Addressing Rural Health Disparities in a Pandemic

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, COVID-19 reminds us of the public health crisis facing rural America.

DR. LEE NORMAN:
We are hundreds of thousands of physicians short in the United States and it's going to, with the aging of America, we are gonna get more and more so all the time.

BENJAMIN ANDERSON:
We have some of the deepest disparities in the United States between rural and urban zip codes. And so, when we are able to say, "If you want an opportunity to pursue health equity in a diverse population, to pursue justice in a community that really loves and accepts you," that's about as attractive as anything we can provide. And so, COVID has actually made better the opportunity to recruit and retain medical providers this way.

MARGARET BROCKMAN:
We found that if the providers are satisfied with their work and they're satisfied with the community, they often stay in that rural community.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the search for healthcare providers to serve rural communities and the strategy some states are using to meet these critical needs.

The census numbers tell an ever-worrisome tale—rural America is getting older while medical care in non-urban areas is becoming harder to find. The share of the population 65 years and older is highest in the middle of the country, from North Dakota to Texas. At the same time, the other census data shows fewer physicians are working in these and other rural communities—one of the many disparities laid bare by this year's COVID-19 crisis.

Our guests work in the states where rural populations are among the highest, and the need for providers the greatest.

Benjamin Anderson is vice president of rural health and hospitals for the Colorado Hospital Association. He will explain how the pandemic has created a unique recruitment opportunity for communities.

Margaret Brockman leads the Nebraska Office of Rural Health. She'll be along to tell us about a program that's designed to support and retain providers in rural communities.

But, first we hear from Dr. Lee Norman, secretary of the Kansas Department of Health and Environment, on the challenges aggravated by the COVID-19 outbreak.

NORMAN:
Number one is we always have, in rural areas, a more difficult time with workforce—in other words, having enough primary care physicians, nurse practitioners, nurses, physicians' assistants, and the like—and this has accentuated that because we have a harder time reaching out with fewer people.

But it's also made worse by the fact that, as simplistic as this may sound, we don't have access to broadband internet as readily in the rural areas. So, people who have been accustomed to going in and being seen for care now can't even get that by way of things that require broadband internet. So, those have been a real challenge.

The third one—we don't talk a lot about oral health: both oral health in general, meaning making sure that people's mouths are healthy; but dental care, of course, has been severely impacted. And the density of dentists in rural areas is very low and in the state of Kansas.

Kansas hasn't expanded Medicaid, unfortunately, so there's disparities in terms of access to care. And again, this is more likely in rural areas.

So, I guess in summary, it's kind of: what are the infrastructure things; what are the financial and the healthcare economics; what are the technology barriers; and then, finally, of course, the distances are great. Out there, it can be an hour to the nearest clinic, for example, or hospital by driving, or even more than that for something that you would consider routine—like obstetrical care can be six hours away. So, all the resources are spread more thinly without technology and other kinds of infrastructure.

JOHNSON:
When we talk about the impacts to rural healthcare delivery, there are some issues that have come up as a result of the pandemic. Some of them might've been there already, but they've been made worse now. I'd like to run through some of those that you mentioned on a call to prepare for this conversation a few weeks ago.

One was the training pipeline. You said that there are some challenges with keeping it filled—what are those?

NORMAN:
The challenges are especially two or three things.

One is that there's not enough physicians in rural Kansas. I believe there's 15 out of 105 of our counties have no physicians that have a full-time practice there. How does one encourage a physician to go to a rural area that may not have much in the way of health resources?

Physicians, especially in the more recent generation of physicians, is accustomed to having specialty consultation and advanced technology, like MRI and CT, readily available, and a lot of the rural areas don't have that. So, it's hard to recruit people in so that they feel comfortable.

Kansas Rural Hospital data show us that 70% of our rural hospitals have negative operating margins. So, when you train in a fancy urban or suburban hospital or health system, then go out and interview—check it out to see if I want to go—there are some that might look a bit shabby because they're behind on technology, they're behind on amenities, and just the general appearance. That doesn't instill confidence.

