Q&A: What has health reform meant for rural America?
For the nearly 60 million Americans living in rural areas, health reform is playing out in different ways. These areas often struggle with access to care and attracting enough medical providers. Residents there have distinct health needs, are poorer and less likely to be covered by employer-based insurance. Despite health reform’s promise of expanding coverage, almost two-thirds of the rural uninsured live in states that are not expanding Medicaid, according to the Kaiser Family Foundation.
To learn more about rural health, we caught up with University of Washington professors Eric Larson and Davis Patterson, the director and deputy director of the WWAMI Rural Health Research Center. The Center, which focuses on rural health workforce issues, is one of eight government-funded centers nationwide. Along with rural provider training, they also conduct national studies on access to high-quality care for vulnerable and minority populations. The following Q&A with professors Larson and Patterson has been edited for clarity and length.
Q: What’s the current buzz in rural health?
A: Finances, hospital closure and workforce shortages almost always lead the list of important rural health concerns, but, another issue that has been getting a lot of attention is the opioid addiction crisis in rural America. At our Center, we’ve been looking at who can prescribe buprenorphine, a medication used to treat opioid addiction. As part of a proposal to address the opioid epidemic, new legislation expanded the ability of physicians to prescribe this controlled substance. But other providers, such as nurse practitioners, were still excluded.
The Recovery Enhancement for Addiction Treatment Act would change the law’s definition of “qualifying practitioner” to include nurse practitioners (NPs) or physician assistants (PAs) with the right experience and training. That change could significantly increase treatment accessibility for opioid additions in rural areas, which face troubling provider shortages.
Q: How has the Affordable Care Act changed the rural health landscape?
A: The most important change is increasing access to health insurance for populations that historically have had less access. But many states that have significant rural populations are missing out on a large piece of the ACA by not expanding Medicaid. That’s having an impact on the hospitals in those communities as well because they’re losing a source of reimbursement, something that’s likely contributing to a growing number of rural hospital closures. Plus, they’re still required to implement health information technology, so their margins are thin.
Part of the ACA included an initial bonus payment for Medicaid-reimbursed primary care services. Now that the payment has gone away, we have found a number of providers who said they would reduce or limit care for patients on Medicaid. Some states have implemented Medicaid increases to try and fill that payment? gap, as well as allow for NPs to have the financial bonus as well. In our research, we’ve found that rural providers were more willing than urban providers to see patients even when the federal incentives went away.
Q: Why do you think that is?
A: For rural providers, and especially for those in smaller communities, these patients are a member of a community. They’re a friend of a friend or a relative. There may be a bit more social responsibility in these communities. Rural providers may often be more willing to take a financial hit to care for their neighbors.
Q: Professor Patterson, you’ve conducted a lot of research into community paramedicine. Can you tell us more about your findings?
A: The idea with community paramedicine is to use your existing workforce, emergency medical technicians or paramedics, to help expand primary care and public health services. There needs to be a base of these workers to respond in an emergency, but they may have time on their hands. The idea is to enhance their skills to provide primary care to patients in the community.
Right now, there’s no established payment mechanism in most places (current programs are mostly funded through grants or self-funded) but there’s a lot of promise. If providers can be paid a bonus for keeping patients healthier and out of the hospital, maybe there’s a way to fund a paramedic who can help them achieve these goals. This model could also provide a potential revenue source for rural emergency medical service (EMS) agencies that otherwise struggle financially. The model could nicely bolster the workforce while helping achieve the goals of health reform.
Q: How does it work, practically speaking?
A: The idea is to work with non-urgent, lower-acuity patients — ones that could be helped by a referral to an alternative destination instead of the emergency department, or a patient who just need help with medications. It might be done via a 911 call, but more often it’s a scheduled event, so that EMS providers can plan for it and adjust staffing. They may use a different kind of vehicle, for instance.
Q: Where is this happening?
A: The Centers for Medicare and Medicaid Services (CMS) have awarded innovation grants for community paramedic services. Since 2012, Minnesota has received approval from Medicaid to reimburse for certain services from community paramedics. Most states are exploring this, and CMS is paying attention.
Q: What is going on with telemedicine in rural areas?
A: People mean a lot of different things when they say telemedicine. There’s video conferencing with consulting specialists, such as a nephrologist in Seattle when you’re in central Washington. There are other aspects such as taking pictures of a skin lesion and having a dermatologist looks at it. Radiology is another area where it can be used extensively. Tele-psychiatry and other mental health services are important, especially in rural communities where it’s nice to avoid everyone in town seeing your car parked outside the clinic.
Q: What are the hurdles to more implementation?
A: There are still issues around reimbursement and licensure that complicate this. While there may be exceptions, it’s generally not permitted to provide services across state lines if you don’t have a license in that state. The reimbursement issue is very complicated and we haven’t made the progress everyone imagined two years ago. If the provider isn’t physically present, is that a reimbursable service? The answer is: it depends. There are other models where a psychiatrist will consult with family medicine providers in a remote practice, so the psychiatrist is not directly providing patient care.
Q: What is the role does technology play in this expansion?
A: There are some technology obstacles to increasing telehealth, such as rural areas lagging behind in broadband needed to support telehealth, and the technology to send and receive secure data. But technology is evolving so rapidly; it’s not just about video teleconferencing with specialists. For example, there are now inexpensive attachments for smartphones that can take pictures of the retina. If there’s something suspicious, it can be sent on to an ophthalmologist. A lot is coming up in this field.
Q: What rural health topics deserve more coverage?
A: Dental health. People tend to think of behavioral health particularly with all the news stories on opioids and mass shootings, and oral health gets short shrift. A big area of interest now is integrating oral health with primary care for children and adults. Why is it that we somehow think that oral healthcare is secondary?
Q: Are there any interesting innovations to improve dental health?
A: In Alaska, there are Dental Health Aide Therapists, a development that arose from the Alaska Native Tribal Health Consortium. They explored a model used in New Zealand that uses dental health aid therapists. They work under the supervision of a dentist and are trained to provide preventative dental care and allowed to drill and fill. (Since 2004, they have expanded access to dental care and prevention services for more than 40,000 Alaska Native people living in 81 rural Alaska communities, according to the consortium.) It’s quite contentious – with opposition largely coming from dentists who point to patient safety concerns – but a lot of states are looking at it.