Health Care in Rural Pennsylvania

1. Health Care inRural Pennsylvania An Overview Lisa Davis Pennsylvania Office of Rural Health

5. The Look of Pennsylvania Erie Scranton/ Wilkes-Barre State College Allentown Harrisburg You are here Philadelphia Pittsburgh

6. The Contexts of Rural Health • Place-based Context • High risk occupations such as farming, mining, and forestry/fisheries; migrant farmworker population • The un- and under-insured • People-based Context • Fewer residents exercise regularly, 1/3 are overweight, and 60 percent are at risk for sedentary lifestyles • Prevalence of chronic diseases such as diabetes, hypertension, obesity; behavioral health issues; dental health concerns; mental health issues Source: Behavior Risk Factor Surveillance Survey

7. What is Rural? Definitions of Rural Most define “rural” by default • OMB Definition: Metropolitan/ Micropolitan/Non-metropolitan • Census Definition: Urbanized Area/ Urbanized Cluster • Federal Office of Rural Health Policy Definition: Rural-Urban Commuting Areas • Center for Rural Pennsylvania: Rural/Urban

8. Rural-Urban Commuting Areas (RUCAs) For Pennsylvania Legend Dark Yellow Code 4 (Large Town) Medium Orange Code 5 (High Commuting to Large Town) Light Orange Code 6 (Low Commuting to Large Town) Dark Yellow Code 7 (Small Town) Medium Yellow Code 8 (High Commuting to Small Town) Light Yellow Code 9 (Low Commuting to Large Town) Green Code 10 (Rural Areas) Source: Community Information Resource Center, Rural Policy Research Institute

9. What Makes Ruraland Urban Different? • Geography • # Residents • # of Providers (hospitals, physicians, dental health and mental health, etc.,) • Socio-economic status • Economic and community development • Educational opportunities

10. Who Is Rural? • Nationally – 20 percent of the population lives in areas that are designated as rural • Pennsylvania – 23 percent of the population lives in rural areas

11. Rural PennsylvaniaAt A Glance • One of the most rural states in the nation • 2.8 million rural residents • 42 of 67 counties designated as rural

13. Health Status in theRural United States Health, United States, 2001 Rural and Urban Chart Book, CDC • The 25th annual statistical report on the nation’s health: the first to look at health status relative to communities’ level of urbanization Some Highlights: • Death rates for working-age adults were higher in the most rural and urban areas. The highest death rates for childrenand young adults were in the most rural counties.

14. Rural residents had the highest death rates for unintentional injuries generally and for motor-vehicle injuries specifically. Homicide rates were highest in the central counties of large metro areas. • Both the most rural and most urban areas had a similarly high percent of residents without health insurance. • Residents of the most rural and the most urban areas are more likely to be poor.

15. Teenagers and adults in rural counties were the most likely to smoke. Residents of the most rural communities also had the fewest visits for dental care. • Communities at different urbanization levels differ in terms of age, race, ethnicity, income, and other factors, which affect health status.

16. Health Status inRural Pennsylvania • Fewer residents exercise regularly, 1/3 are overweight, and 60 percent are at risk for sedentary lifestyles • High risk occupations such as farming, mining, and forestry/fisheries; migrant farmworker population • Prevalence of chronic diseases such as diabetes, hypertension, obesity; behavioral health issues; dental health concerns • The un- and under-insured Source: Behavior Risk Factor Surveillance Survey

17. Health Status inRural Pennsylvania State Health Improvement Plan Special Report and Plan to Improve Rural Health Status, Pennsylvania Department of Health, 2000 Average age-adjusted rates were higher in rural areas in the following health status indicators: • Cardiovascular disease • Heart disease • Breast Cancer • Motor Vehicle Crashes • Suicide • Work-related Injury Deaths

18. Selected Rural/Urban Mortality Rates in PA * 2002 Data Crude death rates, not age-adjusted Utilizes Pennsylvania definition of “rural” Source: Center for Rural Pennsylvania

19. The Primary Issue forRural Health Care Is… ACCESS… • … to health care services • … payment mechanisms • … and transportation

20. Health Care Servicesin Rural Areas

21. Physician Distribution • Nationally – Only 9 percent of physicians practice in rural areas • Pennsylvania – 2/3 of primary care physicians practice in the three most populated counties • Access to specialists

22. Workforce Recruitmentand Retention Issues • Frame of reference • Wages • Reimbursement • Medical Malpractice • Isolation • Spousal considerations • Quality, coverage, continuing education • Minority providers and cultural competency • Nursing Shortage

24. Hospital and Physician Distribution in Pennsylvania Source: Center for Rural Pennsylvania

25. Provider Distributionin Pennsylvania Source: Center for Rural Pennsylvania

26. Provider Reimbursementin Rural Areas

27. Reimbursement for Services in Rural Areas • Perception that it costs less to provide services in rural areas • Medicare and Medicaid payments less to rural providers than to urban providers for same services • No economies of scale in rural areas

