In a state like Nebraska, rural access to health care is a topic of major importance. With the state’s only two major cities located within 60 miles of each other near the eastern border of the state, there is a huge area of the state that is considered rural. In 1990, 34% of Nebraska’s population lived in a rural area of the state, however, the rural areas of Nebraska and the rest of the country do not have nearly the same proportion of medical services, primary care physicians, specialists, quality facilities, and economic stability as the urban areas (Nebraska Urban and Rural Populations, 1990 Census). In fact, while 20% of the U.S. population lives in a rural area, less than 11% of the nation’s physicians are practicing in nonmetropolitan areas (NHRA Issue Paper, 1998). Our group explored many different aspects of rural health care, including the patient’s access to both primary care physicians and specialists; the status of medical facilities and equipment in rural clinics and hospitals; the level of uninsured, Medicaid, and Medicare patients; the lifestyle and work environment of the rural physician and the rural patient; and finally, some various solutions that have been offered to help improve the health care for residents of rural America.

1. What type of access does the rural population have to specialty physicians (ie, cardiologists, urologists, neurologists, etc.)?
2. How many choices do rural residents have when choosing a primary care physician? In other words, what is the typical ratio between physicians and town/county population in rural Nebraska?
3. Is access to technology and newer equipment a problem in rural Nebraska?
4. Is it more difficult for clinics and hospitals in rural Nebraska to find competent medical staff-workers (i.e., nurses, clerical, technicians) than in Omaha or Lincoln?
5. Are rural residents more likely or less likely to have health insurance? What are the implications of this?
6. Do rural hospitals have more problems receiving funds and staying afloat than do urban hospitals?
7. Does rural Nebraska have more Medicaid and Medicare patients than does Omaha or Lincoln? What are the implications of this for a Medicaid patient in rural Nebraska? Are "critical access" hospitals (hospitals that are allowed to see more Medicaid patients than is normally allowed) ethical and fair?
8. Do doctors have enough time away from medicine to prevent burnout? Is over-working a problem with quality of care given to patients? Are there any solutions to the problem (i.e., locum tenens)?
9. Do rural patients wait longer before they come and see their doctor (i.e., the farmer who waits a month before he sees the doctor for his hernia), and if so, what implications does this have for the successful treatment of patients in a rural setting? (Modification: question was not addressed in the review)
10. Does the emergency room in a rural hospital go through different cycles of emergencies based on the time of the year (i.e., harvest season, flu season, planting season)? If so, how does this affect a rural patients’ access to quality emergent health care? (Modification: question was not addressed in the review)
11. Is confidentiality a big problem in a small town, where everyone wants to know everything about everybody (psychosocial problems for patients)?
12. Is there a large shortage of female physicians in rural Nebraska? If so, how does this affect a female’s (or male’s) choice for a physician?
13. Is physician privacy a problem in the rural setting, where they seem to be one of the leaders in town and are constantly being "observed"?
14. Do small towns have a greater number of "incompetent" primary care physicians and/or surgeons? (Modification: question was not addressed in the review)
15. What type of physician shortages are there in rural Nebraska?
16. What are some ways of improving the shortages? Are there programs out there that are helping recruit new physicians to the rural area?
17. How do most rural citizens feel about their hospital/clinic/economy in town? (Modification: question was added but not addressed in the review)
18. What affect has satellite clinics had on a rural residents access to health care?
19. What type of long-term care (i.e., nursing homes) and rehabilitation care (i.e., physical therapy, occupational therapy, etc.) is available in smaller towns? (Modification: question was not addressed in the review)
20. Is there a large non-English-speaking population in rural Nebraska? If so, how is the rural healthcare system dealing with the language barrier? How does it affect the healthcare of this population? (Modification: question was not addressed in the review)
21. Do the politics and rivalries of small town clinics and hospitals affect a person’s healthcare access?
22. Is transportation a big problem for people accessing health care in rural Nebraska (i.e., long distance to the clinic, lack of public transportation, etc.)?
23. What role does telemedicine and other technologies have in the present and future of rural health? (Modification: question was added and used in the review)
24. What is the incentive for a physician to choose rural practice? (Modification: question was added and used in the review)
25. How does the hospital influence the rural economy? (Modification: question was added and used in the review)

One major problem with the quality of health care in rural areas is the shortage of health care workers. Sixty-five of Nebraska’s ninety-three counties have been designated shortage areas by the Rural Health Advisory Commission, and most of these have no towns with more than 5000 people (RHAC 1999). The western half of the state is more sparsely populated than the eastern half of the state, which makes providing health care to the individuals living in this part of the state unique.

Specialists are in even greater demand in the western half of the state. Two examples of the geographic discrepancy in physicians come from the primary care fields of OB/GYN and Psychiatry. In the eastern half of the state, the number of persons served per practitioner is 1:5,890 and 1:5,540 respectively. In the western part of the state, that same ratio is 1:22,621 and 1:30,161 respectively (RHAC 1999). This clearly represents a shortage of practitioners who deliver specialty services in the more rural portions of the state. With the shortage of specialists in the rural areas, the family practitioner essentially becomes the area pediatrician, OB/GYN, and psychiatrist. This puts more burden on the family physician to make the decisions regarding patient care which are normally made by specialists in the more urban parts of the state. Because of this, rural physicians are also forced to learn and practice medicine on a broader scale, which can also be a big burden on their professional life.

In particular, there is a large shortage of female physicians in rural areas of the United States (Mueller, interview). This limits the choice a woman has when choosing a physician, especially when it comes to dealing with problems that are unique to women. In many cultures, females must be seen only by a female physician. This may present a serious access problem for these women living in rural America.

