Future of Rural Health Care: Factors Driving the Need for Change April 3, 2008 Brad Gibbens, Associate Director Center for Rural Health UND School of Medicine and Health Sciences Cooperstown Community Forum Cooperstown, ND

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Center for Rural Health • Established in 1980, at the University of North Dakota School of Medicine and Health Sciences in Grand Forks, ND • 5th oldest state rural health office • About 38 separate program and/or projects with 42 staff • 3 National programs (RAC, NRCNAA, Research Center) • Focuses on: – Education, Training, & Resource Awareness – Community Development & Technical Assistance – Native American Health – Rural Health Workforce – Rural Health Research – Rural Health Policy • Web site: http://ruralhealth.und.edu

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Presentation Objectives _____________________________________________

• General issues facing rural health • Maintaining access to quality health services • Availability of a health care workforce • Health care costs

CR H General Issues Facing Rural Health Rural America Population Providers

North Dakota

• 20% of U.S. population tends to have high proportion of over age 65

• 48th of 50 states high proportion of over age 65 and highest over age 85

• 2/3 of HPSAs are in rural areas • Workforce shortage

• Almost 90% of counties HPSA designated • Workforce shortage

Hospitals

• Majority are Critical Access Hospitals

Medicare Payment

• Tends to be lower in rural states

• 33/45 hospitals are CAHs (health care central) • 2nd lowest of 50 states, per enrollee • In top quartile of states on access, quality, and efficiency. (Commonwealth Fund, State Scorecard on Health System Performance.)

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Maintaining Access to Quality Health Services _____________________________________________ •

Sources of care: Where do we seek care in rural North Dakota o Critical Access Hospitals o Clinics (federally certified Rural Health Clinics – RHC and Community Health Centers – CHC or FQHC-look alike o Emergency Medical Services o Public Health and nursing homes

• Sustaining care: What helps to keep rural health care available and viable o Rural Hospital Flexibility Program – CRH, NDDH, NDHA o Rural Health Outreach, Network Development Planning, and Network Development grants – CRH http://ruralhealth.und.edu/ o Rural Assistance Center – CRH http://www.raconline.org/ o Health workforce efforts -- CRH o State Rural Health Association (forming)

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Flex Supported Networks

Board Training Health Information Technology Quality Improvement CAH Specialist Anesthesia Services

Diabetes Care Wellness Services Emergency Preparedness Hypertension Project

Health Occupations

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Availability of a Health Care Workforce _____________________________________________

• Healthcare Workforce Pipeline • Supply and Demand Features • ND Workforce Summit o Statewide meeting representing supply side (educators) and demand side (employers), along with policy makers, associations, and others o Committee system representing core Pipeline functions o Development of Area Health Education Center (AHEC) grant

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Health Care Workforce Pipeline

Wakefield, Amundson, and Moulton, 2006

EFFICIENCY

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International Comparison of Spending on Health 1980 – 2004 Average spending on health per capita ($US PPP)

Total expenditures on health as percent of GDP

7000

16

United States Germany Canada France Australia United Kingdom

6000 5000 4000

14 12

10

04

02

United States Germany Canada France Australia United Kingdom

0

19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04

20

00

20

20

96 98 19

19

19

19

19

19

19

19

19

19

94

2

92

0 90

4

88

1000

86

6

84

2000

82

8

80

3000

Data: OECD Health Data 2005 and 2006.

(Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006) 12

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North Dakota: Distribution of Health Care Expenditures by Service by State of Residence (in millions), 2004 % ND

$ ND

% US

$ US

Hospital Care 42% $1,533 38% $566,886 Physician and Other Professional 23% $866 28% $446,349 Drugs and Other Medical Non-durable's 15% $537 14% $222,412 Nursing Home Care 10% $387 7% $115,015 Dental Services 5% $174 5% $81,476 Home Health Care 0% $18 2% $42,710 Medical Durables 1% $55 1% $23,128 Other Personal Health Care 3% $124 4% $53,278 _______________________________________________________________ Total 100% $3,693 100% $1,551,255 Source: Kaiser Family Foundation State Health Facts

Mortality Amenable to Health Care

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Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* International Variation - 1998

State variation - 2002

150

134

129 130 132

100 75

88 88 81 84

88 92

97 97 99

106 107 109 109

115 115

119 110

103 84

90

50

Fr an ce Ja pa n Sp a Sw in ed en I Au ta ly st ra l Ca ia na da N Ne or w th er ay la nd s G re ec G er e m an y Ne Aus t w Ze ria al D an Un enm d ite ar d St k at es Fi nl an Un d ite Ire la d Ki nd ng do Po m r tu ga l

0

U.S. avg

10th

25th Med- 75th ian

90th

Percentiles

See Technical Appendix for list of conditions considered amenable to health care in the analysis. Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology. 14

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For more information contact: Center for Rural Health University of North Dakota School of Medicine and Health Sciences Grand Forks, ND 58202-9037 Tel: (701) 777-3848 Fax: (701) 777-6779 http://ruralhealth.und.edu

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