Nebraska Rural Health Conference April 24th-25th, 2019 Federal Office of Rural Health Policy Update: The Current State of Rural Health Nebraska Rural Health Conference April 24th-25th, 2019

Health Resources and Services Administration Overview HRSA supports more than 90 programs through grants and cooperative agreements to more than 3,000 awardees HRSA provides access to health care for people who are: Geographically isolated Economically or medically challenged HRSA programs serve tens of millions of people every year, including: Pregnant women, mothers and their families People living with HIV/AIDS People living in rural communities Those otherwise unable to access quality health care

Health Resources and Services Administration Overview Eleven million people living in health professional shortage areas receive primary medical, dental or mental health care from a National Health Service Corps clinician in the past year. Over 61 million pregnant women and children in the U.S. supported by the Maternal and Child Health Block Grant. More than 160,000 parents and children served by the Home Visiting Program Nearly 26 million people receive primary medical, dental, or behavioral health care from a health center. One in four rural residents gets care from a health center. One in 2 people diagnosed with HIV receives care through the Ryan White HIV/AIDS Program.

Federal Office of Rural Health Policy State and Hospital Programs State Offices of Rural Health, Flex and Small Rural Hospital Improvement Programs, Rural QI TA, Small Rural Hospital Transitions Community Based Programs Black Lung, Delta, Opioids, Care Coordination, Network Development and Planning, Quality Improvement, Outreach Telehealth Programs Telehealth Resource Centers, Network Grants, Licensure Portability, Rural Child Poverty, Rural Veterans Health Access Policy and Research Rural Health Research Centers, Rural Health Value, Rural Policy Analysis, RHC Policy and Clinical Assessment New in 2018 & 2019: Rural Community Opioids Response Programs and Rural Residency Programs

The Federal Office of Rural Health Policy Charged with advising the Secretary on how current and proposed Medicare and Medicaid policies impact rural areas, about the ability of rural areas to attract and retain health professionals, and about the access to and quality of healthcare in rural areas FORHP is the voice for rural within the Department of HHS

Resources to Know….. www.ruralhealthresearch.org www.ruralhealthinfo.org

What Does Access to Care Look Like in Rural Communities?

Rural Health Workforce Realities The Federal Office of Rural Health Policy Health Resources and Services Administration Rural Health Workforce Realities Physicians MDs/DOs 5.5/10K non metro vs. 7.9/10K in metro All Primary Care MD/DO/NP/PA 11.6/10K in non metro vs. 16.2/10K in metro Dentists 3.6/10K non metro vs. 5.9/10K in metro Dental Hygienists 4.5/10K in non metro vs. 5.0/10K in metro Source: WWAMI Rural Health Resource Center

Rural Health Workforce Realities The Federal Office of Rural Health Policy Health Resources and Services Administration Rural Health Workforce Realities http://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/09/RHRC_DB160_Larson.pdf

Availability of Behavioral Health Providers http://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/09/RHRC_DB160_Larson.pdf

Rural Hospital Closures 104 rural hospitals have closed as of yesterday morning, including Tilden Community Hospital in 2014. Closed hospital is defined as a facility that stopped providing general, short-term acute inpatient care Some closed hospitals stop providing services altogether but some, like Tilden, continue to provide a mix of services other than inpatient care

The Federal Office of Rural Health Policy Health Resources and Services Administration

The Federal Office of Rural Health Policy Health Resources and Services Administration

Maternal Health – Access to OB Services Between 2004 and 2014: The percent of rural counties with hospital-based obstetrics services declined from 55% to 46%. 179 rural counties (9% of all rural counties) lost access to in-county hospital obstetric services. Women living in rural noncore counties (areas with less than 10,000 residents) were disproportionately affected by the loss of hospital obstetric services. Only 30.2% of rural noncore counties had continual hospital obstetric services compared to 77.9% of micropolitan counties.

Access to OB Services So What Happens After Communities Lose OB Services? In the year after loss of services rural counties not adjacent to urban areas had significant increase in: Out-of-hospital births Births in a hospital without obstetric services Preterm births In the year after loss of services rural counties adjacent to urban areas had significant increase in: Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the US. JAMA. 2018;319(12):1239-1247.