There are many speculations as to why there is this shortage of female physicians. One theory is that many female residents have professionally trained spouses and generally want to ensure that their spouse can find a job in the community. Often, the most important role of a local business is promising a job to a prospective physician’s spouse (Moskowitz 1999). According to Dr. Keith Mueller, there is a need to recruit more females from rural areas and smaller colleges as they are more likely to go back to these areas (interview). Dr. Wilcox believes that often females do not think they could receive time off for having children as easily in rural areas as they could in urban areas. Also, he believes that female physicians tend to spend more time with their patients, which may not be as easy to do in a busy rural clinic (Wilcox, interview). Dr. Robert Bowman believes that the shortage of rural female physicians may be due to the fact that female medical students do not see the kind of role models that they need in rural Nebraska to help them to consider locating in rural areas to practice. He suggests that with the recent slow increase in rural female physicians that we will see more women choosing the rural route.

One of the main causes of physician shortages in rural America is the decreased ability of small towns to recruit and retain their physicians. Recruitment challenges are fairly obvious—there is often not nearly as many cultural opportunities (i.e., theatre, opera, concerts), social opportunities, support networks (i.e., other physicians, wide variety of friends), financial opportunities, career opportunities for spouses, and educational choices as there are in the urban areas. Recruiting a physician who was not raised in a rural community is even more challenging, as they often see even more dramatic differences between rural and urban life. Even once a new physician is recruited to town, there is great difficulty in retaining many of them in their community.

Retention can be related to many of the same factors that are involved in recruitment. The main issues that have been shown to increase the likelihood of a physician leaving the rural area are low salaries, poor facilities and equipment, professional and social isolation, large workload, and spousal influences (Pastor, 1989). If a community is trying to recruit a young physician and their spouse to town, and the town does not have other young professionals or activities for the spouse to participate in, these towns are going to be unsuccessful in the end. Also, many studies have shown that one of the greatest influences on retention is the workload, and thus time restraints a rural physician has. As such, we will focus mainly on that problem and some ways that small towns have tried to improve the lifestyle of their physicians.

One study that was conducted on rural primary care physicians throughout the country found that 24% of them indicated that they were going to leave within 2 years, with over one-fifth of these stating that excess workload was their main reason for leaving. 49% of all the doctors surveyed (not just those planning on leaving) indicated that they were dissatisfied with their workload, which was on average more than 68 hours per week. Those that were satisfied with their workload only worked an average of 58 hours per week (Mainous, 1994). Another study of rural physicians in Minnesota discovered that the greatest stress and greatest source of dissatisfaction among physicians was the "time pressures" of the job. These time stressors included decreased time for families and friends, excess paperwork and phone calls, keeping up with the new medical literature, and being pulled in different directions at work. Nonetheless, the study concluded, overall, that rural physicians were reasonably happy with their lives. Sources of satisfaction included the diversity of patients they saw, their close contact with their physician colleagues, their gratification from patient care, and their relationships with nonphysician health professionals (Pastor, 1989).

What makes a rural physician’s workload so great is the fact that they are often one of the very few, if not only, physicians in the area or county and must meet the needs of the patients on a nonstop basis. Rural physicians, in general, see more patients than urban physicians (Hutchinson, 1998). On top of this they also have emergency room duty, perform procedures and minor surgeries, and provide psychiatric, nursing home, and hospital care. Despite this greater workload, urban physicians in the United States generally earn more money than a comparable rural physician (NHRA Issue Paper, 1998).

Another difficulty that rural medical practices and hospitals are experiencing is the problem of recruiting adequate medical staff, such as nurses and medical technicians. Due to the all-too-familiar financial troubles in rural medicine, it is often difficult to pay the same wages and benefits that larger metropolitan hospitals can. Rural hospitals must draw from the same labor pool that larger hospitals draw from, but with fewer resources to offer. This problem is especially acute in times of labor shortages. According to D. Mueller, state-wide health care worker shortages often show up first and go away last in rural areas (interview).

In theory, there are a lot of improvements that can be made to help recruit and retain physicians in small towns. Things such as decreasing professional isolation and workload, increasing spousal and family support, and having rural training programs for medical students and residents would help. Towns are being forced to decide what the best method is to alleviate the burden on their rural physicians. The concept of community oriented primary care and the use of locum tenens are two solutions that have been used recently with varying success.

Many towns are realizing that they can no longer have either rivaling or separate medical services within the town or area. They have found that joining hospitals, private providers, primary care clinics, local health departments, and area specialists together has increased the continuity of care, improved the satisfaction of the physicians, and has decreased the lack of certain medical resources for a community (Tymann, 1996).

The use of locum tenens (Latin for "to hold place of or substitute for") in rural America has also increased a great deal in recent years. Small towns, who are in desperate need of additional help or need to fill the gap after a physician leaves town, are turning to these temporary replacements until they can find a permanent physician. The percentage of physicians who are considered locum tenens has risen from 4% in 1987 to 15% in 1999, partly as a result of their great utility in rural America (NEJM Recruiting News Online, 1999). The use of locum tenens during a time of great need saves the town resources and a great deal of money, and also allows for referrals and revenue to stay somewhat steady (Phillips, 1997). However, there is another side to the issue of using locum tenens. The rise in locum tenens over the years has been partly due to physicians leaving rural areas to have more freedom and less time restraints as a locum tenen. Also, many people in small towns do not like seeing physicians who are only temporary. Instead, they often crowd over to the existing doctors in town and overload their practices, causing an even greater amount of stress in their practices.

Many medical students plan to practice in rural settings some day because they appreciate the friendliness, sense of community, and overall quality of life that can be found in a small town. Others, however, need something more—an extra push—before they’ll consider practicing in a rural area. Recognizing the problem of physician shortages in rural settings, the federal and state governments and individual medical schools have established programs designed to encourage current and future doctors to set up rural practices. These programs offer a variety of incentives in the form of scholarships, loans, and rural residencies, in order to persuade practitioners to make the move from urban to rural. The state also has programs to attract high school students into health care fields along with residencies that train in rural areas.

