, over four-fifths of respondents (38 of them for designation. 45) believed that there were areas or populations in their State that had health personnel shortages or Seren States indicated that there were areasOr were medically underserved but were nut designated populations in their States that were inappropriate) as Federal HMSAs or MUAs (table 11.17). Fourteen designated as Federal HMSAs or MUAs table States had designated such areas as Slate health 11-17). Ser etal respondents speculated that inappro- personnel shortage or medically underserved areas. pf .tte designations existed due to the lack of zer iew These areas tended to be rural parts of the State, of MUA designations. areas with specialty shortages (i.e., shortages of obstetricians) and nonphysician shortages, and areas States engaged in seretal othez aetivines related where the population- to-phy sician ratios were below to designating underserved areas (table11- 18). the Federal HMSA cut-off. State designatedpopula- Forty percent of States (18 of 45) weic delineating dons included Medicaid and indigent populations. primary care serviee areas. the majy.ity of States When asked why these areas oz populations were not (32 of 45) were conducting special surveys of federally designated, respondents replied either that primary ...are providers to monitor shortage areas oi the areas lacked incentives to apply (e.g., limited underserved areas, one -third of these were doing so NHSC personnel a-ailability) oz that the State as a part of HMSA designation and zedesignation 3 308 Health Care in Rural Anserka Table 11-18Shortage Area Designation Activity, hy State, 1989 Nes filed at least Has filed at Dlfines its own one primary care least one MUA shortage areas for Delineates Conducts special HMSA application applications certain health primary care surveys of primary Atate4 sidce 1985 since 1985 practitioners service areas care providers Alabama X Alaska X AXitana X Arkansas X Colorado X Delaware X Florida X Georaia X Hawaii X Idaho Illinois X Indiana X Iowa X Kansas X Kentunky X Louisiana X Maine X Maryland X Michigan X Minnesota X Mississippi X Missouri X Montana X Nebraska X Nevada X New Hampshire New Jersey New Mexico New York X North Carolina X Ohio X Oklahoma X Oregon X Pennsylvania X Rhode Island X South Carolina X South Dakota X Tennessee Texas X Uteh Vermont Virginia Washington X West'Virginia U Wideman NOTE: X yes: ? - don't know no response: blank .no tOnly the 45 States that reskonded to OTA's survey ofshortage and underterved areas are included SOURCE: Oft of T9 hw^1^6, Assessment. 1990 activities. S.-neSines reported sur eying each lonr able to conduct surveys because of the lack of physiciat as a part of their relicensing procedure, staff time. and som... State: conewted annual surveys of CHCs, hospktals, )r health departments. Other reasons for HMSAs AND MUAs: PROBLEMS doing surv.tys included monitoring obstetrician and AND ALTERNATIVES sursing shortages and determining the number of private phyacians accepting Medicaid patients. One There .tre ovu problems Anherent m the identifica- respc reported that their organization wa.s no tion and prioriuzation of health serv shortage 331 Chapter 11-4dentifykg lInderserved Populations309 areas. First, the terms "shortage" and "under in the total hours worked, allocation of time to service" are hard to define, second, the measure- different practice activities, and productivity (718). ment of various indicators of shortage and under- In 1983, Berk and colleagues questioned whether service is constrained by the limited availability of accurate t,nd current local data. Despite these HMSA criteria result in a valid distinction between areas with adequate access to medical care and those problems, the Federal Government has pursued its with inadequate access (85). They evaluated four efforts to designate needy areas since the late 1960s and has relied on HMSA ar, 4 )1',UA designations to measures of access to health care for populations residing in and out of HMSAs: target Federal resources. 1. the likelihood of having any physician visits The distinction between HMSAs and MUA/Ps (in 1977), has not always been clear. The concept of medical 2. the number of physicit ti visits, underservice is broader than that of health man- 3. travel time to usual source of medical care, and power shortage, since the former relies on a number 4. waiting time in the medical provider's office or of indicators of need, while the latter is primarily place of practice. concerned with underservice attributable to lack of health personnel (339). Much of the confusion The authors tbund that differences in access to associated with the purpose and validiti of the health care were better explained by differences in Federal designations stems from the ambiguous mcome, racial composition, and msurance coverage meanings of the terms "shortage" and "medical than by differences in physician supply. Based on underservice." these fmdings, they suggestedthatcriteria be developed that would more closely link factors limiting access and utilization with low levels of Shortage Area Designations physician supply, and they concluded that the Federal policies to redistribute physicians through physician redistribution effort was "a relatively the NHSC program were based on the premise that inefficient mechanism for reducing inequities in relative physician shortages were associated with access to care." impaired access to care. The NHSC program was In 1983, the criteria used to designate HIvISAs initially tied to CHMSA designations in the early were evaluated as was required by law (Public Law 1970s to increase the number of providers in areas 97-35), arid four alternative designation criteria were with a relative undersupply. evaluate& The concept of shortage was broadened by I. the IMU, changes in the HMSA designation criteria estab- 2. the Utilization Deficit Index (developed by lished in 1978. Shortage was not only measured by researchers at the National Center for Health the relative supply of providers to an area, but also Statistics), by taking into consideration socioeconomic barriers 3. the Deaths Averted Index (de%eloped by re- to access and other indicators of need. The designa- searchers at the Urban Institute), and tion of populat: on groups as HMSAs was an 4. the Use/Need Index (also developed by re- additional means of addressing the specific access searchers at the Urban Institute) (682). problems that face certain populations.20 Identifying what the indicators of shortage should be and While the taISA criteria stress piovicter availa- deciding how they ought to be prioritized were bility, the IMU considers both availability and major concerns inthe development of HMSA health status measures, and the other three indices all criteria. emphasize health status and health care utilization. The shortage area designations that would be One point of criticism of HMSAs has been their produced by the HMSA trid alternathe methods reliance, despite these changes, on population-to were compared and contrasted. The alter natn eb provider rauos. Critics have suggested that these were assessed according to how well they ranked ratios do not reflect differences between specialties counties in terms of need, access, health status, 714"Access" has berm deftned broadly as the absence uf geographic. f manual, and cap4...oy barriera 11,14 m4..4. aimo.datm, xablitg,6.. tcactt ura; d to), afford (pay for), and obtain in a timely manner health services that atc wanted or desired (682) 3 11t, - 310 Health Care ir Rural America utilization, insufficient capacity, and health person- that underserv ice should be defined as deviations nel availability. from those standards. Although differen' groups of counties were identi- Kushman evaluated the IMU as a predictor of the fied by the different alternatives, all methods identi ability to obtain physician services using California fied a core group of the same counties. These Medicaid claims (329). He found that the IMIJ counties were predominantly poor, rural counties in explained only one-fifth of the vanation in the the South (682). The HMSA criteria appeared to be number of claims across counties. When nonwhite the most effective in ranking counties by relative and urban populations were considered as independ- availability of health persorzelnot surprising, ent variables in addition to the rmu, the regression since the other methods did not necessarily empha equation explained nearly one-half of the variation size personnel availability. in claims. Kushman concluded that the IMU did not adequately reflect barriers to physician services In this 1983 evaluation, HRSA also evaluated the faced by nonwhite and rural persons and that criteria used to determine "degree-of-shortage" programs using the IMU run the risk of misallo- groupings among EDISAs. The agency found that eating resources toward whites and urban dwellers. the priority groupings: I) gave undue importance to differences in population-to-practitioner ratios and Other noted limitations of the 1MU include the certain measures of unmet need, 2) did not consider IMU's insensitivity to consumers perceptions of the size of affected populations, and 3) did not take health care needs and the w a) individuals select and into account unmet demand or area attractiveness utilize health services (330), the absence of a c'ear (682). Despite some effons to develop better degree- dermition of "rational service area," and the lack of of-shortage criteria, the original priority groupings consideration of needs and available servil.eS in continue to play a role in the allocation of NI-ISC contiguous areas (339). personnel. Criticisms that current measures of undersei ...e may not be adequately identifying areas in greatest If nderserved Area Designations need prompted a 1987 study of the usefulness of health status, as measured by sentinel health events, Th: lack of a generally accepted definition of to identify underserved areas (55). Sentinel health med,cal underservice has generated considerable events are medical conditions that, by virtue of their criticism. Wysong, for example, criticized the IMU presence or prevalence in a population, indicate a for its failure to define medical underservice di- 1- k of access to acceptable-quality preventive and rectly, noting that the MU simply attempted to uLner primary health care. Examples of sentinel predict the assessments experts would ma.t2 if they health events include dehydration in infants; mea- actually visited sites (742). Critics contend that the sles, mumps, or polio in children; and advanced lack of any empirically verifiable concept makes the breast cancer or invasive cervical cancer in adult 1MU difficult to interpret and also difficult to defend women. Identifying areas and populations that are as a basis for policy formation (682). potentially underserved involves calculating the Several studies examined how well the IMU relative rate of sentinel events among different areas or populations. The study found that sentinel health identifies residents with poor access to health care. events were effective in identifying underserved Kleinman and Wilson used data from the 1973 and urban areas, but results were inconclusive in rural 1974 Health Interview Surveys to determine whether areas At present, the most promising use of sentinel residen.s of rural areas satisfying MUA require- heath events ic as a supplement to existing methods, ments had poorer access to medical care than others to identify certain populations groups and subgroups (321). No difference was found between MUAs and that may have impaired access (55). "adequately served" areas in volume of physician visits per resident, and only a small difference was SUMMARY OF FINDINGS found in the proportion of residents with one or more visits per year. MUA residents used some preventhe While there ate no definitive crueria that define services less and nonsurgical hospitalizatiin more. what constitutes the "adequate" supply of health The authors concluded that there was a need for care in given area, the Federal Government has specific objective standards of appropriate care and developed measures of "shortage" and "medical 3 ;3 Chapter H-1dentifying Underserped Populations 311 - underservice" that attempt to kentify areas and tions concern the use of IMU weights and cut-off populations with a relative lack of health care. point that have not been reexamined since 1976, the ambiguous status of MUA designations during the As measured by personnel shortage, rural health past decade, and decreases in the incentives for needs remain high. Contrary to predictions, and States to apply for MUA designation. despite overall increases in physician supply, the number of designated primary care HMSAs actu- There appear to be a substantial number of areas ally increased 30 percent between 1982 and 1988. and populations that have health personnel sh W- in 1988, 29 percent of the U.S. rural population ages or aro medically underserved but are not (16.5 million people) lived in designated primary designated as Federal HMSAs or MUAs.In 1986, care HMSAs.States continue to request new short- there were 95 nonmetro counties that qualified as age designations. Where demand for designations HMSAs based on whole-county population-to- has declined, States report that it has been due in part physician ratios21 but were not designated as HMSAs to the decreased availability ot incentives linked to OH). It is also possible that a number of subcounty these designations (e.g., NHSC personnel zid new areas may have also qualified but not applied for CHC funds) and the lack of funds to engage in HMSA designation. Four-fiftlis of respondents to designation activity. OTA's survey (38 States) believed that there were In general, States regard HMSA criteria as rele- areas or populations in their State that had health vant and workable. Points of dissatisfaction include personnel shortages or were medically underserved the cut-off point of 3,500:1 for the population-to- but were not designated as Federal HMSAs or primary care physician ratio (which is often regarded MUAs. as being too high), the lack of adequate considera- uon of the productivity and the actual availability of Some States have engaged in activities to help fill physicians, and the often long processing time in the gaps where Federal designations do not associated with designation. The use of HMSA adequately address special State problems.At least priority groupings as a means of allocating resources 22States use their own designation criteria either has also been challenged. The prioritization process alone or in conjunction with HMSA or MUA is not as public as it could be. The critem used to criteria, to implement State health personneldistri- determine the HPOL list, on winch NHSC personnel butien programs.Examples of other State designation- placements are based, have never been pubhshed. reated activities include defining shortage areas for physician specialties or for nonphysician health care Unlike HMSAs, MUNI' designations attempt to providers, defining primary care service areas, and measure health underservice by considering pnmar using State surveys of primary care providers to ily measures of health service demand rather than monitor health personnel shortages and medically supply.Although the MUA criteria may well be a underserved areas. better measure of impaired access than the HMSA criteria, the Federal identification and administra- &ate critena are gentian) more speLific or more tion ofMUAlPs has some major problems.Becatbe lenient than Federal aitena, a nd they am baler ed by MUAs have not undergone a regular rev iew since the States to be more sensitive to the needs ofrural 1981, they cannot be viewed as an accurate indica- and frontier areas, to specialty shortage areas (e.g., tion of the current level of medical undersen ice, obstenicians), and to needs that must be met quickly.. either on an individual area or national basis. Other State shortages of reso.zces and staff, how erer, hare potential problems associated with MUA designa- limited designation activ ities. nIncludes dociors of medicine only 20-810 0 - 90 - 11 013 3 .4 Chapter 12 Problems in the Recruitment and Retention of Rural Health Personnel CONTENTS Page INTRODUCTION 315 FACTORS AFFECTING PHYSICIAN SPECIALTY CHOICE 315 FACTORS INFLUENCING WILLINGNESS OF HEALTH PROFESSIONALS TO PRACTICE IN RURAL AREAS 316 Personal Factors 316 Professional Factors 318 Economic Factors 323 Concerns of Allied Health Professionals 330 SUMMARY OF FINDINGS 331 Factors Affecting Physician Specialty Choice 331 Factors Affecting Location Choice 331 Figures Figure Page 12-1. Average Number of Hours Worked and Average Number of Patients Seen by Physicians, by Specialty and Location, 1988 317 12-2. Average Liability Insurance Premium as a Percent of Average Gross Income of Self-Employed Physicians in Selected Specialties, 1982-88 329 Tablet Table Page 12-1. Number of Hours Worked Per Week and Number of Weeks Worked Per Year by Registered Nurses, by County Population Size, 1988 318 12-2. Coverage and Direct Payment for Services of Midlevel Practitioners 321 12-3. Registered Nurses Employed in Nursing: Percent of Time Spent ill Various Professional Activities and Percent Enrolled in Advanced Nurse Education Programs, by County Population Size, 1988 324 124. Income of U.S. Physicians (as a Percentage of Average Physician Income) by Specialty and Praaice Location, 1977 through 1986 325 12-5. Average Annual Salary Range of Physician Assistants by Community Size, 1989 325 12-6. Average Annual Salary of Registered Nurses, by County Population Size, 1988 326 12-7. Average Prevailing Charges for Selected Procedures by Geographic Location, Actual and Adjusted for Differences in Practice Costs, 1987 327 12-8. Medicaid Maximum Payments and Medicare Maximum Allowable Charges for Selected Ser.rices, 1986 328 :3 7 f; Chapter 12 Problems in the Recruitment and Retention of Rural Health Personnel INTRODUCTION Critics assert that the current medical education system encourages specialty and academic practice The future supply of rural headh professionals is and discourages students from pursuing priir...y dependent on a sufficient supply of professionals care (206,506,556,604,608). It is commonly be- appropriately trained for rural practice, and their lie% ed that medical school graduates are increas- willingness to locate and remain in rural areas ingly electing nonprimary care fields because these Factors affecting health professionals' specialty and are more piofitable. Althuugh earning potential is location choice fall into three general categories. not frequently mentioned by medical students as a motivator of specialty choice (58,61), a recent 1. personal factors (e.g., work hours, social analysis suggests that it may be a factor (180). In opportunities, spouse employment, and school- 1987, the median net income of office-based family ing for children); practitioners (FPs) and pediatricians was roughly 2. professional factors (e.g., opportunities for one-half that of office-based ophthalmologists, diag- professional consultation, community and pro- nostic radiologists, orthopedic surgeons, and anes- fessional acceptance, and opportunities for thesiologists. Net specialty income correlated posi- career advancement); and tively with both the number of applications per 3. financial factors (e.g., ell- itional debts, in- available residency position and the percentage of come, and practice costs). available residency positions filledfor various specialties (180). klthough recent attention has focused on eco- nomic disincentives to rural practice, noneconomic Other factors may also be contributing to the issues also play a critical role in recruitment and 4..urrent trend away from primary care specialties, retention of rural hearth professionals. For some including: professionals, the perceived amenities of rural prac . tice outweigh its disadvantages. For others, the most the perception that primary care practice is less attractive salaries would not compensate for the prestigious or less intellectually challenging perceived drawbacks of rural areas. This chapter than other specialties (206,326), presents an overview of factors affecting health the belief that primary care residencies and professionals specialty and location choices. It also primary care practice are more demanding and discusses more specifically some of the key prob- require longer hours than other specialties lems in recruitment and retention of rural health (61,312), and professionals. The chapter is largely concerned with the lack of positive role models in the primary physicians because of the relative abundance of care specialties (206,506,556,604,608). studies and data on physician recruitment and The three factors most frequently mentioned by retention. Many physician tecmitment and retention 1989 medical college seniors as the most important issues, however, apply generically to other health determinant of their specialty choice were intellec- professionals as well. tual content of the specialty (30 percent of gradu- ates), type of patients encountered (16 percent), and physician role models in the specialty (12 percent) FACTORS AFFECTING (61). Very few seniors indicated that their choice PHYSICIAN SPECIALTY CHOICE was based on the "prestige" of that specialty within the medical profession (60,64 Because rural areas rely so heavily on primary care physicians (see ch. 10), the reci.itment of Over two-thirds of 1989 medical school seniors physicians into pnmary care is dal rust step in rural indie.ated di-' they had determined their current physician recruitment. The recruitment prmess thus specialty preterenLe during the third ot fourth year begins in the earliest stages of medical education. of niedkal st..hoo1 (61). A substantial proportion (13 315 316 Health Care in Rural America percent) indicated that they had chosen a specialty FACTORS INFLUENCING before entering medical school (61). About two- thirds of 1988 and 1989 seniors who indicated a WILLINGNESS OF HEALTH specialty choice had changed their preference dunng PROFESSIONALS TO PRACTICE medical school. in both years, those students had IN RURAL AREAS most frequently rejected the specialties of family practice, internal medicine, general surgery, and In the overwhelming majority of studies reviewed obstetrics/gynecology (60,61). The three reasons by OM, personal characteristics and professional most commonly given for the decision agamst a concerns were found to be of greater influence than financial factors on the location choices of physi- previously considered specialty were excessive de- mands on time and effort, inconsistency with cians. The concerns of rural physicians apparently have not changed appreciably over the years. A student's personality, and negative clerkship experi- study of physicians practicing in rural areas in 1967 ences (60,61). (90) found areas of concern similar to those identi- fied by more recent surveys. Most physicians A study of 1983 medical school graduates found practicing in rural areas are satisfied with their jobs that receipt of a Federal scholarship was the most (239,405,461), although one study found even powerful predictor of selection of a primay care higher satisfaction rates among urban physicians specialty (168). This same study found that women (239). and married students were more likely than others to enter a primary care field, and that high levels of Personal Factors student indebtedness were somewhat associated Preference for rural or urban practice location with preferences for nonprimary care specialties and seems to depend more on a personal preference for intent to enter academic, research, or administrath e rural or urban living than on specific charactenstics positions (168). of rural or urban settings (239). Rural upbringing is a major influence on the decision for rural practice Some States and regions send a relatively lugh (71,90,142,144,165.239,280,311507,592.719), as is proportion of their medical graduates into primary the preference for a rural lifestyle (239,405.507). care. A study of 1983 medical school graduates From 1978 to 1986, however, the number of enrolled (544) found that the percentage of graduates entering medical students from nual areas decreased by 31 family practice res; dencies was highest in the Pacific percent while the total number of enrolled students (17.5 percent) and Mountain (16.1 percent) regions. remained essentially the same (500). This decrease Regions with the lowest percentages were New was primarily due to a drop in the number of applicants from these areas (500). England (7.1 percent) and the Middle Atlantic (8.1 percent), In 7 States, at least 20 percent of graduates Low zr socioeconomic background (124,238), ex- entered family practice residencies,' in 10 States and perience in the National Health Service Corps (333), the District of Columbia, fewer than 10 percent did and partkipation in a loan forgiveness program tied so.2 New York, which continues to have the highest to service obligation (372) are also associated with number of medical graduates per year of any State, ,hoice of a rural practice location. Minority physi- sent only 3.2 percent of its graduates into family cians are more likely to practice in areas with large practice residencies in 1988 (744). For individual minority populations, suggesting that the recruit- medical schools, percentages in 1983 ranged from ment of minority medical students may help allevi- 0.8 percent at Cornell University in New York to ate the critical medical manpower shortages in some 34.2 and 38.5 percent, respectively, for the Univer- of these areas (507,669). sity of North Dakota and Oral Roberts University in The locations of both undergraduate and graduate Oklahoma (544) In general, private medical school medical education are also important determinants graduates are less likely than public school gradu- of physician practice kx.ation. An analysis of 1982 ates to choose a primay care specialty (168). data found that 39 percent of all physicians were elbese States were Mossissippi. Colorado. New Hampshire. washongton. Iowa. North Dakota, and Arkansas (544, 2Tbese States were New York, Nevada, Connecticut. Massadiusetts, Rhode Isiand. Hawau. Otegun. Cseconpa. Nlish Lamina. and Missoun 544. Chapter 12Problems in the Recruitment and Retention of Rural Health Personnel317 Figure 12-1Average Number of Hours Worked and Average Number of Patients Seen by Physicians, by Specialty and Location, iggga A. Mean number of hours spent per week in B Mean :lumber of hours spent per week in direct professional activities. 1988 patient care activities. 1988 70.8 81.2 82.2 ao physicians10 Oensratnaind7 practice 0051striesi9ynecology All 9111411claas donor:Mies:97 Practice ObetetrIcs/07nece1097 MB All nommtroamMetro 41.000.000 =I Metro 4.000.000 121111All searastro Metre 41.000.000 C Metro .1.000,000 C. Mean number of total patient visits per week. 1988 D. Mean number of office visits per week. 1988 170.1 127.5 Ali physicians Generslitsmily pract.ceObstetrics, oyasoroor All payetclans oenerslitamilv emus* Obeliereceigyeer.o owl All noranotro EM Metro .1.000.000 CO Winn 4000.000 EaAll sononstro EZ3Metre 4000.000 EZI ialro .1.000.000 aDoes not include osteopathic physkians. Federal physicians, residents. and physicians not in pahent care. bindudes physicians in ail spedallies not listed. 0Exdudes physIdans In radiology. psychiatry. anesthesiology, and pathology. SOURCE. Moe of Technology Assesereent. 1990. DMa from M... Gorstairm ono r...Vr. :ivavouvuorno, MeOles. Pio.te. 1089 (Chicago, IL: Amedcan Meddil Association, 1989). practicing in the same State where they received leisure time has been cited as a source of job their undergraduate training, and 51 percent were dissatisfaction amoag rural phy sicians (461). Phy si- practicing in the same State where they received cians ia rural areas work more hours and see more their graduate training (112). Graduates of public or patients per week than do their urban counterparts less prestigious medical schools and training pro (figure 12 1) (218). For..11.o practitioners in isolated grams were more likely than other graduates to rural communities, hours of c.ovetage may be remain in the State of their training. General and Lontinuuus, with little or no opportunity for respite, family practitioners (GNPs) and obstetrician/ vacation, or continuing education. gynecologists (OBIGYNs) were more likely than Available data on work hours of registered nurses other specialists to practice in the State where they (RNs) reveal little difference between rural and obtained their medical degree or specialty training urban areas for these professionals (table 12-1) (112). (317). Adequate personal time plays a significant role in Another area of {..umern for rural health profes- physician location decisions (405), and lack uf sionals is the availability of employment opportuni- 3 ;-) 318 Health CareinRuralAmerica Table 12. i Number of Hours Worked Per Week and Number of Weeks Workud Per Year by Registered Nurses, by County Population Size, 1988 Mean muMber of weeks Mean nuMber of hours County population size* worked per yeerb worked per weekb All U.S. counties 49.9 34.5 More then 50,000 residents 49.9 34.5 50,000 or fewer residents 49.9 34.7 25,001 to 50,000 residents 50.1 34.9 10,001 to 25,000 residents AC.8 34.5 10,000 or fewer residents 49.7 34.4 aCounty population size does not necessarily reflect metro or nonmetro status. biluMber of weeks and hours in principal. position. SOURCE! D.A. KInd18, University of Wisconsin, Madison, WI, and B. Movassaghl, Ithaca College, Ithaca, NY, unpublished analysis of data from the 1988 National Sample Survey of Registered Nurses (provided by the Division of Nursin8, Bureau of Health Profesaions) conducted under contract with the University of North Dakota Rural Health &near& Center, Grand Forks. ND, 1989. ties for their spouses. In general, small rural commu- vancement, ability to meet continuing education nities provide limited professional opportunities, acquirements for recertification, and statutory, regu- and local communities often have to "recmit the latory, and reimbursement restrictions on profes- spouse" when trying to attract a provider to the area. sional autonomy and scope of practice. This section Forty-four percent of 1989 senior allopathic medical describes the barriers that some of these concerns students were either married or engaged to be create for health professionals in rural environments. married(61).Of these students' spouses or spouses- to-be, 18 percent were also physicians, 59 percent Physician Concerns were in other professional occupations, and 83 Ability to keep up with advances in medicine and percent intended to work after their spouses had availability of adequate support facilities can be key compieted their medical education (61). factors in physician location decisions (405), but The availability of quality educadon for children these amenities tend to be present to a lesser degree and the availability of social and cultural activities in rural than in urban areas. For physicians who are also have been cited as possible disincentives to already pracdcing in rural areas, factors associated rural practice, although urban as well as rural w ithjobsatisfaction include the quality of physic ia n- physicians mention the lack of these amenities as patient relationships, avaiiability of good facilities, disadvantages to their current practice location technical quality of medicine, practice autonomy (239). (239), diversity of patients, and personal gratifica- tion derived from patient care (461). Factors associ- Professional Factors ated with job dissatisfaction include heavy workload/ long hours, lack of professional and educational Health professionals may be dissuaded from resources or distance from other health facilities choosing -ariural practice location due to either a (239,405,461), bureaucratic interference(239),and perceived or an actual lack of professional opportu- meeting expectations of high quality care(461). The nities and benefits. Unlike their urban counterparts, perceived oractual lack of professional resources in many rural health picifessionals do not have easy rural areas may discourage some physician- from access to professional colleagues, consultations and locating there. second opinions, medical libraries, or continuing education. Moreover, rural primary care physicians Preference for Group or Salaried "iroctice may infrequently treat many condidons, and rural Trends toward group and salaried practice have technical personnel may fmd it difficult to maintain serious impfit.ations for smaller rural communities. competence in skills they rarely practice. Other Young physicians today tend to prefer practice professional concerns that may influence the loca arrangements that guarantee them a fixed income don choices of health professionalsparticularly and other desired benefits, will as iegulaz hours, nonphysiciansinclude opportunities for career ad acation time, and a dose inufessional -ummunity 340 Chapter 12Problems in the Recruitment and Retention of Rural Health Personnel319 (378). A recent survey of 300 medical residents Midlevel Practitioner Concerns (327) found that 51 percent preferred group practice, 30 percent preferred employment in health mainte- Factors influencing the location decisions of nareza organizations (11M0s), and only 1 percent midlevel practitioners (MLPs)4 have not been stud- preferred patnerships with established physicians. ied as extensively as those influencing physicians, HMOs, however, are rarely located in rural areas but isolated studies indicate that professional con- (bee ch. 5), and group practices may have trouble cerns play a key role. In a recent survey of graduates generating sufficient patient volume in very MA from a certificate-level nurse practitioner (NP) conununities. training program in eastern North Carolina that places most of its graduates in rural practice, the four American Medical Association (AMA) da.a con- primary incentives for choosing a particular site firm that young physicians are increasingly choos- were professional autonomy, good salary benefits, ing salaried over private practice, but they also adequate me.fical backup, and educational opportu- suggest that many of these physicians change from nities (337). Many MLPs are required to participate salaried to private practice before the fifth or siath in accredited continuing education programs in year of their career (218). It is not known whether order te maintain licensure, but those practicing in physicians tend to remain in the same community or rural areas may have difficulty accessing accredited move to larger or smaller communities when they, programs. Federal and State restrictions on MLPs' leave salaried practice. Increasing educational debts scope of practice and on reimbursement for their (see "economic factors" below) may be one reason services are key concerns for MLPs and are likely to behind the trend towards salaried practice, but this influence their location decisions_ has not been shown empirically. State Restrictions on Scope of MLP Services Impact of IlosprtalClosures on Physician Supply The quality of care delivered by MLPs within their The large number of rural hospital closures in recent areas of competence has been described as at least years raises concerns about effects on the availabil- equal to that provided by physicians (617), and some ity of rural office-based physicians. The presence of States allow certain MLPs to provide these services a hospital has been found to play a significant role in independent settings. Other States, however, in the initial location decisions of physician special- sharply limit the types of services MLPs may ists but a lesser role for primary care physicians provide and the conditions under which they may be (90,241,576). Less is known about the effect of provided. Such diverse policies may influence the hospital closcre on local physician supply. A recer. location decir tons of MLPs. study found no contiusive evidence that rural The practice of NPs is governed by State nurse hospital closure reduced the availability of local practice acts. States always require collaboration office-based generalist or specialist physicrins dur- with or supervision by a physician, but they vary in ing the periods 1970-80 and 1980-853 (2.1:1). A ir specific terms and conditions. NPs can and do recent Minnesota _urvey examined the issue pro- practice without direct physician supervision in all spectively. When asked whether the closure of their States.5 In 1990, 32 States allowed some form of local hospital would affect their decision of where to prescriptive pnvileges for NPs, but only three States practice, only 21 percent of rural physicians replied allowed NPs to prescribe medication without ny that it would not affect then decision compared with cosigning or approval by a physician (603). 64 percent of physicians in the Twiii Cities metro area and 50 percent of phy.icians in the Duluth and The professional autowmy of physician assis- Rochester metro areas (173). Individual cases where tants (PAN) is mai more limited. A fundamental hospital closure has endangered access to physkian diffeience is that PA pradke is defined under State services have been reported (267). medical practice acts. Forty-nine States6 and the "Mentor noted twopossible thmtanons an die study method that may have affeaed i& resulis 1 Aix mukavauscht f husplaal Ln.a h 1.r beat too imprecise. and 2) the availability of other hospital facilities nearby was not taken into account. 4includes thine practitionen (liPs). physician assistants iPAs), writhed wasc- midwives (COL), and ,erldicAS rciossicacif nursc dueltlicUlts (CRNAs) (see eh. 10). 3Restrictive interpretation of nurse practice acts in otie or two States may ht..., the scope of NP practice (603) 6The exception a New Jersey. whsre PM are =desalt, rewignaed Width pram:yards and as pane-Lined cu 4vrLuri. ars FeJetal fa, .Lt4c;!t!) 3,4, 1 320Health Care in Rural America District of Columbis allow PAs to provide medical matters of economic concer n for their employers and services under physician supervision, but the nature professional concern for the MLPs themselves, and and extent of the supervision vary. All of these States they may play a role in MLPs' location decisions. except Colorado permit some conditions under which PAs can practice without a physician physi- Table 12-2 summarizes coverage and direct pay- cally present in the room. Fewer States allow PAs to ment for the services of MLPs under Medicare, Medicthd. and other third-party payers. MLPs re- practice with off-site physician supervision? As of March 1990, 24 States and the Distnct of Columbia ceive thirdparty reimbursement for their senices allowed PAs to prescribe some medications (/92).8 directly or indirectly (thrcugh their employers or kesLictions such as these prevent the utilization oi supervising .4rysicians). Reimbiniement for MLPs PAs in rural satelli: or remote practice settings. under Medicare and Medicaid is limited to certain settings and conditions, and reimbursement by other Institutional and medical restrictions on scope of third-party payers varies dramatically by State and practice, li-bility coverage costs and availability, by insurance plan. and stringent educational requirements present bar- riers to CNM practice (24 ,617). These barriers may MedkareAlthough reimbursement of MLPs be of particular concern to rural CNMs who practice under Medicare Part B ha- expanded over the past in remote areas and therefc..fa require a greater degree two decades, it is still subject to many restrictions of autonomy. As of 1989, 5 States required a and, witA `ew exceptions, payments are made to the bachelo-'s or master s degn:e in nursing for nurse- employer rather than directly to the MLP. Legisla- midwifery practice. - n..1 19 States required continu- tion passed in 1982 (Public Law 97-248) authoziad ing education units for either RN or nurse-midwife indirect Medicare rtimbursement for PA and NP license renewal (25). All nurse..-aidwives certified services delivered without direct physician supervi- by the American College of Nurse-Midwives are sion within HMO settings. Subsequent legislation required to complete continuing education umts tor auihorized indirect Medicare reimbursement for PA certification renewal (191). Some rural CNMs have services delivered under physician supervision in difficulty fulfilling continuing education require- hospitals and nursing homes, for assistance duntig ments due Ns lack of recognized continuing educa- surgery , and for PA services Jefivt .eu in rural Health Manpower Shortage Areas (HMSAs) (Public tion programs in some.,tes and areas. These CNMs must travel to regional workshops to receive Laws 99-509, 100-203). Legislation in 1989 (Public training, often at their own expense (191). Law 101-239) authorized indirect Medicare rum- bursement iTor the services of NPs in skilled nursing As with NPs and PAs, restrictive State (nuBe) facilities. Recent reports indicate an Increased d. pravice acts limit autonomous...ivi practice in mand for PAs in v.-min hospital settings (sc.\ ch. some States (191). Thirty-one States did not grant 10). Medicare reimbursement for NPs and PAs in prescriptive privfieges to CNMs in 1989, although HMO settings may limn the supply of these practi- some are now considering changes LI their policies.* tioners in rural areas, since it increases ti.e demand Moreover. some State hospital licensing laws pre- for NPs and PAs in HMOs predominantly urban vent hospitals fsom allowing CNMs admitong settings. Anecdotal reports indicate increased de- privileges (191). mand for PAs in some rural clinics followmg the 1987 amendments (/92)_ Reimbursement Disincentives for MLPs and Their EmployersA major barner to the utilization NPs, PAs. and CNMs m cernfied rural health of MLP.s is the limited coverage for their services cbmcs (RHCs) obtaLn indirect cost-based reunburse- under Medicare, Medicaid, and other third-party ment under Medicare for their ervices.1" Although plans (617). Reimbursement issues for MLPs are RHC legislation was passed m 1977 (Public L Aw 7According to the Antentan Academy of Physician AssistaMs. PA practise in satelhte or remote settings would be difficult if not.1possolite in ai lost five States due to language in or interptetati4o of medical practice acts These States are Colorado, Louisiana, Mississippi, New Jersey. and South Carolina (192) qn additto,` .1 do nod allow PAS to prescnbe drugs do allow them to ihspense cert.un prescnphon drugs t / (+2p 1 91n 19 Slates an 1 t of (\.lom.bor, presenptive pnvtleges ate audion, ed, hut the scope of theAunt} c Nits lataily In two Mates CNM prescriptive author. a thane% y the State Attorneys General (191' mServices of chni..al psychologists - .ocial workers furnished in kbri are also minibur by Vedic4ue r-1 1 a) t 4,, Table 12-2Coverage and Direct Payment for Services of Midlevel Practitioners° Nurse Physician Certified Certified Registered Practitioners (liPs) Assistants (pAs Nurse-Midwives (CNMs) Nurse Anesthetists (-04s) Third-party payer Coverage Direct payment Coverage Direct parment Coverage Direct parnent Coverage Direct pnyment Medicare: Fart A No No $o No No No No No 5.. b Some d E, Part 11 Some No No Yes Yes Yes Yes .tzt HMOse Yes NA Yes NA NA NA Yes NA -1 State Medicaid programst Some A few Some No Almost all Almost all Most At least 20 States -tesg States States States States States States Medicare and Medicaid As Rural Health Clinzcsb Yes No Yes No Yes No NA NA cr Private insurancel Some Some No No Some Some Some At least 13 Er States States States States States States 3 3 NOTE NA . not applicable. 4"Coverage" means reimbursement is provided to the employer"Direct payment means that reimbursement is made directly to the practitioner "Services" meats services that are typically and characteristically provided by physicians Most payment for midlevel practitioner services, whether direct or indir-A, is at levels lower than a physician would receive for comparable services. 4. bDirect reimbursement for CRNA services was mandated in 1986. Direct reimbursement for CNN services delivered without direct physician g, supervision but in accrdance with State practice acts was mandated in 1887 cltdirect Part 8 reimbursement for the services of 14Ps in skilled nursing failitier was mandated in 1989 dMedicare reimb.....ement Pot FA services delivered under physician supervision in hospitals, nursing homes. and as assistants during surgery was mandated in 1986 Medicare reimbursement for PA services furnished in rural primary care Resta' Manpower Shortage Areas was mandated in 1987 Payment is made to the supervising physician or to the employer 0 °Prepaid payments to certain Health Maintenance Organizations (HMOs) for NP and FA services were e.ndated in 1982 f States have theoption of reimbursing for RP. FA. and CRNA services but are required to reimburse for the services of CNMs delivered without direct physician eupervision $1989 legislation required all States to reimburse directly fr the services of pediatric and family nurse practitioners in all settingsThe new policy is scheduled to take effect in June 1990 bClinics certified under Pubkic Law 95-210 (see ch 3) Reimbursement is indirect and is cost based rather than prospective ao ilndicates whether States have laws that require or permit private insurers to cover or directly reimburse for the services of /Ws. PAs. CNMs, and CRNAs SOURCEOffice ef Technology Assessment, 1990 rt 4 -5 4 I) ,?-4 1.1 144 322 &altb Care in Rural America 95.210), implernentajon among States has been indireu cosebased reimbursement under Medicaid highly uneven. Over 2,000 counties in all 50 States (see above). qualify for RliCs,tt yet in 1989 only 470 RHCs -Ater" ExeeEting the previous provisions, States are not certified in 37 States (table 5-15). In 8 States, each required to reimburse Ms and NPs under Medicaid, of which had mole ttan 40 qualifying counties, there were no RliCs at all (table 5-15). Under the law, but at least one-half of States exercise their option to do so to sonie extent (418). The method of reim- PALPs can work without direct physician supervi- bursement in these States varies. Several States limit sion only withhi the proseripticiis of State nurse and direct reimbursement to NPs to certain procedires, medical praceice sets. Reasons for the lack of RIICs in some States may incite& restriettons on MLP such as obstebics. At least 20 States directly rei-Course CRNAs under Medicaid f(J).12 Most scope of practice and resiteenee from in: taedical mho. States also reimburse CRNAs under Medicaid, profession (516) or simply tack of awreeness of the eengram. The RHC certification process can be but tne teethed cf reimbursement may be indirect (e.g., throngh a hospital) (601). lengthy and can cause nth .etancial difficulty for some clinics (see eh 5). The abdity of clinics in ?rib44 1nsurancePriNate insurance coverage rtnal IfivISAs to obtaie feeir-service revnburse- :AMU* sza-viees b aries both by mdividuai insurance ment irom Medicare for PA services (see abuse) plan and by State. In some States, legislationtier while seeking certification I'm* ease dm fmancial relaires or allows third-party payers it. rein burse for burden on time clinics. but clat'ee, stilt cannot ubteLe NILP sers ices (table 12-2), but some plans r .ernburse such reimbursement rer the sr-vices of INIP, (192). In States where there ts no mandate. Twerey-six (See che 3 and f, for ferthet de:cursioa of the iuxii States eithe r. allow or mandate direct nnvate thud- Healthlinic A arid barriers to its implementa- party reimbursement for NP services, and 7 others tion.) .el-% or mandate direct reimburserrieut tor certified psp tliatrie NPs (603). NPs have succeeded in Unlike most other MLPs, certified registered obtaining direci reimbursement from some . fate, nurse anesthetists (CRNA,e) may hill Mediea plans. As of 19E9, 20 States had mandated private directly for then services. Direct Medicare reim- insurance reimbursement for CNM services, but the bursement ';ot CRNAs was mani7ated ui1986 'ethod of reimbursement -..aries (25). Most private (Public Law 99-509). The Amemain Asweiateni of third-party payers reimbie. e either directly or Mese Anestheusts, howevei,believes that reim- reedy for CRNA sereices, and at least 13 Statce bursement is too low (23). requite direct reanbursemere fortheir services (601). Medicuid--Legislation in`.)80 (Public Law 96- Nurse Concerns 499) required that States reimburse for CNM sent- ices under Medicaid, regardle ss. of whether these Rural lItIrt-es tete laek. ea 0 ppormeittes (AI career services are pi ovided wider direct ph> ;icier supers i &I% eileemunt, Lw salanes, and increased responsi- sion. Legislation in 1985 (Public Law 99 272) bilityfotneienursing tasks as sources of job further directed that CNM-operiaed birthing eeeters dissatisfactioa, The same factors have been .155001- do not have to be administered by physie lens le Aesi with reeent declines in applicants to nursing order lc qealify for Medicaid reimbursement. Legisla- programs (..98). Lack of professional autonomy tion in 1989 (Public Law 101 -230) required States to (e.g.,inabilityto influence their own practice provide direct reimbursement under Nledieaid fie env ironmTnt and eharactenstics) is regarded by the services of pediatric and family NPs, regardless mare aa one of the key factors affecting nurse of whether the NP is under the supervision ef r.:.tention and job satisfaction (232,262,310,370. associated with a physician or other health care 469,593,717,733.). A study of muses in rural Geor- provider (effective July1, 1990). PAs. NPs. and gia hospitals found personal characteristics-- CNMs in desig.atol nuai health clinics also reeeise ineluding age, edueation, salary,marital status, and "TVs ..anunderesnuationof the total number of quaLfyurg vu dories, sinceordy iml,rdesqu. ing norm fro tuunite Leda Publw Law 9S-d: to. clinics) .norurbardad areas of metib nuts tan aim, qualify A.c areis meet the nicrl, hal 41.itAiauvo astavd,...ally boacrserved Amor a pnmary Care IIMSA (web. I I) 12This Itgure is baited on a survey kom....ted severa1 years ago. and more Sig.:es may now be reimbursing Jireoly OW) 3 Chapter 12Problems in the Recruitment and Reicntion of Rural Health Personnel323 nurnher of dependentsto be relatively unimportant predictors of rural huspital nurses' job satisfaction (232). The influence of titese factors on those nurses' initial location decisions, however, was not studied. Nurses in remote settings may be less likely than urban nurses to have opportunities for career ad- vancement (e.g., upgrading from a licensed practical/ vocational nurse to an RN or from an RN to an advanced nursing position) due to poorer access to education programs and less flexible work sched- tdes. Nurses in more poputated counties are more likely than those in less populated counties to be enrolled in nursing-related educational programs (table 12-3) (317). Rural RNs also spend more time in supervisory and administrative activities than do their urban counterparts (table 12-3) (317). Whether this dit;:rence is looked on favorably by RNs is not known, but it does diminish the amount of time these Photo credit Gal Moorroy nurses spend in direct patient care (table 12-3). Nurses in many rural hospitals are wiled upon to RNs in less populated counties are less likely than assume a mde range 01 responsibilifes due to the others to have bachelors' degrees (table 10-43) hospitals' small size and limited resources. (317). The availability of upgrade programs for RNs without bachelor's degiees is a key issue for RNs in rural areas %kilo want to become certified as CNMs, CRNAs, NI's, or ogler nurse specialists. Although Costs of Education and Student Indebtedness certificate-level advanced nurse training programs ao exist, their numbers are decreasing (263,073). Minion in many health professions schools has Moreover, mug c.rgIni7ations that certify advanced been increasmg faster than inflation. During the nurses require a bachelor's or waster's de3xe (263), period 1980-81 to 1986-87, average medical school and there have been movemems in some States tuition increased by 125 percent for students attend- towards the bachelor's degree at the entry-level ing a public school in their State ot residence (671). degree in professional musing (69Si. In fact, m the First-year tuition in osteopathic medical schools mid-1980s North Dakota heeame the ftrat State to increased by 17 percent from 1982 to 1984 alone require a bachelor's degree in ntwing for RN (670). Tile average cost of tuition, fee.s, and other licensure (263). expenses at United States medical schools ui aca- demic year 1987-88 ranged from $13,7,;5 for stu- dents attending public schools in their State of &ottani. Factors residence to $25,629 for students attending private medical schools (673) Minion in 41types of nta.sing programs has also been increasing (673). In publicly Economic concerns mfluence rural health person- nel recruitment and retemion at many stages. In- supported associate degree nursing program:, tui- tion increased by 65 percent from 1985-86 to creasing costs of health professions education can 1989-90 (673). discourage students from choosing health careers. Heavy educational debt loads, perceh ed or aetuai Recem redactions in eke av1u1..ibilityl ,f .eliolai , rural-urban income differentials, and leunbursement ships and other forms uf tinan...ial .ud have forued policies that penallre certain spek.talties or geo- medieal students to burrow more heacil} in order o graphic areas may influence practite eLices. Other nnance their educatioi. (168). A .. Lukas of 1:tho-aitun variables, such a.srising malpractice insurance hal. e increased. ;0., have thc levels and frequent.) of premiums, may also influence studeitts' and profes- inde:ktedne ss arnorkt, health pracositaral sauol grad- sionals' career and practice choices. uates. it recent Study of students in allopathic and 04) e* $) tro 324 Health Care in Rural America Table 12.3 Registered NursesEmployedin Nursing. Percent of Time Spent in Various Pi ofessional Activities and Percent Enrolled in Advanced Nurse Education Programs, by County Population Size, 19.18 Percent distribution within each county size categorv4 Counties Counties Counties Counties Counties 50.000 with fewer with 25,001 with 10.001 with 10,000 All U S. or more than 50.000 to 50,000 to 25.000 or fewer counties residents residents residents residents residents Cerrently sorolle41 tp education program for morsia6-related degree: Yes 11.2 114 8 9 9 3 7 8 104 So 88 3 88.1 90 8 90 4 92 1 89 6 Unknown. 0 5 0 5 0.2 0 3 0 2 0 0 Totalb 100 0 100.0 100 0 100 0 100 0 100 0 Percent time spent in: Administration. ... 10 4 10 3 12 1 11 3 13 ^ 13 0 Consultation 6 5 6 5 5 9 54 6 8 5 0 D.,.ect patient care 64 6 65 0 6^ 8 62 1 59 1 58 5 1 6 1 3 1 3 1 2 14 Supervision.. . 11 3 11 0 15 0 14 5 15 2 17 0 Teaching. . 5 1 5 2 4 4 48 3 9 4 1 Other. . 0 4 04 0 5 04 0 7 0 1 Totalb . . 100 0 100 0 100 0 100 0 100 0 100 0 I aCounty population size does not secessarily reflect metro or nonmetro status bFercentages may not add to 100 Jue to rounding SOURCE D A Kindi, Universit; of Wisconsin. Madison, WI, and HMovassaghi. Ithaca College. Ithaca. NY. unpublished analysis of data from che 1988 National Sample Survey of Registered Nurses iprovided by the Division of Nursing. Bureau of Health Professions) conducted under contract with the Unisersity of NortL Oskota Rural Beaiti .erch C_Ater. qrand Forks. ND 1989 osteopathic medicine, dentistry, orometry, and pharmacystudents (673). The average educational veterinary medicine estimated that throe-fourths of debt of baccalaureate isursmg students in 1988 was these students cover 70 to 90 c,trcent of their $10,056 in pcblic institutions and $12,939 in pnvate educational costs through loans averaging $10,000 instittmonstl9a).14 for each year they are in school (52). The average educational debt of senior allopathic medical stu- Heavy debt loads may cause financial difficulties dents" more than doubled from 1980 to 1989, from for physicians durilg specialty training a id during $!7,200 to $42,374 (61671). In 1%9, 81 percent of `he earl:, year: of prac 'ice. Henred et al. estimr.ted senior allopathic medical students reported some that a resident with $40,000 in undergaduate debt level of educational debt, and 29 percent were in ho is training in a relatively inexpensive city will debt in excess of $50,000 (6/ ). The average educa- experience a deficit of $4,890 during internship and tional debt of senior ostepathic medical students will have a nevtive cash flow throughout his or her increased by 30 percent from 1985 to 1988 alone. residency (254). Residents with debts in excess of from $49,600 to $64,700 (21). $80,000 may accumulate an 1iditional debt of $75,000 or more during a 5-year residency program Indebtedness of other health professionals can (254). also be substantial. In 1987, the average debt of dental graduates was t39,000 (673). The amount e on the relattonship bt.uween indebted- doubled from 1979 to 1984, and ithas since ness and location choice is scarce and inconclusive. increased at an annual rate of 6 percent (673). In A recent &tut. y of indebtedness issues by the Bureau 1987, average indebtedness was $33,600 for gradu- of Health Pi ofessions (670) concluded that the ating optometry students and $13,000 for gradcating current scarcit2 of rescarch on the effeo:, of mdebt- tItncludes debt from premedical education Included in the average are students who reporred uo eduational debt 1413accalaureate nursing student debt based on data from case studiesin only IDinstitutions 3 Chapter 12Problems in the Recruitment and Retention of Rural Health Personnel 325 edness on career and location choices may be due in Table 124income of U.S. Physicians (as a pan to the relative newness of high student indebted Percentage of Average Physidan Income) ness. If educational costs and indebtedness levels by Specialty and Practice Location, 1977 through1986' continue to escalate at their current rate, financial considerations will probably become more promi- Percent of average nent factors in students' and graduates' career and U.S. physician income practice choices. 1977-78 1985-86 Income and Practice Costs Income by specialty General/family practice 82.8 68.3 Factors such as lower income and increased Internal medicine 98.2 91.2 number of patients with inadequate insurance cover- Pediatrica 76.5 68.2 age have been cited as sources of job dissatisfaction Income by teoarembit area among rural physicians (405,461). The extent to Nonmetropolltan areas 95.9 86.8 which economic concerns such as these actually aData are an average of 2 Years' aurveys. affect health professionals' location decisions has SOURC); Reprinted with permission from P.G. Barnett not been assessed directly, but perceived or actual and .7.E Midtaing, "PubLic Policy and the lower income may serve as a disincentive to rural Supply of Primary Care Physicians," 'MAR 262(20):2864-2868, 1969, table 5 (Copyright practice. 1989, American Medici:a Association). Based on data from: M.L. Gonzalez and D.W. Em- The incemes of rural physicians are lower and mons, Socioeconomic Characteristics of Med.. have not increased as rapidly astheaverage income ical Practice 1987 (Chicago, IL. American of all physicians (table 12-4) (68). Some of the Medical. Association, 1987). smaller increases are probably due to the fact that Table 12-5Average Annual Salary Range of many rural physicians are primaly cue physicians, Phcian Assistants by Community Size, 19/39° who have also witnessed relatively slow rises in income. Less is known about rural/urban differences Community sizeb in the incomes of other health professionals. PAs Fewer than10,000 to More than practicing in smaller communities are more likely to 10,000 250,000 250,000 have low salaries than PAs practicing in larger Salary range residents residents residents communities (table 12-5) (/ 7). There are consider- Percent of nhYsiclan assistants able differences in average RN salaries among Ltis ihan $20,000 $ 3 4 counties of different population sizes, with RNs in $20.000-630,000. 20 17 12 $30.000-$40,000 44 46 41 the least populated counties receiving only 76 $40,000-$50,000 ,0 23 26 percent a the annual salaiy of RNs in the most Greater than $S0.000 10 10 15 populated counties (table 12-6) (31 7). The extent to None listed 1 1 which these eifferences reflect cost of living ot other Total° 100 100 100 factors is unknown. aThis informationis derivedfrom the American Academy of Physician Assistants' 1989 Prescriptive Physician IncomeNearly 30 percent of physi- Practice Survey and is statistically representative cian Mcome is from government sources, much of it uf membei end nonmembei physician assistants in from Medicare (68). Geographic variations in Medi- communities of ei:.1 sizes bcommunity size does not tof1ect metro nr nonmetro care payments for equivalent physician services. location which can be considerable (152396,475,609,615). CPerrenta8e3 may not add tO 100 due to ro,mding have been a subject of considerable attention from :-..OURCE American Aademy of Physi..ian Assistants. the Physician Payment Review Commission (PPRC) Alexandria. VA. anounished data fic.m the 1989 PA Prescriptive Practi(e .7orveY and other interested parties. Payments within a given provided to C$TA in 1989 locality to different practitioners who provide equiv- alent services also vat), (475.562;. These vanations specialty, because methods for setting payment rates are probably an underlying cause of geographic for different speciahstsare notconsistent among variations in payment within a given physician Medicare's insurance can iers'(652). TNedo.4.,PartflicambunementisbAndledaduush48insurankxaftursunssubmildwukuuwdA,milci.h4mumAmiwatali.m144-m. camersinlurnsubmiircimbutscavent totals tothc HoakhCarc rinazangiUmanstratavnunatpiancrl) basis * .) Ci so, 5 J26 Health Care in Rural America Table 12-6Average Annual Salary ot Registered Among the 13 procedures studied, charges for Nurses, by County Population Size, 1988 hospital and office visits to internists and FPs showed substantially greater variations among lo- Average annual calities than did other services (475), a fact that may County population size. salaryb be of particular significance in rural areas where All U.S. counties $27,432 internists and FPs constitute a larger part of the 50,000 or more residents 27,790 physician population. A study of geographic varia- Fewer than 50.000 rsidents 23,516 tions in Medicare surgical fees found that, both 25,001 to 50.000 residents 24.335 before and after adjusting for practice costs, rural/ 10,001 to 25.000 residents 22,774 10,000 or femer residents 21,365 urban differences were much smaller than differ- ences across large urban areas (396).11 Wide varia- eCounty population size does not necessarily reflect tion acroas rural areas of the same size has also been metro or musette status . bAnnual earnings in principal position. noted. in rbr example, prevaling charges for SOURCE. D.A. Kindig, University of Wisconszn. a total hip replacement were $2,400 in rural Missis- Madison. WI. and U. Movassaghi. Ithaca sippi and $990 in rural Kentucky (475). Such College, Ithaca. NY, unpublished analysis examples are not isolated incidents, and they cannot of data from the 1988 National Sample Survey of Registered Nurses (provided by be explained by differences in practice cests alone the Division of Nursing. Bureau of Health (475). Professions) conducted under contract with theUniversity of North Dakota Rural Less is known about geographic and specialty Health Research Center. Grand Forks, ND. variations in Medicaid reimbursement for physician 1989. services. By law, Medicaid is prohibited from Under Medicare's current "customary, prevail- paying more than Medicare would for a particular service (see ch. 3), although in practice it may ing, and reasonable" (CPR) method for determining occasionally do so. in many cases, however, Medi- physician payments, which will remain in place until caid appears to pay considerably less. Table 12.8 1992 (see ch. 3), the United States is divided into compares Medicare and Medicaid payments for two approximately 240 "prevailing charge localities" common procedures in each State in 1986. Depend- administered by 48 insurance carriers. Within each ing on the State, the maximum Medicaid payment locality, the carriers compute a "prevailing charge" ranged from 33 to 125 percent of Medicare's for each physician service (475). A 1986 survey of maximum alloy able chars: for a brief followup 39 caniers found that 5 carriers did not distinguish office visit, and from 14 to 104 percent for an among specialistsin calculating the prevailing appendectomy (610). These percentages must be charge, but that 17 carriers calculated a separate regarded with caution, because the analysis com- "prevailing charge' for each specialty (tt.i2). pared the highest Medicare-allowed charge any- where in a State to the average maximum Medicaid payment statewide. However, the analysis does PPRC studied geographic variatioes in prevailiag Ilustrate the extreme variation in both Medicare and charges for 13 procedures and found notable varia- Medicaid reimbursement. tions among urban and rural counties of different sizes (table 12-7) (475). Prevailing charges were Rural physicians may be hatder hit by low generally lowest in the smallest rural areas and Medicare and Medicaid reimbursement rates be- cause they have proportionateiy greater Medicare highest in the largest urban areas. Alter adjusting for and Medicaid caseloads than those of their urban cost of practice, however, these variations evened counterparts, A recent survey of Minnesota physi- out considerably (table 12-7).16 PPRC concluded cians found that the median Medicaid caseload was that these analyses "cast doubt on the existence of 15 percent in rural Minnesota compared with 5 major inequities between rural and urban areas in the percent in the Twin Cities metro area (173 ). Rural aggregate," but that greater inequities do exist physicians sun-eyed were more likely than physi- among specific localities, both urban and rural (475). uans Statewide to leport a recent increase in then lPPRC uses the Geograpluc Pracuce Cost Index (GPO) to adjust for gcographsc deffesences in ost of pos.-tux ',Mese researchers also used tbc GPCI to adjust for practice costs. :3 ! 9 Chapter 12Problems in she Recruitment and Retention af Rural Health Personnel327 Table 12-7Average Ptevaning Charges lox Selected Procedures by GeographicLAGaliOn,Actual aro.: Adjusted for Differences in Practice Costs, 1987 (in dollars) County size and classification* Large Small Large Small All Procedure (splcialist) urban urban rural rural counties Comprehensive office visit (internist) Actual 83 76 69 68 77 AdJusted 76 79 76 77 77 Comprehensive office visit (family practitioner) Aatual . 72 63 55 53 64 AdJusted 65 65 61 60 63 Limited office visit (internist) Actual 26 22 20 18 23 Adjusted 24 23 22 21 23 Limited office visit (family practitioner) Actual 24 21 19 18 21 Adjusted .. 22 21 21 20 21 Hospital care, comprehensive (internist) Actual 94 88 80 79 88 Adjusted 87 90 90 89 89 Hospital care, comprehensive (family practioner) Actual 84 81 75 71 80 Adjusted 77 83 83 80 80 Hospital care, limited (internist) Aetual 29 23 21 20 25 Adjusted 27 24 23 23 25 Consultation, comprehensive (internist) Actual 118 98 89 85 102 AdJusted 106 100 99 96 102 EKG. complete (internist) Aetual 39 36 34 33 36 AdJusted 38 37 38 37 37 Chest x-rey (internist) Aetual 44 39 37 37 40 Adjusted 40 40 42 41 Upper GI mndoseopy (gas .nterologist) Actual , 361 327 313 285 335 Adjusted 338 334 347 321 339 Gallbladder removal (genera/ surgeon) Actual . 1,042 893 810 794 920 Adjusted. C66 122 907 3°9 933 Cetaraet removal (ophthalmoIgIst) Actual...... 1,867 1,593 1.521 1,563 1.681 Adjusted 1,718 1,628 1.701 1,776 1.685 MOltiservice index Actual 114 97 90 86 101 Adjusted 104 99 100 98 101 aLarge urban w metro counties of 1,000.000 or more residents. smell urban - metro count.es with fewer than 1,000,000 residents. large rural nonmetro counties with 10,000 or more residents. small Kuid, nonmetru counties with fewer than 10,000 Le31dents. SOURCE. Physician Payment Review Commission, Annual Report to Conxress March 1988 04ashinstun. DrMar,h 1.988). tibles 8-5 and 8-7. Medicaid caseload (78 percent v. 52 percent) (173). physicians i 42 percent of phy siLians in the Twin Rural Minnesota physicians were also more likely Cities and 35 pers..ent uf physkians in Duluth and than their urban counterparts to report rek.ent in- Rochester metru arus), and in the proportion of all creases in the proportion of their Medicare patients their patients w hu lack any form uf basic health who are unable to pay their bills (61 percent of rural insurance (173). ;.) 328 Health Care in Rural America Table 124-Medicaid Maximum Payments end Medicare Maximum Allowable Charges thr Selected Services, 1986' (in dollars) - Br:ef followuP of.fice visit Appendectomy_ Medicaid as Meeicaid as Medicaid Medicare permit of Medicare Medicaid Medicare percent of Medicare Alabama $11.70 $20.70 56.5 $405.00 $412.60 90.1 Alaska 28.41 24.70 115.0 NA NA NA Arkansas 12.00 14.40 83.3 275.00 412.60 66.7 California 11.64 30.00 36.8 353.68 825.20 42.9 Colorado 11.75 15.50 75.8 280.00 433.20 64.6 Connecticut 880 24.80 35.5 276.00b 700.00 39.4 Delaware 12.86 21.00 80.3 390.35 492.70 74.2 District of Coluabia 20.00 25.00c 90.9 315.00 515.60c 61.1 Florida 10.00 211.60 40.3 197.50 874.60 29.3 Georgia 15.60 15.00 104.0 399.50 600.00 66.6 Hawaii 13.25 16.50 80.3 453.66 660.10 68,7 Idaho 10 50 14.60 71 9 336.40 476.10 70.7 Illinois 11.50 25.00 46.0 270.00 605.00 44.6 Indiana 17.30 16.50 104.8 533.00 515.75 103.3 Iowa NA 30.00 NA NA 500.00 NA Kansas 15.00 16.70 89.8 268.00 536.20 50.0 Kentucky 13.00 16.50 78.8 401.60 515.75 77.9 Louisiana 10.69 la.so 65.6 411.16 722.00 56.9 Mains 8.00 WA VA 217.50 536.40 40.5 Maryland 10.50 22.00 47.7 202.00 515.70 39.2 Massachusetts 8.00 NA NA 233.00 515 75 45 2 Michigan 7 75 23 50 33.0 271 50 399 00 68 0 Minnesota 15.75 NA NA 520 00 519 90 100 0 Mississippi 11.55 NA NA 295 05 510 00 57 9 Missouri 16.00 20 70 48 3 220.00 567.40 38 8 Montana 11.30 14.70 76.9 342.88 489.90 70.0 Nebraska 18.30 16.30 100.0 453.9: 453.90 100 0 d Nevada 15.82 24.70 64.0 673.72 742.70 90.7 New Hampshire 6.00 12.40 48.4 225.00 490.00 45.9 New JersOF 9.00 20.60 43.7 211.00 660.20 32.0 New Mexico 11 50 17.20 66 9 396.15 579.60 68.3 b New York 7.00 20.60d 34 0 160 00 1.140.20 14 0 North Carolina 13.10 16 50 79 4 378 00 70 5 North Dakota 8.20 12 40 66 1 ::: 8: 90 8 Ohio 12 00 20 60 58 3 3431 05: 65 4 Oklahoma 11.00 20,70 53 1 500.G0 :1:.71;0 82.0 Oregon 11.07 18.50 59.8 387.98 577.60 67.2 Pennsylvania 13.00 25.00 52 0 301.50 515.70 58.5 Rhode Island 14.00 20.63 67.9 205.00 515.75 39.7 South Carolina 9.50 14.62 65.0 307.40 69.7 South Dakota 12 00 12 40 96 8 345 00 44155.1g4 75 7 Tennessee 18 00 14 40 125 0 449 50 536 50 83 8 Texas NA 24 75b NA NA ele sod NA Utah 9 92 12 40 80 0 430 12 NA NA Vermont 8 00 12 40 64 5 225 00 490 00 45 9 Virginia 6,30 NA NA 236.25 515.60 45.8 Washington 13.92 17.70b 78.6 290.23 576.60 50 3 West Virginia 30.00 16,50 60.6 230.00 515.75 44.6 Wisconsin 16.23 18.10 89.7 432,85 663 80 65.2 Wyoming 16.30 14.40 113.2 483.50 464 30 104.2 Simple average 12 43 18 56 67 0 317 97 557 47 60 6 NNE: WA not available 'Maximums shown under Medicare aad Medicaid are for physician specialist services. unless otherwise noted In many States, there is a lower Medicare maximum for general practitioners services, only a few Medicaid programs make this distinction Medicaid maximums are statewide averages Medicare maximums are the ,highest aiiowable charges anywhere in the State Arizona had no feneral Medicaid progrim in :98f. "Maximum payment toi general practitioner. value for specialists .s unavailable cInclucles Maryland suburbs d Information available only for part of State 5 1 SOURCE: U.S. Congress, Congressional Resaarch Service. Medicaid Source Book BackAround Data and Ana1111:. Nouse of Representatives Committee on Energy and Cmmerce, Print No 100-AA (Washington. DC U S Government Printing Office, November 1988). tables 0-3 and 0-4 Chapter 12Problems in the Recrustment and Retention of Rural Health Personnel 329 Physician Practice CostsA Mesheal Econom- Figure 12-2--Average Liability Insurance Premiums as ics survey of 1987 physician practice costs found a Percent of Average Gross Incomes of Self-Employed that rural physicians had higher mean professional Physicians in Selected SpeciaMes,b 1982-88 expenses than did their urban auci nburban counter- Percent of gross mcome parts (269). This same survey showed that solo 12 physicians' practice costs accotrited for a percent- age of their gross income greraer than that for physicians in group practke." .krnerican Medical Association data indicated that median professional expenses for rural G/FPs were $14,000 higher than those for GfflPs in the largest urban areas in 1988 (218). Although surveys of physicians such as these suggest rural practice costs are higher than urban ones, other data show per-unit rural costs to be lower. While AMA and Medical Economics data based on reported annual outlays per physician, Medicare uses the Geographic Practice Cost Index, which uses per-unit input prices for the various practice cost components (e.g., nonphysician em- 1982 1983 1984 1985 1986 1987 1988 ployee salaries, malpractice insurance pirmiums, equipment costs), to set fees for specific services. Obstetrics/gynecology These per-unit costs are generally lower in rural than Sullen( in urban areas (475). infernal medicine Medicalmalpractice liability insurance premiums Family /general prectKe as a percentage of gross income have increased more dramatically for providers of obstetric care than for &Mean net income plus mean professional expenses other medical specialties, although these increases bOoes not include osleopalhic physmans now appear to be leveling off (figure 12-2) (36218). SOURGE Office of Technology Assessment, 1990. Data from M High premiums may discourage physicians and Gonzalez and O W Emmons. Socioeconomic Chwevfensbcs of Medics 1 Piiii.i.ce19891Chicago.11. Amencan Medical Mama. CNMs from practicing obstetrics, particularly in Don.I 489), and Amen= Medizai ASsociation. Center for areas where volume of cases is low, or where women Health Pokey Research, Scaoeconomic Chafaclensbcs 0 lifecfca I Practice 1987 (Ctecego. IL: 1967) cartzot r.ty the full costs of care. (The impact of rising malpractice insurarce premiums on the avail- ability of rural obstetra services is discussed in Although more ettallengmg totranslate into greater detai in ch. 15.) purely economic terms, certain other practice "costs Dramatic variations in physicians' malpractice may be higher for rural than for urban physicians, s ich as: insurance premiums exist among States. For exam- ple, in 1985, annual premiums for 013/GYNs in longer work and on-call hours (figure 12-1h Florida (excluding Dade and Broward Counties), higher costs of maintaining medical equipment Arkansas, and North Carolina were $92,830, $18,950, due to technician travel costs, and $15,290, respectively (636). Premiums in these States for general practitioners providing minor difficulty subsidizing through patient revenues surgery were $16,700, $3,700, and $3,000, respec- the costs of maintaining expensive ly.t mfre- tively (636).19 No studies have been conducted to quently used medical equipment and date to determine the direct effects of premium high volumes of uncompensated care fur ugne increases on providers' choices of practice location. physicians. taPPRC found subsuumai differences to the figures reported by dm MIrvey and uthen undu ,. ied dunng ihSdniC tdiit 19A11 figureS are kr the same degree of coverage 330 Health Care in Rural America Concerns of Allied Health Professionale° radiology services and medkal laboratory services, but it may be fiscally unable to hire both a certified A Florida study(572)found that the greatest radiologic technologist and a certified medical problems with the recruitment and retention of allied laboratory technologist. Furthermore, a fully certi- health professionals (AHPs) in Florida's small rural fied medical laboratory technologist may be over- hospitals were general short supply of AH:Ps and qualified for work in a facility that only provides a difficulty in recruiting AHPs to work in rural areas. limited range of services. Ideally, such a facility Recommendations of the study included: would hire a single individual who was certified in development of cross-training programs, both fields, but such individuals are in even shorter recruitment of students from rural areas, supply than single-skilled AHPs. development of rural training siLs, and formation of networks through which rural There are two major barriers to the use of hospitals could share the services of certain multiskilled AHPs. First, there are few programs that hard-to-find MIN(572). offer formal cross-training for AtIPs. It is not knewn how many of these, if any, are in null areas. Some State licensure requirements for AHPs were also hospitals provide formal on-the-job training for their cited as a bather to rural recruitment and retention multiskilled AHPs(424),but this involves a com- (572). Small rural hospitals were particularly dissat- mitment of resources that small rural facilities may isfied with Florida's licensure requirements for not have. respiratory therapists, laboramy technologis:s and technicians, and radiologic personnel. Some hospi- Second, State licen sure and regulation policies in tals indimed a need to broaden certain bcensure some cases do not permit limited licensure of health requirements to permit personnel to perform a wider professionalsi e,licensure for a narrower range of range of functions, while other recommended that *ills than the profession tvically performs. Return- licensure requirements be nara wed for hospitals ing to the example above, the rural intermediate care that provide a more limited range of procedures. facility may not require the full range of skills that Some hospitals noted that practice regulations are m a fully trained and certified radiologic technologist some cases too stringent, and that certain AHPs could offerIdeally, the facility would train a should be permitted to function with less direct certified medical laboratory technologist to perform supervision. For example, Florida law prevents a more limited range of radiologic tasks (e.g., simple licensed laboratory technicians from perfornung x-rays) This solution would be feasible only if the procedures (e.g., drawing blood, plating cultures) State offered limited licenses for radiologic technol- when a licensed medical Li...oratory technologist1S ogists or had more flevible staffmg requirement.s for not physically present in the room 072). intermediate care facilities. It is likely that informal Although fulfilling continuing education require- cross-training of AHPs has been occumng in rural ments was cited as a problem for Florida's rural facilities for some time, but in some mstances the AIIPs, hospitals and professional organizations felt use of such professionals may fall outside the that current requirements were appropriate and proscriptions of State laws and regulations should not be changed due to the provider's location (572). In its 1989 report, the Institute of Medicine's Committee to Study the Role of Allied Health Multiskilled AHPs Personnel described licmsure as the "most restric- tive typl of regulation" and concluded that "its Small rural facilities that have a lower volume of effectiveness in protecting the public has not been specific services may not need full-time specialized i--onclusively demonstrated" (288). The Committee AHPs, but they may be required to hire certain types recommended that States increase flexibihty m of personnel in order to provide those services. For current licensing laws to allow more overlap m example, a remote rural intermediate care facility scope of practice foi sume occupations and to allow would be required to provide limited diagnostic alternative routes to licensure(288). 