In October 2014, I attended the Oregon Rural Health Conference in Bend, OR. It was my third time attending the conference and I found a familiar forward-thinking amalgam of healthcare leaders from all corners of Oregon. Most conferences exude some level of enthusiasm for networking and new ideas, along with a feverish craze for self-serve coffee. However, this is always a unique conference experience for me. In addition to the usual conference tones, there is an extra helping of camaraderie, shared purpose and family that is inspiring for a medical student such as myself.
Presentations covered the areas of Alternative Payment Models (APMs), workforce issues, and data-driven process improvement approaches. While these topics are interesting in-and-of-themselves, looking at them through a rural lens also spurred my curiosity for how rural and underserved are defined, and how this affects the structure of the primary care system. Throughout the conference, I repeatedly heard the term, “Rural Health Clinic” (RHC), and wondered what they were and how they compare to Federally Qualified Health Centers (FQHCs).
Next year, as an Oregon Rural Scholar, I will spend 12 weeks in a clinical rotation at a family medicine clinic in a rural area of our state. I am honored to have such an opportunity, and I am incredibly excited to learn more about healthcare issues in rural settings by listening to patients, working with providers and getting to know the community. For now, however, I want to understand what rural means through healthcare policy and research lenses.
As with many of my ventures into systems learning, it helped to take a two-pronged approach—simultaneously appreciate the broad strokes of issues affecting rural populations and examine RHCs more narrowly. Down the rabbit hole I went, and after a blur of browser windows, papers and government websites, I learned a little more about a big part of the primary care delivery system.
Here’s the gist:
Broad Strokes of Rural Healthcare-Related Issues
1. Rural Demographics
Individuals living in rural areas face unique barriers to achieving and maintaining good health. Rural residents are of lower socio-economic status, older, less educated and in worse health than their urban counterparts. Rural Medicaid populations are demographically distinct from both rural low income uninsured and low income privately insured populations.
2. Rural Health Systems
Medicaid is a crucial component of rural health systems, providing coverage for one in six rural citizens, as rural residents are 50 percent more likely to be covered by Medicaid than their urban counterparts. Studies have found that preventable hospitalizations are more likely to occur in rural hospitals than urban.
3. Access/Utilization in the Rural Environment
These factors are compounded by a lack of providers and long travel distances to healthcare facilities. In addition, cultural aspects of rural life such as self-reliance and perceptions of healthcare need can affect and individual’s likeliness to access care. Previous studies have found that rural populations are more likely to have a usual source of care yet less likely to utilize preventive services than their urban counterparts.
What does “rural” really mean?
A variety of taxonomies have been applied by policy makers and healthcare researchers. However, most definitions were not created to explicitly address healthcare issues. All definitions use some measure of population density, and some incorporate information about travel distance and commuting patterns between different areas. Check out Table 1. (source: Smith, Dickerson, Wendel et al.)
Defining Health Services Access
Three main HRSA measures of health service access are used by health policy makers and health service researchers: Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA) and Medically Underserved Population (MUP). The definitions are applied to urban and rural areas alike, and are based on provider-to-population ratios along with other measures related to the health of a population (sources: Smith, Dickerson, Wendel et al., Medicare Benefit Policy Manual) .
So what are some differences between RHCs and FQHCs?
This is going to resemble alphabet soup, but read carefully and hopefully it will all make sense.
RHCs are primary care clinics that receive special reimbursement rates from Medicare and Medicaid, and were created to increase access to primary care services in rural areas. RHCs must be located in a Census Bureau-designated Non-urbanized Area (Table 1) and either a Medically Underserved Area (MUA) (Table 3), Health Professional Shortage Area (HPSA) (Table 2) or a Governor-designated Shortage Area. There are currently 69 RHCs in Oregon and 4,000 RHCs across the U.S.
An FQHC can be in either a rural or urban area, but must be located in a MUA or serve a Medically Underserved Population (MUP). One clinic cannot be simultaneously designated as both a FQHC and a RHC. Specific requirements apply to both RHCs and FQHCs for the types of service they must offer, sources of reimbursement they must accept and the number and type of providers they must employ. (source: Medicare Benefit Policy Manual)
Medicare and Medicaid payment methodologies differ between RCHs and FQHCs, but all are aimed at covering the cost of care. Additionally, by meeting these requirements, RHCs and FQHCs become eligible for grants that can help serve their respective populations.
Defining the Definitions
Learning about health systems and medicine simultaneously sometimes feels like learning the same thing in two different languages. Each language draws from a different set of rules and context. While it takes time to learn about a given subject through multiple perspectives, it is exciting to adapt the various definitions to one another. Talking with patients about the challenges of long travel distances to clinics or seeing the financial effects of an RHC or FQHC designation will bring greater meaning and thoughtfulness to definitions used in the literature or to make policy, and visa versa. Translating, integrating and reconciling different approaches to understanding an issue is not only a robust way of knowing, it’s also really fun!
Table 1. Different Definitions of Urban and Rural (source)
|Census Bureau||Urbanized Area (UA)||Census Tract and/or Census Block w/ ≥ 50k|
|Urban Cluster (UC)||Census Tract and/or Census Block w/ > 2,500 and < 50k|
|Nonmetropolitan Area (Rural) – Not a UA or UC||Not a UA or a UC|
|White House Office of Management and Budget (OMB)||Metropolitan Statistical Area (MSA)||County w/ core urban area of ≥ 50k|
|Micropolitan (Rural)||County w/ core urban area of ≥ 10k and < 50k|
|Neither (Rural)||County w/o above core urban areas|
|National Center for Health Statistics||Metropolitan||Definitions similar to the Census Bureau and OMB|
|USDA – Urban Influence Codes (UICs)||Stratifies OMB definition into a 12-point scale||County-based w/ city size and commuting characteristics|
|USDA – Rural Urban Continuum Codes (RUCC)||Nine-point scale||Counties stratified into six nonmetropolitan and three metropolitan area types, w/ distance to metropolitan areas and commuting info|
|Rural Urban Commuting Area (RUCA) codes||Up to 33 categories (although 3-4 categories are used)||Census tract-based using Census Bureau definitions w/ distance to metropolitan areas and commuting info|
Table 2. Health Professional Shortage Area (HPSA) types and their definitions (source)
|HPSA Type||Must meet ≥ 1 Type-specific requirement|
|Health Professional Shortage Area (HPSA)||Geographic Area||(3,500 : 1) ≤ (Pop : FTE PCP)|
|(3,500 : 1) > (Population : FTE PCP) > (3,000 : 1) + an unusually high need for PC services|
|Population Group||Pop group has access barriers preventing use of the area’s PCP|
|(Population of group : PCP) ≥ (3,000 : 1)|
|Members of Federally recognized American Indian tribes automatically designated|
|Facilities||Correctional institutions or non-profit and/or public facilities|
Table 3. HRSA definitions of underserved (source)
|Basic measure||IMU Index Components (all apply to both MUA and MUP designations)|
|Medically Underserved Area (MUA)||Index of Medical Underservice (IMU)||PCP/1k population|
|Infant Mortality Rate|
|% Population below FPL|
|Medically Underserved Population (MUP)||IMU score for a specific population group|
|% Population ≥ 65 years old|
Table 4. Basic RHC and FQHC designation criteria (source)
|Designating Agency||Qualification||Designating Agency||Qualification|
|Rural||Census Bureau||Non-urbanized Area||No requirements||Can be in an urban or rural area|
|Shortage Area Designation||HRSA||MUA, HPSA or Governor-designated Shortage Area||HRSA||MUA or MUP|