Rural Health Research and Related Reports

Topics

Rural Health Systems and Hospitals

Telepharmacy Rules and Statutes: A 50-State Survey

Telepharmacy is increasingly seen as a valuable tool to provide important clinical services to remote and underserved areas of the country. Since 2001, when North Dakota became the first state to enact regulations allowing the use of telepharmacy, a number of states have established rules and statutes specifically authorizing dispensing medication to patients via technological means, explicitly not requiring direct contact with a pharmacist.

The most recent versions of administrative rules and legislative statutes governing the practice of pharmacy, as of August 31, 2016, were analyzed for all 50 states. For this study, a state qualified as permitting telepharmacy only if it authorized the operation of telepharmacies for drug delivery to the retail (outpatient) market. Specific authorization for telepharmacy was found in 23 states. Another 11 states have pilot programs or waivers that would enable telepharmacy; and, 16 states have no rules or legislation authorizing telepharmacy. Among those states authorizing telepharmacy there is significant variation in the requirements regulation the operation of telepharmacies. Nearly half of the states authorizing telepharmacy impose geographic limitations (e.g. proximity to other pharmacy/telepharmacy locations), most restrict the types of facilities that may be used as a remote pharmacy location, most have specific rules governing the staffing of telepharmacy locations; and, several have regulations regarding the inter-state provision of telepharmacy services.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.1503
keith-mueller@uiowa.edu

Working Women of the Commonwealth

In honor of National Women's History Month in March, this report focuses on the status of women in the Keystone State's labor force. Just over 2.8 million women participated in Pennsylvania's labor force from 2011 to 2015 which accounted for 47.9 percent of the total labor force. Women were more likely to be employed in the private, non-profit sector and were concentrated in healthcare, office, education, and social service occupations. Statewide, women's median earnings as a percent of men's earnings was only 68.5 percent with Philadelphia County having the most equitable ratio of female-to-male earnings (85.0 percent). Social services, office, healthcare, and life/physical/social sciences were some of the most equitable paying occupations in Pennsylvania for women while legal, transportation, and sales were the least equitable.

2016 County Health Rankings Released

The County Health Rankings & Roadmaps program helps communities identify and implement solutions that make it easier for people to be healthy in their neighborhoods, schools, and workplaces. Ranking the health of nearly every county in the nation, the County Health Rankings illustrate what we know when it comes to what is keeping people healthy or making people sick. The Roadmaps show what we can do to create healthier places to live, learn, work, and play. The Robert Wood Johnson Foundation collaborates with the University of Wisconsin Population Health Institute to bring this program to communities across the nation.

Now in its seventh year, the County Health Rankings continue to bring revealing data to US counties. This report offers key findings from this year’s Rankings release and includes answers to the following questions:

A. How Does Health Vary Across Rural and Urban Counties?

B. How Do Health Gaps Among Counties Differ by State?

C. What Are the New Measures of Each County’s Health?.

2016 County Population Estimates Released

Pennsylvania’s southeast and southcentral counties continue their growth into the second half of the decade according to today’s release of the 2016 County Population Estimates. The five fastest growing counties include Cumberland, Centre, Lebanon, Lehigh, and Lancaster. Elsewhere in the state, however, most counties have experienced losses in their total populations.

Sullivan County had the highest decrease in 2016 at 2.5 percent while other counties continued their downward trends since 2010 such as Cameron, Cambria, Susquehanna, Forest, and Elk. Decreasing populations across the state have resulted in low rankings nationally for county population growth with nearly half of Pennsylvania’s counties falling in the bottom 50 percent of the nation.

Read the full brief here.

Demonstrating Critical Access Hospital Value: A Guide to Potential Partnership

Using a market based approach; this guide assists CAH leadership in identifying ways to demonstrate the value they bring to potential partners including networks, affiliations, payers, community-based organizations, or accountable care organizations. http://ruralhealthvalue.org/TnR/Governance.php

Contact information:
A. Clinton MacKinney, MD, MS
Co-Principal Investigator
clint-mackinney@uiowa.edu

Community Factors and Outcomes of Home Health Care for High-Risk Rural Medicare Beneficiaries

Outcomes of care varied by region of the country for rural Medicare beneficiaries receiving home health services for high-risk conditions, including acute myocardial infarction, heart failure, pneumonia, and chronic obstructive pulmonary disease. Rural beneficiaries in the East South Central and West South Central Census Divisions had lower rates of being discharged to the community and higher rates of hospital readmission and emergency department use. Rural beneficiaries in New England, Middle Atlantic, West North Central, and Pacific Census Divisions had higher rates of being discharged to the community and lower rates of hospital readmission and emergency department use. Differences in rural beneficiaries’ home health outcomes appear to be related primarily to the region of the country where they live rather than other included community factors such as rurality of beneficiary residence (large, small, or isolated small rural areas), county-level economic status, and availability of local health resources.

Contact Information:
Tracy Mroz
WWAMI Rural Health Research Center
Phone: 206.598.5396
tmroz@uw.edu

Medicare Accountable Care Organizations: Quality Performance by Geographic Categories

Medicare Accountable Care Organizations (ACOs) continued to spread in non-urban counties. This policy brief provides an analysis of the differences in ACO performance on the quality measures among the Medicare Shared Saving Program (MSSP) ACOs with varying levels of rural presence. We classified ACO geographic categories as urban, mostly urban, mixed, and rural based on county location of ACO providers and county Urban Influence Codes.

Analyzing performance data released by the Center for Medicare and Medicaid Services, we find that ACOs located in rural counties performed better than urban ACOs on three quality domain scores (Care Coordination/Patient Safety, Preventive Health, and At-Risk Population) and the overall quality score in Performance Year 2014. ACOs in mixed and mostly urban categories performed as well as urban ACOs on these three domain scores and the overall quality score. Urban ACOs performed better than ACOs in other geographic categories on Patient/Caregiver Experience score. ACOs in all geographic categories improved their quality performance between 2014 and 2015.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Spread of Accountable Care Organizations in Rural America

This policy brief updates a RUPRI Center analysis of the presence of Medicare ACO’s in rural areas of the United States in 2013. Using participation data through 2015, the current brief finds that there has been broad growth in the number of places where ACO participating providers can be found. Rural interest in the ACO model is strong, with participating providers found in 41.8% of non-metropolitan counties. A recent CMS fact sheet reported that 65 (15 percent) of Medicare ACOs included at least one participating Rural Health Clinic, and 55 (13 percent) included at least one participating Critical Access Hospital. Clearly, there is rural interest in the ACO program and CMS initiatives like the ACO Investment Model (AIM) – designed to encourage the formation of new ACOs in rural and underserved areas – will enhance the level of interest.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Comparing the Community Benefit Spending of Critical Access, Other Rural, and Urban Hospitals

The ACA increased focus on the safety net role of tax-exempt hospitals, specifically on their charity care and other community benefit policies and activities, by amending portions of the IRS tax code which clarified and expanded hospital charity care obligations and community benefit reporting requirements. This policy brief examines variations in the types and levels of hospital charity care, other community benefit spending, and community-building activities across Critical Access (CAH), other rural, and urban hospitals.

The Financial Importance of the Sole Community Hospital Payment Designation

The purpose of this study was to assess the financial importance of the Sole Community Hospital (SCH) program by investigating: 1) the proportion of SCHs that was reimbursed at the hospital specific rate between 2006 and 2015; 2) the profitability of providing services to Medicare patients in SCHs between 2006 and 2015, and; 3) the financial consequences if the SCH program had not existed in 2015.

Conclusion: If the SCH program did not exist, the study findings suggest that there would be: 1) significant financial consequences for most SCHs, and 2) geographic variation in the magnitude of the financial consequences.

Contact Information:
Sharita Thomas, MMP
North Carolina Rural Health Research and Policy Analysis Center
sharita.thomas@unc.edu

The Impact of the Low Volume Hospital (LVH) Program on the Viability of Small, Rural Hospitals

Intro: The purpose of this research was to investigate the financial experience of LVHs in comparison to other rural hospitals.

Methods: Descriptive and bivariate statistics (non-parametric equality of medians, Wilcoxon rank-sum, t-test and chi-square) were used to identify rural LVHs, compare rural LVH characteristics to those of rural non-LVHs, and to simulate the potential profitability consequences of changes to the LVH program.

Results: Based on this analysis, only one percent of current LVHs would continue to qualify for the LVH adjustment under the 2005 standards.

Conclusion: Without additional action from policymakers, the ACA LVH program will expire on October 1, 2017, and the program will revert to the original 2005 standards. Allowing the LVH program to revert to the 2005 standards is likely to have a negative financial impact on LVHs and could impair access to care for Medicare beneficiaries residing in more isolated rural areas.

Contact Information:
George Pink, PhD
North Carolina Rural Health Research and Policy Analysis Center
Phone: 919.966.1457
gpink@email.unc.edu

Data about Appalachia at Your Fingertips

Every year, the Appalachian Regional Commission (ARC) uses an index-based county economic classification system to identify and monitor each county in our Region to illustrate which counties are considered economically distressed, at-risk, transitional, competitive, or have reached “attainment." This involves creating a national index of county economic status by comparing each county’s averages for unemployment, per capita market income, and poverty rate with national averages. With this data, they create a map illustrating the economic status of each of the 420 counties that helps their state partners develop effective grant proposals. Now, they have made the data behind the map even more accessible with their redesigned Data Reports page. With this resource, researchers and other data lovers can easily search each Appalachian county’s economic status dating back 15 years or look at the poverty, education, income, population density, and other statistics at the county level in comparison to the rest of the state and the rest of the country. And they have also made a simple way to see how some of these key economic indicators have historically played out across the Region. This statistical treasure trove is the most comprehensive collection of data about Appalachia available.

Trends in Risk of Financial Distress among Rural Hospitals

From January 2005 to July 2016, 118 rural hospitals have closed permanently, not including seven others that closed and subsequently reopened. The number of closures has increased each year since 2010, and in the first half of 2016, the closure rate surpassed two closures per month. Hospital closures impact millions of rural residents in communities that are typically older, more dependent on public insurance programs, and in worse health than residents in urban communities. Identifying hospitals at high risk of closure and assessing the trends over time may inform strategies to prevent or mitigate the effects of closures.

In a previous findings brief the NC Rural Health Research Program described the Financial Distress Index (FDI) model, which assigns hospitals to high, mid-high, mid-low or low risk levels for 2016 using 2014 Medicare cost report and Neilsen-Claritas data summed to market areas. Using data from 2011-2014, this brief updates and describes the distribution and trends in the risk of financial distress among rural hospitals for the 2013-2016 period by state and census region.

Contact Information:
George Pink, PhD
North Carolina Rural Health Research and Policy Analysis Center
Phone: 919.966.1457
gpink@email.unc.edu

Supply and Distribution of the Behavioral Health Workforce in Rural America

There are large differences in the supply of behavioral health providers available to treat rural residents when compared to their urban counterparts. Nationally, the provider to population ratio of psychiatrists and psychologists in Non-Metro counties is less than half the ratio than in Metropolitan counties. Additionally the supply of social workers, psychiatric nurse practitioners and counselors in rural counties is much lower than urban counties. Non-Core counties have the lowest provider to population ratios for all of the five provider types studied. Seventeen percent of all non-core counties lack any of the behavioral health providers studied.

