Rural Health Care Trends and Policy Issues Facing Nevada Residents

John Packham, PhDDirector of Health Policy Research

Nevada State Office of Rural Health and Office of Statewide Initiatives

University of Nevada, Reno School of Medicine

April 11, 2017

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Data from the Nevada Rural and Frontier Health Data Book – 2017 Edition

• Biennial production of the Nevada State Office of Rural Health, UNR Med

• Most comprehensive source of county-level data on health, health care, and health determinants in Nevada

• Additional information www.unr.med.edu/osi

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A Snapshot of Rural and Frontier Nevada in Six Maps

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Distribution of Population by County and Region

Rural and Frontier Counties– 14 counties– 86.9% of land mass– 281,019 population– 9.7% of state population– 2.9 residents per square mile

• Urban Counties– 3 counties– 13.1% of land mass– 2.9 million population– 90.3% of state population– 182.7 residents per square mile

Source: Office of Statewide Initiatives (2017). Healthcare Resources in Nevada. Nevada Rural and Frontier Health Data Book 2017, p. 4, Map 1.

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Distribution of Nevada Population by RUCAs

• RUCAs: Rural-urban commuting areas• A more specific population

classification tool• Dense urban areas• Enormous rural, frontier, and

unpopulated areas• Urban counties have substantial

rural/frontier regions (i.e. Washoe, Clark)

• Rural/frontier counties have areas economically tied to urban areas (i.e. Lyon, Nye)

Source: Office of Statewide Initiatives (2017). Rural-Urban Commuting Area Codes. (2016). Nevada Rural and Frontier Health Data Book 2017, p. 5, Map 2.

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Unique Geography of Rural and Frontier Nevada

Average Distance from a Rural Hospital to:

• Nearest incorporated town: 46 miles

• Nearest hospital: 54 miles

• Nearest tertiary hospital: 108 miles

• Office of Rural Health & NRHP: 261 miles

Source: See Nevada Rural and Frontier Health Data Book 2017, p. 174 Map 6.1.

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Unique Terrain

• 150 mountain ranges• US Highway 50 –

“the loneliest highway in America”

• Travel time measured in hours not minutes

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Rural Health Care Challenges in Nevada

• Lack of access to essential health care services in many regions of rural and frontier Nevada, including mental and behavioral health

• High rates of uninsured and other cost barriers• Growing proportion of patients with public

health insurance coverage• High levels of chronic disease and associated

risk factors associated with chronic disease

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Rural Health Care Challenges in Nevada

• Persistent threats to the economic viability of rural hospitals, clinics, and other services

• Health workforce shortages – physicians, nurses, mental health professionals, other clinical and non-clinical staff

• Unique transportation challenges affecting the receipt of timely care

• Competition with urban areas (90.3% of the state’s population) for public resources

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Demography of Rural and Frontier Nevada

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Population Change in Nevada – 1990 to 2016

Region 1990 2016 Percent Change

Rural & Frontier 165,197 281,471 70.4 %

Urban 1,036,559 2,646,472 155.3 %

Nevada 1,201,756 2,927,943 143.6%

Source: Nevada State Demographer’s Office. (2016). See Nevada Instant Atlas, http://med.unr.edu/statewide/instant-atlas/county-data-map

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Population – 1990 to 2016Percent Change

-50

0

50

100

150

200

250

Perc

ent Nevada Average

Rural & Frontier Urban

Source: Nevada State Demographer’s Office. (2016). See Nevada Instant Atlas, http://med.unr.edu/statewide/instant-atlas/county-data-map

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Population Aged 65 and Over – 1990 to 2016Percent Change

0

100

200

300

400

500

Perc

ent

Nevada Average

Rural & Frontier Urban

Source: Nevada State Demographer’s Office. (2016). See Nevada Instant Atlas, http://med.unr.edu/statewide/instant-atlas/county-data-map

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Hispanic Population – 1990 to 2016 Percent Change

-100

100

300

500

700

Perc

ent

Nevada Average

Rural & Frontier Urban

Source: Nevada State Demographer’s Office. (2016). See Nevada Instant Atlas, http://med.unr.edu/statewide/instant-atlas/county-data-map.

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Veterans Population – 2016Percent of Total County Population

0

5

10

15

20

25

Perc

ent

Nevada Average

Rural & Frontier Urban

Source: U.S. Department of Veterans Affairs. (2016). See Nevada Rural and Frontier Health Data Book, p. 48, Table 1.24.

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Health Insurance Coverage in Rural and Frontier Nevada

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Health Insurance Coverage – 2014Population Aged 64 and Under - Uninsured

02468

10121416

Perc

ent U

nins

ured

Nevada Average

Rural & Frontier Urban

Source: U.S. Census Bureau. (2016). Nevada Rural and Frontier Health Data Book 2017, p.67, Table 3.1.

