Looking Back, Looking Ahead

Major Changes in Rural Health and Human Services

by Beth Blevins

Since this is our Tenth Anniversary issue, we’ve tapped some folks who have appeared in past issues—as well as those new to these pages—to discuss significant trends and topics in rural health and rural human services from the last decade and what might be coming in the next ten years.

“There has been a fundamental shift from treating patients to treating diseases.”
Dr. Monnie Singleton
rural health clinic CEO/physician
“Children as a whole are not faring well.”
Christine James-Brown
Child Welfare League of America
“The biggest change has been slow but steady policy change related to Medicare reimbursement.”
Tom Morris
Office of Rural Health Policy
“I think a better question might be ‘What would I want human services to look like in 10 years?’”
Jocelyn Richgels
Rural Policy Research Institute
“We will see the rapid rise, revision and adoption of new health initiatives.”
Denny Berens
former director Nebraska
State Office of Rural Health
“Rural health networks can and will play an important role in the development of new models of health care delivery.”
Rebecca Davis
National Cooperative of
Health Networks Association

What do you think are the most significant changes in rural health over the last 10 years?

Monnie Singleton, MD

Monnie Singleton, M.D.
Rural health clinic CEO/physician

I think what I have seen in terms of rural health are:

  1. Fewer primary care physicians in rural.
  2. Increased workloads on rural primary care physicians who are left.
  3. Primary care physicians in solo and/or small group practices are providing less in-patient care. Because of this, there has been a fundamental shift from treating patients to treating diseases. Most of our practice is solely in the outpatient setting, in our offices. If the patient needs to be hospitalized, he is followed and treated by hospitalists and specialists instead of his primary care physician.
  4. Hospitals are acquiring more rural physicians’ practices.
  5. An increase in obesity—especially childhood obesity. Because of that we are now treating chronic conditions such as Type II diabetes, hypertension and dyslipidemias (high cholesterol) in pediatric populations—which was essentially unheard of 10 years ago. More children are being diagnosed with ADD and ADHD than ever before, and they are being diagnosed at much younger ages.
  6. More patients are getting health information from the Internet and are self-diagnosing and diagnosing for their friends and families. A little bit of information can be a dangerous thing! Because of the information patients are accessing, they usually present with increased levels of anxiety and depression.
  7. Medications are becoming more expensive and, although they have potentially less side effects than the older medications, I don’t see where they are reducing the rates nor the complications of the chronic diseases compared to the increase in the cost. In other words, the value is not particularly impressive.
  8. Drug addiction has been ever increasing and prescription drug addiction has exploded.

What do you think we will see in the next 10 years?

  1. Even fewer primary care physicians in rural.
  2. Fewer solo and small group practices, expansion of Accountable Care Organizations (ACOs), and increases in the number of people who will have health insurance.
  3. Shifting roles of health care workers—the scopes of practices for physician assistants, Nurse Practitioners, medical office assistants, nursing assistants, and the like will be widening; new disciplines are already emerging (such as community health workers).
  4. Growth in the patient-centered medical homes (PCMH) and increase in the number of people who will have health insurance. But these things are not going to necessarily create healthier populations.
  5. There will be an increase in the number of foreign physicians, which could impact cultural competence and sensitivity adversely.
  6. An increase in Internet-based medicine and fewer face-to-face encounters between patients and physicians.
  7. The health care industry will probably continue to play the “follow the dollar” games, so when resources are allocated for exercise and behavior modification support, the gamut of health care industry personnel will rally around providing more of these services.

Monnie Singleton, M.D., is the founder, president and Chief Executive Officer of Rural Health Management, which currently runs two rural health clinics in South Carolina. The company evolved out of Singleton Health Center, established in 2002 by Dr. Singleton. Dr. Singleton has advised the U. S. Secretary of Health and Human Services as a member of both the National Advisory Committee on Rural Health and the National Health Service Corps.

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What do you think are the most significant changes in rural health over the last 10 years?

