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RHQ

Winter 2018

Rural Health Quarterly

“Those towers are going to go up, and you’re going to have great, great broadband!” - PRESIDENT TRUMP, JANUARY 8, 2018

What’s really at stake in the great rural broadband debate? - PAGE 29

A Publication of the F. Marie Hall Institute for Rural and Community Health


TELEHEALTH AT THE CROSSROADS MAY 30-31 SAN ANTONIO, TX JW Marriott HILL COUNTRY RESORT & SPA

REGISTER TODAY! www.crossroadsconference.us


CONTENTS //

WINTER 2018 all about access Rural access to health care means much more than simply having access to health insurance.

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Medicare extenders Congress extends vital payments to rural hospitals – for now.

18

Freestanding ERS Can freestanding ERs replace rural America’s struggling hospitals? It’s complicated.

20

STATE of crisis

COVER STORY RURAL BROADBAND SAVES LIVES Is high speed broadband on the way to rural America, or will federal regulators simply define away the problem?

Texas ranks highest in the United States for maternal mortality.

23

RECOVERY ROOM

28

Closure of state hospital proves a boon to mental health services in Southwest Georgia.

We Have a Problem...or Do We?

36

Are states filling out rural death certificates correctly? Why vital statistics are vital to improving health care outcomes.

AHEC NATION

11

Area Health Education Centers operate in almost every state in the nation. Here’s what a few of them are up to.

Dramatic Increase in Rural STDs plagues mountain west Gonorrhea is spreading like wildfire in western states, and researchers have several theories to explain why.

12

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39

RHQ CONFERENCE CALENDAR It’s time to start circling some dates as the 2018 conference calendar kicks into high gear.

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DEPARTMENTS //

RURAL HEALTH QUARTERLY

Volume 2, No. 1 Winter 2018

Publisher Billy U. Philips, Jr., Ph.D., executive vice president and director of the F. Marie Hall Institute for Rural and Community Health, Lubbock, TX Editor in Chief Scott G. Phillips

// RURAL REPORTS 6 -10

// RURAL RESEARCH 11-13

Section Editors Debra Flores—Health Education Travis Hanson—Health Technology Catherine Hudson—Rural Research Ronald N. Martin—Behavioral Health Cameron Onks—Public Policy Copy Editor Melanie Clevenger Research Associate Debra Curti

// PUBLIC POLICY 18-26

// BEHAVIORAL HEALTH 36-38

// HEALTH TECHNOLOGY 28-34

// HEALTH EDUCATION 39

CORRECTION: The introduction to the “RHQ Rural Health Report Card” published in our previous issue stated that USDA Rural-Urban Continuum Codes define a county as rural if it has a population under 50,000 people. This is not always the case, however. A U.S. county with a smaller population may be coded as metropolitan (urban) if it is adjacent to an urban county. This clarification in the definition of Rural-Urban Continuum Codes does not alter or otherwise impact the report card rankings or grades. We regret the error.

Web Developer Miguel Carrasco Contributors Coshandra Dillard Erica Hensley Sharon Hunt Barbara Mantel Robert Posteraro Bram Sable-Smith Ryan N. Schmidt Cindy Uken Contacts and Permissions Email RHQ at RHQ@ttuhsc.edu. For more contact information, visit www.ruralhealthquarterly.com. Rural Health Quarterly is a free publication of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.

SPRING 2018 | RHQ   3


YOU STOPPED SMOKING NOW START SCREENING

RHQ Rural Health Quarterly

Rural Health Quarterly (ISSN 2475-5044) is published by the F. Marie Hall Institute for

Rural and Community Health, 5307 West Loop 289, Lubbock, TX 79414, and the Texas Tech University Health Sciences Center. Copyright 2018—Texas Tech University Health Sciences Center. The articles published in Rural Health Quarterly do not necessarily reflect the official policies of the F. Marie Hall Institute or of the Texas Tech University Health Sciences Center. Publication of an advertisement is not to be considered endorsement or approval of the product or service.

FRANK QUIT AFTER SMOKING 22,000 PACKS OF CIGARETTES OVER 30 YEARS

Rural Health Quarterly is published four times a year and distributed without charge upon request to individuals residing in the U.S. meeting subscription criteria as set forth by the publisher.

RHQ ADVISORY BOARD Ogechika Alozie, associate professor/chief medical informatics officer, TTUHSC El Paso Paul Fowler, associate dean for the School of Medicine Administration, TTUHSC Permian Basin Coleman Johnson, special assistant to the President, TTUHSC Retta Knox, RN, Hart School-Based Health Clinic, Hart, TX Susan McBride, Ph.D., RN, School of Nursing, TTUHSC Linda McMurray, executive director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriguez, senior managing director for CMHC, TTUHSC Ken Stewart, Ph.D., director of Community Development Initiatives, ASU, San Angelo, TX

Now there’s a new screening that can catch lung cancer early and could save lives. Talk to your doctor or learn more at

Dr. Julie St. John, assistant professor, TTUHSC Abilene Shari Wyatt, rural health specialist, State Office of Rural Health, Texas Department of Agriculture


RURAL

REPORTS

ALABAMA //

ARIZONA //

The University of Alabama is receiving $128,664 to create a telemedicine platform to connect the Pickens County Medical Center Emergency Department with local ambulances in the latest round of Distance Learning and Telemedicine (DLT) grants from the USDA.

The University of Arizona and the Arizona Department of Health have partnered on a $2.2 million grant to train first responders in rural Arizona to administer Naloxone, the drug used to counter opioid overdoses. Two people a day are dying in Arizona of opioid-related overdoses.

mhealthintelligence.com | 01.22.18

kawc.org | 01.22.18

RURAL HEALTH REPORTING FROM ACROSS THE NATION AND AROUND THE WORLD

CALIFORNIA //

ALASKA //

ARKANSAS //

Alaska’s Statewide Suicide Prevention Council recently published a five-year plan outlining problem areas and strategies. The sparsely populated region of Alaska known as the Kusilvak Census Area, home primarily to Alaska Natives who mostly work in the fishing industry, has the highest suicide rate of any county-level jurisdiction in the country.

A new agreement between the Arkansas College of Osteopathic Medicine and the Eastern Oklahoma Medical Center is expected to create a long-term boost for rural health care in LeFlore County. Per the agreement, a portion of the 150 students will spend their third year of medical education training in rural clinics and hospitals.

As much as 41 percent of smogcausing nitrogen oxide emissions in California are coming from heavy fertilizer use in the state’s Central Valley, according to a new report released by UC Davis researchers. The fertilizers simulate soil microbes that can convert nitrogen to nitrogen oxide, a potent greenhouse gas and pollutant linked to asthma, other breathing problems and heart disease. The rural Central Valley region grows more than half of U.S. vegetables, fruits, and nuts.

www.governing.com | 02.07.18

kawc.org | 01.22.18

eastbayexpress.com | 02.01.18

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united kingdom

MEXICO

The Royal Flying Doctor Service has warned it will be forced to abandon some of its health work in rural Australia unless the federal government reinstates some of the $10.2 million in funding cuts made last year.

Environmental factors are believed to play a key role in the U.K.’s longer rural lifespans. Air pollution bedevils urban dwellers of all classes, and noise pollution and the density of fast-food outlets are also much higher in urban areas.

Rural Mexico is benifting from a new wave of interest in “curandería,” an umbrella term for the traditional rural healing practices which employ everything from herbal medicine to ancient, Native Mexican spiritual practices and talk therapy. A growing disenchantment with Western medicine is likely the reason for the trend. A sense that “pharmaceutical companies are just businesses” and that “doctors no longer approach their patients in a loving way” has gripped conventional medical relationships.

theaustralian.com.au | 02.14.17

www.citylab.com | 02.13.18

www.ozy.com | 02.08.18

AUSTRALIA

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In the U.K., location is more important for longevity than economic status, a University of Liverpool study found. Across the U.K., rural residents actually live longer than their urban counterparts, the study found.


What’s news in your neck of the woods? Let us know: Email: Email your rural health news to RHQ at RHQ@ttuhsc.edu

U.S. Mail: Rural Health Quarterly, F. Marie Hall Institute for Rural & Community Health, 5307 West Loop 289, St. 301 Lubbock, Texas 79414

Voicemail: Prefer to call? Leave us a message at (806) 743-9891 FAX: (806) 743-7953

Web: Find more RHQ contacts at ruralhealthquarterly.com or follow us on Facebook at facebook.com/RuralHealthQuarterly.

COLORADo //

HAWAII //

Colorado’s Senate has given initial approval to a bill that would expedite the construction of high-speed broadband service in rural areas by taking money from a state fund that has long subsidized rural telephone service. Gov. John Hickenlooper says he wants to raise broadband availability in rural Colorado from 70 percent now to 100 percent by 2020.

The state of Hawaii will build a new 144-bed forensic psychiatric facility to help ease overcrowding at the Windward Oahu campus. Site work is scheduled to start in March on the five-acre site in Kaneohe and will be completed in the summer.

GEORGIA //

bizjournals.com | 01.29.18

Florida’s Senate Health Policy Committee has approved legislation to allow the creation of “remote dispensing site pharmacies.” Committee Chairwoman Dana Young said the bill provides increased access to pharmaceutical services that are not always available in rural areas

The growth of telemedicine in Georgia continues. A new federal grant will allow Augusta University to create a two-way connection with emergency rooms at five rural Georgia hospitals, providing remote consultation and health care services to their ER patients. The five hospitals are in Colquitt, Cordele, Swainsboro, Sandersville and Washington. Another new telehealth program will allow 100 diabetic patients in rural Central and South Georgia to monitor their diabetes from home and interact with their doctors using a tablet.

pharmacist.com | 02.09.18

kawc.org | 01.22.18

idahostatesman.com | 01.11.18

WEST AFRICA

PUERTO RICO

aspentimes.com | 02.07.18

FLORIDA //

IDAHO // The state of Idaho has a 10-year plan to increase graduate medical education in the state. The plan would add new training programs at locations all around the state in an effort to fill gaps in rural care. Idaho ranks “49th out of 50, both in the number of doctors per-capita and in the number of medical residents per-capita.”

m

NEW ZEALAND A new study published by University of Auckland researchers suggests that offering financial incentives for doctors and nurses to take jobs in rural areas may be proving successful. Researchers say they were surprised to see an association between higher levels of student loan debt for both medical and pharmacy students and a preference for rural practice. International studies have also found a connection between high student debt and graduates choosing to work in rural areas.

The fallout of the Ebola epidemic in West Africa has been particularly challenging for rural Ebola survivors, health experts and humanitarian workers say. Urban survivors tend to have better access to public health services than those in rural settings.

The number of suicides in Puerto Rico increased by nearly one-third, or 29 percent, in 2017. Health specialists and doctors say the spike can be linked to the aftermath of Hurricane Maria that struck the island on September 20, 2017.

www.odt.co.nz | 02.12.18

www.latimes.com | 01.26.18

alternet.org | 02.13.18 SPRING 2018 | RHQ   7


Rural Reports //

ILLINOIS //

MARYLAND //

Lurie Children’s Hospital of Chicago is receiving $252,673 from a USDA grant to connect the hospital to 20 hospitals and clinics across the state. The program will enable rural hospitals to connect via telemedicine with Lurie Children’s Hospital’s emergency department for emergency care consults.

