Guest Editorial: Access Issues in Rural Healthcare and Opportunities for Improvement

We live in a world in which we need to share responsibility. It’s easy to say ‘It’s not my child, not my community, not my world, not my problem.’ Then there are those who see the need and respond. I consider those people my heroes. ~ Fred Rogers

Despite an array of federal and state legislative policies and focused efforts from the medical community, rural healthcare disparities in the United States remain a persistent conundrum for many reasons. The lack of access to healthcare based on geographical barriers, lack of insured residents, and older, sicker, patients who live under the poverty threshold compound the issue. Additionally, many rural areas are deemed Healthcare Provider Shortage Areas and/or Medically Underserved. Through technological advances, some compelling resources and opportunities are becoming more widely available. For the system to improve, legislators, the medical community, and the rural residents themselves need to work together to improve the discordance between healthcare quality and availability of urban and rural settings.

The definitions of rural and urban are fine-tuned after each decennial census is completed. In general, sparsely populated areas that are a good distance from urban areas and have low housing density describe rural areas. According to the US Census Bureau, urban areas make up about 3% of our land mass in the United States but are home to roughly 80% of our population. Whereas rural areas are the opposite and comprise 97% of our land mass and about 20% of our population. Urban clusters have between 2,500 residents and less than 50,000 and urban areas have at least 50,000 people. The remaining land space that does not fit those definitions are considered rural. In 2019, the estimated number of rural residents was just over 57.5 million and this population has experienced about 0.5% annual decline over the last few years. (1) Despite the slight decline, we are still considering the care of a very large number of residents, more than the entire country of Italy.(2) The livelihood of those living in urban areas rely on the rural population for products and services including those from farming and agriculture.

Another important result of each decennial census is the direct impact on apportionment, the process of distribution of the 435 members to the US House of Representatives for each state based on the updated population. Those government officials help decide the allocation of hundreds of millions of dollars of federal spending including Medicare and Medicaid, children’s insurance programs, substance abuse programs, and can strongly impact the efficacy of providing care to rural populations.(3) For example, as a result of the most recent 2020 Census, Texas gained 2 seats in the house, 5 states gained one seat each (Colorado, Montana, Florida, North Carolina, and Oregon), and 7 states lost 1 seat each (California, Illinois, Michigan, New York, Ohio, Pennsylvania, and West Virginia) (4) Maintaining a thorough understanding of respective state’s rural environment and developing a dialogue with legislators may open avenues to improve accessibility and quality of care.

Figure 1. Trends in rural and urban age-adjusted (all-cause) mortality for the United States (1970–2016). Reproduced from Cosby et al7 with permission. Copyright © 2019, American Public Health Association.

Texas, as an example, has a vast amount of rural land, similar to the country as a whole, making up roughly 80% of the total land area of the state. More than half of the counties (177 out of 254) in Texas are rural. Based on recent data, a whopping 75% of counties are designated Health Professional Shortage Areas and/or Medically Underserved, 64 counties have no hospital and 25 counties have no primary care physician.(3) The residents that live most rurally may have to commute more than 3 hours to the closest healthcare, and as clinicians realize, that may be the difference between life and death in the setting of a myocardial infarction, cerebrovascular accident, or trauma. An older Swedish study found that for every 10 km additional distance, the probability of surviving a myocardial infarction declines by 2%.(5) Texas leads the country in the number of rural hospitals that have closed in the last decade, followed by Tennessee, then Oklahoma. Closures of each of these facilities leads to a local loss of about 170 jobs and a 22 million dollar payroll cut, lost revenue for the local government, lower school enrollments that creates lower funding, and local businesses may also suffer.(6) Focus on creating the appropriate healthcare setting based on each community’s needs may lessen the likelihood of future closures.

Rural residents are indeed at higher risk of devastating chronic health problems. A focused rural health report and Presidential Advisory from the American Heart Association and American Stroke Association eloquently describes the burden of modifiable cardiovascular risk factors.(7) Discussed are the higher rates of obesity, hypertension, diabetes mellitus, mental health, and substance abuse disorders. Rural citizens also report active tobacco use at a rate of 25% rural compared with 16% in metropolitan centers. Smokeless tobacco also is about 5.5% higher in less populous areas. The trends in all-cause mortality have decreased over the last few decades, but the decline is less prevalent in rural counties.

It is disturbing that some counties have no access to providers at all and it is even more unlikely for rural residents to have access to specialists in areas such as cardiology, endocrinology, or mental health.

One study determined that a 1 per 10,000 population increase in primary care providers decreased all-cause mortality 5.3% per year. As there is a documented shortage of primary care providers, particularly in rural areas, it has been proposed that increasing the availability of physician assistants (PA) and nurse practitioners (NP) may compensate. Several studies have suggested that PAs and NPs provide a similar quality of services and may contribute to cost-containment, particularly in rural areas. (8,9) Furthermore, a cross sectional study by Groth et. al. of patients with severe hyperlipidemia (LDL-C > 190 mg/dL) determined that if a patient was seen in a cardiology office, their likelihood of being prescribed a statin, a high-intensity statin, or a proprotein subtilisin kexin type 9 inhibitor (PCSK-9 Inhibitor) was much higher leading to a lower mean LDL-C level in those patients.(10)

Figure 2. Results of a cross-sectional cohort study, estimating statin utilization by intensity, from an electronic medical record-based hyperlipidemia registry (n = 14 867; defined as ever having an LDL-c ≥ 190 mg/dl since January 1, 2000.)

