“Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act”

“Availability of healthcare providers for rural veterans eligible for purchased care under the... Background: Military Veterans in the United States are more likely than the general population to live in rural areas, and often have limited geographic access to Veterans Health Administration (VHA) facilities. In an effort to improve access for Veterans living far from VHA facilities, the recently-enacted Veterans Choice Act directed VHA to purchase care from non-VHA providers for Veterans who live more than 40 miles from the nearest VHA facility. To explore potential impacts of these reforms on Veterans and healthcare providers, we identified VHA-users who were eligible for purchased care based on distance to VHA facilities, and quantified the availability of various types of non-VHA healthcare providers in counties where these Veterans lived. Methods: We combined 2013 administrative data on VHA-users with county-level data on rurality, non-VHA provider availability, population, household income, and population health status. Results: Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these Veterans lived in primary care shortage areas, while the majority (70.2%) lived in mental health care shortage areas. Most lived in counties that lacked specialized health care providers (e.g. cardiologists, pulmonologists, and neurologists). Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population in counties that were farther from VHA facilities (30.7 VHA-users / 1000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1000 adults in counties within 20 miles of VHA facilities, p < 0.01). Conclusions: Initiatives to purchase care for Veterans living more than 40 miles from VHA facilities may not significantly improve their access to care, as these areas are underserved by non-VHA providers. Non-VHA providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care. Keywords: Access, Veterans, Rural health Background rural areas. Depending on the method used to define Veterans Health Administration (VHA) is the largest in- rural areas, 22–30% of VHA enrollees live in rural areas, tegrated healthcare delivery system in the United States compared to 15–20% of the US population [2, 3]. This (US), with ~ 5.9 million Veterans using VHA for some makes VHA an important provider of healthcare in rural form of healthcare in 2015 [1]. Veterans are more likely areas of the US. than the overall United States (US) population to live in VHA has worked to improve access to care for rural Veterans using a variety of strategies, including building * Correspondence: Michael-ohl@uiowa.edu of Community Based Outpatient Clinics (CBOCs) in rural VA Office of Rural Health (ORH), Veterans Rural Health Resource Center- communities, reimbursing Veterans for travel to VHA Iowa City, Iowa City VA Medical Center, Iowa City, IA, USA care sites, and promoting use of telehealth [4]. A more re- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA cent strategy for improving access relies on purchasing of Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ohl et al. BMC Health Services Research (2018) 18:315 Page 2 of 7 care from non-VHA providers in communities closer to of the relatively small numbers of Veterans and unique Veterans’ homes. Following a series of highly-publicized geography in these states. events surrounding problems with access to care, Con- A VHA-user was defined as any Veteran who accessed gress enacted the Veterans Access, Choice, and Ac- any VHA care in 2013 in inpatient or outpatient med- countability Act of 2014 (aka the “Choice Act”)[5]. ical, mental health, or substance use treatment settings. This act directed VHA to offer to purchase care from We determined whether individual VHA-users were eli- non-VHA providers for Veterans who live more than a gible for non-VHA care under the Choice Act, based on 40-mile drive from the nearest VHA care site, or who their estimated driving distance to the nearest VHA care are unable to obtain needed care in VHA within a site that provided any form of inpatient or outpatient “reasonable period” (i.e. generally within 30 days). care (i.e. < 40 miles or > 40 miles). We used Federal In- Eligibility for purchased care by the 40-mile criterion is formation Processing Standards (FIPS) county codes to particularly relevant to Veterans living in rural areas of link each VHA user to data on county of residence. the US. Data on non-VHA health care providers were obtained The transformation of VHA from a deliverer of care to from the 2013 Area Health Resource File, a publicly- a purchaser of care will have implications for both rural available data set provided by the US Health Resources Veterans and the broader rural healthcare delivery system and Services Administration (HRSA) [6]. Counties were in the US. From the point of view of Veterans and VHA, a classified as health professional shortage designations for challenge will be to identify and contract with non-VHA primary care and mental health care using criteria created providers in communities where Veterans live. This may by HRSA, based on provider-to-population ratios [9]. be particularly difficult in communities that are already Primary care provider (PCP) shortage areas were defined underserved by healthcare providers. From the point of as < 1 PCP per 3500 persons. Mental health care shortage view of the overall health care delivery system and non- areas were defined as either: 1) < 1 psychiatrist / 20,000 VHA providers in rural areas, the challenge will be to persons and < 1 PCP / 6000 persons; OR 2) < 1 PCP / accommodate an influx of patients previously cared for by 9000 persons; OR 3) < 1 psychiatrist / 30,000 persons. VHA, which has disproportionately served rural areas. We also determined the availability of various non-VHA To better understand potential challenges associated providers of specialized care in each county, including with purchasing of care for rural Veterans under the psychiatrists, cardiologists, pulmonologists, neurologists, Choice Act, we identified VHA-users who were eligible and physical medicine and rehabilitation (PM&R) special- for purchased care based on distance to VHA facilities, ists. Only non-federal physicians involved in patient care and quantified the availability of various types of non-VHA were counted. We also determined the number of com- providers in counties where these Veterans lived. We also munity health centers and community mental health characterized areas where Veterans were eligible for pur- centers for each county. Community health centers were chased care, including measures of rurality, household in- limited to HRSA-grantees and community mental health come as a proxy for socioeconomic status, population centers were limited to certified Medicare providers. All health status, and the