• Accessing Rural Health Care

    AAFP to HRSA: Primary Care Services Best Delivered by FPs

    October 09, 2019, 04:03 pm News Staff – The AAFP recently responded to a request for information from the Health Resources and Services Administration regarding rural communities' access to health care services.

    rural landscape with church

    In an Oct. 9 letter to HRSA Acting Administrator Thomas Engels, the AAFP answered a series of questions about rural health care access while telling the agency about the AAFP's work in this area, including the recently launched Rural Health Matters initiative.

    The letter, signed by AAFP Board Chair John Cullen, M.D., of Valdez, Alaska, noted upfront that 17% of AAFP members currently practice in rural communities across America -- the highest percentage of any specialty.

    The Academy also listed multiple underlying causes for the rural health care crisis, such as low Medicaid payment, closure of many rural hospitals, hospital and insurance consolidation, and high-cost EHRs.

    Core Health Care Services

    "HRSA must ensure that rural communities have access to maternity, emergency and primary care services across generations," said the AAFP in response to a question regarding core services needed and how best to deliver them. "All of these services can be provided by well-trained family physicians." 

    Furthermore, noted the letter, "Every community should have a plan for addressing obstetric, pediatric and traumatic emergencies, though the details will vary significantly based on distance to tertiary care, weather and community capabilities."

    The AAFP urged HRSA to align core health care services with the AAFP's definition of primary care, which includes health promotion and disease prevention, health maintenance, counseling, patient education, and diagnosis and treatment of acute and chronic illnesses in a variety of health care settings.

    A high percentage of rural family physicians currently are willing to accept new Medicaid patients despite payment rates for primary care that range from only 33% to 66% of Medicare payment rates, depending on the state, the letter observed.

    Story Highlights

    However, "To improve the delivery of care in rural areas, we implore HRSA, HHS and its Rural Health Task Force to advocate for urgent state and federal efforts to raise Medicaid physician payment levels to at least Medicare rates for services rendered by a primary care physician," said the AAFP.

    "Lack of parity between these rates has disproportionately impacted access for rural, low-income, disabled, and elderly Medicaid enrollees," said the letter. Many physicians simply can't afford to take on new Medicaid patients due to low payment rates.

    Provision of Services

    Regarding the types and relative numbers of health care professionals needed to provide core health care services to rural populations, the AAFP said, "Rural communities are heterogenous and their needs vary community to community."

    "For smaller communities, a core family physician group can provide robust care while minimizing physician burnout from excessive on-call duties and lack of sleep. Patient-to-physician ratios may need to be adjusted for smaller communities to allow this core group to practice," said the letter. Larger populations may allow for more subspecialist and nonphysician clinicians.

    In addition, "HRSA must support recruitment of family physicians to rural areas," said the AAFP, by increasing

    • student choice of the specialty,
    • the number of family medicine residency positions,
    • support for residency programs, and
    • funding for existing and new rural training tracks.

    The AAFP also urged HRSA to review an annotated bibliography by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care that provides valuable information on health care disparities, distribution of the physician workforce in rural America and the current system for graduate medical education financing.

    Additional Factors to Consider

    Regarding other factors HRSA should take into account when identifying core health services needed in rural America, the AAFP suggested the agency first look at network adequacy.

    "Strong network adequacy standards promote the primary care medical home model as a way to deliver higher quality, lower costs and a stronger patient-physician relationship," said the letter.

    Furthermore, "Primary care capacity should be the focal point of network adequacy, and HRSA should examine the percentages of family physicians and other primary care physicians participating in rural areas," noted the letter, pointing to recent research that showed a robust supply of primary care physicians was associated with lower mortality rates.

    However, noted the AAFP, when determining network adequacy, ratios of primary care physicians to covered persons should reflect only full-time physicians and not those who practice part time or in multiple locations.

    "In addition, nonphysician providers (i.e., nurse practitioners and physician assistants) should not be counted because listing these providers creates the illusion that there is more access to physicians" than actually is the case, said the AAFP.

    Additionally, when identifying rural communities' needs, HRSA must also consider

    • distance to the nearest hospital;
    • transportation options;
    • availability of community services; and
    • each community's infrastructure, including quality of roads and availability of health IT support services -- especially internet access.

    The letter directed HRSA to HealthLandscape's UDS Mapper resource as a valuable tool for displaying existing services and identifying service needs.

    Measuring Access, Quality

    Regarding how to best measure access to rural services and quality of care in rural communities, the AAFP again directed HRSA to an existing HealthLandscape tool -- the Health Workforce Mapper -- that allows visualization of the geographic distribution of physicians and nonphysician clinicians in rural and non-rural areas.

    Additionally, "The AAFP cautions against penalizing primary care physicians in rural areas where there is low or limited access in accepting new patients since there are multiple factors in the physician supply chain outside the control of a practicing physician," said the AAFP.

    Regarding performance measurement programs and associated measures, the AAFP insisted that organizations must have control over the dimensions involved.

    "Lack of control over significant factors in rural America negatively impact the ability of rural physicians to perform well on many existing performance measures," said the AAFP, listing factors such as

    • a shortage of primary care physicians;
    • lack of subspecialists, particularly those trained in behavioral health;
    • patient transportation issues;
    • high Medicaid and uninsured populations;
    • closure of ERs; and
    • lack of OB services.

    The AAFP encouraged CMS to use performance measures to identify gaps in community services and population outcomes while stressing that measures "should not lead to financial penalties for low performance as penalties simply exacerbate an already difficult situation."

    Furthermore, quality reporting in rural settings should be similar to existing policy that applies to rural health clinics.

    "This would require assessment and a quality improvement plan but would not require reporting of quality measures. Quality improvement efforts require transparency and a safe space to allow honest assessment of care without fear of punishment and without pressure to increase revenue or produce bonus payments," said the Academy.

    The AAFP further insisted that physicians "must have a key leadership role in QI efforts, with patients, clinical teams and community partners as key players."

    "On their own, individual health care professionals have limited ability to drive outcomes in health and health care and are constrained by the environment and systems in which they practice," the letter explained.

    Lastly, the letter referred HRSA to the AAFP's policy on advancing health equity that outlines principles to address the social determinants of health in alternative payment models.