Missouri Gov. Mike Parson gathered stakeholders and industry leaders for a Rural Health Care Summit in Bolivar early in December 2018, as lawmakers prepared for the 2019 legislative session.
Parson's budget for this year included more than $700 million in investments in infrastructure and rural health as part of a push for improved health care for rural Missouri called Reimagine Rural Health Care.
A year after the summit as part of this push, Parson and the Missouri Hospital Association have developed additional policy recommendations they hope to implement as part of next year's budget.
"The new policies build on 2019 accomplishments, which were assembled from core rural health challenges," an MHA news release states.
The goal of the summit was to identify working solutions to address the challenges and unmet health care needs of rural Missourians.
Attendees of the summit wanted to develop a set of recommended policy solutions that could help advance rural health without expending significant new amounts of energy, according to Dave Dillon, MHA vice president of public and media relations.
"The whole focus of that summit was to try to figure out, 'How do we do a better job of bringing health care to rural Missouri?'" Parson said in an online message released last week. "Two things we know have become important - one, to have broadband all across our state in all parts of rural Missouri; two, to build up our workforce so that workforce will be available to deliver those health service needs for the people in rural Missouri."
Mid-Missouri's rural health worries
Rural health is a concern for local health care providers.
St. Mary's Hospital in Jefferson City provides a clinic network that includes facilities that have received federal designations as rural health clinics, according to Jessica Royston, marketing and communications manager. They are intended to increase access to the hospital's primary care services for patients in rural communities.
All of the hospital's primary care clinics are recognized as Patient-Centered Medical Homes, which means they use evidence-based, patient-centered processes that focus on highly coordinated care and long-term, participative relationships, she said in an email to the newspaper.
"The (patient-centered) home is a model of primary care that combines teamwork and information technology to improve care, improve patients' experience of care and reduce costs," she wrote. "Medical homes foster ongoing partnerships between patients and their personal clinicians, instead of approaching care as the sum of episodic office visits."
Patients' care in the homes is coordinated across the health care system.
The hospital reaches 10 counties, and its rural health clinics serve Belle, Lake Ozark, Tipton and Versailles.
Rural health care providers at Jefferson City Medical Group were not available to be interviewed for this article. Capital Region Medical Center did not respond to media requests.
A new look at rural health
The Reimagine Rural Health 2020 agenda centers around infrastructure that supports health and health care, the health care workforce, and increased access to primary and behavioral health care, according to the MHA.
For the current year, the investments focused on 10 subjects, Dillon said. They were to expand or provide access to behavioral health services, primary care providers, care for substance abuse, quality health care, and telehealth and telemedicine. They were also to advocate for improved infrastructure, identify determinants of health, encourage innovative payment models, create partnerships and support workforce enhancements.
Stakeholders distilled the 10 subject areas down to three - strengthen infrastructure, invest in rural workforce development, and increase access to care and services, Dillon said.
"We're helping to build access for individuals who live in rural areas," he said. "(MHA is) working to get items in both the governor's recommended budget and the Legislature."
Three pathways to rural health
Many of the recommendations come at very low cost, Dillon said. They may include legislation, rule-making changes or budgetary items.
The MHA website provides a framework for Reimagine Rural Health at web.mhanet.com/reimagine-rural-health.
The site suggests infrastructure improvements to benefit rural health care would include improvements to rural roads, public transportation and broadband.
By expanding broadband in rural Missouri, lawmakers can create new opportunities for health care delivery, according to the site.
Beyond the benefits to rural businesses - such as agriculture or warehousing - expanded broadband could allow for remote home monitoring and direct-to-provider services.
"For states that are trying to serve rural populations, changing how they can practice has helped broaden access to primary care," Dillon said.
Expanded broadband will give rural Missourians access to specialists working outside their communities, and keep rural patients from having to travel for certain care. But rural Missourians also have to reach health care providers.
"Public transportation in rural areas can be sparse," the MHA website says, "and for rural residents with special needs, it can be nonexistent."
Leaders should support programs like HealthTran, which provides transportation to medical patients in south-central Missouri who otherwise have limited or no transportation and are forced to use expensive transportation options to meet health care appointments, according to ruralhealthinfo.org.
HealthTran has helped improve access and outcomes and reduced preventable emergency room visits, according to the site.
Data on the website show rides average about $3 per local trip and $81-$150 for round trips to reach specialists, depending on the distance.
Beneficiaries of the service include mostly elderly, disabled and Medicare/Medicaid-dually-eligible patients referred to the program by their health providers.
Of the program users, 33 percent are seeking mental health services, 26 percent have multiple conditions, 20 percent report other issues and 15 percent have diabetes.
The MHA website also cites hospital closures (14 rural Missouri hospitals since 2014) and poor roads as hurdles to access.
In May, TRIP (formerly The Road Information Program) released a report that found the state has the 13th worst rural roads in the nation. It found 21 percent of Missouri's rural roads are rated as poor, and 27 percent are rated as in mediocre condition.
During the 2019 legislative session, lawmakers approved a $301 million bond issue to pay for repairing or replacing 215 (mostly) rural bridges.
The MHA suggests the state improve funding to improve access to rural broadband and pursue a federal initiative announced in early October. The Rural Opportunities to Use Transportation for Economic Success (ROUTES) initiative.
The initiative is to consider using U.S. Department of Transportation discretionary funding and other financial opportunities to improve nationwide outcomes for rural transportation infrastructure.
