Trying to understand and close the rural health care gap
Many of the health care challenges facing the United States, including lack of utilization of preventive care, socioeconomic factors that affect access to and ability to afford health care, and the shortage of primary care clinicians, are affecting residents of rural areas disproportionately.
Those factors were borne out earlier this year in a study released by the CDC, which reported an increased risk for death from heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke in rural areas when compared to urban ones.
According to the CDC, the all-cause mortality rate in 2014 in urban areas was 704.3 per 100,000 population, compared with 830.5 per 100,000 in rural areas, which comprise approximately 15% of the U.S. population.
“We are working to better understand and address the health threats that put rural Americans at increased risk of early death,” then-CDC Director Tom Frieden, MD, MPH, said in one of the last press statements released before he stepped down as director. “To close this gap we are working to better understand and address the health threats that put rural Americans at increased risk for early death.”
Art Kaufman, MD, clinician and vice chancellor for community health at the University of New Mexico, which is ranked as one of U.S. News & World Report’s top 10 rural medicine programs, explained that a change in the data led to some changes in the mindset at CDC.
“The CDC has been focused on specific acute and chronic diseases. It has provided a very important and effective service for the nation. But newer data over the past decade have emerged showing that specific acute and chronic diseases are not only a consequence of specific behaviors with adverse consequences — smoking, not wearing seat-belts, unprotected sex, inactivity, etc. — but that those risky behaviors are a consequence of the environments in which we live. These are often referred to as the social determinants of health — income, school achievement, social inclusion, built environment, access to fresh fruits and vegetables, adequate transportation and utilities, etc.,” he said.
“Each of these adverse social determinants are far more prevalent in rural than in urban communities as a whole,” Kaufman continued. “These are now growing as a focus of attention, bolstered by capitated payment reform that rewards health outcomes — keeping people healthy, addressing adverse social determinants, supporting prevention — all of which we call ‘going upstream,’ instead of just providing medical services to treat disease after it occurs — what we refer to as ‘downstream.’”
A report in the MMWR seemed to recognize that funding can make a difference in closing the gap.
“An increased emphasis on need and epidemiologic burden of disease as major factors in targeting future allocation of public health and prevention funding might contribute, among other factors, to bridging the mortality gap from the five leading causes of death between rural and urban areas in the United States,” Macarena C. Garcia, DrPH, Center for Surveillance, Epidemiology, and Laboratory Services, CDC, and colleagues wrote.
While financial barriers will require system-wide reform that will take time to bring to fruition, experts say there are measures rural clinicians can implement now to begin to close the daunting gap that exists in the mortality rate between rural and urban areas.
However, some of the health care providers and researchers Healio Family Medicine spoke to expressed concern that since some of the solutions, such as telemedicine, are not so easy to implement, and that barriers like geography cannot be changed, and thus some sort of mortality rate gap will always exist.
Understanding the barriers
Kaufman noted that although screening and prevention guidelines are “exactly the same” in urban and rural areas, access and providers are different. And in situations where a patient needs to see a specialist, a new set of challenges sometimes emerges.
“If you’re in a large multi-specialty clinic, you have resources at your fingertips — nutritionists, social workers, different specialists that are readily available. For example, in some urban clinics, you have behavioral health clinics in the middle of our clinics, so there’s no stigma, you can refer internally,” he said. “If you’re in a rural area... you don’t have any of those, you have to refer out, and the dilemma there is when you refer out you [could] have a cost issue, your transportation may have to go 100 miles. It’s very difficult to translate a quality or a screening or a treatment protocol from an urban area to a rural area that has lots of resource needs.”
A report by the National Conference of State Legislatures illustrates the workforce shortage that plagues rural areas, noting that although about 20% of the nation’s population lives in a rural area, only about 10% of the nation’s physicians are located in these types of communities.
The physical isolation of rural areas also contributes to worse outcomes in cases of injury and acute health episodes, according to Vaughn Morgan, MD, a family medicine clinician at Community Health Centers of Central Wyoming. His facility in Dubois is in a town with fewer than 1,000 year-round residents surrounded by national forests and parks and the Wind River Reservation.