2°5oc Ch. 10 for a description of allied bea!th pioressionals Chapter 12Problems in the Recruitment and Retention of Rural Health Personnel 331 SUMMARY OF FINDINGS vacation or continuing education leave. These prob- lems may also apply to MLPs in isolated mral areas. Factors Affe:ting Physician Specialty Choice A strong preference for group and salaried practice, most often found in urban areas, has been noted Unfortunately for the future supply of rural among medical residents. Studies examining the physicians, physicians are increasingly choosing impact of hospital closures on rural physician supply nonprimary care specialties. Reasons for this trend are inconclusive or conflicting. include perceptions that primary care practice is less intellectually challenging and more demanding in Lack of opportunities for caree: advancement and time and effort. Lack of faculty role models in poor access to continuing or ads anced education primary care may be an additional factor. Preference may dissuade nurses from choosing rural practice for nonprimary care specialties has also been linked locations. For nurses already in rural areas, lack of to expected earnings and to high les els of indebt- educational resources may pres ent them from seek edness. ing advanced nursing degrees, thus stifling a poten- tial source of rural nurse MLPs. Public medical schools produce a larger pro- portion of primary care physicians than do private A major barrier to the utilization of MLPs in schooLs, and some States and regions send relausely autonomous settings is the limited corerage for high proportions of their medical graduates intu their services under Medicare, Medicaid, and other primary care. Receipt of a Federal scholarship ke.g., thiniparty plans. Restrictive State practice acts NHSC) is also strongly associated with the choice 4/ can also present barriers to the utilization of MLPs primary care. in independent rural settings. Although third-party reimbursement for MLPs has improved during the Factors Affecting Location Choice past decade, it is still limited to certain settinp, and Physician location decisions are more depend. it is usually indirect rather than direct. ent on personal and professional than on financial Recruitment and retention of some AHPs in factors. Factors such as preference for rural or urban regulated rural settings, such as hospitals and i'xing, availability of recreational, sccial, and oil nursing homes, are hindered by limitations of State tura' ac tivi ties, adequate backup facilities, opportunity licensing 1aws that do not permit the cross. for professional consultation and continuing educa licensing uf AHPs to perform broader ranges of don, shorter work hours, and opportunity for group functions. practice have been identified as key determinants in the choice for rural or urban practice. Employment Economic Concerns opportunities for spouses may also play a key role in The costs of medical and other health professions the location decisions of young physicians. Other education have risen sharply in recent years. Student factors strongly associated with the decisicx. for indebtedness has also increased dramatically and is rural medical praclice include lower socioeconomic particularly pronounced fur medic4 graduates. Al- background, experience in the National Health though there is IIS yet no conclusive evidence of the Service Corps, and participation in a loan forgis e effect of indebtedness on location choice, the ness program tied to service obligation increasing preference among medical graduates For nonphysicians, job satisfactionts more for salaried practice suggests that economic con . heavily influenced by professional autonomy and cerns such as indebtedness do play a ..ok in opportunities for career advancement. However, practice decisions, and they may dissuade recent financial considerations may be unportant in the graduates from establishing private pra, s in initial recruitment process. rural areas. The average incomes of both primary care physi- Personal and Professional Concerns dans and niral physicians have increased more Compared with urban physicians, physician, in Jlow 14 than those fur other phyaicians. Based on the rural areas work longer hours, see more paticnia limited information (tradable, it appears that phj . per week, and have more office i isits per week. Sulu sicians in rural practice care fur a larger percent. practitioners in isolated rural commumtics may has c age of Medicare , Medic aid, and uninsured patients continuous hours, with little or u a opportunity fur than their urban counterparts. Thus they may be 3714 332 Health Care in Rural America penalized by low reimbursement rates (particularly PAs and nurses in smaller i..ommunnt..:.s have for Medicaid patients) and higher volumes of lower incomes thr! :hose in larger cummunines, but uncompensated care. In addition, many "intangi- it is not clear to what extent these differmces reflect ble" costs may be greater for rural than for urban cost of living or other factors. physicians (e.g., long& work hours and costs of maintaining infrequently used equipment). Low operating margins make it difficult for many It remains unclear to what extent rising mal- rural health facilities to compete for AH135 and practice insurance costs are affecting the outmi- nurses in the national labor market by raising gration, immigration, or practice of rural health salaiies and offering other incentives. In addition, professionals. Obstetric care providers face particu- licensere requirements can limit the use of multi- larly high premiums. Premiums have increased rapidly during the last decade, but they are now skilled AHPs in small rural facilities theneither beginning to stabilize. The impact of the "habihty need nor csn afford to employ several AHPs to crisis" may be weater on rural than on urban areas perform separate functivis. due to lower caseloads among rural practitioners and higher proportions of lowet paying patients. 3 Chapter 13 Strategies To Recruit and Retain Rural Health Professionals CONTENTS Page INTRODUCTION 335 ZIDUCATIONAL STRATEGIES: PREPARJNG HEALTH PROFESSIONALS FOR RURAL PRACI10E 335 Medical Education Strategies 335 Educational Strategies Fot Other Health Proi assionals 339 The Area Health Education Centers (AHEC) Piottram 343 STRATEGIES TO REDUCE PROFESSIONAL ISOLATION 346 Consrhative and Educational Opportunities Through Telecommunications .... 346 Opportunities for Vacation and Educational Leave 348 FEIERAL STRATEGIES TO ADDRESS ECONOMIC CONCERNS 348 The Resource-Based Relative Value Scale (RBRVS) 348 Medicare Bonus Payments 350 TARGETED STRATEGIES FOR AREAS 01- ACUTE AND CHRONIC SHORTAGE 351 The National Health Service Corps 352 Service-Contingent Scnolarships for Nurse Practnioneis and Nurse-Midwives . ...358 Satellite Clinics and Increased Utilization of MLPs in Rural Areas ...359 RECRU1TMXNT Awl) RETENTION IN THE PRIVATh sEcrog... ..359 Local Hospitals .359 Community and Migrant Health Centers ...360 STATE EFFORTS IN HEALTH PERSONNEL DISTRIBUTION ...... 361 State Activities 61 antracteristics of Program Success 362 SUMMAR i OF FINDINGS 366 General Strategies for "anal Recruitment and Retention ...3o6 Medicare Reimbursemeat Strategies 367 Strategies Lot Acute and Chronic Shortage Areas ... 367 Private Jector Strategies 368 State Activities 3.'.a. 368 Boxes Box Page 13-A. Wanted: aural Physician 336 13-B. The WAM2 Program 337 13-C. Example of a Rural-Oriented Training Program for Nurse Practitioners 341 13-D. Selected Area Health Education Center (AHEC) Activities 344 13-E Examples of Midlevel Practitioner and Satellite Clinics in Rural Areas 360 Figures Figure Page 13-1. Disnibution of Area Health Education Center (AREC) Programs by State, 1988 347 13-2. Funding Levels and Source of Funding for State Health Professions Distribution Programs, 1980 and 1985 365 13 -3. Focus of 112 State Health Professions Distribution Programs Identified by the Bureau of Health Professions, 1986 365 Tables Table Page 13-1. Federal Support for Physician Assistent Training Programs, Fiscal Years 1972-1989 .... 340 13-2. Federal Grants and Cooperative Agreements Awarded in the Allied Health Area, Fiscal Years 1967-1990 343 13-3. Location and Funding Status of Area Health Education Center (AHEC) Projects 345 13-4. Federal Funding of the Area Health Education Centers (AHEC) Program, Fiscal Years 1978-1990; and lmpa a of the AHEC Programs, Fiscal Year 1988 346 13-5 Changes in Physicians' Medicare and lbtal Revenues Under Medicare's Resource-Based Reladve Value Scale (RBRVS), by Specialty 34: 13-6. enange in Medicare Payments Under Medicare's Resource-Based Relative Value Scale (RBRVS) in Metropolitan and Nonmetropolitan Areas 349 13-7. National Health Service Corps: Binding and Participants in Field, Scholarship, and Loan Repayment Programs, Fiscal Years 1971-89 353 13-8. Volunteer Placements Made Through the National Health Service Corps (NHSC) Recruitment Branch, 1988 and 1989 354 13-9. Federally Salaried Personnel in the \Tational Health Service Corps (NHSC) by Obligation Status, 1989 355 13-10. National Health Service Corps Providers by DLipline, 1981 and 1989 355 13-11. States Officials' Ratings of the Effectiveness of Selected Federal Programs in Improving the AvailaUlity ef Health Services in Nonmetropolitan Health Personnel Shortage and Medically Underserved Areas 362 13-12. State Health Professions Distribution Programs 363 13-13. States' Level of Effort in Health Professions Distribution Compared With Their Underserved Nonurban Populations 364 3 Chapter 13 Strategies To Recruit and Retain Rural Health ProfessionaLs oW .....11Mulauli. INTRODUCTION interventions on physicians' choices of specialty and practice location is difficult to determine. Many Faced with threatened or actual shortages of programs that use such interventionshowever, health care professionals, rural communities re place a large percentage of their gradaates in rural spond by attempting to retain existing professionals pra.nce sites.Available ev idence suggests that and recruit new ones (box 13-A). The economic, comprehensive programs are more successful than geographic, and social disadvantages of some raral brief rural preceptorships or residency rotations in areas, however, continue to limit their ability to influencing the decision for rural or primary care compete effectively for health professionals. The practice (150). previous chapter examined factors that may infiu- ence the specialty and location decisions of health In addition to providing targeted funding to health professionals. This chapter examines and evaluates professions training programs, the Federal Govem- various strategies that have been used to recruit and ment ha. also sponsored a number of student retain health professionals in rural areas. These assistance programs, including the Exceptional Fi- include focused educational strategies (e.g., prinary nancid Need Scholarship Program, the Health care and rural-oriented health professions educa- Professions Student Loan Program, and the Health tion), strategies to reduce professional isolation !iducation Assistance Loan Program. The Federal (e.g., telecommunications networks for rural health Government also pros ides student assistance indi- personnel), strategies to address economic concerns rectly through traineeship grants to educationnl (e.g., improving reimbursement to rural and primary institutions (see ch. 3, table 3-1). These programs care physicians), and targeted suategies for the most affect both urban and rural students, but information severe shortage areas (e.g., service-contingent loans regarding the numbers of rural participants is not and scholarships and the development of gatelhte available. The Health Careers Opportunity Program clinic networks). and other pi ograms administered through the Bureau of Health Profe. sion's (BHPr's) Division of Disad- vantaged Assistance hay-, supported training for EDUCATIONAL STRATEGIES: more than 50,000 disadvazraged and minority stu- PREPARING HEALTH dents since 1977 (675). These programs have effec- PROFESSIONALS FOR tively encouraged disadvantaged and minority stu- dents to enter health professions training programs RURAL PRACTICE and heiped retain them in such progreans. This section examines educational strategies to recruit and retain rural health professionals and linaergraduate Medical Education describes Federal programs that may contribute to The Federal RideFederal support of aader- such strategies. It also describes specific projects k,raduate primary ...are medical education is hauled that do not necessarily receive Federal funding but to family practice. Section 780 of the Public Rtalth may be models for new or expanded Federal and Service Act authorizes grants to establish, munair. State initiatives. and improve departments of family medicine in medical schools. Funding under this section de- Medical &fixation Strate,7!....) creased by 30 percent between 1981 and 1988 (from $9.5 million to $6.6 million) (671). Special experiences during medical education can have a strong positive influence on physicians' Examples of Rurul-Oriettled I.'ndergraduak Pro- decisions to practice primary care and to practice in gramsSome shouls require atudents to partki a rural area (72,165 ,212,442,443,576). These experi- pate in ntra: oriented training. The University of ences include pnmary care-onented undergraduate Nebraska Schou. ot Medkinc requircs an 8-week curricula, rural preceptouJups and residency rota- rural preceptorship &ring the junior or senior year, tions, and other types of decentralized educational where students work in a rural medic..I practite eiodels. The irue impact of particular educational under the supervision of a local phy sician "precep- -335- 3 *Fs magenumniiiistrow.vst 336 Health Care in Rural America ...... 111,... Box 13-AWanted: Rural Physician Parker: Prairie,Minnesoia: Inthe summer of 1989, the district hospital in the farming town of Packers PraUie, Minnesota (Population 917) offered a $5,000 rewanl to anyone who could fmd a family practitioner (472). A "wanted" poster and a cover letter were sent to every doctor and moiical student in Minnesota, Nebrasica, North Dalnel, and Sou% Dakota; the poster was put up in strategic places from Parkos Prairie to Minneapolis, advenising the $50,000 to $75,000 pcsition (472). The bounty and advenised salary were apparenny not high enough, and after several months the hospital was forced to hire a recruiting firm (581). The firm will charge from $12.000 to $20,000. regardless of whether it succeeds in fmding a physician, and is urging the hospital to incn-ase the salary to $125,000 (581). As of March 1990, Parkers Prairie still had not found a physician. It had also lost its administrator to a neighboring hospital that offered a better salary and benefits (581). The 21-bed hospital's sole physician reports that the $5,000 BEWARE hospital is heavily in debt and is in imminent danger of closmr For a Family Practice Medical Doctor. Graphics reprinted with permasice of Adam:armor. ($81). With three physicans, the hospital might be able o Pertiers Pram Mawr Hospital. Perkers Plaine. MN generate enough patient revenue to survive. The presence of larger hospitals in neighboring communities may also contribute to ti.... hospital's financial difficulties by drawing too' patients away If the hospital does close_ its physician plans to remain in the community in pnvate pracuce, referring patients to a hospital 20 miles alt":581). According to a survey conducted by the Minnesota Hospital Association. 78 percent of Minnesota's rural hospitals were actively recruiting physicians in 1989 (173). Like Parkers Prairie, few of them were successful; en the average, hospitals had been searching for 17 months (173). Delta. Utah. The administrator of a medical center in the desert town of Delta, Utah (population 84300i also resorted to a bounty system to fmd a physician. One of the town's three physicians had left, and during the 4 months without a replacement, the other two doctors were "worked to death" (259). After professional recruitment firms failed to fmd a physkian, the administrator enlisted the entire Delta commumty in the search. offenng $5,000 as fmder's fee for a family practitioner who would agree to practice in Delta for at least 3 years. The community succeeded. All three attractive candida:es who emerged within 2 months after the bounty was announced were relatives of Delta residents The reward went to a man whose father-in-law agreed to move his general practice from Slidell, Louisiana to the Utah town in September of 1989 (259). Slidell. a community of over 12,000 residents. remains adequately served by 13 primary care pf ysicians (156). tor." A survey of past panicipants found that the experiences with preceptor faculty (165). At the preceptorship had been a significant factor in the University of New Mer.;co, all medical students cno icetoenter residencies ina primary care must spend at least 1 month of clerkship time in a specialty (72). The Kirksville College of Osteo- rural area (573). pathic Medicine in Kirksville, is..:...c.uri requires senior students to complete a 4-month iotation in a Other schools offer rival-oriented training on an nnal 1.4te1lite clinic (165). The clinics are located in elective bash. The Universit3 of New Mex.u.,:i eight communities that have no resident physician, School of Medicine offers a special Priniary Can r.nd students are supervised by faculty preceptors Curriculum track as en ahernative to the more who visit each site daily. The rural c linics expemence traditional curriculum (513). The .pecial curriculum was found to be the most influential factor ia the emphasizes sel-directed learning and patient prob- choice for rural pr*etice lofati on among graduates ol lem analysis in order to better [Impart tbe physician the college. Other factors associated .vitb the choke to practice vo ith confa....nce in remote settings whefle of a rural practice location were rural origin and trained consultants may iot be available Durmg the r - Chapter 13Strategies To Recruit and Retain Rural Health Professionals 337 first year of study, a student spends a full 4 months in a nue area of the State under the direction of an Box 13-BThe WAMI Program approved preceptor, learning what it is like to live In 1971, the WAM1 (Washington-Alaska-Montana- and work in a rural area (573). Thirty.one percent of Idaho) Program was estabhslied to improve the the students in the special track have chosen family geographic distribution of physicians within tne practice as a specialty, compared with 10 percent of four-State area, which encompasses almost one students in the traditional tack (353). fourth of the total land mass of the Upited States (4). The University of Washington in Seattle, having the Another example of an elective program is the only medical school in the entire region, agreed to Rural Physician Associate Provam at the University accept 21.) students each from Montana and Idaho of Minnesota Medical School. Created in 1970, the and 10 students from Alaska into each year's program provides a 9- to 12-month rural clinical medical school class. In 1975, the program Was preceptorships for third-year medical studentsVO2). decentralized in order to further mprove distribu- Of all former program students in practice in 1986, tion of general/family practitioners throughout the region. The first 2 years of training are now taken 57 percent were in communities of 10,000 or fewer at the University of Washington School of Mxii- resident& The program has played a major role in one in Seattle and at smaller institutions such as the improving the primary care physician-to-population University of Alaska at Fairbanks and Montana ratios in Minnesota's rural (nonmetropolitan) coun State University in Bozeman. During the third and ties. Studies comparing program and nonprogram fourth years, or the "clinical phase" of the pro- zrndents at the medical school indicate that students gram. all students participate in clerkships in family participating in the program have higher ley els of practice, internal moilkine, obstetrics and gynecol- confidence in behavioral, surgical, verbal, and ogy, pediatrics, and psychiatry in Seattle as well as interpersonal skills than do nonpariic:pating stu- in 17 more remote towns throughout the WAMI dents, as well as higher degrees of computer 1 aeracy region. Graduate residents in family practice, pedi- (702). atrics, internal medicine, and psychiatry at the University of Washington also rotate service in lb reduce isolation and improve the quality of real areas throughout the WAMI region (4). education received by students at remote tranine A study of 42 WAM1 aiuroni practicing in Alaska sites, schools can use telecommunic ations networks in 1986 (179) found that 52 percent were practicing to link these sites directly to the sponsoring institu- in small towns and 91 percent were in famay tion. For example, the University of Utah School of practice. The amount of time spent in Alaska Medicine's rural family practice preceptorship pro- clerkships positively correlated with the number of gram uses microcomputers to provide students in graduates choosing to practice in small Alaskan towns. Of graduates in small towns, 36 percent remote sites with the opportunity to conduct active reported that without the WAM1 program they medical literature searches (235). Participating stu- would have been unable :a medical school dents reported feeling less concerned about their (179). ability to keep up-to-date on the latest medical knowledge, and felt more confident in their own skills (235).1 program experience were practcmg in rurai areas in In addition to pioviding mral clinical training 1981, compared with 13 percent of all U.S. physi- opportunities, some schools have decentralized the cians 01. Of graduates 'A ith WAMI experamce, 61 most basic components of medical education in percept were in prunary care practice order to influence the location choice .of their prat.tice, general practice, general internal medicine, graduates. Perhaps the best known example of a or beneral pediatrics), compared with 35 perccni uf decentralized iredical education program is the all U.S. physicians (4). WAMI program (see box 13-fl). Since the program began in Z975, it has larzely achieved its original Selective A&issidnof Rural Students .n goal of improving !he geographic distribution of ther strategy used b, some medical blAWIS IS physicians in the four-t tte area. A recent study selective recruitment of stadents predisposed to showed that 23 percent Faduates with WAMI rural practice (e.g., student vith rural bacl.grounds). Prhis proyect was fundol in pr t by the Natiblria' "sbraty of Medicine 3 c 338Health Care in Rural America Medical schoo's that have changed admission poli- Medicare reimbursed hospitals approximately $3 cies to favor rural students have increased the billion in 1988 (672).2 Recent and proposed reduc- number of graduates who chose rural and underserv- tions in Medicare reimbursement for GM costs ed practice (154,375,498499). For example, grad- (138) have caused particular concern among primary uates from the Physician RI/adage Area Program at care residency programs. Studies have shown that Jeffeison Medical College in Philadelphia, which family practice (FP) residency programsespecially recruits such students, were 7 to 10 times more likely those in ambulatory care settingscannot usually than other graduates to practice family medicine in cover thcir costs through patient can revenues rural or underserved areas (499). (128,139,305 ,464). Reduced funding may lead hos- pitals to reduce the number and size of their A study of the rural-oriented primary care medical residency programs; if so, those programs most school curriculum at Michigan State Univelany's Upper Peninsula campus fryind that most Upper likely to be di ..ontinued are primary care residen- Peninsula graduates were themselves from rural cies, which contribute the least to tospital revenues (113,138). areas (100). Graduates were more likely than their "down state" counterparts to choose rural practice Critics of the current medical education system and family practice (100). At the Kirksville College have reconunended that more primary care specialty of Osteopathic Medicine in Missouri, about 50 training programs be moved to the ambulatory care percent of the students who graduated between 1930 setting, where most pnmary care medical practice and 1984 came from towns of fewer than 25,000 occurs (338,521,606). Development and mainte- residents (165) In 1981, students from smaller nance of ambulatory care taming programs would towns were much more likely than students from probably require further targeted funding to help larger towns to be practicing in rural areas (165). offset some of their additional costs.3 Unfortunately, rural yolth may be discouraged Federal funds to encourage the production of from choosing a medical career because of poorer primary care physicians have decreased consider- secondary educational resources in some rural areas ably over the past decade. Federal grants to /41 (325) or because of the high costs of medical residencies decreased by 25 percent from 1980 to education. As noted in chapter 12, the proportion of 1988, from $27.1 million 19 $201 =lore (676). enrolled medical students who are from rural areas Fedrral grants to general internal medicine and decreased by almost one-third between 1978 and general pediatric residency programs decreased by 1986 (500). 28 percent during the samc period, from $19.3 n Ilion to $13.9 million (68).3 Graduate Medical Education The Omnibus Budget Re,vnciliation Act of 1987 The Federal RoleThe Federal Government, (OBRA 87" authorized a program to fund four Rural through the Medicare program, furds graduate Health Medical Education Demonstration Projects. medical education (GME) in allspecialties tr; Under this program, hospAak sponsoring res:dency reimbursing hospitals for costs associated With such program... apply for grants to develop 1- to 2,-month e.tlucation. In addifion, the Federal Governmee clinical experiences at small rural hospitals for subsidizes both undergraduate and graduate primary physicians who have completed 1 year of residency care training programs and demonstration projects in training. ParthApating residents receive stipends and rural areas. benefits based on the reimbursement rate of the 2nis &mount included nate $ I Nihon in direct costs (c g. reaching costs. resrdaits salaries. administrative expenses) and just over S billion in mthrtht COM (additional operating costs assumed to be tssociated with the teaching funcuone g. increased use of ancillary services. increased cost ofiligb-tecb testingan) treatment facilities) 3Certain OMB costs may be higher in ambulatory care semngs. due to dicfere.i.....s in the logistics of leaching in these sextmgs For example. Iewcr sta.'entsMay be involved in an ambulatory visit than during a lengthier hvseitahratior., and the increased Mu.mon of ambulatory visi( s due to student Uwolvemeni may decrease thc total patient volume of the facility hosting the magram 672) Before 1986. Medicate only rcimbumed tor outpatient care oduCation if it wm provided in hospitals The Omnibus Budget Reconcthauon Act of 1986 (Public Law 99.509j broadened reimbursement to include educational costs in any outpae-at care settings wbcre ahospital incurred "all or substantially all ' of Me trauma eost 4Funding is authorized under se coon 786(a) of the public Health Serv lee Act Figures do not include fundmg for faculty developmem projects 5Funding is authonted under Sectioz 794 of the Public Health Srvice Act Figures do not mckidc funding tor Liculty deveiopmetn projects 6Fublie Law 100-203 Ciapter 13Strategies To Recruit and Retain Rural Health Professionals 339 sponsoring hospital rather than that of the small rural West Virginia than any proe,gam besides the Ntl hospital, and payment to the sponsoring hospital is tional Health Service Corps" (533). adjusted for additional costs unique to the program. The demonstration objectives are to determine Decentralized residency programs also provide unique opportunities for faculty and can contribute appropriate components for rural residency pro- grams and to show how such programs can be to the well-being of both sponsoring and local duplicated in other areas at minimal cost. The hospitals. A rural teaching practice operated through the Department of Family Medicine at the State Omnibus Budget Reconciliation Act of 1989 (OBRA University of New York at Buffalo is composed of 89)7 expanled the number of demonstration projects a four-physician group practice serving two rural to 10. Projects began in mid-1989 and last for 3 communities (529). The four physicians are full- years. time faculty at the univers;rv. and the group practice Examples of Raral-OrientedGraduate Programs provides unique rnral educational experiences for A unique program in Montana. a State with no FP medical students, residents, and fellows. The prac- residency program of as own, provides satellite tice more than covers its annual costs, represents a rotations in rural Montana communities for FP substantial portion of the primary care referral base residents from about 80 out-of-State programs at the university teaching hospital, and has contrib- (442,443). Participating residents complete their uted to stabilizing the occupancy rates of local rural rotations under the supervisior of board-certified hospitals (529). physicians. The prograk.has not only enabled Educational Strategies For Other Montana to attract residency Faduates from other Health Professionals States, butit has also helped to improve the geographic distribution of physicians within the Midlevel Practitioners (MLPs) State (442,443). The Federal RoleThe Federal Government has supported PA training programs for nearly two A pediatric residency program at a medical center decades (table 13-1). Since a major decline in 1982, in Hanover, New Hampshire places medical resi- funding has remained relatively stable. Approxi- dents in rural pediatric practices viewed as "teach- mately three-fourths of the 52 PA training programs ing laboratories,' where they are exposed over a in operation in 1989 received Federal support (192). 3-year period to various aspects of mral practice. Of Some of the federally funded PA programs have a the first 14 residents to complete the program, 12 rural focus, and all are mandated to encourage their were in primary care practice in 1985 and 8 were graduates to practice in health personnel shortage practicing in rural lceations in various States (309). areas. Continued suppolt of PA training programs, A general surgery rest.: -ncy program at the Univer- particularly those with a rural orientation, is likely to siiy of Louisville in Keatucky provides optional have a positive effect on rural PA supply. rotations in rural areas. A survey of physicians who graduated from the program between 19-1 and 1981 The Federal Government also supports the trazu . found that a significantly larger percentage tit* those ingt.rfcertified nurse-midw ives (CNMst, nar.ke who were practicInb in rural than al urban areas had praetitionerk, asIPs), andet-titled registered nui se participated in the optional rotations t57) anesthetists (CRNAs) r.hrough the Nurse Practkaon- er and Nurse Midwifery grant program and the NUrse A program launched in V79 4 the Marshall Aneatheust Traineeships and Programs grant pro- University School of Medicine allows FP residents gram. Although these proglanis are not entirely to take 1-3 years out of their training to practice in tledb-ated to the aaining of students for rural underserved communitieA hile earning masteis' practice, they do fund some rural- foeusedR projects degrees in community health. The pop= director Funding for the Nure Practitioner and Ntht.,e- believes that "thi program haa aceounted for moie Midwifery grant program i;hanged lithe betueen years of physician serviee in undersened areas of 1980 and 1990 -front $13.0 rralhon to $13.4 surlhon ?Public Law 101-239 *Classilkatoon of a fr,derally fandca lei v:. trakn.ng pp.i 4.mai- to..11 ye, i baWti 4161 lb.: 4p1PC.14 416,..tI 1" ti1C 11G Ittil iur41 0 Ihc , !bp .06 etscription. 340Health Care in Rural America Table 13-1Federal Support tor Physician Assisioat Training Programs, Fiscai Yeats 072-1989 Total number Authority* Fiacal Year Amount funded of programa HMEIA Contracts 19/2 $ 6,090.109 40 Section 774(a) 19/3 6.20.999 39 1974 8,129,252 43 1975 5,994.002 40 1976 6,247,203 41 Section 701(8) 1977 $ 8,172.441 39 nd 197R 8,685,074 42 Section 783(a)(1) 1979 8,453,666 42 1980 8,262.968 43 1981 8,019.000 40 1982 4,752.00C 34 1983 4,752,06J 34 1904 4,a24,650 34 1985 4,441:76 37 1986 4,548.013 36 1987 4,275.0(0 36 1908 4,549.973 37 Sections 701(8) and 788(d) 1989 4.452,00o. 38 a PUblic Realth Service Act. SOURCE. U S. Department of Health and Human 6p-vice.Hea' h Rosourcea and Services Administration, Bureau of 2:lth Protestations, Physician Assistant Program Fiies. Rockville, MD, August 1989 , (table 3-1), It funded 11 rural-focused NP projects Carolina has been very sucessful in placing gradu- and one rural-focused nurse-midwife project in ates in rural practice (337). A similar program at fiscal year 1988. Most of the grantees were family Georgia Southern College has also been successful practice, primary care, or geriatric care NP training (see box 13-C). The Primary Care Associate Pro- programs providing rural clinical experiences and gram based at Stanford University and Foothill rural-oriented curricula for their students. Of the 208 College in California trams PAs and NPs to provide NP. training programs operating in 1984, almost services in medically underserved areas (230). The one-half received some support from the Federal program has community-based training sites that Government (671), The Nurse Anesthetist Trainee- recruit their own students locally and have suc- ships grantprogram10received $1.1 million in ceeded in retaining over 70percent of their graduates appropriations in 1990, an increase over 1989 in the local areas (230). aPpropriations (see table 3-1). The number of rural programs funded is not known. Decentralized education programs have been Examples of Rural-Oriented MLP Training hailed as highly effective means of unproving ProgramsNP and PA training programs with recruitment ar.d retention of MLPs and otl.sr health rural-oriented curricula have been highly effective in professionals in rural areas, but the degree of placing their graduates in ntral and underserved decentralization required has been debated q.,O). communities (209230,337,5090535). Some of these Completely decentralized programs ti.e., those that programs selectively recruit studen:s who already ploy ide ar components of the educational process at have job commitments in the local area once their the remote site) have higher operating Logs than training is completed. A certificate-level NP training those that decentraiLe only the terminal tor amicali programfitEast Carolina University in North phase of training, and they may not be any more 9Punding is authorized under Section 822(a)of the Pubhc Health ServIce Act loPunding es authorized under SCCOOG 831 of thc Public Health Service Act. Chapter 13Strategies To Recruit and Retain Rural Health Professionals 341 bachelors' degrees in rural areas (see table 10-43, Box 13-CExample of a Rural-Oriented box 13-C). Training Program for Nurse Practitioners Georgia Southern College's certificate program Nurses for family nurse practitioners (FNPs) emphasizes Rural experience during basic training may help development of strong generalist skills and an understanding of cultural and health care beliefs of to better prepare nurses for general hospital as well rural populations in southeast Georgia (209). It as rural practice. Nursing studeats participating in provides rural clinical experience under the supervi- elective rural rotations report that these experiences sion of faculty experienced in rural practice. MIMS- are more valueble than those available :n urban sions policies favor students living or practicing in facilities because they allow students to practice a rural areas, or whohave expressed a commitment tc wider range of skills 4 ith a greater degree of practice in nual areas on completion of the pro- independence (482). Nursing students in a rural gram. Of the 75 FNPs who graduated from 1981 to hospital preceptorship program who later took 1988, 74 percent were working in medically under- employment at the hospital reporter' feeling more served nual areas in1988, providing care to comfortable with patients and less overwhelmed by populations characterized by low income, low the orientation process (599). education, and high mortality rates. A 1985 survey showed that over 90 percent of program graduates lb make rural nursing more attractive, to Improve were still in Georgia, and 83 percent were employed retention of nurses who are already in rural areas, as NPs (209,535). This program received Federal and to improve the rural supply of nurse MLPs (NPs, grant fusling from 1982-87, without which the CNMs, and CRNAs), rural -.lases need acc..ss to continuar.on of the program would have been advanced training programs that will allow them to "highly unlikely" (209,535). upgrade their skills without having to leave their The program has had difficulties recruiting families or place of employment. students in reeent years due to a change in the American Nurses' Association (ANA) certification The Federal Government supports general nurse policy (209). Beginning in 1992, the ANA will training through the Advanced Nurse Training, require a baccalaureate degree in nursing for NP Nusing Special Projects, and Nursing Demonstra- certification (263). Not all States require ANA tion Project grant programs. None of the grant certification for NP practice, but Georgia does, and programs are entirely dedicated to rural trammg, but a lack of baccalaureate-prepared registered nurses all fund some rural-focused projects.' in the area has caused marked decreases in program enrollment (209). Funding for the Advanced Nurse Training grant program increased from $12.0 million in 1980 to $17.3 million in 1988, but it decreased to $12.8 effectiveat retaining graduates in those areas million in 1990 (table 3-1)." In fiscal yeal 1988, this (230).h1 program funded three rural-focused projects in Georgia, North Dakota, and Wyoming (679). These A new barrier to the recruitment of rural nurses projects involved rural nurse specialty b aining into NP programs is the recent change in American programs a nd expansion of a master 's level program Nurses Association (ANA) NP certification policy. in rural nursing. The Nursing Demonstration Project The ANA now requires a bachelor's degree for NP grant orogram funded four rural-focused projects in certification (263). In States tha' require ANA fiscal year 1988 (679). certification for NP practice, decentralized training Funding fur the Nursing Special Projects grant programs the* recruit local nurscs may not be viable program decreased from $15.0 mink& in 1980 to due to a relative lack of mgistered nurses (RNs) with $12.9 million in 1990 (table 3-1)." This program °The Pnmary CarcAsmstatt Program us Cal4f.orma. ful ezamptc, (taws NPsan4 Ms through built pdai...4,,s ow hab toured fovs4 ea1o4o. iticsoon IV= among students who took only Mc. terminal phase stf traurigig at tilt Nateahlt 4.allei to bk. CAM highr thou einuald siu.krus *h.. WWI. iht%MUM, of their training al Mose sites (230) °See footnote 8. °Funding Is authonzed under Section 821 of the Public Health Service Ad °Punesmg is authorized under Section 820 of the Public Health Service Act 2 s 4 I s: .1. 342 Health Care in Rural Amer.ca funded 39 ruralfocused projects in fiscal year 1988 primary area of study (e.g., radiography) with the and 40 such projects in fiscal year 1989 (679). option to pursue certification ehgibility in a second Projects included: area (e.g., medical technology) through an addi- tional year cf course work (424). After administra- continuing education programs for rural nurses tors found that many students were r.ot utilizing their on a variety of nursing topics; multiple competencies due to strict departmental outreach and off-campus programs to provide lines in hospitals, the program was redesigned to baccalaureate degrees to RNs in rural areas; combine complete competencies in either radiogra- programs toupgrade licensed practical/vocational phy or cardiorespiratory care with competencies in nurses (L.P/VNs) to RNs; emergency medical services/technology, health care geriatric, home health, critical care, family, management, gerontology, or computer science community, and preventive nursing trwning (424). programs; and nursing preparatory education projects (679). Although demand for multiskilled AHPs is con- siderable (see ch. 10), only a small numfoer of formal Some of the special projects used telecommumca- cross-training programs are currently in existence tions to provide nursing education in remote areas (424). A documentation project conducted by the (679). National Multiskilled Health Practitioner Clearing- Allied Heqlth Professionals house of the University of Alabama at Birmingham in 1988 identified only 75 programs nationwide Rural-oriented training has also been effective m offering multiple compelercy training. These pro- recruiting allied health professionals (AHPs) to rural grams are located primarily in community colleges areas. A linkage program between the University of and 4-year or graduate institutions. The study Alabama a Birmingham and several of the States' junior colleges provides clinical training opportuni- identified only four programs located in hospitals. ties for AHP students in underserved sites (91). Programs can be generic, preparing students in two or more areas of practice, or they can be "add-on" Students receive their first year of training at a junior college, and the second year at the University ot programs that expand the competency of individuals :heady certified in one area (424). Alabama Medical Center in Birmingham. Their last weeks of clinical training are completed at smaller f...oeral funding of AHP training has declined health care facilities throughout the State (91). After eonsidet ably since its peak in the 1970s (table 13-2) 11 years of the program, a study found that 56 (288,674), In 1974, nearly $30 million was awarded percent of graduates returned to their home counties in grants, eouperativ e agreements, and contracts ni to we ;k (143). Other schools that offer rural training allied health. hi 1986, the figure was zero. Lack of opportunities to AHP students include the Univer- data has prevented assessment of the impact of sity of Wisconsin Medical Technology program and Federal funding in allied health (288). OBR.A 89 Kentucky Southern Community College (288). The (Pubhc Law 101-239) approved $750,000 for the relatively short length of most AHP training pro- Allied Health Speciai Projects grants program, and grams presents an excellent opportunity for local $726,000 was appropriated. The program is de- recruitment of students. The development of decen- signed to improve allied health program adinuustra- tralized trainint, progrAms such as these appears tiOn and expand etuollments in allied health pro- likely to impro e AEP supply in participating grams. Only 7 to 10 grants were to be awarded m communities. August 1990, but by mid-January 1990, the BHPr had received almost 1,000 inquiries about the Rural-oriented training of AHPs with a smgle program (4?). skill, however,ill not satisfy the unique staffmg needs of many mral facilities. What are needed ,?.re OBRA 89 iuso authorized a new grant program programs that teach students a broader range of skills entitled Interdisoplindry Traineohips for Rural and offer eligibility for dual or multiple certification. Areas. This program, funded at $2 25 million m One such program, which was started with the help 1990 (table 3-1), will support interdisciplinary of a Federal grant in the early 1970s, is located at health professions training programs m rural areas, Southern Illinois University at Carbondale. Origi- and it could conceivably serve as an additional nally, students in the Carbondale program pursued 4 suure of support fiA the training a certain AHPs. ' 1 ; 1 Chapter I3-Strategies Tr Recruit and RetainRural Health Professionals 343 Tab.e 13-2-Federal Grants and Cooperative Agreements Awarded m the Allied Health Area, Fiscal Years 1E7-1990 Awards (In milEons of dollars' Fiscal Advanced Training Special Special Basic year traineships inimitutes improvements projects improvements Other Total 1967 0.24 0 0 0 3.29 3 53 1968 1.20 0 o 0.80 9.75 11.75 1969 1.55 o 0 1.23 9 75 12 53 1970 1.54 0 0 1.23 9 70 12.47 1971 2.46 0.48 0 4.40 9 70 17 13 1972 2.59 0.32 10.50 7.63 0 a 21 04 1973 1.05 1,14 7.00 5.64 o 15.73 'we o o 10.50 0 0 10.50 1974 2.56 1.00 16.00 10.13 o 29.68 1975. 2.61 0.96 10.19 6 87 0 20.62 1976 2.56 1.00 10.50 8 20 0 22.26 1977 2.33 0.64 8.91 8 41 0 20.20 1978 1.44 0.92 0 14 35 0 16.71 1979 1.49 1.01 0 8.15 0 10 65 1980. 0.89 o 0 4 25 0 0.14b 5.80 1981 ) 0 0 0 51 0 37b 0 07 1982.... 0 0 0 0 0 0 1983 0 0 0 0 0 0 1984 0 0 0 0 0 0 gl 0 91 1905 0 0 0 0 0 o884 0 1086 0 0 0 0 0 0 1987... 0 0 0 0 0 0 1988 0 0 0 0 0 0 1989 0 0 0 0 0 0 l000d o 0 o 0 73 o (2 25)e 0 73f aReleased impounded funds. bMilitary Experience Directed Into Health Careers (AEDIHC) cooperative agreement funds Grants for allied health personnel in health pro..mtion and disease prevention d Figuresrepresent appropriations and not award amounts Awari amounts were not yet available at ilia time of this study. *Rural Health Interdisciplinary Traineeship grant appropriationsHot all of this monei will go towards traineeships in the allied health professions. f Excludes Rural Health Interdiscipliner?Traineeship program funds. SOURCE. Institute of Medicine, Allied Nieth Services AvoidinA Crises (Washington, DCNational Aademy Press. 1989), table 5-4, U.S. Department of Health and Human Services. Public illalth Service. Health Resources and Services Administration, Bureau of Health Professions, Division of Associated and Dental Health Professions, Rockville, MD, unpublished data provided by F Paavola in 1990 The Area Health Education Centers Federal funding of an indiv idual AHEC may not (AHEC) Program exceed 9 years (see ch 3). The wide impact and success of AHEC-sponsored programs (box 13-D) The AHEC program" encourages training of indicate that Federal investment in these programs health personnel in primary care and emphasizes the relationship between educational experiences and has encouraged State and local participation in health care delivery. AHECs provide decentralized activities addressing the geographic maldistribution clinical education experiences for a variety of health of all varieties of health professionals_ Each project professional trainees by linking academic resources must contribute at least 25 percent in matching funds of medical schools with local health facilities and from State or other sources, and some have contrib- agencies. AHECs also provide continuing education uted considerably more(627,677).Twenty three for health professionals in remote cOmmullItles 'MEC proirams are now funt.tioning without Fed OM. eral fundiDg, and 18 more are mov lig towards 15Seecb.3 Ora descripsion of AMCprograin authonvitionandfuudin8 20-810 0 - 90 - 12 Qt3. 3, Box 13-DSeleCted Area Health Education Center (AHEC) Activities Arkona. AHECs in Arizona provide tural training experiences for medical residents, nursing studenu, health educators, and 'tiler health professions students 4 clinks serv ing Arizona's migrant farmworker populauon. Heahh professionals already serving migrant populations dist) ha,e access to continuing education programs throuti the AHECs (380). Arkansas: Programs of the Arkansas AHEC have contributed to improvements in the geographic distribution of physicians in the State. Since 1981, recruitment of family practitioners through AHEC-sponsored residency programs has been responsible for the elimination of physician shortages in 9 previously designated shortage areas. Over one half of the graduates of these residency programs locate in towns of fewer than 2,..,000 residents (151). North Carolina. A survey of all physicians who settled in rural North Carolina m 1976, 1977, and 1978 found that activities of North Carolina's AHEC program had been instrumental in those physicians' hxation decisions. The State has experienced dramatic improvements in physician-to-population ratios dunng the past decade t376). Seventy-three percent of all physicians who participated in a rural-or' tnted famdy practice residency program operated by the Mountain AHEC in Asheville since iu inception in 1978 remained within the region to pracuce (582) Over one-half of these practitioners are located in communities of 10,000 or fewer residenu 082). The AHEC has also been involved in developing off-campus baccalaureate programs for registered nurses, clinical training sites for both undergraduate and graduate nursing students, and continuing education opponwuties for nurses and ether health professionals in mral areas (101). Oldahoma: The Oklahoma AHEC program provides preceptorship opportunities at Indian Health Service clinic sites and tribally operated clinics and hospitals for a variety of health professions students (231). South Carolina: An AHEC in mral South Carolina coordinates with educational directors in hospitals thrmighout the region to deteroine the continuing educational needs of hospital employees. Programs to address identified needs are conducted at the facilities demonstrating greatest need, or at central locations where health professionals from all facilities attend The AHEC program also serves the continuing education needs of nonhospital-based pharmacists, dietitians, nutritionists. nurses. and emergency medical personnel within the region (729). Texar AHECs in Texas are creating teecommunkation linkages between health saence centers and small mral hospitals for consultation and patient referral. The health scienie center provides the hardware, and the AllEC provides the health care specialists and information sources requited to meet the needs of participating institutions. Other cooperative projects of the AHEC include joint pharmaceutical and supply purchasing, emergency transport information, and shared provider services (170). Virginia: The Western Tidewatzr AHEC on Virginia's Eastern Shore provides multidisciplinary expertences in health promotion/disease prevention among migrant farm worker populations fur students m dentistry, dental hygiene, medical technology, nursing, and medicine (712). WAM1. The WAMIJAHEC program (serving the States of Washington, Alaska, Montana and Idaho through the University of Washington School of Medicine in Seanio operates a Rural Hospital ?meet funded by the WK. Kellogg FouLda6on Its purpose is to examine the plight of rural hospitals within the region. This project represents an expansion beyond the typical AHEC program goal., m% olv ing adminorative. planning, and policy personnel in addition to health care practitioners (44) independence (table 13-3) (677). The first genera AHECs may cover portions or all of aSutc. While tion of AHECs (table 13-3), although intended as partial-State AHECs may be rural or urban, State- multidisciplinary efforts, de v oted the greater poruon w ide AHECs can encompass oath rural and urban of their resources to physician education (210). In projects. Figure 13-1 Jcpkts the distribution of the the second and third generations, and to the continu- % arious types of AHECs across the country 0577). ing activities of first generation projects, a greater AHECs are involved in a wide variety of educa- emphasis has been placed on nonphysician educa- tional and service adiviiieL, ranging from rural tional interventions (210). Federal funding for AHECs clinical experiences for health professions students has remained relatively stable during the past decade it)research on the financhd viability of rural (table 13-4) (677). hospitals (box 13-D). AF1ECs in Arizona, New 4 ). , -, I ' 1 I Table 13-3Location and Funding Status of Area Health Education Center (AHEC) Projects location of Calendar v... Ant projects 1972176 1977 1978 1979 1980 1981 1942 1993 1904 i9St :996 :9.57 tA I 1 Posiod of Foderel funding_ State and local fondiog nest generation (PUblic Lew 92-157) Ilifornie (Control San Joaquin Veliy) ( ) Illinois ) Main (Tufts) ) Minnesota Missouri I ) No#114,xleo (Navajo Nation) I North Caroline ) North Dakota C ) South Caroline ) Totes (South) W. Virginia ) Second generetien (PUblic Lew 94-404) Colorado Maryland Pennsylvania (Pittsburgh) Washington. DC Connecticut H hueetts Mow Jossey Ohio South Dakota California (statewide) lenses Vlaftinie Third asheriptiert Aiii01 Oeorgie/Alebame Michigan Oklahoma Tenn TaIO. (west) California (College ot Osteopathic Medicine) Florida (SECOH) Kentucky Maine (College of Osteopathic Medicine) New Mexico wstingtcm (WA AK MID) Florid& (Uriv of Maml . j keyed& MOM Some projete received vistll AVEC special initiative " ,erds after the Federal funding phase SOVICL V S Deportoont of ccat* and SUDM Services, Health Resources And Services Administration. D4reeu of PAAith Professsons Divtelon of )edicine. "The Ar of 3rpe1th Education Cantors Program Toen one Gown Wor)in4 Togiothor tn 114cove U. NA:40. HOOlth, ROCkvitle. MD, 196.: 3 346 Health Care in Rural America VA. 13-4Federal Fundirg of the Area Health ing sites (677). kn AHEC m Washington State has Education Centes (AHEC) Program, Fiscal YGars established an offie of rural health that engages Ln 1978-1990; and mpact of the AHEC Programs, numerous research and service activities relating to Fiscal Year 1988 the States' =al health czre needs Appropriationa The goals and priorities of AHECs differ depend- Fiscal year (in $ millions) ing on their geographic location. While urban 1978 $17 0 AHECs concentrate on graduate medical education, 1979...... 20 0 health professions career opportunity programs, 1930. . 21 0 health education and nutrition programs, and under- 1981... 21 0 2382...... 18 2 graduate medical education, rurat AHECs tend to 1983 11 9 emphasize nursing education and continuing profes- 1984.... 17 co sional education (210). Rural AHECs also have 1985 ...... 18 0 1986 17 2 devoted a substantial portion of their resources to 1987 18 0 providing support for area National Health Strvice 1988... 18 0 Corps (MSC) providers and career mobility for 1989 16 9 1990. sb nurses (210). A recent national study found that nonmetro counties with AHECsespecially coun- Funding and impact. fileal Tsar '-'54 ties not adjacent to metro countieshad greater AMC programs (Sec )81(a)(1)) growth in primary care physician supply bttween Amount awarded. .. $15 5 mili,In 975 and 1985 than counties without AHECs (281). Numbr of projects. . . luMber of regional centrs 43 Although response to local needs undoubtedly Number of States served 21 dictates some of the differences between rural and 781(a1i2)) Sneoial intatiativesa (Sec urban AHECs, tufferences in opportunities to con- Amount awarded $1 7 million Number of projects 2c duct certain types of training programs may be Number of States srved 10 &lather important factor. For example, compared with urban AHECs, rural AHECs may allocate fewer 4107.9 million were awarded as contracts under the META authority from 1972 throws'1976 resources to undergraduate na...fical education pro- bA separate but similar program, ue Hea:th Ed.,at4on grams because they are more remote from medical Training Centers Program, %as authorized 4n 1988 schools and have fewer local resources (210). Also, (Public Law 100-607) and was appropriated $4 0 million in 1990. The program focuses on the train- rural communities may not consider student training ing of halth prufassiowals in ar, along the programs as important as the need for trained U S Alexico border The $10 5 milli 1HEC approp- ithysidans in the area, especially if there IT no riatior here is exclusive of that $4 million aSet ch. 3 for an explanation of APEC special init- guarantee that these students will reran) to the area iative funding. to practice (210). 5uURCE: U.S. Departme.a. of Health and Human Ser- vices, Health Resources and Services Admi- "ZRATEGIES TO REDUCE aistration, Burau of Health Professions, Division of Medicine.'The Area Health PROFESSIONAL ISOLATION Education Centers ProgramTown and Gown Working Togther to Improve the Nation's Consultative and Educa:al Opportunities Health," app II. Rockville, MD, 1968 Up- &Lel by OTA. Through Telecommunications One means of increasing the xofessional re- Mexico aad Texzs ernphasta reel ament of health sources available to rural practitioners is improve- profes.ionals to serve Hisparuc vommi 077 ,. mera of telocommunkations networks, through Other AHECs focus on training of health profession- which health pr_4essionals ha,.e at.ess to consult- als to serve Native Amencan and black populations. ants, literature databases, new technologies, and AHECs operated through Meharry Medicalollege, continuing education programs Mc-ehouse School of Medicine, and Charles R. The KARENET system. operated by Texas Tech Drew University have demonstrated successVith Uruversity's Halth Sciemes Center, places a com- increasing the nurnbci of black health professions puter terminal by each patient bed ii. partaapaung students in the AHECs' in:derserved clinical train ru huspuals. enabling ut.eU consultame contact Chapter I3Strategies To Recruit and Retain Rural Health Professionals 347 Figure 13-1Distribution of Area Health Education Center (AHEC) Programs by State, 1988 1 - INANEC (frogOn desIgned : at4EC Prostafro ees,94*4 tor e ,n. Stale ter uoctient of the State SOURCE U.S. Depanment of Health and Human Scrums. Health Resources and Seneces Admmistrabon. Bui eau al Health Prolesshms, Onesionot Medocme. "The Area Health Educadon Centers Program Town and Gown Woddng Together to Improve The Nrbores Health," Rocionlle. MD, 1980 with st wialists at the Hezhh Sciences Center in telephone, no matte. how distant. Users at up to 57 Lubbock(268).16Another project, MEDNET, .1., li sites can participate s-nultaneousIy (259). be a two-way interactive video network linking A recent initiative at the National Library of Texas Tech speuialists to mral physicians. The use Medicine (NLM) focuses on making NLM products of these programs is expected to decrcase traveling and servicuTs available to health professionals in time for patients and health provLers, as well as isolated ruralandinner city areits 422). The NLM's improve occupancy rates in rural hospitals that Regional Medical Library Progran. -s a nomputer- would otherwise be obliged to refer problem cases io accessed network of nearly 3,000 medical libranes the Health Sciences Center (268). serving all 50 States. Libranes participating in the network have agreed to provide services to help Teleconference networks, such as the South health professionalF Went...), locate, and obtain Dakota Medical Information Exchange (SDMIY), infonnation (422). established in1981 at the University of Sou- i Health professionals in rural areas, however, may Dakota at Sioux Falls, are cap:ibie of reaching not have ready access to computers and telephone hundreds of people across hundreds of miles at lines that enable them toUt.the service (422). relatively low cost (259). Strictly an ---_-_dio system, Purchase of requ red hardware (e.g., computers, SDM1X offers a series of 1-hour continuing medical satcllite sending and receiving aquipment) may a!so education programs for physicians and additional be a major barrier to utilization of telecommuni..4- programming for medical suppc .. staff. Unlike soi.-.:. tions technology, particularly for solo prov tders ...I teleconference networks, SDM1X is not a fixed isolated nr 11 areas. kSumc people have suggested network aad thus can accommodate any site with a durd-party reimbursement for patiem wiz-related :Me program wrsfuoded by the WK Kellogg Foundation, and hardware was provided by AT& F r).-1 1 A2=4=1=11.1=4111 348Health in Rural Ante&.8 telecommenications costs (83).) Other disadv an- ing pay ment to primary eare providers a the exeense tages of telecommunications technologies are their of payinent for secondary t are serv ices ()BRA 87 level of complexity and the training they may (Public Law 100-203) introduced a number af require on the part cf physicians and other users. incremental changes that included: NLM has recommended additional funding for a permitting maximum annual increases in physi- program that would bring iradividual health profes- cians' charges to Medicare to be higher for sionals into the network, as well as for expansion of primary care services than for other services, a grant program that would bring NLM's products setting minimum levels for prevailing charges and services to a larger number of isolated medical for prima!), care services," and facilities (422). authorizing bonuses above and beyond what Opportunities for Vacation and Medicare would normally pay for p)ysician 2ducational Leave services delivered in designated Health Man- power Shcrtage Areas (HMSAs) (see below). Some rural health professionals may be unable to take professional or personal leave because there is OBRA 89 (Public Law 101-239) introduced more no one to replace them while they are absent. The general payment reforms to further increase pay- "burnout" problem may be particularly cevere fc. ment for primary erz services. This law establhhed solo practitioners in isolated rural ar who are oil a resource-based relative value scale (RBRVS'i as call continuously. lb address this problem, some the basis for Medicare physician payments as of States have developed speciallocum mums services January 1, 1992, to be phased in fully by 1996. to provide relief for rural practitioners. For example, tinder the RBRVS, differences in payment among a Robert Wood Johnson Foundation-fanded project different tyres of physician specialists for the same in Montana is developing a registry of providers service win be eliminated gradually over time, and available :or temporary placement in rural Montana a highertelative value than in the past will be placed ommi .aities (126). on "evaluative and management services"tlie types of services most of,en performed by primary Savilite clinic networks and physician-midlevel care physicians (475). Unlike the current system, team practices can also help to reduce professional which 'rases payments on "customary, prevailing, isolation_ These strategies are discussed later in this and reasonable" charges for specific sermes within chapter. specified prevailing charge localities4,zee chs. 3 and 12), payments under the new system will be FEDERAL STRATEGIES TO determinec, by a relative value scale that is based on ADDRESS ECONOMIC three components: work, practice expenses, and malpractice expenses. Geographic adjustments" CONCERNS will be applied fully to practice expenses and The Federal Government has tr ken .ps to malpractice, but only to one-fourth of the work increase Me4icare payments to primary c..e and component (which represents appmunately 60 rural physician, 0 ier .,,rategies to address eco- percent of each fee) (475). nomic concerns of rural practicee.g. Federal and D:tailed projections of the impact of tie RBRVS State educational loan repayment programs and physk ians ant' :eneficianes cannot b t made at other private sector effortsare discussed ;der in tin lona 'oecnuse the r-v. fee schedule ht..; not yet this chapter. been t1evelope41. The Physician Payment Review The Resou-ce-Bwd Relative Value Scale pyjj (PPRC) prdicts that rural physicians will fare well tn. 4c. theflewplan because they are (RBRVS) mostly primary ..art physicians, and because the A nember of statutory changes in Medkare geographa.4..1.14t of 1AN'mg adjustment wili only apply payment to physicians ha ve been aimed at increa.s- to one-founh of the %%irk eornponent (475).-- "For most son/ices. the Medicare fee is determtoci according to the po.44."r., 'e forpJlik YerVii.f: %It 4 gcu it44ity tinder this legislahok however, the mum= allowable payment for MEW). %At, 14 Ct. 4..i1M41 on SO pcitei 4 41 illy not, average prevailing %barge, regardless of the local invading charge. laGeogtaphic adjustments tower payments In areaS with lower toi ... ot lo:ong Chapter 13Strizegies To Recruit and Ramp Rural Health Prqfe.utc,.... c 349 Table 13-5Changes in Physicians' Medicare u.d Table 13-6--Change. in Medicate iayments Undet Tota: Revenues Under Medicare's Resource-Rased Medicare' Resuurce-Based Reabte Value ocaie Relative Value Scale (RBRVS), by Specialty* (RBRVS; in Metropolitan ar,J Aroo*1 Percent charge In Percent DrWice reVenues from Areab group chango4 Specialty Medice7.b All sourcesc ------ '4:01'ty Medical Internal mediCi1e.. 1/ 4 3.Ot,OOt population Family practice. 38 6 Medical 10 DermatoloSY 1 NA Surgical 15 SurSicel All rhysiciors -4 Ophthalmology. -16 -S 1.000,000 V, 3,000 '.100 General surgery. . -10 -5 Medical 14 Orthopedic surgery -7 -3 Surgical .1, Urolohy All physi.iany 5 Thorac surserY. -20 -9 Fewer than 1,000.000 Ot(larrigoloay 6 NA Medical Obstetrics/gynecology Surgical Hospital-based All tlhysiciant RadiologY... -21 -7 Nonmetro couLtY Pathology... NA 25.0010. population NOT" OA w not aveliable Medif.al 28 °These estimates a*: based on an earlier version of Surgical RB/RVS awl do not reflect the effect of the All Physic..,ms 12 geographic csat of living whicn will Fewrr than 2S.000 apply to 2. percent of the work component underte Medical f4 vorsion adoptAd in Public Law 101-239 Surgical -8 bMedicare prosram payments are exclusive of balance All p)'ysicians i3 bills (see text). -- clncludes revenues from all payers RBRVS otiv 4Esttrated ch.. es refl)ct the difference between applied to Medicare r-venuesMedicare assignment average 1988 charges .ander reasonable charge rates are assumed to be unaffected by the new RBRVS payment/ and fee schedule charges under the version fee schedule and 100 percent of ba'arce bill: (at of RBRYS adopted in 1989 (luhlic Lew 101-239) 120 percent of the prevailing charge) aro assumed bMetro and nonmetro counties Accounted for 84 and 16 to be collectedEstimaces of non-Medicare revenues percent (respectively) of Mecii:are allowed amounts are unavailable for some specialties in 1988 SOURCE Physician Payment Review Commission, AnnuAl SOblia Physician Payment Rev1ew C:emics3on, lpgsort to Coriunss. 1933 (Washington. DC Renott to Congress 190 (Washington. DC PPRC. 1989o, table 9-8 PPRC, 1490 1e 2-3 Based on a simulated model, PPRC predicztti the Lugest urban ait.as, rnedit.a1 spek:ialists rn rural under the new system, specialties that will rcceivz &teat ss .11 have the greatest eases (tabl13-6) the greatest increases are those that engage in a (475). greater proportion of "evaluanve and management' ' as opposed to "procedure' servicese.g., family Restrictions on bilance bilhng will go into effect practice and internal medicine (table 13-5) (475). before the new fe4 schedule. "Balance billing" is Surgical and hospital-based snecialties (e 8., oph- th. -Iffereace between what Medicare will pay (the thalmology, radiology, and pathdogy) will lose the most. Within specialties, the impact of the new fee "allowed eh- ge") and what the physician actually schedule will depend on the proportion of evt.ltiative charges the patient (the "billed charge"). Under the and management setvices performed (475i. 1989 legislation, no physician will be permitted to charge beneficiaries more than 115 percent of the Chatys in overall Medicare reimbun merit to Medicalallow ed charge. The full re Ariction will physitians w.11 probably be greater in meal than in apply beginning in 1991 to ph) Earians who chaiged urban areas, with the greatest increme., in the *ithin this Limn ifl 1990, but it will he phased =n smallest rural areas (475). Medical spec alties as a milre aratlaally for ph) sitians who 4..h.uged (Joist.) group will increase the:r Medicare income in all but ninit in 1990 Omits will be 125 peront in 19;) I , 3 72 350 flealili (..are in Rural America i 1 120 percent in 1992, and 115 percent thereafter) higher fees. OBRA 89 (Public Law 101-239) in- i (475). creased the bonus to 10 percent and expanded area eligibility to all rural primary care HMSM (izelad- Balance billing restrictions are likely to have a ing population and facility designations), effective somewhat negative effect on the income of phys-- clans who have historically charged outside of January I, 1991 newly allowed limits.° For example, a physician As of January 1989. all Medicare camers20 we:e who gets $12 from Medicare for a visit and who required by the Health Care Financing Administra- charged $24 in 1990 will only be able to charge $15 tion (HCFA) to post information about the bonu.5 in 1991--a 40 percent reduction in total income for provision in their periodic bulletins, which are that Ash. Although beneficiaries in rural areas report distributed to an physicians practicing within their balance billint to a slightly Lesser extznt than their arta (;10). The bulletins listed qualifying HMSA urban coz;iterparts (4/5), rural areas in which counties within each carrier's area. Once phys':ians physicians balance bit more extensively undoubt- have identified qualifying sites of service, the) edly exist A preliminary analysis by PPRC found indicate by special codes ontheir claimforms which thai Medicare income reductions due to I alance selvices were provided at those sites. The bonus is billing limits will occur more frequently for primary then automatically paid to the physician or physician :are practices and practices in niral areas than for group on the claim form.2i Individual claims are no; others, but that very few of these practices would verified by the carrier, although hCFA requires that experierke reductions in excess of 5 percent of carriers conduct an annual audit of a random sample current Medicare revenues (475). of at least 10 claims for the top 3 percent of eligible Because it could make pnmary care pracuce more physicians to determine the %alidity of those claims economically attractive to physicians, the RBRVS (110). may be a powerful long-range straws- for improv- The bonus program entails a number of problems ing the supply of Prima!) care spedists. This and uncertainties. First, it is not clear whether a le could, in turn, improve the rural supply of physicians percent bonus on Medicare payments iz sufficient to by expanding the pool of specialists most needed in =act or retain physicians in HMSAs (242). Al- those areas On the c.her hand, its impact on the though physicians1ve been found to respond t 1 geographic distributi ,, f primary r'a.:' physicians increased Medic& e ar d Medicaid reimbursement by may be limited due to competing urban demands for accepting more Medicare and Medicaid patients or these providers (e.g., by health maintenance ,,;gani- by providing increased care to patients they already zations). see (161,266,395,508,564), the strength of the in- centive will vary depending on the Medicare or Medicare Bonus Payments Medicaid i.aseload of the ph?sician. The increase in payment rates should result :ri increased income for OBRA 87 (Public Law 100-203) authorized a 5 many physicians, however. One analysis of rural percent bonus on Medicare reimbursement for all physician reimbursement found that a 7 percent physician services provided in i .mmetro class 1 and increase in reimbursement rates (from ail sources) class II geographic Funny care HM,SAs (see ch. 11 would produ,e a 26 percent increase in imome fo, discussion of HMSA5). The objective was to (710).22 incrnse access to physician ser. ices for Medicare bieficiaries residing in these greas by. I) attracting Second. the primary c..are HMSA may not be the physicians to *hese HMSAs, and 2) induc;ng physi- most suitable toolfor identifying areas wnere cians already in the areas to stay by offering them Medkare benefkiaries have pcm access to services. 19Studtes have shown that ball ace billing is soroogly related to beneficiary medial _osts A large proportion of bat i k.0 hilhng is contenitated among a small group of baieficanes wan h.gh medical costs (475) The geographi . locations of these benefluanes have n. it been studied 20Modicare P -n 3 rermbursetnent is handled thr_ugh 48 inburance camels Pksivans schwa ihcir dams io me .:41 -nos for reonibursemein. and the carriers m turn submit reimbursement totals t the Health Care Financing Administration (HCFAfr on a quanerly bast 2IPlaysic on services provided in ceMfml Rural Health Clinics (RHO do out qualify !or the bonus RID_ s re. epee ,..o si-baseu uther mat Respective reuriburseriaast for physician son ices under Public Law 95-210 (sec ch 3) 22Theparemetersusee in this model wcfc based ..11 only one ((the Case study sites. so the caau f qiwes will hot appiy to ali ruralpraktr.c..I pie finding that a given increase NI reimbursement tars ca a pioduce a greater increase on physivan no, oine. however. applies generaliy ,1, Ili ,4 'Iwril Chapter 13Strategies To Reel tat and Retain Rural Health Professionals 351 Legislatively, the bor.as program ar 'ics to all Finally, evaluation of the Fog-am is seriously physician services raiderri in the designated meat., hampered by lack of data regarding the number and regardless of the playsician's specialty. Primary c...re percentage of qualified physiclans receiv ing th HMSA designalon criteria however, do not con- bonus. In the third quarter c: 1989. .vhen the Eider the presui, - of all physician specialists. In program v. as fully implemented, $425,00 were particular, inv./ may fait short of identifying areas spent on bonus payments (456).--' Carriers report to with low avanability of noi.primary care services. HCFA the total number of chezts written each The criteria Mc:ude specialists vilio are less likely to quarter, but the total number does not distinguish see Medicare paLents (e.g., pediatricians and obste- between cheas to incyviduals and checks to groups tricians) but exclude nonprimary care specialists of physicians (//0). Carriers coulo.' provide in forma who may have large Medicare caseloads:21i HCFA tion to DHHS regarding the types of services lor and the Bigeau of Hes Ith Care Delivery aid which physicians are receiving bonuses, since such Assistame i-SHCDA) have received complaints information is included on compu erized claims frompsychiahists in designatecpsychiatric HMSAs24 .-orins, but they are currently not required to do so. who felt they should also be teceiving the bonus. As currently implemented, is likely that the program is affecting a large number of subspecialists TAPGETED STRATEGIES FOR who travel to qualifying a:eas and provide services, AREAS OF ACUTE AND as well as physicians whose practices are actually CHRONIC SHORTAGE located in these areas. From the infonnatlon pro, vided to HCFA by the carr4ers, however, itis Scholarship and loan bpayment programs tied to imponible to determine w tt types of ph,/ sk ians are a ben ice obligation hav e been used successfully by receiving the ..oconuses. both the Federal and State governments to influence Third, identification of HMSA boundanes has the supply of health profevionals in rural and been problematic, since they do not al%ays conform unrserved areas. A 1971 study of 11 such State to easily identifi-d county boundaries. Physicians in programs operating between 1958 and 1969 found sub-county HMSAs must determine wbidi of then that 60 percent of participating students served their service sites ale eligible based on maps provided by obligations by practicing in =al areas. 38 percent HCFk (HO). These maps must be frequently bought out of their obligationsP and 2 percent updated to reflect changes in HMSA designations defaulted or their obligations (372). At the Federal (110). level, the islISC has provided service-contingent scholarship and loan repayment opportunities, and a 3ourth, the effectiveness of the incentiv e may be separak program ha., provided service-contingent recuced by the instability of the HMSA designahon. Jtholnships to NPs. A 1936 btudy by the BHPr HivISAs are revicwed at least once every 3 years isee concluded that sen ice-contingent student aid pro- cli.11), and since designation is dependent on grams with high buyout penalties were succescful physician-to,pfpulation rptios, physicians locating mecaanisms for short-term recruitment of health in an HMCO cr...4.1d in fact precipitate its i.edesig- professionals to rural areas and areas identifie ii s nation, discontinnmg eligibility for the bonus. In at beiag medically under serv ed (685). This study also least one mstance, a roral physician with a large found that programs paying attention to the continoi Medicare caseload who had been receiving the 5 mg needs cot obligated professionals in such areas percent bonus decided to leave the area when it lost ma) be moze likely to .etuin those profcssionals pa.st its designation (and eligibilEy for the bonus) (430). the period of obligation (685). 