Friday, March 10, 2017

The rural health landscape (Part I): Women's health—A snapshot

For several years now, there has been significant discussion about the pendency of a healthcare crisis in the United States. Whether the crisis is best characterized as a shortage of doctors generally (projections released by the Association of American Medical Colleges in 2016, for example, suggest that physician demand will continue to grow faster than supply, with an expected shortfall of up to 95,000 physicians by 2025) or as an understaffing within particular specialties (i.e., “a mismatch between what kind of doctors the nation is producing and the kind of doctors it needs”), it seems clear that certain populations experience scarcities more acutely. As a recent New York Times article rather succinctly noted:
Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. . . . A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.
Previous blog posts have explored rural healthcare in the context of disability services, mental health services (here and here), telemedicine (here, here, and here), abortion deserts across the United States, and abortion services in Arkansas and North Dakota, California, Louisiana, Mississippi, Texas (here, here and here), and Wisconsin.

This post is the first in a series that explores the rural health landscape as it stands—on the cusp of burgeoning technological advances, shifting population demographics, and changes in political leadership. These posts highlight a few (of the many) special hardships rural Americans face in the healthcare sector and, where applicable, evaluate potential steps forward.

Part I of this series provides a snapshot of women’s health in rural areas, with an emphasis on access to reproductive services. In that context, this post also cursorily assesses the prudency of empowering mid-level providers to independently care for patients in communities that consistently struggle to recruit physicians or otherwise experience access barriers.

Parts II and III of this series focus on professional midwifery as part of the patient care model. Part IB explores the historical origins of midwifery in the United States.  Part III is an interview with a recent and accomplished graduate from Columbia University’s Nurse Midwifery Program who is slated to begin clinical work serving rural New Mexico.

Part I: Women’s Health in Rural America—A Snapshot

As recently noted on this blog, there is a dearth of maternal healthcare services in rural America. Only 6.4 percent of ob-gyns practice in rural communities. As a result, over ten million rural women are without an ob-gyn. Infant mortality rates in rural counties exceed the national average, sometimes by more than 100 percent. Nationally, the rate for cesarean deliveries was 32 percent in 2015, a distressingly high percentage given that the World Health Organization recommends that national rates not exceed 10–15 percent. Typically, if a woman is eligible to have a vaginal delivery, there are few advantages—and serious risks—associated with having a C-section. According to a recent study published in Health Affairs,
Although common, cesarean delivery is major abdominal surgery that carries distinct risks compared with vaginal delivery: greater chance of infection, injury, blood clots, and need for emergency hysterectomy. It also can cause persistent pain, compromise the establishment of breastfeeding, and complicate later deliveries. Cesarean delivery is often performed to improve neonatal outcomes and mitigate risk; however, it is associated with a greater risk of asphyxia, respiratory distress, and other pulmonary disorders in infants.
Astonishingly, women are three times more likely to die during cesarean delivery than a vaginal birth. At the individual level, this equates to 18.2 maternal deaths per every 100,000 live births—in large central metropolitan areas. In rural areas, the ratio is 29.4 deaths per every 100,000. And it is not only with respect to reproductive care that rural women suffer. Rural women experience higher rates of suicide and depression, higher incidences of cervical cancer, and are less likely than their urban counterparts to be in compliance with mammogram screening and pap smear guidelines (for further discussion on rural women’s increased likelihood to be diagnosed with late-stage breast cancer, see this post).

Of the many proposed solutions to address the yawning gaps in healthcare access across the United States, increasing and integrating mid-level providers into patient care models is (at least to this author’s mind) one of the most promising. Indeed, but for hesitancy on the part of organized medicine to “cede professional turf to nurses,” there is little reason not to endorse a reallocation of clinical responsibilities to nurse practitioners, physician assistants, and other sub-specialists. “The preponderance of empirical evidence indicates that, compared to physicians, nurse practitioners provide as good—if not better—quality of care[, and] patients are often more satisfied with nurse practitioner care—and sometimes even prefer it.” Given statistics like those discussed above, there is good reason to consider expanding mid-level providers’ scope of practice, for rural women especially.

