Comparing the Health Workforce Provider Mix and the Distance Travelled for Mental Health Services by Rural and Urban Medicare Beneficiaries.

PURPOSE: To describe the mix of health professionals who care for rural and urban seniors suffering from mood and/or anxiety disorders, the quantity of services they receive, and to understand where beneficiaries receive care for mood and/or anxiety disorders and the distance and time they travel for care. METHODS: We used 2014 Medicare administrative claims data to examine access to health care for fee-for-service Medicare beneficiaries aged ≥ 65 years who received outpatient services for mood and anxiety disorders. We classified providers into 9 categories: (1) family physicians/general practice, (2) internists, (3) nurse practitioners (NPs) and physician assistants (PAs), (4) psychiatrists, (5) psychologists, (6) clinical social workers, (7) emergency medicine physicians, (8) other physicians, and (9) other providers. We calculated the 1-way driving distance and travel time between the beneficiary residence and provider location. We classified beneficiaries into 1 of 4 geographic categories based on their residence ZIP Code. FINDINGS: Urban beneficiaries had an average of 2.7 visits for mood and anxiety disorders, while rural beneficiaries had 2.4. Generalist physicians and NPs/PAs provided 50.8% of all visits. Urban beneficiaries saw more behavioral health specialists (34.3%) than rural beneficiaries (16.1%). NPs and PAs provided more than twice as much of the care for rural beneficiaries (14.8%) as for urban beneficiaries (6.4%). Rural beneficiaries travelled about twice as far as urban beneficiaries. CONCLUSIONS: Rural and urban Medicare beneficiaries received care for mood/anxiety disorders from different mixes of health care providers, and ensuring access for rural populations will require innovative solutions.

Projected Contributions of Nurse Practitioners and Physicians Assistant to Buprenorphine Treatment Services for Opioid Use Disorder in Rural Areas.

The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.

Service provision and quality outcomes in home health for rural Medicare beneficiaries at high risk for unplanned care.

Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies.

Geographic Variation in the Supply of Selected Behavioral Health Providers.

INTRODUCTION: In 2015, an estimated 43.4 million Americans aged 18 and older suffered from a behavioral health issue. Accurate estimates of the number of psychiatrists, psychologists, and psychiatric nurse practitioners are needed as demand for behavioral health care grows. METHODS: The National Plan and Provider Enumeration System National Provider Identifier data (October 2015) was used to examine the supply of psychiatrists, psychologists, and psychiatric nurse practitioners. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). Claritas 2014 U.S. population data were used to calculate provider-to-population ratios for each provider type. Analysis was completed in 2016. RESULTS: Substantial variation exists across Census Divisions in the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners. The New England Census Division had the highest per capita supply and the West South Central Census Division had among the lowest supply of all three provider types. Nationally, the per capita supply of these providers was substantially lower in non-metropolitan counties than in metropolitan counties, but Census Division disparities persisted across geographic categories. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6%) and the West North Central Census Division (69%). Higher percentages of non-metropolitan counties lacked a psychiatrist. CONCLUSIONS: Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S. Disparities exist across Census Divisions and geographic categories. Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder.

Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service.

What Is the Potential of Community Paramedicine to Fill Rural Health Care Gaps?

Community paramedicine (CP) uses emergency medical services (EMS) providers to help rural communities increase access to primary care and public health services. This study examined goals, activities, and outcomes of 31 rural-serving CP programs through structured interviews of program leaders and document review. Common goals included managing chronic disease (90.3%); and reducing emergency department visits (83.9%), hospital admissions/readmissions (83.9%), and costs (83.9%). Target populations included the chronically ill (90.3%), post-hospital discharge patients (80.6%), and frequent EMS users (64.5%). Community paramedicine programs engaged in bi-directional referrals most often with primary care facilities (67.7%), hospitals (54.8%), and home health (38.7%). Programs provided assessment, testing, preventive care, and post-discharge services. Reported outcomes were promising, but few programs used rigorous evaluation methods. Rural-serving CP programs provided services to shift costs to less expensive settings and provide appropriate care where vulnerable patients live, but more evidence is needed that care is safe, effective, and economical.

Workforce issues in rural surgery.

Almost one quarter of America's population and one third of its landmass are defined as rural and served by approximately 20% of the nation's general surgeons. General surgeons are the backbone of the rural health workforce. There is significant maldistribution of general surgeons across regions and different types of rural areas. Rural areas have markedly fewer surgeons per population than the national average. The demography of the rural general surgery workforce differs substantially from the urban general surgery workforce, raising concerns about the extent to which general surgical services can be maintained in rural areas of the United States.

Trends in perinatal and infant health disparities between rural American Indians and Alaska natives and rural Whites.

OBJECTIVES: We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (AIAN) persons and rural Whites over time. METHODS: We compared perinatal and infant health measures for 217 064 rural AIAN births and 5 032 533 rural non-Hispanic White births. RESULTS: Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985-1987, 36.3%; 1995-1997, 26.3%) and postneonatal death (1985-1987, 7.1 per 1000; 1995-1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985-1987, AOR = 1.55; 95% confidence interval [CI] = 1.41, 1.71; 1995-1997, AOR = 1.46; 95% CI = 1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985-1987, ARR = 1.67; 95% CI = 1.65, 1.69; 1995-1997, ARR = 1.84; 95% CI = 1.81, 1.87) persisted. CONCLUSIONS: Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group.

Access to cancer services for rural colorectal cancer patients.

CONTEXT: Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE: To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation. METHODS: Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS: Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS: Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Access to specialty health care for rural American Indians in two states.

CONTEXT: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. PURPOSE: To examine specialty service access among rural Indian populations in two states. METHODS: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). FINDINGS: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. CONCLUSIONS: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

Low-bandwidth, low-cost telemedicine consultations in rural family practice.

BACKGROUND: Telemedicine, based on the use of interactive video consultations, is being used more commonly in rural settings. This development is potentially important to rural patients because there are fewer physicians, particularly specialist physicians, in rural areas. Declining costs of telemedicine equipment and transmission have created increased access to these technologies for rural family physicians and their patients. METHODS: This study considers satisfaction levels of rural family physicians, academic-based specialists, and rural patients in 130 consultations between rural physicians, rural patients, and urban academic specialists. To increase the practicability for rural use, low-cost equipment and low-bandwidth digital telephone transmission lines were utilized. Data were collected using questionnaires that were completed by patients, family physicians, and specialist consultants after each consultation. RESULTS: All categories of participants noted very high levels of satisfaction. CONCLUSION: Telemedicine-based consultations are well accepted by rural patients, rural family physicians, and urban academic specialist consultants. This approach could offer a useful adjunct to rural health care.