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Health and Health Care in the Frontier
This chapter establishes the notion that frontier dwellers fare worse than their urban counterparts on many measures of health. Disparate access to medical and dental care, as well as mental health, likely contributes to these health disparities. Public health services are lacking in the frontier, and the majority of emergency services are provided by volunteers. The provision of emergency and trauma care is one of the main differences that sets frontier nurse practitioners (NPs) apart from NPs working in less remote areas. Therefore, special attention is given to the provision of emergency medical services (EMS) in the frontier. The chapter concludes with a discussion of recruitment and retention of health care workers in the frontier.
HEALTH STATUS OF FRONTIER DWELLERS
As the frontier designation is fairly new and little is known about the health status of populations living specifically in these areas, rural population health outcomes are included in this section. Health status includes data regarding disease prevalence, pathophysiologic process, and morbidity and mortality rates. Premature mortality, defined as death before 75 years of age, is greater among rural dwellers than among their urban counterparts. Specific causes that lead to this difference include higher death rates from unintentional injuries, suicide, chronic obstructive pulmonary disease, and diabetes. Specifically, the death rate for persons aged 1 to 24 years was 31% higher in rural versus urban counties (Eberhardt & Pamuk, 2004).
Health outcomes are worse in rural/frontier areas for patients with conditions that account for a large percentage of early deaths, that is, heart disease (Bhuyan, Wang, Opoku, & Lin, 2013; Kulshreshtha, Goyal, Veledar, & Vaccarino, 2014), cancer (Nguyen-Pham, Leung, & McLaughlin, 2014; Singh, 2012; Weaver, Geiger, Lu, & Case, 2013), diabetes (Hale, Bennett, & Probst, 2010), and chronic obstructive pulmonary disease (Jackson, Coultas, Suzuki, Singh, & Bae, 2013). In rural agricultural areas, farmworkers have a greater exposure to cancer-causing agents, resulting in higher than average rates of brain, stomach, lymphatic, and hematopoietic cancers.
Rural/frontier residents are also less likely to receive preventive health care. From 1998 to 2005, frontier residents had the overall lowest screening rates for colorectal cancer compared to other demographic groups (Cole, Jackson, & Doescher, 2012). In the most isolated rural areas, 78.7% of women travel at least 60 minutes to the nearest hospital offering perinatal services (Rayburn, Richards, & Elwell, 2012) and are significantly less likely to receive counseling related to smoking, alcohol/drug use, and contraception (McCall-Hosenfeld & Weisman, 2011).
Frontier youth have additional risks. Children raised in rural agricultural areas are at higher risk of exposure to pesticides and have higher rates of related illnesses (Ricketts, 2000). Rural counties also report higher rates of childhood obesity, ranging from 17% to 25.9% compared to the national average of 15.8%. One study, which investigated the prevalence and correlation of high body mass index in rural Appalachian children aged 6 to 11 years, found childhood obesity rates of up to 38%, with boys 23% more likely to be overweight (Montgomery-Reagan, Bianco, Heh, Rettos, & Huston, 2009). Teens in the frontier are at a higher risk for suicide than those living in urban areas, with the highest rates occurring in the western frontier states (Frontier Education Center [FEC], 2003). According to the 1999 National Children’s Center report on suicide of teens aged 15 to 19 years, the highest rates were in the states of Alaska, Wyoming, Montana, South Dakota, North Dakota, New Mexico, Utah, Arizona, Nevada, Idaho, and Colorado. Communities are trying to combat these high suicide rates by creating strong linkages between schools, health care providers, and mental health programs; however, many of these resources are nonexistent in frontier areas (FEC, 2003).
