December 2019

Rural Health Priorities: Assessing Disparities Outside of Chicago

By: Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Illinois (BCBSIL)

The Illinois Rural Health Summit Planning Committee published key findings in October 2018 that demonstrate disparities in access to health care services and disease incidence. The report found that there are primary care physician shortages in 30.3% of Illinois small and rural hospitals. This climbs to shortages of 93.7% in small and rural hospitals for behavioral health services. Whereas there are 87.1 primary care physicians per 100,000 individuals in large urban counties, this number drops to 45.5 per 100,000 in rural counties. Psychiatrists number 12.6 per 100,000 and 1.6 per 100,000 in urban and rural counties, respectively. This report also found higher numbers of opioid prescriptions and overdose deaths, greater readmission rates for the elderly, and less nutrition and physical fitness opportunities for youth in rural areas.¹ This report demonstrates that a person’s ZIP code is an important factor when it comes to overall health and wellbeing.

BCBSIL is committed to addressing health equity and identifying which, and to what extent, social determinants of health (SDoH) contribute to the health of our members. Though headquartered in Chicago, we realize that not all 8.1 million members reside in Chicago, but throughout Illinois. We’re proud of the fact that we offer coverage in all 102 Illinois counties, of which 62 are considered non-metropolitan counties. To help further address the health and wellbeing of our members in these non-metropolitan counties, we’ve begun a clinical initiative titled “Rural Health Priorities.” 

While developing our clinical Rural Health Priorities initiative, we felt early on it was important to partner with providers to help assess needs and focus our efforts on enhancing care for our members in rural locations. In other words, we wanted to determine if our perspectives, programs, goals and perceived needs aligned with the network of clinicians delivering care. We distributed a survey to participating Value Based Care (VBC) groups, including providers who are more likely to render care and interact with this membership. VBC Medical Directors and Administrators were invited to rank issues as high, moderate or low priority. The top three issues ranked high priority by survey participants were Behavioral Health Access, Health Equity (HE)/SDoH and the Opioid Epidemic. And these are some of BCBSIL’s top priorities, too.

The statistics mentioned above reflect the disparity in numbers of psychiatrists available in urban versus rural Illinois counties. Rural provider recruitment challenges may include lack of familiarity with rural life as most medical students come from urban areas. The decision to work or live in a rural location instead of an urban one may depend on many factors, including social program opportunities or the preferences of providers and their families. We are actively engaged in finding alternative solutions. Leveraging technology is one method that may help improve access to behavioral health services in rural areas. For example, starting in 2020, we are looking to partner with our VBC groups to provide telepsychiatry services to our retail HMO membership. We hope this strategy will create an opportunity to not only increase much-needed access and care but also serve as a means to broaden how we use technology for other members in the years to come.

Our programs and initiatives to address HE and SDoH go hand in hand with our Rural Health Priorities initiative. We must emphasize that in no way is it meant to be inferred that one place is better to live than another. Rather, these initiatives signify that we must all be cognizant that where people live or work contributes to their health and develop strategies to incorporate these components into an individual’s care. We have included a HE/SDoH continuing medical education (CME) component as a quality metric for participating HMO medical groups in 2019 and are expanding this to Accountable Care Organization (ACO) contracts in 2020. We are also looking to our VBC groups to determine and use an SDoH screening tool that is best suited to their member and provider communities and report their findings and how this helps them to address improving care and outcomes. For more information, refer to the related article in this month’s issue titled, Adding Value: Addressing Health Equity in the HMO. 

The opioid epidemic cannot be addressed without collaboration. As an example, we’ve partnered with our pharmacy colleagues at Prime Therapeutics. In August 2018 Prime began by allowing only a seven-day supply of opioids for members who were considered opioid-naïve (with exceptions being allowed in some cases based upon diagnosis or discussions with a member’s provider). Since that time, we have conducted claims analyses and other initial research and our findings for BCBSIL members agree with the state of Illinois that opioid prescription rates are higher in rural settings. Along with this challenge, there are fewer physicians in rural areas who can provide medication assisted therapy (MAT). This gap in care is something we are hoping to help address through outreach to providers in the months to come.

Other areas on our VBC survey that were identified as moderate priorities included Diabetes/Diabetic Complications, Maternal/Child Health and Colon Cancer Screening. These areas are concerning to BCBSIL, too. Participating VBC groups have diabetic measures as part of their quality metrics. We are looking into ways we can help increase awareness and availability of important services such as prenatal care opportunities and colorectal cancer testing options for our members outside of Chicago and the collar counties.

We don’t expect changes overnight and we know everything can’t be addressed all at once. What we do see is the need to augment SDoH screening and analysis of results to continue to help find ways to support enhancements that factor a patient’s ZIP code into the care they receive. What’s more important and positive is that the goals and programs at BCBSIL are in alignment with the needs and priorities identified by providers such as VBC network participants. By working together, we can rely on one another’s strengths to address shared priorities concerning the health and wellbeing of your patients and our members in all the Illinois communities we serve.

Learn more about Dr. Derek J. Robinson

¹ Rural Health Summit (March 5, 2019). Southern Illinois University (SIU) School of Medicine, Department of Population Science and Policy. The State of Rural Health in Illinois: Great Challenges and a Path Forward. Accessed Nov. 4, 2019, at https://www.siumed.edu/popscipolicy/highlights/rural-health-summit.html.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.

Prime Therapeutics LLC (Prime) is a separate pharmacy benefit management company contracted by BCBSIL to provide pharmacy benefit management and other related services. BCBSIL, as well as several Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.