Filling the primary-care gap in rural, low-income clinics

Filling the primary care gap in rural, low-income clinics
Filling the primary care gap in rural, low-income clinics

Rural medicine “can be one of the most rewarding things any health care professional can do,” says Ann Davis, PA-C, Director of State Government Affairs at the American Academy of Physician Assistants. But it is important for clinicians to carefully weigh the upsides, like incentives, against the challenges.

Clinicians must realize that working in a rural clinic essentially means less pay, longer hours, and seeing more Medicaid patients.

“Yet, there's something special about your patients being your neighbors,” Davis said. “There's nothing like it. But I think you need to make sure if you're planning a career in rural medicine that you have your eyes wide open to all of the realities.”

However, rural clinicians should realize that they will rarely be able to leave work at the clinic.

“People ask questions at church or the grocery store,” Davis said. “That's fine and great—you just have to anticipate it. And make some rules for yourself, about finding weekends out of town, to give yourself enough down-time for your uptime to be completely engaged.”

The birth of the RHC program

There are more than 3,600 Rural Health Clinics (RHCs) in the USA.  In 1977, the U.S. Congress created the RHC program, which reimburses Medicare and Medicaid at higher “allowable cost” rates than most clinics and hospitals.

To qualify as an RHC, a clinic must assist a non-urban and medically underserved population, in an area with a shortage of health professionals. RHCs must also employ a PA or NP.1 The U.S. Health Center Consolidation Act of 1996 further created the Federally Qualified Health Center (FQHC) reimbursement designation, covering more than 1,120 clinics that help medically underserved communities, including migrant health centers and health care clinics for the homeless. FQHCs are not required to employ PAs and NPs, though many do. They tend to be located in urban areas, but may operate anywhere.1 Unlike RHCs, FQHCs must be nonprofit or publicly-owned.1

As of 2008, RHCs and FQHCs must implement and maintain quality assessment and infection control programs.2

“The goal was to ensure rural areas had access to healthcare, and it's been quite successful,” Davis said. “The PA profession has shown a sustained commitment to caring for people in rural areas. Right now, PAs are nearly twice as likely to be in rural areas, as physicians. That's a good way to do it. Some clinics are just too small to support a physician. If a physician in a neighboring town can supervise a PA, that's ideal.”

The upshot of working in a rural setting

PAs and NPs tend to have more responsibility in rural settings, with less immediate day-to-day supervision.

“PAs really do the same things a physician would do,” Davis says. “Diagnosing and treating patients with acute and chronic diseases, determining the need for subspecialty care, helping patients interpret what they hear from their specialists, and follow-up.”

New federal support will mean increasing demand for PAs and NPs nationwide, Richard D. Muma, PhD, MPH, PA-C, an associate provost and professor of Public Health Sciences at Wichita State University in Kansas said in an interview.

“If all goes as planned under the Affordable Care Act, there will be more funding for the rural and federally-qualified health clinic programs,” Muma, who also chairs the FQHC Group within the Hunter Health Clinic in Wichita, said.

Muma expects a “huge influx of new patients” at his clinic, thanks to the new federal support, as well as increased demand at FQHCs nationwide for advanced-practice nurses and PAs at rural and low-income urban clinics.

More jobs and incentives for NPs and PAs

“We'll be hiring more physicians, PAs and NPs,” Muma said. “All kinds of new PA programs are being developed— there are now 160, the most established in the past 10 years. Twenty more are in the development stage, nationwide.”

The Affordable Care Act also bolsters National Health Corps incentives for clinicians working in underserved areas, Muma noted.

“They offer $50,000 loan forgiveness to PAs, NPs, MDs and dentists, if you commit to two years,” he explained. “There are also programs that pay students to go to PA school if they will commit to serving in rural areas.”

Some states offer incentives, as well. In Kansas, Governor Sam Brownback developed “rural opportunities” zones, including loan forgiveness for clinicians who go to rural areas for several years.

Rewarding challenges

Clinicians will often see more challenging cases than they would in more affluent communities, such as more advanced chronic disease at diagnosis, and more occupationally-related injuries, particularly agricultural injuries involving heavy equipment.

“Most of the typical diseases—hypertension, diabetes, heart disease—are what you see in urban populations, but they tend to be uncontrolled chronic diseases in rural areas, because there are fewer preventive services. That makes them more of a challenge,” Muma said.

Typically, diagnosis at later stages of disease also results in greater outcome disparities in underserved communities. Patients with psychiatric illness and, increasingly, substance abuse disorders are also frequently seen in rural clinics, according to Davis.

“Fortunately, telepsychiatry, which involves the use of electronic devices and real-time video conferencing, is a rising field, and can help rural clinics address these many of these issues,” she said.

Nonetheless, the biggest challenge to a career in rural health care is not the advent of more complicated disease management.

“The problem for some clinicians in rural practice is that it is really very isolating,” Muma said. “PAs are often the sole provider for a whole county. We're finding it's really hard unless you're from the area, married or with a partner, or have family there. And a lot of times, the community just doesn't have jobs for a spouse or family members.”

In a survey of 2,000 practicing PAs, Muma and a team led by his colleague Barbara Smith, PhD, PT, a professor of physical therapy at Wichita State University, found that those PAs graduating from rural high schools were significantly more likely to wind up practicing at rural clinics.3 Also, regardless of specialty, PAs identified that the potential employment opportunity for their spouses or significant others was the most important consideration in their choice of where to work.3

“I think the people who most enjoy rural practice are the people who grew up in rural areas,” Davis agrees. “A lot of PAs are second-career professionals—EMTs, for example—and that's a good background for rural practice, because it requires a lot of frontier spirit.”

Politics this election year introduced a certain amount of uncertainty to the mix, Muma acknowledged, but he believes bipartisan support for FQHCs will continue whether or not the Affordable Care Act survives the coming year or two.

“The more time that passes, the more people will become familiar with the ACA and, I believe, more comfortable with it. The Bush Administration really pushed for the Rural Health Clinics Initiative, so I expect that to continue; it was a Republican initiative.”

Rural health care has broad support among policymakers, Davis agreed.

“Rural health care is important not only for individual patients, but the communities,” she emphasized. “If a rural clinic closes and patients are forced to go elsewhere for care, while they are out of town, they're not buying groceries or goods locally, and that's an economic drain.

”Patients also appreciate being seen close to home. “It's reassuring,” Davis said. “Now, if I get cancer, I don't want to be treated in my little town. But for patients with very complicated diseases, coordination of care is very important, and that's something PAs are just great at. The PA can call grandma and the vascular surgeon!”

Bryant Furlow is a freelance medical writer and health-care journalist based in Albuquerque, New Mexico.


References

  1. US Health Resources and Services Administration (HRSA). Comparison of the Rural Health Clinic and Federally Qualified Health Center Programs. 
  2. US Centers for Medicare and Medicaid Services (CMS). CMS issues proposed changes in conditions of participation requirements and payment provisions for rural health clinics.
  3. Smith B, Muma RD, Burks L, Lavoie MM. Factors that influence physician assistant choice of practice location. JAAPA. 2012;25(3):46-51.
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