Frontier dwellers also experience disparities related to emergency and trauma care. Studies have shown that rural areas have proportionately higher mortality rates due to injury, with decreasing population density as the strongest predictor of county-specific trauma death rates (Centers for Disease Control and Prevention [CDC], 2001; Rutledge et al., 1994). Type and severity of injury are among the multiple factors contributing to these high mortality rates, as well as problems accessing appropriate emergency care. Studies have shown that lack of appropriate emergency response is one of the most important factors contributing to increased injury death rates in rural areas (Peek-Asa, Zwerling, & Stallones, 2004); however, studies also indicate that the availability of advanced life support (ALS) prehospital care increases survival rates (Gabella, Hoffman, Marine, & Stallones, 1997; Kearney, Stallones, Swartz, Barker, & Johnson, 1990; Svenson, Spurlock, & Nypaver, 1996; Zwerling et al., 2005).
ACCESS TO HEALTH CARE SERVICES
Disparate access to health care has been linked to poor health status. The geographic isolation that characterizes frontier areas poses unique challenges relating to access to, and delivery of, health care services (Ricketts, Johnson-Webb, & Taylor, 1998). The concept of space, in relation to space between services and populations, as a causative factor in health care inequity between groups has been termed spatial inequity (Thomas, Lowe, Fulkerson, & Smith, 2011, p. 76).
Spatial health care inequity is related to availability of rural hospitals and medical providers. Rural America has 20% of the nation’s population but less than 11% of its physicians and less than 16% of its registered nurses (Health Resources and Services Administration [HRSA], 2014). Workforce shortages are especially serious in frontier communities (National Rural Health Association, 2012). Over the past 20 years, the numbers of rural physicians and hospitals have declined due to changes in both reimbursement and rural health policy. Between 1980 and 1998, the total number of community general hospitals decreased by 11.8% due to closures, mergers, and conversions, which in turn forced more physicians out of the rural areas (Ricketts, 2000). In response to rural hospital closures, the Medicare Critical Access Hospital program, part of the Balanced Budget Act of 1997, was developed to financially shore up rural hospitals through the provision of cost-based reimbursement for outpatient, emergency, and limited inpatient services (Reif & Ricketts, 1999).
FEDERAL PROGRAMS TO ADDRESS HEALTH DISPARITIES IN THE FRONTIER
Spatial inequity regarding access to health care has been a federal concern since the early 1970s. With the passage of the Medicare Bill in July 1965, the federal government assumed a responsibility for the health care coverage of elderly Americans regardless of geographic residence. Rural underserved Medicare recipients had limited access to health care; therefore, the Rural Health Clinic Act of 1977 was passed to incentivize rural practice and increase access to care. The Act authorized development of the Rural Health Clinic program that provides enhanced reimbursement rates for Medicare and Medicaid services. The Act also authorized Medicare and Medicaid payments for services provided by NPs and physician assistants (PAs) regardless of physician presence (Wasem, 1990). Furthermore, the Act promoted the use of NPs or PAs by mandating that 50% of the services in rural health clinics be provided by NPs, PAs, or certified nurse-midwives (CNMs).
In rural areas, smaller populations dispersed over wide areas frequently result in economic disincentives for private providers (Wagenfeld, 2000). Therefore, the federal government funded programs to recruit physicians to rural and remote areas. To ameliorate the economic disadvantage of rural physician practice, the National Health Service Corps (NHSC), the largest public program addressing the geographic maldistribution of the U.S. health care workforce, began a medical student loan repayment program to encourage physicians to work in specific underserved sites. In 1991, the NHSC added NPs and CNMs to their student loan repayment program (Earle-Richardson & Earle-Richardson, 1998). To benefit from this program, providers agree to practice in a designated health care professional shortage area for a minimum of 2 years. In 2009, this program was bolstered by the American Recovery and Reinvestment Act, which allotted a $300 million supplement to the NHSC. During the Recovery Act period, March 2009 through February 2011, the increase in numbers of NPs recruited was proportionately higher than all other health care professionals (Pathman & Konrad, 2012).