Contact Information:
Eric Larson, PhD
WWAMI Rural Health Research Center
Phone: 206.616.9601
ehlarson@uw.edu

Aligning Forces for Quality Initiative: Summative Findings and Lessons Learned from Efforts to Improve Healthcare Quality at the Community Level

The volume features three guest commentaries and eight original research reports by the Aligning Forces for Quality (AF4Q) evaluation team. Collectively, the evaluation reports present the summative findings and lessons learned from the 10-year evaluation AF4Q. Specifically, the articles provide in-depth information on AF4Q's research design; background and evolution; interventions in the main programmatic areas of the initiative; AF4Q's longitudinal impact on measures of population health, quality and experience of care, and cost of care; and the AF4Q alliances' challenges to sustainability.

Graduates of Rural-Centric Family Medicine Residencies: Determinants of Rural and Urban Practice

The researchers surveyed graduates of family medicine residencies with a mission to produce rural physicians to understand physician characteristics, experiences, and attitudes that affected their practice location choices. Influential factors included partner or spouse characteristics, residency experiences, and practice community amenities. Some physicians are clearly self-selected into rural practice, but much needs to be done, particularly during and after residency training, to sustain their interests and to encourage other physicians to embark on rural careers.

Contact Information:
Davis Patterson, PhD
WWAMI Rural Health Research Center
Phone: 206.543.1892
davisp@uw.edu

Quality Measures and Sociodemographic Risk Factors: The Rural Context

Researchers and policymakers have publicly discussed and debated whether or not to adjust provider quality measures for differences in patient characteristics. Lacking in this discussion, however, is a nuanced understanding of how adjustment should be conducted within a rural context and what impact it might have on patients and providers when quality measures are used for benchmarking and payment.

The purpose of this project was to identify how rurality and key sociodemographic variables might affect quality-of-care outcomes and to estimate the potential impact on quality measurement.

Contact Information:
Carrie Henning-Smith, PhD
University of Minnesota Rural Health Research Center
henn0329@umn.edu

How Could Nurse Practitioners and Physician Assistants Be Deployed to Provide Rural Primary Care?

New (2014) rural enrollees in the insurance plans available on federal and state exchanges—platinum, gold, silver, bronze and catastrophic plans—are expected to generate about 1.39 million primary care visits per year. At a national level, it would require 345 full-time equivalent (FTE) physicians to provide those visits to new rural enrollees. This study uses data on rural insurance uptake, expected utilization and productivity of physicians, physician assistants (PAs), and nurse practitioners (NPs) to examine how different mixes of physicians, PAs and NPs might be able meet expanding population requirements for care. There is substantial regional variation in the need for providers to meet the needs of new enrollees, with high levels of need found in East North Central, West North Central and South Atlantic Census divisions.

Contact Information:
Eric Larson, PhD
WWAMI Rural Health Research Center
Phone: 206.616.9601
ehlarson@u.washington.edu

Geographic Variation in the Profitability of Urban and Rural Hospitals

Between January 2010 and January 2016, 66 rural hospitals have closed, a majority of them in the South. Understanding where some hospitals are succeeding, compared to those that are not, is important as policy makers try to craft sustainable models of health care for rural areas. To help policy makers, researchers, and communities understand which hospitals are likely to be less profitable, the North Carolina Rural Health Research Program’s brief, Geographic Variation in the Profitability of Urban and Rural Hospitals, describes the current geographic variability of hospital profitability by comparing the 2014 profitability of CAHs, other rural hospitals (Medicare Dependent Hospitals, Sole Community Hospitals, and rural PPS hospitals, denoted as “ORHs”) and urban hospitals by census region, census division, and state.

Contact Information:
Sharita Thomas, MMP
North Carolina Rural Health Research and Policy Analysis Center
sharita.thomas@unc.edu

2012-14 Profitability of Urban and Rural Hospitals by Medicare Payment Classification

More Americans are now aware of the financial challenges faced by rural hospitals. Media coverage of the 66 rural hospital closures between January 2010 and January 2016 has highlighted the health care access and economic challenges facing rural America. Rural hospital closures are not a new phenomenon – hundreds of rural hospitals closed in the 1980s and 1990s. Recognizing that many rural hospitals are the only health care facility in their community and that their survival is vital to ensure access to health care, federal policymakers created four classifications of rural hospitals that qualify for special payment provisions under Medicare: Critical Access Hospitals (CAHs), Medicare Dependent Hospitals (MDHs), Sole Community Hospitals (SCHs), and Rural Referral Centers (RRCs). In this brief, the NC Rural Health Research Center compares the profitability of urban hospitals to that of rural hospitals for fiscal years 2012-2014 based on size and rural Medicare payment classifications.

Contact Information:
Sharita Thomas, MMP
North Carolina Rural Health Research and Policy Analysis Center
sharita.thomas@unc.edu

Prediction of Financial Distress among Rural Hospitals Research Brief Released

From 2005 through 2015, more than 100 rural hospitals have closed their doors to patients in need of inpatient services. To better understand factors affecting rural hospital financial distress and to develop an early warning system to identify hospitals at risk of distress, the North Carolina Rural Health Research Program developed the Financial Distress Index (FDI). The FDI model forecasts the risk of distress in two years using the most currently available hospital financial performance, government reimbursement, organizational characteristics and market characteristics. The objective of the brief, Prediction of Financial Distress among Rural Hospitals, is to: 1) describe the ability of the FDI model to identify a group of rural hospitals facing an increased closure rate and 2) evaluate the potential impact drivers of the FDI model may have on the percent of hospitals at high risk of financial distress and closure.

Contact Information:
George Pink, PhD
North Carolina Rural Health Research and Policy Analysis Center
Phone: 919.966.1457
gpink@email.unc.edu

Geographic Variation in Risk of Financial Distress among Rural Hospitals Research Brief Released

From 2005 to 2015, 112 rural hospital closures have been identified (North Carolina Rural Health Research Program, 2015). Although six of these closed hospitals have since reopened, the remaining closures impact millions of rural residents in communities that are typically older and poorer, more dependent on public insurance programs, and in worse health than residents in urban communities.

The Financial Distress Index (FDI) model (see NC Rural Health Research Program Findings Brief, Prediction of Financial Distress among Rural Hospitals) assigns hospitals to high, mid-high, mid-low or low risk levels (in two years) using current hospital financial performance, government reimbursement, organizational characteristics and market characteristics. Using 2013 FDI risk levels, this brief, Geographic Variation in Risk of Financial Distress among Rural Hospitals, describes the geographic variation in the proportion of rural hospitals forecasted to be at high risk of distress in 2015.

Contact Information:
George Pink, PhD
North Carolina Rural Health Research and Policy Analysis Center
Phone: 919.966.1457
gpink@email.unc.edu

Pilot Testing a Rural Health Clinic Quality Measurement Reporting System Policy Brief Released

More than 4,000 Rural Health Clinics (RHCs) serve the primary care needs of rural communities, and are therefore an important source of primary care and other essential health services for rural residents. Unfortunately, the Rural Health Clinic Program is plagued by a lack of data on the financial, operational, and quality performance of participating clinics. In light of the significant expansion of quality performance reporting and growing use of performance-based payment approaches, it is critically important that RHCs be able to compete in this changing healthcare market. To this end, we piloted the reporting and use of a small set of primary care-relevant quality measures by a geographically diverse sample of RHCs. This policy brief reports on the results of this pilot with a focus on assessing the feasibility and utility of the reporting system and quality measures for the participating RHCs.

Contact Information:
John A. Gale, MS
Maine Rural Health Research Center
Phone: 207.228.8246
john.gale@maine.edu

Physician Assistant Training Programs Producing Rural PA Research Brief Released

The proportion of physician assistant (PA) graduates who enter practice in rural settings has dropped over the last two decades, though PAs still continue to enter rural practice at a higher rate than primary care physicians. Between 2000 and 2012, 10% of PA training programs produced about 34% of rural PAs; those same programs produced only 14% of all the PAs graduating in the same period. This study identifies the PA training programs that produced high proportions and/or numbers of rural PAs and the program characteristics associated with that success.

Contact Information:
Eric Larson, PhD
WWAMI Rural Health Research Center
Phone: 206.616.9601
ehlarson@u.washington.edu

Federal Office of Rural Health Policy Resource Guide Now Available Online

The Federal Office of Rural Health Policy (FORHP) has developed a resource guide for new applicants and grantees. The FORHP Resources Guide is a compendium with an array of relevant resources, tools and services organized by topic area that will assist with the development and sustainability of rural health projects, organizations and networks.

Mortality and Life Expectancy in Rural America Policy Brief Released

The National Advisory Committee of Rural Health and Human Services recently published a policy brief titled ‘Mortality and Life Expectancy in Rural America’. Life expectancy at birth for the population as a whole has been increasing for over a century. In the past few decades, urban-rural disparities in mortality and life expectancy have been increasing. However, rural counties overall have seen smaller increases and some have seen actual declines in life expectancy during that period. The largest disparities in mortality and life expectancy can be found in Appalachia, long a region of persistent rural poverty. Though this brief has a focus on the Appalachian region, it will offer information and recommendations on the topic of rural mortality and life expectancy that are relevant across the nation.

The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities

This study describes the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals.

The Effect of Surgery on the Profitability of Rural Hospitals

Small rural hospitals are often the sole health care provider in their communities and the only source of care for many people. The provision of surgery in rural hospitals saves the lives of many trauma victims and people with surgical emergencies. Surgery can also have a substantial impact on the finances of a rural hospital as well as the local economy. This study determines the effect of surgery on the profitability of rural hospitals.

Financially Fragile Hospitals: Mergers and Closures

Rural hospitals serve as major sources of health care and employment for their communities, but recently they have been under increased financial stress. Although hospital closures are nothing new, the recent pace is unprecedented; the National Rural Health Association has reported that the number of rural hospital closures in the past year was more than in the previous 15 years combined. This article examines why the number of rural hospital closures is accelerating and the effect on communities.

Rural Hospital and Physician Participation in Private Sector Quality Initiatives Policy Brief Released

Some private sector quality initiatives could potentially have a significant impact on the quality of rural health care, particularly in rural markets that are dominated by a single large insurer, as these insurers are likely to have both the resources to implement an initiative and sufficient leverage to motivate rural provider participation. This project examined private sector quality reporting and quality improvement initiatives being implemented by dominant insurers in states with significant rural populations. The policy brief profiles twelve different initiatives (half focused on physician quality improvement, half focused on hospital quality improvement.

Contact Information:
Michelle Casey, MS
University of Minnesota Rural Health Research Center
Phone: 612.623.8316
mcasey@umn.edu

Free Clinics in the Rural Safety Net Research Brief Released

This brief explores two issues. First, the locations of free clinics and their availability in rural counties are examined across all 50 states. This information was derived from clinic listings on the website of the National Association of Free and Charitable Clinics (NAFC). Second, through telephone interviews with leadership at 14 of the 21 state free clinic associations, researchers explored issues facing free clinics during the current period of change. Issues examined include perceived changes in demand subsequent to implementation of the Affordable Care Act and different funding models and strategies used by free clinics.

List of Cleanest Hospital Rooms in Pennsylvania Hospitals Released

Several critical access hospitals made the list of hospitals in Pennsylvania for which 84% or more patients reported that their room and bathroom were “always” clean. For reference, Pennsylvania's average rate for patients reporting their room and bathroom were "always" clean is 74 percent. The national average rate for patients reporting their room and bathroom were "always" clean is also 74 percent.

