What is Rural? and Rural Healthcare Alphabet Soup CU SOM Rural Track Mark Deutchman MD

Definitions, access and payment What is rural? What are HPSA’s, MUA’s, RHC’s, FQHC’s? What is a critical access hospital? What is primary care? What is an MLP? What is access to care?

Questions What is urban, metropolitan, rural and frontier? How many counties does Colorado have? How much of Colorado fits into which category? What are Colorado’s healthcare needs

Urban is better defined than rural US census bureau defines “urban” as “places of > 2500 people. US OMB defines a “metropolitan area” as “core area containing a large population nucleus, together with adjacent communities having a high degree of economic and social integration with that core.”

Urbanized area “A central place and its “urban fringe”, or surrounding territory, which is populated by at least 50,000 people.” Colorado’s UA’s: Boulder, Colorado Springs, Denver, Fort Collins, Grand Junction, Greeley, Longmont, Louisville, and Pueblo.

Colorado according to US Census Bureau: Urban Population Rural Population Total Population 3,634,746 666,515 4,301,261 84.5% 15.5% 100% Colorado according to US Office of Management and Budget (OMB): Metropolitan Population Non-metropolitan Population Total Population 3,607,656 693,605 4,301,261 84% 16% 100%

Colorado’s Metropolitan Areas (16 counties in white)

The “county” issue in the West OMB defines metro areas by county regardless of how large or how sparse the rest of the county is. A very small town, distant or isolated from a city, but within the same county is still considered metropolitan. Dramatic effect on funding opportunities “Census Tracts” permit communities within metro areas to be defined “rural”.

Eligible Census Tracts Within Metropolitan Counties Adams 84, 85.13, 87.01 Arapahoe None Boulder Denver Douglas El Paso 38, 39.01, 46 Jefferson Larimer 14, 17.02, 19.02, 20.01, 22 Mesa 12, 15, 18, 19 Pueblo 28.04, 32, 34 Weld 19.02, 20, 24, 25.01, 25.02

Frontier An additional definition, useful in the West. “A county with six (6) or fewer people per square mile (or maybe 7). Based on counties. 23 of Colorado’s 64 counties: 43% of land mass 3% of population

Other definitions Community of under 25,000 not part of an urbanized area Isserman definition: Rural – population density of less than 500 per square mile and 90% of the population is in a rural area or the county has no urban area with population of 10,000 or more Urban – population density of density of at least 500 per square mile, 90% of the population lives in urban areas, the population in the urbanized areas is at least 50,000. Mixed Rural – meets neither the rural or urban definition and has a population density of less that 320 per square mile Mixed Urban – meets neither the rural or urban definition and has a population density of at least 320 per square mile

RUCA Codes The rural-urban commuting area (RUCA) codes classify U.S. census tracts using measures of population density, urbanization, and daily commuting.

Using RUCA Codes To determine your census tract, please go to http://www.ffiec.gov/Geocode/ (you must set Year=2011 to get 2000 census tracts) and type in your address information. The most recent RUCA codes are based on data from the 2000 decennial census. The classification contains two levels. Whole numbers (1-10) delineate metropolitan, micropolitan, small town, and rural commuting areas based on the size and direction of the primary (largest) commuting flows.

Resources: Http://www.coruralhealth.org www.coloradohealthinstitute.org http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation.aspx http://webarchives.cdlib.org/sw1wp9v27r/http://www.ers.usda.gov/Briefing/Rurality/WhatisRural/

Table 1. Rural-Urban Commuting Areas (RUCAs), 2000 1  Metropolitan area core: primary flow within an urbanized area (UA) 2  Metropolitan area high commuting: primary flow 30% or more to a UA 3  Metropolitan area low commuting: primary flow 5% to 30% to a UA 4 Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 (large UC) 5 Micropolitan high commuting: primary flow 30% or more to a large UC 6 Micropolitan low commuting: primary flow 10% to 30% to a large UC 7 Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small UC) 8 Small town high commuting: primary flow 30% or more to a small UC 9 Small town low commuting: primary flow 10% to 30% to a small UC 10 Rural areas: primary flow to a tract outside a UA or UC urban core: 1.0, 1.1 other urban: 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, 10.1 large rural core: 4.0, 4.2 other large rural: 5.0, 5.2, 6.0, 6.1 small rural core: 7.0, 7.2, 7.3, 7.4 other small rural: 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, 9.2 isolated rural: 10.0, 10.2, 10.3, 10.4, 10.5, 10.6

Healthcare alphabet soup

HPSA Health Professional Shortage Areas may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups or medical or other public facilities. Primary Care: population to practitioner ratio of > 2,000:1 Dental : a population to practitioner ratio of > 3,000:1 Mental Health: a population to practitioner ratio of 10,000:1 http://bhpr.hrsa.gov/shortage/

MUA Medically Underserved Areas/Populations Medically Underserved Areas (MUA) may be a whole county or a group of contiguous counties, a group of county or civil divisions or a group of urban census tracts in which residents have a shortage of personal health services http://bhpr.hrsa.gov/shortage/

MUP Medically Underserved Populations (MUPs) may include groups of persons who face economic, cultural or linguistic barriers to health care. http://bhpr.hrsa.gov/shortage/

Colorado’s HPSAs http://www.cdphe.state.co.us/pp/primarycare/index.html

Colorado MUAs and MUPs http://www.cdphe.state.co.us/pp/primarycare/index.html

Where are rural Colorado healthcare providers and facilities located and how are they organized ?

