Keith J. Mueller

Fatal motor vehicle crashes: variations of crash characteristics within rural regions of different population densities

OBJECTIVE While it is known that motor vehicle crash (MVC) fatality rates are inversely related to population density, there has been no description of which crash variables are related to population density. The purpose of this study was to describe crash characteristics of fatal MVCs and to determine which crash characteristics are related to population density. DESIGN This is a retrospective review of fatal accident reporting system (FARS) records. They represent four different population density regions over a 5-year period in a four-state midwest region. RESULTS There were 10,932 people in 6,318 vehicles who were involved in 4,970 fatalities. Occupant fatality rates per 100,000 persons were inversely related to population density. The variables related to lower population density were more light and heavy truck types, more frequent alcohol use and higher levels of intoxication, more frequent crashes that are noncollisions on less heavily traveled roads, more frequent crashes on gravel surface types, more frequent occupant ejection, and delayed medical care. CONCLUSION Rural areas are not homogenous in terms of fatal MVC crash characteristics. By analyzing fatal MVC crash characteristics in regions with different population densities, many crash variables were found to be related to population density. By understanding which characteristics about fatal MVCs are related to population densities, different interventions could be targeted to different rural populations.

Health Status and Access to Care Among Rural Minorities

This paper provides a review of the scholarly and applied literature published between 1970 and 1993 on health and health care access problems among racial and ethnic minority group members living in rural U.S. areas. Results on the distribution of specific illnesses and diseases, and utilization of medical services are summarized for two major minority groups—African Americans and Hispanic Americans. Findings generally document the expected pattern of rural and minority disadvantage. A review of the conceptual and methodological limitations of existing research suggests that research does not yet permit any clear understanding of the underlying structures and processes that give rise to racial health disparities. Very little is known about the health of rural minorities living in some areas of the country, for example, the west north central United States (Kansas, Missouri, Nebraska, Iowa, North Dakota, South Dakota and Minnesota).

Rural Health Policy

“You’ve come a long way, baby.” This well-known slogan comes from advertisements for Virginia Slims cigarettes, introduced with great fanfare as cigarettes for women. Seeing women smoke was one more indication in the 1960s and 1970s of the cracking of societal barriers to equal treatment for women. Some progress. As we know now better than in the 1960s and 1970s, getting more women to smoke was to confuse apparent equity and the best interests of the target population. Is the same thing true of striving for equity in health care services? Is it in the best interests of rural residents to have the same system as that available to urban residents? Are we making the cigarette example mistake of confusing equal access to the same delivery system with the ultimate goal of improved quality of life?

Tracking the effectiveness of health care reform in China: A case study of community health centers in a district of Beijing

OBJECTIVES To track and evaluate the effectiveness since 2007 of urban health reform policies in Beijing that provided universal health insurance and strengthened local government-owned community health centers (CHCs). METHODS Pre- and post-reform data on outpatient visits, staff, and financial statements among all CHCs in a district in Beijing were analyzed by the nonparametric Kruskal-Wallis method. Field surveys were also conducted to supplement the statistical analysis. RESULTS The post-reform data showed a substantial increase in outpatient visits at the district level, but the number of outpatient visits was flat at the CHC level. In addition, short-term CHC responses to reform policies, such as employment growth, and operating expense-to-revenue ratio, have not been cost effective. CONCLUSION The overall increase in outpatient visits at the district level, including at large hospitals, conceals the fact that CHCs within the district were unable to attract a greater number of patients. The lack of operational efficiency in the process of establishing and transforming CHCs may put the primary care system at financial risk in the long run. Well-synchronized policy measures should be considered in future reforms, especially in shaping the behaviors of patients, CHCs, and physicians.

