Elderly individuals age 65 and over constitute the majority of the Medicare population, and among Medicare beneficiaries, health care access problems are greater among individuals with low incomes, in poor health, and with four or more chronic conditions. These and other barriers may lead to rural-urban differences in health care use among the elderly. This study uses the 2011-2013 Medicare Current Beneficiary Survey to compare health access and use of health services among fee-for-service Medicare beneficiaries age 65 and over in rural versus urban settings, and the factors associated with rural access problems. Findings from this study will help policymakers understand the needs of the growing elderly population and how best to adjust Medicare benefit design and service delivery to reduce barriers to care.  

FMI: Yvonne Jonk, PhD

The proportion of U.S. residents aged 85+ is expected to grow substantially in the coming decades with the impact of this growth in rural areas likely to be particularly pronounced. In light of this population’s significant health and other vulnerabilities and high costs, this project will use data from the Medicare Current Beneficiary Survey (MCBS) to examine rural-urban differences in health care use and expenditures among Medicare enrollees aged 85 and over.

FMI:  Yvonne Jonk, PhD

Out-of-pocket spending for health care services has been on the rise as deductibles and other cost-sharing requirements among the privately insured increase.  This quantitative, nationally representative study will use the Medical Expenditure Panel Survey (MEPS) to examine health plan characteristics and out-of-pocket health care spending by non-elderly, community dwelling, rural and urban residents. Using bivariate and multivariable analyses, we propose to examine the:

• characteristics of private health insurance plans held by rural versus urban residents
• out-of-pocket costs, total premium and spending for privately insured rural versus urban residents
• percentage of health care spending paid out-of-pocket by rural versus urban residents and whether there are differences in out-of-pocket spending for individuals with chronic or acute health conditions, by events or socioeconomic characteristics?
• differences in out-of-pocket spending by plan characteristics
• percentage of rural versus urban household income represented by out-of-pocket health care spending, and whether this varies by socioeconomic and health plan characteristics

FMI: Erika Ziller, PhD

The elderly are at serious risk for opioid dependence or other harms due to higher prescribing patterns. However, there is a lack of literature on the rural-urban difference in the use and misuse of prescription opioids. Understanding these differences will help rural areas better target prevention and treatment options. We will address opioid prescribing rates among Medicare beneficiaries, using the Medicare Current Beneficiary Survey and describe differences in socioeconomic, health, and functional status of beneficiaries using prescription opioids and the general population using bivariate and logistic regression analyses. The impact of opioid use and medication-assisted therapy on health services utilization and costs will be assessed using difference in differences models.

FMI:  Yvonne Jonk, PhD

The closure of psychiatric beds in rural hospitals increases the wait time for mental health care and forces correctional facilities as well as hospital emergency departments, skilled nursing facilities, nursing facilities, and other health care providers to bear the burden of housing these patients until services become available. This study will examine trends in the closure of psychiatric beds by rural hospitals using the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Services Locator, the American Hospital Association (AHA) Annual Survey of Hospitals (2010-2017), and the Area Health Resources File.

FMI: John Gale, MS

While the Affordable Care Act (ACA) led to pronounced gains in insurance coverage in rural areas, particularly among low-income individuals, rural residents continue to have higher rates of uninsurance than their urban counterparts. Research also suggests that paying for health care remains a substantial rural concern: A recent survey of rural adults identified financial challenges, followed by health and health care issues, as the most pressing problems facing rural families, with many citing affordability as the reason for delaying or foregoing needed care. Although we know that health care affordability remains a concern for many rural residents, it is unclear to what extent factors such as insurance coverage gains or the growing trend of high deductible health plans (HDHPs) have influenced rural experiences of cost-related barriers to care, and whether rural populations continue to experience more such barriers than do urban residents. This quantitative, nationally representative study will address this research gap by comparing rural and urban differences in health care access and affordability.

FMI: Erika Ziller, PhD, erika.ziller@maine.edu

Rural Health Clinics (RHCs) address geographic access barriers for rural Medicare and Medicaid beneficiaries and, over time, have come to be recognized for their role in serving vulnerable rural populations. Over 4,000 RHCs serve rural communities in 44 states, and are considered part of the safety net by policymakers and rural advocates. Recommendations for updating and improving RHC policies and regulations have foundered on the lack of data on RHCs, which creates challenges in developing support for changes in the RHC program. Building on our extensive body of work on RHCs and our 2003 RHC Chartbook, this project will produce a comprehensive, descriptive chartbook detailing the characteristics and status of RHCs nationally.

