Key Initiatives That Could Positively Impact Rural Healthcare

Introduction

While researching my article on rural healthcare, I quickly recognized the need for a series of articles on the subject. My research ignited a passion in me that I do not always have as I address diverse healthcare topics. I attribute this passion to the people and organizations I interacted with during the research phase of writing this series, as well as my anger related to the plight of residents in rural America. The healthcare challenges in rural America have been long-standing, and now is the time to address them in a strategic and sustainable manner.

As noted in my first blog in this series , residents in rural America (or as some states call the “frontier”) have historically been facing multi-faceted challenges that impact directly or indirectly their health status and overall quality of life.

Many people and organizations are tirelessly addressing these issues, but one can sense in them both a feeling of commitment, but also a sense of frustration that so much more needs to be done.

The term Social Determinants of Health is widely used in the healthcare world. The connection between health status and social determinant barriers is no more meaningful and impactful than in rural America. To effectively meet the needs of rural residents requires a marriage between direct clinical services (especially primary care) and initiatives/collaborations that focus on social determinants of health.

Approximately sixty million people live in rural areas across the United States, including millions of Medicare and Medicaid beneficiaries.

In this blog, we will identify some of the key stakeholders working to improve overall health in rural America, as well as initiatives that could potentially make their role more impactful.

Primary Care Physicians in Rural America

The Problem

The American Academy of Family Physicians?characterizes primary care as follows:

“A primary care practice serves as the patient's first point of entry into the health care system and as the continuing focal point for all needed health care services…Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings.”

As one can clearly understand from the above definition, the presence of an accessible primary care practice in rural America is critical to the health status of its residents, and that is the challenge.

Per the National Rural Health Association (NRHA) 2022 Policy Agenda , “77% of rural counties are Health Professional Shortage Areas, and nine percent have no physicians at all. Ease of access to a physician is greater in urban areas. The patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas. This uneven distribution of physicians has an impact on the health of the population.”

As noted by healthcare reporter Dylan Scott in the June 8, 2023 article in Vox , “Scholars from Harvard and the London School of Economics published a research letter in JAMA Open Network last year a study that tracked the trends in the health care workforce for different types of communities in the US. They found that the number of primary care doctors in rural counties, adjusted for population, dropped from 2010 to 2017, while that figure stayed steady for small and large metro areas. More than half of America’s rural counties lost primary care doctors over the study period, while most metropolitan counties saw an increase. “Physician shortages may contribute to current gaps in population health between urban and rural counties,” the authors wrote. They said their study showed the need “to redistribute physician resources to match the unequal health burden experienced by rural and urban populations in the US.”

The shortage of primary care physicians in rural areas continues to trend downward. In fact, the federal government projects a shortage of over 20,000 primary care physicians in rural areas by 2025 .

What is the answer to address this disturbing trend?

Potential initiatives to positively impact primary care physician shortages in rural areas:

Increasing Primary Care Residency Slots in Rural America

As further noted by healthcare reporter Dylan Scott in the June 8, 2023, article in Vox .

“The structure of the country’s pipeline for training doctors plays a significant role in the shortage of primary care physicians in rural areas. One consistent finding in health care economics research is that physicians tend to end up practicing for the long term close to where they perform their residency — the formative first few years after medical school where they have several additional years of on-the-job training, usually in a hospital, before they start to practice on their own.

Though there has been some improvement in recent years, 98 percent of the residencies funded by Medicare are in urban hospitals. Because the formulas that dictate Medicare’s residency funding have mostly been left unchanged since they were created in the mid-nineties, the medical training pipeline has not been meaningfully remade to address the current misdistribution of the country’s physician workforce.

Based on what we have learned about doctors’ career choices, getting more medical students to perform their residencies in rural communities is critical to addressing the specific physician shortages currently limiting health care access in the United States.”