“For acute medical emergencies and acute major injuries, outcomes are always going to lag behind urban areas, simply because of geography,” he said. “With remoteness and a small population, by definition you are not going to have any and all medical coverage available locally – it's just not (nor ever will be) economically feasible. For those of us who choose to live in areas like this, it's simply recognized that for specialized care, one will simply have to travel to get said care.”
“Here in Dubois, we are more than an hour away from even a qualified [emergency room]. If you fall off a horse near Jackson, Wyoming and rupture your spleen, that is likely survivable because the emergency room/hospital in Jackson has a blood bank and a surgeon available 24/7; if that same accident happens 75-80 miles away near Dubois, you are very likely going to bleed to death before you even make it to an [emergency room].”
“The [myocardial infarction] you have walking on the streets in Denver is likely to be eminently survivable, but that same [myocardial infarction] that happens on the street in Dubois may very well not be survivable, because even by helicopter transport, you are more than an hour away, and longer, from a catheter lab and/or stroke center,” he said.
Rural communities are also isolated from financial resources, said Juanita Sapp, MD, an internal medicine doctor with Heritage Health Center, Powell, Wyo., a town of less than 7,000 residents.
“Rural areas are vastly under-funded by grants from the federal government,” Sapp told Healio Family Medicine. “For example, Washington DC has about the same population as Wyoming but gets 100 times more grant health dollars yearly than Wyoming. Perhaps if rural areas had access to those dollars our patients would have more services available.”
Access to education and affordable health care are also significant contributors to these disparities, Morgan said.
“In terms of chronic disease health care, the major issue is trying to get education out to the population in terms of preventative care, but the other major barrier is the affordability issue, i.e. until there is a coherent national health care insurance policy regarding affordable availability, rural areas are always going to lag behind, because... in an urban setting, people know they can go to an [emergency room] and by law they will be seen regardless of ability to pay.”
Kaufman also said there is not enough of a priority on societal issues that affect an individual’s health and well-being.
“We spend far less on social services than the other [Western] countries, and unless you have a balance between health services and social services, then you’re only dealing with the services that effect about 10% to 15% of what makes us healthy,” he said.
Focusing solely on the time in the clinic ignores many of the drivers that are affecting patient’s health, agreed Carrie Henning-Smith, PhD, MPH, MSW, department of health policy and management, School of Public Health, University of Minnesota Rural Health Research Center, one of the 10 federally funded rural health research centers in the United States.
“We’ve spent so much time thinking about health care, but research has shown the majority of health is driven not by what happens in the doctor’s office, but by what happens in the rest of our lives,” she said in an interview. “Things like poverty, education, employment opportunities, transportation, recreation and social opportunities, the environment... all have a much bigger impact on a person’s health than anything any one individual or individual provider can do. We should focus on quality of care and access to care, and also put funding and attention on those social determinants of health.”
Center of the opioid crisis
The disparities in health outcomes have been thrust into the spotlight lately by the nation’s opioid epidemic, one of the most significant public health crises of the last decade, and one that has disproportionately affected rural America, straining already meager resources.
When it comes prescription opioid misuse, it is “particularly problematic in some rural areas,” Khary K. Rigg, PhD, department of the mental health and law policy, University of South Florida and Shannon M. Monnat, PhD, wrote in a 2014 article that appeared in International Journal of Drug Policy. They also wrote that the origins of the epidemic can be traced back to rural America, citing a study that looked at oxycontin addiction at a psychiatric facility where 298 of the 579 admissions from October 2000 to March 2002 to the facility’s addictive disease unit were for the treatment of opioid abuse or dependence.
Other research indicates the epidemic is still robust in those areas.
“Although all states have demonstrated an increase in nonmedical prescription opioid morbidity and mortality during the past decade, death and injury from nonmedical opioid misuse are concentrated in states with large rural populations, such as Kentucky, West Virginia, Alaska and Oklahoma,” a study published in 2014 authored by Katherine M. Keyes, PhD, department of epidemiology, Columbia University, and colleagues stated.