Tom Morris

Tom Morris
Office of Rural Health Policy

I would look back longer than ten years. The biggest change for rural health policy has been a slow but steady policy change related to Medicare reimbursement that has taken into account the unique low-volume environment in which rural hospitals and providers practice. Policy changes related to the introduction of swing beds, the creation of hospital designations such as Critical Access Hospitals (CAH), Medicare Dependent Hospitals and Sole Community Hospitals have helped to stabilize access to inpatient, outpatient and emergency medical services in many rural communities. Couple that with the expansion of Rural Health Clinics and Federally Qualified Health Centers as well as the National Health Service Corps and you see the development of a base level of rural health infrastructure that has stabilized health care delivery in many rural communities. I would point to the creation of the CAH designation and the Rural Hospital Flexibility program as one of the real public policy success stories of the past 25 years. After a significant number of rural hospital closures in the 1980s, there was a realization that we had to find a new model of organizing and paying for health care services in small rural communities. There were a series of small hospital demonstration programs through the early and mid-1990s, which led to the creation of the CAH designation. Just as critical, policymakers at the time paired that designation with a grant program run in partnership between the States and HHS to focus on quality and performance improvement and emergency medical service integration that has provided a backstop of resources to help CAHs adapt to an ever-changing health care landscape. The passage of Medicare reimbursement for telehealth services was also a key development that has increased access to services for many rural residents.

What will be the biggest change(s) in the next 10 years?
I would point to two key developments. The first is the linking of provider reimbursement to quality measures and eventually outcomes. This transition to paying for services based on volume to one based on value is critical for all health care providers but has the potential to continue to level the playing field between urban and rural health care delivery by focusing on an independent and objective result. The second is the implementation of the Affordable Care Act and expanded coverage for rural residents. Rural communities tend to be more dependent on public insurance programs and the individual and small business insurance markets. The Medicaid expansion and the insurance reforms should help increase choice and make coverage more affordable for rural residents such as farmers, ranchers and small business owners and employees that have traditionally struggled to find affordable private coverage. Increased coverage should also then improve the economic viability of clinics and hospitals since they’ll see reductions in uncompensated and charity care. The added benefit of increased coverage is that folks will have a regular source of care since they’ll now have coverage. Given that rural residents tend to have higher rates of mortality, the potential to get rural residents into regular care could help improve outcomes. It will be interesting to see what role telehealth plays in the coming years. It has never been a particularly good fit in the fee-for-service world but as reimbursement increasingly focuses on outcomes there may be opportunities to see if telehealth can drive better health outcomes.

Tom Morris is the director of the Office of Rural Health Policy.

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What do you think are the most significant changes in rural health over the last 10 years?

Dennis Berens

Dennis Berens
Former Director of the Nebraska SORH

The significant changes over the past 10 years have been impacted by what has happened in the near past: for example, the Affordable Care Act, as well as the Fiscal Cliff. But what is most important is the shift from linear thinking models to organic thinking models. We have been pushed out of our boxes/silos into a new world of connectedness. We could no longer provide health and health care systems from the cottage industry model of the agrarian age because our citizens and some providers see the “whole” of the people needing to be served. Policymakers were slow to see this shift but scrambled to address this with quality, bundled payment models, new insurance reform models, telecommunication policy and across border regulations.

Other important changes:

  • The advent of telecommunications in health care and the related health policy. We are now beginning to see how to connect players in our health and health care models that were almost impossible 20 years ago.
  • The continued sharp drop in the number of medical students wanting to serve in Primary Care practices. New Federal and state supports have and will continue to be developed.
  • The role of the citizen in addressing our personal health and health care systems issues. Young people are pushing policymakers to address food safety, preventive care, water quality and general livability issues in this nation, which is tied to feed lot management, pipeline and fracking expansion, air pollution, and food protection.
  • The Critical Access Hospital (CAH) model. The continued support for this model saved many of our rural facilities. The challenge today is marked by the shift in demographics that leaves some of our CAHs vulnerable.
  • The introduction of new types of health professionals. These include mid-level providers trained in mental health, senior care, other primary care, and some specialty services. Also important, the creation of the Community Paramedic model, which enhances the role of paramedics to provide non-emergency services.

What will be the biggest change(s) in the next 10 years?
The biggest changes likely to come will have much to do with continuing to be a nation in FLUX, in a world that is in FLUX. We will see the rapid rise, revision and adoption of new health initiatives. Citizens will have a greater voice in these initiatives. The policy challenge will be for leaders to come forward at all levels to ensure that their voices are heard. In health care this will mean finding a new balance between command and control models and the need for creative, holistic models that allow the needed blend of people to help with the care for each of us.

