1. Expand Access to Behavioral Health Services
The Parson administration has made workforce investment a priority. Few workforce sectors have as much opportunity for growth and long-term stability as health care. Behavioral health providers are in especially high demand as rural Missouri has an acute shortage. Nearly all of rural Missouri is a Health Professional Shortage Area for Mental Health, leading to patient boarding in hospital emergency departments and inpatient care. Behavioral health clinicians who agree to practice in these areas can participate in loan repayment assistance programs through the National Health Service Corps. In addition, Missouri should examine behavioral health programs to identify and eliminate any barriers for those who wish to practice in rural areas.
Missouri could expand access to rural behavioral health services through better integrated primary care services. The Substance Abuse and Mental Health Services Administration has partnered with the Health Resources and Services Administration to produce resources for rural providers, in addition to federal funding for innovative training programs.
The state could access federal Medicaid funding to support behavioral health through state waivers authorized by the Trump administration. Pursuing waivers in these areas would increase the state’s capacity to deliver high quality behavioral health services in areas of greatest need.
Stronger partnerships between Community Mental Health Centers, rural primary and acute care providers, and Federally Qualified Health Centers would improve the capacity of health care providers to treat behavioral health problems locally. Better integration of community-based outpatient care could expand opportunities for rural Missourians to receive behavioral health care close to home.
Rural areas also could benefit from greater use of hotlines, better support of family caregivers, and education and outreach resources.
2. Expand Access to Primary Care Providers
A primary health care system with the capacity to ensure that individuals receive the care they need, manage chronic conditions and live healthy lives is essential. The Parson administration is committed to building a better Medicaid program and a more efficient health care system. The foundation of that effort must be improved primary care access and performance. Six rural Missouri counties lack a PCP, and 71 lack obstetrics coverage. And, there’s a large disparity in the number of primary care physicians between urban and rural communities. These disparities are evident in access to oral health services, and pharmaceuticals and pharmacist consulting, as well.
As people age, their need for health care services increases. By 2030, more than 25 percent of Missourians will be over age 65. Research shows that 90 percent want to age in place. A series of challenges exist for the state’s rural health care system – 46 percent of Medicare beneficiaries are located in rural areas of the state, and there’s an increased demand for care, a primary care practitioner shortage, an aging workforce and worsening health status. In addition, the closure of six rural hospitals since 2014 further strains the system.
The following are multiple approaches to address the primary care shortage.
- Increase the number of available residency slots. Missouri’s medical school enrollment increased by 10.6 percent from 2006 to 2016, but residency slots have not kept pace.
- Increase the use of nurse practitioners and physician assistants by removing barriers that prevent them from utilizing their education and training in their practice. The majority of nurse practitioners are trained in primary care. Researchers estimate that 60 percent of preventive care services can be performed by such health professionals.
- Continue to support the University of Missouri-Columbia School of Medicine’s Rural Track Pipeline Program to promote rural medical training in undergraduate and medical student education.
- Develop stronger recruiting and retention programs through scholarship and student loan repayment programs, like the state’s Primary Care Resource Initiative for Missouri or the National Health Service Corps, and, more importantly, create opportunities for rural communities to “grow their own” health care talent through career pathways.
- Integrate clinical pharmacists as members of the primary health care team, optimizing health outcomes by ensuring safe and effective use of medications. The American Society of Health System Pharmacists has had a position on the use of pharmacists in primary care since 1999.
3. Increase Access to Care for Substance Use Disorder
The opioid and substance abuse crisis is one of the greatest public health threats facing Missouri. Overdose deaths now exceed traffic-related fatalities in Missouri. Changes in state policy, and targeted investment in intervention and recovery, could help curb the high toll on rural communities, which tend to be disproportionately impacted by this epidemic.
The Parson administration voiced support for enacting a statewide prescription drug monitoring system during the 100th Missouri General Assembly. Missouri is the only state in the country without a state-legislated PDMP. As a result, the state is missing federal funding opportunities to assist health care providers in their ability to identify and treat patients with, or at risk of developing, opioid use disorder. The benefit of a robust PDMP has been established by the Centers for Disease Control and Prevention as a tool to prevent multiple prescriptions, and thus reduce the risk of OUD. More than 80 percent of Missourians and 90 percent of providers are covered by the St. Louis County Department of Public Health’s PDMP system. Unfortunately, there still are more than 50 — primarily rural — counties and municipalities outside of the PDMP network.
