geography and the u.s. federal office of rural health ... · • rucas include county, census tract...

Geography and the U.S. Federal Geography and the U.S. Federal Office of Rural Health Policy Office of Rural Health Policy

Rural Health Research CentersRural Health Research Centers

ESRI International Health Users GIS ConferenceESRI International Health Users GIS ConferenceChicago, IllinoisChicago, Illinois

20052005

Michael ShambaughMichael Shambaugh--Miller, Ph.DMiller, Ph.D..The Rural Policy Research Institute Center for Rural Health PoliThe Rural Policy Research Institute Center for Rural Health Policy Analysis cy Analysis

University of Nebraska Medical CenterUniversity of Nebraska Medical Center


The Rural Health Research Center The Rural Health Research Center (RHRC) Program is designed to help (RHRC) Program is designed to help policy makers, both in Washington and policy makers, both in Washington and throughout the Nation, better throughout the Nation, better understand the problems that rural understand the problems that rural communities face in assuring access to communities face in assuring access to health care for their residents. health care for their residents.


The Centers study critical issues facing The Centers study critical issues facing rural communities in their quest to rural communities in their quest to secure adequate, affordable, high secure adequate, affordable, high quality health services for their quality health services for their residents. residents.

The Centers' research findings inform a The Centers' research findings inform a wide audience of National, State, and wide audience of National, State, and local decisionlocal decision--makers concerned with makers concerned with rural health. rural health.


Each year, specific research topics Each year, specific research topics for the Centers are selected jointly for the Centers are selected jointly by the Research Center Directors and by the Research Center Directors and the policy staff of the Office. the policy staff of the Office.


Eight Centers Eight Centers have have cooperative cooperative agreements agreements with the Office with the Office for FY2005for FY2005--2008 2008 •• five General five General

Centers Centers •• three Analytic three Analytic

CentersCenters

ÊÚ

ÊÚÊÚ

ÊÚ

ÊÚ

ÊÚ

ÊÚ

ÊÚNCRHRPAC

NORC

MRHRC

WWAMI

WICHE

RURPI-CRHPA

UMRHRC

SCRHRC

ORHP RHRC'sAnalyticÊÚGeneralÊÚ

ORHP RHRC's Type

South Carolina Rural Health Research Center, University of South Carolina, Columbia, S.C.• Topic of concentration: Health disparities

Maine Rural Health Research Center, University of Southern Maine, Portland, MA.• Topic of concentration: Rural behavioral health

Upper Midwest Rural Health Research Center, University of Minnesota, Minneapolis, MN.• Topic of concentration: Quality of care in rural areas

Rural Health Research General CentersRural Health Research General Centers

Western Interstate Commission for Higher Education (WICHE) Center for Rural Mental Health Research, Boulder, Co.• Topic of concentration: Mental health

Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Rural Health Research Center, University of Washington, Seattle, WA.• Topic of concentration: national rural health workforce

research

Rural Health Research General CentersRural Health Research General Centers

National Opinion Research Center (NORC) Walsh Center for Rural Health Analysis, Bethesda, MD.

• Topic of concentration: Impact of Medicare Policies on Rural Communities

•• Current and past research includes:Current and past research includes:Analysis of the impact of disproportionate share (DSH) payment Analysis of the impact of disproportionate share (DSH) payment structure options on rural hospitalsstructure options on rural hospitalsAssessment of public health infrastructure in rural areas. Assessment of public health infrastructure in rural areas.

Rural Health Research Analytic CentersRural Health Research Analytic Centers

North Carolina Rural Health Research and Policy Analysis Center, University of North Carolina, Chapel Hill, N.C.

• Topic of Concentration: Federal Insurance Programs (Medicare and Medicaid) and Their Effect on Rural Populations and Providers

• Past and current research includes:Describing Geographic Access to Physicians in Rural America Using Statistical Applications in GISDevelopment of a New Methodology for Dental Health Professional Shortage Area DesignationImpact of The Medicaid Budgetary Crisis on Rural Communities: A 50-State Survey



http://www.shepscenter.unc.edu/research_programs/rural_program/mapbook2003/index.html



http://www.shepscenter.unc.edu/research_programs/rural_program/maps/maps.html


Map Categories

Defining "Rural"Demographics of Rural America

Health Status IndicatorsRural Hospitals and Skilled Nursing Facilities

Critical Access HospitalsHealth Workforce SupplyServices and Programs

North Carolina Maps

Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, University of Nebraska Medical Center, Omaha, NE.

