A View from the Periphery — Health Care in Rural America
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《新英格兰医药杂志》
Urban Americans tend to view the rural United States as a larder, a playground, or a place to retire. But although agriculture now employs less than 3 percent of the nation's workforce, more than 50 million people — 20 percent of our population — live in places defined as rural by the 2000 Census. Inhabitants of rural areas are generally older, poorer, and less likely to have health insurance than inhabitants of urban areas. Enormous regional variation masks the fact that rural America contains pockets of deep poverty; of the nation's 500 poorest counties, 459 are in rural areas.1
Rural America exists at the periphery of our society; it is defined in relation to its urban counterpart as comprising places with relatively low population density that are remote from urban centers. These areas must import most of the equipment and people needed to provide health care, from health care professionals to hospital architects.
One of the signature characteristics of the rural health care system is the relative shortage of health care professionals. As the Figure shows, the diffusion gradient for physicians is particularly steep: the smaller and more remote the place, the more difficult it is to attract and retain physicians.2
Figure. Numbers of Practicing Physicians per 100,000 Population in the United States.
Rural areas differ qualitatively from urban communities in terms of their reliance on generalists for medical care. Forty-one percent of the physicians practicing in small rural areas — towns of fewer than 10,000 people — are family physicians, and an additional 19 percent are general internists and pediatricians. The number of graduates of U.S. medical schools who are interested in primary care in general, and family medicine in particular, has decreased rapidly during the past eight years — a change that may lead to shortages of rural physicians as the current generalists begin to retire. Moreover, very few medical schools or residency programs are located in rural areas, exacerbating the recruitment challenges faced by these communities.
Although the flow of physicians to rural areas can be increased by selecting students from rural backgrounds and training them in medical schools and residencies with tracks focused on rural health care, few schools sponsor such programs.3 Despite federal and state efforts to bolster training, academic health centers value research-intensive, specialized models of care over primary care, and their main product is urban specialists.4 At the same time, the public school systems in many rural communities are weak, and the number of rural students admitted to medical schools has decreased by almost 50 percent over the past decade. Thus, shortages of physicians in rural areas may worsen.
Rural hospitals — a critical part of the health care system in most small communities — are a product of federal policy. We owe the existence of most of our stock of aging rural hospitals to the federal Hill–Burton program initiated after the Second World War. Because most inpatients cared for in the country's 2200 rural hospitals are Medicare beneficiaries, the fiscal well-being of these hospitals has oscillated with changes in Medicare reimbursement. When Medicare ratcheted down reimbursements in the late 1990s, many rural hospitals approached bankruptcy.5
(Figure)
A Physician Examines a Newborn at a Hospital in Rural Idaho.
Photo courtesy of Roger Rosenblatt.
Largely because of political pressure to rescue these hospitals, Congress created the Medicare Rural Hospital Flexibility Program in 1997, establishing a new kind of rural inpatient facility — the Critical Access Hospital. These facilities are exempt from the strictures of Medicare's prospective payment system and receive "reasonable-cost" reimbursement for services. The creation of this category provided a fragile safety net for small rural hospitals, the majority of which will have been certified as Critical Access Hospitals by 2005.
This new status recognizes that small rural hospitals are qualitatively different from urban facilities. Hospitals operating under this rubric generally have 25 or fewer beds, hospital stays averaging less than 96 hours, and 24-hour coverage in the emergency department. Most small rural hospitals can manage easily within these requirements — a reflection of their primary roles as providers of basic emergency and short-term services and as anchors for local health care systems. Patients who require longer stays or more complex interventions are referred to larger institutions or transferred after their condition has been stabilized. A substantial number of hospitals in larger rural areas have not chosen Critical Access Hospital status, since many of them act as sophisticated referral centers for surrounding communities.