Critical Access Hospital Locations Available

The complete list of 1,333 critical access hospitals (CAHs) in the nation has been updated as of September 1st and is publicly available. Select a state from the drop-down menu and see a list of CAHs (click on column headings to sort), or download the complete data as an Excel spreadsheet.

Care Coordination in Rural Communities: Supporting the High Performance Rural Health System

Care coordination has emerged as a key strategy under new health care payment and delivery system models that aspire to achieve Triple Aim objectives—better patient care, improved population health, and lower per capita cost. Achieving these objectives requires conceptualizing and planning care delivery in a new way that not only involves coordinating medical care, but helping people get the care and the support services they need to address the “upstream” social determinants of health. In rural places, these are especially important considerations. While care coordination models vary, all include multidisciplinary teams and networks, a person-centered focus, and timely access to and exchange of information. The purpose of this paper is to examine care coordination programs and processes that affect rural people and places to discover what is happening now in rural communities, how different programs and approaches are working, who benefits, and make policy recommendations that will facilitate care coordination efforts in support of high performance rural health system development.

Developmental Strategies and Challenges of Rural Accountable Care Organizations

This Policy Brief shares insights into initial strategic decisions and challenges of four Accountable Care Organizations (ACOs) with a rural presence, one from each census region (West, Midwest, Northeast, and South). Semi-structured on-site interviews were conducted with ACO leaders and key stakeholder group representatives (e.g., board members, physicians). The four ACOs were formed as a step toward a value-driven rural delivery system, recognizing that ACO participation may not have a short term return on investment. Common value-enhancing strategies included care management, post-acute care redesign, medication management, and end-of-life care planning. The four ACOs also emphasized the importance of access to data for population health management, care management, and provider participation. While several challenges need to be addressed, these insights can inform development of other rural ACOs.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Developmental Strategies and Challenges of Rural Accountable Care Organizations

This Policy Brief shares insights into initial strategic decisions and challenges of four Accountable Care Organizations (ACOs) with a rural presence, one from each census region (West, Midwest, Northeast, and South). Semi-structured on-site interviews were conducted with ACO leaders and key stakeholder group representatives (e.g., board members, physicians). The four ACOs were formed as a step toward a value-driven rural delivery system, recognizing that ACO participation may not have a short term return on investment. Common value-enhancing strategies included care management, post-acute care redesign, medication management, and end-of-life care planning. The four ACOs also emphasized the importance of access to data for population health management, care management, and provider participation. While several challenges need to be addressed, these insights can inform development of other rural ACOs.

Click to download a copy: Developmental Strategies and Challenges of Rural Accountable Care Organizations


RUPRI Center for Rural Health Policy Analysis
University of Iowa
College of Public Health
Department of Health Management and Policy
145 Riverside Drive, N200 - CPHB
Iowa City, IA 52242
Phone: (319) 384-3831
Fax: (319) 384-4371
Web site: www.public-health.uiowa.edu/rupri

Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition

The patient-centered medical home (PCMH) model both reaffirms traditional primary care values such as continuity of care, connection with an identified personal clinician, provision of same day- and after-hours access and also prepares providers to succeed in the evolving health care system by focusing on accountability, continuous quality improvement, public reporting of quality data, data exchange, and patient satisfaction. However, little is known about the readiness of the over 4,000 Rural Health Clinics (RHCs) to meet the PCMH Recognition standards established by the National Council for Quality Assurance (NCQA). This policy brief reports findings from a survey of RHCs that examined their capacity to meet the NCQA PCMH requirements, and discusses the implications of the findings for efforts to support RHC capacity development.

Key Findings

  • Based on their performance on the “must pass” elements and related key factors, Rural Health Clinics (RHCs) are likely to have difficulties gaining National Center for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) Recognition.
  • RHCs perform best on standards related to recording demographic information and managing clinical activities, particularly for those using an electronic health record.
  • RHCs perform less well on improving access to and continuity of services, supporting patient self-management skills and shared decision-making, implementing continuous quality improvement systems, and building practice teams.
  • RHCs are likely to need substantial technical assistance targeting clinical and operational performance to gain NCQA PCMH Recognition.

Contact Information:

John A. Gale, MS
Maine Rural Health Research Center
Phone: 207.228.8246
jgale@usm.maine.edu

Use and Performance Variations in U.S. Rural Emergency Departments: Implications for Improving Care Quality and Reducing Costs

The purpose of this brief is to describe the geographic variation in the use of EDs for non- emergent health conditions across rural and urban areas as well as by U.S. Census Regions. Potential risk factors including patients’ socioeconomic characteristics, geographic location and level of primary care resources are identified. Quality of care indicators, limited to wait times and the length of the visit for rural and urban EDs, are also addressed.

Contact Information:

Yvonne Jonk, PhD
North Dakota and NORC Rural Health Reform Policy Research Center
Phone: 701-777-0871
yvonne.jonk@med.und.edu

New Flex Monitoring Team Policy Brief Examines CAHs' Receipt of EHR Incentives

This policy brief describes current Critical Access Hospital (CAH) participation in the Medicare and Medicaid Electronic Health Record (EHR) incentive programs and compares CAH participation by state.

Monitoring CAH progress in achieving Meaningful Use (MU) is not the role of the Flex Program and Flex Program funds cannot be used to help CAHs achieve MU; however, Flex Programs can share the information in this policy brief with other state stakeholders to increase awareness of the need to help CAHs achieve MU, since CAHs will be subject to Medicare payment reductions if they do not successfully demonstrate meaningful use by 2015. Particular attention should be focused on smaller CAHs that may be facing greater challenges in achieving MU than their larger counterparts

Advancing the Transition to a High Performance Rural Health System

Despite decades of policy efforts to stabilize rural health systems through a range of policies and funding programs, accelerating rural hospital closures combined with rapid changes in private and public payment strategies have created widespread concern that these solutions are inadequate for addressing current rural health challenges. This paper presents strategies and options that rural health providers may use in creating a pathway to a transformed, high performing rural health system, which are then categorized into four distinct approaches. We elaborate each approach, and discuss a related set of public policy implications that should be considered when following each strategy. We follow the discussion of policy implications with four demonstration ideas that reflect the essential elements of each strategic approach in achieving the aims of a high performing rural health system.

Please click on the following link to download a copy:

RUPRI Health Panel Paper

RUPRI Health Panel Brief

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RUPRI Center for Rural Health Policy Analysis
University of Iowa
College of Public Health
Department of Health Management and Policy
145 Riverside Drive, N200 - CPHB
Iowa City, IA 52242
Phone: (319) 384-3831
Fax: (319) 384-4371
Web site: www.public-health.uiowa.edu/rupri

Surgical Services in Critical Access Hospitals, 2011

This brief describes the types and volume of major surgical services provided in Critical Access Hospitals (CAHs) across four regionally representatives states in 2011. Of the surgery volume performed in CAHs, on average 77% was performed on an outpatient basis and 23% inpatient. Operations on the musculoskeletal system, the eye, and the digestive system accounted for 67% of all surgical procedures performed in CAHs. Most reports of surgery volume in CAHs focus on inpatient procedures, thus missing a significant portion of the surgery volume that CAHs perform. CAHs offering outpatient procedures that complement inpatient surgical capacity are providing the communities they serve significant and valuable services through access to both convenient and emergent surgical care services that lessen many of the health care burdens associated with travel for surgery and follow-up care.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Muncy Valley Hospital Receives Award for Quality Improvement in Rural Health

University Park, Pa. - Muncy Valley Hospital, in Muncy, Pennsylvania, part of the Williamsport, Pennsylvania-based Susquehanna Health received the 2014 Louis A. Ditzel Award for Quality Improvement in Rural Health from the Pennsylvania Office of Rural Health (PORH) at a ceremony at the hospital on Jan. 7, 2015. The award was accepted by Ronald Reynolds, hospital president, and C. Cynthia Whipple, director of nursing. Read more at the following link:2014_Louis_Ditzel_Quality_Award_Muncy_Valley_Hospital_1-20-15.doc

Rep. Glenn Thompson (R-PA5) Applauds PORH and the 2014 Pennsylvania Rural Health Award Recipients

http://www.c-span.org/video/?c4521567/rep-glenn-thompson-rural-health

2013 Pennsylvania State Health Assessment Released

The Bureau of Health Planning is pleased to announce the release of the 2013 Pennsylvania State Health Assessment. This comprehensive assessment provides a “one-stop” summary of information on health status, health risks and healthcare services in Pennsylvania. It will support the department’s and our partners’ work in developing priorities and policies, garnering resources and planning actions to improve the population’s health.

Appalachia Data Portal and Readmissions Explorer Launched

The Appalachia Data Portal was created as an online tool for exploring demographic, education, income, and health disparities for the 420 counties in the Appalachian region. The tool allows users to visualize economic, demographic, and other types of data using maps, graphs and trend charts. It provides multiple methods for exploring population indicator disparities throughout the Appalachian region, and is a helpful tool for identifying health disparities and bright spots within the region.

The Appalachia Readmissions Explorer is an interactive mapping tool that allows users to quickly compare readmissions for hospitals in the Appalachian Region. Hospitals are colored red, yellow, or green – based on whether hospitals have readmissions worse, no different, or better than the national average.

AHRQ Releases Rural Health Care Chartbook

On August 27, 2015, the Agency for Healthcare Research and Quality (AHRQ) released its latest Chartbook on Rural Health Care. With rural populations as one of ten priorities for AHRQ research an quality measurement, the chartbook puts a rural lens on more than 250 measures – including access to health care, affordability, and leading causes of morbidity and mortality – found in the agency’s National Healthcare Quality and Disparities Report (QDR) released earlier in 2015. The chartbook data show that, compared to residents of suburbs, residents of rural areas received lower quality of care for more than a quarter of the measures tracked. In addition, residents of rural areas experienced lower access to care for 40 percent of measures compared with those living in suburbs.

Rural EMS Report Released

Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States, compares availability of prehospital emergency personnel in urban and rural areas and shows that “rural agencies had lower staff skill levels, higher reliance on volunteers, higher vacancy ratios, and less access to oversight” from medical directors at the scene and en route to definitive care. Conducted by the WWAMI Rural Health Research Center, the study advises that rural agencies “may need to find more robust sources of funding to recruit and retain an adequate workforce, which in turn could require a shift from volunteer to paid staffing.”

The 21st Century Rural Hospital: A Chart Book

This Chart Book uses available data to present a broad profile of the 21st century rural hospital and includes such descriptors as: Where are they located? Whom do they serve? What traditional hospital services do they provide? How do they ensure outpatient services for their community? What other community benefits do they provide or enable for citizens in their area? How are they doing financially? How are they supported by federal programs?

The pages of The 21st Century Rural Hospital: A Chart Book are each designed as a pull-out document and describe many aspects of today’s rural hospital. Each page includes charts comparing rural hospitals to each other and to urban hospitals across different dimensions such as levels of rurality, US Census region, and hospital size. Important data points are emphasized and an illustrative rural hospital is highlighted. Those who are unfamiliar with today’s rural hospital may be surprised by many data points shown here; others may use this document to research a particular data point.