23See Ch. I I fot a desenpime of pnmary HMSA designation eniena mpsychiatiy and primary care are the only physician spec-ohms ka which the Federal Government c offend dcaoglaca HMSA ec at 1 i rtkNE1SC physicians compkung then obligated service who decide to 4tay in the HMa A and are Mei, wavaltic,1 la thc Thy.....an h. p.1.4..1.114,q, ratio 4=1a..4ation (see eh I I). 26ThiS figure may be an overestimation since it mcludcs some second *area paym, were &Lived dig. 30 proce,ung Ifficultus rsc-bobtship and loan fuuds under ah of tht.se programs were reTayabk at thc ungtual =ow pluv tracteat Duc J the Lugc percentage of .1,,,Icra. choosing to buy out of their oohgation, some State and Federst progr.umhoc zaLrease4 theWpm. perialLo to dowtlei triple the or-owl 1.,at Sebolarship amount plus interest 0 4 352 Health Care in Rural America Other strategies for addressing the needs of these semd in "rural" areas (inciudmg those in remote communities include increased use of MLPs Indian Health Service sites), and 30 percent served and satellite clinics. in "urban" areas (689)," The National Health Service Corps The overwhelming majority of scholaships were awarded to medical students (both allopathic and The NNSC has been the single most direct Federal osteopathic); the rest went to students in a variety of program addressing health personnel distribution other health professions (including dentistry, nurs- duzing the last two decades. Since 4971 it has piaced ing, pharmacy, optometry, and veterinary medicine) over 16,500 health professionals24 in federally (662). Students could qualify for up to 4 years of designated HMSAs (663). The genesis of the pro- scholarship if they indicated an interest in primary gram was the Emergency Health Personnel Act of care and promised to serve 1 year ir a federally 1970 (Public Law 9i-623), which authorized the designated HMSA for each year of scholarship Secretary of the Department of Health, Education, received, with a minimum 2-year service obligztion. and Welfare (DHEW) to assign commissioned Payback began when students had completed their officers in the Attic Health Service in areas training, although some physicians opted to serve designated as having critical shortages of health before or during specialty training ,662). As of manpower and services. In 1971, 20 physicians in January 1990 80 percent of scholarship recipients the Public Health Service Coinmissioned Corps had served or were serving their obligation, 16 located in these areas. To expand this small corps of percent had repaid tileir scholarship awards,21 and 4 heaLui professionals, Congress authorized a scholar- percent had defaulted (346). The default rate is ship program in 1972 (Pubuc Law 92-5851 that expected to decline with a new amnesty program, obligated professionals to similar service. In 1987, a which permits defaulters to pay back their obligation small authorization was made available for two loan through service (662). repayment programs: one administered by tae Fed- eral Government, and the other administered by the The Leap Repayment Program-1987 legisla- States In 1988, funding for the scholarship program tion (Public Law 400-177) authorized the creation of was largely discontinued,29 and a Volunteer Pro two programs through which the Federal Gove.. gram was established to recruit non- obligated hez..1th ment would subsidize the repayment of educational professionals to HIVISAs. loans health professionals in return for service in designated HMSAs. Sources of NHSC Personnel The Federal Loan Repayment Program recruits The Scholarship ProgramThe NHSC Scholar- providers and repays their loans at a rate of up to ship Program was first funded in 1974 at a level of $20,000 a year if thcy provide pnmary care health $3 million (table 13-7) (6.'8). Funding peaked at services in a qualifying HMSA (661). Participants $79.5 million in 1980, with over 6,000 new or must serve from 2 to 4 years (661) The progrun continuing scholarships, and then decreased steadily placed 132 participants in 1988 and 1989 (table until 1989, when no new funds were appropnated. 13-7) (659). Scholarship recipients undergo an r verage of 6 years of education before they are available to serve (346); The State component of the program provides consequently, the peak nurrber of professionals Federal monies to States for the repayment of health serving their obligation occurred in 1986 (table prefessionals student loans. States must cover all 13-7) (618). Over 13,000 students have been awarded administrative COEts, and they must provide at le&st scholarships under this program, and approximately 25 percent of total loan repayment funds Mb. 10,400 eventually ser ved (or are loving) their Qualifying areas fot State loan repayment place- obligation In the field (689). Some 70 percent of ments are determined by the individual States. 23As of December 31, 1989. ihe total numba of health professiorals placed through the MSC since Pic beginning of the program wzgi 1f).560 This includes all health professions dtsciphnts A54 all recruitment categoncs (I c , volunteer, obhgated. am' commissioned corps) t6d3r 29A small WOO= of money was available for scholarships in fiscal year 1989 due to mprogrammirg of ..enain loan repayeat fun is t ,ce table 11-7) "The MSC defines 'rural as nonurbanized areas. some Of which arc located within metro ounties (I) 31In the early yearsof the program. scholarship recipients whc did not serve in IIMSAs had to repay the pnimpai plus interest. in later yeav. ihepenalty was incicased to triple the pnnemal tins interest 0891 '1 v Table 13-7National Health Service Corps. Funding and Participants in Field, Scholarship, and Loan Repayment Progiams, Fiscal Years 1971-89 FieldP-oar.ma Setelarnip Prnaramb inan RepayMent Program' Appropriation Year-end 4proprtation Awards Appropriation d Fiscal Year (8 thousands) field stray-4th (S thousands New Continuation Total ($ thousands) Awards 1971. $3.000 20 NA NA NA NA NA NA 1972 12.574 181 NA NA NA NA NA NA 1973 11.000 330 NA NA NA NA NA NA 1974.. . 9,787 405 83,000 372 0 372 NA NA 1975.... 14,055 488 22,500 1,499 1,864 NA 1976... 28.662 600 22.504 1,759 3,4::3NA5,201 NA NA 1977. 24,354 690 40.000 2,092 1 491 3,573 NA NA 1978 . 39,696 1,425 64.0 000 5,057 NA NA 197f 62,969 1,826 75.000 4::0279 6.409 NA NA 1988... 74.075 2,080 79,500 i:,iii 4.38' NA NA 1981.. 84,739 2,33^ 63.400 182 4,175 64,T NA NA 1982. 95,078 2." 1 42.500 1601 2,289 2.449 NA NA 1983 . 93,391 2,865 15.458 1440 795 937 NA NA 1984. . 91,000 2,609 6.300 691 98 167 NA NA 1985 .. 75,000 2,958 2,300 37° 12 49 NA NA 1986 . 58,500 3.304. 2.201 361 ' 0 NA NA A 1987 . 19.884 2,742 2,300 46. 46 NA NA 1988 31.442 2.097 2.202 361 4 915 20 1989 39,866 1,o40 2.9538 4e 6 49 3.9)3 112 ------NOTENA . not applicable 1The NHSC field budget funds the salaries ot federally mployed assignees. the tr.!vel costs of rew and torrent assigm-es. varlo.s clinical support activities, technical assistance to States, and recruitment and retention activities of the program From 1971 through 1978, ell NHSC field placements were NHSC-salaried since 1979, there has been a trend away tram 8113C-salarie1 position and towards other types of placement From 1983 through 1988. portinns of the original NHSC Field Piogram appropriations were reprgrammed into the budget for Community and Migiant Health Centers to heip par the salaries of NH5C assignees in those centers Field Progiam appropriations ,ro this table exclude reprogrammed 411*utits bThe NHSC scholarship program provided scholarships to health professions students In exthange tor serove in a designated stortage area when the), completed their training The minimwm service obligation WS 2 years. and the majority ,af scholarships went to medizal students 'Figures in this table refer only to the Federal Loan Repayment Fv,gram 1The number of NM personnel in the field at thc end of the calenisr ypar ln.ludes per,,,nnolI., al: ht.ol!h liuciplinos. both volunteer and obligated, in both NHSC and 1HS sites 1Multiyear awards t7hi5 figure was quoted over the telephone by MISC statf .n Januarv 1910 ;Reprogrammed from State loan repayment funding fer 10..9 Originally. no funding wiz appropriated tI Now In14:49. Vo' ,-o only 1 mil?ion of ths 3 o million appropys.o.),, f^y ebe State loan RepaYment Program was useA ii.1'4AI tho remainder we, 4;4-1 award 43 new scholarships for exceptionally financially needy medical students SOURCES 0 S ..:ongress. Office of Technology Assessment, Clinical Stalling in the Indian Health Servire. Special Report tWashirgt:n, DCOTA. February 1987). 0 S Department of HeaLth and Human Services. Health Resources and Serticei. Actrrin..,r4fir,n, bureau of Nealth Care Delive v and Assistance. unpublished data provided by G Goubeau. Nov 9, 1981 03 -a C 4 0 1 1.) CS 354 Health Care in Rural America Table 13-8Volunteer Placernems Made Through the Nattonth Health Set vcu ;:olps trittSC,Rau uitment Branch, 1988 and 1989 1988* 1989 Type of placement. Physician? Otherc Total Physicians') Otherc Total Nosed 191 4 195 :34 44 278 MSC Loan Repayment° . 18 2 20 97 15 112 Indian Health Service (IHS)f.., 62 476 538 123 540 663 Other° a 53 61 17 253 270 Total volunteer placementsh 279 535 814 471 852 1,323 °Figures for 1986 are estimates, since the program dataoase had not Yet been established hincludes MDs and Ws. °Includes all nonphysiclan heeltn personnel (e g nuise practitioners. physician'assistants. dentists, nurses, pharmacists). d Includes individualsmatched to Federal community and mizrant health centers C/MHCsi or to HHSC freestanding sites. Most individuals are hired by the C/MHC, but a small proportion may be salaried directly by the Federal Government. Individuals at freestanding sites estabtish their own practices °All OHSC Federal Loan Repayment recipients are recruited through the HHSC recruitment branch They are not true "volunteers," because they are under obligation to serve in HMSAs. but are included in the official volunteer placement- uount fIncludes all volunteer health professionals recruited to IHS facilities and service areas tkrough the HNC recruitment brenchmgthrough I. recruitment efforts, but excludes those participating in the IHS Loan Repayment Program. °Includes (a) individuals matched to non-federally funded sites in BMSAs where the commu.lity is able to suppoit the pra:titioner's salary, (b) individoals p1acc1 in the Bureau of Prisons or other Federal program sites besides C/MHCs and freestanding HHSC sites hAll catetories may include individuals recruited into the Public Health 5ers.tce Comniss.oned :,,rps through the HNC volunteer recruitment program SOURCE U SDepartment of Health and Hqmen Services. %ealth Resources and:,ervicesAdministrat,vt,. Bureu of Health Care Delivery and Assistance, Divssim of National Health Service Cor,s,uip,Ab:Asheddata provided to OTA on Dec le, 1989 and Jan 18. 1990 although le criteria are subject to approsal FedeI pnsons. federally funded commumty and BHCDA (662). States also set their owa priorities migr health centers), and other HMSA facilities concerning types ofhealthpersonnel to recruit. In or communities t062). The program is advemsed by fiscal year 1988, approximately $1 million w the re.ional offices. %Ouch male lists of placement awarded to seven State programs (661). In 1988, the bites available to medical rethdency programs and State programs placed 74 physicians, 2 MLPs, other health professionalbchools.These hstz. include 5 RNs, falling short of the 110 total placements all HMSAa, regaidless of degree of shortage group- vicipated for that year (689). ing or prionty ranking. Although higher priority FIMSAs are inchhied on the volunteer placement The Volunteer Programs ..nne providerb may list, volunteers, w ith few exceptions, tend to go to not be interested in or eligible for scholarslups and thelower pnonty sites (662).12 In 1989, the program loan repayment but may still be interested in practu.t. matched 1,33 volunteers, ofwhikh 36 percentwere in mral or underserved areas. The NHSC Volunteei physicians, to qualifying sites (table 13-8) (663). Program, officially begun in 1988, acts as a recruit- Most physicians recruited are placed in NHSC sites, ment service for the NHSC, the Indian Health while most ether health personnel are placed in Service, other Federal facilities and programs (e.g.. Indian Health Service sites (table 13-8) 063).' 125eeh Ilforadescnpnunofihevanuespia.eniernwppiatunic) lwausedbytheNlaCfora.notaiship.ivanrvpayincni.andbulunieciperivrinel "ThismaybeducinpantvtbefaathatIndianliaddiScnivtanchicadtubehuspilab,whid.kuocagtsaleincedfornuracanduiherssunOys.oao hcabhpersonaellbanNlISCi mdOther saes (i6.7)Also, ao noteddi die W.de. thc 0-15figuresonauo.. ellei kies maac duoughreaustmentchons mho than NHSC ' sl Chapter 13Strategies To Recruit and Retain Rural Health Professiona4 355 Table 13-0Federally Salaried° Personnel ,n the Table 13-10Nabona1 Health Ser vice Corps Providers National Health Service Corps (NNSC byDiscipline, 1981 and 19890 Obligation Status, 1989 Provider fiscal year Obliaation_Status discipline 1981 1989 Nonobligatedb Employment Scholarship or Loan Physicians 7,272 7.187 status obligors repayment Total General practice.. 1.098 84 Family practice... 2.038 614 Commissioned corps 20 118 138 Internal medicine 2,088 671 988 248 Civil service 124 16 140 Pediatrics Obstetrics/gynecology 454 242 Total 144 134 278 Psychiatry 417 215 Other 209 75 *Personnel in the NHSC mho receive their salaries 98 directty from Cho NOSC. Dentists 957 319 17 1:Includes some scholarship recipients +dm completed Nurse practitioners.. 0 their service obligation but delided to stay ou in Physician assistan.s.... . 111 Nurge-midwives. 88 1 the NHSC commissioned corps. Podiatrists in 27 SOURCE: U.S. Department ot Health and Human Ser- Other 319 17 vices. Health Resources and Services 2,347 Administration. Bureau of Health Care Total. 9,157 Delivery and Assistance. Division of National. Health Service Corps, unpublished aNumbers in this tab..* differ from year-end field at. .45th. "bars in table 13-7 because they reflect data provided to OTA Jan24. 1990 th. number oi providers servibg at any time from Oct1, 1980 to Sept. 40, 1981 or ins Oct. 1, 1988 Commissioned Officers in the NHSCCom- to Sept. 30, 1989 reher than the number of missione4 officers in the NHSC are a subset of the providers present in th. field at the end of the calendar year. Numbers both obligated and Public Health Service (PHS) Commissioned Corps. nonobligatod providers. They are a mobile cadre of health professionals who :-)OURCE. U.S. Department of Health and Human Ser receive their salaries directly from the NHSC and are vices, Health Resources and Services Admin- istration, Bureau of Hea.th Care Delivery deployed in high priority HMSAs. NHSC scholar- and Assistance. Division of National Health ship or loan repayment recipients as well as nonobli- Service Corps, unpublished data provided to gated volunteers can choose to join the NHSC OTA Feb 7, 1990 Commissioned Corps if positions are available. Like other PHS Commissioned Corps personnel, how- ever, they are subject to periodic transfer from one grams in quaafy ing sites. The majority of field site of service to another. placements have been and continue to be physicians As funding for the NHSC Field Program has (table 13-10) (663). MLPs (nurse-midwives, NPs, decreased, so have the number and proportion of and PAs) represented a signific.t proportion of the NHSC commissioned officers and other NHSC- total field staff in 1981, blt their numbers have salaried perso7d1el.34 While commissioned officers dropped to almost zero (table 13-10) (663). The once represented the ma.;;rity of field staff, they now number of dentists as a proportion of all NHSC make up only a small pcfcentage. Of the 1,948 total providers has also decreased (table 13-10) (663). field staff in 1989 (table 13-7) (659), only 278 (14 percent) received their salaries through the NHSC The four basic mechanisms used to place NHSC (table 13-9) (663). Of these 278, approximately personnel are: one-half were commissioned officers and the re- mainder were civilian employees liable 13-9) (663). Federally Salartedproviders receive their salaries directly from the NHSC; Placement of NHSC Personnel: The Field Program Private Practice As.ngnment ("PPA" ) providers are salaried through facilities that The NHSC Field Program places personnel fi om have Federal grant money (from non-NHSC scholarship, loan repayment, and volunteer pro- sources) dedicated for that purr3SC(e g , fed 74L additionto NHSCCOffitaissconed officers.some 4.sviban NHSt. personnel also tett lyetheir Wanes directly(Not dic NHSC 3 f1,11 356 Health Care in Rural America erally funded Community and Migrant Health service populations would be able to retain them Centers); beyond their period of obligateri service. Private Practice Salaryproviders are sala- ried through projects or facilities thia do nor Part of the rationale behind the transition to loan have Federal grant money dedicated for auk repayment waS that commitments near the end of purpose, but who are located in qualifying training would prove more valid than early commit- areas; melts as indicators of enduring interest in primary Private Practice Option ("PPO" )providers cam and practice in an ualerserved community set up their own private practice m an HMSA, (689) In addition, a loan repayment progam would without any fmancial assistance from Cie Fed- recruit personnel to the field immediately, while a eral Government (662)." scholarship program f.as a long "pipeline" between receipt of scholarship and start of servict.. Moreover, Until 1979, the year in which the first large group since potential loan repayment pIrticipants would be of scholars came out of the "pipeline," the majority aware of the specific placement opportuliities availa- of field pkcements were volunteers or commis- ble before signing a contract, they might make more sioned officers (662). In 1979, the field strength informed decisions and be less likely to "default" more than doubled due to the addition of obligated on their obligations (689). scholars. It peaked in 1986, with 3,304 NHSC personne136 practicing throughout tile United States. I.oan repayment and scholarship prqrams may Field strength de...cased by 36 racent from 1986 to attact different types of providers (689). Physicians 1988 (table 13-7) (6i8,659), and it will connnue to and other health professionals with high educational decrease as the "pipeline" &ries up and current debts may fmd NHSC loam repayment an attractive personnel complete their service obligations. NHSC incentive. Scholarship programs may be mo- : effec- Field Program funding has declined dramatically tive for recruiting nurses, MLPs, and allied health since its peak in 1983 (table 13-7) (6/8,09). The professionals because their educational costs and number of HMSA designations and the number ot associated debts are lower than those of physicians. physicians needed to remove these designations, The NESC Scholarship Program also attr acted many however, have remained relatively -stable dunng this minority and disadvantaged students who otherwise time (see ch. 11). might not have been able to afford medical school. Of scholarship recipients who completed their Problems and Changes Over Time obligations and for whom data are available, 17 in NRSC Programs percent were black, and 9 percent were from other minority groups (689). Over the years, changing needs of underserved communities, changing preferences of health profes- Although the Federal Loan Rep,:yment Program sionals, and reductions in the NI-1SC budget have gave priority to NPs and CNMs, 115 of the total 132 caused the NHSC to adapt its recruitment and placements in 1988 and 1989 were physicians, placement strategies. because few CNMs and NPs had applied (662). Although one explanation for their low . Amnon Sources of NHSC PersonnelTo earn scholar- rate is the lower debt burden of CNMs and NPs," it ships, students make commitments from 4 to 8 years is likely that lack of infozmation was also a major (the average has been 6 years) before they are due to reawn for the lack of candidates. It has been reported serve (346). However, during the course of their that over one-half of CNM training program direc- studies many factors (family characteristics, career tors had not heard of the program as of fall 1989 interests, etc.) can change their ultimate specialty (191). and location preferences. In some cases, NHSC scholarship recipients changed their primary care The State Loan Repayment Program was intended preference to nonpriirary care specialties (662). to improve recruitment by decentralizing efforts and undermining chances that communities with small encouragmg State investment ut loan repayment "TcChnicid assistance in site development and practice management is provided through regtonal and State NHSC offices )6The "year-end fkld strength.' column in table 13-7 includes commissioned and obligated NHSC held staff m an health prolessmnal fields "Mime contend dtat MI-Ps, because then professtooal income is considerably lower than that of phyucians, may find loan repayment an attractive incentive even with relatively small debt burdens (191) Chapter 13Strategies To Recri.tt and Retain Rural Health Professionals 357 activities. The 25 percent matching requirement, percent were FPO 059). The changing pattern of however, may dissuade some of the neediest States salary and placement mechanisms reflects a ane from Ppplying. This concern, as well as others within of concerns. BHCJA about the success of the program during its first year, prevented the planned expansion of the In the early 1980s, policy makers supported the program in its second year. use of the PPO as a way of reducing the Federal financial burden accruing from the growing number In fiscal year 19R9, BHCDA official^ requested of obligated scholars emerging from the pipeline. rcongressional permission to redirect $b.9 million However, in the mid-1980s, the NHSC reduced the originally appropriate-' for new State Loan Repay- number of PPO placements in response to concerns ment pr^grams to Federal NI-1SC scholarships (224). about the short-term and kmg-term viability of During the first year of the program the original independent private practices in small, remote com- seven State grantees had difficulty finding sufficient munities (662). numbers of participants to use awarded funds (689). According to State grantees, however, BHCL" \ had The NHS C had once also held that the PPO would given them insufficient time in which to recruit improve retention by increasing physicians per- participants and make awards. States were notified sonal investment in a location (78), a position which about the program in September of 1988, and they has since been questioned. Onginally, PPO obhgors had only 1 month to identify qualifying health were only permitted to locatc in areas ,yith mom- professionals.38 Inability to use funds for repayment mies sufficient to sustain a pri vete practice, but this of undergraduate loans, a low maximum allowable requirement was eliminated in the Health Programs yearly repayment rate, and a lack of candidates with Extension Act of 1980 (Public Law 96-538), pre- sufficient levels of debt have also been cited as sumably to allow PPOs to fill the gaps left by the possible reasons for States' limited success during decreasing number of NHSC-salaried physicians. the first year (689). Faced with drastic decreases in funding for the The new NHSC Volunteer Program h& suc- NHSC field progiam, scholarship graduates were ceeded in attracting a significant number of person- sometimes told that the PPO was their only option nel since its inception in 1988, but it might have a short of triple indemnity repayment or default (78). greater impact if additional incentives were availa- (Practice management and other technical assistance ble to practitioners serving in HMSAs. As of 1991, were presumably available through a State contrac- physicians locating in rural primary care HMSAs tor's office or through the regional office, but the will be eligible for a 10 percent bonus on Medicare degree of support from these offices may ha. - raried reimbursement (Public Law 101-239). Additional greatly.) incentives might include reimbursement for travel for practitioners and spouses making site selection During the 1980s. use of the private practice visits, and tax breaks or lump-sum bonuses for assignment (PPA) increased in response to the health personnel who practice in HMSAs. Volunteer growing need for physicians and other health recmitment is also hampered by a lack of recruiting personnel in federally funded community and mi- staff in the Federal and regional offices (662). grant health centers (C/MHCs), as well as to the same budgetary concerns that inspired the increased Methods of Placing NHSC PersonnelMost use of the PPO placement (662)." The shift to PPA field placements were NHSC-salaried up until 1979, placements also reflected concerns raised by expeti but thereafter a shift toward other salary sources ence with PPO. The NHSC had come to behe%e occurred (224). In 1988, only 15 percent of NHSC that pi icing personnel within structured sy stems of field positions (excluding those at Indian Health care w as more stable than placing them inSuit) Service sites) were NHS C-salaried, 54 percentwen; practice in L.ommunities un.tble to sui port such PPA; 23 percent were private practice salary; anft 8 practices (662). 311Infonnation on specific State programs was gamed thoughtelephune Lutnersatiunswith program- administrator% "To cover the saianes of the gmwmg number ol PPA personnel, *bsuistial pumas. (.1 the ongnial ISc IdJ Plop dos4ppsupriativli..*co. reprogrammed into tbe budget for Cas1HCs from 083 through 1988 ;.'241, Fur example. in 1967. $O 5 million wen. rcpiograniaidd u i..,1411Cs NHSC-salaned personnel are present in some C/MHCs, but the majonty of NHSC personnel in these tatillocs aie PPA Sonic Ch4HC, arc Flo' ll{ designated HNISAs. but may be approved for bitiSC obbgated personnel placoncin if they derrionstmc buffit init need i662, 358 Health Care in Rural America As a result, C/MHCs har- come to depend heavily obligations. Such communities might lack continu- on the NFISC for physicians. PPAs accounted for ity of service, but they were at least assured more than one-half of all NI-ISC placements in 1988 personnel. Mowever, recent declines in the number (659), and obligated NI-ISC physicians wounted, of NHSC personnel will result in fewerreplacements for over one-half of all physicians in Cf.v1HCs in for these communities. The Scholarship Program 1989 (411,4 '4). Even within the more Aructured placed approximately 200 practitioners in 1988 and PPA settings, however, retention of NHSC person- approximately 120 in 1989 (66440 In 1991, only 74 nel is a problem. Financial constraints prevent PM scholars will be mailable for placenrrit (710. sponsors from offering salaries competitive with If the goal is to create lasting systems oi ;are, the those in the private sector, consequently, PPAs often NHSC could also be regarded as havirg been leave C/MIICs once their periods of obligation end (414). reasonably effective. Thirty-five percent NFISC scholarship recipients wito completed their obliga- The Changing Role of Commissioned Officers tions in fiscal year 1989 e.ther remained at their in the NHSCIn the late 1970s and early 1980s, service site or relocated to another HMSA (346).41 physicians whose obligations were ending were told A national survey of physicians practicme in small they could remain on salary in their communities if (fewer than 10,000 residents) rural counties found they joined the NHS C as commissioned officers, and that 15 percent of these physicians were either a number of them did so (662). In 1985, however, the currently or formerly affiliated with the NHSC Public Health Service (PHS), as part of a general (405). A study of Virginia PPO physicians who effort to revitalize its Commissioned Corps, reas- completed their obligations between 1981 and 1986 signed all commissioned officers, including those in indicatedpracnce site retention rate of close to 45 the NFISC (6oh.). Many opted to leave the Corps percent (704).42 when asked to move (78). This reaction brought to light what might be an inherent contradiction The Volunteer and Loan Repayment Programs between the goals of the NFISC and the PHS have been unable to fill the gap left by the dwindling Commissioned Corps. While the major goal of the supply of obligated NHSC scholars. The 635 physi- NFISC is to recruit and retain health professionals in eians43 recruited to HMS As through the vtliinteer areas of need, the goal of the PHS Commissioned Program in1988 and 1989 (oble13-8) (663) Corps is to maintain a mobile cadre of health represent only 15 percent of the estimate,: numberc.: professionals who can be transferred as needed. physicians xeded (4,104) o remove all primary Some critics have proposed that the PHS waive the care HMSA designations in 1988 (see table 11-5). The 115 physicians placed ender loan repayment transfer requirement for NHSC commissioned offi- cers currently serving in remote, high-need areas durirg the same period represent oaly an additional 3 percent of physicians needed. MLPs can substitute g.. so- -e frontier counties) (389). for physicians in some of these aites, but the NHF^ has recruited very few in recent years (table 13- Iv, Evaluating the Impact of the NHSC (663). NFISC success varies depending on its percoved goal. If the goal is to place providers in high-need Senicc-contingent Scholarships for Nurse areas, without regard to their len& of service )1 these areas, the NHSC has been very effecuve; Practitioners and Nur.:2-.I1idwaes percent of scholarship recipients completed their FOOM 1978 through 1981, the Federal Govern- obligation or were still serving in 1990 (346). Until ment provided $3.2 million to NP and nurse-miclw tie the mid-1980s, communities served by NHSC pro- training programs to fund service-conu. gent schol- viders could rely on NHSC replacements if these arships for students t720). Just over 400 students providers decided to relocate on completion of their were awarded scholarships over the 3-year period. 40Numbers mclude nonphysician pers.mnel. 41A telephone stuvey in bte hoe 1989 ot all physictans due 10 complete thew ahlouton m Ji Asked whether 40 nom diev were ttlummog m elf current praence cr tg to an ILVISA or nori-HMSA 42Seven of the 29 PPO phystmos departed to enter specialty omitting ptogramN 43Excludes Federal Loan Repayment Program pamapanis 1) 1111WEIL,111.1==immillriali mar= Chapter 13Strategies To Recruit and Retain Rural Health Professionals 359 Although administratively separate from the NHSC, only or physiciaa-MLP gaff structures (103). The receipt of scholarship under this program was also clinics with physicians on staff saw more patients tied to a service obligation in a primary care HMSA. per week, charged higher fees, and relied to a lesser Unlike the NTISC program, however, the burden uf extent on nonrevenue funding sourt..eb than those finding a placement site was on the participant, and staffed solely by MLPs (103). many participants had considerable difficulty find- ing sites where they could serve." Participants RECRUITMENT AND RETENTION complained that their schools had not made explicit IN THE PRIVATE SECTOR the requirements of the scholarship contract and sometimes had even given them false information Local Hospitals (720). In spite of the reported difficulties, however, Physicians from 70 to 75 percent of the students served their obligations, approximately 15 percent repaid their Raralhosptals, which rely on local physicians for awards, approximately 4 percent were granted vs ail. - patient referrals, have a vested interest inthe ers, and only 5 percent defaulted (720). availability of office-based phy sicians within their service areas. Hospitals may encourage physicians Satellite Clinics and Increased Utilization of to locate or to stay in the area to stay by offering MLPs in Rural Areas them various types of assistance, including low- interest loans, subsidized office space, and guaran- The satellite clinic model can address the health teed income levels (see ch. 7). care needs of small and remote communities while offering the economic and professional advantages Because such arrangements 4.411 be v iewed as of group practice airangements. In this model, compensation to a physician from an entity to which physicians or MLPs from a group practice located in he or she refers patients, they may technically fall a more urbanized ccmmunity travel to remote sites within the proscriptions of Medicare's antikickback to see patients for a few days each week. Alterna- provisions (see ch. 7).46 Many rural hospitals had tively, some practitioners mzy staff the satellite hoped that recently proposed "safe harbor" regula- clinics full-time to reduce the time spent in Ifdllsit tions would prov ide some certainty in this area and between sites. The physician -MLP team model can ofrould uphold the legality of recruitment and reten . successfully address the needs of remote rural [ion strategies that have prov en essential for institu- communities (see box 13-E). It can also help to ease tional surv iv al. A$, discussed in chapter 7, however, the professional isolation and long work hours of the proposed regulations (issued in January 1989) rural physicians. MLPs have been found to increase offered little protection for any of these strategies. physician productivity (617). Nurses Historically, MLPs have been more likely than A study of nurses in rural Mississippi hospitals physicians to locate in rural and underserved areas, (453) attempted toIdentify retention strategies but increasing demand for their services in urban nurses perceived as potentially effective. Those settings may change this (see ch. 10). In some States, restrictive nurse practice acts or reimbursement most frequently mentioned included opportunities for upward career mobility, tuition reimbursement policies also influence the practice arrangements of for educational upgrade, bonuses based on years of MLPs and may discourage them from rural practice service, improved pension plans, 24-hour clinical altogether (see ch. 12). In other States, MLP-staffed clinics can be very effective (box 13-E). consultations, higher salaries for night and weekend shifts, and conflict management and resolution Although overall trends in the numbers of rural muliadisms (453). A recent study found that wage clinics staffed only by MLPs are not known, a study increases have repeatedly succeeded in reducing of 44 such clinics which had exkted in 1975 found past nurse shortages but have not kept pace ugh the that many had e.ther closed or converted to physician- present nursing shortage (7). 44Reasons Mentioned inducted. t,ompeinion fig mita*IdaMSC persubmt. *Ito *Ant: pLitea tho....01FCACIdianti itgivilai kafp.t.a anti uerc gi.u6 priority, inability Of fat,ditleS illqualifyingareas AC g . tommutotyhedidiol:filers) it+pay pana.lptifila44i.int4.out utmaillifigiic4., alp.rt ,wants I. relocate to qualms sites (720) 455ec 1128B of the Social Security Act, 42 USC f 1320a-7b II i".# 360 Heald, Care in Rural America Box 13-EExamples of Midlevel Practitioner and Satellite Clinics in Rural Areas OregonSixteen of Oregon's 44 rural primary care clinics were staffed solely by NPs or PAs in 1988 i8/). Oregon law permits NPs to own and operate their own clinics and to practice without direct physician supervision. Legislation passed in Oregon in 1979 enabled PAs in ,:tate-designated medically disadvantaged areas to practu_e with off-site physician supervision and to prescribe and lispense certain medications. Medicare and Medicaid reimburse for the services of PAs, Ws, and CNMs in clinics certified under the Rural Health Clinics Act (Public Law 95-210), and all private insurance plans in Oregon are required by statute to reimburse for NP services. Although some private plans do not cover the services of PAs. legislation currently pending in Oregon would require them to do so(81). A clinic in Condon, a town of 750 people that is 70 miles from the nearest full-service hospital, is started by two full-time PAs who are supervised by a family physician 90 miles away (81). The supervising physician sees patients at the clinic for four hours once every two weeks, and maintains daily telephone contact with the PAs. The PAs. who offer a wide range of basic primary care services, are accessible on a 24-hour basis. X-rays an.: read initially by the PAs and diagnosis is confirmed by appropriate specialists. A radiotelephone is used to transmit EKGs to cardiologists in Portland for final interpretation. The clinic is certified under Public Law 95-210 and is supported through a special tax district It has attracted a dentist aad a nntal health specialist who lease office space and see patients in the clinic 1 or 2 days a week (81). A clinic in Dexter is owned by two NPs and is staffed by the owners and an additional NP (81). Annual increases in patient visits continue, indicating a high lev el of acceptance of the chnic staff by die community. Mental health services are provided on a contractual basis by a mental health NP in a nearby town. linhke the Condon clinic. the Demer clinic is not suppotted through a special tax district, and with 40 percent of its service population uninsured it has had to adopt strict payment requirements. Financial constraints liMit die scope of primary care services it can provide For example, X --s must be taken at the consulting physudan's office untd the Clinic raises enough money for its own equipment (81). KentuckyA physician in Hyden. Kentucky works in a joint practice team with six NI's in a network of 4 rural clinic sites, a hospital, a home health agency, and an advanced school of nursing (602). The joint-practice 1n-mgement greatly expands the number of patients the physician can treat directly or indirectly. It is not unusual i me of the satellite clinics to serve as many as 500 patients a month (602). A typical week for the physician involves 300 miles of driving to the hospitals and clinics. Each day begins with patient rounds at the hospital and proceeds with services at one of the clinics. On Friday. the physician sees patients at the two busiest clinics, and then spends the afternoon at the home health agency or in tdministnitive meetings The physician is also responsible for making home visits to assess the conditicn and needs of patients whose care is then assumed by home health nurses (602). This unique and largely successful team approach is hampered by some regulatory obstacles. For example. due to Kentucky laws that prohibit NPs from prescribing medication, they must contact the physician by telephone whenever such medications are needed. Allied Health Professionals salaries and benefits, instituted scholarship pro- grams, improved management training, hired na- A study of AHP supply and recruit ment in tional recruiting firms, and establishei, .ornmittees Florida's small rural hospitals (572) found that, to address employees' concerns (572). compared with urbhospitals, rural hospitals were paying higher salaries to laboratory and radiographic Community and Migrant Health ('enters personnel and higher entry-level salaries to nuclear medicine technologists and respiratory therapists. Appr..ximately 800 NHSC physicians will com- Although most rural hospital AHPs were local p.ete their obligations at OMHCs in I990-91, but residents, a substantial proportion of laboratory and due to a decline in obligated NHSC scholarship radiologic personnel commuted from urban areas. recipients, fewer than 250 replacements will be More importantly, rural hospitals recruited most available (414). Physician shortages may be particu- their new AHP staff from urban areas. Conse- larly severe in smaller rural CIMHCs that are more quently, to compete with urban facilities for quali- sensitive to the loss of a single physician and have fied personnel, s-nall rural hospitals had increased greater difficulty finding a replacement i414). Chapter 13Strategies To Recruit and Retain Rural Health Professionals 361 To stem the projected physician shortfall, C/MHCs la fiscal year 1989, the Bureau of Health Care must either retain NHSC physicians past the term of Delivery and Assistance (BHCDA) awarded ap- their obligations, or they must successfully recruit proximately $22 million in grants to C/MHCs to non-NHSC pL, sicians. The average salary of improve personnel recruitment and retention (662). C/MHC primary care physicians is considerably It is too early to evaluate the effectiveness of this lower than what those physicians would make in the initiathe on the retention of NHSC physicians in or private sector (411), and fmancial constraints limit the recruitment of new personnel to C/MHCs. the ability of C/MHCs to compete with the private sector for the physicians they need. STATE EFFORTS IN HEALTH PERSONNEL DISTRIBUTION A 1987 study comparing recruitment and reten- tion strategies used in health maintenance organiza- Where Federal and local efforts are unsuccessful tions (HMOs) and C/MHCs found that C/MHCs in overcoming shortages of health personnel, States may step in. In fact, in an OTA survey of State rural lagged well behind HMOs in the breadth and extent of their activities (411). Only 48 percent of the health activities conducted in 1988, States most compensation components (e.g., pensions, associa- frequently ranked personnel issues as the greatest tion membership, cost of living increases, loan problem for the health of their rural populations (see repayment) and only 19 percent of the incentive ch. 4). Although respondents noted that provider provisions (e.g., extra compensation for weekend recruitment and placement activities had addressed work, teaching) used by HMOs were used by some needs, many felt further program development C/MHCs (411). Many HMOs use productivity- was warranted. based incentives to attract and retain staff, but the Table 13-11 show s how State officials rate ce,-tain Department of Health and Human Services has Federal programs for improvmg the availability of reportedly discouraged C/MEICs from this practk e health savices to now-taro IlMSAs and Medically (411). C/MIICs that do employ such strategies, Underserved Areas.' rhe programs most frequently however, have found them to be very effective (411). listed as effective were the NHSC (35 States), For example, the Southern Oh:Health Services C/MHCs (33 States), the Rural Health Clinics Ac.. Network, a private, nonprofit organization providing (21 States), and AHEC activities (15 States). Ironi- health services in 14 rurai Appalachian commuri cally, the program tiost frequently listed as meffec- ties, modified its physHan compensation plan by tive was also the Rural Health Clinics Act (10 linking annual salary increases to quality and States), it was followed by Medicare Physician productivity (725). The development of this plan Bonus Pay ments (9 States) and AHEC activ ities (9 was viewed as a significant factor in the retention of States).4" Responding officials in a number of States 70 percen! of the Network's NHSC phy sicians after were not familiar with Federal support of primary their obligations had been completed ("25). HMOs care education programs, loan repayment programs, also use loan repayment plans to recruit and retain or the Medicare oh) sician payment bonus. physicians, but C/MHCs cannot use their Federal grant funds for such purposes (411). State Activities The number of health personnel distribution C/MIICs do cngage in precep..aship programs to activ ities varies considerably from State to State a greater extent than HMOs and have found that ths:y (table 13-12) 085). Programs most commonly used aid in staff retention (411). Preceptorship program., in Stateb to unproye the geographic disthbution of not only give C/MHC physicians the opportunity to health professionals are placement sen ices (43 teach but also help link C/MHCs to the academic States), sen ice-contingent loans and scholarships resources of educational institutions. In addilion. (36 States). sen ice contingent educational loan these programs provide the centers an opportunity to repaymem programs (27 States), targeted primary recruit participating students (411). care training opportunities (28 States), preceptor- *Then data ate from MA's 1989 Survey of Stale Heat di Pet wand and Medwally L ad ei serNod Ai.4U kstsTattiont Sec app Lt t....upyvt the suricy instrument and a description of survey methods . avcof die man states law AHECs as'Ineffauve. dtd not Wit tiiAHLC. tine hadjus. atancti an AHLCin 1 Att.and Orc t. did havc AHLCa 362 Health Care in Rural America Table 1111States Officials' Ratings of the Ef:ectivaness of Selected Federal Programs in improving the Availability of Health Serbices in Nonmetropolitan Health Personnel Shortage and Medically Undersened Areaso Number and_Percent of States rating the Proaram as. Federal program VE S I VI NF DK/NO NR National Health Service Corps. 14(321) 21(482) 6(14%) 0 (02) 0 (01) 2 (5%) 1 (2%) Support of primary care educational programs... 2 (52) 9(202) 6(142) 1 (2%) 5(11%) 16(362) $(112) Area Health Education Center (AHEC) activities... 3 (72) 12(272) 5(112) 3 (71) 1 (22) 14(22) 6(14%) CommunitY health centers 21(48%) 12(27%) 2 (52) 1 (22) 2 (52) 4 (92) 2 (52) Rural Health Clinics Act 5(II%) 16(36%) 8(182) 2 (52) 2 (5%) 8(182) 3 (7%) Medicare physician bonus payments 4 (92) 5(112) 5(11%) 4 (92) 3 (72) 19(43%) 4 (92) b Other 3 (/%) 1 (2%) 0 (0%) 0 (02) 0 (0%) 0 (02) 40(912) NOTE: VE = very effective, E effOctive I ineffective. VI = very ineffective, NF = not familiar with Federal program; OK/NO = don't know or no opinion. NR = no response. Data from OTA's 1989 surveY of States on health personnel shortage and medically undeeserved area designation (see app 0). 80nly 45 States responded to the survey. bOther Federal programs specified included Cooperative Agreement Fund and Rural Primary Health Care Initiative. lwo States specified State Programs State physician training programs and State loan repayment programs. SOURCE: Office of Technology Assessment. 1990 ships (24 States), and AHECs (25 States) (table were using their own designations to implement the 13-12).48 Other methods include malpractice insur- prtsgrams (see ch. 11). ance subsidies, bonuses to physicians in rural A 1986 BHPr study found that in only one-half of shortage areas, and recruitment travel assistance the States was a State's level of effort in health (627).Physicians made up the bulk of providers professions distribution (as measured by number of actually recruited by respondents to OTA's survey, programs, number of program participants, and but recruitment efforts were reported for a wide program funding) related to the size of its underserv- range of health professionals. Many States tried ed and rural populations (table 13-13) (685). State unsuccessfully to recmit NPs and PAs (see ch. 4, budget constraints, political climate, and number of table 4-6). slots in health professions training programs also can affect a State's level of effort'685).The same ro target resources to areas of greatest need, study found that financial support for non-Federal States mayidentifyareas of health personnel short- hualth professions distribution programs increased age or medical underservice. While some States substantially from 1980 to 1985 (figure 13-2) (685). have developed their own shortage area designation In nominal dollars, total support increased by 75 criteria, many States lack the resources or the percent dunng this time (from $42 nullion in 1980 foresiet to implement a designation program and to $73 million). rely on Federal designations to identify areas and populations of need. Three-fourths of States (34 of 45) responding to a second OTA survey on shortage Characteristics of Program Success area designation activity49 used some type of short- The 1986BHPr study identified 113 health age area designation (either Federal or State), to professions distribution programs in 42 States (fig- target their placement activities" and 21 of these ure !3-3) (685).51 Ir general, tntegrated strategies 4114u Jaen of stalcS reflect responses to area separate studies Gained out between 1986 and1989 (secLivic13-t2) Some Pragra Ms may have been discontinued, and programs in some stales may not be reflected viSee app. D. glen respondents indicate that their states did not have any health pmonnel disinbutiun prugrams mmHg shunsge ace designauons,andI respondent answered "don't know." Mese programs are also reflected in table 13-12 , -1 Chapter 13-$n-ateg i k!cruit and Retain Rural Health Professionals 363 Table 13-12State Health Professlonr Distribution Programs' Financial Inosnavos II &bastioned programs du& training Ard m practice Other 11 e g I ai 1a 8 fiigri s E G a 8. i a 1 11I ..3 ic l E i V 1Ili815 II Ii1 II I 1 1 1 f s s .i 1 I11 p!4 iinil id li 8 iz 8 3 S 1 1 6 6 Alabama 0 X OA 0 Alaska X X Arizona 0 0 X 0 0 A o Arkansas 0 0 X 0 X 0 A X 0 X 0 A 0 0 California X X Colorado A Connocticut Delawaro A A A Florida ...... X 0 0 0 0 X 0 0 A Georgia x x 0 X Hawaii Idaho . 0 X o 0 A Illinois X 0 X 0 A 0 o Indiana A A o Im o X 0 A Kansas X X 0 X X 0 A X A Kentucky . XO 0 0 XO X X0A 0 A 0 A Louisiana A Moine 0 X 0 0 X 0 X 0 0 X 0A tAwfiand 0 0 0 0 X 0 A X A 0 A Massachusetts X X X X X Michigan X X 0 0 X Minnesota X 0 A Mississippi o o X 0 0 A 0 0 0 Missouri o o X 0 A 0A0 Montana x N e b r a s k a 0 0 X 0 A O A O 0 o Nevada o o A X NVII Hampshire ...... Now %brow X 0 X 0 0 0 0A A New Moloo 0 0 X 0 0 X X 0 X 0 X 0 A 0 New York XO X X 0 X X0A 0 A 0 North Carolina 0 0 X 0 X 0 X 0 0 0 North Oakola X A (Nilo 0 X 0 0 0 adahoma X 0 0 X 0 X 0 X 0 Oregon X 0 X 0 X A 0 0 Pennsylvania X X X A Rbade Ward X South Carolina 0 X 0 X OA X 0 o South Dakota o o o -, Tennessee X X 0 0 0 Texas X 0 0 0 X X A 0 A Utah 0 0 X o Vonmat **a X X 0 A 0 X Washington X 0 X 0 0 0 X 0 A A 0 A 0 0 West WgInia 0 o X 0 X A 0 0 A Wisconsin X Wyoming X A Total X 15 8 9 11 4 25 3 1 0 15 1 3 0 0 0 0 Total 0 20 5 20 21 2 27 4 1 1 16 2 6 13 5 3 4 Total A 0 0 0 0 0 23 0 0 0 37 0 0 24 0 0 0 Total overa, .. . 28 11 24 25 6 36 7 2 1 43 3 8 27 5 3 4 80ala am bawd or 4itoommaratoom .0*QondAled m1946, 1 RM. andl 90 04.1seond below, &twin's...some/ow wows voy maynclhave wren coptomooy ass000 toe vonow meow Hof al ammo kyludaltho onvo actfray witisoodisa a cooped them ma swam fastoon Mu. mi e i 9088.am in neallr. ilutioltporis4411 vtit 0001414100neaan Kowloon* &Modica programs drodly. Oda this hao 0111co ..41achnology Aftwensanl voysto 999 and I Nth 9:999100 Stmo cilium AS onto nopunow ere too i Oho; (a 1 actinmogy Awwww* Survey. beg orgy 46 %Mos responder:11*th° 190 ftrtorg moo spy C Fre4. sumo moons may novoDOM9999:0100.1 ci .99.00119903 between sato ono Iota LEOSND: Data from U S Dispartmont of Health and Hawn Sorrow, 14oalth Rasourcas and Somecen AdamobWon, Sono. of Health 9sofoneons. (Ahoy ci ions Aomrso ono Wisn60mmte ComPonallor of Sfif H06fr AW0Hothl 0044w800 Progilfra $986. 01445 Nib N9 HRF 00064 (Rockville, MU HASA, orbot 1950 Vr Data from Ottise or Tectaxkgy Armament. 1959 Survey of Statos on Health Possonne Shortage and Modica*" Undomomod Avow two app -Data from. Offois al Tochrology itasommoot 1908 Smvw of State Rural Health Activates (ow app 0) SOURCE 091c. of Tochrology Amoustood. 1990 364Health Care in Rural Amerka Table 13.13States' Level of Effort In i2th Professions Distribution Compared With Their dnserved and Nonurban Populations a (Jnserved population Percent nonurban State Level of efforta (in thousands)b populationa Alabama 4 362 40 Alaska 3 74 36 Arizona...... 2 135 16 Arkansas 3 177 46 California 2 751 9 Colorado 4 66 19 Connecticut 4 70 21 Delaware 4 18 29 District of Columbia... 4 65 0 Florida 1 808 16 Georgia 1 592 36 Hawaii 4 16 14 Idaho 2 128 46 Illinois. 3 909 17 Indiana 4 210 36 Iowa 3 78 41 Kansas 1 33 33 XentuckY... 1 247 Ag Louisiana.... 4 551 31 Maine 2 218 16 MarYland 2 177 20 Massacbussets. 2 49 53 Michigan 3 353 29 Minnesota.. . 4 73 3: Mississippi.. 4 395 53 Missouri 4 444 32 Mbntana 2 70 47 Nebraska 4 60 37 Nevada... 4 76 15 New Hampshire 4 24 48 New Jersey... 4 187 15 New Mexico... . 3 230 28 New York., .. 1 562 19 North Carolina. 1 46. 52 North Dakota. . 68 51 Ohio . 3 554 27 Oklahoma 1 111 33 Oregon.. 3 184 32 Pennsylvaria.... 3 558 31 Rhode Island. . 3 31 13 South Carolina 2 253 46 South Dakota. ... 4 8+ 53 Tennessee.. 3 291 40 Texas 1 884 20 Utah...... 4 61 16 Vermont.. I. 31 66 Virginia 2 283 34 Washington.. 1 126 27 West Virginia . 4 282 64 Wisconsin.. 4 273 36 Wyoming 2 38 37 aLevel of effort is derived from a combination of three variables (1) number of programs. (2) funding. an.1 (3) number of participants in the progrom -I" ind.cates the highest Level of effort. while "4" indicates the lowest level of effort. bThe estimated unserved population is computed by multiplying the number of practitioners in designated Health Manpower Shortage Areas by the population-to-practitioner cutoff ratio of 3.500 1(in special cases. 3.000:1) and subtracting the figure from the area population aPorcent of State population residing in nonurban areas. 1980 census SOURCE: U.S. Department of Health and Human Services, Healt'l Resources and Services Administration. Bureau of Health Professions, Office of Data Analysis and Management. Compendium of State Health Professions Distribution_plograms. 1986 OHMS PubNo ODAM-2-87 (Washington. DCU S Government Printing Office 1986). table 4 3 . Chapter 13Strategies To Recruit and Retain Rural :lealth Professionals 365 Figure 13-2Funding Levels end Source of Funding winga numbcr of diffaent ins:.entiv esweltfound to for State Health Professions Distribution Programs, be more successful than programs using only a 1980 and 1985' siagle strategy to increase the presence or health Prorate professionals in tinderserved communi6es. Combin- 75 -$ IZEI Local .. , 704 , Federal ing educational and financial practice incentives ss e= State with selecnve recruitment of students and practice 004 66 6t 6 site development were found to reinforce health SO 1. 4.104 professionals' choices of specialty and pracnce 45 ***-- 40 location both during their education and throughout 35 their career. As of 1986, however, many States were 30 j 25 .1 still pinning their hopes and funding on separate, 20 1 single strategies(685). 15 10 5 Of the 39 fmancial iicentive programs identified 0 1950 ins ieee ises in the BHPr study, 35 required service in designated Nominal dollars Real dollare shortage areas(685).In general, service-contingent .68 programs reported fundng levelsandsovIces in 980 and 19b5 programs were found to be an expensive but bkfusted for inflation. successful means of attracting providers to rural and SOURCE: U.S. Depwtment of Health and Human Services. Health Resources and Services Administration, Bureau of Health underserved areas. The programs with strict buyout Professions, Office of Data Analysis. and Management,Corn- provisions (e.g., high interest rates or other penal- peathin OfStale Health Protosslors DaMbutioa Programs 1986.DHHS Pub. No. HRP-0906954 tflocicville, MD. HR5A, ties) had the greatest success in getting students to November 1980. fulfill their service obligations. Selective recruit- ment of students predisposed to rural practice (e.g., Figure 13-3Focus of 112 State Health Professions Distribution Programs gdentified by t he Bureau of Health Professions, 1986 Guaranteed income Experiences Prmary during AN EC Loans care ressdenc.ea education 11% / 2% 13% :37% Seal purchase Aid in 7% Placement practice 14% 28% Preceptor, 111 pa 12% 01her Ot acholarehipa 5% 1% Service contingent loans Other and echoleFehlpe loans 31% 3% Financial incentoves 35% SOURCE U.S Department of Health and Human Services. Health Resources and Sei vices Administration. Bureau of Health Professions. Moe of Data Analysts and Management. Compendium of State Health Professions Orstabuson Programs. 1986.DHHS Pu') No HRP-09069134 (Rockville, MD HRSA, November 1986) 366Health Care in Rural America students who grew up in rural areas) also Unproved hs...1 developed program.s with targeted primary care the success of service-contingent programs (685). training opportunities in rural and uadersenred areas (685). Most of these programs reported that the During the past 2 years, a number of States have majority of their graduates remained in the State to passed legislation creating or expanding service- practice Eighteen programs in 10 States provided contingent scholarship, loan repayment, or tuition special educational experiences (mostly rural pre- reimbursement programs for health professional' . ceptorships) to undergraduate medical students (685). rural and underserved areas 018,196,197.. ntly, Texas, Nevada, and Hawaii have passed 301,311,358,364,365,366,371,393,434,435 ,-.. r .islation authorizing the planning or establish- 596,598,703,722). Oregon recently passed a ment of rural-oriented health professions training iequiring the Oreson Health Sciences University to selectively recruit medical students predisposed to programs (240,434,597). Maine and Florida have passed legislation to establish special allied health rural practice (454). Scholarships or loan repayment training programs (198,365). Other curricular inno- for underrepresented minorities have been e.oved vations include enrichment programs to increa:,e the recentlr in Louisiana (357) and California (1 18). number of students from minority and rural back- Programs to provide assistance to practitioners grounds, and the various activities of AHECs establishing or maintaining practices in underserved (685).52 For example, 1989 Oregon legislatron communities are also common (table 13-12) (685). mandated that the State AHEC provide continuing The BHPr study found that the effectiveness of these education for rural physicians (454). programs depended on the level of ongoing support once a practitioner had been placed (685). Programs SUMMARY OF FINDINGS providing fmancial assistance for establishing a practice as wet' as technical assistance in managing General Strategies for Rural Recruitment and maintaithng it had gitater success in retaining personnel in underserved areas than programs that and Retention simply acted as a placement service (685). Recent Exposure Pi rural practice during health pro- State activities include 1989 Oregon legislation fessions training can influence location decisions establishing tax credits for physicians practicing in as vell as better prepare health professionals for certain rural areas (454) and legislation in North the realities of rural practice. Decentralized educa- Carolina and Arizona authorizing compensation or tional programs that offer training opportunities at m.alpractice insurance subsidies for physicians pro- rural sites are not only beneficial to the students, but viding prenatal and obstetric care in rural and they may contribute to retention of providers already underseAred areas (53,444). in the area. These programs have demonstrated success in placing their graduates in rural and Many States use educational strategies to address underserved areas Selective recruitment of students rural health personnel needs. Thirty-nine States have public medical schools, many of which were de- from rural areas has also been found to increase the proportion of graduates who locate in rural areas. signed to produce more primary care physicians for the State and to increase educational opportunities in Cross-training program.s may improve the abil- certain areas (685) Graduates of public medical ity of rural facilities to hire certain alhed health schools are more likely to choose firimary care and professionals as well as improve the attractiveness practice in underserved areas than graduates of of rural practict for these personnel. Training private schools (168,455). The BHPr study found coukl be provided in a formal educational setting or that 8 States without their own public medical on the job. State lkensing laws and hospital staffing schools purchased seats in other State schools. Of requirements that present barriers to the training and these, programs with a service commitment pro- use of multicompetent allied health personnel will duced proportionately more snidents who returned have to be made more flexible before such strategies to their home States (685). can be adopted. Some schools offer more specialized distribu- The Federal Government, through Medicare, sab- tional programs. Eleven States in the BHPr study sidizes GME. Medicare funding of GME does not snbe 12 AHECs 111 the BHPr study woe ongmaIly foicrally funded. but now operde mostly on stale fundtng t ' 4., t 1 Chapter 13Strategies To Recruit and Retain Rural Health Prcfessionals 367 distinguish among medical specialties on the basis be sufficient todmdC,tr new phy sicians to HMSAs. of undersupply, oversupply, or other indicaton. If Furthermore, the effectiseness uf the program Ind) anything, Medicare reimbursement of GME puts be reduced by the instability of the HMSA designa. primary cart training at a relath e disads antage, tion. Small changes in the number of practitioners in especially when the educe' sn takes place in ambu a HMSA can result in existing physicians in that latory care settings. HMSA becoming ineligible for the bonus. The Federal Government aiso yrovides some Telecommunications networks can be used to targeted fundiag to primary care health professions Ales iate professional isolation for rural practi- education programs. With the exception of certain tioners, prosiding them with nsultatie oppor- nurse and advanced nurse training programs, tunities as well as continuing education. laIturli however, such funding has ck creased considerably knens servkes that proside temporary replaczments during the pazt decade. Since 1980, targeted fund- for health professionalb in remote rural areas can ing of primary care graduate and undergraduate help to alleviate concerns oser lack of 1, acation and medical education has decreased td more than 25 professicnal leave time. percent. Federal support of PA training programs is approximately one-halt of what it was in 1981. A Strategies for Acute and Chronic Shortage scholarship program for NPs and nurse-midwives Areas who agreed to serve in HMSAs was discontinued in Service-contingent scholarship programs and 1982. Federal support for allied health education peaked at $30 million in 1974, but in 1990 only loan repayment programs have helped recruit $726,000 were appropriated for allied health grants health professionals to shortage areas and have and contacts. been used by a number of States as well as the Federal Government. The most effective programs AHECs are a source of innovative programs in have been those that provide ongoing support to ruraloriented health professions education, and participants during their sen ice obligation. Satellite they have been successful in recruiting and retain- clinic networks that use MLPs can also improve log health personnel in rural areas. AHECs hese tin availability of health services id remo,e areas. tended to emphasize physician rather dim, nonphy In some States, however, practice acts and reim- sician training. The unique funding mechanism of bursement restrictions present the use of MI-Ps in AHECs make them a model for Federal-State autonomous settings. cooperation in health professions training and distri- Funding for the NHSC. which has placed more bution efforts. Some AHECs have come to play a central coordination and research role for rural than 16,500 health professionals in underserved areas since its inception in 1971, has decreased health in their home States. dramatically in recent years. This decrease will Medicare Reimbursement Strategies mean a drastic reduction in the number a NHSC field staff available for placement in a relatively The implementation of RERVS for physician stable number of designated shortage area.s. payments under Medicare will probably enhance the incomes of most rural physicians. The full The NHSC Scholarship Program, which has been almost entirely defunded, was highly impact of the ne w payment system will not be felt tor successful in placing personnel in shortage several years, and it is not yet possible to predict its areas. The Scholarship Program may be a impact on rural physician supply. particularly appropriate incentive for health The impact of the Medicare Physician Bonus professionals who would not be candidates for Payment Program, recently expanded to provide a loan repayment due to lower levels a educa- 10 percent bonus on Medicare payments for all tional debt (e.g., MI-Ps, nurses). The scholar- physician services provided in all rural primary ship program also provides valuable opportimi- care HMSAs, is also unknown. Current reporting ties for students who are eccnonucally disad- requirements are too minimal to enable an e- aim s antaged. Targeting scholaship funds to MI-Ps tion of the program's impact. A 10percent bonus un rather than to physicians might increase the Medicare payment may be a sufficient incentive for total number of scholarships awarded without physicians to stay in HMSAs, but it is not likely to increasing overall expenditures. 3 3 368 Health Care in Rural America The NHSC Federal Loan Repayment Program a.4 -Tung new strategies to recruit and retain medical has placed mostly physicians; probably due to and other staff. To date, however, many of these poor information dissemination, it was unsuc- strategies (e.g., linking salaries to productivity) have cessful in attracting many MLPs. been limited by fmar.tial and administrative con- The NHSC State Loan Repayment Program has straints. It is too early to evaluate the impact of not been adequately tested. Only seven States Federal grant funds made available io C/MHCs in have been awarded funds, and they had insuffi- fiscal year 1989 for recruitment and retention cient time in 1988 to award contracts. activities. The NHSC Volunteer Recruitment Program, which began in 1988, has had notable success State Acthities in placing physicians and other health person- States responding to an OTA survey ranked nel in lower priority HMSAs, but it might have personnel issues as the most pressing rural health a greater impact if additional incentives were problem. Thirty-eight of 50 States responding to the available to providers to locate in these areas survey were involved in personnel recruitment and if additional recruitment staff were availa- activities, most of which were directed at physician ble. recruitment. Several States reported unsuccessful In 1988 and 1989, the 750 physicians recruited attempts to recruit NPs and PAs. through the NHSC Federal Loan Repayment and States use a wide range of recruitment methods, Volunteer Programs represented only 18 percent of including service-contingent loan forgiveness and the estimated number of physicians (4,104) needed scholarship programs, other financial incentives, to remove all primary care HMSA designations in =al-oriented health profe sions education, selec- 1988. The Scholarship Program will place only 74 tive recruitment of students, technical assistance in practitioners (including nonphysicians) in 1991. practice development and maintenance, and place- Reductions in the number of NHSC commissioned ment services. The most effective State Programs officers and NHSC-salaried civilian field staff also are those that employ multiple strategiese.g., a seriously limit the ability of the NHSC to place scholarship or loan repayment program which both personnel in areas of the most critical need. Many places personnel in needy areas and provides them NHS C sitesparticularly federally funded OM HCs with ongoing financial or technical support. Service- are faced with the impending loss of obligated contingent programs with high buyout penalties NHSC physicians for whom there will be no seem to be effective for temporary recruitment of replacements. health personnel to shortage areas, but retention of Private Sector Strategies these personnel may require additional commitment of resources. Cooperation among existing programs Rural hospitals may use fmancial incentives to is key to program success. attract physicians to the area. Such incentives State level of effort in rural health personnel include guaranteed income, free office space, and loans; but the current vagueness of Medicare's recruitment and retention varies widely and does not antikickback provisions can make these strategies correlate with measures of ruralness or measures of need State activity in and contributions to health dangerous for hospitals. Faced with the threat of professions distribution progams have increased future nurse shortages, hospitals are also focusing on significantly during the last decade, but many States nurse retention issues. For mral areas, key issues for still rely heavily on Federal dollars to fund these hospital nurse recruitment and retention include efforts When asked what Federal programs had access to continuing education and opportunities for been effective in improving health services availa- career advancement. bility in rural shortage areas, State officials most Federally funded C/MHCs, faced with the im- frequently mentioned the NHSC, C/MHCs, the pending loss of 800 NHSC physicians in 1990, are Rural Health Clinics Act, and the AHEC program. 0 - Chapter 14 Conclusions: The Availability of Health Personnel in Rural Areas 3 13 CONTENTS Page SUPPLY OF HEALTH PERSONNEL 371 IDENTIFYING SHORTAGE AREAS: FEDERAL AND STATE EFFORTS 372 RECRUITMENT AND RETENTION OF RURAL HEALTH PERSONNEL 372 Educational Strategies 373 Financial and Professional Strategies 374 Strategies for Acute and Chronic Shortage Areas 375 Chapter 14 Conclusions: TheAvailability of HealthPersonnel in Rural Areas SUPPLY OF hEALTH PERSONNEL shortages are impossible to determine, evidence shows that a substantial number exist: Although the supply of health professionals is telatively lower in rural than in urban areas, it is * In 1988, 111 counties, all of which were rural, probably nonetheless adequate in many rural areas. had no professionally active physician (511). Some rue, areas, however, continue to have severe As of December 1988, over 16 million people shortages oi health professionals, even in she face of (29 percent of the U.S. rural population) were recent growth in national supply. Their situation is residing in federally designated rural primary likely to worsen unless targeted efforts are made to care Health Manpower Shortage Areas (BMSA5). attract health care providers. Other rural areas may In comparison, only 9 percent of urban resi- also face inadequate supply in the future due to dents were located in urban primary care slower growth in national supply and competing IrtvIS As (665 ,686). If residents of qualifying demand for primary care providers in urban areas. but wide 'vitiated areas were included, the numbers would be even larger. Rural ILMSAs Physician supply has increased over time in both are concentrated in the South and in the West urban and rural areas. In fact, during the past decade, North Central and Mountain States. the most populated rural (nonmetropolitar.) counties Nearly 1,800 primary care providers (physi- experienced even greater growth in phy sician supply ...lam or midlcvel practitioners) w ould be needed than did urban counties. However, rural areas in to eliminate rural primary care prov ider short- general still have fewer heolth professionals per ages in designated HMSAs (665). capita than does the Nation as a whole, and tia: The number of mral primary care HMSAs has least populated counties have the fewest. In 1988, not changed appreciably during the past dec. for example, nual counties had fewer than one-half ade. IS many patient care MDs per capita as did urban counties, and small rural counties1 had fewer than Current national shortages of midlevel practi- one-fourth as many. Between 1979 and 1988, rural tioners (Mills)/ registered nurses (RNs), and counties with fewer than 10,000 residents had a 17 allied health professionals (AHPs), along with percent increase in the number of patient care projected national shortages of dentists, will simi- physicians per capita, compared with 25 percent in larly have a disproportionately negative effect on the largest rural counties and 24 percent in the smaller rural communities. The shortage of these United States as a whole (686). Reductions in the personnel, coupled with Mure declines in primary number of new National Health Servio- Corps care physician supply, may have serious implica- (NHSC) placements may further slow the diffiision tions for the availability of basic health care in some of physicians to less populated rural areas. rural communities. Most rural phyc.cians are primary care physi- Assessing rural health personnel availability, cians.2 Unlike most other specialties, the future particularly for no physicians, is severely hampered supply of primary care physicians is in danger. by lack of national data. There are no recent national Projected shortages will disproportionately affect data available on the rural/urban distribution of smaller rural areas. AHPs. Data OP. licensed practical/vocational nurses (LP/V/45) are also old, and national data on nurse Although the exact number and location of vacancies generally are limited to hospital and communines with acute or persistent physician nursing home settings. Infortnativn on the diATibu. 1Noameuo counties with fewer than 10.000 resideMs. 20steopathic physicians make up a substanual propotlion of thcA prunary -a4 phy4o.a0S. parlo.ulaity io small rural -vuows Includes nurse practitioners, physi..ian &swam. -ertified nurse-midwives. and certifi4 zogislard nurse anesthetists 371 lion of physician assistants (PAs), certified nurse- critical. State criteria and designations are more midwives (CNMs), and optometrists is only availa- likely than Federal designations to be sensitive to the ble by community size and does not permit raral/ needs of specific areas, address specialty shortages, urban distinction.Itistherefore impossible to and respond quickly to changes in local conditions. integrate or compare data on the distribution of these Programs that use provider-based designations proftssionals with data on physicians. The common belief that PAs are more likely than physicians to such as the HMSA to target resources should recognize the vulnerability of small rural areas to locate in rural areas, for example, cannot be con- dedesignation. Small rural areas can lose their firmed with currently avaiiable data. designation, and all associated resources, with the gain of even a single physician. One way to ensure IDENTIFYING SHORTAGE AREAS: that the effects of these programs are long-lasting FEDERAL AND STATE EFFORTS might be to provide time-limited incentives that are tied only to the initial desivation status of the area. 