Additionally, I talked about healthcare finance and a higher percentage of uninsured people. There is concern especially with the healthcare economics—for going to medical school, it's not unusual to come out with $300,000 worth of debt. And then, to be taking care of a high number of people, no matter what your ethical intent is—to care to the underserved and the medically indigent—if you can't pay the bills, then that's not a secret for success.

We do have some programs in this state of Kansas—and they are not unique to Kansas, necessarily—but there's many of our areas, rural and also urban, have been designated healthcare shortage areas. So, there's low-cost loans and loan repayments system. There's ways that foreign medical graduates who've trained in this country can go through what's called the Conrad 30 Waiver process to allow them to have a visa that will allow them to continue to work in the state of Kansas.

And then the last big bucket that I think bears mentioning is that, compared to some states, Kansas has not been very liberal, I guess, about having expanded scope of practice for nurse practitioners and physicians' assistants. So, on one hand, we have areas that are unserved by what I would call primary care—and if you use that, it would be primary care physicians, meaning family physicians, general internists, general pediatricians. And on the other hand, licensing has been stonewalled that allows for broader scope of practices for nurse practitioners or PAs through a collaborative practice agreement with a physician that they're paired up with.

So, there's a mismatch between geography, economics, and the training pipeline. And none of the first two things I mentioned help at all in making it enticing for a young physician—and his or her family, perhaps—to go out into the rural parts of the state.

JOHNSON:
These were all challenges before the pandemic. Are they worse now?

NORMAN:
Yes, they are worse now.

You know, this derailed so many plans—people have kind of hunkered down—and I think we're a little bit too soon into it to see, you know, if we have an 18 or 24 month pipeline for getting out from underneath this pandemic. That seems like a long time, but my experience with the coronavirus in the Middle East, it didn't peak out there until the fourth year. So, can we hold our breath and tread water for four years, or 18 months, or 24 months?

And so, I think people are becoming more cautious and more hesitant about making a major life change. And face it—most medical students who have gone to a residency or, you know, 16 years into their training before they then go out on their own, they don't want to take a big risk on something that's decidedly different than where they have done their training which, for the most part, are urban, kind of state-of-the-art hospitals.

JOHNSON:
You also have a long military career on your record. Do you think that we might see the same sort of thing that we saw after 9/11? A lot of people signed up for first responder careers, a lot of people enlisted in the military.

What about this time around? More people in public health, more people in medicine?

NORMAN:
You know, I think it's too soon to really know, but I don't think it has the same nationalistic pride—and I use the term nationalistic in the most positive sense.

You will recall that—and I remember it very clearly—in 9/11 of '01, it was an external threat, and different kinds of people of all ages, and race, and gender, and everything banded together for a common enemy.

And this COVID-19—I tell you, it has exposed an underbelly that has been shocking in terms of the political divide, the racial divide. And, granted, everything that's going on with protests and the like does not necessarily relate to COVID-19. But I think that, in many regards, COVID-19 was a powder keg that has ignited so many things kind of from the underbelly of our society, and I think it's very destabilizing.

And I've seen people are retrenching because, yeah, we have a common enemy as a virus, but it's not something you can feel, touch, and really feel like, "I can go out and do my part for it by signing up." As close as we've come to that is mask wearing as a beacon of commitment; and yet, there's just about as many—or more—of non-mask wearers who say it's a bunch of hooey and don't believe that does any good, and that there's a conspiracy on these COVID-19 numbers, and somebody is trying to dupe us.

So, the level of trust in 9/11 of '01 was we trust our leaders, we trust where we're going to this external threat, and we have to protect ourselves together. In this one, I think we've seen fragmentation of some of the societal threads that have held us together.

JOHNSON:
So, if we can't count on people rallying around the cause to make things better for all of us, what's the answer?

How do you get more people involved in the sorts of careers going forward?

NORMAN:
Well, I think, you know, there's not one single mechanism that works, and especially if you're talking about rural health care during an era of coronavirus or COVID-19.

But I think that: one, it starts with selecting people into medical school that are voicing a desire to be in rural areas and giving back to society in some manner. I mean, granted, we need all specialties and you're not gonna have a neurosurgeon wind up in Liberal, Kansas, you're not gonna have a joint replacement surgeon up in Colby or some little town. They are, by definition, always going to be in urban areas.

