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					                  California
              Rural Health Update
               December 2006



 Department of Health Services
Primary and Rural Health Systems Branch
        State Office of Rural Health1
2
                              Rural Definition
  Most California counties have rural areas; however, the State and
  Federal definitions of “rural” are not consistent. The State definition
  designates approximately 80% of the total land mass of 156,000
  square miles as rural.
                                     State
  Medical Service Study Area (MSSA) MSSAs are sub-county
  designations defined by the California Health Manpower Policy
  Commission.
                  Total California MSSAs 541
  Rural MSSAs have 250 persons or less per square mile and no
  Township of more than 50,000.
                   Total Rural MSSAs 186
  Frontier MSSAs have less than 11 persons per square mile.

                   Total Frontier MSSAs 56

                                                                            3
Source: OSHPD Geographic Information System Census 2000
                           Rural Definition
                                  Federal
Federal Agencies use various definitions of “Rural” to allocate resources,
certify healthcare providers, and monitor population shifts.
U.S. Census Bureau
• The bureau defines a “Rural” area as not being in an Urban area using
   a population center of 50,000 as basis for urban (Source: US Census
   Bureau-Census 2000 Urban and Rural Classification)
Office of Management and Budgets (OMB)
• OMB defines “Rural” county as being outside of Core Based
   Metropolitan or Micropolitan Statistical Area. (Source: Federal Register
   – Standards for defining Metro/Micro Statistical Areas/County).
Office of Rural Health Policy (ORHP)
• ORHP uses several methods to determine geographic eligibility for grant
   programs including: (1) the OMB Core Based Statistical Areas, and (2)
   the Rural-Urban Commuting Area codes (RUCAs). Under the RUCA
   definition, degrees of rurality are coded from 1-10 by their proximity to
   urban areas and the portion of the population that commutes from rural
   to urban areas. (Source: www.HRSA.gov)
                                                                         4
     California State Office of Rural Health (CalSORH)


Rural Counties are Defined as Counties with a MSSA Rural
Land Mass 80% or Greater

•   Rural Counties (43)
    Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado,
    Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake
    Lassen Madera, Mariposa, Mendocino, Merced, Modoc, Mono,
    Monterey, Nevada, Placer, San Benito, San Bernardino, San
    Joaquin, San Luis Obispo, Santa Barbara, Shasta, Sierra,
    Siskiyou, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tulare,
    Tuolumne, Yolo, and Yuba

•   Urban Counties (15)
    Alameda, Contra Costa, Los Angeles, Marin, Napa, Orange,
    Riverside, Sacramento, San Diego, San Francisco, San Mateo,
    Santa Clara, Santa Cruz, Solano, and Ventura.



                                                                  6
                              Rural California

California’s Rural Population Continues to Increase

•    The State population at the 1990 Census was 29,760,021. Population at
     the 2000 Census was 33,871,648. An increase of 4,111,627, or 12%.
•    The rural population at the 1990 Census was 3,232,000 and the 2000
     Census reported 3,896,000 rural residents, an increase of 664,000, or
     20%.
•    Between January 2005 and 2006

        The State population was estimated to have grown from 36,728,196
         to 37,172,015, which translates to a 1.21% growth.

        The Urban population is estimated to have grown from 32,256,894 to
         32,630,748, which translates to a 1.16% growth.

        The Rural population is estimated to have grown from 4,471,302 to
         4,541,267, which translates to a 1.56% growth.


Source: Department of Finance January 2006
                                                                             7
                            Rural California


California’s Rural Population Is Older

• There are a greater proportion of residents of rural counties that
  are 55 years of age and over compared to residents of non-rural
  counties:
    28.7% vs. 25.4% respectively

• There are a fewer proportion of residents of rural counties 25 to 34
  group compared to residents of non-rural counties:
    19.2% vs. 21.21% respectively

)




    Source: 2005 Behavioral Risk Factors Survey                          9
                                 Rural California

California’s Rural Population is Diverse
•   Proportionately there are more white non-Hispanic residents in rural counties than in
    non-rural counties:
      2004 59.2% vs. 50.9%        2005 58.7% vs. 50.0% respectively

•   There are proportionately fewer black non-Hispanic and Asian/ Pacific Islander
    residents in rural counties than in non-rural counties:
      2004 4.3% vs. 6.6% and 5.1% vs. 13.3% respectively
      2005 4.3% vs. 6.6% and 6.1% vs. 14.6% respectively

•   Proportionately there is a greater number of American Indian, Eskimo or Aleut
    residents in rural counties than in non-rural counties:
      2004 3.4% vs. 1.0% 2005 2.2 vs. 1.0%

•   The proportion of rural residents that are of Latino/Hispanic origin in
    2004 was 28.0 % and 28.3 % in 2005 compared to the urban population of
    28.4% in 2004 and 28.3% in 2005.



