ACCESS TO HEALTH SERVICES

Rural environments present unique challenges for health care access. There are often shortages of medical personnel in rural areas, as well as transportation and distance barriers to care and an increasing economic destabilization of rural health care services.

Since the mid-twentieth century, physicians have favored urban and suburban practice locations over rural areas. Physicians often need lucrative practices to repay high education debts, and they have been trained to use costly new technologies in diagnosis and treatment. Rural practice locations typically generate lower income for the physician and have fewer and older technology resources than urban and suburban locations. Modern medical school graduates are rarely well prepared to practice in rural environments. Consequently, rural communities suffer chronic physician shortages.

Physician shortages are most visible in primary prevention, diagnosis, and treatment. Public health systems and an array of alternative primarycare providers often fill in the gaps. Primary care may be provided by nurse practitioners, physician assistants, or home-health nurses. Practice locations include publicly or charitably subsidized comprehensive primary-care centers or categorical service clinics (e.g., prenatal care, family planning, immunizations) situated in central locations, mobile clinics, and in patient's homes. Specialty physician services (such as psychiatry or dermatology) may also be available through intermittent clinics in local facilities, such as health departments, churches, or schools.

Advances in medical technology, increasing costs, and market forces contribute to the economic destabilization of many rural health care systems. Small rural health care providers, especially hospitals, cannot afford the equipment and personnel necessary to treat the entire array of modern disease and injury. Coronary bypass surgery, artery repair, advanced trauma care, and other complex procedures require specialized medical teams, equipment, and facilities. Such resources are economically viable only in hospitals and surgical centers with high volumes of patients. Consequently, rural residents must often travel great distances to access more costly and complex levels of care.

Accessing complex care in urban medical centers often generates a patient perception that all rural hospital care is of lower quality. People with financial resources and the ability to travel tend to use distant urban centers even for less complex needs. The majority of patients admitted to rural hospitals are either too frail to withstand travel to distant hospitals or cannot afford either the travel or the cost of care in urban areas. Neither of these populations generates reimbursements adequate to cover the costs of services. Many rural hospitals and providers have diversified services to increase revenues. However, this strategy often fails and the hospital must close. Closures leave the very old, the disabled, and the poor with no access to hospital inpatient care, and the entire community is left with no access to urgent or emergency care. In addition, the area suffers from the significant loss of employment.

As costs increase, public and private insurers must struggle to control their expenditures. Prices, or fee scales, for services include the minimum estimated cost of providing each service. Price controls most severely affect rural health systems, especially home-based or mobile services. Because of the distances between service locations or patient residences, the cost per unit of service is often many times greater than in urban locations. For example, a home health nurse may visit five patients in a morning within an urban apartment building, while a nurse in a rural setting may visit only one or two patients, spending most of the time traveling. The urban nurse will be reimbursed for five visits and the rural nurse for two, yet the time expended is the same. Home-based services in rural areas must, therefore, access public or charitable subsidization in order to remain economically viable.

Low population density and greater travel times and barriers in rural areas affect service availability, the ability of people to get to those services, and the economic viability of the services. Lower population density also means a lower volume of patients and less provider income. Reduced fees and the refusal of insurers to pay for care often destabilize private professional practices in rural areas, leading to greater shortages of personnel.

The lower the population density and the larger the area over which the population is distributed, the fewer the available health services and the longer the travel distances to access these services. Emergency medical services in such areas are scattered over great distances and often staffed with volunteers who have other jobs. Emergency care for severe trauma or major acute illnesses, such as stroke and heart attack, may take longer to arrive than in other areas, causing increased morbidity and mortality. Poor roads or geographic barriers, such as mountains or rivers, magnify the effects of distance. More remote areas with the capacity to pay for the technology, such as western Kansas, are beginning to use telemedicine to improve access for primary care and certain specialty care, such as psychiatry and dermatology.

Susan W. Isaac

Heather Reed

(see also: Immunizations; Migrant Workers; Poverty and Health; Prenatal Care; Prevention; Primary Care; Public Health Nursing )