Other changes:

  • Smartphone apps. They will afford a new level of health connectivity and exploration, allowing patients to track their own progress and providers to address multiple patients at the same time from any location.
  • Rural connectedness in health care services. As technology and costs increase for all providers, the need to associate with other knowledge-based partners becomes the new norm, with cooperatives better able to address insurance, technology, professional shortages and professional training, and financial stabilization.
  • Protection of rural space. With the importance of high quality food, water, energy and quality of life now on our minds we will want to protect our rural places so they can continue to nurture us.
  • The redefinition of rural. In a nation where 70 percent of our population is urban, “rural” has to become more than an idea and a set of myths. It is where our food, our energy, our water, our new products from old and new agriculture, and a renewed interest/exploration in quality of life in our society come from.
  • A new connectedness. Health and health care should be the linkage to start this new model development, which should find better and newer ways to provide the care that small communities need.
  • CAHs evolving into regional health and health care facilitators/coordinators. Regional Health Cooperatives will become the facilitating entity for an area, defined by the users of the services offered.
  • EMS moving from an emergency care model to an “Every Member Served” model. The location and training of rural EMTs make them a crucial part of the redesign of local rural health care; they could serve every member in the community. Community members will be trained in First Aid and other life saving skill sets, and we will find ways to keep our workers safe and our homes accident free.
  • Rural Demographics. In this next decade, we will see the final impacts of the Dust Bowl, the Droughts, the fires, and the economic changes that moved people out of our rural communities in the past. We will be forced to clearly identify who is presently living in rural America and then find out what health care services and policies we should be advocating for.
  • Primary Care. Rural and remote places will be where we can find some of the best solutions because they know how to recruit, train and use scarce resources. There will be a local, state, multistate and national push to improve our primary care model in the United States.

Dennis (Denny) Berens is the former director of the Nebraska Office of Rural Health, a position he held for 22 years. He now runs the organization Nebraska Times LLC. He was interviewed in the Summer 2012 Rural Spotlight.

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What will be the biggest change(s) in human services in the next 10 years?

Jocelyn Richgels

Jocelyn Richgels
Rural Policy Research Institute (RUPRI)

For the next couple of years we’ll continue to have belt-tightening—it is unlikely that we are going to get more government funding in the foreseeable future. The responsibility is going to fall back to the states and to the counties in ways not seen before. Most people recognize these scenarios to be the case. But this does present opportunities if there is a corresponding flexibility in how localities can meet their needs—and localities are prepared to take advantage of that. As counties continue to lose physical presence in human services, they’ll move to an online presence. It opens up new access for rural—if they have broadband. I don’t see us going back to a physical human services staff in every area of human service delivery and every locality.

I think a better question might be “What would I want human services to look like in 10 years?” There are two models of service delivery I would like to see set up in rural areas around the country. One is the family resource center, where you’d have a services coordinator for families with children and the broader community. It would be a one-stop place to apply for services like SNAP and child care subsidies, etc. You could also get basic health services there like blood pressure checks and vaccinations. And it could offer parenting, exercise and cooking classes to engage the whole community. The second is the healthy campus concept. This is a new model for keeping a physical health care presence in the community. A rural hospital undergoing transition might begin to include care for people given outside the home—to include things like day care and assisted living facilities as part of a remodeling or add-on. Or, in conjunction with urgent care or an ER, you might have a family resource center so that a primary care doctor in the hospital could send someone down the hall to the food pantry, if they knew they were experiencing food insecurity, or to sign up for human services.

It’s an alternative way of delivering human services when there are fewer resources and less staff. You are unlikely to have a specialist in every aspect of human services delivery in every county. Instead you could have a coordinator working in the family resource center or healthy campus who could offer a more comprehensive approach to a family’s problems and direct them to other resources if necessary.

Jocelyn Richgels is the Associate Director of National Policy Programs at the Rural Policy Research Institute (RUPRI), a position she has held since September 2004. For more information, see her RUPRI Biographical Sketch.

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What have been the biggest change(s) in human services in the last 10 years—and what will be the biggest changes in the next 10 years?

Christine James-Brown

Christine James-Brown
Child Welfare League of America

For me, the two most significant changes in the external environment that impact how to provide child and family services in rural areas are technological advancements and the diversification of the population. These will become even greater issues in the next 10 years.