FMI: John Gale, MS

This study will use the Medical Expenditure Panel Survey to examine out-of-pocket spending on prescription medication from 2014-2017. Specifically, we propose to analyze total spending and out-of-pocket spending for rural versus urban residents. We will identify the percentage of prescription drug spending that is paid out-of-pocket by rural and urban residents—across all drugs and within certain drug classes of interest (e.g., medications for diabetes, behavioral health conditions, asthma, and cancer). We will also examine how rural and urban out-of-pocket spending for prescription drugs differ based on health insurance coverage and other socioeconomic variables.

FMI: Erika Ziller, PhD

Rural residents are disproportionately  likely to be diagnosed with and die from lung cancer compared to residents of urban areas. While elevated rates of rural smoking are likely to be a factor in these rural-urban differences, little is known about tobacco treatment prevalence in rural primary care. This study will use the National Ambulatory Medical Care Survey to compare rural and urban rates and predictors of tobacco counseling and tobacco treatment medication prescribing by primary care providers to their smoking patients.

FMI:  Jean Talbot, PhD, MPH

This study will use Medicare claims data to describe the scope and intensity of services provided to Medicare beneficiaries by independent and provider-based Rural Health Clinics (RHC)s. This study will address the following research questions:

• What are the most common diagnoses for Medicare beneficiaries using RHCs?
• What are the characteristics and intensity of the services (e.g. E&M services, other procedures) provided by RHCs?
• Are there differences in the intensity and type of clinical services provided by different types of RHCs (i.e. provider-based vs. independent) and across the rural continuum and/or census divisions/regions?
• What types of non-RHC services are RHCs billing to Medicare Part B (e.g. care management, telehealth, inpatient E&M services, other procedures)?
• How do estimated fee for service payments to RHCs under CMS’s changes to the outpatient E&M codes in 2021 compare to the 2021 per-visit reimbursement cap?

FMI: John Gale, MS

Research indicates that rural residents use the emergency department (ED) at higher rates than their urban counterparts, with recent analyses indicating that this rural-urban difference has been increasing. Additional studies suggest that rural residents are more likely to visit the ED for a non-emergent reasons. However, the reasons for these higher rates remain unclear. This difference could be the result of rural primary care access barriers, including availability of after-hours care, or could be related to lower education or other factors affecting knowledge of appropriate healthcare use. This study will use the 2014-2017 Medical Expenditure Panel Survey to analyze the factors associated with rural versus urban residents’ non-emergent ED use.

FMI: Erika Ziller, PhD

The needs of rural children with SED and the burden these needs place on their families are intertwined and may place these rural children and their families at “double jeopardy” of having their mental health and other needs go unmet. Using the National Survey of Children with Special Health Care Needs (NS-CSHCN) and information on community characteristics from the Area Resource File (ARF) we examined the factors associated with whether children and their families have their needs meet across the rural continuum. View or download the Research & Policy Brief or the full report.

This study used data from the 2010 Medicaid Analytic eXtract (MAX) file, in-depth policy reviews to examine differences in the use of institutional and home and community-based service (HCBS) use by older adults across urban and rural areas, and the policy and community factors that contribute to differences or comparability in use. View or download the Research & Policy Brief.

Building on studies showing differences in how rural and urban older adults access and use long-term services and supports (LTSS), this study will use national, standardized Medicare and non-Medicare nursing home assessment data (MDS 3.0) to to assess rural-urban acuity differences among newly-admitted older nursing home residents. Study findings will inform federal and state policy strategies to enable rural (and urban) older adults to access LTSS services most appropriate to their social, health, and functional needs. This study is complete and findings were published in The Gerontologist (doi:10.1093/geront/gnaa183).

FMI: Yvonne Jonk, PhD, yvonne.jonk@maine.edu

Previous research has shown that rural adolescents are more likely to use alcohol than those in urban areas adolescents and that the more rural the area, the higher the use. Moreover, current knowledge suggests that risk and protective factors may operate differently for rural adolescents. This study used five years of NSDUH pooled data to examine the underlying factors that account for urban-rural and intra-rural differences in adolescent alcohol use and how this knowledge may be used to develop targeted alcohol prevention and intervention programs for rural youth. View or download the Research & Policy Brief or the full report.

