Future Health of Rural America

1. Future Health of Rural America Health Care Reform: Meeting the Needs of Rural Communities

2. Overview • Rural communities face challenges in recruiting and retaining high quality physicians, nursing and allied health professionals. • This will lead to a worsening health care shortage in rural communities and will in turn impact access and quality of care in rural communities. • Primary care physicians leading an integrated health care team is the only viable concept ensuring universal access to a medical home. • Historically, there have been many creative ways to attract health care personnel to rural communities. But, new state based and national innovations are needed. • Rural and state level workforce issues must be an integral part of the broader national health care reform that must take place in the few years to avert a national crisis.

3. Looming crisis in workforce in rural primary care in Kansas. • Rural Physicians on average: • Work longer hours • See more patients per day • Have less control over work hours • Are “on-call” more frequently • Have a broader scope of practice • Have less opportunity for professional interaction • Receive about the same level of compensation • New Physicians value: • More time for family • Shorter work week • Quality of life over monetary rewards

4. Workforce crisis predicted by the AAMC and others will be magnified in rural areas • Start seeing worsening in as little as 8 years • Already there is a crisis in many HPSA’s

5. Rural populations are one of the largest medically underserved groups • Problems with having enough qualified doctors • PA’s and ARNP’s not going into rural primary care either • Geographic challenges with large distances to get to medical help • Access to preventive and early intervention unavailable • Disparities for many of the health markers • Tobacco use • Obesity • Chronic Diseases • Aging population with increasing health needs • Increasing rates of immigration with increased rates of uninsured

6. Uninsured are Rural:% of County Residents in Kansas that were Un-insured in 2003

7. Immigrant Populations are largely Rural:% of County Population that claimed Hispanic or Latin on the 2000 Census

8. Many Living in Poverty are Rural:% of county residents that were living in poverty in 2000 census

9. Challenges for rural communities in recruitment and retention of Physicians and other Health Professionals • Recruitment to rural areas for all health professions • Professional health workers • Training in Tertiary Care Centers • Value of rural practice not emphasized • Students see that • Rural work hours are too long with “call” • Limited people to share “call” • Limited opportunities for spouse • Concerns about education for children

10. Physician specific challenges • Challenges with payment for services • Many uncompensated services are magnified when available time is limited • Phone advice • Email • Professional letters • Test result review and analysis • Case management • QI • Public education • Payer mix unfavorable • Frequently 50% or more Medicare/Medicaid • Compete with urban discounted services • Private pay (uninsured) can be high • 20% in my rural practice • 2% in my urban Practice

11. Physician specific challenges • 1 and 2 physician practices no longer sustainable • Office staff needed to meet billing, coding and documentation is unaffordable • Not to mention computer based systems • Practices are hospital/health system owned • Can work very well • Potential for source of friction • Work hours and "call" issues • No one to relieve call • Pay for locum tenens to cover time off • Paperwork burden very high – after hours

12. National decreased interest in Primary Care specialties KUMC – Top in the Nation for selection of FM Residency • AAMC study and others site • Student debt burden • Lifestyle • Work hours • Paperwork/Administrative burden in ambulatory practice • Many students express interest in primary care on admission and change their mind during school % KUMC matching in Family Medicine, Unpublished data from the Kansas Academy of Family Physicians

13. Available FM residency positions have decreased until this year. http://www.aafp.org/match2008/graph1.pdf

14. Average Starting Salary http://merritthawkins.com/pdf/mha2004_inpatient.pdf

15. Rural patient’s access to medical care is hindered • Lack of insurance • Uninsured • Underinsured • Practices are regionalized and geographic challenges exist in rural areas • Practices are overwhelmed due to few practitioners and high numbers of patients causing a shift to crisis/episodic care • Tools for chronic disease management and electronic health record are costly and unaffordable by small practices

16. Couldn’t have designed a system better to discourage students from entering a rural primary care medical practice

17. Proposed Solutions • Change admissions criteria for medical school • Select for students more likely to choose primary care • Patient-centered medical home • Reform payment of medical services • Reform medical malpractice • Financial incentives to choose rural practice • Practice enhancements for rural practice • Identify and enhance local rural and primary care programs that work to attract students to health care fields