Some people may falsely believe that students who participate in primary care residency programs in rural settings would not receive as quality of an experience as those that participate in programs in urban areas. In fact, the opposite may be true. In rural areas there are fewer students in the residency program which allows for more personal attention. Patients in rural areas many times are sicker and older than one would see in urban settings. There may also be more opportunities for hands on learning in a rural residency program as well as opportunities to collaborate with community-based organizations in order to better address both clinical and social determinants of health in a coordinated manner.

Enhance Recruiting of Students from Rural Areas Into Medical Schools

The Council of Graduate Medical Education’s (COGME) April 2022 Report stated the following:

“Studies have consistently found that physicians who grew up in rural areas are more likely to stay and practice in rural settings, and that counties with providers who have strong ties to the local community have better health outcomes. Therefore, scholarships and other incentive programs for those who come from rural communities promise to increase the rural health workforce, and in turn, broaden access and improve health outcomes.”

As further noted in the journal article, in The Journal of Missouri State Medical Association , “one study found that students from a rural background were 10 times more likely to prefer to work in rural areas.”

An important long-term strategy for recruiting rural residents into medical school and, specifically, primary care is establishing a pipeline starting as early as middle school within their communities. Ideally, if the medical school is in rural America, medical students could also play a mentoring role to high school students that show a potential interest in medicine. One of the challenges in rural school districts is the absence of math and science courses that would provide sufficient rigor for the students to prepare for college and medical school. Colleges or universities within the region may be able to supplement these prospective students’ education through online or virtual education in those subject matters.

Loan Repayment Programs

Per a paper by American Progress:

“The high cost of medical school limits the number of students who apply and attend.?High levels of student loan debt can lead physicians to pursue high salaries, which can incentivize practicing in populous urban areas over less populous rural settings. States can take two policy approaches to help make medical school more affordable and to encourage providers to practice in rural communities after graduation: loan repayment and loan issuance and assistance.

Loan repayment programs are initiatives under which a state repays or facilitates the repayment of student loans for qualifying healthcare providers. The National Health Service Corps’ (NHSC) State Loan Repayment Program (SLRP), for example, is a partnership between states, territories, and the NHSC to promote physician practice in rural communities.* Under the program, clinicians specializing in primary care, dental care, and behavioral or mental health care can receive up to $50,000 in federally funded loan repayments. While the NHSC SLRP has had a positive effect overall, there are several aspects of the program that reduce its efficacy in promoting rural practice.

Foremost is the reality that the repayment amounts, while substantial, comprise a small amount of the total debt accrued by the average doctor during medical or dental school. The most recent data from the Association of American Medical Colleges estimate the average medical school graduate debt in 2021 at $203,062.

In addition to the issue of low funding, onerous state eligibility requirements for the NHSC SLRP can also reduce the program’s efficacy. The federal standards for the program allow providers to practice in a wide range of settings, including in federally qualified health centers (FQHCs) and FQHC look-alikes, rural health clinics, Indian Health Service clinics, and private practice.?States should ensure that their participation requirements align with the full breadth of the federal program to maximize participation.

In addition to loan repayment programs, states can also operate or supplement existing loan issuance programs. For example, the Rural Illinois Medical Student Assistance Program (RIMSAP) offers student loans to medical students who complete a portion of their education in rural settings.”

Increasing access to primary care physicians in rural areas through the J-1 Visa Waiver

The J-1 Visa Waiver program for foreign medical graduates (FMG) seeking entry into the U.S. for graduate medical education (GME) should be continued and expanded.

Rural areas often have difficulty recruiting and retaining physicians. Due to these challenges, many rural communities fill their physician vacancies by recruiting International Medical Graduates (IMGs) who have done their medical training under the J-1 visa exchange visitor program.

Primary care physicians’ compensation needs to increase, especially in rural areas of the country.

Many students start medical school with the hopes of going into primary care, but then the financial realities hit them. As their student loans mount and they become aware of the financial pay differences between the specialties, many transition to the more highly rewarded specialties.