Medicaid reimbursement generally is not available for nonelderly adults cared for in inpatient psychiatric facilities, or “Institutions of Mental Disease.” However, the Trump administration extended the opportunity for states to apply for waivers that would include lifting the “IMD exclusion” to allow states to expand treatment options and capacity for Medicaid participants with opioid addiction or conditions of serious mental illness/serious emotional disturbance. Pursuing waivers in these areas would increase the state’s capacity to deliver high quality behavioral health services in areas of greatest need.
Providing evidence-based OUD treatment to low-income, uninsured women of childbearing age with substance use disorder prior to pregnancy could reduce the medical and societal costs associated with neonatal abstinence syndrome. Through a federal waiver, Medicaid coverage could be expanded for substance abuse treatment without new state revenue. The initiative could use cost avoidance for NAS-related care to redirect spending for substance abuse treatment. This would reduce state and federal spending in other areas as well, including foster care, and create a cumulative savings of approximately $14.5 million throughout a decade.
Beginning in 2019, federal funding will be available to assist rural communities planning to implement OUD prevention, treatment and recovery-oriented systems to reduce opioid misuse and overdoses. The grants provide communities an opportunity to conduct in-depth gap analysis, identify workforce shortages in the behavioral health field and construct a strategic plan to position applicants to receive additional implementation funding in August of 2019. A coalition of organizations, including the Missouri Rural Health Association, Missouri State Office of Rural Health, Missouri Primary Care Association, Missouri Department of Mental Health, Missouri-USDA Rural Development and the Missouri Hospital Association, formed the Missouri Rural Community Opioid Response Team to assist applicants and align statewide efforts.
In September 2018, seven Missouri communities were awarded grants through the Rural Community Opioid Response Program — the greatest number of awards for any single state. In November 2018, HRSA announced a second round of the RCORP one-year planning grants. The funding will allow the RCORT to support additional rural communities through the application process and assist them in aligning their efforts with opioid crisis efforts statewide.
4. Ensure Access to Quality Health Care
Gov. Parson chose Citizens Memorial Hospital in Bolivar, Mo., to hold his Rural Health Summit. The hospital, recently honored with its third Missouri Quality Award, is an excellent example of how rural care isn’t a choice between distance and quality.
Nonetheless, health care in rural Missouri is challenged by fewer resources per capita, an older population and, for some regions, less healthy behaviors. Exacerbating this problem is the fact that six rural hospitals have closed in the past four years, creating greater distances for rural residents. For example, after the closure of a hospital in Kennett, Mo., area residents are anticipated to travel more than 1 million additional miles to receive hospital care.
Although health status in rural Missouri may be among the lower rankings across Missouri, the quality of care provided to rural residents meets and sometimes surpasses other regions of the state and country. Care provided in Missouri’s rural hospitals was among the reasons MHA was selected as the 2018 American Hospital Association Dick Davidson Award Recipient for Leadership in Quality.
Hospitals also are employing innovative approaches to community health, care coordination and population health. An example is the community paramedicine program. The program trains paramedics and emergency medical technicians to operate in expanded roles in support of primary care. The program is designed to reduce emergency room visits, readmissions and preventable hospitalizations. Adhering to a standardized curriculum, first responders improve access to prevention, disease management and primary care. Federal innovation grants and private payers are exploring expanded use of this new care delivery model. However, of the nine community paramedic programs in Missouri, only two serve rural communities in Higginsville and Farmington. Expansion of this program — and others such as community health workers — build on Missouri’s nationally recognized health-home model, known as the Primary Care Health Home Initiative.
The state also could examine incenting partnerships between health care providers and schools to develop school-based health centers. These programs have the potential to have positive effects for children with asthma and other chronic conditions.
Helping all citizens who are eligible for Medicaid assistance get enrolled and remain enrolled ensures health care providers will be paid for the care they deliver, but also opens the door to treatment for citizens with chronic conditions, as well as regular screenings for children and pregnant women. Simplifying eligibility processes and reducing barriers to coverage improves access to care and lowers state administrative costs. The state could enhance its administrative effectiveness through strategic partnerships with local health care providers and social services organizations that have regular contact with Medicaid-eligible citizens.
Long-term care services and support for seniors and people with disabilities will be important with the aging population. Ensuring access to home- and community-based services, and empowering rural communities to help design programs that meet their needs, will be essential.