density of VHA-users in the overall physician and facility measurements were from 2013. population. Availability of specialty providers and facilities in each county were categorized as any or none. County-level rurality was classified using Urban Influ- Methods ence Codes (UIC) created by the US Department of Data sources Agriculture’s Economic Research Service [8]. Following We gathered person-level data on VHA-users from na- a commonly-applied framework, we collapsed the 12 codes tional VHA enrollment files for the year 2013, and linked it into a four level measure of rurality: 1) metropolitan / (i.e. to county-level data on: 1) non-VHA provider availability counties with population clusters > 50,000 people, UIC from the Area Health Resource File (AHRF) maintained by 1–2); 2) non-metropolitan / –adjacent to metropolitan the Health Resources and Service Administration (HRSA); areas (UIC 3–7); 3) nonmetropolitan - micropolitan (i.e. 2) median household income and total adult population not adjacent to metropolitan counties but with town/ over age 18 from the American Community Survey (ACS) urban cluster of 10,000–50,000 people, UIC 8); and 4) fielded by the US Census Bureau; 3) rurality based on nonmetropolitan - remote (i.e. the remainder, UIC 9–12). Urban Influence Codes (UIC) created by the Economic For simplicity, we refer to these groups as metropolitan, Research Service of the US Department of Agriculture; rural – adjacent, rural-micropolitan, and rural-remote [8]. and 4) health status measures from the Robert Wood We used median household income as a county-level Johnson County Health Rankings [6–8]. We compiled proxy for socioeconomic status. Median household income data for 3107 counties in the contiguous US. VHA-users values were single-year, model-based estimates from and counties in Alaska and Hawaii were excluded because the 2009–2013 Small Area Income and Poverty Estimates Ohl et al. BMC Health Services Research (2018) 18:315 Page 3 of 7 (SAIPE) provided by the US Census Bureau [10]. Based completed using SAS software v9.2 (Cary, NC). All ana- on inspection of county-level distributions of median lyses were approved by the Institutional Review Board at yearly household income, we categorized counties as median the University of Iowa. household income < $30,000 (i.e. roughly bottom decile of counties), $30–$40,000; $40,000–$50,000; $50,000–$60,000; Results and > $60,000 (i.e. top decile of counties). Overall, 416,338 (7.6%) of 5,511,483 VHA-users were eli- County-level health status measures were drawn from gible for non-VHA care under the Choice Act, based on the County Health Rankings & Roadmaps program, a residence more than 40-miles from the nearest VHA collaboration between the Robert Wood Johnson Founda- care site (Table 1). VHA-users who were eligible for pur- tion and the University of Wisconsin Population Health chased care based on distance were much more likely Institute [7]. As a proxy for population health status, we than the overall US population to live in counties that used age-adjusted years of potential life lost (YPLL) per were any category of rural (87.9% vs. 17.1%), rural- 100,000 people, aggregated over three years (2010–2012). remote (20.5% vs. 2.2%), median household income < The reference age was 75. For example, a person who dies $40,000 per year (40.4% vs. 10.7%), very poor population at age 45 would contribute 75–45 = 30 YPLL. The county- health status (28.4% vs. 10.3%), primary care shortage level YPLL is a sum of individual YPLL over all premature areas (15.8% vs. 4.2%), and mental health care shortage deaths in a county. Rates per 100,000 people were given areas (70.2% vs. 22.0%). VHA-users eligible for purchased after adjusting for differences in the age distribution care based on distance were much less likely than the gen- over counties. YPLL values were missing for 134 counties, eral population to live in counties with median household which were excluded from analyses of health status. income over $60,000 per year (4.4% vs. 26.3%). All differ- County-level health status was categorized as Very ences were statistically significant with p <0.01. Poor, Poor, Good, and Very Good according to quartiles In general, there was limited availability of non-VHA of YPLL. health care specialists in areas where Veterans were eligible for non-VHA care based on distance to the nearest VHA Analysis care site. The majority of VHA-users eligible for purchased We began by examining the distributions of the overall care based on the 40 mile criterion lived in counties US adult and VHA-user populations according to charac- with no psychiatrists, cardiologists, pulmonologists, neu- teristics of counties of residence, including non-VHA pro- rologists, PM&R specialists, or community mental health vider availability, rurality, household income, and health centers (Table 1). Nearly half (47%) lived in counties with status. We further stratified the VHA-user population ac- no community health center. cording to eligibility for purchased care under the Choice When limiting analyses to the ~ 1.1 million VHA- Act based on driving distance to the nearest VHA care site users residing in rural counties, we found that 324,162 (i.e. < 40 miles or > 40 miles). We repeated analyses (27.8%) were eligible for purchased care from non-VHA for the subset of all VHA-users living in rural counties. providers based on distance to VHA care sites (Table 2). We used Chi-square tests to compare distributions across In general, availability of non-VHA providers was even county categories. more limited for rural Veterans eligible for purchased Because non-VHA providers will be more impacted by care under the Choice Act, compared to the entire popu- reforms to purchase care for Veterans in areas where lation of Veterans eligible for purchased care. Availability VHA has recently delivered care for larger portions of the of non-VHA mental health providers was especially lim- overall population, we also calculated the density of VHA- ited for these rural Veterans. For example, 75.4% of rural users in the total adult population (i.e. VHA-users / 1000 Veterans eligible for purchased care under the Choice Act adults), according to county rurality and distance to the lived in counties that were mental health care shortage nearest VHA care site. Counties were categorized ac- areas, and 73.3% in counties without psychiatrists. cording to their distance to the nearest VHA care site To estimate the potential impact of Choice Act re- by estimating the driving distance from the population- forms on non-VHA providers in rural communities and weighted centroid for each county to the nearest VHA areas far from VHA facilities, we next examined the care site. Population-weighted centroid coordinates were density of VHA-users in the overall adult population, ac- determined based on 2013 