       Source: 2004 and 2005 Behavioral Risk Factors Survey                          10
                              Rural California

Education Level
•   Proportionately more residents of rural counties have received high school
    diplomas compared to residents of non-rural counties:
    2004 26.3% vs. 20.0% respectively
    2005 26.8% vs. 21.0% respectively
•   Proportionately fewer residents of rural counties are college graduates compared
    to residents of non-rural counties:
     2004 16.5% vs. 23.1% respectively
     2005 16.0 % vs. 22.7% respectively
•   Proportionately fewer residents of rural counties have completed post-graduate
    degrees compared to residents of non-rural counties:
    2004 10.7% vs. 15.9% respectively
    2005 10.2% vs. 15.7% respectively


•   Source: 2004 and 2005 Behavioral Risk Factors Survey
                                                                                 11
                                            Rural vs. Urban Comparison of Education Level

                                                                                                                                        Lower levels of
                                                                                                                                        education
                                                                                                                                        attainment are
                                                             Rural                                 Urban
                                                                                                                                        over-represented
                                                                                                                                         in Rural Areas,
                          30.0%
                                                                              21.5%                                         NO SCH      and under
                                        19.5%
                          20.0%              16.6%                                                                                      represented in
                                                                                                                    12.0%
                                                                                                             9.8%           <12 GR
                          10.0%                      7.7% 7.0%                                                                          Urban areas.
Deviation from Expected




                           0.0%                                                                                             HS GRAD     Individuals who
                          -10.0%
                                                                                               -3.3% -3.0%                               have obtained
                                                                                  -8.5%-7.2%
                                                                                                                            TECH SCH
                          -20.0%
                                                                                                                                        College degrees
                                                                 -22.4%
                                                                                                                            SOME COL
                                                                                                                                        are over
                          -30.0%                                     -27.6%
                                                                                                                                        represented in
                          -40.0%
                                                                                                                            COL GRAD
                                                                                                                                         Urban areas and
                          -50.0%
                                   -49.3%
                                                                                                                            POST GRAD
                                                                                                                                         markedly under
                          -60.0%
                                                                                                                                         represent in
                                                                                                                                        Rural Areas.



                              Source: 2005 Behavioral Risk Factors Survey
          Rural vs. Urban Comparison of Veteran Status


100.00%
                                                88.49% 89.61%
 90.00%
 80.00%
 70.00%
 60.00%
                                                                Rural
 50.00%
                                                                Urban
 40.00%
 30.00%
 20.00%         11.51% 10.39%
 10.00%
  0.00%
                  Have Military                   No Military

  Source: 2005 Behavioral Risk Factors Survey
                                            Rural vs. Urban Comparison of Marital Status




                                                                                                           Separated, Never
                                                                                                           Married and
                                           Rural                                      Urban
                                                                                                           Unmarried
                          20.0%               16.7%
                                                                                                  14.4%
                                                                                                           Couples are
                          10.0%    7.6%                                                 8.6%
                                                                                               5.7%
                                                                                                           under
Deviation from Expected




                                                                             0.9%                          represented in
                           0.0%
                                          -2.0%                      -3.3%
                                                                                                           Rural Counties
                          -10.0%                                                    -7.2%
                                                                                        MARRIED
                                                                                                           while being
                                                       -13.0%
                          -20.0%                                                        DIVORCED           over-represented
                                                   -19.9%                               WIDOWED
                          -30.0%                                                        SEPARATED          in Urban areas.
                                                                                        NEVER MARRIED
                                                            -33.1%                      UNMARRIED COUPLE
                                                                                                           Widowed persons
                          -40.0%
                                                                                                           Are markedly
                                                                                                           over-represented
                                                                                                           in Rural counties.



                             Source: 2005 Behavioral Risk Factors Survey
                              Rural California

Socioeconomic Indicators
•   The proportion of residents of rural counties compared to residents of non-rural
    counties that fall below the Federal poverty level changed between 2004 and
    2005:
    2004 17.3% vs. 18.5% and in 2005 16.2% vs. 15.9% respectively

•   The proportion of residents of rural counties compared to residents of non-
    rural counties that fall between 100% and 200% of the Federal poverty level in
    2004 was 21.5% vs. 16.9% and in 2005 was 19.2% vs. 12.8% respectively

•   About the same proportion of residents of rural counties earn less than
    $20,000 per year compared to non-rural counterparts
    2004 24.3% vs. 24.1% and in 2005 24.4% vs. 21.7% respectively
•   A lower proportion of residents of rural counties earn more than $75,000 per
    year compared to non-rural residents in:
    2004 23.3% vs. 29.1% and in 2005 25.6% vs. 33.6%



Source: 2004 and 2005 Behavioral Risk Factors Survey
                                                                                   15
                                     Rural vs. Urban Comparison of Employment Status


                                 60.00%
                                              53.7%

                                 50.00%   47.5%
    Percentage Rural vs. Urban




                                 40.00%


                                 30.00%
                                                                                                                    Rural
                                                                                                                    Urban
                                 20.00%
                                                      15.4%
                                                           11.9% 11.1%
                                                                      10.4% 10.7% 9.9%   10.4%
                                                                                                 9.0%
                                 10.00%
                                                                                                        4.9% 5.1%


                                 0.00%
                                          Employed     Retired     Self   Homemaker      Unable to       Student
                                          for Wages              Employed                  Work




