Why You Should Read this Chapter
The physician assistant (PA) profession was envisioned and created in the 1960s to fulfill a growing gap in access to health care because of a shortage of primary care physicians. Using the field-tested skills of ex-military corpsmen as an “assistant to the primary care physician,” it was believed that PAs could extend the practice reach of physicians to underserved communities and populations with less cost. Although changing demographics and trends have shifted PAs to more urban practices and less primary care focus, there remains tremendous potential for the profession to help shape the health of rural communities and individuals and continue to fulfill the vision of its originators.
What is Rural, and Why Does it Matter?
Our perspectives on the definition and culture of rural America today are very different from how we perceived rural in the mid-20th century or even in the current context of the 21st century. For many, the word rural often paints a vision of open farmlands; untouched forests; rolling hills; and a sparsely populated, rustic environment. Although many rural people do live in such surroundings, other rural residents live in areas just adjacent to urban areas, and their sense of being rural comes as much from their lifestyle as from the actual environment ( Fig. 46.1 ).
The U.S. population shift since 1990, from rural to urban, occurred steadily as a result of changing lifestyles, economics, and postdepression and postwar transitions. In 1910, the rural population accounted for 71.6% of the total population but by 1940 had dropped to 52.2%; 1950 was the first time the U.S. population had become predominantly urban with only 43.9% rural. Over the past 60 years, rural communities continued to erode, and between 2010 and 2014, the rural population dropped from 19.3% to 15%, although some areas of high recreation and retirement options have seen increases. The growth in urban populations was not primarily in the “core” inner cities; in fact, the majority of growth in urban areas from 1930 to the present was in the suburbs, increasing from 13.8% to 50% of the total urban population (80%) ; 65% of all U.S. counties are classified an nonmetropolitan ( Fig. 46.2 ).
When considering rural America, caution should be used to not put everyone into the same basket; each rural community is distinct, and each U.S. region has distinct characteristics that help define its rurality. For example, small towns in rural New England are different in character from the open plains and communities of Montana or Wyoming; these characteristics reflect the economic, ethnic, and social differences unique to each area.
So why does defining “rural” matter? More than 40 federal programs use rural definitions to allocate facility and grant funding and support resources—for example, the National Health Service Corps, Rural Health Clinics (RHCs) and Federally Qualified Health Center (FQHC) designations, Critical Access Hospital (CAH) designation, and Universal Services Telecommunications Grants. In addition, the PA concept was envisioned at a time when there was a significant shortage of primary care physicians nationally, particularly in rural and suburban areas. Understanding the dynamics of rural health care, then, is important to understanding the evolution of the PA profession and future opportunities for PAs in rural practice settings.
Characteristics of Rural Populations and Communities
Definitions of Rural
Federal and state policymakers are often required to define “rural” and “urban” in order to develop and apply policies appropriately. What seems like a simple task, however, can become complicated because agencies at both levels of government use differing methodologies to define these terms depending on the population targeted, geographic determinants, and the specific purpose of the program. There are at least three major federal agencies that define rural: the U.S. Census Bureau, the Office of Management and Budget, and the U.S. Department of Agriculture Economic Research Center. See complete definitions at ric.nal.usda.gov/what-rural . Because each agency defines rural differently, it can be a challenge for communities and health systems to know exactly which programs they quality for and how to access resources.
Frontier counties, another designation created for federal programs in 1990, were initially described as counties with very low population densities of no more than six people per square mile (compared with a national average of 73 years). The frontier designation was used inconsistently by the agencies that track rural populations and health, so a national consensus process was implemented by the Frontier Education Center and funded by the Federal Office of Rural Health Policy (FORHP) in 1997. The purpose of the process was to develop a new definition recognizing that “frontier” described not only physically isolated areas but also areas relatively isolated because of geography, weather, or other factors. The final report was published in April 1998 and provides a matrix, based on a maximum of 105 points, that can be used to determine the relative frontier status of any area. The determinants include population density per square mile, distance in miles to services and markets, and distance in time to services and markets. The 2010 U.S. Census includes 445 “frontier” counties with populations of less than 6 people per square mile. See frontierus.org/frontier-definitions for complete definitions by application.
Several features set rural communities apart, such as employment, income, poverty, and age level as noted in Table 46.1 .
|Unemployment (%), ∗ 2015||5.8||5.4|
|Annual per capita earnings ∗||$31,415||$41,244|
|Median household income, ∗ 2012||$41,198||$52,988|
|Poverty rate—overall (%), ∗ 2014||18.1||15.1|
|0–17 years of age, 2013||25.2||21.1|
|18–64 years of age||17.6||14.1|
|65 years of age and older||10.5||9.3|
∗ Data from U.S. Department of Agriculture. Rural Poverty & Well-being. www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being.aspx .