Contact Information:

Kristie Thompson
North Carolina Rural Health Research and Policy Analysis Center
kweisner@email.unc.edu

Additional Resources of Interest:

A Rural Taxonomy of Population and Health-Resource Characteristics

This policy brief reports the newly developed taxonomy of rural places based on relevant population and health-resource characteristics; and discusses how this classification tool can be utilized by policy makers and rural communities. Using the most current data from multiple sources, we applied the cluster analysis to classify 10 distinct types of rural places based on characteristics related to both demand (population) and supply (health resources) sides of the health services market. In descending order, the most significant dimension in our classification was facility resources, followed by provider resources, economic resources, and age distribution. Each type of rural places was distinct from other types of places based on one or two defining dimensions.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Alcohol & Drug Abuse

Rural Opioid Abuse Prevention and Treatment Strategies: The Experience in Four States

Although opioid use rates are comparable in rural and urban counties, rural opioid users tend to be younger, unmarried, have lower incomes, and are more likely to lack health insurance, all vulnerabilities that may negatively impact their ability to seek treatment and recover. Additionally, the rural health care system is characterized by numerous resource, workforce, access, and geographic challenges that complicate the delivery of specialized care for OUDs in rural communities. The nature and scope of the opioid crisis vary across rural communities and require multifaceted, community-based strategies to address the problem. Based on interviews with key stakeholders in Indiana, North Carolina, Vermont, and Washington State, this qualitative study explores promising state and community strategies to tackle the opioid crisis in rural communities and identifies rural challenges to the provision of OUD prevention, treatment, and recovery services.

Contact Information:
John A. Gale, MS
Maine Rural Health Research Center|
Phone: 207.228.8246
john.gale@maine.edu

Families in Crisis: The Human Service Implications of Rural Opioid Misuse

This policy brief released by the National Advisory Committee on Rural Health (NACRHHS) discusses opioid use disorder in rural areas, which face great challenges given their limited health and social service infrastructure. Fatal opioid overdoses in rural areas have increased at unprecedented rates from 2012-2014 and now are as high as or higher than rates in all metro areas. The Committee issued several recommendations on how the Department can respond to this crisis.

Rural Opioid Abuse Research Brief Released

Opioid abuse is the fastest growing substance abuse problem in the nation and the primary cause of unintentional drug overdose deaths. This study examined the rural-urban prevalence of non-medical use of pain relievers and heroin in the past year and the socio-economic characteristics associated with their use as well as treatment history and perceived need for treatment; perceived risk of using drugs; and other risky behavior. Rural opioid users were more likely to have socio-economic vulnerabilities that might put them at risk of adverse outcomes, including limited educational attainment, poor health status, being uninsured, and low-income. Rural heroin users—especially men and those in poor health—were less likely than urban to say there was a great risk in trying heroin only once or twice.

Contact Information:
Jennifer Lenardson, MHS
Maine Rural Health Research Center
Phone: 207.228.8399
jennifer.lenardson@maine.edu

Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder

The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. Researchers sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians.

Research Highlights Rural Adolescent Use of Prescription Painkillers

Adolescents who live in rural areas and small towns and cities are more likely to abuse prescription painkillers than adolescents who live in large urban areas, according to sociologists.

Adolescents -- youths between 12 and 17 -- in rural communities are 35 percent more likely to have abused prescription painkillers in the past year than adolescents living in large cities. Adolescents who live in small cities have a 21 percent greater likelihood of abusing prescription painkillers than their large urban counterparts.

"Over 1.3 million adolescents abused prescription opioids within the last year," said Shannon Monnat, assistant professor of rural sociology, demography, and sociology, at Penn State. "With this number of adolescents there are major implications for increased treatment demand, risk of overdose and even death from these opioids."

Area Deprivation is Higher Among Rural Counties – but Not All Rural Counties Are Deprived

This brief from the South Carolina Rural Health Research Center is the first of two in a series that provides policy makers and interested parties with information on the role of residence and community deprivation on potentially avoidable hospitalizations among children. This brief describes the development of the area deprivation index, examines area deprivation across all U.S. counties, and describes findings when applied to rates of potentially avoidable hospitalizations among a nine-state sample of children.

Fact Sheet

Webinar Recording Available: Prevalence of Opioids and the Workforce to Provide Treatment in Rural and Urban Settings

Holly Andrilla from WWAMI, and John Gale along with Jennifer Lenardson from Maine provided an overview of their research on opioid use, workforce, and availability of treatment in rural and urban settings followed by a Q&A session.

The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. The Federal Office of Rural Health Policy has funded research at the WWAMI and the University of Southern Maine Rural Health Research Centers to explore the prevalence of opioids in rural and urban settings, as well as availability of workforce to provide treatment for opioid use disorder.

View related research projects:

Contact Information:

Shawnda Schroeder, PhD
Rural Health Research Gateway, PI
Phone: 701.777.0787
shawnda.schroeder@med.und.edu

Additional Resources of Interest:

Access to Health Care Services

Access to Obstetric Services in Rural Communities

Access to obstetric care in rural communities is critical to ensuring good maternal and child health outcomes. Although over 28 million reproductive-age women live in rural U.S. counties, 43% of rural counties in the U.S. had no hospital-based obstetric services in 2002. Media coverage and reports since then have indicated that the number of rural hospitals providing obstetric care has been decreasing; however, the national scope of these access problems has not been quantified.

A recent project by the University of Minnesota Rural Health Research Center has resulted in two policy briefs which examine the closure of hospital-based obstetric services in rural areas from 2004 to 2014: one takes a national perspective, while a second brief documents state-level variability on the same topic.

Issues Confronting Rural Pharmacies after a Decade of Medicare Part D

The financial viability of small rural pharmacies became a concern following the advent of Medicare Part D in 2005. Previously receiving payment directly from Medicare based on charges, pharmacies now are reimbursed by private insurance plans per the terms of contracts offered by those plans. There was a significant increase in the number of rural pharmacies that closed following the implementation of Part D, but that rate of closures has moderated in recent years. This brief assess the issues that threaten the sustainability of small rural pharmacies after more than 10 years of experience with Medicare Part D.

Rural independent pharmacies that were the only retail outlet in their Primary Care Service Area were identified (n=643) and an invitation to participate in a brief, electronic survey was sent to those with a known email address (n=430). Responding pharmacies (n=118, 27.4%) indicated four issues in particular that were considered both major and immediate: delays in updates to maximum allowable costs (MACS), charges for direct and indirect remuneration fees, competition from mail order pharmacies; and, status as a “non-preferred pharmacy” for Medicare Part D plans.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Differences in Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders Among Children in Rural and Urban Areas

CDC researchers looked at available data reported by parents of children aged 2-8 across the U.S. and report that, in rural areas, one in six children was diagnosed with mental, behavioral and developmental disorder (MBDD).  At 18.6%, the prevalence of MBDD in rural children was higher than urban at 15.2%.

The report finds a numbers of factors correlating with high prevalence of MBDD in children and, for both rural and urban children, a higher number experienced health care, community and home challenges than children without an MBDD.  Factors that were common for families in rural communities include experiencing financial difficulties (e.g. hard to cover basics like food or housing), living in neighborhoods with limited amenities (limited or no availability of sidewalks or walking paths, community and/or recreation centers, or libraries), and lacking a medical home (i.e., a family doctor or nurse and regular office visits).

Webinar Recording Available: Obstetric Care Quality and Access for Rural U.S. Women

Katy Kozhimannil, PhD, MPA, Associate Professor, University of Minnesota School of Public Health, and Director of Research at the University of Minnesota Rural Health Research Center presented findings from recent studies on the quality of obstetric care in rural hospitals, the workforce providing obstetric care in rural areas, and the predictors of non-local childbirth for rural women. The focus of this presentation was on understanding whether rural pregnant women have access to the care they need, and whether rural hospitals have the capacity to meet the needs of rural women and families.

Contact Information:
Kristin Trelstad
Rural Health Research Gateway
kristin.trelstad@med.und.edu

Racial Disproportionality and Disparity Issue Brief

Research has consistently shown that certain racial and ethnic groups, including African-Americans and Native Americans, are overrepresented in the U.S. child welfare system. The child welfare field has moved from acknowledging the issue to formulating and implementing solutions. Child Welfare Information Gateway recently updated the issue brief Racial Disproportionality and Disparity in Child Welfare that delves into the prevalence of racial and ethnic disproportionality and disparity in child welfare, reviews the latest literature on the topic, and highlights current State and local initiatives to address disproportionality.

This brief provides strategies that can help child welfare administrators, program managers, and policymakers address these issues in general and at certain points in the child welfare process, including focusing on prevention and early intervention, ensuring unbiased reporting, and ensuring that families of color have access to culturally competent services.

Visit the Information Gateway site today for more information on racial and ethnicity in child welfare and ways to close the gap.

Trends in Rural Children's Health and Access to Care

The past ten years have seen positive trends in the availability of health insurance coverage for children, coupled with worsening trends for poverty. The South Carolina Rural Health Research Center used three iterations of the National Survey of Children’s Health (2003, 2007, 2011/2012) to examine whether rural children have benefited equally from any improvements in health insurance, health care use and health status.

Webinar Recording Available - Ups and Downs: Trends in Rural Children's Access to Care

Jan Probst, PhD, Professor, University of South Carolina, and Director of the South Carolina Rural Health Research Center presented findings from a study based on the National Surveys of Children’s Health. For many groups of rural children, access to care rose between 2003 and 2007, but dipped slightly in 2011-2012.

Upcoming Webinar:

Save the date for an upcoming webinar, Obstetric Care Quality and Access for Rural U.S. Women, on January 11, 2017.

Contact Information:
Shawnda Schroeder, PhD
North Dakota and NORC Rural Health Reform Policy Research Center
Phone: 701.777.0787
shawnda.schroeder@med.und.edu

Alternative Models to Preserving Access to Emergency Care

This policy brief from the National Advisory Committee on Rural Health examines alternatives for provision of emergency care and ancillary services in the light of the recent surge in rural hospital closures. The Committee is concerned with how rural communities can maintain timely access to emergency and other core healthcare services in communities too small to support a full-service hospital but which need more services than offered by a typical primary care clinic.

Vulnerable Rural Counties: The Changing Landscape, 2000-2010

Overall findings suggest that rural America experienced the recession that ended the 2000–2010 decade more severely than did urban America. Loss of income, declining population and reduced health care resources marked the period for most rural counties. Rural counties will need continued monitoring in the present decade to ascertain whether these adverse trends continue and to identify any policy approaches that can serve to ameliorate losses in health care services.

For more information, see the Fact Sheet.

Contact Information:
Kevin Bennett, PhD
South Carolina Rural Health Research Center
Phone: 803.251.6317
Kevin.Bennett@sc.edu

Trends in Rural Children's Health DataSpeak

A recent DataSpeak webinar from the Maternal and Child Health Bureau features SCRHRC research into rural children, presented by Dr. Jan Probst.  Dr. Probst presented the first results from our study of trends in rural children’s health, derived from three rounds of the National Survey of Children’s Health (2003 2007, and 2011-2012). Other presenters include Dr. Alana Knudson of the Walsh Center for Rural Health Analysis for NORC, speaking on causes of mortality among rural children, and Dr. Steve Holve, chief clinical consultant in pediatrics for the Indian Health Service, addressing the unique problems faced by American Indian youth.

Click here to view the webinar.

Rural-Urban Differences in Anticipated Need for Aging-Related Assistance

The South Carolina Rural Health Research Center at the Arnold School of Public Health, University of South Carolina is pleased to announce the release of a findings brief "Looking Ahead: Rural-Urban Differences in Anticipated Need for Aging-Related Assistance."  The brief and fact sheet are on their website at http://rhr.sph.sc.edu or can be accessed through the links below.

