By NORMAN WALZER and LaVONNE STRAUB

Health care in rural Illinois

This is the first in a series of articles on the health care system in Illinois. This article on rural health care in Illinois will be followed by an article focusing on urban health care in Illinois.

Rural areas both in Illinois and across the U.S. faced major economic setbacks in the early 1980s. When the economic recovery started in mid-decade, many rural counties did not participate as fully as did urban areas. Rural counties were faced with population declines, and today their per capita incomes remain substantially below urban averages. This poor rural economic performance also adversely affected social and cultural institutions in rural America. Public services in rural areas changed and, during this process, made both residents and policymakers apprehensive about prospects for the future and quality of life in rural areas.

Not the least of the services affected by the rural transformation is health care. Prior to the mid-1980s, rural residents were accustomed to having a local hospital meet most of their primary and emergency medical needs. Primary care doctors and dentists had been considered service providers, even in relatively small communities. The economic declines and population losses in rural counties, combined with the development of expensive high-tech medicine and the tightened reimbursement via government health programs nationwide, changed this situation. Residents began to add health care to the list of services for which they shopped outside of their local community.

There has been much attention in the news media and public forums about access to health care and the quality and costs of health care. Several ideas have gained the stature of "accepted wisdom." The first is that health care can be analyzed independently of the economic and sociodemographic transformations taking place. Without consideration of these broader changes, that is, viewing rural health care in its proper context, conclusions about rural health care may not be correct.

The second of these accepted wisdoms is that quality and access are synonymous when it comes to rural health care. Access to care is often defined as quality of care. A specific number of providers within a defined geographical area, although representing a high level of access for rural individuals, may not determine the quality of care received. (The ratio of primary care physicians relative to population within a specific area is often used as a guide in making policy decisions related to health care access.) Access to care could perhaps be better measured by how well providers meet the demands set by rural individuals. Quality of care is often defined in terms of a traditional model of care, that is, one hospital per community, and by the level of specialized services and medical technology offered. Rural communities, however, due to their economic situation, geographic location and population, may require different standards of measurement. A hospital closing in a rural community may result in lack of access to this nearby, traditional health care facility. But, the combination of a remaining local clinic coupled with access to care in a nearby large hospital in an urban area may actually improve service quality.

The final accepted wisdom about rural health care is the idea that changes in rural health care policy must come only from policymakers or politicians. Models of health care delivery designed in Washington, D.C., — or even in Springfield — do not necessarily fulfill the needs of rural residents for their health

More flexibility is required not only in rural health care policy but also in the government reimbursement and regulatory system to accommodate change

care as those residents define their needs. Rural residents understand their economic and demographic environment and should be involved in designing health care for that environment. More flexibility is required not only in rural health care policy but also in the governmental reimbursement and regulatory system to accommodate change. Many rural communities in Illinois and some states in the West have already begun to change health care practices and policies.

Using the number of providers and services located within a region as a measure of access is often misleading. Does a community hospital with fewer than, say 10 beds, and outdated medical technology or part-time staff represent adequate access to service? While access to a local hospital has been critical in the past for emergency cases, current technology and miniaturization of medical equipment may mean

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that a fully staffed ambulance can provide service of quality equal to or better than in an emergency room at a small or understaffed hospital.

Before access to care in rural communities can be properly analyzed, "rural" must be defined in a meaningful way. Seventy-six counties in Illinois are not in Metropolitan Statistical Areas. Yet, rural areas also exist within counties labeled as Metropolitan Statistical Areas. Arbitrary county boundaries cannot capture vast differences among rural communities, nor can they highlight similarities among some rural and urban areas.

Keeping in mind the vast differences among rural areas, a community's ability to support medical services depends upon its economic base and income as well as the level of its taxes and subsidies. Yet, at the same time that services have become more expensive and sophisticated, the capability of rural areas to fully utilize and support them economically has declined.

Several factors determine utilization and support of health care services, thereby affecting access in a general way. Demand for health care services depends on population, composition and health status of that population, and current economic conditions and trends. Rural counties in Illinois experienced disproportionate population declines during the 1980s in comparison with other Illinois counties, as residents migrated in search of better employment opportunities. According to 1990 Census data, 70 of 76 nonmetro counties in Illinois declined in population during the 1980s.