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Medicare Enrollment – 2016Percent of Population

0

5

10

15

20

25

30

Perc

ent

Nevada Average

Rural & Frontier Urban

Source: Centers for Medicare and Medicaid Services (2016). Nevada Rural and Frontier Health Data Book 2017, p. 74, Table 3.8.

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Health Insurance Coverage – 2008 to 2014

Region 2008 2014Change – 2008 to 2014

Number Percent

Nye County 8,562 5,555 -3,007 -35.1%

Rural Counties 51,951 35,187 -16,764 -32.3%

Nevada 529,091 416,208 -112,883 -21.3%

Source: Office of Statewide Initiatives. 2017. Nevada Rural and Frontier Health Data Book – Eighth Edition. Reno NV: University of Nevada, Reno School of Medicine.

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Public Health Insurance Coverage – 2011 to 2016

Program 2011 2016Change – 2011 to 2016

Number Percent

Medicaid 33,492 50,961 17,469 52.2%

Medicare 50,804 60,343 9,539 18.8%

Medicare Rx 26,271 37,530 11,259 42.9%

Source: Office of Statewide Initiatives. 2017. Nevada Rural and Frontier Health Data Book – Eighth Edition. Reno NV: University of Nevada, Reno School of Medicine.

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Health Insurance Coverage – 2014

12.3 12.0

18.4

26.3

13.311.3

16.1

27.3

15.8

9.9

17.3

27.4

0

5

10

15

20

25

30

Source: Office of Statewide Initiatives. 2017. Nevada Rural and Frontier Health Data Book – Eighth Edition. Reno NV: University of Nevada, Reno School of Medicine.

Total Population Under 19 Under 65 Under 65 & Below 138% FPL

Percent of Population Groups Who are Uninsured

Nye County Rural Counties Nevada

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Population Health Status in Rural and Frontier Nevada

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Obesity Prevalence – 2013Percent of Population

0

5

10

15

20

25

30

35

Perc

ent

Nevada Average

Rural & Frontier Urban

Source: Centers for Disease Control (2016). Nevada Rural and Frontier Health Data Book 2017, p. 85, Table 4.2.

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Tobacco Use – 2014Percent of Population

0

5

10

15

20

25

Perc

ent

Nevada Average

Rural & Frontier Urban

Source: Centers for Disease Control (2016). Nevada Rural and Frontier Health Data Book 2017, p. 87, Table 4.4.

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Behavioral Health Risk Factors – 2013/2014

12.5

31.529.7

18.415.6

9.0

24.6

21.3

17.0 17.6

7.2

28.726.1

15.116.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Diabetes Diagnosis Obesity Prevalence Physically Inactive Tobacco Use Excessive AlcoholConsumption

Percent of Adult Population

Nye County Nevada United States

Source: Office of Statewide Initiatives. 2017. Nevada Rural and Frontier Health Data Book – Eighth Edition. Reno NV: University of Nevada, Reno School of Medicine.

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All Cause Mortality Rate – 2014 Age-Adjusted Deaths per 100,000 Population

0

200

400

600

800

1,000

Nevada Average

Source: Office of Health Statistics and Surveillance. (2016). Nevada Rural and Frontier Health Data Book 2017, p.104, Table 4.21.

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Diseases of the Heart – 2014 Age-Adjusted Deaths per 100,000 Population

0

50

100

150

200

250

300

Nevada Average

Source: Office of Health Statistics and Surveillance. (2016). Nevada Rural and Frontier Health Data Book 2017, p.105, Table 4.22.

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Malignant Neoplasm (Cancer) – 2014Age-Adjusted Deaths per 100,000 Population

0

50

100

150

200

Nevada Average

Source: Office of Health Statistics and Surveillance. (2016). Nevada Rural and Frontier Health Data Book 2017, p.106, Table 4.23.

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Chronic Lower Respiratory Disease – 2014 Age-Adjusted Deaths per 100,000 Population

0

50

100

150

200

N/A

Nevada Average

Source: Office of Health Statistics and Surveillance. (2016). Nevada Rural and Frontier Health Data Book 2017, p.107, Table 4.24.

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Lung, Trachea, and Bronchus Cancer – 2014 Age-Adjusted Deaths per 100,000 Population

0

25

50

75

100

125

Nevada Average

Source: Office of Health Statistics and Surveillance. (2016). Nevada Rural and Frontier Health Data Book 2017, p.108, Table 4.25.

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Leading Causes of Death – 2014

285.9

176.9

88.0

63.8

40.6

191.3

161.9

52.1 45.332.8

167.0 161.2

40.5 42.1 36.5

0.0

50.0

100.0

150.0

200.0

250.0

300.0

Heart Disease Cancer COPD Lung Cancer Stroke

Number of Deaths per 100,000 Population

Nye County Nevada United States

Source: Office of Statewide Initiatives. 2017. Nevada Rural and Frontier Health Data Book – Eighth Edition. Reno NV: University of Nevada, Reno School of Medicine.