UNMC and the state of Nebraska are leaders in establishing programs that entice students to "go rural." Rural high school students are educated about rural health opportunities by the Rural Health Education Network. They learn about possibilities in health care and opportunities that are available. The Rural Health Opportunities program offers spots in professional schools out of high school if the individual is committed to returning someday to a rural area of the state to practice. In addition, UNMC sends first year medical students into rural areas after their first year of medical school. This is designed not only to observe and practice medicine, but also to live in a rural community and experience rural life. Third year students spend an eight-week rotation in rural areas with the same goals in mind.

Additionally, third year medical students can apply for the Primary Care Program for residency in family practice or internal medicine. Students in this program begin training as an internal medicine intern in their fourth year of medical school. They then do a year of family medicine and then continue on with either family medicine or internal medicine following that. Tuition is waved for the fourth year of medical school, and the student receives a stipend for living expenses. The last year of the residency focuses on training in critical care and advanced procedures, which prepares the physician for practice in rural medicine. Once completed, the graduate of this program is required to practice in a rural community for at least two years (UNMC Dept. of Family Med, Internet).

A similar program that UNMC uniquely created was the Accelerated Residency Program Track. This also begins in the student’s fourth year of medical school, and has the same stipend and tuition waiver. This is a three-year family practice residency and a fourth-year procedural fellowship program. In its 8^th year of existence, 90% of the graduates of this program have stayed within Nebraska and 70% have entered practice in rural towns with less than 5,000 population (UNMC, internet).

Another option for graduating medical students wishing to pursue a career in rural medicine is the Rural Training Track (RTT) residency in Family Medicine. This program offers residents two years of training and living in a rural Nebraska community. After completing the program, the new family physician is not obligated to stay in a rural area. Most participants, however, do decide to continue practicing in or near the community in which they trained (UNMC Dept. of Family Med, Internet).

Direct financial incentives also exist for medical students and practitioners considering a career in rural medicine. The State of Nebraska provides funds for scholarships (which cover the cost of medical school tuition) and loan repayment programs to those who agree to practice in one of the many medical shortage areas found throughout the state. Generally, one year of rural medical practice is required for each year of scholarships or loan repayment accepted by the provider. All primary care physicians, psychiatrists, and general surgeons are eligible for these loan repayment programs. Nebraska’s rural medicine programs have proven to be very successful, as shown by the fact that over 80% of the physicians who complete the RTT or Primary Care Track residencies decide to stay in rural practice (UNMC Dept. of Family Med, Internet).

Many other states in the country now have programs designed to produce rural physicians. This shows that the shortage of rural physician is not just a local problem, but is present throughout the nation. A recent article in the Journal of the American Medical Association reviewed all state incentive programs in the country as of 1996 (Pathman, et al., 2000). It found at least 82 distinct programs in 41 states, which provided incentives ranging from scholarships, loans, loan repayments, and direct financial payments to residents and physicians who practice in underserved areas. These state programs enlisted a total of 1306 physicians that year, which again illustrates the effectiveness of such programs in addressing rural health needs.

The federal government also attempts to supply physicians where they’re needed most through the National Health Service Corps. This program, which began in 1970, provides loan repayments, scholarships, and salaries in return for service in federally designated health professional shortage areas throughout the country (NHSC, Internet). Currently, there are relatively few NHSC physicians practicing in Nebraska, especially compared to other states. This is primarily due to the success and quality of the state of Nebraska’s and UNMC’s programs in placing physicians in rural Nebraska (Mueller, interview).

Patient and physician access to quality health care is related to the economy of the community. The health care sector is often one of the major employers and source of economy for the small town, and without it, the towns feel like they would struggle to maintain a viable economical base. It is difficult, however, for hospitals and clinics to maintain a profitable margin and to supply that economic base.

There are several barriers to seeking health care in rural communities, not the least of which involves the cost of care. Insurance, Medicaid and Medicare, and hospital access are all concerns of rural populations. The percentage of uninsured in the rural population, like the national average, has risen dramatically in the past several years reaching an estimated 15.7% in 1999. This is lower than the urban average of 16.4% who are uninsured. However, a disproportionately large number of the insured rural population have inadequate insurance, often purchased through a small business or private insurance, which often has very large deductible and/or co-pay. In addition, a higher percentage of rural residents are more than 100% below the poverty line, 27.9% vs. 25.5% in the urban population (Pol 2000). These factors, coupled with a larger rural elderly population, results in more expensive emergency room visits because rural residents are less likely to seek help until their illness reaches emergency levels (RUPRI 1998).

Access to a hospital is also of increasing concern in rural communities. Since 1980, more than 400 rural hospitals have closed (RUPRI 1998). 15.9% of rural hospitals experience negative total margins, as opposed to 9.8% by their urban counterparts. This is in part due to the large percentage of operating costs in rural hospitals paid for by Medicare. Of rural hospitals with less than 50 beds, 47% of their operating cost is paid for by Medicare, and 12% is paid for by Medicaid (Mueller and McBride 1999). Currently, Medicare reimbursement favors urban areas in many ways. These reimbursements are grouped into categories called diagnostic related groups (DRG), which assigns a payment rate based on the resources used in the care of a patient. The DRG is then multiplied by the area wage index, which is calculated through a complex set of variables based on cost of labor in a rural area (employee wages), and the occupations (level of education) of the people employed by the hospital. Urban areas are more likely to employ a greater percentage of people with higher degrees, and are also more likely to pay their employees higher wages. These differences have resulted in an average 25.3% greater reimbursement to urban hospitals. (Wellever 2000)

The Balanced Budget Act (BBA) of 1997 also poses potential hardship to rural hospitals. Signed into law by President Clinton on August 5, 1997, this area is currently a key focus of the Rural Policy Research Institute (RUPRI) (Mueller Interview). Much of the savings to the government through the BBA comes by way of decreasing Medicare reimbursements for inpatient, outpatient, and a variety of other services provided by the hospital. This will impact rural hospitals more than their urban counterparts because of their dependence on these government systems for the majority of their operating costs. For example in Missouri, where the Rural Policy Research Institute Office is located, the state will lose an estimated $79 million in 2002 when the changes take full effect (Mueller and McBride 1999).

