A fundamental challenge facing small communities is the high cost per capita of providing health services.176 Investments to make services available in sparsely populated areas produce services for fewer people than do similar investments made in more populated areas.
Because of the economic base needed to support expensive medical services, access to services becomes increasingly difficult as communities become smaller and more isolated. Rural residents may lack access not only to specialty services and tertiary care but also to such basic services as emergency care, primary care, mental health and substance abuse treatment, and dental care. Realities regarding economies of scale mean that some services needed for people in rural areas are only available in urban areas.177
Attracting and retaining clinicians in rural areas remains a challenge due to isolation, limited health facilities, and lack of educational opportunities for their families.178 The primary workforce shortage in rural areas has continued to worsen even as researchers and policy-makers have sought for solutions.179 Various federal programs target the need for improved access in rural areas, such as additional support and incentives for clinicians, clinics and hospitals in rural areas.180 New care models expand use of physician assistants and nurse practitioners (a requirement to be federally qualified as a Rural Health Clinic). Telemedicine has been used to increase access to various services, including mental health, emergency care, and pharmacy, in remote areas.181 Health IT has also been used to provide access to specialty care, facilitate communication between rural primary care teams and specialists, monitor patients remotely,182 and provide linguistic congruity in care to Hispanic patients.183 However, adoption of technology such as telemedicine and EHRs has been slowed by lack of broadband Internet connectivity in many rural areas.184, 185 To help these communities progress, the Federal Communications Commission FCC is investing up to $400 million to expand broadband access to rural health care providers.186
The disadvantage faced by rural health care providers in terms of resources as well as the digital divide has created concern among advocacy organizations for rural providers’ ability to participate in a number of federal opportunities, particularly requirements for EHR adoption to meet meaningful use standards. Providers without sufficient Internet access may receive a hardship exception from meeting these standards, but concerns remain over the widening adoption gap between rural and urban health care providers.187, 188 The National Rural Health Association recommends further timeline extensions and resources to help rural facilities adopt EHR technology.189
Various health professionals, rural health advocates, and states have been heavily involved in discussions about these definitions, along addressing with agricultural and environmental concerns. Part of the difficulty is lack of adequate data about where clinicians are practicing, and the physicians assistants and nurse practitioners who play an important role in providing care in many underserved areas are not always identifiable in claims data190 There is also lack of agreement over how to define and count the various types of primary care providers191 and whether and how mid-level providers should count relative to physicians.192 HRSA is working with many of these stakeholders to create a minimum data set that would allow for better workforce tracking and planning.193 There has also been joint effort by HRSA’s Office of Rural Health Policy and the Department of Agriculture’s Economic Research Service (ERS) to define frontier geographic areas in order to identify and target policies at the most remote areas.