Census data, using the cording to county rurality and distance from VHA care MABLE/Geocorr tool from the Missouri Census Data facilities. Somewhat counterintuitively, we found that Center [11]. Coordinates of VHA facilities were collected VHA played a greater role in delivering care for the from the Department of Veterans Affairs National Center overall adult population in counties that were more rural for Veterans Analysis & Statistics, furnished by ESRI and farther from VHA care sites (Fig. 1). The proportion (http://www.va.gov/vetdata/maps.asp). Driving distances of US adults using VHA care was overall 37% greater in were estimated using ArcOnline [12]. Other analyses were counties that were more than 40 miles from VHA care Ohl et al. BMC Health Services Research (2018) 18:315 Page 4 of 7 Table 1 Percentages of overall US adult population and VHA users, by eligibility for purchased care based on distance to VHA facilities, and characteristics of county of residence County Characteristic % US Adult Population % VHA users Overall < 40 Miles > 40 Miles N = 5,511,483 N = 5,095,145 N = 416,338 Rurality Rural - Remote 2.2 3.5 2.1 20.5 Rural - Micropolitan 2.8 3.9 3.2 12.2 Rural - Metro Adjacent 10.0 13.8 11.2 45.1 Metropolitan 85.0 78.8 83.5 22.1 Median Household Income $0–29,999 0.4 0.6 0.3 3.6 $30,000–39,999 10.2 14.0 12.1 36.9 $40,000–49,999 31.6 38.9 38.9 39.4 $50,000–59,999 31.5 28.6 29.6 15.9 $ > 60,000 26.3 17.9 19.1 4.2 Health Status Very Poor 8.4 11.5 10.2 28.4 Poor 15.9 21.4 21.0 26.1 Good 29.0 31.7 32.3 24.5 Very Good 46.6 35.4 36.5 21.0 Health Professional Availability Primary Care Shortage Area 4.0 5.0 4.2 15.8 Mental Health Care Shortage Area 20.2 25.2 21.6 70.2 County without: Psychiatrist 10.2 13.6 10.1 56.3 Cardiologist 12.2 16.7 12.7 65.7 Pulmonologist 15.7 21.2 16.7 76.5 Neurologist 14.6 19.4 15.2 71.1 PM&R Specialist 18.1 24.6 20.1 78.8 Community Health Center 15.1 18.2 15.8 47.0 Community Mental Health Center 57.0 62.3 59.8 93.0 Age-adjusted years of potential life lost per 100,000 persons PM&R: Physical Medicine and Rehabilitation sites, compared to counties within 20 miles of the near- purchasing care from non-VHA providers may have est VHA care facility (30.7 VHA-users / 1000 adults in limited impact, because there are relatively few non- counties over 40 miles from VHA care vs. 22.4 / 1000 in VHA providers in these areas to provide this care. counties within 20 miles of VHA care, P < 0.01). The This finding has implications for VHA efforts to improve density of VHA-users increased from 21.7 VHA-users access to care for rural Veterans. In addition to reforms to per 1000 adults in metropolitan counties to 36.1 VHA- purchase non-VHA care, VHA should continue to develop users per 1000 adults in rural remote counties (p < 0.01). other strategies for improving access to care for Veterans in areas far from VHA care sites. Examples include pro- Discussion grams for in-home telehealth visits and subsidized trans- We found that the majority of VHA-users who were eli- portation, both of which currently exist but could be gible for Choice Act purchased care based on distance to expanded [4, 13]. VHA should particularly work to develop VHA facilities lived in rural counties. These counties were programs to improve access to VHA mental health and underserved by non-VHA providers, and in particular by medical specialty care in rural areas, because there are providers of mental health and medical specialty care. few non-VHA providers in these areas to deliver this Efforts to improve access to care for these Veterans by care through purchasing agreements. More generally, Ohl et al. BMC Health Services Research (2018) 18:315 Page 5 of 7 Table 2 Percentages of rural VHA-users, by eligibility for purchased care based on distance to VHA care sites, and characteristics of county of residence County Characteristic % Rural VHA users Overall < 40 Miles > 40 miles N = 1,165,646 N = 841,484 N = 324,162 Rurality Rural - Remote 16.4 12.5 26.4 Rural - Micropolitan 18.6 19.7 15.6 Rural - Metro Adjacent 65.0 67.8 58.0 Median household income $0–29,999 2.6 1.9 4.3 $30,000–39,999 37.8 36.0 42.7 $40,000–49,999 45.0 47.7 38.1 $50,000–59,999 12.8 12.8 12.7 > $60,000 1.8 1.6 2.2 Health Status Very poor 29.0 27.7 32.4 Poor 27.4 28.0 25.9 Good 25.9 27.2 22.4 Very good 17.7 17.1 19.3 Health Professional Availability Primary Care Shortage Area 12.5 11.2 15.9 Mental Health Care Shortage Area 65.5 61.7 75.4 County without: Psychiatrist 47.4 41.4 63.0 Cardiologist 56.5 50 73.3 Pulmonologist 69.8 63.5 85.9 Neurologist 63.6 57.4 79.7 PM&R Specialist 73.9 68.7 87.3 Community Health Center 46.5 44.3 52.2 Community Mental Health Center 92.2 91.4 94.0 VHA should support broader policy efforts to increase assume care for relatively large numbers of Veterans the overall supply of health care providers in rural areas, currently using VHA care. This is true both because as Veterans disproportionately live in these medically- VHA has recently cared for a larger proportion of the underserved areas. population in these areas compared to counties closer Somewhat counterintuitively, we also found that the to VHA facilities, and because Veterans in these areas relative role of VHA as a health care provider in the arenow generally eligiblefor purchasedcareunder the overall community – as measured by the proportion of Choice Act. However, we found that there are few non- adults using VHA care – was greater in counties that VHA providers in these areas to take on care for Veterans. were rural and farther from VHA care sites. This was Taken together, these findings indicate that VHA reforms likely due to two factors. First, areas far from VHA facil- to purchase care may stress already overburdened rural ities are generally rural, and residents of rural areas are providers. more likely to join the all-volunteer military and to be The majority of VHA-users eligible for purchased care Veterans [14]. Second, although Veterans in these areas based on distance lived in counties that were not only must travel to obtain care in VHA care sites, there are rural and underserved by non-VHA providers, but also few local, non-VHA options for care. Healthcare providers lower income and lower health status. Reforms that in the predominantly rural areas that are more than move VHA towards purchasing care should include ef- 40 miles from VHA care sites will likely be asked to forts to strengthen existing safety net providers in these Ohl et al. BMC Health Services Research (2018) 18:315 Page 6 of 7 Fig. 1 Density of VHA-Users in the total adult population over age 18 (VHA-users / 1,000 adults), by county distance to VHA facilities and rurality low income and low health status areas, so that they are evaluate the impact of purchased care on overall health- better able to care for Veterans currently using VHA care use and