Source: 2005 Behavioral Risk Factors Survey
                              Rural Health Status


Self-Reported Perception of Health Status

• Proportionately fewer residents of rural counties described their general
  health as excellent compared with residents of non-rural counties:
  2004 23.7% vs. 24.1% respectively
  2005 22.1% vs. 25.1% respectively

• A greater proportion of rural residents described their general health as
  fair or poor compared with residents of non-rural counties:
  2004 16.8% vs. 14.9% respectively
  2005 15.9% vs. 14.8% respectively


Source: 2004 and 2005 Behavioral Risk Factors Survey



                                                                         17
                              Rural vs. Urban Comparison of Self Evaluation of General Health



                                                                                                                      Although Rural and
                                                   Rural                  Urban
                                                                                                                      Urban dwellers do
                                                                                                                      not appear to differ
                                                                                                                       reliably in terms of
                          35.0%                                  31.7%                                                their self evaluation
                          30.0%                                                                                       of physical or
                          25.0%                                                                                       mental health, or
Deviation from Expected




                          20.0%
                                                                                                          Excellent   their estimates of
                          15.0%                                                                           Very Good   the degree to which
                          10.0%                                                                           Good
                                                                         3.6%
                                                                                                                      they have been
                           5.0%            2.9%                                                           Fair
                                                  1.2%                                        1.3%                    physically restricted
                           0.0%                                                                           Poor
                                                                                -1.2% -0.5%                           during the last 30
                           -5.0%                         -3.0%
                                                                                                                      days; Rural dwellers
                          -10.0%   -8.4%
                                                                                                                       are markedly more
                          -15.0%
                                                                                                 -13.7%
                          -20.0%
                                                                                                                      likely to evaluate
                                                                                                                      their General Health
                                                                                                                      as poor than are
                                                                                                                      Urban dwellers.
                           Source: 2005 Behavioral Risk Factors Survey
                         Rural vs. Urban Comparison of Self-Assessment of Poor Health




                         7.00%
                                                         6.11%
                                                                                         A higher percentage
Percentage Poor Health




                         6.00%
                                                                                          of Rural residents
                                             4.63%                   4.76%
                         5.00%                                                           consistently rated
                                 4.05%
                                                                                         their health as poor
                         4.00%                   3.55%                           Rural
                                     3.06%                   3.24%       3.10%           compared to their
                         3.00%                                                   Urban   Urban counterparts.

                         2.00%

                         1.00%

                         0.00%
                                 CY2002      CY2003      CY 2004     CY2005



Source: 2002, 2003, 2004, and 2005 Behavioral Risk Factors Survey
Rural vs. Urban Comparison of Self Declared Days of Poor Mental Health

                              70.00%
                                       61.2% 60.7%
                              60.00%
 Percentage Rural vs. Urban




                              50.00%

                              40.00%
                                                                                                                     Rural
                                                                                                                     Urban
                              30.00%
                                                     23.7% 24.6%

                              20.00%

                              10.00%                               4.4% 5.5%   5.2% 5.1%               4.8%
                                                                                                              3.2%
                                                                                           0.6% 1.0%
                               0.00%
                                       No Days         1 to 7      8 to 14     15 to 21 21 to 29 30 to 31
                                                       Days         Days        Days     Days     Days

        Source: 2005 Behavioral Risk Factors Survey
                           Rural Health Status

 Risk Behaviors

 • A slightly higher proportion of residents of rural counties compared
   to residents of non-rural counties indicate that they are current
   smokers:
   2004 15.5% vs. 14.8%
   2005 15. 8% vs. 14.10%

 • A slightly smaller proportion of residents of rural counties are at risk
   of chronic alcohol consumption compared to residents of non-rural
   counties 2005 (4.8% vs. 5.0% respectively)




                                                                          21
•Source: 2004 Embargo and 2005 Behavioral Risk Factors Survey
                           Rural Health Status


Health Conditions

• A greater proportion of residents of rural counties have been told by a
  health professional that they have high blood pressure compared to
  residents of non-rural counties:
  2004 23.7% vs. 21.0%
  2005 26.7% vs. 24.0%

• Of those residents of rural counties that have been told that they have
  high blood pressure, almost two-thirds in 2005 (66.0%) are taking
  blood pressure medication.




Source: 2004 and 2005 Behavioral Risk Factors Survey
                                                                      22
                           Rural Health Status


Health Conditions (continued)
• A greater proportion of residents of rural counties have been told by a
  health professional that they have diabetes compared to residents of
  non-rural counties:
  2004 7.5% vs. 6.9% respectively
  2005 8.1% vs. 6.4 % respectively

• A greater proportion of residents of rural counties have been told by a
  health professional that they have asthma compared to residents of
  non-rural counties:
  2004 14.6% vs. 13.6% respectively




                                                                      23
Source: 2004 Embargo and 2005 Behavioral Risk Factors Survey
          Rural vs. Urban Comparison of Medical Equipment Needs



120.00%

100.00%                                         94.24% 95.39%

80.00%
                                                                Rural
60.00%
                                                                Urban
40.00%

