Primary care is the most reliable means of ensuring patient and community health in rural communities, PCDC asserts in recommendations to the federal government.

“To meet its responsibility, primary care must be reinforced with sound policies and adequate resources,” the organization notes in its submission to the Health Resources and Services Administration (HRSA) and the U.S. Department of Health & Human Services (HHS) Rural Health Task Force.

Below is the full text, which includes specific suggestions for reducing barriers to care.

Recommendations from the
Primary Care Development Corporation (PCDC) to
HRSA and the HHS Rural Health Task Force
RE: Rural Access to Health Care Services RFI

October 9, 2019

The Primary Care Development Corporation (PCDC) appreciates the opportunity to provide comments to the Health Resources and Services Administration (HRSA) and the U.S. Department of Health & Human Services (HHS) Rural Health Task Force on “Rural Access to Health Care Services Request for Information.”

PCDC is a national nonprofit organization and Community Development Financial Institution dedicated to building equity and excellence in primary care. We have advocated for primary care for 26 years and assisted over 1,000 primary care practices in rural communities as well as urban neighborhoods in more than 40 states and territories. Our mission is to create healthier, more equitable communities by building, expanding, and strengthening the national primary care infrastructure.

PCDC provides flexible and affordable services and financing to fast-track funding and expansion for rural providers, bolster vital health services, and enhance provider recruitment and retention in rural communities. We also work with rural practices to achieve patient-centered medical home (PCMH) recognition and support rural providers with a wide range of capacity building services to improve health outcomes and implement new, effective, and cost-saving efficiencies.

Since our founding in 1993, PCDC has improved primary care access for more than 10 million patients by leveraging more than $1.1 billion to finance over 130 primary care projects. Our strategic community investments have built the capacity to provide 3.5 million medical visits annually, created or preserved more than 10,000 jobs in low-income communities, and transformed 1.8 million square feet of space into fully functioning primary care practices. Through our capacity building programs, PCDC has trained and coached more than 9,000 health workers to deliver superior patient-centered care. We have also assisted more than 550 primary care practices — encompassing some 2,250 providers — to achieve patient-centered medical home recognition, improving care for more than 10 million patients nationwide. For more information, please visit pcdc.org .

Question 1 – What are the core health care services needed in rural communities and how can those services be delivered?

Increasing Rural Access to Capital to Strengthen Primary Care and Other Vital Health Services

Underserved rural communities have the most pressing need for primary care services but are served by dwindling numbers of providers and institutions that lack resources to expand and improve services. Access to primary care is one of the most frequently cited and urgent health problems facing rural populations. Primary care provider and workforce shortages are significant obstacles to increasing access to care. And in rural areas, primary care providers are often the only source for primary care, behavioral health, social support services, and more.

We must work towards primary care access parity for people living in rural communities and encourage capital access and reimbursement models that reward proven, quality programs.

PCDC is a nonprofit community development financial institution and mission-driven lender with strong ties and commitment to expanding and enhancing quality primary care in underserved communities. We have an intimate knowledge of the substantial capital needs of health centers, safety net systems, and other rural providers as they invest in and maintain access to care for hard-to-reach and underserved rural populations.

We encourage HRSA and the HHS Rural Health Task Force to consider opportunities for coupling capital grants with additional financing to increase rural providers’ access to capital and accelerate the pace of development projects. These investments could be other grants, tax credits, fundraising, and debt. Enhancing capital grants with private investments and other public funding would allow for greater impact, more providers to receive funding, and more robust public-private partnerships. For example, the U.S. Department of Treasury Community Development Financial Institutions Fund’s New Markets Tax Credit (NMTC) Program provides tax incentives for investments in business or economic development projects in distressed rural or urban counties, including capital investments in health care facilities.

Primary Care Makes the Difference Between A Life-Threatening Chronic Condition and A Preventable, Manageable, and Treatable Condition

Primary care is the foundation for integrating the full spectrum of health and social services to improve health outcomes, and is the key to sustainable, accessible, and equitable health systems in both rural and urban areas. It is a cornerstone of healthy, thriving communities and helps keep families healthy, children ready to learn, and adults able to pursue their careers.