That really shines a bright light on where are we with primary care and, for that matter, how do we even define primary care? Because you don't necessarily have a uniform definition of what that is. I typically think of it—and I've been a family doctor for 42 years. I went to a medical school in Minnesota that was built to train people to go into primary care and is still existing that way.

It gave training tracks into rural communities so people could feel comfortable so that when they get kicked out of the nest when they're done with the residency, they go land in with a very specific focus on preventive care, primary care, chronic disease management, emergency services, and has really great tight emergency medical services, including transport, because everything can't be taken care of, and there's nothing scarier than being stuck with somebody with, let's say, a critical hand injury, and it's you and a technician on that night in the emergency department. So, there has to be a great relationship with partner organizations that are the more tertiary type centers.

So, it takes an integrated approach. And we, I think, have done parts and pieces of the integrated approach in the state of Kansas, and yet we're not to perfection yet. But that will help provide the comfort people need to go out to rural areas where they're kind of quote, "going it alone," unquote a little bit more so than they would be in an urban area.

JOHNSON:
Who drives the solution? Is that the public health official like you, or is it the private sector, the universities, all of the above?

NORMAN:
You know, that's a—the locus of control and where does it lie?

I think it's all of those in partnership. And there lies one of the weaknesses, is that I can tell you, as an agency secretary of health and environment, we can do a lot to sustain public health in the 105 counties in the state of Kansas. In my agency, we survey in accredited hospitals in the state of Kansas. So, we have parts and pieces.

It's kind of like the old metaphor of the blind man and the elephant—the medical schools, they have specific training goals and what meets the needs of the funding agency. For example, the Kansas state legislature funds the University of Kansas School of Medicine—the legislature has a stake in this. Medical society, maybe a little bit; hospital association, maybe a little bit; Center for Medicaid and Medicare Services, a CMS through federal match pays for the majority of Medicare and Medicaid dollars.

They have ways to incentivize and there can be alternative payment mechanisms that can be put in place to incentivize an integrated health system approach. Because right now, quite honestly, the payment systems are mostly in a modified fee for service basis, which lends itself to doing more, but not necessarily rewarding those who integrate by providing the glue across a primary care system.

JOHNSON:
The bottom line, though—you've got to find more people because the needs in rural America are real and they're not being met.

NORMAN:
Absolutely. We are hundreds of thousands—in just in talking about physicians alone—we are hundreds of thousands of physicians short in the United States and it's going to, with the aging of America, we're gonna get more and more so of all the time. And that's even with physicians hanging on and practicing longer than they used to in the past. But we're still way short.

JOHNSON:
Benjamin Anderson is vice president of rural health and hospitals for the Colorado Hospital Association. His members struggle with health disparities every day. For them, the pandemic didn't reveal the inequities—it only made them worse.

ANDERSON:
So, there have already been inequities between rural and urban communities around health outcomes and healthcare access. There is already a large number of rural hospitals that were fragile financially. And what COVID has done is really shined the light on that or exploited those vulnerabilities, as well.

We at the Colorado Hospital Association have been really neck deep in dealing with COVID response work. We've categorized the challenges into what we would call the four S's—which are staff, supplies, space, and spending—and many of the challenges that we've faced are in any of these areas.

Staff, of course, making sure that staff are protected, that we actually have access to staff. In many hospitals, even before COVID, there was a significant nurse shortage, there were technical workforce shortages, leadership and governance shortages. And so, really, when COVID hit, it put a further strain on that area.

Same with supplies. We've had a big push in Colorado for PPE because there have been nurses that have been saying they've been expected to go to work without adequate protection, and that's really an unthinkable circumstance when you think of that through the lens of a nurse. And so, the Colorado Hospital Association has been leading significant efforts around ensuring that we're hacking the supply line and getting PPE to the end of the supply line, places that would not normally have access to it, not because they don't have a group purchasing organization, but they just don't have the buying power to ensure they get what they're ordering.

Third being space—just really running a risk of running out of beds in certain areas and in other areas it's more of a ghost town, and trying to figure out how to manage the discrepancy there.

And then, finally, of course, there's been a major cash shortage. When many rural hospitals have less than 50 or 60 days of cash on hand, and then we go to months with shutting down all of our outpatient services, of course this puts rural hospitals in a very, very dangerous situation.