The Medicare, Medicaid and SCHIP Balanced Budget Refinement Act of 1999 will provide some relief for rural hospitals. It provides $17 billion in an attempt to offset the cuts made in the BBA of 1997 and their effects on rural hospitals. The Act also allows small rural hospitals until 2004 before implementing the new payment system outlined in the BBA, giving them time to qualify for Critical Access, Medicare dependant status, or sole community hospital status (Mueller 1999). Of these possibilities, the Critical Access Hospital holds the most potential for keeping hospitals open in needed areas, while also providing a source of great debate among many rural physicians (Cordes 1998).

The BBA of 1997 established a new category of hospitals termed Critical Access Hospitals (CAH). A facility wishing to apply for Critical Access status must be a nonprofit hospital participating in Medicare. They may provide acute inpatient care for up to 96 hours before discharging the patient or transferring them to another facility. The hospital must also be more than a 35 mile drive to another hospital or CAH. Critical Access will allow the hospital to stay open by receiving Medicaid payments based on "reasonable cost" rather than the traditional reimbursement system (Cordes 1998). There are approximately 45 of these hospitals in Nebraska, and more applying every year.

A viable health sector is an important component of a community’s infrastructure. It is an essential component for community growth and development, and it is critical for quality of life preservation. This is especially true in a rural area where attraction of firms to provide jobs and economic growth can be extremely difficult without the availability of high quality medical services. It is also important for retaining existing businesses and attracting retirees (Doeksen 1998). Aside from its contribution to existing quality of life and economic growth, the health sector provides significant direct economic benefits through employment and income effects on a community. A rural hospital is often the largest employer next to the school system in a small town (Doeksen 1998). Health-generated employment often is about 10 percent of a rural community’s employment. Income resulting from a rural hospital ranges between $700,000-$1,000,000 for the community. This does not even take into account the effect the hospital has on other businesses in town. Retail sales and sales tax collections also increase due to the pool of people from out of town that come in for health care. If the health sector increases or decreases in size, the medical health of the county as well as the economic health of the county will be greatly affected. When a rural hospital closes, it not only effects health access, it effects business and the viability of the town (Doeksen 1998).

Rural doctors play a key role in the relationship between individual health care and the health of the community. The physician gathers information directly from patients in the office, through family members, by personal observation, and in conversation with other people in town. This information can have the power to improve health and help at-risk persons to access care; or, it can make it difficult to practice medicine or even live in the community.

Confidentiality is a big problem in rural health. Although there are ethical dilemmas involved in medical care everywhere, small towns especially have familiarity and closeness of community life that can make navigating the customary ethical minefields even more treacherous. It is common for caregivers to be looking after friends and family when the community is small; these interlocking relationships and dependencies of small-town life can make confidentiality nearly impossible. It can become intensely difficult for both physician and patient when they need to discuss issues such as sexually transmitted disease, abortion, substance abuse, or family violence. The rural doctor or nurse inevitably becomes the "carrier of every town secret". This burden is significant, as rural clinicians may become less socially involved and increasingly withdrawn as their tenure lengthens until they eventually feel themselves, ironically, to be outcasts (Lancet 1999).

Adolescent pregnancy in rural areas is an important example of where confidentiality comes into play. Although sexual activity of adolescents is similar between rural and metropolitan areas, rural females under the age of 19 have higher birth rates (16%) compared to females in metropolitan counties (12%) (Skatrud 1998). This seems to be related to the fact that access to health services, especially family planning, is more restricted in the rural areas. There is a great unmet need for contraception and sexual education in these areas. Although social isolation, lack of educational and economic opportunities, and limited access to health services are key issues in this problem, confidentiality may be one of the biggest barriers. Rural family doctors tend to be more conservative in their attitudes compared to city doctors, and adolescents tend to find it more difficult to ask them questions on birth control because of fears of confidentiality. Rural adolescents are also more likely to look at their doctor not only as their caregiver but also as a father-figure.

Not only is it more difficult to talk to their family doctor about contraception, but it is also hard to purchase contraception at the local level. Most of the time, the only place that has condoms in town is the local grocery store and they know everyone that works there. The relatively fewer numbers of health professionals in rural areas, weaker infrastructures for transportation and information, low rates of insurance coverage, and reluctance to accept social services also reduce the likelihood of rural teens receiving adequate preventive or reproductive care. Access to family planning services is especially problematic in rural areas, where health departments provide the majority of rural contraceptive services, compared with a wider variety of providers and sites in urban and metropolitan areas (Skatrud 1998).

One of the major tasks of rural health systems is attracting additional market share to keep viable and to be able to provide a wide range of services. The loss of a physician is a critical time in a community. Ideally, communities will have enough critical mass of doctors to keep the clinic going. Some go the extra mile to recruit constantly in order to reduce the time it takes to replace a physician. Delays in replacement can mean that local patients leave the community for services at another location. It may be difficult to get those patients back. As such, some hospitals and practices have adopted some innovative approaches to improve market share and viability.

One way to improve access to health care in rural areas is through the use of satellite clinics. This allows the residents of the town to gain access to health care without having to drive substantial distances. This is especially beneficial for the elderly who prefer not to travel. Specialists also travel to rural areas, which improves the level of care that patients in rural areas receive. Communities unable to support a physician by themselves can use satellite clinics to provide care to those individuals in the most economically feasible manner.

