Susan M. Skillman

Health Status and Use of Services Among Families With and Without Health Insurance

In the last decade, the total number of uninsured persons in the United States has increased 24% to an estimated 17% of persons under 65 years of age.12 More than half of uninsured adults are employed, the majority belong to low-income families, and approximately one third of all uninsured individuals are under 18 years of age.3 The number of

The contribution of physicians, physician assistants, and nurse practitioners toward rural primary care: findings from a 13-state survey.

Background:Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages. Objectives:For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. Methods:A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and &khgr;2 testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location. Results:Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and after-hours call coverage (all P<0.001). Conclusions:Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.

WHO ENROLLED IN A STATE PROGRAM FOR THE UNINSURED : WAS THERE ADVERSE SELECTION ?

Managed care plans may hesitate to participate in programs for uninsured persons because they fear adverse selection, whereby only the sickest people or highest users would choose to join the program. We studied this issue in Washington States Basic Health Flan, a demonstration program that provides subsidized health insurance for families earning less than 200% of the poverty level. We interviewed people in three counties who enrolled in the program, and compared them to people in the same counties who were eligible but did not enroll. There were substantial differences between enrollees and eligibles in education, age, income, employment, race, and insurance status. In spite of these demographic and access differences, health status was remarkably similar for enrollees and eligibles, with the few significant differences favoring the enrollees. In addition, previous and subsequent use of health services was similar or lower for enrollees. The results for health status and utilization were similar across the three counties, even though the counties and the providers were quite different. We conclude that there is no evidence of adverse selection. This is welcome news for the health plans, but suggests that the BHP may not have reached those most in need of insurance.

Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI program as a case study.

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation’s most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals. The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

Health Information Technology Workforce Needs of Rural Primary Care Practices

PURPOSEnThis study assessed electronic health record (EHR) and health information technology (HIT) workforce resources needed by rural primary care practices, and their workforce-related barriers to implementing and using EHRs and HIT.nnnMETHODSnRural primary care practices (1,772) in 13 states (34.2% response) were surveyed in 2012 using mailed and Web-based questionnaires.nnnFINDINGSnEHRs or HIT were used by 70% of respondents. Among practices using or intending to use the technology, most did not plan to hire new employees to obtain EHR/HIT skills and even fewer planned to hire consultants or vendors to fill gaps. Many practices had staff with some basic/entry, intermediate and/or advanced-level skills, but nearly two-thirds (61.4%) needed more staff training. Affordable access to vendors/consultants who understand their needs and availability of community college and baccalaureate-level training were the workforce-related barriers cited by the highest percentages of respondents. Accessing the Web/Internet challenged nearly a quarter of practices in isolated rural areas, and nearly a fifth in small rural areas. Finding relevant vendors/consultants and qualified staff were greater barriers in small and isolated rural areas than in large rural areas.nnnDISCUSSION/CONCLUSIONSnRural primary care practices mainly will rely on existing staff for continued implementation and use of EHR/HIT systems. Infrastructure and workforce-related barriers remain and must be overcome before practices can fully manage patient populations and exchange patient information among care system partners. Efforts to monitor adoption of these skills and ongoing support for continuing education will likely benefit rural populations.

Nurse Practitioner Autonomy and Satisfaction in Rural Settings

Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice.

Faculty supervision of NP program practicums: A comparison of rural and urban site differences.

Abstract:Results of a survey of NP education programs were analyzed to describe factors influencing clinical placement of students in rural clinical rotations, methods used to evaluate NP students in their clinical rotations, and whether the frequency and type of faculty evaluations differed by urban or rural clinical sites.