JOHNSON:
How are the hospitals in rural areas of your state holding up through all of this?

ANDERSON:
We've been very fortunate, through advocacy work and through support from our federal legislature, that we've gotten some federal relief money that's been helpful there. Our hospitals, many of them had to make some difficult choices. They had to furlough or lay off staff, eliminate positions, and those are in areas where there have been COVID outbreaks. Those are also in areas where there have been none, but those hospitals were doing the right thing by shutting down all services that may possibly spread the disease.

So, it's a mixed bag, as far as that goes. Some that were very fragile previously have benefited from some of the relief funds and the question remains how much of that would need to be paid back. So, they're working through that right now, but we don't know of any impending closures in Colorado now. For decades, there's not been a rural hospital closure, and so we would like for that not to start during COVID, and so we're keeping a close eye on that.

JOHNSON:
We hear so many stories about communities that have one doctor, or a hospital with only four or five people working there.

Is the shortage as bad as we think it is in rural America?

ANDERSON:
I think it depends on the community. It really does.

So, rural America can't really be described in one identity because there are several major identities within rural healthcare delivery in the United States. I mentioned three in Colorado.

We have the resort communities, which have their own set of challenges related to housing. When, say, an average house is $800,000 or a million dollars, where does the support worker live?

Then, we've got the western slope, which has definitely a significant migrant or immigrant population that has their own challenges, and they've got some poverty involved there. There's definitely some geographic isolation related to the mountains.

And then, we have the eastern plains, which really are almost all independent, small, rural hospitals trying to make a go of it, and they have their own challenges around cash shortages, and workforce stuff, and their own geographic isolation.

And so, when you look at the shortage around physicians, it's going to depend on the region and it's going to depend on the community. I would say that there's definitely a national shortage and that shortage is growing.

JOHNSON:
What have you done to attract new workers to underserved areas?

ANDERSON:
Traditionally, we work through, you know, a lot of the common approaches—we have low crime, low cost of living; we've got a great quality of life here; you get to hunt and fish, or, you know, your kids are in schools with small class sizes; and, you know, we have this one suburban-like home with brick on the front of it, you can live here; and we have a nine hole golf course that, if you play it twice, it's 18 holes—like, come here, we have the greatest small town in America! And that really just hasn't worked.

And so, at CHA, we hosted an event that we began hosting around the United States called Rural Recruitment Re-Imagined. We've hosted it in Kansas, in Texas, in North Dakota, and all also here in Colorado. And, essentially, it was a day-long interactive workshop with how to redesign how we recruit primary care providers that is very much focused on purpose.

We are recruiting a generation of millennial doctors who is more mission-driven and purpose-driven perhaps than any generation in American history. They're more aware of needs around the world. They're very much committed to health equity, to justice. They got into primary care—especially the brightest ones—got into primary care not because they had to, but because they want it to. They've got in full-scope family medicine because of that.

And so, what we essentially started with in this workshop was we've got to begin by defining our own mission, vision, values, and goals as an organization and community, and make sure those are cleaned up and in check. And many times, rural communities, rural hospitals, haven't looked at those in 20 or 30 years when some lawyer wrote them back in the 1980s. And so, we have to really encourage them to look through what motivates us as an organization. What are our values? What is our strategy and where are we going? What's the vision?

And once that's clearly defined and can be stated in an elevator ride, we began to look at what are the motivations of the doctors that would move to rural areas.

JOHNSON:
What sort of benefits do you have to offer to get quality people to come work in small towns and remote areas?

ANDERSON:
Well, it's interesting you ask that because the benefits aren't always financial. When we think of benefits, we think of paid time off, and we think of money, and we think of loan repayments, and, you know, three or four day work weeks, and a significant signing bonus plus a housing bonus plus a stipend during residency, and all of these things that can end up equaling more than a half a million dollars a year to try to recruit, for a first year expense, to try to recruit a primary care doctor in your community. That just isn't sustainable for rural communities.

What we did was we became students of what motivates them and what benefits do they really value, and what we have found after about 10 years of recruiting is that, really, it is not the finances that they're after. It's community. It is simply being able to answer who will be my family here.

