1. Geography and the U.S. Federal Office of Rural Health Policy Rural Health Research Centers 10th Biennial MAGIC Symposium April 23-27, 2006 Westin Crown Center Kansas City, Missouri Michael Shambaugh-Miller, Ph.D. The Rural Policy Research Institute Center for Rural Health Policy Analysis University of Nebraska Medical Center Nebraska Center for Rural Health Research

2. Rural Health Research Centers The Rural Health Research Center (RHRC) Program is designed to help policy makers, both in Washington and throughout the Nation, better understand the problems that rural communities face in assuring access to health care for their residents. The Rural Health Research Center (RHRC) Program is designed to help policy makers, both in Washington and throughout the Nation, better understand the problems that rural communities face in assuring access to health care for their residents.

3. Rural Health Research Centers The Centers study critical issues facing rural communities in their quest to secure adequate, affordable, high quality health services for their residents. The Centers study critical issues facing rural communities in their quest to secure adequate, affordable, high quality health services for their residents. The Centers' research findings inform a wide audience of National, State, and local decision-makers concerned with rural health. The Centers' research findings inform a wide audience of National, State, and local decision-makers concerned with rural health.

4. Rural Health Research Centers Each year, specific research topics for the Centers are selected jointly by the Research Center Directors and the policy staff of the Office. Each year, specific research topics for the Centers are selected jointly by the Research Center Directors and the policy staff of the Office.

5. Rural Health Research Centers Eight Centers have cooperative agreements with the Office for FY2005- 2008 Eight Centers have cooperative agreements with the Office for FY2005- 2008 five General Centersfive General Centers three Analytic Centersthree Analytic Centers

6. South Carolina Rural Health Research Center, University of South Carolina, Columbia, S.C. Topic of concentration: Health disparities Maine Rural Health Research Center, University of Southern Maine, Portland, MA. Topic of concentration: Rural behavioral health Upper Midwest Rural Health Research Center, University of Minnesota, Minneapolis, MN. Topic of concentration: Quality of care in rural areas Rural Health Research General Centers

7. Western Interstate Commission for Higher Education (WICHE) Center for Rural Mental Health Research, Boulder, Co. Topic of concentration: Mental health Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Rural Health Research Center, University of Washington, Seattle, WA. Topic of concentration: national rural health workforce research Rural Health Research General Centers

8. National Opinion Research Center (NORC) Walsh Center for Rural Health Analysis, Bethesda, MD. Topic of concentration: Impact of Medicare Policies on Rural Communities Current and past research includes:Current and past research includes: Analysis of the impact of disproportionate share (DSH) payment structure options on rural hospitals Analysis of the impact of disproportionate share (DSH) payment structure options on rural hospitals Assessment of public health infrastructure in rural areas. Assessment of public health infrastructure in rural areas. Rural Health Research Analytic Centers

9. North Carolina Rural Health Research and Policy Analysis Center, University of North Carolina, Chapel Hill, N.C. Topic of Concentration: Federal Insurance Programs (Medicare and Medicaid) and Their Effect on Rural Populations and Providers Past and current research includes: Describing Geographic Access to Physicians in Rural America Using Statistical Applications in GIS Development of a New Methodology for Dental Health Professional Shortage Area Designation Impact of The Medicaid Budgetary Crisis on Rural Communities: A 50-State Survey Rural Health Research Analytic Centers

10. Examples of Quick Response and Long Range Research Rural impact of the Medicare Modernization Act of 2003. Rural impact of the Medicare Modernization Act of 2003. Development of the Rural - Urban Commuting Area classification schema. Development of the Rural - Urban Commuting Area classification schema.

11. Medicare Modernization Act of 2003: What Did The Government Want? Original legislation did not define urban, suburban or rural. Original legislation did not define urban, suburban or rural. The definition used would establish the number of beneficiaries falling under each level of the access standards for each service region. The definition used would establish the number of beneficiaries falling under each level of the access standards for each service region.

12. Medicare Modernization Act of 2003: What Did The Government Want? Thus, the definition of rural in the final rule adopted by the Centers for Medicare and Medicaid Services (CMS) will determine the application of the access standards to rural beneficiaries. Thus, the definition of rural in the final rule adopted by the Centers for Medicare and Medicaid Services (CMS) will determine the application of the access standards to rural beneficiaries.

13. Medicare Modernization Act of 2003: What Did The Government Want? The proposed rule defined rural as any ZIP code with fewer than 1,000 persons per square mile. The proposed rule defined rural as any ZIP code with fewer than 1,000 persons per square mile.

15. Other Rural Definition Options Office of Management and Budget Office of Management and Budget Bureau of the CensusBureau of the Census Rural is everything that isn’t MetropolitanRural is everything that isn’t Metropolitan Rural – Urban Commuting Areas Rural – Urban Commuting Areas U.S. Department of Agriculture in cooperation with ORHP / HRSA.U.S. Department of Agriculture in cooperation with ORHP / HRSA. A scale based upon overall population, largest community size, and commuting patterns.A scale based upon overall population, largest community size, and commuting patterns.

18. Medicare Modernization Act of 2003: What Did The Government Want? Under the access standards in the MMA, 30% of rural Medicare beneficiaries do not have to be included within 15 miles of a retail pharmacy. Under the access standards in the MMA, 30% of rural Medicare beneficiaries do not have to be included within 15 miles of a retail pharmacy. Though counterintuitive, the more generous the definition of rural, the more beneficiaries are excluded from the 15- mile access standard. Though counterintuitive, the more generous the definition of rural, the more beneficiaries are excluded from the 15- mile access standard.