Rural areas also contain a large contingent of elderly and low-income residents whose lack of transportation or immobility creates more demand for local health care. A disproportionate share of this population is also unable to pay for health care privately and thus depends on public programs, which in recent years have burdened providers, especially hospitals. This is not a problem exclusive to rural providers; however, many rural hospitals have been reimbursed at rates substantially less than their urban counterparts, thus threatening their economic viability. (One solution to low rural hospital reimbursement is federal designation as a Sole Community Hospital.)

While the elderly and low-income populations in rural communities create a high level of demand, the reverse is often true for other segments of the rural population. Rural businesses include a larger share of small employers without health care coverage as a standard benefit, placing greater burden for financing health care on individuals. The result of this combination of high demand paid from public dollars plus low demand due to lack of insurance coverage is that rural communities experience difficulty attracting and retaining health care personnel, affording medical technology and facilities, and providing access to quality health care through traditional arrangements.

Have these changes necessarily meant poorer health care access for rural residents? The answer is complex. The question is: What is appropriate care and what is reasonable care for the population? For certain, there is less specialized medical care in rural areas than in urban areas. This difference was less noticeable in earlier years when there were fewer specialists practicing. The reality today is that the specialized nature of many current medical resources requires a population base not

Metropolitan and nonmetroplitan Illinois counties, 1985 (Cook County is omitted) Nonmetro Metro Characteristics (n=76) (n=25) Providers (per 100,000 residents) **Registerd pharmacists 53.64 61.33 *Active RNs 682.86 869.36 *Physicians 67.47 122.25 Hospital beds 480.49 506.00 *Number EMS vehicles 32.37 20.77 *Health manpower shortage .47 .04 *Significance at .01 level. *Significance at .10 level.

found in many rural counties. Technological advances will only heighten this trend. So, residents in rural counties must travel, outside their community for these specialized health care services, and this may improve rather than diminish the quality of that care. The more important issue is access to primary care. Loss of medical personnel, many times accompanying a hospital closing, can threaten even basic services. Rural areas certainly have experienced greater declines in medical personnel than have urban counties. By 1987 they had smaller numbers of providers per population (see table 1). For instance there was an average of 67 physicians per 100,000 population in rural Illinois counties compared with an average of 122 per 100,000 population in metro counties, although this comparison includes specialists. Again, one explanation for the fewer primary care physicians in rural areas is that the economies and populations are inadequate to sustain medical personnel who seek a sufficient financial return on their education and training investment. However, motives governing where doctors locate are more complex than just economics, and there are many reasons why professionals are unwilling to locate in more remote rural settings.

Evaluating access to care based on the number of providers is difficult, especially when presented by county. Rural residents often cross county boundaries to purchase health care services, as they do to purchase other goods and services. The growth of regional discount or shopping centers has diverted business away from the main streets of many small rural communities, and a parallel trend is occurring with medical services. Treatment at a large medical center within commuting distance may cost more, but if paid by the patient's insurance carrier, this cost is not borne by the patient. This commuting for health care, of course, reduces demand for medical services in rural areas, threatening their very existence. Low occupancy rates in some rural (and urban) hospitals made closing an economic necessity. The existence of a hospital itself is not as critical as the replacement of that hospital with some other means of primary care services.

Access to health care in rural communities may be considered adequate if: a) primary care is provided through alternatives

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to the traditional hospital-based arrangement, such as a local clinic or regularly scheduled outpatient care provided by hospitals in larger urban areas; and b) residents lacking transportation are transported to larger health care centers for specialized care.

Given continuing demographic and economic trends, any solutions to the rural health care access question must consider various options. For example, clinics in underserved areas, many of which are rural, are expanding because reimbursement policies have changed. Those clinics can provide an excellent source of basic primary care. The elderly and indigent could be transported for specialized medical needs using the vans and mini-buses that are operated by many agencies in rural areas with federal and state support.

Any definition of access to care defies strict measures because barriers come from both the demand and supply sides. Generally, "access to care" describes how easily and quickly a given population with given medical problems can obtain appropriate and reasonable care. Lack of financial resources can inhibit access even if providers are nearby. On the other hand, provider reluctance to accept under/uninsured clients represents a barrier to access even when providers are accessible. Access should be defined in terms of both provider availability and consumer factors, such as income, insurance coverage and health care demands.

