After using an “all hands on deck approach,” the White House Rural Council was able to produce a package of new job initiatives that were announced at the White House Rural Economic Forum. The Council’s recommendations, which leverage existing programs and funding, include making HHS loans available to help more than 1,300 Critical Access Hospitals recruit additional staff, and helping rural hospitals purchase software and hardware to implement health IT. The specifics are below:

Increasing Rural Access to Health Care Workers and Technology

Increasing Physician Recruitment at Critical Access Hospitals: HHS will issue guidance to expand eligibility for the National Health Service Corps loan repayment program so that Critical Access Hospitals (those with 25 beds or fewer) can use these loans to recruit new physicians. This program will help more than 1,300 CAHs across the country recruit needed staff.  The addition of one primary care physician in a rural community generates approximately $1.5 million in annual revenue and creates 23 jobs annually.  The average CAH creates 107 jobs and generates $4.8 million in payroll annually.

Expanding Health Information Technology (IT) in Rural America: USDA and HHS will sign an agreement linking rural hospitals and clinicians to existing capital loan programs that enable them to purchase software and hardware needed to implement health information technology (HIT). Under current conditions, rural health care providers face challenges in harnessing the benefits of HIT due to limited access to capital and workforce challenges.  Rural hospitals tend to have lower financial operating margins and limited capital to make the investments needed to purchase hardware, software and other equipment.

The health status of rural residents are intertwined with geography, economy, individual habits and genetics as well as access to care. The result of the dynamic interplay between these factors is a population that tends to experience a higher rate of: accidents, suicides, people with low income, public health insurance eligibility and uninsured than their metropolitan counter-parts.

Policy solutions for rural health have taken many forms including: loan repayment programs (Federal and State); construction of schools, hospitals and clinics; National Health Service Corps; J1 visas (non-US trained physicians); and telemedicine. While each of the policy solutions have its merits and effected rural health disparities to varying degrees, the basic mismatch of providers to residents still exist and create a very real access to care problem.

Hopefully this latest package combined with those provided by ACA will increase access to health care in rural areas.

Helpful Rural Health Terms to Know

Rural Health Clinics (RHCs): Clinics in official “rural designated” areas that provide a “safety net” for health care delivery.  There are approximately 3,800 Rural Health Clinics nationwide that provide access to primary care services in rural areas[i].

Federally Qualified Health Centers (FQHCs): “Safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless that meet the Centers for Medicare and Medicaid Services (CMS) criteria for FQHC designation. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities[ii].

Health Professional Shortage Areas (HPSAs): These areas, designated by Health Resources and Services Administration (HRSA), have shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), demographic (low income population) or institutional (comprehensive health center, federally qualified health center or other public facility). [iii]

Medically Underserved Areas (MUA): Areas that are designated by HRSA in which residents have a shortage of personal health services.  They may be a whole county; a group of contiguous counties, a group of county or civil divisions; or a group of urban census tracts. [iv]

Medically Underserved Populations (MUPs): Groups of people who face economic, cultural or linguistic barriers to health care as defined by HRSA.[v]

Criteria for Rural and Urban Designation

Rural definitions are typically based on the following three concepts; administrative, land-use, or economic[vi]. Each definition provides considerable variation in socio-economic characteristics and well-being of the measured population[vii]. This process becomes more confusing when more than one definition is used during policy creation and evaluation.

However, one of the major criteria for Rural Health Clinics is to meet the Census Bureau’s standard of rural. The standard is straightforward- is a definition based on exclusion. Simply put, in order to meet the definition of rural an area cannot meet the Census Bureau’s definition of urban (see below)[viii].

The Census Bureau does not define suburban[ix].

Urban: All territory, population, and housing units located within an urbanized area (UA) or an urban cluster (UC). UA and UC boundaries encompass densely settled territory, which consist of: 1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and 2) surrounding census blocks that have an overall density of at least 500 people per square mile[x].

Rural: The Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urban areas (UAs and UCs). The rural component contains both place and non-place territories. Geographic entities, such as census tracts, counties, metropolitan areas, and the territory outside metropolitan areas, often are "split" between urban and rural territory, and the population and housing units they contain often are partly classified as urban and partly classified as rural[xi].

[i] Centers for Medicaid and Medicare Rural Health Clinic Fact Sheet (April 2009), available at http://www.cms.gov/MLNProducts/downloads/RuralHlthClinfctsht.pdf (last accessed August 2010)

[ii] Centers for Medicaid and Medicare Rural Health Clinic Fact Sheet (April 2009), available at  http://www.cms.gov/MLNProducts/downloads/fqhcfactsheet.pdf (last accessed August 2010)

[iii] U.S. Department of Health and Human Services, Health Resources and Services Administration Shortage Designation: HPSAs, MUAs & MUPs (May 28, 2010) http://bhpr.hrsa.gov/shortage/ (last accessed July 2010)

[iv] Ibid

[v] Ibid

[vi] Cormartie,J.; Bucholtz S.(Economic Research Service) Defining “Rural” in Rural America (2008) Volume 6 Issue 3 available at http://www.ers.usda.gov/AmberWaves/June08/Features/RuralAmerica.htm (last accessed August 2010)