Historically, primary care physicians have been paid significantly less by Medicare and commercial payers than other physician specialists. As we transition to a risk/value-based health system that is focused on keeping patients and populations healthier, the role of the primary care physicians should be moved to center stage. Primary care physicians’ compensation needs to be rewarded because of this new value-based role. The greater the role that primary care physicians play in our health system, the more the return on investment from a societal perspective will be enhanced.

The story needs to be told - Primary care physicians have the potential to have a more rewarding experience when they practice in rural settings.

Primary care physicians in rural areas can be more impactful on their patients’ health vs. primary care physicians in urban settings. While a primary care physician faces many challenges in practicing medicine in rural areas, their role is enhanced over their brother and sister physicians in urban settings.

Primary care physicians in urban areas often complain that they have just become a gateway to specialists, especially in integrated health systems. They are under extreme pressure to see as many patients as possible, which limits their ability to fully engage with their patient. When one of their patients is admitted to the hospital, they, often, lose contact with them until they are released. Many primary care physicians in urban areas are frustrated that they no longer can exercise the skill set they were trained to utilize.

In rural areas, out of necessity, the primary care physicians play a much greater role and are much more likely to enter a trusted relationship with their patients. If that primary care physician grew up in rural America, the trust and engagement between physician and patient becomes even greater.

Case Study – Programs that focus on addressing the primary care physician shortage in rural and underserved areas in Ohio

As noted in the Graduate Medical Education April 2022 report , “One vital resource already in place in many rural areas of the United States is the Area Health Education Centers (AHEC) program, which provides grants to schools of medicine and nursing to develop and enhance education and training networks within communities, academic institutions, and community-based organizations. The AHEC networks focus on training programs to improve the supply, distribution, diversity, and quality of healthcare providers, and in turn, increase access to health services in rural and other medically underserved areas.”

In my home state of Ohio, AHEC’s program is headquartered at the University of Toledo College of Medicine & Life Sciences. The Ohio Statewide AHEC program is a vital initiative that works to bring the resources of its seven participating medical schools to communities throughout the state. Improving health care in rural and urban underserved areas is the goal.

A strength of the Ohio AHEC program is the flexibility that permits each medical school to continually assess, reassess?and establish programs to address the unique healthcare issues in their regions.

As noted in my first blog on rural healthcare , I served as the Associate Dean over Clinical and Community Services in the late 1990s at Ohio University Heritage College of Osteopathic Medicine (OUHCOM). OUHCOM was the primary provider of clinical services for the uninsured and Medicaid recipients in Southeast, Ohio, in the foothills of the Appalachian Mountains. Counties in this rural region are not only the poorest in Ohio, but among some of the poorest counties in the country.

The Office of Rural and Underserved Programs (ORUP) at OUHCOM prepares learners in medical school and residency for patient-centered primary care in rural and underserved communities, and for the generalist specialties of primary importance to these communities, through community engagement, ongoing curriculum design, program implementation and assessment, faculty development, student support?and medical education research.

The Rural and Urban Scholars Pathways?program (RUSP) is a co-curricular opportunity unique to OUHCOM.?When launched in 2013, the purpose of RUSP was simple: To prepare future physicians to practice in medically underserved communities with a strong focus on rural communities. Many of the medical students who have graduated from this pathways program are now practicing in rural areas in Ohio and other parts of the country.

The purpose of the RTT Collaborative is to sustain health professionals’ education in rural places through mutual encouragement, peer learning, practice improvement, and the delivery of technical expertise, all in support of a quality rural workforce. To learn more about the domains and competencies of rural practice and education, click?here .

Additional settings to provide primary care for residents of rural America

Federally Qualified Health Centers (FQHCs)

Federally Qualified Health Centers (FQHCs) (have historically been a key stakeholder in providing care to underserved residents of rural America. According to the Health Resources and Services Administration (HRSA) , FQHCs offer a sliding fee scale based on income. FQHCs provide comprehensive services (either on-site or by arrangement with another provider), including:

• Preventive health services
• Dental services
• Mental health and substance abuse services
• Transportation services necessary for adequate patient care
• Hospital and specialty care

Rural Health Clinics (RHCs)

A Rural Health Care Clinic (RHC) is a clinic designed to provide quality care to patients in rural areas. They are Medicare certified programs that must be established in areas designated as rural shortage areas.