Critical Access Hospital Must be or have been a licensed hospital in the past 10 years Must be located in a rural area. Must have no more than 25 beds; any combination of swing beds or acute. Must maintain an average length of stay of no more than 4 days, or 96 hours, annually. Must have written agreements with another, larger hospital(s) for appropriate transfer and communication about patients.

Certified Rural Health Clinic A Rural Health Clinic (RHC) is a primary healthcare clinic located in a non-urbanized area that has been shown to have a shortage of healthcare services or healthcare providers, and has been certified as a Rural Health Clinic under Medicare. The greatest benefit of the program is cost-based (enhanced) reimbursement from Medicare and Medicaid. As of May 2007, there were 44 RHCs in Colorado.

What is required to become a certified RHC? • Be located in a non-urbanized area; • Be located in a MUA or HPSA that was designated within the past 3 years • Provide outpatient primary care services; • Utilize the services of at least one mid-level practitioner at least 50% of the time the clinic is open • Have a physician to provide medical direction • Meet health and safety requirements set by Medicare and/or Medicaid. Have a physician to provide medical direction who is present for sufficient periods of time, at least once in every 2-week period to oversee patient care services, provide consultation and supervision, and be available through direct telecommunication; and

What is a FQHC ? http://www.ask.hrsa.gov/downloads/fqhc-rhccomparison.pdf

Required Services

Cost-based reimbursement http://www.ask.hrsa.gov/downloads/fqhc-rhccomparison.pdf http://www.ask.hrsa.gov/downloads/fqhc-rhccomparison.pdf

Access to care “Access” and “Coverage” are two distinctly different things that are often confused. “Coverage” refers to a payment system and the services that are included in that payment “Access” refers to how readily available services are.

Percent of Colorado Population without Health Insurance and Below 200% FPL, 2000

Primary Care Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate. Primary care provides patient advocacy in the health care system to accomplish cost-effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care http://www.aafp.org/online/en/home/policy/policies/p/primarycare.html

Primary Care Practice A primary care practice serves as the patient's first point of entry into the health care system and as the continuing focal point for all needed health care services. Primary care practices provide patients with ready access to their own personal physician, or to an established back-up physician when the primary physician is not available. Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care practices are organized to meet the needs of patients with undifferentiated problems, with the vast majority of patient concerns and needs being cared for in the primary care practice itself. Primary care practices are generally located in the community of the patients, thereby facilitating access to health care while maintaining a wide variety of specialty and institutional consultative and referral relationships for specific care needs. The structure of the primary care practice may include a team of physicians and non-physician health professionals. http://www.aafp.org/online/en/home/policy/policies/p/primarycare.html

Primary Care Physician A primary care physician is a generalist physician who provides definitive care to the undifferentiated patient at the point of first contact and takes continuing responsibility for providing the patient's care. Such a physician must be specifically trained to provide primary care services. Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient's medical and health care needs - not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient. http://www.aafp.org/online/en/home/policy/policies/p/primarycare.html

MLP Midlevel practitioner: May or may not be involved in primary care Physician Assistant Nurse Practitioner Certified Nurse Midwife May or may not be involved in primary care

How does presence of primary care affect access to care?

Colorado 2002

Colorado without Family Medicine

Primary Care Health Professions Shortage Areas By County

Primary Care Health Professions Shortage Areas With Family Physicians Removed in 1999

Why is this the situation?

U.S. Physicians – types 2/3 (sub)specialists 1/3 generalists 2/3 (sub)specialists (Note: 25% of Peds grads subspecialize 82% of IM grads subspecialize )

US physicians 2004 883,532 596,131 MD’s 32,908 DO’s 629,039 (67%) in direct patient care 596,131 MD’s 32,908 DO’s 207,937 primary care 18,086 primary care 80,220 are FP or GP 13,615 13.5 % are FP or GP 41.3% are FP or GP

What does the physician workforce of other countries look like ? “In every other developed country, 50 to 70 percent of the physicians are generalists. In the United States, however, the proportion of generalists (family physicians, general internists, and general pediatricians) has declined from 42 percent in 1965 to less than 30 percent today. Because fewer than 15 percent of medical students graduating in 1991 and 1992 intended to become generalists, this precipitous decline has actually picked up speed.” http://content.nejm.org/cgi/content/full/328/13/961 Source: Specialty Distribution of U.S. Physicians -- The Invisible Driver of Health Care Costs NEJM Volume 328:961-963 April 1, 1993 Number 13