[vii] Ibid

[viii] U.S. Census Bureau Census 2000 Urban and Rural Classification (2009)

http://www.census.gov/geo/www/ua/ua_2k.html last accessed August 2010

[ix] U.S. Census Bureau Census 2000 Urban and Rural Classification: Question and Answer (2009)

https://ask.census.gov/cgi-bin/askcensus.cfg/php/enduser/std_adp.php?p_faqid=623&p_sid=CSWjaK5k&p_created=1092150238&p_sp=cF9zcmNoPSZwX3NvcnRfYnk9JnBfZ3JpZHNvcnQ9JnBfcm93X2NudD0mcF9wcm9kcz0mcF9jYXRzPSZwX3B2PSZwX2N2PSZwX3BhZ2U9MQ!!&p_search_text=rural%20definition last accessed August 2010

[x] U.S. Census Bureau Census 2000 Urban and Rural Classification (2009)

http://www.census.gov/geo/www/ua/ua_2k.html (last accessed August 2010)

[xi] Ibid

Some experts say no, but only time can tell...

PPACA incorporates a number of provisions intending to expand the primary care workforce, equip primary care practitioners with new technological capabilities, and reorient our delivery system with payment and organizational reforms. However, some experts believe that  these reforms maybe too little too late (pardon the puns):

The medical education timetable is at odds with the timetable for healthcare reform. Consider a college graduate who enters medical school this fall and plans to pursue a family medicine career because of more generous financial aid and the promise of improved reimbursement under the reform law. He or she would not graduate until the spring of 2014. Tack on another 3 years of residency training and that new family physician would not be on Main Street, ready to give an appointment, until 2017.

Check out Solving Primary Care Shortage Requires More Than New Healthcare Reform Law from Medscape Medical News to get the full picture.

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"I already have a doctor I’m happy with."
One of the main obstacles to health reform has been the resistance of Americans who already have health insurance.  They are pretty satisfied with what they have and frightened that change can only hurt them.  The same is seen in Americans’ attitudes to the primary care shortage.  Most Americans with insurance have a primary care doctor that they are satisfied with.  Where’s the shortage and why should they care?  Why should we invest hundreds of millions of dollars into training more health workers when they already have a doctor they’re happy with?

The truth is that whether you are insured ore nor or have a doctor or not, the primary care shortage affects us all.    The most important affect is that of waiting times which have dramatically increased for all patients.  For example, a recent study showed that the wait times for a non-urgent appointment to see a family doctor were as high as 63 days in many cities.  Long waits extend physical and emotional pain, cause conditions to worsen, delay diagnosis and treatment, worsen outcomes, and cause some people to forgo care completely.   To worsen matters, many people who cannot get an appointment with their primary care provider in a timely manner resort to the Emergency Room where they drive up the cost of health care for us all and delay care for the critically ill.  With non-emergent patients unnecessarily clogging up the ER, the patients who truly need to be seen are neglected.

You may also think that you don’t need a primary care provider.   For example, you may have a cardiologist that you see regularly and she takes care of all your health needs.  Yet, a preponderance of evidence shows that those patients who see a primary care provider who coordinates all their care with specialists have better health outcomes and lower health bills than patients cared for exclusively by specialists.

A Practical Experiment
For those readers who may still be doubting, I’ll suggest a practical experiment.  Call your primary care physician’s office and tell the scheduler that your back has been hurting for a week and you would like to see your doctor.  My bet is that you won’t be able to get an appointment for at least a week if not longer.  Then ask the scheduler when you can schedule an appointment for an annual physical exam.   You’ll probably be given a date several months in the future.  Then tell the scheduler that a family member is considering being seen by your doctor as a new patient.  Is your doctor even taking new patients?  If you’re lucky enough to get a “yes”, ask when your relative can schedule an annual physical.

The Price Paid by Rural Americans
The situation is worse for the over 60 million Americans living in rural America; the primary care shortage is deeper in rural American than metropolitan America.  As part of the “hollowing out of the middle” the US has not invested enough in training primary care providers with an inclination to serve rural communities or in structuring payment systems that incentivize providers to work in rural areas.   A recent study in central Texas on insured patients showed that 25% of them had trouble getting to see a doctor in the last year.    The US relies on rural America for much of its food production and light industry yet rural America is on its own when it comes to their health.

The Coming Wave
If you don’t think there is a primary care provider shortage, just wait until the more than 40 million uninsured Americans finally get insurance and a title wave of previously unmet need lands on the primary health system.   In addition to their pent-up demand, the uninsured tend to be lower income than the insured and have worse health status than middle and upper income Americans of the same age.  Even without the addition of the newly insured, shortages of over 125,000 doctors are being predicted by 2025.  That number will worsen if demand for their services is increased.

So whether you have insurance or not, the primary care shortage affects you.  We need a rapid expansion in the training of all different types of primary care providers, including pediatricians, family practitioners, internal medicine specialists, nurse practitioners, and physician assistants.  Only then will we have enough hands to do the work.