'lb target limited resources effectively, Federal Alternatively, designation status might be main- and State governments must be able to identify tained for a specified "grace period" after changes needy areas Although much progress has been made that would otherwise precipitate dedesignation have during the past decade in developing criteria for this occuned. purpose, Federal and S tate governments need to coordinate and expand their efforts in order to RECRUITMENT AND RETENTION identify shortages of a wider range of health proftssionals in a manner more sensitive o local OF RURAL HEALTH PERSONNEL conditions. The iuture availability of health personnel in rural Existing Peden...1 designations can identify short- areas depends a: two factors. First, a sufficient age areas nationwide according to a single set of number of health professionals must be appropri- basic criteria. However, they have a number of ately trained to practice in rural areas (e.g., trained as limitations: generalists or primary care specialists). Second, rural areas must be able to attract and retain these Medically Underserved Area (MUA) designa- personnel. tions have not been reviewed since 1981. The incentive to apply for designation has Personal and professional concerns play at least av great a role as financial concerns in the location probably decreased due to the reduced availa- bility of Federal resources that flow to desig- decisions of health professionals. Educational, nated areas and to a lack of State and local fmancial, and other interventions must therefore work in concert to improve the attractiveness of mral resources needed to identify areas. In 1986, for example, there were 95 mral counties not practice. Strategies that have demonstrated effec- tiveness in improving the recmitment and retention designated as HMSAs although they qualified on the basis of whole-county physician-to- of rural health personnel in the past include: population ratios (511).4 rural-oriented health professions training, Federal criteria do not currently take into selective recruitment of students with mral account measures of health care access such as backgrounds or with interest in rural practice, the level of insurance coverage in the area, service-contingent scholarship and loan repay- which can have a significant impact on the ment programs, and availability of services to the population. networks to provide continuing education and HMSAs and MUAs are very general measures professional consultation to health profession- and cannot adequately identify local shortages als in remote areas. of particular providers or specific types of The Federal role in these strategies can be direct services (e.g., obstetric care). (e.g., placing personnel in underserved areas) or an Even with a more coordinated and active Federal indirect role of initiation and encouragement (e.g., designation program, State bwolvement will be through support of rural health professi.ms educa- AMDs only. Chapter 14Conclusions: The Availability of Health Personnel in Rural Areas 373 tion and State loan repay ment or scholarohip pro- nursing education in rural areas w ere improved, rur .1 granu). practice might be more attractive to nurses, and the supply of advanced practitioners (e.g., NPs, CNMs, Educational Strategies and certified registered nurse anesthetists) could increase These practitioners, along with PAs, are Educational strategies can enhance the supply of crucial providers in rural areas without enough rural health professionals by overcoming some of the personal and professional bathers to rural physic ians. practice. These barriers include a lack of opportuni- Specia nonphysiCan programs to target might ties for professional consultation, continuing educa- incluae: tion, or career advancement. Educational interven- tions can also help health professionals feel more programs to i.. 7ade rural LPIVINIs to RNs; confident practicing in semi-isolation. The Federal programs through which nual RNs can earn Government can pursue educational strategies by bachelor's degrees; targeting its health education resources to primary programs to train rural RNs as NPs, nurse- care and rural-oriented programs and by supporting midwives, and nurse anesthetists; rural continuing education efforts. PA training programs; rural-oriented dental education programs; The supply of rural physicians is greatly depend- crosstraining programs for certain AHPs; and ent on the supply of primary care physicians, but multidisziplinary training programs with arum: existing trends increasingly result in medical stu- focus. dents' seeking other specialties. The current trend away from primary care medical specialties is linked Federal p.ecedents exist for almost Al of these to professional and fmancial concerns of medical programs, 'Jut few of them have a rural set.aside or graduates, as well as to reduced availability of specific standards for participating rural programs. residency training slots. Targeted Federal funding Although data are scarce, it appears that shortages for primary care undergraduate and graduate medi- of some AHPs are especially critical in rural areas. cal training programs can give these programs a General rural shortages are compounded by the fact greater advantage, but such funding has decreased in that many rural facilities cannot suppoit specialized recent years. Weighting Medicare funding for gradu- AliPs on a full-time basis. The training and use of ate medical education would probably have an even greater impact on the redistribution of resources multiskilled AHPs, however, are hindend by strict licensure requirements, inflexible hospital staffing towards primary care specialties, although it would requirements at both the State and Federal levels, probably encounter some political opposition. and a lack of formal educational programs. To Ta increase the supply ofrural primarycare address these issues, training programs could coor- physicians, targeted funding could be used to dinate with State licensing boards in examining ne vi develop and expand rural-oriented training pro categories of AHP licensure, Federal and State grams, which have been effective in placing their autLuities could examine facility staffing require- graduates in underserved rural areas. Current Fed- ments, and Fet'eral oi State assistance could be eral funding for primary care medical training provided to establish local training programs and supports some rural-oriented training programs, but support trainceships in rural community colleges or there is neither a specific set-aside nor a specific set hospitals. of curricular requirements for these programs. To Continuing education, which is required for ensure effectiveness, nual program funding might licensu. e of many health professionals, is particu- be tied to specific curricular components and/or to some measure of outcome (e.g., proportion of larly difficult :to obtain in rural areas,either due to unavailabilit, of accredited programs or thc inability graduates plar* 'a rural areas). of rural practitioners to find temporary replacements Educational strategies are also key in the recruit while they attend pror...iis. The Federal Area ment and retention of many nonphysician health Health TAucation Centers (AHEC) Program pro- personnel. If iIre training programs were located in ides , mechanism foi adde ...sing continuing educa (or provided same training in) rural sites, more flif41 tion Leeds in rural areas, but its influence is not students could be recruited. If access to advanced universal. Telecommunications can also be used to 3 )7 374 Health Care in Rural America provide continuing education, but programs are ment in such programs, but its financial support has expensive to develop and do not exist for many types decreased considerably during the past decade. of health professionals. Time-limited tax incentives, lump-sum bonuses, Improved telecommunications networks can re- or other aid in practice for physicians, MLPs, and duce professional ixdation, improve quality of care, nurses in rural shortage areas may also help to offset and improve personnel recntitmeitt and retention by educafion and practice expenses and income disin- linking providers in remote areas to educational and centives. Such incentives could be tien to a limited consultative resources. A number of model networks service obligation and could be recaptured if the see already in place. The equipment and training individual were to leave the area before the end of his costs of starting such networks can prohibit their or her obligation. development and successful implementation, how- ever, and support may be needed to extend the The fmancial disadvantages of rural practice for benefits of telecommunications to practices and physicians include fewer opportunities for salaried facilities that lack them. practice and perceived lower practice income. Rural practitioners may face additional expenses such as AHECs provide both rural-onented chmcal edu- travg to service sites and to required continuing cation experiences and continuing education for a education programs. Also, since a higher proportion variety of health professional trainees. The Al4EC of rural than urban residents lack health insurance, program is an excellent example of how Federal private phyi kian3 in meal practice may handle support can encourage State and local participation higher volumes of uncompensated care. in activities addressing the geographic maldistnbu- lion of all varieties of health professionals. Existing Some Federal policies that address these financial AHECt might be used as coordination points for disincentives are already in place. For example, other Federal health professions distribution pro- Medicare's newly adopted method of paying physi- grams operating within or near their service areas cians, the resource-based relative value scale, will (e.g., the NHSC and federally supported rural- probably increase primary care physicians' incomes, oriented health professions training programs). although its ultimate effect on rural physician supply remains uncertain. Financial and Professional Strategies Medicare bonuses for physician services deliv- Health professions students may be dissuaded ered in rural primary care HMSAs can also ease the from primary care specialties by high levels of financial burden of rural practice for some physi- indebtedness, perceived higher incomes in the non- cians, but again, the actual impact of this program on primary rare specialties, and other concerns. In rural physkian availability is unknown. To improve addition, the high costs of education and reduced the program's accountaLity and the abilityto availability of scholarship aid may prevent economi- evaluate its effect:., mess, reporting requirements cally disadvantaged rural students from pursuing and program evaluatiun could be made nore rigor- health careers and returning to practice in nual areas. ous (e.g., include ev aluation of the characteristics of physicians who are availing themselves of the Strong financial incentives may be needed to bonus). Thc effect of Medicare's bonus payments attract new physicians and other health professionals might be further i-iproved if States provided similar to underserved rural areas. Remote communities bonuses under Medicaid, expanding both the will have increasing difficulty finding young physi- strength of the incentive aad the number of physi- cians who are willing and fmancially able to cians it reaches. establish a private practice. Programs that help students offset the high costs of education by direct MLPs are well-suited for practice in low-density fmancing (e.g., scholarship programs) or by absorb- and underserved areas. The apparent recent trend ing accrued debt (loan repayment programs) would among some MLPs toward urban practice is unfortu- help to alleviate these problems. Such programs nate for rural areas, particularly fox tht.me that may could be tied to a service obligation and/or to not be able to attract and suppoit theservicesof participat;ln in rural-oriented training programs. physicia.is. Rural areas would probably be more The Fedetal Government has a history of involve- attractive to 211LPs if existing barriers to autono 3 k -:. Chapter 14Conclusions. The Availability of Health PersonnelinRural Areas 375 mous practice were addressed Such bathers in- of these in rural areas. In 1988-89, however, the clude: NHSC placed 750 volunteer or loan repayment physiciansinHMSAsonly 18 percent of physi- limited opportunities for Medicare, Medicaid, and other third-party reimbursement; cians needed to remove those shortages.5 The State restrictions on scope of practice and number of obligated scholars continues to wane; only 74 will be available for placement in 1991. professional autonomy, especially for PAs; Although MLPs at one time represented a substan- lack of access to continuing education in rural areas; tial proportion of NHSC field staff, the IiIHSC has placed very few in recent years. malpractice liability insurance costs; and lack of acceptance by the medical profession. All elements of the programscholarship, loan repayment, and volunteerare needed to maximize Improved Medicare and Medicaid reimbursement the program's effectiveness. Loan repayment can for MLPs could increase the number willing and able attract health professionals with high debt loads to practice in remote settings. The Rural Health (e.g., physicians and dentists) and can draw them to Clinics Act (Public Law 95-210), which piomotes shortage areas immediately. Scholarships ma., be the use of MLPs by guaranteeing indirect Medicate more effective for recruiting health professionals and Medicaid reimbursement for their services, has not been implemented in many aress due to regula- who spend less time in training and have lower debt loads. Scholarship programs also provide opportuni- tory barriers, resistance from the medical profession, or simply through lack of interest or awareness of ties to students who would otherwise be unable to finance their education. 'lb improve the retention of eligibility criteria. NHSC personnel, scholarships and loan repayment Reimbursement policy needs tu be carefully could be targeted to students in rural and primary coordinated with Sate practice az. ts to allow for .are-oriented training programs and to students from professional autoaomy while maintaining quality rural and undersen-ed areas. The volunteer progiam and effectiveness throu h an adequate level of could be more effective if it offered additional physician oversight. State regulatory changes could incenthes to providers locatmg in HMSAs, and if be guided by State or Federal models, and they could additional recruitment staff were available m the be influenced through Federal Medicaid policy. Federal and regional offices. Many States are heavily involved in health Strategies for Acute and Chronic picifessions recruitment. Because their efforts are Shortage Areas more localized than federally adminismred pro- grams, State loan repayment and sch-larship pro- Even with an adequate supply of health profes- grams might often be more effective in recruiting sionals, many communities will continue to have great difficulty recruiting providers; either because and retaining nual health professionals. They may they lack a suffitient population base to support a also be in a better position to coordinate efforts from various entities in the State to provide ongoing pradico or because they are otherwise perceived to be unattractive locations. Such areas are unlikely support for personnel serving in shortage areas The NHSC State Loan Repayment Program might en- to be able to maintain adequate health care access hance these efforts; however, this fledgling program without some degree of State or Federal interven- has not been given an adequate trial and has not been tion. able to demonstrate its full potential. In addition, The cotherstoae of Feclet.ii efforts to address under its current structure, this program limits the chronic health personnel shortages has been the types et personnel Stat-s can recruit to those with NHSC. The NHSC has tremendous potential for high debt loads (e.g., certain physicians). If fouds improving the short-term and long-term supply of could also be used for scholarships, States tould providers in such areas, but its effectiveness is recruit a wider range of health pro:essionals. The presently limited by funding constraints. In Decem. Federal 4....mponents of the NHSC are important foi ber 1988 an estimated 4,104 primary care providers plac..e, personnel in areas nut reached by State were needed to remove HMSA designations, 1,794 efforts. Me proportion who wore placed in nonmetro HMSAs is unknown. 20-810 0 - 90 - 13 0L3 1-) In addition to the NHSC, the Federal Governmeat ir. these areas. Such puhuies might include promot- could enhance personnel availability in nual areas of 4 Medicare certiEcation of rural health chnics and chronic shortage through policies that promote encouraging States to oN, ercome barriers to MLP satellite clinics, particularly those statied by MLPs, practice. Part V Two Examples of Specific Services 4i) 1 Chapter 15 Maternal and Infant Health Services in Rural Areas CONTENTS Page INTRODUCITON 379 MATERNAL AND INFANT HEALTH INDICATORS: URBAN AND RURAL DIFFERENCES 379 Infant and Fetal Mortality 379 Low Binhweight and Prematurity 387 Fertility 388 Maternal Mortality 388 MATERNAL AND INFANT SERVICES IN RURAL AREAS 389 Use of Prenatal Care 389 Access to Rural Maternal and Infant Care 390 MODEL RURAL MATERNAL AND INFANT SERVICE PROGRAMS 410 SUMMARY AND CONCLUSIONS 412 Boxes Box Page I5-A. Obstetric Provider Availability: Selected State Reports 391 I5-B. Selected State Response to Obstetric Shortages and Malpractice Insurance and Liability Issues 397 Figure Figure Page 15-1. Medicaid Coverage of Pregnant Women and Infants. April 1990402 405 Tables Tabie Page 15-1. Selected Cause-Specific Infant Death Rates for Metro and Nonmetro Areas Adjusted for Race, 1987 380 15-2. Fetal and Infant Health Indicators by State and Metropolitan/Nonmetropolitan Area, 1985-86 381 15-3. Infant Death Rates and Fetal Death Ratios by Race in Metropolitan and Nonmetropoatan Areas, 1987 387 15-4. Percent of Births That Are Low Birthweight and Pretemi by Metropolitan and Nonmetrepolitan Areas, 1986 388 . 4 15-5. Fertility Rams by Metropolitan and Nonmetropolitan Residence, 1988 389 15-6. Maternal Mortality by Metropolitan and Nonmetropolitan Residence and Race, 1986 389 15-7. Live Births by Month Prenatal Care Began, by Race and Residence, 1987 390 15-8. Painatal Health Care Indicators in Poor Rural Countries 391 15-9. Live Births by Type of Birth Attendant, by Race and Place of Delivery, 1987 392 15-10. Ratio of Active MD General/Family Practitioners, Active MD Obstetrician/Gynecologists, Active MD riediatricians, and Active DOs per 100,000 Reproductive-Age Women by State and Census Region and Division, 1987-88 393 15-11. Number and Resident Population of Nor.metropolitan Counties Without an Active General Practitioner, Family Practitioner, or Obstetrician/Gynecologist, by Region and State, 1988 195 15-12. Percentage of Family Physicians Who Care for Obstetric Patients at Various Le/els, by Metropolitan/Nonmetropolitan Arca and Census Region, July 1988 396 15-13. Percentage of Active AAFP Members Who Perform or Do Not Perform Routine Obstetric Care in Their Hospital Practice, by Region and Location of Practice, 1988 399 15-14. Adequacy of Prenatal Care for Medicaid Recipients and Uninsured Women, by Area of Residence, 1986-87 401 15-15. Barriers to Earlier or More Frequent Prenatal Care Cited by Medicaid Recipiems and Uninsured Women Who Had Recently Delivered, 1986-87 402 15-16. Insurance Coverage of Women Aged 15 to 44 Years, by Residence and Marital Status, 1985 404 15-17. Strategies To Streamline Medicaid Eligibility, January 1990 406 15-18. Proportion of Community Hospitals Reporting In-Hospital Births, by Hospital Bed Size and Location, 1987 408 15-19. Average Number of Deliwries in Metropolitan and Nonmetropolitan Community Hospitals, by Bed Size, 1987 408 15-20. Mothers With Ultrasound and EJectronic Fetal Wareing During Pregnancy or Labor, 1980 409 15-21. Proportion of Community Hospitals With a Neonatal Intensive Care Unit, by Hospital Bed Size and Location, 1987. 410 4 03 Chapter 15 Maternal and Infant Health Services in Raral Areas INTRODUCTION Carolina were among the States with high black infant mortality in rural areas (19.9 and 19.6 per Nearly a million babies are born each year' in 1,000 births) (table 15-2). Causes of infant death rural America. Maternity care for women and vary somewhat by urban and rural residence. In newborn care for infants are basic components of the 1987, infant death rates4 attributable to conditions health care gystem and, like emergency services, are originating in the perinatal period, such as respira. considered essential to a community's public health wry distress syndrome, were somewhat lower, but (207). Yet there is evidence that many rural commu- deaths caused by congenital anomalies, sudden nities have lost or are losing the capacity to provide infant death syndrome (SIDS), accidents, and pneu- these basic services their residents (525). Provid- monia were somewhat higher in rural than in urban ing maternal and infant services in rural areas can be areas (table 15-1). difficult, particularly in areas of very sparse popula- tons, because specialized providers and technolo- In 1987, infant mortality rates were 2 percent gies may be required. Further, transportation sys- higher for whites but 8 percent lower for blacks in tems must be available when obstetric emergencies rural than in urban areas (table 15-3). Neonatal occur that require the advanced systems of care deathsthose occurring in early infancy, before the usually found in urban areas. 28th day of lifeoccur at about the same rate for urban and rural whites, but the rate for blacks is 10 This chapter reviews the status of rural maternal percent lower in rural than in urban areas. Post- and infant health, evidence of problems in access to neonatal deathsthose occurring in later infancy, and availability of obsteinc services and providers, from 28 days to age oneare 10 percent higher for and Federal interventions that affect access to whites but 3 percent lower for blacks in rural than in maternal and infant care. Lastly, the chapter de- urban areas (table 15-3).5 The lower neonatal death scribes selected maternal and infant care programs rate in rural areas is offset by higher fetal mortality. that have been effective in improving access to care Petal mortality ratios6 were 6 percent higher among in rural areas. whites and 14 percent higher among blacks in rural than in urban areas (table 15-3).7 MATERNAL AND INFANT HEALTH INDICATORS: URBAN The apparently higher incidencf fetal deaths in rural areas couM be onease of rt...atively low rural AND RURAL DIFFERENCES neonatal death rates. It inay be that babies who Infant and Fetal Mortality would die at or before birth (and would be reported as fetal deaths) in rural areas would be successfully In 1987, infant mortality2 was 2 percent higher in resuscitated and live for short periods of time in niral than in urban areas (10.07 v. 9.88 deaths per urban areas. When fetal and neonatal deaths are 1,000 births) (table 15-1).3 In 1985-86, Wyoming, combined (perinatal deaths), rural perinatal mortal- Idaho, and Maryland were among the States with ity ratios are 2 and 3 percent higher than urban ratios high white infant mortaiity in rural areas (11.3, 10.8, for blacks and whites, respectively. Interpreting the and 10.8 per 1,000 births), and Georgia and South differences in urban and rural fetal mortality is tin 1987, 22 pacent of babies 039.335 of 1809.394) were born to rural (nonmetropolhan) residents (650) :Infant mortality, as measured by the infant mortality rate. is tbe annual number of deaths of infants less than I year of age. divided bythe annual number of livc butbs (IS) 3Infant mortality rates were standardized for race (white. Mach, other race) using methods descnbed by Das Gupta (159) 4Cause.specific infant death rates were adjusted to account for differences in the distnbution of racial groups in urban and rural areas (1$9) 4.1..xonatal Mortality accounts for 65 percent of all infant deaths. The leading causes of neonatai atonality arc low birthwagln, premalunt y. and congenital anomalies, wtuk the leodmg causes of postneonatal mortality are SIDS, congenital anomalies, and accidents 017) elle feud mortality ratio is delmed as tbc annual number of fetal deaths (of 20 woks or more gestation) divided by the annual number oflwe births (15.647). Vaal, neonatai. and posmeonatal monaluy ratios/rates are shown for urban and rural areas by Mate in table 15.2 -379- 4'r4 Table 15-1-Selected Cause-Specific Infant Death Rates tor Metro and Nonmetro Areas Adjusted for Race, 19872 Metro Nonmetro Percent Percent Number of of all Death rate Nurher of of all Death tate Cousin of death deaths deaths (Per 1.000) deaths deaths (per 1,000) All causes 30.157 100.0 9.88 8.251 100.0 10.07 Conditions originating in the perinatal periodh 14,514 48.1 4.71 3,556 43.1 4.39 Short gestation and low birthleighta 2.799 9.3 0.89 555 6.7 0 70 RespiratorY distress sYndrome 2.597 8.6 0.86 686 0.3 0.84 Other respiratory conditions of neWborn° 2.813 9.3 0.92 743 9.0 0.91 Congenital anomaliesf 6,053 20.1 2.03 1,831 22.2 2.19 Sudden infant death srldromell 4,010 13.3 1.32 1,220 14.8 1.48 Accidents end adverse effectsh 654 2.2 0.21 296 3.6 0.36 Pneumoniai 519 1.7 0.17 147 1.8 0.1A aRates wore standardized using the method described by Das Gupta in "A General Method of Decomposing a Difference Between Two Rates Into Several Components," Demoaraphr, vol. 15. No. 1, February 1978, pp. 99-112. hThese conditions originating in the perinatal period include International Classification of Diseases MD/ (Ninth Revision) 760-779 *These conditions originating in tha perinatal period include ICD 765, dThis condition originating in the perinatal per.od includes ICD 769. aThese conditions originating in the perinatal period include ICD 770 f Congenitalanomalies include ICD 740-759. 0Sudden infant death syndrome includes ICD 798.0. hAccidents and adverse effects include E800-E949. 'Pneumonia includes ICD 480-486. SOURCE: U.S. Department of Health end Human Services. Centers tor Disease Control. National CenLer for Health Statistics. 2110.1 Statistics of the United Statea. 1987. vol II. MortalitY, Part B 1989, DUNS Pub No (PHS) 89-1102. table 2-15 (Washington. DC: U.S. Government Printing Office. 1989). 4 40 Table 15-2Fetal and Inbnt Health Indicators by State and MetropoiitanlNonmetropolitan Area, 1985-86 Infant Neonatal Post.neonetal Fetal Perinatal Low-hirth- State mortality rate4 mortality ratab mortajty ratec mortality ratio _mortality ratio° weight ratef_ by region Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro NonmetrG Kew England Maine... .. 10 1 7 5 6 9 5 0 3.2 2 5 6 3 5 8 13 2 10 6 5 3 4 9 Nhite 10 2 7 6 7 0 5 1 3 2 2.6 6 3 5 9 13 3 10.9 5 2 4 9 Bleck...... - - New Hampshire 8 $ 10 3 $ 7 6 9 2 8 3 6 5 3 6 0 11 0 12 7 4 0 5.4 Nhite 8 6 10 2 5.8 6 7 2 9 3 5 5 4 6 0 11 2 12 7 q 8 5 4 Black.. .. ------Vermont.... 9 9 9 0 6 0 3 0 6 4 13 6 12 4 5 3 5 6 Nhite 10 0 6 8 5 9 2 9 6 4 13 8 12 3 5 2 5 5 Black ... ------ Massachusetts 8 8 6 8 6 2 5 7 2. £ 3 1 6 6 6 ) 12 f 12 1 $ 8 4 Nhite .. 7.9 8 9 5 7 5 8 2 3 - 6 2 5 5 :: 9 12 3 5 4 4 5 - - - , Black . 19 8 14 0 5 8 11 7 25 7 10 6 Rhode Island 61 8 6 1 2 5 0 1) 14 3 6 5 4 5 White 3 4 6 0 2 4 7 6 13 6 6 1 4 1 Blaek - 11 6 Connecticut 9 7 7 3 7 5 5 1 2 2 6 9 4 P 14 4 9 8 6 7 5 6 White .. 9 z 7 4 6 3 5 .3 I 4 6 2 4 7 12 5 9 9 5 6 5 7 Black.. . 19 8 l!' 4 4 4 '1 6 20 I) 3 Middle antic New Yt . 10 9 9 3 / s 6 4 1 4 a 4 0 9 A C 17 4 14 4 73 5 5 Nhite 9 3 9 2 5 6 5 1 2 7 2 g 8 6 8 0 15 4 14 3 5 7 5 S Black 16 4 ID 7 5 / 14 4 44 6 12 3 9 1 New Jersey 10 4 7 9 7 0 5 A 3 4 2 1 6 1 6 0 15 1 11 8 7 0 5 5 7 ; ", 4 Nhite.. . 8 4 5 9 5 6 2 5 2 3 7 0 12 5 11 5 S 5 S 2 Black 18 7 11 8 5 5 12 '4 24 0 12 4 11 '1 Pennsylvania 10 8 9 4 7 4 6 1 3 4 3 5 8 9 8 1 16 3 IS 2 6 g 5 / White 8 9 9 1 6 2 0 3 2 7 .3 4 8 0 8 8 14 2 lc 1 5 5 5 7 , Black 20 1 - 13 5 6 6 li 2 26 7 13 6 11 7 NOTE Batasarenot shown for areas with fewer than an ovehtF. Hyphens ( ) are used tc, denoto Iowa: than 30 ovents (Continued on ne4 page) 4.17 4 ."=) Table 15-2-Fetal and Infant Health Indleators by State and Metropolltan/Nonmetropollt an Area, 1985-86-Continued Infant Neonatal Post-neonatal Fetal Perinatal low-birth- State mortalit, rate mortality rate, mortality rate mortality ratiod mortality ratio weiaht rate loy region Metro No..motro Metro Nonmotro Metro Nonmetro Metro Nonmetro Metro Nonmittro Matro Nonmotro Nebraska 10.2 9.5 7.0 5.9 3.3 3.6 14.2 13 4 5 8 5.1 ::White 8.9 9.3 6.3 5.8 2.7 3.4 6.7. 7 12.0 13.2 5.1 5.0 Black 19.4 11.4 - 12.5 23.9 11 6 Kansas 9.6 8.8 6.0 5 1 3.6 3.6 6.4 6.7 12.4 11.7 6.5 5.9 White 9.0 8.5 5.7 5.0 3.3 3.5 5.9 6.4 11.6 11.3 Black 15.2 0.2 . 10.9 * 20.1 - 1::: ::: South Ataantic Delaware 14.4 10.9 10.6 8.2 3.8 2.7 6.6 8.5 17.2 16.8 7.5 7.2 White 11.0 10 1 8.1 7.9 5.6 6.4 13.7 14.3 5.8 6.0 Black 26 8 19.5 - 29.4 23 5 13 5 10.9 Maryland 11.8 12.1 8.3 7.7 3.5 4.4 8.3 7 1 16.6 1..8 7.8 6,6 tilito 9.1 10 8 6.2 6.8 2 9 3.9 6 4 6 7 12.6 13 6 5 5 5.3 Black 18.2 16.5 13.3 10 5 4 9 12.7 26.0 18 8 12.6 11.7 , rAltrict of Columbia. 20.9 16.6 4 9 12.4 28.4 - 12.7 - ohito. 12.0 9.1 - - 14.4 - 5.1 - Blaea 23.9 18.3 5.6 14 5 - 32.8 14 7 Virginia 11.5 10 5 8.1 6 7 3.., 3 8 10.2 12.1 18.3 18.8 7 0 7.1 White. 9.2 8 8 6 5 5 6 2 8 3.3 6 4 :0.7 14.9 16.2 Black 18 8 17.6 13.4 11 7 5 4 5 9 16.1 18.2 29 5 29 9 1:.; 1::: West Virginia... 9.7 10 9 6.6 7.2 3.1 3.7 7 6 8 3 14.2 15 3 6 2 7.4 Whits 9 3 10.4 6.3 6 8 3 0 3 6 7,3 8.4 13.6 15 2 5.4 7.1 _ _ - _ Black - - 9 8 12.9 North Carolina.. 11 5 11.8 7 9 7 4 3 6 4 4 8 1 9.2 16 1 16.7 77 8 2 White 9.7 8.8 6 7 5 5 3 0 $.3 6 7 7 6 13 4 13.2 5 9 6.2 Black 17.2 18 1 11 8 11.8 5,4 6.3 12.3 12.5 24.1 2..3 12.5 12.3 South Carolina 13 1 14.6 9 2 9 / 3.9 5.0 10.1 11 1 19.3 20 8 8.2 9.2 White 9.7 10.2 6.7 6 9 3.1 3 3 7.6 7 9 14.3 14 8 6.0 6.0 Black 20.2 19 6 14.6 12.7 5,6 6.9 15 3 14.6 29 8 27.4 12.6 12.7 Georgia 12.0 13.4 8.3 9 0 3.7 4.5 11.1 12.8 19.4 21.8 7.9 8.4 White. . 0,1 10.1 6.3 6 9 2 8 3.2 8.5 11.0 14.8 17.9 Black 17 9 19.9 12 3 13 0 5 6 6.9 16.0 16.3 28.3 29.3 1::: 1::: Florida 11.0 11.8 7.4 7.0 3.7 4.8 8.5 9.0 15.9 16.0 7 6 7.2 White 8 8 10.4 6.0 5.9 2.8 4.5 6 9 7.1 12.9 13 0 6.0 5 8 Black 18.1 17.2 11.6 11.1 6.3 6.1 13.5 16.2 25.3 27 3 12.6 12.4 4 OTE: Rates are not shown tor areas with fewer than 30 events. Hyphens 4-) are used to denote fewer than 30 events. 410 Table 15-2-Fetal and Infant Health Indicators by State and MetropolltanINonmetropolltan Area, 1985-86--ContInued Infant Neonatal Post-neonatal Fetal Perinatal Low-birth- State mortality ratea ,mortmlityrate mortality ratec mor alitY_ratiod mortality ratioe wuiAllt rates by region MetroNonmetro Metro Nonmetro MetroNonmetro MetroNonmetro MetroNonmetro MetroNonmetro T.440. Mama Central Ohio 10.0 9.9 6.9 6.2 3.7 3.(, 7.4 7.2 14.4 13.5 6.8 5.8 White 9.3 9.7 6.1 6.1 3.2 3.6 6.7 7.1 12.8 13.3 5.7 5.7 Black 17.2 11.0 - 6.2 11.1 22.1 21.0 12.1 8 3 Indiana 11.4 10.2 7.6 7.2 3.8 3.0 7.5 7.3 15.1 14.6 6.6 5.8 White 10.0 10.1 6.6 7.0 3.5 3.0 6.6 7.4 13.2 14.4 5.8 5.7 Black 20.6 - 14,2 6.4 12.4 - 26.6 - 11.8 10.5 Illinois 12.3 9.8 8.4 6.3 4.0 3 5 7.8 7 5 16 2 13.8 7.6 5.7 White 9.2 9.5 6.5 6.1 2.8 3.4 6 4 7.2 12.9 13 3 5.4 5.6 Black 21.9 17.8 14.3 - 7.6 - 11.9 16.2 26.2 26,4 13.9 10.6 Michigan 11.8 9.1 8.2 5.7 3.6 3.4 5 8 5.5 14 0 11.2 7.1 5.3 White 9.2 9 0 6.2 5 6 3.0 3 4 5 2 5.5 11.5 11.2 5 5 5.3 Black 22.7 - 16.4 - 6.3 - 8.1 - 24.5 - 13.8 8.6 Wisconsin 9.2 9.1 5.6 5 8 3.6 3 3 6 6 5.9 12.2 11 7 White 8.2 9.0 4 9 5.7 3.3 3.3 5 6 5.9 10.5 11 7 ::: 44.6 7 Black . 17.3 11.4 6.0 13.0 25.3 12.4 - West North Central Minnesota 8.9 9 2 5 6 5 3 3 3 3 9 6.1 6 8 11 7 12 1 5.2 4.3 White 8.6 9 3 5 5 5.5 3 1 3 8 6 1 6.8 il 5 12 3 4.8 4.2 Black 16.2 6.9 7 4 17.5 11 6 Iowa 9.8 8.4 6 3 5.3 3.5 3 1 5 3 6.5 11 7 11.8 5.5 4 9 White 9.7 8.3 6 3 5 2 3.4 3 i 5.2 6.6 11.5 11.6 5.2 4.9 - Black - - 11.6 Missouri 10.9 9.4 7.1 5 7 3 9 3.7 6.2 7 3 13.3 13.0 7 1 6.2 White 9.1 9.3 6.0 5 6 3 0 3.7 5.2 7.1 11 2 12.7 5.5 5 8 Black ...... 16.3 - 11.1 7.1 10 1 21.2 21 1 12.8 11.8 North Dakota .... 9.1 8.1 5 3 4.4 3.8 3.7 7 0 5.6 12 3 10.0 5.1 4.8 White 9.4 3.3 5.$ 4.2 3.9 3.5 7.3 5.0 12.t 9.2 5.1 4 5 - Black ------South Dakota 12.0 11.5 7.2 6,0 4,7 5.5 5.7 6 4 13.0 12 5 5.4 5.4 White 12.3 9.0 $.3 3.6 - 6.1 13 6 11.4 5 3 5.0 Black - - - - NOTE: Rates are not shown tor areas with fewer than 30 events. Hyphens (-) are used to denote fewer than 30 events. (continued on next page) 4 1 1 Table 15-2-Fetal and Infant Health Indicators by State and Metropolitan/Nonmetropolltan Area, 1985-86-Continued Infant neonatal Post-neonatal Fet1 Perinatal Low-birth- Stet. mortality rate mortalityretab mortality rate* mortality ratiod mortailt7 ratLe weight ratet by region Metr4Bonmetro Metro lionmetro MetroNonmetro Metro Nonmetro MetroNonmetro MetroNonmetro Rest Swatheentrel gentumbY 10.4 10.7 6.7 7.1 3.7 3.6 8.0 8.4 14.7 15.6 7.1 7.0 White 9.2 10.5 5.8 7.1 3.4 3.4 7.2 8.0 13.0 15.1 6.2 6.8 Bleck 17.6 14.0 12.0 5.6 13.1 16.4 25.1 24.7 13.8 10.8 Tenneeeee 12.1 9.4 8.1 5.4 4.0 3.9 8.8 8.2 14,9 13.6 8.0 7.6 White 8.9 8.6 5.9 4.9 3.0 3.7 5.8 7.2 11.7 12.2 6.1 8.9 Block 20.1 15.8 13.7 9.6 6.3 6.2 9.2 15 2 22.9 24.7 12.8 12.7 Alabama 13.0 12.7 9 1 7,9 3.9 4.8 10.2 12.3 19.3 20.2 8.1 7.9 White 10.2 9.8 7.0 6.7 3.2 3.1 7.6 9.8 14.7 16.5 5.9 6.0 Black 18.6 18.4 13.3 10.3 5.3 8.1 15.4 17.0 28.7 27.3 12.4 11.3 Mtieeieelppi 11.5 13.7 7.5 8 3 4.1 5.3 10.4 12.1 17.9 20.5 8,1 9.0 White 9.5 9.0 6.3 5 5 3.2 3.4 7.1 7.8 13.4 13.4 6.0 6.0 Bleck 15.3 18.3 9.8 11.1 5.5 7.1 15.9 16 2 25.7 27.4 11.9 12.0 Meet South Metre/ Arkenso 11 2 10.8 6.8 6.0 4.4 4 7 7.8 8.2 14 7 14.3 8.2 7.5 White 9.9 10.0 6.1 5 9 3.8 4.0 6 8 6.9 12 9 12.8 6.7 6.2 Bleck 15.7 13.9 9.3 6.7 6.4 7.3 10.6 12.7 19.9 19.4 12.5 12.0 Louisiana 12.6 10.6 8 4 6.6 4.2 4.0 8.6 9.2 17.0 15.7 8.9 8.3 White 9.1 7.9 6.4 5.1 2.7 2.8 6.3 6.9 12.7 12.0 5.9 5.0 Bleck 10.0 15.5 11,5 9.3 6.5 6.2 12 3 13.4 23.7 22.7 13.2 X2.6 Oklahoma 10 8 10.3 6 8 6.0 4,0 4.2 7 4 8.2 14.2 14.2 6.5 6.3 White 10.3 10.7 6.5 6 3 3.8 4.4 7 0 8 1 13.6 14.4 5.8 6 1 Bleck 18.5 15.7 11.3 7.2 - 10,7 - 22,0 21.0 11.6 11.9 Txes 9.6 9.9 6.1 5 9 3.5 3.9 7.0 7 8 13,1 13.8 6.8 6.8 White 8.7 9.3 5 6 5.7 3.1 3 6 6.5 7.3 12 1 13.0 5.9 6.2 Bleck 15.7 15.6 9 9 8 5 5.8 7.1 10.0 12 1 19.9 20 6 12.2 12 1 ilemmelbs Montane 10.5 9.8 4 6 5.5 5.9 4.2 6.7 7.4 11.3 12.9 6.0 5 7 White 10 5 8.8 5 2 5 9 3 6 7.1 11.7 11.7 6.0 5.7 Black - - Idaho 11.5 10.7 6 2 6 6 5.1 4.1 7 5 6.9 13 8 13.5 4.9 5.5 White 11.5 10.8 6 3 6 6 5 2 4.2 7.7 6 7 14 0 13.3 4.9 5.4 Bleck - - - W y o m i n g 12.4 11.4 5 8 5.6 6 3 17 5 I I 6.6 7 0 White 12.7 11.3 6.0 5.3 6.3 17.1 12.3 6 6 7.0 Bleck- ... - - - - - 180/H: Rote. ar not shown tor areas with fewer than 30 events. Hyphens (-) aro used to denote tower ..han 30 outwits. 'Mb le 1S-2-Fetal end Infant Health indicators by State and Metropolltanitionmstropolitan Area, 198546-ContInued Infant Neonatal Post-neonatal Fetal Perinatal Low-birth- State mortality catch mortality rataC mortality ratiod mortality ratio° weight ratef by region MetioNonmetro MetroNonmetro MetroNonmetro MetroNonmetrn Metro Nonmetro MetroNonmetio Ce..oredo 9.2 8.2 5.5 5.1 3.7 3.1 8.1 9.4 13.6 14.5 7.8 7,4 White 8.8 8.4 5.2 5.2 3.6 3.2 8.0 9.4 13.1 14.6 7.3 7 4 Black 16.7 9.'4 6.8 10 9 - 20.8 - 13.8 - New Mexico 10 4 9.9 6.5 5.4 3.9 4.5 4.5 5.6 10.9 11.0 7.1 6.9 White 9.7 9.9 5.9 5.9 3.9 4.0 4.3 5.8 10.2 11.7 7.1 7 2 Black - . - . . 9.8 9.3 Arizona 9. 9.8 6.0 4 8 3.5 4.9 6.2 7.4 12.2 12 3 6.2 6.3 White 9.z 9.2 5.8 4,9 3.4 4.3 5.9 7.6 11.7 12 5 5.9 6.4 Black ...... 14 0 - 10.0 - - 9 8 19.8 12.1 9.8 Utah e c 9.3 5 1 5.6 3.9 3.7 6.6 6 8 11.7 12.4 5.6 5.3 White... 9 1 9.5 5 2 5.8 3 9 3.7 5.5 6.8 11.7 12.5 5.5 5.3 Black .... - . ------10.3 - Nevada... 8.9 8.4 5 1 3 5 3.8 4.8 6 6 9 9 11.7 13.4 7.3 6.5 White 8.7 8 4 5.0 3 8 3 7 4.6 6.3 9 2 11.2 13 0 6.3 6.2 Black 14 0 . 10 2 18.5 _ 13.2 Pacific Washington.. . 10.2 10.4 5.9 5 5 4.3 4.9 61 6.0 11 9 11 6 5,3 4 7 Mite 10.3 10.3 5 9 5 4 4 4 4 o 5 8 6 3 11 7 11 7 4,9 4.6 Black. . ,. 13.2 - 8.3 49 9 1 - 17.4 - 10.7 - Oregon.. . 9 4 10 0 5 0 5 1 4 5 5.0 6 0 7 4 11.0 12 4 5.1 5.2 White. .... 9 3 9 9 48 5 0 4.5 4.9 6 1 7 4 10.9 12 4 4 9 5 2 Black . . 17 0 - - - 18.1 - 11.1 California. 9.2 9.8 5 8 5 4 3 4 4.4 6 7 7,2 12 5 12 6 6.0 5 4 White 8.0 9 0 5 6 5 5 3 2 4.3 6 3 7 2 11.9 12 7 5.2 5 L Black 16.4 10.1 6 2 11 4 21.5 - 12.0 8,7 Alaska. 9 1 12 0 4 9 62 4 2 5 8 6.0 7 8 10.9 14 0 4 8 4.6 White. 90 10.6 4.7 62 43 4 4 5 4 7 4 10 1 13 6 4.3 4.1 Black. . . . _ . . . _ . 9 0 9.6 Hawaii... 9.7 7.0 6.5 4 6 3 2 2 4 9 4 9 5 15.9 14 1 6.6 6.8 - White 8 1 - 5 4 - - . 6 0 13.4 18 6 5.3 5.6 Black.. ... 22.0 - 9.0 - NOTE: Ratos are not shown for areas with fewer than 30 events Hyphens (-) are used to denote fewer than JO events. (continued on next page) 4 ; 5 Table 15-2Fetal and In lant Health Indicators by State and Metropolitan/Nontnetropolitan Area, 1985-86Continued °The infant mortality rate is the number of infant deaths (under 1 year of age) in 1985 and 1986 divided by the number of livebirths during 1985 and 1986. Infant mortality is shown as deaths per 1,000 live births. bile neonatal mortaLity rate is the number of neonataL deaths (under 28 days) in 1985 and 1986 divided by the number of Live births d4ring 1985 and 1986. Neonatal mortality is shown as deaths per 1,000 live births. °The postaeonatal mortality rate is the number of postneonataL deaths (from 28 days to 1 year of age) in 1985 and 1988 divided by the number of live births during 1985 and 1986. Postneonatal mortality is *boon as deaths per 1,000 live births. dThe fetal mortality ratio is the number of fetal deaths in 1985 and 1986 divided by the number of live births during 1985 and 1986. Fetal deaths include only those with stated or presumed period of gestation of 20 weeks or more.Fetal mortality is shown as deaths per 1,000 live births. °The perinatal mortality ratio is the number of fetal deaths and aeonatal deaths (under 28 days) in 1985 and 1986 divided by the number of live births during 1985 and 1986. Fetal deaths include only those with stated or presumed period of ge.itation of 20 weeks or more. Perinatal mortality is shown at deaths per 1,000 live births. fThe low-birthweight rate is the washer of live births weighing less than 2,500 grams in 1985 and 1986 divided by the number of live births during 1985 and 1986. Low-birthveight is shown as the number of low-birthweight births per 100 live births. SOURCES: U.S. Department of Health and Human Services, Centers for Disease Control. National Center for Health Statistics, Vltal Statistics of the United States-1985. vol, II. MortalityPart 3, DHHS Pub. No. (PUS) 88-1102, table 8-2; Vital Statistics et the United States, 1286. vet.II-5rtality, Part II, Di= Pub. No. (PHS) 88-1114, table 8-2: Vital Statistics of the United States. 1985. vol. I. Natality, IMIHS Pub. No. (PHS) 88-1113, t4a10 2-2; Vital Statistics of the United States__ 1986__vol Natalitx, DHSS Pub, No. (PHS) 80-1113, table 2-2 (Washington, DC U.S. Government Printing Office, 1987, 1988, 1988, and 1989, respectively). 4 If4i Chapter 15-Maternal and Infant Health Services in Rural Areas387 Table 15-3-Infant Death Rates ... r-tal Death Ratios by Race in Motu opehtan and Nonmettopoh tan Maas', 1987 Metro Nonmetro Urban Balance Urban Balance Total places° of area Total places° of area Infant mortality rated 10.2 10.8 8.6 9.8 10.2 9.7 white infants 8.6 8.9 8.0 8.8 9.1 8.7 nonwhite infants 15.5 15.7 14.2 15.0 14.8 15.1 bladk infants 18 1 18.1 17.7 16.7 16.3 16.9 Neunseta1 mortality rate 6.6 7.0 5.6 6.1 6.3 6.0 whits infants 5.5 5.7 5.1 5.4 5.6 5.4 nonehite infants 10.1 10.2 9.6 9.4 9.0 9 5 black infants 11.9 11.9 12.3 10.7 10.1 11.0 PostammaalWitaortalltlr mutat 3.6 3.8 3.0 3.7 3.9 3.7 white infants 3.1 3.2 2 9 3.4 3.5 3.3 no:White infants 5.4 5.5 4.6 5.6 5.8 5.6 bladk infants . 6.2 6.2 5.4 6.0 6.2 5.9 rota resrtaiityratio$ 7.6 7.9 7.1 7.9 8.2 7.8 white infants 6.6 6.7 6.4 7.0 7.3 7.0 nonwhite infants 11.3 11.0 12.7 12.5 11.9 12.8 bladk infants . 12.7 12.4 14.8 14.5 13.7 14.9 aDeaths era recorded by maternal residence, not place of death, bUrban places in metro counties are those with populations of 10,000or more in 1980. !Urban places in nonmetro counties are those with populations of 10,000 or more but fewer than 50.0J0 in 1980. 'Intent mortality rote: The annual number of deaths among children less than 1 year old as a proportion of the annusl number of live births. fffeaaatalmortalityrote:The annual nuMber of deaths Joring the first 27 days of life as a proportion of the annual number of live births. fftetneonatalmortalityrate: The annual nuMber of desths that occur from 28 days to age 1 as a proport.on of the annual nuMber of live births. &Fetal.mortalityrattle: The annual author of fetal deaths occurring at gestations of 20 weeks or more as a proportion of the annual number of live births. SOME. U.S. Department of Health and Human Services, Centers for Disease Control, National Center for Health Statistics= Vital Statistics of the United States1987 vol//. Mortality, Part B. DOHS Pub No (PliS) 89-1102. table 8-2 (Washington, DC; U.S. Government Printing Office, 1989). difficult because of regional variation in reporting or infant death. An equal proportion (30 percent) of fetal mortality (647). pregnant women in urban and rural areas have at least ore medical condition that seriously affects The higher posineonatal mortality rates in rural pregnancy (8). Some information regarding smoking- areas could be explained if deaths of high-risk associated risks is available from the 1985 Health infants were postponed beyond the neonatal period. Interview Survey, which found that rural women This could occur if, for example, high-risk rural were just as likely as urban women to report infants are less likely to survive after being dis- smoking cigarettes in the 12 months preceding the charged from remote tertiary centers because they birth of their last child (32 percent). However. have limited access to continued specialty care and women smokers in rural areas were more likely to social service support (277). Another explanation cut down smoking and less likely to quit (38 percent for the relatively high rural postneonatal mortality is cut down; 19 percent quit) than were urban women the higher incidence in rural than urban areas of (35 percent cut down; 22 percent quit) (o49). infant deaths attibutable to congenital anomalies, SIDS, and accidents-all significant causes of Low Birthweight and Prematurity posineonatal mortality. In an Alabama study, infec- tion was identified as a contributor to the high rural Babies that are born too small or too soon ate more postneonatal mortality (176). likely to die; if they survive they are more likely to require hospitalization and very expensive, sophisti- There is limited information about the maternal cated care (417). There are only slight differences in risk factors that increase the chances of hav ing a fetal low birthweight tatesq between urban and rural towbinhweight babies lue those born welt:lung less than 51/1 pounds (2.500 grams) 4 ; 9 388 Health Care in Rural America Table 15-4-Percent of Births That Are Low BIrthweIghto and Pretermb by Metropolitan and Nonmetropolitan Areas, 1986 Low blrthweight Preterm Low birthweiaht and oreterm Metro Nonmotro Metro Nmweetro Metro Nonmetro All races& 8.89 6.49 6.33 6.21 3.12 2.88 White 5.60 5.75 5.08 5.20 2.51 2.52 Bleck 12.66 11.72 11.88 12.79 5.97 5 52 &Births weighing less than 2.500 grams ere low birthwsigLt. bBirths occurring at 20 to 36 weeks are preterm births. Cincludes V*406 other than white end black. MICE: U.S. Department of poalth and Human Services, Centers for Disease Control. National Center for Heaith Statistics, Vital Strtistics of the United States. 1986. v41. DUNS Pub He (PHS) 88- 1123, table 1-88 (Washington. DC: U.S. Government Printing Office. 1968). white infants, but among blacks, low birthweight all racial and ethnic groups (table 15-5) (630). rates are 8 percent lower in rural than urban areas Women in rural areas are more likely tohdveat least (table 154). Colorado and New Mexico are among one child, especially at younger ages. In 1988, for the States with the highest proportion of white example, oN.er one-third (34 percent) of women age low-birthweight newborns in rural areas (7.4 and 7.2 18 to 24 in rural areas reported having children percent) and West Virginia, Tennessee, and South compared with less than one-quarter (24 percent) in Carolina are mons the States wit:: the highest urban areas (630). Correspondingly, a greater pro- proportion of black low-birthweight aewborns in portion of births occur to teenage mothers in rural rural areas (12.9, 12.7, and 12.7 percent) (table than urban areas (15 percent v. 12 percent) (050). 15-2). Despite these differences, the number of births expected in a woman's lifetime is similar for rural The apparently higher incidence of fetal deatns among blacks could be depressing the incidence of and urban women (630). low-birthweight newborns for the same reason that Women in rural areas are much less likely than it may be an explanation for low rural neonatal death urban women to have had elective abortions. In rates-rural low-birthweight fetuses may not be 1987, only 14 percent of abortion patients were rural surviving until birth or may be dying at birth and residents, yet rural residents made up 23 percent of reponed as fetal deaths. There are relatively fewer the population (217). very-low-birthweight black babies reported in rural than in urban areas, which could be explained by either differential mortality or reporting (646). Maternal Mortality Pretermbirths9occur somewhat more frequently in Maternal mortality among rural women is worse rural than urban areas for toth whites and blacks than for urban women in general, but mortality rates (table15-4).1° for both have decli led over time. In 1980. 334 Fertility women died from conditions related to complica- tions of pregnancy andchildbirth.12In that year Fertilityrates11are higher in rural dun in urban matern.4 mortality rates" were 23 percent higher in .zeas, although this pattern is not consistent across rural than urban areas (10 8.2 maternal deaths 9Premature babies are those born at 20 to 36 weeks gestalten (646) ollie incidence of both low *thy/eight and prematunty a nearlyIlk same at what an4 rural at,...ta tut whams. but Ivebla-ks tt isughtty higher in urban than nual areas (table 154). "The fertility me tsdefined bcre as thenumberahKbuth4to *omen age18to 44 Jo19. divided by the tstartated nautical pvpubtrunotwomen 18to 44years of age (630). 12p4 sterna loonality ineludes deaths due to4oniplawniunsot pregnant.).aildborth,andthePuerperium obi.. mod ut 42 days hniutstngthe termination of prepanc)r) Causes of malerhal mortaLty oxhide utcnix hernonhitge, toxemia. and with:14ftanalwatuttath{ivlo {hal wrillp114.4lG pregnancy such as diabetes and infections (e.g.. mberculesis. syphilis) (647) "The maternal monahty rate a the annual number of deaths related toprcgnatky tinaticti by the annual atenbcr 01 hire birs6 4rl:i) Chapter 15Maarnal and Want Health Services in Rural Areas 389 Table15-5Fertility Rates* by Metropolitan and Nonmetropolitan Residence, 1988 Metro Central Noncentral Total Total city city Nonmetro All races 69.7 68.5 73.1 65.4 74.6 Whit 66.0 64.4 67.4 62.7 71.9 Block 87.0 86.8 69.6 60.3 88.8 Hispanic' 94.0 96.6 96.3 97.1 58.2 *Fertility rates annual live births per 1,000 women age 18 to 44 bPersons of Nispattic origin may be of any race. SOURCE. U.S. Department of Commerce. Bureau of the Census, 'Fertility of American Women. June 1988 Current ?Mutation RaDerts, Series P-20, No. 436, table 4 (Washington. DC. U S Government Printing Office, 1989). per 100,000live births)." As of 1986, the total Table 15-6Maternal Mortality* by Metropolitan and number of maternal deaths had declined to 272. In Nonmetropolitan Residence and Race, 1986 1986, maternal mortality rates were still slightly hightr in rural than in urban areas, but the highest Number Death rate rates occurred in the most densely populated urban of deaths per 100,000 areas (table 15-6). U S 272 7 24 Metro . . 210 7 22 Urban placesb.. 170 8 40 MATERNAL AND INFANT Balance of erea 40 4 51 SERVICES IN RURAL AREAS Nonmetro. . . 62 7 30 Urban placesc 13 6 98 Balance of area 49 7 40 Use of Prenatal Care White. ... 146 4 91 Black ... 117 18 83 Prenatal care prevents many poor pregnancy All. other . 126 19 40 outcomes, especially among women who are at high a Maternal mortality rate is the annual number of risk of adverse outcomes, and augmented nrenatal deaths related to pregnan,y divided by the annual care programs targeted to high-risk women appear to number of live births b Urbanplaces in metro counties are those with improve the onset and frequency of' prenatal visits populations of 10.000 or more in 1980 (561 ,619). The three basic components of' p. natal ell.ban places in nonmetro counties are those with care are (697): populations of 10,000 or more. hut fewer than '0,000 in 1680 early and continuing risk assessment. SOURCE S Department of Health and Human Ser- health promotion, and vices. Centers for Disease Control. Nation- al Center for Health StatisticsVital Sta- medical and psychosocial interventions and tistics of the United States. 1986. vol followup (which may include referral to, or II. Mortality. Part B. DHHS Pub No (PBS, consultation with, other specialized providers). 86-1114, tables 8-9. 8-5 (Washington. DC U S Government Printing Office. 1988) Prenatal care ideally involves frequent provider- patient contacts that begin before or earlyin Women living in rural areas that include a large pregnancy (697). Rural women are slightly less economi., ally disadantaged population might be likely than urban women to begin prenatal care expected to ha% e les:,4ebsto prenatal care. This during the fust trimester of pregnancy, but more expectaticn is borne oat for w kite women,greater urban women have no prenatal care at all (table proportion of white pregnant women in poor rural 15-7). counties'5received inadequate prenatal care in Mlbesemortality rates wareadjusted for maternal age and race (159). 'Shim rural counties include the 332 nonmetro counties in 20 States that had at least 25 Imam ot tcsalcrus Ii nig toctun Mc 1 1..4cr.1ijei crt) thicsbuld In 1979 (554 161nadequato prenatal (Ale as either care that begins dual* the thud trimesterof pregnaru. y u no prenatal care k558, 4 21 390Health Care in Rural America 'fable 15.7-Live Births by Month Prenatal Care Began, absolide shortages of obstetric providers, by Race and Residence,1987 shortages of obstetric providers who participate in the Medicaid program, Metro Nonmetro a lack of insurance coverage and the inability to Totalbirths 2,970,059 839,335 pay for obstetric services, lst-2nd month 54.67 49.23 a decline in the number of hospitals equipped 3rd month 20.16 23.43 4th-Oth month 16.87 19.70 and staffed to provide obstetric services, and 7th-9th month 3.91 4.54 residents' geographic isolation from services No prenatal care 2.08 1.46 and poor access t- :egional perinatal care Rot stated 2.30 1.65 systems. Mite 2.120,927 701,561 Availability of Rur al Obstetr ic Provider s lst-2nd month 58.58 $2.02 3rd month .. 20.00 23.61 Supply of Proviers in Rural Areas-Infoimation 4th-6th month 14.58 17.71 7th-9th month 3.28 3.87 from a number of ...de surveys indicates that there No prenatal care. 1.58 1.16 have been declines in the availability of obstetric Not stated 1.99 61 providers (box 15-A). This, coupled with the low population density that characterizes many rural DIsOk 538,822 102,745 lst-2nd month.... 38.88 34 41 areas, results in longer travel times to obstetric 3rd month 20.87 22 51 providers for rural than for urban residents (see ch. 4th-6th month 26.25 30.65 10, table 10-16).18 7th-9th month 6,34 7.71 No prenfttal care 4.39 3.03 Maternity services may be delivared by any of Not stated 3.28 1.68 three groups of providers: obstetricians, other physi- SOURCE U SDepartment of Health and Human Sex cians (primarily family physicians (FFs)), and other vices, Centers for Disease Control, Nation- practitioners, such as certified nurse-midwives al Center for Health Stetistics. unpUblish- 'id tabulation from the Natality Statistics (CNMs). In 1987, births in urban and rural areas Branch. November 1988. were almost equally likely to be attcnded by a physician, but nonphysician providers were most 198418 than white pregnant women nutionally. likely to deliver babies in the most urban areas' 9 (4.2 Black women residing in such areas, however, were percent of births) and in the most rural areas" (3.5 more likely to have received adequate prenatal care percent of births). Black women were more likely than black women nationally (table 15-8) (5511)." In than white women in both urban and rural areas to 1985, infant mortality and the incidence of low have had a nonr 4sician provider (table 15-9). birthweight were higher for both black and white infants born in poor rural counties than in the Nation Obstetricians provide most obstetric care in urbail as a whole (table 15-8) (558). areas, but in rural areas one-half to two-thirds of all obstetric care providers are FPs (349,543). in 1988, there were only 25 obstetricians per 100,000 women Access to Rural Maternal and Infant rare of reproductive age in rural areas, compared with 61 in urban areas (table 15-10). Obstetricians are even Available evidence suggests that fetal, infant, and less available in smaller nonmetro counties ksee ch. maternal mortality are somewhat higher and that late 10, table 10-11). The absence of obstetricians in prenatal care is more a problem in rural than in urban many rural areas is partially offset by the presence of areas. Access to maternity and infant care in rural general and family practitioners (G/FP5) (including areas could be impaired by: doctors of osteopathy (D0s)) who are trained to 17Doriag the period 1980to 1984. the States with the highest levelsof inadequate prenatal Larc in poor rural counties were an the southwest v.c. New Mexico. Texas, Utak and Arizona) (558). 111tural residents travel an average of 24 minutes to reach an obstemcian/gynewloglat and 20 nunutes iozcaiiiao IT ineonrasi with urban residents who, on average, travel 19 and 16 minima to reach these providers (644) 31.kban places within metro counties. 10141onterhan places in nonmetro condlics. Chapter 15Maternal and Infant Health Services in Rural Areas 391 Table 15-8Perinatal Health Care Indicators In Poor Rural Countless National Pont rural counties White Black NhiteBlack Infant mortality (1985) 9.3 18 2 10 0 19.2 Low birthweight (1005) 5.6 12.4 6,6 12.6 Inadequate prenatal care (1984)b .. 4 7 9,6 4.9 7.3 'Poor rural ounties include the 332 nonmetro counties in 26 States that had at least 25 peruent uf residents living below the Federal poverty threshold in 1979. bPercent of births to women who receive either no prenatal care ox who began receivial5 care during their 0.0 trimester of pregnancy. 1984. SOURCE J. Shotland. DL000in, mid EHaas, Off to a Poor StartInfant Health in Rural America (Washingtun, DC: Public Voice for Food and Health Policy. October 1988). Box 15-AObstarie Provider Availability: Selected State Reports ArizonaOf available rural obstetric providers (D0s. G/FL, and obstetricians), :78 percent kported that they conducted deliveries in 1989, compared with 74 percent ofprt...ders id 1985.Of those dis.ontinuing obstemc practice, 87 percent cited malpractice concerns as the reason. F.orty -four percent of physicians that h-kd cease. delivering babies said they would resume if there was a malpractke insurance subsidy available (221). ColoradoAs of July 1988, there were 18 rural counties in Colorado with no private prartke maternity care providers. Over 1,000 women living in these counties had babies and had to travel an av -.rage of 32 miles to deliver (136). IC4VtlA1986 suney found that of 49 physicians who had provided obstctnc ser. ices since 1981. 152 (31 percent) had discontinued providing them because of liability considerations. Of these 152, 78 deschbed their practices a. rural (225). MissouriA 1988 survey of 328 rural GIFP's showed that 40 ent practiced obstetrics, but that there had been a 27 to 40 percent decre....,e since 1984 in the number of obstc.- providers in rural areas (745). MontanaA 1989 90 survey found that 12 percent of physicians who Lad provided obstetric services at one time had dropped obstetric care. As many as 35 percent of FPs aad 9 percent of obstetnuans had dropped obstetrics. Only 29 percent of physkians a ho ever ptovided obstetric services reported that they hd not limited theu ser ices to Medi:aid patients, decreased the number of deliveries they perform, decreas.the level of high risk obstetric care, or limited their practices in any way. The costof professional liability insurane was i.ned most often asthe reason obstetric providers had changed their practices (174 North CarolinaIn1989-90, therewere over 4,000 births in 20 .aostly rural counties that had no obstetric providers (i.e., physicians, nurse-midwives) (537). TexasAs of 1989, 43 percent of rutal physicians had curtailedobstetn k.beAlaband 84 Lountles offered no labor or delivery services (97) Wast 'anThe proportion of rural G/FPs providing obstetnc care fell from 80 percent in 1977 to 67 percent in 1986. Only 38 percent of urban G/FPs provided obstetric care in 1986 (526). derver obstetric care. In 1988, rural aseas had more there were 156 physicians trained to provide obst%- G/FPs (137 per 100,000 -women of reproductive age) ric servkes (i.e., G/FPs, obstetricians, and DOs) per than did urban areas (108 per 100,000 women of 100,000 rural womet. of reproductive age. In con- reproductive age) (table 15-10). trast, there were 242 per 100,000 in the mral areas of The availability of mral physicians traineJ to States in the West North Central Region (table delF.er ciLste.fic care v aries by region. In mral areas 15-10). Over half a million rural residents liv e in of the East South Central region of the country counties that are v. ithout a pnysician traxed to :lsee app. P for a list of states ia each Klima. 4 .-t3 392 Health Care in Rural America Table 154--Live Births by Type of Birth Attendant, by Race and Place of Go livery, 1987 Total nuMber Attendanl of deliveries Physician Midwife° Other Metro All 2,970,059 96.3 3.4 0 6 White 2,290,927 96.4 3.0 0.6 Black 538,822 6.1 3.2 0.7 Urban places 50,000+ 411 1.483,338 95.7 3 5 0.7 Waite 993,102 95.6 3.6 0.8 Black 402,301 96 2 3.X 0.7 Urban places 10.000-49.999 All 579,993 96.6 2 9 0 5 White 485,907 96.$ 2 7 0 5 Black 67,160 95.2 4,1 0.6 Balance of area All 006.728 97.1 2.4 0.5 White . 811,010 97.1 2 4 0 5 Rack 69,361 95 9 2.4 0 7 Bkrimmtro ...... 839,335 96 6 2 8 0.6 White 701,561 97 1 2 3 0 6 Black. 102,745 96 5 3.0 0.5 Urban pieces 10.000-49,999 All 183,260 07 1 2.5 0.4 White...... L46,735 97 A 2 2 0 4 Black 29.343 96 4 3 2 1 3 Balance of area All.... 656.075 96 5 2 0 0 6 White... 554,826 97 0 2 4 0.6 Black 73.402 965 2 9 0 5 °Midwife includes lay midwives. and certified and noncertified nurse midwives SOURCE: U.S. Departmenc of Health and Human Services. Centers For Disease Control. National Center for Health Statistics, 1087 Natality, unpublished tabulation. 9, iber 1988 deliver obstetric care (table 15-11),22 and other areas smaller population base t 3,000 to 4,000 residents) are without available obstetric services because than do obstetricians (who require about 11,000 many physicians trained to provide obstetric serv- residents) (33 1). 1.n 1988, 9 out of every 10 FPs (91 ices do not provide them. In 1988, for example, there percent) had hospital admitting privileges, but of was 'r sionh Carolina 1 nonmetro county without a these less than one-third (29 percent) reported that physician trained to deliver obstetric care (table they currently practiced obstetrics (545). FPs in rural 15-11), but 18 nonmetro counties that lacked obstet- ric services because available physicians and CNMs areas are almost twice as likely as urban FPs to offer were not providing them (512). routine obstetric care (43 v. 23 percent). There are, however, sizable regional differences in the extent to G/FPs are particularly well .;uited as obstetric which rural FPs provioe obstetric care. Only 15 providers in areas of low population density because percent 0: rural FPs provide obstetric caze in the they can provide both obstetric and nonobstetric South Atlanfic region, compared with 70 percent in care "1-3Consequently, GLFI's generally require a the West North Central region (table 15-12). 22In contrast. there am only 2 metro counties, with a total population of 21.900. that arc without a physician tamed to provide obstetnc care 1983.33 peroent of all physician visits and 70 peicent of adult visits to physicians en rural areas were to lamely physicians 444 7) 4 4 Table 15-10-Ratio of Active MD General/Family Prectitioners, Active MD Obstetrician/Gynecologists, Active MD Pediatriciens, end Active DOs per 100,000 Reproductive-Age Women by State and Census Region and Division, 1067-686 Number of physicians Per 100.000 raproductive.mie womenb MD general/family MD obstetrician/ G/FP + practitioners avnecolonists MD pediatricians° DOs4 08/ONN 4. po Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro United States 108,0 137.1 61.4 24.5 69.7 22.3 44.0 30.8 213.4 192.4 Mezthiest 87.0 121.4 66.4 31.7 86.4 34,1 51.8 35.4 205.2 188.5 New England 73.7 154.7 63.5 37.5 03.3 $0.6 18.5 39.7 155.7 231.9 Connecticut 73.4 NA 75.8 NA 87.5 NA 8.0 NA 157.2 NA Maine 138.9 172.8 46.7 32.8 52.0 35,4 116.5 77.1 302.1 202.7 Massachusetts.. .. 82.3 127.3 60.3 48 5 86.4 54,6 10.5 12.1 133.1 187.9 New Hamrihire. 97,1 172.7 50.6 42.4 54.1 70 7 7.6 12.6 155.3 227.7 Rhode Island 71.0 NA 58.5 NA 88 0 NA 45.6 NA 175.1 NA Vermont 132.0 133.8 86.5 33.7 111.5 53.4 11.4 26.7 229.9 194,0 Middle Atlantic 91.6 108.1 67.4 20 3 87 5 27.5 63.2 33.7 222.2 171 1 New Jersey 80.4 NA 63.9 NA 86.0 NA 73.5 RA 222.8 NA New York 75.1 103.5 74 5 31,7 105 1 30 1 16.9 8.9 168.5 144.1 Pennsylvania 127.8 112.5 58 0 27.1 59.0 25.0 126.0 57.6 311.5 197.2 Midwest 112 3 145.2 54 7 18 2 61 1 17 0 71.4 50.4 238.4 213 8 East North Central... 106.6 130.8 54.4 19.9 60.2 18.9 75.2 40.6 236.2 191,3 Illinois 107,3 143.3 59.2 21,8 69 1 20.4 30.9 16.1 197.4 181.2 Indiana ...... 146.4 139 7 40.5 17.3 42.2 13.7 23.4 17 8 210.3 174 0 Michigan... 78 2 104.8 56.9 18.9 54 7 18.1 164.9 94 9 300.0 218.6 Ohio-- 108 8 102.1 55.0 22.6 64.4 21 3 87.8 55.2 249.6 172.9 Wisconsin 121.8 177 7 49 0 17 5 56.5 20.5 28 6 14 2 199.4 200 4 West North central 131 0 163 4 55.6 16 1 63 0 14 5 59.1 62.8 245.7 242.3 Iowa .. ,. ,. 143.2 156.7 40 3 12.5 51 5 11.0 138.6 54.3 322 1 223.5 Kansas... . 140.6 168 4 52 7 20 6 55.8 22.9 60.2 46.6 253.5 215.6 Minnesota . . 170.6 206 7 49 3 14.3 62.2 11 2 6 1 10,5 226.0 231 5 Missouri . ,. 78 5 96 8 87 6 18.1 74.1 12 4 93.5 178.1 239,6 293.0 Nebraska. 138.5 201 2 58,8 11.4 67 7 15 4 8 4 4.0 205.7 216.6 North Dakota 189.9 187 1 56.6 24 8 52.0 18 0 12 2 11.3 08.7 222 2 South Dakota.... . 204.9 193 A 50 2 16 4 48 2 17 4 10.0 a g 261.1 23S.1 South...... 107 5 128 6 64.3 25.8 65.6 22 1 31 4 18.1 203,2 172.5 South Atlantic. . 112 0 123.6 70 5 31 7 73 5 27,7 29.4 14 6 211.9 169.0 Delaware 109 7 73 6 63.5 35 7 72 2 39 9 69.3 25.2 242 5 134 5 Distt. of Columbia 91.4 NA 130.8 14A 133 1 NA 10.3 NA 248 5 N. Florida .... ., 140 4 145.1 64.5 31.3 65.2 28.1 65 I 35.1 270 0 211 5 Georgia 74 6 113 1 64.7 32.1 58.5 21.9 20.7 11 8 160 0 :57.0 NOTE: NA does not apply In Rhode Island and Connecticut, snme counties are part MSA and part non MSA. These counties were catego- rit'd as MSA counties in the Area Resouice File, In Alaska, the entire State is categorized as MISA (Alaska has no conties). (continued on next page) 425 41 fr Taste15-1G-Ratio ot Active MD General!Family P actitioners, Active MD ObstetriciamGynecologists, Active MD Pediabicians, and Active DOs per 100,000 Reproductive-Age Women by State and Census Region and Division, 1987-884-Continued Number of Physicians per 100.000 reProductive-ate womenb MD general/family MD obstetrician/ GP/FP .0. practitioners JOrnecolotists 14Del-sc DOsd OB/GYN 4. DO Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro Metro Nonmetro MarYland 89.9 122.6 98.8 59.1 116.3 36.1 10.8 7 2 199 5 188.9 North Carolina 106.6 119.4 61.9 31.7 65.3 29.8 7.7 3,8 176 2 154 9 South Carolina 140.9 124.0 53.7 2P 5 46.9 25.6 5.4 6.5 200.0 159.0 Virginia 102.8 141.0 62.2 31.4 68 5 26.5 11.3 5.7 176.3 178.1 West Virginia 145.2 122.5 54.1 28,0 44.4 32.4 40 1 52.0 239.4 202.5 Eest Sc Central.. 109.2 122.0 61.9 23.1 62.6 20 8 8 3 10 9 179 4 156.0 Alabam. 107.2 112.1 59 1 20.4 53.8 16.3 8 4 7 2 174,7 139.7 KentuckY 126.4 125.9 57 1 24.7 68.1 25 0 9 5 9.2 193.0 159.8 Mississippi ..... 108.7 128.6 61.8 28.9 64.5 23 5 9 6 0 9 180.1 166.4 Tennessee 101.7 120.5 66.6 16.9 66 1 16 3 7 4 16 3 175 7 153,7 West South Central 100 0 143 0 55.9 19.1 55.8 14.9 43 8 30.7 199.7 192.8 Arkansas...... 150.4 183.5 57.3 20.1 63 1 15 0 6 7 11 2 214 :. 214 8 Louisiana 82.8 120.7 69 6 22.4 65.8 15.6 3 6 3,3 156.0 146.4 Oklahoma.. . . 108.2 125.1 51.1 20.0 50.7 15 5 126 6 74 8 285.9 219 9 Texas ...... 99.5 143 2 53.3 16 6 53.7 14.3 43 8 32 8 196.6 192.6 West 127 0 157.2 59,0 29.8 65 8 26 9 25 0 25 8 211.0 212 b Mountain 111 0 151 0 56 6 27 1 57.8 24.7 53 2 29.9 220.8 208.0 Aritona. ... 125 7 144 8 65,2 30.2 65 4 30 9 105 3 47 0 296.2 222.0 Colorado 106 5 174 7 53 3 14 5 57 5 17 3 46 3 55.9 206.1 245.1 Idaho. . 119.7 146 6 41 3 26 1 33 0 20 5 16 5 17 8 177 5 190 5 Montana.... 71 9 168 8 41 9 33 8 45 9 26 7 8 0 19 7 121.8 222 3 Nevada .. 96,1 184 5 51 3 26 0 31.2 21 3 32 7 23 7 182 1 234 2 New Mexico,. 119.5 123,1 60 6 30 6 68 8 31 ., 51 9 34 7 232.0 188 4 Utah...... 93 1 152 1 55 0 24 9 64.1 21 2 6 0 7 5 154 1 184.5 wyoming 199,7 139 7 16 8 29 5 13 3 23 8 2 8 12 5 Pacific .. 131 2 166 6 59 7 33 8 67 9 30.0 17 6 19 8 41:::04. 2200 1.7 Alaska 127 8 NA 29 4 NA 33 s NA 27 2 NA 184 4 NA California 129 5 170 8 61 8 34 7 72 1 29,4 13 3 13 6 204.6 219 1 Hawati 78 0 175 6 74 4 69 9 80 1 66 0 28 7 19 4 1132 1 265.9 Oregon,- 115 5 150 2 59.0 30 8 48 5 24.6 42 4 22.0 216.9 203,0 Washington 164 0 175 5 46 7 25,5 50 7 26.6 31 7 25 5 242 4 226 5 NOTE. NA doss not apply. In Rhode Island and Connecticut. some counties are part MSA and part non MSA These counties were catego- rized es MMA counties in the Area Resource File.In Alaska. the entire State is categorized as MSA (Alaska has no counties) 41"Active" MDs and DOs (doctors of osteopathy) include physicians in patient care, research, administration, and teaching Data from the American Medical Association as of Jan. 1, 1988. Data from the American Osteopathic Association as of 1987 bPopulation of women age 15 to 44, 1984. Based on estimates from the Current Population Survey, LS Census Bureau, cDoes not includes pediatric subspecialties. dincludes all active DOs, regardless of specialty orientation SOURCE, T.C. Ricketts, Rural Health Research Center, University of North Carolina, Chapel Hill, NC Analysis of unpublished data 427 (provided by the Health Resources and Services Administration) conducted under contract to the Office of Technology Assessment Chapter 15-Maternal and Infant Health Services in Rural Areas 395 Table 15-11-Numbet and Resident Population ol NonmetropolitanCourtinWithout an Active Genefal Practitioner, Family Practitioner, or Obstetician:Gynecologist, by Region and State, 1555°6 ti saber of Resident NuMber of Resident =metro population nonmetro population counties of counties of (A) column A (A) column A United States 147 528,300 Northeast 1 4,000 Smith (continued): New England 0 0 E.sc South Central 9 83.600 Middle Atlan*.ic 1 4,900 Alabama 1 13,200 New York 1 4,90:, KentuckY 2 14,400 Nadlest 59 184,800 Mississippi 3 19,200 East North Central... 4. 25,500 Tennessee 3 16,800 Illinois 1 5,300 West South Central 23 84,700 Indians 1 5,400 Arkansas 1 8.200 Michigan 1 1,900 Louisiana 1 24,500 Wisconsin 1 12,960 Texas 21 52,000 West Worth Central... 55 159,300 Vest 34 72,100 Reuses 4 12,600 Mountein 29 56,300 Missouri . 16,100 Colorado 5 11.600 Nebraska 22 45,000 Idaho 4 13.100 North Dakota 12 42,400 Montana 11 17,000 South Dakota 15 40.200 Nevada 2 3.200 South 53 266.500 New Mexico 2 5.900 South Atlantic 21 118,200 Utah 4 6.700 Florida 2 14,200 Pacific 5 t3,800 Georgia 15 73,300 California...... 1 1,200 North Carolina 2 9,700 Oregon 3 5,000 Virginia 3 21,000 Washington 1 7.600 °Includes physicians in patient care, research, administration, and teaching. Includes all act.ve doctors of osteopathy (D0s) regardleas of specialty. IND data as of Jan. 1, 1988. DO due as of 1987. Population es of 1987. SOURCE. T.C. Ricketts, Rural Wallth Research Center. Universityof Noith Carolina. Chapel NiliNC AnatYsis of unpublished date (provided by the Health Pesourcesand Services Administration) conducted under contract to the Office of TechnologY Assessment. FPs in rural areas are much more likely than those deliver babies do so in hospitals (342), but practition- in urban areas to provide complicated obstetric ers in many States report medical staff bylaws that delivery services, services to high.ribk patients, and pi ohibit appointment of nonphysician care manag- cesarean sections (table 15-12) (545). Nonetheless, ers. (See ch. 11 for a discussion of State regulatory the majority of rural FPs do not handle complica- barriers that affect mid-level practitioners.) tions, so they are heavily dependent on obstetricians for backup. The Impact of aedical Professional Liability Issues on Obstetric Provider Availability in Rural CNMs are registered nurses v,ith additic..al train Areas-In some cases, the conditions of rural ing to provide obstetric and gynecological care to practice have contributed to the decline of rural essendally normal newborns and women. As of obstetric prov iders-the lack of coverage foi time 1990, nearly 4,000 CNMs had been certifiet: by the off, limited consultation opportunities, and difficul- American College of Nurse-Midwives and an esti ties with referrals to larger hospitals (336). Increas- mated 60 percent were providing obstetric serv ingly, however, the high costs of premiums for (see ch. 10 for a discussion of the supply and medical malpractice coverage and fears of lawsuits distribudon of CNM5). Most CNMs are in urban have been cited as major factors contributing to the areas and most are employed by hospitals, HMOs, oi decline. A recent repon a the institute of Medicine birth centers (44 percent) or by physicians (25 (I0M) concluded that theie has been a significant percent) (342). Nearly 90 percent of CNMs that decline in rhe number of obstetric providers practic- liEstimatessic based ona19813 =Rey of 2.3631=1*m uf thc Amcmao Culkgs uf Num Madoavcs. The surbcy -spume ram pcnAtu d 396 Health Care in Rural America Table 15-12Percentage of Family Physicians Who Care for Obstetric Patients at Various Levels, by Metropolitan/Nonmetropolitan Area and Census Region, July 1988 Complicated High Cesarean Census region Routine care deltvery risk sections Total Metro 22.9 5.9 3 2 2.3 Honnetro 43,1* 23.2* 25 3* 12.6* Now England Metro 17.1 4 3 2.9 2.1 lionmetro 41.? 10.5 5.8 2 3 Middle Atlantic Metro 11.9 1 3 0.0 0.0 Nonmetro 18 2 3.8 0 0 0 0 East North Centrel Metro ...... 31.2 7 3 4 8 0.5 Honmetro 609* 33.3* 24 1* 92* Nest North Central Metro 46 6 14 4 7 5 4 8 Nommetro, 69.8* 42 a* 23 6* 10a* South Atlantic Metlo... 10 4 4 9 2 4 1 2 Nonmetro. . 25.0 5 0 2 0 0 0 East South Central Metro 8 5 1 4 0 7 0 7 Nonmetro.... 16 4* 9 4* 70* 63* Meat South Central Metro.. 21 4 7 3 1 6 6 3 Nonmetro... 39 7* 26 4* 23 1* 306* Mountain Metro.. 21 0. 5 9 1 6 1 6 Nonmetro. 58 4 24 5* 24 1* 182* Pacific Metro.. . 27 4 57 5 9 3 9 Nonmetro 44 9* 22 4* 12 2* 16 3* *HINE. Statistically signifi,ent et P 0 25 using a standardirel normal 2 test for compaiing proportiow, (a one-tailed test) aBased on a survey of active members *4 'he Merican Academy of Family Physicians SOURCE: G. Schmittling and CTsou, Ohstetric PrivileRes for Family Priysir,.7ms ,tipnal ,Sourn41. of Family Practice 29(2) 170-184. 1980 ing in rural areas since the early 1980s. Furthermore, concluded that the costs of litigating obstetrical a substantial number of providers are limiting the malpractice claims bave not decseased greatly. Their services provided to high-risk women because they suggested interventionstot...uibthe decline of fear being sued. Physicians are increasingly report- obstetrical prov iders included (289). ing a reduction in their Medicaid caseloads, at least in part because of professional liability concerns State alternatives 24.) thetortsystem(e.g.. (289). no-fault compensation for certain impaired A number of States have instituted reforms in infants). response to concerns over c'_tric malpractice federally spot..t:d demonstration projects and costs (box 15-8). Nevertheless, the IOM report studies of proposed State legislation, 4 J Chap:er 15Maternal and Infant Health Services in Rural Areas 397 Box 154Selected State Responses to Obstetric Shortages and Malpractice Insurance and Liability Issues ArkansasEstablished a grant program to increase aceess to nurse midwifery smuts in medically underserved areas (533a). ArizonaSubsidizes physicians who provide obstetric services in rural areas (53.7a). ColoradoLimits total liability to $1,000,000 and noneconomic fosses to $250,000, makes phy siceins not liable where birth injuiy results fron, genetic disorders or other unav oidable natural ,..ause-.,, and establishes a 3 yeax statute of limitations (532). FloridaIn 1988, enacted 4n injured-infants plan that includes no-fault eompensation, vuluntary arbitration systems, and immuniN for physkians ueating patients in emergency rooms (367), Established 4 grant program iti hicrease access to nelee-midwifery service.; in medically underserved areas (533a). GeorgiaMakes loans to physicians who reeently eompleted their medical edueation. Loans may be :epaid through practice in mral areas. Priority will be giv en to physkians weializing in, and activ el, practicing, ubstemcs (428). Missis;IpieExpanded the definition of "State employee' to include physieians providae serviees under a contract with the State so the physician avoids individual liability exposure (38) MontanaLimits the immunity of providers who render birth-related seniees in emerge Lie) situations (292). NevadaIn 1987, created a pretrial medkolegal streening panel in hopes of curbing the ex--eseive cost of malpactice insurance. In 1989, Nevada malpractice premiums decreased 11 percent (SOS). North Car olinaIn 1988, funded a pilot program to eompensate family physicians and ubstencians who agree to provide prenatal and obstetric care in counties whkh are underserved in respeet to these senket (331). South CarolinaExpanded the definition of "State employee" to include physivans providing serve-es that are paid for by a salary approiniated by a eovernmental entity, therein avoiding individual habilay exposure OS). TexasAssumes limited liability for malpractice tiai.os against doctors who provided at least 10 pereent charity care dying the previous insmance poLcy year. OurLy care includes senies provided under the State's indigent care prog.am, Medicaid, Maternal and Chi:J Health blo:k giant programs, and pimary health and migtant health programs Providers must still maintain malpractke insuranee but eligible practitioner :. may qualify fur a premium discount, in addition to added liability protection provided by the State (292) VirginiaIn 1987, enacted a no-fault compensation program for birth-reiated injuries (367). WashingtonContracts with or directly employs qualified obstetric providers, then pays, through Iugher reimiArsement, that portion of their malpraetice premiums that represents the 4.are they provided to eligible (indigent or underserved) pregnant women (292). a detailed, federally sporsored national data- expansion of the National Health Service Corps base on malpractice claims that would include (NHSC). information on malpractice insurance rates, payouts, settlements, and claims, FPs delivering obstetric services pay malpractice more systematic asz4ssment of new obstetrie insurance rates that are two to three times higher and related technologies, than those of their counterparts who do not practice extending the personal immunities offered by obstetrics (348). In some States, insurers are begin- the Federal ihrt Claims Ace or equivalent ning to adjust physicians maipracuce Insurance coverage, to ail peactitioners of obstetric t..ei e at rates for the nutaber of deliveries performed (528). Community and Migrant Health Centers (C/ Where such adjustments are not made, howev er, MfiCs), insurance premiums continue to be a greater burden State programs to indemnify or subsidize the for rural G/FPs and CNMs because these providers medical professional liability premium:. of generally hay e few er obstetric patien ts over w hom to obstetric providers who participate in Medicaid spread the cost. Physkians wht provide backup fur or otherwise provide care to low income women, CNMs often have to pay additional malpuetke and insurance premiums (29). 4 I.) 1. 398 Health Care in Rural America Estimating the impact of malpractice concerns on services in rural areas if there were a decline in the availability of rural obstetric providers is diffi- premium costs.27 cult because there are few national data available that distinguish rural from urban providers. 1nfonna- In a 1988 survey of C/MHC directors:28 two don about obstetrk providers responses to malprac- thirds (67 percent) of respondents indicated that the tice issues comes from two surveys. one conducted medical malpractice problem had affected either by the American College of Obstetricians and their ability to furnish obstetric services or their Gynecologists (ACOC) and one by the American scope of services (278). Centers reported .4fficulties Academy of Family Physic: ins (AAFP). In the most in recruiting and retaining staff and in establishing recent ACOG survey (1987), 12 percent of obstetncians and maintaining contractual arrangements with provid- gynecologists reported that they no longer practiced ers Many centers have relied on physicians availa- obstetrics because of the risk of malpractice suits. ble through the NHSC. The Federal Tort Claims Act An additional 27 percent ieported decreasing the formerly insured both commissioned officers of the level of high-risk obstetric care, and 13 percent NHSC and NHSC scholarship graduates who reported decreasing the number of dehvenes they worked as civilian employees of the Public Math handled (29).25 This survey did not distinguish urban Service, but since 1984 most NHSC physicians from rural obstetricians. placed in health centers have not been covered by the Act because they no longer receive their salaries directly from the NHSC. Consequently, health According to a 1986 AAFP survey, the proportion centers have had to provide malpractice coverage of FP5 giving up obstetrical practice is even higher from Federal grant funds and other revenue sources. than that observed among obstetricians. This survey As malpractice insurance costs have increased, the showed that 23 percent of AAFP members who had magnitude of this burden has increased in tandem, ever provided obstetric care had stopped because of reducing the centers' ability to provide care. Further- malpractice concerns (12). This development is a more, with declining numbers of NHSC physicians potentially serious threat to access to obstetric care available, centers' salary costs have increased in in rural areas, because rural women are more order to compete for physicians on the open market. dependent on Flkaor their care. From a 1988 survey that distinguished rural from urban FPs, however, it Forty-three percent of C/MHC representatives appears that rural FPs are much more likely than surveyed reported turning patients away because of urban FPs to Fovide obstetric services, especially to staff shortages (278). Several centers reported that high-risk patients (see table 15-12) (545).26 Among they had no one to whom they could refer the FPs that were not performing obstetrics, more urban patients they could not serve, either because private than rural FPs reported that they did not practice providers would not take the patients or because obstetrics because it was "not desired" (59 v. 50 there were no other locally available providers. percent), while more rural than urban providers cited Several 4; enters also reported that they were forced "liability cost3 prohibitive" (34 v. 25 percent) as a to discontinue care of women at the time of delivery reason for not performing obstetrics (table 15-13). because the FPs or CNMs on staff were not Based on the AAFP survey results, OTA estimates permitted to perform deliveries29 and could not that there could be a signifcant (up to 42 percent) identify community physicians to whom they could increase in the availability of FPs providing obstetric refer patients for delivery care. One center reported Inhere data represeat response% to a survey of ACOG members fewer than Otn-Lilf of those surveyed 148 MGM/ tesponded to ih, survey (2v). An estimated 63 percent of obstetrician/gynecologists are members of ACOG (125). 2611ds survey included the responses of active members of the Amman Ausdemy of Family Ptiymt.iaro. Mote than inree-iounna t lo 2 percent) ot those stuveyed responded. An estimated 66 percent of general and family practitioners me members of AAFP t520). 