20.00%
                5.76% 4.61%
 0.00%
                     YES                             NO

  Source: 2005 Behavioral Risk Factors Survey
                               Rural Health Status
Clinical Preventive Measures


• A slightly smaller proportion of residents of rural counties were likely to have
  had a flu shot in the last twelve months than residents of non-rural counties:

   2005 23.24% vs. 24.31

• A slightly larger proportion of residents of rural counties have had
  Pneumonia shot than residents of non-rural counties:

   2005 22.03% vs. 20.20




 Source: 2005 Behavioral Risk Factors Survey                                 25
                                                      Clinical Preventive Measures
                                  Rural vs. Urban Comparison of Respondents Not Having
                                                     Medical Exams
                             80.00%



                                              69.4%
                             70.00%   67.6%

                                                              61.9%
                                                      60.0%
                             60.00%
PERCENTAGE OF ANSWERING NO




                             50.00%

                                                                                                                                    RURAL
                                                                      39.1% 39.9%
                             40.00%                                                                                                 URBAN

                             30.00%                                                 26.9% 27.0%



                             20.00%
                                                                                                     13.8%
                                                                                                             12.5%
                                                                                                                            11.3%
                             10.00%                                                                                  7.1%



                              0.00%
                                      Blood Stool     Colonoscopy       PSA for     Digital Rectal      CBE          Mammogram
                                         Test            Exam           cancer          Exam

                                                                            EXAM TYPES


Source: 2004 Embargo Behavioral Risk Factors Survey
                                        Rural vs. Urban Comparison of HIV Testing


                               70.00%
                                                    60.12%
  Percentage Rural vs. Urban




                               60.00%                                    54.54%

                               50.00%                           45.46%
                                           39.88%
                               40.00%                                               YES
                               30.00%                                               NO

                               20.00%

                               10.00%

                               0.00%
                                               Rural                Urban

Source: 2005 Behavioral Risk Factors Survey
                                          Rural vs. Urban Comparison of HIV Test Sites
                             45.00%
Percentage Rural vs. Urban


                             40.00%     38.6%
                                                37.9%


                             35.00%
                                                                 32.5%

                             30.00%
                                                        27.0%

                             25.00%                                                                                                                                            Rural
                             20.00%                                                                                                                                            Urban
                                                                           15.6% 15.1%
                             15.00%


                             10.00%
                                                                                             7.0%
                                                                                                               5.1%   5.1%      4.9%   5.3%
                              5.00%
                                                                                                    2.6%
                                                                                                                                               1.3%   0.9%              0.7%
                                                                                                                                                                 0.5%
                              0.00%




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                                                                                 Where Tested For HIV

                     Source: 2005 Behavioral Risk Factors Survey
                          Rural Health Status


Preventive Measures


• Of those responding, a smaller proportion of residents of rural counties
  compared to residents of non-rural counties said they had participated in
  some form of exercise (e.g., running, calisthenics, golf, gardening or
  walking) during the past month:
  2004 77.6% vs. 79.1% respectively
  2005 75.0% vs. 78.6% respectively




Source: 2004 and 2005 Behavioral Risk Factors Survey
                               Rural vs. Urban Comparison of Days of Vigorous Exercise

                             30.00%
                                                                 27.2%
                                                             25.5%
Percentage Rural vs. Urban




                             25.00%
                                                     19.9%
                             20.00%
                                                  17.4%

                                          14.1%
                                      14.1%                              14.1%     14.3%
                                                                                       13.9%
                                                                                                                     Rural
                             15.00%                                          13.1%
                                                                                                                     Urban
                                                                                                          10.5%
                             10.00%                                                                           7.6%

                                                                                               4.1%4.2%
                              5.00%

                              0.00%
                                       ONE        2 DAYS 3 DAYS 4 DAYS 5 DAYS 6 DAYS 7 DAYS
                                       DAY
                                                          Days of Vigorious Exercise

Source: 2005 Behavioral Risk Factors Survey
       National Rural vs. Urban Comparison of Child Health

Children who live in rural areas are more likely than
their counterparts in urban areas to face particular risks
to their health and well-being and are more likely to:
• Live in poor families
• Have higher mortality rates
• Use tobacco
• Not be breastfed

Regardless of location of residency, approximately 84%
of children are reported by their parents to be in excellent or very
good health.