Access to advanced medical technology is another issue of concern in rural Nebraska. As rural hospitals are generally small and not well funded, they cannot afford the most advanced medical equipment available. This, of course, can be a major barrier to quality care. In Nebraska, this problem has been largely overcome by the cooperation between rural hospitals and medical facilities to share expensive equipment and services. For example, several adjacent communities might share a regional dialysis center, which is a service that every community needs but one that no single community could support on its own (Mueller, interview).

Other opportunities for improving rural access to medical technology are being made possible by the development of computers and the emergence of the Internet. These rapidly advancing technologies hold the promise of not only improving access to care, but may also dramatically improve the quality of care. For example, the emergence of new telecommunication technology offers the possibility to provide a careful history and physical examination by a competent clinician that is many miles from the patient. Certainly there are several other ways, many of which have yet to be discovered, that these new technologies will be used to benefit rural residents.

According to the American Telemedicine Association’s 1997 Report to the U.S. Congress, telemedicine is defined as the exchange of medical information from one site to another, via electronic communications, for the purpose of treating patients, educating patients and providers, and improving overall patient care.

In rural areas, patients may not only have to travel many miles to see their primary care physician, but may then have to drive many more miles for any needed sub-specialist care. In some rural areas, particularly those near a large city, sub-specialists will often make rural visits. However, their reach is often limited to a several hour radius from the city (Satorius, interview).

Many experts think that the United States has an oversupply of physician specialists and academic medical centers, yet there is a vast population of people in rural areas lacking the resources of the academic centers both in terms of physician care and education (Kvedar 1998). Telemedicine offers a possible means of bridging this gap.

Telemedicine is currently being used on a limited basis for remote consultation through video conferencing with a sub-specialist, usually for radiology, pathology, dermatology, and psychiatry (Dormann 2000). In addition, cardiologists have used remote monitoring to monitor pacemakers, cardiac information, and vital signs in the ICU setting (Kvedar 1998). In Nebraska, the Good Samaritan Health System in Kearney offers the most elaborate system of telemedicine for the treatment of patients. Cardiologists at Bryan LGH in Lincoln monitor EKG readings, pacemakers, and Halter cardiac monitoring systems across the state of Nebraska.

Finally, remote education is used to provide information from academic medical centers and sub-specialists to primary care physicians.

As one can see, the possible uses of telemedicine are potentially limitless. It offers a solution to the health care needs of those in rural areas, as well as the educational needs of the primary care physicians providing the health care. However, there are several major barriers to the development of telemedicine that have to be addressed prior to its wide spread use to provide health care in the rural setting.

For long term success, a telemedicine program must be profitable or at least break even. To do so, however, would require a change in the way for which health care is paid. The handbook of Current Procedural Terminology, which defines how physicians and hospitals bill their patients, explicitly states that evaluation and management services must be conducted in a face-to-face manner (Kvedar 1998). Traditionally, physicians have not billed for telephone consultation time. The only exceptions are radiology and pathology, which explains the success of telemedicine in these two areas. In addition to the question of when a patient is billed, the question of who is billed needs to be addressed as well. If both the primary care physician and a sub-specialist participate in the telecommunication conference, do they both get paid? A possible solution is that the primary care physician would not have to be in the room with their patient while they are consulting a specialist (Mueller, interview). However, this approach raises questions of continuity of care.

The major barrier to health care via telemedicine in rural areas is Medicare’s refusal to pay for it. Medicare and Medicaid set the national trends when it comes to health care in the U.S., and most major insurance companies follow their lead. Currently, the only telemedicine Medicare will reimburse is radiological consults (Dormann 2000). The issue of Medicare payments is the fundamental issue that needs to be resolved before telemedicine can expand.

Congress, however, is reluctant to authorize Medicare payment for telemedicine since they do not see an immediate saving of money. In fact, it might cost more in the short term as people access health care that was previously unavailable to them (Mueller, interview). But in the long term, better access to care may actually save money as diseases are diagnosed earlier, thereby avoiding costly complications. Where telemedicine has been successful, such at Good Samaritan Hospital, they have had to rely on private and public grants to pay not only for the technology, but also the physician’s time.

A second major barrier to the widespread development of telemedicine is the issue of privacy and patient confidentiality. The public has a strong negative response to the use of electronic medical records because of the fear of their inappropriate disclosure and use, especially by insurance companies and HMOs (Kvedar 1998). Hopefully, such fears will be somewhat alleviated as the public grows more accustomed to electronic record keeping and as encryption technology effectively keeps unauthorized users away from personal medical information.

Finally, the issue of medical licensing and liability is a barrier to the development of telemedicine. Currently, physicians can only practice and offer consultation in the states where they are licensed. Thus, the use of telemedicine by a physician is restricted to the states in which he or she is licensed. The cost for obtaining a medical license in each state is prohibitively expensive, ranging from $400 to $1500 per state (Dormann 2000). Therefore, there is a need for a national medical license in order to encourage the spread of telemedicine.

Given the current barriers to telemedicine, the best use of the current technology, especially the Internet, may involve physician education such as in the Grand Rounds format. Recent studies suggest that physicians learn more effectively through individualized, practice-based educational interventions than through traditional lecture oriented-continuing education (Wiliams 1996). This may be the most promising application of telemedicine, as it is relatively easy to implement and it provides important lifelong learning tools that benefit both the rural physician and his or her patients (Zollo 1999). The University of Nebraska Medical Center has placed a strong emphasis on this aspect of telemedicine, specifically Internet education, as indicated in their Distance Education/Telemedicine Taskforce Report (Sitorius, interview).