Measurements of quality differ for primary, specialty and preventive care. Quality of health care is often measured by specialized services and medical technology or by the traditional model of health services provided by a community hospital. Many small hospitals cannot afford expensive medical equipment, given its relatively infrequent use. Comparisons of rural and urban counties in terms of technical facilities and personnel always show rural counties at an apparent disadvantage. However, if individuals in rural communities can commute to another community to receive specialized care, they will often receive a higher level of quality care than a small rural community hospital could provide. The presence of a community hospital in rural areas does not always mean excellent quality of care. Quality primary care is often best obtained from a clinic or a physician.

Rural hospitals and clinics can use specialized equipment more effectively through mobilized facilities. Some cooperating institutions share highly specialized equipment on a regular schedule to rural providers. This approach offers additional services, which otherwise would be unavailable in sparsely populated areas.

Quality, however, is not related solely to equipment and specialized services. Lack of trained medical personnel, particularly in primary care, is critical when judging the quality of services rendered. Unfortunately, many variables in rural areas work against the attraction and retention of medical personnel. Relatively high malpractice insurance associated with medical specialties, such as obstetrics, compounds the problem as does low Medicaid reimbursement to physicians and hospitals. In sparsely populated southern Illinois, for instance, obstetrical care is becoming rare. In 1990, 35 counties, mostly in rural southern and mideastern sections of Illinois, had no obstetric services.

In response to the low and late reimbursements by the state to physicians and hospitals, the Illinois Hospital Association has made reform of Medicaid payments a top priority. The association claims reasonable access to quality hospital care is denied many Illinois residents because of the low and late Medicaid payments. While Medicaid-covered patients are less prevalent in rural areas than in urban areas, larger urban hospitals are better able to absorb Medicaid's payment scheme because of patients with high incomes and more generous insurance coverage able to pay higher fees, thus offsetting low and late Medicaid payments.

Reductions in malpractice insurance costs have been considered for rural areas. Limits on noneconomic damages, such as psychological distress associated with an accident or improper treatment, have been recommended on many occasions, and Gov. Jim Edgar addressed this issue in his 1991 State of the State message. Lowering malpractice insurance premiums is no guarantee that the quality or access to obstetric services will improve, but certainly it would remove an economic stumbling block.

Lowering malpractice insurance premiums is no guarantee that the quality or access to obstetric services will improve, but certainly it would remove an economic stumbling block

Several federal and state programs are designed to attract medical personnel to medically underserved areas, but as long as conditions of practice favor urban areas, this task is difficult. Local efforts to recruit personnel can be expensive as rural communities compete with each other for a limited number of qualified personnel. The National Health Service Corps program encourages physicians to practice in underserved areas — urban as well as rural. (Limited success phased down the program, but in 1990 it was revamped and reauthorized, with funding increased to $91.7 million.)

Illinois is one of many states with state medical scholarship and loan programs for students; the Illinois Farm Bureau also supports medical scholarships. Between 1985, when the state scholarship program was reactivated, and July 1990, 14 out of 38 recipients (37 percent) were practicing in rural areas. The national nursing shortage in rural areas has prompted Illinois to initiate a scholarship program for nurses as well.

These scholarship programs provide an economic incentive to students with an orientation toward practicing in rural areas to retain their rural focus. And these programs partially offset many students' preference for practicing in better served areas. Participants are required to practice for a specific amount of time in designated locations, in the hope that

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the experience will be positive and they will stay there after the obligation has been met. If conditions of practice, such as lower payments and limited opportunities for education and career advancement, are not changed, however, the likelihood of retention beyond the required commitment is low.

Fundamental differences in the practice of medicine, nursing and health care between rural and urban settings are important. Research on both medical and nursing education shows that professional education programs focus more on urban than on rural practices. Schools, especially those in states with large rural areas, recruit students with rural backgrounds hoping they will practice in a rural area. However, if the education focuses on specialized, high-tech medicine without explicitly preparing students for a rural setting, this recruitment tactic succeeds and fails at the same time because students who may enter into rural practice will be unprepared for the rural environment. Thus, the relatively low emphasis on rural practice in education programs may be as critical as the sparsity of facilities and especially primary care services in rural areas.

