A team of healthcare policy researchers investigated issues around Medicaid utilization in one rural North Carolina county, and came to some broader conclusions about the challenges of Medicaid management nationwide. In “Hot-Spotting North Carolina’s Medicaid Transformation,” published online on Nov. 5 in the Health Affairs Blog, Kushal T. Kadakia, a Rhodes Scholar pursuing an MSc in global health at the University of Oxford; Shivani A. Shah, an M.D. candidate at Harvard Medical School; and Barack D. Richman, J.D., Ph.D., a professor of all and of business administration at Duke University and a visiting scholar in the Department of Medicine at Stanford University, find that a severe shortage of physicians and challenges with transportation are keeping that county’s residents massively using hospital emergency departments and the county’s Emergency Medical Service (EMS) out of sheer necessity.
At the core of the crisis: that county, on state’s mountainous western border, has only four physicians serving the entire county. Among other recommendations, the researchers insist, must be an investment in telehealth capabilities, and the empowerment of local public health officials.
As the authors begin, “If you live in Graham County, North Carolina, there’s a good chance that one of your neighbors went to the hospital last year—not necessarily for a surgery or an emergency, but rather because the emergency department (ED) is their primary care physician. We first encountered this rural county when we began our research on North Carolina’s Medicaid program. In this era of rising health care expenditures, our first objective was to determine which counties had the costliest Medicaid beneficiaries. To our surprise, urban centers such as Raleigh and Charlotte were far down on the list. Instead, Graham, a county on the state’s mountainous western border, rose to the top.”
In that context, the researchers ask, “What causes a county to become the state’s costliest place for health care? This was the riddle that guided our research. We expected to see lavish technologies and patients with complicated conditions, but the answer we found was quite different: When Medicaid beneficiaries became sick, they went to the hospital because no physician was nearby. And because transportation was often lacking, these patients called for an ambulance. In short, they sought the most expensive care because that was the only care available. It is not novel to discover a linkage between longstanding provider shortages in rural areas and communities’ poor health outcomes,” they note. “Yet, while researchers and reporters have rung alarm bells about hospital closures, less attention has been paid to the gradual decay of the outpatient care delivery infrastructure.”
What to do about this situation? The authors write that “The stories of counties such as Graham are critically important as North Carolina embarks on a landmark overhaul of its Medicaid program. While proposed reforms to address social determinants of health, such as NCCARE360 and Healthy Opportunities Pilots, and advocacy for Medicaid expansion are promising steps, they represent necessary but not sufficient policy actions for rural patients. The availability of front-line care and the effectiveness of care coordination depends first and foremost on the care delivery infrastructure within a community—infrastructure that is rapidly eroding in places such as Graham,” they emphasize.
Given that Graham County’s physician workforce has remained static for decades, with little hope of massive new support from the federal or state governments, the researchers recommend a serious investment in telehealth, writing, “Bolstering telehealth capacity could reduce disruptions in care delivery induced by transportation barriers,” and noting that at present, Graham County residents are driving two hours to Asheville to see specialists.
They note that “The North Carolina General Assembly had previously passed a bill authorizing the state’s Department of Health and Human Services to explore potential reforms to telehealth policies, and the current Medicaid Transformation legislation includes provisions to increase reimbursement of virtual services at parity with in-person services. The Office of Rural Health already operates a telehealth program for psychiatric services, and the proposed policies could support investments in analogous infrastructure for chronic disease management that could be useful in areas such as Graham.”
Also important, they write, would be “expanding access to non-physician providers,” including nurses, pharmacists, and community health workers, who, they say could help fill important gaps in care delivery. “One strategy,” they write, “is to rethink workforce roles in leaner health systems. For example, some rural hospitals have received funding from their states to train advanced practice nurses as hospitalists to fill inpatient staffing gaps. A similar model could be adopted for primary care practices in areas with physician shortages. This is already the case in Tyrrell County, North Carolina, which lacks even a single practicing physician. Instead, the local Columbia Medical Center is run by a nurse, who provides primary care services to the entire county.”
Ultimately, they conclude, “North Carolina Medicaid—like US health care more broadly—stands at an inflection point in its journey to value-based care. Yet, long-term progress can be made on insurance reform without also tending to the status of the delivery system. It makes little sense to debate physician reimbursements if there aren’t any nearby physicians. Meaningful health policies for rural America must focus on the needs of those Americans and the resource gaps that surround them. With a reliable and affordable delivery system in place, a sensible Medicaid policy will follow easily.”