In addition to effective enrollment, looking at creative and innovative ways to reduce the uninsured rates in rural Missouri could help provide needed financial stability. Many health care providers are struggling financially for a variety of reasons, including the extra debt load they carry for uncompensated care. Six rural hospitals have closed in Missouri throughout the past four years, and 47.1 percent of rural hospitals in the state operated with a negative margin in 2016. In 2017, Missouri’s uninsured rate was 9.1 percent — with higher rates in the rural parts of the state.
5. Allow and Encourage Innovative Payment Models
Missouri’s new director of the MO HealthNet Division, Todd Richardson, has been charged with evaluating the state’s Medicaid program to determine how to reduce costs and increase value. One option is to identify opportunities for innovation.
Traditionally, health care providers have been paid set fees for discrete services rendered, and hospitals paid for inpatient care on a per diem basis. These volume-based services are inflexible and offer no opportunity for health care providers to adapt their approach to new, value-based approaches for delivering care to their patients and communities.
Expansion of Missouri’s nationally recognized Primary Care Health Home Initiative has the potential to improve health outcomes, incent rural providers to remain in rural communities, and save scarce rural health care funding by directing the focus of care on prevention and wellness. The program doubles down on rural communities by allowing these dollars to stay local. Missouri's health home program is showing positive results in Missouri's rural communities.
The key to success of the Primary Care Health Home program and other provider-led initiatives is that with local control and funding, the initiatives permit great flexibility, allowing hospitals and other providers to offer programs that meet individual community needs. And with further creative thinking and design, they could permit nontraditional services that may be critical to improving patient care, which would not be reimbursable under a traditional “fee-for-service” system.
Exploration of Accountable Care Organizations also may show promising results for some rural communities, although changes are being made in the program that forces hospitals to assume more risk. This may make ACOs less feasible for rural hospitals.
Missouri has been a national leader in using nontraditional funding sources to finance its Medicaid program. Strong partnerships between the state and hospitals, nursing facilities, pharmacists and emergency transportation providers have allowed Medicaid provider taxes to flourish and generate billions to support Missouri’s health care safety net. Maximizing allowable Medicaid provider tax opportunities and creatively tapping local government health care resources to earn the federal Medicaid match can provide opportunities to finance rural health system innovations without burdening the state’s general revenue budget.
6. Collaborate to Identify and Address Social Determinants of Health
Health care only is one component of maintaining good health. Rural Missourians face increasingly constrained access to health-enabling amenities such as nutritious food, recreation and gainful employment. These social determinants of health are defined as “the conditions in which people are born, grow, live, work and age.” The multidimensional nature of SDOH reach far beyond poverty and require a systemwide approach to effectively moderate their effects on health outcomes. The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received and are not readily modifiable by health care providers.
Addressing the root causes of these community-based problems will require coordinated federal, state, local and private resource allocation. Resources should be delivered to the most at-risk populations and communities to improve outcomes and ensure returns on investment are maximized. The most at-risk populations and communities in rural Missouri can be defined as those with the highest rates of social complexity, or SDOH.
Limited health and social resources can be targeted using social and health-related data. Researchers can identify the highest risk rural ZIP codes, and through diagnostic coding, identify the most at-risk patients residing within those communities, with increasing accuracy. With this information, the Parson administration could engage stakeholders to target and coordinate resources from the departments of Health and Senior Services, Social Services, Mental Health, Economic Development, Labor, and others to improve community resources and more effectively improve health — individually and communitywide.
7. Expand Telehealth and Telemedicine
Missouri has made significant progress on telehealth since the release of MHA’s report in 2017. Enacted in 2018, House Bill 1617 rescinded many clauses that restricted the use of telemedicine. Now, Missouri’s Medicaid-enrolled providers can deliver services through telemedicine any time they can provide the same level of service as an in-person encounter and the service is within the scope of services offered by the provider, without any geographic restrictions.
The Missouri Telehealth Network also is leading the way with the innovative Show-Me ECHO program, an educational resource that shares the expertise of health care professionals from academic settings with providers located in rural areas that would not otherwise have access to continuing clinical education.
Although Missouri has been a national leader in expanding its reach for telehealth services, it could benefit from an examination of its current programs, including constraints on their use. Through participation in interstate medical licensure compacts, physicians could more easily become licensed in multiple states.
New federal support for telehealth was recently adopted as part of the farm bill, including new funding for distance learning and substance abuse telehealth programs. Missouri must prepare to take full advantage of these resources when the programs are launched and funding becomes available.
