Rural Health Access & Workforce

1. Rural Health Access & Workforce Tim Size RWHC Executive Director for the Wisconsin Legislative Council Special Committee on Health Care Access August 24th, 2010

2. Outline of Talk • Who is RWHC? • What I Will & Won’t Focus On Today • Rural Context of Access Barriers • Examples of Workforce Issues • Potential Areas for Legislative Action

3. RWHC Mission & Vision Mission Rural WI communities will be the healthiest in America. Vision RWHC is a strong and innovative cooperative of diversified rural hospitals; it (1) is the “rural advocate of choice” for its Members and (2) develops & manages a variety of products and service Specifics re services available at http://www.RWHC.com

4. RWHC by the Numbers • Founded 1979 • Non-profit coop owned by 35 rural hospitals (net rev ≈ $3/4B; ≈ 2K hospital & LTC beds) • ≈ $7M RWHC budget (≈ 75% member sales/dues; 20% other sales, 5% grants) • 7 PPS & 28 CAH; 24 freestanding; 11 system affiliated

5. Insurance ≠ Rural Access to Care Workforce shortages hit rural first and hit harder: Currently Dental, Mental Health, EMS, Pharmacy & Primary Care Coming Our Way Nursing, General Surgery, & Local Hospitals

6. Topics I’m Not Focusing on Today Many issues critically impact rural health: • Wellness, Prevention & Public Health • National/State Health Insurance Reform • Quality & Cost of Care • Rural Provider Reimbursement • State Medicaid Budget • Fed. Expansion Community Health Clinics • Liability Reform, etc …….

7. Rural Health: Myths that Mislead • Rural residents don’t want to get care locally • Rural folks are naturally healthy, need less • Rural health care costs less than urban care • or Rural health care is inordinately expensive • Rural quality is lower; urban is better • Rural hospitals are just band-aide stations • Rural hospitals poorly managed/governed

8. Rural Health: Reality • Smaller and more disperse population = smaller businesses & providers that may struggle financially. • Patients assess quality of care higher in rural than urban facilities; academic studies show both higher and not quite as high depending on various factors. • On average, rural patients older, poorer and less healthy. • Patients less likely to have job based insurance. • Universities and colleges often don’t recruit or educate students to be practitioners in rural communities. • Lower payment rates to rural locations & primary care. • Some perceived sacrifices of rural life & practice.

9. Rural Age, Poverty & Behavior = Health  Source for above national rates: National Rural Health Association Web Site 2/23/10

10. Health Status by WI Counties Highest Quartile (white) Second Quartile (grey) Third Quartile (light green) Lowest Quartile (dark green) 3/4 urban counties better than average vs 1/3 rural counties. Calculated from the 2010 “Wisconsin County Health Rankings,” University of Wisconsin Population Health Institute

11. Rural Health in Wisconsin: Mixed Picture • Rural health less good than suburbs and small cities. • Rural Wisconsin & our inner cities often both face significant and, in many ways, similar challenges. • Variability exists across rural places… • In Wisconsin, rural populations fare better than rural populations in many other states • Retirees, vacationers, minorities, and migrant labor pose unique challenges for some places • Race/ethnicity remain strong predictors of health outcomes, in rural places and cities alike Source: Shaun Golding, Wisconsin Office of Rural Health Epidemiologist, 5/10

12. The Single Most Important Picture of Health in Wisconsin Our health is driven by factors that are more individual & immediate like our behaviors & health care, but also by factors that are more community wide & longer term like social and economic factors. Source: “The weights for the factors are based upon a review of the literature and expert input, but represent just one way of combining these factors.” Wisconsin County Health Rankings,University of Wisconsin Population Health Institute, 2010

13. Aging  = Demand  + Supply Flat Source: Dennis K. Winters, Chief, Office of Economic Advisors, Wisconsin, Department of Workforce Development, 9/07.