Although adverse childhood experiences (ACEs) have been identified as important risk factors for the development of chronic illness and harmful health behaviors, researchers have not yet systematically examined ACEs and their linkages with health outcomes in the rural context. Using data from the data from the Behavioral Risk Factors Surveillance Survey, research staff assessed the prevalence of adverse childhood experiences (ACEs) in rural populations and examined associations of ACEs with health outcomes in rural versus urban settings. View or download the Research & Policy Brief.

Rural veterans face unique barriers to care including insufficient communication and coordination of care provided across multiple settings—both within and outside of the Veteran’s Administration. To help reduce these barriers, multiple agencies within the federal government have promoted technology as an opportunity to improve access and care coordination to veterans living in remote areas. Most recently, programs in Maine, Montana and Alaska have received grants to use health information technology (HIT) to expand and integrate services—including mental health services—for rural Veterans. However, little is known about the challenges these programs face on the ground, or what conditions and program strategies may facilitate success. This case study of Maine’s program identifies best practices and barriers for implementing rural HIT initiatives that could inform future strategies in this population. View or download the report.

Research staff designed and conducted a national survey of rural health clinics, both independent and provider-based, to determine the current level of health information technology adoption and readiness in these clinics. View or download the Research & Policy Brief or the full report.

Rural counties may be potentially vulnerable to an HIV or hepatitis C outbreak among persons who inject drugs. Using mixed methods, we provide an understanding of the rural areas at risk of an outbreak based on their state and county characteristics and an assessment of their public health infrastructure.  Completed publications:

• Capacity of Rural Counties to Address an HIV or Hepatitis C Outbreak
• Voices From the Field: A Qualitative Study of the Challenges and Promising Practices of Rural Public Health in Addressing HIV and Hepatitis C (Journal of Health and Human Services Administration, in press).
• Webinar presented April 12, 2017

FMI: Amanda Burgess, MPPM, MPH (amanda.burgess@maine.edu)

Heroin use has grown significantly in recent years, particularly among those reporting nonmedical use of opioid pain relievers before initiating heroin. Past research has indicated that opioid pain reliever use is higher among specific rural populations than urban, including adolescents and young adults. This study examined the rural-urban prevalence of non-medical use of pain relievers and heroin in the past year and the socio-economic characteristics associated with their use as well as treatment history and perceived need for treatment; perceived risk of using drugs; and other risky behavior, using data from the National Survey of Drug Use and Health (NSDUH). Key informant interviews with officials in four were conducted to understand the challenges and promising practices in monitoring opiate prescribing and diversion, prevention interventions, and opioid prevention and treatment infrastructure in rural communities.The project is complete, with a Research & Policy Brief focusing on prevalance statistics and a Working Paper and associated Research & Policy Brief highlighting  treatment strategies in four states. This project also resulted in a book chapter: Lenardson JD, Smith ML. Catastrophic consequences: The link between rural opioid use and HIV/AIDS. In: Parks FM, Felzien GS, Jue S, eds. HIV/AIDS in Rural Communities: Research, Education, and Advocacy. New York, NY: Springer International Publishing; 2017:89-108. doi: 10.1007/978-3-319-56239-1_7.

This study reviews the opportunities and challenges reform initiatives under the Affordable Care Act present for rural communities. The study assesses four types of organizational models for delivering integrated care management. Each model has different strengths and drawbacks, weighing for and against implementation in rural areas. View or download the Research & Policy Brief or the report here.

This project examined strategies, models, and policy options for improving access to, and quality of, rural long-term services and supports. View or download the Research & Policy Brief here.

This study assessed whether uninsured rural residents have different levels of access to care than their urban counterparts, and the factors associated with any differences (including sub-analyses for individuals with identified chronic conditions). In doing so, it will provide policymakers with critical information for improving rural health systems. View or download the Research & Policy Brief.  This study also resulted in a peer-reviewed article: Ziller, E.C., Lenardson, J.D., & Coburn, A.F. (2012). Health care access and use among the rural uninsured. Journal of Health Care for the Poor and Underserved, 23(3), 1327-1345.