As the U.S. population ages, more adults will require assistance with activities of daily living. However, a person's beliefs and expectations about future needs and how these needs will be met may vary between rural and urban pre-retirement aged adults. This project analyzed nationally representative data from the 2011 and 2012 National Health Interview Survey to ascertain how rural and urban adults aged 40–64 view their future needs and coping.

Questions pertaining to this brief should be directed to:
Janice C. Probst, PhD
Phone: 803-251-6317
jprobst@mailbox.sc.edu

State Variations in the Rural Obstetric Workforce

The overall frequency and the increasing rate of obstetric units closures in rural hospitals raises concerns about access to obstetric care among rural women, who experience poorer health outcomes than their urban counterparts. Rural hospitals face obstetric unit staffing challenges due to day-to-day variability in the census of obstetric patients, and as well as challenges with retention, recruitment, training, and scheduling of obstetric clinicians. Many types of staff are necessary to successfully run an obstetrics unit. Across both urban and rural settings, there is regional variation in the types of clinicians attending deliveries

This policy brief describes the obstetric workforce in rural hospitals by state for nine states: Colorado (CO), Iowa (IA), Kentucky (KY), New York (NY), North Carolina (NC), Oregon (OR), Vermont (VT), Washington (WA), and Wisconsin (WI).

Contact Information:
Peiyin Hung, MSPH
University of Minnesota Rural Health Research Center
hungx068@umn.edu

Adverse Childhood Experiences in Rural and Urban Contexts

Adverse childhood experiences (ACEs) are disturbances in family relationships that deprive children of the security and emotional support they need for healthy development. Although a recent report by the Health Resources and Service Administration indicated that rural children have higher rates of ACEs than their urban peers, we know of no studies examining rural-urban differences in adults’ exposure to ACEs. This study was designed to address this research gap and to inform health system initiatives geared toward mitigating the impacts of ACEs on rural populations.

Contact Information:
Jean Talbot, PhD, MPH
Maine Rural Health Research Center
jean.talbot@maine.edu

HIT Strategies for Improving Health Access for Rural Veterans Research Brief Released

This paper reports on the design and implementation of a first-in-the nation project to expand rural veterans’ access to healthcare by establishing a bi-directional connection between Maine’s statewide health information exchange (HIE) and Veterans Administration facilities and centers. The paper reviews key factors that have contributed to implementation challenges and successes and lessons relevant to efforts to create interoperable health IT systems across multiple, complex organizational settings.

Contact Information:
Karen B. Pearson, MLIS, MA
Maine Rural Health Research Center
Phone: 207.780.4553
karen.pearson@maine.edu

Conrad 30 Waivers for Physicians on J-1 Visas: State Policies, Practices, and Perspectives

States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban underserved areas. This study collected quantitative and qualitative information from states to assess how state policies and practices shape IMG recruitment and practice in underserved areas through Conrad 30 J-1 visa waiver programs. This report, the second of two, describes findings from interviews with Conrad 30 program personnel in 32 states and includes information on J-1 waiver physician retention for states with available data.

Contact Information:
Davis Patterson, PhD
WWAMI Rural Health Research Center
Phone: 206.543.1892
davisp@uw.edu

Outcomes of Rural-Centric Residency Training to Prepare Family Medicine Physicians for Rural Practice Research Brief Released

Little is known about how well various types of rural-centric family medicine residency training programs produce physicians for rural practice. This study examined program content and training locations as well as rural and urban practice outcomes for graduates of rural-centric family medicine residency training programs. Though numerous family medicine residencies seek to produce rural physicians, most programs required fewer than eight weeks of rural training. Among those with eight or more weeks of rural training, no single program characteristic or model offered sustained advantages over any other type in producing high yields to rural practice.

Contact Information:
Davis Patterson, PhD
WWAMI Rural Health Research Center
Phone: 206.543.1892
davisp@uw.edu

Exploring Rural and Urban Mortality Differences Research Products Released

Exploring Rural and Urban Mortality Differences examines the impact of rurality on mortality and explores regional differences in mortality rates. This study used a quantitative analysis approach drawing upon the data available from the National Vital Statistics System (NVSS) at CDC WONDER. Exploring Rural and Urban Mortality Differences contains visual aids which displays indicators of mortality rates by cause of death (multiple cause of death), age group, rural-urban status, region, and sex for populations 15 years of age and older cross-referenced to tables and statistical results.

Access to Rural Home Health Services Research Brief Released

Access to home health care can be challenging for rural Medicare clients. Key informants for this study from across the U.S. detailed these obstacles, which include financial, regulatory, workforce, and geographic issues, as well as solutions that merit consideration. Rural communities, especially those served by small and non-profit home health agencies, will likely benefit from payment reforms that reward quality services while providing incentives to innovate and use best practices in home health care.

Contact Information:
Susan M. Skillman, MS
WWAMI Rural Health Research Center
Phone: 206.543.3557
skillman@uw.edu

Minimum Distance Requirements Could Harm High-Performing CAHs and Rural Communities

Since the inception of the Medicare Rural Hospital Flexibility Program in 1997, over 1,300 rural hospitals have converted to critical access hospitals, which entitles them to Medicare cost based reimbursement instead of reimbursement based on the hospital prospective payment system (PPS). Several changes to eligibility for critical access status have recently been proposed. Most of the changes focus on mandating that hospitals be located a certain minimum distance from the nearest hospital. The article concludes that establishing a minimum distance requirement would generate modest cost savings for Medicare but would likely be disruptive to the communities that depend on these hospitals for their health care.

Poorer Quality Outcomes of Medicare-Certified Home Health Care in Areas with High Levels of Native American/Alaska Native Residents

This study examined whether quality indicators reported to the Centers for Medicare and Medicaid Services (CMS) by Medicare-certified home health care agencies are equal in areas with high Native American or Alaska Native (NA/AN) concentration. Identifying gaps in quality among multiple measures of home health care for high-risk areas allows practitioners and home health care service providers to target quality improvement interventions.

The Rising Rate of Rural Hospital Closures

Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities.

Implications of Rural Residence and Single Mother Status for Maternal Smoking Behaviors Research Brief Released

Findings from this study indicate that rural mothers are significantly more likely than their urban counterparts to be smokers, smoke frequently, and smoke heavily, even after adjusting for factors known to increase smoking risk. The authors suggest that methods for extending insurance coverage for smoking cessation interventions through the Affordable Care Act and Medicaid be considered. Additionally, anti-smoking initiatives at the local, state, and national levels could play an important role in decreasing rural-urban disparities in smoking-related morbidity and mortality.

Contact Information:
Jean Talbot, PhD, MPH
Maine Rural Health Research Center
jean.talbot@maine.edu

Federal Office of Rural Health Policy Calls for Abstracts

The Federal Office of Rural Health Policy is sponsoring a special themed issue of the Journal of Health Care for the Poor and Underserved dedicated to exploring innovative models and methods as well as evidence-based practices which have the potential to improving access, health care quality and patient outcomes within rural communities. Topics of interest include, but are not limited to, workforce retention and recruitment, hospital closures, health equity, health information technology, care coordination, population health and financing models.

They are announcing a Call for Abstracts for this special themed issue. The following types of full manuscripts will be considered: Original Papers, Commentaries, Brief Communications, Reports from the Field, Columns, and Reviews. All cover letters, title pages and abstracts are due no later than 11:59 p.m. (EST) on December 15, 2015 to JHCPUHelp@hrsa.gov and addressed to the Federal Office of Rural Health Policy Editorial Team. For additional information or questions, please contact the FORHP editorial team at: JHCPUHelp@hrsa.gov.

HSS Awards up to $22.9 million in Planning Grants for Certified Community Behavioral Health Clinics

The Substance Abuse and Mental Health Services Administration (SAMHSA), in conjunction with the Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary of Planning and Evaluation (ASPE), awarded a total of $22.9 million to support states throughout the nation in their efforts to improve behavioral health of their citizens by providing community-based mental and substance use disorder treatment. The planning grants are part of a comprehensive effort to integrate behavioral health with physical health care, utilize evidence-based practices on a more consistent basis, and improve access to high quality care. These planning grants will be used to support states to certify community behavioral health clinics, solicit input from stakeholders, establish prospective payment systems for demonstration reimbursable services, and prepare an application to participate in the demonstration program. Pennsylvania was awarded $886,200.

USDA Awards 21 AgrAbility Grants to Expand Access to Farming for Americans with Disabilities

Penn State was one of 21 universities to receive funding to assist farmers and ranchers living with a disability to continue being active in agriculture. USDA’s National Institute of Food and Agriculture (NIFA) awarded the grants, totaling more than $4million, through the AgrAbility Program. Funded projects deliver educational programs that advance farmers’ and health professionals’ knowledge in the area of farm safety; adapt new technologies for farmers with disabilities; provide direct service to agricultural workers; and encourage networking to facilitate information sharing with individuals and organizations not employed by AgrAbility.

Atlas of Rural and Small-Town America Released

The U.S. Department of Agriculture (USDA) Economic Research Service has released an Atlas of Rural and Small-Town America, a compendium of statistics on people and jobs in rural areas as well as factors that impact local economies such persistent poverty, economic dependence and population loss. The Atlas culls data from the most recent American Community Survey, the annual update to the U.S. Census, and includes an interactive map detailing population change for each county in the country.

Policy Brief Assesses Differences in Readmission Penalties Between Rural and Urban Hospitals

The Centers for Medicare & Medicaid Services’ (CMS) Hospital Readmissions Reduction Program reduces Medicare payments for hospitals determined to have “excess” rates of patient readmissions for specific conditions. This brief assesses rural-urban differences in the proportion of hospitals that received penalties under the Readmissions Reduction Program over time, and whether condition-specific hospital readmission rates differed for rural and urban hospitals.

Brief Illustrates the Role of Free Clinics as Rural Safety Net Providers

The South Carolina Rural Health Research Center at the Arnold School of Public Health, University of South Carolina is pleased to announce the release of a research brief “Free Clinics in the Rural Safety Net, 2014.”

This brief explores two issues. First, we examine where free clinics are located and describe their availability in rural counties across all 50 states. This information was derived from clinic listings on the website of the National Association of Free and Charitable Clinics (NAFC). Second, through telephone interviews with leadership at 14 of the 21 state free clinic associations, we explore issues facing free clinics during the current period of change. Issues examined include perceived changes in demand subsequent to implementation of the Affordable Care Act and different funding models and strategies used by free clinics.

Fact Sheet

The Intersection of Residence and Area Deprivation: The Case of Hospitalizations from Ambulatory Care Sensitive Conditions Among Children

This brief from the South Carolina Rural Health Research Center is the second in a series providing information on the role of residence and community deprivation on potentially avoidable hospitalizations among children. This brief describes the findings from a nine-state sample of children’s hospitalizations and discusses the potential implications for rural health research and policy.

Fact Sheet

Report Highlights Health Care Availability for Children Based on Geographic Location

The South Carolina Rural Health Research Center has released a report, The Intersection of Residence and Area Deprivation: The Case of Hospitalizations from Ambulatory Care Sensitive Conditions Among Children, the second in series of briefs providing information on the role of residence and community deprivation on potentially avoidable hospitalizations among children. This brief describes the findings from a nine-state sample of children’s hospitalizations and discusses the potential implications for rural health research and policy. For more information, contact Janice Probst, PhD, South Carolina Rural Health Research Center, at 803-251-6317, or to jprobst@mailbox.sc.edu.