• Topic of concentration: Medicare: Impact of payment and quality policy on the delivery of health care in rural areas

•• Past and current research includes:Past and current research includes:Creating a GIS of All Rural U.S. PharmaciesCreating a GIS of All Rural U.S. PharmaciesDefinition of Rural in the Context of MMA Access Standards for Definition of Rural in the Context of MMA Access Standards for Prescription Drug Plans. Prescription Drug Plans. Health Services at Risk in "Vulnerable" Rural PlacesHealth Services at Risk in "Vulnerable" Rural PlacesA Rural Perspective Regarding Regulations Implementing Titles I A Rural Perspective Regarding Regulations Implementing Titles I and II and II of the Medicare Prescription Drug, Improvement, and Modernizatioof the Medicare Prescription Drug, Improvement, and Modernization Act n Act of 2003 (MMA).of 2003 (MMA).An Analysis of Availability of An Analysis of Availability of Medicare+ChoiceMedicare+Choice, Commercial HMO, and , Commercial HMO, and FEHBP Plans in Rural Areas:FEHBP Plans in Rural Areas: Implications for Medicare ReformImplications for Medicare Reform


Examples of Quick Response and Examples of Quick Response and Long Range ResearchLong Range Research

Rural impact of the Medicare Rural impact of the Medicare Modernization Act of 2003.Modernization Act of 2003.

Development of the Rural Development of the Rural -- Urban Urban Commuting Area classification Commuting Area classification schema.schema.

Medicare Modernization Act of 2003:Medicare Modernization Act of 2003:What Did The Government Want?What Did The Government Want?

Original legislation did not define Original legislation did not define urban, suburban or rural.urban, suburban or rural.

The definition used would establish The definition used would establish the number of beneficiaries falling the number of beneficiaries falling under each level of the access under each level of the access standards for each service region.standards for each service region.


Thus, the definition of rural in the Thus, the definition of rural in the final rule adopted by the Centers for final rule adopted by the Centers for Medicare and Medicaid Services Medicare and Medicaid Services (CMS) will determine the application (CMS) will determine the application of the access standards to rural of the access standards to rural beneficiaries.beneficiaries.


The proposed rule defined rural as The proposed rule defined rural as any ZIP code with fewer than 1,000 any ZIP code with fewer than 1,000 persons per square mile.persons per square mile.

Figure 1: Rural Areas as Defined by the TRICARE Retail Pharmacy Program

Note: Alaska and Hawaii not to scale

Source: ZIP Code population classifications from #MDA906-03-R-0002, DoD, 2003. Population data from U.S. Census, 2000. ZIP code spatial files based on U.S. Census ZIP Code Tabulation Areas, 2000.Cartogrraphy: RUPRI Center for Rural Health Policy Analysis, 2004.

Classifications by Person per Square Mile (ppsm)Rural - less than 1,000 ppsm

Suburban - 1,000 to 2,999 ppsm

Urban - more than 3,000 pppsm

Classifications by Person per Square Mile (ppsm)

Other Rural Definition OptionsOther Rural Definition Options

Office of Management and BudgetOffice of Management and Budget•• Bureau of the CensusBureau of the Census•• Rural is everything that isnRural is everything that isn’’t Metropolitant Metropolitan

Rural Rural –– Urban Commuting AreasUrban Commuting Areas•• U.S. Department of Agriculture in cooperation U.S. Department of Agriculture in cooperation

with ORHP / HRSA.with ORHP / HRSA.•• A scale based upon overall population, largest A scale based upon overall population, largest

community size, and commuting patterns.community size, and commuting patterns.