Maryland’s unique rate-setting system for hospital services is getting a one-year extension from the federal government. Under a federal waiver, Maryland Medicare payments are based on rates set by a state commission, instead of national federal payment principles.

mhealthintelligence.com | 01.22.18

INDIANA // The Indiana State Department of Health has awarded $127,000 to first responders serving 34 rural counties to help prevent fatal overdoses. The funding will be used to provide 3,388 naloxone kits, train first responders on administering naloxone, and expand referrals to appropriate treatment and recovery communities. casscountyonline.com | 01.31.18

IOWA // A new study from the University of Iowa found that patients were seen six times more quickly at rural hospitals using telemedicine in their emergency department than in hospitals without telemedicine. The study also found length-of-stay at the ED was shorter for patients that had telemedicine care.

KENTUCKY // Kentucky became the first state with a work requirement for Medicaid. This summer, the state will require many people who get taxpayer-funded health insurance to work or volunteer at least 80 hours a month. Half a million people will be asked to use their smartphones to log their hours so the government can keep track. There are exemptions to the work requirement, including pregnant women, full-time students and others. abcnews.go.com | 02.09.18

modernhealthcare.com | 01.08.18

MICHIGAN // Beginning this fall, teams of Central Michigan University students from multiple health care-related disciplines will visit area rural homes to check the health of residents. The program will serve the medically underserved rural community and expose students in health professions, social work and other fields to geriatric medicine. themorningsun.com | 01.25.18

LOUISIANA // Thirteen Lousiana sheriffs, mostly from rural parishes, have filed suits against opioid manufacturers and distributors, joining a national stampede of civil lawsuits alleging that drug companies have “saddled taxpayers with huge costs by recklessly creating opioid addicts.” theadvocate.com | 01.27.18

MINNESOTA //

Construction has begun on the Patterson Health Center in Harper County, Kan. The project is designed to offer a new model for rural health care delivery.

School-based health clinics that were forced to slash programs after having their funding unexpectedly cut will get an infusion of unspent tobacco settlement funds to restore services. School clinics are often a critical source of health care in rural Maine.

The Minnesota Department of Agriculture launched a six-week workshop series aimed at educating farmers’ families and friends, as well as law enforcement, about farmers and mental health. The “Down on the Farm” sessions teach people in farming communities to recognize the warning signs of mental and emotional distress and provide information about resources that are available to farmers.

www.bizjournals.com | 12.11.17

pressherald.com | 02.01.18

www.mndaily.com | 02.06.18

www.healthcaredive.com | 01.16.18

MAINE // KANSAS //

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MISSISSIPPI // Mississippi state senators have passed the “Opioid Crisis Intervention Act.” The bill sponsored by Sen. Sally Doty, R-Brookhaven, would shield individuals reporting a victim of an overdose from arrest. The proposal also establishes a pre-arrest diversion program. In November, the Clarion Ledger reported that 195 people were confirmed to have died of opioid overdoses in the state. The bill now heads to the House for consideration. www.clarionledger.com | 02.07.18

MISSOURI // Since 2000, 79 of 114 Missouri counties show a rise in white mortality rates among ages 25-59, according to a report recently released by the Missouri Foundation for Health and created in partnership with Virginia Commonwealth University’s Center on Society and Health, and the University of Pittsburgh. Researchers cite an increase in what they refer to as “deaths of despair” – fatal drug overdoses, alcohol poisonings and suicides. stlamerican.com | 02.01.18

NEBRASKA //

NEW YORK //

According to a new report, Nebraska saw a 15 percent increase in its behavioral health workforce between 2010 and 2016. The report was compiled by the Behavioral Health Education Center of Nebraska, established by the Nebraska Legislature in 2009 to increase residents’ access to behavioral health care by bolstering the workforce.

The New York State Office of Mental Health will receive $500,000 from a USDA grant to create a telemedicine network encompassing 19 hubs and 66 sites, including schools, clinics, doctors’ offices, correctional facilities and nursing homes. The project will also improve access to mental health services for the Seneca Nation of Indians and the Tuscarora Nation of Indians through Western New York Independent Living.

www.omaha.com | 01.20.18

mhealthintelligence.com | 01.22.18

NEVADA // The University of Nevada, Reno School of Medicine offers specialty residency tracks in rural and primary care. A new PA (physician assistant) program, a type of medical profession that is greatly expanding and helps fill the gap in rural care, received 800 applications for only 24 open positions. The program is set to begin in July 2018. www.nnbw.com | 01.28.18

Project Lazarus — a nonprofit started in Wilkes County — is helping residents overcome addiction across North Carolina. The project promotes addiction treatment and uses peer guides, who are people in long-term recovery that help others find their way through treatment and recovery. dailytarheel.com | 01.29.18

NORTH DAKOTA //

NEW MEXICO //

Veterans account for one of every five suicides in Montana. The suicide rate for Montana veterans in 2016 was 70.4 deaths per 100,000 population, much higher than the non-veteran rate of 29.0.

A new Nurse Licensure Compact (NLC) was passed by New Mexico legislators in January. Health care organizations have had difficulty recruiting nurses to work in rural areas of the state. The multi-state licensure compact, allowing nurses with a multistate license to practice in participating states, may lessen that burden.

mtstandard.com | 02.06.18

currentargus.com | 01.28.18

MONTANA //

NORTH CAROLINA //

The North Dakota Farmers Union and North Dakota State University Extension hosted a summit in January to talk about the stresses farmers are facing. Farmers have the highest suicide rate of any occupation in the U.S., according to a 2016 study by the Centers for Disease Control. jamestownsun.com | 01.31.18

OKLAHOMA // Several tribes in Oklahoma are planning major investments in health care, including a Cherokee project that will be the largest joint venture in Indian Health Service’s history. newsok.com | 01.14.18

SPRING 2018 | RHQ   9


Rural Reports //

OREGON //

VERMONT//

Oregon voters approved hundreds of millions of dollars in health care taxes in a special election in January. Large hospitals will pay a 0.7 percent tax, and insurance companies will pay a 1.5 percent tax on most policies, which they are allowed to pass along to consumers. That tax revenue will enable Oregon to qualify for $630 million to $960 million in federal Medicaid matching funds.

The use of telemedicine technology has been growing recently in Vermont as hospitals look for ways to more easily reach rural patients. Last year, the Legislature approved a bill designed to further expand telemedicine and make it easier to obtain insurer reimbursement. Telepsychiatry service is also expanding this year to Brattleboro Memorial Hospital.

www.oregonlive.com | 01.23.18

SOUTH CAROLINA // People who live in South Carolina can expect to die years earlier than their counterparts in most other states, according to the research by the Population Reference Bureau, a private nonprofit think tank in Washington, D.C. The bottom 10 states for life expectancy are all in the South. Reasons for the disparity include poverty, higher rates of cancer and other diseases, smoking rates, obesity and lack of insurance. greenvilleonline.com | 01.22.18

SOUTH DAKOTA // Bryan Slaba, CEO of Wagner Community Memorial Hospital, was recently announced as the recipient of the American Hospital Association’s 2018 Rural Leadership Award for his work to promote telemedicine in rural communities. In 2009, Slaba helped implement the eEmergency program, which allows hospital staff to simply push a button to activate a camera and connect with a certified physician and critical care nurse team in Sioux Falls. www.usnews.com | 01.22.18

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TENNESSEE // The Servolution Health Services rural health clinic, located in Speedwell, Tennessee, provides primary, dental and mental health services regardless of your ability to pay. Servolution was certified in November as a rural health clinic and is also one of the only providers in the area to take certain insurances. The clinic also offers well child physicals, child vaccines, sports physicals, women’s health services and DOT physicals. middlesborodailynews.com | 02.09.18

vtdigger.org | 01.15.18

VIRGINIA // Research shows that the incidence of black lung disease is on the rise among coal miners. The cluster of cases at three clinics in southwest Virginia studied by NIOSH researchers is the largest ever reported in scientific literature. www.bna.com | 02.09.18

TEXAS // As part of the first phase of the Texas Mental Health Grant Program for Justice-Involved Individuals, up to $12.5 million in grant funds will go to programs to address mental health issues outside of the criminal justice system. everythinglubbock.com | 01.23.18

UTAH // The House Education Committee in Utah has endorsed legislation to create a two-year telehealth mental health pilot program that could be accessed by rural public schools that are experiencing a shortage of school counselors and social workers. www.ksl.com | 02.13.18

WASHINGTON // Washington cattle rancher William “Bill” Crosetto, who passed away on January 25 at the age of 75, has left his multimillion-dollar estate to Inland Northwest Community Foundation. The gift will create two new $1 million funds that will support health care in rural Washington communities. www.kxly.com | 02.12.18

WISCONSIN // Federal funding ran out late last year for a program to connect rural Wisconsin veterans to housing and recovery services. An extension bill is being considered by lawmakers. www.wpr.org | 02.08.18

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Rural Research //

We Have a Problem. . . or Do We? Vital statistics are vital to improving rural health care outcomes

M

ortality rate is reported as the number of deaths in a population in a unit of time, and the data typically comes from vital statistics records, primarily death certificates. However, when that information is collected inconsistently it could lead to interpretations that are unintentionally misleading. Catherine Hudson An issue that is prominent in the headlines, DIRECTOR FOR RURAL maternal mortality, relies on death certificates as HEALTH RESEARCH the primary source of data. Maternal mortality, F. Marie Hall Institute for defined as “pregnancy-related death of a woman Rural and Community while pregnant or within 1 year of the end of the Health pregnancy,” has been on the rise in recent years. According to recent reports, Texas in particular has had a dramatic increase in pregnancy related deaths. According to vital statistics records, Texas’ maternal mortality rate has jumped 87 percent, from 18.3 for the five years from 2006 to 2010, to 34.2 for 2011 to 2015. News regarding this issue has caused many, including legislators, to take notice and ultimately propose new action. Texas Gov. Greg Abbott signed a bill which would allow the Task Force on Maternal Mortality and Morbidity more time to look closer and try to determine the cause of the increase. But is the problem as bad as it appears? A study published in Birth earlier this year revealed that while there was an increase in maternal mortality, it appears that increase may not have been as dramatic as reported. The problem? Inaccurate and/or over-reporting the cause of death on death certificates. Information can be recorded on a death certificate by a medical examiner or, as is the case in many rural areas, by a Justice of the Peace. The required training for these two positions varies greatly and may lead to divergent perspectives and interpretations as to the cause of death. Changes to the death certification process have been made as recently as 2006 by adding a check box asking if the person who died was pregnant or had been pregnant within the last year. Although this change is an improvement, there is the still the possibility of inaccurate reporting. A recent joint report published by the Maternal Mortality Review Committees in Colorado, Delaware, Georgia and Ohio said it best: “There is a clear need for ongoing technical assistance as we continue to build the analytical capacity required to address the myriad of maternal and child health problems that plague our nation. Without strong, accurate data we cannot effectively measure the problem nor work toward effective policy change and program development that improves birth outcomes.” Successful policies and effective practice depend on the availability of good information. Therefore, the accuracy of our health data is critical. We can do better, but only if we make it a top priority.