271h1s estimate mums that the AAFP survey is applicable to an GP/M. and that those practittuners that stated that prohibitive Immo cow prevented them from practicing obstetrics would indeed mei, tit reenter vbstenn ptunce if 1AALs were ledlit.C4 Of chminatod. The AAW annoy did not specifically ask about fear of a malpmctice stOt as a deterrent to praake and even if malprauve insaramt ..usb were reduced, some physpaans may not enter or reenter pinta& practice because ol such &am 21At Ore tint* of the survey there were 546 Communny and MAgrant Health Centersfty cies a a sum* ot 139 enters t42 percent) responded to the Survey (278). 29Catter providets were prohibited from delivering babto inha by thea tu.dprak-ta.c. ilCIA)1:101-C pukocs vi bc.4..ftsc tuk..0 busman allowed nenvenes only by obstetricians (278). 4 .' 2, Table 15-13Percentage of Active AAFP Members Who Perform or Do Not Perform Routine Obstetric Care in Their Hospital Practice, by Region and Location of Practice, 1988 Perform4d Performed Roams iipt performed aroma time not matter:Mr* ob41err1ft, Total in hoopitel with Rot Roamed Hot Priviled40 Liability oasts Re hoenitel Ho hospital No r0000p numbet 'notice econsultatiop pareant/(norbot) doired denied prohibitive department PR041$40 liven **Lai 34,444 29 0 0 1 10 7 (24.111) SS 3 O./ 21.11 1 / 11 0 2.6 Metro 17.506 23 3 00 76 4 (11.181) 19.1 0 7 24 1 1 4 9 7 2 1 Menmotte 9.079 41 4 0.2 56.4 (5.121) 50.1 0 4 12.8 4.7 9 4 2.4 Rertheemtb 5,231 14 7 0 4 64 9 0,401 61 0 0 6 16 t S 2 11 1 1.0 Matto 2,980 11 1 0 S 06 4 (2.50) 65 9 0.6 16 6 4.7 9 1 1 1 Rommetto 894 26 S 0 0 71 / (641) 12 1 0 0 11 4 5 5 6 G 2 6 Midwmatb 9.1366 GI 4 0 2 52 4 0.1341 16 6 0 0 27 S 2 6 10 7 2 S Matto 4,791 16 4 0 0 61 2 (5.020) 17 1 0 0 27 S 3 8 9 6 1 / donmetto 1.04 66 0 0 0 14 1 (1.014) 51 0 0.0 11.8 1 9 11 0 2 4 seuthb 11,211 17 5 0 S 62 2 0,1091 24 6 1 4 24 6 4.0 11 6 2 7 Motto 5,161 14 2 0 S 05 4 (4,421) 59 o 1.6 21 S 3 9 9 4 2 7 Monmatro 1,f15 21 $ 0 S 76 S (2,601) 51 0 0 6 29 1 6 0 10 2 1 9 Wes4b I, 772 42 5 0 S 67 S ($.220) 49 0 0 1 12 S 1 S 14 2 2 0 Matto 4,115 26 0 0 1 71 i (5.116) SS t 0 2 10.4 1 4 10 6 1 8 Montwitro 1,516 51 7 0 4 4/ 0 (726) 44 0 0 0 45 0 0 6 6 2 0 '1040014400 shown te U. wei8htod 040onsos of 3.552 top000sou R..pooso woc. weighted to rafiart the :eine:meg of active NW monhoto Tho ourooT tuonton on oholon tzno prootino woo Aot en4wsted by 1 3 portant of respondents 61141e54ento is unknown foe 21 7 percent a *nth physicians, 19 5 Receipt 02 Mi060itorA AIOIGianG, 24 I pet4ent oi SING60to yhysitimie, and 22 I pst444It Of w41414101 physsai4n4 SOURCE The moeti44n Aomiemw of EamilY Rh74ieions. tabuletion prepared for OM by Chtis Robinson and Gordon Schmittlink, 1969 4 14 413 400 Health Care in Rural America that it was forced to send all patientsnearly 700 a over one-half (52 percent; m communities with over yearto the local hospital emergency room foi 500,000 residents (28).11 Furthermore, obstetricians deliveries (278). in smaller communities tend to have practices that include a higher proportion of Medicaid deliveries Provider Participation in MedicaidMany ob- (28).32 stetric providers do not provide services to women who are uninsured or who have Medicaid coverage. Although it would seem that low physician Although States have expanded their Medicaid participation might hamper access to care, a govern- programs to cover more poor women, there is ment study found that few women who had recently widespread concern that physicians will be not be delivered a baby and were uninsured or had Medi- available to care for newly eligible women (347). caid coverage bad had problems finding a health care According to a 1987 survey of all 50 States, 89 provider to see them (614). According to the percent of representatives of Maternal and Child 1986-87 General Accounting Office (GAO) survey, Health block-grant-funded programs and 63 percent rural uninsured or Medicaid-insured women were of Medicaid program representatives said that they more likely to have had adequate prenatal care (46 were experiencing significant problems in Medicaid percent)33 than were women residing in large urban provider participation for maternity care. Low par- areas (29 percent) or other urban areas (42 percent) ticipation was found to be a particularly acute (table 15-14).34 Furthermore, a higher propordon of problem in rural areas: 35 of the 50 States reported uninsured or Medicaid-insured women in rural than problems in rural areas while only 3 said they had urban areas reported no problems in receiving problems in suburban or urban areas (347). prenatal care (33 v. 25 percent) (table 15-15). In In general, providers who do not serve Medicaid general, uninsured or Medicaid-insured women in patients report that their major reasons are low all areas reported that not recognizing that they were reimbursement and concerns about malpractice suits pregnant, financial problems, and transportation and malpractice costs (347). In 1986, the average problems posed the greatest barriers to obtaining Medicaid fee was approximately 44 percent lower care (table 15-15) (614). Less than 3 percent of the than the average national charge for total obstetric women surveyed reporte d the lack of "local doctors, care ($1,437).3° Many State agencies are trying to midwives, or nurses" as a barrier to care, but women improve provider participation through a variety of in rural areas were more than twice as likely as urban mechanisms that include raising fees, using alterna- women to report the absence of a provider as a tive providers (e.g., CNMs),providing case manage- barrier (4 6 v. 2.0 percent) (614). Eight percent of ment, and initiating outreach and public relations uninsured and Medicaid insured women reported activities aimed a: providers (347). that they "could not get a doctor, midwife, or nurse to see them," but this problem was not greater in Although provider particiption in Medicaid seems rural than in urban areas (table 15-15). The GAO to be a problem, evidence from provider suney s investigators conclude that increasing reimbursement shows that physicians in smaller communities are might expand the choice of prov iders available to more likely tha n other phy sicians to prov ide sen ices Medicaid-eligible women, but it would not improv e to at least some Medicaid patients. An estimated 63 .1(.4.,Css to prenatal care as much as using limited percent of obstetricians provide services to Medi- resources to expand Medicaid eligibility(614). caid patients, but 85 percent of obstetricians in GAO's findings may not be applicable to all rural communities with 50,000 or fewer residents prow ide areas, huve%cr, because the study included women obstetric services to this group compared with just delivering in unly 13 rural hospitals. Rural 6-ommu- "As of 1986, b l e d w a i d p a i d l e s s t h a n h al f o f t h e pro ailing e o m m u a t r y a m i g o s tu t ubskah.4.arc m at least :3 &web. In Flunda. M...kahi paha way 17.5 percent of tbe prevailing communal charge whereas a Nebraska. Mot/kW paid 76 i pv;.ent .if the wmanumty adage 047). "A 1989 study of Alabama obstetric providers showed that rural tuwns With Weber prupurowis viptouuuttg., 4,..,..epubg M ,...aal..aat. *etc fuvie likely to retain obstetric providers than nual towns with relatively few such providers (1024). "A 1989 survey of pediainwans showed that overall pankepatiou In the Medkald program tabdtimod Nike 1;6.4 ow that pedtainwanb fiigh.ii.iii$ in rural =ZS are mom hkely than urban pedannuans tu pamupate and w ha* e unrestrkted parowpaituo di the Mcdkaid pi wpm .".,.1, "Adequateprenatat otre wasdefmed as %are beguming in the fast inmate and ahluding 5 kit mute v i..via fin a pitglitual vf 36 vi ilium ,,vtax., "Wometi %Westland hog, 3: tommunales in 8 Slams w ptuvhie a nux a natal, Lliediugi vked whak aid idigi, anal" 111S +A diffachi Pan& of the country (614). di1' 4 's Chapter 15-Maternal and infant Health Services in Rural Areas 401 Table 15-14-Adequacy of Prenatal Care° for Medicaid Recipients and Uninsured Women, by Area of Residence,198647 Total Inadeouate b Intermediatec Adeauated (1,157) Humber Percent NuMber Percent RuMber Percent Largerm*mme 507 128 25.23 233 45.06 146 28.80 Medicaid 197 42 21.32 94 47.72 61 30.96 Uninsured 310 86 27.74 139 44.84 85 27 42 Otbez. urban 348 68 18.97 135 38.79 147 42.24 Medicaid 198 30 15.15 81 40.91 87 43.94 Uninsured 150 36 24.00 54 36.00 60 40.00 2mra1. 302 36 11.92 128 42.38 138 45.70 Medicaid 210 21 10.00 89 42.33 100 47.62 Uninsured R2 15 18.30 39 42.39 38 41.30 °The Institute of Medicine prenatal care index (developed by D. Kessner) is used to classify the adequaLy of prenatal care. 4Care beginning in third trimester or including 4 or fewer visits for a pregnancy of 34 or more weeks. 0Care beginning in the second trimester or including 5 to 8 visits for a pregnancy of 36 or more weeks. dears beginning in the first trimester and including 9 or more visits for a pregnancy of 36 or more weeks. %men delivering in 39 hospitals in 32 communities in 8 States were interviewed. Large urban includes large metro areas, other urban includes other metro areas. SOURCE, U.S. Congress, General Accounting Office, Prenatal CareMedicaid Recinients and Uninsured Women Obtain Insufficient ccreHRD-87-137 (Washington. DC. V SGovernment Printing Office, 1987). rides without hospitals or other facilities are likely delive.ies in mai areas, compared with 13 percent to have greater access bathers to obstetric services. of urban deliveries, were classified as "self/family- pay" or "no payment." Nationally, about 6 percent Inability To Pay for Care of total hospital charges are nct paid and maternity In 1989, the average charge for a vaginal delivery services accountforabout 40 percent of this in the United States was 84,334 (including physician uncompensated care (392). In 1982, rural deliveries and hospital charges), but the average charge was accounted for nearly one-half (46 percent) of all about 10 percent lower in rural than in urban areas uncompensated deliveries, yet rural deliveries repre. (9,392).35Women in rural areas, particularly poor sent only 23 percent of all deliveries (9). Some of the women, are more likely to have problems tinancing difficulties in paying for maternity care can be traced maternity set vices because they lack insurance to the fact that the raral poor are less likely than the coverage or their insurance does no* cover maternity urban poor to have Medicaid coverage (530) (see ch. services. 2). Most w,..:ten in both urban and rural areas (77 Medicaid-As of 1984, 17 percent of all delivery percent) have private insurance and a comparable charges were paid by Medicaid (9). Between 1975 proportion of rural and urban women of reproductiv e and 1990, the percentage of poor persons covered by age are uninsured (18 percent v. 16percent in 1985) Medicaid nationwide dropped from 63 to 50, but (9). Runt women, however, have more private subsequent congressional {-hangea have reversed the in.surance coverage through individual polic1es that bend for pregnant women and Infants (292,. As of are less likely to cc .er maternity care (table 15-16) April 1990, all States must extend Medicaid eligibil- (9).36Consequently, rural women are more likely ityto all pregnant women and children up to age 6 than urban women to be responsible for paying for whose family Incomes are at or below 133 percent of their deliveries themselves. In 1982, 19 percent of the Federal poverty lever k Public Law 101-290). Is1heaveragcchargefotatzsareandeloczyttas$7,633t9).Thewatodelit,e.andtarefolaptemanacbAbywittimajult.outpli,411vobtanbtfintat higher. 16Insuranco potions that aft through employers vf 15 ka facet employees or Met at nut employment mimed alt LW 'Nailed tow ter mata tatty tate. Nationally, approximately 9 per..eat uf repaitlth.tive ago *umerk tebut.i 3 nolla i *Amen) have private mbutant.t. pukh.ics that du out ..4.04,t, tritheintry cam (4 "The Fredmmd pevcnylevc1 Hi 19901s $10,5604er a fmndy of darcm (419) 4 1(-; Table 15-15-Barriers to Earlier or More Frequent Prenatal Care Cited by Medico id Recipients and Uninsured Women Who Had Recently Delivered, 1986437 All waken Women with inadequate prenatal rare a Large Other Large Other total urban urban Rural Total urban urban Rural (1,157)(507) (348) (302) (726) (361) (201) (164) Barrier* Logistloel/scooss to heal* services: Did not have anyone to telt* care of other children 0.02 9.86 B 33 7.62 11.71 6.47 0.46 12 80 Could not miss work or school 5.53 7.10 2.01 6.95 6.75 8.03 2 99 9.54 Did not have a way to get to clinic or doctor's office 16.16 13.02 17.53 19.87 20.25 16,07 21.89 28.05 No local doctors, midwives, or nurses 2.60 1.97 2.01 4,64 3 86 2.49 3.48 7.32 Could not Set 4 doctor, midwife. or nurse to see them 7.07 6.31 9.77 8 28 9 SO 8 03 10,95 10.98 Did not know where to go fox care 8.9C 11.83 4.02 9.60 11,16 14.13 5.97 10.98 Felt the wait in the doctor's off1ce or clinic was too long 8,64 10 85 7.1$ 6.62 11.57 13.02 10.45 9 76 Felt the office hours were not convenient.. . .19 30 3 74 3 31 6.34 7 43 4 98 5.49 Could not get an appointment earlier in pregnancy 11.58 13.02 11 78 3 94 13 50 :4 40 14 43 10,37 Cannot speak English well and could not find enyone who spoke their language . 1 O. 1 97 0 00 0 66 1 24 1 94 0 0 1,22 Thought the. alight have problems with immigration people . 1.73 3.94 0.00 0 00 2 20 4 43 0 0 0.0 Women'. Attitudes, beliefs, sod experience*: Did not think it was important to see a do...tor, nurse, or another medical person earlier or more often...... 6.83 8.48 5 45 5 63 5 68 10 25 6 97 7.32 Did nIt want to think about being prsnant. 10.72 11 05 9.77 11,26 l. 64 12.47 15.42 14 02 Had -many other problems to worry about core 8.30 9 86 7.47 6.62 '1.29 11.91 11.44 3 76 Did not know that they were pregnant. 24.63 24.85 22 41 26 42 0 37 27 15 29.35 29.89 Not sure they wanted to have the baby so didn't go to see a doctor, madw4fe. or nurse .. 7.09 9.47 4 60 5 96 8 82 11 08 6 47 6.71 Table 15-15-Barriers to Earlier or More Frequent Prenatal Care Cited by Medicaid Recipients and Uninsured Woolen Who Had Recently Delivered, 1985-87-Centinued All women Womeo w1th tnadeqq:WLJMUIEWW.4.4l11-4 Large Othar Large Other Total urban urban Rural Tot41 never' urban Ruial (1.157)(507) (343) (302) :770 (361) (201) (164) Mamma's attitudes, beliefs, sad amparisecea: Knew whet to 10 since Off hod been pregnant before 42.45 15.38 10,34 9.91 10.25 13.28 i5 92 12 20 Were a little afraid of medical tests and examinations 6.38 10,85 6,90 5.96 10 10 12./9 6,46 7.93 Were afraid to find out they were pregnant. 6 47 7.10 %.E2 10 60 i0 19 8.31 12.44 11.59 Did not want to tell baby's rather. parents, cw other family members 7.69 4 73 8.33 11.92 10 33 5.52 13 43 16 =6 Did not like the doctor's ox nurse's attitudes 3.80 4.14 2.30 4 97 t.51 5.26 3.48 6.54 Financing Did not have enough money to pev for visits 22.39 25.64 16 09 24.17 26 $3 31,02 21 f9 30,49 Not eligible for Medicaid...... 4.O3 4.93 4.60 5.30 5 37 5.26 5 4) 5 49 Had problems with Medicaid . 0.83 7.10 7 47 5.63 8,04 6.59 9.45 6.54 Other 4.41 5.33 4 60 2 05 5 23 5 26 5 e7 4 88 No Problem 29.39 24 85 39.05 32.78 11.63 16,34 i3 '11 'Caro beginning in third trimester or including four or fewer visits fnr a prognen:.y of 34 or more weeks. Women delivering i 4 hospitals in 32 communities in 8 States were interviewed. SOURCE U.SCongress, Coneral Accounting Office, Prenatal Care Medicaid Reciniereaxlijaalikuilmallaln Inaufltcsent Cate, Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on Government Operat Rouse of Repreaentslives, U.S. Congress, HR' 87-137 (Washington, DC, U,S Cover-neat Printing Office 1987). 404 Health Care in Rural America Table15-16Insurance Coverage ofWomen Aged 15 to 44 Years, by Residen.0 a. Mantel Status, 1985 Residential status/ Other Number of women marital etatus Group Individual Medicaid government, None in samp'. (i.000s) AU mem 671 10x 91 41 171 56,152 Metro 68 9 9 3 16 41,610 Nonmotro 65 12 18 14,543 Merrialmommta 7$ 10 4 5 11 29,241 Mots* 79 9 3 5 10 20,789 Nonmetro 74 12 4 4 14 8,452 Ramommied mamma 55 10 15 3 23 26.912 Metro 56 10 15 2 23 20,821 Nonmetro 52 12 14 3 25 6.092 NOTE. Percentages do not add up to 100 because women may haveinsance from more than one source. SOURCE_ Alan Guttmacher Institute, The Financing of Maternity Care In the 11Mited Stateg (New York, NY 1F87). p. 379. As of January 1990, 4 States had extended Medicaid eal providers (e.g., C/MHCs) to make temporary s....,verage of these groups to 150 percent of the Medicaid eligibility determinations for pres.iant Federal poverty level, and 15 States had extended w omen and provide services until they are fo mally coverage to 185 percent, the fullest extent permitted enrolled in the program. This option helps to ensure by the Federal Government18 (figure 15-1) (see ch. that pregnant women, who in rural areas miy be far 3, table 3-3) (419). States categorized as "rural"' from the Medicaid application site, are ..ared for are less likely than "...ban" States (30 v. 46 percent before ant.- durmg the application prooess. of States) to have opr:d to extend coverage beyond the lewl required by law. Placing Medicaid eligibility determination vt.ork- ers at public health clinics (in some areas on a circuit Several States h..ve streamlined the Medicaid nding basis) or allowing mail-in applications wu-stei application and enrollment process, making it easier probably facilitate Medicaid enrollment in rural fc.r pregnant women to become eligible for coverage areas (277). Rural States, however, have been less quickly. Mr.sr States, for example, no longer review likely than urban States to "outstation- eligibility pregnant womens'aSSOISwhen de .:amining eligitil- workers (26 v. 42 Ferceia) to 1 ospitals, local hea,th ity, but more "rural" tikn "urban" States review departments, prenatal care clinics, and C/MHCs assets (19 v. 8 percent) (table 15-17). Asset restric- (table 15-17). tions can result in exclusion from Medicaid cover- age of poor rural f.milies that h-..ve small farms, Other Federal Sources of Services to Low, work tools, or a car or truck (277). income WomenIn addition to the Medkaid pro- gram, several Federal Government programs are "Rural" States are somewhit more likely than designed to increase access to maternal and infant "urban" Statc r. to offer continuous (85 v. 75 percent care for poor and disadvantaged populations. Three of States) anc presumptive ligibility (52 V. 46 of these are described below percent of Statcs) (table 15-17). States with continu- ous eligibility do not requirt a women to re- The Maternal and Child Ikalth determine her eligibility during ir shortly after her &ant provides mune) it.States to pw . ate inaternal pregnancy. Continuous Melicaid coverage is impox And child health care to low IL-twine, underned tant for rural families, who may have seasomd, pregnant women, infants, and children 4et...h.3). In fluctuating income Lvels that could otherwise 1987, $395 million was appropriated to the States periodically make them ineligible for benefiu (277). (49C), whal usedportion of the money for free or Presumptive eligibilhy allow publicly fimded äni subsidized prenatal and well -ehild care in pJblic. "Social 5trzs have bolstered Medicaid expansionsbyenacting ...ate-funded program.> for pregnant*mguand children i//://y Thc21 States that ranked in the top 15 hotpeit.gmtapopulation oonnictiv the top 15 fin nuntbas UI 1IV!U..tIU icaidcuis. w cm °mellowedbtee asOitalbc ramming States and thc Distrtcl of Colunitta ,verc categonred as urban tree elt 2, tabk 2 2/ 4 ,") Chapter 15Maternal and Infant Health Services in Rural Areas 405 Figure 15-1Medicald Coverage of Pregnant Women and Infants, April 1990 Tffialika.a& , PercentNumber of of povertyStates 133 30 134 - 184 4 District of Columbia > 185 17b !Number of States and the Disfict of Columbia vAlaska uses Stale funds to a aid COvOrage up to 185% u 1 80019 parts uf Me SAW C.aliss food, NA* Jelisuy. dJ RS AilMOM u )late hailtt tu OA lel o3 woe age to 200%. Masauchusetb and Hawaii have passed legislation tu provide v. eve. sai access tu health ...ale lçiu ell individuals a I thee States, SOURCE. National Governors Association, State Coverage of Piegnant Women and ChadianJanuary 1990. Arasmoglon. DC. Jaavary 149, health clinks, he. dth educatk ii, outreach to pregn.0 t bcated in rur4l areas. Scrvices provitk4 inclutf; women, and transportation servkes. In 1987. MCH preventive care, firmly planning, diagnostic and block grant expenditures accounted for about 10 emergent.) care, and transportation. More than percent of Statestotal maternal and child health 200,000 pregnant women received maternity are at expenditures. At that time, State health agencies C/MHCs during 1988 (413). In many communities. used about one-third (31 percent) of MCH block. CIMHCs are the sole source of comprehensive grant fundsabout $121 millionto support local maternity and infant hea:th care.' health departments (496). In 1988, and p-ain in 1989, C/MHCs received $20 Community and Migrant Health Centers provide million in adt,...ionalft nding" to improve and primary health care sen ices, including maternity ...azngthen their capacit, to serve pregnant women services, in medically underserved areas (see chs. 3 and 'nfants. The fwiding was to be used to enhance and 5). Sixty-one percent (319) of C/MHCs are the Oility of C/MHCs to: 400ne-fifth of women receive ears from a pubis. prorider ke 8.. a ho,pital uutpa.. I' ..tcpanuicat. a C.A410.7. .rihAeal ts..thti depart mutt,. *ink thc remainder receive prenatal care in pnsate physicians' onces (289) 4111e adVilonal funding came through DIMS' infant mortality initiative 4 4 0 20-810 0 - 90 14 0L3 406 Health Care in Rural America Table 15-17--Strategies To Streamline Medicaid Eligibility, January 1990 OBRA 1986 Optionse Qtber State initiatives Outstanding Dropped Continuous Presumptive eligibility Shortened Expedited States assets test ligibility aligibility morkers application ligibilityb Alabama X X X X X Alaska X X X Arizona X X Arkansas X :, X X California Xc Colorado X Connecticut X X Delaware X X X X X District of Columbia X X Xc Florida X X X X X Georg. X X X X Hawaii X X X Idaho X X X Illinois X X Indiana X X X Iowa X X Kansas X X XentuCky X X X X Louisiana X X X X X Maine X X X Maryland X X X X Massachusetts X X X X Michigan X X X Minnesota X X X X Mhesissippl X X X Missouri X Montana X Xc Nebraska X X X Nevada X Xc Now Sampshire X Nam Jersey X X X Xc Nam Mexico X X X X New fork X X X North Caroline X X X X North Dakota Obio X X Oklahoma X X Oregon X X X X Pennsylvania X X Rhoda Island X South Caroline X X X X South Dakota X X X Tennessee X X X X Texas X X X X Utah X X X X Vermont X X X x X virightla X X X Washington X X X West Virglnia X X X X Wleconsin X X X X Wyoming X X Total 44 41 25 17 12 9 AOptions States noy pursue that were introduced by the Omnibus Budget Reconciliation Act of 1986 (see text). bEapadiied ligibility is the process mhereby Stetas give priority in the Medicaid determination process to applicants mho are pregnant. cFuture implemontetion date. SOURCE: National Governors" Association. 'State Coverage of Pregnant Women od Children-January 1990." Washington. DC. January 1990. 41 Chapter ISMaternal and Infant Health Services in Rural Areas 407 provide comprehensive case-managed perina . services are unavailable (348). In Southeastern tal ambulatory Care services, Missouri, for example, some high-risk pregnant enrich the services of C/MFICs through addi- women have to travel cmer 250 miles to reach a tion of staff for outreach, health care, and university hospital for their deliveries, in Texas, nutrition education, some pregnant women are sent by ambulance to develop or expand service delivery systems for deliver their babies in hospitals 150 miles away women and infants, including contractual ar- (348). rangements with community obstetricians to serve patients at health centers that do not have When rural hospitals close, ready access to their own obstetrical staff and formal referral delivery services diminishes. However, available arrangements with local and regional hospitals, evidence suggests that few hospitals that have closed and were the sole source of care in rural communities better coordinate services between C/MliCs (252) (see ch. 5). As of 1987, many more rural than and other local public and private providers of urban community hospitals with fewer than 300 health and health-related services (627a). beds provided delivery services (85 v. 64 percent) (table 15-18). Smaller hospitals in rural areas are The infant mortality initiative funds were to be much more likely than comparable urban hospitals targeted to areas with high or increasing infant to offer delivery services. For example, of hospitchls mortality rates. In 1988, however, this funding was with fewer than 25 beds, less than one-third (29 sufficient to place projects in only one-third of percent) of the urban hospitals but more than three health centers (206 centers), and many grantees did fourths (77 percent) of rural hospitals report deliver- not receive enough to carry out necessary activities ies (table 15-18). Of hospitals that perform deliver- (412). ies, rural hospitals have fewer births per hospital The Supplemental Food Program for Women, than do urban hospitals of comparable size. In Infants, and Children (WIC) provides nutrition hospitals with 100 to 199 beds, for example, there education and supplemental foods, such as infant are on the average 451 births per rural Lospital, formula, milk, eggs, and cereals, to low-income compared with 790 in urban hospitals (table 15-19). pregnant or nursing women, infants, and young Evidence suggests that many patients are migrat- children who are at "nutritional risk."42 In 1988, 65 ing from rural areas to deliver their babies in more percent of WIC service sites were located in rural diatant urLan hospitals: areaso and 40 percent of WIC participants were rural residents (730). In 1987, $1.6 billion in Federal A 1985 national health care consumer survey funds were used for the WIC program, but only 53 showed that almost one-half (47 percent) of percent of pregnant women, infants, and children rural residents were gothg to other areas fur with incomes below the poverty level received WIC specialized care, such as women's services benefits (496,569). (303). In the North Central States between 1980 and Loss of Hospitals and Hospital-based 1987, there was a 20 percent decline in rural Obstetric Care births per hospital and a 5 percent increase in In 1987 almost all deliveries (over 98 percent) in births per hospital in urban hospitals (577).44 both arban and rural areas occurred ni hospitals In 1988, 50percent of pregnant women residing (650). Pregnant women need to be able to reach a in rural Alabama did not deliver at the nearest hospital with delivery services within a relatively nual hospital prov ;ding obstetric serv ices. Here, short period from onset of labor, but there are some women traveled tu deliver an average of 23 reports that women in rural areas are traveliag great miles, over one-third went to hospitals in metro distances to deliver their babies because local areas (102b). 42Nutritidnal risk includes a history of poor pregnancy outcomes. gon-deficancy ammo, and inadequare dietacy patterns 13Areas with a population of fewer than 25,000 were defined as rural. 44Whethes this dui; occurred because of a lack of asadabiliry of delivery sal, ices, because high risk pregnars.ms vicic incicAsuit,ry he...* iefured to urban centers, or because patients41lo5e to MINIXLB urban ATM Is ILLABVWil BLS& represented ivpchAati vi luicti twniudi adolda.hvia.06 4)87 aid so the shift of births to urban areas could jeopardize the financtal stabihly of mai hospitals (577) 442 408 Health Care in Rural Anterica "Min 15-18Proportion of CommunityHospitals" Reporting in-Hospital Birihs,b by Hospital Bed Size and Location, 1987 Metro %Mastro (Total numberof (Total number of hospitals in hospitals in Bed site Percent bedsit. category) Percent luidsize category) Total hospitals 84.3 (1,957) 85.4 (2.584) 8-24 29.0 (31) 77.0 (200) 25-49 .. 54.5 (143) 81.5 t817) 50-99 57.4 (427) 88.0 (893) 100-199 63.9 (756) 92.0 (539) 200-299 74.0 (600) 91.1 (135) *Community hospitals, defined here as short-stay, non-Federal, nonspecialtY hospitals (see app. C), bilospitals reporting births are those reporting at Least one birth. SOURCE: °taco of /eehnology Assessment, 1990. Dmta from the American Hospital Association's 1987 Annual SurvirY of Hospitals. Table 1549Average Number of Deliveries in Motropolitan and Nonmettopollten Community Hospitals,' byBed Size, 19871' Averagt_deliveries per hospital Metro Noometro Average (NuMber of Average (Humber of Bed size deliveries hospitals) deliveries hospitals) Total hospitals 831 (1,259) 257 (2.207) 6-24 1Z.7 (9) 46 (154, 25-49 183 (78) 96 (666) 50-99 367 (245) 223 (768) 100-199 790 (483) 451 (496) 200-299 1.281 (444) 818 (123) aCommiunity hospitals. defined here as short-stay, non-Federal. nonspecialty hospitals. bAnalysis is Limited to those hospitals with fewer than 300 beds and reporting at least 1 birth SOURCE: Cof*fre of TechnlOgY Assessment, 1990 Date from the American Hospital Association's 1987 Annual go of Hospitals. In 1986, o.third or more of obstetric patients case study, for example, nearly one-half (45 percent) in the service area of 25 of Washington's 33 of women who resided in a rural hospital service area rural hospitals° were having their babies in a were driving over 50 miles to deliver even though hospital outside of 'hair community. Li some the iocal hospital had physicians on staff. Women cases, patient outmigration occurred because a using the local hospital were more likely to be under community hospital had stopped offering de- 18 years old, unmarried, and not a high school livery services, but 28 of 33 hospitals were still graduate than women traveling outside of the area offering obstetric services at the end of the for care (591). Thatthe number of deliveries per study period (433). available physician declinedhelve the physicians Some reports link a decline in the number of themselves began to drop obstetrics suggests that physicians available to delis er babies to the dosuie patient migration anti a subsequently greater propor- of hospital obstetric units (336,591). It is difficult to tion of high-risk patients in their practices may have determine whether the precipitating factor was that prompted some local physicians to drop the service physicians stopped delivering babies or that patients (591).4' In rural Alabama, evidence suggests that left the local hospital to deliver elsewhere. In one rural obstetric units dose because women stop using Oiturai hospitals awe definedSS All SCISO-CAle, thpilikalfa _ damsoffewer than 50 beds 4odkkaled MSCthan 15 ewes from a my of 30.000 popubition Mgreater (433). 46AccOldiag tothecase study.the Physicians Prtm Ming most V the care waned .onteauc cu Mel& ubsteirit scrvic.es tout could not afford the mailnaeticeiasuraoce ($91). 4.) Chapter 15-Maternal and Infant Health Services in Rural Areas 409 Table 15-20-Mothers With Ultrasound and Electromu ;:etal Monitoring During Pregnancy or Labor, 1980 Ilectronie fetal momitorina during Idborc Race Residence All races White Black All races White Black All locations 29.3 29,1 30.8 47.2 47.1 47.6 Motto 32.0 31.8 34.9 51.6 51.1 54.7 South 3t.1 31.7 29.8 50.4 49.6 53,4 Other regions 32.4 31.6 38.6 52.3 51.6 55.8 Sonnets* 24.2 24.5 19.0 38.8 40.2 29.3 South 22.3 234 18.5 37.9 40.4 29.1 Other regions 25.8 25.4 39.4 40.1 aWomen with at least one ultrasound during pregnancy. btased on 5,343 births included in the National Natality Survey. Based on 7,504 births included in the National Natality Survey. SCMRCE: J.C. Kleinman, M. Cooke, S. Machlin et al., *Variation in Use of Obstetric Technology, Health.13 S. 119.1 (PBS) 84-1232 (Bethesda, MD: December 1983). them. Here, large numbers of women migrated from monitoring strips to permatologists in a distant rural hospitals long before they slopped providing center for interpretation. If a problem is detecied, a obstetric services (1020. helicopter and support team are dispatched to transfer the mother to a regional center (132,259). In contrast, a 40-bed hospital in Nevada pro- gressed from providing only 7 to 73 percent of the Access tt, Regional Systems of Perinatal Care county's deliveries through sonie deliberate steps aimed at winning back obstetric patients after a In the aggregate, events that n.:7 require special- period of patient outntigration to urban hospitals ized care occtr relatively frequently. Twelve percent (505). These steps included: of women have at least one major complication of pregnancy, 11 percent of women have a major attracting and organizing necessazy personnel complication of labor, nearly 20 percent of deliver- and implementing a team approach with obstet ies occur by cesarean section (8),41 and about 4 to 6 ric morbidity and mortality conferenct percent of newborns require neonatal intensive care providing equipment such as ultrasound ma (619). For indiv idual rural practitioners with small chines and fetal monitors to improve care obstetric practices, however, these occurrences are quality, and relatively infrequent. To assure access to care when publicizing the availability of obstetrk sen 4-omplications arise, regional systems of perinatal° ices. care have been organized in some areas so that Some women may choose to obtain prenatal care low-risk patients are cared for by primary care and deliver in more distant hospitals because of practitioners in community hospitals and clinics greater access to medical technologies. In 1980, while high-risk patients are seleaively triaged (and pregnant women in rural areas were less likely than sometimes transported) to p- as and facilities urban women to receive ultrasound or electronic equipped to provide specialit.care. These perina- fetal monitoring (table 15-20). Urban/rural differ- tal centers are usually located in urban areas (549). ences were especially great for black women (322). In 1987, for example, fewer than 2 percent of rural hospitals and 6 percent of urban hospitals with fewer Communications technology is malting it easier than 300 beds had a neonatal intensive care unit for rural providers to offer obstetric monitoring to (NICU) (tabl.: 15.21). There are relatively fewer their patients. Facsimile machines, for example, are pediatricians in rural than arbar areas to 4.4ie for used by some rural practitioners to transmit fetal seriously ill newborns (table 15 10). t980, cesarean SectiOli births occlusal slightly more frequently m urban 08 patent, than rural areas 06 paccnt, k9) 48Perfnalid refas to the paned shortly before and after birth. n is .anuusly deftred as beg-attune 1%6 Lli wmpletivii ut 4114 iv Loth Wia:k vt gestation and ending 7 to 28 days after birth. t4rI WIII/P9Awgrz.r. 410Health Care in Rural America Table 15.21Proportion of Community Hospitals With a Neonatal intensive Care Unit, by Hospital Bed Size and Location, 1987 __Hetro Honmetro (Total number of (Total number of hospitals in hospitals in Bed sits Percent bedsit. categorY) Percent bedsit. category) Tata hospitals 6.4 (1.057) 1.7 (2.584) 8-24 0.0 (31) 0.0 (200) 25-49 0.0 (143) 0.0 (817) 50-99 .9 (427) 0.7 (893) 100-199 4.6 (756) 4 (539) 200-299 14.3 (600) 11.9 (1351 aCommunity hospitals, defined here as short-stay. non-Federal. nonspecielty hospitals. Analysis is limited to hospitals with fewer than 300 beds. SOURCE. Office of TechnoLogy Assessment, 1990. Data from the American Hospital Association's 1987 Annual Survey of Hospitals. in many areas, regionalization appearsto be pitals can utilize transfer agreements and rapid concentrating high-risk infants in faciliaes equipped transportation systems to facilitate access to special- to care for them (249,527). When physicians work- ized obstetric units and NICUs. ing in community hospitals refer a large number of bigh-risk obstetric patients, the need to transport MODEL RURAL MATERNAL AND sick neonates from these hospitals is lower. In Iowa, INFANT SERVICE PROGRAMS for example, 78 percent of very-low-birthweight births occur in specialized hospitals (249).4' In other Severalcomponents of health care programs have areas, a regionalized approach to perinatal care has been identified as contributing to declines in infant not yet fully evolved. In upstate New York, for mortality in rural areas:" example, many high-risk babies are still being placement of publicly supported obstetric pro- delivered in small rural hospitals (155). A 1988 vides in the community (e.g., physicians, study found that regionalized perinatal care systems Chals, or nurse practitioners), have generally deteriorated over the last several the availability of obstetricians either locally or years. The study indicated that in some areas on a consultant basis, competition has replaced cooperation among hospi- the provision of obstetric services for low-risk Ws providing perinatal care (425). Futtnermore, patients by public health nurses with support many community hospitals are upgrading their from local physicians, neonatal prograirs, regardless of whether the num- the presence of perinatal transport systems and ber of high-risk infants is sufficient to maintain training, either professional skill levels or program economic high WIC utilization, viability (248,425). implementatio..n of tracking and management There will always be a number of presumed systems, program flexibility and a lack of strict program "low-risk" deliveries that have unanticipated com- plications, so rural hospitals that offer obstetric boundaries, servico must maintain the capability to perform interagency coordination and cooperation, and community concern and leadership (465). emergency procedures such as cesarean sections, which involve surgical, anesthetic, and post- Demonstration programs funded privately and operative capability (402). Alternatively, rural hos- through the Federal Government have attempted to 40specialized hospitals include level two and three centers Before the regtormhzed system was developed, thew infants were just as likely to be horn in a level one hospital where resources needed to care for Mese mfants may aot have been available 049). soThe Bateau of Health Care Delivery Lad Assistance funded a study to keen() floors that have 4..oninbutod to4ctestsisig attainmonatity rates in rural commies over the past IS years The National Rural Health Assouation seleted four ...ommunitics to study mi 1.uuwaha. ieas. Montana,andSouth Carolina with populations between 10,000 and 35.000 (4a). 4.:5 Chapter 15Maternal and Infant Health Services in Rural Areas 411 redres;, problems of access to care and high infant establish sy sterns for perinatal data analysis, mortality in rural areas. In addition, many States including the matching of birth and death have initiated innovative programs to improve certificates; perinatal outcomes. monitor and establish mechanisms for improv- The Rural Infant Care Prop-am," funded from ing quality of care for pregnant women and 1980 to 1984 by the Robert Wood Johnson Fo.inda- newborn- including the creation of maternal don, was designed to give poor mai families access and perinatal mortality committees; and to regional networks of perinatal care by linking organize the flow of patient., ao that those with their local public health units, physicians, and the highest risk of a poor outcome could be hospitals with tertiary medical centers (517).52 An cared for in appiopriate perinatal centers. evaluatio n of the program showed that infant mortal- ity declined in the target populafions and among Through the Federal Improved Child Health high-risk groups (223). Among the program compo- Program (ICHP), 8 States were awarded 5-year nents that were included were: grants to assist targeted counties in improving infant mortality (579). Evaluations of some of the projects screening for high-risk pregnancies and provid- ing followup to those identified in special located in rural areas show that they were effective clinics; in increasing prenatal care use but unsuccessful in changing the incidence of low-birthweight (468, implementing health education and nutrition 579). programs; establishing neonatal hotlines so that local The MCH block grant program funds service providers could obtain medical consultation; demonstration projects, State staff development implemendng a system for transporting high- programs, and other initiatives to help States de- risk women in labor and newborn infants to velop their MCH programs (66). In 1989, for hospitals with NICUs, example, 24 ongoing projects specifically related to using CNMs, nurse educators, and pediatric rural maternal and infant health care were funded nurse practitioners to supplement physician through the grant program (687). Among the funded care; projects were those supporting health promotion in conducdng in-service education programs for rural black communities and consultation visits to local providers; and high-risk pregnant women in rural clinics by a team training and employing lay outreach workers of perinatal specialists (687). for patient recruitment, followup, and transpor- tation to the clink or hospital for care. In some rural areas, adverse overall economic Federal programs implemented in the mid-1970s conditions may overshadow the effects of special contributed to declines in infant mortality by facili- health care interventions. A program implemented tating the development and use of pennatal centers in an impoverished rural area in Appalachias's failed (215). From 1976 to 1979, 32 States plus the District to improve neonatal mortality despite the operation of Columbia and Puerto Rico were funded through of free hospital- and community-based clinics and The Improved Pregnancy Outcome (IPO) Program" the provision of home health visits by outreach to undertake the following activities (215): workers (515). Despite the Indian Health Service's regionalized system of perinatal care, which in- perform needs assessments for the pro% ision if dudes nurse-midwives performing low-risk deliver . perinatal services; ies and trained indigenous workers providing home- write State perinatal health care plans, based care, infant mortalit,is1 I/2 times higher defme levels of perinatal care; among Native Americans than among all U.S. educate providers of health care; residents (616). 51The Rural fafant Care Program is also briefly described in app E. Stren medical schools in owe Slates were funded (517)- States and not the Federal Government selected 1ocattons of services to be provided under the grant 215) Mlle Family Health sermes program ol Eastern Kentucky was funded by the Rohm Wood Johnson TWOrl1a4lvil .1,04 oficr4ie4 (on. 1)-4 io 1978 (515). 4 ''.' "0 412 Heakk Care in Rural America Innovative programs may be difficult to admin- consequence of the high cost of malpractice ister in rural areas without a flexible approach. In insurance and fears of lawsuits. It is more difficult California, for example, rural implementation of the for rural providers with small obstetric practices to Comprehensive Perinatal Service Program," which pay for malpractice premiums, because insurance provides risk assessments, prenatal services, case rates often do not consider practice volume. Rural coordination, and perinatal and parenting education, FPs not providing obstetric care are much more has been handicapped by strict program require- likely than their urban counterparts to cite costs of ments for support staff. Several rural counties do not liability insurance as a deterrent. Based on analyses I have the trained health educators, social workers, of AAFP survey data, there could be a ssgncant and registered dieticians that are required to admin- increase in the availability of FPs providing ister the program (133). obstetric care in rural areas if malpractice insur- ance premium costs declined. Two-thirds of C/ SUMMARY AND CONCLUSIONS MHCs, important providers of obstetric care in many rural areas, also report that medical malprac- Fetal, infant, and maternal mortality are dispro- tice problems have affected their ability to furnish portionately high in rural areas. The fact that rural obstetric services. women are less likely than urban women to receive early prenatal care probably contributes to the Uncertain is whether low obstetric provider par- relatively high perinatal death ratios in rural areas. ticipation in the Medicaid program is wore of a Sharp declines in the availability of rural obstetric problem in rural than in urban areas. ReFesentatives Foviders, leaving none in some areas, are ,... zbat- of MCH block-grant-funded and Medicaid programs ing access problems. Over half a million rural report particular problems with low physician partic- residents live in counties that are without a ipation in rural areas, and yet obsieuic Fovider and physician trained to deliver obstetric care. There consumer surveys suggest that rural obstetric pro- are fewer obstetricians available in rural than urban viders are more likely to be participating. Neverthe- areas, but G/FPs who provide obstetric services less, one survey of uninsured and Medicaid-insured partially compensate for this deficiency. The pres- women show ed that as many as 8 percent of women ence of physicians trained to provide obstetric delivering babies in rural hospitals could not get a services varies widely by region. Southern States doctor, midwife, or nurse to see them for prenatal appear to have the fewest trained providers, and over care. 250,000 residents of 53 Southern counties are Although CNMs are important potential provid- without obstetric providers. ers of rural obstetric services, they are few in number In many ateas, physicians trained to provide and the majority are located in urban areas. An obstetric services are not doing so. Surveys of FPs, inability to obtain malpractice insurance or physi- who are the primary sourco of ob.;etric care in cian backup, and in some cases, State practice laws rural areas, show that rural FP5 are almost twice have prevented nonphysician obstetric providers as likely to be delivering babies as their urban from practicing in rural areas. counteiparts and are providing a wider range of Hospitals in rural areas are much more likely to obstetric services. Nevertheless, while over 40 percent of rural FPs are providing routine obstetric offer delivery services than urban hospitals of similar size. However, evidenc,.. suggests that in care nationally, fewer than 20 percent are providing some rural areas women travel great distances !o routine care in some mral areas of the South. deliver their babies in hospitals 0 'ide their own Several factors may contribute to a rural physi- communities. These patients may oe attracted to cian's decision not to practice obstetrics. There may obstetric services such as birthing rooms and sophis- not be adequate coverage for firm: off, consultation ticated perinatal services and technologies. When may be unavailable, and referrals to larger hospitals patient outmigration occurs, it is the well-insured, may be difficult to make. A number of States report higher income, and well-educated patient who that a large proportion of physicians are eliminat- leaves the local community for care, leaving behind ing or limiting their obstetric practices as a direct the uninsured and Medicaid patients. Rural provid- OThe Comprehensive feriaatal Service Program is cosponsored: by the Meds-Cri program and the States Maternal and Chdd Health Branch 4.. I Chapter 15Maternal and Infant Health Services------in Rural ---- Areas------413 ers left to care for these patients may fmd it difficult States are quite dtpcndent on Fedeial it sourtes to to maintain a practice or to afford liability coverage. provide matern -.! ..nd child heahl. .u* Ms. In 1987, There may also be an erosion of public confidence nearly three-fourths k 73 percent) of Status maternal in local rural hospitals that may not !lave the capital and child health expenditures derived from Federal to invest in up-to-date obstetric equipment. Without sources (496). Federal programs such as Medicatd, technological support, some providers may drop the Mal block grant program, and CllitliCs are obstetric services, considering them too risky. Some especially important in rural areas since rural rural hospitals experiencing patient outmigration for obstetric services have successfully reversed this women are relatively less likely to have medical trend by reorganizing the existmg obstetric service, insurance that covers pregnancy evenses. The upgrading equipment, and advertising available inability to pay for obstetric services is a serious services. New communications technologies, sul-h problem in rural areasin 1982, rural deliteths as facsimile machines, are improv Mg rural obstetric aLcuunted furmarl! um.half of till antunikt n- providers' rapid access to obstetic monitoring sated deliverks. services. Although rural hospitals are much more hkel) Gov ernmem or plicate!) fundcd programs have than urban hospitals to offer obstetnc care, the) are :.uttevsfull) reduted mfant mortalit)in targekd much less likely to offer specialized care. Regional- mral areas Componcnts of these progr.um thatare ized perinatal care helps to ensure that rural feltto have tontnhuted to thtat MILL eN include residents have access to specialized (are when putaitivsupported ohsteuk prov iders. midlev el obstetric or neonatal emergencies arise, but there practitioners, pennatal transportamm y stems. inter- is evidence that regionalized systems of care have agency coordinatioti, and outreath o. orkers that deteriorated over the past several years.P.tst recruit pancnis and plot tde fid km up And Iran pot Federal grant progr.iins were successful in promot- ing the development c)f regionalized sv stern.; ot town perinatal care. Chapter 16 Rural Mental Health Care 4 .,', 9 CONTENTS Page INTRODUCTION 417 RURAL MENTAL '''EALTH 417 Menial Health Sums 417 Alcohol and Drug Abuse 418 FEDERAL PROGRAMS 418 SERVICES IN RURAL AREAS 420 Availability 420 Trends 424 Other Issues 425 RURAL MENTAL HEALTH PERSONNEL 426 Mental Health Professionals 426 Other Rural Mental Health Providers 430 Training for Rural Mental Health Personnel 431 MENTAL AND PHYSICAL HEALTH LINKAGES 432 CONCLUSIONS 433 Box Box Page 16-A. The Rural Mental Health Demonstrations 421 Figure Figure Page 16-1 Geographic Distribution of Counties With at Least One Provider and With No Listed Provider .,. 427 fablev Table Pai!e 16-1 Stress Among Nktv)peliton and IN4)ninutropohtan Residents 418 1(-2. Prevakt of Mental Health Problems Among Nebiaska Residents. 1981 and 1986 . ., . 4P-) 16-3. Inpatient Menul Health Sen tkes ;anti IkdN t)Coono, Twe 19s1 -122 16-4 Percent of Conimun.Hospit.ds Providing Pswh.otrit Ser. ice, b.Counz.v Type no Hospital S3it19S7 0}-c>lcoholid Owe Ahwe t .t,Ihtte 1 Onentauon10: 7 1, ci! NI Ali,. ef,1 ''''' ..! oNHL, t `...r% ,14111;*. hre, i(o 1redi.C,%.11/ 411 tt, ,011.113. fi t 1-1! qt&Ili ;aro, ic''t l'ettelai Vs% s )I:, td:* alt.; VN Ns.r).1'. punt'.I "i f.' 1I 1'i. *, 4 t Chapter 16 Rural Mental Health Carel ,111.11/ .. INTRODUCTION RURAL MENTAL HEALTH Structurally, the mental health care system in the United States exists almost entirely apart from the Mental Health Status physical health care system, yet the two systems have many parallels. Like the physical health Reliable data on the prevalence of mental disor- system, the mental health system is called on to offer ders in rural residents are scarce. Those available suggest that differences in mental health status preventive services (e.g., educational sessions for between mral and urban residents are slight. parents of difficult children), other primary care services (e.g., therapy for individuals suffering from In the 1985 National Health Interview Sun ey, a stress), inpatient services (e.g., for substance abuse slightly smaller proportion of rural (nonmetio) than treatment), followup and long-term care (e.g., fur urban residents reported that they had experienced individuals with chronic mental disorders), and stress over the past 2 weeks, with women in either on-site crisis services (e.g., for victims of violence). setting more likely to report stress than men (table Mental health professionals comprise a wide variety 16-1)(649).Rural residents were also less likely to of social workers, nurses, clinical psychologists, and seek help for a personal or emotional problem, even pvchialrists. after accounting for their lower reported stress (see table 16-1). In practice, however, the mental health services Using epidemiological data from North Carolina,2 available to indivicix (10 not always appear as a researchers have found some minor differences in coordinated whole, and the distinctions between the prevalence of mental health disorders among physical and mental health are often blurred. Family urban and rural residents. Major depression and practitioners, for example, are the providers of anxiety disorders were more prevalent among urban choice for many individuals with mental health residers, while rural residents were more likely to report cognitive ,Jeficits(e.g., memory deficits, problems. Individuals in many other professions distmientation) (5,?..153). The researchers found no (e.g., the clergy, teachers and school counselors) rarai/urban differences in rates of antisocial person- also provide substantial amounts of mental health ality or schizophrenia (92). Small studies m other care. In rural areas, where the numbe, and scope of areas have found that rural residePtshavehigher providers and services cin be very timned. these rates of manlc-depressive psychoses than urban providers become an integral part of die mental resident:.72) and are more akely to be clinmally health "system." depresstd(140),although the latter finding is not sepported by the North Carolina data. This chapter reviews existing data on the comp tr- NatiGnal mortality statmics from 1980 suggest ative mental health status of rural and urban pop da- that, after acLounting for differences ir age, ',ex, and tions. It then describes die major Federal programs na. tat distribution. rural residents hay- slightly supporting mental health care in rural areas and knver uide rates than do urban rideuii0.11 summarizes what is known about the provision of O. i2 per 1.000 residents} (620). Observers hme mai meetal health services in.; the avadabilit5 jf icported bitth stilt.kk ran., An sortle et. ollortilt. ally rural mental health providt s. Finally, the cluptcr di sire:shed ruid tre, s during the paNt decade discusses models for linking physical and mental but At 1., not known wia.tbei ,,te1al1 tatcts hai,e health services. trhe preparatson of thas chapter was aided by the assistance of Lou Wiensitowsko. 70 11c. MD 2TheNationa1lnalitute of Mental Health1N1M1s, supports ongoIng cludantolotrakal t +at 1 t.t. k+ t kill). 1 Lt... MU. New Haven, CT, Daham. NC. and the State of CAOraduNodata horn the ColorAdoSHC. IA.k! ruc.4ink. I ict 1.0,0401 .1 ibe Aerates. only the North Carolina recearchexpliedly ha. du ltukat ,...uupi% 11w vpul.ttoori ii. ..atiplokei.1 tut, nik .% ,aowever, and since 1983 the "rural" sue has been calegonrof .ts tnetropoluan .",41 -417 1 418 Health Care in Rural America Table 16-1Stress Among Metropolitan and Nonmetropolitan Residents Percent of populalSon reporting stress All Men Women Metro Nonmetr Metro Nopwatro Metro Nonmetro Exposed to mental stress in job (adults) in past year. 16 9 152 178 156 159 147 Experienced moderato or greatdr stress within past 2 weeks... 52.7 47 1 508 454 543 487 Stress had some effect on health in past year ... 44 4 47,2 385 361 407 496 Sought help for personal or emotional problem LA past year. 11 7 92 85 6 1 145 121 SOURCE: U.S. Deparbment of Health and Human Services, Centers for Disease Control. National Center for Health Statistics. unpublished dat. from the 1485 National Health Interview Surve,. Economic crises did apparently increase mental (92.643).There is soma evidence that the popularity health problems in some rural communities in the of particular substances in rural communities fol- 1980s. Beeson and Johnson found that, among lows urban trends, but at a lower level. For example, households in Nebraska, rates of psychological a study of a rural middle school in the Rockies distress for those in farm communities rose from the showed marijuana use among studerts was ap- lowest in 1981 to among the highest in 1986 (tat e proaching urban rates by the late 1970s(736).In the 16-2) (77). In North Dakota, also heavily dependent early 1980s, students at the same school adopted on the farm economy, the State Department of wore conservative attitudes toward drugs and exhib- Human Services documented substantial increases ited less marijuana use (735.737). from 1980 to 1986 in domestic v.-lice (from 950 Alcohol dependence, in contrast, is appareialy to 3,450 cases), child abuse (from 1,685 to 3,021 cases), and death by suicide (from 73 to 93 cases) higher among rural than urban residents (92). Rra1 adults are more likely than urban adults to report (423).Rural mental health facilities personnel in bouts of heavy drinking; 26 percent of adult rural North Dakota cited depression as the primary mental thinkers reported at least 5 days of heavy dnnking in health problem in their communities (423). 1985, compared with 24.5 percent of their urban Heffernan and Heffernan found that family stress counterparts(649).The pattern is more complex in was a major concern anlong 42 families they studied adolescents, compared with urban teenagers, rural that were forced out of farming(245).Nearly all of teens are more likely to have ustd alcohol but are the adults became depressed upon leaving the farm, slightly less likely to report days of very heavy and over one-half cortinued to experience depres- drinking(643).Rural residents also report more sion. Common behrvioral responses included with- drinh.ing and driving than urban resithnts(649). drawal from family and friends,inere:sed physical Local factors can contribute to high substance aggression, and increased smokingr drinking. Children were reportedto have b.:come more abuse In a rural Mkhigan county with 16 percent unemployment, almost one-fourth of 6th-, 7th-, and anxious, demanding, aggressive, and reuelhous, and Rth -graders surveyed reported occasional marijuana their academic perfomance womned. Adolescents increased their use of alcohol and became more use, and one-fourth reported bouts of sickness from drinking. In both cases the frequencies were signifi- w' ndrawn(423). cantly higher than national norms (538539). Alcohol and Drug Abuse FEDERAL PROGRAMS Drug abuse is less common in rural than in urban areas. Use of and dependence on marijuana, cocaine, Direct Federal invol,,ement in the provimon ol hallucinogens,PC13,3and heroin is less common mental health care dates to the Community Meetai among rural than urban resideats in every age group Heald-. Centers Act of 1963 (Public Law x8-164). 11111..., VCP is the common abbreviation fol phereyclidine Chapter 16Rural Mental Health Care 419 Thai16-2Prevalence of Mental Health Problems Among Nebraska Residents, 981 and 1986 Percent of residents in area with mental health problem Rural° Urban° _Lameurban° Scala 1981 1086 1981 1986 1981 1986 1981 1986 Depression 11 21 18 20 11 16 16 15 Anxiety 11 12 16 17 12 12 13 12 Psychosocial dysfunction. 7 13 6 11 9 10 9 12 Cognitive impairment...... 18 15 15 13 14 16 14 14 General psYchopatholosY... 12 13 11 14 13 15 17 12 Percent scoring high on three or mere scales 6 15 8 11 7 9 8 9 Number of cases 307 244 457 466 457 500 606 650 °Categories are based on Census burm 1 definitions. Ruralincludes only individuals in commnities of lower then 2,500 residents who do net live on farms. SOURCE: P.GBeeson and H.R. Johnurri, -A Panel Stud/ of Change (1981-19eo) in Rural Mental Health Status. Effects of the Rural Crisis," paper presented at the National Institute of Mental Health National Conference on Mental Health Statistics, Denver, CO. May 1087. which authorized suppi.:rt for the construction of facilitate collaboration w ith CMHCs (457). The community mental health ctaters (CMHC5).4 The program was terminated in 1981. Act required States to be divided into service delivery areas (catchment area0 that each contained Subsequent mental health legislation in 1980 75,000 to 200,000 people. The legislation required (Public Law 96-398) stressed services to under- served and unserved populations, including (for the that centers provide inpatient, outpatient, and partial rust time) rural residents. To receive a grant under hospitalization services: emergency services; and this legislation, however, rural CMHCs were also consultation and education services. Congress later required to serve at least one of the other taigeted expanded the CMHC model to include services populations (i.e., children, elderly, poor, or ch.roni- targeted to specific populations (e.g., e Ildren, the cally mentally ill individuals). elderly), substance abuse services, scpening courts and other community agencies, and transi Tht. Omnibus Budget Recontalianaa Act of 1981 tional housing and followup care for those leaving kPubhc Law 97-35) consohdated most previous inpatient psychiatric facilities (Public Laws 91-211, mental health programs into a block giant, under 94-63, 95-622, and 96-32). By 1981, 768 CMFICs hich funding was not contingent on providing had received grants and 296 of these 438 percent) specific mental health servies or targeting services were located in cities of 25,000 or fewer residents to specific populatkm (scc ch. 3). This legislation (483). repealed the collaboration agreement provisions of the 1980 law, cut funding levels by up to 30 percent In 1978, Congress made CMHC funding contin- (51), and eliminated most CMHC reporting require- gent on collaboration with related agencies, includ- ments. Substance abuse grant funds were subse- ing school systems, child care agencies, courts, quently incorporated into the block grant (see ch. 3). Because of the greater perceived substance abnae social service agencies, and health departments pioblem in urban areas, Congress cha, -ed the (Public Law 94-63). To facilitar collaboration allocation formula for the grant in 1988 to give between physical and me.lal health services, the greater weight to States with larger urban and youn8 National Institute ef Mental Health (NIMH) and the adult populations (Public Law 100-690). Bureau of Health Care Delivery and Assistance (11HCOA)5 gave each of 58 community health Recently, rtual issu s in mental I..za!th legislation eciiterstwe-thirds of which served rural ay. is-- have regauedsibility. In 1986, NIMH held :wt.) funds to hire a mental health "linkage workc:" :0 PuLiy ronuns on Ruial Stress where participaats 4HIShough no special funding or mamba% wetc targeted fut /11.14l Arca,. h1Mr1 bad aput unk. aufl pei tki..43 oil BOW Mena. from 1967 tO 19111 (4581 5170interly the Bums.' of Commurity Alth Stmces 4 420 Health Care in Ru. al America reported high rates of suicide, depression, and stress 3HCDA and the Alcohol, Drug Abuse, and in paes of rural America. Congress subsequently Mental Health Admunstration tADAMHA) recently passed the Rural Crisis Recovery Program Act of signed an interagency agreement to provide funding 1987 (Public Law 100-219), which required the to primary care agencies for substance abuse pro- Secretary of Agriculture to provide one-time fund- grams (343). The 3-year grant program began July 1, ing for programs to develop educational, retraining, 1989 and disbursed $9 million to nonprofit primary and counseling assistance for farmers and rural care provid., ^to develop plans to work with families adversely affected by the farm crisis.6 substance ...Arse treatment providers. Although the program might be highly appropriate to rural areas. Congress also appropriated $1.2 million to NIMH due to the hrge number of grant requests all awards in September 1987 to establish Rural Mental Health were made to urban rectpients (343). Demonstrations (Public Law 99-591). These were designed to help States promote comprehensive In early 1990, NIMH es.abhshed an Offic... of health, mental health, and human services in rural Rural Mental Health Research to coordinate and communities and to fund rural mental health pro- administer relevant reseanh and demonstration grams to address problems resulting from the farm studies (141,641). This offke will administer a crisis. The law specified that only States most newly advertised research effort that will include adversely affected b} the farm crisis would be grants to rural mental health reAearg.h %enters ir40). eligible for funding. Thirteen States were Wenn- fied,7 and fourlowa, Mmnescia. Nebraska. and SERVICES IN RURAL AREAS South Dakotaeach received $300.000 for a period Availability of 18 months to develop comprehensive rural mental health programs (see boX 16-A). Mental Health Serv ices ReLent mformation on tnental healthscrv ice Ltgislation in 1988 (Public Law 1(Xi-69(ii re- dehvery in rural aleas1..minimal Since the consoli- quired that 15 percent of Fedend funds appropriated dation ttf programs into the block grant in 19$1, under the block grant bescaside for rural mental Slates Fave tux been required to keep records or health demonstration projects. Smce NIM1.1 was report back to the Feoeral Go% eminent in any detail already spending an equivalent amount of demon- about the population served111 ("MHO.or the stration money on rural proFcts, the legislation had .eraces client. receive NIMH collectstril)sum- hitle um-imitate impact on fedcrallfunded ettorts mary Information zhrough two bierimal evs of (547) nit:mai health v.tre tav %lines (nisi Unlike the geneml mental health programs. the Basedtin OW It data. Community Suppoit l'rogramtCSh,launched In do.Annented draMdlik, chi elv e l'ut 1977. is designed speutically to ass.st Slates and utkul area. intht, .1.*alahlittifok_al inpattent local communities develop vompielicnsive s) stems itte..1,11 healthNerviies Alino.a two-thirds tinelro of care for adults with seriouslv dp...ibling mental 'unties 013 percent) h.td kinti of inpaticnt health probiems (M)) Its goa: t.. to plovok emci- st,rvit, es in 19S3, but on1 percent ot noinnetio gericy care while helping dic Ind iv klual reim egrate kouninhal)t,t1. that'tiered k.tiaerh Cs. into the comnrinny tt,), hnkmg the individual with fi.tbk(-?) 4 70 ) it% adabtlity ntnsi e.non- formal low:lenn support- --e.g., food st.unps. CND IC metro otuntio, ,t10 iridnormou* servicesand enhancing, inforni,d sunportme !ter nonrrietto tountie.vr.ith utb.in population,. tbv the works of familics and friends) The program doc s nor (*ensusdefinition) of mote than 200)1). s4 percent specifically target rural meas. but several rural had inpatient inental he.dih scruvesn stall. communities have CSP projccts and maylenef4 nasi.onI 7 pen ent tA 2.110 noninetto ountws from its focus (in integrated care. consumer vivo!, eA ith urhan yoputattons h.,iinpatlem ment,_ and community outreach wes7(0 fibs bw hill upon ruhilk tq, ma, II '06 AI to,tik rtioa, , i othei mental health sem Ile IStales were ( olviado lcorrm Muir. 14;,.. or.;; ult r.1,1 00t,t 0 I , Vermont. and Wisconsin ('hapter 16---kural Mental Health Care 421 _ Bar 16-AThe Rural Mental Health Demonstrations The four Rural Mental Health Demonstrations were designed to assist States in de ;eloping 0,114re-01,n-4r mental health, health, job retraining, and employmeat servic:s to rural communities Akhuugh all induct...I SLUR and local components, they had very different emphases An evaluation of the lour Jciriori.trathq, pI.ijvZ442 completed in Januar 1990 (147). Iowa's State component included: interagency collaboration (e.g.. with a State interagency rural crisis effort). knowledge development (e.g., a survey of the speual services being pro; ided ts: CMI IC, to rur,il populations, a mental health needs assessment based on a survey of rural Iowan: ), training programs (e.g., workshcps for school ..ounselors and fileilhli health and alliid prott -.ioual ,, and technical assistance (e.g., to the Agricultural Extension Service's niral outreat il and 4..lwnsdIng program, At the local level. Iowa placed professionals or paraprofessionals directly in the 4. ommun a, c,er; cd lir tit CMIICs to develop comprehensive outpatient. consultation, and education "ervil.es Minnesota's State program included: an interagency State Advisory Committee i which included both mental health arid Agri, olturt ctlit talk. technical assistance to the local demonstration efforts, and die development of a videotape on the problems, ot nind women, which 0...1., thtd at a it It. oritcrtritt w it a die val.1of teleconference technology for holdintt nwerings among disperstd groups At the local level. the State funded outreach . oordm.uort at three CM11C,.. who inirlernentotou,ulta0,,,, arid education activities in their catchment alre4h it' g, a 'pee: he!....r- rrograin at a lot .11 togh sthooli"?4, Nebraska's project included the development of educational materials le g. apaiophici oh tress in.magell.vat ts, .1- rur ti adults a il..ik Ilk r guide to a cumculum for fifth grader, on the emoitoral aspects of rural lifei a tontract with Interchnrch MuuNtriec of NehratLi to pro. lilt training aoa ....,,II., ni, :I, uprt ,i i k .;1,,,i e h li paraprofessional cm s hotline and fled toonselhig et tons, a conference on rural mental health, and a data collector, and litet,t(ure revleW erfort '0 apf)LIIt: sti tgle's tor st il it t . lute:ration The local direct sem ice component .li lhe prele,i 10,1utted itvo neittrallitional toodds 41 mental he,ilib. ar. A ''tscuit-nding mental health prolessional At. j goat:A am. iic threi primal% t XI: plo . t. 1.11i. +tilt t N,alid a ILK iit d health professional located in a t oval ): A.4.1101 cvo4-:.1-'t% ho rot:Med st -vb. ct,. dIttrov.'d Lanier+ i Totris Daxotaproictt differed iretti thos: ;l1 the ,oh.,-r dim Siai,- ni !LI .!011..,1to: ( -OW11, th " .+, participial,. I.t;tate.levd activoitcv uvre limited to the de..:lopment 4%1 educ anonal matetial,.. i c g .!,r,_,:or. . ti 'NI.....*: .1, I. . awl a pamphlet and i ;o videotapes cal rural menta' health topi, . lFti the development ot matztiak to assist the (*Milt 's in desigiong !hell :, S. 4 survey, and a -,iirvev 01 puhlit vcrvice pro% Wei-. Oh ,1% ,trem(,,,,, of I VP it t 1 The loc. I projects ji the 10 panicipamag CMIK's ou. lti.k ti t. lu, atm:IA as II S It. ,111)1,',1 .st Iil* .2, h. ;Ai :...$1 greAs w(irkshops). t onsultatioa and education Jou, ,i..,, n4r .110.i Wilkie) A it 1% ki-.,, , it I. iv 1, ., .' tsit, 33's ! I educators and law enfortement pmfc s'ionals 10 help tutut andcrstand and ft t .tit. 4.111,'I1t.i :I !Os OA It tt01itti adoleseeni3). estabb4hmein of peer kopp4m pour., and ho.. I m.(.. .,.... 'nut .-.,.1 I.,.' , 10,!.1.... 1.1 Iwo!if, office) 0.441 General ac4. hissp;htiN jje the RP' asaitarolit,. .! J. 01on.'i . most cce-unon providers of inpatient Meotel bcoith healthst'l ; 4111 tit ilk it. , set-vim (214 Nonetheless, rural acute-care coin tkterounc Ihe et..tAl 5..% P 1;.41..}..est it c mutiny hospitals have fewer short-term psthi.itiut lora! Arca'. eaolds .Ii k . 1;h, '% ih.1t, ,Irt,,Ilti; inpatient beds then do urban hospitals tave,ar inp3 II, li.u% . Cr,- It t' hit -slit re Is lt tk es' .1hilt. AI v. 5 9 beds per hospital. respe tivelv;a!)tl o.irmaer ..rti otI I' .it Ii.) . relationship holds true for hospitals ot eser , Iht .1* t LI'" 0141 . *1 1,"" 1 I category 025). Nei Railsh toc1lt.11.a so. 1 1 4 fr 422 Health Care in Rural America Table18-3Inpatient Mental Health Services and Reds by County Type, 1983 Humber (percent) Estimated median number Average nember of counties with of inpatient mental of facilities with some inpatient healta beds per county some inpatient Number of mental health All Counties with mental health County type counties services counties services services per county All counties 3.137 774 (25) 0 52 2 5 Metro counties 735 466 (63) 29 120 3.5 Nonmetro counties 2.402 308 (13) 20 1 3 20,000 or more population.. 292 158 (54) 11 20 1 3 Adjacent to metro area 1'7 76 (52) 18 1 4 Sot adjacent 145 82 (57) 13 20 1 3 2.500 to 19,999 1,325 145 (11) 26 1.2 Adjacent to metro area.... 560 57 (10) 0 32 1 2 Not adjacent 765 88 (12) c 20 1 2 Fewer than 2,500 785 5 (<1) 22 1 0 Adjacent to metro area.... 221 2 (<1) 20 1 0 Sot adjacent 564 3 (<1) 22 1. 0 SOURCE: WO Wegenfeld, H F. Goldsmith, D. St.les et al., "Inpatisnt Mental Health Servics in Metropolitan and HOnmetropolitan Counties," Journal of Rural Communit, Psycholomy 9(2)12-28, 1988 four urban areas studies but ranged from 8 to 10 in (567). But like other rural services, emergency the four rural study areas (228). Another study of mental health services face problems of logistics, CSP participants found that rural clients were less staff inconvenience, and costs entailed by covering likely than urban clients to receive needed services large distances (390). Providing on-siicrisis serv- (567). ices may be especially problematic. Rural crisis services also reportedly use fewer techniques for A 1979 study assessing mental health service needs assessments, provide less public education needs found that central cities, as espectsxl, were about the service, and provide more limited training more likely than other areas to have available a of Crisis workers than do urban crisis services (390). comprehensive set of services. Catchment areas that included both metro and nonmetro counties also had Observers have reported that, v tule urban areas rtlatively high rates of comprehensive servke avail- have a variety of agenc ies and orgabizations offering ability. Surprisingly, within all-nonmeiro catchment crisis programs, CMHCs are the principal rural areas, the least densely populated areas8 were auually providers of crisis serv ices (390). Acute-care corn- the most likely to contain a comprehensive set of munity hospitals play a smaller role in rural areas; services (355). compared with almost 32 percent of urban hospitals, only 17 percent of rural hospitals provide psychiatric As is the case for inpatient psychiatric care, rural iergency services on site (625). acute-care general hospitals provide fewer outpa- tient, emergency, and specialty psychiatric services Substance Abuse Treatment Services than do their urban counterparts (table 16-4). Psychi- atric outpatient services are provided by more than Alcohel and drug abuse treatment facilities are twice as many urban as rural hospitals (14 v. b relatively weli represented in rural areas, although percent, respectively) (625). rural facilities serve a disproportionate],small number of patients. Seventeen percent of all treat- Emergency mental health services are particularly ment facilities are in nonmetro counties (see table crucial in rural areas. Rural residents with serious 16-5), bur they serve less than 14 percent of all mental illnesses rely more heavily than do urban patients (642). Eight percent of the alcohol-only residents on crisis services, even after accounting for treatment facilities are located tn nonmetro counties, differences in emergency service availability and but these facilities serve only 5 percent of the total need (567). It is likely that the heavier rural usage is patient population. Possible esplanatixis for these related to thc lack of other mental health services f.ndings are that rural treatment availability 14.: 5Nonineiro counties en which less than 50 percent of the population lived it Census-dcfined urban areas -111MENny/M1.11.10. Chapter 16Rural Mental Health Care 423 Table 16-4Percent of Community Hospitals Providing Psychiatric Services, by County Type and Hospital Sim° 1987 Nonmetro Metvo Service 6-24 25-49 50-99 100-199 200-299 6-24 25-49 50-99 100-199 200-299 Child psychiatric services 0 1 3 5 1 15 8 29.5 0 1 6 55 13 1 24 5 Geriatric psychiatric services 1 6 17 6 4 16 3 36 4 0 08 58 17 7 33 6 Psychiatric emergency services...... 7 7 80 14 7 27 9 53 8 0 49 127 328 50 1 Psychiatric education... 0.5 1 7 6 0 17 1 37 1 45 16 99 188 36 4 Psychiatric consultation and liaison 3.8 37 10.3 19 4 37 9 45 123 146 27 1 39 4 PsYchiatric partial hospitalization . 3 8 1 2 4 6 9 1 10.9 0 .3 3 44 87 17 0 Psychiatric Outpatient services 2 2 20 4 5 9 9 24 2 0 4 1 58 127 12 6 Chemical dependency outpatient services 3 8 53 3 5 14.6 23 5 0 115 110 203 29 I aHospital size as measured by number oft,tal beds Specialty psychiatri c. hospitals and hospitals with more ttem 300 beds are not included in thistable The number of tonmetro hospitals in the latter category is wry SOURCE. Office of Technology Assessment. 1990 Data from the American Hospital Association's 1987 Survey of Hospitals Table 16-5--Alcohol and Drug Abuse Treatment Facihties. Location and Facility Orientation, 1987 Facility tvne Alcohol Combined location and facility function only alcohol and drug Total Large metro areas (population more than 100.000) Treatment...... 1.383 2.479 3.062 Prevention/education 867 2.122 2,909 Other 7/6 1.522 2.298 Other metro areas Treatment .. 177 752 929 Prevention/education 144 624 769 Other ;02 478 580 Sonnets° areas Treatment... 138 838 976 Prevention/education 118 716 834 Other 67 407 554 Stibtotal Treatment 1.698 4.069 5.767 Prevention/education 1 130 3.462 4.592 Other... 945 2.407 3.432 Total (unduplicated count) 2.112 5.1'6 7.458 sounu U.S. Department of Health and Human Services. Alcuhol. Drug. and Mental Health Administration National Institute of Alcohol Abuse and Alcoholism. unpublished def.& from the National Drug and Alcoholism Treatment Unit Survey. Oct30. 1987 greater than demand, that rural facilities aie smaller abuse faolities as a whole(642).Mental health than urban ones, or that rural residents are less 4...enters (e.g., CMHCs) are the most common sites for willing than urban residents to seek help for mental akohol treatment in rural ommunities, accountmg health problems or from local facilities.Rural for 42 pet-Lent of the akohol treatment caseload residents are slightly underrepresented in substance (642). 4 " Tebie 16-6Percent of Alcohol end Drug Abuse Treetment Foci titles Pr4viding Specified Services, by County Type, 1987 FegllitY locationa Service Largo metro °the. metro Nonmetro 48.4 Hotline...... 30 7 42 6 Outreach services...... 48.2 53 4 62 8 Early intervention services 44.7 51 4 61 1 Employee assistance program 31.1 40 0 45 6 Teen suicide prevention P.3 11 7 1*.0 Self-help 4roups.. .. 