Since the 1970s, the federal government and individual states have been actively trying to improve rural health care delivery, and today the majority of the nation's approximately 1000 Community and Migrant Health Centers — local nonprofit, community-owned providers — are in rural areas, providing care for an increasing proportion of rural residents. The establishment of the Office of Rural Health Policy in 1987 signaled a congressional desire to create a focus for developing rural health policies within the federal government and for effectively catalyzing policy-oriented research. The sheer number of programs reflects the political reality that most states have a substantial rural population whose elected representatives vigorously represent their interests. The most effective interventions are those that support the education of primary care clinicians, increase the flow of providers to rural areas, strengthen and support rural health care institutions, and integrate rural health care into larger regional systems.
Although they may live at the geographic periphery, rural patients increasingly demand access to the same spectrum and quality of care as their urban counterparts. Improving the quality of rural health care requires the integration of providers and institutions into larger systems, through the creation of networks and the use of electronic health records and telemedicine. Many complex services cannot be supplied safely or at a reasonable cost in rural communities. Effective rural systems must be based on a menu of core services, delivered largely by generalists in stable hospital and outpatient settings that are linked to regional centers.
Ensuring stability is a challenge. Because of the small size of many rural delivery systems, the loss of a hospital or a provider can undermine an entire local system. Congress has temporarily created an island of fiscal equilibrium for smaller rural hospitals through the Critical Access Hospital program. No such national policy has emerged with regard to the health care workforce. Because medical and nursing programs are dominated by academic health centers with relatively little experience or interest in rural medicine, training has not met national needs. If we are to maintain high-quality patient care in rural communities, we need to develop mechanisms to attract and retain clinicians who are willing to practice in rural settings. Rural health care systems — because of their size and geography — will always be somewhat fragile. But a concerted national policy to sustain strong rural health care institutions — and the personnel to staff them — can ensure that access to and quality of care do not lag behind those in urban areas.
Dr. Rosenblatt reports having received grants from the Office of Rural Health Policy.
Source Information
From the Department of Family Medicine, University of Washington School of Medicine, Seattle.
References
Ricketts TC III, ed. Rural health in the United States. Oxford, England: Oxford University Press, 1999.
Larson EH, Johnson KE, Norris TE, Lishner DM, Rosenblatt RA, Hart LG. State of the health workforce in rural America: profiles and comparisons. Seattle: WWAMI Rural Health Research Center, August 2003.
Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA 2001;286:1041-1048.
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? JAMA 1992;268:1559-1565.
Report to the Congress: Medicare in rural America. Washington, D.C.: Medicare Payment Advisory Commission, June 2001.(Roger A. Rosenblatt, M.D.)
Rural America exists at the periphery of our society; it is defined in relation to its urban counterpart as comprising places with relatively low population density that are remote from urban centers. These areas must import most of the equipment and people needed to provide health care, from health care professionals to hospital architects.
One of the signature characteristics of the rural health care system is the relative shortage of health care professionals. As the Figure shows, the diffusion gradient for physicians is particularly steep: the smaller and more remote the place, the more difficult it is to attract and retain physicians.2
Figure. Numbers of Practicing Physicians per 100,000 Population in the United States.
Rural areas differ qualitatively from urban communities in terms of their reliance on generalists for medical care. Forty-one percent of the physicians practicing in small rural areas — towns of fewer than 10,000 people — are family physicians, and an additional 19 percent are general internists and pediatricians. The number of graduates of U.S. medical schools who are interested in primary care in general, and family medicine in particular, has decreased rapidly during the past eight years — a change that may lead to shortages of rural physicians as the current generalists begin to retire. Moreover, very few medical schools or residency programs are located in rural areas, exacerbating the recruitment challenges faced by these communities.
Although the flow of physicians to rural areas can be increased by selecting students from rural backgrounds and training them in medical schools and residencies with tracks focused on rural health care, few schools sponsor such programs.3 Despite federal and state efforts to bolster training, academic health centers value research-intensive, specialized models of care over primary care, and their main product is urban specialists.4 At the same time, the public school systems in many rural communities are weak, and the number of rural students admitted to medical schools has decreased by almost 50 percent over the past decade. Thus, shortages of physicians in rural areas may worsen.