Figure 2: Rural Areas as Defined using the Office of Management and Budget (OMB) Category of Nonmetropolitan, 2003

Note: Alaska and Hawaii not to scale

Source: U.S. Census Bureau, Census 2000 and OMB, 2003.Cartography: RUPRI Center for Rural Health Policy Analysis, 2004

Rural-urban classificationUrban/suburban (metropolitan counties)

Rural (micropolitan and non-core based statistical area counties)

Rural-urban classifications based on OMB categories


Under the access standards in the MMA, Under the access standards in the MMA, 30% of rural Medicare beneficiaries do not 30% of rural Medicare beneficiaries do not have to be included within 15 miles of a have to be included within 15 miles of a retail pharmacy.retail pharmacy.

Though counterintuitive, the more Though counterintuitive, the more generous the definition of rural, the more generous the definition of rural, the more beneficiaries are excluded from the 15beneficiaries are excluded from the 15--mile access standard.mile access standard.

Rural and Urban/Suburban Per Tricare

11,105,917

25,980,972 7,794,292Urban Beneficiaries

Rural Beneficiaries

30 Percent of RuralBeneficiaries

Rural and Urban/Suburban Per OMB

29,329,715

7,756,894

2,327,068

Urban Beneficiaries

Rural Beneficiaries


Rural and Urban/Suburban Per RUCA

26,169,706

10,916,903

3,275,071

Urban Beneficiaries

Rural Beneficiaries


#

#

## #

#

## #

##

### #### # #

# # ####

# # ##

# #

# ## ## ## #

## ##### # # ## ## #

## # # #

# ##

# ## # #### ### ## # #

## # #

# ###

#

#

## #

# #

# ##

##

##

#

Figure 5: Hypothetical areas that must be served, using TRICARE definition of rural, assuming drug plans

contract with largest chain pharmacies in a multi-state region

Map constructed as follows:1. Top three chains identified by number of outlets in each state (none in North Dakota).2. All outlets plotted.3. All outlets buffered at 15 miles.4. All ZIPS pulled for which any part was within the 15 mile buffer (liberal allowancesince criteria is "on average").5. Resulting areas contained 70% or rural elderly population, thus criteria was achieved without needing any additional ZIP codes.

Source: #MDA906-03-R-0002, DoD, 2003Cartography: RUPRI Center for Rural Health Policy Analysis, 2004.

Chain pharmacy locations#

Urban-suburban areas

Sevice areas covering 70% of rural elderly

Remaining rural areas

Medicare Modernization Act of 2003:Medicare Modernization Act of 2003:What Did The Government Get?What Did The Government Get?

The final rule maintained the TriThe final rule maintained the Tri--Care definition of rural but through Care definition of rural but through discussion with the research discussion with the research community agreed to implement it at community agreed to implement it at the state not regional level as the state not regional level as originally planned. originally planned.

Rural Rural -- Urban Commuting AreasUrban Commuting AreasThis collaborative project between Health Resources and Service Administration's (HRSA's) Federal Office of Rural Health Policy (FORHP), the Department of Agriculture's Economic Research Service (ERS), and the WWAMI Rural Health Research Center was funded by the ERS and FORHP. (Principal Developers: Richard Morrill, PhD; John Cromartie, PhD; and Gary Hart, PhD)

SHORT DEFINITION• RUCAs include county, Census tract or ZIP code classification schemes that utilizes the

standard Bureau of Census urban area and place definitions in combination with commuting information to characterize all of the above spatial entities regarding their rural and urban status and relationships.

Latest RUCA Version 2.0 (July 2005), based on 2004 ZIP codes (there are 41,928 cases) and 2000 Census commuting data.