See the following link to better understand the differences between a FHQC and a RHC .

Certified Community Behavioral Health Clinics (CCBHC)

“As of September 2022, 60.58% of Mental Health Professional Shortage Areas were located in rural areas.”

“Certified Community Behavioral Health Clinics represent an opportunity for states, through their Medicaid program, to improve the behavioral health of their citizens by providing community based mental and substance use disorder services. A Certified Community Behavioral Health Clinic model is designed to ensure access to coordinated comprehensive behavioral health care. CCBHCs are required to serve anyone who requests care for mental health or substance use, regardless of their ability to pay, place of residence, or age - including developmentally appropriate care for children and youth.”

Hospitals in Rural Areas

Per a recent report from the U.S. Government Accountability Office (GAO) “Having a local hospital or access to care is critical in an emergency situation where minutes can make a big difference. But?we have found that many rural residents are seeing their local hospital close. More than one hundred (or 4% of) rural hospitals closed from 2013 through 2020. As a result, residents had to travel about twenty miles farther for common services like inpatient care, and forty miles farther for less common services, such as alcohol or drug misuse treatment.

We also found, as you might expect, that rural areas without hospitals also generally had fewer healthcare providers overall compared to those without closures.

Local rural healthcare facilities may choose to join healthcare networks or affiliate themselves with larger healthcare systems as a strategic move to maintain or improve healthcare access in their communities. These affiliations or joining of healthcare networks may improve the financial viability of the rural facility, provide additional resources and infrastructure for the facility, and allow the rural healthcare facility to offer new or expanded healthcare services they could not otherwise provide. However, the benefits of an affiliation with a larger healthcare system may come at the expense of local control.”

As noted above, while there are financial and service benefits to rural hospitals merging with larger urban hospital systems, there is also a cost, related to a loss of local control. It is critical for rural hospitals if they go down the merger road, to choose the correct partner. They need to study previous mergers by large urban systems, especially with hospitals in rural areas, to determine if the primary focus of the merger was patient referrals to the urban mothership. One question that needs to be answered is the following: Did these prior mergers result in not only investments in the rural hospital, but also an investment in the community, especially regarding collaborative initiatives addressing social determinants of health.

As noted in the Rural Health Information Hub (RHIH) , there are multiple strategies being used to improve access to healthcare in rural areas, especially as hospitals or their service lines close. Examples include:

• In 2023, a new Medicare provider type will be implemented, the?Rural Emergency Hospital, which is designed to maintain access to emergency and outpatient care in rural areas. For more information, see the?Rural Emergency Hospital ?topic guide.
• Freestanding Emergency Departments (FSEDs)?are?defined ?by the American College of Emergency Physicians (ACEP) as a “facility that is structurally separate and distinct from a hospital and provides emergency care.” ACEP provides FSED operational and staffing recommendations. A November 2016?Rural Monitor?article,?Freestanding Emergency Departments: An Alternative Model for Rural Communities , further defines an FSED and describes the two types, while discussing the financial sustainability of the model.?After Hospital Closure: Pursuing High-Performance Rural Health Systems without Inpatient Care , a June 2017 RUPRI Health Panel report, discusses case studies from 3 rural communities that transitioned to new models of care, including freestanding emergency department services, increased telemedicine capacity, and specialty care. The report also describes a range of different delivery options for communities that lack hospital inpatient care.

Efforts to Improve the Workforce

An adequate workforce is necessary for maintaining healthcare access in a community. To increase access to healthcare, rural communities must use their healthcare professionals in the most efficient and strategic ways. This might include allowing each professional to work at the top of their license, using new types of providers, working in interprofessional teams, and creative scheduling to offer clinic time outside of regular work hours.