65.7 59 5 57 9 Transportation 18 8 20 3 19 8 Crisis intervention 47.7 60.3 69.8 atarge metro m tietropoll:an areas of more than 100,000 residents, other metro m all other metropoll'.an areas, nOnmetro m all normetropolitrn areas. SOURCE: U SDepartment of Health and Human Servicee. Alcohol. Drug, and Mental Health Administration. Na- tional Institute of Alcohol Abuse and Alcoholism. unpublished data from the National Drug and Alcoholism Treatment Unit Survey. Oct. 30. 1987 Tebie 16-7Alcohol Treatment Facilities by Client-to-Counselor Retios end Locetion, 1987 Facility 1ocatie3a. Client-to-counselor Laree metro Other metro Nonmetro ratio Number Percent Number Percent NuM4.er Percent Inpatient 2.004 100 0 426 100 0 301 100 0 1-4 518 25 8 151 35 4 83 27 6 5-9 1.088 54 3 212 49 8 162 53 8 10 or gree.er 398 19 9 63 14 8 56 18 6 Outpatient 2,446 100 0 626 100 0 804 100 0 1-4 4151 17 0 110 17 6 107 13 3 5-9 478 19 5 02 1F. 1 145 18 0 10 or greater 1 p.51 61 5 414 66 1 5t,2 68 7 %argot Metro = metrOpolitali areAs 4f rpx,re th4r 100 nr.0recilorts, other me'r. all other Petropol.tat areas. nonmetro all nonmetropoiltan SOURCE U S Department of le.a1th anl UtzmAn A:, Ag 4h1 .4tAA 1.1v.,tr. A1m'n1for141-znNa !zonal InstI4 tcr' Aluse o fimr. I 1,0 N Alcoholism -nzt C., lic, Urban andruralsubstance abuse treatment facih- Tred% ties have different service patterns (table 16-6) (642). While facilities in urban areas are more likely Two notable changes in mental health services to offer seIf-help groups, a larger proportion of rural have taken place since the implementation ol the facilities pro-ide hotline services. outreach services, block grant First, CMHCs have tended to empha- eaily intervent on sevices, teen suicide prevention Rue servIces that can be billed on a fee-for-service services, and crisis intervention Compared with basis and are covered by third-party payers te g urban facilities, rural alcohol treatment facilities one-on one psych tame therapy) A survey of 36 have slightly better counselor-to-client inpatient urban and rural CMHC administrators fromStates ratios, but we outpatient ratios (table 16-7) (642i found that they had reduced services and training after the block grimi went into effect, one-half had Rural acute-care hospitals are le...slikely than increased billable servites.indfee.; to :over the loss equivalently sized urban hospnals to provide alcohol of Fedend resources (185) A .audy examining and chemical dependency outpatient services. Only programming inno i. awns in rural CMHCs in 12 9 percent of all rural hospitals, compaied with 20 Madwestern Stdtet &oncluded that the CMHC dircc percent of urban hospitals, provide outpatient sub- tor. were .0 concerned with billable hour. and stance abuse services (see table 16-4) (625i tees-tor sers ice that the relative benePts ot case- Chapter 16Rural Mental Health Care 425 Table 16-8percent 41 Rural° Community Me -tat Health Center Directors Who Expended Efforts on Program innovations, 1988 Effort exnended_ Program dimension Little or none Some Moderate or heavy Rural development 61 10 13 Support groups (staff facilitated) 76 12 12 Sotline 71 11 27 Media programs 61 18 20 Stimulating self-help groups 59 15 24 Coordinating services SO 21 29 Crisis ratervention 48 20 30 Consultation and education 28 24 47 a"Rural" mental healt.11 centers in tnis study were. 1) any centers located outside a city of 50,000 or more people and outsIde of a metro arse, and 2) centers whose catchment reas included Lugo porticns outside zilch areas. bRows add to less than 100 percent because some respondents did not provide elite. SOURCE. J. Mermelstein and P. Sundet, Factors Influencing the Decision To Innovate. The Future uf Community Responsive Programming." Journal of Rural Communitv Psvcholoav P(2):61-75. 1988. finding programs, such as hotlines and support mental health provam expenditures c community groups, were overlooked as a potential strategy for services increased by 10 percent between 1981 and increasing utilization and income (383). Fewer than 1985, while mental hospital expenditures decreased one-hi.lf of CMHC directors reported expeading any by nearly 5 percent (540). A survey of 71 CMHC significant efforts on support groups, self help iAinical directors founi that the greatest expansion in groups, and crisis hotlines, and only a little more sen ices during 1983 and 1984 was m do treatment than one-half expended any significant efforts on and partial hospitalization (304). crisis intervention or service coordination (table Rural CIATICs in the 1970s were more dependent 16-8). than urban ones on Federal support (67), and a recent Second, in accordance with both Federal and State analysis found no reason tbelieve that the situation policies, CMHCs have tended to emphasize services had anged (423). Whatever the trends in their for persons with severe and peis.,stent mental illnos financial support, rural CMHCs seem to have at the expense of services for the less seriously or iesponded through retrenchment rather than through less chronically ill. Dowell and CLuio found that rnnoation. A survey of State mental health directors prevention, education, and consultation hen ices survey ed in the mid-1980s found that these directors were the first services to be cut after the block grants listedthe development of model rural CMHC went into effect (174). Another post-block-graut .services as second to last in a list of 62 pnorities (5) survey found that all three of the highest ranked priorities of mental health program directors focused Other Issues on services for the chronically mentally ill(5). Perhaps because of this shift in emphasis, many One rural service problem is the lack of awareness CMHCs were ill-egtupped to deal with the increase among rural residents that mental health services in acute mental health problems associated with the exist and can be helpful. Flaskerud and Kviz farm crisis of the early 1980s (383). surveyed 3,057 residents of rural counties in six Midwestern States and found that fewer than one- The shift to increased services furseriously half knew of av ailable treatment i.enters and say iCes mentally ill patients was accomphshed tinin for mental health and subsume abuse problems crease in outpatient and partial hospitalization rather k19 ). Fehr and Tykr found that only 40 peicern of than through an increase in residential and other rural North Dakota burs resf indents knew of the inpatient care. After ..djusting for inflation, State menial health 1inithat sem ed .heir catchment area 9Unadjustcdchangcsmcrpcodinucsdurmgthis MAC were AD nuca. t AA SU ()MEW on. arainutitly%al, AA' dnaAAA MLR 11)Nil( Ill,Pitllosp....IS That figura mcludc both urban and rural arras (189). Even in communities where the clinics were RURAL MENTAL HEALTH located, only 52 percent of residents were aware of services (189). PERSONNEL An initiative in Illinois reported some success in Mental Health Professionals improving awarenes s of mental health services. This State program used community education, a crisis A study of professionally trained mental health hotline, and outreach workers with farm experience personnel (i.e., psychiatrists, Ph.D. psychologists, to reach farm families under stress (119). The social workers, master's level psychologists) done in program coordinators decided to operate the pro- the early 1980s found that there were more counties gram separately from the local CMHCs, a feature without such professionals than there were counties that initially engendered considerable opposition to with at least one type of mental health professional the program by some CMHC direttors (119). (1,687v.1,393) (figure 16-1) (324). Counties without mental health personnel had lower educa- Transportation for both clients and professionals tional levels and were 'more rural" than those with is a serious rural mental health service issue. providers. Although catchment areas are no longer used for Federal purposes, many States continue to use them The uneven dist zrsion of mental health profes- for funding and service requirements (105). The sionals is most notable for psychiatrists. average size of a rural catchment area ranges from Although both urban and rural areas have 5,000 to 17,000 square miles (depending on the experienced recent increases in numbers of definition of rural). The Fzderal mandate for these psychiatrists, the number of non-Federal psy- areas to comprise at least 75,000 people resulted in chiatrists per 100,000 residents in rural areas is such large service delivery areas in some States that still less than one-fourth the urban number (3.6 other legislative tequirements for accessibility and v. 15.9) (tel,:e 16-9) (686). continuity of care became difficult to meet for many In 1981, 61 percent of all rural residentsover of the most rural areas. One catchment area in 34 million peoplelived in designated psyclu- Arizona, for example, is over 60,000 square miles. atric personnel shortage areas (665). One in Montana is 50,000 square miles, and one in Staff psychiatrists are less likely to be found in Kansas covers 20 counties (13 of which have no rural than in urban general hospitals of a'l sizes town with over 2,500 residents). Some rural dis- (table 16-10); over 90 percent of the 1+vion's tances were so great that continuity of care and 1,890 rural hospitals with fewer than 100 beds followup services were virtually impossible to have no psychiatrist on staff (625). provide. Rural residents travel for substantially longer times tovisit psychiatrists than do urban Difficulties in obtaining mental health care confi- residents (averaging 33 v. 24 minutes, respec- dentially can also act as a barrier to services (356), tively) (644). particularly for rural youth. A survey of adolescents Living in a rural area reduces an individual's in a small town in the Midwest showed a preference probability of seeing a psychiatrist by more for specialized clinics over private physicians' than 30 percent (548). offices for particularly sensitive matters such as contraception and substance abuse (149). Adoles- Psychologists are also apparently disproportion- cents also prefer not to be accompanied by parents ately distributed between urtan and rural areas, when they seek health care for problems like although national data are lacking. One study of depression (381). psychologists who received their doctorates from programs supported by the NIMH between 1968 and Other problems for rural mental health service 1980 found that11 percent were practicing in delivery include communication (e.g., high tele- communities of fewer than 50,000 residents (540). phone costs), large numbers of patients who cannot In contrast, of psychologists who were trained in the or will not pay for care, difficulty in recruiting and 20 existing rural mental health programs, or who retaining mental health professionals, and a lack of expressed an intentiou to obtain rural training, 24 suitable service models (458). percent worked in small communities (546). 4 c 0 Chapter 16Rural Mental Health Care 427 Figure 16-1--Geographie Distribution of Counties With at Least One Provide: and With No Listed Provider NOTE: Counties with at least one provide# are shaded, these with no listed providers aro unshaded SOURCE DKnesper.J P C Wheelei , and D.J Pegroiccan lden.atHedu. Sei vices Providers Distribution Ai-ioss Unglues in me Unnecl $ialesi Anemia+ Psychologist 39(1.., 1424 1434, December 11io.. Dopynght 1984 sy ihe Arnencan Psychological Asecoetion Repootoci or permission Master's-level clinical psychologists areless pendent psychologists practicing outside the educa- numerous than Ph.D. psychologists, but they are tional system (155a).) more evenly distributed. An extrapolation of data for the 10 States with the largest rural populations found A preliminary study of six Statesip found that that the average number of doctoral-level psycholc. sot '41 workers are the most widely dispersed mental gists per 1Gv,000 residents was 14, compared with health practitioner gtoup in low-income niral areas 19.0 for the total population (571). The average and are more likely than either psychiatrists or number of masttes-level psychologists in these 10 i.syt-hologists to tloose to practiceUl(hoe areas States was 9.2 per 100,000, compared with 10.1 per (table 16-11) (416). In about 25 percent of all the 100,C00 for the entire United States. (Many master's counties studied, social workers were the only level psychologists have a limited scope of practie mental health priAiders. Furthermore, a substantial or must work under supervision. Only three States- propurtionofountiet with no mental health provid- Minnesota, Vermont, and West Virginiapermit ers were contiguous with counties served only by master's-level personnel to hold licenses as inde- social workers (416). Killinoia Michigan. Oklahoma. Texas. Honda. and West Virginia 4 qi 428 Health Care in Rural America Table 16-9Non-Feueral Psychiatrists by Metropolitan; rural practice unless they are trained to contend with Nonmetropolitan Location, 1975 and 1988 the uniquely rural needs. Ret e per Percent Isolation adversely affects recruitment and reten- 100.000 144417,1 1 at lOn tion of mental health professionals in many rural 1975 1400 1975-00 communities (163,233). The isolation of some rural United States (t .tal) 10 0 12 9 289 mental health professionals can spawn strong inter- Metro. 12 4 1S Q 28 2 dependent relationships and innovative arrange- Nonmetro 2 6 6 15 4 r, .nts among colleagues. In communities without 50,000 and over° 3P 5 t 47 0 p..ichiatrists, for example, the primary care physi- 25,000 - 49.9995 2 6 J1 17a cians who must authorize the medications for their 10 10 - 24,999° 1 4 12 k mentally ill patients may consult with their local less than 10,000° Ob 1.1 8 29 7 psychologist colleagueswho are prohibited from 6+ persons/sq mib 0 5 u 8J s <6 persons/scr nab 0 7 3 1 4 prescribingregarding information about the medi- cations (II I). In other areas. centrally based psychi- °Includes only nonmetro counties atrists may provide substantial amounts of services bIry Aides only'punnet ro cut,rt let oV lew«r (%0.. rot _dents through telephone consultation to rural therapists SOURCE U S Depart melit of 40110. 471 I0.4min :or and nurses on site (247). A pan-time satellite clinic vices Health keseiii ø. .J ',tv.,ec Aimar staffed by a group of nonpsychiamst health profes- Istration, ,f haa1't, sionals w;th some spec-uty expenise leg, family unpub 1 i shed data i; ^eltne Area S..- .411r. File (provided by H ; set-sires, the chronically mentally di) proved 446C- essfuI in enhancing service availability and mini- A study of the Nebraska community mental ficalth mum)! professional isolathm in Maine i120) workforce between 1981 in.d 1988 found that rural ike other health profesqoaals, mai mental centers relied heavily on masicr's-k% el pioression- professionals often must become generalists als, wink employees in urban centers were predomi- Pi.:.".t4.45S) They may need to develop tech- nately bachelor's level and below t5.S3 ) Although im community outreach. monitor persons there was a substantial decreAse in rural staff during ss ehr.au.illfls. uonsuh v,ith leacherc to heir the period, the decrease was most!in nonmedical hildit.1, in (listless. or develop training modules for staff; the number of full- tnne-equivakntnieial stress o, magement Moreover, in rural areas iner.tal staff did not decrease significantly hcalth pro'essiondls must become part of dw com- ineints te bs. effeo e G:V4) The oserlap between lzisenhart and Ruff visited10 mental health pci sonal and professional roks4. an lead to burnout centers and concluded that urban and rural $ 'ental tiai .'ntlit hew, een protcsionai imparnalits Mitt health professtonals provide different ,.0-4. Nes to ik soiLil.1.1116 s lor the patient. this ovetlap Iako clients (182). They with mcie ,risis situations, respond to othei staff sett It es members' needs and concerns, and develop a DeiW(11111N.t' \ atIllfled tile 11f4it ltkti iu SI.Ile-ittilded luta! .111(1 ill ( ill sensitivity and commitment lo the loyal community WAnneion State (497) " The% tound that rural In contmt. the urban mental health professional wa.,, flier ap,sis woe irsore likely to he geocrahsts.Tend able to concentrate on developing specialized skills irlewileill Mt) uicmore di mines). 106hileU111,111 (e.g., treating behavioral disorders) and focus more thefuriNfs tt ete HUM, .1)0.11111PM roistrwetisutti on professional issues such as publishing articles urban therapiNti.. on al therapists spent mote new in and continuing education (182) The different style support\eft it es le . ativeledel, of care required in rural communities may discour- tomparahte rune in indirect serviees IC vpi Stli age psychiatrists and psychologists from choosing a two'. etio,4 :1.:onli in islth nu. ilmid - 01"Rucul" and ' 'urban" were deirnedb k.ountopopulatz,n Kura! colter.. we!, ' J"I.L.' "1, Inv al p,.1,0, jun : and urban Cetlicri were lotnicd in IS coilinitinihe,. %Nab nom (ban 46 OW re,i.len,. Table 16-10Average Humber of Mental Health Professionals° in Community Hospitals, by CountyType and Hospital Size, 1987 Metro Nonmetro Hospital size Social SocIA (number of beds) b Psychiatrists Psychologists uorkersb Totalc Psychiatrists Psychologists workers Toteic 6-24 0 3 00 0 1 04 00 00 0 1 0 1 25-49 .. 0.6 00 03 09 0 1 00 03 0 3 50-99. . 1 0 01 0 7 18 2 .0 07 0 9 100-139 3 0 03 2 53 08 0 1 14 2 3 200-299 6 3 04 42 .10 23 h 2 28 5 J Total 34 03 22 59 04 8 1 2 (<300 beds) glIncludes bath full-, 4 and part-tme pers.-inel knot full'time equivalents, part-time staff are weighted the sAme 4S full-tim. slAt:) Figures for psychiatristert ior 'ull-time staff only bSacial workers may hold positions not associated with the provision of mental health services te g eitscharke cTotal includes all full-time psychiatrists and all full-and part-ttme psychologists and sociai workers SOURCE; Office of Techno.ogy Assessment, 1989. Data from A erican Hospital Associatio IS.81 Sutvev t MEMMIIIIIMMIRMOME.4.1160Alls 430 ireaith Care in Rural America Table 16-11Percent of Couotles Served by Mental Health Providers in Slx States Psychiatrist. Psychologist psychol,,gist and end socia! Social Other State social worker worker onlY worker only combination' None Illinois 29 19 33 13 6 Michian 43 27 28 1 1 Oklahoma 1.8 14 34 30 4 Texas 1.9 10 26 40 3 Florida 52 5 16 18 West Virginia... . 37 35 26 4 6 4Primari3y paychietrist and &nisi worker. SOURCE: National Canter for Social Policy end Pract.ca, "kep.rzt ot the Geographic Distrib. 'on of Mantel Ilealth Providers; A Pilot Study." uapublished manuscript, Silver Spring, I. July 1984 urban communities, individual psychotherapy Ix as treated by mental health specialists (10,503). More the direct service most frequently provided, and specifically, in 1984: family and group therapy were provided at roughly Nonpsrhiatrist physicians provided almost the same level ,..moss communitief' (.497). one-hali (48 percent) of the patient visits No single office at AWN has responsibility for resulting in the diagnosis of a mental disorder. mental health personnel issues. The Health General practitioners, family practitione s, and sources and Services Administration (HRSA) has internists accounted for over three- fou.ths (7- the administrative capatility to identify mental percent) of these diagnoses. health shortage area designations, but nakional data Primary care Physicians referred these patients sences describing nonpsychiatric mental health to a mental health professional in only 5 pert. en:. isro;essionals and the locations of their practices are of the episodes. not available (except or professionals who work in About 85 percent of all psychoactive drug speciarzed mental health facilities). prescriptiors were made by nonpsychiamsts. Over one-fourth (28 percent) of nonpsychiatrist Other Rural Mental Health Providers visits were for psychological problems. Anxiety and nervousni ls accounted for 11 Primary Care Physicians percent of the reasons pc wle visited a physi- Mental and physical health care s- trns are cian (655). interdependent in both rural and urbar.eas. Pri- These numbers are not specific to rural areas, mary medical care is an impertant part menial where the relative lack of mental health prriession- health service delivery because primary care physi- als in rural areas may lead to particularly heavy cians and clinics are the tint cor.t in the care dependence on primary care physicians as sources of systein for many patients, they ofteassume long- mental health care. Only 5 percent of visits to term respor NIA), for the care of their patients, and pvcbiatrists occur in rural area. In contrast, 30 they can help to integate services for the pvient (2). percent of ari visits to physiciar.s by patients with Orgy 19 percent of respondents o a zlit vey of rum: psychiatric diagnoses are made it rural areas, as are North Dakota residents listed mente heelth scivicc maw!. 16 percent ca the 2hysician visits hat include some as their first choice 'or treatment for psychotherapy (155). Clearly, mral nonpsychiatric nervous, or er otional problems,' while physit .s physicians are providing substanLAI amounts of were . liked as the first choice by 50 percent of the mental 1%-h care. respondents (189). For seriously mentally, ill pa- tients on long-term drug therapy in rural areas, primary care physicians may be the only persons ,,dlied Mental Health Profmsionals, available who an authorize the needed preszrip- Pareprofessionals, and Volunteers dons and monitor patients' progress. Members of the 0- -gy are professionals who are In fact, four times as many peop't are treated for particulartj import....i pro% idt..rs of some rillmen- mental health disorders by primary caregivers as 4-e 40 health servi4-es. In the North Dakota survey, 4: 4 't) witscIliVIEKIPAPICEMMINSEEM811=Mik. Chapter ItRural Mcn.-" kakis Care 431 percent of respondents listed the clergy as their fi,st placement ,546,56ee Lea-apiary programs do eust. choice of help for "family problems" (189). Liehteestein et al. detenhe the development of a 1-year training program designed to provide out- Local paraprofessionals with no formal academic reach services (consuitation. educadun, and commu- mental health training can fill some of the gaps in rural mental health provision. These individuals nity organizational deeeloprnent) in two nirai com- munities (351). Stedents Ln the program reported receive training and consultation from mental health moderate skill acquisition and positive cemmunity professionals on topics such as crisis management response. Bergstrom et al. describe another mral case identification, and community education. D'A uge' d mental hea:th training program that included a suggests that paraprofessionals can increase com- practienm in rural consultation and education 194). munity awareness and acceptance of mental health service r. and promote mental health through such A mental health Area Health Education Center in North Carolina reports success in developing contin- mecharnsms as conducting training in "life skills" (e.g.. parenting), developing self-help groups, end uing education programs for rural professiorals and strengtheng natural helping systems (informal faeilitatmg linkages bieweee rural mental health generaliste, and cer.aal specialists (227). networks of community residents) (160). They can aiso identify new eases and act e.3 liaisons between Rural-oriented training seem& to affect die likeli- professionals and the community. hood that graduates will practiee in rural areas, Crisis intervention is one area where rreined although informat:on is scaice tudy of graduates volunteers an sometimes ietivide Important first- of psycholetytr .;eing prograrns supported by level he!p. Volunteers may be an especially critical N1MH between 1968 and 1980 identified two component of crisis services both in remote areas not niral -oriented programs training master's-level psy- served by a local mental health professional end in chologists (546). Of the 66 identified graduates of areas where a 24-hour on-cad professional would these programs, 42 were practicing in small towns or reqe'te a long-distance telephone call or extensive rural areas. This study also found that master's-level travel. students were more likely than doctoral-level stu- dents to remain in the State of their training (546). Helping colimunity members to help each other is another approach duihas been successfully Recent legislation (Public Law 100-607) ex- adapted to rural areas. bi ont. example, ,nental nealth panded Federal sapport for faculty and curriculum professionals LI a CMHC m northwestern Iowa development for health professions training pie- developed support groups and a peer listening grams, including graduate elin;cal psycholoby pro program for fermers and their families (3). The grams. Since the support applies onl:, ie doctoral- community response was so overwhelmmg that the el taking programs, and there are no pain isions CMH4 2. staited support groups in satellite chines and for taaget:ng hmding .o nual-orienred pro:,ects, thi& reported a tenfold mcrease in the utilization of its prov iskia may have little eft-eel on the av a;tabslirv of services. psychologists in rural areas. However, the legisla- tion also extended the Federal loan repayment Mutual- and self-help groups that focus on a program to allied health professionals, including COMMA Me !ea! or mental health pre._ tem are clinical psychologrsts, who practice in rural areas. another approaci for including local residents in mentrd health care. These groups, which have grown A shori-terni eontinuang edueation progum for dramatically in pepularity over the past decade, rueal practitieners (not to exceed 5 days) 1%, dS provide residents with the opportunity to help ea tiarodueeel in 19E8 and is adimnistered by NIMH. other cope widi strese, solve problem, develop a Th Depression warenes. Recognititin, and Treat- sense ef belonging, share knowledge and experi- mere program targets rural and agricultural areas ences, and educate themselves about medieal alter- affeeted by the farm crisis and was deFigned to natives (229.344.638). provide current inferrnation on the recognition, diagnosis. am treatment of depressive disorders to Trening,Ar Rural Mental Health Personnel the general public, mental health professionals, and primary care physicians (639). Programs in medi- Fewer than one-thud of mental healtn training , ine, psyehology. nursing, dud sotatil tvork are programs place any emphasis (en rum! :raming and eligible for funding. 4 41 432 He,...;th Care in Rural America Prima.ry,care physicians receive limited training gency .erv ices to health center patients, evaluate..7. in mental health issues. For example, the 6-* eek health center patient.. for psychiatric problems. clerkship in psychiatry for all third-year students is provided short-term psychotherapy, and referred the briefest among the five standbrd third-year patients. Linkage workers were usualiy psycholo- clinical rounls (587). Medical students' coarsswork gists (41 percent) or social workers (38 percent). in behavioral sciences is similarly limited, ancluat- Most of the linkage workers' time was spent in the ing to approximately 5 percent of the medical primary care setting, with 27 hours per week d:voted collet:: class curriculum (587). Limited training may to consulting with primary care professionals, pa- explain why primary care physicians are less able tient ev aluation and therapy were the services mcst than mental tealth professionals to diagnose mental frequently provided. The linkages resulted in several disorders accurately (47) 1.% ler the Health Profes- organizational changes, including increased interac- sions Educaronal Assistance Act of 19^- 6 (rublic hurl among clinical, administrative, and board staff, Law 94-484), NIMH operated severel initiatives to joint recordkeeping, and shared adnunistrr five serv- promote mental health taining for primary care kes. Linkages appeared strongest where there Was physicians (547). However. the tict and le program shared administrative control between the mental expired in 1980. and physical health care providers and where the linkage worker spent equal time across primary care MENTAL AND PHYSICAL and mental health settings (104). HEALTH LINKAGES The motivations for implementing linkage pro- The notion of linking physical and mental health grams differed between mral and urban areas. Rural care is not new, but it may be especially useful in health center directors implemented programs pri- rural artas betzuse of limited resources (e.g., marily in order to provide direct treatment and personael, buildwgs, funding) and services. Link- consultation, only 1- percent reported that establish- ages may also help to -educe the e,ma associated ing a mechanism tt refer patients to he CMHC was with the mental health system.ossible models the most important factor. In contrast. 43 perccot of ütlude: urban health center directors listet: referral opportu- nities as the primary motivating factor (114). a contractuat agreement het .veen providers for referral ani'ormation Broskows'... .ound that the most common linkage a mental health staff person in a holth center to benefits reported by agency directors were. provide screening and information lo patients. a mental health unit in a health center to provide increased awareness and detection of mental direct services, health problems by primary care provideis, a mental health professional in the health .:.are more appropriate utilization of health and setting to consult with physicians and other mental health services, health professionals and to provide direct incrensed access to mental health services, mental health services, especially for the hard to reach populations a "linkage worker" to advise primary care (e.g., elderly, minorities, and the poor), health personnel on patients with mental health reduced waiting for primary care patients and problems (but provide no direct sorvices to recNced burden of primary care staff, patients), raid provision of comp ehensive care with the improved information and records exctiange, mental health and health professonals workin and together on each case (476). better continuity of cale (104). An evaluation of several linkage efforts of the Few problems were reported, and most reported 1970s concluded that internal o-ganizational teams were. eventually soh ed They included diffiaulties in and linl-age agreements between organizations were recruiting qualified hakage staff, pi oviding ade- the most successful (104). In these efforts, th.e quate space for the ltnkage worker, and developing mental health professionals consulted with health a.tequate tiansportatuA between sites for referrals. center staff about their patients. provided inscrs ce Problems of space and transportation wert. more training to the health center staff, provided emer Lornmon in rurai than in urban programs (114). . Oft 4 I , Chapter 16Rural Mental Health Care 4:3 The threat of losing autonon:nd interdiscipli- the use of primal) care physicians, volunteers, and nary and orsamzarional rivalias are major barriers pazaprofessionals may be particularly appropriate to linkages(104,706).Arguments often revolve because of the scarcity of mental health pn fession- around laho gets reimbursed, who controls the tasks als. for the ixakage worker, and who controls policy for the /lane agreement(104,121).Steps to overcome Federal and State funding of seraices such as these bathers inclutl: technical assistance and train- proentioa, education, and consultation axe espe- ing for the linkage w .aker and for directors, and cially important to rural areas, because these serv- mcreasma the awareneas of health and mental health ices are not reimbursable by most payers and there officials of then role in facilitating (or hindering) may be no private sourcw at' such services. In most linkage initiatiaas(104). States,it appears that service requirements for CMHCs have been reduced to those likely to Scveral apparently successful examplee of link- produce revenue (e.g., psycht lerapy, partial hospi- age ageements are found in the literature(,3,407, 484,637), ard such statements ate a component of talization), while funding for preventive services, consultation with other health and human service some of the Rural IV ental Health Demonstrations (see box 16-A). In 0. case study, Boydston professionals, public education, and evaluation have been reduced. Riading of rural mental health in described the efforts of a social worker working with local physicians to provide mental health services general also may have been reduced, but the lack of (98), The researcher concluded that collala ation data precludes a &in conclusion. In fact, since the resulted ia better case detection, smoothea trair4- implementation of the block grant there has been msufficient data to support any significart evalua- dons braween the phyaical and mental health care tion of Federal rural mental health funding efforts. systeras, and improved client attitudes about mental heeds teatment. In this case, the physicians came to value the mental health services because they Rural mental health professionals face problems sunder to those encountered by other health profes- allowed the physicians more time to treat physical problems(98). sionals. They hme fewer practice-specific training programs, fewer coheagues with whom to discuss A recent mformal survey oi.20 rural States found professional issues, and more diverse demands on that none Save instituted any program incentia es for their time than do their urban counterparts. Rural health and mental health linkahas, although all uf neatal health professionals are also isolated in many them expressed interest (171). ways. They often lack the opportunity to discuss caw with other professionals, must make decisions CONCLUSIONS alone, and lack opportunities for supervision or The prevalence of mental disorders in rural mentoring. Primary care physicians, who piovide much rural mental health care, receive relatively Americans is similar to that of their urban counter- hale training in mental health diagnosis and treat- parts. The services available to rural residents are ment, usually more limited, however, both in number and in scope, and those that do exist are generally The lack of psychiatrists and doctoral-level psy- px .. ided hy nonpsychiatric professionals. Psychia- chologists in imml azeas, the proportion of mental trists arc entirely absent in most rural commumties health care provided by nonpsychiatnc physicians, because alternaaae sources of mental health and the need to provide mental health services in services are scarce, rural mental health facilities and ways and sett.Mgs acceptable to rural residents all personnel may be torn between the compet;ng suggest that in.egrating attal health and other demands for services to cluouicall) mentally ill health care is especially important in rural WM individuals and services Iindividuals experiencing Linkares between the physical and mental health temporary distress or less debilitaing problems. systems that arprovided by social workers, psy . Innovative approaahes (e,ga expanding the Commu- chologists, and pazaprofegionals play an important nity Support Program to mclude more rural delivery role in extending mental heaith servicas Unfortu- models) deserve investigation for both populations. nately, Federal stimulation of linkagT efforts has Such approaches must build on ibe professionals and waned since the implementation of the mental heal 1 paraprofessiona1s m ailable, Models that incorporate block grant in 1981. 1 ,.+1434 Health Care in Rural America Despite the apparent success of the short -liN oil to s. I measure.. as c.hangcs in inappropriate uuliza- Federal linkage program no er aluation of the tion of social mid health care setb i-es and the most ultimate effectiveness of the pr..wgrant was :eider effectbe interorganizational linkage models fot u.zen. Renewed efforts could include more attention different rural environutms (537). 1 1 I 1 1 i \ I 1 \ i i 1 1 1 Appendixes Appendix A Method of the Study This assessment v.as prompted by congres. aal con for the first tune on October 26, 1988. At this meeting the cem about the state of rural health care as the 1.;ii0s drew panel discussed some background materials, suggested to a close. Reported high rates of rural hospital closures, and reviewed plans for the pruject, and ideatified some difficulty recruiting hsalth professionals to nue settings, kriportant issue areas to bc included in the stud). and concern about the future competitiveness and finan- cial viability of rural providers were contributing issues in As a core component of the study, project staff held the request for this study. three field workshops to discuss specific rural health topics and to hear presentations on these topics from local In April of 198S, the Senate Rural Health Caw: us asked and regional health practitioners, adminioators, and that the Office of Technology Assessment (OTA) under officials. The meetings were organized by the National take a broad assessment of rural health care that would Rural Health Association under contract to OTA. The rust include, but not be limited to: of these meetings, on rural hospitals, was held on Jan. 11, a discussion of criteria to identit+ or measure 1989, in Scottsdale, Arizona. The second, on hsalth rurality, personnel issues (with special emphasis on the needs of an overview of mral health and identifican on of rural "frontier" areas) was held on Feb. 28, 1989 in Bismarck, hsahh trends, North Dakota. The third, addressing health care issues in a discussion of the place of new health technologies rural areas of heavy poverty, was held on June 15, 1989 in Meridian, Mississippi. A brief summary of the invited in the rural health care system, i_nd an assessment of educational and information needs participants and presentations at these meetings is found of rural health professionals and factors that affect in appendix G. these professionals' dacisions to locate in rural areas. During the course of the assessment. OTA conducted Members of the Caucus signing 0- - request letter included two separate surveys of States to identify the level and a member of OTA's Technology Assessment Board, the scope of their mral health activities. The first survey, Senate Minority Leader, the Osman of the Senate conducted in spring of 1988, provided an overview of Committee on Environment and Public Works and the State activities related to rural health and priorities and Chairman of the Senate Select Committee on Indian problem areas as identified by State personnel. All 50 Affairs. In May 1938. a letter reiterating these concerns States responded to this survey. The second survey, and supporting the request was received from the ranking conducted in the summer of 1989, focused specifically on minority member of the Senate Committee on Labor and State aztivities and experiences regarding the desigaation Human Resources. of health personnel shortage areas and medically under. served areas. Forty-five of the 50 States returned this The proposed assessment was approved by the Technol survey. The methods, instruments, and respondents for ogy Assessment Board on June 21, 1988 and began in these surveys are presente4 in appendix D. Survey results August of that year. During the early part of the project, are presented m chapters 4, 11, 12. and 13, depending on OTA staff consulted with consumer and professional the topic addressed by the survey question. organizations, Federal and State agency pe rsonnel, health services researchers. mdependent health professionals, In addition ta the fieli workshops and surveys OTA and other interested individuals in order to identify critical conducted site visits, literature rev iews, and extensh e issues and gamer suggestiorfot candidates for ita conversations with State officials and rutal health profes study's advisory panel. The advisnry panels for OTA sionals. Data collection was an important part of this studies vide OTA staff in selecting material and issues assessment, and a substantial amount ef information was to consieer and review the written work of the staff, bui derived from data supplied by a variety of individuals and the pawls are not responstiale for the content of final oronizations. Many of the data were previously unpub reports. lished, and the cooperation of these individuals and organizations was tremendously helpful to OTA. OTA The advisory panel for this assessment consisted of 20 also purchased from the American Hospital Association members with expertise in, or important perspectives on, the results of its 1987 Survey of Hospitals and analyzed rural hospital and clinic administration, rural medical and these data in-boire. Appendix C summnrizes some nut ag practice, nzral health services research, State teelnacal and definitional issues related to that analysis. hsalth system planning and administration, rural eco- r.onuc development, grants assistance, and health proles A preliminary draft of The repun was iev le wed by the sons education. The gaud, chaired by James Bernstein ot ads assay panel and discussed by panel members at the the North Carolina Depanment of Human Resources, ma ."..ond and last meeting of the panel on Januar) 26.1990. 437 20-810 0 - - 15 al 4 71 438 Health Care in Rural America Subsequently, a revised draft was sent. either in part or in ..ommissioning of the papers din] the expens.* of whole, to more than 150 Federal and State officials, workshop partkipants. A sumniary of ibis report is representatives of interested parties, and other experts for contained in appendix H. their review ard comment. The final draft, incorporating Background papers commisfioned by OTA dunng th revisions based on reviewers' commeats. was transmitted to the Technology Assessment Board in late March 1990. course of the assessments of Health Care in Ris al America and Rural Emergency Medical Services are In addition to the main report, this assessment of rural listed below.' lom Hoffman of Washmgion. DC indexed health care included two other publications. The staff the report paper, Defining "Rural" Areas: Impact on Health Care Policy and Research, was released in July 1989 and J Chin, "Rural Emergency Medical Semi...es. A discussed the health care policy implications and uses of Rtview of the Literature.'" April 1989. various alternative ways of defining rural areas and M.L Dube, "The Legal En. ironment Affeomg the populations. The Special Report, Rural Emergency Medi- Delivery of Rural Health Cares- July 1989. cal Services, released in November 1989, was written by U. Shuman and H. Wolfe, &salmi. A Mode; tor 01A staff based on background papers, a workshop. and RtIfal EMS Syt tuns Planning.' July 1989. additional sources of informntion. The Department of D.C. Stamper, "Status of All Medwal Transport Transportation provided financial support for both dr Systems." May 1989 JAB papers Van prenatal under contract to OTA Funding fur he three bailp.nind mem rekwog to cnicageni.% MVZIM-al scrviteS. ilOwevta. wa3 provided by the US. Department of Transportation ..msfrmentfp,, WSW ..,111111=MREININIPMIRIMIMIDSEPOMMIIMMig Appendix B Ackno wledgments This repon was greatly aidetlby the contnbutions of many ;Jodi% iduals. OTA staff extend special thanks to the man) people who took the time to provide information, respond to survey s. and participate in field workshops. In addition, OTA would like to thank the following individuals for their assistaw.c. (11us acknowledgment Auuld not be .strued to imply that the individuals either endorse or disagree with the ronclusions of the report.) Charles Alfero Jerry Coopey Albuquerque. NM Office of Rural Health Policy Rockville, MD Nancy Batzand The Robert Wood Johnson Foundation Philip Cotterill Princeton, NJ Health Care Financing Association Baltimore, MD Peter Beeson Office of the Governor Roger C. Courtney Lincoln, NE American As.lociation of Colkqes of Osteopathic Medicine Vida Behn Washington, DC New York State Department of Health Albany, NY r"'nK. Cromler University of CO.Tat cticut Suzette Berm Storrs, CT Connecticut Department of Health Jake Culp Hartford, CT Office of Rural Health Policy Sylvia Roeder Rockville, MD American Hospital Association Marcia DaigIe Chicago, IL DHH Primary Care Project Cathy Boelke Baton Rouge, LA Wisconsin Department of Health and Social Sers ices Division of National Health Service. Corps Madison, WI Rocicville, MD John Bonds Lee Dixon New Hampshire DIVISIOn of Public Health Sent...es Intergovermental Health Policy Projtct Concord. NH Washington, DC Jennifer Boulanger Jean Dufresne Prospective Payment Assessment Conunission Office of Inspector General Washington. DC Department of Health and Liman Services Atlanta, GA Diane Bo Nen Idaho Department of Heaith and Welfare Gar Elison Boise. ID Utah Department of Health Salt Lake City, UT Sharon Cagen Karen Erdman Rhode Island Department of Health National Alliance for the Mentally Ill Providence. RI Arlington. VA Michelle Casey Curtis Erickson Minnesota Depart ment of Health Great Plains Health Alliance, lnc, Minneapolis, MN Phifiipsburg, KS Don Coffey Bill Finerfrock Department for Health Services American Academy of Physician Assistants Frankfort. KY Alexandria, VA Tim Condon Jack Geller Alcohol, Drug Abuse. and Mental Health Assouation University of North Dakota &Aloof of Medi. Inc Rockville. MD Grand Forks. ND -439- 4-14t) 440Health Care in Rural America Gzegory Glass Jeanette Klemczack Florida State Health Office Michigan Department of Public Health ThIlabassee, FL Lansing, MI Sophie Glidden Ken Kochanek Maine Department of Human Services National Center tor Health Statistics Augusta, ME Hyattsville, MD Guy Goubeau Ann Koontz Bureau of Health Care Delivery and Assistance Bur= of Maternal and Child Health and Resource Rockville, MD Development Helen Grace Rockville, MD WX. Kellogg Foundation Yvette Lamb Battle Creek, MI Arkansas Department of Health Holly Grason Little Rock, AR AssociaCvn of Maternal and Child Health Programs Richard C. Lee Washington, DC Bureau of Health Professions J. Patrick Han Rockville, MD North Cealrai Wisconsin Office of Rural Health Harvey Licht Wausau, WI Department of Health and Environment Hannan Hein Santa Fe, NM The University of Iowa Hospitals and Clinics Iowa City, IA Diane Makuc National Canter for Health Statistics anis Hogan Hyattsville, MD Physician Payment Review Commission Washington, DC Keith McCarty Montana Hospital Research and Education Foundation Hospital Data Center Helena, MT American Hospital Association Chicago, IL Joan McConnel Alabama Department of Public Health Alison Hughes Montgomery, AL University of Arizona 'Meson, AZ Steven McDowell Office of Rural Health Dana Hug,hes Topeka, KS Bakeley. CA Jeff Human Dick Merritt Office of Rural Health Policy Intergovernmental Health Policy Project Rockville, MD Washington, DC Charles Huntington Carole Mier American Academy of Family Physicians Mountain Management Washington, DC Ojo Sarco, NM Ernesto Iglesias Evelyn Moses California Department of Health Bureau of Health Professions Sacramento, CA Rockville, MD Wilma Johnson Hermoz Movassaghi Bureau of Health Professions Ithaca College Rockville, MD Ithaca, NY Withal L. Jones Lindy Nelson Greater Meridian Health Clinic Colorado Department of Health Meridian, MS Denver, CO Sheny Kaiman Andrew W. Nichols National Rural Health Association University of Arizona Washington, DC 'Meson, AZ 4 7.1 Appendix BAcknowledgments 44! Greg Nycz Elsie Sullivan Marshfield Medical Research Foundation Bureau of Health Care Delivery and Assistanct Marshfield, WI Rockville, MD Lucy Ozalin Ella Tardy Bethesda, MD Mississippi State Department of Health David Palm Jackson, MS Nebraska Office of Rural Health Lined- le Mary Thompson Utah Department of Health Lany PAM Salt Lake City, UT Agency for Health Care Policy and Research Rockville, MD Jan Towera Richard Penns American Academy of Nurse Practitioners American Association of Colleges of Pharmacy Lowell. MA Alexandria, VA Elisha Tyler Dawn Phifibert U.S. Public Health Service Recruitment Project Health Policy Council McLean, VA Waterbtuy, VT Mary Uyeda Luci Phillips National Association of Counties Washington Department of Health Washington, DC Olympia, VIA Dena Puskin Bob Van Hook Office ocRural Health Policy National Rural Health Association Rockville, MD Kansas City, MO Steve Rosenberg Morton Wagenfeld Rosenberg and Associates Western Michigan University B olinas, CA Kalamazoo, MI hfichael Samuels Susan Walter Univeraity of South Carolina Martinsburg, WV Columbia, SC Rachael Schwartz Cathy Wasem Office of Rural Health Policy National Petinatal Informatirm Center Providence, RI Rockville, MD Peter Shaughnessy Elizabeth Wennar University of Colorado Health Sciences Center U.S. General Accounting Office Denver, CO Washington, DC Bernard Simmons Jerri We>ton Southwest Health Agency for Rural People Agency for Health Care Polky and Research Tylertown, MS Rockville, MD Ymi Size Lou Wienckowski Rural Wisconsin Hospital Cooperative Rockville, MD Sauk City, WI Howard Stambler Donna Williams Bureau of Health Professions National Rural Health Association Rockville MD Kansas City, MO Joel Suldan Sidney M. Wolfe McDermott, WilL & Emery Public Cid= Health Research Group Washington, DC Washington, DC 4 15 Appendix C Definitions of Hospitals in OTA Analyses of 1987 American Hospital Association Survey Data ununit) hospitals inAujed in the OTA analyses dre Table C-1 Data On tha Number of Sole Community jermed ab all non-Federal', gel:mil; shon stay tless !tun Hospitals (SCHs) and Rural Referral Centers (RRC9), 30 days), nonspectaky hospitals responding to the Ameri- 1297 can Hospital Association (AHA) 1987 annual survey of SCHs RRCs U.S. hospitals. (Community hospitals with long-term care Number on HCFA list 367 229 units having patient stays longer than 30 days are Number identified M AHA date 313 217 included). This dermition differs slightly from ARA' s DMInenoe (%) 54(t4.7%) 12 (5.2%) definition of community hospitals, which also includes aOthce of Technology Assessment analyses are based on these Amos. non-Federal, shon-stay specialty hospital& SOURCE: aka of Technolog; Assessment. 1990 Federally designated sole community hospitals (SCHs) and nual referral centers (RRCs) are those identified as may also include hospitals that have'..)sed. The data on existing in 1987 or later, according to lists provided by the slippage are presented in table C-1. Health Care Financing Administration (HCFA) that were matched with the list of community hospitals in the OTA The217ommunity hospitals included in the OTA analyses. The OTA analyses do not include every analyses that arc lefinedasfrontler are those located in designated SCH and RRC, as in some cases hospital counties with populd.;JDdensities with 6 or fewer persons names of lists supplied by HCFA do not correspond to the pei square mile. The list of 387 frontier counties was names L.: hospitals available from the AHA data file. 'This tabulated from 1985-86 county population estimates may be due to name changes as a result of reorganization, based on the 1980 census and was supplied by the buyouts, tmrofers of ownership, or other factors. The lists Na.iondi Association of Counties in Washington, DC. ;Hospitals controlled by Fodenti agencies. sub as tk Department of VeteransAffairs mil the !attain Health Jen,b.,are not Am MOW &SBA I Appendix D Background Material for Two OTA Surveys Methods 7. legislative affairs relating to rural health; and 8. rural health-relafed publications. OTA's 1988 Survey of State Rural Health Activities Respondents were then asked to identify, from the Survey Instrument and RespondentsA written eight general activity categories, the three that were questionnaire was designed to assess State involve- their organization's highest priorities for action, and ment in nnal health programs and activities (a copy to indicate any special populations (e.g., children, of the questionnaire and a list of respondents' names elderly, low income, racial/ethnic groups) to which and addresses follow the methods section in this their previously identified rura bealth activities appendix). A draft of the survey instrument was were targeted. Respondents were asked to rank six reviewed by selected individuals and by two of the general health illue areas (e.g., medical liability eventual respondents, and it was subsequently re- insurance costs/availability, payment issues. health vised in accordance with their comments. provider issues) according to which were the most pressing issues for mral health in the State, with the Respondents for the survey were identified option to add and rank any of their own priorities not through brief telephone interviews with State health listed. Respondents were also asked to rate on a officers or other individuals known to be knowl . six-point scale their level of involvement in several edgeable about rural health activities within that specific health services (e.g., acute health cai e, child State. Multiple responses were rcceived from 13 health care, long-term care, mental health care). Due States where 2 or more organizationally independent to inconsistencies in interpretation of and response., entities were identified as playing a major role in to this section', however, responses were not in- State rural health planning, development, research, cluded in the analysis. and/or policy (see ch. 4, figure 4-1). A total of tif respondents reported for the 50 States. Data Collection and AnalysisData were col- lected on the mailed survey form from all 50 States. The survey solicited basic descriptive information After being received by OTA, the data were summa- including the agency's specific Hirai health objec. rized on a standardized form and sent back to the tives, location in the State organizational structure, respondent for verification. For States with more and origins (e.g., legislative or administrative)_ than one respondent, all respondents weft sent both Respondents were asked to indicate whether they a copy of their response surnmary and the summaries had been directly involved during the past 3 years in from the other respondents in their State. The specific rural health activities within the following verified (or corrected) data were used for the 8 general categories: analysis. Information about budget and staff size was also collected, but because these items were not 1. provider recruitment/placement; addressed consistently2, budget and staff data were 2. financial assistance to local organizations, for the most part excluded from analysis. While 3. technical assistance to rural communities, spe,ific budget data were not comparable, analy sis health facilities, and health providers; of funding sources was conducted to examine the 4. rural health research; degrees of dependence of responding oiganizations 5. mial health sy stems coordination and iniplementa on Federal, State, and ptivate or other dol!ars. For tion; this reason, only budget ehanges and sources are 6. education; reported. Tolluw0P Om ianversalivris with icspun, ain revealed dist many thought this 4rAmori 4-4 die ma bey diceutt 6. ciii.a itvunaeb.cloilae, irc,, a nivolvernent in the Jelvoy of these spew& straits. nither than two vemeat in research. planning. and 4evelopme4 aliiniea. 2Difference% tn Stale budgeting and recurding piouedures as well al differenues di &co defnuouas vf nag Limited die au:unan wait utufiinii../ of finnactal data voilected through die survey. Seven Slates did uut respond tu this swain uf rue survey . acid di. :mamas 43 used a.aliery A authud3 todeiermme iheantourn ol ghat budges mem on rural health a.wisutu. Some scsipuoJaosIaloi the tout. Stine health budge% ,Abei i -imputed tk nue. health budgetaaa pertenzageof It.:. total Sian bead, badge' abwrotag tu the prupyruun of gig& leadcma ,s sisithwuutio..L.die Sisk. and NAlie Saks repotted specific budget allocations for rural health inidatives. -443- 4 7 7 444 Health Care in Rural America Data from the States with more than one respon- effective, either by the organization itself or by dent were combined to reflect the total picture of outside individuals, or 3) the amount or source of State activities For items requiring a single response funding for any specific activity. These limitations (i.e., priorities, rankings, and ratings), a primary may affect the comparability of data among States. respondent was selected by the OTA staff based on their judgment regarding which respondent ap- The degree to which individual States identified "rural health" issues as separate from general health peared most generally knowledgeable about the issues and addressed them in a targeted manner breadth of the State's activities. varied greatly from State to State. The survey did not For purposes of analyses, States were livided in prescrib e a definition of "rural" for respondents, but three fashions First, States were divided into four left the definitional issue up to the individual States. standard regions. Northeast, South, Midwest, and What is considered "urban" in North Dakota may West (see app. F for the States included in each be considered "rural" in New Jersey or Pennsylva- region) Second, States were classifted as "more nia. Some of the more urban States may not identify niral" or "less rura " depending on the percentage rural health as a specific issue because such a small of their population residing in nonmetropolitan areas proportion of their population is affected, while in 1986.3 Third, States were divided according to some of the more rural States may not regard "rural whether the respondents in that State were reporting health" as a Eeparate set of issues because most of activities of an identified "office of rural health," or their population is rural. As a result, some of the an office whose primary responsibility is to admini activities listed by respondents were not specifically ster Ir. the health needs of rural areas of the State.' targeted to rural areas, but were provided to the State as a whole. These differences may also affect the This survey does not provide ;... complete picture crparability of State data. of State-conducted Or State-funded rural health- related activities, but it does give us a basis for OTA'S 1989 Survey of States on describing State activities. Respondents were often in specific bureaus, divisions, or sections of State Hea It h Person n el Short age a n d Medically Underserved Areas departments of health, .! did not always respond on behalf of the department or the State government A second OTA survey was designed to examine as a whole. Rather, they tended to describe only the State activity i.nd satisfaction with the Federal activities in which they were directly involved. designation of health manpower shortage areas Rural health-related activities of other State depart- (HMS A s) and medically underserved areas MUAs). ments or agencies and independent activities of State The questionnaire was reviewed by 10 people universities and colleges(e.g., university-based familiar with shortage area designations and was offices of niral health or Area Health Education subsequently revised based on their comments ia Centers) were for the most part not captured.' copy of the questionnaire follows the methods Chapter 4 includes a list of the entities in each State section in this appendix). In July 1989 OTA mailed whose activities were reported in the survey re- the questionnaire to the individual in each State sponse The survey also did not attempt to deter- responsible for designating health personnel short- mine. 1) the degree to which the respondents or their ages and medically underserved areas.6 Respondents agencies were involved in any given activity; 2) the were encouraged to consult with other involved degree to which any particular activity 1. deemed parties in their States when responding to the 3"More rural" States (those with more than 50percent of their population residing in nonmetropolitan areas) are Idaho. Vermont. Montana, South Dakota. Wyoming, Mississippi, Maine. West Virginia, North Dakota, Arkansas. Iowa. Alaska, Kentucky. Nebraska. and New Mexico. Ali other Rams are coosidered "less nual". 4A State was identified a baying an office of rural health if a) the name of one or more of the responduus mg.inuanons within thatState included the term "rural", or b) the organization was etherwise known to have a mission pnmanly related to rural health. States with offices of rural bealth (hereafter referred to as "ORH States") were Arizona, California. Codneenciit. Goergia, Nebraska, Nevada, New Mexico. North Carolina. North Dakota. Oregon, Texas, and Utah All other States were classified as "non-ORH Status." Stases with offices of -localor 'communityhealth were not classified as "ORH States." although the roles of these offices may be similar to the role of an office of rural health . sln some States, AHRCs operatii.g pnmarily on State funding and uni.,enity-based offices of rural health with Stale budget amhonly were included if ihey had been identified as appropriate respondents during the identification process &The list of respondents was based in part on a list supplied by the Office of Shortage Dtaisguloun. Bureau ol Health Care Delivery and Assistance. Other respondents were Identified through phone cads to Stale health department officials 4 Appendix DBockground Material for Two OTA Surveys 445 questionnaire. Forty-five of fifty States returned if States had sufficient resources to monitor questionnairesa 90 percent response rate. (No list health personnel shortage tnd medkali) un of respondents to this strvey is included in this derserved areas; and appendix because some responses were confiden- tial.) what Federal programs were perceived to have The goals of OTA's survey were to learn: had the most positive effects on shortage and underserved areas. how satisfied States were with Federal designa- tion criteria and processes; Data analysis included variable frequencies and if and why interest in Federal designations had increased or decreased over the last 5 years; some regional comparisions. if States were using their own health personnel shortage areas or medically underserved area designations and, if so, how they were used; 7Cahfunita,Connectical, lowklylusacbuserts.aul North Dakota did not return quest/um:rams Wy um.og was also eutuded from the sun e) anal) (IS bocaase. as ofhine 1988, the mason responsible fur HNISA/ieftdt desitplauuns was .A4 anti 11 has sake been left to oda, edb4 k ountret and hospnah to do their own desipations. 4 *7 9 446Health Care in Rural America List of Respondents to OTA's 1988 Survey of State Rural Health Activities NOTE The first respondent listed under each State was the "primary respondent", whose msponses to the ranking and rating sectiuns were used to express State rural healta issucs and priorities. "IP" indicates the entity whose activities are reported in the survey response. Budget data may not be reported for the same entity, but for a more specific division. "**" indicates the person who completed the questionnaire. A Joan McConnell William Avritt Raymond Seabolt Director Chief Director Planning and Program Development Rural and Community Health Division Primary Health Care Section Bureau of Environment & Health Service Dept. of Health Services Room 100 Standards 714 P Street 878 Peachtree Street, N.H. Dept. uf Public Health Sacramento, CA 95814 Atlanta, GA 303:.9 434 N. Monroe Street Room 249 * Rural and Community Health Division * Primary Health Care Section Montgomery, AL 36130-1701 ** Lawrence J. McCabe, Jr., Chief, ** Rita C. Salain, Community Health Bureau of Environment & Health Service Hospital and Medical Standards Program Specialist Standards ** Naomi Halverson Margaret Gerould David Foulk Deputy Director Director Dwayne B. Peeples Division of Health Planning and Analysis Center for Rural Health Division of Public Health Office of Statewide Health Planning & Georgia Southern College Dept. of Health & Social Services Development L.B. #8148 P.O. Box H-06 1600 9th Street, Room 440 Statesboro, GA 30460 Juneau, AK 99801 Sacramemo, CA 95814 * Center for Rural Health. Georgia * Division of Public Health. * Office of State Health Planning & Soufiern College Dept. of Health and Social Services Development ** David Foulk ** Dwayne B. Peeples ' Ernesto Iglesias. Manager, Small & Peter Syoinsky Rural Hospital Project Alison M. Hughes Deputy Director for Planning, Legislation Associate Director and Operations Lindy Wallace Rural Health Office Hawaii Dept. of Health Health Planning Consultant University of Arizona P.O. Box 3378 Colorado Dept. of Health 3131 East Second Street Honolulu, HI 96801 4210 E. 1 1th Avenue llicson, AZ 85716 * Dept. of Health Denver, CO 80220 * Rural Health Office ** Peter Sybinsky ** Alison M. Hughes * State of Colorado ** Lindy Wallace Diane Bowen Charles McGrew Supervisor Disector Susette Benn Office of Health Policy & Resource Section of Health Facilities, Services & Center for Chronic Diseases/Urban/Rural Development Systems Health Division of Health Arkansas Dept. of Health 150 Washington Street Dept. of Health & Welfare 4815 W. Markham Hanford, cr 06106 450 W. State Street, 4th Floor Little Rock, AR 72205 * State of Cormecticut Boise, ID 83720 * Section of Health Facilities, Sem ces & ** Susette Benn * State of Idaho Systems **Diane Bowen ** Yvette Lamb, Director, Richard Stehnan Office of Primary Care Deputy Director Alvin B. Grant Division of Public Health Acting Director Charles Cranford Cooper Bldg. P.O. Box 637 Center for Rural Health Dhector Dover, DE 19903 Illinois Dept. of Public Health Arkansas Area Health Education Center * Division of Public Health 53.1 West lefferson Program ** Marihelee Barren, MCH Director Springfield, IL 62761 Univenay of Arkansas for Medical * State of Illinois Sciences Gregory Gass ** /dvin B. Grant 4301 W. Markham, Slot 599 Administrator Little Rock, AR 72205 Florida Health Manpower Program Keith Main * AR Area Health Education Center 1317 Winewood Boulevard Director Program Tallahassee. FL 32399-0700 Public Health Research Division ** James L MeFadin, Associate Director,* State of Florida Indiana State Board of Hedth Administration ** Gregory Glass A , 1310 West Michigan Street Appendix DBackground Mo. dfcr- Two OTA Surveys 447 P.O. Box 1964 Jonathan Foley Thomas R. Piper Indianapolis, IN 46206-1964 Maryland Dept of Health & Mental Direr- A * $tate of Indiana Hygiene C4 -tficate of Need Program ** Keith Main 201 W. Preston St., RM 314-B Dept. of Health Baltimore, MD 21201 P.O. Box 570 Mary Ellis * Primary Care Cooperative Agreement Jefferson City. MO 65102 Director Unit. * Certificate of Need fr.:.gram Dept. of Public Health Dept. of Health and Mental Hygiene ** Thomas R. Piper Lucas State Office Building ** Jonathan Foley Des MAXIM IA 50319-3075 Charles Mgenes * State of Iowa Susan Bernstein Chief ** Louise Lex. State Health Planner Director Health Planning Bureau Office of Local and Regional Heanh Dept. of Health & Environmental Sciences Steve McDowell Massachusenr Dept. of Public Health Cogswell Building, Capitol Station Director 150 Tremont Street Helena, MT 59620 Office of Rural Health Boston, MA 02111 * Bureau of Health Planning Dept. of Health and Environment * Dept. of Poblic Realth ** Charles Aefienes Landon State Office Building, 10th Floor ** Susan Bernsteki & Hillel Liebert. 900 SW Jackson District Health Officer. Western David Palm lbpeka, KS 66612-1290 Massachusetts Director * State of Kaxisas Nebraska Office of Rural Health Lou Crosby ** Steve McDowell Dept. of Health Policy Chief P.O. Box 95007 Don Coffey Division of Health Facility Planning & Lincoln. NE 68509 Manager Policy Development * State of Nebraska Health Resources Development Branch Bureau of Health Facilities ** David Palm Division for Health Policy 8c Resource Michigan Dept. of Public Health Development P.O. Box 30195 Joseph Jarvis Dept. of Health Services Lansing, M148909 State Health Officer 275 East Main Street * Division of Health Facility Planning & Division of Health Nevada Dept. of Human Resources Frankfort, ICY 40621 Policy Development * State of Kentucky ** Lou Crosby 505 E King Stmez Carson City, NV 89710 ill* Don Coffey Jim Parker * Division of Health Dircctor Patrick O'Connor " Ron Lange. Administrative Community Health Services T;ivision Ditector Health Services Officer Dept of Health Division of Policy & Program 717 Delaware St., S.E. Caroline Ford Development Minneapolis, MN 55440 Director Dept. of Health & Hospitals * Dept. of Health Office of Rural Health 655N. 5th Street, Suite 307 ** Wayne R. Cadson. Mecum, University of Nevada Baton Rouge, LA 70802 Community Development Mackay Science. Rm. 201 * State of Louisiana Reno. NV 89557-0046 ** Marcia L. Daigle, Director, Ella Tardy * Nevada Office of Rural Health Primary Care Coordinating Unit Director ** Caroline Ford Office of Primary Care Liaison Sophie Glidden Mississippi State Dept. of Health William T. Wallace. Jr. Office of Health Planning and P.O. Box i700 Director Development Jackson, MS 39215-1700 New Hampshire Division of Public Health 151 Capitol Street, Station 11 * Office of Primary Care Liaison Services Augusta, ME 04333 " Ella Tardy 6 Hazen Drive * State of Maine Concord. NH 03301 ** Sophie Glidden Lorna Wilson * Division of Public Health Services Director 4* Jolm D. Bonds, Assistant Director for Jeanette Washington ision of Local Health & Institutional Planning Health Planner Services Maryland Health Resources Planning Dept. of Heald) Viktoria K. Wood Commission P.O. Box 570 Research Scientist P.O. Box 2679 Jefferson City, MO 65102-0570 New Jersey Dept. of Health Baltimore, MD 21215-2299 Bureau of Primary Care. Local Health Development Services 301/764-3?23 Division of Local Health & Institutional 379 West State Street MD Health Resource Planning Services Trenton, NJ 08623 Commission ** George A Thomas. Jr. Program * State of New Jersey " Jeanette Washington Coordinator. Bureau of Primary Care * Viktoria K. Wood 4 8 448 * Health Care in Rural America Harvey Licht Susan Ewing-Rarnsay * Divisien of Hospitals Pzogram Manager Head ** William White Primary Care Section Primary Care Section Dept. of Health & Environment Ohio Dept. of Health Sharon K. Cagen P.O. Box 968 246 N. High Street Project Dhector Santa Fe, NM 87501-0968 Columbus, OH 43266-0118 Cooperative Agreement for Primary Care * Primary Care Section * Primary Caze Secdon Services ** Harvey Lidt ** Susan Ewing Ramsay Rhode Island Dept. of Health 75 Davis Street Charles Alfero Suzanne Nichols Providence, RI 02908 Director DireCtor * State of Rhode Island New Mexico Health Resources, Inc. Oklahoma IL..alth Planning Commission ** $haman IC. Cagen P.O. Box 27650 Dept. of Health Albuverque, NM 87125 Thomas McGee 1000 NE 10th St. Director * New Mexico Health Resources, Inc. Oklahoma City, OK 73152 ** Charles Alfero Office of Primary Care * Oklahoma Health Planning Commission Dept. of Health and Environmental ** Howard H. Vincent Paul Fitzpatrick Control 2600 Bull Street New York State Dept. of Health Don K. LeaVitt Columbia, SC 29201 Division of Planning, Policy, and Resource Executive Director * Office of Primary Care Development Oklahoma Physician Manpower Training McGee Empire State Plaza Commission Corning TowerRoom 1656 P.O. Box 53551, Rm. 21 I Bernie Osbert Albany, NY 12237 IWO NE 10th St. Rural Health Manager * State of New York Oklahoma City, OK 73152 South Dakota Office of Rural Health ** Assistant Chief Health Planner * Thysician Manpower Training Dept. of Health James D. Bernstein Commission 523 E Capitol Chief ** Don K. Leavitt Pierre, SD 57501 Noah Carolina Office of Health Resources 4 Dept. of Health Brent VanMeter Development ** Bernie Osberg 701 Barbour Drive Deputy Commissioner for Specie.; Health Services Scot Graff Raleigh, NC 27603 Dept. of Health Manager * Office of Health Resources Development Rural Health Program ** James D. Bems.ein P.O. Box 53551 1000 NE 10th St. University of South Dakota School of Eugene S. Mayer Oklahoma City, OK 73152 Medicine Program Director * State Dept. of Health 2501 W. 22nd Street 14orth Carolina AHEC Program ** Brent VanMeter Sioux Falls, SD 57117-5346 CB #7165 Medical School Wing C * University of South Dakota School cf thiiversity of North Carolina/Chapel Hil: Marsha R. Kilgore Medne Chapel Hill, NC 27599 Manager ** Scot Graff State of Oregon Office of Rural Health * North Carolina AHEC Program Eloise Hatmaker 4* Eugene S. Mayer 1174 Chemeketa St. NE Salem, OR 97301 Division of Health Access 100 9th Avenue North Robert M. Wentz State of Oregon Nashville, TN 37219 North Dakota State Dept. of Health & 0* Marsha R. Kilgore * State of Tennessee Ccertolidated Laboratories ** Ray Davis, Director of Physician Judicial Wing 2nd Fl Stephen Male Placement, 600 E. Boulevard Ave Director & Annette Mentes, Health Planner BiallEtIck, ND 58505-0200 Bureau of Health Financing & Program * State Dept. of Health Development Albert Randall **Robert M. Wentz Pennsylvania Dept. of Health Associate Commissioner for Community P.O. Box 90 & Rural Health Jack Geller Harrisburg, PA 17120 Dept. of Health Acting Director * Bureau of Health Financing & Program 1100 W 49th Street The Center for Rural Health Services, Development Austin, TX 78756 Polley & Research ** Stephen Male * Dept. of Health University of North Dakota 00 John Dombroski, Director, Primary 501 Columbia Road William White Health Care Services Program Grand Forks, ND 58201 Division of Hospitals * Center for Rural Health Services, Pennsylvania Dept. of Health Ellen Witless Policy & Research P.O. Box 90 Director of Rural Health *0 Lynen Krenerka, Grants Coordinator Harrisburg, PA 17120 Dept. of Agriculture 4 Appendix DBackground Material for Two OTA Surveys 449 P.O. Box 12847 Budington, VT 05402 Division of Health Austin, pc 78711 * State of Vermont 1800 Washington Street, East Dept. of Agriculture Ouistine Finley Building 3, RM 206 00 Ellen Widess Raymond O. Perry Charleston, WV 25305 Claudia Siegel Director * Dept. of Health Director of Medical Programs Office of Planning and Regualtory " George W. Lilley, Jr. Texas Higher Education Coordinating Board Services P.O. Box 12788 Division of Health Planning Richard C. Heinz Ausdn, pc 78711 Dept. of Health Higher Education Coordinating Board 1010 James Madison Building Coordinator ** Claudia Siegel 109 Governor Street Primary Care Programs Richmond, VA 23219 Division of Health Robert W. Sherwood, Jr. * Stare of Virginia P.O. Box 1808 Director " Raymond O. Peny Madison, WI 53701-1808 Bureau of Irscal and Rural Heahh Systans * State of Wisconsin Utah Dept. of Health Verne Gibbs 288 North 1460 West, P.O. Box 16660 Health Planning Administrator ** Richard C. Heinz Salt Lake City, UT 84116-0660 Dept. of Health State of Utah Mailstop OB-43F R.L. Matti ** Robert W. Sherwood, Jr. Olympia, WA 98504 Director Dept. of Health State of Wyoming Health Dept. Christine Finley " Verne Gibbs Health Planner Cheyenne, WY 82002 Vermont Dept. of Health George W. Liffey. Jr. * Wyoming Health Dept. 60 Main Street--Box 70 Acting Administrator ** Lary Goodmay 4 N1.O ) 450 Health Care in Rural America SURVEY OF STATE RURAL HE. 1ES Spring 1988 Office of Technology Assessment US. Congress Washington, D.C. 20510-8025 Conducted by the Office of Technology, Assessment US. Congress i GENERAL DESCRIPTION ist tete t (St SI A IS itt,ItAt *HAI Itl ACTtt Stith Ottsnrestem Name Address. Phone Nense(fille of director Name/Tule of other INI.M.C.1.104 hey coat= Nameffitle of person I READ OVER Tilt SURVI I CAREFULLY If yau have nosy questions, conlaet Leah completing survey Wolfe or Marc Zli merman at..e Office of Technology Assessment, Health Program, Year established V S Congress. Washington, DC 203104025 (202/2211.6590) Type of orgasisorea Sale Goverrinient-homd UnIveflily.bsitd 2 Please feel free to attach separate sheets whenever more room is needed fOr s Pi aaaaa leert.pesSit resPOnst Orber (describe) 3 Please note that for each item in the ACTIVITliS section, we are interested only in activities your mutilation is CUR RENTLY involved us OR las been mvolved in DURING THE PAST ) YEARS SMIORL.MiLblidaZ 4 Please melte use of the 'other catenaries throughout the surveY to capture any llf tural health &townies ere only pen of your orgenighon's fi$P01130bittlit. scsivirres/programs that we bave not included in our ehmklists Don't forget NO dela& phase make the ingenue ripostes band 04 there activities alone ) then other attivilleS ill the epees provided Number of pm* on staff FTE (Include profeseionst. administrative. support) S Meuse enclose any representative literature/pubbcations you may have that will help describe your aerivities/Programs in g detail, and feel free to reference this Total anneal Midget (es mtal Ocettems (seclude federal, state. kcal. Private, and literalute nt any Point in the survey (ell . See p 26 of enclosed Annual Report for lee.for-service inceme) description ofour demonstration projects ') A Portage-Paid enveloPe has been Provided FY ET $ for this purpose FY ss $ 6 When You hum finished. Please enclose the completed questionnaire as well as any FY at $ related literature On she Pustage-Paid envelope Please return the survey by breakdown. % Federal funding II Load public Nodule la SON funding IS Fee.for.service iacome _ 5 Privele funding lee . foundation Smog) Plane lite Private funding tourney THANK YOU FOR YOUR TIME AND COOPERATION. PLEASE comma oN NEXT PAGE 1 4a5 4b I. GENERAL DESCRIPTION ICONTINOLIa 1 ACMITISb A) Whal are VOW ordanstation's ;veal health Obje Chi"' (gado& tour ofticrat mandate, it applicable Mau chect those twat health *eh. dies *Mew iii nthtCh yeAr nedanitatroit Ms been DIRECTLY Inot.ea DoRING 'ESSE PAST 3 YEARS II your pup mason engages *teas engaged In *AY Seth/tiro that ate not tutted here, pleas. Cheek 'other and describe these amounts to the space provided A PROVIDER MCRDITMENTIPLACEMENT NO. We have not done any provider Wroth:tent or tthrotthent to the Ust 3 Ythrt If NO. ere there WO other agenciesforgantrations to yrott State ghat dot Please mve names. ITS, endade/have ensaded in the setontes *duetted below , 1 I ; D) Wan taut orgemantion established on the authorise of State Innate* ec thoroth an (plate put i if you reerMted but did l*t plAte anYenc) edminemative moon? M D 1/D Os PhYSICian Atesstante N s Mental hearth Professionals Nurse hummer* Other (Plum *only types log awe 4. PLACED OVER THE PAST 3 YEARS - ep. L P N C. Physical Memnon. Pharametsts) assammeauatrhsai-zkitthilmitzt gun formventusheneYsnent penman Oder* describe? - State sChinarshiPt No eschuge for service se host mem C) Where within tho orgnamationat unclose of the State government we you bested? (negro Otbet flautist erteentdOE nweide u muninitosat chart if minable) If you am gm a Dam agency, Unt it year rolatiOnehitt tO the State government? Placement service Other PLEASE CONTINUE ONNen?Ace PLEASE CONTINUE ON NEXT PA:2 2 4 '7 4 3 ACTIVITIES iCONTINGEO/ 2 ACTIVITILS. C. TECHNICAL ASSISTANCE icor RI FINANCIAL ASSISTANCE TO LOCAL ORGA ilLATIONS NO, we have ea provided any financial assistance dunes the pest 3 Years 49 Ammessclil AstallgalikIldaklegitaltdtil It NO, are these soy other ageocres/osgeressiOns in yeur Stale Mu du, Facility desetoemenlkoristructios consuls .on Nese give sass. Oracle trehOlsoll issuance Management mistime YES, we have provided/Most& the Mei or ftnancial assistance checked below Other Tvee et armee% &skew* (e ssvril communises. local osganissiOns. educational institute:ins) Os RESEARCH Loom loon-aimiend NO. we hare not dooe any rural health refetreh in At past 3 years SI NO. ere these any other ageecies/erginamions IA $us stale that de, Dicer( avlsaielY . Please ihn asset Matchiog furies Yu, hass dOnciam dolor research on the rollowieg topics (check all that arslyt Gibes (describe).. Health ddr$0010ti 22-sttls services utilisation Ct TECHNICAL ASSISTANCE nom rah- g sotbrday & moreahly) NO. we here oot provided My technical assistance Cease the put 3 yews Heath mate*. coordination lr NO. ate them sai other agestiet/erpnirations Ii yew State that det New give Rasa Instti000 COveelde 111 runt population Medl Whit& hisurescemets/araitabihty New techeolegy (e.sdiffuses. utilization) we have movided/Proelee the tYMS Or sechnkst assistance checked below Quality a cue Runt Impale (I) HIASAIMUA/MUP &agitations Other; (2) itaisgamaltnatsimamaitin Stetted& aril health Deeds essasseet Mat or hst Statewide easeateene °dm Dee* imeessents (describe) ONliesireity Saud &settlement Gnat amenities ssOstssee neFrege &eels* Menne idestWitatim Wee ?LEASE CONTINUE ON NEAT 'AGE PLEASE CONTINUE ON T4CE 4 `..!9 401) 2. ACTI1 !MS ICON I NUM I Al I lt E: (tURAL HEM Ell S1STEMS COORDINATION AND KIN EMENTATION NO. we have not totaled ala any rural health MIMI ettOtatnalsOn or ampkmentation O EGIS1.ATI1 E AFFAIRS dune, the pan I years NO. we have apt towed aft ant ke.,lThte Want during the oast 1 years It NO. see thtee ins Otlalt ateeta.e$/otosituahool an yew Slate that (10.' It NO. ate thete ant Who wen, Ors or)07101111011$ so Your Sale that do, Please give moles _ . _. Please gave names - . - Va. we have enga5ed,0105450 iii die eels Chetked below 1ES, we hese eageged/engage an the aChvIhet eheehad Mow Develepacig alhancet between hoe/melt Pets:moment ot sea totee/commattre io Wren rural health care mum EllaILJDZSAT types of parlament: 4. g urbanheral. latge/inuill) urethane wins tegislanne/legolative commoluses on haat Mak,. Mee% °Cher Dtheloprog Himmel between kneads eed other medial service tacileies (e.g, CHC's, pravele phystmene, septet health centers, minty health dots H PUBLICATIONS Pkdaheepaz type, Cst estempante Please check below my rural health-10mM pubhcamoris your thmesertion has produced during the past dna yearsEnclose represeasamve samples at possible Awned reporl Into:wawa Packers Research rePetts Evaluation tettOrta Newspepet snacks Developing athlete, epa owevieg hospatals mg , MMHG CNC% printe Osmoses. Newsletter mental heath amen. meaty health degaseemeAtleost eeptestalbertest towel alticles Poky recommeadations t types ot Inettcipeats. Other I: PRIORITIES Please cheek below lit _Minn memo areas whith arc currently yew hilliest Mott= Elmesel health armor clishmt Otycloteneat Or Other fulancial instant Meese desathe A PROVIDER REMITMENT/PLACENENT P EDUCATION Other B RNANCIAL ASSISTANLE TO LOCAL ORGANIZATIONS 0 LEGISLATIVE AFFAIRS C TECHNICAL ASSISTANCE IL PUBLICATIONS 13- RESEARCH Ez EDUCATION E. RURAL HEALTH SYSTEMS COORDINATION NO, we lave sot aimed la say educational activities durum the mit 3 ran AND IMPLEMENTATION It NO, are there soya:Am species/ow ammo to yam Stale that do/ noise give sasses 3. SPECIAL POPULATIONS DP 0.104060MIO. MOO* assmINIaso161 Please (heck below special termlettons OS which oaY et yam programs or *Charnel YES, we ler.0 eligagingrocoge ia the edecabonal Writhes elected below You lehaested above are/Fave been lpeeditilly witted. Medleal god other health aretemIN4 odueaSee Chddren Rectal/Ethnic groups Canon health odualtien thegthAts Elderly Please specifr COatIouttlE odeadOlt Programs Me feral moviden Low Imam WIWI& feral health IlOnfeeezet2 Migrant workers Unweaned Other Pregneet womb Other PLEASE CONTINUA ON NEXT PAGE PLEASE CONTINUE ON tan' PAGE 7 4 1. MAJOR RURAL 181ALT11 CARE OELWERY ISSUES IN hOUR STATE S QUESTIONS ssea .1.010 Maw detenbe btitlly (A) Wee WAWA sculiones and programs m tout State that have keen GENERAL ISSUE& The f011owsel IS a list of health care DELWEItt issues se eletel Wee Please terecure a s011teuleg twit heolth mutt. and Hi *at 1111.thts PrOillint you 00u4d like u. tank each of the am hues by weedy of the woe in you Stare. wag "1 to indicate the bunt let el yolk Slate IN TIIE FUTURE SO iddetts theft effete Problem um the smallest problem acesList awl took ay *thee health am DEleVERY mules in the Wee INOeiged, spaudetg the making settle as Decesuse rem me (Lath ouubce oat% tbit A) Cogent Activates (3) Welds Provirke mum le g . shortages. mentitaleid/retennotO Hesse specify: Medical Isibdity isoureace cosishvailahddy Meeting the meds of Waal populations (e edecly. nogrott workers. high-rot pregmochs) payment Woos (e.d, Medicate otban/rutel thflereatiel. iosorsoce controls) Quality of care Services suites (e ghospital closures restrvetunag, systems Mumble & development Other B) Fulgro Attivisisi (3): SPECIFIC SEWICRS using OAmale (lambed below Please itvhcare the amount of attention yaw Gemination & CURRENTLY devoting to each of the fotiowias RAVING SCALE: 0 I . 