• Further ZIP Code methodology information:http://www.fammed.washington.edu/wwamirhrc/

Further Census tract methodology information:

• http://www.ers.usda.gov/briefing/rural/ruca/rucc.htm

Further county level methodology information:• http://www.ers.usda.gov/Data/RuralUrbanCommutingAreaCodes/

http://www.fammed.washington.edu/wwamirhrc/http://www.ers.usda.gov/briefing/rural/ruca/rucc.htm

Rural Rural -- Urban Commuting AreasUrban Commuting AreasVersion 2.0 RuralVersion 2.0 Rural--Urban Commuting Areas (RUCAs) Urban Commuting Areas (RUCAs)

11 Metropolitan area coreMetropolitan area core: primary flow within an : primary flow within an urbanized area (UA) urbanized area (UA) 1.0 No additional code1.0 No additional code1.1 Secondary flow 30% to 50% to a larger UA1.1 Secondary flow 30% to 50% to a larger UA

22 Metropolitan area high commutingMetropolitan area high commuting: primary flow : primary flow 30% or more to a UA30% or more to a UA2.0 No additional code2.0 No additional code2.1 Secondary flow 30% to 50% to a larger UA 2.1 Secondary flow 30% to 50% to a larger UA

33 Metropolitan area low commutingMetropolitan area low commuting: primary flow : primary flow 10% to 30% to a UA10% to 30% to a UA3.0 No additional code 3.0 No additional code

UA=Urbanized AreaUA=Urbanized AreaUC=Urban Cluster UC=Urban Cluster

Rural Rural -- Urban Commuting AreasUrban Commuting Areas4 Micropolitan area core: primary flow within an Urban Cluster o4 Micropolitan area core: primary flow within an Urban Cluster of 10,000 to f 10,000 to 49,999 (large UC)49,999 (large UC)4.0 No additional code4.0 No additional code4.1 Secondary flow 30% to 50% to a UA4.1 Secondary flow 30% to 50% to a UA4.2 Secondary flow 10% to 30% to a UA4.2 Secondary flow 10% to 30% to a UA

5 Micropolitan high commuting: primary flow 30% or more to a lar5 Micropolitan high commuting: primary flow 30% or more to a large UCge UC5.0 No additional code5.0 No additional code5.1 Secondary flow 30% to 50% to a UA5.1 Secondary flow 30% to 50% to a UA5.2 Secondary flow 10% to 30% to a UA 5.2 Secondary flow 10% to 30% to a UA

6 Micropolitan low commuting: primary flow 10% to 30% to a large6 Micropolitan low commuting: primary flow 10% to 30% to a large UCUC6.0 No additional code6.0 No additional code6.1 Secondary flow 10% to 30% to a UA 6.1 Secondary flow 10% to 30% to a UA

7 Small town core: primary flow within an Urban Cluster of 2,5007 Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 to 9,999 (small UC)(small UC)7.0 No additional code7.0 No additional code7.1 Secondary flow 30% to 50% to a UA7.1 Secondary flow 30% to 50% to a UA7.2 Secondary flow 30% to 50% to a large UC7.2 Secondary flow 30% to 50% to a large UC7.3 Secondary flow 10% to 30% to a UA7.3 Secondary flow 10% to 30% to a UA7.4 Secondary flow 10% to 30% to a large UC 7.4 Secondary flow 10% to 30% to a large UC


Rural Rural -- Urban Commuting AreasUrban Commuting Areas8 Small town high commuting: primary flow 30% or more to a 8 Small town high commuting: primary flow 30% or more to a small UCsmall UC8.0 No additional code8.0 No additional code8.1 Secondary flow 30% to 50% to a UA8.1 Secondary flow 30% to 50% to a UA8.2 Secondary flow 30% to 50% to a large UC8.2 Secondary flow 30% to 50% to a large UC8.3 Secondary flow 10% to 30% to a UA8.3 Secondary flow 10% to 30% to a UA8.4 Secondary flow 10% to 30% to a large UC 8.4 Secondary flow 10% to 30% to a large UC

9 Small town low commuting: primary flow 10% to 30% to a small 9 Small town low commuting: primary flow 10% to 30% to a small UCUC9.0 No additional code9.0 No additional code9.1 Secondary flow 10% to 30% to a UA9.1 Secondary flow 10% to 30% to a UA9.2 Secondary flow 10% to 30% to a large UC 9.2 Secondary flow 10% to 30% to a large UC

