Opportunities and Challenges Facing Rural Public Health Agencies - PowerPoint PPT Presentation

Opportunities and Challenges Facing Rural Public Health Agencies Kate Beatty & Michael Meit

Rural Health Disparities Trends in Age-adjusted Mortality Rate by Sex and Rurality, 1999-2015 500 450 400 350 300 250 200 150 100 50 0 Aggregate U.S. Nonmetro *Aggregate includes both Metro and Nonmetro. Both rates are inclusive of individuals ages 25-64. Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2015 on CDC WONDER Online Database, released December, 2016. Accessed at http://wonder.cdc.gov/mcd-icd10.html

Rural Health Disparities: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by rurality 20 18.9 18 16.1 15.9 15.2 16 14 11.3 12 11.0 Percent 9.7 1999 10 8.7 2010-2011 7.8 8 5.2 6 4 2 0 Large central Large fringe Small metro Micropolitan Non-core Ivey-Stephenson, A. Z. (2017). Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death — United States, 2001 – 2015. MMWR. Surveillance Summaries, 66.

Rural Health Disparities: Adult Smoking Cigarette smoking among persons 18 years of age and older by rurality 30 28.5 27.1 25.4 27.0 25 26.1 22.6 21.6 20 20.0 Percent 17.8 1997-1998 15 15.8 2010-2011 10 5 0 Large central Large fringe Small metro Micropolitan Non-core Meit, M., Knudson, A., Gilbert, T., et al. (2014). The 2014 Update of the Rural-Urban Chartbook. Retrieved from: https://www.ruralhealthinfo.org/resources/5696

Rural Health Disparities: Obesity Obesity among persons 18 years of age and older by rurality 40 36.9 34.9 35 30.6 29.0 30 27.4 25 Percent 22.7 1997-1998 20 20.5 2010-2011 19.8 19.1 17.7 15 10 5 0 Large central Large fringe Small metro Micropolitan Non-core Meit, M., Knudson, A., Gilbert, T., et al. (2014). The 2014 Update of the Rural-Urban Chartbook. Retrieved from: https://www.ruralhealthinfo.org/resources/5696

Rural Health Disparities: Activity Limitation Limitation of activity caused by chronic health conditions among persons 18 years of age and older by rurality 20 18.2 17.6 18 18.8 15.8 16 17.1 14.0 14 13.0 14.7 12 12.9 Percent 11.9 1997-1998 10 2010-2011 8 6 4 2 0 Large central Large fringe Small metro Micropolitan Non-core Meit, M., Knudson, A., Gilbert, T., et al. (2014). The 2014 Update of the Rural-Urban Chartbook. Retrieved from: https://www.ruralhealthinfo.org/resources/5696

NACCHO LHD Analysis by Geography • Investigate differences between urban and rural health agencies in terms of: – Funding sources; – Clinical and population-based service provision; and – Impact of health reform on health department’s role . • Identify opportunities and challenges facing rural public health agencies

Methods – Quantitative Analyses • Data – 2016 NACCHO National Profile of Local Health Departments data • Zip codes of LHDs were used to identify corresponding Rural Urban Commuting Codes (RUCA), which served as the measure of rurality – “Small rural” – Included census tracts with towns < 10,000 population and tracts tied to small towns – “Large rural” – Included census tracts with towns between 10,000 and 49,999 and census tracts tied to those towns through commuting – “Urban” – Included census tracts with towns > 50,000

NACCHO Profile Analysis – Small versus Rural Urban Large Rural Small Rural Total n(%) n(%) n(%) <50,000 224 (20.2) 205 (18.5) 680 (61.3) 1109 50,000-99,999 126 (40.9 136 (44.2) 46 (14.9) 308 100,000+ 438 (85.4) 58 (11.3) 17 (3.3) 513 Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

Methods – Quantitative Analyses • Variables Analyzed 1. Revenue sources – Local, state, Federal (direct and pass through), Medicare and Medicaid, private insurance, patient personal fees, non-clinical fees and fines, private foundations, other revenue sources 2. Population-based services – Epidemiology and surveillance, population-based primary prevention, regulations, inspections and licensing, other environmental and population-based services 3. Clinical services – Immunizations, screenings, treatment for communicable diseases, maternal and child health, and other services – LHD’s response indicated whether or not the service was performed directly by the LHD, contracted out by the LHD, or provided by others in the community independent of LHD funding