Telemedicine can connect multiple health care providers, nurses, sub-specialists, and family members at different locations to establish a team approach of providing health care that has been successfully used in the academic health care centers. In addition, the patient can not only play a role in the consultation, but may also observe the physician-physician discussions without having to carry health information from one provider to another. This team approach is not necessary for all patients, but may be superior in the treatment of very sick patients with multiple disorders or for the evaluation of the necessity of a high risk intervention (Williams 1996).

Nothing, however, will ever replace the importance of a careful examination by the clinician. Since the age of Hippocrates, physicians have been trained on the importance of face to face encounters as a means of collecting data. Such inborn tendencies make the growth of long-distance medicine and electronic solutions a slow progression at best (Kvedar 1998).

Health care of those in rural Nebraska is sometimes hard to attain due to the fact that large distances often separate patients from their primary care physicians and sub-specialists. While telemedicine offers future possibilities to meet the needs of these individuals, there are many barriers that need to be addressed first. In the meantime, telemedicine can improve the quality of health care in rural areas through the use of continuing physician education and electronic access to information from academic health centers such as UNMC.

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• Nebraska Center for Rural Health Research: This organization conducts and analyzes research related to improving health care deliver to rural areas. The center focuses on special populations among rural residents whose needs for assistance are unique. The organization can be contacted at 402-559-5260.
• Rural Policy Research Institute: This organization conducts policy relevant research to assist policy makers and citizens in understanding the rural impacts of public policy and programs. They can be contacted via at 573-882-0316.
• Rural Health Education Network: RHEN works to get high school aged children involved and interested in rural health care. It also provides continuing education for health care workers in rural areas. They can be reached at 402-559-8946.
• Nebraska Office of Rural Health: Define and promote the development of a health care system that assures the availability and accessibility of quality health care services to meet the needs of the residents of rural Nebraska. They can be reached at 402-471-2337.
• Licensing and Accrediting: This group monitors health care facilities and professionals to insure individuals and facilities in Nebraska are administering an appropriate level of care to those receiving care in the state. They can be reached at 402-471-2115.
• Planned Approach to Community Health (PATCH): Patch is a process that involves and enables members of a community to plan, implement, and evaluate programs designed to reduce the burden of disease in their community. They can be reached at 402-471-2101.
• Nebraska Rural Health Association: This organization brings together health agencies to discuss health issues for individuals in rural areas. Members of this organization then sit on committees for advocacy groups for rural health. It can be reached at 402-483-1039.
• Emergency Medical Services: This program works with Nebraskan’s to imrove their level of personal health and their community wide public health. They ensure adequate and appropriate health care resources are accessible and available to all people of Nebraska. They can be reach at 402-471-5578.
• Medical Search Institute: This company does hospital and facility analysis of towns. They identify problems and make recommendations on recruitment and retention of physicians. They also do background checks on the prospective physicians who are applying for the position. They can be reached at 913-236-0028.
• National Rural Health Association: National Membership organization whose mission is to improve health and health care of rural America and to provide leadership on rural issues through advocacy, communication , education and research. They can be reached at 816-756-3140.
• Agromedicine: This program is designed to help rural resident sbecome more aware of medical issues that affect their lives and helping medical professionals understand the unique aspects of rual life and how to best serve rural patients. More details about the program can be found by calling 402-559-8946.
• Nebraska Public Health Association: This group focuses on the public health of all Nebraskans. It also identifies access issues for the population in rural areas. They can be contacted at 402-483-1039.

Our first site visit was to Dr. Keith Mueller who is a full professor at UNMC and director of two research centers, the Nebraska Center for Rural Health Research (NCRH) and the Rural Policy Research Institute (RUPRI). The NCRH is a federally funded program that was formed in 1988 for problem identification and analysis in rural Nebraska. The primary focus of the NCRH is research. They provide information to UNMC, federal, state, and local government. RUPRI is a federally funded program that was formed in 1993 to propose and analyze legislation effecting the health and well being of rural communities.

The needs this research meets for the rural population are three-fold. First and foremost is the impact the research centers have on rural policy legislation at all levels (Dr. Mueller was just appointed to a national rural health advisory committee by U.S. Health and Human Services Secretary Shalala). Their current focus is on the balanced budget act of 1997 and its effects on delivery of health care services in rural areas, specifically on the ability of rural Medicare beneficiaries to access needed services. The centers also look at how information networking technology can be used to sustain rural health care systems. Second, the information obtained by the centers is shared with local communities to help them identify unmet needs and develop resources to meet those needs. For example, there is a need for assisted living facilities in Nebraska and they have identified many areas in which different communities could pool their resources to meet this need. Lastly, the centers provide education to rural physicians and residents on aspects pertaining to rural health legislation. For example, they produce a Grand Rounds series in which they simulcast issues pertaining to rural problems all over Nebraska.

Rural health care providers play an integral role in both NCRH and RUPRI. Through surveys and direct research involvement, rural physicians provide information to the centers on such things as access to health care, fears of technology, and adequacy of resources. Health care professionals are also part of the RUPRI Rural Health Panel.

The main goal Dr. Mueller hopes to accomplish through NCRH and RUPRI is to sustain rural health care delivery via public policy. In fact, the majority of the policy produced by the centers is integrated into legislation, often on a federal level. Other goals of the centers are to improve rural health access through technology, such as telemedicine. Dr. Mueller feels that a gradual integration would be the most effective way to expand the current use of technology among rural physicians. By first getting physicians comfortable with telemedicine through its use for continuing education, he felt that the physicians would then be more comfortable using the technology for patient consultation. Currently, this resource is being used effectively for behavioral health. As of now, Dr. Mueller feels that the biggest problem with this technology is funding to put the technology into place and the reimbursement after it is in place. He also feels that the technology now in place is being underutilized, especially by the rural sector.

