The annual National Rural Health Association conference and Health Equity Conference were held in San Diego on May 9-12, 2017. The following is a summary of takeaways from presentations and 1:1 discussions with attending healthcare providers.

Rural Healthcare Challenges

The challenges facing healthcare in rural U.S. communities are many. Between 15-20% of our U.S. population lives in rural areas spread over 90% of our country. Rural populations are poorer, sicker, older and less likely to be insured than their urban counterparts. They are at a greater risk of death from heart disease, COPD, cancer, stroke and unintentional injury than urban patients.

These problems are compounded by difficulty in accessing healthcare due to geographic isolation and a shortage of physicians. On average there are only 39.8 primary care physicians per 100,000 rural patients compared to 53.3/100,000 in urban areas. This shortage means rural patients must travel long distances (30 – 100 miles) just to access healthcare. Transportation to healthcare was a problem frequently raised during these conference.

How rural healthcare is coping with the physician shortage. 

Recruiting physicians to practice in rural areas has historically been challenging. Now it’s compounded by an impending nationwide shortage of 61,700 – 94,700 physicians by 2025. How is rural healthcare dealing with this problem? The 3 primary solutions discussed at the conferences were: incentive programs, Community Health Workers and telemedicine.

Incentive programs – Incentives include medical school scholarships, medical school loan repayment and rural J1 visa waivers. However, these usually result in temporary not long-term fixes. Programs are now being implemented to recruit physicians interested in living and practicing in rural communities. Dr. Ellen Hartenbach talked about a new residency program at the University of Wisconsin, Madison that addresses OB/GYN shortages. The main premise of the program is that “people who are ultimately going to practice in a rural setting are people who are interested in it, who have a rural background, and people who have experience in a clinical environment in the rural setting”. The program offers 80% of it’s training in Madison, with the remaining 20% performed in 4 nearby rural towns.

The problem of OB/GYN shortages in rural communities is severe. Rural hospitals are dropping OB/GYN specialists at an alarming rate because they are not cost effective in areas where a low number of births/year does not offset the cost of hiring an OB/GYN. As a result women have to travel long distances for prenatal care and to deliver their babies. One attendee said pregnant women in his community travel 70 miles to a hospital with a OB/GYN. Another attendee shared that pregnant women in his rural community are “camping out” in advance of their due dates in cities where their doctor practices, just to make sure they can get to the hospital and doctor when they go into labor. Geographic isolation coupled with poor travel conditions can make these scenarios even more frequent.

Community Healthcare Workers (CHW) –  This resource is being implemented with increasing success in rural communities. There were several presentations showing success in Texas, Kentucky, Mexico/U.S. border communities, etc. The information here is from a presentation by Debra Flores, PhD, Managing Director, TTUHSC West Texas AHEC. She said on-the-job training, state certification and community college are part of the training required to become a CHW. They are not healthcare professionals, but assist providers by engaging with patients in the community. CHW are from the local community and so have a level of patient trust and understanding of cultural differences that allow them to work closely with patients to understand behaviors that may affect health. CHW are especially helpful in working with chronic disease patients. Dr. Flores pointed out that only 20% of patient health outcome is due to medical care and genetics. The remainder is determined by behavior, nutrition & exercise, lifestyle choices, employment, education/literacy, financial, physical barriers and environment. CHW can identify which of these factors may be negatively impacting patient health.

Telemedicine – This technology seems like a good fit for helping solve the problem of physician shortages and is in fact gaining traction as part of the healthcare team at hospitals in these areas. Telemedicine is covered by Medicare under a narrow definition as follows: “Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.  This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.” See this ACEP FAQ sheet for more details.

Eagle Telemedicine was one of the companies presenting at the conferences. They have a system for use at hospitals that includes telestroke, telecardiology, teleICU, telepsych, telenephrology and physician availability for night shifts. Dr. Talbot McCormick, President & CEO at Eagle Telemedicine stressed the importance of making sure the healthcare providers get hands-on service for the entire implementation and regular communication afterwards. He said in general patients, physicians and hospital staff are receptive to telemedicine. Most staff and hospitals are capable of handling more serious cases if they get telemedicine support, allowing the patient to stay at the local hospital instead of being transported to another community. Without this resource, patients are shipped to bigger hospitals because the rural hospitals don’t have real-time access to a specialist. This is a problem rural hospitals want to avoid since they cannot afford to lose patients. More importantly, it’s problematic for patients because it removes them from their community. Another telemedicine company, AMD, services a range of global markets: critical access hospitals, retail clinics, correctional facilities, retirement communities, skilled nursing facilities, mobile medical clinics, school-based health clinics. Attendees asked both companies whether broadband access is an issue. Both replied that has not been a problem since their technologies are not “bandwidth hogs”.

Advantages cited for use of telemedicine by healthcare professionals included: ability to reach a larger patient base, real-time access to specialists when needed, cost savings, patient & physician retention, support for staff.

Sylvia Norman, CEO & Co-Founder at Sandhill Crane Diagnostics, Inc.

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