Rural hospitals — a critical part of the health care system in most small communities — are a product of federal policy. We owe the existence of most of our stock of aging rural hospitals to the federal Hill–Burton program initiated after the Second World War. Because most inpatients cared for in the country's 2200 rural hospitals are Medicare beneficiaries, the fiscal well-being of these hospitals has oscillated with changes in Medicare reimbursement. When Medicare ratcheted down reimbursements in the late 1990s, many rural hospitals approached bankruptcy.5
(Figure)
A Physician Examines a Newborn at a Hospital in Rural Idaho.
Photo courtesy of Roger Rosenblatt.
Largely because of political pressure to rescue these hospitals, Congress created the Medicare Rural Hospital Flexibility Program in 1997, establishing a new kind of rural inpatient facility — the Critical Access Hospital. These facilities are exempt from the strictures of Medicare's prospective payment system and receive "reasonable-cost" reimbursement for services. The creation of this category provided a fragile safety net for small rural hospitals, the majority of which will have been certified as Critical Access Hospitals by 2005.
This new status recognizes that small rural hospitals are qualitatively different from urban facilities. Hospitals operating under this rubric generally have 25 or fewer beds, hospital stays averaging less than 96 hours, and 24-hour coverage in the emergency department. Most small rural hospitals can manage easily within these requirements — a reflection of their primary roles as providers of basic emergency and short-term services and as anchors for local health care systems. Patients who require longer stays or more complex interventions are referred to larger institutions or transferred after their condition has been stabilized. A substantial number of hospitals in larger rural areas have not chosen Critical Access Hospital status, since many of them act as sophisticated referral centers for surrounding communities.
Since the 1970s, the federal government and individual states have been actively trying to improve rural health care delivery, and today the majority of the nation's approximately 1000 Community and Migrant Health Centers — local nonprofit, community-owned providers — are in rural areas, providing care for an increasing proportion of rural residents. The establishment of the Office of Rural Health Policy in 1987 signaled a congressional desire to create a focus for developing rural health policies within the federal government and for effectively catalyzing policy-oriented research. The sheer number of programs reflects the political reality that most states have a substantial rural population whose elected representatives vigorously represent their interests. The most effective interventions are those that support the education of primary care clinicians, increase the flow of providers to rural areas, strengthen and support rural health care institutions, and integrate rural health care into larger regional systems.
Although they may live at the geographic periphery, rural patients increasingly demand access to the same spectrum and quality of care as their urban counterparts. Improving the quality of rural health care requires the integration of providers and institutions into larger systems, through the creation of networks and the use of electronic health records and telemedicine. Many complex services cannot be supplied safely or at a reasonable cost in rural communities. Effective rural systems must be based on a menu of core services, delivered largely by generalists in stable hospital and outpatient settings that are linked to regional centers.
Ensuring stability is a challenge. Because of the small size of many rural delivery systems, the loss of a hospital or a provider can undermine an entire local system. Congress has temporarily created an island of fiscal equilibrium for smaller rural hospitals through the Critical Access Hospital program. No such national policy has emerged with regard to the health care workforce. Because medical and nursing programs are dominated by academic health centers with relatively little experience or interest in rural medicine, training has not met national needs. If we are to maintain high-quality patient care in rural communities, we need to develop mechanisms to attract and retain clinicians who are willing to practice in rural settings. Rural health care systems — because of their size and geography — will always be somewhat fragile. But a concerted national policy to sustain strong rural health care institutions — and the personnel to staff them — can ensure that access to and quality of care do not lag behind those in urban areas.
Dr. Rosenblatt reports having received grants from the Office of Rural Health Policy.
Source Information
From the Department of Family Medicine, University of Washington School of Medicine, Seattle.
References
Ricketts TC III, ed. Rural health in the United States. Oxford, England: Oxford University Press, 1999.
Larson EH, Johnson KE, Norris TE, Lishner DM, Rosenblatt RA, Hart LG. State of the health workforce in rural America: profiles and comparisons. Seattle: WWAMI Rural Health Research Center, August 2003.
Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA 2001;286:1041-1048.
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? JAMA 1992;268:1559-1565.
Report to the Congress: Medicare in rural America. Washington, D.C.: Medicare Payment Advisory Commission, June 2001.(Roger A. Rosenblatt, M.D.)