outcomes for rural Veterans. care. Others have previously noted the role of VHA as a safety net provider in our national health care system, Conclusions and this must be kept in mind during reforms that move The majority of VHA-users eligible for purchased care VHA away from delivering care and towards purchasing based on distance to VHA facilities lived in counties that of care [15]. were rural, underserved by non-VHA providers, lower Our analyses have limitations. First, there is potential income, and lower health status. It may often be difficult for ecological fallacy in county-level analyses. Associations for VHA to purchase care for Veterans living more than apparent at the county-level may not hold at the individ- 40 miles from VHA facilities, because these areas are ual level. This is an inherent challenge in using county- already underserved by non-VHA providers. VHA should level data, which was necessary to combine the mostly continue to develop telehealth programs to deliver care to county-level data sources used in our analyses. For the Veterans in rural areas underserved by both community same reason, we used a county-based measure of rurality and VHA providers. Such programs are a necessary using urban influence codes. A rurality measure using a complement to initiatives to purchase in-person care from smaller area unit may provide somewhat different results. community providers. In addition, we examined availability of non-VHA pro- Abbreviations viders at the county-level, and in some cases providers ACS: American Community Survey; AHRF: Area Health Resource File; may have existed in relatively nearby communities in CBOC: Community Based Outpatient Clinic; HRSA: Health Resources & Services Administration; PCP: Primary Care Provider; PM&R: Physical Medicine neighboring counties. The administrative data on VA & Rehabilitation; UIC: Urban Influence Code; US: United States; VHA: Veterans enrollees were from 2013, which were the most recent Health Administration; YPLL: Years of Potential Life Lost data available at time analyses were initiated. The geo- Acknowledgements graphic distribution of Veterans is subject to change The views expressed in this article are those of the authors and do not over time. necessarily represent the views of the Department of Veterans Affairs or the Future studies of initiatives to improve access for rural United States government. Veterans by purchasing care from community providers Ethics and consent to participate should evaluate the balance between community provider The analyses were approved by the Institutional Review Board at the University availability and care needs of Veterans in smaller, defined of Iowa (IRB # 200502805). A waiver of informed consent was granted for this rural regions in the US. In addition, these studies should retrospective study using a large administrative database. Ohl et al. BMC Health Services Research (2018) 18:315 Page 7 of 7 Funding 13. Shore P, Goranson A, Ward MF, Lu MW. Meeting veterans where they're @: Dr. Ohl is recipient of a Career Development Award through VA’s Health a VA home-based Telemental health (HBTMH) pilot program. Int J Psychiatry Services Research and Development (HSR&D) program (CDA #11–211). Med. 2014;48(1):5–17. 14. Lutz A. Who joins the military?: a look at race, class, and immigration status. Journal of Political and Military Sociology. 2008;36(2):167–88. Availability of data and materials 15. Wilson NJ, Kizer KW. The VA health care system: an unrecognized national All publically available data used in this study are available from the authors safety net. Health Aff (Millwood). 1997;16(4):200–4. on request (i.e. data from AHRF, ACS, County Urban Influence Codes, and Robert Wood Johnson County Health Rankings & Roadmaps data). Aggregate data on number of VA users for US counties are available from authors on request. Authors’ contributions MO, MC, AT, and MVS contributed to obtaining data, study design, data analysis, interpretation of results, and manuscript drafting. MM contributed to study design, data analysis, interpretation of results, and manuscript drafting. MVW and TH contributed to study design, interpretation of results, and manuscript drafting. All authors have read and approved the final version of the manuscript and are accountable for accuracy and integrity of this work. Competing interests No authors report conflicts of interest. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details VA Office of Rural Health (ORH), Veterans Rural Health Resource Center- Iowa City, Iowa City VA Medical Center, Iowa City, IA, USA. Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. Department of Geographical and Sustainability Sciences, University of Iowa, Iowa City, IA, USA. Center for Mental Healthcare and Outcomes Research, Central Arkansas VA, Little Rock, AR, USA. Received: 5 May 2016 Accepted: 11 April 2018 References 1. Veterans Health Administration. National Center for Veterans Analysis and Statistics, Utilization Data [http://www.va.gov/vetdata/utilization.asp]. Accessed 16 Jan 2016. 2. Veterans Health Administration. About Rural Veterans [http://www. ruralhealth.va.gov/about/rural-veterans.asp] Accessed 26 Apr 2016. 3. Health Resrouces & Services Administration. Defining Rural Populations. [http://www.hrsa.gov/ruralhealth/aboutus/definition.html] Accessed 16 Jan 2016. 4. Kehle SM, Greer N, Rutks I, Wilt T. Interventions to improve veterans' access to care: a systematic review of the literature. J Gen Intern Med. 2011;26(Suppl 2):689–96. 5. Department of Veterans Affairs. Expanded access to non-VA care through the veterans choice program. Final rule. Fed Regist. 2015;80(209):66419–29. 6. Best AE. Secondary data bases and their use in outcomes research: a review of the area resource file and the healthcare cost and utilization project. J Med Syst. 1999;23(3):175–81. 7. Robert Wood Johnson Foundataion. County Health Rankings Data [http:// www.countyhealthrankings.org/rankings/data]. Accessed 16 Jan 2016. 8. United States Department of Agriculture. Measuring Rurality: Urban Infuence Codes [http://www.ers.usda.gov/data-products/urban-influence- codes.aspx] Accessed 16 Jan 2016. 9. Health Resrouces & Services Administration. Shortage Designations: Health Professional Shortage Areas and Medically Underserved Areas/Populations [http://www.hrsa.gov/shortage/] Accessed 16 January 2016. 10. United States Census Bureau. Small Area Income and Poverty Estiamtes [http://www.census.gov/did/www/saipe/] Accessed 16 Jan 2016. 11. Missouri Census Data Center. MABLE/Geocorr12: Geographic Correspondence Engine [http://mcdc.missouri.edu/websas/geocorr12.html] Accessed 16 Jan 2016. 12. Esri. ArcGIS Online [http://www.esri.com/software/arcgis/arcgisonline]. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Health Services Research Springer Journals

“Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act”

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Abstract

Background: Military Veterans in the United States are more likely than the general population to live in rural areas, and often have limited geographic access to Veterans Health Administration (VHA) facilities. In an effort to improve access for Veterans living far from VHA facilities, the recently-enacted Veterans Choice Act directed VHA to purchase care from non-VHA providers for Veterans who live more than 40 miles from the nearest VHA facility. To explore potential impacts of these reforms on Veterans and healthcare providers, we identified VHA-users who were eligible for purchased care based on distance to VHA facilities, and quantified the availability of various types of non-VHA healthcare providers in counties where these Veterans lived. Methods: We combined 2013 administrative data on VHA-users with county-level data on rurality, non-VHA provider availability, population, household income, and population health status. Results: Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these Veterans lived in primary care shortage areas, while the majority (70.2%) lived in mental health care shortage areas. Most lived in counties that lacked specialized health care providers (e.g. cardiologists, pulmonologists, and neurologists). Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population in counties that were farther from VHA facilities (30.7 VHA-users / 1000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1000 adults in counties within 20 miles of VHA facilities, p < 0.01). Conclusions: Initiatives to purchase care for Veterans living more than 40 miles from VHA facilities may not significantly improve their access to care, as these areas are underserved by non-VHA providers. Non-VHA providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care. Keywords: Access, Veterans, Rural health Background rural areas. Depending on the method used to define Veterans Health Administration (VHA) is the largest in- rural areas, 22–30% of VHA enrollees live in rural areas, tegrated healthcare delivery system in the United States compared to 15–20% of the US population [2, 3]. This (US), with ~ 5.9 million Veterans using VHA for some makes VHA an important provider of healthcare in rural form of healthcare in 2015 [1]. Veterans are more likely areas of the US. than the overall United States (US) population to live in VHA has worked to improve access to care for rural Veterans using a variety of strategies, including building * Correspondence: Michael-ohl@uiowa.edu of Community Based Outpatient Clinics (CBOCs) in rural VA Office of Rural Health (ORH), Veterans Rural Health Resource Center- communities, reimbursing Veterans for travel to VHA Iowa City, Iowa City VA Medical Center, Iowa City, IA, USA care sites, and promoting use of telehealth [4]. A more re- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA cent strategy for improving access relies on purchasing of Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ohl et al. BMC Health Services Research (2018) 18:315 Page 2 of 7 care from non-VHA providers in communities closer to of the relatively small numbers of Veterans and unique Veterans’ homes. Following a series of highly-publicized geography in these states. events surrounding problems with access to care, Con- A VHA-user was defined as any Veteran who accessed gress enacted the Veterans Access, Choice, and Ac- any VHA care in 2013 in inpatient or outpatient med- countability Act of 2014 (aka the “Choice Act”)[5]. ical, mental health, or substance use treatment settings. This act directed VHA to offer to purchase care from We determined whether individual VHA-users were eli- non-VHA providers for Veterans who live more than a gible for non-VHA care under the Choice Act, based on 40-mile drive from the nearest VHA care site, or who their estimated driving distance to the nearest VHA care are unable to obtain needed care in VHA within a site that provided any form of inpatient or outpatient “reasonable period” (i.e. generally within 30 days). care (i.e. < 40 miles or > 40 miles). We used Federal In- Eligibility for purchased care by the 40-mile criterion is formation Processing Standards (FIPS) county codes to particularly relevant to Veterans living in rural areas of link each VHA user to data on county of residence. the US. Data on non-VHA health care providers were obtained The transformation of VHA from a deliverer of care to from the 2013 Area Health Resource File, a publicly- a purchaser of care will have implications for both rural available data set provided by the US Health Resources Veterans and the broader rural healthcare delivery system and Services Administration (HRSA) [6]. Counties were in the US. From the point of view of Veterans and VHA, a classified as health professional shortage designations for challenge will be to identify and contract with non-VHA primary care and mental health care using criteria created providers in communities where Veterans live. This may by HRSA, based on provider-to-population ratios [9]. be particularly difficult in communities that are already Primary care provider (PCP) shortage areas were defined underserved by healthcare providers. From the point of as < 1 PCP per 3500 persons. Mental health care shortage view of the overall health care delivery system and non- areas were defined as either: 1) < 1 psychiatrist / 20,000 VHA providers in rural areas, the challenge will be to persons and < 1 PCP / 6000 persons; OR 2) < 1 PCP / accommodate an influx of patients previously cared for by 9000 persons; OR 3) < 1 psychiatrist / 30,000 persons. VHA, which has disproportionately served rural areas. We also determined the availability of various non-VHA To better understand potential challenges associated providers of specialized care in each county, including with purchasing of care for rural Veterans under the psychiatrists, cardiologists, pulmonologists, neurologists, Choice Act, we identified VHA-users who were eligible and physical medicine and rehabilitation (PM&R) special- for purchased care based on distance to VHA facilities, ists. Only non-federal physicians involved in patient care and quantified the availability of various types of non-VHA were counted. We also determined the number of com- providers in counties where these Veterans lived. We also munity health centers and community mental health characterized areas where Veterans were eligible for pur- centers for each county. Community health centers were chased care, including measures of rurality, household in- limited to HRSA-grantees and community mental health come as a proxy for socioeconomic status, population centers were limited to certified Medicare providers. All health status, and the density of VHA-users in the overall physician and facility