Rural Health Today
Rural Nebraska Health Facts
Nebraska covers 76,872 square miles, with a 2018 estimated population of 1,929,268 people – 664,330 living in rural areas (USDA-ERS). Lincoln, the capital, is located in the southeastern region of the state. The state’s largest cities are Lincoln, Omaha and Bellevue. According to 2018 data from the U.S. Census Bureau, 88.3% of the state’s population is white, 5.1% is African-American, 2.7% is Asian, 1.5% is American Indian or Alaska Native, 0.1% is Native Hawaiian or Other Pacific Islander, and 11.2% is of Hispanic or Latino origin.
According to data.HRSA.gov, as of October 2019 Nebraska had:
- 64 critical access hospitals
- 145 rural health clinics
- Eight federally qualified health center sites located outside of urbanized areas
- Eight short term hospitals located outside of urbanized areas
People living in rural communities face a unique combination of obstacles and challenges that are often different from those in urban areas. Some of these differences relate to the demographic and socioeconomic status of the population. For example, the percentage of the population over 65 in rural Nebraska is 19.6 percent as compared to 10.7 percent in large urban areas. As a result, rural populations tend to have a higher prevalence of chronic conditions. There is also a smaller and declining population base in most parts of rural Nebraska. In addition, a total of 33 counties have less than six people per square mile. This problem is further magnified because of the lack of public transportation.1 Access to care in rural areas has been a critical challenge for several years. There is currently a shortage of many types of health professionals, including primary care practitioners, mental health professionals, dentists, physical therapists, pharmacists, and many others. Rural populations also have a higher uninsured rate and generally less adequate insurance coverage because of the higher proportion of small businesses. The lack of health care providers and no or inadequate insurance coverage has led to fewer annual wellness/preventive checkups and less health screenings for rural residents. In comparison with their urban counterparts, rural residents are less likely to have their cholesterol checked every five years and less likely to have been screened for colon, breast, and cervical cancer.2 Rural residents are also at greater risk of chronic disease because of specific risk factors. For example, about 32 percent of rural residents were obese as compared to 28 percent in large urban areas. Rural residents have slightly higher hypertension rates, are more likely to binge drink, less likely to wear seat belts, and less likely to consume fruits and vegetables. Finally, they are less likely to engage in physical activity and visit a dentist during the year.3_____________________
1 Department of Health and Human Services, Division of Public Health, “Nebraska Health Status Assessment 2015,” August, 2015, p. 2.
2 Department of Health and Human Services, op. cit., p. 58.
One of the strategies to reduce the number of uninsured in the Patient Protection and Affordable Care Act (ACA) was to expand Medicaid for a portion of the low-income population. Under the 6 ACA, Medicaid coverage would be available to all individuals with incomes at or below 138 percent of the Federal Poverty Level (FPL). However, in 2012, the Supreme Court ruled that individual states could decide whether to expand Medicaid. In November of 2018, a referendum was passed by the voters in Nebraska and Medicaid expansion is scheduled to be implemented in October of 2020. The benefits of Medicaid expansion have been well-documented. In a recent issue brief, the Kaiser Family Foundation found that Medicaid expansion states experienced significant gains in health insurance coverage, especially among the low-income population, and it has improved access to care, the utilization of services, and the affordability of care. There also appears to be an association between Medicaid expansion and certain positive health outcomes (e.g., lower cardiovascular mortality rates). In addition, this brief reported positive effects of expansion and several economic measures such as state budget savings, revenue gains, and overall economic growth.4 In rural areas, Medicaid plays an important role in addressing coverage gaps. Because non-elderly individuals are less likely to have private coverage as compared to urban areas, Medicaid expansion has led to significant coverage gains.5 Medicaid expansion also appears to affect rural and urban hospitals differently. Since rural hospitals are more reliant on public payers and generally have lower operating margins, rural hospitals had greater increases in Medicaid revenue than urban hospitals.6 . Research also shows that in states that expanded Medicaid there were reductions in uncompensated care costs and fewer uninsured hospital and clinic visits.7 Another study found that uncompensated care costs decreased from 4.1 percent to 3.1 percent of operating costs in expansion states.8 One study found that Medicaid expansion was associated with improved hospital financial performance and less likelihood of closure, especially in rural areas. 9 Medicaid expansion may place a strain on primary care capacity although many studies have concluded that providers have expanded capacity or have increased participation in Medicaid after expansion has occurred. Other studies have found very little change while a few studies have reported that expansion was linked to problems with provider availability.10___________________
4 Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Madeline Guth, “The Effects of Medicaid Expansion
under the ACA: Findings from a Literature Review,” Issue Brief, Henry J. Kaiser Family Foundation, August 2019.