This two year project assembled a cohort of Rural Health Clinics (RHCs) across thirteen states to participate in a sentinel quality measurement process. During the first year of the project, the project team worked with the cohort of RHCs along with an expert panel of RHC and quality measurement experts to identify, develop, and refine of a discrete set RHC quality measures. During the second year, the cohort implemented the reporting process, collected data from the RHCs on the quality measures, and evaluated the measures in terms of performance and quality improvement. View or download the Research & Policy Brief on the pilot testing of the RHC quality measurement reporting system..

This study will assess rural versus urban income volatility, the potential effects on states’ efforts to ensure continuous health insurance coverage to individuals enrolled in Medicaid expansions or Exchange plans under the Affordable Care Act, and develop policy recommendations to address any observed differences. View or download the Research and Policy Brief.

Recently, the access modules of the National Health Interview Survey (NHIS) have been modified to delve more deeply into individuals’ experiences of barriers to care. These new questions on access, use, and affordability, implemented in response to the Affordable Care Act (ACA), represent an important opportunity to better understand rural-urban differences in access to care and to monitor ACA implementation from a rural perspective. Using the 2011-2012 NHIS, this study provides detailed information about rural-urban differences among adults under age 65 in perceived affordability of health insurance coverage and services prior to implementation of the Affordable Care Act. View  or download the Research & Policy Brief.

To examine differences in health care access and affordability among rural children with public (i.e., Medicaid or CHIP) and private health insurance coverage, the study addressed the following research questions, using data from the 2011-12 National Survey of Children’s Health: Do low-income rural families report differences in access to health care services for their publicly versus privately insured children? What are the differences in families’ perceived affordability of premiums and cost sharing for low-income children with public versus private health insurance coverage? How do these patterns of access to care and affordability vary between rural and urban children with public and private coverage? View or download the Research & Policy Brief.

While estimates indicate that the uninsured rate among rural children has dramatically decreased since the 1997 passage of the State Children’s Health Insurance Program (CHIP), it is not clear whether or not coverage has become more stable and uninsured spells shorter. The purpose of this study was to investigate changes in insurance stability among rural and urban children following CHIP, and whether this was affected by specific state eligibility and enrollment policies or clusters of policies. This study found that following the CHIP’s implementation, health insurance coverage and continuity increased among low-income children, particularly for those living in rural areas. By CHIP’s maturity, coverage for rural children improved so much that their uninsured rate dropped below that of urban children. View or download the Research & Policy Brief.

This project explores health care use and barriers to health care access among disabled Medicare beneficiaries under 65 in rural and urban areas. The study is based on quantitative analyses of the 2009-2013 Medicare Current Beneficiary Survey, finding that the characteristics of nonelderly Medicare beneficiaries with a disability reflected the differences observed between rural and urban populations overall, with certain rural subgroups reporting greater challenges accessing care. Download or view the Research and Policy Brief.
FMI: Erika Ziller, PhD erika.ziller@maine.edu

Numerous studies have found that rural residents are more likely to be uninsured than urban residents. This coverage difference is generally due to more limited access for rural workers to employer-sponsored health insurance. Lower wages, and the tendency for rural residents to work for small employers, account for this reduced access. This study explores the impact of changes in employment status on insurance coverage for rural and urban workers. View or download the Research & Policy Brief or the full report.

This study used data from the Nationwide Emergency Department Sample (NEDS) and information from a panel of rural emergency care experts to assess the impact of the opioid crisis on rural emergency departments (EDs). Findings will help inform policies designed to help rural health care systems and communities address the growing problem of opioid abuse. Completed publication:

• Opioid-Related Visits to Rural Emergency Departments

FMI: Jean Talbot, PhD, MPH (jean.talbot@maine.edu) or Erika Ziller (erika.zillermaine.edu)

This study used the 2005-2010 panels of the Medical Expenditure Panel Survey to compare the prevalence of concurrent mental health and chronic illnesses across rural and urban populations and to describe relationships among comorbidity, residence, and healthcare use. Findings will inform public and private decisions on how best to allocate new resources available for mental health/primary care integration efforts. The resulting policy brief examined patterns of diabetic preventive care use among adults with diabetes to determine whether these patterns vary according to respondents’ rural/urban residence or the presence/absence of a mental health diagnosis. View or download the Research & Policy Brief.

