Health Disparities in the Rural American WestMichele Barry, MD, FACP, FASTMH

Professor of Medicine and Tropical DiseasesSenior Associate Dean for Global Health

Director, Center for Innovation in Global HealthSenior Fellow, Woods Institute for the Environment

Stanford University

Lower rates of physical activity

and seat belt usage

Less health insurance, and trauma centers

Higher rates of cigarette

smoking, htn, and obesity

Older, poorer, and

sicker

National Vital Statistics System, 2014

Health Issues: Rural Americans vs. Urban Americans

Rural California

Rural California

California Health Care Foundation (2012)

• Rural Health Clinics (RHCs) - Medicare/medi-Cal and undocumented people - Account for 44% of total rural primary care - Largely financially unstable

• Patients in RHCs - High food insecurity- Smoking and cardiovascular diseases- Obesity and diabetes - Difficulty accessing care

Rural California & Agricultural Workers -800,000

National Agricultural Workers Survey (2012)

• Of migrant and seasonal workers - 41% got treated by private providers- 31% at Migrant Health Centers- 14% at dentists’ offices- 11% at hospital/emergency room- 3% unreported

• Only 3/5 of agricultural workers reported using US health care services in last 2 years; 8% used health care services in other countries.

c

While almost 20% of Americans live in rural areas, only 10% of all

practicing physicians do.

Gondi & Patel (2016)

Physician Shortages in Rural Areas

Conrad30 (2010)

Physician Workforce

Projected US Physician Shortages

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

2008 2010 2012 2014 2016 2018 2020

Num

ber o

f Phy

sici

ans

Without ACA With ACA

AAMC, Center for Workforce Studies (2014)

Conrad30 (2010)

Rural Physician Workforce

• 2/3 of all Health Professional Shortages are in rural areas

• There are 75 physicians/100,000 residents in urban areas, compared to 55 physicians/100,000 residents in rural areas

Growth in Number of Medical SchoolsSelected countries with growth rates greater than 25% since 2002:

AAMC (2016)

Growth in Number of Medical SchoolsSelected countries with growth rates greater than 25% since 2002:

United States 178 20 11.2%AAMC (2016)

25% of physicians are international medical graduates

Brain Drain and Globalization

Bundred et al., Migration of Health Professionals, Harvard Policy Review, 2004Mullen, F., The Metrics of the Physician Brain Drain, NEJM, 2005

Country Physicians/100,000 Population

% IMG Workforce

% from low-income country

US 293 25% 60%UK 231 29% 75%

International Medical Graduates-Specialties37% of all US Internists

28% of all Pediatricians27% of all Family Medicine physicians

Primarily work in underserved or rural areas

H1b Worker Visas Conrad 30 J-1 Visas – rural services

International Medical Graduates

CNN (2017)

• 7,500 physicians • Allows employers to bring in skilled

foreign workers. High demand and lottery based

• Expedited processing is currently halted under Trump administration

• 1500 medical trainees each year• Waive 2-year home residency

requirement for J1 visa • Conrad 30 participants are required to

work in rural or medically underserved areas for a minimum of 3 years

• President Trump’s temporary immigration ban in January further restricted IMGs from all countries

• Put a strain on rural and underserved communities that rely on these physicians

NHSC (2017)

• National Health Service Corps (1972) student loan repayment for med students/$120,000—3 year commitment

• NHSC-approved sites include Rural Health Clinics and Federal Indian Health Services

• Licensed health care providers earn up to $50,000 toward student loans in exchange for 2-year commitment at NHSC-approved site

• Individual State Loan Repayment Programs also exist

Loan Forgiveness

Perry, Zulliger, and Rogers (2014)Rural Health Information Hub (2017)

• CHW are public health workers - trusted members of the community- speak the same language - share the same ethnicity/socio-

economic status

• CHWs provide - basic health screening tests- referrals to health and social services

• 85,000-200,000 CHWs practice in US, ----- (5.0 million worldwide)

Community Health Care Workers (CHW)

Perry, Zulliger, and Rogers (2014)Rural Health Information Hub (2017)

Community Health Care Workers (CHW)

• Concept of Task Shifting• Patient-Provider

Communication

• CHW are public health workers - trusted members of the community- speak the same language - share the same ethnicity/socio-

economic status

• CHWs provide - basic health screening tests- referrals to health and social services

• 85,000-200,000 CHWs practice in US, ----- (5.0 million worldwide)

Gondi & Patel (2016)

Rural Health and Technology

• Telecommunication allows rural PCPs to consult with specialists at faraway urban centers

• Telehealth also allows rural areas to receive time-sensitive consults in emergency situations

• Google Glass has allowed expert clinicians to advise on physical exams and surgeries remotely

• Drones used to deliver medication and telehealth capabilities.

More research on urban-rural disparities

Increased loan forgiveness for

rural PCPs

Community Health Care Workers and

Task Shifting

Stronger rural advocacy to

inform healthcare policy

Increase science education/outreach for rural students

Telemedicine & Telehealth

Global Health is Local Health

Where to Go Next to improve Rural Care??

Disruptive Technology