Primary care is the first point of comprehensive care, addressing all that contributes to a person’s health and well-being, from childhood through old age. It is the critical, cost-effective care and services that help prevent, identify, and treat common conditions such as asthma, diabetes, and heart disease before they become more serious, costly, and difficult to treat. It is screening, diagnosis, and treatment; referral to and coordination with other care settings and providers; health education, preventive services, and more. It includes family and adult medicine, community behavioral health, women’s health care, and geriatrics.

While barriers to access vary across rural populations, two pressing issues are a chronic shortage and poor retention of primary care providers (PCP). Effectively managing chronic conditions such as diabetes, hypertension, and cancer is a substantial challenge for rural residents and providers, particularly in locations where residents have disabilities or limited transportation options. Preventive care utilization is often lower in rural areas, including lower rates of vaccination and reproductive health services, and is associated with poor access to primary care.

There are a multitude of ways to reduce barriers facing rural residents and primary care providers. An in-person visit to a PCP is the most traditional delivery method. Attracting new primary care health workers to rural counties should be a top priority of HRSA. We strongly recommend implementing programs that allow for loan forgiveness, scholarships, or financial aid in return for practicing for a set period in a rural community. Programs such as these have shown to be valuable in recruiting new providers and addressing the workforce shortage. Additionally, medical school residency programs are often focused on acute care settings in major urban areas. Working with academic medical centers to increase community health and rural exposure in both medical school and residency training would allow students and doctors to better understand the needs of rural communities and work in more diverse care settings.

Telemedicine is a key delivery method for overcoming transportation and mobility barriers for rural residents. We urge HRSA to create policies and increase reimbursement to expand the use of telemedicine nationally. Advances in telemedicine have led to improved access and quality of care for many rural residents. Travel time can be reduced substantially, which is especially important for patients with chronic conditions that require frequent encounters with their providers. Through telemedicine, rural providers and residents alike can connect with specialists who would otherwise be out of reach.

In-home visits are another way to deliver primary care to rural residents and address the transportation barrier. We encourage HRSA to expand home visit models for those with limited mobility, including the use of visiting primary care providers. Transportation is often a limitation when seeking medical care, especially in rural areas that experience harsh winter weather and for people without access to private transportation — particularly older adults. Eliminating the barrier of transportation is crucially importance in rural areas because they have a disproportionately higher percentage of adults aged 65+ than urban and suburban areas. In addition to expanding in-home visits, HRSA should consider increasing funding for programs that provide transportation to medical appointments for those without vehicles.

Question 4 – How should we measure access to health care services in rural communities? What are the best ways of measuring quality of care in rural communities?

Primary care access is when a person can receive the needed primary care services that are timely, affordable, and in a geographically proximate location. Such qualities are largely dependent on the availability of health care practitioners and facilities, the quality of these services, and whether providers accept a patient’s health insurance or provide care without regard to ability to pay.

There are specific measures that can address issues regarding robust access to care. First, measuring the number of PCPs per 10,000 people identifies rural areas that may struggle with long wait times or further travel for an appointment due to a workforce shortage. An increase of one primary care physician per 10,000 people can generate 5.5% fewer hospital visits, 11% fewer emergency department visits, and 7% fewer surgeries. Second, the percentage of uninsured adults aged 18-64 shows adults who are unable to access primary care due to lack of coverage. Third, rural areas tend to have higher rates of residents on public insurance programs. Identifying the percentage of PCPs that accept Medicaid and Medicare in a rural region can shed light on the inability for residents to access care due to their type of insurance coverage. Finally, measuring preventable emergency department visits per 100 people shows both the strain on health care resources and costs in a region and the need for additional PCPs in a rural area.

Conclusion

PCDC appreciates the opportunity to comment on HRSA’s information request on rural access to health care services. With overwhelming evidence of its positive impact on improving health care quality and outcomes while lowering health care costs, primary care is the most reliable means of ensuring patient and community health. To meet its responsibility, primary care must be reinforced with sound policies and adequate resources. We look forward to working with HRSA and the HHS Rural Health Task Force to support these goals in rural communities.

Thank you for your consideration of PCDC’s recommendations.

Contact:

Patrick Kwan, Senior Director of Advocacy and Communications
Primary Care Development Corporation
45 Broadway, 5^th Floor, New York, NY 10006
(212) 437-3927 | pkwan@pcdc.org