Access to Obstetrical Services Rural Maternity and Obstetrics Management Strategies Program (RMOMS) The RMOMS pilot program intends to demonstrate the impact on access to and continuity of maternal and obstetrics care in rural communities. Up to three cooperative agreements 4-year award Year 1 is for planning activities (up to $600,000) Years 2 through 4 are for implementing activities (up to $800,000) TA Webinar: April 30, 2019 Application Deadline: May 24, 2019

Pharmacy Closures 1,231 (16%) independently owned rural pharmacies closed 631 rural communities that had at least one retail (independent, chain or franchise) pharmacy in March 2003 had no retail pharmacy in March 2018

Tracking ACO Coverage in Rural Areas

Scope of Practice

Rural Health Disparities

Life Expectancy at Birth (Years) by Levels of Rurality, United States, 2010-2014 Source: Singh GK, Siahpush M. American Journal of Preventive Medicine. 2014;46(2):e19-e29 (updated data)

Potentially Excess Death In 2015, a higher rate of potentially excess deaths occurred among rural Americans than urban Americans from: Heart disease More than 26,700 excess deaths 43.6% in rural areas; 27.9% in urban areas 56% higher in rural areas than urban Cancer More than 18,800 excess deaths Overall cancer deaths declined between 2003 - 2017 declined less in rural (1% per year) vs. large urban areas (1.6% per year) Unintentional injuries More than 13,200 excess deaths 59.6% in rural areas; 43.5% in urban areas 37% higher in rural areas than urban Chronic lower respiratory disease More than 11,600 excess deaths 56.0% in rural areas; 31.9% in urban areas 75% higher in rural areas than urban 23

Suicide Mortality https://www.cdc.gov/nchs/data/databriefs/db330-h.pdf

Chronic Obstructive Pulmonary Disease https://www.cdc.gov/mmwr/volumes/67/wr/mm6707a1.htm Limited Access to Respiratory Therapy COPD Underdiagnosed Significant Driver in Costly Re-Admissions

Cancer Average Annual Age-Adjusted Rates of New Cases of Common Cancers (2009-2013) and Deaths from Common Cancers (2011-2015) Overall, nonmetro rural areas had lower incidence rates but higher death rates Some variation by type of cancer

Addressing the Opioid Epidemic

Addressing the Opioid Epidemic

Addressing the Rural Opioid Challenge Unique Challenges: Limited Infrastructure Access to Needed Services (MAT, DEA-waivered Clinicians, etc.) Stigma Scale The Rural Community Opioids Response Program: Build on Lessons Learned from Early Program Investments Rural Opioid Overdose Reversal Program Rural Health Opioids Program Executive and Legislative Branch Support 2018: $130 Million $30 Million for Loan Repayment 2019: $120 Million

Collaborating for Rural Across HHS

The challenge…. The concern…. How will rural providers with special payment types designed to maintain access to services in rural and underserved communities fully participate in new payment models? The concern…. That the very payment policy provided to maintain access in rural and underserved communities may now undermine participation in innovative care delivery and payment models going forward… ….and ultimately undermine access to services in those rural and underserved communities.

CMS Rural Health Strategy Apply a rural lens to CMS programs and policies Improve access to care through provider engagement and support Advance telehealth and telemedicine Empower patients in rural communities to make decisions about their health care Leverage partnerships to achieve the goals of the CMS Rural Health Strategy

Rural Involvement in CMS Innovation Center Models and Programs Rural-Relevant Models Medicare Shared Savings Program ACO Investment Model Comprehensive Primary Care Plus Accountable Health Communities (AHC) Model Frontier Community Health Integration Project Regional multi-payer concepts, e.g., global budgeting (MD, PA)

Rural Focus at Centers for Disease Control (CDC)

Connecting with HRSA

HRSA Needs Your Help Become a HRSA Grant Reviewer https://www.hrsa.gov/grants/reviewers/index.html

FORHP Weekly Announcements Rural-focused Funding Opportunities Policy and Regulatory Developments Affecting Rural Providers and Communities Rural Research findings Policy updates from a Rural Perspective To sign up: Email Michelle Daniels at mdaniels@hrsa.gov

www.ruralhealthinfo.org

Contact Information Sarah Heppner Director – Policy Research Division sheppner@hrsa.gov Kerri Cornejo Policy Coordinator kcornejo@hrsa.gov Federal Office of Rural Health Policy (FORHP) Health Resources and Services Administration (HRSA) Phone: 301-443-0835 Web: www.hrsa.gov/ruralhealth/ 40

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