In addition, a study led by Mark Faul, PhD, MA, of the CDC, that was published in 2015 analyzed data from 42 states who provided ambulatory data to the National Emergency Medical Services Information System. They reported that the opioid drug overdose rate was 45% higher in rural communities. Particularly troubling is that many of the challenges associated with rural health– limited access to urgent care, shortfalls in federal support for health care and substance abuse, limited time for education, negative pressures on social determinants of health – directly impact the ability to develop and enact on-the-ground solutions for the opioid epidemic.
Jack Westfall, MD, MPH, project principal investigator, University of Colorado, Denver, told Healio Family Medicine that addressing the epidemic will take several steps.
“It is important [for rural communities] to address the opioid use disorder problems at many levels,” he said. “First, we must initiate and lead more community-level conversations about opioid use disorder. This will educate the public, may decrease stigma, and make folks aware that there are treatments and solutions. Second, we need to expand access to care and management of opioid use disorder in primary care... Third, we need to provide the practice tools for care in the form of education, training, and also assistance meeting the regulatory requirements of caring for patients with opioid use disorder.”
Westfall acknowledged that finding the time for education and training can be “tricky” and referenced a program called Implementing Technology and Medication Assisted Treatment and Team Training in Rural Colorado (IT MATTTRs), which, as he puts it, “brings the training to the practice.” The components of IT MATTTRs include screening and diagnosing opioid use disorder in primary care practices, then engaging the patient in medication assisted therapy and prescribing buprenorphine that is delivered in these same practices.
IT MATTTRs, which received a grant from the Agency for Healthcare Research and Quality, will be implemented in two dozen physically isolated counties across Colorado, a state that was second only to Oregon in terms of nonmedical use of prescription pain relievers in the past year among those aged 12 and older, according to 2010-2011 data appearing in the National Survey on Drug Use and Health.
Heather Kovich, MD, chief of staff of the Northern Navajo Medical Center in Shiprock, New Mexico, told Healio Family Medicine that their opioid addiction services entail basic outpatient assistance such as behavioral health counseling, and that some of her physicians prescribe suboxone for opioid addiction.
Shiprock is a town of about 8,000 residents just east of Four Corners where Utah, Colorado, Arizona and New Mexico come together and 200 miles from the nearest tertiary care center in Albuquerque.
Other ways that Kovich and her staff try to stem the tide of opioid addiction is by fulfilling the mandates in the Indian Health Manual, which has components based on pain management, pain management training, pain assessment, pain treatment, use based on sound clinical judgment and compliance.
She added that her medical center also operates two smaller satellite clinics about 40 miles from the hospital that are staffed a few days each week to help the most physically isolated of patients.
“These clinics are small, but adequate. The smallest one has two exam rooms, plus space for checking in and triaging patients, and dispensing medications,” Kovich said. “Medical providers generally love their days at these clinics. They are more closely connected to the community in this setting. I have also heard from patients that they appreciate getting care closer to home and that they feel connected to their providers.”
Closing the gap
In the CDC release, Frieden stated that rural health doctors can screen patients for high BP; participate in state-level comprehension control coalitions; reinforce the importance of physical activity and healthy eating; promote motor vehicle safety and smoking cessation; and be more judicious in prescribing opioids for pain.
Looking more broadly at Frieden’s suggestions for closing the mortality gap, Kaufman said partnerships between rural and urban practices through telemedicine is another strategy that can be utilized.
“There are networks can be put into place that can put the resources of both the rural and urban areas together,” he said. “You don’t have to set up a massive system, you can set up a network in which there’s a benefit for a rural provider to have access to the kinds of resources [in urban areas]. This can be done by telehealth, by specialty clinics that are set up, and training community health workers.”
While telemedicine may have a role in connecting rural hospitals and other facilities with specialists for acute care, there are practical limitations to its role in chronic care.