The initiative is to help rural stakeholders pursue DOT grants and financial products and instruct them in how to use data-driven approaches to access them. ROUTES includes a transportation infrastructure council that is to identify critical rural transportation concerns and coordinate efforts to overcome them.
Developing the health care workforce
The Parson administration has emphasized workforce development - the second area of focus - since the governor took office.
In January, he signed three executive orders streamlining the Missouri Economic Development Department and reduced its size. He moved five agencies out of Economic Development - the Division of Energy, Division of Workforce Development, the Missouri Economic and Research Center, the Public Service Commission and the Office of Public Counsel.
The moves will allow Economic Development to focus on bringing jobs to Missouri and ensuring the state has a quality workforce, he said.
"Building the health care workforce in rural Missouri is a natural extension of the governor's jobs program," the MHA website states. "Moreover, there are added benefits of strengthening the rural health care workforce, including maintaining and ensuring rural Missourians can receive health services locally."
This year's investments supporting the health care workforce included $501,000 for loan repayments (for providers in Health Professional Shortage Areas), $425,000 for primary care physician training (for telehealth psychiatry), creation of a $10 million "Fast-Track Workforce Grant" program, $18.9 million for "Missouri Excels" (to develop or expand employer-driven education), and "Missouri One Start," which consolidates initiatives supporting new business.
MHA suggests targeted investments would improve access to primary care while reducing the primary care workforce shortage in rural Missouri.
Suggested policies include:
Participation in the Interstate Medical Licensure Compact for physicians. The IMLC is an agreement (currently between 29 states) that allows licensed physicians to practice in multiple states, if the physicians meet agreed upon eligibility requirements.
Expand the capacity of advanced practice registered nurses to address the health care needs of rural Missourians.
Increase spending for health workforce development initiatives.
Expand and increase funding of the Fast Track workforce development initiative.
Clarify how physicians and certified registered nurse anesthetists will manage the use of controlled substances in surgical anesthesia.
Ensure health insurance companies promptly decide whether to add new physicians or other practitioners to their provider networks.
"A rural community fortunate enough to recruit a practitioner is ill-served by long delays in getting them credentialed and compensated for treating rural residents," the MHA said.
Lack of access
The third area of focus - improving access to primary and behavioral health care in rural communities - is essential to ensuring people lead healthy lives, receive the care they need and are able to manage chronic conditions.
Six rural Missouri counties lack a primary care provider. Seventy-one lack obstetrics coverage.
The MHA released a report in August 2018 - "Primary Care Physicians: Missouri Workforce Update" - that shows rural Missourians are doubly disadvantaged because they are among the poorest communities in the state. Rural populations in Missouri are also older than urban populations. In 2020, 21.2 percent of Missourians in rural counties will be 60, according to the report. In 2030, the percentage is expected to have increased to about 25.1 percent.
And the Missouri Department of Health and Senior Services considers 99 of the state's 101 rural counties as Primary Medical Care Health Professional Shortage Areas (PMCHPSA). Those areas are considered to have shortages of primary medical care, and dental or mental health providers, according to the report. They have too few primary care providers, high infant mortality, high poverty and large elderly populations.
Compared with urban residents, people living in rural areas have higher rates of smoking, obesity, cancer and heart disease; shorter life expectancy; and lower percentages of rural residents have high school diplomas.
Unfortunately, only 21.5 percent of medical school graduates remain in Missouri after graduation.
The state needs more clinicians to address behavioral health concerns in rural Missouri, according to the MHA. If clinicians agree to practice in PMCHPSAs, they can participate in loan repayment assistance programs through the National Health Service Corps.
Federal Medicaid funding is also available to support behavioral health by using state waivers. The waivers could increase Missouri's capacity to deliver high-quality behavioral health services in rural counties.
The federal government created a program two years ago - the Certified Community Behavioral Health Clinics (CCBHC) - to begin dealing with the dearth of mental health services offered in rural communities, according to Brent McGinty, president and CEO of Missouri Coalition of Community Behavioral Healthcare. The coalition was formed to enable Missouri citizens to have access to quality mental health care, while improving their quality of life.
The clinics are required to provide nine services - mental health crisis services, screenings and assessments, patient-centered treatment planning, outpatient mental health and substance use services, primary care screenings, case management, psychiatric rehabilitation services, peer and family support, and intensive community-based mental health care for veterans and members of the Armed Forces.
The clinics move away from an old medical model and is closer to an urgent-care model, McGinty said.
"Everyone gets to be seen when they need to be seen," he said. "It may be that you (are in a crisis and) just need someone to talk to. We can get you to see a psychiatrist today."
With 15, Missouri has the most CCBHCs in the nation. It also leads the country by offering 200 access points (or clinic sites), McGinty said.
A proposed budget item for the upcoming year has the state Department of Mental Health looking to expand the clinics to sites in Cape Girardeau and Sikeston, he added.
The MHA suggests these policies for the upcoming budget cycle:
Add CCBHC organizations in more rural areas - thereby providing more caseworkers.
Develop and promote health literacy and patient education initiatives serving rural areas.
Conduct or commission an analysis of the role of social determinants of health in impeding access to care.
Increase funding to reduce waiting lists for services for developmentally disabled.
Clarify state government's intent to allow use of telemedicine to comply with state and federal standards.
"These ideas are interconnected," Dillon said. "They are built around what we've seen in other states."