CMS Seeks Nominations for Hospital Advisory Panel

On August 28, 2105, the Centers for Medicare and Medicaid Services (CMS) published a notice asking for nominations to the Advisory Panel on Hospital Outpatient Payment (HOP. Of special interest to rural facilities, one of the tasks of the Panel is to review and advise on requests to change supervision levels for hospital outpatient therapeutic services. Rural hospital leaders are encouraged to apply for this opportunity in order to ensure that this group includes expertise that takes into account the unique perspective of smaller and geographically isolated low-volume hospitals. Nominees must be employed full time by a hospital, health system, or Critical Access Hospital (CAH), and have technical expertise on the Panel’s topic areas. The HOP Panel may be asked to provide input to CMS on a range of policies impacting the Outpatient Prospective Payment System so rural providers paid under PPS should consider participating on the panel. Nominations are due Tuesday, October 27 and should be emailed to APCPanel@cms.hhs.gov.

Rural and Urban Differences with Regard to Medicare Part D Plans

Two new RHRC policy briefs compare Medicare Part D prescription drug coverage for rural and urban beneficiaries. The first examines the Part D plans themselves in terms of available options and costs, while the second examines beneficiaries' experiences with their Part D plans.

Differences in Part D Plans Offered to Rural and Urban Medicare Beneficiaries

Rural and Urban Differences in Choice of and Satisfaction with Medicare Part D Plans

Contact Information:

Carrie Henning-Smith, MSW, MPH
University of Minnesota Rural Health Research Center
henn0329@umn.edu

Additional Resources of Interest:

Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States

This study uses a survey of all ground-based prehospital emergency medical services (EMS) agencies in nine states (AR, FL, KS, MA, MT, NM, OR, SC, WI) to examine supply and demand for emergency response personnel, the involvement of medical directors, and the availability of medical consultation, in rural and urban agencies. Compared with urban EMS agencies, rural agencies had lower staff skill levels, higher reliance on volunteers, higher vacancy ratios, and less access to oversight and skill maintenance through regular interaction with a medical director and online medical consultation during emergency calls. Agencies in isolated small rural areas were the most distinct from other rural and urban agencies, having the most volunteers (both EMS providers and medical directors) and paid staff vacancies.

Contact Information:

Davis Patterson, PhD
WWAMI Rural Health Research Center
Phone: 206.543.1892
dpatterson@fammed.washington.edu

Additional Resources of Interest:

Rural Women Delivering Babies in Non-Local Hospitals: Differences by Rurality and Insurance Status

This policy brief describes the extent to which rural pregnant women give birth in non-local hospitals, and to analyze current patterns of non-local delivery by rural women's health insurance status and residential rurality.

Key Findings:

  • In nine geographically-diverse states with substantial rural populations, 25.4% of rural pregnant women delivered their babies in non-local hospitals in 2010 and 2012.
  • Rural women living in more densely populated rural areas were less likely to give birth in a non-local hospital (19.5%) than those in less densely populated rural areas, either next to a metropolitan area (35.9%) or not (33.7%).
  • Privately-insured rural women were more likely to give birth in non-local hospitals than rural women who were covered by Medicaid (28.6% vs. 22.5%).
  • Rural women with Medicaid coverage were more likely than privately-insured women to deliver their babies in a hospital where more than half of all births were covered by Medicaid (63.8% vs. 36.7%).

Contact Information:

Katy Kozhimannil, PhD
University of Minnesota Rural Health Research Center
kbk@umn.edu

Characteristics of Rural Accountable Care Organizations (ACOs) - A Survey of Medicare ACOs with Rural Presence

In this policy brief, we present the findings of a survey of 27 rural ACOs focusing on characteristics important to their formation and operation. We find that a majority of responding ACOs were formed from pre-existing integrated delivery systems and had physician and hospital participants with prior risk-sharing and quality-based payment experience. In addition, physician groups played a leading role in the formation and management of the ACOs.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Federal office of Rural Health Policy announces Rural Network Allied Health Training Program

In response to the White House Job-Driven Training initiative, the Federal Office of Rural Health Policy (FORHP) is pleased to announce the release of the Rural Network Allied Health Training Program (Allied Health Training), a new one-time funding opportunity.

The Allied Health Training Program supports the President’s Rural Health Care Initiative by focusing on rural recruitment and retention activities and builds upon the accomplishments of the Rural Health Workforce Development (RHWD) pilot program, which ended in 2013. As a result of the RHWD Program, approximately 4,000 program participants completed their rural training/rotation, and of these, almost half said they plan on returning to practice in a rural area and a number of them have. Moreover, there was a significant economic impact of $19 million within rural America from FORHP’s $12 million investment via the RHWD Program.

The Allied Health Training Program will support the development of formal, mature rural health networks that focus on activities that achieve efficiencies, expand access to, coordinate and improve the quality of essential health care services, and strengthen the rural health care system as a whole. This purpose will be achieved through the recruitment, clinical training, and retention of allied health professionals.

This program will further support integrated rural health networks that can partner with local community colleges and other accredited educational institutions (such as vocational and technical colleges) to develop formal clinical training programs. These formal training programs will target enrolled rural allied health professional students, to include displaced workers and veterans, in completing a rural, community-based clinical training rotation and obtaining eventual employment with a rural health care provider.

FORHP will hold a technical assistance webinar on Wednesday, February 11, 2015 at2:00 PM Eastern Standard Time to assist applicants in preparing their applications. The toll-free call-in number (for audio) is 800-857-9638, and the passcode is ALLIEDHEALTH. The Adobe Connect webinar URL is https://hrsa.connectsolutions.com/ruralalliedhealth/.

Rural-Urban Chartbook

In 2001, the Centers for Disease Control and Prevention (CDC) published Health, United States, 2001 With Urban and Rural Health Chartbook. The CDC Chartbook was widely used in directing rural health policy and programming and had not been updated since 2001. The Rural Health Reform Policy Research Center updated the 2001 report to examine the current trends and disparities in urban and rural health. The analyses were based on the most recent data available (2006-2011) from the National Vital Statistics System, Area Resource File (Health Resources and Services Administration), U.S. Census Bureau, National Health Interview Survey (National Center for Health Statistics), National Hospital Discharge Survey (National Center for Health Statistics), National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration), and the Treatment Episode Data Set (Substance Abuse and Mental Health Services Administration). Output included aggregate data stratified by geographic region and urbanization level.

Findings suggest that rural residents fare worse than their urban counterparts on a number of measures, including rates for smoking, death from chronic obstructive pulmonary disease (COPD), and suicide. Overall, residents of rural areas have less access to physicians and dentists. While the nation’s health has generally improved over the past decade, urban/rural disparities in health status and access to care persist across a variety of measures, and have grown for some measures (e.g., COPD).

Contact Information:

Alana Knudson, PhD
North Dakota and NORC Rural Health Reform Policy Research Center
Phone: 301.634.9326
knudson-alana@norc.org

Home Health Care Agency Availability in Rural Counties

A range of medical services can be provided in the home setting, allowing patients to be discharged from hospital or inpatient rehabilitation settings more quickly. Medicare reimburses for six types of home health care: skilled nursing, physical therapy, occupational therapy, speech pathology, medical social work, and home health aide services. In November 2011, the Centers for Medicare and Medicaid Services modified Medicare reimbursement for home health care, seeking to control costs by reducing inflation-associated adjustments in charges. In the past, changes in reimbursement may have affected rural home health care agencies more adversely than those in urban areas. The purpose of the current report is to describe the status of home health care service delivery in the rural U.S. in 2008, before passage of the Patient Protection and Affordable Care Act and related efforts.

We used Medicare Compare Home Health Agency files for 2008 to examine two aspects of home health care (HHC) across the United States: HHC agency availability and quality of services provided. Home health agencies are required to report the geographic areas they serve by ZIP Code; they are also required to report quality results across a range of 12 outcomes. This report is based on agency reports; we did not independently verify that services were actually provided within all listed areas.

Contact Information:

Janice C. Probst, PhD
South Carolina Rural Health Research Center
Phone: 803.251.6317
jprobst@mailbox.sc.edu

Update: Independently Owned Pharmacy Closures in Rural America, 2003-2013

Pharmacists provide a range of health services and their loss can have serious implications for the provision of health care, especially in rural areas. Previous policy briefs from the RUPRI Center for Rural Health Policy Analysis have documented the decline in the number of independently owned pharmacies in rural area, especially between 2003 and 2010. This update shows that the number of independently owned rural pharmacies has, with some minor fluctuations, continued to slowly decline. In addition, the number of rural retail pharmacies (including independent, chain, or franchise) that were the only pharmacy in the community has remained relatively stable since 2010.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Support for Rural Recruitment and Practice among U.S. Nurse Practitioner Education Programs

Describes nurse practitioner (NP) education programs across the United States to identify those actively promoting NP practice in rural areas; describes their use of education methods that may promote rural practice; and identifies barriers to recruiting rural students and providing rural NP clinical training. Programs reported that relocating or commuting to campus-based programs, limited rural training opportunities, and affordability were barriers for rural students.

Contact Information:

Susan M. Skillman, MS
WWAMI Rural Health Research Center
Phone: 206.543.3557
skillman@uw.edu

Cancer

American Lung Association Releases "State of Tobacco Control 2017" Report

The American Lung Association has released the results of its annual “State of Tobacco Control” report, which tracks progress on key tobacco control policies at the federal and state level, assigning grades based on whether laws are protecting citizens from tobacco-caused death and disease. 

Pennsylvania’s State Summary:
Tobacco Prevention and Control Program Funding: F
Smokefree Air: C
Tobacco Taxes: D
Access to Cessation Services: F
Tobacco 21: F

State Goals:

  1. Support a Youth Tobacco Prevention Package to include: 
    • Increase funding for tobacco prevention and cessation
    • Increase the Licensure fee to sell tobacco products
    • Increase the age of sale for tobacco products to 21
  2. Remove the exemptions from the current Clean Indoor Air Act that restricts smoking in public places and workplaces.

Latino/Hispanic Cancer Burden Report for Pennsylvania

Significantly higher relative risks were seen in Latino Pennsylvanians compared to non-Latinos for cancer incidence during the 2002-2005 and 2006-2009 time periods, many trends were continued in year 2013 as well. Data year 2013 is the most up to date cancer-related data available at the time of this reporting. As Latino populations continue to grow, as they have been for the past few decades, the differences will become even more apparent between the cancer incidence of Latino and non-Latino populations. This creates a need for the institution of preventative programs directed at Latino populations to circumvent and avoid the additional cancer incidence burden on the Pennsylvania population which would manifest if this populations needs are not met with regard to its cancer burden.

American Lung Association Releases “State of Tobacco Control 2016” Report

The American Lung Association has released the results of its 14th annual “State of Tobacco Control” report, which tracks progress on key tobacco control policies at the federal and state level, assigning grades based on whether laws are protecting citizens from tobacco-caused death and disease. This year’s report also highlights the fact that one in four kids in the U.S. still use tobacco products, and that urgent action is needed by our elected officials to address the tobacco epidemic.