Another area that Dr. Mueller feels is a major barrier to rural community health resources is the shortage of unskilled laborers. Not only do hospitals have difficulties finding skilled laborers such as nurses, lab technicians, and secretaries, they also have problems finding custodians, food service workers, and volunteers for additional help. This limits the care provided by the rural hospital to essential services. Not only is the hospital affected, but other community programs such as Hospice, Meals on Wheels, and other charitable organizations are also affected.

One area that Dr. Mueller sees progress in is with the integration of Critical Access Hospitals in rural communities. He feels that this has kept the doors open for many rural hospitals facing closure due to financial burdens. These hospitals are able to provide additional services to members of the rural community above and beyond what a clinic may provide. Keeping these hospitals alive has not only kept access to quality health care available, but has also kept several counties from going under with the hospital.

We feel that both the NCRH and RUPRI are doing an excellent job for health care in rural America. They work very effectively together through integration of up-to-date research with effective policy. We were very impressed with the progress that these groups have made in impacting rural health from analysis of policy to implementation through legislation. At this time, we do not feel that we could make any recommendations as the centers are already effecting every aspect of rural health.

Dr. Mueller was a wonderful source of information for all aspects of rural health. Through him, we discovered that rural health is much more diverse than we had originally thought. We also learned how important legislation is to rural health. He helped us to understand that Medicare, while seen as a nuisance in urban communities, is often what keeps rural hospitals afloat, especially Critical Access Hospitals. We also gained an appreciation for the dedication of the researchers at the two centers. Not only do they do the research for the purpose of academia, but they are also outspoken advocates for rural society. As potential future rural physicians, we feel that our experience with Dr. Mueller not only helped with our project but also opened our eyes to other realities faced every day by the rural physician that we had not previously considered.

One of our two site visits was to the Memorial Health Clinic in Aurora, Nebraska. We visited with John Wilcox, M.D., who has been a family physician in the community for 25 years, longer than any other physician in town. He spent the first 22 years of his career with two other partners in private practice in town. In 1997, the local hospital began talks of merging his practice and the other local medical practice into one hospital-owned medical clinic. After working out a financial commitment and the construction of a new clinic with the hospital board, both practices agreed to the merger, thus creating a single medical facility with six family physicians and a general surgeon, physicians’ assistant, and nurse practitioner. The main clinic and hospital serves most of Hamilton county, and the two satellite clinics in Clay Center and Harvard serve most of Clay County as well.

Unlike what we expected to find, Dr. Wilcox gave no indication of any politics or hard feelings between the hospital board, administrators, and physicians. Also, he indicated that all of the physicians took the merger very well and he was surprised at how well everyone got along after being rivaling clinics for so many years. The clinic and hospital has numerous specialists visit throughout the month, and it also has a CT scanner, diagnostic laboratory, physical therapy offices, and a pharmacy within its building. He believes that they have really become a model for other rural clinics to follow in the future.

Dr. Wilcox emphasized that the key to making any rural clinic work was to make sure that you surround yourself with competent and friendly people. He credits the success of the clinic to the hospital board and administration, which is a rather uncommon complement from a physician’s mouth. He explained that the hospital is usually operating in the red, but that the clinic’s revenue is what keeps the entire operation afloat. However, that should change in the coming months, as the hospital was just granted "critical access" status two months ago.

The patients in Aurora have access to health care continuously through the emergency room, and Monday through Saturday in the outpatient clinic. They also have access to a general surgeon at all times, and are just 25 minutes away from a trauma center and numerous specialists in Grand Island. Dr. Wilcox did believe that he had more Medicare patients than most urban areas, but he did not think they had as many Medicaid patients. As is the common sentiment among many physicians, he did complain about the lack of adequate reimbursement from the governmental programs. He was also upset that Medicare did not yet pay for prescription drugs while Medicaid does.

Dr. Wilcox stated that rural practice has provided him with a very rewarding career over the years. In a word, he said he mostly enjoys the lifestyle. He liked the fact that he did not have to worry about his children’s safety on the streets and in the schools. He enjoys the freedom of existence in the smaller town, and he also likes the freedom he has to practice a wide scope of practice. Also, he argues that the money is much better in Aurora and many other rural towns than it is in the cities. These rural clinics are getting so desperate to recruit physicians from the cities that they have to often offer similar salaries. Combine that higher pay with a lower cost of living, and he believes he has a financial advantage in the small town. He did point out that he believed rural physicians have many more responsibilities, such as obstetrics, hospital rounds, and emergency room duties, than does the urban physician.

He also pointed out that finding competent medical staff was a lot more challenging in the rural setting. He did see it getting better in the future, as the small towns are now offering more competitive salaries. However, Aurora is presently struggling with a shortage of nurses, which forced them to recruit four new nurses from Korea who will join the staff once they complete their American training.

He also believes that there is a problem finding and maintaining competent physicians in rural Nebraska. He attributes this to the lack of oversight and credentialing in small towns, which could allow for the hiring and perpetuation of an incompetent physician. He also believes that there is an undersupply of female physicians in rural Nebraska. All of Aurora’s physicians are male, and they really have not had much luck finding excited and committed female physicians to join their practice.

Finally, Dr. Wilcox did see a great future for rural medicine in Nebraska. He sees funding as the number one determinant of success, but he also sees many other possible sources of excitement. Things such as telemedicine, traveling specialty clinics, the merging of community resources together for greater efficacy, and the rural training that students and residents receive are such areas of hope for rural medicine.

The vast majority of the state of Nebraska is rural and like most areas of the United States, the need for adequate health care in these areas is not being met. This group explored several different aspects of health care in rural Nebraska including patient access to primary care, sub-specialist care, the status of rural hospitals and clinics, the lifestyle and work environment of the primary care physician, and the status of Medicare and Medicaid in rural areas. Finally, the group addressed some of the efforts to alleviate the shortage of health care in rural areas.