14. WI Physician Workforce - Now “There is currently a shortage of primary physicians in rural and inner-city areas of Wisconsin. Specifically, there is a shortage of primary care physicians in rural Wisconsin, and in Milwaukee in designated Health Professional Shortage Areas.” Source Text: “Who Will Care For Our Patients?” 2008 Update, by the Wisconsin Council on Medical Education and Workforce Source Map: Wisconsin Office of Rural Health and the Wisconsin Department of Health Services, 2/10

15. WI Physician Workforce - Forecast Most likely scenario shows a small shortfall in 2030 for all physicians, with the worst-case shortfall of 44%. However, for primary care physicians, the most likely scenario predicts shortfalls = 8% by 2020, and 14% by 2030. The worst-case shortfall is 57%. Source Text: “Who Will Care For Our Patients?” 2008 Update, by the Wisconsin Council on Medical Education and Workforce

16. Physician Distribution & Retention More even distribution and better retention needed to improve WI’s Physician population • Retention rates were highest for physicians who completed both Undergraduate Medical Education (UME) and Graduate Medical Education (GME) in the same state. Two thirds (66.2 percent) of the physicians who completed UME and GME in the same state stayed in state to practice. In terms of overall retention (i.e., UME and GME were completed in the same state), 8 of the top 10 states were in the South and West.* • Wisconsin above average at 70% (MN 72.2%) • 2009 WI Act 190 provides $1 Million for Rural Residency and Loan Assistance programs. Progress to be reported to Legislature. Source: 2009 State Physician Workforce Data Book, Nov. 2009, AAMC

17. One Success Story - We Need More Of Them! • WARM is dedicated to improving the supply of physicians in rural WI & health of rural WI communities. • Students receive extensive clinical training in rural Wisconsin during 3rd & 4th yrs. • Students learn to address medical issues that are unique to rural areas. • Only rural focused program in the nation that supports a student’s pursuit of any specialty.

18. Nursing: False Calm Before Storm • Recession has brought a temporary reprieve. • Some graduates currently unable to find open positions. • Retirements postponed a few years until the economy—and portfolios—pick up. • Many clinicians have seen their spouses lose their jobs and have increased hours to make ends meet. • Many hospitals have hiring freezes. • Once the economy improves, shortage roars back.  • Aging population will prove that the healthcare workforce shortage never really went away. Source: “Has the Nursing Shortage Disappeared?” by Rebecca Hendren at www.healthleadersmedia.com, 8/10/10:

19. Rural Wisconsin’s Dental Shortage • Need more sites providing dental services • Need more Dentists to accept Medicaid (low payment = low participation) • 2009 WI Act 356 provides $10 Million in borrowing for match for construction of a rural “dental education outreach facility” Source: Wisconsin Department of Health Services Primary Care Programs Shortage Designations

20. Recent Changes WI Regulatory Environment • 2009 WI Act 28 (Budget Bill) • Nurse Workforce Survey. • Bureau of Medical Board Services created. • Simplifying the process of obtaining a Wisconsin license for physicians already licensed in Minnesota. • MED 8.08 Physician Assistant Prescribing Rule. • Enabling the licensure of foreign-trained dentists. • Accepting more national exams for dentist licensure

21. What Do We Need to Do Now? (1 of 2) • Develop more rural residencies and training tracks. • Incent increase in proportion medical students at both schools who are from rural WI and likely to go back. • Major expansion in number of graduates of our two medical schools or develop a third medical school. • Grants for BSN prepared nurses to get Master’s degree. • Require workforce survey for all health professions at time of license application and assure capacity to use data to forecast our workforce supply and demand. • Enable the licensure of foreign-trained professionals until we can grow our own.

22. What Do We Need to Do Now? (1 of 2) • Simplify process of obtaining a WI license. • Increase reciprocal recognition of license for experienced health professionals. (e.g. Certified Nurse Assistants licensed in Iowa are needed in southwest WI, but haven’t been unable to readily gain certification by DHS.) • Work with the ARRA Multi-State Task Force (WI, IL, IN, IA, KS, MI, MN, MO, NE, SD) that will, through a collaborative process, develop an interstate licensure portability program. (Judy Warmuth at WHA is our representative.)

23. We Can’t Afford Further Delay

24. Rural Health Resources • RWHC Web: http://www.rwhc.com/ • Wisconsin Office of Rural Health: http://worh.org/ • For the free RWHC Eye on Health e-newsletter, email office@rwhc.com with “subscribe” on subject line. • Rural Assistance Center at www.raconline.org/is an incredible federally supported information resource. • The Health Workforce Information Center is RAC’s new “sister,” a comprehensive online library re health workforce programs, funding, data, research & policy www.healthworkforceinfo.org/ • Wisconsin State Journal Special Report: Rural Health: http://host.madison.com/special-section/rural_health/