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Tuesday Jul 23, 2019

Academy Takes Aim at Rural Health Challenges

"The radio reminds me of my home far away, and driving down the road I get a feeling that I should have been home yesterday, yesterday"
-- John Denver,
Country Roads

[letter cubes spelling challenge]

I have shared multiple times in this blog that I am a product of rural Oklahoma. My father was a rural family physician, and my earliest understanding of our health care system was shaped by my exposure to his practice and the families he cared for.

First-contact, comprehensive, coordinated and continuous primary care wasn't the latest delivery system reform fad -- it was just how things were done. There were no hospitalists, there were no emergency medicine physicians. There were some family docs, a couple of surgeons, an obstetrician or two, and a lot of patients.

As I grew older, the romance of those days faded, but my respect for those physicians who practice in rural communities and my frustration with the lack of resources our society provides to these physicians and communities has increased.

AAFP President John Cullen, M.D., recently wrote an excellent Leader Voices Blog post on his experiences as a rural physician. If you haven't read it, I encourage you to do so. Dr. Cullen walks the walk. He is a rural family physician to his core. I must admit that Dr. Cullen reminds me a lot of my father -- except he snow-skis and he lives near bears.

According to the Health Resources and Services Administration, about 46 million people, or 15% of the U.S. population, live in rural communities.(www.hrsa.gov) According to AAFP member statistics, 17% of family physicians practice in rural communities -- far exceeding the percentage of any other physician specialty. If there is a physician in a rural community, it is most likely a family physician. This uniquely positions the AAFP to take on a prominent leadership role in identifying and solving the major health care issues facing rural communities -- a role we gladly accept.

The Academy has launched a new rural health initiative led by my colleague, AAFP Senior Vice President for Health of the Public, Science and Interprofessional Activities Julie Wood, M.D., M.P.H. Dr. Wood is a family physician who practiced in rural Missouri early in her career.

The initiative has several objectives that were outlined in Dr. Cullen's blog post. I would like to share some insights regarding one of the objectives. The AAFP's advocacy agenda on rural health care focuses on three pillars:

  • practice sustainability,
  • maternal mortality/obstetrical deserts, and
  • rural health care infrastructure (physician workforce, critical-access hospitals, broadband, etc.)

The AAFP has expanded its engagements with Congress, the administration and governors on rural health issues. We are actively engaged with the Congressional Rural Health Caucus, as well as with several working groups focused on rural health issues -- especially obstetrics and maternal mortality. We also are engaging the HHS Rural Health Care Task Force. Our engagement with HHS has included participation in several strategy sessions with CMS and HRSA.

In June, Dr. Cullen spoke at the National Governors Association meeting,(www.nga.org) outlining key policies that will contribute to a more robust rural health care system and workforce. Also in June, the AAFP co-hosted an event that focused on maternal mortality(www.ruralhealthweb.org) with CMS, HRSA and the National Rural Health Association.

We have connected with other organizations that share our interest in protecting and growing the rural health care delivery system and workforce. The most prominent of these connections is our engagement with NRHA and our work with the Rebuild Rural Infrastructure Coalition,(rebuildrural.com) a cross-industry coalition focused on improving rural communities.

This work will not be easy. The economic and socioeconomic challenges facing rural residents and their communities are numerous. Although there are a variety of issues that impact the economic viability of rural communities, we know that access to health care is one of the most important; sadly, access to health care in many of these communities is becoming less available.

As a result, we are seeing negative health outcomes for individuals living in rural communities. In a report detailing the five leading causes of death in the rural United States,(www.cdc.gov) the CDC draws attention to statistics demonstrating that life expectancy for individuals living in rural areas is significantly lower than for those in urban communities. Here are three key findings:

  • In 2014, the overall all-cause, age-adjusted death rate in the United States reached a historic low of 724.6 per 100,000 population.
  • Mortality in rural (nonmetropolitan) areas of the United States has decreased at a much slower pace, resulting in a widening gap between rural mortality rates (830.5 per 100,000) and urban mortality rates (704.3 per 100,000).
  • During the period 1999-2014, annual age-adjusted death rates for the five leading causes of death(www.cdc.gov) in the United States (heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke) were higher in rural areas than in urban areas.

In the same report, the CDC outlines several reasons why we see this widening gap in life expectancy, but I think the two primary areas where we should focus public policy are

  • Residents of rural areas tend to be older, poorer and sicker than their urban counterparts.
  • Social circumstances and behaviors have an impact on mortality and potentially contribute to about half of the determining causes of potentially excess deaths.

These two items closely align with the AAFP's analysis of the challenges facing rural communities. The rural population is older and sicker and has limited access to health and social services. Health literacy and access to transportation are also key challenges that must be factored into public policy discussions. Finally, we know that individuals who live in rural areas are more likely to have health care coverage through Medicare or Medicaid. The lack of payer diversity applies economic strain to rural family physicians, making it challenging for them to maintain their practices.

We are excited about this work and ready for the challenges it brings. To those of you who are practicing in rural communities, thank you. We look forward to hearing from you and learning how we can help you help your communities.

Wonk Hard: Rural Family Physicians

As I mentioned above, rural family physicians account for 17% of AAFP membership. According to Academy research and statistics, this is who they are:

  • 62% are male
  • 31% are independent practice owners
  • 20% are new physicians (seven or fewer years in practice)
  • 12% are osteopathic family physicians
  • The average age is 51.6 years
  • 89% use an electronic health record
  • 87% provide geriatric care
  • 84% provide care to infants and children
  • 55% provide hospital/palliative care
  • 52% provide inpatient care
  • 47% provide emergency care
  • 40% deliver babies (average of 11 deliveries per year)
  • 83% accept new Medicaid patients in their practice, compared to 67% of urban/suburban family physicians.

Posted at 08:30AM Jul 23, 2019 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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