Source: The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation 2005


                                                                                         31
Births and Deaths
    Rural vs. Urban Comparison of Births from 2000 to 2002


                                                                   Though there were
                                                                   Significantly more
                                                                   Births in Urban
                                                                   counties the
                                                                   Actual Birth Rates
                                         25.46%                    were the same:
                                                                   15.0 per Thousand


                                                                   •   Rural
                                                           Rural       Births: 404,265
                                                           Urban
                                                                   •   Urban
                                                                       Births: 1,183,636


             74.54%




Source: CA Vital-net, Expert Health Data Programming EHDP 2006
    Rural vs. Urban Comparison of Age Adjusted Rates for All Causes Death
                        Calendar Years 2000 to 2002
                             AADR Per 100,000
            RURAL                         URBAN

                                                                 As unified
  900.0
                                                                 Clusters,
                       791.5
  800.0
                                  730.5
                                                                 Urban Counties
  700.0                                                          experience much
                                                                 greater numbers
  600.0
                                                                 of deaths, but not
  500.0
                                                                 necessarily
  400.0                                                          greater death
  300.0                                                          rates than the
                                                                 Rural County
  200.0
                                                                 clusters.
  100.0

     0.0



Source: CA Vital-net, Expert Health Data Programming EHDP 2006
      Rural vs. Urban Comparison of Age Adjusted Death Rates for leading Causes of Death
                                Calendar Years 2000 to 2002
                                      AADR Per 100,000
                                                                                                                                                   Rural and Urban
                                                                                                                                                   Comparisons AADR
                                     200.0
                                                                                                                                                   Death Rates per 100,000
                                                     177.1 180.3
                                     180.0                         170.3                                                                           Ischemic Heart Disease:
                                             169.1
                                                                                                                                                   Urban: 177.1
                                     160.0                                                                                                         Rural: 169.1

                                     140.0                                                                                                         Malignant Neoplasm:
                                                                                                                                                   Rural: 180.3
          Age Adjusted Death Rates




                                     120.0
                                                                                                                                                   Urban: 170.3

                                                                                                                                                   Chronic Lower
                                     100.0
                                                                                                                                                   Respiratory Disease:
                                                                                                                                           Rural   Rural: 50.0
                                      80.0                                                                                                         Urban: 39.5

                                      60.0                                                                                                 Urban   Pneumonia:
                                                                           50.0
                                                                                                                                                   Urban: 28.1
                                                                                  39.5
                                      40.0                                                                                                         Rural: 23.1
                                                                                                28.1
                                                                                         23.5          23.1 20.3
                                      20.0
                                                                                                                                                   Diabetes
                                                                                                                   11.2 8.9
                                                                                                                               5.5   6.9           Rural: 23.1
                                                                                                                                                   Urban: 20.3
                                       0.0
                                              Ischemic     Melignant        Chronic Pnuemonia          Diabetes    Intentional  Assault
                                                                                                                                                   Suicide:
                                                Heart      Neoplasm          Lower                     Mellitus     Self-Harm (Homicide)
                                              Disease                      Respiratory                              (Suicide)                      Rural: 11.2
                                                                            Diseases                                                               Urban: 8.9
                                                                                     Causes of Death
                                                                                                                                                   Homicides:
                                                                                                                                                   Urban: 6.9
                                                                                                                                                   Rural: 5.5
Source: CA Vital-net, Expert Health Data Programming EHDP 2006
HEALTH CARE PAYMENT SOURCES
                         Rural vs. Urban Comparison of Lack of Health Insurance
                                      Calendar Years 2002 to 2005


                       18.00%
                       16.00%
    % NO HEALTH PLAN




                       14.00%
                       12.00%
                       10.00%                                                     Rural
                       8.00%                                                      Urban
                       6.00%
                       4.00%
                       2.00%
                       0.00%
                                 CY2002     CY2003      CY2004      CY2005


Source: 2002 to 2005 Behavioral Risk Factors Survey
                                 Rural vs. Urban Comparison of Health Insurance Types
                                                                                                                                                             Of those
                                                                                                                                                             Respondents
                                                                                                                                                             that had Health
                            50.00%                                                                                                                           Insurance:
                                              46.3%

                            45.00%    42.6%                                                                                                                  Rural Residents
                            40.00%                                                                                                                           derive a higher
PERCENTAGE WITH PLAN TYPE




                            35.00%
                                                                                                                                                             percentage
                                                                                                                                                             of Insurance from:
                            30.00%

                                                                                                                                                     Rural   •   Employer
                            25.00%
                                                      20.0%            19.9%
                                                                               21.4%                                                                 Urban   •   Medicare
                            20.00%
                                                              17.2%                                                                                          •   Own Plan
                                                                                                              15.2%
                            15.00%
                                                                                        11.5%
                                                                                                9.4%
                                                                                                                                                             Urban Residents
                            10.00%                                                                     8.1%
                                                                                                                        6.1%
                                                                                                                                                             derive a higher
                                                                                                                               4.9%
                            5.00%                                                                                                                            percentage of
                                                                                                                                       1.4%

                            0.00%
                                                                                                                                              0.4%
                                                                                                                                                             Insurance from:
                                                                                                                        RY




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                                                                               TYPE OF COVERAGE                                                              •   Medicare
                                     Source: 2005 Behavioral Risk Factors Survey
                                  Health Insurance

   Medi-Cal

   • According to data from the DHS/Medical Care Statistics Section,
     20.0 % of residents in rural counties were beneficiaries of Medi-Cal
     services in FY 2005-06 compared to 16.6% in non-rural counties

   • Of the 6.5 million residents of California who were beneficiaries of
     Medi-Cal services in fiscal year 2005-06 1.9 million, or 30.0% live in
     rural areas