28. Health InsuranceIn Rural Areas

29. Insurance StatusIn Rural Pennsylvania • Between 10 percent and 12 percent of state’s residents are uninsured at any given time. Current estimates are that about 8-13 percent of the population are uninsured • One in 10 of non-elderly residents • Who are the un- and underinsured? • Employees/owners of small businesses • Full-time workers • Low-income families and children • Fastest growing rate is among those earning $25,000 - $49,999 Source: Robert Wood Johnson Foundation, Kaiser Family Foundation, Pennsylvania Department of Insurance

30. Insurance Statistics Source: Center for Rural Pennsylvania

31. Source: Center for Rural Pennsylvania

32. Areas of Medical Underservice Designation • Health Professional Shortage Areas (HPSAs) • Primary Care HPSAs • Geographic HPSAs • Population HPSAs • Facility HPSAs • Dental Health HPSAs • Mental Health HPSAs • Medically Underserved Areas (MUAs) • Medically Underserved Populations (MUPs) • Population MUPs

33. Health ProfessionalShortage Areas (HPSAs) • Identifies an area as having a shortage of health care providers on the basis of availability of primary care physicians • Demonstrated lack of access to health care due to distance, overutilization or access barriers • Ratio of primary care provider to population of 3,500:1 OR One physician for every 3,000 to 3,499 persons (3,499:1 to 3,000:1) plus demonstrated “unusually high need” for health care services

34. Benefits of HPSA Designation • Student loan repayment and placement through the National Health Service Corps • Eligibility for the Pennsylvania Loan Repayment Program For Students

35. Benefits of HPSA Designation For Health Care Providers and Facilities • Increased Medicare reimbursement • Eligibility for Rural Health Clinics • Enhanced federal and state grant eligibility • Funding preferences for primary care providers

36. Medically UnderservedAreas (MUAs) • Based on ratio of primary medical care physicians/1,000 population and • Infant mortality rate and • % of population with incomes below poverty level and • % population > 65 years of age. • Uses an Index of Medical Underservice (IMU) from 1 to 100 • Score of < 62.0 qualifies for MUA designation

37. Benefits of MUA Designation • Eligibility to develop clinics • Enhanced federal grant eligibility For Health Care Providers and Facilities

38. The Health Care Sector as Employer in Rural Areas

39. The Economic Impactof Health Care • Health care is one of the top employers in any county • Health care employs almost 12 percent of the rural workforce • Annual revenues of $73 million in average rural county • Each health care dollar “rolls over” 1.5 times in the local economy • Concern of keeping these dollars local Source: Pennsylvania Rural Health Association

41. Why Do Rural Residents Stay? • This is home • Social-cultural issues • Commitment to community • Distrust of suburban/urban areas

42. National Rural Health Efforts • Shortage area designations • National Health Services Corps • J-1 Visa Waiver program • Rural Health Outreach and Rural Network Development grant programs • Medicare Rural Hospital Flexibility/Critical Access Hospital program • Community/Migrant Health Centers, Federally Qualified Health Centers, and Rural Health Clinics • And more…

43. State Support • Pennsylvania Department of Health Community Challenge Grants • Pennsylvania Department of Health State Rural Health Plan • Pennsylvania Rural Development Council • Center for Rural Pennsylvania • Community Health Improvement Partnerships • Centers for Medicare and Medicaid Services rural connection

45. The PennsylvaniaOffice of Rural Health • One of 50 state offices of rural health in the nation • Federal/State Partnership • Charged with: • Coordination • Technical assistance • Networking • Partnership development • Provider recruitment and retention

46. The PennsylvaniaOffice of Rural Health Mission The mission of the Pennsylvania Office of Rural Health is to enhance the health status of rural Pennsylvanians through advocacy, outreach, education, applied research, and special programs and projects.

47. Focus • Compiling, analyzing, and disseminating information to policy makers, health providers, health educators, and health administrators; • Strengthening the existing network of rural providers, planners, and advocates by encouraging partnerships and identifying opportunities for collaboration and cooperation; • Increasing awareness of an advocacy for rural health needs, opportunities, and policy issues; • Acting as a liaison between academia, state government, professional associations, and the general public; and • Conducting applied research into health care issues in rural Pennsylvania.

48. Initiatives • Education • Rural Health Conference • Grant writing workshops • Migrant and Immigrant Health conference • Swimming Pool Applicators Pesticide Training Program • Emergency Preparedness • Outreach • Newsletter • Advocacy • Farm Safety Programs

49. Initiatives • Advocacy • Committee participation • Legislative education • Special Projects • Rural Hospital Programs • Swimming Pool Applicators Pesticide Training Program • Rural Health Farm Worker Protection Safety • Special populations: women’s health, migrant farmworkers, etc.

50. Initiatives • Applied Research • Provider distribution • Home health care • Dental Health • Small Employer Benefits Options