Methods – Qualitative Analysis  Several selection criteria were used to develop a list of potential health departments for the case studies. Expanding or State Medicaid Number of Geographic Case Study Type Reducing Expansion LHDs meeting Service Area Direct Services Status criteria Urban Health Department Urban Reducing Expanding 47 Micropolitan Large Rural Health Department Expanding Expanding 11 (Large Rural) Rural Small Rural Health Department Reducing Expanding 41 (Small Rural)  From the list of eligible health departments for each case study type, we intentionally selected health departments we thought may be able to highlight the diverging roles of public health agencies in urban and rural communities

Methods – Qualitative Analysis • We conducted interviews with representatives of the following health departments: – Urban – Louisville Metro Department of Public Health and Wellness (Kentucky) – Large Rural – Clinton County Health Department (Ohio) – Small Rural – Lincoln County Health Department (Washington)

Findings – Revenue Sources • Proportion of revenue by rurality Proportion of revenue Urban Large Rural Small Rural Sig. Local Sources 42.8 25.6 22.2 0.001 State Sources 15.7 21.1 19.3 0.001 Federal Pass Through 16.1 20.1 22.6 0.001 Federal Direct 2.7 1.0 1.0 0.001 Medicare/Medicaid 6.0 13.3 15.2 0.001 Private Insurance 1.1 2.9 3.4 0.001 Patient Personal Fees 1.3 2.7 2.7 0.001 Non-clinical Fees & Fines 8.8 6.0 2.9 0.001 Private Foundations 0.5 0.8 0.8 NS Other 2.8 2.5 3.7 NS  Urban HDs rely more heavily on local sources than large rural and small rural LHDs  Both large rural and small rural LHDs rely more heavily on state and federal pass through revenue than urban LHDs  The proportion of funds that came from clinical funding sources, including Medicare/Medicaid, private insurance, and personal patient fees were significantly higher for large and small rural HDs compared to urban LHDs.

Findings – Revenue Sources Local Health Department Revenues by Degree of Rurality Small Rural Large Rural Urban 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Local Sources State Sources Federal Pass Through Federal Direct Medicare/Medicaid Private Insurance Patient Personal Fees Non-clinical Fees & Fines Private Foundations Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

Findings – Service Provision • Clinical Services – In terms of services performed by the LHD directly, rural LHDs were more likely to provide immunizations, screenings, treatment of communicable diseases, and maternal and child health services than urban LHDs. • Population-based Services – In terms of services performed by the LHD directly, rural LHDs (both large and small) were more likely to report conducting communicable disease and infectious disease epidemiology and surveillance. – Urban LHDs were more likely to provide environmental surveillance.

Findings • Urban Health Department – Louisville Metro Department of Public Health and Wellness (Kentucky) – Louisville is a large city with three major hospitals and a strong FQHC that sees the majority of the remaining uninsured population, so the HD no longer needs to serve in the role of safety net provider – HD has transitioned away from providing direct clinical services to focus more on policy and systems change – HD has a strong local tax base which allows them to support these activities

Findings • Large Rural Health Department – Clinton County Health District (Ohio) – HD serves a population of 42,000 people with 11 full-time and 12 part-time staff – In collaboration with a consortium of LHDs in Ohio, Clinton County Health District has established a billing system for their immunization program • Since health reform, more individuals have become insured in Clinton County, but there continue to be access issues – Generating revenue from their expanded immunization program has helped sustain and expand other programs

Findings • Small Rural Health Department – Lincoln County Health Department (Washington) – HD serves a population of approximately 10,000 with 5 full-time employees – As a small agency with limited capacities, the Lincoln County Health Department has always provided fewer direct clinical services compared to larger rural agencies – HD has stopped providing immunizations, STD and HIV testing, instead leveraging their strong relationship with the public hospital district and other providers to ensure access to services – HD has transitioned to role of “convener” – however, noted that this was only possible due to their collaborative relationship with the hospital district, which all small rural LHDs may not have