18. Change admissions criteria • Many more students apply to medical school than are accepted • Studies show that the matriculants ranked lower academically at the time of admission do as well in medical school. • Those on the “alternate list” • Studies show that students with lower GPA’s and MCAT’s tend to choose primary care. • What makes a great doctor may not correlate purely with academic ability once a threshold is reached. • Students that don’t get in: • Many re-apply and get in • Some matriculate at another school • Some attend medical school off-shore

19. Patient-Centered Medical Home • The tools of a "medical home" will need to be provided up front to be effective • Start paying for preventive services • Start PMPM fees to implement system • Target high-utilization populations and diseases first to initiate savings to the system • Then share the savings with all contributors • Focus needs to be on the patient with services from a physician-lead health care team • Solutions need to be at both the state and national level to be effective • Electronic health records (EHR) • Incentives to patients and medical team for case management and improved outcomes • Patients have few tools now to manage their own care • New ways to interact with physicians

20. Educational Programs • K-12 • Programs in rural areas that encourage health professions • College • Enhance programs in rural colleges • Rural programs in larger universities • Medicine, Nursing, Allied Health • Rural programming • Make Primary Care the kind of thriving, exciting, personal health care practice that will naturally attract students of all disciplines • Post graduate training • GME funding for rural training rotations • Specific GME premium for rural programs • ARNP / PA programs that emphasize rural and primary care

21. Not giving enticements…but removing barriers • Student indebtedness • Reduced income at start up • Lack of vacation time coverage • Burdens of medical malpractice • Professional medical support systems (“curb-siding”)

22. Removing barriers • Student indebtedness • Loan repayment programs • Loan forgiveness for service programs • Reduced income at start up • Tax abatement programs (Start-up – 5 yrs) • State - $5,000 tax credit • Federal - $10,000 tax credit • Lack of vacation time coverage • Locum tenens programs for first few years • Burdens of medical malpractice • Special malpractice coverage for frontier areas • Professional medical support systems (“curb-siding”) • Incentives for adjacent communities to form professional cooperatives

23. Incentives for patients • People are the central link in the health care chain • Incentives that reward healthy behaviors • Incentives for non-smokers • Free or reduced cost medications for those that control chronic diseases • Incentives for maintaining healthy BMI • Sharing the health care savings for a healthy community

24. Remove the health insurance (or lack of) barrier of access to care • Remove prior authorizations • Time and personnel consuming • Reward primary care visits for: • Disease prevention • Healthy living counseling • Chronic disease case management • Universal coverage plan for ALL Americans • Stop loss of “coverage” for chronic diseases • Patients that lose coverage due to job change • Incentives for carriers to focus on long-term health and not short-term coverage while insured

25. Align incentives to move the health care system in the right direction • Pay for performance cannot work without the tools to make evaluations and corrections • Outcomes are the natural measure of improved health of the population • Incentives to reward physician communication and team management • Incentives to reward use of the medical home and not the ER • Incentives to reward compliance with treatment plans • Incentives to reward evidence based medical practice

26. Hinge pin is communication • EHR needs to have the following characteristics: • Interoperability across the US health care system • Dashboard/browser can be unique • Point of service • Ease of use • 3x5 card • What’s really needed in medical documentation • Privacy safeguards • Access / encryption / owner / business and government issues • Web based • Case management capable • Population management capable • Real time monitoring for epidemic out breaks • Subsidized or inexpensive that allows for physician and patient access and health management

27. Minimize the siphoning of health care funds that go to activities that have minimal effect on healthy outcomes • Administrative costs • Redundancy in the system • Practice of defensive medicine • Testing • Procedures • Documentation • Paperwork/form burden

28. Other considerations • Create rural health careers programs that identify and groom students in small rural communities. • Emphasize quality of life for rural physicians. • Develop rural training sites using distance learning technology enrolling health careers students of all disciplines to remain in or close to their home. • Regional medical school campuses • Distributive model for medical education • Develop programs that provide a “full ride” for those willing to live and work in frontier areas.

29. Don’t give physicians more to do, give physicians the tools to do more. Thank you