   • Although approximately 10% of California’s population live in rural
     areas, they represent 30.0% of Medi-Cal beneficiaries




Source: DHS-Medical Care Statistics Section Oct 2005, Jan 2006, Apr 2006, and
July 2006 Quarters and DOF 2005 Population;                                     39
Rural 43 Counties and Urban 15 Counties (No City Adjustments)
                    Patient Payer Source for Clinics in Rural Counties
                                   Sorted High to Low

                      2%          RURAL CLINICS
                             0%
               2%
         2%                                             Medi-Cal

    6%                                                  SelfPay_SlideFee
                                                                            Clinics in Rural
                                                        All_Othr_Payers     Counties receive
     10%                                          30%
                                                        Medi-Cal_Mgn
                                                                            over 70% of their
                                                                            patient payments
                                                        Private_Insurance   from:
                                                        Medicare
                                                                            •    Medi-Cal 30%
                                                        Free
                                                                            •    Self Pay Slide
                                                        Healthy_Families         Fee 22%
                                                                            •    All Others 14%
                                                        County_CMSP/MISP
                                                                            •    Medi-Cal Mgn
     12%                                     22%        Others                   12%
              14%




Source: Office of Statewide Health Planning and Development 2005 Annual Clinic Report
                   Patient Payer Source for Clinics in Urban Counties
                                  Sorted High to Low

                               URBAN CLINICS
                          1%                              SelfPay_SlideFee
                    2%            0%
              3%
      3%                                                  All_Othr_Payers

4%                                                        Medi-Cal                Clinics in Urban
 7%
                                               23%                                Counties receive
                                                          Medi-Cal_Mgn
                                                                                  over 70% of their
7%                                                        LA_County_Partnership   patient payments
                                                          Free                    from:

                                                          Private_Insurance
                                                                                  •   Self Pay Slide Fee
                                                          Medicare                    23%
                                                                                  •   All Other Payers
                                                          County_CMSP/MISP
                                                                                      21%
 11%                                                 21% Healthy_Families         •   Medi-Cal 18%
                                                                                  •   Medi-Cal Mgn
                    18%                                   Alameda_Alliance
                                                                                      11%
                                                          Medicare_Mgn



           Source: Office of Statewide Health Planning and Development
                             2005 Annual Clinic Report
       Uncompensated Care Reported by Clinics in
     Expanded Access to Primary Care Program (EAPC)


• Expanded Access to Primary Care Program (EAPC) reimburses
  clinics for providing care to patients whose incomes are at or below
  200% of the Federal poverty level and have and have no means to
  pay for care

• Uncompensated care visits reported by community clinics in the
  Expanded Access to Primary Care Program in rural and frontier
  MSSAs increased by 3.4% respectively between 2004 and 2005
  compared to an increase of 4.3% in urban clinics.




•   Source: Office of Statewide Health Planning and Development Annual Clinic Report
    2004 and 2005 (EAPC)
                  Rural vs. Urban Comparison of Hospital Discharge by Payer
                                     Sorted High to Low

                                                      Medicare -Traditional
                                    RURAL
                  4%   3%      2%                     Medi-Cal - Traditional
                                    0%                                          Rural Hospitals receive
           4%
                                              40%     Other Third Parties -
                                                                                over 70% of their patient
     13%                                              Traditional               payments from:
                                                      Other Third Parties -     • Medicare – Traditional
                                                      Managed Care
                                                                                   40%
                                                      Medi-Cal - Managed
                                                                                • Medi-Cal - Traditional
                                                      Other Payers
                                                                                   20%
       14%
                                                                                • Other Third Parties -
                              20%
                                                      Medicare - Managed           Tradition      14%
                                                      County Indigent
                                    URBAN
                                                       Other Third Parties -    Urban Hospitals receive over
                                                       Managed Care
                              1%                                                70% of their patient payments
                                                       Medicare -Traditional
                    3%
                         3%                                                     from:
                                            29%
             5%
                                                       Medi-Cal - Traditional   • Other Third Parties –
      6%                                                                            Manage Care 29%
                                                       Medicare - Managed       • Medicare – Traditional
      10%                                                                           26%
                                                       Medi-Cal - Managed       • Medi-Cal – Traditional
                                                                                    17%
                                                       Other Third Parties -
                                                       Traditional
            17%                       26%              Other Payers

                                                       County Indigent
Source: Office of Statewide Health Planning and Development (OSHPD) 2005 Hospital Annual Financial Data Report
         Rural vs. Urban Comparison of Hospitals Patient Discharge by Type
                               Sorted High to Low
                                      RURAL                        Medical-Surgical          Rural Hospitals, over
                 5%
                      4%   2%    1%                                                          90% their discharges are
                                                                   Perinatal                 for the following Service
                                                                   Intensive Care Unit
                                                                                             Types:
     16%

                                                                   Skilled Nursing           •   Medical Surgical
                                                                                             •   Perinatal
                                                                   Pediatric
                                                                                             •   Intensive Care Unit
                                                        72%        Others