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Grant WATCH // LOUISIANA HEALTH AND EDUCATION DISPARITIES COLLECTIVE IMPACT GRANTS Provide funding to coalitions working to close the gaps in health and education for Louisiana’s children by addressing structural inequities and access.Website: bcbslafoundation.org. Deadline: March 1, 2018.

COLLABORATIVE APPROACHES TO WELL-BEING IN RURAL COMMUNITIES Provides funding to support rural communities in Texas in their efforts to transform the environments to support resilience, mental health and well-being. Website: hogg.utexas.edu/rural-communities. Deadline: March 7, 2018.

NATIVE YOUTH AND CULTURE FUNDING OPPORTUNITY Provides funding for projects that focus on native youth and incorporate culture and tradition to address social issues such as drug and alcohol abuse, teen pregnancy, mental health or other social issues. Website: firstnations.org/grantmaking. Deadline: March 8, 2018 (Letter of Intent).

MINNESOTA GOOD FOOD ACCESS PROGRAM: TECHNICAL ASSISTANCE GRANT Provides funding to increase the availability of affordable, nutritious, and culturally appropriate food, including fresh fruits and vegetables, for underserved communities. Website: www.mda.state.mn.us/grants/ grants/gfaptechassistance. Deadline: March 14, 2018. SPRING 2018 | RHQ   11


Rural Research //

Dramatic Increase in Rural STDs Alarms State Health Officials BY CINDY UKEN

R

esistance to antibiotic treatment is making gonorrhea – a common sexually-transmitted infection that can lead to infertility – much more difficult, and sometimes impossible, to treat, which is troublesome, especially in some rural areas of the U.S. where public health officials are reporting dramatic increases in the disease. The spike is evidenced in this snapshot of rural America: •

Wyoming experienced a six-fold increase in the rate of gonorrhea infection from 2012 to 2016, said Courtney Smith, communicable disease surveillance program manager for the Wyoming Department of Health. In South Dakota, gonorrhea has increased five-fold statewide over the past decade, according to the South Dakota Department of Health. In North Dakota in 2016, the state recorded 1,005 cases of gonorrhea, almost a 50 percent increase from 2015, according to

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the North Dakota Department of Health. In 2012, Montana reported 108 confirmed cases of gonorrhea. In 2016, the state reported 864 cases. In Yellowstone County, Montana’s largest county, there were 16 times as many gonorrhea cases in 2016 as there were four years earlier. The number of cases grew from 14 in 2012 to 234 cases in 2016.

The World Health Organization (WHO) attributes the rise in gonorrhea cases, at least in part, to increased urbanization and travel. But rural public health and Planned Parenthood officials, those who work in the trenches and see the infected, have additional theories. They attribute the spike to better, more reliable testing methods coupled with the increased popularity of dating hookup apps that often lead to anonymous sex. They even say what federal health officials seem reluctant to say: There is likely no one single reason for the staggering increases in gonorrhea. What they do acknowledge is that the alarming increases are pummeling rural areas that are already vulnerable by virtue of their geography.

RURAL RATES ON THE RISE Rural residents are more likely to be poor, lack health insurance or rely substantially on Medicaid and Medicare; they also travel longer distances to receive care or to access a range of medical, dental, and mental health specialty services, according to the American Congress of Obstetricians and Gynecologists. Additionally, in 2008, only 6.4 percent of obstetrician–gynecologists practiced in rural settings. “STDs are an equal opportunity threat – they don’t discriminate based on age, race, socio-economic status or location,” said Dr. Sarah Traxler, medical director of Planned Parenthood Minnesota, North Dakota and South Dakota. “But people

living in medically underserved, rural areas are at higher risk because they are more likely to lack health insurance or have a low income and are unable to access basic health care. As we see rates of STDs rising across the country, we should be finding ways to expand access to health care generally – including testing and treatment for STDs – especially in rural areas.” Condoms, once considered a must-have to guard against STDs and the hallmark of the safe-sex message, are now considered a nuisance and worse. In a national survey conducted by the Kaiser Family Foundation, researchers discovered that: • • •

One in six believes that having occasional unprotected sex is “not that big a deal.” 70 percent regard birth control methods other than condoms as “practicing safer sex.” 50 percent regard condoms as a sign of mistrust, infidelity or promiscuity.

Opposition to wearing condoms has become so prevalent that it is commonly referred to as “condom bias” or “condom fatigue.” The terms are used to describe the negative feelings those using condoms have toward them and how tired they are of using them. A study by Emory University showed that nearly one-third of the men surveyed reported that they have lost an erection after having put on a condom. Given the choice of between maintaining an erection and using a condom, many men are choosing to go without protection, which could be a contributing factor to the rise in gonorrhea cases. Those who have a bias against using condoms, according to the Emory study, associate condom use with: • • •

Lack of sexual spontaneity Unpleasant taste and smell Reduction of sexual pleasure for both men and women


• • •

Condom use may be seen as a declaration of distrust or infidelity Condom use may be seen as a sign of sexual promiscuity Fear of being identified as “high risk,” or as part of a condemned population such as injecting drug users.

Rural health officials say that while that’s all true, there are still some missing pieces that could help complete the puzzle as to why gonorrhea cases and other STDs are on the upswing.

SEEKING A SOLUTION Shari Renton, HIV, STD and Viral Hepatitis Surveillance Coordinator for the North Dakota Department of Health, said there are a “number of things” that are likely contributing to the spike. “I think it’s complicated to really understand why,” Renton said. “Testing technologies have changed over the last decade or longer and with that we have better tools to identify infections. It could be that more providers are actually following testing recommendations more closely and that we may be diagnosing and treating more cases that would have previously gone undetected.” The increased popularity of sexual “hookups” is also likely playing a role, Renton said. “We know that many people are having more anonymous sex or sex with people they don’t know the names of, so it’s hard to make referrals to get these individuals in and tested which can lead to more spread of the infection in the community,” Renton said. Moreover, she said, though funding has not been reduced or clinics closed, there is definitely a barrier to access. “We do not have STD clinics and some of the local public health units do not offer STD services. We do have many other places for individuals to go to receive services, yet access and utilization of clinics due to being affordable, are issues that curb people accessing care for a number of things, not just STDs.” Derrick Haskins, communications

director for the South Dakota Department of Health, echoed Renton’s sentiments. He said while there are many possible reasons for the increase, “a risk factor we seem to be seeing more often is the use of hook-up apps such as Grindr and Tinder.” Grindr is a geosocial networking app geared towards gay and bisexual men, designed to help them meet other men in their area. In Montana, Planned Parenthood has seen an increase in positive gonorrhea cases in its patients, especially in people 24 years old and under, said Jill Baker, director of Learning for Planned Parenthood of Montana.

Opposition to wearing condoms has become so prevalent that it is commonly referred to as ‘condom bias’ or ‘condom fatigue.’ This increase is likely due to multiple factors. Under the Affordable Care Act and Montana HELP program, more people have health coverage to access preventative screenings during routine exams. “While screening has increased, there is still much stigma and privacy concerns for young people accessing preventative measures like condoms,” Baker said. “This is especially true in rural areas where it is very likely that a young person will personally know the local health care provider and pharmacist and worry about their confidentiality. These confidentiality concerns may be real or perceived, but still remain a barrier to access.” In addition, access to accurate information about reproductive and sexual health is dismal at best for young people in the state, Baker said. Often parents and teens both feel ill-equipped and embarrassed to bring up the subject. In addition, only 22.6 percent of schools teach all 19 HIV, STI, and pregnancy prevention topics recommended by the

state. Teachers are also ill prepared to teach on sexual health topics. More than 800,000 people in the United States are estimated to get gonorrhea infections each year and more than half of those infections go undetected, according to the Centers for Disease Control and Prevention (CDC). People get gonorrhea by having vaginal, anal or oral sex with someone who has the disease. “The increase in gonorrheal infections in Yellowstone County is particularly worrisome because the disease has become increasingly resistant to the antibiotics used to treat it,” said Tamalee St. James, RiverStone Health Director of Community Health Services and Deputy Health Officer for Yellowstone County. Health care providers across the country share the concern. Ten years ago, the CDC recommended five antibiotic treatment options for gonorrhea. Only one recommended option remains, a combination of two antibiotics given together. Antibiotic resistance led the CDC to list gonorrhea as one of the three most urgent drug-resistant threats. Left untreated, gonorrhea can cause serious health problems, including chronic pelvic pain, life-threatening ectopic pregnancy, and infertility in women. In men, untreated gonorrhea can lead to a painful condition in the tubes leading to the testicles. Having the infection also increases the risk of getting and transmitting HIV. The medical community desperately needs new antibiotics to treat gonorrhea and longer-term a vaccine to prevent it, according to the WHO. Until then, the best approach is prevention, according to public health officials. Consistent and correct condom use and limiting the number of sex partners can help reduce the risk of gonorrhea and other sexually transmitted diseases. Anyone who is sexually active should discuss risk factors and testing with a health care provider. While symptoms of gonorrhea may include discharge and pain during urination, often people have no symptoms, according to the WHO.

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SPRING 2018 | RHQ   13


All About ACCESS BY RYAN N. SCHMIDT, PHD, MBA, MS, CMRP ROBERT POSTERARO, MD, MBI, FACR SHARON HUNT, MBA, FACHE

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he purpose of this article is to highlight the challenges and concerns that surround the commonly heard term called “access” to care. Often times, people simply associate access to care with whether or not an individual has health insurance. However, access to care has several components associated with it. Access to health care was first defined by the Institute of Medicine (IOM) in 1993 as “the timely use of personal health services to achieve the best health outcomes.” Attaining good access to care requires three discrete steps: (1) gaining entry into the health care system, (2) getting access to sites of care where patients can receive services and (3) finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust. Likewise, health care access is measured in several ways: (1) structural measures of the presence or absence of specific resources that facilitate care, (2) assessments by patients of how easily they can access health care and (3) utilization measures of the ultimate outcome of access to care.