5 Julia Foutz, Samantha Artiga, and Rachel Garfield, “The Role of Medicaid in Rural America” Issue Brief, Henry J.
Kaiser Foundation, April 2017.
6 Brystana Kaufman, Kristin Reiter, George Pink, and George Holmes, “Medicaid Expansion Affects Rural and
Urban Hospitals Differently,” Health Affairs, Vol 35, No 9, September 2016, pp 1665-1672.
7 Larisa Antonisse, et al., August 2019, op. cit.
8 David Dranove, Craig Garthwaite, and Christopher Ody, “Uncompensated Care Decreased at Hospitals in
Medicaid Expansion States But Not at Hospitals in Nonexpansion States,” Health Affairs, Vol 35, No 8, August
2016, pp. 1471-1479.
9 Richard Lindrooth, Marcelo Perraillon, Rose Hardy, and Gregory Tung, “Understanding the relationship Between
Medicaid Expansions and Hospital Closures,” Health Affairs, Vol 37, No 1, January 2018, pp. 111-119.
10 Larisa Antonisse, et al., August 2019, op. cit
According to the Health Resources and Services Administration, the total number of primary care physicians, physician assistants, and nurse practitioners in the U.S. is expected to increase nationwide by 2020, but the increasing supply will not be adequate to meet the growing demand for primary care services. The demand for services is expected to increase because of the expanding aging population, the growth of the total population, particularly in urban areas, and to a lesser extent the expanded insurance coverage under the Affordable Care Act.11 The imbalance between supply and demand has a significant impact on both rural and urban areas where many older physicians are nearing retirement age and will need to be replaced. For example, 37 percent of family practice physicians in rural Nebraska are 55 years of age or over and 44 percent of family practice physicians in the urban areas of Nebraska are aged 55 or older.12 In addition, the rising level of student debt and lower reimbursement rates make rural areas less attractive to new physicians. The demand for primary care practitioners in urban areas is expected to increase sharply because of a growing population base, expanded insurance coverage, and new alternative delivery models of care (e.g., Accountable Care Organizations) which emphasize a greater use of primary care and preventive services. The expanded use and recruitment of primary care practitioners in urban areas may greatly magnify the shortages in rural areas. While many rural areas face challenges in the recruitment and retention of physicians, physician assistants and nurse practitioners, the supply of other health professionals such as dentists, pharmacists, mental health practitioners, physical therapists, and occupational therapists is also inadequate to meet the need. Most rural hospitals, physician clinics, and nursing homes are forced to pay a nationally competitive wage rate in order to attract these health professionals to their communities. However, the reimbursement rates allowed by Medicare and other third-party payers are often based on local costs, which may not be sufficient to pay these competitive rates. Although Nebraska has benefited from the federal National Health Service Corps programs, the number of qualified shortage areas has declined in the past several years. As a result, Nebraska has relied on the state-funded student loan and loan repayment programs to encourage health professionals to practice in state-designated shortage areas. Since the inception of the loan repayment program in 1994, a total of 565 eligible health professionals have practiced or are practicing in shortage areas with a default rate of only 8.3 percent.___________________
11 The U.S. Department of Health and Human Services, Health Resources and Services Administration, “Projecting the Supply and Demand for Primary Care Practitioners through 2010,” Retrieved from http://bhpr.hrsa.gov/healthworkforce/index.html12 Unpublished data obtained from the Health Professions Tracking Service, College of Public Health, University of Nebraska Medical Center, November 2019.
