Abstract
Introduction
Rural health clinics (RHCs) are facilities that receive cost-based reimbursement from Medicaid and Medicare to provide primary care for rural populations. They must be located in both a US Census Bureau nonurbanized area and a primary care health professional shortage area, medically underserved area, or governor-designated shortage area, and must employ either a nurse practitioner or physician assistant on-site at least half of the time that they are open. RHCs are also required to provide referral arrangements with hospitals for services they cannot provide directly. 1 Unlike community health centers, RHCs are not mandated to provide comprehensive primary care services, and while most do provide uncompensated care, they are not required to do so.2,3 The rural populations served by RHCs tend to be less healthy and more likely to be uninsured compared with their urban counterparts. 4 Compounding the problem, recruitment and retention of providers in rural areas is a persistent challenge.5,6
The Patient Protection and Affordable Care Act (ACA) presents RHCs with new opportunities and challenges. By expanding Medicaid, creating private health insurance exchanges with government subsidies, and establishing coverage mandates for individuals and large employers, the ACA is primarily concerned with reducing the number of uninsured Americans. Like other safety net providers, RHCs likely hope to experience increased revenue from the newly insured. However, increased coverage is expected to generate increased demand, and RHCs may lack the capacity to handle this demand.7-9 The ACA also ushers in a series of delivery system reforms designed to control health care costs and improve quality by emphasizing value over volume. While reformed payment structures, such as Accountable Care Organizations (ACOs), represent a new opportunity for RHCs, there are concerns about RHCs’ ability to integrate with other providers under ACO structures. 10 The capacity of RHCs to respond to these changes has not been examined. Therefore, we sought to evaluate the current and future capacity of RHCs in Iowa under the ACA.
Methods
Working with members of the Iowa Collaborative Safety Net Provider Network and a national advisory committee, we developed an online survey instrument to collect data from the 142 RHCs in Iowa. The survey asked about current capacity and demand for services, projected increases in capacity and demand, and organizational readiness for change. Specifically, we asked about current staffing levels, additional employees needed to be fully staffed, ongoing efforts to recruit staff, difficulties in recruitment, and how staffing needs are expected to change as the result of ACA implementation. We also asked about the scope and perceived adequacy of current service provision, including ability and processes used to make and track referrals, and provide services essential to patient-centered care. Finally, we asked respondents about their expectations regarding any changes in the number of unique patients and number of patient visits in the wake of ACA implementation. We sent an e-mail invitation to each RHC director with a unique link to the online survey instrument during the summer of 2013 and allowed approximately 2 months for respondents to receive reminder emails and complete the survey. The University of Iowa Institutional Review Board determined that this study was not human subjects research.
Results
We received completed surveys from 27 RHCs, for a 19% response rate. We recognize the limitations of these data, but they are the only data we know of to be collected on this important topic, and our findings are revealing. Moreover, other published survey studies of RHCs have had response rates as low as 8.1% 11 and 10.7%, 12 reflecting the difficulties inherent in studying RHCs.
On average, respondents expect that 50.9% of the uninsured they serve will gain insurance coverage because of the ACA (range: 2 – 100%), and 59.2% of RHCs anticipate an increase in the size of their patient population as a result of ACA implementation, with 14.8% expecting a substantial increase. Only a small proportion of clinics (18.5%) indicated that the number of patients would stay the same or decrease. Accordingly, the RHCs we surveyed anticipate that their provider needs will increase either somewhat (59.3%) or substantially (11.1%) as the ACA is implemented. However, RHCs already face current staffing challenges.
The survey results shown in Table 1 suggest that RHCs in Iowa operate with a relatively small clinical staff, composed primarily of registered nurses, physicians, nurse practitioners, and physician assistants. The proportion of RHCs in Iowa reporting a vacancy for one of these positions ranged from a low of 3.7% for registered nurses to a high of 37% for physicians. RHCs indicated a high degree of recruiting difficulty for physicians (80%), physician assistants, and nurse practitioners (both 50%). Primary reasons cited for recruiting difficulties included the need for RHC physicians to provide obstetric and emergency care (cited by 4 respondents), the rural location of RHCs (cited by 6 respondents), and issues around inadequate salaries and the lack of loan forgiveness for newly licensed physicians (cited by 4 respondents).
Health Care Workforce, Staffing Vacancies, and Recruitment Activity at RHCs, 2013.
Abbreviations: RHC, rural health clinic; FTE, full-time equivalent.
Despite staffing difficulties, most RHCs in Iowa (near or more than 90%) report that their ability to provide or refer for the services in Table 2 is “adequate” or “very adequate.” However, only 29.2% of RHCs in Iowa consider their ability to provide or refer for behavioral health to be adequate, and only 63.2% consider their ability to provide or refer for dental services to be adequate. While most RHCs provide same-day acute care appointments, more than one-third do not provide after-hours medical care. RHCs in Iowa report relatively few barriers in referring patients for specialty care, although more than 70% of RHCs reported that it was “somewhat difficult” or “very difficult” for them to refer their patients for mental health services, 18.5% reported difficulty in making neurology and rheumatology referrals, and more than 11% reported difficulty in making referrals for dermatology, dental care, or oncology.
