Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream?

At a food bank distribution event in rural Idaho, our Community Health Workers (CHWs) are conducting one of their free health screenings. Perhaps sensing that something is amiss within his body, a male in his late fifties reluctantly requests to be screened. Although his blood pressure and depression screening are normal, his hemoglobin A1c is quite high at 12.9% and his body mass index is above 35 Kg/M². He is uninsured and suspicious of the CHW’s affiliation with organized medicine. He is even more wary of the unwelcome news that he has uncontrolled diabetes mellitus. Without intervention, the impact of this new diagnosis will reduce the quality and length of his life. It will also likely further impoverish him.

While refusing a referral to our primary care team, he engages with the CHW and receives the offered education and information on how best to manage his condition. Through ongoing work with the CHWs, his health status gradually improves; this success has been achieved on his terms. We have met the patient where he is geographically, financially, and psychologically to foster success. By 18 months, his HbA1c now has lowered to 7.8%. While not perfect, if he can sustain this over time, he will likely live a more prosperous life. This is healthcare that reaches where traditional care does not. Despite its value, only the most progressive payers in the US recognize and compensate systems for this value.

Our health system consists of two Critical Access Hospitals and eight clinics scattered throughout a region in the rural and frontier portions of Northern Idaho. We have the daunting mission to provide primary care services for approximately 30,000 people dispersed over an area larger than the state of Massachusetts. This is a beautiful area with thick coniferous forests, mountains, deep river valleys, and rolling hills with prairie farms. The isolation culturally and geographically is more than can be measured on a map.

When I came to this rural community nearly three decades ago, like many of my physician colleagues, it was a sense of mission and purpose that made me strive to improve the health inequities in rural America.^1,2 Initially, I believed that with enough skill and knowledge, I could “fix” what was holding back the prosperity and health of our community. With time, that effort would bring me to the humble realization that my presence and skill, while important, was not enough alone to change the inequities in our rural communities. The best work I could offer as a physician could easily fail as a consequence of an imperfect system or a medical culture not aligned with creating value. As a result, for the next two decades of my career, I placed extra effort on building reliable healthcare systems and an aligned medical culture. A relentless focus on safety, quality, patient experience, and the development of team-based care has been impactful. Still, a substantial portion of outcomes for patients are not touched by these efforts as they are largely driven by factors beyond the walls of our hospital and clinics.

Although our clinics provide a range of services, they are not accessed by all; logistical or cultural barriers can put the care we offer out of reach. Like many groups in America, health outcomes and equity for rural America fall short. To address this, our health system has placed intense focus on creating an integrated, highly performing Patient Centered Medical Home (PCMH). Yet, to leverage the best health outcomes for this community, we must extend beyond the bricks and mortar of our PCMH to reach rural patients where they are. While CHWs alone do not fill the economic, educational, or other structural disparities in rural communities, they provide an accessible conduit to the resources that may be available to address these and leverage improved health outcomes for disadvantaged rural populations. Although rural resources are often limited, if they are not accessed, they have no impact.

The rural and frontier cultures of America can adversely impact healthcare delivery. It is not unusual for rural patients to make medical decisions highly influenced by personal experience, word of mouth, or concern for financial ruin. A large multi-center study referenced by a trusted physician may still not hold sway over the experience of a family member, a neighbor, or, in some cases, a CHW. The Covid-19 pandemic has demonstrated that this is now more universal as postings on social media may influence medical decisions often over the weight of scientific evidence. In all settings, CHWs can help bridge these cultural gaps. Furthermore, the healthcare workforce shortages that are being experienced as we move through the pandemic are likely to create an enduring challenge. To continue to provide the needed care access, the US healthcare system must adapt to learn and implement effective ways to leverage resources such as CHWs to deliver care.

It is at the rural livestock auctions, county fairs, food banks, community walks, home visits, and educational events where our CHWs engage our community. They identify and address social determinants of health. In our system, when a Social Determinant of Health is identified, our CHWs successfully complete referrals 68% of the time to address this. Our CHWs screen for and provide steps to manage undiagnosed, high-impact diseases such as cancer, hypertension, depression and diabetes. Through their sponsorship of community fitness programs and provision of education on topics such as mental health, chronic pain, and nuitrition, they can intervene close to the source of illness. For many, they are the pathway to access necessary care. If we are to move effectively to address health inequities, the high cost of care, and improve the health and overall experience of care in our rural communities, CHWs are an essential ingredient in that solution.

Since the CHW care model is not constrained by any specific design, those considering implementing a CHW program have some freedom to align the program to the needs of their population and their system. There are many areas where CHWs can be considered a valuable adjunct to care. These include strategies to align CHWs with population health goals and performance in Value Based programs for a system. If care access is a key driver of outcomes for a population, systems may consider aligning CHW with the primary care teams to improve outcomes. The ongoing public health crisis with Covid-19 also opens opportunities to utilize CHWs, often in collaboration with Public Health Departments, to impact outcomes for at risk populations. These are all areas that can be considered although, in the absence of a payment model that supports this work, it can be challenging to implement such programs.

Our journey to improve rural health outcomes has shown that the nontraditional elements of our care team, such as the CHWs, when coupled with highly reliable traditional healthcare, may be the missing elements to achieve healthcare value and equity for rural and frontier populations.³ Yet, lacking a payer model to support this, the cost of such programs is sustained only by grants and uncompensated, mission-driven investment by our rural not-for-profit health system. Partnership from the payers is essential, although often lagging or absent even though, along with patients, the payers are the primary beneficiaries of this low-cost innovation.

If we are to move forward to improve healthcare value and reduce inequities, it will take shared investment between payers and providers to create this success. The disruption that will be necessary to address health inequities in rural America requires this partnership.⁴ The creative work that happens beyond the bricks and mortar of our healthcare facilities requires new engagement and investment by all to make this a reality. It cannot spontaneously generate itself.

Declarations

Conflict of Interest

The author completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reports no significant conflict of interest, financial, or other exists.