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With reports that within the next 20 years rural America could face a dangerous primary care shortage of up to 30,000 physicians, the issues of policy and innovation continue to weigh on the hearts and minds of those both providing and receiving care in rural communities. 

Earlier this month, the Obama administration released a new set of rules addressing managed care plans under Medicaid and the Children’s Health Insurance Program, known as CHIP. While the assessment of 1,425 pages touts strengthening and modernization of existing rules, as with any release of new rules, there are key areas emphasized with the hope of bringing sweeping changes for positive results in care sustainability of rural communities.

Now states must set “maximum time and distance standards” to ensure there are enough physicians placed to provide “right care, right time” to patients. This sounds great—it’s right and noble that each state’s autonomy to make key decisions in how care is delivered, vs. a cookie-cutter concept, should be given priority. The bottom line is the maximum time and distance will be left up to individual states to decide. 

Here is where the debate begins. Headlines say this is the game changer that rural has been waiting for, but health officials say not so fast, and that the leeway could be dangerous. If you read between the lines, the concern is how these new standards will be implemented, executed, enforced, and maintained.

Most research shows there are more Medicaid patients in rural areas, with rates as high as 21 percent, vs. 16 percent in metro areas, but only 10 percent of physicians are actually located in rural America. But greater than the struggles of numbers and percentages is the actual concern over the development/definition of a standard to be imposed. Let’s take a closer look at what seems good in theory, but will result in working out the devilish details of meaning and development: 

Rural Health Worries Superseding Proposed Solution: 

  1. How do you set a standard in states where the population isn’t evenly distributed, even in states that provide more of a rural population? In some states, rural populations might be greatly concentrated in one key area, but in many they might be dispersed, with great distances between communities.
  2. How will terrain, weather, and industry impact the standard?
  3. Is the standard really addressing access, while jeopardizing equity of care and care delivery? Does this widen the barriers of access and delivery of rural healthcare?
  4. How do issues of quality, patient safety, patient and physician engagement, and better patient outcomes fit within the standard?
  5. Will this standard create a better system or a burdened system?
  6. Has CMS thoroughly thought this through as a “champion of solutions,” or has it increased stress on states already burdened with healthcare issues, including those caused by the ACA, Medicaid Expansion, or lack thereof? Some would say CMS has made a great attempt to recognize workforce shortages and care delivery vulnerabilities, but they aren’t offering innovative support and provisions to provide care.
  7. Should CMS be more supportive in supporting rural innovation and technology that truly meets the needs of rural populations?
  8. At the state level, will physicians be working directly with state health officials to produce “healthy” guidelines?
  9. Will states be setting high allowable treatment times and distance maximums that, while making it appear on the surface that physicians will be compliant to meet standards, actually put the health of individuals at risk? Can you imagine the impact on health and safety if there is a long time allowed, such as two- to three-hour window(s), and distance maximums up to 100 miles? What will “healthy” baseline state standards be considered that will be truly safe?
  10. Will medical schools become more active in implementing “reality” within the curriculum and residency program(s)?
  11. Will this serve as a greater recruitment tool for states with rural populations, or be seen as another hindrance dressed as a solution. Will state standards themselves compete as recruitment tools?

Who will measure the success of the standard, and how? Will it be the state Medicaid Directors in combination with a board? What are the baselines, and how nimble and quick will states be to change or tweak the standard?

We end where we begin, with more questions than answers. Ultimately, we need to decide how to define the standard CMS is proposing as a solution. Will states at least agree to a standardization of point persons or officials who will have oversight in each state to at least set a standardization of the standard? Will there be a great burden in how states will decide, implement, oversee, and review the standard, and what guidance will be used to improve or adjust it? And finally, how rapidly will states begin to design and adapt the standard, as this will require an inordinate amount of time, strategy, energy, and resources to galvanize, enforce, and sustain?

Rural will see if this is a “rule for success” or “recipe for disaster” in attempting to address the physician shortage vs. creating more vulnerability in the form of increased health disparities and access barriers.   

Certainly there is more to come. 

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill.  A former hospital CEO and regional rural strategy executive, Janelle is a past National Rural Health Association Rural Fellow, Rural Congress member Nebraska Rural Health Association President.  She is currently the Nebraska DHHS Chair of The Office of Minority Health Statewide Council addressing needs of rural, public, minority, tribal and refugee health and is serves on the Regional Health Equity Region VII council as Co-Chair of Rural Health and Partnerships.  Janelle holds a masters and doctorate in communications and recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx.  

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