According to the US Census Bureau, approximately 60 million, or one in five Americans, live in rural areas. Rural areas are sparsely populated, have low housing density, and are far from urban centers, and these factors create unique and complex challenges when providing healthcare to this population.
After completing their training, physicians and nurses often gravitate to urban areas. The patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas, according to data from the U.S. Department of Health and Human Services (HHS). This discrepancy makes access to care more difficult, and data collected by the Rural Health Information Hub indicates that this negatively impacts care outcomes and even life expectancy in rural areas. Due to the scarcity of specialists such as mental health providers, dentists, and oncologists, patients must often travel significant distances to seek these types of care.
Compounding the impact of the shortage of primary care physicians and in parallel to it, access to care has further been impacted by an increase in closures of rural community hospitals. According to the Government Accountability Office’s (GAO) analysis, 64 rural hospitals closed from 2013 through 2017. This represented approximately 3 percent of all the rural hospitals in 2013 and more than twice the number of closures of the prior 5-year period. The GAO's analysis further shows that rural hospital closures were more prevalent in the South, among for-profit hospitals, and among hospitals that received the Medicare Dependent Hospital payment designation, one of the special Medicare payment designations for rural hospitals. The national shift to ambulatory care, which resulted in reduced hospital occupancies, worsened the financial burdens of these rural hospitals, resulting ultimately in their closure. These closures often inevitably portended the decline in other medical services that depended on these hospitals for their livelihood, for example ambulance services, home health services and outpatient laboratories.
The opioid epidemic has had a significant, disproportionate impact on rural America as well. The rate of opioid overdose deaths is 45 percent higher in rural than in metro areas, according to data from the National Rural Health Association. This is likely multifactorial: a combination of socioeconomic factors and reduced access to mental health providers, pain treatment, and addiction treatment centers and specialists. Because of the geographical realities in rural areas, access to emergency services is not as readily available and many more overdose cases result in death due to unavoidable delays in arrival of emergency teams capable of pharmacologically reversing an impending lethal drug overdose.
Rural healthcare providers face significant challenges, and the resulting provider burnout and health outcome disparities are real. Developments in health information technology (HIT) offer some needed hope.
Widely available telemedicine capabilities enable rural health systems to overcome the impact of geographic distance and resource scarcity. Patients meeting virtually with their providers can significantly decrease the burden of travel and consequent poor access. Mental health services are well suited for virtual visits, as are follow-up visits after surgical procedures or monitoring patients with stable chronic conditions.
Rural health providers often practice solo or in small groups and, at times, are professionally isolated. Health IT tools offer great promise in reducing this isolation by providing video consults with specialists. Rural providers can even do live consults with colleagues in real time—an empowering and helpful option.
As an example, the University of Washington Division of Pain Medicine offers weekly TelePain sessions, a videoconference with specialists with expertise in the management of challenging chronic pain problems. The UW TelePain program significantly increases access to experts who provide real-time support in the care and treatment of the most challenging chronic pain patients.
Mounting evidence shows that poverty and other social determinants of health significantly and negatively impact health outcomes. According to the Rural Health Information Hub, rural residents tend to be poorer, with about 25 percent of rural children living in poverty. On average, per capita income in rural areas is lower, and the disparity in income is even greater for minorities in these areas. The negative health impact of poverty is often mediated through lack of health insurance or under-insurance, which may deter these individuals from seeking medical care and from adhering to care recommendations.
Smoking rates are also higher in rural areas, as are deaths from motor vehicle accidents and youth suicide. Chronic conditions such as diabetes and COPD (chronic obstructive pulmonary disease) are more prevalent, and when present, less well controlled, adding further burden to rural providers’ already thinly stretched resources.
Contributing to this complex healthcare landscape, higher percentages of older adults also live in rural areas. Many of the healthcare challenges faced by residents of rural areas are amplified significantly in the elderly. Geographical distance, access to care, poverty, isolation, the scarcity of food programs such as Meals on Wheels, elder day care and long-term care programs, all impact healthcare complexity and outcomes in this vulnerable population.
Healthcare provider organizational are increasingly leveraging technology to address the social factors that impact rural patients’ health. As example of one innovative approach to reducing disparities in access to care is the effort by the Patient Access to Pharmacists’ Care Coalition which is working to enact federal legislation to enhance access to care for Medicare beneficiaries in underserved communities. The coalition is proposing an amendment to Medicare rules that would increase medically underserved seniors’ access to health care through pharmacist-provided care. Since nearly 95 percent of the U.S. population lives within 5 miles of a pharmacy, according to data from the National Association of Chain Drug Stores, and improving access to pharmacist’s services by creating appropriate Medicare reimbursement rules holds significant promise.
Dr. Betty Rabinowitz is the chief medical officer of NextGen Healthcare. She has more than 25 years of extensive clinical experience and expansive knowledge of population health and value-based practice transformation.