Given the limited success of continuing the traditional model of services in rural areas due to uncontrollable economic and social factors, a rethinking of what constitutes both quality and access is needed. This is especially important in that: a) rural conditions affecting retention of traditional care are likely to worsen; and b) there is an absence of solid findings that overall health status is improved only under the traditional model.

Consequently, rural areas need flexibility to structure the delivery of care. Residents in remote areas may require clinics, long-term care facilities and mid-level practitioners to provide education and basic care, but they may have to rely on regional centers for less frequently used, specialized care. Input from rural residents should be sought regarding their priorities for health care relative to other services affecting their quality of life. Initiating new ways of health care delivery beyond the traditional model will be to no avail if the individuals in rural communities are not ready to adapt to a new way of receiving health care services.

The adequacy of access to and quality of health care has traditionally been determined in Congress and the General Assembly. Only recently have attempts been made to gain input from rural consumers. There is now more acceptance of the notion that access to care in rural areas is perhaps best measured by the perceptions of rural residents. An Illinois Rural Life Panel was started in 1989 to gather information from residents about a wide variety of issues, including quality and access to health care. (Further information on this panel is at the end this article.)

Overall, respondents were split in attitudes about satisfaction with health services, depending on whether they live in a rural county with no hospital and no clinic or in a rural county in which there is a clinic certified for reimbursement as a rural health clinic but no hospital (see table 2). Those in counties without a hospital or a clinic are generally less satisfied with facilities and doctors. Only 37 percent of these respondents were satisfied with medical facilities compared with 49 percent in counties without a hospital but with a certified clinic; 54 percent in rural counties overall were satisfied with medical facilities.

From this study, clinics seem to represent a substantial primary care option, but the sample sizes in some counties were small and these findings must be considered tentative. For primary care needs, more than 70 percent of respondents preferred their nearest hospital or clinic.

An important finding is the high level of satisfaction with emergency services, especially in counties without a hospital or a clinic. Given the infrequent use of emergency services by respondents, however, additional research is needed. Both certified clinics and emergency services are emerging as a real (and psychological) asset in remote areas, and their potential for improving access to care in rural areas should be fully explored. Further study revealed that approximately one-third of respondents travel outside their community even when services are available locally.

Ways in which rural counties can provide access through various options must be examined further. Replacing lost hospital beds and personnel with community clinics, satellite clinics and a wider range of medical staff is important. Conversion of hospitals, or parts of hospitals, into clinics for outpatient care has already started in Illinois. A major advantage is that Medicare and Medicaid reimbursement is 25 percent to 75 percent greater when providers are Certified Rural Health Clinics.

There is reason for both optimism and pessimism regarding rural health care in the 1990s. Optimism is justified because various groups in Illinois are working to improve access. These groups include public agencies, elected representatives, private organizations and volunteer groups. The Center for Rural Health in the Illinois Department of Public Health was created recently to support this emphasis on access to care in rural Illinois. A governor's Rural Health Task Force, convened by then-Lt. Gov. George H. Ryan in 1989, recommended, among other policies in its 1990 report:

1. tort reform to establish a cap on noneconomic damages in malpractice suits;

2. development of funding proposals for demonstration projects in rural communities;

3. aggressive promotion of the Federal Rural Health Clinic Act to Medicare providers and technical assistance to providers interested in becoming certified as clinics; and

4. state funding to create additional scholarship programs for health professionals as incentives for rural practice.

Implementing the task force's recommendations will not be easy when the state budget is under seige, nor when existing health care organizations are affected. Residents and institutions alike are threatened by change. Loss of a hospital, even when underutilized, is often viewed as a serious setback when no other alternatives are offered. In reality, moving to a more efficient clinic or other suitable delivery system can bring more affordable primary care service and free up a building for alternative uses, but acceptance of these changes requires flexibility in thinking about health care delivery.

A recent example of a successful hospital conversion occurred in east central Illinois. Douglas County Jarman Hospital in Tuscola was suffering financially due to low inpatient occupancy rates; local residents evidently were purchasing health care elsewhere. A combination of strong community interest and out-

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side assistance from the Center for Rural Health and the Illinois Farm Bureau converted Douglas County Jarman to a primary care clinic. Affiliated with Carle Clinic in Champaign-Urbana, the clinic uses satellite commmunication to permit residents access to primary care providers at Carle. The community task force now is working on developing emergency services for Douglas County residents.