In general, rural areas have higher rates of poverty, older adults, health disparities, low income, occupational injury, and unemployment. Rural populations are less likely to have health insurance, retirement plans, and other benefits because the majority of employers have fewer than 50 employees and often are not able to provide those benefits at reasonable cost, although the Patient Protection and Affordable Care Act (PPACA) of 2010 now provides some incentives for employers to do so. Workers are often seasonally employed and may work in high-injury occupations, such as mining, timber, fishing, and farming. Nonmetro populations typically have lower education levels than metro areas.
Although the prevailing impression of rural America is that it is primarily agricultural in nature, the percentage of population involved in traditional agricultural work (farming, forestry, mining, and fishing) reflects about 9.6% of industry ; still less than 6% of the U.S. population is directly involved in farming. Manufacturing (34.8%), tourism and recreation services (16.7%), and destination retirement living (16.5%) have accounted for the bulk of employment in nonmetro areas of the country for the past decade. More recently, employment in the service sector has increased to 41%; government to 15.6%; and transportation, trade, and utilities to 17.3%.
Farm productivity has continued to increase because of changes in technology, equipment, and techniques, and therefore the transformation of farmland to other uses has been much slower than the decline in employment. Farm households that do remain in agriculture are likely to also have nonfarm revenues from other sources to supplement income and maintain the farm. In addition to these changes, farmlands are under increasing pressure from urban fringe expansion to be sold and developed for large housing tracts, recreation areas, manufacturing plants, and retirement villages.
There are multiple challenges regarding the aging population in nonmetro areas stemming from factors such as outmigration of youth, aging in place of the existing population, increased migration of metro population to nonmetro areas, fewer health resources and access points, and declining number of rural health care services.
The role of population aging on Medicare and access to health care will intensify, especially since the large baby boomer generation began to turn 65 years old in 2010. Key issues that will lead to changes include
Nonmetro areas will continue to have an increasing percent of elderly population.
Compared with metro areas, nonmetro older adults generally have lower incomes, lower educational attainment, and a higher dependence on Social Security income, creating demand for medical, social, and financial assistance.
There will be continuing difficulty in accessing health care because of a reduced number of primary care and specialty providers and services.
One of the more recent trends that counteracts the previous information is the increasing number of metro aging populations that have moved and continue to move to nonmetro retirement communities typically adjacent to metro areas. This population group skews the data because they are often more affluent and mobile, have higher education levels, are more likely to be married than living alone, and typically have private insurance. 48
Minority Population Trends
Compared with the 2000 U.S. Census, 2010 Census data show that racial and ethnic minorities increased from 18.3% of nonmetro residents to almost 20%, with Hispanics and Asians the fastest growing minority groups. American Indian numbers increased also, but this is believed to be due to the increased number of people reporting American Indian heritage on the census questionnaires. The Hispanic rural population (9.3%) moved ahead of the African American population (8.2%) in the past decade and is now the fastest growing ethnic population in the rural counties, having a 46% increase since 2000. Less than 2% of the rural population is Native American, but that still comprises more than 50% of their total population. Asian, mixed race, and Pacific Islanders total less than 3% of the rural population. It is important to note that Hispanic and African American minorities are tied historically and geographically to large areas of the country: African Americans are significantly overrepresented in the small and rural towns in the southeastern states, and Hispanics in the four states of Texas, California, New Mexico, and Arizona (slightly more than 50%).
Although immigration brings new and diverse populations to nonmetro areas, which can revitalize small towns economically and demographically, those same increases create pressures in the local economic structure and raise concerns about increased demands for social services, education, and barriers to assimilation. The Hispanic population had been primarily a rural-based group, with roughly 90% of all Hispanics living in nonmetro areas throughout the 1990s, but recent census data reflect a wider dispersion across the country and into more urbanized areas (suburban, 12.7%, and urban, 27.3%). Although legal and illegal immigration generated the primary increase in the Hispanic population before 9/11, the subsequent decrease in illegal immigration from Mexico because of multiple major congressional acts significantly reduced the flow of Hispanics into the United States. The Hispanic population had the greatest increase in population by 46% in the past decade primarily because of increased birth rates.
The influx of a broad mix of immigrants and the continuing shift among geographic areas creates significant challenges for rural communities that for generations have had populations based in European cultures, often from the same regions or cities. These changes require a paradigm shift for communities in regard to accommodating language differences in schools and businesses, religious beliefs and the availability of churches, clothing and food purchases, and social and health accessibility.