As we think about access to care, it becomes clear that some characteristics of access seem more intuitive (direct) while other aspects are more educational (indirect). This distinction suggests a need for additional population-based dialogue about the topic. Further, rural communities are most impacted by access-related issues and the need for sustainment of health-related services. DIRECT ACCESS: A – AFFORDABILITY Affordability is not only associated with one’s ability to pay for health care services. It also includes an employer’s legal requirements to include health care insurance within an employee’s benefits package. Employer-sponsored health insurance requires the employer to match the overall cost of the insurance premiums and share the fiscal responsibility. Further, those businesses with fewer employees are at a disadvantage to negotiate overall premium pricing. For example, a small business (more likely in the rural communities) with 60 employees cannot bargain insurance premiums

comparative to a large corporation of 10,000 employees. Given this, it creates great cost variations for employees and often for companies that can least afford it. C – COMMUNICATION Communication is a key element when describing current concerns within health care. Physicians and nurses need to become better preventative educators, identifying health risk factors and appropriate health behaviors concerning the patient. Further, patients need to fully understand the risk factors being presented to include the fiscal implications of their own health. This becomes more difficult in rural communities as access to health professionals, impactful treatments and health technologies are more scarce. C – CARE COORDINATION Care coordination is directly correlated to communication and those health providers who provide it. The fundamental difference is care coordination focused on the clinician to clinician interpretation, treatment options and recommended modalities of treatment


and how that is effectively coordinated for the patient. This includes the seamless movement of clinical information, insurance referrals and the appropriate and timely sharing of the patient record. The electronic medical record (EMR) and portability of such a record within and between health care facilities become more challenging in rural communities. E – EDUCATION (INTERVENTION) Education is often viewed as the solution in preventing the overall health decline of patients. This would include the public health education received and the level of education of the person to receive it or prevent illness. An overall healthier patient will reduce the cost of their health care while increasing the quality of their life. However, the sole purpose of health education is to impact the overall outcome of the health of a patient. Education becomes the intervention of measurement and often proves to be quite ineffective and inefficient in influencing the behavior of a patient. This would mean that health education in itself does not significantly modify human behavior. Additionally, those with lower levels of education are least likely to have access to health care services or to be able to afford the overall costs of unhealthy living. However, those same persons are the ones most likely to engage in unhealthy life choices given the conditions in which they are currently living and the influential environment in which they are living. S – SHORTAGE (PHYSICIAN/NURSING) Physicians and nurses are less likely to practice and stay in rural communities. The majority of physicians, nurses and, particularly, specialists that choose to practice in the rural communities were typically raised in

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that community and/or a rural community such as the one represented. The more specialized the physician/ nurse, the greater the shortage in the rural communities. The federal government has recognized this and developed incentives like loan repayment options through programs such as the National Health Service Corps. However, the physician/nursing shortage continues to create a hardship for those often in the greatest need. S – SUSTAINMENT Sustaining complex care for rural patients, typically geographically and fiscally separated from its urban counterparts, is of great concern. Often, care is a continuum of treatment modalities facilitated by both physicians and the technology they represent. Rural patients often do not follow-up on their interventions (medications, labs, scans, etc…) given the geographic limitations and the continual collective requirement to address multi-faceted medical issues. The cost of treatment, travel and absenteeism at work becomes a criteria for which a choice between maintaining employment and continued medical care is often made with great hesitation.

INDIRECT ACCESS A – AGING According to the U.S. Census Bureau, there are more than 44 million U.S. residents (13 percent of the population) age 65 years and older. The elderly account for more than 34 percent of the overall spending in health care, with nearly half of that spending occurring during the last six months of life. As the US population continues to grow, there will be continued economic and political pressures to reduce or limit health care benefits

and costly treatments. This is directly correlated to the lack of a youthful population (number of taxpayers in the nation impacted by lower national birth rates) to pay for elderly federal health services. C – CHRONIC (DISEASE) Chronic disease can be categorized into the following areas: (1) unmanaged (2) needs to be continually managed (3) difficult to manage (4) too costly to manage or (5) unmanageable. Unfortunately, all too often the health of individuals become unmanaged (starting with lack of self-care), later developing into a state that needs to be continually managed. This continual management requires the intervention of physicians/nurses often as the gatekeepers to technological interventions such as pharmacological services. Rural communities are often most impacted given the lack of services and the fiscal and geographic requirements to travel for care. This leads into a state of being difficult to manage given the overall cost to manage it and time needed to manage the condition. Inevitability, disease(s) tend to manifest if left unattended into an unmanageable situation. C – COMORBIDITY (COMPLEXITY) It is important to understand that a disease-state can include multiple diseases and/or conditions for which the management of these conditions become more complex. As the complexity of management increases, so does the number of specialists that a patient needs to see to manage their care. Moreover, the management of this care is often coordinated between independent offices for which the times and dates of that care can vary and become even more difficult to manage. Rural patients can become


even more challenged in meeting multiple appointments on differing days given their commute to and from the urban areas in which the complex care is managed. E – ENVIRONMENT The environment in which one is raised and educated is often overlooked but should be considered more closely. The utilization of health care services is often related to access to care. However, persons may have grown up where access was not an option, therefore, services were not utilized, as would have otherwise been advised. Given this, these persons often believe that you only use health care services under the conditions of emergent care (life, limb, or eye sight). Their experiences did not suggest that preventative measures, annual physicals or family health check-ups are necessary to prevent long-term problems. Many preventable conditions are discovered through regular checkups and the analysis of blood/urine samples discovered during checkups. This is dependent on patients both coming to regular check-ups and communicating the symptoms they have experienced. S – SOCIAL (DETERMINANTS) Social determinants of health are, according to the World Health

Organization (WHO), “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies and politics.” Income level, educational attainment, race/ethnicity and health literacy all impact the ability of people to access health services and to meet their basic needs. Rural residents are more likely to experience some of the contributing social factors that impact health, such as poverty. S – SERVICES (HUMAN) Human services could include safe and affordable housing, income supports, food assistance, job training and other critical services that help the poor and vulnerable rural residents maintain their health and the health of their family members. Addressing the social determinants of health through the provision of human services has the potential to help control health care costs and attain a more efficient health care system. Ensuring that patients who use the health care system frequently, such as those with chronic conditions, have their other needs met may lessen the stressors that contribute to chronic conditions, reduce the amount of health care resources they require

and reduce unnecessary hospital readmissions. CONCLUSION: Access to care (direct and indirect) is of national concern for reasons that far exceed simply providing insurance. Several factors influence the type of care a patient receives while this article highlights the correlative factors associated with the efficient and effective management of care. Population and preventative health focuses on the relationship that should exist and be sustained between the patient and the physician/nurse who manages that care. Education through health literacy is necessary for patients to administer self-care through prevention while physician/nurse-led patientcentered accountability impact the time-sensitive treatment needed throughout the human lifespan. Those living in rural areas are more likely to be negatively impacted given the long-term effects of mismanaged care and the current transition from transactional health care to population and preventative-based health care systems. Solution-centered dialogue surrounding the complexities of these challenges to include access issues is needed in order to effectively transition from conditions of chronic sickness to a state of physical and mental health wellness.

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SPRING 2018 | RHQ   17


PUBLIC POLICY //

Medicare Extenders: Congress Extends Vital Payments to Rural Hospitals – For Now

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hen Medicare was created in 1965 through Title XVIII of the Social Security Act, hospitals were faced with a unique problem: patients now had the means to access care; however, the rates at which hospitals were reimbursed by the state and Cameron Onks federal governATTORNEY ments through F. Marie Hall Institute the Medicare for Rural and Community fee schedule Health were often insufficient to cover the hospitals’ costs for providing that care. Consequently, smaller rural hospitals with a disproportionate share of Medicare beneficiaries were unable to cover their operating costs and a flood of rural hospital closures occurred throughout the United States. In all, from 1980 to 1989, more than 230 rural hospitals closed across the country. To correct the disparity between costs and payment and stem the tide of rural hospital closures, beginning in 1990, Congress enacted a number of supplemental payment systems for qualifying hospitals, so called “Medicare Extenders” that provide extended payments to qualifying facilities in addition to the payments prescribed by the Medicare fee schedule. These new payment systems significantly improved the operating budgets of rural hospitals and effectively cauterized rural hospital closures. Two particular payment systems have proven to be especially important

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to keeping rural hospitals open: the Medicare Dependent Small Rural Hospital Program (MDH Program) and the Increased Inpatient Hospital Payment Adjustment for LowVolume Hospitals (LVH Program). Medicare Dependent Hospitals (MDHs) are Inpatient Prospective Payment System hospitals located in rural areas, with 100 or fewer beds, for whom at least 60 percent of inpatient days or discharges are attributable to individuals entitled to Medicare Part A benefits during the hospital’s cost reporting period or periods. For discharges on or after October 1, 2006, and before October 1, 2017, MDHs are paid for their inpatient operating costs based on the federal rate, or, if costs are higher than the federal rate, the federal rate plus 75 percent of the amount by which the federal rate is exceeded by the MDH’s updated hospital-specific rate payment based on its fiscal FY1987 or FY2002 costs per discharge, whichever of these hospital-specific rates is highest. Similar to the Medicare Dependent Hospital Program, the Increased Inpatient Hospital Payment Adjustment for Low-Volume Hospitals provides additional Medicare payments to qualifying hospitals in order to subsidize the operations of low-volume providers, and sustain and expand access to care in rural areas. Under the original rules, to qualify as an LVH, a hospital had to be located 25 miles or more from the nearest "subsection (d)" hospital and have less than 800 Medicare discharges. These rules were later amended by the Affordable Care Act to allow hospitals to receive increased low-volume payments for discharges starting in FY2011 on the condition that they were located more than fifteen 15 miles from the nearest subsection (d) hospital and had fewer than 1,600 Medicare discharges. Both the MDH program and the LVH program provide rural hospitals the additional funds necessary to stabilize their budgets while continuing

to provide a multitude of services. Today, some thirty years after their creation, the crisis that Medicare Extenders were meant to address has been largely forgotten, and, aside from budget meetings and conversations among hospital stakeholders, the importance of the Medicare Extender programs has been forgotten with it. So much so that on September 30, 2017, Congress allowed both the MDH program and LVH program to expire. As a result, as of October 1, 2017, all previously qualifying MDHs no longer had MDH status and were set to be paid based only on the Medicare fee schedule. Similarly, as of October 1, 2017, the low-volume hospital qualifying criteria and payment adjustment methodology reverted to that which was in effect prior to the amendments made by the Affordable Care Act, effectively disqualifying a number of hospitals from receiving the payments. Congressional inaction quickly led to panic and an outpouring of support for the MDH and LVH programs from hospital associations and rural health advocates, as their budgets in FY18 and ahead were threatened with dipping further into the red. For example, on January 17, 2018, as Congress worked to pass a continuing resolution to fund the federal government and reauthorize the Children’s Health Insurance Program (CHIP), hospital associations across the country, including the American Hospital Association, urgently lobbied Congress to enact extensions for the MDH and LVH programs as part of the continuing resolution. Without these Medicare Extenders, hospital associations and stakeholders argued, reduced rates for rural providers would force many hospitals to reduce services or close their doors entirely, further limiting access to care for rural Americans. Similarly, in January of this year, the National Rural Health Association (NRHA) sent an urgent message to its constituents imploring them to contact their Congressional representatives and advocate for Medicare


Extenders. Jessica Seigel, Government Affairs Communications Coordinator for the NRHA, stated that “Rural Medicare Extenders are essential to slowing the rural hospital closure crisis. Proposals to alter the Low Volume Hospital Adjustment, like in the Senate Finance bill, or cut the Critical Access Hospital swing-bed program, like in the House Ways and Means bill, are unacceptable. The extensive and damaging cuts already experienced by rural hospitals have resulted in forty-four (44) percent of rural hospitals operating at a loss.” Unfortunately, there is data to back these assertions. Dr. George Pink and other researchers at the North Carolina Rural Health Research and Policy Analysis Center reviewed the fiscal health of more than 2,300 rural hospitals. They found that 9 percent, nearly 1-in-10 rural hospitals, were at high risk for financial trouble. "These more vulnerable populations," Pink said, "are at increased risk of losing access to some types of health care, exacerbation of health disparities and loss of hospital and other types of local employment." The situation is all the more dire when you consider the fact that MDHs total margins are the lowest of any hospital classification currently recognized in law. With that fact in mind, it becomes clear that payments based solely on the Medicare fee schedule, and not tied to operating costs, will place these hospitals and their patients at risk of closure and cessation of services. The effects of rural hospital closures are not limited to reduced patient access and health care outcomes; they also harm rural economies. Rural hospitals are often one of the largest employers in rural areas – approximately 14 percent of total employment in rural communities is attributed to the health sector. Rural hospital closures cause a significant loss of revenue in rural economies (up to 20 percent in some cases) as well as reduce per capita income and increase

rural unemployment. According to iVantage, a healthcare analytics firm, if 673 additional hospitals were forced to shut their doors, 99,000 direct health care jobs and another 137,000 community jobs would be lost. Over ten years, rural communities could lose as much as $277 billion in GDP.

