Health Care in Rural Pennsylvania An Overview Lisa Davis Pennsylvania Office 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 Rural Most 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 Legend Dark YellowCode 4 (Large Town) Medium OrangeCode 5 (High Commuting to Large Town) Light OrangeCode 6 (Low Commuting to Large Town) Dark YellowCode 7 (Small Town) Medium YellowCode 8 (High Commuting to Small Town) Light YellowCode 9 (Low Commuting to Large Town) GreenCode 10 (Rural Areas) Source: Community Information Resource Center, Rural Policy Research Institute

What Makes Rural and 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 Pennsylvania At A Glance  One of the most rural states in the nation  2.8 million rural residents  42 of 67 counties designated as rural

Health Status in the Rural 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, 2001 Rural 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 in Rural 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 in Rural Pennsylvania  Cardiovascular disease  Heart disease  Breast Cancer  Motor Vehicle Crashes  Suicide  Work-related Injury Deaths State Health Improvement Plan Special Report and Plan to Improve Rural 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 StateRuralUrban All Causes*10.5/1, /1, /1,000 Heart Disease*310.6/100, /100, /100,000 Accidents*37.2/100, /100, /100,000 Diabetes*29.7/100, /100, /100,000 Suicide*10.8/100, /100, /100,000 AIDS In 2002, 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 for Rural Health Care Is… ACCESS…  … to health care services  … payment mechanisms  … and transportation

Health Care Services in 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 Recruitment and 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 Hospitals181 (100)76 (42)105 (58) Patient Care Physicians41,447 (100)5,930 (14)35,517 (86) Primary Care Physicians16,838 (100)2,783 (17)14,055 (83) Dentists8,353 (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 Practitioners4,363 (100)570 (13)3,793 (87) Physician Assistants2,456 (100)518 (21)1,938 (79) Nurse Midwives288 (100)61 (21)227 (79) Pharmacists12,913 (100)1,964 (15)10,949 (85) Source: Center for Rural Pennsylvania Provider Distribution in Pennsylvania

Provider Reimbursement in Rural Areas

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 Insurance In Rural Areas

Insurance Status In 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, Pennsylvania Department of Insurance

Insurance Statistics State (%)Rural (%)Urban (%) Enrolled in Medicare2,095,240 (100)470,774 (22)1,624,466 (78) Eligible for Medicaid1,567,428 (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

State (%)Rural (%)Urban (%) Enrolled in PACE257,745 (100)91,288 (35)166,457 (65) Enrolled in Adult Basic Coverage 44,702 (100)16,047 (36)28,655 (64) Enrolled in S-CHIP133,462 (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 Professional Shortage 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 Underserved Areas (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 Impact of 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 Pennsylvania Office 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 Pennsylvania Office 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 Health 202 Beecher-Dock House University Park, PA Telephone: (814) Fax: (814)

Pennsylvania Rural Health Association P.O. Box 1632 Harrisburg, PA (717)