If I'm going to move my spouse and two young children into this community, who will be my family here? Who will be their grandparents, surrogate grandparents, because we are moving away from our own parents, so they're going to be far away from them? Who will be my brother- and sister-in-law? Who will be my kids' cousins? Who will watch our kids so that we can have a date? Who would treat us as though they would treat their own children?

That's actually the benefit that they desire the most, more than any of the others. And it's not that loan repayment doesn't matter, that certainly is a factor, but it's common in virtually every state. If you don't have a robust loan repayment program in your state, get with the program. That's a no brainer. But that's not what is going to move somebody to one rural community versus another because that's so common.

A fair but not exorbitant salary—we want to make sure that people are being paid fairly, not being taken advantage of.

Paid time off is a big deal. In fact, it's a bigger deal than money. I have seen some of the physicians we've recruited be willing to take a contract for $178,000, $175,000 a year as a full-spectrum family doctor in a rural community being given 10 weeks of paid time off per year to go do international mission work, to go on vacations, head to Disneyworld, take time off, go hunting, go into the mountains, whatever they want to do with it. But that time off to recharge is extremely, extremely important.

And then, as we've gotten into full-scope family medicine—which is a doctor that is an inpatient-outpatient care, OB, C-sections, trauma care—that they're willing to do the call, but it needs to be equitably distributed.

So, we really built a structure for recruitment around four non-negotiable principles, and the first one is standardized roles. We would refuse to recruit one pediatrician, one internist, one OB-GYN, and one family doctor into a community where everyone's on call for themselves. No, we don't have the dollars to spend that way. And so, we've structured our recruitment around standardizing those roles, number one.

Number two, equitable call structure, making sure that the most senior doctor there is not saying to the newest one, "Dad gum it, I did it back in the 1980s, I was on call 12 years straight," because the new doctor is thinking, "Well, you were a fool if you were doing that. I'm not going to do that." So, making sure that every physician, every medical provider—including mid-levels—are on call equitably.

And the third one is fair compensation—I mentioned that—not exorbitant but fair.

And the fourth one is just ensuring that there is a mission-driven culture within an organization.

When we have that in place, when we can clearly communicate that that exists, and then when we visit with physicians about who are you, what matters to you, tell me about your family—we spent the majority of our time focusing on who these people are as people, not as doctors. We can tell by them working a locum shift or two if they're qualified, we can get references from the residency.

Really, we want to know what are their motivations, who are these people, and what can we do to love them well while they live in our community, what can we do to ensure that they're glad they moved there three years later? And that process begins, really, from the first interaction. And I would tell you that I've never recruited a doctor that I haven't offered to first go to their home in their community, wherever they're training or wherever they're practicing.

JOHNSON:
After 9/11, we saw more people sign up to be police officers, firefighters, paramedics, more people joined the military.

Do you think that more people will become healthcare professionals because of what's happening now?

ANDERSON:
I wonder.

I think if this next generation coming up under the millennials is anything like the millennials—if they are that mission-driven—I do think that you will attract some very mission-driven people into the healthcare field.

I don't think that will happen on accident. I think it is coming upon us that are in the healthcare delivery space now—at state associations and state government, at hospital association, various healthcare leaders in health systems—to really focus on bringing up the next generation. The clinical workforce, the technical workforce, and, I think most importantly, leadership and governance—we've got to bring up transformational leaders.

So often in rural communities and with rural hospitals, we're seeing baseline plant managers that know how to milk a Medicare cost report for another $100,000 dollars, and that is not going to get us where we need to go. It hasn't gotten us where we need to be, and it's not going to get us to where we need to go.

We need to be very intentional about looking for the edgiest training programs in the United States, leveraging those resources to invest similarly in leadership as we have in developing the clinical workforce. We spent hundreds of millions of dollars—even billions of dollars—training, recruiting, and retaining very good clinicians for rural areas in the United States. We spend comparatively nothing in training, recruiting, and retaining the people that sign their paychecks, the people that will develop or not develop the systems that will determine if those clinicians burn out or thrive.

And so, we've got to make a similar investment at a state level. And so, if there are state health officials that are listening to this podcast, if there are state association folks that are listening to this podcast, it's really important that we think through systemically, how do we develop rural transformational leaders in our communities and for our healthcare delivery systems.