Today, some thirty years after their creation, the crisis that Medicare Extenders were meant to address has been largely forgotten...

Fortunately, it seems Congress has been paying attention. On February 8, the Senate passed the Bipartisan Budget Act of 2018 to reopen the federal government, which the President signed the same day. Included in the bill are extensions for the MDH and LVH Programs through October 1, 2022. Legislatures even went a step further than some advocates had requested, expanding the qualifying criteria for the LVH Program from 1,600 discharges of individuals entitled to, or enrolled for, benefits under Medicare part A to 3,200 discharges for fiscal years 2019 through 2022. Why Congress decided to include the Medicare Extenders in the budget bill instead of renewing them through separate legislation prior to their expiration is not clear. As is often the case with must-pass legislation, such as the federal budget, it is a convenient vehicle to which members of Congress can attach and pass controversial or unpopular legislation. However, since Medicare Extenders have bi-partisan support, the delay in renewing them is more

likely a testament to the current conditions in Congress than to any other factors (Congress allowed CHIP, a very significant program that provides health care coverage to nearly nine million children, to remain expired for more than 100 days as they negotiated other issues). Regardless of Congress’s motivations, one thing is clear: the Medicare Extender programs, rural hospital funding, and the issues which surround them, will all be back in the national spotlight in five years. Since 2010, 83 rural hospitals have closed across the United States, with 14 rural hospitals closing in Texas alone. Other hospitals have been forced to reduce staff and cut services, and as many as 700 more hospitals are at risk of closing within the next ten years. Although both extensions provide additional security for hospitals’ operating budgets for the time being, institutionally speaking, five years is an insignificant amount of time. Due to the limited term of the extensions, hospital associations and their stakeholders cannot rely on the MDH and LVH programs to exist beyond 2022 and must now incorporate that additional risk into their strategic planning. As a result, certain program and/or hiring expansions may not occur, because hospitals do not have the necessary assurances that would make those investments secure. While the five-year extensions may pacify rural hospitals and constituents until after the 2020 Presidential election, legislatures still have not resolved the underlying issue: insufficient payment to rural hospitals under the Medicare fee schedule. Since both programs are set to expire again in the next five years, expect to see rural health care – particularly rural health care funding – continue to play an increasingly important role in American policy and politics as the next expiration date for these programs moves closer.

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SPRING 2018 | RHQ   19


PUBLIC POLICY //

Can Freestanding ERs Replace Rural America’s Struggling Hospitals? It’s Complicated. BY BRAM SABLE-SMITH

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hen the hospital closed in rural Ellington, Missouri, a town of about 1,000, the community lost its only emergency room, too. That was 2016. That same year, a local farmer had a heart attack. “He was a young man. He was just in his 50s,” said Christy Roberts, president of the Ellington Chamber of Commerce. Though the farmer lived just five minutes from the shuttered Ellington hospital, he had to be transported to an emergency room in Poplar Bluff, a 60-mile drive on winding one lane highways. He didn’t make it. “By the time he got there, there just wasn’t enough that they could do for him. His heart was too damaged,” Roberts said. “We really do feel like people have passed away because we did not have those emergency services.” Just over 40 percent of rural hos-

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pitals lose money each year due to dwindling community populations and a patient base that’s older, poorer and sicker than most. As a result, about 700 rural communities across the country are at risk of losing their hospitals, and access to emergency services. And 82 rural hospitals have closed since 2010, leaving towns like Ellington scrambling to fill the health care void. One solution could be to run small, freestanding emergency rooms in these small towns. But as community leaders in Ellington found out, that’s not so simple. AN OVERBURDENED CLINIC On a chilly afternoon four days before Christmas, Karen White circled the outside of the empty hospital building in Ellington. White is CEO of the only medical practice left in Ellington, a primary care clinic that sees patients on a sliding scale fee. White pointed to the old emergency department entrance on the side of the building. A sign on the door reads “This facility is closed. Emergency care is available at these locations...” and gives the distance and drive times to the two nearest emergency rooms: Iron County Hospital (48 minutes driving

time), and Poplar Bluff Regional Medical Center (1 hour 10 minutes). “It’s a requirement when a facility closes that they have to post where the next nearest facility would be, and the drive time and mileage,” White said. When the hospital closed, her clinic took on a lot of the medical care load in the county — including emergency cases. Patients have shown up in the clinic mid-stroke and mid-heart attack, she said. It’s been difficult. Her staff were not prepared for such a dramatic increase in volume. The clinic’s primary care physician left under the stress. “She really felt the weight being the only doctor in the county,” White said. There’s no full-time physician in Ellington anymore. White can staff her primary care clinic with nurse practitioners — and she does — but it doesn’t change the fact that many of the clients who show up there should be going to an ER. They just often can’t get to one in time. So White started wondering about logistics of opening an ER by itself in the community. It’s a concept known as a “freestanding ER,” an idea introduced in the 1970s as a way to maintain access to emergency services in rural areas. Communities have tried the


concept in other parts of the country, including neighboring Kansas and Illinois. And to White, it seemed like the perfect idea for Ellington. “Anyone you talk to in the community, we want our hospital back. But if we can’t have our hospital back, can we at least have an ER?” White said. REGULATORY HURDLES Priya Bathija of the American Hospital Association said rural health care providers are changing how they deliver health care. They can offer more specialized services now than they used to be able to. There’s less need for overnight stays and more demand for outpatient and emergency care. However, despite the changes, “a lot of our laws and regulations have not accounted for that,” Bathija said. Freestanding ERs are not recognized on the federal level, meaning they can’t bill Medicare for services. Unless that changes, there’s no federal money to support freestanding emergency departments. Without federal money, these facilities pop up in places

that can sustain them, which is urban areas, not rural ones. Thus, even though they were originally proposed as a concept for solving the rural access problem, the majority of the roughly 400 freestanding ERs in America right now are located in cities. Karen White examines the roof of the shuttered hospital in Ellington, Missouri. She says if the hospital were to be reopened its roof would likely need to be replaced. Freestanding ERs have garnered a lot of criticism in Texas, which has more than 180. The ERs have a reputation for issuing surprisingly expensive bills, and have even been blamed for driving up regional health care costs. But most of Texas’s facilities were built to be alternative options in crowded urban health care markets like Houston, Dallas and San Antonio. In a rural town such as Ellington, however, the only choice could be between a freestanding ER and nothing. But each state regulates the facilities differently (if they regulate them at all), which poses a different set of challenges. For instance, not every

state requires freestanding ERs to treat every patient that comes in the door regardless of insurance status, the way hospital emergency departments do. And when Karen White looked into the possibility of a freestanding emergency room in Ellington, she found out that Missouri does not allow them at all. It’s a rule she said the state needs to revisit. “Look at everything that has been lost. Look at all of the hospitals that have closed. How many of those could have transitioned over to emergency medical centers and still been operational? That’s the question they need to ask,” White said. For now, she said the community will look for ways to reopen Ellington’s hospital. It’s the only way to bring emergency services back to town.

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This story was produced by Side Effects Public Media. Bram Sable-Smith is reporting this series during a yearlong Reporting Fellowship sponsored by the Association of Health Care Journalists and The Commonwealth Fund.

Each rural hospital across the country is point located in grey if having a positive 2016 operating profit margin, orange if having a negative operating profit margin not exceeding -3 percent, and in red if having an operating profit margin below -3 percent. Map courtesy of The Chartis Center for Rural Health, 2018.

SPRING 2018 | RHQ   21


BEHAVIORAL HEALTH //

TH HID

In the frontier state of Montana, where kids are taught from a young age to “cowboy up,” suicide has a stranglehold on its people. Residents, many of whom live in isolation, are killing themselves at a rate faster than almost any other place in the nation. Mental health, public health and even government 22  RHQ | RuralHealthQuarterly.c officials are scrambling to find a way to halt what has been deemed a crisis.

22  RHQ | RuralHealthQuarterly.com


STATE of CRISIS

HE ID-

Maternal Mortality in the Lone Star State BY COSHANDRA DILLARD

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com

Summer 2017 | RHQ  

ver the last few years, all eyes have been on Texas women’s health, from the controversial defunding of family planning programs to an increase in maternal mortality rates. Texas not only has the highest 23 maternal mortality rate in the United States, but it also has one of the highest rates among developed countries. SPRING 2018 | RHQ   23


With heightened awareness, there may be some solutions in sight. Following a special session in the Texas Legislature in August, lawmakers passed a bill to extend the work of the Maternal Mortality and Morbidity Task Force through 2023, created to help reduce pregnancy-related deaths and severe maternal morbidity. Teams of medical professionals, as well as reproductive advocates, are also working to ensure rural patients aren’t forgotten in this crisis. According to the Centers for Disease Control and Prevention and the National Center for Health Statistics, the maternal mortality rate in Texas went from 30.2 per 100,000 live births in 2011 to 38.7 in 2012. While the state has since seen improvements, Texas’s mortality rate still remains higher than national rates, which have ranged from 19.3 in 2011 to 21.5 in 2014. Texas Department of State Health Services data shows that between 2011 and 2012, there were 189 maternal deaths. A majority of the deaths occurred later than 42 days after delivery and black women made up a disproportionate share of maternal deaths during this period. The Maternal Mortality and Morbidity Task Force was created in 2013 to address the spike, and initially, was set to expire in 2019. A group of physicians concerned about those numbers had been working on getting legislation two years prior. “At that time there was a group of us, including physicians with the American Congress of Obstetricians and Gynecologists (ACOG), who were working to establish a maternal mortality study to better understand what we were seeing,” says Dr. Lisa Hollier, medical director at Texas Children’s Hospital and chairwoman of the task force. In addition to the task force, a Perinatal Advisory Council has also been formed. WHY IT’S HAPPENING Medical professionals have acknowledged that maternal mortality has