8. Advocate for Improved Infrastructure
Gov. Parson has championed investment in infrastructure. The state’s newly formed Broadband Development Office is leading the way by connecting stakeholders and aligning efforts to improve broadband coverage. The challenges to rural infrastructure are significant and have implications for rural health. The expansion of broadband internet to rural communities remains a challenge, as 22 percent of Missourians still lack access to high-speed internet. Missouri must continue to find funding to provide high-speed internet access for the “last mile” in rural Missouri. Expanded broadband benefits more than just health care. Today’s agricultural producers, and current and future economic development opportunities, rely on high-speed internet services. Both the Missouri Farm Bureau and the Missouri Chamber of Commerce and Industry have included expansion of broadband services in their strategic initiatives.
Expansion of broadband internet services benefits the health of rural Missourians and provides opportunities for continuing education and financial prosperity. In addition to providing valuable internet services, the expansion of broadband creates job opportunities for local communities. Establishment of high-speed internet services will enable new health technologies, such as remote home monitoring and direct to provider services, that will increase access to health services.
Public transportation in rural areas can be sparse, and for rural residents with special needs, it can be nonexistent. Access to transportation is essential to maintaining the health of rural Missourians. Support for innovative models like HealthTran should be part of Missouri’s policy. Access to care and transportation can allow rural residents to age in place — strengthening individual health and supporting connected families and communities.
Missouri’s poor roads, and the greater distances to care for rural residents, complicate access to care. Rural hospital closures, which can lead to other health care providers leaving the community, exacerbate travel to care.
Finally, Missouri’s rural health care infrastructure — access to hospitals, physician services, and pharmacy and dental health — is in jeopardy. When these health care providers leave, they create medical deserts in rural parts of the state.
9. Support Emergency Services
Rural residents are at a higher risk of traumatic injury, including unintentional injuries from vehicle accidents, falls, drug overdoses, fires and drownings, than urban residents. Moreover, farmers use machinery that can expose them to crushing injuries that can require trauma care. Access to robust emergency services is essential to support lifesaving care.
There is limited access to specialized emergency care in rural Missouri. Outside of the Kansas City and St. Louis metropolitan areas, there are two designated trauma centers north of Interstate 70 — Northeast Regional Medical Center in Kirksville, a level III center, and Mosaic Life Care in St. Joseph, a level II center. In southeastern Missouri, Saint Francis Medical Center in Cape Girardeau, a level III center, is the only designated trauma center. Missouri’s pediatric trauma centers are in metropolitan areas. Accordingly, rural residents often must rely on high-cost air ambulance transport or extended ground ambulance trips.
The state’s Time Critical Diagnosis program sets standards for emergency care of stroke, STEMI (a type of heart attack) and trauma throughout Missouri. Responding to a 2018 legislative discussion of TCD funding, legislators and the Parson administration reiterated their strong support for maintaining the TCD program. Providers and policymakers are collaborating to explore possible TCD enhancements.
A number of health care coalitions — collaborative networks of health care organizations and their public and private sector response partners — have been created throughout the state to coordinate emergency care during disasters. These coalitions were formed using federal emergency preparedness funding. There is opportunity to align the parallel, established systems of preparedness and response with day-to-day care delivery. For example, interoperable platforms between EMS and emergency departments should include notice of a mass casualty incident or the routing of a trauma patient to the most appropriate facility.
In Missouri, 95 counties have a Crisis Intervention Team Council — a collaboration of law enforcement and behavioral health community partners dedicated to helping individuals in crisis by implementing the Missouri Model of CIT. Statewide adoption of the CIT model by all Missouri counties would benefit health providers, law enforcement and other stakeholders in some of Missouri’s most rural counties.
10. Empower Partnerships
Vibrant communities are characterized by organizations collaborating for the betterment of all its citizens. Several rural Missouri communities currently participate in Communities of Excellence 2026, a program that promotes collaboration among key sectors of the community, and Healthy Places for Healthy People, a program that joins community leaders and health care partners to create walkable, healthy, economically vibrant downtowns and neighborhoods that can improve health, protect the environment and support economic growth.
Both the Health Resources and Services Administration and the U.S. Department of Agriculture offer assistance to organizations working to develop stronger rural partnerships. Small communities may lack the resources to produce the data and create the narrative necessary for submitting a grant application. The state’s Office of Primary Care and Rural Health should be funded to bolster support of rural communities hoping to compete for federal funding.
Health-related resources and assets are available throughout rural Missouri at health clinics — including FQHCs and rural health clinics — and through the state’s cooperative extension programs. Better integration of these resources — with collaborative efforts targeting primary care and health improvement — could extend wellness deeper into rural communities.