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Health Care Workforce in Rural and Frontier Nevada

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Primary Medical Care Health Professional Shortage Areas (HPSAs)

• Most regions of rural and frontier Nevada are federally-designated HPSAs

• 10 rural counties are single-county HPSAs

• Most rural and frontier census tracts of Clark and Washoe Counties are Primary Care HPSAs

Source: Bureau of Health Professions, Health Resources & Services Administration. (2017). Nevada Rural and Frontier Health Data Book 2017, p. 130, Map 5.1.

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Physician and Primary Care Workforce – 2016Number per 100,000 Population

Profession Rural &Frontier Urban Nevada

Allopathic Physicians (MD) 70.5 188.6 176.8

Adv Practitioners of Nursing (APN) 25.0 42.8 41.0

Osteopathic Physicians (DO) 15.9 24.2 23.4

Physician Assistants (PA) 23.6 25.6 28.6

Primary Care Physicians (MD & DO) 36.1 74.5 70.6

Source: See references for Tables 5.7 through 5.44 in Nevada Rural and Frontier Health Data Book 2017, p. 168, Table 5.45.

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Mental Health Professional Shortage Areas

• All 14 rural and frontier counties are mental health HPSAs

• With the closure of numerous rural mental health clinics, access to mental health services in rural areas is major public health issue

Source: Bureau of Health Professions, Health Resources & Services Administration. (2016). Nevada Rural and Frontier Health Data Book 2017, p. 148, Map 5.3.

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Mental and Behavioral Health Workforce – 2016Number per 100,000 Population

Profession Rural &Frontier Urban Nevada

Alcohol, Drug, & Gambling Counselors 48.8 41.5 42.1

Marriage & Family Therapists 16.4 26.3 25.2

Psychiatrists 0.1 7.1 6.8

Psychologists 4.2 14.5 13.4

Clinical Social Workers (LCSWs) 14.3 25.1 24.0

Source: See references for Tables 5.7 through 5.44 in Nevada Rural and Frontier Health Data Book 2017, p. 168, Table 5.45.

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Dental Health Professional Shortage Areas

• 8 of 14 rural and frontier counties are dental HPSAs

• Majority of census tracts in rural Clark County are also HPSAs

• Counties such as Churchill, Humboldt, and Lyon have historically been dental HPSAs

Source: Bureau of Health Professions, Health Resources & Services Administration. (2017). Nevada Rural and Frontier Health Data Book 2017, p. 140, Map 5.2.

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Oral Health Care Workforce – 2016Number per 100,000 Population

Profession Rural &Frontier Urban Nevada

Dentists 38.3 56.0 54.1

Dental Hygienists 35.5 36.0 35.9

Source: See references for Tables 5.7 through 5.44 in Nevada Rural and Frontier Health Data Book 2017, p. 168, Table 5.45.

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Health Care Resources• 14 hospitals with 2,249

employees and a payroll of $140.9 million, including 13 Critical Access Hospitals (CAHs)

• 40 federally designated Rural Health Clinics (RHCs) & Community Health Centers (CHCs)

• 13 tribal clinics and medical centers

Source: National Association of Community Health Centers. (2017). Centers for Medicare & Medicaid Services (2017). Nevada Rural and Frontier Health Data Book 2017, p. 4, Map 1.

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Major Rural Health Policy Issues

• Addressing the financial barriers to care, including high numbers of uninsured (and underinsured)

• Addressing geographic barriers, unique time and distance issues, e.g., telemedicine

• Ensuring the economic viability of low-volume, remote rural hospitals and clinics

• Aging physical plant and capital needs• Outmigration of patients from rural areas• Concerns about financing of long-term care an

other services for an aging population

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Major Rural Health Policy Issues

• Mental and behavioral health care needs and barriers• Integration of primary and mental/behavioral health

services, integration of medical care and public health • Chronic health workforce shortages and an aging

physician workforce • EMS workforce and resource deficits• Underdeveloped public health services and local

boards of health • State budget issues and historic underinvestment in

health care and public health

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Resources from the Office of Statewide Initiatives and UNR School of Medicine

Nevada Rural and Frontier Health Data Book – 2017 Edition

OSI Programs and Projects

• Nevada Office of Rural Health• Nevada Flex Program• Nevada SHIP Program• Project ECHO Nevada and rural

telemedicine • Nevada Area Health Education

Centers• Health Workforce Research and

Policy Program • Nevada AIDS Education and

Training Center

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Contact info

John Packham, PhDDirector of Health Policy ResearchOffice of Statewide Initiatives and

Nevada State Office of Rural HealthUniversity of Nevada, Reno School of Medicine

(775) 784-1235 / jpackham@med.unr.eduhttp://www.med.unr.edu/osi

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