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much to do with the incidence of illness in women and limited access to obstetric services. But it’s not that simple. “It’s not going to be a single cause,” Hollier says. “We’re not going to identify one thing. It’s very complex and involves a lot of different factors that place together systems.” The Maternal Mortality and Morbidity Task Force found that the leading causes of maternal death during that spike were cardiac events, drug overdoses, and hypertensive disorders. However, the task force reported that data quality issues related to the death certificate makes it difficult to identify a maternal death. Dr. Alyssa Molina, a family medicine physician who provides obstetrical care in rural Eagle Lake, Texas and a member of the Perinatal Advisory Council, wonders if the way in which data is reported paints an accurate picture. “We hadn’t seen changes (in Eagle Lake) in morbidity or infant mortality rates,” says Molina, who notes that the facility where she works has a low volume of obstetric cases. “Honestly, it surprises me to see those numbers when it came out.” Molina says one factor that may be underestimated, particularly in rural areas, is the lack of access to mental health services. She believes mental illness may be connected to some of the causes of maternal deaths, such as overdose and suicide. In fact, the task force’s 2016 report noted that chronic illness and depression often co-exist in patients. “It’s difficult to get psychiatric care for pregnant women or to a treatment facility for substance abuse,” Molina says. “It’s an issue across the state. It affects everybody. We need more mental health care across the board.” For one thing, there is a stigma attached to mental illness or substance abuse, and care for these issues aren’t readily available in rural areas, especially for patients without health insurance. Texas has the highest rate of uninsured in the country. In addition, women who are on Medicaid—

which pays for more than half of Texas births—are dropped from the program 60 days after delivery, leaving no access to post-partum care. While the significantly high maternal death rates seem to be decreasing, the sharp jump a few years ago is still of concern. Plus, there are risks that have increased with time as cultures change. “Right now, we have moms who are older, more women who have previous infections, and we’ve seen significant increases in obesity, in diabetes and in high blood pressure,” Hollier says. It doesn’t help that health facilities are becoming a thing of the past in some communities. At least 82 rural hospitals have closed and obstetric services are disappearing from rural facilities across the country, making it harder for women to access services near their home or have urgent care in the event of an emergency. In Texas, at least 14 hospitals have closed since 2013. While there aren’t many studies examining the impact this has had to mortality rates in rural Texas, those who work there understand its potential harmful effects. “Closing of rural hospitals is a huge problem,” Molina says. “A lot of those hospitals stop specialties before they close. When a woman can’t get care near her home, it increases the risks.” The more remote a hospital is, the more challenging it is to handle a birth. Limited resources, coupled with limited ambulance services in rural areas, could be disastrous for a mother and baby going into distress during delivery. SOLUTIONS ON THE HORIZON States such as North Carolina are making strides to reduce the maternal mortality rate and have closed the gap between black and white women. Texas officials hope to mirror that same success. There are two areas the Perinatal Advisory Council hopes to address in regards to rural areas: utilizing


telemedicine and implementing levels of maternal care. The council is creating criteria, based on ACOG recommendations, for this model. “What that does is standardize care within those levels and helps women go where they need to go to get risk-appropriated care,” Hollier says. “Rural hospitals have been a part of drafting what those rules look like. I think that’s an important piece of the puzzle.” Molina works at Rice Medical Center, which serves the 3,600 people in Colorado County and some patients from Austin and Wharton counties. She represents rural hospitals on the council. The key, Molina says, is to be able to identify who is going to be in trouble before she’s actively in labor. It is critical to have a plan to get them to an accommodating facility. It’s a framework already established for neonatal units. “So we know that when sick babies are in the hospital that are equipped to care for babies they do better,” Molina says. “In other states’ regional special centers with levels of care outlines, the mortality rate is lower. The idea is to create levels of care to guide centers to make it easier to transfer to hospitals based on [the] acuity of care they can provide.” The Perinatal Advisory Council meets six times a year, and the next report from the Mortality and Morbidity Task Force will be released in 2018. THE MOST VULNERABLE While only 11 percent of births were to black women, they make up about 29 percent of maternal deaths in the state. To tackle this disparity, the medical community recognizes they must understand and address social determinants that impact health. “We’re going to have to do that to be more successful,” Hollier says. “The recommendations that we

FIGURE 1: RATES OF PREGNANCY-RELATED HEMORRHAGE AND/OR BLOOD TRANSFUSION IN TEXAS BY RACE/ETHNICITY, 2012

Source: CHS Hospital Inpatient Discharge File, 2012. Prepared by: Office of Program Decision Support, FCHS, DSHS, 2016.

made in 2016 were really looking at access to care, at screenings and referrals for health services, and intervention to improve outcomes. I would really like to see the gap between African American and all other women go to zero.” But Marsha Jones, executive director at Dallas-based The Afiya Center, who advocates for reproductive justice and works to bring awareness about health disparities among black women, thinks closing the gap requires more radical action. “The issue is not understanding,” she says. “The issue is ‘do we have the political will to change it?’” Jones grew concerned about the status of black maternal health after reading mortality and disparities reports. She and her staff set out to make this a priority at The Afiya Center.

“The risks in rural areas are greater for women, especially women who are lesser resourced and black or in other ways marginalized,” Jones says. Jones points to the state’s handling of family planning services and limited access to Medicaid as having a disastrous effect on black women’s health. “Texas legislators’ refusal to expand Medicaid has led to the closing of many hospitals in the more rural areas, so this decreases access to health care because of limited financial resources and transportation,” she says. Texas Gov. Rick Perry began cutting family planning programs in 2011, which resulted in the closing of 25 percent of family planning clinics. Jones says this impacted black women the most.

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FIGURE 2: RATES OF PREGNANCY-RELATED HEMORRHAGE AND/OR BLOOD TRANSFUSION BY TEXAS COUNTY IN 2012

Source: CHS Hospital Inpatient Discharge File, 2012. Prepared by: Office of Program Decision Support, FCHS, DSHS, 2016.

“It also impacts how and when women will enter into care during pregnancies which limits the abilities for care providers to identify conditions that can be treated ongoing or throughout pregnancies,” she says. “After birthing, if these same barriers to care exist, women cannot remain in care to continue treatment started while pregnant. When you limit resources to your most vulnerable population the outcomes can very easily result in death or serious illness.” She adds, “When these clinics closed it caused many women to lose temporary access while having to seek out other, and for some, permanent access until they became pregnant or some other health conditions, which most

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likely meant using the ER as your first resource. Closing these clinics under the guise of preventing abortions carries a much bigger burden and we are seeing the results now.” Jones says cultural incompetency and racism dictate how black women are treated, even when they have resources and access to care. “It is centered in racial discrimination” she says. “It is a direct result of how black women are received when they enter the health care system that is riddled with bias about Black women’s bodies.” Jones says she hasn’t seen the results she would like to see, but her organization has suggested some strategies. It begins with using a reproductive

justice framework. This includes allowing women to decide when and if she will have a child, and the conditions in which she’ll give birth. Social support to improve maternal outcomes include safe environments, healthy communities and freedom from fear of any form of violence, she says. “Using this framework would allow for the centering of black women’s voices, experiences, traditions, leadership and ingenuity to create solutions and strategies to address this issue,” Jones says. “(We should) look at the successes of other states as best practices for Texas legislators to replicate, creating policy that’s effective.”

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ince early 2009, Texas A&M University’s Telehealth Counseling Clinic, in Bryan, Texas, has been offering free mental health counseling sessions to underserved individuals in the rural Brazos Valley Region. The program began in Leon County to the north and, over time, expanded to four other surrounding counties. The clinic and five community centers, one in each county, are outfitted with big screens and HIPAA-secure high definition teleconferencing equipment. Doctoral students, under the supervision of a licensed psychologist, sit in front of the screens and connect to patients at the centers through a business class internet service paid for by the communities. Patients are required to travel to their local community center for at least one counseling session using video, said psychologist Carly E. McCord, PhD, an assistant professor at the Texas A&M School of Public Health and the director of clinical services at the Telehealth Counseling Clinic. But many of the followup sessions are done from patients’ homes. The same reasons that keep patients from traveling an hour or more to Bryan, where most mental health providers in the region are located, prevent them from traveling five minutes down the road to their community center, she said. “They don’t have a vehicle or they don’t have funds to put gas in their vehicle or their physical health is so poor that it is difficult for them to leave the house,” said McCord. But there is a problem with doing home sessions, she said. They’re done by phone and without video. That’s because many patients do not have high speed internet access and so cannot support video on their personal devices. And many are low income and cannot afford a smart phone that could handle video through a software application. Not all patients need to make visual contact with their counselors at every session, but it certainly helps, said McCord. “That’s why the digital divide is so important,” she said. DEFINING BROADBAND Telehealth includes much more than patients videoconferencing with remote health care providers. It allows medical specialists at regional and urban hospitals to examine patients in rural hospitals and emergency physicians to provide care to patients being transported by ambulance. It allows general practitioners to virtually examine patients at home and nurses to monitor the vital signs of a patient discharged from the hospital. Health care providers can exchange health information, from health records to x-rays and CT scans, while patients can access their health care provider’s patient portal to check on test results. But the necessary bandwidth—the amount of data

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that can be transmitted in a fixed amount of time—is not always available in rural America. Telehealth usually requires broadband, which, at its most basic definition, means the ability to move large amounts of data over telecommunications networks quickly. However, "large” and "quickly" are relative terms, and their meaning has changed over time as the uses for broadband have expanded and become more sophisticated. Three years ago, the Federal Communications Commission redefined fixed broadband, which is typically delivered over copper wire, cable or fiber and, in some of the more remote areas of the country, over fixed wireless. That’s where the signal travels wirelessly between a fixed transceiver installed in a home or building and a telecommunication company’s transmission towers. The FCC raised the minimum download speed from 4 Mbps to 25 Mbps—megabits per second—and the minimum upload speed from 1 Mbps to 3 Mbps. In a stroke, the agency more than doubled the number of rural households without broadband access at the time, from 20 percent under the former standard to 53 percent under the new one. The FCC does not set a minimum broadband standard for mobile wireless service. Satellite technology currently delivers less than 25/3 Mbps, and the latest generation of mobile wireless that connects cell phones and other mobile devices, 4G LTE, can provide speeds of 10 Mbps down and 1 Mbps up, according to the agency. (Open Signal, a company that measures mobile network performance, says the latest data show an average download speed for 4G LTE of about 14 Mbps.). 4G LTE is fast enough for video conferencing and for monitoring the biometric data of home-bound patients, said Patty Upham, director of FirstHealth Home Care in North Carolina, whose nurses monitor patients for the first 60 days after discharge from FirstHealth’s health system. “4G has been very successful,” said Upham. “Patients can have a blood pressure cuff near their bed, a scale in their bathroom and a tablet on their kitchen table, and it all connects wirelessly through bluetooth.” The tablet then transmits the data over the 4G mobile wireless network to FirstHealth Home Care’s secure website. Nurses also conduct video visits with patients using the tablets. But 87 percent of rural Americans are “without access to LTE services with a minimum advertised speed of 10 Mbps/1 Mbps,” according to a 2016 FCC report. That compares to 45 percent of Americans in urban areas. Even where fast mobile wireless service is available, it is not fast enough for a physician to listen to breath sounds or perform a remote eye exam, according to experts. For the kinds of telehealth that require the quick transmission of a lot of data, fixed broadband is necessary. But there again, the digital divide, while shrinking, is firmly in place. According to the 2016 FCC report, 39


87 percent of rural Americans are without access to high speed mobile LTE service.

percent of rural Americans lack access to fixed broadband with the latest minimum standard of 25/3 Mbps, compared to four percent of Americans in urban areas. “We have a moral and statutory obligation to do better,” said then FCC chairman Tom Wheeler in a statement when the report was released. BROADBAND AND RURAL HEALTH To better understand what the digital divide means for health care, in 2016 the FCC launched a mapping platform that tracks both broadband access and measures of health for every state and county. Some of the key findings from the FCC’s 2017 analysis include: •

Rural counties are 10 times as likely as urban areas to have fewer than 50 percent of households with fixed broadband access and more than 10 percent of residents with diabetes. More than 60 percent of rural Americans live in counties that have high burdens of chronic disease, such as diabetes, as well as low broadband

connectivity. Hospital stays that could have been prevented with appropriate care are 150 percent higher in counties with the lowest broadband access.