Rural America will continue to face many challenges with the continuing population shift to metropolitan areas and aging of the rural population, increasing presence of immigrant populations, changing economies, and lack of resources. Health policymakers will need to be creative in recognizing and meeting local, regional, and national health care needs.
Access to Health Care
The issue of access to health care is of great concern. The definition of access is informed by the context of people, place, provider, and payment. It can no longer be viewed as only being able to physically get to a source of care and the availability of services. As important is whether the type of facility and provider are appropriate for the care needed (individual or community) and what types of payment options are available. Lack of specialty physicians and advanced diagnostic and treatment modalities may still create access issues for rural populations with increased chronic disease and poverty.
Geography plays an important role in limiting access because rural residents must often travel longer distances and may have natural boundaries, such as mountains, rivers, and federal parks and forests that have no through roads. Distance is often compounded by weather conditions, which can make travel hazardous or limit air evacuation efforts; twisty two-lane roads; and lack of public transportation in rural areas ( Fig. 46.3 ).
The locations and availability of health and social services create access issues as well. Health care providers are often found in county seats or similar population centers and often are not able to provide adequate outreach to less populated areas for financial, staffing, or other reasons. Those with special needs—such as people with physical or mental disabilities—who may need personal assistance to access care are even more disadvantaged by these factors. In addition, federal and state programs set up to address these issues are often targeted toward children with special needs or older adults. Unfortunately, many rural communities do not have the population to qualify for the special funding or to support the services.
In looking at rural population data, it has been frequently noted in the past that many people did not have health care insurance, a significant barrier in accessing services. Rural populations tend on average to be older and poorer, have more chronic disease, and have lower levels of education, all of which can contribute to a lower health status and a higher need for health care. The 2010 Census showed there were 49.9 million people without health insurance in the United States—16.3% of the population; this was up from 46.6 million in 2006.
The PPACA attempted to meet several challenges of access to care by (1) increasing funding for health profession education and training programs, (2) increasing the availability of health clinics and centers to minimize distance factors, and (3) expanding insurance coverage through both the private and public sectors to cover more families and individuals. The debate rages as to its success, but research following the PPACA impacts show that the uninsured rate from 2008 to 2014 dropped 40% in states participating in the Medicaid expansion program and 29% in nonexpansion states. Although the PPACA significantly expanded coverage that benefitted rural areas, legislation at the federal and state levels curtailed expansion in a number of states.
The 2010 Census shows that nationally, the metropolitan uninsured rate was 19% overall; the nonmetro rate (communities under 2500) was considerably higher at 23%. There are multiple reasons why there were fewer insured individuals: many small businesses could not afford to pay full benefits for their workers, and many rural jobs are seasonal or require only part-time work and therefore are not covered for benefits. Extended benefits to family members, dental coverage, and sick leave also have been less often available to workers.
Another critical aspect of access to health care is the availability of qualified health professionals. Data from 2010 reflect that although slightly less than 20% of the population was rural, only 9% of physicians practice in those areas. Looking at PAs in rural communities, Cawley et al. report that 12% of all PAs work in nonmetro areas, a decrease from 15% in 2010. For primary care PAs, the numbers increase to 22% working in rural versus 78% in urban settings.
The 2013 American Academy of Physician Assistants (AAPA) Annual Survey notes that 17% of rural primary care PAs are employed in certified RHCs, FQHCs, and CAHs, reflecting the continued important role nonphysician providers play in ensuring access to health care services in underserved areas. In addition to the general maldistribution of physicians, the imbalance of physicians by ethnicity as noted in the American Association of Medical Colleges (AAMC) 2014 report on Diversity in the Physician Workforce:
Whites and Asians are overrepresented in the U.S. physician population. Whites comprise 72.4% of the 2010 U.S. population and 75% of the physician population. Asians and native Hawaiians and other Pacific Islanders comprise 5.2% of the U.S. population and 12.8% of the physician population.
Hispanics, blacks, and American Indians and Alaska Natives are underrepresented in the U.S. physician population, comprising 16%, 13%, and 0.9% of the U.S. population and 5.5%, 6.3%, and 0.5% of the physician population, respectively.
This becomes an important note when considering the growth of Hispanic and other nonwhite populations in nonmetro areas, as well as the need for greater numbers of culturally and linguistically appropriate health care providers and facilities.
According to recent research, multiple media reports, and federal job sites, the growth of the PA profession continues to climb. Projections for the future indicate it will be one of the top jobs for the next decade or more, especially in rural and urban underserved areas. The challenge will be for the profession to capture potential applicants who increasingly match the new demographics of the nation and especially rural populations.