Location and Adequacy of Rural Health Clinic Service Provision, 2013.
Related to referrals, the ACA’s emphasis on value-based purchasing increases the need for RHCs to provide patient-centered services, including care coordination, care management, case management, and the ability to analyze health data to identify high-risk patients for targeted interventions. For this study, we defined care coordination as “ensuring that referrals to other health care providers occur, follow-up appointments are made, and other coordination of care occurs within the health care system,” care management as “helping patients manage their chronic health conditions, educating about home care and compliance, and medication adherence,” and case management as “helping patients connect to community resources such as dieticians, wellness programs, public health and assistance programs.” As shown in Table 3, a majority of the RHCs we surveyed report providing patient-centered services either directly or by referral, although a minority reported engaging in data analysis at their clinic.
Rural Health Clinic Provision of Patient-Centered Services, 2013.
Finally, we investigated RHCs’ readiness for change, which is the product of change commitment and change efficacy. 13 RHCs responding to our survey appear to have only a low-to-moderate degree of change commitment, based on just 29.6% of respondents indicating that they “wanted to change” in response to health reform, while 44.4% of respondents indicated feeling that they “have little choice but to change” and 3.7% “feel obligated to change.” (The remaining 22.2% did not respond to the question.) Change efficacy is a product of task demands, resource availability, and situational factors. 13 However, while nearly all RHCs (90.4%) report knowing what steps they need to take to respond to the challenges health reform may present, only 19% agree that they have the human, financial, and material resources necessary to respond to the challenges of health reform, and 52.4% report that the current circumstances they face will limit their ability to respond to the challenges of health reform.
Discussion
Rural health clinics are an important part of the primary care safety net in many rural communities, but the impact of the ACA on RHCs has not been widely studied. The expansion of both private and public insurance coverage under the ACA is likely to lead to both new and increased utilization of primary care services, which will require an adequate supply of providers. The RHCs we surveyed already struggle with staffing vacancies and difficulties in rural recruitment and retention. The ACA appears poised to exacerbate these capacity constraints.
In addition to workforce limitations, we find that access to mental health services is particularly limited in rural communities. Adults in rural communities are more likely to rate their mental health status as fair or poor 14 and 34% of Iowans who will be newly eligible for mental health benefits under the state’s version of the Medicaid expansion (the Iowa Health and Wellness Plan) report their mental health status as fair or poor. 15 Clearly, in rural communities, there will be a need and an increased demand for mental health services. Yet, 88% of the responding RHCs provide mental health services by referral and over 70% report difficulties being able to refer patients for mental health services.
Both the limited workforce and the limited access to mental health services foreshadow another challenge for RHCs: the ability to participate in ACOs and patient-centered medical home recognition. Through the establishment of ACOs and patient-centered medical homes, the ACA encourages delivery system changes to make the health care system more efficient by paying providers on the basis of patient outcomes rather than the volume of services. Within this new model of care delivery, successful providers must consider population health, must coordinate with other providers in their community, and must provide appropriate patient-centered services like care management.
Proper staffing with the skill set needed for these new activities, as well as enhanced data analytic, electronic infrastructures, and the ability to absorb some financial risk could be essential for participating with private health systems in an ACO. The same may possibly be true regarding RHC’s participation in Medicaid programs as they move in this same direction. Results from our survey (data not shown) indicate that RHCs rely very little on community health workers and other non-health care professionals to conduct these activities, relying instead on senior clinical personnel such as physicians, physician assistants, and nurse practitioners to provide care coordination, care and case management, and to identify high-risk patients. Efforts to educate and incentivize RHCs to develop partnerships for indirect care activities may relieve pressure on current staff and encourage more efficient utilization of the workforce.
We must acknowledge some limitations of our study. First, we chose to focus only on RHCs in Iowa. Therefore, the results may not be generalizable to other states. However, Iowa is representative of many other rural states, and ranks in the top 10 nationally in absolute number of RHCs by state. Second, our response rate was lower than ideal, although it is certainly comparable to other published survey studies of RHCs.11,12 To the extent that respondents answered differently than nonrespondents would have, we may have obtained different results. However, we have no reason to suspect systematic response bias.
As ACA implementation continues, the perennial problem of recruitment and retention of providers in rural areas will become of increasing concern. Similarly, it will be important to understand how RHCs move forward in the reformed health care system, and the extent to which they are included as members of ACOs given their limited resources and remote practice setting. While the results of our study suggest that RHCs have limited capacity to respond to the opportunities and challenges of the ACA, neither we nor our survey respondents are prescient, necessitating retrospective research in the future to assess the impact of the ACA on RHCs more fully in a nationally representative sample of RHCs.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this work was provided by a grant from the Commonwealth Fund.