measurements were from 2013. population. Availability of specialty providers and facilities in each county were categorized as any or none. County-level rurality was classified using Urban Influ- Methods ence Codes (UIC) created by the US Department of Data sources Agriculture’s Economic Research Service [8]. Following We gathered person-level data on VHA-users from na- a commonly-applied framework, we collapsed the 12 codes tional VHA enrollment files for the year 2013, and linked it into a four level measure of rurality: 1) metropolitan / (i.e. to county-level data on: 1) non-VHA provider availability counties with population clusters > 50,000 people, UIC from the Area Health Resource File (AHRF) maintained by 1–2); 2) non-metropolitan / –adjacent to metropolitan the Health Resources and Service Administration (HRSA); areas (UIC 3–7); 3) nonmetropolitan - micropolitan (i.e. 2) median household income and total adult population not adjacent to metropolitan counties but with town/ over age 18 from the American Community Survey (ACS) urban cluster of 10,000–50,000 people, UIC 8); and 4) fielded by the US Census Bureau; 3) rurality based on nonmetropolitan - remote (i.e. the remainder, UIC 9–12). Urban Influence Codes (UIC) created by the Economic For simplicity, we refer to these groups as metropolitan, Research Service of the US Department of Agriculture; rural – adjacent, rural-micropolitan, and rural-remote [8]. and 4) health status measures from the Robert Wood We used median household income as a county-level Johnson County Health Rankings [6–8]. We compiled proxy for socioeconomic status. Median household income data for 3107 counties in the contiguous US. VHA-users values were single-year, model-based estimates from and counties in Alaska and Hawaii were excluded because the 2009–2013 Small Area Income and Poverty Estimates Ohl et al. BMC Health Services Research (2018) 18:315 Page 3 of 7 (SAIPE) provided by the US Census Bureau [10]. Based completed using SAS software v9.2 (Cary, NC). All ana- on inspection of county-level distributions of median lyses were approved by the Institutional Review Board at yearly household income, we categorized counties as median the University of Iowa. household income < $30,000 (i.e. roughly bottom decile of counties), $30–$40,000; $40,000–$50,000; $50,000–$60,000; Results and > $60,000 (i.e. top decile of counties). Overall, 416,338 (7.6%) of 5,511,483 VHA-users were eli- County-level health status measures were drawn from gible for non-VHA care under the Choice Act, based on the County Health Rankings & Roadmaps program, a residence more than 40-miles from the nearest VHA collaboration between the Robert Wood Johnson Founda- care site (Table 1). VHA-users who were eligible for pur- tion and the University of Wisconsin Population Health chased care based on distance were much more likely Institute [7]. As a proxy for population health status, we than the overall US population to live in counties that used age-adjusted years of potential life lost (YPLL) per were any category of rural (87.9% vs. 17.1%), rural- 100,000 people, aggregated over three years (2010–2012). remote (20.5% vs. 2.2%), median household income < The reference age was 75. For example, a person who dies $40,000 per year (40.4% vs. 10.7%), very poor population at age 45 would contribute 75–45 = 30 YPLL. The county- health status (28.4% vs. 10.3%), primary care shortage level YPLL is a sum of individual YPLL over all premature areas (15.8% vs. 4.2%), and mental health care shortage deaths in a county. Rates per 100,000 people were given areas (70.2% vs. 22.0%). VHA-users eligible for purchased after adjusting for differences in the age distribution care based on distance were much less likely than the gen- over counties. YPLL values were missing for 134 counties, eral population to live in counties with median household which were excluded from analyses of health status. income over $60,000 per year (4.4% vs. 26.3%). All differ- County-level health status was categorized as Very ences were statistically significant with p <0.01. Poor, Poor, Good, and Very Good according to quartiles In general, there was limited availability of non-VHA of YPLL. health care specialists in areas where Veterans were eligible for non-VHA care based on distance to the nearest VHA Analysis care site. The majority of VHA-users eligible for purchased We began by examining the distributions of the overall care based on the 40 mile criterion lived in counties US adult and VHA-user populations according to charac- with no psychiatrists, cardiologists, pulmonologists, neu- teristics of counties of residence, including non-VHA pro- rologists, PM&R specialists, or community mental health vider availability, rurality, household income, and health centers (Table 1). Nearly half (47%) lived in counties with status. We further stratified the VHA-user population ac- no community health center. cording to eligibility for purchased care under the Choice When limiting analyses to the ~ 1.1 million VHA- Act based on driving distance to the nearest VHA care site users residing in rural counties, we found that 324,162 (i.e. < 40 miles or > 40 miles). We repeated analyses (27.8%) were eligible for purchased care from non-VHA for the subset of all VHA-users living in rural counties. providers based on distance to VHA care sites (Table 2). We used Chi-square tests to compare distributions across In general, availability of non-VHA providers was even county categories. more limited for rural Veterans eligible for purchased Because non-VHA providers will be more impacted by care under the Choice Act, compared to the entire popu- reforms to purchase care for Veterans in areas where lation of Veterans eligible for purchased care. Availability VHA has recently delivered care for larger portions of the of non-VHA mental health providers was especially lim- overall population, we also calculated the density of VHA- ited for these rural Veterans. For example, 75.4% of rural users in the total adult population (i.e. VHA-users / 1000 Veterans eligible for purchased care under the Choice Act adults), according to county rurality and distance to the lived in counties that were mental health care shortage nearest VHA care site. Counties were categorized ac- areas, and 73.3% in counties without psychiatrists. cording to their distance to the nearest VHA care site To estimate the potential impact of Choice Act re- by estimating the driving distance from the population- forms on non-VHA providers in rural communities and weighted centroid for each county to the nearest VHA areas far from VHA facilities, we next examined the care site. Population-weighted centroid coordinates were density of VHA-users in the overall adult population, ac- determined based on 2013 Census data, using the cording to county rurality and