The federal government and national foundations remain active in promoting rural health care. This support includes legislation to ease government payment differentials between rural

. . . the clinic uses satellite communication to permit residents access to primary care providers at Carle

and urban areas, and demonstration projects to explore alternative models for delivering and financing rural care. Federal Rural Health Clinics are one example of an alternative model. These clinics are authorized by the state to take advantage of more generous and flexible federal reimbursement policies, and they employ mid-level practitioners to offset physician shortages. The Illinois Department of Public Health has made significant progress in promoting clinics. There was only one clinic in the early 1980s, and now there are 11.

Recent research and demonstration projects have made rural communities better able to develop models of health care access that fit their individual community needs. While this trend may run counter to traditional thinking that health care decisions are made "elsewhere," local decisions imply local ownership and support as well as satisfaction. The Robert Wood Johnson-funded projects in several western states, such as Alaska, Montana and Washington, provide valuable information about the power of local involvement in designing a community's delivery system. A major effort in these states has been local input and enlisting the cooperation of relevant groups in making a realistic assessment of what health care services are needed and can be supported by rural communities. The Center for Rural Health in Illinois follows this approach of assisting rural communities in determining their health care needs and establishing an effective delivery system.

Alternative arrangements, such as infirmaries or nurses' stations, may require more flexibility than permitted by traditional practice regulations and reimbursement programs. Full acceptance and implementation of new forms will require health care professionals and their associations to modify existing procedures. As many as 10 states have modified legal and regulatory conditions to encourage development of alternative hospital models for rural areas. Models being tried in California, Colorado and Montana may be of significance to regions in Illinois. The components involve retention of basic and primary care providers locally, while transferring more specialized services to larger centers. Formal linkages are then created between the remote facilities and regional centers to provide effective health services.

Even though government reimbursement programs and state regulations often have prevented some options, the likelihood of no care as an alternative has brought creativity and a relaxation of more stringent rules, such as those governing reimbursement. In Illinois, a major piece of legislation. Senate Bill 2277 (Public Act 86-1187), was enacted in 1990 to improve the delivery of health care services; it has a significant rural component. Provisions include assistance to counties to establish and operate regional ambulance systems and to modify emergency medical services. Primary health services will be assisted by grants and scholarships to allied health professionals agreeing to locate in manpower shortage areas or those areas lacking necessary health care services. The Center for Rural Health in Illinois plays a major role in working with other sponsors to alleviate access problems in shortage areas and facilitate demonstration projects.

A less optimistic attitude about the future of care alternatives is based on the reality of limited resources. It is necessary to choose priorities and adopt realistic goals. The long-term economic and demographic trends, noted earlier, are not likely to change in the near future. A range of options should be considered, including nontraditional approaches. Traditional approaches that are not cost effective, such as investment of funds in procuring for rural areas medical personnel who are not likely to stay, should be lower in spending priorities for the scarce funds available. A better option is to address how to increase the utilization and purchases of medical care already available in the region, making sure transportation is provided and financial barriers are reduced.

Flexibility in designing services and local input regarding priorities for services should be promoted. Under the Hill Burton Act, which funded hospitals throughout the U.S., the federal government viewed rural and urban the same way. Under the Medicare Prospective Payment System, the federal government views rural health care as different and less expensive than urban care. Neither view is appropriate in designing health care delivery and financing. A generic, "one model fits all" approach has left residents of rural communities with too few choices. A more flexible approach to rural health care is needed if access to care and quality of care issues are to be properly addressed and adequately resolved.

Norman Walzer is a professor of economics and director of the Institute for Rural Affairs at Western Illinois University. LaVonne Straub is an associate professor of economics at Western Illinois University and is on the board of directors of the Illinois Rural Health Association. The authors thank Poh P'ng for assistance in data tabulation and Chris Atchison and Mary Ring of the Illinois Department of Public Health for their comments.

The Illinois Rural Life Panel is part of the Illinois Institute for Rural Affairs. Funding is provided by the Office of Lt. Gov. Bob Kustra. For more information about the panel, contact Dr. Paul C. Thistle-thwaite, Illinois Rural Life Panel, Western Illinois University, Macomb, Illinois 61455; Telephone (309) 298-1404.

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