2 . .. , .1 . . 3 devoting NO devetiod MORT atteotitio to 1110 *Motion to this th.os may use act muster same then once ) Aeons health cue Home health aro Clain health cam Load teem cue Emergency medical am Mu Smith cate littolek posotioulDestue 0 care pseveatialb Other Other 'MANX YOU VERY MUCH FOR FOUR TIME AND COOPERATION. PE EASE coNrmtre ON mexr PAGE Please refers survey by ter Ann Wolfe. Health Fromm. Office of &theology Asseamest, US. Congress, Weibmphist. DC 20510-8025 4 ,13 4 \I July 24, IV49 CONGRESSIONAL OFFICE OF TEENNOLOGI ASSSSitaNt'S SURVEY OFsrAttsoN e twscribe any otohltms (hi . yoo have had in designating primary care HEALTH IIRSOWNLI SHORTAGE AND personnel shortag, in the met (i e. nomettopoliten) NIDICALLY UNOIRSERVED AREA DESIGNATIONS of your Stat. (e g deS411.0100$ lib frontler areas/ Data Nome/Mta of person complatIng envoy 7 To what extent do astea with the following stetementa name/Title of othat rentmot(): A ptimary cote HESA's otiosity stooping (i . group IA) ia ood neasure 0! the HNSA's relative &gra* o( orlmaty tato health Orgenisa.ten Naas: personnel shortage Addraos: none' Sttonsly agree Agxaa D iaagree Sttongly &pastas. A. tiOn't No opinion I NOV settenod ate you with tho tttrotia used to dasignote F 1 WOW Cownont fiallakilikliasmonrShatus-usal (IusA8)7 vlrymationati Satisfiad Diesationod h Allocation et Fteetel reef...nue ID lased so NSA prltrity Vox, gleargieflad stoops Doti'r know opinion .___Strensly mgt...... _Astes iiisegtaa pielOa &set b." why you aro setioned Or dissonsfled ...... Sttonsly disaster D on't know opinion Cooasont Mtimt thongs. would you ouggeat in tho esfmatm.fipro 11151 crl.atia thet wad imptmvo Idontifitetion of ptInaty tete petsonnet shortage I Please Drieflg d the ttands In ROA doeignmtIon aCtiwir, In yoUr 11Stata's nettopentan and nonmotrepalitan atoms ainta MOO b. Vbst aspects of Cho Wear. Coreligucurette eta jowl and should be cicalae:SY 4 > 4 Stn40 IOSS, hes 0.0 demand for Federal primary Core ioug designation inClaSild. dtaglissd or Ltbaintd..02-4644 for motto end nommetropoiltam 0 If any federal trinity Care MSS designations hese neon jettleweA since arose In your State! MOM19113. Inda out g000totlevel of seils'action with the federel LOYILV Dossed for Primary Cara Very satisfied lES4-113.11S11474.06 Ptrooslitso Susttianasalssa Satisfied Di fled increased very nvah Very di fled Ina aaaaaa aftewhat .,__Jhner know Remained the maw Doss not apply, no review Do a 4 ameaUsr No opinion 0. 4 'tory much nowt know If tied or di fled. whet espertfe/ ef the review process have Do*. not apply led to your aaaaa faction or di faction? S Please ladlcato whacker mach of tle following f hoe InCilaaad. gaminsor hadag_agauOn the demand !orminiPrimary Caro NIOn deeisnations in your State einem 164$. F hoe increased Dootaasad Mad no Don't 9 Is your State defining shottage fot physician apeetalrisa (a g . taltdr.C: 42aAnd disead Law OlitCyn) or for non physician health tars providers (a g , nurses), e . Need for PM oruonnel Yee b. lt,railebtliry of NNSC peraomnel 00 c Rural Health Clinics acr don't know d. Midiesto physician bonus payment I. Crate programa linked re NNS* If yea. sootily the typo of providers for which shottage aaaaa ate designation defined end briefly describe designation criteria (or, if available. f Other atrach). g Other 6 Mas your Scats filed any ?asap., ragg_gglg applications since MS, Yes (If no. skip toqUaatiOtt6.) s sigsraixaggiaurodAreas Mal Don't know (If don'r knoo, skip to question s ) Mow astiefted eta you with tha criterin used to elealgasta tpdaret gapicallyQpitunratuaug(MOW? 7 la amoral, what is yam level of satisfaction with how Federal Primary Qtr. NNSA epplicationo heft boon precoaradr fisd Satisfied levy satisfied Di fled Serialise -----Nerydi lofted Oisseriefied Don't know Very dissatisfied ___soopinion Oon't know Ito opinion Slew describe why yos ars satisfied or dissatisfied It aariafiod er disaatiaPied,vhataedecr(o) of ShiUsLissILIS-StasAl lad to your satisfaction or disaatistection! 4 )7 Sillot qhmoim 'mold von SuggSt let tho **dots) 8k4 tilt.lIA lhAl would 5 moo ),"r WU. Mod AO' DMA mypilrattone Slat. lOoSt lOpitOft Ideetttl,Alloo of oditAlly modctsorood Aioas, Vas No fif no, skip te .4.01011 / ) Dou'r Lao. (If 401V( knoy skip sto qmottion 7 ) 6 IA &Mittel. vital iS yoUi )ovoi of satisfaction vith boy tadaral KVA b ifee aspects of she erttrris era goo,: end should be retailed, applications ere sroreilfe Vett satisfied Satisfied Dissoclotiod VorY dissatisfied Don't knov t Describe any problems that you have had In dcsignasing 6cdiestly go opinion undoisorved at... in surel (1 s sonsetropolicsa) stems of your Ststo (..g , designations Is freortor areas) it Mittens./ Ot dissatieficd. obit oopocr(ol of cho parificarlon Protest lcd co your satisfaction Of OIMBottftliOCIOR7 2 noose brhoffu describe trends in MVS designation activity In your Scatc's 7 Yee is your loyal of satisfaction with she frequency of rockfish MS secropolitan end sinmetropolltsft aaaaa Stile0 1980. rev(ew, ..__Very satisfied Satisfied Dissatisfied Very Ofeastlefied boo,t k000 Since 190S. les the demand for fadotal Oseignstion Incraffispl. 0MCKSAIld No opinion Or remained the iaOt tot MR/0 and neosecroPolitats in yout Stec*? netresolite gosectronolltuo Plasma coomolc on vhy .9clarise of ditassiefied end if di...tittle& 1816.rieliutima 0PecIfy bet often cbe Illes should be rawiawsd end why louvered wry ouch 1. Increased ommovhor itusalmed the ease Dotressod steashat boorsooed wry loth Don't know $ to vbac ascent do you agree or disagree with thit nth Does net apply Different criteria should be used when teetering Padoral IfIlts the% byre sateellehed Podorel services fe.g , Community Health Comets) In the 4 Pleat. todtooto **ober mach ot sbo fottowtog tutors boo ibaithmag. if . dlOwfwiell Ow had ap_otta on the demand for fedora WA dosigoosiono to your Staub sites MVO. factor has. Strongly ayes Inc 0 Docreserd Had oo boo,s __Agrees Ditegres Lana: WAN Atamti Wm& Emu ,....."trougly disagree a. IWO tr CNCo know b. Oustlobtltey ot CNC funds Po opinion e. Rural Health Clinics Ate ... d. Stars prograss linked to Mb dmotinactos Cremona: s. Ottior t. Orbar - 4 g If youc State twos 5 deeignotion 9th%. than the I.detal,BSSa 94 Mot 1 noes you. Stets have health pessonnel distribution pcoscaac thst nag some dgaigetttions to identlir shortage typo of shoctcs. etas Seelsnasiont Why doscn't your State use the federal WA oc WA designation ho the*e Yea NO (If no. sklp to Swatter' 2 ) 0/Wt Warm (If don't know skip to saosslon 2 ) If yes, pleas. check all /sus health personnol dioscibution mgrs., ptomain in you. Stmts. and for mach chock.4 propos !maltase vitather the Faderel 10116. KVA or Stets criscrls gro usod to impisaont tha prows 2 In your sagigh. sc there aaaaa or population. in yous Statt that In sts *post prowldod below. briofly gusgag enysragamiissaas have hosith possonnal shortasos or are moditally undarservod Dot Au sg/LESLA that ase used (or, if ...Habit.. astas10, Altuatad as PW4*X4 OSSA. or Mast Paaggem Pt ***** Pe $ Shoetsita Desisnasion Wood Yas Don's know State :ArIALAI Ke opinion litiaLtUnthanti-11428116.. Xt.,k ha 0116 bilsaaLltd I Bascaticsol Prosconst If /As, pleas. d.gsslbe these aaaaa /populasIons and why they have AOC e. ANKCe bean doglsnotsd b. Tarsocsd Primary Coss csalning eppossunislcs (e.S.. saelttonclas) c Seas purchases d froceptocships e Othoneducational prestos If ISA. asto any of these aaaaa /populations ate dosisnosed a* AULT health porsonnol shostagg es medically undos*erwed 2 FiAASCiAl Incaosives Oaring Tref:alms Servic..concInseus loam, sod scholarships b haft looms c Waft ccholarships d. Saar financial /mortal,. 3 Aid Lm Practice s. Plocomsoc 3 la Your SILLULA. ate those aaaaa /populations that ars isiggsgulssily bCussentsadin.& designated 4S Federal IIMSAs or 10/As (I c atses/t4pulasions %has do nos c loans hew a ghettos. of health porsonnel or thec are nos medically d. Health professions gshool undossereed)t loan scpsyseoc Kaipcsecie. subsidy N O I Othor ehl imptActly. Yas Dea's knew 4 Othot Prossam(a) Pe opinion a If Xis. plaess esplgin why tha tecignotion(*) ese inoppsoptiato Plaaao bliatlY dsaarthr, so, AtahoftallOall20=ilitthi that ata agad (og, If avallebio, attach). 0 0 4 In your 121012D. how ettective have (he (*Hoeing rt.:14441 ptograrte) hee n !spraying thy availability of health services in your State's Does you] Slot. enndInt Ans eel Itaveys 01 ',towels, rare rworldets to gaggigragalAug health patconnel shortage and rodicatty undstoetved eoeitot 160.1050 /nndreseeved AtPAS pi As wet tf vow NNSA/KVA desiguatior errtcitee ? YE . Very Effective E Eftctler so 1 . Ineffective Don't kwo, VI . Very ineffectIve RP . Nog tardier with Feocral program it Iggpieta. briefly destribe the surveys DK . Don't brow NO No *Onion EL S I II HE IE E2 EIDISA1.21541.41RA National Neolth Sorwice 0 Nes the vi(hdraral of Federal pisoning resources (e g Stat. Health Supaort of Primary Ker. Planning and Developoent Agency (SHPDA) tonna) hod e Poaltigo, oologtvo. 044mational propene or no effect en your Stato's ability to proper* roqueots tor NNSA/HUA ABM activicios designation? Coumonity Health Centers Hurst Health Clinics Act Very positive (describe) HeJicare physician poyeset bonus Privet* loon :pulent p005ceD6 Somoubet v.:mitt... (describe) Sonevhst negative (describ0 (ether chap MSC) vory motto. eeeee Ms) Other (speolfy). No otiose Other (specify)._ g In general. ere your Stategoderal roeourcos adequote for maintaining en accurst. and up.to.dats sot of boatel% personnel shortage aaaaa end nederaily urdersorvod tees? S HNSA add/1114 designations wore originaliy signed ro seot the nude of the NHSC and CNC p:ogreme. In your =Loin. hmo sppsoortsto aro theca Vos desigeations for gang Toderal programs such se tho luta Dooith clinics So Art ead Hedlcus incintlwo payment./ Valet know No ol'eion oppropristo approprlote It gg. plosso describe what resourcos ere Inadequate looppropriato Don't know No opinion 10 11.gullskig. oleos. sand In any Stare sus you hews prepared that *how 6 mooyour state &Inmost* prfrerv dere servile* sloes/ the location, ot any of the following rederal ANSA.. KW. State- designated oho:rage teas. ONCe. VESO sites. certified Rural Health Yoe Clinic*, and/or priest, care :grotto aaaa No Don't knee If It21. plosse brief)/ dos4:10 how tho areas ere &timid 5 ,1 10- o genbra_rdansents PP provide may &edit generel todoente that you have about the detts n of prleety gate pet.onnel shortege &t es ot eedleally undereervad o hot have not been coveted edeonetely by this questionnaire? CO4116fati !loms return rhis questionnaire by imungs_A,121f in thegelf.edeteseed envelope enclosed or sand go: Alga Hush°. Office of Teohnology As...anent Health Program 440 Pennsylvania Avenue. S.E. Voehtnpron. D.C. 20003 41- Appendix E Rural Health Care Projects Funded by the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation1 Private foundations have played a significant role in tiev clop and enhance lirdtages between ruial health promoting innovative rural health care projects. These senices and tertiao medical centers and create foundations have intended to -stablish the basis for regional netwodis of perinatal care. Although some lasting, effective change through creative project plan of the medical services under this program were cut ning and design, research and experimentation, education bo,...k or reorganized after Foundation funding ended, and training, and encouraging the coordination of corn the regional relationships and services in many munity resources. Two of the major foundations t!..,4 have States that showed dear improvements in maternal provided innovative support for rural health care pro- and infant care remain substantially in place. cams are The Re-rt Wood Johnson (RWJ) Foundation The Rural Hospital Program of Extended Care of Pthiceton, NJ and the W.K Kellogg Foundation of Services was launched in 1981 to =outage small Battle Creek, MI. P ;cent relevat.: projects supported by rural hospitals to develop swing-bed services:7 Fiv e the RWJ and Kellogg; foundations are described briefly State hospital associations were funded to develop below. the capability to provide technical assistance and education to interested mai hospitals. The Founda- The Robert Wood Johnson Foundation tion subsequently funded 26 individual hospitals to implement their particular swing-bed models and The Robert Wood Johnson Foundation, established in funded an evaluation of the program, which found 1972, in recent years has focused much of its efforts on positive benefits both to the hospitals and their building and strengthening the infrastructure of the nual conuntmities. health care system. The following describes those projects Rural Efforts To Assist Children at Home, a project that are most specifically focused in this area. that began in 1984, was funded in cooperation with Rural -onented :raining aai-v:iies supported by the the Florida Depanment of Health and Rehabilitativ e Foundation in the early 1970s included, scholarship Servi-es and the University of Florida Medical support to encourage students from underserved Center. Under the p:ogram, 20 nuises from nual areas to go into medicine (a precursor of the National communities received special training to assist Health Seivice Corps), and institutional support to univ ersity -based pediatric specialists and local phy develop primasy care naining programs for physi sicians in providing routine management of chroni- cians, physician rpsistants, child health practitioners, :ally ill children in the runal communities where they nurse practitioners, family care assistants, and emer lived. The nurses also worked with schools and gency care providers who represented those practi families to assist them in meeting the medical and tioners most needed in underserved areas. rehabilitative needs of the children. Florida subse- The Rural Practice Project was launched in 1975 to quently extended the program statewide. demonstrate how medkal piactices might be devel The Hospital Based Rural HeJlth Care Program, oped in nual seas so as to Meet both the health care which began in 1987, funds consortia of rural needs of the conununity, and the financial a- I hospitals. 14 goal is to allow rural hospitals to professional needs of rural physicians. Foundation explore soategies to arengthen then financial posi- fands were used to cover the openuing deficits of the tions, to explore alternatives to closing (e.g., conver- 14 model rural practices for a period of 4 years. Some sions and diversificatian) and, where applicable, to sites were unable to achieve financial stability, , and help them to close. The program emphasizes the several had considerable staff turnover in physicians. dev elopment of regional affiliations to enable appro- The availability of a hospital to a practice was found priate referrals outside the community, , and to enable to be critical w financiad and professional sun ival dosure and conversion efforts to be examined within and development. a regional context. Thineen sites were funded and The Rural Want Care Program, initiated in 1979, some 185 hospitals participate in the program. funded 10 medical schools to work with State health In July, 1989, the Foundation awarded grants to 13 departmems in improving perinatal care in isolated community health care projects n.. by and for rural areas. The objective of this program was to American Indians ancl Alaska natives. Included arc 'Intonation tot tha appeals& was provided by haw) Dana' .4 Thi kubeit %lewd Jvhasun Fuundauua 404 Maui C44hot uf dot, Wil. Kelogg Poradation. 2See ch. 6 for a diasnion of hospital swing bed service& 50 -462- Appendix E.Rural Health Care Projects 463 projects designed to prevent alcohol and drug abuse, Target communities are chanerized by high rates control diabetes, reduce domestic violence, and of teenage pregnancy, trauma, substance abuse, improve maternal and infant hcalth among tribal sexually transmitted diseases, high levels of pov erty populations in eight States. and unemployment, few numbers of health care facilities and personnel, and poorly coordinated social services. The W.K. Kellogg Foundation In 1985, the University of North Dakota and The W.K. Kellogg Foundation, established in 1930, Lutheran Hospitals and Homes Society began a concentrates most of its health-related philandeopy in the 5-year project (the Affordable Rural Coalition for areas of community-based, problem-focused health serv- Health (ARCH)). The project's purpose is to reor- ices. Rural efforts focus on new collaborative approaches ganize health stir% ices to develop models of compre- for health servicesdelivery, rural leadership development, hensive, integrated, cost-off, live health care deliv- and training of local government officials. Recent major ery in several small conunur'nes in North Dakota, Foundation projects pertaining fully or in part to rural Colorado, and Wyoming. Such restructuring may health care am described below. take into account both horizontal (hospital to hospi- A 3 -year project in northeasternMontgomety County, tal) and vertical (hospital to nursing home to home MD, which began in 1986, funded the creation of a care, etc.) relationships among major health care community-wide tietwork of volunteers to Provide providers. A second goal is the establishment of a support services not available to isolated elderly. future-oriented, participatory process for communi- Secondary goals were to transfer a share of the ties wishing to be involved in designing an optimal :-...sponsibility for care of the elderly from the mral health care system. government to the community, and to provide Initiated in1983, a regionalized demonstration meaningful social roles for adolescents and elderly project at the University of Washington School of through an intergencrational volunteer network. Medicine is designed to restructure the services Prelimintry results suggest that the volunteer seri, provided by selected rural hospitals in the States of ices have decreased the need for r ime hospital and Washington, Alaska, Montana, and Idaho. Itis nursing home services aM provided relief to fend intended to demonsuate ways rural hospitals in this lies. region can assess and modify their financial structure In 1989, the University of Illinois instituted a 3-year and the types, quantity, and quality of services project whose goal is to train community-based, provided. paraprofessional, primary care outreach workers to link people in need of services with health care A joint project with the National Rural Health providers. The project is oriented to both rural and Association and the Hospital Research and Educe. inner-city residents. don Trust, which started in 1987, includes ;3 rural The Medical College of Georgia, in 1988, began a conununity-oriented primary care demonstrations 3-year project to reduce infant mortality and improve for the improvement of community-based health maternal and infant health in rural east central services. The project awarded grants to a variety of Georgia. Activities include establishing a case man- community health and human service organizations agement system for high-risk newborns using an (e.g., group practices, community hospitals, public electronic database and discharge planning snd health departments, and social service agencies), infant tracking progmm and using a nurse-managed whe.work with community leaders to define conuramity- based health service needs and implement necessay mobile health unit to promote timely access to health care for mothers, infants, and children in a medically reorganization. underserved rural area. The 6-year Alliance for Rural Health Management In 1988, the Children's Defense Fund started a Improvement project, which began in 1982, devel- 3 year project to reduce infant mortality and morbid oped a 7 pan rural health cam improvement program ity and adolescent pregnancy in rural Marlboro for rural hospitals in 13 western States. The project GoontY, SC- The project used outreach workers to provided training and job development for small provide health education and promote maternal hospital executives and trustees, developed a volun- compliance for self-care of the mother and care of teer consulting corps of retired health care execu- her infant. tives; encouraged rural health care/small business A 4-year project started by Mississipprs Alcorn alliances and joint practice among rural hospitals, State University, in 1987, is intended to improve improved quality assurance committees in rural access to health services for adolescents by prov id health care settings, nd prov ided rural postgraduate ing mobile health screc..ing and services for youth in fellowships to recent health administration gradu- nine rural and urban communities in Mississippi. ates. 4.) 4 464 Health Care in Rural America Two projects at the Univer ity of Alabama at matched with health center preceptor sites. On Birmingham have fnrused oa improving education completi.A of the residencies, individual residents of allied health professionals. The first project, will be %ached with health centers where they will which began in 1976, established and disseminated be prepared to assume management positions. a curriculum to train allied health generalists who A 4-year project by the University of Missouri, could perform a variety of basic tasks (e.g., assist in started in 1987, is developing support services to patient examinations, administer medications, and assist the elderly to remain in home settings in their keep medical records). A second project, which community. The "Center On Rural Elderly" serves began in 1987, involves a series of claringhouse as a resource center for health and human service activities to document multiskfiled models through- professionals interested in serving elderly who out the couno, develop a consaancy program of reside in small towns and rural communities. It experienced educators and practitioners, and dissem- disseminates educational materials on topics such as inate information on multiskilled practice, including preventive health services, support for caregivers, an updated, state-of-the-art publication and direc- and intergenerational relations between elderly per- tory. sons and younger generations. In addition, Center In 1987, the National Association of Community staff am producing a planning guide to assist in the Health Centers (NACHQ began a 3-year project to development and implementation of educational produce well-informed leaders for federally funded programs for local elderly groups and the develop- community and migrant health centers (urban and ment of programs to enhance the community in- rural) The program selects qualified candidates to be volvement and leadership of recently retired persons. Appendix F Census and DHHS Regions Census Regions Northeast South Midwest West NC, England South Atlantic West North Central Mountain Conk 'talent Delaware Iowa Arizona Maine Florida Eansas Colorado Massachusetts Georgia iv innesota Idaho New Hampshire Mar/land Missouri Montana Rhode Island North Carolina Nebraska Nevada Vermont South Carolina North Dakota New Mexico Virginia South Dakota Utah mid Atlantic West Virginia Wyoming New Jersey East North Central New York East South Central Ohio Pacific Pennsylvuria Alabama Indiana Alaska Kentucky Illinois California Mississippi Michigan Hawaii Tennessee Wisconsin Oregon Washington West South Central Arkansas Louisiana Oklahoma Texas U.S. Department of Health and Human Services (DHHS) Regions Region I Region IV Region VI Region IX Connecticut Alabama Arkansas Arizona Maine Florida Louisiana California Massachusetts Georgia New Mexico Hawaii New Hampshire Kentucky Oklahoma Nevada Rhode Island Mississippi Texas Guam Vermont North Carolina Region VII Region X South Carolina Region II Tennessee Iowa Alaska New Jersey Region V Kansas Idaho New York Missouri Oregon Illinois Nebraska Washington Region III Indiana Region VIII Delaware Michigan Maryland Minnesota Colorado Pennsylvania Ohio Montana VhSinia Wisconsin North Dakota West Virginia South Dakota Utah Wyoming o f; 466 Health Care in Rural Amerfea Figure F-IU.S. Showing Census Divisions and Regions WEST MlOWEST NORTHEAST Pacific I Mountain West East Middle North Central North Central Atlantic EngI yr RN NY MI RI CT PA NJ MD DE Washington, D.C. East West South South Central Central South Atlantic SOURCE U.S. Bureau of the Census. SOUTH 5 1 -7 ' I Appendix G Field Workshops1 During the course of the Rural Health study, the Office improve public image and perceived quality, of Technology Assessment (OTA) held three field work- air and ground transport in EMS network. shop& At these workshops, invited participants presented trained six licensed practkal nurses to registered problems and suggested strategies and discussed them nurses, with attending OTA staff, advisory panel members, and educate physicians to maximize reimbursement. observers. Elton Summers, Administrator, Gila County General The first workshop, held on January I I, 1989 in Hospital,Globe, AZRepresents a 35-bedpubtc (county) Scottsdale, Arizona, addressed issues and strategic op- hospital in a town of about 7,000 people. There is a tions for small, isolated hospitals; larger rural hospitals competing nonprofit hospital about 6 miles away. and those operating in more competitive environments; and rural hospitals in multibospital systems or othcr Problems affiliations. On February 28,1989, OTA held a workshop about $1 million in uncompensated care rout of $8 on health personnel issues, with a special emphasis on the million total), needs of "frontier" areas, in Bismarck, North Dakota. seen as social sen ice agency by community and lbpics included training, recruitment, retention, and county government, practice issues for rural health professionals. The third low occupancy rates. workshop, held on June 15, 1989 in Meridian, Missis- Strategies sippi, addressed issues related to providing primary care improve business management, to rural populations, especially those in persistent pov- long-tenn strategy to try to merge with competing erty. libpics included payment and financing, access to hospita1.2 care, and practice capacity and organization. Summary of presentations from invited workshop Harold Brown, Chief Executive Officer (CEO), Prai- rie du Chien Memorial Hospital, Prairie du Chien, participants follow. nRepresents a nonprofit hospital with 49 acute beds, swing beds, 4 skilled beds, 2 respite beds, home health, Scollsdak, Arizona and hospice. The next hospital is 30 miles away and the next large hospital is 65 miles. The hospital was in the Small, Isolated Hospitals black last year. It has 62 percent occupancy in its acute James Armstrong, Pregdent, Sierra Vista Hospoal, care beds, which generated 57 percent of its revenue. Of Truth or Consequences, NMRepresents a 34-bed the remaining revenue, 24 percent is from outpatiela Adventist hospital in a community of 7,000. The next services. hospital is 75 miles away. The community has a large Problems influx of tourists in the summer and semipermanent access to capital for modernization and expansion, retirees in the winter. Seventy to eighty percent of the proposed prospective payment for ambulatoty serv- hospital's patients receive Medicare. ices would pay only 70 percent of x-ray costs and 67 Problems percent of lab, lost $500,000 last year, low Medkare reimburst- regulations for many senkes are not sensitive to ment, rural sitUation. 30 to 40 percent of population is going elsewhere for Strategies care, maximized Medicare payments through high base expanded need for elderly and emergency medical year costs, services (EMS) due to tourism and retirees, diversifying from inpatient to outpatient services, physician and nurse recruitment and retention, developing local funding via foundation and fund- community slo w to change. raising, Strategic-- report cards for doctors on handling cases and cut expenses or forego staff expansion, patients. 1All thine wodabop were arranged tmda ioatract by the Natawwl Rural Health Aisso..tanun. The atecuag at htibut, Misasapps was anawged by the National Rend Health Association with assistance final dm Nammal Assowatcoa kit Cutneauniry Health Cauca. die Masosaipp Puma* Cate Association, and the Alabama Manly Health Care Association. 2In *989. Cita Calor/ Genetal Hospital annotaced plaas to map nab the nearly), ampivfa huspasi, 4g bal Wm. "willow% Huspitaa. -467- Sa8 468 Health Care in Rural America Mil M. Welch, Administrator, Elko General Hospital, Douglas I' onnesbeck, Administrator, I..ogan Regional Elko, NVRepresents a 50.bed public hospital ik no Hospital, Logan, VTRepresents a 150-bed hospital county subsidy. The service area s growing rapidly and that is a member of Intermountain Health, Inc. The now has 27,000 people, but the county's population community is growing and has a diversified economic density is still 1.6 per square mile. It is about 150 miles base. to the next hosPital Problems Problems access to capital, physician shortage acute, 6 deciding "what you are and what you are not," increasing accounts receivable, Medicare reimbursement. competidon with urban hospitals outreaching into Strategies area, business-based strategic planning, ficility designed for inpatient services, but about 50 strong guest relations program, percent are outpatient service& acute-care case management program. Strategies Virginia Goodrich, Executive Vice President, New intense community-based physician recruitment, Mexico Hospital AssociationRepresents Rehoboth- using contract collection firm, McKinley Christian Health Care, Gallup, NM, created by local media campaign to retain market share, the merger of a 41- and a 81-bed hospital. The current developing statewide rural hospital consonitan, hospital has 74 acute care beds. The area has a multicultu- use consultants to help identify problems and ral population and a depressed economy. planning with board. Problems competing, inefficient hospitals in the same town. Larger Rural Hospitals and Those in More large indigent population, Competitive Environments Medicare reimbursement inadequate, training costs high due to multilingual requirements, Patrick Linton, CEO, l'avapae Regional Medical red tape in working with Indian Health Service Center, Prescott, AZRepresents a 129-bed hospital in hospital, a town of 25,000. Over 30 percent of the population is high accounts receivable, over 65 years old. About 54 percent of revenue is from community image maLes recruiting difficult. Medicare and 9 percent is from Medicaid. Strategies Problems merged facilities with agreement to protect jobs for low rural payments from Medicare and resulting low I year, morale, cut 100 jobs after 1-year hiatus, lack of access to capital, eary merger of medical staffs helped bring harmony, aging physical facility, methodical attention to and elimination of accounts high proportion of elderly. receivable, Strategies serious planning effort for merged facility. Geriatric Resource Center (foundation funded) to case manage patients and families, Rural Hospitals in Systems or Other Affiliations joined State federation of six hospittis to raise capital. James R. Beeler, Director of Planning & Marketing! Regional Operations, Samaritan Health Service, Phoe- Steve Ward, Director, Shared Services & Outreach, nix, AZRepresents system of 18 facilities (mostly SL Mary's Hospital, Grand Junction, CORepresents leased or managed), of which 4 are hospitals ranguig from a 294-bed rural referral renter (RRC) in the mountains. 25 to 84 beds in size. Problems Problems indigent care costs risica, heavy subsidy of one 22-bed rural hospital. competition from urban itferral centers. manpower recruitment and stabilization, physician issues, Strategies access to capital. hvorable payments under RRC designation, considering transportation for physician care and Strategies other services, converted troubled hospital to other uses, strong outreach and marketing program to solidify internal recnaingilocum tenens, market. joint venture with physicians in managed care plan, . 5 Appendix GField Workshops469 prescreening outreaching specialists, Strategies air transport of specialists to rural areas, board retreats, pooled bond fund provides access to capital, peer support visits to provide internal review and local fundraising. assistance, joint purchasing, Keith Lundberg, Executive Director, Health Services management information system and cost report Consortium, Seattle, WARepresents a voluntary sharing. shared services consortium established in 1973 under the auspices of a large teztiary center. There are 15 mral Cathy Comito, Network Coordinator, Mercy Hospital community hospitals in the consortium. Consortium, Des Moines, IARepresents a consortium consisting of 10 mral hospitals within a 100-mile radius Problems-- of Mercy Hospital in Des Moines. Eight of the hospitals low utilization, are county; two are nonprofit. Five are managed by Mercy recruitment and retention of physicians. and five are affiliated. Strategies Problems coordinated case management, isolation, focused referral relationships, inefficiency. developing physician leadership, Strategies tangible incentives for patient care relationships. local autonomy is key, Carole Guinahs, R.N., Asst.Vice President for no management fees are charged, Medical Staff Services, Parkview Episcopal Medical training progiams for all levels oi persoanel. Center, Pueblo, COParkview joined with Rose Medi- hospitals purchase services from consortium, cal Center in Denver to form the Rocky Mountain Health :onsortium-wide conferemes for board and adminis Alliance to provide a link for mral institutions and trative staffs. physicians to the resources at tertiary care facilities and garner referrals for the larger hospitals. Bismarck, North Dakota Problems Physician Issues urban hospitals seen as "black hole" for referrals, rurals losing market share due to poor image, Nelson Tilden, Ph.D., President, Medical Search training and continuing education needs, Consultants, I nc., Overland Park, KSOperates a small few resources for new equipment and services. consulting firm that recruits physician, particularly for rural areas. Strategies specialty Physicians contract to return patients to Problems Mild physicians. lifestyle expectations of young physicians often antithetical to rural practice, training programs for rural doctors, nurses and increasing numbers of women physicians whose administrator:, spouses often have trouble finding positions in mral inventory 'eduction program; equipment purchase communities and who tend to have different practice and placement, styles and needs (e.g., more time with family, child grantswriting assistance, care, etc.). marketing and strategic planning assistance. Strategies Gordon Russell, Administrator, HiPlains Hospital, revitalize the National Health Service Corps (NTISCi. Hale Center, TXRepresents the West Texas Independ implement the Resource Based Relative Value Scale ent Affiliated Hospitals, a group of about 30 mral (RB/RVS) quickly. hospitals that are about 40 miles apart covering an area the establish a "Peace Corps"-type program that re- size of New York. The hospitals average 49 beds in size, quires all graduating physicians to serve in a and most are public. medically underserved area, Problems encourage programs to provide "call" coverage, not enough money, competitors hive too much professional interaction, and emotional support for money, physicians. low Medicare reimbursement, Frank Newman, PhD., Director, Monteuur Area isolation resulting in unsophistkated systems and Health Education C enter (AIIEC), Bozeman, MT resistance of change, Represents interests and concerns of Montana's 45 pear Review Organization problems. frontier counties. In 1987.52 percent of the counties in the 20-810 0 - 90 - 16 Q13 s 1 o 470 Health Care in Rural America State were designated as Health Manpower Shortage Carol Miller, President, Mountain Management, Ojo Areas. There are 60 hospitals and 45 are rural hospitals of Sarco, NMRepresents concerns of * 'frontier" areas. 60 beds or less. Problems Problems cutbacks in Federal funding, maldistribution of physicians is a problem despite physician maldistribution, the fact that the State has a physician-to-population reductions in funding hay e crippled rural and frontier ratio of 1:650. Only 33 percent (417 doctors) are conununities' ability to recruit health professionals, serving the rural 70 percent of the population, medical indigency is a primary barrier to access. all of the Stare's small rural hospitals are losing money, Strategies Indian reservations have a very hard tiro. recruiting restore and improve the NI-ISC, doctors and low retention rates. expand Medicaid to assure the same coverage in all a 90 percent occupancy rate exists in the State's States, nursing homes, but only a 25 percent occupancy in provide tax credits and incentives for rural practice, the rural hospitals, provide locum tenens coverage for doctors' vaca- the two federally funded community htalth centers tions and continuing medical education (CME), (CHCs) are both in urban areas. make Federal CHC and MSC programs more available for small sites in rural and frontier areas. Strategies creation o f State offices of rural health and State rural health associations, Nursing Issues Indian health programs have retained a klitime Lois Merrill, Dean, College of Nursing University of recruiter which placed 16 doctors last year, North Dakota, Grand Forks, NDRepresents concerns CHCs should be established in rural areas, of nurses and their employes. the WAMI (Washington, Alaska, Montana, Idaho) program of rural rotations, Problems the AMC maintains and publishes practice vacancy na .41 nurses and facilities can't afford additional lists each month, and helps recruit doctors to the training required by modern practice, State. reimbursement for rural hospitals makes them una- ble to compete with urban hospitals for nurses, Gerald Sailer, M.D., United Clinics, Hettinger, ND urban hospitals are raiding rural areas for nurses, Represents a 17-doctor practice in a medically remote direct reimbursement for advanced degree nurses is area. The practice created a health maintenance organiza- unavailable. tion (HMO) that ceased operations in January 1989. Strategies Problems support outreach education, peer support is unavailable unless through group financial aid should recognize the needs of adults, practice or other arrangements, reimburse rural hospitals equitably, recognizing the time for family must be planned into physician increased demand and pay scales for nerses, retention plans, provide indirect payments for nurse m ining as is doctors often are not educated for the demands of available for physician training, rural practice, direct reimbursement for nurse practitioners, nurse payments for rural doctors and hospitals is very low, midwives and certified registered nurse anesthetist s. procedure-oriented physicians are paid much more than cognitive physicians. Sue Ebertowski, R.N., Director of Nursing, Mercy Hospital, Williston, NDRepresents a 125-bed rural Strategies hospital, 200 miles from the nearest tertiary hospital. It is adopt RB/RVS without geographic differences, paid rural rates and has an occupancy rate of 35 to 40 equalize urban and rural payments for similar percent. The nursing staff has a 21 percent turnover rate services for both hospitals and physicians, and currently has no vacancies. pay for nurse-anesthetist services ar cost in hospitals eligible for Sole Conununity Hospital (SCH) desig- Problems nation, obsolete job and work structures, develop payment rates for rural HMOs that are not insufficient job feedback, based on Usual and customary rates, which perpetu- lack of participation in decision-making, ates payment inequities, first line manager deficiencies, refine the defmition of and payments to assure that ineffective nurse-to-nu:se relationship, necessary hospitals survive. ineffective nurse-to-physician relationships, 5 /I Appendix GField Workshops 471 nonproductive nurse-to-ancillary department rela- it Potpourris of Related Issues tionships, high stress among nurses, Dwayne 011erich, Ph.D., Academic & Research Af- lack of innovative environment, fairs, University of North Dakota School of Medicine, deficient internal and external image of nursing, Grand Forks, NDRepresents general economic con- untargeted and ineffective recruitment marketing, cerns of rural North Dakota, where agricultural economy inadequate wage systems, has been poor, retail sales have dropped, and population nursing technology lag, and jobs have declined. underdeveloped strategic plans for the nursing or- Problems ganization. underemployment of rural residents, Karen Pederson-Halle, R.N., Lake Regional District lack of outreach training available that will allow Health Unit, Devils Lake, NDRepresents a health rural, residents to train while employed or in their department unit that serves five counties, an area of 5,835 own communities. square miles. There are 6.6 full-time equivalent nurses, and the Unit should have four more nurses to meet Strategies standard staffing ratios. The Unit provides community need assistance grants for transition from fanning to other employment, health nursing, WIC, family planning, health screening and environmental health services to a population of over programs to develop leadership within local re- 38,000. sources, need support for students for travel, tuition and child Problems care, salaries are considerably lowerthan in local hospitals should use new communications technology for and even lower compared to city hospitals in the local training. State, the area is not considered attractive to many nurses Tom Robertson, Director, Southeast Montana Rural with the largest town having a popuiation of only Health Initiative, Glendive, MTRepresents a county 750, health department that serves a geographically large little chance for advancement, five-county area with a population of 85,000. He is also declining funding for public health programs, part,time director of the SE Montana Rural Health difficult to identify results from preventue care, Initiative, a primary care program that no longer has need to be better versed in polnics and public funding from the CHC program. Most of the people in the speaking. area consider themselves lucky to live within 50 miles of a phys' 'Ian or a physician's assistant (PA). Strategies increase funding for public health programs, Problems. train nurses for community and rural practice, rex- itment and retention of all health personnel, develop career ladders within region. especially ;..mergeacy medical technicians (EMTs), very long drives for training and services with no one Hurdis Griffith, R.N., Ph.D., University of Texas, picking up the costs of that travel, Austin, TXRepresents concerns of rural nurse practi- EMT testing is often provided 200 to 300 miles tioners (NP s). away, Problems low pay rates for health professionals is a disincen- low pay for NPs (rural NPs average $13.36/hr), tive for retention. lack of recognition of capabilities of NPs to function independently, Strategies State laws and their interpretation are sometimes real training through.An rural and frontier areas funded barriers to Implementation of Rural Health Clinics by the Public Health Service, Act (RHCs), payment for more services not covered by current many third-party payors do not reimburse for NPs* home health programs for frontier areas, services. allow more flexibility in productivity and other standard in the CHC Program, Strategies allow more multiple-county CHC projects. simplify RIIC reporting, which is currently not feasible in small sites, Pam Locken, Administrator, Isabel Community Clinic, establish NP trameeships to help tram local nurses to Isabel, SDRepresents a CFIC staffed by a solo PA become NPs, whose backup physician supeivisor is 104 miles a way by provide direct reimbursement for NPs services. air ti msport. The clinic is between two Indian reserva 512 472 * Health Care in Rural America lions. It is 60 miles to the nearest hospital. The average per capita for health care than urban areas, age in the three-county service area is 19 years old. rural people are disproportionately poor and often Problems ineligible for Medicaid, poor counries with low tax base, rural CHCs serve 50 percentf all CHC users, but no backup for PA when he is on vacation or ChM receive only 41 percent e.if Federal CRC funding, travel, nnal CRCs are required to provide the same scope of bad weather limits ability to transport, services, but lack the economies of scale of larger nearest pharmacy is 55 miles away, practice& Indian Health Service will not ackqowledge PA's Strategies prescription. compulsory service for providers completing train- Strategies ing, certification as RHC allows payments to 4,ov er Improve reimbursement under the Rural Health relatively high per unit cost, Clinics and the federally Funded INIth Centers all staff are cross-trained to do others' jobs, Programs, use starter doses for preseziptions until mail truck 4;an expand the Hospital Transition Grant Program to deliver medications. inchide CHCs, Denise Denton, Rural Health Field Coordinator, increase funding for the NEISC, Utah Department of Health, Salt Lake City, UTUtah allocate funds targeted for special populations (AIDS, is 83 percent frontier and about 90 percent rural. The homeless, infant mortality, etc.) on the same basis as State's rural health effort was begun with a NHSC basic appropriations. contract in 1982. At that time the State had 12 to 15 new Penella M. Washington, Health Resources Develop- Corps assignees per year, and a tool of 25 to 33 assignees meat Section, North Carolina Department of Human in the State. In 1986 the number of new assignees was Resources, Raleigh, NCRepresents the State of North four, and in 1988 there were no new assignees. Carolina's concerns regarding helping provide). s become Probiems certified as RHCs. family physician supply is too small to meet the need Problems in toth urban and rural areas, timeframe for certification (from date of application need better training for communities on how to to date eligible (or claim reimbursement) is too long recruit and retain, (6-9 months), professional liability is driving doctors out of rural centersawairingcenificarionmustdiscontinueMedicare/ practice, Medicaid billing during the approval process, caus- grantwriting abilities of many rural communities is ing cash-flow problems, weak, midlevel providers are required to be write at least inequitable reimbursement for physicians provides a 60 percent of the time the clinic operates, which disincentive for rural practice. limits staffing flexibility, Strategies annual recertification surveys are conducted without provide locum renew coverage for doctors, PAs and prior notification of the clinic, hence appropriate NPs, personnel may be absent. Current methodology for tie midlevel providers in with teaching hospitals, c. .culating productivity screens contains disincen- provide financial incentives for medical schools to tives for exceeding productivity standards, do rural programs, documentation required for reimbursement for bad develop a more relevant rural curriculum for training debt is often difficult for small clinics to produce, health professionals. HCFA regions and intermediaries interpret program regulations inconsistently. Meridian, Mississippi Strategies Payment and Financing make federally funded CHCs automatically eligible for RHC certificarion, and ctreamline process to no Alan Strange, Ph.D., Consultant, National Associa- longer than 3 months, tion of Commwdly Health Centers, Washington, DC k goer midlevel provider requirement to 50 percent of Represents the concerns of the Nation's federally funded time the clinic is open based on a 12-mohth fiscal 536 CRCs, of which 329 (63 percent) are rural. year, Problems advise clinics of recertification surveys in advance, rural areas receive 42 percent fewer Federal dollars develop a " team approach to tumputing productivity, 5I4:1 Appendix CrField Workshops 473 simplify the bad debt recovery process by paying 90 Access to Care percent of estimated bad debt. Rims Barber, Director, Mississippi Human Services William A. Cum, M.D., F.A.C.P., Carrollton, AL Agenda, Jackson, MSRepresents the conceras of the Represents a private medical group practice that cmsists nual poor. of four internists. The local hospital has a medical staff of 10. Local citizens recently passed by a 3 to I margin a 3 Problems percent sales tax to support the local hospital. slow Medicaid application processir 0.., transportation for the rural poor is dinicult to find Problems and expensive, problems of rural hospitals, doctors, etc. are inter- home environments often lack basic amenities, connected, high rates of teenage pregnancy. structural changes imposed from above won't work; Strategies we need to look for "free market" approaches, develop a program of "community facilitators" inequitable reimbursement is the major problem for within CHCs or other entities, both rural hospitals and doctors, simplify eligibility and expand coverage under aiternative model that would turn nual hospitals into Medicaid, simple triage and transport facilities *ill not be mandatory Medicaid par....ipation for doctors to effio..".ent or effective. assure that the poor have services vailable. Strategies Mickey Goodson, Executive Director, Georgia Ass,- reform the payment system for Medicare and Medi- dation for Primary Health Care, Atlanta, GA Repre caid to provide equitable payments fur rural docio.s sents primary care providers in Georgb, which has 159 and hospitals, counties (120 with hospitals, 150 with physiciar.). adopt the RB/RVS with adjustments for cost of Nineteen percent of the rural population is poor. practice, not cost of living, Problems reform Medicaid. economic status is still a major obstacle to access, indigent care burden falls heavily on ruml providers, Clinton Smith, M.D Director, Division of Medicaid, maldistribution of doctoP a her health profes- Office of the Governor, Jackson, MSRepresents the sionals. Mississippi Medicaid Program. Strategies tlems more emphasis on comprehensive primary care shortages of doctors, nurses and other health profes- models of delivery, sionals to practice in rural areas, provide universal access to basic services. rising rates of uncompensated care in hospitals, Susan Jones, M.D., West Alabama Health Services, hospitals and doctors dropping obstetrical service, Eutaw, ALRepresents a primary care center that transportation, even though it is reimbursable under sponsors a three-county program to retiuk..e leen pregnan- Medicaid, cies and improve pregnancy outcomes. categorical eligibility for Medicaid unfairly restricts coverage. Problems shortage of physicians for rural practice, Strategies high infant monality mtes in rural areas that are twice provide focused incentives for people to enter liealth as high for black infants. professions and practice in nual areas, Strategies provide fair reimbursement under Medicaid and funding for programs targeted for speufa prablems 1,4dicare; equal for both urban and rural providers, and population segments, allow states to nt?cth ely increase payments for doelop comprehensive sy stems which include trans obstetrical care, portation, tracking systems and home visiting, develop public M.asportation in gum' areas, revitalize the NHSC. dissociate Medicaid eligibidty frAn ...tad to Famihes Pamela H ammock, State Health Office, Tallahassee, With Dependent Children, and use more universal FLRqresents the State of Florida, which passed a law standard such as Federal poverty level, in 1984 to create the kublic Medical Assistance Trust expand Medicaid coverage for persons between 21 Fund, funded by a combination of taxes an hospital and 65 years. revenues and general nwenue from the State. The Fund 5 1 4 474 Health Care in Rural Amerka has supported primary care projects in all 67 counties and Strategies permitted the State to expand Medicaid coverage. more NHSC physicians for rural practice, Problems regionalized training for small clinics to help with efficiency and quality, rising and maldistributed indigent care costs, poor access to primary health care, establish linkages with community agencies and restricted Medicaid eligibility. programs, more CHC funding to cover increasing indigent care Strategies load State funds similar to the Florida mood can work to provide additional access for the poor and provide Bernard Simmons, Executive Director, Southwest funds for other developmental 1 aposes. Health Agency for Rural People, Tylertown, MS Represents a primary health care center in a rural area with Practice Capacity and Organization no shortage of health manpower but with a high rate of poverty. Steven Shattls, Executive Director, Valley Health Systems, Huntington, WVRepresents a primary care Problems health system with a wide array of services, including a financial barriers prevent access to care for many perinatal program (which serves 70 percent of the eligible residents, women Ma 10,000 square mile area) and to the homeless. teen pregnancy rate is 25 4 percent, The system is located IP West Virginia, which is initial perception of program as a "Federal clinic" dependent on coal mining in a deep economic depression, with low participation from White population. and nearly bankrupt Strategies Problems expand Medicaid to include more of population, high reliance on the NHSC for physician manpower interact with local private providers to give "team and low retention, approach" to health care, categorical funding restricts ability to use funds to funding for midlevel providers to help clinics meet the needs of the community, become certified Au. R.HCs, limited funding and reimbrrsement, funding for social workers or others to act as case transportation, managers. coordinated care impo-tant but difficult in rural areas. Shirley Parker, Executive Director, liturel Forklear Strategies Fork Health Centers, Clahfield, TNRepresents a joint approaches to retention with hospitals and network of four small clinics located In Eastern Tennessee and Kentucky in areas where organized health care was public and private providers, first provided by "camp doctors" hired by the mining more fiexibiPy and creativity in usmg categorical companies. Fifty-five percent of the people in the service funding, have incomes below the poveil level. more aggressively seek categorical funding, mom money for case management programs. Problems Al Fox, Executive Director, Health Development high proportion of indigent care, Corp., Tuscaloosa, ALRepresents a system that pro- recruitment and retention, vides primary health care for six counties. Its initial need for automation of baling and bookkeeping mission was to recruit and place health professionals in functions, practices that would become gat& private practices. Over high cost for medical liabihty insurance, an 11-year period. it placed 16 physicians and 3 dentists increasing facility repair and IT aintename costs. iu independent practices. In 1987, it changed its program Strategies to conform with the CHC Program to opemte comprehen- increases in grant funds should be tagged to increas- sive health centers ratherthan setting up private practices. ing patient load and indigent care load, Proble .1--- excess program income should be retained by centers hospital closures hurt recruitment and retention to use or to save as they see fit, efforts, tort reform needed on malpractice, need for stronger working relationships with public provide tax credits or deductions for rural dos-turs, health. better reimbursement for mid-level providers, need for standardization in small clinics, more rural-based training programs for physicians, low per capita inzomes and high indigent care load. renovation money should be made available. 5 1 5 Appendix H Summary of OTA Special Report on Rural Emergeitcy Medical Services The average U.S. resident *ill need ambulance service tance in unproving the supply and level of skills cf rural at least twice in his or her lifetime, and for some of these krehosPital and hospital based EmS pros iders. Increas,4 patients, delays in receiving emergency care will contrib f4deral assistance rould inJude support of EMS trainlng ute to death or permanent injury. The one-quarter of and contmumg education En ograms, and State resuit ment Americans who live in rural areas, which occupy four- and placement programs. fifths of the country's land area, face special problems in Option 2: Congress could re4.nre the Department of receiving emergency care.Itis difficult to deliver Transportation (DOT) to reev aluate the standard curricula emergency medical services (EMS) to widely dispersed for EMS providers. populations quickly, and in small rural communities there may be less than one emergency call a day. This relatively Federal Guidelines or Standards low volume of calls may mean that a rural ambulance Option 3. Federal legislation couid fa.;ilitate the service cannot support itself financially and that rual development of national consensus guideline:, or stand EMS providers have difficulty maintaining their special- ards for prehospital EMS providers. ized skills. The time it takes to reach emergency patients Option 4: Federal legislation could facilitate the may always be longer in some rural areas than urban areas development of national consensus guidelines or stand- because of distances between services and rural residents. ards for specialized EMS facilities such as trauma centers. While problems rdating to population dispersion are Such guidelines or standards ought delineate the role of not easily amenable to intervention, many of the problems small rural hospitals in EMS care. rural EMS providers are having in delivering EMS care Federal EMS Technical Assistance can be alleviated with additional resources and system- wide planning. Among these problems are. Option 5. Congress could fund DOT and DHHS to augment technical assistance to State EMS offices. EMS personnel shortages; inadequate advanced training opportunities for avail- Federally Sponsored EMS Research and Demonstra able EMS providers; tion Programs a lack of medical supervision of local EMS operations, Option 6. Congress couid fund DOT and DIMS to antiquated equipment (e.g., 4: onununications equip augment their EMS research and demonstration programs ment); and encourage the investigation of EMS problems unique poor public access to EMS, and to rural areas and providers. The research efforts of DOT's an absence of regionalized systems of speualized National Highway Traffic Safety Administration, and EMS care, such as tranma systems. DIIHS's National Center for Health Services Research The Federal role in supporting State EMS programs has and Centers for Disease Control, could be coordinated to waned in recent years, but evidence of senous unpedi- address a broad range of outstanding research questions ments to (platy EMS care in rural areas argues for an Federal Incentivcs fur Planning and EMS Systems increased Federal role. Limited Federal resources might Development successfully be used tc: Option 7: Congress could augment support of promote training of EMS providers, existing Federal programs that address EMS, namely the facilitate the development of national comer s DIMS Prey Linty e Health Block Grant program and guidelines or standards for prehospital EMS pro,. ,d DOT's State and Community Highway Safety Grant ers and EMS facilities; Program. Consideration could be given to earmarking provide technical assistance to States; funds within these grant programs for EMS. support EMS-related research and demonstration Option 8: Congress could establish a new EMS projects; and categorical grant program within DHHS. provide incentives for States to Implement EMS planning efforts. Targeting EMS Resources to Rural Arc-s Specific Federal options to be considered include: Option 9: To accommodate the diversity of rural areas, any Federal EMS resources provided to States Federal Initiatives in EMS Training could be ned to implementation ()fa comprehensive State Option 1: Congress could fund the Department of plan tat addresses thatSkire'srural EMS system Health and Human Services (DHHS) to provide assis- problems. -475- 5 i 6 Figural:IU.S. Department of Health and Human Services SECRETARY UNDER SECRETARY CHIEF OF STAFF OFFICE OF HUMAN PUBLIC HEALTH CARE SOCIAL DEVELOPMENT HEALTH FINANCING SECURITY GERVICE ADMINISTRATION SERVICES ADMINISTRATION ! Alcohol, Drug Abuse anti A0miniatrallons klanlal Has lth Admin. 0111 ol Esse. OpratIona 011ie. Ott on Aging Fottg and Orlin Admin. 0111c. alt no Aoatiolata ya tam lot Chill:iron. *kith. Cntoto lor Olaoaaa Control Adminlatrator lor f IOW OparatIona sad Familia. Has ith Raa. and Sam Admin. ffstarnal Allaira H as/Inds and Appeal. hitr Not Ivo Amaricsna Indian Hsith Clary Ica Menu. snd Support - Polloy and Procdureal on ovoloponantal National Inatituta 01 Health Sat,' lc.. Aosaaamni Dissial Mina (Mica 01 Clomp Proventin OptatIona Mgml., eclat. and Porstonnell Ottico ot Program and Health PrOMOIlen Coorglnotlon one Revlon Of is, pi MIntorIty Health Policy . sha Actuary Agncy Icr Toxic - Canital Oorationa Subatancoa snd Wass,. Policy i FAMILY SUPPORT ADMINISTRATION OFFICE OF: - Family Assistance - Refugee Resettloment: - Child Support Enforcement rr - Community Servicea Figure 1-2Health Resources and Services Administration OFFICE OF THE ADMINISTRATOR r -1 OFFICE OF OFFICE OF EQUAL RURAL HEALTH OPPORTUNITY AND POLICY CIVIL RIGHTS L__ 1 'OFFICE OF PLANNING., OFFICE OF OFFICE OF 1 I OFFICE OF ! EVALUATION AND . POLICY OPERATIONS AND COMMUNICATION COORDINATION MANAGEMENT LEGISLATION 1 1 1 I BUREAU OF MATERNAL AND 1 1 BUREAU OF i BUREAU OF HEALTH CARE cHn.c HEALTH AND RESOURCES HEALTH rROFESSIONS DELIVERY AND ASSISTANCE DEVELOPMENT 519 524 Appendix J Glossary of Terms Access: Potential and actual entry of 4 rqulation intu the beneficiary more than the applkable deductible and health care delivery system. coinsurance amounts. For physicians and suppliers Accounts receivable: Me full amount of patient care who do not accept assignment, payment is made by charges owed to a hospital or other health care facility. Medicare directly to the beneficiary, who is responsi- Average days in accounts receivable refers to the ble for paying the bill. In addition to the d eductible and average number of days it takes a hospital or other coinsurance amuants, the beneficiary is liable for any facility to collect the full amount uf patient care difference between the physician's actual charge and charges. Medicare's reasonable (allowed) charge. Accreditation by JCAHO: A statement by the Joint Merage length of stay : Average stay of hospital patients Commission on the Accreditation of Healthcare Ottani from admission to discharge during a particular zations (JCAHO) that an eligible health care organiza reporting period, desived b, 1.iding the number of don, such as a hospital, complies wholly or substan inpatient days by the number of admissions for the daily with JCAHO standards. period. Acute care: Services within a hospital setting intended tu Bad debts: Patient care charges owed to a facahty that the maintain patients for medical and surgical episodk facility considers to be largely uncollectable. care over a relatively short period of time. Balan ce billing: In the Medicare program, the practice of Admissions: Number of patients, excluding newborns. billing a Medicare beneficiary in excess of Medicare's accepted for hospital inpatient serv ke during a panicu allowed charge. The "balance billing" amount would lar reporting period (American Hospital Assodation be the difference between Medicare's allowed charge definition). and the physician's (or other qualifying provider's) Allowed (or allowable) charge (under Medicare). See billed charge (See tkuomary, prevailing, and reason . customary, prevailing, and reasonable charges. able charges, allowed charge, and billed charge.) Alternative facility licensure: The process by whkh a Billed charge: In the Medicare program, the physician's State creates a new category of licensed health care (or cupplier's) actual (billed) cLarge for a service. facility or new licensure rules for existing categories uf Compare with customary, prelading. and reasonable facilities for the purpose of maintaining the v lability charges. a' accessibility of certain facilities or services. Birthweight: The weight of an Infant at the time of Am .ulatory care: Medical services provided to patients delivery. who are not inpatients of hospitals.Itincludes Board-certified physician. A ph) sician who has com- outpatient hospital care. pleted requirements of advanced training and practice Ambulatory surgery : Scheduled stgical services pro in a particular medical specialty and has passed vided to patients who do not remain in a hospital examinations offered by the national 4-ertifying board overnight. The surgery may be performed in hospital for that specialty. operating suites or procedure rooms w itbin a freestami Breakev en financial status. The punt in operations at ing ambulatory care center. which a business (e.g., health care facility) neither Ancillary services or technology: Medical technology loses money noT makes a profit. or services used directly to support basic clinical ...pita! expenditures: The 43usts (including borrow ing services, including diagnostic radiology, radiation costs) of purchasing a capital asset(e.g., plant, therapy, clinical laboratory, and other special services. equipment), Antitrust laws: Laws such as the Clayton Act (15 IJS.C. Carrier (Medicare). See Medkareanterneihartea or 12-27) that prohibit institutional mergers and acquisi- carriers. tions, exclusive contracts. joint ventures, and other Case mix: The relative frequeno of admissions of business dealings in areas that may substanbally arioth types of patients, reflectiag different needs for ekeduce competition or have the tendency to produce a hospital resources. littionopoly, and consequently hav e a detrimental effet Certificate of Need (CON) laws. A uernikate required on consumer welfare. by State law and issued by the State Health Planning Assignment: A process whereby a Medkare benefkiary and Dev elopmem Ageny to an loan idual or organiza assigns his or L. right to payment from Medicare tu tam proposing to ...onstruct or modify a health facility, the physician or supplier. In return, the physician or or offer a new or different health service. CON supplier agrees to accept Medicare's reasonable re_ognizes that the proposed facility L.ceded (i.e., it allowedcharge as payment in full fulf.,overed dues not e.reate an excessive supply of services ur add The physician (or supplier) may not charge the unnecessary costs to the heat. care system). 