distance from VHA care MABLE/Geocorr tool from the Missouri Census Data facilities. Somewhat counterintuitively, we found that Center [11]. Coordinates of VHA facilities were collected VHA played a greater role in delivering care for the from the Department of Veterans Affairs National Center overall adult population in counties that were more rural for Veterans Analysis & Statistics, furnished by ESRI and farther from VHA care sites (Fig. 1). The proportion (http://www.va.gov/vetdata/maps.asp). Driving distances of US adults using VHA care was overall 37% greater in were estimated using ArcOnline [12]. Other analyses were counties that were more than 40 miles from VHA care Ohl et al. BMC Health Services Research (2018) 18:315 Page 4 of 7 Table 1 Percentages of overall US adult population and VHA users, by eligibility for purchased care based on distance to VHA facilities, and characteristics of county of residence County Characteristic % US Adult Population % VHA users Overall < 40 Miles > 40 Miles N = 5,511,483 N = 5,095,145 N = 416,338 Rurality Rural - Remote 2.2 3.5 2.1 20.5 Rural - Micropolitan 2.8 3.9 3.2 12.2 Rural - Metro Adjacent 10.0 13.8 11.2 45.1 Metropolitan 85.0 78.8 83.5 22.1 Median Household Income $0–29,999 0.4 0.6 0.3 3.6 $30,000–39,999 10.2 14.0 12.1 36.9 $40,000–49,999 31.6 38.9 38.9 39.4 $50,000–59,999 31.5 28.6 29.6 15.9 $ > 60,000 26.3 17.9 19.1 4.2 Health Status Very Poor 8.4 11.5 10.2 28.4 Poor 15.9 21.4 21.0 26.1 Good 29.0 31.7 32.3 24.5 Very Good 46.6 35.4 36.5 21.0 Health Professional Availability Primary Care Shortage Area 4.0 5.0 4.2 15.8 Mental Health Care Shortage Area 20.2 25.2 21.6 70.2 County without: Psychiatrist 10.2 13.6 10.1 56.3 Cardiologist 12.2 16.7 12.7 65.7 Pulmonologist 15.7 21.2 16.7 76.5 Neurologist 14.6 19.4 15.2 71.1 PM&R Specialist 18.1 24.6 20.1 78.8 Community Health Center 15.1 18.2 15.8 47.0 Community Mental Health Center 57.0 62.3 59.8 93.0 Age-adjusted years of potential life lost per 100,000 persons PM&R: Physical Medicine and Rehabilitation sites, compared to counties within 20 miles of the near- purchasing care from non-VHA providers may have est VHA care facility (30.7 VHA-users / 1000 adults in limited impact, because there are relatively few non- counties over 40 miles from VHA care vs. 22.4 / 1000 in VHA providers in these areas to provide this care. counties within 20 miles of VHA care, P < 0.01). The This finding has implications for VHA efforts to improve density of VHA-users increased from 21.7 VHA-users access to care for rural Veterans. In addition to reforms to per 1000 adults in metropolitan counties to 36.1 VHA- purchase non-VHA care, VHA should continue to develop users per 1000 adults in rural remote counties (p < 0.01). other strategies for improving access to care for Veterans in areas far from VHA care sites. Examples include pro- Discussion grams for in-home telehealth visits and subsidized trans- We found that the majority of VHA-users who were eli- portation, both of which currently exist but could be gible for Choice Act purchased care based on distance to expanded [4, 13]. VHA should particularly work to develop VHA facilities lived in rural counties. These counties were programs to improve access to VHA mental health and underserved by non-VHA providers, and in particular by medical specialty care in rural areas, because there are providers of mental health and medical specialty care. few non-VHA providers in these areas to deliver this Efforts to improve access to care for these Veterans by care through purchasing agreements. More generally, Ohl et al. BMC Health Services Research (2018) 18:315 Page 5 of 7 Table 2 Percentages of rural VHA-users, by eligibility for purchased care based on distance to VHA care sites, and characteristics of county of residence County Characteristic % Rural VHA users Overall < 40 Miles > 40 miles N = 1,165,646 N = 841,484 N = 324,162 Rurality Rural - Remote 16.4 12.5 26.4 Rural - Micropolitan 18.6 19.7 15.6 Rural - Metro Adjacent 65.0 67.8 58.0 Median household income $0–29,999 2.6 1.9 4.3 $30,000–39,999 37.8 36.0 42.7 $40,000–49,999 45.0 47.7 38.1 $50,000–59,999 12.8 12.8 12.7 > $60,000 1.8 1.6 2.2 Health Status Very poor 29.0 27.7 32.4 Poor 27.4 28.0 25.9 Good 25.9 27.2 22.4 Very good 17.7 17.1 19.3 Health Professional Availability Primary Care Shortage Area 12.5 11.2 15.9 Mental Health Care Shortage Area 65.5 61.7 75.4 County without: Psychiatrist 47.4 41.4 63.0 Cardiologist 56.5 50 73.3 Pulmonologist 69.8 63.5 85.9 Neurologist 63.6 57.4 79.7 PM&R Specialist 73.9 68.7 87.3 Community Health Center 46.5 44.3 52.2 Community Mental Health Center 92.2 91.4 94.0 VHA should support broader policy efforts to increase assume care for relatively large numbers of Veterans the overall supply of health care providers in rural areas, currently using VHA care. This is true both because as Veterans disproportionately live in these medically- VHA has recently cared for a larger proportion of the underserved areas. population in these areas compared to counties closer Somewhat counterintuitively, we also found that the to VHA facilities, and because Veterans in these areas relative role of VHA as a health care provider in the arenow generally eligiblefor purchasedcareunder the overall community – as measured by the proportion of Choice Act. However, we found that there are few non- adults using VHA care – was greater in counties that VHA providers in these areas to take on care for Veterans. were rural and farther from VHA care sites. This was Taken together, these findings indicate that VHA reforms likely due to two factors. First, areas far from VHA facil- to purchase care may stress already overburdened rural ities are generally rural, and residents of rural areas are providers. more likely to join the all-volunteer military and to be The majority of VHA-users eligible for purchased care Veterans [14]. Second, although Veterans in these areas based on distance lived in counties that were not only must travel to obtain care in VHA care sites, there are rural and underserved by non-VHA providers, but also few local, non-VHA options for care. Healthcare providers lower income and lower health status. Reforms that in the predominantly rural areas that are more than move VHA towards purchasing care should include ef- 40 miles from VHA care sites will likely be asked to forts to strengthen existing safety net providers in these Ohl et al. BMC Health Services Research (2018) 18:315 Page 6 of 7 Fig. 1 Density of VHA-Users in the total adult population over age 18 (VHA-users / 1,000 adults), by county distance to VHA facilities and rurality low income and low health status areas, so that they are evaluate the impact of purchased care on overall health- better able to care for Veterans currently using VHA care use and outcomes for rural Veterans. care. Others have previously noted