Rural Health Care Systems: Hospitals, Clinics, and the Safety Net
The health status of rural populations tends to be poorer than that of urban populations and is often compounded by higher levels of poverty, aging, and unemployment as noted earlier. Rural populations tend to have higher rates of chronic diseases, and health outcomes are dependent on factors such as adequate access to necessary and affordable health care services, distance and geography, and personal behaviors that contribute to poor health. Ethnic minorities, a growing population in rural communities as noted, have higher incidences of health disparities and lack of access to services, lack of health care insurance, and higher poverty rates. Census data from 2010 note that almost 10% (9.8%) of children younger than age 18 years were uninsured, as well as 20.8% of African Americans, 30.7% of Hispanics, and 11.7% of non-Hispanic whites.
The health care delivery system in rural America is trying to respond to many and varied problems. Although some of these also exist in urban underserved areas, many are unique to rural America. The rural health care system is often more loosely organized than its urban counterpart and much more thinly spread. Its component parts are similar, but many of the more familiar ones are missing or are present in only skeletal form. What appears in any given system varies with the degree of remoteness and the resources of the community. Mounting evidence of the relative decline in rural health care includes the closure and deteriorating financial condition of local hospitals and, more important, the difficulty of recruiting and retaining physicians, midlevel providers (PAs and nurse practitioners [NPs]), nurses, and other health care personnel.
Over the past 4 decades, a wide range of health policies and programs have been developed and implemented to mitigate these issues and assist rural Americans in improving their personal and community health status. The overall effect has been to create a health care “safety net” that includes clinics, hospitals, free clinics, and public health services that improve access to care regardless of ability to pay.
Hospitals: Transitioning Models of Service
As the demographics and economic basis of rural communities changed over the past 4 decades, rural hospitals faced significant challenges in maintaining services, staff, and providers. Several federal initiatives were created to assist these hospitals in finding a new way to not only survive but also continue to meet community needs in a more effective and efficient way ( Fig. 46.4 ).
After World War II, as the nation’s population was rapidly growing in suburban and rural areas, Congress passed the Hill-Burton Act in 1946 that gave hospitals, nursing homes, and other health facilities grants and loans for construction and modernization. State plans were to be developed to encourage expansion of health care facilities so that all people in the state would have access to care. By applying for and accepting the grants, the facilities agreed to provide free or reduced-cost emergency and other services to persons who were unable to pay, they had to serve all persons residing in the facility’s area, and later they had to participate in the Medicare and Medicaid program. The Hill-Burton program stopped providing funds in 1997, but about 300 health care facilities nationwide are still obligated to provide free or reduced-cost care. Many of these facilities are still in their original buildings and struggle to find the capital resources to build new facilities or modernize.
During the 1970s and 1980s, the federal government experimented with a variety of alternative community hospital models to retain as much access to services while reducing costs and need for expansive facilities and staffing. The Medical Assistance Facility program authorized by Congress in 1990 set up a demonstration project in Montana to explore options around a limited services facility on a smaller scale than a fully accredited hospital. There were seven test sites and six control sites in Montana, and the model was deemed a relative success. It was also a significant opportunity for PAs and NPs because the model relied on use of midlevel practitioners to maintain access to care in these communities.
The Omnibus Budget and Reconciliation Act of 1989 established another alternative model: the Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH). This model was also based on a limited service facility staffed primarily by PAs and NPs, and there were test sites in seven states across the nation. The more rural RPCHs and larger EACHs were provided a higher cost-based Medicare reimbursement to improve financial stability, and the development of regional networks was encouraged.
Critical Access Hospitals
Congress later passed the Balanced Budget Act in 1997, which included provisions building on the successes of the MAF and EACH/RPCH models. The Medicare Rural Hospital Flexibility Program was established to continue to allow hospitals to refine the limited-service models, and in October 1999, all MAF and EACH/RPCH programs were grandfathered into the federally designated Critical Access Hospitals (CAH) program. Its purpose was to improve rural health by addressing access and quality of care issues for rural citizens through partnerships among the federal government, state government, rural CAHs, acute care urban hospitals, emergency medical services (EMS), and rural communities.
The Flex Program consists of two separate but complementary components:
A Medicare reimbursement program that provides reasonable cost reimbursement for Medicare-certified CAHs is administered by the Centers for Medicare & Medicaid Services (CMS).
A state grant program that supports the development of community-based rural organized systems of care in participating states is administered by the Health Resources and Services Administration through the FORHP.
To receive funds under the grant program, states must apply for the funds and engage in rural health planning through the development and maintenance of a State Rural Health Plan that
Designates and supports the conversion of CAHs
Promotes EMS integration initiatives by linking local EMS with CAHs and their network partners
Develops rural health networks to assist and support CAHs
Develops and supports quality improvement initiatives
Evaluates state programs within the framework of national program goals.