10 10 Rural areas: primary flow to a tract outside a UA or UCRural areas: primary flow to a tract outside a UA or UC10.0 No additional code10.0 No additional code10.1 Secondary flow 30% to 50% to a UA10.1 Secondary flow 30% to 50% to a UA10.2 Secondary flow 30% to 50% to a large U10.2 Secondary flow 30% to 50% to a large U10.3 Secondary flow 30% to 50% to a small UC10.3 Secondary flow 30% to 50% to a small UC10.4 Secondary flow 10% to 30% to a UA10.4 Secondary flow 10% to 30% to a UA10.5 Secondary flow 10% to 30% to a large UC10.5 Secondary flow 10% to 30% to a large UC10.6 Secondary flow 10% to 30% to a small UC 10.6 Secondary flow 10% to 30% to a small UC


Rural Rural -- Urban Commuting AreasUrban Commuting Areas

The RUCA codes can be used in many The RUCA codes can be used in many different ways in various types of health different ways in various types of health related research and program development related research and program development and implementation. and implementation.

There are 30 codes. The large number of There are 30 codes. The large number of codes facilitate the aggregation of the codes codes facilitate the aggregation of the codes to fit specific needs of those using them for to fit specific needs of those using them for health, demographic, geographic, and other health, demographic, geographic, and other types of uses.types of uses.


In almost all cases, the RUCA codes should In almost all cases, the RUCA codes should be aggregated for use. be aggregated for use.

•• For instance, it may be appropriate to aggregate For instance, it may be appropriate to aggregate them into two groups: rural and urban. them into two groups: rural and urban.

•• In other instances, it may be appropriate to create In other instances, it may be appropriate to create a specific group for the purposes of targeting a a specific group for the purposes of targeting a program (e.g., limiting a telehealth subsidy program (e.g., limiting a telehealth subsidy program to codes 7.0, 7.4, 8.0, 8.4, 9.0, 9.2, 10.0, program to codes 7.0, 7.4, 8.0, 8.4, 9.0, 9.2, 10.0, 10.3, and 10.5 10.3, and 10.5 –– the smaller and less functionally the smaller and less functionally related to urban and large rural places). related to urban and large rural places).

Rural Rural -- Urban Commuting AreasUrban Commuting AreasThe way in which they have been used most is to The way in which they have been used most is to aggregate the codes into four categories. This is aggregate the codes into four categories. This is a generally useful aggregation that is useful for a generally useful aggregation that is useful for most health related work. most health related work.

•• Urban focusedUrban focused: 1.0, 1.1, 2.0, 2.1, 2.2, 3.0, 4.1, 5.1, 7.1, : 1.0, 1.1, 2.0, 2.1, 2.2, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.18.1, and 10.1

•• Large Rural City/Town focusedLarge Rural City/Town focused: 4.0, 5.0, and 6.0: 4.0, 5.0, and 6.0

•• Small Rural Town focusedSmall Rural Town focused: 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, : 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.28.4, 9.0, 9.1, and 9.2

•• Isolated Small Rural Town focusedIsolated Small Rural Town focused: 10.0, 10.2, 10.3, : 10.0, 10.2, 10.3, 10.4, 10.510.4, 10.5


The percentages of the estimated 1998 US population for The percentages of the estimated 1998 US population for these groupings are:these groupings are:•• UrbanUrban, 77.6%, 77.6%•• Large ruralLarge rural, 9.3%, 9.3%•• Small ruralSmall rural, 6.9%, 6.9%•• IsolatedIsolated, 6.1%. , 6.1%.

•• The advantage of this definition is that it splits urban and rurThe advantage of this definition is that it splits urban and rural in al in approximately the same way as does the OMB Metro definition but approximately the same way as does the OMB Metro definition but at the sub county level and it divides rural into three relevantat the sub county level and it divides rural into three relevant and and useful categories. In many studies and programs, it makes sense useful categories. In many studies and programs, it makes sense to separate the large rural cities/towns (say a place of 30,000 to separate the large rural cities/towns (say a place of 30,000 population with many medical providers) from those places that population with many medical providers) from those places that have 1000 population and are isolated from urban places. It is have 1000 population and are isolated from urban places. It is clear that under most circumstances these two types of places clear that under most circumstances these two types of places differ greatly and should be considered separately.differ greatly and should be considered separately.