“Fifty percent of ... those without internet services — is in rural areas,” Roger D. Wells, PA-C, a physician assistant in Howard County Medical Center, Saint Paul, Neb., a town of approximately 2,300 people about 2 hours west of Omaha told Healio Family Medicine. “So, if you take that and you say okay, ‘If that’s true, then what is telehealth going to do for us?’ It just doesn’t work.”
Wells, who is also chair of the National Rural Health Association’s Clinical Services Constituency Group, noted that some of his relatives are among the 9.4 million Americans estimated to use still be using dialup internet connections.
“My father- and mother-in-law use almost all of their broadband for the month by using Medicare.gov. [Telemedicine] is a great pipedream — you’re going to try to treat 15 million people by calling them and taking blood pressure and telemedicine? We have to find different ways that are already in progress and utilize what’s already being used and successful in other arenas.”
Kovich acknowledged that telemedicine is not the be-all, end-all, of closing the health gap between rural and urban communities.
“Telemedicine can be helpful in meeting some clinical needs, particularly for some specialty care,” she told Healio Family Medicine. “However, it cannot meet all of the health care needs in a rural community.”
Physicians who are versatile are especially helpful in meeting their patients’ needs, particularly in rural locations. Kovich said she and the staff at her facility try to get the most out of a patient’s visit, which sometimes means seeing fewer patients in a day.
“We try to ‘max-pack.’ This is an established strategy in primary care to improve availability of appointments by consolidating as much as possible into each office visit. Max-packing accomplishes two purposes — it decreases the time and travel burden for the patients, which, in rural settings can be significant. It also helps keep appointments open for other patients. We don’t have enough physicians, but we try to be as accessible as we can to our community. This means not scheduling extra appointments. We need those slots for other patients,” she said in an interview.
“It is not unusual for me or my colleagues to handle six to eight problems in a given visit. I think that this is particularly helpful in getting preventive care done. I don’t have patients come in separately for preventive services — scheduling mammograms or colonoscopies, doing pap smears, etc. — I just add that to their visit when they come for other things,” Kovich continued. “I think that this increases the rates of my patients having had these screening services. We don’t want to create extra visits for patients. If we can handle something that day, we really try to do it. Most of us also handle administrative tasks over the phone – lab or x-ray results, medication refills or questions, etc.”
To further help close the gap, Henning-Smith suggested primary care physicians in rural areas should query patients on more than just health matters.
“As much as [they] are able, they can ask their patients questions, not just ‘What hurts in your body?’ or ‘What’s happening in your body?’ but ‘Do you have enough money for food?’, ‘How are you eating?’, ‘Do you have time to exercise?’, ‘Do you have transportation to get where you need to go?’,” she said. “I think a physician can ask about those to try and understand the bigger picture and maybe understand why a patient is not compliant with the medical advice they’re getting.”
However, Sapp said it will take a lot more than asking questions to change rural health outcomes.
“I don’t think that I ask about healthy eating or physical activity any less than my counterparts in the city,” she said. “Asking patients if they have money is second nature to my clinic’s staff since we use a sliding fee schedule. Just asking patients [these questions] does not solve the inequity in health.”
Wells said collaborations with likeminded stakeholders, such as schools, may offer one strategy for improving rural health outcomes.
“[By] working with the public health department, we did all the immunizations for influenza last year by going into the school... It was much more successful to get [students and parents immunized] by having them come in through the school,” he said. “In addition, one of the providers from our clinic goes to the school every Wednesday to talk about wellness, smoking, drug abuse, mental disease, diabetes, strokes, heart attacks. Those are the kinds of things we’ve been initiating — it’s not all successful, but at least it’s a start.” – by Janel Miller
Disclosures: Frieden worked for the CDC at the time his comments were made. Neither Henning-Smith, Kaufman, Morgan, Sapp nor Wells reported any relevant financial disclosures. Healio Family Medicine was unable to determine neither Faul’s, Garcia’s, Keyes’s, Kovich’s, Monnatt’s, Rigg’s nor Westfall’s relevant financial disclosures prior to publication.