Federal programs such as the NHSC are limited to areas of the country that are designated health professional shortage areas (HPSAs). This designation is based on an extremely low ratio of patients to available physician providers as well as a number of other extenuating factors such as special populations or geographical distance (Loynd & Constantino, 2008). These areas are further delineated as primary care health professional shortage areas (P-HPSAs), mental health professional shortage areas (M-HPSAs), and dental health professional shortage areas (D-HPSAs).
ACCESS TO MENTAL HEALTH IN THE FRONTIER
State and local rural health leaders identify mental health and mental disorders to be the fourth most often identified rural health priority (Gamm, Hutchison, Dabney, & Dorsey, 2003, p. 165); however, the extent to which the NHSC program addresses physician shortages for mental health care is far less than that for primary health care. This is evidenced by a study of more than 5,000 established P-HPSAs, which found that 29% were eligible for NHSC support compared to 7% of M-HPSAs (Loynd & Constantino, 2008). The extent of this disparity is also borne out in the number of mental health workers in rural areas compared to urban areas. In the period from 2008 to 2010, there were 3.0 rural psychologists versus 6.8 urban psychologists per 10,000 people. In the allied mental health professions, the differences are not as wide. The difference in the number of counselors was 8.4 versus 9.9 per 10,000 and 14.4 versus 17.4 social workers per 10,000 people (HRSA, 2014).
To mitigate these differences, the National Center for Frontier Communities proposes a new type of mental health provider for the frontier, the behavioral health aide (van Hecke, 2012). In this proposal, the locally recruited workers would identify people in need of behavioral health services, connect them to the services and programs for which they are eligible, and help craft and/or implement a mental health care plan. The emphasis on this new type of worker is early intervention and case management. Credentialing and training preparation criteria would be influenced by local needs and vary by state. One of the main functions of the behavioral health aide is to facilitate client entry into eligible programs; however, in the frontier these programs are sparse.
ACCESS TO DENTAL HEALTH IN THE FRONTIER
There are nearly 50 million people living in D-HPSAs nationally, and more than 31 million Americans have no reasonable expectation of finding a dentist in or near their community (PEW Center on the States, 2011). As a result of the geographic maldistribution of dentists, 4,000 areas are federally designated as D-HPSAs, where only 3% of dentists practice (Voinea-Griffin & Solomon, 2016). In American Indian and Alaska Native communities, the dentist-to-population ratio is 1:2,800, nearly twice the national average (American Academy of Pediatrics, 2011). In frontier communities this shortage leads to significant issues regarding access (van Hecke, 2012).
Some states are seeking novel solutions to the problem. For example, Alaska has developed a workforce model that may alleviate the dental care shortage in this frontier state. The following synopsis describes the dental health aide therapist (DHAT) model that is currently in operation:
Alaska’s DHAT model is the first in the United States, and is based on New Zealand’s dental nurse model. Alaska’s DHATs practice in remote sites; sites that are managed by tribal regional health corporations. An essential part of Alaska’s DHAT program is that DHATs are recruited from the rural and frontier areas where they serve. There are two reasons for this. First, locally recruited students are more likely to work and live in these rural and frontier areas on a long-term basis. Most dentists are recruited and trained outside rural and frontier areas, and are less likely to choose to practice in remote areas.
Dental therapists are closely tied to their supervising dentists through telemedicine and phone consultations. This relationship of the DHATs is designed to be similar to the supervisory tele-relationships between physician and physician assistants and includes prospective discussion of cases, concurrent availability of consultations, and retrospective quality review of the patients seen by the DHAT. (Agency for Healthcare Research and Quality, 2012)
In addition to Alaska’s DHAT program, another allied dental health worker, the registered dental hygienist, also shows promise for frontier areas. Dental hygienists can legally provide direct access care in 36 states (American Dental Hygienists’ Association direct access).
The term direct access:
Allows a dental hygienist the right to initiate treatment based on his or her assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship. (American Dental Hygienists Association, 2004)
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