Pennsylvania’s State Summary:
Tobacco Prevention and Cessation Funding: F
Smokefree Air: C
Tobacco Taxes: F
Access to Cessation Services: F

The American Lung Association in Pennsylvania calls for the following three actions to be taken by PA elected officials to reduce tobacco use and exposure to secondhand smoke:

  1. Remove the exemptions from the current Clean Indoor Air Law
  2. Increase the current cigarette tax by at least $1.00 per pack and create tax equity between cigarettes and tobacco products
  3. Increase funding for tobacco prevention and cessation programs

CDC and NCI Release Cancer Statistics Report

The 1999–2012 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2012, 1,529,078 Americans received a new diagnosis of invasive cancer, and 582,607 Americans died of this disease (these estimates do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers expected to be diagnosed).

This year’s report features information on invasive cancer cases diagnosed during 2012 among residents of 49 states, six metropolitan areas, and the District of Columbia—geographic areas in which about 99 percent of the U.S. population resides. Incidence data are from CDC’s National Program of Cancer Registries (NPCR) and NCI’s Surveillance, Epidemiology, and End Results (SEER) Program. Data from population-based central cancer registries in these states and metropolitan areas meet the criteria for inclusion in this report. The report also provides cancer mortality data collected and processed by CDC’s National Center for Health Statistics. Mortality statistics, based on records of deaths that occurred during 2012, are available for all 50 states and the District of Columbia.

The report includes new data:

  • Five-year relative survival data for selected cancer sites by race, sex, and age group for 2001 through 2011.
  • Incidence rates and counts for Puerto Rico for 2008 through 2012 by sex and age, as well brain tumor and childhood cancer data.

Oral Health

Dentist Supply, Dental Care Utilization, and Oral Health Among Rural and Urban U.S. Residents

Do adults in rural locations report lower dental care utilization or higher prevalence of dental disease or both compared with their urban counterparts? This analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) shows that residents of non-metropolitan counties were significantly less likely than residents of metropolitan counties to report having a dental visit or teeth cleaning in the past year and significantly more likely to report undergoing tooth extraction. These findings persisted even when controlling for demographic factors, income, insurance and health and smoking status. Policies aimed at increasing the supply of generalist dentists who will choose to work in rural areas may reduce these substantial rural/urban disparities in access to oral health care and dental outcomes.

Contact Information:

Eric Larson, PhD
WWAMI Rural Health Research Center
Phone: 206.616.9601
ehlarson@u.washington.edu

Medicare and Medicaid

Changing Rural and Urban Enrollment in State Medicaid Programs

County-level data on Medicaid enrollment growth before and after ACA implementation were obtained and analyzed by rural and expansion status for 36 states—19 Medicaid expansion states and 17 nonexpansion states. As expected, average county-level Medicaid enrollment growth differed between expansion and nonexpansion states. In addition, metropolitan growth rates were higher than micropolitan and rural growth rates, although this difference was more evident for nonexpansion states than expansion states. At the state level, much variation was observed both in the urban/rural differential and across states in the same expansion category. Even in most nonexpansion states, there was some growth in Medicaid enrollment, likely due to the “woodwork effect”. Possible relationships exist between these geographic variations and pre-ACA Medicaid eligibility levels and the uptake of Health Insurance Marketplace coverage.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Medicare Advantage Enrollment Update 2016

Analysis of Medicare Advantage (MA) enrollment data from March 2015 and March 2016 showed that national enrollment in MA and other prepaid plans increased from 16.7 to 17.6 million enrollees (from 31.1% to 31.5% of eligible beneficiaries). This 5.5% national growth rate is significantly lower than that seen in previous years. During the same period, non-metropolitan enrollment in MA and other prepaid plans increased from 2.1 to 2.2 million enrollees (from 21.2% to 21.8% of eligible beneficiaries). The non-metropolitan growth rate of 5.3% is also significantly lower than that seen in previous years.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Rural Medicare Advantage Market Dynamics and Quality: Historical Context and Current Implications

Quality ratings of Medicare Advantage (MA) plans were linked to MA payment in an attempt to incentivize quality improvement, beginning in 2012. There is significant variation in the quality ratings of MA plans that are available to rural beneficiaries. Historical factors tend to influence the quality star ratings of MA plans, including the age of the contract and the historical HMO penetration rate. In addition, plans entering and exiting the MA program can have an impact on average star ratings, as plans exiting the program typically have lower scores than new plans entering the MA market. This analysis indicates that the limited availability of high-scoring MA options in rural areas is likely impacting the enrollment of rural MA beneficiaries into high quality plans, as fewer rural beneficiaries than urban beneficiaries are enrolled in plans with high quality ratings. Overall, MA quality scores have been increasing since 2012; however, average quality scores of plans in rural areas continue to lag behind those in urban areas, possibly due to the historical factors and MA market dynamics since these differ in rural and urban places. Targeted adjustments may need to be made to MA plan payment to encourage MA plans operating in rural areas to achieve similar quality ratings to those in urban areas or to encourage high-quality MA plans to expand their service areas in rural markets.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Are Rural Older Adults Benefiting from Increased State Spending on Medicaid Home and Community-Based Services?

In a shift away from institutional long term services and supports (LTSS), the federal government and states have pursued an array of strategies for expanding access to home and community-based services (HCBS) over the past few decades. Yet, little is known about variations in the availability or use of Medicaid HCBS within states, across rural and urban areas. This study used the national Medicaid Analytical Extract claims data file (2008) to examine differences in HCBS use and expenditures among rural and urban older adult Medicaid beneficiaries receiving LTSS. The study found that rural Medicaid LTSS users were less likely to receive HCBS and more likely to receive nursing facility services than their urban counterparts. The proportion of LTSS spending for nursing facility services was significantly greater among rural than urban LTSS users and expenditures for personal care, home health, hospice, adult day care, and rehabilitation were all significantly lower for rural LTSS users compared with those living in urban areas. Multivariate analyses showed that beneficiary characteristics alone do not explain the observed rural-urban differences in HCBS use and expenditures. State policies and other factors such as urban and rural differences in the availability and supply of HCBS and nursing facility services, are likely important contributors to differences in HCBS use and expenditures.

Contact Information:
Andrew F. Coburn, PhD
Maine Rural Health Research Center
Phone: 207.780.4435
andrew.coburn@maine.edu

Characteristics of Medicaid Beneficiaries who use Rural Health Clinics

Rural Health Clinics (RHCs) (currently numbering about 4,100) have served patients from underserved rural areas for nearly 40 years. Although Medicaid is an important payer for RHCs, little is known about Medicaid patients and the services provided to them. This study describes the population who used RHC services from four Medicaid states. A substantial number of RHC users in California, Georgia, North Carolina, and Texas are identified as Medicaid enrollees, ranging from approximately 100,000 to over 800,000 people per state. Demographic characteristics vary substantially by state. Fifty to 79% of the RHC user population are coded as living in a rural area following the Federal Office of Rural Health Policy definition. However, 20% of the RHCs in these four states are not in areas defined as rural. This description of RHC users should assist policy makers and researchers in understanding and planning for the population who receives services from RHCs.

Contact Information:
Marisa Domino, PhD
North Carolina Rural Health Research and Policy Analysis Center
Phone: 919.966.3891
domino@unc.edu

Medicare Costs and Utilization Among Beneficiaries in Rural Areas

Ten percent of all Medicare beneficiaries account for 59% of all program expenditures. Although studies have shown that high per-capita spending does not directly correlate with high-quality care, little attention has been paid to where the high-cost areas are in rural communities and what strategies can be used to effectively manage their spending patterns.

The purposes of this study were to: 1) assess the relationship between service utilization patterns and costs for rural Medicare beneficiaries across the rural continuum (i.e., in places where Medicare spending is highest, what services are most likely to be used?); 2) examine the relationships between rural beneficiaries’ service utilization and health care delivery market structure; and 3) evaluate strategies and policies to address high costs in specific rural contexts.

Contact Information:
Carrie Henning-Smith, PhD
University of Minnesota Rural Health Research Center
henn0329@umn.edu

Rural Medicare Advantage Plan Payments in 2015 Policy Brief Released

Payment to Medicare Advantage (MA) plans was fundamentally altered by the Patient Protection and Affordable Care Act of 2010 (ACA). This brief finds that while plans operating in both rural and urban areas have experienced a reduction in MA payment, the reduction in rural payment overall has been less significant. In addition, MA plans have lower quality, on average, than plans in urban areas; therefore, rural beneficiaries could benefit from incentives for MA plans to improve quality. However, MA plans operating in many rural areas do not have the same monetary incentives to improve quality as most urban areas because they are often ineligible to receive quality-based bonus payments.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Thirty-Day Readmission Rates Among Dual-Eligible Beneficiaries

Dual-eligible beneficiaries represented 19% of Medicare and 14% of Medicaid enrollment in 2009. Of Medicare discharges among dually eligible beneficiaries, 21.5% resulted in a 30-day rehospitalization. Little has been published regarding dual-eligible beneficiaries' readmission rates and factors affecting readmission. This study conducts a cross-sectional analysis of Medicare claims, restricted to 297,084 beneficiaries with a hospitalization from February 1, 2009, through November 30, 2009.

Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Post-discharge

Hospitals are focused on improving postdischarge services for older adults, such as early follow-up care after hospitalization to reduce readmissions and unnecessary emergency department (ED) use. Rural Medicare beneficiaries face many barriers to receiving quality care, but little is known about their postdischarge care and outcomes. This study conducts a retrospective analysis of elderly Medicare beneficiaries discharged home using the Medicare Current Beneficiary Survey, Cost and Use files, 2000-2010.

Medicare Value-based Payment Reform: Priorities for Transforming Rural Health Systems Policy Brief Released

In January, 2015, Department of Health and Human Services (HHS) Secretary Burwell announced new goals and timelines for moving Medicare reimbursement from fee-for-service to value-based payment. These payment changes are driving delivery system reforms (DSR) by making health care organizations more accountable for patients’ health as well as population and community health. Payment and delivery system reform, however, is concentrated in urban centers, and Medicare rural payment policies that were designed to strengthen rural health providers and systems are now complicating payment and delivery system reform in rural areas. The inclusion of rural providers in Medicare payment reform is critical for the program and for the 23 percent of Medicare beneficiaries who reside in rural areas. Rural Medicare beneficiaries should have the same opportunity as their urban counterparts to benefit from payment reform’s positive effects including strengthened primary care, embedded care coordination, and improved clinical quality.

This paper describes five recommendations to facilitate rural inclusion in value-based payment and delivery system reform:

  1. Organize rural health systems to create integrated care.
  2. Build rural system capacity to support integrated care.
  3. Facilitate rural participation in value-based payments.
  4. Align Medicare payment and performance assessment policies with Medicaid and commercial payers.
  5. Develop rural appropriate payment systems

For more information, see the Executive Summary

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Rules for the third and final stage of Meaningful Use Announced

On October 6, the Centers for Medicaid & Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) announced rules for the third and final stage of Meaningful Use, the set of standards for using Electronic Health Records (EHRs). The new regulations aim to “ease the reporting burden for providers, support interoperability, and improve patient outcomes.” CMS provides a fact sheet on EHR Incentive Programs going forward and seeks public comment, particularly from rural providers, about quality measurements aligning with the Medicare Access and CHIP Reauthorization Act (MACRA).

Research Brief Examines Medicare Post-discharge Rehabilitation Care Delivery

The South Carolina Rural Health Research Center at the Arnold School of Public Health, University of South Carolina is pleased to announce the release of a research brief “Post-discharge Rehabilitation Care Delivery for Rural Medicare Beneficiaries with Stroke.”