There has been a chronic shortage of behavioral health professionals in rural Nebraska for many years. The shortages of personnel include psychiatrists, psychologists, licensed mental health practitioners, advanced practice registered nurses practicing in psychiatry mental health, alcohol and drug abuse counselors, and others. Currently, out of the 90 rural counties, the RHAC has fully designated 81 counties and nine counties have been partially designated as mental health shortage areas. The shortage of nearly all types of behavioral health professionals severely limits the availability and accessibility of these services and has a serious impact on the health outcomes of rural Nebraskans. In addition to the shortage of behavioral health professionals, there are many other 9 factors that limit the provision of these services, including the lack of care coordination between behavioral health professionals and primary care physicians, social exclusion factors, stigma labels, and lack of anonymity. Also, many primary care practices fail to screen for behavioral health problems (e.g., depression, substance use disorders, and suicide). As a result, some patients are not referred to a behavioral health professional before their problems become more severe. Also, some primary care physicians lack the training and expertise to effectively or efficiently treat patients in need of behavioral health services. The RHAC is supportive of an integrative approach to providing behavioral health services in rural Nebraska. This approach would integrate mental health professionals into existing primary care settings. Research shows that most patients prefer to receive their behavioral health care from their family physician.13 The plan proposed here would allow patients to be seen in the comfortable, familiar environment of their primary clinic; an approach that would help considerably in reducing the stigma associated with behavioral health treatment. Having mental health professionals available in primary care settings would also help deal with other rural problems such as provider isolation and would allow for an integrated approach for care that would treat the whole individual. There are other promising strategies to address the workforce shortage. Telehealth has been used effectively in Nebraska and in other states. This model has a great deal of potential for the delivery of high-quality behavioral services, although presently this modality is underutilized. Another strategy already underway is to increase the number of mid-level providers. Recently, the University of Nebraska Medical Center began training through an executive fellowship focused on substance use disorders along with Project ECHO. Additionally, they began training advanced practice registered nurses and physician assistants with a specialty in psychiatry. In 2019, there were 44 advanced practice registered nurses practicing psychiatry in rural communities and all but 12 of them worked in communities with a regional hospital (e.g., Kearney and Scottsbluff). There are only four physician assistants practicing psychiatry in rural communities.14 Since 2014, the number of advanced practice registered nurses has grown by 15, but the number of physician assistants has not changed. However, these relatively new programs have the potential to expand the number of behavioral health professional in rural Nebraska._____________
13 Mims, S. (April 6, 2006). Integrated Health Care: Involving Primary Care Physicians in the Continuum of Care. Presentation at the WNC Symposium on Mental Health and Substance Abuse. Asheville, NC.
14 Unpublished data from the Health Professions Tracking Service, University of Nebraska Medical Center, November, 2019.
The health care system in the United States is undergoing a major transformation and these changes are likely to have both a positive and negative impact on the rural health care system. Many of these changes such as a new focus on population health, the use of new technologies, and new types of health care workers have been discussed in other sections. The main driver of these changes is a shift in payment strategies from fee-for-service and cost-based reimbursement to value. Value has been defined “as better health care (improved clinical quality, patient safety, and patient experience) and lower per capita cost.”15 This new emphasis on value has led to the development of new delivery models, including the patient-centered medical home (PCMH) and accountable care organizations (ACOs). These new models have financial incentives to improve health outcomes and control costs (e.g., reducing avoidable hospitalizations, improving cancer screening rates, and increasing immunization levels). In a patient-centered medical home model (PCMH) and other alternative delivery models, the emphasis is on providing health care services that are more accessible, continuous, timely, patient-centered, and coordinated. There is also a greater focus on preventive services (e.g., providing mammograms, cholesterol and blood pressure screenings, and up-to-date immunizations). With this model, there is also financial incentives to improve care coordination with behavioral health providers, public health professionals, and long-term care support services. Numerous PCMH clinics have developed in Nebraska, but new revenue streams are needed to build the capacity and keep these models successful. Funding for pilot projects has also been provided by the DHHS Division of Public Health to encourage local public health departments to collaborate with PCMH clinics on implementing diabetes prevention programs and using community health workers to encourage patients with chronic diseases to make lifestyle changes (e.g., increase physical activity and eat more nutritious foods)._______________
15 Charles Alfero, et al., “Advancing the Transition to a High-Performance Rural Health System, “Rural Policy Research Institute,” November 2014, p. 3.
Emergency medical services are an essential and often unrecognized component of the rural health care system. The goal of the EMS system is to provide a coordinated, timely, and effective response to medical emergencies. These services are essential in rural areas because of the distances between population centers and the need to transport patients from hospitals and nursing homes in small communities to larger facilities. Although emergency services/skills are essential, many challenges exist in small communities. These challenges will only intensify as the demand for health care services expands because of a growing elderly population, more chronic illnesses, and new technological innovations. One of the major challenges is to recruit and retain volunteers who are interested in becoming EMTs and paramedics. Some of the major factors contributing to this problem are: (1) the work is often emotionally stressful and burnout may occur, (2) the compensation and benefits are low or non-existent for volunteers, (3) it is difficult to maintain coverage during the day because many volunteers work out of town and/or employers may not allow EMTs to miss work, and (4) the training and educational requirements are considered excessive by some volunteers.