                                                                   Medical-Surgical
                                       URBAN
                           1%   1%                                 Perinatal
                      2%
                                                                                             Urban Hospitals, over
                 2%                                                Acute Psychiatric
            3%
                                                                                             90% their discharges are
      5%                                                           Pediatric                 for the following Service
                                                                   Intensive Care Unit
                                                                                             Types:
      6%

                                                                   Skilled Nursing
                                                                                             •   Medical Surgical
                                                                   Neonatal Intensive Care   •   Perinatal
                                                                   Unit
                                                    64%            Rehabilitation Center
                                                                                             •   Acute Psychiatric
      16%                                                                                    •   Pediatric
                                                                   Others


Source: Office of Statewide Health Planning and Development (OSHPD) 2005 State Utilization Data File of Hospitals Report
                 Healthcare Services Providers

Licensed Health Care Facilities in Rural/Frontier Areas 2005
Clinics
          • 227 licensed community clinics
          • Rural – 195 Frontier – 32

Total Active Rural Clinics 244

Acute Care Hospitals
       • Rural – 66

Home Health Agency
      • Rural 97          Frontier 7

Source: OSHPD Licensed Healthcare Database 2005




                                                               45
                  Healthcare Services Providers

Licensed Health Care Facilities in Rural/Frontier Areas 2005

Other Licensed Health Care Facilities Include:

   Chronic Dialysis Clinics             46 Rural
   Surgical Clinics                     42 Rural
   Hospice Facilities                   18 Rural   3 Frontier
   Acute Psychiatric Hospitals           1 Rural




Source: OSHPD Licensed Healthcare Database 2005
                                                                46
Rural

Health

Program

Support
                       Rural Health Program Support
The Federal, State and local governments provide grant support for
health services in California.

California Department of Health Services (CDHS) administers programs
designed to strengthen the rural infrastructure.

Clinic Programs include (Amount in Millions):
   Seasonal Agricultural Migratory
   Workers Program (SAMW)– 2005 $6.8/2006 $7.4
   Indian Health Program (IHP)-2005 $6.4/2006 $6.4
   Rural Health Services Development
   Program (RHSD) – 2005 $8.2/2006 $8.7
   Expanded Access to Primary Care
   Program (EAPC) – 2005 $30.2/2006 $30.2



Source: CDHS-Primary and Rural Health Care Systems Branch - 2006
                                                                       48
                 Rural Health Program Support
              California State Office of Rural Health

CDHS-Primary and Rural Health Care Systems Branch administers rural
assistance programs with funding from the Federal Office of Rural Health
Policy These are:

•   State Office of Rural Health (CalSORH)
•   Critical Access Hospital Program (CAH)
•   Small Hospital Improvement Grant Program (SHIP)
•   J-1 Visa Waiver Program




                                                                       49
               Rural Health Program Support

              CalSORH Highlighted Program Components


Core Activities that provide a statewide Information source

Flex/Critical Access Hospital Program provides training
and technical assistance for CAH certification
• Currently 23 CAHs and 26 CAH eligible hospitals
• Distributed $135,000 for infrastructure improvements and QA
   programs

Small Hospital Improvement Program assists small rural
hospitals with special project funding
• There are 48 grantees awarded $8,487 each



                                                                50
               Rural Health Program Support
           CalSORH Highlighted Program Components (Cont)

J-1 Visa Waiver Program enables foreign medical graduates to
remain in this country in exchange for providing services in
underserved areas.

• HR 4997 to extend this program until 2008 has passed the House of
  Representatives, and its companion S2425 is currently in the Senate

• States are to continue processing waiver requests

• Currently, California has processed 11 visa waiver requests, and
  two have been accepted by the State Department

3 R Net is the national provider recruitment web page
• CalSORH continues collaboration with the Rural Health Policy
   Council to maintain this resource

                                                                     51
                     Rural Health Program Support

Federal Office of Rural Health Policy Funding for California Fiscal
Year 2006-07 :
State Office of Rural Health
Federal Budget                          $7,264,000
California Portion                      $ 146,400

Medicare Rural CAH/Flex Grants
Federal Budget              $22,230,000
California Portion          $ 414,000

Small Rural Hospital Improvement Program
Federal Budget               $ 14,490,000
California Portion           $    428,832


•   Source: Federal Office of Rural Health Policy 2006

                                                                      52
                        Rural Health Program Support
Federal Office of Rural Health Policy Funding for California Fiscal Year
2006-07 : (cont)
Rural Health Network/Outreach Grants
Federal Budget                     $ 17,720,000
California Portion    (Net)         $   000,000
                   (Outreach)       $   649,120 (4 grants)

Rural Health Research (Rural Research Centers and Mini Grants)
Federal Budget                         $ 8,700,000
California Portion                     $ 0,000,000

EMS Training AHED Grants
Federal budget                                       $ 1,241,042
California Portion                                   $ 0,000,000