The primary problem with health care in rural areas is simply the lack of health care workers in those areas. The Rural Health Advisory Commission has designated sixty-five out of ninety-three counties in Nebraska as health care shortage areas. This shortage is most acute in the western half of the state. For example, with regards to the fields of OB/GYN and Psychiatry there is a five-fold and six-fold difference respectfully between the number of persons served per practitioner in the eastern half of the state versus the western half. Such discrepancies in specialty areas simply increase the burden on the local family practice physician. In addition, there is a disproportionately low percentage of women physicians in rural areas, mainly due to cultural and family barriers.

One of the main reasons for the shortage of health care workers in rural areas has been the inability of rural towns and hospitals to either recruit or retain physicians. Recruiting physicians who come from a rural background is more successful than those from an urban background since they not only are used to the environment but are fond of the closeness of the community and the friendliness of the people. There are several issues involved in the decreased likelihood of either recruiting a new physician or retaining a current one. Salaries tend to be lower in rural areas, facilities and equipment may be in poor condition, and there may be a degree of professional and social isolation, especially if there is only one physician in a community. Many studies have shown that the high workload and stress may be the biggest contributor to decreased retention of the rural physician. Rural physicians usually see more patients than their urban counterparts. In addition, they often have more paper work, take more call, and perform a variety of extra tasks such as minor surgeries, psychiatric care and nursing home care that are usually delegated to more specialized physicians in the larger urban setting. Despite these perceived obstacles, many rural physicians find satisfaction in the diversity of patients they see and close relationships they form with both patients and the community.

Many towns have tried to resolve the health care shortage in rural areas by pooling their resources and joining several area clinics or hospitals into one. They combine services so that one facility will one handle certain procedures and care and another facility will handle the rest. In addition, many rural communities have turned to satellite clinics that are staffed by a local physician on certain days of the week. This is beneficial to the elderly who often cannot or prefer not to travel long distances for health care.

The emergence of new telecommunications and internet technology offers the possibility to provide a careful history and physical when the physician and patient are many miles apart. The use of telemedicine has been explored for its potential to reach those areas where there is a shortage of health care workers. In rural areas, patients must often travel great distances to visit their primary care physician as well as a subspecialist.

Currently, telemedicine is being used in a limited capacity in Nebraska, primarily with radiology, pathology, and dermatology. The Good Samaritan Hospital in Kearney has been particularly successful in these areas. The potential uses of telemedicine are limitless, however there are several major barriers to its widespread adoption as a means to provide health care in rural areas. First, under the current system for billing for physician services, patient care must be conducted in a face-to-face manner. The only exceptions are pathology and radiology, which may explain the success of telemedicine in these areas. In addition, there is some confusion to who will be able to bill for telemedicine time, the specialist, the primary physician, or both. Secondly, there is some hesitation by the public to the development of telemedicine due to the perceived risk on privacy and confidentiality. Third, the issue of licensing and liability over long distances and between states has not been decided. Finally, and perhaps most importantly, Medicare only reimburses for radiological consults using telemedicine. Medicare and Medicaid set the national trends when it comes to health care in the United States. Given the large proportion of patients that use Medicare in rural areas, this is the fundamental issue that needs to be addressed if telemedicine is be used to meet the health care needs of those in rural areas.

Besides the shortage of health care workers in the rural areas, there are several economic barriers to seeking health care in these areas. The percentage of uninsured persons is slightly lower in rural areas than in urban areas, however, many rural residents have inadequate insurance with a high deductible that is almost as bad as no insurance. Such residents will be less likely to seek health care until the problem becomes serious, and thus very expensive. In addition, there is a higher percentage of people living below the poverty line in rural versus urban areas, thus when a health crisis occurs, a financial crisis often follows.

Many rural hospitals are closing, and those that remain open are often deep in debt, deeper than their urban counterparts. Medicare is responsible for approximately 47% of the operating costs in rural hospitals and on average its amount of reimbursement is lower than comparable insurance companies. In addition, the Balanced Budget Amendment of 1997 decreases the Medicare reimbursements, which has had a proportionally greater effect on rural hospitals. The BBA of 1997 did establish a new category of hospitals called Critical Access Hospitals to try to offset the budget cuts. In order for an institution to qualify, it must exist 35 miles from another hospital and be a non-profit organization. The Critical Access Hospital will allow the hospital to remain open by receiving Medicare payments based on reasonable costs rather than the traditional reimbursement system. Finally, a rural hospital or clinic not only contributes to the health and well being of the community but also of its financial success. A rural hospital is a major employer and increases tax revenue for the local government. When a rural hospital closes, it not only effects the health care of that area, it effects business and the viability of the town.

In order to meet the challenges of delivering quality health care to those in rural areas, the United States government, the state of Nebraska, and UNMC have developed plans to increase the number of health care workers in rural areas. UNMC sends first-year medical students to rural areas for a three week summer rotation, and an eight week rotation for third year medical students to increase their exposure to the opportunities of practicing in rural areas. In addition, UNMC students may apply for the Primary Care training track where students complete their fourth year of schooling as an intern in either Family Medicine or Internal Medicine. In addition, the Rural Training Track offers students interested in family medicine to complete two years of their residency in rural areas. The State of Nebraska offers funds for scholarships and loan repayment plans for those physicians and students who promise to practice in rural areas.

The National Health Service Corp also provides loan repayments, scholarships, and salaries, in return for health care services in federally designated health professional shortage areas. However, there are relatively few such physicians in Nebraska, primarily due to the success of the in-state programs.

Access to quality health care is now being recognized as a right for all Americans. There are many unique challenges present in rural America that make it difficult for these Americans to receive the same quality of health care as their urban counterparts. However, there have been some great strides in recent years to improve rural access to health care. And, with the hope of technology and the dedication of future practitioners, there is even a more exciting future ahead for rural health care.