The Rural Health Information Hub Rural Healthcare Workforce topic guide discusses how rural areas can address workforce shortages, such as partnering with other healthcare facilities; increasing pay for staff; adding flexibility and incentives to improve recruitment and retention of healthcare providers; and using telehealth services. The guide also discusses state and federal policies and programs to improve the supply of rural health professionals, such as loan repayment programs and visa waivers.

The Council of Graduate Medical Education’s (COGME) April 2022 Report stated the following:

“There is a need to invest in the recruitment and training of individuals from rural communities into the health professions by developing pipeline programs and promoting opportunities for medical and health professions education. There are also opportunities to recruit and train paraprofessionals such as medical assistants and community health workers, who can contribute to the health care team. Current investments in workforce training do not adequately address rural health disparities or bolster the rural health workforce.

With the emphasis on and importance of team-based care, programs to expand the supply of health care services should capitalize on local resources. For example, primary care capacity can be increased by empowering adequately trained and licensed personnel, such as registered nurses (RNs), advanced practice registered nurses (APRNs), physician assistants (PAs) and pharmacists, to provide a broader range of services within their scope of practice as part of the care team.”

Expanding the scope of practice for Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs)

As noted by the Council of Graduate Medical Education’s (COGME) April 2022 Report which stated the following:

“Nonphysician providers represent an important portion of health care provider supply, and state policies should ensure that these providers are being incentivized both to practice within the state and work in rural communities. Scope-of-practice regulations vary significantly by state, which reduces states’ abilities to promote these nonphysician providers. Two of the most significant barriers to practice for APRNs and PAs include practice independence and prescriptive authority.”

Community Paramedicine

Community Paramedicine?is a model of care where paramedics and emergency medical technicians (EMTs) operate in expanded roles to assist with healthcare services for those in need without duplicating available services existing within the community. As noted in the Rural Health Information Hub (RHIH) , multiple strategies are being used to improve access to healthcare in rural areas. Examples include:

?The Community Paramedicine ?topic guide describes how this model of care can benefit rural communities and covers steps to starting a rural community paramedicine program.

The Community Health Worker Model

One common theme in my readings and discussions about potential initiatives that would have a positive impact on social determinants of health in rural areas was the importance of reinforcing the para-professional Community Health Worker Model (CHW) . “CHWs can help to address the shortage of health professionals in rural and underserved communities and act as a liaison between providers and patients. The Community Health Worker certification requires 130 hours of training.

CHWs promote health within a community by assisting individuals and communities to adopt healthy behaviors. Serve as an advocate for the health needs of individuals by assisting community residents in effectively communicating with healthcare providers or social service agencies. Act as liaison or advocate and implement programs that promote, maintain, and improve individual and overall community health. May deliver health-related preventive services such as blood pressure, glaucoma, and hearing screenings. May collect data to help identify community health needs.”

A value added to this model is that it becomes a source of employment for rural residents.

The CHW model is a cost-effective way to improve the health status of residents of rural communities. While CHWs are effectively being utilized in rural communities throughout the country, there is still a significant shortage of them which is mostly attributed to the lack of short and long-term funding of this important initiative.

Funding for CHWs comes from a variety of sources, but many times it is in the form of a short-term grant, which, if not renewed, will create a disruption in providing valuable services for this neglected population. It is important that we as a society develop long-term, uninterrupted funding sources for CHWs.

As noted in a recent article in Health Affairs, “CHWs are trained health care providers who are engaged in communities and neighborhoods to deliver public health information, educate citizens about health issues, especially prevention, and connect citizens with health resources they might otherwise not have access to, due to health illiteracy or lack of internet or smartphone access.