With diversification, the challenge is how to ensure that there are culturally competent child and family service workers available to serve an increasingly diverse rural population and that these workers have the services and supports that they need to serve the children and families. This is a big challenge for rural communities that already have a shortage of workers and that struggle to find cost effective ways to make sure that the workers have the most up-to date training. Building the cultural competence of workers is a concern in the field as a whole but for rural communities the concern is greater because of worker shortage, the challenge and cost of getting workers to some of the centralized training that is available to help them become more culturally competent and because as new populations move into urban areas, there’s the potential for someone in that area to already understand that culture—but this is not so in rural areas.

In many child and family services systems, including child welfare, technology is being used to do things like increase access to data about clients, help workers track their cases or to access on line training and to allow clients to access services and interact with workers using the Internet. In rural communities access to the Internet is not universal. To the extent that technology can be accessible in rural areas it can alleviate some of the problems caused by distance but, unfortunately, there are many rural communities that do not have the appropriate technological infrastructure to support these types of advancements. To the extent that rural communities do not have the access that they need to technology they can be left even further behind as child welfare and other child and family systems increase their use of technology for service delivery and accountability purposes.

In rural areas not only do they not have a child welfare agency, they don’t have good access to services to help keep children out of the child welfare system or to leave the system faster. This includes health and mental health, substance abuse, domestic violence services as well as services and supports to secure economic stability for families. Some of these services could be more readily available as rural communities build their technological infrastructures, but there are certain services that families and children need that should be done in person, and it’s difficult getting workers to rural areas.

And poverty is a big issue in rural areas. There was a study in 2002 that said that single rural women with children are the poorest cohort in the country—it’s still true. That’s what is happening to children across the board. Children as a whole are not faring well.

Christine James-Brown has been CWLA President and CEO since April 2007. Previously, she worked at United Way International, and has served on school and advisory boards. For more information, see her CWLA Biography page.

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What will be the biggest change(s) in rural health in the next 10 years? More specifically, how will rural health networks meet the needs of rural patients in the next 10 years?

Rebecca Davis

Rebecca Davis, Ph.D.
National Cooperative of Health Networks Association (NCHN)

NCHN defines rural health networks as a collaborative of at least three like-minded entities (organizations that deliver health care services) that join together to improve health outcomes for rural communities and advance a common mission. The new models for value-based reimbursement currently being developed, such as Accountable Care Organizations, bundled payments, and value-based purchasing may be difficult to implement in rural health care markets. Rural health networks can and will play an important role in the development of new models of health care delivery that will succeed in rural markets. Networks can support health care delivery through their ability to assist their members with group purchasing, increased efficiency among its members, addressing a community care need that cannot be addressed by one single health care provider organization, shared staffing, coordination and implementation of new services, launching of health information technology initiatives, and health care cost reduction.

I see two areas that rural health networks are positioned to provide both leadership and coordination of programs to their memberships as additional provisions of the ACA are implemented. Rural health networks can play a significant role in the implementation and delivery of wellness initiatives and implementation of the various methods and models of health information technology. Some networks currently assist their members with information technology needs, but in the future, most networks will be expanding their programs to include support for telemedicine, HIE, IT shared staffing, and/or equipment purchase and maintenance.

And the other area of change I see for health networks is a movement toward evidence-based outcome measures for the network organization. Historically, networks have focused on ROI (return on investment) for their members and have documented millions of dollars over the years that networks have saved their members. In today’s health care environment, network organizations must develop and implement core evidence-based measures for the organization that directly ties to patient outcomes for their members and the communities their members serve.

As new models of rural health care are explored and implemented, rural health networks should be considered as an essential component of the coordinated rural health care delivery system. Network organizations comprised of rural providers and community leaders understand the unique challenges of rural health care delivery and are positioned to provide a leadership role in meeting the needs of rural communities and their patients.

Rebecca Davis is the Executive Director of the National Cooperative of Health Networks Association (NCHN), a role she has served since July 2006. In addition, since 2003, she has held a faculty appointment in Rural Health Policy at the Virginia College of Osteopathic Medicine. Davis was interviewed in the Winter 2012 Rural Spotlight.

Opinions expressed are those of the interviewees and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Winter 2013 Issue