This qualitative project focused on understanding the reporting requirements for RHCs related to CMS’ Merit-Based Incentive Payment System as well as the challenges in doing so and options to support RHC reporting. View or download the Research & Policy Brief.

Health insurance literacy is central to identifying eligibility for coverage and subsidies, choosing a plan, and using optimal healthcare services. This study examined rural-urban differences in knowledge and/or use of the Affordable Care Act Marketplaces; subsidies; the health insurance mandate; and health insurance terms and concepts. View or download the Research & Policy Brief.

Twenty-one percent of individuals covered by Medicare live in rural counties. Although Medicare provides near-universal coverage for seniors, and is an important source of health insurance for individuals with disabilities, many face gaps between the care they need and the costs Medicare will cover. These gaps can be damaging to beneficiaries financial well-being, and put them at risk of problems accessing health care services. This study evaluated rural-urban differences in out-of-pocket spending, supplemental coverage, and variation in spending by type of service. View or download the Research & Policy Brief or the full report.

This study assessed whether use of office-based care and psychotropic medicine by children differs between rural and urban areas, as well as the role of insurance coverage and availability of mental health providers on use of these services. View the report here.

Using the 2007-2010 National Health Interview Survey, this study examines rural residents’ enrollment in high deductible health plans and the implications for evolving Affordable Care Act Health Insurance Marketplaces. View or download the Research & Policy Brief or full report.

Preventive health services and screenings are an important component in the continuum of care provided to individuals across all ages. Yet, research has shown that rural residents use fewer preventive health services and screenings.This study used the National Health Interview Survey to examine receipt of preventive health services (cholesterol check, fasting blood sugar test, mammogram, pap smear, and receipt of the HPV vaccine) by rural and urban women over the age of 18. Findings indicate that rural women were less likely than their urban peers to receive preventive health services, and that some of the differences may be explained by rural-urban differences in sociodemographic characteristics. However, even when controlling for these characteristics, lower use of mammogram or HPV vaccine among rural remained. Outreach efforts targeted to rural women, along with policies and programs designed to improve access to rural women’s cancer screening and HPV participation, are needed. A recent Research & Policy Brief has been published and is cited in the Rural Health Research Gateway’s April 2019 Research Recap: State of Women’s Healthcare Utilization and Health Indicators..

FMI: Erika Zilller, PhD

This study examined changes in the delivery of mental health services by rural health clinics (RHCs), their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services. View or download the Research & Policy Brief or the full report.

The purpose of this study is to fill the knowledge gap about the extent to which CO-OP plans are participating in rural markets, their relative costs compared to other products, the challenges that CO-OPs have faced in reaching rural areas, and the strategies used to address these challenges. Using a mixed-method approach, we will combine quantitative analysis of administrative data with targeted case studies to examine the rural availability and pricing of CO-OP plans, and the early experiences of these plans. Findings will provide important information about the early availability, price-competitiveness, and implementation experience of these CO-OP plans as they have sought to serve rural markets and consumers under the ACA. View or download the Research & Policy Brief.

In the coming decades, the older adult population of the United States is projected to expand significantly. This demographic shift will pose challenges for the nation’s health care and long term services and supports (LTSS) systems. Rural areas are likely to experience a disproportionate share of this growth, due to existing rural infrastructure deficits and the relatively high needs of rural elders. In order to help rural communities meet the increased demand for health/LTSS services, rural stakeholders and policymakers will benefit from having a current, broad-ranging, detailed profile of health care/LTSS needs and use patterns among rural and urban older adults. The proposed project aims to create such a profile through a literature review and analysis of data sets including the American Community Survey, the Area Health Resource File, and the Medicare Current Beneficiary Survey. Findings from this project on the characteristics of the “oldest-old” are available in a Research & Policy Brief available for viewing or download.