JOHNSON:
Actually, I wanted to ask you about that.

How can state and territorial health officials help hospitals recruit new talent to rural areas or underserved communities?

ANDERSON:
That's a great question. I think what we do is we model after the good work that's already being done in the clinical space.

We take kids who are right out of high school who are strong in the sciences and we feed them into undergraduate programs that are good pre-med programs. Biology teachers at the high school level are plucking these kids out and they're sending them through saying, "You need to come back and be my family doctor."

And then, they go to these undergraduate programs where they're grown, they're cultivated there. And then, they get into medical schools. And we have one in rural Colorado at the University of Colorado, the school of medicine. It's a rural training track that is very effectively run or executed, and so it really cultivates these kids as they continue to come through medical school.

And then, they go into one of 10 residencies in 14 sites in Colorado where they're sent out to the rural sites to grow. And then, after that, they, of course, many of them are placed into rural Colorado.

We need to do something like that for leaders where we identify the student body president, the FCA President, and these kids in school that are natural-born leaders, that have this talent for this. And we need to get them in early into healthcare delivery leadership type of programs, or training, or exposure to those things through mentoring, things like that, and then taking that into graduate schools.

JOHNSON:
You're very passionate about this, we can tell from your responses.

What's your hope for the future of healthcare in rural America?

ANDERSON:
Thought about that. This is 4th of July weekend, and what came to my mind was the words, "We hold these truths to be self-evident, that all people are created equal, and they are endowed by their creator with certain unalienable rights, and among these are life, and liberty, and the pursuit of happiness."

And as health equity has risen to the center of the national conversation over the last 20-30 years, it has largely excluded—unintentionally—that discussion has largely excluded rural America.

And my hope is that this 2020 year, in the midst of a pandemic, enough of light was shined on the disparities between rural and urban that we say that is not okay anymore, and that your zip code should not determine your health outcome any more than your race should, or your gender should, or your insurance status should, should not determine your health outcome.

And so, I dream of a time when a rural American can have just as good of a chance of life, and liberty, and the pursuit of happiness as an urban American, as an inner city American, or a suburban American, that we really would hold these truths to be self-evident, that we really all would be equal.

JOHNSON:
As chief of Nebraska's office of rural health, Margaret Brockman's mission is to support providers working in rural communities. With the help of many private and public partners, her office has created more than 100 medical home care models across the state.

BROCKMAN:
So, the patient center medical home is for the primary care physician and for your primary care needs. And so, you can come in there and be seen for all kinds of medical needs. So, once you're seen by the physician there, they can refer you on to the specialist. And the whole team is involved in your care, making sure that they're following up on a routine care and preventative care, as well as episodic care.

JOHNSON:
The model sounds like a great idea for patients, but it also helps providers.

BROCKMAN:
The medical homes have been found to increase patient satisfaction, and provider satisfaction, and staff satisfaction. So, if we have providers that are happy with the work that they're doing, and they're not feeling overwhelmed, and they're getting to do the work that they like to do and they love to do, and they're not having to do all the other stuff that they really weren't trained to do and don't enjoy doing, then they are going to be more satisfied and have the ability to stay, to be retained.

JOHNSON:
Brockman says officials are still evaluating the benefits of the medical home concept.

In the meantime, the state has developed a toolkit to help others looking for new ways to improve rural care and keep providers on the job.

BROCKMAN:
The tool kit is ready to go and the toolkit has all the information that they would need to put together. They can do it at their own pace.

They can initially identify, you know, what are the things that they have in place already? What are the things that maybe they're lacking? And then, what are the things that they will need to put in place to be able to become a maternal medical home?

So, it looks at coordination: do they have access to care? Are they providing a complete plethora of access to care? Do they have the coordination? Do they have telehealth available? Are they coordinating with specialists when they need to? For those kinds of things, do they have educational resources available for their patients when they need to do that?

And so, in the next couple months here, we plan to start doing some seminars and broadcasting some webinars on how to utilize the tool kit and how to be able to become a maternal medical home for those providers in Nebraska that want to do that.

JOHNSON:
You can find links to information about the tool kit and other resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.