Health Care inRural Pennsylvania

An Overview

Lisa Davis

PennsylvaniaOffice of

Rural Health

Pittsburgh

State College

Philadelphia

Harrisburg

Scranton/Wilkes-Barre

Allentown

Erie

You are here

The Look of Pennsylvania

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

What is Rural?

Definitions of RuralMost 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

Rural-Urban Commuting Areas (RUCAs)For Pennsylvania

LegendDark 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

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

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

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

RWHC Eye On Health

"Your test results confirm that you are more careful about what you put in your car than your mouth."

Health Status in theRural United States

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 children and young adults were in the most rural counties.

Health, United States, 2001Rural and Urban Chart Book, CDC

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.

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.

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

Health Status inRural Pennsylvania

Cardiovascular disease Heart disease Breast Cancer

Motor Vehicle Crashes Suicide Work-related Injury Deaths

State Health Improvement PlanSpecial Report and Plan to ImproveRural Health Status, Pennsylvania

Department of Health, 2000

Average age-adjusted rates were higher in rural areas

in the following health status indicators:

Selected Rural/Urban Mortality Rates in PA

State Rural Urban

All Causes* 10.5/1,000 10.9/1,000 10.3/1,000

Heart Disease* 310.6/100,000 340.9/100,000 299.0/100,000

Accidents* 37.2/100,000 41.8/100,000 35.4/100,000

Diabetes* 29.7/100,000 33.8/100,000 28.2/100,000

Suicide* 10.8/100,000 11.9/100,000 10.3/100,000

AIDSIn 2002, 0-4.99 new cases in the most rural

counties (Pennsylvania Department of Health) * 2002 Data Crude death rates, not age-adjusted Utilizes Pennsylvania definition of “rural”

Source: Center for Rural Pennsylvania

The Primary Issue forRural Health Care Is…

ACCESS…

… to health care services … payment mechanisms … and transportation

Health Care Servicesin Rural Areas

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

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

Hospital and Physician Distribution in Pennsylvania

State (%) Rural (%) Urban (%)

Acute Care Hospitals 181 (100) 76 (42) 105 (58)

Patient Care Physicians

41,447 (100) 5,930 (14) 35,517 (86)

Primary Care Physicians

16,838 (100) 2,783 (17) 14,055 (83)

Dentists 8,353 (100) 1,624 (19) 6,729 (81)

Source: Center for Rural Pennsylvania

State (%) Rural (%) Urban (%)

Nurses160,115

(100)29,746 (19)

130,369 (81%)

Nurse Practitioners 4,363 (100) 570 (13) 3,793 (87)

Physician Assistants 2,456 (100) 518 (21) 1,938 (79)

Nurse Midwives 288 (100) 61 (21) 227 (79)

Pharmacists 12,913 (100) 1,964 (15) 10,949 (85)

Source: Center for Rural Pennsylvania

Provider Distributionin Pennsylvania

Provider Reimbursementin Rural Areas

RWHC Eye On Health

Rural?Pay them less.

They grow their own vegetables.

RWHC Eye On Health

Rural?Pay them less.

They grow their own vegetables.

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

Health InsuranceIn Rural Areas

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, PennsylvaniaDepartment of Insurance

Insurance Statistics

State (%) Rural (%) Urban (%)

Enrolled in Medicare

2,095,240 (100)

470,774 (22)1,624,466

(78)

Eligible for Medicaid

1,567,428 (100)

453,375 (29)1,114,053

(71)

Total Enrolled in HMO Private HMO Medicare HMO Medicaid HMO

5,377,684 (100)

71.6 %8.5%19.9%

1,229,309 (23)

78.2%8.5%13.2%

4,148,375 (77)

68.2%8.9%22.8%

Source: Center for Rural Pennsylvania

Source: Center for Rural Pennsylvania

State (%) Rural (%) Urban (%)

Enrolled in PACE 257,745 (100) 91,288 (35) 166,457 (65)

Enrolled in AdultBasic Coverage

44,702 (100) 16,047 (36) 28,655 (64)

Enrolled in S-CHIP 133,462 (100) 41,832 (31) 91,630 (69)

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

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

Benefits of HPSA Designation

Student loan repayment and placement through the National Health Service Corps

Eligibility for the Pennsylvania Loan Repayment Program

For Students

Benefits of HPSA Designation

Increased Medicare reimbursement Eligibility for Rural Health Clinics Enhanced federal and state grant eligibility Funding preferences for primary care providers

For Health Care Providers and Facilities

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

Benefits of MUA Designation

Eligibility to develop clinics Enhanced federal grant eligibility

For Health Care Providers and Facilities

The Health Care Sector as Employer in Rural Areas

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

Why Do Rural Residents Stay?

This is home Social-cultural issues Commitment to community Distrust of suburban/urban areas

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…

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

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

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.

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.

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

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.

Initiatives

Applied Research Provider distribution Home health care Dental Health Small Employer Benefits Options

Pennsylvania Office of Rural Health202 Beecher-Dock House

University Park, PA 16802Telephone: (814) 863-8214

Fax: (814) 865-4688

http://porh.cas.psu.edu

Pennsylvania Rural Health AssociationP.O. Box 1632

Harrisburg, PA 17105-1632(717) 561-5248

http://www.paruralhealth.org/