The FCC reports and the mapping platform looked at household broadband access, but Brian Whitacre, a professor in the agricultural economics department at Oklahoma State University, wanted to know what kind of access hospitals and other health care providers, such as clinics and medical practices, have to high speed broadband. After all, much of the most sophisticated telehealth services are between regional or urban hospitals and their rural counterparts. The latest government data available is from 2014, and Whitacre found that once again, there is a large digital divide. Forty-two percent of metropolitan hospitals had access to download speeds over 50 Mbps, while 22 percent of non-metro hospitals had access to such fast broadband, he found. “It’s going to be really hard for rural hospitals to provide

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all the data files they need as part of an information exchange if they don’t have that 50 Mbps connection,” said Whitacre. “Transferring CT scans and X-rays is going to take a lot longer with these slower connections, and some facilities are still running on less than 3 Mbps, which is crazy.” The gap was even wider for clinics, private practices and other non-hospital health care facilities. Fifty-six percent of those health care providers in metro-areas had access to fast download compared to 10 percent in nonmetro areas. “It’s possible that things have improved for health care providers since 2014,” said Whitacre, “but nobody is gathering that data on an aggregate level now.” BARRIERS TO RURAL BROADBAND Rural America’s local telecommunication companies are doing their best to close the digital divide, said Joshua Seidemann, vice president of policy for the NTCA, the rural broadband association which represents nearly 850 independent, community-based telecommunications companies. Fiber provides the highest speeds, said Seidemann. And the biggest barrier to providing all rural customers with fast broadband is the cost of running that fiber, he said. His organization’s members typically have 5,000 to 20,000 customers who live in areas with a population density of maybe one person per square mile. “Sometimes you’re going to have to run a mile of fiber for just one household,” said Seidemann. “Or you might have a cluster of houses, but there can be miles in between those clusters.” In addition, the terrain can be challenging, he said. NTCA members serve 40 to 50 percent of rural America, said Seidemann, with the rest served by the big national companies, such as AT&T, Verizon and Frontier. But those publicly traded companies, who answer to shareholders, are going to invest in areas where they will earn the greatest return, and that is not in small communities in rural America, he said. “If you are served by a publicly traded company and you live in a rural area, by and large you will not have access to robust broadband in the manner that you would have if you were served by our members,” said Seidemann. Residents in rural communities do not have much choice of provider, according to FCC data. Only 13 percent of rural Americans have more than one service provider offering fixed broadband, compared to 44 percent in urban areas. FEDERAL & STATE PROGRAMS On January 8 at the American Farm Bureau Federation Convention in Nashville, Tennessee, President Trump

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Dr. Brian Whitacre, a professor in the agricultural economics department at Oklahoma State University, wanted to know what kind of access U.S. health care providers have to high speed broadband. His research found a wide digital divide between urban and rural hospitals and clinics. (Photo courtesy of The Journal Record)

signed an executive order to streamline the permitting process for building broadband facilities on federal land. “Those towers are going to go up and you’re going to have great, great broadband,” said Trump. He signed a second executive order directing Secretary of the Interior Ryan Zinke to develop a strategy for expanding rural broadband. The executive orders implemented some of the recommendations in a report released the same day by the president’s Task Force on Agriculture and Rural Prosperity. The task force identified rural broadband as fundamental to promoting rural prosperity and recommended the formation of a rural broadband strategy. It also recommended revising federal regulations to encourage private investment and reviewing the effectiveness and duplication of federal broadband programs. But Tim Marema, the editor of the Daily Yonder, a nonprofit online news site focused on rural issues, called the report “long on rhetoric and short on specifics” in a recent article. The federal government has several programs to help close the digital divide. The Rural Health Care Program helps eligible health care providers pay for telecommunications services, including broadband. It has two parts. The Healthcare Connect Fund, established in 2012, provides a flat rate,


65 percent subsidy to eligible healthcare providers. The Telecommunications program, established in 1997, ensures that eligible rural health care providers pay no more than their urban counterparts for telecommunications services. The FCC has $400 million a year to spend on the Rural Health Care Program, an amount that hasn’t changed since its inception. But in 2016, for the first time, the program was oversubscribed. “So everyone had to have a pro-rata reduction in the amount of money that they otherwise would have gotten because demand exceeded supply,” said Virginia attorney Jeffrey Mitchell, who specializes in FCC policies. The FCC has the authority to increase the cap, said Mitchell, but he thinks that is unlikely. “There is a sense now in a fiscally conservative environment that the FCC probably wouldn’t do that unless they got some clear indication on a bipartisan basis that Congress wanted the FCC to increase the amount of money available in this program,” he said. “We have been hearing from many in the health care community about the situation and are carefully considering the appropriate response,” said FCC spokesperson Katie Gorscak in an email. The Connect America Fund is another, much larger FCC program to bridge the digital divide. That pot of money, capped at $4.5 billion annually, goes to the telecommunications companies providing voice and broadband connectivity in rural areas. However, carriers receiving money from the program do not have to meet the FCC’s latest minimum standard for broadband. Instead, they are required to provide only

speeds of at least 10 Mbps down and 1 Mbps up. Under the program, AT&T rolled out fixed wireless internet service with those speeds in 18 states between last April and September. In addition, “There is some concern that the money in the Connect America Fund is not enough to do what it is supposed to do,” said Mitchell. On January 16, FCC Chairman Ajit Pai addressed those concerns, proposing to add more than $500 million to the fund. It is now up to his fellow commissioners to negotiate amongst themselves and vote on whether to adopt some form of the order. Twenty-two states have programs that support carriers providing telecommunications services, including landline phone service, wired broadband, fixed wireless and mobile wireless, in high cost and remote areas, according to the Maryland-based National Regulatory Research Institute, the research arm for utility regulatory commissions of the fifty states and the District of Columbia. “State high cost funds generally support the smaller rural carriers. It is not going to the cable companies. The cable companies are outside this formula,” said Sherry Lichtenberg, principal researcher at the institute. New York has begun a particularly aggressive program to bring high speed internet to every state resident by the end of 2018. Launched in 2016, New York’s Broadband for All is using $500 million from bank settlements after the financial crisis for matching grants to companies who will build networks providing broadband speeds of at least 100 Mbps (download) in most places, and 25 Mbps in the most remote, underserved parts of the state.

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5G wireless is not the solution for rural broadband access, say many experts. 5G “requires huge [population] density and will only be offered in those places that have high levels of density and short hops between a fiber and the consumer device.”

THE FUTURE Meanwhile, several bills have been proposed in Congress that seek, in one way or another, to expand high speed broadband across rural America. For example, the Advancing Innovation and Reinvigorating Widespread Access to Viable Electromagnetic Spectrum Act, or the AIRWAVES Act, would encourage the government auction of more spectrum—the invisible airwaves over which signals and data travel—that would make next generation wireless broadband networks, called 5G, possible. AT&T, Verizon and T-Mobile are currently piloting 5G. The bill also would require that 10 percent of auction proceeds go to building wireless broadband infrastructure in rural communities. But 5G itself is not the solution for rural access, say many experts, including Blair Levin, a non-resident senior fellow at the Brookings Institution, a think tank in Washington, D.C., and a former FCC official in the Obama administration where he oversaw the development of a National Broadband Plan. That’s because 5G, even though it is wireless, still needs fiber between a provider’s base station and its transmission towers. Politicians may be excited about 5G, but Wall Street recognizes that “5G is extremely expensive to do, it has a very uncertain demand curve, it requires huge [population] density and will only be offered in those places that have high levels of density and short hops between a fiber

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and the consumer device,” said Levin. “Well, that’s not rural America.” In the meantime, the FCC is considering setting a speed benchmark for mobile wireless networks for the first time, at 10/1 Mbps. In addition, the FCC is considering deeming an area to be served by broadband if it has access to such mobile wireless service, even if 25/3 Mbps fixed service is not available. The result of both proposals, if approved, would be to suddenly increase the number of households considered to have access to “broadband” without any changes to actual service. In other words, the FCC could define away much of the problem with a stroke of the pen. In reaction to that prospect, a group of eleven organizations committed to accessible broadband kicked off a social media campaign in January to convince the FCC not to make such a change. Its message appears to have gotten through. On January 18, FCC Chairman Pai distributed a draft report on broadband deployment to his FCC colleagues, which concluded that “mobile broadband service is not a full substitute for fixed service.” “It appears that the FCC has reconsidered its plan to view mobile and fixed broadband as equivalent,” said Lichtenberg. “This would maintain the status quo.” The FCC has not yet scheduled a vote on the proposals, but industry observers say it is possible the vote will take place in mid-February.

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BEHAVIORAL HEALTH //

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RECOVERY ROOM Closure of state hospital proves a boon to mental health services in Southwest Georgia BY ERICA HENSLEY

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n 2013, 35-year-old Ryann Hancock was busted for manufacturing methamphetamine. She lived in Dawson, Georgia, her life had been off track for some time, and she lost custody of her son after being charged with a felony. That same year, 80 miles away in Thomasville, the 45-year-old Southwestern State Hospital was shut down by the state. It housed about 100 people, about half with serious developmental disabilities, and had a few beds for people in crisis – usually psychosis or substance abuse – who needed a few days of stabilization. But it was old, expensive to operate and a contradictory model to the state’s recent push to transition mental health and developmental disability services to communities per a 2010 agreement with the U.S. Department of Justice. After Southwestern's long-term residents were moved to group homes across the state, some of the hospital’s funding was reallocated to regional service providers for 24-hour a day crisis centers—like the 34-bed unit at Aspire Behavioral Health, the Albanybased agency that provides mental health and substance abuse services to eight southwest Georgia counties. The windfall enabled Aspire to help patients who might once have been hospitalized, says director Kay Brooks, and to manage their needs in ways that favor prevention over institutionalization. Brooks says successful communitybased support relies heavily on people like Ryann Hancock, who is now a certified peer specialist at the agency she credits with saving her life. Hancock works every day to give people the hope that took her thirtyfive years to find. She leads detox groups and teaches newly hired staff how to interact with patients in crisis. She advocates at the state capitol and community board meetings. If there’s a recovery event anywhere in the state, she’s there. “There used to be jails, institutions or death,” she said, “but now recovery happens.”


