Rural Primary Care Challenges Extend Beyond Physician Supply

Increasing access to primary care services in poor and rural communities means approaching the issue on multiple fronts, including telemedicine, patient engagement, and coordinated care, a payer's report suggests.

Rural and economically disadvantaged areas of the country pose a daunting challenge to boosting primary care services, a recent UnitedHealth Group study has found. But there is no single pathway toward expanding access and capacity, it suggests.

"Approximately 50 million Americans live in areas with an under-supply of primary care physicians. Most of these areas are rural," says the report, "Advancing Primary Care Delivery: Practical, Proven, and Scalable Approaches."

"Increased roles for nurse practitioners and physician assistants would add to the system's overall primary care capacity, and could help target capacity to areas where there are fewer primary care physicians," the report suggests.

Payer Calls for More Primary Care Docs, Team Care

But to improve primary care services in communities, increasing the number of physicians in the country will not be enough, the report concludes.

Richard Migliori, MD, executive VP of medical affairs and chief medical officer of UnitedHealth Group, said in a statement: "This research shows the value of improving primary care capacity, not only in terms of improving patients' health but also in catching problems early and avoiding unnecessary and costly hospital services."

In addition to the findings on primary care in rural and economically disadvantaged areas, UHG also reported that:

• Primary care office visits represent 55% of the 1 billion office visits annually nationwide. Full implementation of the federal Patient Protection and Affordable Care Act could add 25 million primary care office visits annually.
• High rates of avoidable emergency room visits and avoidable hospitalizations indicate many patients could be treated more cost effectively at primary care facilities.
• Payment policy is a "significant barrier" to improving primary care services. Medicare and Medicaid often pay less when NPs and PAs deliver a service compared to when a physician delivers the same service, the study said.
• Building multi-disciplinary teams is effective at helping primary care practices leverage available resources to see more patients.
• Electronic health records and data exchanges help primary care practices improve care coordination, elevate quality, and reduce costs.

Rural California Experience
Earl Ferguson, MD, PhD, a cardiologist who practices in rural areas of California, said his experience mirrors many of the UHG report's findings.

In his experience, the biggest problems with primary care services in rural areas are:

• "The failure of some primary care providers to concentrate on comprehensive care coordination that must involve a network of all the specialists necessary for providing care
• "The lack of the health information technologies needed to coordinate that care."

"We need to recognize that primary care can't do everything alone. Primary care providers must be the coordinators of comprehensive care, but specialty care is essential to assist them in the ongoing management of many of their patients," says Ferguson.

To boost primary care services in rural and economically disadvantaged areas, it is critically important to leverage human and technological resources, Ferguson said.

He has been doing cardiology and general medicine consults in a rural health clinic of less than 2,000 people 80 miles from his hospital via telemedicine for more than a decade. 

"With readily available assistance, the primary care nurse practitioners have markedly improved their capability to handle patients with congestive heart failure, hypertension, diabetes, and other conditions. They have learned to handle the routine care of some complex diseases without my direct supervision and know when they need a consult and assistance. Compared to other consults I'm asked to provide for other providers, the PCNPs from this community are almost always appropriate, and my review of their records confirms that they are managing these patients well," he reports.

Lee Barron, MBA, serves as CEO, CFO and COO of the Southern Inyo Hospital District, which operates the small rural health clinic in Lone Pine, CA, where Ferguson has been providing consulting services. Lone Pine is nestled in a valley between the Sequoia and Death Valley national parks.

"We have found with many of our highly complicated patients that have multiple diseases that their quality of life is not impacted unless we address the 'whole' patient," Barron says.

"Many times, their biggest worry or hurdle to care is the fact that they might not have adequate transportation, or that they do not have access to appropriate food, or they are depressed or concerned about their family's welfare, and a very long list of other issues that directly impact their health and well-being."

In rural areas of the country, a concerted effort is needed for primary care providers to effectively manage care coordination, she says.

"With care coordination, we are addressing all of their issues. Through the first interview-visit process, we identify along with the patient what their primary concerns are, which may have nothing to do with their diagnoses, and then we follow-up with resources and support."

"Once we have been able to address their other issues," she says, compliance rates "[have] soared with medication and treatment."

Bigger Picture
Ferguson, who works as a cardiologist and director of cardiovascular imaging at Ridgecrest Regional Hospital, says the primary care lessons he has learned in rural settings can be applied at community hospitals that bridge the gap between rural and urban areas of the country.

Ridgecrest, CA, has a population of slightly more than 28,000 and is located about 150 miles north of Los Angeles. The nearest larger city and larger hospital is 80 miles away.

"We have now set up a similar coordinated cardiovascular care program in our hospital's rural health clinic," Ferguson said. "Our program is coordinated by a PCNP who is available every weekday, makes decisions on what studies and consultations are necessary, and arranges consultations with specialists that rotate through our Cardiovascular Care Clinic."

For complicated cardiac cases, Ridgecrest Regional Hospital has established contracts with a cardiology group and large hospital in the Los Angeles metropolitan area, he said.