Another challenge is the lack of research and data about the effectiveness of the EMS system and patient outcomes. Although some states, including Nebraska, are collecting EMS performance data (e.g., length of time to reach a destination), major gaps still exist and the analysis of the data is very limited. Without the widespread adoption of improved communication systems and health information technology that will allow the exchange of patient information across the continuum of care, it will be very difficult to evaluate the quality and performance of the EMS system related to patient outcomes. Finally, although the coordination of EMS units has improved more effective communication systems, in some areas, the coordination between EMS and hospital systems needs to be improved.
To improve coordination and communication among EMS providers and between EMS providers and other health care services (e.g., hospitals), a new vision is needed. This vision needs to take into account EMS roles and responsibilities that include health care, public health, and public safety. This new vision and the strategic initiatives to achieve the vision need to consider which entities should lead this effort and ultimately ensuring that EMS has the capacity and resources to meet the needs of all people in rural Nebraska. Consideration should also be given to identifying the strengths and weaknesses of alternative models and what standards need to be established to evaluate the quality and performance of the EMS system. In Nebraska, no public or private entity is responsible for the scope, authority, and operation of local EMS systems. Finally, it will be critical to identify potential local, state, and federal funding sources, existing and new incentives, and reimbursement policies to make the EMS system more effective and efficient.
In rural Nebraska, the percent of the population over 65 years of age is considerably higher than in urban areas. With an older population, rural areas have a higher proportion of chronic illnesses, creating a need for in-home care and long-term care services. Despite a greater need for services, access to these services is limited by the lack of public transportation, an inadequate supply of health care providers, limited in-home support services, and inadequate resources to pay for these services. Access to home health and in-home services vary considerably across the state. Although long-term institutional care services (i.e., skilled nursing care and assisted living care) are generally available, these services are more expensive and many of these facilities receive a significant proportion of their revenues from Medicaid. In addition, all critical access hospitals have swing beds for long-term care patients. While it is critical to have an adequate supply of long-term care beds, it appears that there is an imbalance between institutional care and in-home care. New technology and greater support services such as home monitoring devices would allow a greater share of the aging population to remain in their own homes for a longer period of time and would reduce costs.
Electronic technologies are transforming the rural health delivery system and they have the potential to expand access to services, improve the quality of care, and provide clinical and managerial data that will support informed decision-making. For example, electronic health records have already been implemented by most hospitals and the majority of physician clinics. While these data are now generally used for internal decisions, in the future they will be shared among all providers. New technology has improved the quality of care through e-ICUs, remote EKG readings, teletrauma, e-pharmacy, telebehavioral health, telemedicine access to specialty care (e.g., cardiologists), and home monitoring systems. Unfortunately, most of these new technologies are greatly underutilized because of low reimbursement policies, lack of training, and practice cultures.16 Another major challenge in rural Nebraska is the lack of high-speed internet access and the cost of this access. To address this challenge, The Rural Broadband Task Force (RBTF) was created with the enactment of LB 994 in 2018. The purpose of the RBTF was to review the issues related to the availability, adoption, and affordability of broadband services in rural Nebraska. The findings and recommendations of the RBTF were released in October 2019. Some of the major findings included:
- Only 63 percent of rural Nebraskans have high-speed internet access defined by the RBTC as fixed broadband of at least 25 Mbps down/3Mbps up.
- Nebraska lags behind the U.S. average and neighboring states in fixed and mobile broadband availability.
- There is a wide variation in broadband availability by county and local exchange carrier. Although the report did not focus on rural health care, broadband service can help rural residents in many ways, including (1) research health topics online, (2) access electronic health records, (3) make appointments and communicate with health care providers, (4) access primary and specialty care via telemedicine, and (5) participate in home monitoring telehealth services.
16 “The Future of Rural Health,” The National Rural Health Association, 2013, pp. 18-20.
18 “Rural Broadband Task Force – Findings and Recommendations,” Nebraska Information Technology Commission, Office of the CIO, October 2019.
Selected Social Determinants of Health for Rural Nebraska
9% of its residents lack health insurance (Kaiser, 2017). According to the USDA Economic Research Service, the average per capita income for Nebraskans in 2017 was $50,809, although rural per capita income lagged at $47,492. The ERS reports, based on 2017 ACS data, that the poverty rate in rural Nebraska is 11.8%, compared with 10.2% in urban areas of the state. 9.7% of the rural population has not completed high school, while 8.8% of the urban population lacks a high school diploma according to 2013-2017 ACS data reported by ERS. The unemployment rate in rural Nebraska is at 2.7%, while in urban Nebraska it is at 2.9% (USDA-ERS, 2018).