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July 27, 2011

Rural health white paper released by UnitedHealth Group think tank

The UnitedHealth Center for Health Reform and Modernization released a white paper today on Modernizing Rural Health Care.  To quote from the UHG presser,

  • [The paper] projects an increase of around 5 million newly insured rural residents by 2019 – even as the number of physicians in rural America lags
  • Quality of care is rated lower in rural areas in 7 out of every 10 health care markets; both physicians and consumers in rural areas more likely to rate quality of care lower than those in urban and suburban markets
  • Innovations in care delivery – particularly telemedicine and telehealth – can absorb future strain on rural health care systems

The paper inventories the current state of health care for the 50 million Americans living in a rural setting -- and it's not pretty.  The question, of course, is why does rural health compare unfavorably to urban health metrics, and what can be done to improve matters?

The answers proffered are not particularly surprising.  Access to primary care providers and specialists is limited in the rural setting, it's likely to get worse, and the workarounds we've tried to put in place -- everything from clinicians "riding circuit" to telemedicine -- need to be implemented more broadly and need to be supplemented by additional resources. 

The resources needed include nurse practitioners, for example, whose hands are tied by restrictive scope of practice rules in heavily rural Southern states, and guidelines that could make them more effective primary care providers in an era of physician shortages; conversions of existing rural health care facilities to more current, relevant, uses. 

The resources needed also include dollars -- lots of cold, hard, cash -- to support this workforce, these guidelines, these facilities, needed collaborations with urban providers, and to bootstrap telemedicine beyond its current use, primarily for imaging, to expanded uses that can fulfill the promise seen in studies of pilot projects: quicker diagnoses, avoided costs, better outcomes.  Changes in telemedicine rules are also needed, e.g., relaxation of local licensing and credentialing requirements, so that rural access to telemedicine is not unreasonably limited.

In sum, I see the bottom line as, well, the bottom line.  An unspecified amount of money -- in the form of price supports and funding for other system supports -- will be needed in order to realize the promise of successful pilot programs in rural health. 

If we can learn from history (so that we may not be doomed to repeat it), we must remember that price supports can have unintended consequences.  For example, the federales can point to a great success in the form of the Department of Agriculture's extension centers -- the ONC's RECs are modeled on them -- but the danger to keep in mind when thinking about that model is that a couple of generations later the productivity of family farms, which was at first changed for the better, accelerated out of control thanks to continued meddling by the feds.  Consolidation of properties into factory farms was encouraged, resulting in a monoculture which has done irreparable harm to the environment.  I am not suggesting that enhanced Medicaid funding under the ACA for rural health improvement will lead to ruin, just that we need to always remain cognizant of the effect that pushing on one side of the balloon may have on the other.

Furthermore, one of the key lessons of the experience to date seems to be that programs arghmust be tailored to local conditions and cultural expectations in order to work well.  Thus, while a handful of inspiring program examples are offered -- drawn from rural Wisconsin to the Navajo Nation -- developing a comprehensive set of solutions addressing the issues presented in this paper will not be easy. 

All in all, we may have an understanding of what needs to be accomplished, but it is less clear just how to do it, and how to pay for it.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

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