In?Indiana , North Carolina , and?Texas , local and state governments have invested funding into CHW training programs and have seen the positive effects of CHW interventions in rural communities. Along with their health education roles, CHWs have helped?advocate ?and expose the structural vulnerabilities of rural health systems and the populations they serve. In remote areas that have limited access to health care providers, internet access, or public transportation, CHWs can combat all those barriers by bringing care into their communities at a fraction of the cost of a rural hospital or health system. In some cases, people in these communities would not receive any medical care without the work of CHWs.”

Case Study – How a medical school in rural America serves the residents in the region?

As the community-facing arm of the Ohio University Heritage College of Osteopathic Medicine, Community Health Programs works to address the health needs of individuals across a 24-county region in Southeast Ohio. The Heritage College's Community Health Programs is comprised of three parts: the Heritage Community Clinic, Family Navigator Program, and COMCorps.?

• The Heritage Community Clinic is a free and charitable clinic which provides quality health care at no cost to primarily uninsured and underinsured individuals across Southeast Ohio. Clinical services include primary care, women's health, sexual health and wellness, diabetes care, referrals to dermatology and adult vision care, health screenings, adult and childhood immunizations, osteopathic manipulative medicine, childhood hearing and vision screenings, and a food pantry that provides emergency food assistance. Care is provided by a nurse practitioner, a team of registered nurses, a licensed practical nurse, volunteer physicians, medical students, and health professions students.
• The Family Navigator Program provides intensive navigation services to pregnant clients, delivered by a team of registered nurses. Navigators work to address the social determinants of health with their clients, providing compassionate guidance and resources to help clients achieve and health pregnancy and birth outcome. RN navigators assist clients with linkages to social services such as WIC, shelter, food assistance, childcare, and more. Assistance with medical needs is almost provided including referrals for substance use disorders, mental health, dental care, and pediatrics.
• The COMCorps AmeriCorps program is a national service program which provides members the opportunity to create and support social and physical environments that promote good health and wellness for all in Athens and surrounding counties.?Through their service, members and organizations will address social determinants of health with a trauma-informed approach directing members in creative, community-generated solutions to pressing local needs. Many of their COMCorps members go on to pursue careers in medicine, public health, social services, and nonprofit leadership.

Community Health Programs operates in tandem with the Consortium for Health Education in Appalachia Ohio (CHEAO) , which is the Area Health Education Center (AHEC) serving a 21-county region of Southeast Ohio. Sharing leadership with Community Health Programs, CHEAO AHEC bridges community and university to ensure that Southeast Ohio's medical providers are able to recruit, train, and retain a qualified health professional workforce.?

OUHCOM’s currently has two mobile clinics, and they are in the process of adding a third mobile clinic to service the rural counties in Southeast, Ohio.

These mobile clinics provide prevention and healthcare services where people live and work. They overcome barriers of time, money, and trust, and provide community-tailored care to vulnerable populations.”

Concluding Comments

In the first blog in this series , we covered the healthcare challenges in rural America.?In this blog, we focused on the key stakeholders working to improve overall health in rural America, as well as initiatives that could potentially make their role more impactful. There is no silver bullet answer to these healthcare challenges, but as we discussed in this blog, there are some promising initiatives that, if funded in a sustainable way, could have a long-term positive impact on the region.

As we discussed, the key initiatives that can make a difference in rural healthcare includes the following:

• Increase in primary care physicians (more primary care residency programs in rural locations, recruiting more medical students from rural areas, and loan repayment incentives)
• Increase in sustainable funding for FQHCs, Rural Clinics, and Community Health Workers
• Rural pipeline programs starting in high school focusing on healthcare workforce recruitment and training.

In the next blog in this series, we will focus on potential collaborative initiatives (with a special focus on the rural elderly) among stakeholders that could result in a measurable impact in the health status of residents in rural America. We will also explore innovative payment methodologies and funding sources that could potentially be the glue that incents stakeholders to further work together to address both the clinical and social determinant barriers that negatively impact the health and quality of life of residents of rural America.

??Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry—particularly the health insurance, physician and hospital sectors—he’s focused on strategic advising and community outreach.?Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry.

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