Rural Rural -- Urban Commuting AreasUrban Commuting AreasComing UpdatesComing Updates

It is likely that investigators will be It is likely that investigators will be provided with the means to divide provided with the means to divide the 4 coded places and their the 4 coded places and their associated places (e.g., 5s) into associated places (e.g., 5s) into those of varying population (e.g., those of varying population (e.g., less than 25,000 population).less than 25,000 population).


It is likely that a "remoteness" tool will be created that It is likely that a "remoteness" tool will be created that shows the road distance and travel time between non "1" shows the road distance and travel time between non "1" and "2" coded places and all other coded places (e.g., and "2" coded places and all other coded places (e.g., road distance from small rural towns to the nearest edge road distance from small rural towns to the nearest edge of an urbanized area). Likewise, the shortest road of an urbanized area). Likewise, the shortest road distance to large rural cities (code 4) and all other places distance to large rural cities (code 4) and all other places will also be provided. will also be provided.

•• This will allow a user of the codes to subset the RUCA codes This will allow a user of the codes to subset the RUCA codes based on their remoteness as measured by road distance. The based on their remoteness as measured by road distance. The travel data are now available for version 1.11 of the RUCAstravel data are now available for version 1.11 of the RUCAs

see the see the "Travel Distances to Urbanized Areas and Larger Rural "Travel Distances to Urbanized Areas and Larger Rural TownsTowns““

•• http://www.fammed.washington.edu/wwamirhrc/rucas/modifier.htmlhttp://www.fammed.washington.edu/wwamirhrc/rucas/modifier.html


It is likely that a version of the RUCA codes It is likely that a version of the RUCA codes will be available that allows the codes to be will be available that allows the codes to be used in work that involves aspects of used in work that involves aspects of regionalization. regionalization. For example, identifiers would be available For example, identifiers would be available so that code 5 places could be linked to so that code 5 places could be linked to their large rural cities (code 4 places) and their large rural cities (code 4 places) and in the case of 5.1 codes be linked to their in the case of 5.1 codes be linked to their secondary commuting urbanized areas secondary commuting urbanized areas (code 1 places) .(code 1 places) .

Nebraska Center for Rural Health Research

Funding OrganizationsFunding OrganizationsFederal Office of Rural Health Federal Office of Rural Health Policy Policy –– Health Resources and Health Resources and Services AdministrationServices Administration•• www.ruralhealth.hrsa.gov/www.ruralhealth.hrsa.gov/

Rural Policy Research InstituteRural Policy Research Institute•• www.rupri.org/healthpolicy/www.rupri.org/healthpolicy/

Nebraska Center for Rural Nebraska Center for Rural Health Research.Health Research.•• www.unmc.edu/ruralwww.unmc.edu/rural

University of Nebraska Medical University of Nebraska Medical CenterCenter•• www.unmc.eduwww.unmc.edu

http://www.ruralhealth.hrsa.gov/http://www.unmc.edu/rural

Geography and the U.S. Federal �Office of Rural Health Policy �Rural Health Research CentersRural Health Research CentersRural Health Research CentersRural Health Research CentersRural Health Research CentersRural Health Research General CentersRural Health Research General CentersRural Health Research Analytic CentersRural Health Research Analytic CentersRural Health Research Analytic CentersRural Health Research Analytic CentersRural Health Research Analytic CentersExamples of Quick Response and Long Range ResearchMedicare Modernization Act of 2003:�What Did The Government Want?Medicare Modernization Act of 2003:�What Did The Government Want?Medicare Modernization Act of 2003:�What Did The Government Want?Other Rural Definition OptionsMedicare Modernization Act of 2003:�What Did The Government Want?Medicare Modernization Act of 2003:�What Did The Government Get?Rural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting AreasRural - Urban Commuting Areas�Coming UpdatesRural - Urban Commuting Areas�Coming UpdatesRural - Urban Commuting Areas�Coming UpdatesFunding Organizations

geography and the u.s. federal office of rural health ... · • rucas include county, census tract...

Documents