5 -478 Appendix JGlossary of Teims 479 Certification by HCFA: A statement by the Huhn Care number of hospital, regardless of the at.tual or praakal Financing Administration (HCFA) that a hospital or r teans (e.g., roads) available to trav el between theSe health care institution meets HCPA's conditions of hospitals. participation. Certification by HCFA is requited foi Customary, prevailing, and reasonable (CPR) charge Medical* and Medicaid rehnbursemem. method (Medicare): The method used by carriers to Certified Rural Health Clinic (RHC): A fat.ility (or can detemune the approved charge for a particular Part B of a facility), engaged mainly in the provision cf service from a particular physkian or supplier based on outpatient primary medical care, that is eligible to the actual charge for the service, previous charges for receive cost-based Medicare and Medicaid reimburse the serv ke by the phy sician or supplier in question, and ment primarily by virtue of its. (1) location in a previous charges by peer physicians or suppliers in the Census-defined rural health manpower shortage area same locality. Customary charge: In the absence of (HMSA) or medically underserved area (MUA) and unusual medical cin.umstances, the maximum amount (2) employment of at least one midlevel practitioner that a Medkare carrier will approve for payment for a (i.e., phy..ician's assistant, nurse practitioner, or nurse particular service provAed by a particular physician midwife). practice. The carrier computes the customary charge Community Health Centers (CHC* Health care facili- on the basis of the actual amount that a physician ties fimded by the U.S. Department of Health and practice or supplier generally charges for a specific Human Services to provide comprehensive primary seivice. Prevailing charge: In the absence of unusual health services ki both rural and urban areas where medical circumstances, the maximum amount a Medi- there are shortages of medical personnel and services care earner will approve for payment for a particular Community Mental Health Center (CMHC): An service provided by any physician practice within a organization (or affiliated group of organizations), that particular peer group and locality (see "prevailing received Federal funding under the Community Men- charge locality"). Generally, this amount is equal to tal Health Centers Act of 1963 to make available a the lowest charge in an array of customary charges that comprehensive set of community-based mental health is high enough to include 75 percent of all the relevant services, including emergency and outpatient care, customary cbarges. Approved or reasonable charge: consultation and education, and partial and complete An individual chargc determination made by a Medi- hospitalization. Computed Tomography (CT) scanners A diagnostic care camel on a cfivend Part B medical service or device that combines X-ray equipment with a com- supply. In the absence of unusual medical circum- puter and a cathode ray tube (television-like device) to stances, itis the lowest of:1) the physician's or produce images of cross-sections of the body. suppliers' customary charge fot that service; 2) the Congenital abnormality or anomaly: Any abnomiality. prevailing charge for similar services in the locality; 3) whether genetic or not, 'hat is present at birth. the actual charge made by the physician or supplier; Contiguous area: As it relates to HMSAs, an area in and (4) the carrier's private business charge for a close proximity to an area under consideration for comparable service. Also called allowed charge ar designation as a HMSA (proximity is based on travel reasonable charge. time from the population center of the service area to Day treatment: A specialized and intensive form of the center of the contiguous areas) mental health service, less restrictive than inpatient Continuity of care: Medical care that proceeds without care, in which the partially hospitalized patient re- Interruption across time and across different saes and ceives treatment for 5 to 6 hours a day. levels of care. Degree of shortage: See Priority groups. Contract-managed hospitals: General daily manage- Diagnosisa elated Groups (DRGs): Groupings of diag- ment of a hospital by another organization under a nostic categories drawn from the International Classi- formal contract. Managing organization reports di- fication of Diseases and modified by the presence of a rectly to the board of trustees orowners of the msaaged sur6ical procedure, patient age, presence or absence eif hospital. The managed hospital retavs total legal significant comorbidities or compacations, and other responsibility and ownership of the facility (American relevant criteria. DRGs are the case-mix measure Hospital Association defmition). mandated for Medicare's prospective hospital pay- Cooperative or alliance of hospitals and other facili- ment system by the Social Security Amendments of ties: A formal organization working on behalf of its 1983 (Public Law 98-21). individual members for specific purposes (e.g shanng Direct i eimbursement: Payment for services that is of services, development of staff education programs. submitted directly to thc health cue practitioner .ho legislative advocacy). provided those services. "Crow-fly" miles: A term used to describe the straight- Downsizing (of hospitals and other health care facili line or shortest distance in miles between a given ties): Taking actions such as reducing the number of 480Health Care in Rural America beds and staff with the goal of reducing expenses in Fixed costs: An operating expense that does not vary, at order to cope with diminished demand for services. least over the short term, with die volume of services DRG outliers: Cases with unusually high or low resource provided. use Defined by the Social Security Amendments of Freestanding facilities: Faulnies that are not physically, 1983 (Public Law 98-21) as atypical hospital cases that administratively, or financially connected to a hospi- have either an extremely long length of stay or tal, such as a freestanding ambulatory surgery center. extraordinarily high costs when compareto most Frontier counties: Counties with population densities of dischargen classified in the same diagnosis-related 6 or fewer persons per square mile. group. (See Diagnosis-Releted Groups) Geographic Practice Cost Index (GPCI): An index Electronic fetal monitoring: Continuous monitoring of used by Medicare and some researchers to examine the fetal bean rate and uterine contractions through the differences in physician practice cu,ts across geo- use of an electrod: and an amniotic fluid atheter and gtaphic areas. The index is based on per-unit costs. pressure transducer attached to the mother's atidomen. Gross patient revenu..: Consists of the full amount of This process A. used to detect abnormal fetal cardiac. revenue from services rendered to patients, including patterns during labor and delivety. payments received from or on behalf of individual Endowments: Funds established by an institution to patient& accept monetary contributions from private sources. Health Maintenance Organization (HMO): A health Essential Access Community Hospital (EACH): A care crtanization that, in return for prospective per newly designated type of rural hospital created by capita payments, acts as both insurer and provider of Congress in 1989 (Public Law 101-239). Limited to comprehensive but specified medical services. A hospitals in only a few States, EACTis will be facdnies defined set of physicians provide servi;es to a volun- of at least 75 beds that provide backup t,9 Rural tarily enrolled population. Prepaid group practices and Primary Care Hospitals as part of a patient referral individual practice associations are types of I-EMOs. network. Designated facilities will automatteahy qual- Health Manpower Shortage Areas (HMSAs): Areas, ify for Medicare's payment rules for Sole Community population groups, and facilities designated by the Hospitals. Federal Government as having shortages of health "Evaluative and management services": Services, personnel I-EMSAs, which are currently designated for primary care, dental, and psychiatric personnel, are such as office visits, that may involve but Jo not determined piimarily by population-to-ptactitioner depend in a maior way on any medical devices. Expenses per inpatient day: Expenses incuned for ratios. Health Manpower Shortage Area Placement Oppor- inpatient care only, derived by dividing wtal expenses tunity List (HPOL): A list of the most needy HMSAs by the number of inpatient days during a paincular used by the National Health Service Corps in the period (American Hospital Association definition). placement of volunteer and obligated personnel. Extracorporeal shock wave lithotripsy (ESWL): A Hill-Burton program: A Federal program begun in 1946 technique for disintegrating urinary tract stones that to fund health facility consmictioin in areas of need uses shock waves generated outside a patient's body and foster coordination among health care facilities. and does not require a surgical incision. Hospital or health care facility cooperative/alliance: Federal Tbrt Claims Act (FTCA): Enacted in 1946 (28 See Cooperative or alliance of hospitals and other U.S.C.A. sec. 1346(b)(Supp. 088)1 the FrcA allows facilities an injured party to sue the United States Government. Hospital or health care distrkt/authority: A geo- Fee schedule (for physician services): An exhaugtive list graphic area created and controlled by a political of physician services in which each entry is associated subdivision of a State, county, or city solely for the with a specific monetary amount that represents the purpose of establishing and maintaining medical care approved payment level under a given insurance plan. or health-related care institutions. Fertility rate: The annual number of live births per 1,000 Index of Medical Underservice (IMU): The sum of the women of childbearing age (15 to 49 yews) in a weighted values of four indicators of unmet health care defined population as a proportion of the estimated needs in an area (i.e., infant mortality tate, percent of mid-year population of women 15 to 49 years of age. the population 65 and older, percent of the population Fetal death: The product of conception which, after living in poverty, and population-to-primary care separation from its mother, does not breathe or show physician ratio) that is used to determine its status as other signs of life required to mee. the World Heaith a Medically Underserv.d Area. IMU values range Organization's criteria for a live birth. Comp..re live from 0 to 100, with !owc . ssAires indicating increasing birth. medical underservice. Fetal mortality ratio:The annual number of fetzl deaths Indirect r eimbursement. A situation wherein a health as a proportion of the annual number of live bh-ths. care practitioner can be reimbursed for his or her C. e) Iio Appendix AGlossary of Term.: 481 services, but ean only obtain sueh reunbursement ity inelude uterine hemorrhage, toxemia, and underly through the employmg physician or health care ing medical eonditions that complicate pregnancy suil facility. as diabetes and infections (e.g., tuberculosis, syphilis). Infant mortality : Death in the first y cal 'Aide. It includes Mater nal mortality rate. The annual number of mato neonatal mortality and posineonatal mortality. nal deaths related to pregnancy as a proportion of the Infant mortality rate: The annual number of deaths annual number of live births. among children less than 1 year old as a proportion of Medicaid: A Federal-State medical assistance program the annual number of live births. authorized in 1965 to pay for health care services used Inpatient care: Medical services provided to patients by people defined as medieally needy or categerically admitted to hospitals for overnight stay. needy. Categorically needy persons are low-income Inpatient days: Number of adult and pediatrie day s uf aged, blind, disabled, first time pregnant women, or care, excluding newborn days of care, in a hospital families with dependent children_ Medically needy rendeted during a particular reporting penod (Amen persons are any of the abor e whose incomes are abov e can Hospital Association definition). eligibility limits for the categorically needy but who Insufficient-capacity criteria: Criteria specifie to pn hav e high medical expenses that reduee their resources mary care and dental HMSA designations that signify below established limits. the inability to obtain health services in a timely Medically Enderserved Areas (MUAs); Areas deter- fashion (e.g., unusually long waiting times for appoint mined by the Federal Government to feu e inadequate ments, high percentage of area practitioners not access to health care as determined by the Index of accepting new patients). Medical Underservice Intensive care: Hospital sen iee units designed lc meet Medically Undersened Populations (MCPs). Pupula the special needs of patients who are seriously or trims not meeting WA criteria that are designated as criticallyillor whu otherwise need intense and underserved based on unusual loeal eonditions that specialized nursing care. may affect the area/population. Joint venture: A relationship in which two ut more Medicare: A mtionwide, federally administered health parties enter into a busines.s as co-owners uf a specifi e insurance program authorized in 1965 to cover the eost project(s) to share in profits and losses. of hospitalization, medical care, and some related Live birth: According to the World Health Organization, senices for eligible persons over age 65, persons "the con4Jete expulsion or extraction from its mother rectiv ing Social Seeurity Disability Insurance pay of a product of conception, irrespectiv e of the duiation ments for 2 years, and persons with end stage renal of pregnaney, which, after such separation, breathes ur disease. Mediear.. consists of two separate but i.00rdi shows any other evidence of life such as beating of the nated programshuspital insurance (Part A) and heart, pulsation of the umbilic...1 cord, or definite supplementary medical insuranee (Part B). Health movement of voluntary muscles. This definition is insurance protection is available to insured persons the basis for most States' requirements governing the without regard to income. reporting of live births. Compare fetal death. Medicare conditions of participation. Requirements Local health depart ments (LHDsl: Municipal or county that hospitals and ether institutiunal Providers must government-operated facilities providing baaie pea meet in order to be allowed to reeeive pay ment for sonal and environmental health services. Medkare patients. An example is the requirement that Long-term care: Health care for nonacute conditions hospitals conduct utilization review. (e.g., convalescent care for a person with an extended Medicare intermediaries or carriers. Fiscal agents or permanent disability). Includes skilled nursing CAM ktypically Blue Cross plans or i.ommercial insurance (long-term care requirmg the supervision and frequent funs) under eontract to the Health Care Finaneing services of a skilled nurse) and intermediate care ithe Administration fur admuustratiun of speeifie Medieare routine provision of health related care to individuals tasks. These tasks include detemiining reasonable not reqWring skilled nursing care). costs for covered items and services, making pay- Low birthweight babies: Live births weighing le.a than meets, and guarding against unnecessary use of 5-1/2 pounds (2,500 grams). covered services for Medicare Pan A payments. Magnetic resonance imaging (MRI). A techniace. that Intennedianes alsu make payments foi home health produces images of the body by measuring the reaetion and uutpafient huspital sen tees eovered 'eider Part B. uf nuelei (typically of hydrogen protons) in magre.. MedicarelMedicaid beneficiary. . One who reeeives fields to radiofrequency waves. coverage for health services under Medicare or Medi- Maternal mortality: Maternal mortality includes deaths caid. due to complications of pregnancy, childbirth, and the Medicare uperating margin. Revenues received by a puerperium (the period of 42 days following the health care provider from Medieare less the presider's temunation of pregnancy). Causes of maternal mortal operating costs *Ancred by Medieare pay m:nts. di A' 1 A 482 Health Care in Rural America vided by Medicare revenues and multiplied by 100. to urban areas) to receive health care and other Medicate revenues and costs not covered under services. Medicare's prospective payment system (e.g., capital Outpatient care: Services provided in a hospital and that expenditures, medical education costs) are excluded. do not include an overnight stay. Merger (of health facilities): The union of two or more Outpatient surgery : See Ambulatory surgery. formerly independent institutions under a single own- Overhead costs: Includes costs to a health care facility ership, accomplished by the complete acquisition of that are not direct labor (i.e., payroll expenses) such as one institution's assets or stock by another institution. employee fringe benefits and other expenses mdirectly Migrant Health Center (MHC): A center that receives related to patient care operations. Federal funds to provide primary health care to migrant Partial hospitalization: A planned transitional progtam and seasonal farmwotkers and their families. of mental health treatment savices after psychiainc Metropolitan Statistical Area (MSA): As defined by the hospitalization or residential tzatment when a patient U.S. Office of Management and Budget, an MSA is a no longer needs 24-hour care. county or group of counties that includes either a city Patient margin: A measure of dm profitability of patient of at least 50,000 residents, or an urbanized area with care, calculated as (patient cant revenues minus total at least 50,000 people that is itself part of a county/ costs) divided by patient care reveaues. See ago net counties with at least 100,000 total residents. patient revenues. Multlhospital system: Two or more hospitals that are Peer Review Organizations (PROs); PROs are organi- owned, leased, sponsored, or contract-managed by a zations established in 1982 (Public Law 97-248) with central organization (American Hospital Association which the U.S. Depanment of Health and Human definition). Services contracts to review the appropriateness of Negative operating margin: A loss that CIC41115 when settings of care and the quality of care provided to costs of operation exceed revenues. Medicare beneficiaries. Neonatal intensive care unit (NICI.J): A specialized Perinatal care: Medical care pertaining to or occurring in hospital unit combining high technology and highly the period shortly before or after birth, variously trained staff that nuts seriously ill newborns. defined as beginning with the completion of the 20th Neonatal mortality rate: The annual number of neonatal to 28th week of gestation and ending 7 to 28 days after birth. deaths as a proportion of the annual number of live Perinatal mortality: Fetal and neonatal deaths com- births. bined. Neonatal mortality: Death during the first 4 weeks of Perinatal mortality ratio: The annual number of perina- life. tal deaths as a proportion of the annual number of live Net patient revenue: For a hospital or other health care births. facility, consists of gross patient revenue less deduc- Physician Payment Review Commission; A commis- tions for contracnial adjustments (amounts of patrnt sion established by the Comprehensive Omnibus charges not paid by insurers), bad debts, charity, and Budget Reconciliation Act of 1985 (Public Law other factors. 99-272) to make recommendations to Congress and Net total revenue: Consists of net patient revenue plus all the Secretary of Health and Human Services on various otherrevnue of a hospital or other health care facility, issues relating to changes in physician payment under including contributions, endowment revenue, govern- Medicare. ment grants, and all other payments not attributable to Positive operating margin: A surplus that occurs when r t care. revenues exceed costs of operation. Non..ropolita n Statistical Area (NonMSA); Any Postneonatal mortality: Deaths that Occur from 28 days atea not in an MSA. to age one. Obstetric care: Medical care received during pregnancy. Postneonatal mortafity rate: The annual number of labor and delivery, and the period immediately follow- postneonatal deaths as a proportion of the annual ing birth. number of live births. Occupancy: Ratio of average number of inpatients Preceptorship: An arrangement whereby a student takes (excluding newborns) receiving care to the average part of his or her training under the supervision of an number of beds in a hospital set up and staffed for use active practitioner at that practitioner's worksite. For (i.e., statistical beds) during a particular reporting example, an office-based physician in a rural area may period (American Hospital Association definition). serve as a preceptor for a medical student, instructing Operating costs: The ongoing expense of operating a the student in the various aspects of nual medical health care facility. practice. Outmigration: As used in this report, the movement by Premature births; Babies born between 20 and 36 weeks rural residents outside their communities (particularly gestation. (also called preterm births) 5 '5 Appendix JGlossary of Terms 483 Prenatal care: Medical services delivered from concep Rational sery ice areas: To be proposed for HMSA tion to labor. Prenatal care and intrapartum care designation, an area must be "rational" for the combined are referred to as maternity care. Early delivery of services based on criteria governing the prenatal care is care received in the first trimester of size and boundaries of the area and consideration of pregnancy. such famors as established transportation routes and Prevailing charge (Medicare): See Customary, prevail- language barriers. ing, and reasonable (CPR) method. Relative Value Scale (RVS): A list of all physician Prevailing charge locality (Medicare): A particulai services containing a cardinal ranking of those services geographic locality within which Medicare determines with respect to some conception of i alue, such that the prevailing charges and sets payment under Part B for difference between the numerical rankings for any two medical services provided by physicians and other serv ices is a measure of the difference in i alue betw een qualifying health care practitioners. There are approxi those services. (A "resourcebased relative value mately 240 separate prevailing charge localities in the scale" will soon be used by Medicare for reimburse- United States. ment of physician services.) Primary care: A basic level of health care, asually Reproducthe-age women: Women between and mclud provided in an outpatient setting, that emphasizes a ing the ages of 15 and 44 years. patient's general health needs. Respiratory Distress Syndrome (RDS): An acute respi- Primary care physicians (as defined for HMSA desig ratory disorder that in premature infants is thought to nation purposes): Family and general practitioners, be caused by a deficiency of pulmonary surfactant. In general pediatricians, obstetricians and gynewlogists, sev ere form, patients often need mechanical assistance and general internists. to breathe. Priority groups: The ranking of designated HMSAsUnto Retrospectiv e cost-based reimbursement. A payment four groups according to population-to practitioner method for health care services in which hospitals (or ratios and indications of high need and insufficient oilier prov iders) are paid their incurred ,osts of ireating capacity (group 1 IIMSAs indicate greatest need). patients after the treatment has occurred. In this "Procedural" services: Services that are dependent in a country. the tenn has traditionally leferre4 to hospital substantial way on the use of a medical der ice. payment, since other providers have generally been Contrast "evaluative and management servkes." paid on the basis of charges instead of costs. Procedure (medical or surgical): A medical technology Rural Primary Care Hospital (RPCH). A newly involving any combination of drugs, devices, and designated type of mral hospital created by Congress provider skills and abilities. Appendectomy, for exam in 1989 (Public Law 101 239). Limited to hospitals in pie, may involve at least drugs (for anesthesia), only a few States, RPCHs will be small facilities that monitoring devices, surgical devices, and the skilled pro: ide emergency and mmimal inpatient care and will actions of physicians, nurses, and support staffs. be eligible for special reimbursement under Medicare Prospective payment: Payment for medical care on the (also see Essential Acc.e.ss Community Hospitals). basis of rates set in advance of the time period in which Rural Referral Centers (RRCs): Tertiary -care mral they apply. The unit of payment may vary hospitals, usually large, that serve a wide geographic individual medical serv ices to broader categories, such area. Hospitals that qualify as RRCs must meet .:nam as hospital case, episode of illness, or person (capita size and referral characteristics, and are eligible to tion). Compare retrospecip e cost based reimburse receive special cansiderations under Medicare's pro ment. spective payment system. Prospective Payment Assessment Commission "Safe harbor" i egulations. Regulations proposed by (ProPAC): A commission established by the same law the U.S. Department of Health and Haman Services that created the DRO- based prospective payment that would spetify which practices of hospitals and system for Medicare (Public Law 98 21) to advise the other health care prov iders would not be unethical Secretary of Health and Human Services on various under the Medicare and Medicaid anti luckback prove activities needed to maintain and improve that pay- sions. ment system. Sentinel health events: Medical conditions that, by Provider participation (in Medicare or Medicaid). The v Irma of then presence or prevalence in a population, provision of care by a physician to patients who are indicate a lack of access to acceptable, qualit), primary covered by either Medicare or Medicaid. care services. Examples include dehydration in in luality of care: The degree to which aciions taken or not fants, measles, mumps, or polio in children, and taken increase the probability of beneficial health advanced breast cancer or invasive cervical tamer in outcomes and decrease risk and other untoward adult women. outcomes, given the existing state of medical sc.ierk.e Skilled narsing facility (SNP). A facility rhai provides and art. skilled nursing care (see long-term care). A "distinct- 5 ,-)6 484 Health Care in Rural America part SNP' is a distinct unit within the hospital that long-tenn care services from us State health planning provides such care (i.e., beds set up and staffed and development agency. specifically for this service), is owned and operated by Tax appropriations: Subsidies available to health care the hospital, and meets Medicare certification criteria. facilities from State or local govemment taxes. Sliding fee scale: A schedule of discounts In charges for Tax-exempt revenue bonds: Bends generally are evi- services based on the consumer's ability to pay, dence of a debt in which the issuer (borrower) promises according to income and family size. to repay the bond's holder. A revenue bond is issued Sole Community Hospital (SCR): A nual hospital. by a government (bon)wer) to taxpayers (bondholder) usually small, that is presumed to be the only source of to raise funds in anticipation of tax receipts, and then local inpatient hospital care to area residents by nature repaid from tax revenues once they are received. Most of their isolated location, weather conditions, travel bonds issued by governments are tax-exempt, that is, conditions, or absence of other hospitals. Federally the bondholder pays no Federal income tax on mtetest designated SCHs receive special considerations under earned. Medicare's prospective payment system. Third-party payment: Payment by a private insurer or Strategic planning: A rational process by which an government program to a medical provider for care health care organization (e.g., hospital) determines its given to a patient. best course of action. This involves effectively balanc- Total hospital margin: A measure of hospital profitabd- ing community needs for health services with the ity, calculated as (total Tevenues minus total costs) organization's suengths and ability to use available divided by total revenues. Total revenues include resources, and producing practical plans to implement private contributions and public subsidies as well as strategies that are financially fees ibl e an d acceptable to patient care and other revenue. consumer needs (American Hospital Association defi- Ultrasound: High-frequency sound waves that can be nition). focused and used to picture tissues, organs, structures, Sudden Infant Death Syndrome (SIDS): The sudden or tumors within the body. Ultrasound is particularly and unexpected death of an infant, for reasons that useful forin uteroexaminations of the fetus. remain unclear even after autopsy. SIDS is the most Uncompensated care costs: Deductions from patient common cause of death in the post-neonatal period. care revenues that are attributable to charity care and Swing beds: Licensed acute-care beds designated by a bad debts(for which the health care facility never hospital to provide either acute or long-tern care expects to receive payment). services. A hospital qualifying to ieceive Medicare and Unusually high-needs criteria: Criteria specific to the Medicaid reimbursement for care provided to swing type ofHMSA primary care, dental, psychiatric) bed patients must be located in a mral area (as defined that are indicative of an unusually high need for by the U.S. Bureau of the Census), have less than MO medical care (e.g., pove ty rates, population without acute care beds. and when applicable must have fluoridated water supply, and high prevalence of received a certificate of need for the provision of alcoholism). References 5Is References' 1. 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Index ammoENSVS1111MISOMINS Index At cidents and accident prevention American Optometric Association, 274 migrants, 80 Anesthetists, 250, 257-259, 322, 340 seatbelts, 43, 54 Anti-Drug Abuse Act of 1988, 77 mban v. rural, 43, 54 Antimist law, 186-188, 189, 190-192, 193 Accuired immune deficiency syndrome, 298, 304 Anpalachia, 41, 411 Arum disease, 43, 45 Area Health Education Centers (AHECA 21-22. 78, 100. 299, elderly, 57 301, 343-346, 361, 362, 367, 373, 374 migrant workers, 53 Arizona, 93, 344, 366, 397 see Emergency and acute care personnel supply/demand, 251, 253, 267. 274. 275. 391 Administration and administrators Arkansas, 92, 93, 105, 344, 397 community nealth centers, 160-161, 182 Association of 4rnericon Medical Colleges, 226 Federal, 14, 2.4-25, 75, 76, 81 Attitudes hospital, 82, 113, 160-16: alternative delivery models, acceptance of, 212 Medicaid, State role, 68-70, 74, 98, 105 intetprofessional prejudice. 212, 375. 433 Medicare, 181 personal health status, 43, 47. 57 record technicians, 278, 280, 283 professional career choices and, 115, 316-319. 322-323, 331 State-level. 24, 68, 89-91, 96-97, 98, 99-101, 104, 106 Aadiologists, 280 see also Regulations Autome'Ales, 43 Adolescents, 95, 427 Age factors, 6, 38, 40-41 Beliefs, see Attitudes dentists, 270 Black Americans, 40, 380. 387, 388. 389-390 insurance coverage, 48 Black lung disease, 80 physicians, 247-248, 282 Bleck grants,9,28.61, 62,75-17 90-91. 214,400.404-405.411, regional distributions, 42, 50. 54, 55, 56 412, 419, 420, 433 urban v. rural, 54 Bo-der Health Educe:ion (enters. 78 see also Children; Elde' Bureau of Health Care Delivery and Assistance, 79, 183, 293, Agencies on agiol, 172 174 354. 357. 366. 419. 420 Agency for Health Caac Policy and Research. 9. 61, 82 Bureau of Health Professionals, 25. 106, 243 24. 273. 301.324, Agriculture, 41, 42, 46, 418 335, 362-363, 365 Department of Agriculture, 41 Farmers Home Administration, 14. 139440, 205 California, 16. 93. 11;9. 191. 201-202. 203. 205. 206-207. 411 see also Migrant workers Canada, 229, 231 AIDS, 298, 304 Capital investments Aid to Families with Dependent Children, 68-69, 70 equipment. 92. 93. 114, 329. 409 Alabama, 168, 190, 342, 407 hoc-.sls, 14,137-140, 162,188-189. 191. 192-193,203.205. Alaska, 337, 344 £3 Alcohol abuse, 418. 424 and, 64. 65 Alcohol, Ding Abuse, and Mental Health Administration. 76. State fmancmg. 103, 104 420 Career chow-% profelsionals, 3.5, 316-319. 322-123. 331 Alcohol. Ding Abuse, and Mental Health block grant. 9, 61, f 2, Census Bureau, 35, 38, 40 76-77, 419, 420 ontral U.S.. 150, 238, 242, 243. 260. 371. 407 Allied health professionals. 19, 13it :88 332 Certificates of need, 188-189, 191. 192-193. 203. 205 definitions. 275. 279-280 Cenifieation. see Licenses end permits education, 21-22. 275, 280-281 '283, 284, 330, 342. :73 Cernited nufse-mgavives, see Midwwes licensing. 281, 330 Llmntable orgae:easons, IR9 mental health, 27, 431 4LIT: Volut. -ers and volunteetuig multiple competencies, 21-22. 280-2ftl. 284. 330. '32 Children tecruitment and retention problems, 330 331,360 adolescent ..e.lth services. 95 427 supply/demand, 275, 277-278 282-28371 disabled, 73 see also Lab technicians; Rade.. ogists; Record technicians education, 318 Allopathic medicine, 220. 225, 232, 249. 318,323-324 immunization, 43. 47. 75, 76 Ambulatory services, see Outpatient services infant mortality, 25, 26. 8r. 288, 293, 298, 304. 305. ?79. 380, American Academy of Family Physicians, 229 398. 399, 412 387, 412 American Acailcny of Nurse Practitioners, 251 mental health. 418 American Board of Family Practice. 226 pediatric dentists. 270. 271. 272 American College of Nurse-Midwivea, 255, 320 screening. 70, 75 " I American College of Obstetricians and Gynecologists. 398 see also Materna, 4. I infant care American Hosnital Association, 111, 165-166, 278 Cholesterol, 76 American Medical Association, 226. 230. 275. 319. 329 Chronic disease. 5, 6. 43. 45, 54. 198. 305 American Nurses Association, 341 AIDS. 298,304 518 Health Care in Rural Arnerka black lung distose, 80 Delaware. 71, 93 of elderly, 57 Demography, 5-7, 3544 hemophilia, 75 ago factors, general, 6, 38, 4041, 42, 4S, 50. 54, 55. ..6. hypertansion, 53, 76 247-248. 270, 282 0,7migrim workers, 33 Census llureau 35. 38, 40 renal. 64, 65 definitional issues. 35, 37, 38. 40-41, 5.i-54, 72. 298 Clayton Act, 185 elderly, 40-4', 50-52, 54, 55, 56-58. 145, 172, 174. 205, Clergy, 430-431 247-248, 270, -. 3, 305 Clinics, sce Community and Migrant Health Crafts; Commu- epidemiology, 82 nity health centers, Rural health clinics; Satellite climes hospitals and. 6, 13, 37, 111-113. 117-120, 121, 143-144 Colorado, 160, 169, 202, 203, 320, 391 tow-density arm,. access issues. 6, 13, 37. 118.120, 144-145, Committee on Labor and Human Resources, 5 150, 153, 168, 213 Con.nunity and Migrant Health Centers (C/MHC), 8, 9, 12,13, migrant workers, 52-53. 54-55. 59, 78. 80, 83, 104, :94 14, 361 minority groups. 6,40,53, 54, 78,79, 83, 272-271, 298, 304, maternal and infant care, 24-25, 398, 405, 407 316, 335, 380, 387, 388. 369.390. 411 mental 14. ith sersoces, 28 mortality, 5, 25, 26, 43, 44, 54, 20, 288, 293, 298, 304, 305, Natioaal Health Sea. :ce Corps, 357-358, 360-361, 368 309, 379, 380, 387, 412 research. 17 outmigration, 12, 17, 37-38, 78, 146-147, 153, 211 standards. 13 professional petsonird, supply, 5, 8, 17-19, 20, 25, 116, 145. Cceman health centers, 79-80, 124-128, 129, 151, 152-153, 219-784, 309-310, 311, 318, 319, 3-e1-376, 390400, 158-159, 160, 172-173, 174, 183, 192, 197, 211. 426-431 administration, 160-161, 122 research, 82 mental health, 711,76, 419. 432 State-level data, 39, 40 ecorkunic factors, 140-142, 14,-146 transidon grams, 81 understrved areas, kiignation, 293, 299, 306, 308 underserved areas, 61, 126, 150, 287-311, 361, 362, 372. see Community mental health centers, see Mental health service.; also Health Manpower Shortage Areas Community Mental Healt:' Comers Act, 76, 418-419 ace also Geographic factor., Income, personal, Metropolitan Community Support Program, 420, 421422 areas, Poverty; Regional trends, Sox differences Comprehensive Alcohol Abrse and Alcoholism Prevention. Demonstration projects, 17 Treatment, and Rehabilitation Act, 76 Area Health Eeucrion Centers, 21 22, 78, 100, 299, 301 COmputer science elderly abuse prevention, 17-1 databases, 26, 397 hospitals, alternative, 201-202, 211-212 telecommunications, 337, 346-348, 409 maternal and infant care, 26-27, 75, 396.4,10412 Conferences and meetings medical schools. 93 mental health, 419-420 mental health care, 29, 420. 421, 433-434 midlev:i practitioners, 24 networks, 214 Cooperatives, 169-172, 198 swing bed, 73-74, 105 Coordination, 15-17. 213-214 Dentists and dentistry, 19, 22. 47-48, 50. 80 multifacility alliances, 12, 124, 144, 161, 169-175. 177, 212 education. :cats, 423 State role, 89-91, 94-95, 96 r, 98. 100-101, 104, 204-205 Health Manpower Shortage A-eas, 28f,. ?91, 294 Corporate restnicturing, 167-168 hygienists, 277, 27S Costs Medicaid. 73 ambulatory surgery. 13. 57, 80, 134-136 pediatric. 270, 271, 272 conimunity health centers. 141-142 supply/demand, 268-272, 283 education. professional, 63, 64. 64, 3 "174, 331, 338, 374, Depa....nent of Agricuituie, 41 423 -mpanravit of Health and Human Serices. 82, 125, 185. 199 hospitals, 10. 17. 124, 131-127, 138, 158-159, 164 coordination, 17 licensing, 188 essential services criteria, 14, 16 Medicaid, prospective payment. 7), 164 genetic sc.eening, 75 Medicare, prospective payment system, 51-66.132-134. 158, health cam rgorks, 15-16. 17. 214 164,213 legislative models. 24 physician pract ice, 329, see also Malpractice insusamc physician bonus payment program, 24-25..1C3, 3S0-351, 101. State systems. 103 167, 374 Counseling services. 424, 427 underserved areas. 61, 126, 150, me also lizilth Manpower self-help grourbs. 431 Shonege Areas Court cases, ace Li4 lion see at.o Medicaid. Medicare: Medically Underserved Ao as, Crime and criminals specific admonstra.ive subunits fraud, 13. 14-15. 184-185, 192 Department of Health Bdt cation and Welfare, 287-288, 291 rape. 76 Department of Housing and Urban Development. 14, 203 Criteria, see Standards Department of Justice. i85 Diagnosis. 80. 167, 198. 20 : , 310 Datab3.w.s, 26. 397 Medicaid, 70, 71 ttaimgememptatavati,No wittoopmewauwwwfir-wwwwwwwwwitseggE" 1n1ex 519 Mti lieu.% 16, 52, 70. 61.66 tax exempaons. 167. 181-184, 189-190. 192. 192 :4rysician opinions, 52, 71, 118 underserved areas, criteria. 287-291, 276. 298, 301, 30?-211, prospective payment system, 16, 61-66 362, 172 screening, 43, 70, 75, 80, 167, 411, 432 see also Licenses and permits oicians, 279-280 Emergency sod acute care,5, 12.76,8(.81, 114, 116,145,151, DIUonskule, 190 162, 24 Disabled persons, 6 Health Manpower Shonage Areas, 298 children, 75 intensive care, 114, 115, 409, 410, 411 Dischazge planning, 71, 214 Medicaid/Medicare, 73, 211 Diseases and disorders mental health services, 422 migrant workers, 53, 59 State action, 91, 105. 198, 201, 202, 201 mashie, 53, 80 swing bed program. 73-74, 105, 163-165, 166. 177, 182, 189 substance abuse, 9. 61. 62 76-77, 161 198.419, a2-424.426 tecnnicians. supply/demand, 278, 280 see also Acute disease; Chronic disease see also Essential Access Community Hospitals Drug abuse, see Alcohol abuse, Substance abuzz Emergency Health Pets snnel Act and Amendments, 287, 352 Employment and unemployment Eska. TT q 53, 238, 318 &lied health personnel, 278, 280, 281, 282 Ecoaomic factor.; 6, 42, 54 caves choice, 315, 316-319, 322-323, 331 affordability of heakii can. 5 cqunty classifications, 41 anfitrusr, 135-lb3, 139, 190-192, 193 government, 41, see also National Health Service Corps assessmen$ of, 94 hospitals, 116, 117, 158 community health centers, ;40-142, 145-146 hours of work, women, 229, 317, 318, 129 cooperatives, :69-172, 198 insurance coverage and, 43-4 1, 49 eorpante restnicturing, 167-168 leave, 91, 348 depression, 293 nurses. 24,73, 74,259-263, 264-268, 270. 320, 321, 322, 124 efficiency, hospitals, 145, '58, 162-177, 187, 213-214 satisfaction with job, nonphysictans, 322-323, 331 hospitals, 8,10-12, 17, 111, 113. 123-124, 130-140, 142-146, satisfaction with job, physicians, 318 152, 158. 159, 160-177. 187, 188, 211-214 trends. 42 licensing, 188 underserved areas, designation criteria, 304, 305 mental health, 418 urban v. rural, 41 mergers, 175-176, 185-.87, 192 vacation, 348 personnel recraitment and mention, 22-23. ^4, 77, 92, 93, 98, see also Migrant workers, Recruitment and retention. Wages 183, 185,242,282,32-329.331-332,14R-351. 359, 36!, and salaries 362, 363-366, 367, 374-375 Envu;:nmental health. 80 regional trends, 41, 42 mic substances, 53, 75, 76 uncompensated care, 5, 10. 130, 131, 132, 135. 140.157.211, Ep;demiology, 82 329, 332; see also Uninsured patients fetal and infant health indices, 180-187, 390, 391 see also Antitrust law; Costs; Financing am. rgemects. mental disorders. 417-418, 419. 420 Furbdinz; Income,personal; Market forces and marketing, State collection efforts, 24-25 Poverty; Revenues; Taxes underserv d area indices, 309 Education, see also Mortality patient, 62, 1'i4, 432 Equipmeht, 92, 93, 329 public, 21-22, 80, 314, 118 acute care, 114 see also Prokssional education ultrasound, 409 Effieiency, hospitals, 145, 158, 162-177, 187, 213-214 F..ssential Access Community Hospitals. 13, 65, 204, 2n7, 212, Elderly. 40-41,50-57 54, 55, 56-58, 145, 205 214 arfflneies on aging, 172, 174 Esser.ial services, 13-15, 16, 167, 97499. 211-212 dentists, 270 criteria, 13-15, 66, 198, 204. 213 physicians, 247 -Pt' see also Emergency and acute rare; Sole Community retirement counti-s, 41 Hospitals undenerved areas, 29 I, 305 Evaluation urban v. rural, 40-41, 50-52, 54, 5f, 56 National Health Service Coips. 358 ..e also Medicare see also Needs assessment; Quality control, Stannaras El .1bility Exceptional Financial Need Scholarsh.p Program, 315 acute-care hospitals, 201 Exercise, 41 s.simmimity health centers, 80 Essential Access Community Hospitals, 204, 214 Facilities, see Community and Migrant Health Cenk rs, Com- maternal and child health vants, 75, 404, 406 munity Health Cente,s, Hospitals. M ohifacihry alliances. Medicaid. 68-70, 73-75, 4434, 406 Rural health clinics; Satellite clinics Medicare. 73-75, 181-182, 204 Fantaies and households National Health Service Corps. loan repayments, 22, 77-8, size, fec scales, 80 287, 299, 351, 352-354, 356 spouses of practitioners. 317-318, 331 520 Health Care in Rural America two-parent, Medicaid eligibility, 69 Florida, 93, 169, 202-203, 205, 281, 330, 366, 397 set: alsoChildren hooridation, 76 Famikt practitioners, 226, 229, 231), 233, 245, 316, 317, 335, Foreosting,seeProjections 339, 341, 397-99, 412 Foreigt medical graduates, 229, 231, 247, 248 Firmers Home Administration, 139-140, 205 Fraud, 13, 14-15, 184-185, 192 Forming,seeAgriculture; Migriri workers Funding Federal Housing Act, 138 coinnumity centers, Federa1,8, 79-81, 124-128, 129,140-141, Federal Improved Child Health Program, 411 141, 160-161 -ederal Loan Repayment Progran , 2, 77-78, 352-354, 356, 368 educatioa, professional, 9, 20-21, 335, 339-340, 352-358 .lederal role, 5, 8-10, 13, 61-83 essential services facilities, 14 administrative, 14, 24-25, 75,46, to. Federal, 8-10, 14, 15-16, 22-27, 28-29, 77-83, 890 J, 106, antitrust, 185-18 119, 137-138, 139-141, 160-161, 204, 335, 3118-348, community health centers, fundmg for,b,79-81, 124-128, 332-358,419, 420, 433,see alsoBlock grants 129, 140-141, 142 11-161 local. 157 :du cation, profess ional, 9, 2't4:2, 24, 28,78-79,371, 316, 335, networns, 1546, 17, 214 338-348, 351-339 State,23-V,89-91,93, 100,105-106,130-131,133,363 365, essential servtces criteria, 13-15, 66, 198, 204, : 13 428, 433 Binding, 8-1e, 14, 15-16, 22-27, 28-29, 77-83, 89. '0, 1e6, statistics, 25 119, 137-138, 139-141, 160-161, 204, 335,_ 8-348, see alsoPublic assistance; Student aid 352-358, 419,420, 433;see alsoBlock grants hospitals, assistance, 9, 13-14, 119-120 General Ai-doming Office, 75, 400 land ow -rship, 41 General acutione-s, 226, 229, 233, 243, 268, 270, 317, licenses and permits, 14, 16, 126-1:9, 192 ...o.S-394 395. 397 local systems, relation to, 10, 1°1 Geographic factors, 146-151 maloractice, 26, 396-398 antitrust, 186, 190, 193 maternal and infant care, 9, 7.3-27, 61, 62,75-'6, 80,396, 404, essential services cniena, 14, 204, 213 411, 412 hospitals, 118-120, 144-151, 150, 153, 213, 412 ment0 health services,9,28-29, 76-77, 418-420, 433-434 low-density =as, ateess issues, 6, 13, 37,118-120,144-145, migrant ht,..1di centers, 53, 55, 59, 80;see alsoComntunny 150, 153, i6g, 213 and Migrant Hea:th Centers Medicare, 83, 146, 150 planning, 16-17, 21.. mental health serv tees, 27, 426, 422, 428 policy, 9, 15, 16, 11, 61, 82-83 midwives, 257 recmitment and retention, general, 372-O76 nurse doscribution, 251, 260-268 regulations, 181-138, 192, 199.200, 211, 212 optometrists 274, 276 277 research, 9, 17, 61, 82-83, 420 physician zssisizms d,strihn:ion, 252-255 st.mdards, 17, ; lit, 192, 199-200 physician distribution, 23f, 242, 242, 243, 337 '.itate relation to, 10,14, 15, 23-24,75,87,89-90,93,101,106, remote areas, 15, 17, 21? 30i, 302, 303-308, 1, 361, 362, 368 State distribution effort.i, 361-564 student loan repayments, 22, 77-78, 287, 299, 301, 351, underserved areas, 61, 126, 150, 281-3 n, 361, 362,see also 352-354, 3!.6, 357, 368, 431 Health Manpower Shortage Areas technical assistance, 9, 10, 14, 15, 25, 26, 27, 212 see alsoDemograrhy, Metropolitan areas, Regional trends alsoHea.th Manpower Shortage Areas, Legislation, SPite-level action, Sole Community Hospitals, Transpor- specific Ye.ieral; Medicaid; Medically Underserved Areas, tation Medicaro; National Health Service Corr-spectfic agen- Georgia, 190, 341, "t97 cies anddepanments personnel suppl)/demand, 246-247. 251, 274 Federal To.t Claims Act, L ',97, 3911 Government role Federal 'Pack Comnussion, 185, 18o as employer, 41 Fertility, 388 facility collaboration with, general, 197-207 Financir.g arrangements see alsoFederal role, Local systems, State-level action coop ratives, 169-172, 198 Graduate Medical Education Nationaldvisory Committee. corp trate testructuring, 167-168 220, 247 hospitals, 130-140, 145, 158, 159, 166-177, 183, 187-188, 202,212, 319 Handicapped persons,seeDisabled persons Medicaid, 68, 71-73, 205 Hawaii, 95, 366 Medicare, 16, 61-66, 82, 132-134, 158, 164, 202, 348-350 Health Care Financinz Administration, 24-2. ,1,18.4. 200, 202, mergers, 175-176, 185 187, 192 203, 3'.;13 Omnibus Budget F,oøcj1jauon Acts, 16, 83, 74, 75, 78, 81, Health Careers Opportunity Programs, 335 83, 338, 340, 348, 350, 419 Health education,seeI ...canon, Professional education research, 82 Health Education Assistance Loan Program, 335 State-level, 100, 193, 104 Health insurance, 43-46, 48, 49. 80 see alsoCapital investments; Costs, Heabh Ciire Financing elderly, 50-51 Administration, Malpractice insurance, Public assistance income level and, 44, 46, 49, 54 5 t; Index 521 maternal and inknt care, 401-404 financing arrangements, 130-140, 145. 158, 159, 166-177, iniatvel practitioners, 320, 322 185,187-188,202,212,319 nurses, 322 hmdraising, local, 157 physician income, soorce of, 326 geographic factors, 118-120, 144-151, 150, 153, 213, 412 unirsured, 5, 6-7, 50, 54, 82. 105, 211, 213, 305, 331, 390, unensive care, 114, 115, 409, 410, 411 400, 401-403 licenses and permits, 16, 73-74, 12. 187-188, 192, 199-204 see alsoHealth roaintenance organizations, Medicaid, Medi- lot al efforts, 113, 131, 133, 175-176, 190. 205-;06 care long-term care, 114, 116. 143, 152 Health Maintenance Organization Act, 291 maternal and infant care, 407-409, 410, 412-413 Health maintenance okanizations, 21, 129 170, 229, 255, 2"4, Medicaid, 70-71, 72, 73-7.., 118,131,138-139, 84-185, 201, 291, 319, 320 212 see alsoMedically Underserved Areas Medicare, 16, 51-52, 62-66, 73-74, 118, 120-1 21, 130-135, Health Manpower Shortage Areu (HMSAs), 8, 9, 22, 23, 79, 138-139,181-182,184-185, 192, 199-200,201,202,211, 126, 282, 287-291, 293-294, 295, 371, 372, 375 212 Federal designation, 287. 288-291, 296 298, 301, 303-311 mental health, 163. 421, 422, 426 Medicaid, 74 mergers, 175-176, 185-187, 192, 21 2 Medicare and, 24-25, 67, 68. 74, 303, 32 4, 350-351, 361, 367, multifacility affiances, 12, 124, 144, 161, 169-175 177, 212 374 nurses, employed by, 259-260, 265, 266, 267-268, 270 mental health care, 286, 291, 294 nurses, State regulation of, 188, 189 midlevel practidoners, 320-321 oltmigration and viability, 12, 146-147, 153, 211, 407, 409 National Health Service Corps, n, 296, 298-299, 301, 303, ownership, 1 1 1, 113, 138. 185 309, 352, 354-356, 358, 368, 375 physicians, associations with, 166-167 176-177, 185, 197- State role, 301, 302, .A.i3-304, 303-308. 311, 361, 362 189, 192, 319 technical assistance to, 94 planning, 9, 12, 159-160, 212 volunteer program, 77, 78, 296, 290, 354, 357, 358, 368 'ferry, service population. 64, 65, 118, 145, 167 Health Resources and Services Administration, 25, 75, 79, 80, p.ivaie hospitals, 113, 143, 268, 291, 298 see alsoHealth Manpower Shortage Areas; Medically miblic, 190-192 Underserw.d Areas quality control, 167, 169, 170 Health Services Nock vent, 9 regional factors, 111 122, 148-149, 150, 170 Hemophilia, 75 reorganization, 161-177, 190, 192-193, 197, 211-212 Hill-BmIon Am, 118-120, 132, 137-138 research, 82 Hispanics, 53, 78, 83 revrictions on public hospital:, 13, 103, 162, 212 Historical perspectives revenues, 10, 132-133, 135, 137, 152, 162, 171, 184 demography of U.S., 37-38 specialists, associations with, 114, 143, 170, 171 economies, 42-43 staffing, general, 116, 117, 158, 167, 200 Health Manpower Shonage Areas, 281-28S State gram, 105, 131, 133 Medically Underserved Areas, 291, 293 tax exempt status, 167, 183-184, 189-190, 192 193 research, 82 tax subsidies, 131, 133, 139, 205-206 Home care services, 80, 182, 198 technical assistance to, 94 Medicaid, '0 uansportation to, travel time, 147-149, 213, 412 preventive, 76 uncompensated care, 5, 10, 130. 431, 132, 135, 140,157, 211 Hospitals and hospitalization, 80, 111-124 151.132 urban, cooperation with rural, 171-172, 173, see also Satellite administration, 82, 113, 160-161 clinics AHA, 111, 165-166, 278 urban v ;utak 7-8,10,11, 53, 54, 58, 111, 112, 113-114, 121, allied health personnel, employed by, 278. 280 122, 123-124, 131,143, 153, 158, 171-172,173,190,211, alternative models, 199-204, 206-207, 211-212 407, 408,409, 412-413. 420-421, 422 antitrust law, 186-188, 189, 190-192 193 utilization, 10-11, 48, 50, 51-52, 53. 54, 58, 81, 83, 94, H , capital invesnnents.14, 137-140,161,188-189, 191, 192-193, 112, 117-124, 145, 152, 153, 158 203, 205, 413 see also Essential Access Community Hospitais, Rural closures, 142-146, 153, 319,408 Primary Catt Hospitals, Sole Community Hospitals cooperatives, 169-172, 198 Hospital Survey and Construction Act, see Hill-Burton Act costs and cost containment, 10, 17, 124, 131-137, n8, Hotlines.411, 426 158-15!., 164 Hours of work, 229, 317, 118, 329 demography, general, 6, 13, 37, 111-1n, 117-120, 121, Hypertension, 53, 76 143-144 discharge planning, 73, 214 Idaho, 337, 344 diversification, 162-163, 167-168, 190, 192-193 Illinois, 105, 174, 185-187. 191. 4 26 economic factors,8, 10-12, 17, III, 113, 123-124, 130-140, Immunization, 43, 48, 75, 76 142-146, 157, 158, 159, 16n-177, 187, 188, 211.214 Income, business, see Revenues efficiency, 145, 158, 162-177, 187, 213-214 Income, personal, 6, 25, 38, 40. 42 Wert', 51-52, 58, 145 elckrly, 30, 36 Federg assistance, 9, 13-14, 119-120 Insurance coverage -Ind, 44, 46, 49, 54 52 patient, and travel time to physicia.1, 243 8:, 338, 340, 348, 350, 419 practitioner, 313, 316, 318-319, 325-329, 331-332 PubV... Health Act, 79 sliding scale fees, 75, 80 Public Health Service Act, 78, 335 underserved areas, designat1on criteria, 304, 305 Rural Crisis Recovety Program Act, 420 urban v. rural, and Medicare, 67 Rural Health Clinics Act, 74, 105, 299, 361, 375 see also Poveny; Wages and salaries Social Security Act, 75 Indian Health Service, 411 sole/essential community nospkals, 65 Indians, see Native Americans Licenses and permits Infant mortality, 25, 26, 80, 2, 293, 298, 304, 305, 379, 380, allied health personnel, 281, 330 387, 412 alternatives, 199-204, 206-207, 211-212 Infzctious disems, 80 clinics, 74-75, 94, 105, 126-129, 167, 182, 376 Information and information services family nrace-ionets, 226 on akernatiw strategies, 211 F .zral role, 14, 16, 126-129, 192 confidentiality, mental health patlents, 426 hospitals, 16, 73-74, 162, 187-188, 192, 199-204 databases, 26, 397 Medicaid, 16, 167 long-tenn as tessment, 17 mental health personnel, 422 maternal an1 child health grants, 75-76 midlevel practitioners, general, 319-320 mental heal ,h services, 425-426, 432 phannacists, 272 muti1ed practitioners, cleazinghoure, 342 rhysicians, 308 National Library of Medicine, 347-348 mstrictive, 13, 319-320, 330, 375, 412, 427 public hospitals, disclosure laws, 191, 193 Linking systems rexad technicians, 278, 280, 283 dischar,e planning, 73, 214 telecommunicatiors, 337, 346-348, 409 maternal and infant care, 27 State-level, 83 mental health services, 28, 419, 432-434 see also Statistical programs and activities outreach, 27 Institute of Medicine, 275-276, 330, 395-397 referral, 16. 65, 66, 113, 1..2, 163, 167, 171-172, 176, Insurance, see Health insurance; Malpractice insurance 184-185, 192, 205, 214, 339 Intensive care, 114, 115, 409, 410, 411 Litigation Interdisciplinary approach, 79, 359 antitrust, 184-188, 189 allici health personnel, -nultiple competencies, 21-22, 21/0- hospital diversification, 190 281, 284, 330, 342 obstretic malpractice, 25 Iowa, 95, 105, 173, 391, 421 Loans commercial, 13$ Kansas, 169 Hill-B=on Act, 119, 137-138 Kentucky, 38, 326, 360 low-intemst, 03 niongage's, 93 Lab technicians, 277, 279, 284, 330 student aid, '22, 77-78, 92, 97, 287, 299. 301, 335, 351. Language issues, 80 352-354, 356, 357, 36, 431 speech/language pathologists, 280 Local systems, 5 Itgal issues and services competition, 124 confidentiality, 426 Federal relation to, 10, 197 fraud, 13, 14-15, 184-185, 192 fundraising, 157 see also Crinb, and cririnals, Eligibility, Regulations health departments, 153, 169, 172-173, 308 Isgislation hosphsls, 113, 131, 1.43, 157, 175-176, 190, 205-206 ant:trust law, 186-188, 190-152, 193 State assistance, 93-94, 104 model, 15, 24 taxes, 15, 203-206 public hospitals, 190-192, 193 see also terms begkoung "Communtr) State action, 95-96, 101, 103, 104, 105-106, 190-192, 193, Long-tenn care, 205, 112 366, 396-398 hospitals, 114, 116, 143, 152 Legislation, specific Federal Medicaid/Medicare, 70, 73-74 Anti-Dmg Abuse Act, 77 regional networks, 170 Clayton Act, 185 Community Mental Health Centers Act, 76, 418-419 Maine, 174, 366 Comprehensive Akoho/ Abuse and Alcoholism Prevention. Malpractice insurance, 23, 25, 26, 329. 2,32, 395 400, 112 Treatment, and Rehabilitation Act, 76 midlevel practitioners, 320, 375 Emergency Heslth Personnel ALA and Amendments, 287, 352 State role, 93, 97, 105, 396-400, 412 Federal Housing Act, 138 Manufacturing, 41, 42 Federal Tort Claims Aci, 26. 397, 39$ Market forces and marketing, 94, 160, 167, 169 Health Maintenance Organization Act, 291 antitrust and, 186-188, 189, 190-192, 193 Hill-Burton Act, 118-120, '32, 137-133 physician supply, 242 Mental Health Systems Act, 76 see also Costs Omnibus Budget Reconeiliation Acts, 1*, 83. 74, 75. 78, 81, Maryland, 174 5iv 3 Index 523 Maternal and Child Health block grant, 9. 61, 62, 75-76. 400. physicians and. 22-23. 24-25, 303. 326-327, 331-332, 348- 404-405. 411, 412 351, 367, 374 Maternal and infant care. 25-27, 75-76, 114, 163, 317, 379-414 pn ary care, 19, 20 Federal role, 9, 25-27, 61. 62, 75.76, 80, 396, 404, 411, 412 pro .Jective payment system. 16. 61-66, 82, 132-134, 158, Health Manpower Shortage Areas, 298 164, 213 hospital-based. 407-409, 410 Rural Primary Care Hospitals and. 16, 65 tralpractice insurance, 23, 93, 395-4C0. 412 specialists. 67, 68, 325 Medicaid, 26. 400-401, 404, 406 swing bed program. 73-74. 105, 163-165, 166. 177, 182, 189 migrant worker utilization. $3 wbau v- nissi, 7,9. 43.46. 62-63, 67-68, 131. 326-327, 349 mortality, 25, 26, 80. 288, 293, 298, 304, 305, 379-387, 412 see also Sole Community Hospitals research, 83 Mental health services, 27-29, 80, 417-434 supply/demand, 25, 145, 233, 390-400 community mental health centers, 28, 76. 418-419, 420. 421, transportation, 93 422. 424-425 urban v. rural, 26, 379-387, 390, 396, 400, 404, 407,408, 409, Federal role, 9, 28-29. 76-77, 418-420, 433-434 412 Health Manpower Shortage Areas, 286, 291. 294 see also Midwives hospital diversification, 163 Medicaid, 9, 54, 61, 68-75, 80, 153 hospitals, 421, 422, 426 acute and emergency treatment, 73, 211 linkages, see Linking systems certification requirements, 15, 167 Medicaid. 28, 71 children, 43 substance abuse, 9,61.62.76-77. 163. 298, 419, 422-424,426 dentists, 73 urban v. rural, 27, 417, 418. 420-421, 422424, 425. 428-430, diagnostic services, 70, 71 432 elderly, use of, 50 Mental Health Systems Act of 1980, 76 eligibility, 68-70, 73-75, 404, 406 Mergers, 175-176, 185-187, 192 &lancing arrangeinents, general, 68, 71-73, 205 Metropolitan areas, v. rural areas, 5-7 Health Manpower Shortage Areas, 74 accidents. 43, 54 home services, 70 allied health personnel, 281, 284 hospitals, 70-71,72,73-74, 118,131, 138.139. 184-185, 2 community health centers, 141 212 definition, 35, 40, 54 maternal and infant care, 26. 400, 401-403. 404, 406 dentists. 269-270, 283 mental health services, 28, 71, 271 education, 346 midlevel practieioners. 320, 321, 322, 373, 375-370 elderly persons, 40-41, 50-52, 54, 55, 56 nurses. ard Medicare, 24. 73, 74, 320, 321, 322 health indicators, general, 43, 44. 4% 46, 54, 57 outpatient care, 70, 71, 74, 212 health insurance, 43-46, 48. 404 physicians and. 22-23, 24-25. 63, 64, 65. 74, 303, 326-328, hospitals, 7-8, 10,11, 53, 54,58, 111, 112.113-114,121,122. 400 123-124.131,143,153, 158.171-172.173,190,211,407, specialists. 326 408, 409, 412-413. 420-4,1, 422 State action, 68.70, 74, 98, 105, 400 maternal and infant health, 26, 379-387, 390, 396, 400, 404, swing be/ program, 73-74, 105, 163-165, 166, 177, 182, 189 407,408,49,412 underserved areas, designation, 304, 305, 307, 308 Medicaid/Medicare, 7, 9, 43. 46, 62-63, 67-68, 131, 326-327, urban v. rural, 7, 9, 43, 46, 326-327, 400 349, 400 Medical &manses, 329 mental health.27.411.418, 420-421,422424,425.478-430. Medically Underserved Areas (MUAs), 287, 291.293,294, 296, 432 299, 301, 304-306, 307. 309, 310, 311, 361, 362, 372 midwives, 255 Medicare, 8, 9. 13, 14. 50, 54, 61-68, 80 nurses, 265, 266, 267-268, 270, 282, 283, 317 acute and emergency treatment, 73, 211 optometnsts/ophthalmologists, 276, 277, 2$3 certification requirements. 16. 73-75, 167, 181-182, 199-200 pharmacists, 273-274, 283 diagnostic services, 16, 52, 70, 6t.-66 physicians, 226, 229, 232, 237-238, 242-249, 282, 329, educational costs estimated, 63, 64, 65, 366-367 331-332, 412 educational support. professionil, 20 poveny, 40, 42 eligibility. 73-75, 181-182, 204 property tax, 190 financing arrangements. geru ral,16. 61-66, 82, 132-134, bit. underserved areas, designated, 287, 288, 294, 297, 301, 302. 164, 202, 348-350, 304 geographic factors, 83, 146. 150 utilization of care, 7, 10. 47-50, 50-52, 53, 54, 58, 81, 82, 111, Health Manpower Shortage Areas, 24-25, 67, 68, 14, 303, 112, 117.118, 211 320. 350-351, 361, se.374 Mexico, 78 hospitals, 16, 51-52, 62-6o, 73-74, 118, 120-121, 130-135, Michigan, 338, 418 138-139,181-182.184-185.192, 199-200,201,202,211, Michigan Pnmary Care Atsociation model, 306. "-07 212 Midlevel practnimiers, 18, 24, 74, 158, 182, 199, 203, 352 midlevel practitioners, 24, 320-322. 331, 373. 375-376 education, 21, 250, 319, 320, 339-341, 373 nurses. and Medicaid, 24, 73, 74, 320, 321, 322 Medicare/Medicam, 24, 320-322, 331, 373, 375375 e.npatient care, 67, 74, 212 National Health Service Corps. 355, 356. 357, 375-376 5.r:!4 524 Health Care in Rural America private insurance reimbursements, 320, 322 deaths averted index, 309 recmitment and retention, 319-322, 373, 374-375 infant, 25, 26, 80, 288,293, 298,304, 305,379, 380,387,412 satellite clinics, 168, 359, 360, 367, 376 matunal, 25, 388-389,412 supply/demand, 249-268, 282-283, 371 suicide, 417 see also Allied health professionals, Midwives, Nurses and wban v. rural, 43, 44, 54, 417 nursing; Physician assistants Multidisciplinary approach, see Imeubsoplinev approach Midwestern U.S. Multifacility alliances, 12, 124, 144, 161, 169-175, 177, .:12 elderly, 50, 54 hospitals, I 1 1 National Adviwry Committee on Rural Health, 16 mental health, 425, 426 National Center for Health Statistics, 26, 309 migrant workers, 53 National Health Interview Survey, 47, 387, 417 State role, 91, 92, 93, 97 Nadonal Health Services Corps, 9, 22, 26, 77-78, 92,93,97, 351, Midwives, 18, 21, 24 352-358, 361, 362, 367, 397, 398 define d, 250 Health Manpower Service Areas, 77,296, 298-299, 301. 303. education, 250, 320, 339-340, 341, 356, 358-359 309, 352, 354-356, 358, 368, 375-376 malpractice insurance. 397, 398, 412 midlevel practitioners, 355, 356, 357. 375-376 national association, 255, 320 midwiver, 77, 356, 397 National Health Service Corps, 77, 356, 397 volunteers, i7, 78, 296, 299, 354, 357, 358, 368 puOlic assistance reimbutsements, 321, 322 National Institute of Mental Health, 419-420, 426, 430, 431 supply/demand, 249-250, 256-257, 282, 372, 397, 398,412 National Library of Medicine, 347-348 atligrant workers National Muldslcilled Health Practitioner Cleannghouse, 342 ace...lents, 80 National Residency Match Program, 229 Border Health Education Centers, 73 National Rinal Health Assmiation, 100-101 definition, 52 Native Americans, 54, 78, 411 demography, 52-53, 54-55 Nebraska, 82, 274, 335, 419, 421, 428 federally funded health centers, 53, 55, 59, 80, see also Needs assessment, Fedetal assistance, 9 Community and Migrant Health Centers Nevada, 95, 366, 397, 409 Health Manpower Shonaga Areas, 298 New Mexico, 161, 336, 345-346 research, 83 New York State, 92, 95, 103-104, 146-147, 316 State role, 104 Nonprofit organizations utilization of services, 53, 59 charitable organizations, 189 Migration, from rural areas Health Mznpower Shortage Areas, 289, 291 history of, 37-38 hospitals, 81. 151 hospital viability and, 12, 146-147, 153, 211, 407 see also Volunteers and volunteering research, 17 North Carolina, 92, 159, 163, 167,169, 204-205, 280, 319, 344. Mining, 41, 42, 80 366, 391, 397 Minnesota, 81, 119, 145,162, 170, 246, 248-249, 319, 326-327, North Dakota. 168, 11. 316. 425.426, 430-431 336, 337,422 Nonheastarn U.S.. 92. 93. 97. 260 Minority groups, 6, 40, 54, 78, 79, 83 Northern U.S., 243, 371, 407 Black Americans, 40, 380. 387, 3isli, 389-390 Nurses and Rinsing, 27, 165, 332 Hispanics, 53, 78, 83 anesthetists, 250, 247-259, 322. 340 maternal and infant health. 380, 387, 388, 389-390.411 defmed. 250, 259 migrant workers, 53 educ,tion, 21, 79, 93, 250. 251,257, 259, 260, 264, 265, 266, Native Americans, 54, 78, 411 320,323,324,339-340, 341-342.351,356.358-359,373 pharmacists. 272-273 elderly, education of, 174 professions. personnel, 316 employment, 24, 73, 74, 259-263 264-268. 270. 320. 321, student aid, 335 322, 324 underserv.4 areas, designation, 298, 304 hospitals and, 24. 73, 74. 188. 189. 320, 321, 322 see also Migrant wotkers houts of work, 317, 318 Misr issippi, 38, 326, 397 as linkage agents, 28 Missouri, 189, 336, 338 long-icrin eare, 116 Models, 211-212 Medicaid/Medicare reimbursements, 24. 73, 74. 120. 321. 32 basic services, 197-198, 214 National Health Service Corps. 77 health care networks, 15-16, 17, 168, 169, 214 private insurance reunbursements, 322 licensing alternatives, 199-204, 206-207, 211-212 recruitment and placement, 92. 93. 322-323. 341-342. 359- midlevel practitioners, 24 360, 362 service delivery, 16 research, 83 State legislation, 15, 24, 396 salaries. 326 see also Demonstration projects State hospital regulations, 18%. 189 Montana, 16, 88, 200, 203, 205, 206-2( 7, 212, 337, 339, 344. supply/demand, 18-19, 249. 250-252.257- '58, 269. 270.282, 348, 391,426 283, 371 Mortality, 5 urban areas, 265, 266, 26726X. 270. 282, 283, 317 0'.ar ,.... Index 525 see also Midwives 335-339, 432 Nutritionists, see Dieticians elderly, 247-248 Obesity, 43 family practitioners, 226, 229, 230, 233, 245, 316, 317, 335, Obstetrics, see Maternal and infant care 339, 397-399, 412 Occupational therapy, 114, 277, 279, 283, 284 fraud regulations, restrictive, 13, 14-13, 184-185, 192 Office of Management and Budget, 35 general practitioners, 226, 229, 233, 245, 268, 270, 317, Office of Maternal and Child Health, 26-27 393-394, 395, 397 Office of Rural Health Policy (ORHP), 9, 15, 16, 17,61, 82-83, general practitioners, 226, 229, 233, 245, 268, 270, 317 101 393-394, 395, 397 Offices of rural health (State-level), 90, 91, 96-97, 98, 99-100, geographic distribution, 238, 242, 24 2, 243, 337 106 hospital licensing requirements, 203 Ohio, 168 $ospitals, fmancial associations with, 166-167, 176-177, 185, Oklahoma, 92, 316, 344 187-188, 192, 319 personnel supply demand, 255, 267. 274, 275 hours of work, 317, 329, 331 Omnibuslludget Reconciliation Acts, 16,74, 75, 78, 81, 83, 338, income, 318-319, 325-329 340, 3413, 350, 419 Medicaid, 22-23, 67.68, 71, 72, 73, 74, 205, 304, 308, Op.ometrists, 19, 274-275, 276, 277, 283 326-328, 400 Oregon, 157, 293, 360, 366 Medicare, 22-23, 24-25, 63, 64, 15, 74, 303, 326, 127. Osteopathic medicine 348-350, 367, 374 educational costs, 323-324 as mental health providers, 27, 430, 42, 433 Health Manpower Shonage Areas, 289 National Health Service Corps, 77, 351, 352, 352-359, 398 supply/dernand. 220, 225-226, 231-232, 234-238, 239, 247, opinions, diagnos. , og., 3111 28 2 osteopathic medicne, 220, 225-226, 231 232, 23-238, 239, Outmig.-ation, see Migration 247, 282, 323-324 Outpatient services, 81, 120, 122-123, 152, 162, 165-167, 176, recruitment and retention, 77, 92,93,94, 14'i 167, 170, 183, 201, 202, 212 185, 242, 243, 315-319, 335-339, 351, 3f.2-359, 362 ambulatory surgery, 13, 67, 80, 114, 122.123, 134-136, 162, specialists, lupply, 226, 227-228, 229, 230, 231, 233, 242, 163. 212 324, 331 Medicaid, 70, 71, 74, 212 student loan repayment aid, 22, 77-78, 287, 299, 301, 351, Medicare, 67, 74, 212 352-354, 356, 357, 368 Outreach, maternal and infant care, 27 supply/demand, 5, 8, 17-18, 20, 116, 219-249, 315-316, 318, Ownership of enterprise 319, 324, 371 hospitals, 111, 113, 138, 185 underserved areas, criteria, 288-289, 293, 296, 298, 309 property tax, 189-190, 193 urban v. rural, 226, 229, 232, 237-238, 242-249, 282, 329, 331-332,412 Paraprofessionals, mental health, 27, 29. 431 utilization, 47, 50, 51. 54, 58, 127 Parasitic diseases, 53, 80 see also Malpractice insurance Patient education, 62, 174. 432 Planning Pennsylvania, 163. 189. 246 community health centers. 159-160 Pesticides, 53 discharge, 73, 214 Pharmacology and pharmacists, 80 Federal role, 16-17, 214 education, costs, 324 hospitals, 9 12, 159-160, 212 prnmiptions, 168-169, 320, 430 State, 104-105 snail/demand, 1 9, 272-274, 283 Pests and pesticides, 76 rhysical therapists, 277, 278, 279, 283, 284 Policy issues Physician assistants, 18, 19, 23, 168-169 Federal role, 9. 15, 16, 17, 61, 82-83 defined, 250 State role, 91 education, 250, 253, 319, 320, 339, 340 Population factors, see Demography Medicaid reimbursements, 74 Poverty, 6.7, 38, 40, 42, 44, 54, 80, 10f. Medicare reimbursements, 24, 74 county level classification, 41 recruitment and placement, 92, 93, 362 essential services critena, 14, 204, 213 State reguladon of, 319-320 health care networks, 15 supply/demand, 249, 232-255, 256, 282, 372 hospitals, serving poor, 64, 65, 118, 145, 167 Physician bonus payment program, 24-25, 30.1, 350-35 1, 361, maternal and child health grants, 75, 404 367, 374 Medicare, 213 Physician Payment Review Commission, 3 25, 326, 348, 350 migrant workers, 53 Physicians physicians, travel tune to, 243 allopathic medicine, 220, 225, 232, 249, 318, 323.324 Siam actions, 205 anesthesiologists, 258 student aid, 335 basic services, 199 underseived areas, designation cntena, 289, 291, 293. 298, community health centers, 80 305, 307 education, 63, 64, 65, 220, 225, 226, 249, 316-317,3 23, 324, women, 389.390 - - $26 Health Care in Rural America see alsoMedicaid incomeand practice costs, 315, 316,319,325-329,331-332 PfeMancy, see Maternal and infant care maternal and infant care, 23, 25, 93,145,233, 390100 Preventive care. 47, 54, 80 mental health care, 27-29, 426-427 immunization, 43, 47, 75, 76 optometrists, 19, 274-275, 276, 277, 283 screening, 43, 70, 75, 80, 167, 411, 432 statistics, 24-25 see alsoPatient education supply/demand, 5, 8, 17-19, 20, 25, 116, 145, 219-284, Preventive Health and Health Services block grant, 9, 61, 62, 76 287-311, 3t, 319, 371-376, 390-400, 426-431 Primary care, 5, 79-81, 168-169, 174 turf guarding, 212, 375, 433 closure, 145-146 see alsoAllied health personnel; Bureau of Health Profession- education, 79 als; Employment and unemployment; Health Manpower hospital-based, 167 Shortage Areas; Licwises and permits; Medically Under- Medicare payments, 19, 20 served Areas; Midlevel practidowrs; National Health mental health, 420, 430, 432 Services Corps; Nurses and nursing; Physician assist 184-185, 192, 205, 214, 339 351, 352, 353, 356, 357, 367. 368, 374 Regional trends Screening, 43. 70, 75, 80, 167 age distribution, 42 50, 54, 55, 56 Searbelts, 43, 54 community health centers, 140 Self-help groups. 431 economic factors, 41, 42 Sex differences, 6. 231 funding. 90 see also Women Health Manpower Shortage Areas, 297, 371 Smoking, 43 hospitals, 113, 122, 148-149, 170 Social Security Act, 75 maternal and infant care, 27, 393-395, 396, 399,409-410, 411 Social serviccs and social woiters, 27-28, 8 2 migrant workers, 53 counseling services. 424, 427 neri. -lib, 16, 204, 207. 214, 330 Medicaid, 73 muse supply, 260, 26i-262. 264 sell-help groups, 431 physician assistant supply, 253 Sole Community Hospitals (SCHs)13. 14, 65, 66. 117-118, physician supply, 220, 224-225. 229, 234-238, 239-241 133, 149-150, 153, 213, 270 population characteristics, 41 South Carolina, 344. 397 State-related, 90, 91 5- 'di Dakota, 92-93, 168, 347, 421 r swing bed programs, 166 Southern U.S. underserved areas, 300 economics, 41. 42. 54 utilization, 127 elderly, 50, 54 see also Appalachia; Central U S.; Eastern U.S.; Midwest= hospitals, 150 U.S.: Northeastern U.S.; Southern U.S.; Southwestern nurse supply, 260 U.S.; Western U.S. physician supply, 233, 238, 242. 371 Regulations, 197 State role, 91. 92, 93. 97 Federal, 181-188, 199-200, 211, 212 underserved areas, 299, 303 fraud, 13. 1445, 184-185. 192 Southwestern U.3., 53, 242 State,15, 103,162,188-192,21.212,319-320, 330, 375, 412 Specialists and specialized services, 211, 220, 226. 227-228 see also Eligibility allied health personnel, 275, 277-282 Renal disease, 64, 65 anesthetists and anesthesiologists, 250. 257-259. 332, 340 Research audiologists, 280 access to care, 17, 144-145 thoice of, 315, 316, 331 demography, 83 dental, 268, 271 Federal aid for, 9, 17, 61, b2-83, 420 dieticians, 279-280 market, 94 education, general, 315-316, 3 17. 324. 326 mental iiealth. 420 family practitioners, 226, 229, 230, 233, 245, 316, 317. 335, perinatal care, 26 339, 341, 393-394, 395, 396, 397-399, 412 on regulatory impacts, 15 Health Manpower Shortage Areas. 298 State role, 91, 94,95 hospitals, 114, 143, 170, 171 student debt, 324-325 Medicaid payments. 326 see also Demonstration projects Medicare payments, 67. 68, 325 Respiratory therapi, ts, 278, 279, 280 optomenists, 19, 274-275, 276, 277, 283 Revenues physician assistants, 254, 255, 256 communir, health centers, 140-141, 142, 153 physicians, supply. 226, 227-228, 229, 230, 231, 233, 242, hospitals, 10, 132-133. 135, 137, 152, 162, 171, 184 324, 331 tax exempt, "4, 183-184. 189-190. 192, 193 radiologists. 277-278 Robert Woods Johnson Foundation, 345, 411 underserved areas, dzsignation. 304 Rural Health Care Transidon Grant, 9, 16, 81, 214 utilization, 47, 51 Rural Health Caucus, 5 see also Maternal and infant cam. Midwives, Physician Rural health clinics (RICA 13, 74. 126-127 assistants; Surgery certification, 74-75, 94, 105, 126-129, 167, 182, 376 Speech pathologists. 280 mental health services, 27 Spouses, 317-318, 331 midlevel practitioners, 320, 322 Stand-Ids, 13 Rural Health Clinics Act, 74, 105, 299. 361. 375 community health centers. 13, 183 Rural Health Research Center, 82 essential services, 13-15, 66, 198, 204, 213 Rural Infant Care Program, 411 Federal role, 17, 119, 192. 199-200 Rural Mental Health Demonstrations. 420, 433 supply statistics, 219, 220 Rural Primary Care Hospitals (RPCHs), 16, 65, 204, 207, 212, State role, 91 214 student aid/loan repayment. 352, 354, 356, 431 underserved areas, critena, 287, 288-29' "!96, 299, 298, 301. Safety. see Accidents and accident prevention 303-311, 362, 372 Salaries, see Wages and salaries see also Eligibility Satellite clinics, 168, 359. 360, 367, 376 State-level action, 8 7-106, 197-205 Scholarships, 22,23, 77, 78-79, 92,97, 298, 301, 316, 323, 335, acute and emergency treatment, 91, 105, 198, 201. 202, 203 [ .16&1171.1. 528 Health Care in Rural America administration, 24, 68. 89-91, 96-97. 98, 99-WI, 104, 106 fetal and infant health indices. 380-387. 390, 391, see ,aiso capital investment fmancing, 103. 104 Infant mortality definition, 87. 89 mental health. 29 definition of rural area, variations in, 38 metropolitan statistical areas, 35, 36 educatioi., a 3, 24, 95, 97, 105, 188, 301, 366 perinatal care, 26 Fedaal reit ion to, 10, 14, i.23-24, 75. 87, 89-90, 93, 101, population, 35-60 106. 301. 302. 303-308, 311, 361, 362. 368 professior.al personnel. 24-25 funding, 23-24, 89-91, 93, 100, 105-106, 130-131, 133, 363, professioml practice cost index. 320 365, 428, 433 professional supply data, standards, 219, 22C hospital subsidies, 101, 131, 133 State collection efforts. 24-25 legislation, 95-96, 101.103,104,105-106, 190-192, 193.366. underserved arca indices, 309 396-398 see also Demography; Epidemiology; State.level statistical local areas, assistance to, 93-94, 104 data malpractice, 93, 97. 105, 396-400, 412 Statutes. see Legislation, Legislation, specific Federal maternal and infant care, 396-400, 412 Student aid, 366 Medicaid, 68-70, 74, 98. 105. 400 loans, 22, 77-79, 92, 97, 287. 299. SO. 333, 351, 352-354. mental health services. 421, 425.426, 433 356-357. 368, 431 midlevel practitioners. 319-322 mental health education. 29 nurse supply, 260 scholarships, 22, 23. 77, 78-79, 92, 97, 298. 301, 316, 323, offices of rural health, 90, 91, '16-97, 98. 99-100, 106 335. 351,352. 353, 356, 357, 167, 368, 374 personnel grants, 23-24 tuition reimbursement, 92.93 personnel supply/demand, 246. 246-249, 251. 255. 267, 274. Substance abuse, 9, 61, 62, 76-77. 163, 298,419, 422424, 426 275, 391 Suicide, 417, 420 physician supply studies, 246-247 Supplemental Security Ince -te. 68, 75 primary care, 90, 91, 98, 105 Supplemental Medical Insurance, 61 re= itment and retention, 91.92-93, 94, 96,97,361-366, 368, Surgery, 10, 114. 122 175 ambulatory, 13, 67, 80, 114, 122-123, 134-135,162, 163, 212 regulations, 15, 103, 162. 188-193, -11, 212, 319-320, 330, maternal and infant, 410 375, 412 Medicaid, 71, 326 statistics collection, 25 Medicare. 326 student loan repayments, 22, 78, 92, 97, 301. 351, 352. 354, State regulation, 188 356-357, 368, 431 Swing bed program, 73-74, 10.), 163-165. 166, 177. 182, 189 technical assistance. 15. 91, 93-94, 98. 105. 205, 212 undcrserved areas, 301. 302, 303-308, 311, 372 Task forces, 16.17, 96, 104. ;05 see also Licenses and permits; specific States Taxes State-level statistical data (tables) exemptions, 167, 183-184, 189.190 192, 193 ambulatory surgery, 136 hospital subsidies, 131, 133, 119. 205-206 anesthetists, 258 Incentives, primary caregivers. 23 community alth centeis, 125 local, 15, 205-20o coordination, Y6 property. 189.190, 193 education, 97, 361 Technical assistance general, survey of, 88.89. 91, 98-102 Federal, 9, 10, 14, 25, 26, 27. 212 issues, rankings. 102 maternal and infant care, 26, Health Manpower Shortage Areas, 297 State, 15, 91, 93.94, 98, 105. 205, 212 Medicaid, 72, 98, 321 sta;:stics collection, 25 Medicare, 136, 321 Technalon. 120. 121, 123, 170 maternal and infant health indices. 381-387, 393-395 acate care, 114 migrant workers. 60 allied health personnel, 280-281 nurses. 258, 261-263 ultrasound. 409 optometrists/ophthalmologists supply, 276 Telecommunications. 137, 346-348. 373-174. 409 physician assistants, 253 Telephone services, 411. 426 physhaans, 220, 222-225, 227-228, 230.238, 239-241 Tennessee, 91, 165-106. 189 population, 39. 40 Texas. 93, 95. 105, 157, 160. 189. 344-345, 346, 366, 39/ recruitment and placement, 91, 92-93, 94, 96, 97. 363, 364 personnel supply/demand, 251. 255, 267, 274. 391 msearch. 95 Torts, 26. 396. 397, 398 rural health clinics. 128 see also Malpractice insurance specialists. 2'47-228 Toxic substances, 53, 76 swing bed programs. 166 children, lead.based paint, 75 technical xssistance, Transportation. 17. 80 underserved areas. 308 hospitals, travel time to, 147.149, 213, 412 Statistical programs and activities mental health patients, 426. 432 definitional issues, 3, 37, 38, 40-41, 53.54 physicians, travel time to. 238, 242. 243 71,....M ..10.-.1'-, Index 529 public, 6 charitable organizations, 189 State funding, 93 mental health care, 29, 431 travel time to services, general, 309 National Health Service Corps, 77, 78, 296, 299, 354, 357, Uncompensated care, 5, 10, 130, 131, 132, 135, 140, 157, 211, 358, 368 329, 332 Underserved areas, 61, 126, 150, 287-311 Wages and salaries see alsoHealth Manpower Shonagc Areas; Medically allied health personnel, 281-282 Underserved Areas Medicare, wage index, 62-63 Uninsured patients, 5, 6-7, 50, 54, 82, 105, 211, 213, 305, 331, National Health Service Corps, 35$-356, 357 390, 400, 401-403 mental heaith workers, 28 Urban areas,see Metropolitanareas nurses, 326 Urban Institute, 309 physicians, 318-319, 325-329, 331, 355-356 Utah, 169, 171, 174, 189, 198-199, 251, 255, 257, 337 Washington St t., 147, 159, 197-198, 206, 337, 344, 391, 397, 41-50, 211 408, 428 conununity health centers, 127, 152-153 deficit index, 309 Western US., 41, 91, 92, 93, 97, 149, 150, 316 elderly, 51-52, 58 professional personnel supply/demand, 238, 242, 243, 260, hospital, 10-11,46, 50,51-52, 53, 54, 58,81, 83,94, 111,112, underserved areas, 303 1t7-124, 145, (52, 153, 158 West Virginia, 71, 160, 174 mental health services, 420-426, 432 Wisconsin, 131-132, 168, 170 midlevel practitioners, 359 Women, 163 migrantworkers. 53.59 allied health professionals, 275 physicians, 47, 50, 51, 54, 58, 127 mortality, 25, 388-389 urban v. mral, 7,10,47-50,50-52, 53,54, 58,81, 82,111, 112, pharmacists, 272 117-118, 211 physicians, 229 poor, 389-390 Vacation, 93, 348 rape, 76 Vermonr, 157, 189, 422 see alsoMaternal and infant care; Sex differences Virginia, 174, 185-187, 344. 397, 422 Wyoming, 71, 73, 203 Volunteers and volunteering 5 7 Related OTA Reports Defining Rural Areas: Impact on Health Care Policy and Research--StaffPaper. Examines and identifies Lea 1th service needs of rural subpopulations. 7/89; 68 p. GPO stock #052-003-01156-5; $3.25 NTIS order #PB 89-224 646 Rural Emergency Medical ServicesSpecial Report. Describes the availability and distrfoution of emergency medical service resources, and examines how limited Federal resources can be used to improve rural EMS. H-445, 11/89; 108 p. GPO stock #t52-003-01173-5; $4.75 NTIS order #PB 90-159 047/AS Indian Health Care. Analyzes the quality and adequacy of data on Indian health status; identifies the types and distribution of technologies and services available through the Indian Health Service and other providers, determines dr desirable range and methods of delivery of health-related technologies and services, and develops policy options to improve the selection, provision, financing, itud delivery of technologies and services; and develops policy options to improve the selection, provision, financing, and delivery of technologies and services to Indian populations. H-290, 4/86; 384 p. NTiS order #PB 86-206 091/AS Indian Adolescent Mental HtalthSpecial Report. Evaluates the mental health needs of American Indian and Alaska Native adolescents. H-446, 1/90; 92 p. GPO stock #052-003-01175-1; $3.50 Technology, Public Policy, and the Changing St r uctu re of American Agriculture. Focuses on future and emerging technologies in animal, plant, chemical, mechaniza- tion, and information areas and their implications for agricultural structure. Also explores linkages between policy and slructure for a clearer understanding of the factors that influence the evolution of the agriculture sector. F-285, 3/86; 380 p. NTIS order #PB 86-184 637/AS Information Age Technology a nd Rural Economic Dev elopment. In order to identify economic opportunities and problems for rural communities made possible by information technologies, the study will. 1) describe the status of rural America in the information age; 2) assess the current relevant communications technologies and services; 3) analyze current public sector actions; 4) evaluate emerging communica- tions technologies and services; 5) describe the ways in which communications technologicnay affect rural development; 6) assess the barriers to technological improvements in rural areas; 7) determine whether technology can foster a new era of economic opportunity in rural areas. F-285, 3/86; 380 P. NTIS order #PB 86-184 637/AS NOTE. Repons aro available from the LI.S. Government Printing Office, Superintendent of Documents. Washington, DC 20402-9325 (202) 783-3238. and the National Technical Information Service, 5285 Port Royal Road, Springfield. VA 22161-0001 (7031487-4650. 5 71 Superintendent of Documents Publications Order Form PI PO Protesso Cock Charge your order. rim *6799 It's easy! 1111111111102, ID YES,please send me the following indicated publications: To ths your orders and inquiries(202) 275-0019 Health Care in Rural America (540 pages) GPOstock number 032-003-01203-7; price $22.00. 0 Please sendme your Free Catalog of hundreds of bestselling Govs-Inment books. The total cost of my order is $ (International customers please add 25%.) Prices include regular domestic postage and handling and are good through q'coo After this date. please call Order and Information Desk at 202-783-3238 to verify prices. Please Choose Method of Payment: (Company or personal name) (Please type or print) 0 Check payableto the Superintendent of Documents 0 GPO DepositAccount 111111111111-D (Additional address/attention line) 0 VISAor MasterCard Account (Street address) EME Mil MEM Thank you for your order! (Coy. State ZIP Code) OCrecht card expiration 'late) i / (D._,time phone including area code) (Signature) Mall To: Superintendent of Documents. Government Printing Office. Washington. DC 20402-9325 Office of Technology Assessment The Office of Technology Assessment (OTA) was created in 1972 as an analytical arm of Congress. OTA' s basic function is to help legislative policy- makers anticipate and plan for the consequences of technological changes and to examine the many ways, expected and unexpected, in which technology affects people's lives. The assessment of technology calls for elcploration of the physical, biological, economic, social, and political impacts that can result from applications of sdentific knowledge. OTA provides Congress with in- dependent and timely information about the potential effectsboth benefi- cial and harmfulof technological applications. Requests for studies are made by chairmen of standing committees of the House of Representatives or Senate; by the Technology Assessment Board, the governing body of OM; or by the Director of OTA in consultation with the Board. The Technology Assessment Board is composed of six members of the House, six members of the Senate, and the OTA Director, who is a non- voting member. OTA has studies under way in nine program areas: energy and materi- als; industry, technology, and employment; international security and com- merce; biological applications; food and renewable resources; health; communication and information technologies; oceans and environment, and science, education, and transportation. samma=mammenomm Asomie 573 Appendix 16 EITD U.S. Dept.of Education Office of Education Research and Improvement (OERI) ERIC Date Filmed March 29,1991