Transcript Rural Patients are People, too

Future Health of Rural America
Health Care Reform:
Meeting the Needs of
Rural Communities
Overview
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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.
Looming crisis in workforce in rural
primary care in Kansas.
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Rural Physicians on average:
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Work longer hours
See more patients per day
Have less control over work hours
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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:
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More time for family
Shorter work week
Quality of life over monetary rewards
Workforce crisis predicted by the AAMC and
others will be magnified in rural areas
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Start seeing worsening
in as little as 8 years
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Already there is a crisis
in many HPSA’s
Rural populations are one of the
largest medically underserved groups
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Problems with having enough qualified doctors
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Geographic challenges with large distances to get to medical
help
Access to preventive and early intervention unavailable
Disparities for many of the health markers
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PA’s and ARNP’s not going into rural primary care either
Tobacco use
Obesity
Chronic Diseases
Aging population with increasing health needs
Increasing rates of immigration with increased rates of
uninsured
Uninsured are Rural:
% of County Residents in Kansas that were Un-insured in 2003
Immigrant Populations are largely Rural:
% of County Population that claimed Hispanic or Latin on the 2000 Census
Many Living in Poverty are Rural:
% of county residents that were living in poverty in 2000 census
Challenges for rural communities in
recruitment and retention of Physicians and
other Health Professionals
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Recruitment to rural areas for all health
professions
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Professional health workers
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Training in Tertiary Care Centers
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Value of rural practice not emphasized
Students see that
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Rural work hours are too long with “call”
Limited people to share “call”
Limited opportunities for spouse
Concerns about education for children
Physician specific challenges
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Challenges with payment for services
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Many uncompensated services are magnified when available
time is limited
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Phone advice
Email
Professional letters
Test result review and analysis
Case management
QI
Public education
Payer mix unfavorable
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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
Physician specific challenges
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1 and 2 physician practices no longer sustainable
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Practices are hospital/health system owned
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Office staff needed to meet billing, coding and
documentation is unaffordable
Not to mention computer based systems
Can work very well
Potential for source of friction
Work hours and "call" issues
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No one to relieve call
Pay for locum tenens to cover time off
Paperwork burden very high – after hours
National decreased interest in
Primary Care specialties
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AAMC study and others
site
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KUMC – Top in the Nation for selection
of FM Residency
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
Available FM residency positions have
decreased until this year.
http://www.aafp.org/match2008/graph1.pdf
Average Starting Salary
http://merritthawkins.com/pdf/mha2004_inpatient.pdf
Rural patient’s access to medical care
is hindered
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Lack of insurance
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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
Couldn’t have designed a system
better to discourage students from
entering a rural primary care medical
practice
Proposed Solutions
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Change admissions criteria for medical school
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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
Change admissions criteria
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Many more students apply to medical school than are accepted
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Studies show that the matriculants ranked lower academically at
the time of admission do as well in medical school.
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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:
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Many re-apply and get in
Some matriculate at another school
Some attend medical school off-shore
Patient-Centered Medical Home
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The tools of a "medical home" will need to be provided up front to be
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Start paying for preventive services
Start PMPM fees to implement system
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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
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Target high-utilization populations and diseases first to initiate savings to the
system
Then share the savings with all contributors
Patients have few tools now to manage their own care
New ways to interact with physicians
Educational Programs
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K-12
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College
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Enhance programs in rural colleges
Rural programs in larger universities
Medicine, Nursing, Allied Health
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Programs in rural areas that encourage health professions
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
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GME funding for rural training rotations
Specific GME premium for rural programs
ARNP / PA programs that emphasize rural and primary care
Not giving enticements…
but removing barriers
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Student indebtedness
Reduced income at start up
Lack of vacation time coverage
Burdens of medical malpractice
Professional medical support systems (“curbsiding”)
Removing barriers
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Student indebtedness
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Loan repayment programs
Loan forgiveness for service programs
Reduced income at start up
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Tax abatement programs (Start-up – 5 yrs)
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Lack of vacation time coverage
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Locum tenens programs for first few years
Burdens of medical malpractice
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State - $5,000 tax credit
Federal - $10,000 tax credit
Special malpractice coverage for frontier areas
Professional medical support systems (“curb-siding”)
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Incentives for adjacent communities to form professional
cooperatives
Incentives for patients
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People are the central link in the health care
chain
Incentives that reward healthy behaviors
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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
Remove the health insurance (or lack
of) barrier of access to care
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Remove prior authorizations
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Reward primary care visits for:
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Disease prevention
Healthy living counseling
Chronic disease case management
Universal coverage plan for ALL Americans
Stop loss of “coverage” for chronic diseases
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Time and personnel consuming
Patients that lose coverage due to job change
Incentives for carriers to focus on long-term health
and not short-term coverage while insured
Align incentives to move the health
care system in the right direction
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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
Hinge pin is communication
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EHR needs to have the following characteristics:
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Interoperability across the US health care system
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Dashboard/browser can be unique
Point of service
Ease of use
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3x5 card
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Privacy safeguards
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Access / encryption / owner / business and government issues
Web based
Case management capable
Population management capable
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What’s really needed in medical documentation
Real time monitoring for epidemic out breaks
Subsidized or inexpensive that allows for physician and patient
access and health management
Minimize the siphoning of health care funds
that go to activities that have minimal effect
on healthy outcomes
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Administrative costs
Redundancy in the system
Practice of defensive medicine
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Testing
Procedures
Documentation
Paperwork/form burden
Other considerations
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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.
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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.
Don’t give physicians more to do, give
physicians the tools to do more.
Thank you