The criminal charges against Hancock were heard by the Pataula Judicial Circuit drug court, which supervised her substance abuse recovery and insisted she be treated for post-traumatic stress disorder resulting from childhood abuse. She got a job doing administrative work for a lawyer, who found her ability to relate to his clients highly effective. She fought hard to get her son back, and regained custody last year. When Hancock was offered a job by Aspire, she initially assumed she wasn’t qualified because her past was such a mess. But then she thought about things from the client’s perspective. “If I’m in a hole, I don’t need anybody else to tell me I’m down here, because I got myself here,” Hancock said. “I only need someone to show me the way out, and who better to show you the way out than somebody that’s been in that same hole?” A lot has changed in the southwest corner of Georgia since the Thomasville hospital closed three years ago. “Of course the volume of patients we see has increased,” said Brooks. The mix of patients is also different, with more patients in need of emergency intervention and more who need long-term help. Georgia’s Department of Behavioral Health and Developmental Disabilities has previously partnered with regional agencies like Aspire to provide outpatient services for mental illness and substance abuse, but since 2013 the southwestern region has created three fixed crisis centers with inpatient beds and four crisis teams on wheels, as well as mobile case management squads. The centers are staffed by professionals who offer outpatient services as well. Between Aspire’s beds and the Thomasville and Valdosta agencies’ 48 more, the sprawling 24-county region has more than doubled it’s capacity for behavioral health crisis beds from the former state hospital’s facility, and they’re easier to get to.

After a felony arrest for manufacturing methamphetamine and court-ordered substance-abuse treatment, Ryann Hancock ended up with a job offer at Aspire Behavioral Health in Southwest Georgia. Her peer counseling work is devoted to helping people overcome stigma and begin recovery.

People are admitted because they need to be stabilized during a psychotic episode, for detox, and for a range of other purposes. The goal is to stabilize patients close to their home and family, in a location they can revisit for continued care. Each location also offers a few shorterterm temporary observation beds as well. When a child or adult in a remote area poses a threat to themselves or others, specially trained staff speed to help in one of four well-equipped mobile units. The goal of the mobile units, says Brooks, is to intervene before hospitalization is necessary and to connect people with services that can help. Satellite locations are spread across the eight-county region, so most people don’t have far to go. The closest public psychiatry hospital is in Columbus, but Brooks has sent only 22 patients there in the past two years. Back when people in crisis were routinely committed to Southwestern State Hospital for short stays, they were discharged into communities where gaps in care meant they would almost inevitably have another crisis

and boomerang back to the hospital. “They could fall in a deep hole in between Thomasville and Albany without any follow-up care,” Brooks said. Access to care is better now, Brooks says, but the fact is that poverty, addiction, and untreated health issues continue to plague southwest Georgia as they do other American communities. “I don’t know a family who hasn’t been impacted by tragedy, mental health or substance abuse issues,” she said. Unfortunately, it’s hard for people to acknowledge these problems. Hancock says that a big part of her peer counseling work is devoted to helping people overcome stigma and begin recovery. “My skeletons didn’t just come out of the closet, they came out and did a Vegas show with a Rockettes line!” she said. As shameful as it was to have her name trumpeted on the nightly news for weeks, the circus surrounding her arrest helped her move past the humiliation and start a new life. “I don’t say I was arrested, I say I was rescued,” she said. “That day was the beginning of my life.”

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Bringing Care Closer to Home

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HEALTH EDUCATION //

INDIANAPOLIS, IN (news.uindy.edu) - A summer camp for high school students interested in learning about the field of physical therapy will be available at the University of Indianapolis in Summer 2018. The program will be hosted by MICI-AHEC on the University’s campus and include several field trips.

NATION The AHEC (Area Health Education Centers) program was developed by Congress in 1971 to recruit, train and retain a health professions workforce committed to underserved populations. Today, 56 AHEC programs with more than 235 centers operate in

almost every state in the nation.

TUSCALOOSA, AL (www.wbrc.com) - The University of Alabama’s College of Continuing Health Sciences will partner with five regional AHECs in 2018 to convince high school students from rural parts of the state to consider pursuing health care careers and to practice in places similar to their hometowns. DENVER, CO (patch.com) - AmeriCorps members will work with the six regional AHECs in Colorado and several regional partners across the state to organize community responses to the opioid crisis. The mission of the Colorado AmeriCorps Community Opioid Response Program, or CORP, is to assist communities in implementing strategies to reduce the impact of opioid abuse by coordinating community, youth and provider education events. BOISE, ID (idahobusinessreview.com) - Katrina Hoff, director of Idaho AHEC, was honored with the Idaho Rural Health Hero Award at the Idaho Rural Health Association’s annual meeting on Nov. 7. Hoff was recognized for her efforts in helping the University of Washington secure grant funding to grow the Idaho program from one statewide center based in Boise to three regional centers in north, southeast and southwest Idaho.

PITTSFIELD, MA (www.berkshireeagle.com) - The Berkshire Area Health Education Center reached out to people trying to quit smoking at the inaugural Body, Mind & Soul Health Expo in Pittsfield, Mass. Silvana Kirby, director of Medical Interpreting Training at Berkshire AHEC, also recruited individuals who might be interested in learning how to be medical translators in the county. LAS VEGAS, NV (www.vegaspbs.org) - Desert Meadows AHEC’s CampMED, a three-day immersion experience designed to stimulate students’ interests in science and health care, will return on July 19-21. The program, held at the University of Nevada, Las Vegas, is for students entering the ninth grade in the fall. HOUSTON, TX (txaheceast.org) - Texas AHEC East is working in a coalition with Cities Changing Diabetes— Houston, the Texas Department of State Health Services and the National Association of Chronic Disease Directors to implement the Centers for Disease Control and Prevention’s National Diabetes Prevention Program to prevent or delay Type 2 diabetes in Houston. LUBBOCK, TX (www.wtxahec.org) - West Texas AHEC’s new National AHEC Scholars program will launch in the fall of 2018 with a cohort of 25 trailblazers. The program will award college students up to $1,600 for a two-year commitment and will provide participants with experiences beyond the classroom through rural rotations and interdisciplinary learning. Deadline to apply for the fall semester is May 1, 2018. BURLINGTON, VT (vtdigger.org) - Vermont students in grades 9th through 12th are eligible to apply to one of eleven intensive summer programs through the Governor’s Institutes of Vermont, including a new Health and Medicine Institute in partnership with AHEC. MADISON, WI (news.wisc.edu) - A group of 75 University of Wisconsin–Madison students will hit the road this May to learn firsthand about the diversity of the state’s health care system. As a part of the Wisconsin Express program, which is organized by the Wisconsin AHEC, the students will travel to 11 Wisconsin communities to learn about public health dilemmas across the state.

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RHQ CONFERENCE CALENDAR C

heck out our list of rural health conferences, and let us know if you’re hosting one so we can help spread the word. Email us the details at RHQ@ttuhsc.edu.

Michigan Rural Health Conference March 3 - 4, 2018 Soaring Eagle Casino and Resort 6800 Soaring Eagle Blvd. Mount Pleasant, MI www.mcrh.msu.edu/events Colorado Hospital Association Rural Health and Hospital Conference March 7 - 9, 2018 Denver Marriott West 1717 Denver West Marriot Blvd Golden, CO cha.com Kentucky Rural Health Grant Writing Workshop March 15 - 16, 2018 Historic Boone Tavern Hotel 100 Main Street Berea, KY 40403 United cha.com

Rural Hospital Innovation Summit May 8 - 11, 2018 New Orleans Marriot Hotel 555 Canal Street New Orleans, LA www.ruralhealthweb.org

Wisconsin Rural Health Conference June 27 - 29, 2018 Osthoff Resort 101 Osthoff Avenue Elkhart Lake, WI www.wha.org

National Association of Rural Health Clinics 2018 Institute March 19 - 21, 2018 Hyatt Regency Riverwalk, 123 Losoya St. San Antonio, TX 78205 narhc.org

NRHA Health Equity Conference May 8, 2018 New Orleans Marriot Hotel 555 Canal Street New Orleans, LA www.ruralhealthweb.org

NWRHC Annual Conference March 26 - 28, 2018 Davenport Grand Hotel, 10 S Post Street Spokane, WA 99201 www.wrha.com

Rural Medical Education Conference May 8, 2018 New Orleans Marriot Hotel 555 Canal Street New Orleans, LA www.ruralhealthweb.org

NRHA SRHA Leadership Conference July 17 - 18, 2018 Omni Shoreham Hotel 2500 Calvert Street NW Washington, D.C. www.ruralhealthweb.org

19th Annual Rural Health Conference: Substance Abuse in Alabama April 25 - 26, 2018 Bryant Conference Center 240 Paul W Bryant Drive Tuscaloosa, AL rhc.ua.edu NRHA Annual Rural Health Conference May 8 - 11, 2018 New Orleans Marriot Hotel 555 Canal Street New Orleans, LA www.ruralhealthweb.org

40  RHQ | RuralHealthQuarterly.com

Oklahoma Rural Health Conference May 22 - 23, 2018 Embassy Suites Norman Hotel 2501 Conference Dr. Norman, OK 73069 www.rhao.org Telehealth at the Crossroads May 30 - 31, 2018 JW Marriott San Antonio Hill Country Resort & Spa 23808 Resort Pkwy San Antonio, TX 78261 www.crossroadsconference.us

NRHA Rural Quality and Clinical Conference July 18 - 20, 2018 Omni Shoreham Hotel 2500 Calvert Street NW Washington, D.C. www.ruralhealthweb.org Rural Health Clinic Conference September 25 - 26, 2018 Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street Kansas City, MO www.ruralhealthweb.org Critical Access Hospital Conference September 27 - 29, 2018 Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street Kansas City, MO www.ruralhealthweb.org


www.eagletelemedicine.com


HQ Plaza, 5307 West Loop 289, Suite 301 Lubbock, TX 79414

www.myamerigroup.com/tx

1-800-600-4441 (TTY 711) TXMKTAL-0558-15 12.15

Profile for Rural Health Quarterly (RHQ)

Rural Health Quarterly 2.1 - Winter 2018  

Rural Broadband Saves Lives • Vital Statistics are Vital to Research • Dramatic Increase in Rural STDs Plagues Mountain West • All About Acc...

Rural Health Quarterly 2.1 - Winter 2018  

Rural Broadband Saves Lives • Vital Statistics are Vital to Research • Dramatic Increase in Rural STDs Plagues Mountain West • All About Acc...