the role of VHA as a safety net provider in our national health care system, Conclusions and this must be kept in mind during reforms that move The majority of VHA-users eligible for purchased care VHA away from delivering care and towards purchasing based on distance to VHA facilities lived in counties that of care [15]. were rural, underserved by non-VHA providers, lower Our analyses have limitations. First, there is potential income, and lower health status. It may often be difficult for ecological fallacy in county-level analyses. Associations for VHA to purchase care for Veterans living more than apparent at the county-level may not hold at the individ- 40 miles from VHA facilities, because these areas are ual level. This is an inherent challenge in using county- already underserved by non-VHA providers. VHA should level data, which was necessary to combine the mostly continue to develop telehealth programs to deliver care to county-level data sources used in our analyses. For the Veterans in rural areas underserved by both community same reason, we used a county-based measure of rurality and VHA providers. Such programs are a necessary using urban influence codes. A rurality measure using a complement to initiatives to purchase in-person care from smaller area unit may provide somewhat different results. community providers. In addition, we examined availability of non-VHA pro- Abbreviations viders at the county-level, and in some cases providers ACS: American Community Survey; AHRF: Area Health Resource File; may have existed in relatively nearby communities in CBOC: Community Based Outpatient Clinic; HRSA: Health Resources & Services Administration; PCP: Primary Care Provider; PM&R: Physical Medicine neighboring counties. The administrative data on VA & Rehabilitation; UIC: Urban Influence Code; US: United States; VHA: Veterans enrollees were from 2013, which were the most recent Health Administration; YPLL: Years of Potential Life Lost data available at time analyses were initiated. The geo- Acknowledgements graphic distribution of Veterans is subject to change The views expressed in this article are those of the authors and do not over time. necessarily represent the views of the Department of Veterans Affairs or the Future studies of initiatives to improve access for rural United States government. Veterans by purchasing care from community providers Ethics and consent to participate should evaluate the balance between community provider The analyses were approved by the Institutional Review Board at the University availability and care needs of Veterans in smaller, defined of Iowa (IRB # 200502805). A waiver of informed consent was granted for this rural regions in the US. In addition, these studies should retrospective study using a large administrative database. Ohl et al. BMC Health Services Research (2018) 18:315 Page 7 of 7 Funding 13. Shore P, Goranson A, Ward MF, Lu MW. Meeting veterans where they're @: Dr. Ohl is recipient of a Career Development Award through VA’s Health a VA home-based Telemental health (HBTMH) pilot program. Int J Psychiatry Services Research and Development (HSR&D) program (CDA #11–211). Med. 2014;48(1):5–17. 14. Lutz A. Who joins the military?: a look at race, class, and immigration status. Journal of Political and Military Sociology. 2008;36(2):167–88. Availability of data and materials 15. Wilson NJ, Kizer KW. The VA health care system: an unrecognized national All publically available data used in this study are available from the authors safety net. Health Aff (Millwood). 1997;16(4):200–4. on request (i.e. data from AHRF, ACS, County Urban Influence Codes, and Robert Wood Johnson County Health Rankings & Roadmaps data). Aggregate data on number of VA users for US counties are available from authors on request. Authors’ contributions MO, MC, AT, and MVS contributed to obtaining data, study design, data analysis, interpretation of results, and manuscript drafting. MM contributed to study design, data analysis, interpretation of results, and manuscript drafting. MVW and TH contributed to study design, interpretation of results, and manuscript drafting. All authors have read and approved the final version of the manuscript and are accountable for accuracy and integrity of this work. Competing interests No authors report conflicts of interest. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details VA Office of Rural Health (ORH), Veterans Rural Health Resource Center- Iowa City, Iowa City VA Medical Center, Iowa City, IA, USA. Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. Department of Geographical and Sustainability Sciences, University of Iowa, Iowa City, IA, USA. Center for Mental Healthcare and Outcomes Research, Central Arkansas VA, Little Rock, AR, USA. Received: 5 May 2016 Accepted: 11 April 2018 References 1. Veterans Health Administration. National Center for Veterans Analysis and Statistics, Utilization Data [http://www.va.gov/vetdata/utilization.asp]. Accessed 16 Jan 2016. 2. Veterans Health Administration. About Rural Veterans [http://www. ruralhealth.va.gov/about/rural-veterans.asp] Accessed 26 Apr 2016. 3. Health Resrouces & Services Administration. Defining Rural Populations. [http://www.hrsa.gov/ruralhealth/aboutus/definition.html] Accessed 16 Jan 2016. 4. Kehle SM, Greer N, Rutks I, Wilt T. Interventions to improve veterans' access to care: a systematic review of the literature. J Gen Intern Med. 2011;26(Suppl 2):689–96. 5. Department of Veterans Affairs. Expanded access to non-VA care through the veterans choice program. Final rule. Fed Regist. 2015;80(209):66419–29. 6. Best AE. Secondary data bases and their use in outcomes research: a review of the area resource file and the healthcare cost and utilization project. J Med Syst. 1999;23(3):175–81. 7. Robert Wood Johnson Foundataion. County Health Rankings Data [http:// www.countyhealthrankings.org/rankings/data]. Accessed 16 Jan 2016. 8. United States Department of Agriculture. Measuring Rurality: Urban Infuence Codes [http://www.ers.usda.gov/data-products/urban-influence- codes.aspx] Accessed 16 Jan 2016. 9. Health Resrouces & Services Administration. Shortage Designations: Health Professional Shortage Areas and Medically Underserved Areas/Populations [http://www.hrsa.gov/shortage/] Accessed 16 January 2016. 10. United States Census Bureau. Small Area Income and Poverty Estiamtes [http://www.census.gov/did/www/saipe/] Accessed 16 Jan 2016. 11. Missouri Census Data Center. MABLE/Geocorr12: Geographic Correspondence Engine [http://mcdc.missouri.edu/websas/geocorr12.html] Accessed 16 Jan 2016. 12. Esri. ArcGIS Online [http://www.esri.com/software/arcgis/arcgisonline].

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BMC Health Services ResearchSpringer Journals

Published: May 29, 2018

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