Opportunities for Improvement

Legislative efforts are widely varied across states. A focus group took place among stakeholders with findings presented in Reinventing Rural Healthcare: A case study of 7 upper Midwest states. The Bipartisan Policy Center and Center for Outcomes Research and Education (CORE) hosted this group of more than 90 interested parties to explore the reality of challenges among rural healthcare and opportunities for improvement.(11) Four major take home messages prevailed:

1. Policies must fit each specific community, be flexible for changing demographics, and avoid a “one-size-fits-all” approach.
2. Rural healthcare providers would welcome value-based alternative payment options to allow increased accessibility given a low-patient population and high operating costs.
3. Provide a diverse and sustainable primary care structure for quality care; utilize advanced practice providers (APPs); peak interest of local youth to pursue medicine related occupations and provide space in medical programs for rural residents.
4. Utilize and expand access to telemedicine to connect rural residents to specialists and connect rural providers with peer support.

This nicely summarizes the current state of rural healthcare and offers suggestions to consider for improvement. Local residents and government officials should explore their highest priorities and strategize methods to fulfill their needs, whether it is a critical access hospital, a small in-patient care center, a rural emergency center or a new model. A critical underlying concern is ensuring options are accessible based on assisting the number of uninsured and the available health insurance policies. Lower cost but maintaining quality care is available through the use of advanced practice providers (APPs). Many states already offer autonomy to those highly trained providers working in a rural setting. However, professional responsibility must be upheld for physicians and APPs alike. Staying current with the ever-expanding therapies available for chronic illnesses. This can be achieved in several ways, including joining professional organizations, establishing relationships with mentors, and staying current with medical literature. To enter medicine/healthcare is to become a lifelong student.

Many US medical schools offer specialized pathways to students steering their careers toward rural healthcare to deeply solidify one’s knowledge of the intricacies of practicing rural medicine. One outstanding example is from the University of Missouri that hosts a Rural Scholars Program run by Dr. Kathleen Quinn, Associate Dean for Rural Health. First year medical students apply and are offered an extremely thorough program including lectures, clerkships, site training, and mentorship, as the students move through the Rural Track Pipeline Program.(12) They are given the opportunity to explore potential medical homes to consider as a practice and to develop supportive relationships among colleagues, faculty, and mentors already working in the rural setting.

The steadfast presence of a program out of the University of New Mexico called Project Echo has experienced vast growth and success not only within the United States, but globally. Started in 2003, Project ECHO offers a means to increase the capacity of health workers in underserved communities to assist in maintaining best practices. Utilizing a “hub-and-spoke” structure, teams of specialists or experts (hub) offer telementoring and collaboration as they work through case based learning via videoconferencing (see diagram).(13)

The program currently maintains 920 ECHO programs with 423 hubs in 44 countries. This program has experienced extensive growth and is a viable option for those with established careers in areas of healthcare shortages and medically underserved to ensure quality and best practices for the patients.

Technological advances are propelling modalities into the forefront of healthcare. The first most evident one is telemedicine that catapulted into mainstream clinical practice amongst the COVID-19 pandemic. The benefits are apparent and include better access and convenience for those who live rurally or have mobility problems. The biggest barrier, along with lack of hands-on assessment, imaging, or blood draws, is the lack of broadband in many rural areas.(14) The Telecommunications Act of 1996 put forth the requirement of the Federal Communications Commission to annually reassess the, “availability of advanced telecommunications capability to all Americans” including, in particular, elementary and secondary schools and classrooms”.(15) Within the annual report, in 2019 they found that access was being deployed in a reasonable fashion. It is currently estimated that over 22% of rural Americans and nearly 28% of Tribal land Americans still lack coverage. Concerns for privacy and security while using broadband remains a crucial concern as well as the concern for lack of payer coverage for telemedicine visits.(14) Complacency must not suppress the drive for full access to advanced communication modalities or the push to provide essential payer coverage for this option across all US residents.

A developing and exciting option for delivery of essential healthcare equipment is the use of unmanned aerial vehicles, commonly known as drones. Increasing utilization of drones provides for delivery of equipment such as automated external defibrillators, but also other essential items such as antivenom, vaccines, blood products, medications, and lab samples.(16) Their vast use extends to search and rescue, including water rescues, triaging in disaster areas, and use in telemedicine. Expanding on their use in telemedicine is “hospital at home” which may prolong the amount of time an elderly patient can remain in their home before requiring skilled care in a nursing home or similar environment.

This discussion just skims the surface of the magnitude of issues in the complex rural healthcare system. Focused efforts have risen from legislators and the medical community striving for improvement
in quality and accessibility of a tailored healthcare system that needs to be specific to each community’s needs. Implementing an early and consistent education of rural youth to nudge interest in pursuing a healthcare occupation may lead to ‘taking care of their own’ upon their anticipated post-education return to practice in their hometown. Physicians and advanced practice providers are professionally obligated to avoid professional isolation and connect with organizations, specialists, and maintain best practices for quality care. Use of technology opens previously closed doors for access to medical supplies, including medications, lab samples, and emergency equipment. We have the means, but need to find best customized strategies for our less populated communities.

Disclosure statement: Ms. Jackson has received honoraria from Esperion and Amgen.
References are listed in the 2021-2022 Winter LipidSpin .pdf on www.lipid.org