                                                                           53
Source: Federal Office of Rural Health Policy 2006
                  Rural Health Program Support


• The County Medical Services Program (CMSP) was established in
  January 1983. 34 counties participate in CMSP. On a monthly basis,
  approximately 40,000 indigent adults residing in these counties rely upon
  CMSP benefit coverage
• Beginning October 1, 2005, Blue Cross Life & Health (BCL&H) assumed
  administrative responsibility for CMSP
• Med Impact Health Systems Inc. (Med Impact) administers the CMSP
  prescription drug benefit program 2006-07
   Annual Unduplicated Eligibles: 65,000 (Projected Annual)
   Amount Budgeted: Medical, Dental and Vision $ 193,100,000
                       Pharmacy                    $ 36,000,000




                                                                          54
  Source: County Medical Services Program Governing Board November 2006
                      Rural Health Program Support

Federal, State and Local Government Support
  DHS Local Public Health Services Program (LPHSP) currently
  provides services to 11 small counties with populations of 50,000 or
  less.
   • Total FY 2006-07 Contract amounts are $3,396,571

  DHS Immunization Branch, working through LPHSP, is providing
  immunization grant funds for 10 rural local health departments to
  maintain immunization activities.
   • Total FY 2006-07 contract amount is $60,300




    Source: DHS Local Public Health Services Program November 2006
                                                                         55
Healthcare System Impacts
                   Healthcare System Impacts

Emergency Preparedness


A statewide survey of health care surge capacity, when measured
against federal benchmarks, identified three gap areas:

• The need for Surge Capacity Standards and Guidelines
• Equipment and supplies needed for a moderate event
• Equipment and supplies needed for a catastrophic event

Surge Capacity Planning

• Approximately $200 M from the general fund has been allocated to
  augment federal funds to address gaps in healthcare response capacity
• Funding flows through local health departments and is allocated
  according to a population based formula


                                                                    57
                  Healthcare System Impact
                 Health Information Technology (HIT)

Federal

  Office of the National Coordinator for Health Information Technology
  (ONCHIT), has taken the lead in the national effort to migrate our
  health care processes to an automated environment. Interim National
  Coordination Director is Robert M. Kolodner. Refer to:
  http://www.hhs.gov/healthit/

The Federal administration is focusing on three main areas:
• Regional Health Information Organizations (RHIOs)
• Nationwide Health Information Network (NHIN)
• Driving electronic health record (EHR) adoption
  (refer to ORHP primer Roadmap For The Adoption of HIT in Rural
  Communities
                                                                   58
                       Healthcare System Impact
                   Health Information Technology (cont)
State
California’s HIT roadmap

•   The Governor’s eHealth Initiative established a Broadband Taskforce
    to expedite “rights of way” to accelerate broadband deployment in October
    2006
•   Governor called for a comprehensive HIT plan to be implemented by
    July 2007 and earmarked $240 M in investment funds and grants

The California Regional Health Information Organization (CalRHIO)
Continues to provide direction and leadership. Highlights include:

•   CalRHIO acting a Hub (agent) for proposed county-based mental health
    recipients program funded by the Mental Health Services ACT. (Prop.63)
•   Convened a Steering Committee to address laws on privacy and security of
•   Health information




Source: October 2006 Highlights on Third Quarter Report                         59
                    Healthcare System Impact

                         Deficit Reduction Act


The Federal Deficit Reduction Act (2005) is designed to slow spending
in both Medicare and Medicaid

• Savings of nearly $6 Billion in Medicare over the next five years.

• Net reductions of nearly $5 Billion to the Medicaid over the next five
  years – Policy changes include cost sharing, premiums, benefit
  package options. Access to rural health clinic and FQHC services
  required.

• Allows for pilot programs including Pay-4-Performance and Health
  Opportunity Accounts

                                                                       60
                     Healthcare System Impact

                               Medicare Part D

• California has the largest number of elderly and disabled MediCare
  beneficiaries (More than 4.2 million)

• One million seniors and individuals with disabilities are dual
  eligibles, with approximately 10,000 becoming newly dual eligible
  each month.
• California has approximately 47 stand alone prescription drug plans
  along with a number of MediCare Advantage plans with prescription
  drug coverage
• Eligible beneficiaries in Los Angeles have 77 plans to choose from
• MediCare Part D continues to develop. Five 2006 benchmark plans
  will be eliminated as benchmark plans in 2007


•   Refer to www.nsclc.org and www.cms.hhs.gov                         61
                 Healthcare System Impact
Medi-Cal Managed Care Expansion

Expansion of Managed Care into some rural counties and rural areas will
Include the Geographic Managed Care, County Organized Health System,
And Two Plan models of delivery

Dates of Implementation are subject to change

2007     Marin
2008     Lake, Placer, San Luis Obispo, Sonoma
2009     Fresno, Kings, Madera




Source: CDHS – Medical Managed Care Division


                                                                    62
                     Healthcare System Impact

          California Department of Health Services Reorganization

Senate Bill 162 (2006) established a new Department of Public Health (DPH)
within the California Health and Human Agency, effective July 1, 2007. It
also renamed the CDHS to the California Department of Health Care
Services (DHCS).

DPH Mission will be to protect and promote the health status of Californians
through population-based public health programs and services.

DHCS Mission will be to protect and promote health status of Californians
through the financing and delivery of individuals health care services




                                                                        63

				
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