Stroke is the fourth leading cause of death and the leading cause of long-term disability in the United States (U.S.). Post-discharge care has been shown to be vital in preventing long-term morbidity and improving functionality and quality of life for stroke patients. The most appropriate post-discharge rehabilitation care (PDRC) setting for stroke patients depends on several factors including the patient’s clinical profile, patient preferences, provider recommendations, and proximity to available resources. Limited evidence suggests geographic as well as racial and ethnic disparities in receipt of PDRC.

Fact Sheet

Rural Medicare Advantage Enrollment Update, 2015

Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2015 was nearly 2.08 million, or 21.2 percent of all rural Medicare beneficiaries. This one year increase of 6.8 percent in rural MA enrollment is lower than the increase in national MA enrollment (16.7 million enrollees, up 8.6 percent from March 2014).

Characteristics, Utilization Patterns, and Expenditures of Rural Dual Eligible Medicare Beneficiaries

Dual eligible beneficiaries are known to have a higher disease burden: a higher proportion of dual eligible beneficiaries are disabled, have three or more chronic conditions, report being in fair or poor health or report difficulties with activities of daily living. As a result, Medicare per capita expenditures for dual eligible beneficiaries are nearly double those for other Medicare beneficiaries. The Affordable Care Act (ACA) includes several provisions aimed at improving care and reducing costs of care for dual eligible beneficiaries, including the creation of the Federal Coordinated Health Care Office (FCHCO) and the Center for Medicare and Medicaid Innovation. Located within the Centers for Medicare and Medicaid Services, the FCHCO is tasked with monitoring and improving benefit coordination, expenditures, access, and outcomes of dual eligible beneficiaries. The Center for Medicare and Medicaid Innovation is charged with examining alternative models of care delivery, such as integration of services and joint financing models.

Given the pressing need to improve care while simultaneously reducing costs for dual eligible beneficiaries, it is important to ascertain how rural dual eligible beneficiaries may differ from their urban peers, and to examine potential differences associated with race/ethnicity and region of residence. We used a 5 percent sample of Medicare fee for service beneficiaries for 2009 to examine three related questions about the dual eligible population:

  • What was the 2009 distribution of dual eligible beneficiaries by rurality, race/ethnicity, and region?
  • What was the aggregate and median per capita Medicare spending for dual eligible beneficiaries, and did either differ by rurality, race/ethnicity, or region?
  • What were the characteristics of “high cost” (upper tenth percentile in Medicare expenditures) dual eligible beneficiaries, by rurality, race/ethnicity, or region?

Contact Information:

Kevin Bennett, PhD
South Carolina Rural Health Research Center
Phone: 803.251.6317
kevin.bennett@sc.edu

2014: Rural Medicare Advantage Enrollment Update

Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2014 was nearly 1.95 million, or 20.3 percent of all rural Medicare beneficiaries, an increase of more than 216,000 from March 2013. Enrollment increased to 1.99 million (20.4 percent) in October 2014. MA enrollment increased in both rural and urban areas despite reductions in payment and the conclusion of the MA bonus payment demonstration at the end of 2014.

Some rural counties were reclassified, due to a change in population, and nearly 10 percent of the previously rural MA population is now considered urban; however, the percentage of the rural Medicare beneficiaries enrolled in MA did not change significantly. The majority of growth in rural MA enrollment was in Preferred Provider Organization plans, with over 56 percent of enrollment, while nearly a third of beneficiaries were enrolled in Health Maintenance Organization plans.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

The Effect of Medicare Payment Policy Changes on Rural Primary Care Practice Revenue

Describes the impact of recent Medicare payment updates to the Geographic Practice Cost Indices (GPCIs) portion of the Medicare Physician Fee Schedule (MPFS) on rural primary care providers’ practice revenue from Medicare. Using rural primary care provider Medicare claims from 2009 linked to the 2013 MPFS relative value units (RVUs), the 2013 GPCIs for non-metropolitan localities, and the GPCI updates from the Pathway for SGR Reform Act of 2013, we developed a revenue model to derive estimates of Medicare-related average revenue in 2013 and change-in-average-revenue percentage due to the GPCI updates for 50 non-metropolitan localities. Holding the conversion factor (CF) and RVUs fixed, we found that changes to the GPCIs made between January 1, 2013 and March 31, 2014 resulted in an average 0.12% (median 0.18%) increase in Medicare-derived revenue to rural primary care practices. Without the GPCI work floor reinstatement, however, primary care practices in rural areas would have been disproportionately negatively impacted through lower Medicare-related revenues.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Health Insurance

2016 Rural Enrollment in Health Insurance Marketplaces, by State

In this brief, cumulative county-level enrollment in Health Insurance Marketplaces (HIMs) through March 2016 is presented for state HIMs operated as Federally Facilitated Marketplaces (FFMs) and for those operated as Federally Supported State-Based Marketplaces (FS-SBMs). Enrollment rates in metropolitan and non-metropolitan areas of each state, defined as the percentage of “potential market” participants selecting plans, are presented. Results show that estimated enrollment rates varied considerably across the United States. In particular, estimated enrollment rates in non-metropolitan areas were substantially higher than in metropolitan areas in Hawaii, Illinois, Michigan, Montana, Maine, Nebraska, Wisconsin, and Wyoming. About half of all states, evenly distributed by Medicaid expansion status, had higher enrollment growth in non-metropolitan areas from 2015 to 2016, and in fact aggregated non-metropolitan growth was greater than metropolitan growth in both expansion categories.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Health Insurance CO-OPs: Product Availability and Premiums in Rural Counties

Created by the Affordable Care Act (ACA), Consumer Operated and Oriented Plans (CO-OPs) are private, non-profit health insurers that were designed to increase insurance plan choice and lower premiums in the Health Insurance Marketplaces. Early analyses of the ACA suggested that CO-OPs may be particularly beneficial for rural communities, where fewer individual and small group health insurance options have traditionally been available.

This Research and Policy Brief, authored by research staff at the Maine Rural Health Research Center, explores the early availability and role of CO-OPs in rural and urban counties. We describe the regional distribution and market prevalence of CO-OP products in rural and urban counties and compare the number of products available in counties with and without CO-OP plans in 2014 and 2015. We also examine the proportion of lowest cost silver products for 27 year olds offered by CO-OPs in both years. To better understand the impact of CO-OP closures on consumer choice in the 2016 Marketplaces, we examine how these closures may have affected the prevalence of CO-OP products in rural versus urban counties and overall product availability.

Contact Information:
Erika Ziller, PhD
Maine Rural Health Research Center
Phone: 207.780.4615
erika.ziller@maine.edu

Rural-Urban Differences in Insurer Participation for Marketplace-Based Coverage

The Patient Protection and Affordable Care Act of 2010 (ACA) creates organized Marketplaces through which subsidized private insurance can be purchased by individuals who lack access to public or affordable employer coverage. Insurers’ decisions to offer Marketplace plans in local markets (e.g., counties) have direct implications for the number and types of plans offered and premiums.

The study described in this policy brief aimed to identify differences between rural and urban counties in the number of Federally Facilitated Marketplace (FFM) insurers available to consumers and examine variation in the composition of insurers serving counties, focusing on group affiliation (e.g., Blue Cross Blue Shield, UnitedHealthCare, Humana, Cigna, Aetna) and ownership status.

Contact Information:
Jean Abraham, PhD
University of Minnesota Rural Health Research Center
Phone: 612-625-4375
abrah042@umn.edu

Does ACA Insurance Coverage Expansion Improve the Financial Performance of Rural Hospitals?

The implementation of the Patient Protection and Affordable Care Act (ACA) increased access to health insurance coverage for previously uninsured or under-insured populations. Since rural residents are more likely than urban residents to be uninsured, increased access to health insurance should, in theory, provide a new source of revenue for rural hospitals and, therefore, improve financial performance. To better understand how the ACA’s expansion of insurance coverage has affected uncompensated care, unreimbursed cost, and financial performance in rural hospitals, the NC Rural Health Research Program interviewed rural hospital administrators, state hospital associations, and State Offices of Rural Health (SORHs).

Contact Information:
Kristie Thompson
North Carolina Rural Health Research and Policy Analysis Center
kweisner@email.unc.edu

Health Insurance Marketplaces: Premium Trends in Rural Areas

Since 2014, when the Health Insurance Marketplaces (HIMs) authorized by the Patient Protection and Affordable Care Act (ACA) were implemented, considerable premium changes have been observed in the marketplaces across the 50 states and the District of Columbia. This policy brief assesses the changes in average HIM plan premiums from 2014 to 2016, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places. Since this brief focuses on premiums without accounting for subsidies, this is not intended to be an analysis of the “affordability” of ACA premiums, as that would require assessment of premiums, cost-sharing adjustments, and other factors.

Contact Information:
Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Rural Enrollment in Health Insurance Marketplaces Policy Brief Released

This policy brief provides comparisons between Health Insurance Marketplace enrollment in urban and rural areas of each state and corresponding percentages of “potential market” participants enrolled. This data can help identify places that may benefit from rural-specific outreach, as well as places that may have implemented successful strategies already.

Rural Enrollment in Health Insurance Marketplaces

This brief provides analysis of Health Insurance Marketplace enrollment outcomes for 2015 at the rating area and county levels. Enrollment rates are reported by number of firms participating and for multiple geographic categories: population density, Census region, and metropolitan status of the county. Rural rates are similar to urban rates in many places, but areas of concern exist and may benefit from additional outreach in the future.

Contact Information:

Keith J. Mueller, PhD
RUPRI Center for Rural Health Policy Analysis
Phone: 319.384.3832
keith-mueller@uiowa.edu

Additional Resources of Interest:

Rural Enrollment in Health Insurance Marketplaces

This brief provides analysis of Health Insurance Marketplace enrollment outcomes for 2015 at the rating area and county levels. Enrollment rates are reported by number of firms participating and for multiple geographic categories: population density, Census region, and metropolitan status of the county. Rural rates are similar to urban rates in many places, but areas of concern exist and may benefit from additional outreach in the future.

Health Insurance Marketplaces: Early Findings on Changes in Plan Availability and Premiums in Rural Places, 2014-2015

Analysis of nationwide county-level Health Insurance Marketplace plan and premium data for 2014 and 2015 provides evidence that many low-density rating areas are gaining firms and that average premium growth is low in many rural areas. However, premium growth is somewhat higher in low-density rating areas, and a small minority of rural states have experienced large average premium increases. Thus there is no systematic pattern to rural experiences of HIMs, although some isolated places may be at risk for weak outcomes.

Click to download a copy: Health Insurance Marketplaces: Early Findings on Changes in Plan Availability and Premiums in Rural Places, 2014-2015

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RUPRI Center for Rural Health Policy Analysis
University of Iowa
College of Public Health
Department of Health Management and Policy
145 Riverside Drive, N200 - CPHB
Iowa City, IA 52242
Phone: (319) 384-3831
Fax: (319) 384-4371
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HHS announces auto-enrollment plans for current Marketplace consumers for 2015

Today, the U.S. Department of Health and Human Services (HHS) expects to announce its plans for helping existing Marketplace consumers get auto-enrolled for next year. These plans would give existing consumers a simple way to remain in the same plan next year unless they want to shop for another plan and choose to make changes. Read the press release for more information.