From a legal lens, a provider’s scope of practice is regulated at both the federal and state level. Scope of practice (SOP) laws refer to the rules that govern “which professions may provide specific services, the settings in which they may provide them, and the parameters of their professional activities.” At the national level, Medicare and Social Security laws significantly limit professional practice. Medicare, for example, reimburses nurse practitioners (NPs) for comparable services at only 85 percent of the physician rate. Similarly, NPs are not authorized to autonomously order home health, hospice, or skilled nursing facility services for Medicare patients. The Drug Enforcement Agency forbids NPs from prescribing some opioid addiction medications that physicians can prescribe, a limitation that is particularly significant for rural patients (see recent posts on the opioid epidemic in rural America here, here and here).

At the state level, SOP laws are dictated by state professional boards, resulting in widely variable and often disparate licensing requirements. In nursing, for example, twelve states (including 7 designated “more rural than U.S. average”—Georgia, Michigan, Missouri, North Carolina, South Carolina, Tennessee, and Virginia; and 1 state with a rural majority population—Oklahoma) restrict NP practice by requiring supervision, delegation, or team-management for NPs to provide patient care. In sixteen states, SOP laws require NPs to enter into regulated collaborative agreements with licensed physicians before providing patient care, and limit the setting or scope of one or more elements of NP practice.

A recent report by Health and Human Services noted the impact of restrictive SOP laws, particularly in rural America:
While there may be fewer total NPs in rural areas, NPs were reported to constitute a large proportion of the providers in these areas. NPs in any region of a state may find it burdensome and inefficient to meet requirements for physician collaboration, but this burden was suggested to be greater in rural areas as a result of a shortage of physicians. Although NPs in very rural areas may practice with more autonomy than their urban counterparts, in states with SOP laws that require physician collaboration, NP practice may seem more feasible in urban areas, where it may be easier to meet requirements for physician collaboration. As a result of SOP barriers, opportunities for equitable and efficient care delivery in underserved, rural areas tend to be hampered in such states.
Nurse practitioners are frequently the focus of "mid-level provider" discussions. But the term encapsulates many more professionals. Part II of this series focuses on professional midwives; the interview that follows in Part III discusses, among other things, some of the ways in which mid-level providers are trained and qualified to provide care without physician oversight.


K. Harrington said...

I enjoyed your post! This is a topic I am personally interested in because I see a certified nurse-midwife for the majority of my maternal care. The nurse-midwifes I have talked to in California are very interested in passing legislation to lift some of the practice restrictions you mentioned. In fact, one California state senator has fought to expand the scope of nurse practitioners’ independence in recent years, but so far this has not been successful (

On a previous blog post, I commented that physical physician supervision of nurse practitioners is often quite limited. Although the nurse practitioner may be under the supervision of a doctor, the doctor may only check in 2-3 hours per week. This news article provides a good example of what that relationship might look like (

Because physician supervision is so limited, even states like California that currently have practice restrictions for nurse practitioners and certified nurse midwifes may benefit from increasing their use of mid-level professionals. Physicians could be available for consultation by phone or internet, and advances in telehealth may aid in this process (of course, there is always the added issue of access to broadband for remote rural areas). But like you mentioned, increasing the use of nurse practitioners is only part of the solution. This would not address the larger, more complex issues of rural access to healthcare.

Kyle Kate Dudley said...

I thoroughly enjoyed this post! I knew little about the doctor shortage (or, perhaps more accurately, acute mismatch of practice areas and those interested in practicing). Of course, it would make sense that doctors have less interest in being generalists/internists, and more interest in highly specialized and more lucrative fields. It is also the classic brain-drain story of rural areas lacking in professionals. (I must admit I have, in my past, watched a cheesy television show about a big-town specialist doctor who swallows her pride to go work in rural Alabama as a general practioner:, but I didn't realize that the premise was so accurate.)

I also knew little prior to this post about how great NPs (I've known many in my life and I deeply believe in their work) could solve possibly solve this problem just by being given more autonomy. I stumbled across this article about studies of Nurse Practitioners improving patient outcomes, often more cost-effectively:

I very much look forward to the additional installments of this post, particularly with regard to your friend who is making a conscious choice to take her medical work into rurality.

Thank you for such a thought-provoking topic!