E-mental health programs have been developed in rural areas as a promising approach to address the chronic challenges of low availability of mental health clinicians, long travel distances, and stigma surrounding mental health care. The literature has established the technical feasibility of these programs and interest remains strong in developing and implementing them more broadly. However, we lack a clear understanding of the viability of current rural e-mental health programs – both the business case for starting and sustaining them and the clinical case for what services and functions may be provided _ and what impact they have had. The current rural health environment is changing significantly and it is important to understand where and how e-mental health programs have been established and sustained, what impact they have had, and what value they may add to other initiatives. This policy brief describes the organizational setting, services provided, and staff used in 53 telemental rural health programs. It also outlines the opportunities and challenges for telemental health in the rural health system. View or download the Research & Policy Brief. This project also produced a peer-reviewed journal article on the business case for telemental health in rural communities: Lambert, D., Gale, J., Hartley, D., Croll, Z., & Hansen, A. (2016). Understanding the business case for telemental health in rural communities. Journal of Behavioral Health Services and Research, 43(3), 366-379. doi: 10.1007/s11414-015-9490-7

This study used Medicare cost reports for independent and provider-based clinics to provide a detailed national picture of the financial and operational performance of Rural Health Clinics (RHCs) and described variations in performance related to revenue, costs, staffing, payer mix, productivity levels, and hours of operation across independent and provider-based clinics. The project is completed.  The Research & Policy Brief examines the costs of RHCs relative to Medicare payment limits for different types and sizes of RHC providers. 

To view or download the Research & Policy Brief, please visit: https://digitalcommons.usm.maine.edu/clinics/13/

FMI: John Gale, MS

This study finds rural mothers are more likely than urban mothers to smoke. The authors suggest policymakers consider extending insurance for smoking cessation programs through the Affordable Care Act and Medicaid. Programs at the local, state, and national levels also could help reduce disparities in smoking-related morbidity and mortality. View or download the Research & Policy Brief.

This project is a mixed-methods case study that focuses on the Mental Health First Aid training program, with a view toward clarifying the rural reach, feasibility, impact, and appropriateness of the program for rural communities.This project is complete and a  journal article has been published in the Journal of Rural Health.

In rural communities, residential services provide an important alternative to institutional services, compensating for the fewer available in-home supports. However, rural residential settings have been found to offer less privacy and to be less likely to support aging in place. This study used the National Survey of Residential Care Facilities to evaluate rural and urban differences in the characteristics of residential care facilities and their residents and to assess differences in the impact of these policies on urban and rural residential care service options.The resulting chartbook offers information on part of the rural long-term services and supports (LTSS) continuum—the residential care facility (RCF). Survey results identify national/regional differences between rural and urban RCFs, focusing on facilities, resident and service characteristics of RCFs, and the ability to meet the LTSS needs of residents. View or download the Chartbook.

Rural Health Clinics (RHCs) provide primary care services to rural residents of 45 states. Since RHCs are in underserved rural areas and serve vulnerable populations, many consider them safety net providers. In this paper, we explore whether, and to what extent, independent RHCs are serving a safety net role or have the capacity to do so. This national study investigated and described the safety net role of independent Rural Health Clinics (RHC), examining the market effect of Federally Qualified Health Centers (FQHC) on the safety net role of independent RHCs at the county level. View or download the Research & Policy Brief or the full report.

This project examined: 1) the capacity of Rural Health Clinics (RHCs) to serve as Patient -Centered Medical Homes (PCMHs), looking at their health information technology, technical knowledge, and quality, administrative, and clinical systems; 2) the extent to which RHCs have implemented care delivery and practice management features (i.e., care management, team-based practice, patient tracking, clinical-decisions support tools, after-hours care, etc.) of the PCMH model; 3) the quality improvement infrastructure of RHCs; and 4) the technical assistance and resources needed by RHCs to implement the PCMH model. View or download the Research & Policy Brief or the full report.

Recent research suggests that rates of adolescent alcohol, tobacco, and illicit drug use are on the decline. Early results from the 2016 Monitoring the Future annual survey show a continued long-term decline in adolescent substance use across marijuana, alcohol, tobacco, and misuse of some  drescription medications. This project examines rural-urban differences in substance use among adolescents and young adults using data from the 2008-10 and 2014-16 National Survey on Drug Use and Health. Early findings revealed large rural-urban differences in cigarette use by adolescents so our first set of analyses examined change in cigarette use over time, and we presented these findings in a poster at the 2018 National Rural Health Association meeting, and published an article in the American Journal of Public Health.

FMI: Erika Ziller, PhD