State entities, typically state offices of rural health, could apply for federal “Flex” grants to support the development of CAHs and networks to meet program objectives. As of March 2016, there are a total of 1331 active CAHs overseen by the FORHP.
Modifications to the program have resulted from the enactment of the Balanced Budget Refinement Act of 1999, the Benefits Improvement and Protection Act of 2000, and the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003. These changes have been incorporated into the information presented below.
Criteria for Critical Access Hospital Certification
A rural hospital may be designated as a CAH if the following criteria are met:
Owned by a public or nonprofit entity
Located in a participating State Rural Hospital Flexibility state
One or more of the following is true:
More than 35 miles from any other CAH or hospital
More than 15 miles from another hospital or CAH in mountainous terrain or in areas with only secondary roads
Designated a necessary provider under criteria published in the State CAH Plan
Offers 24-hour emergency care
Provides no more than 25 beds for acute care
May operate distinct part units of up to 10 beds for psychiatric or rehabilitation services
Keeps inpatients no more than an annual average of 96 hours except during inclement weather or other emergencies
Meets staffing and other requirements established in General Acute Hospital or Primary Care Hospital licensing and the State Plan for CAHs
Must have a formal agreement for participation as part of a rural health network. Rural health network defined as an organization of at least one CAH and one acute hospital
Over the past decade, as hospitals faced further implementation costs for new federal policies and regulations, rural and small hospitals again faced financial challenges. To offset these requirements and costs, more recent policy developments include the FORHP’s Small Rural Hospital Improvement (SHIP) Grant Program, which provides funding to small rural hospitals to help them do any or all of the following: (1) pay for costs related to the implementation of Prospective Payment Services (PPS), (2) comply with provisions of the Health Insurance Portability and Accountability Act (HIPAA), and (3) reduce medical errors and support quality improvement.
To be eligible for these grants, a hospital must be (1) small —49 or fewer available beds; (2) rural —located outside a metropolitan statistical area (MSA) or located in a rural census tract of an MSA as defined by the Goldsmith Modification or the Rural Urban Commuting Areas; and (3) a hospital, which is a nonfederal, short-term, general acute care facility. All designated CAHs were included as eligible, as well as hospitals with 50 or fewer beds located in an area designated by any state law or regulation as a rural area or as a rural hospital. Unlike other programs, there is no requirement for matching funds with this program.
More recently, the impacts of the PPACA, such as significantly increased numbers of patients seeking care and changes in reimbursement models, have pushed a number of CAH hospitals to the brink of closure. As of March 2016, there have been 71 hospital closures in the United States, mostly in the southern regions. A variety of factors contribute to the closures, including changing demographics, declining services and inpatient and surgical care, increased Medicare and Medicaid patients (especially in states that did not participate in the Medicaid expansion program), long-standing marginal financial performance, and loss of providers. In addition, several congressional actions related to the PPACA have cut Medicare reimbursement, added more quality and value measures that increase costs, and reduced reimbursement for bad debts—all this in a postrecession environment in which rural areas are still trying to regain their economic footing.
Some facilities have been able to “come back” as rehabilitation centers, nursing facilities, emergency outpatient facilities, or primary care clinics. The FORHP, National Rural Health Association, and North Carolina Rural Health Research Center at the University of North Carolina Chapel Hill are tracking closures and following how communities are responding.
Critical Access Hospitals—Physician Practice Mergers and Acquisitions
Over the past decade, the combination of recruitment and retention difficulties for rural practices, downward spiraling reimbursement payments from public and private payers, and added expense of new federal requirements such as electronic medical records encouraged the merging of rural physician practices with hospitals, many of which were CAH certified. As the overhead costs of owning and managing a practice continued to grow, physicians were more willing and interested in seeking relief through this mechanism. Additionally, such extended hospital linkages help capture market share by creating referral resources within the network. Under the PPACA health care reform requirements, creation of accountable care organizations (ACOs) and accountable community health (ACH) systems and implementation of meaningful use of electronic medical records have pushed more providers to seek collaborations that allow for flexibility and efficient use of resources to maintain adequate levels of local services.
Under the PPACA framework, health care networks (ACOs) would collaborate to lower costs, improve quality of care and services, and improve outcomes. By sharing resources and financial risk, the ACOs would receive better reimbursement, which would be shared proportionately among the partnering entities. In shifting toward a value-based reimbursement model, Medicare and other insurers anticipate overall health care costs will decrease over the next several years, with the difference used to help pay for the increased coverage of uninsured populations.