Rural Health Disparities and the Future of Rural Healthcare

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Rural Health Disparities and the Future of Rural
Healthcare

• Stephen D. Wilhide MSW,MPH
• Executive Director, National Rural Health
  Association
• Email wilhide_at_nrharural.org

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Pastoral Poverty The Seeds of DeclineNew York
Times, December 8, 2002

• Around the country, rural ghettos are unraveling
  in the same way that inner cities did in the
  1960s and 70s
• Decades of economic decline have produced a
  culture of dependency, with empty counties hooked
  on farm subsidies just as welfare mothers were
  said to be tied to their monthly checks.
• turned fertilizer into a drug lab component and
  given some sparsely populated counties higher
  murder rates than New York City Crime, fueled
  by a methamphetamine epidemic that has
• The rate of serious crime in Nebraska, Kansas,
  Oklahoma and Utah is as much as 50 higher than
  the State of New York, the F.B.I. reported in
  October.

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Differences in Response

• Unlike the cities troubles, which generated a
  national debate about causes and solutions, the
  rural collapse has been largely silent, perhaps
  because it happened so slowly.

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Access Factor in Rural America

• Almost one of four rural children live in poverty
• Rural residents are poorer 15.6 live below
  poverty compared to 13.4 non-rural
• Per capita income is greater than 7400 less in
  rural areas (25,944 in urban v. 18,527 in
  rural)
• Fewer Medicaid-eligible rural residents are
  covered
• Almost 75 of non-metropolitan areas are
  Medically Underserved Areas (MUAs)
• Approximately 40 of non-metropolitan residents
  lived in Health Professional Shortage Areas
  (HPSAs) in 1997

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Health Status

• For men 20 years and older death rates for
  chronic obstructive pulmonary diseases (COPD)
  were 30 higher in non-metropolitan counties than
  in large metro counties 1996-1998
• Heart disease death rates for men 20 years and
  over are highest in the most rural counties
• 46.7 of the adult rural population has a chronic
  condition compared to 39.2 of the core
  metropolitan population

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Four Chronic Conditions Account for almost
three-quarters of all deaths in the United States

• Cardiovascular DiseaseHeart disease death rates
  for men 20 years and over are highest in the most
  rural counties
• (about twelve percent higher than in large
  fringe and small metro areas)
• Chronic Obstructive Pulmonary Disease (Death
  rates among men 20 years and older for COPD is
  30 higher in non-metro counties than in large
  metro counties 1996-1998

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Four Chronic Conditions (contd)

• Cancer
• Diabetes

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Future for Rural Health

• Rural is finally on the radar screen for
  Congress and policy makers
• Rural provisions in the Medicare Prescription
  Drug bill may address inequities in payment for
  rural hospitals and other providers such as home
  health agencies, Critical Access Hospitals,
  physicians, ambulances, rural health clinics

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Institute of Medicine Aims for the 21st Century
Health Care System

• Effective-providing services based on scientific
  knowledge
• Safe-avoiding injuries from the care intended to
  help them
• Patient centered-care that is respectful and
  responsive to individual patient preferences,
  needs and values

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Institute of Medicine (contd)

• 4. Efficient-avoiding waste including equipment,
  supplies, ideas and energy
• 5. Equitable-care that does not vary in quality
  because of personal characteristics such as
  gender, ethnicity, geographic location and
  economic status
• 6. Timely-reducing waits and sometimes harmful
  delays

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Rural Health Care Delivery Systems of the Future

• Quality is of paramount concern
• Redesigned systems of care using information
  technology to support clinical and administrative
  processes
• Shift from acute, episodic care to a system of
  prevention and management of chronic and acute
  conditions using evidence-based practice
• Alignment of payment incentives to improve
  outcomes and quality

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Systems for Managing Chronic Health Conditions

• Chronic conditions are now the leading cause of
  illness, disability, and death
• Chronic conditions affect almost half of the U.S.
  population and account for the majority of health
  care expenditures
• As the need for community-based acute and
  long-term care services has grown, the portion of
  health care resources devoted to hospital care
  has declined
• Resources expended on pharmaceuticals has risen
  dramatically

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Development of Care Processes

• The Committee on Quality of Healthcare in America
  at the Institute of Medicine believes the health
  care system must focus greater attention on the
  development of care processes for the common
  conditions that afflict many people.
• A limited number of such conditions, about
  15-25, account for the majority of health care
  services.
• Nearly all of these are chronic

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Care needs to be a collaborative,
multidisciplinary process

• Multiple service providers need to redesign the
  care process to assure a coordinated, seamless
  system of care across setting and clinicians
• An improved information infrastructure is needed
  to establish effective and timely communication
  among clinicians and between clinicians and
  patients
• Care processes based upon evidence-based practice
  and outcome measures must be incorporated

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Rural Health System of the Future

• Care processes will be defined around specific
  conditions based upon evidence-based practice
• Those with chronic conditions will be served by a
  system that emphasizes self-management, care
  planning with a multi-disciplinary team and
  ongoing assessment and follow-up
• The components of this system will be linked
  electronically with a strong information base and
  evidence-based practice guidelines
• Providers in the system will have all necessary
  patient care information in order to work
  together beyond organizational and practice
  boundaries

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Self Management

• Patients will be fully informed
• Patients will be given the necessary information
  and the opportunity to exercise the degree of
  control they choose over the health care
  decisions that affect them
• Patients will participate in care delivery
  whenever possible.
• Care is provided that is respectful of the
  patients perceived needs, values and preferences

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Rural May Show the Way

• Many rural and Critical Access Hospitals are
  working toward developing systems of care
• Community health centers and rural hospitals are
  working together to improved community health
  status
• It may be easier to develop systems of care in
  rural due to fewer resources and the need to work
  together

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Presentation References

• Crossing the Quality Chasm, A new Health System
  for the 21st Century,Institute of Medicine,
  2001
• Rural Health in the United States, Thomas C.
  Ricketts, III, Oxford University Press, 1999
• New York Times article. Pastoral poverty Sowing
  the Seeds of Decline. December 8, 2002