Continuing effects of Medicare Part D on rural independent pharmacies who are the sole retail provider in their community

BACKGROUND The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established funding to allow Medicare beneficiaries to enroll in plans providing outpatient prescription drug coverage beginning in January 2006. The Medicare Part D program has changed the means by which beneficiaries purchase prescription drugs, impacting the business operations of pharmacies. OBJECTIVES To describe the experiences of rural independently owned pharmacies that are the sole retail pharmacy in their community 1 year after implementation of Medicare Part D, in order to learn if the initial financial and administrative problems associated with the implementation of the program in 2006 resolved over time. METHODS A semistructured interview protocol was used in telephone interviews with 51 pharmacist owners of rural sole community pharmacies in 27 states who were identified through a random sampling process. RESULTS The sole community pharmacists interviewed continue to face challenges directly related to Medicare Part D. Dealing with Part D plans and working with patients during enrollment periods remains administratively burdensome. Reimbursement amounts, complexity of dealing with multiple plans, and timeliness of payments continue to be cited as problems which could threaten the viability of independently owned pharmacies who are the sole retail providers in their communities. CONCLUSIONS Actions should be considered to help sole community pharmacies deal with the ongoing administrative and financial challenges of Part D. To ensure full choice for rural Medicare beneficiaries and full access to pharmaceuticals through the ongoing presence of a local pharmacy, the development of a mechanism to structure prescription reimbursement so that drug acquisition costs and related overhead are covered and a reasonable profit margin provided should be considered. Further study is needed to determine how existing policies and regulations can be modified to ensure reasonable access to pharmacy services for rural Medicare and Medicaid beneficiaries.

The March to Accountable Care Organizations--How Will Rural Fare?.

PURPOSE This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). METHODS ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. FINDINGS Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. CONCLUSIONS Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural-relevant ACO-performance measures and provide necessary technical assistance to rural providers and organizations.

The magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions.

Using data from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, we examined the magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs). An estimated

Uninsured hospitalizations: rural and urban differences.

9.5 billion in charges incurred in rural hospitals nationwide in 2002 was found to be associated with hospitalizations due to ACSCs. Our findings suggest that the smaller a rural hospital, the greater the portion of its financial resources used to treat patients with ACSC. Regional variation in ACSC-related hospital charges is generally consistent with the geographic variation in the populations economic status and primary care physician supply-residents of the South region have the poorest access to primary healthcare. In summary, smaller rural communities spend more of their healthcare resources on avoidable hospital inpatient care than do larger rural communities, leaving smaller rural communities potentially fewer resources to spend on preventive and primary healthcare. Health intervention programs and health policies should be designed to increase access to and utilization of appropriate preventive and primary healthcare in rural areas, especially in small and remote communities.

Trends in Community Pharmacy Counts and Closures Before and After the Implementation of Medicare Part D

CONTEXT Few studies have examined hospitalization patterns among the uninsured, especially from the perspective of rural and urban differences. PURPOSE To examine whether the patterns of uninsured hospitalizations differ in rural and urban hospitals and to identify the most prevalent and costly diagnoses among uninsured hospitalizations. METHODS We conducted a cross-sectional analysis of the Healthcare Cost and Utilization Projects National Inpatient Sample representing a total of 37,804,021 hospital discharges, with 4.9% of them generated by uninsured persons in 2002. We compared demographic and clinical characteristics and the proportion of frequent and costly diagnoses by rural and urban hospitals. We used multiple logistic regression models to examine the relationship between preventable conditions and rural and urban hospitals among uninsured hospitalizations. FINDINGS Uninsured persons discharged from rural hospitals were more likely than their urban counterparts to be working-age adults (82% vs 79%) and to reside in a ZIP code area with a median household income of less than

Correlates of health insurance coverage: evidence from the Midwest.

35,000 per year (56% vs 26%). Rural uninsured hospitalizations were more likely to be for preventable conditions than were urban uninsured hospitalizations (P < .001). The proportion of total hospital charges related to preventable hospitalizations was 15.5% in rural hospitals versus 10.0% in urban hospitals. CONCLUSIONS The patterns of uninsured hospitalizations in rural and urban hospitals were different in many ways. Providing adequate access to primary care could result in potential savings related to preventable hospitalizations for the uninsured, especially for rural hospitals.