23. Medicare Modernization Act of 2003: What Did The Government Get? The final rule maintained the Tri- Care definition of rural but through discussion with the research community agreed to implement it at the state not regional level as originally planned. The final rule maintained the Tri- Care definition of rural but through discussion with the research community agreed to implement it at the state not regional level as originally planned.

24. North Carolina Rural Health Research and Policy Analysis Center, University of North Carolina, Chapel Hill, N.C. http://www.shepscenter.unc.edu/ research_programs/rural_program/ mapbook2003/index.html Rural Health Research Analytic Centers

25. North Carolina Rural Health Research and Policy Analysis Center, University of North Carolina, Chapel Hill, N.C. http://www.shepscenter.unc.edu/ research_programs/rural_program/ maps/maps.html Rural Health Research Analytic Centers Map Categories Defining "Rural" Demographics of Rural America Health Status Indicators Rural Hospitals and Skilled Nursing Facilities Critical Access Hospitals Health Workforce Supply Services and Programs North Carolina Maps

26. Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, University of Nebraska Medical Center, Omaha, NE. Topic of concentration: Medicare: Impact of payment and quality policy on the delivery of health care in rural areas Past and current research includes:Past and current research includes: Creating a GIS of All Rural U.S. Pharmacies Creating a GIS of All Rural U.S. Pharmacies Definition of Rural in the Context of MMA Access Standards for Prescription Drug Plans. Definition of Rural in the Context of MMA Access Standards for Prescription Drug Plans. Health Services at Risk in "Vulnerable" Rural Places Health Services at Risk in "Vulnerable" Rural Places A Rural Perspective Regarding Regulations Implementing Titles I and II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). A Rural Perspective Regarding Regulations Implementing Titles I and II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). An Analysis of Availability of Medicare+Choice, Commercial HMO, and FEHBP Plans in Rural Areas: Implications for Medicare Reform An Analysis of Availability of Medicare+Choice, Commercial HMO, and FEHBP Plans in Rural Areas: Implications for Medicare Reform Rural Health Research Analytic Centers

27. About CIRC: The Community Information Resources Center (CIRC) uses spatial information to help visualize “place-based” issues impacting communities across the United States. In addition to serving as a RUPRI core resource for panels and stakeholders, CIRC also coordinates with other national initiatives to help bring a spatial dimension to rural issues. Rural Policy Research Institute (RUPRI) Community Informatics Resources Center, a sister center to the RUPRI Center for Rural Health Policy Analysis, University of Nebraska Medical Center, Omaha, NE.

33. Rural - Urban Commuting Areas This collaborative project between Health Resources and Service Administration's (HRSA's) Federal Office of Rural Health Policy (FORHP), the Department of Agriculture's Economic Research Service (ERS), and the WWAMI Rural Health Research Center was funded by the ERS and FORHP. (Principal Developers: Richard Morrill, PhD; John Cromartie, PhD; and Gary Hart, PhD) SHORT DEFINITION RUCAs include county, Census tract or ZIP code classification schemes that utilizes the standard Bureau of Census urban area and place definitions in combination with commuting information to characterize all of the above spatial entities regarding their rural and urban status and relationships. Latest RUCA Version 2.0 (July 2005), based on 2004 ZIP codes (there are 41,928 cases) and 2000 Census commuting data. Further ZIP Code methodology information: http://www.fammed.washington.edu/wwamirhrc/ Further Census tract methodology information: http://www.ers.usda.gov/briefing/rural/ruca/rucc.htmttp://www.ers.usda.gov/briefing/rural/ruca/rucc.htm Further county level methodology information: http://www.ers.usda.gov/Data/RuralUrbanCommutingAreaCodes/

35. Rural - Urban Commuting Areas Version 2.0 Rural-Urban Commuting Areas (RUCAs) Version 2.0 Rural-Urban Commuting Areas (RUCAs) 1 Metropolitan area core: primary flow within an urbanized area (UA) 1.0 No additional code 1.1 Secondary flow 30% to 50% to a larger UA 1 Metropolitan area core: primary flow within an urbanized area (UA) 1.0 No additional code 1.1 Secondary flow 30% to 50% to a larger UA 2 Metropolitan area high commuting: primary flow 30% or more to a UA 2.0 No additional code 2.1 Secondary flow 30% to 50% to a larger UA 2 Metropolitan area high commuting: primary flow 30% or more to a UA 2.0 No additional code 2.1 Secondary flow 30% to 50% to a larger UA 3 Metropolitan area low commuting: primary flow 10% to 30% to a UA 3.0 No additional code 3 Metropolitan area low commuting: primary flow 10% to 30% to a UA 3.0 No additional code UA=Urbanized Area UC=Urban Cluster UA=Urbanized Area UC=Urban Cluster

36. Rural - Urban Commuting Areas 4 Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 (large UC) 4.0 No additional code 4.1 Secondary flow 30% to 50% to a UA 4.2 Secondary flow 10% to 30% to a UA 4 Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 (large UC) 4.0 No additional code 4.1 Secondary flow 30% to 50% to a UA 4.2 Secondary flow 10% to 30% to a UA 5 Micropolitan high commuting: primary flow 30% or more to a large UC 5.0 No additional code 5.1 Secondary flow 30% to 50% to a UA 5.2 Secondary flow 10% to 30% to a UA 5 Micropolitan high commuting: primary flow 30% or more to a large UC 5.0 No additional code 5.1 Secondary flow 30% to 50% to a UA 5.2 Secondary flow 10% to 30% to a UA 6 Micropolitan low commuting: primary flow 10% to 30% to a large UC 6.0 No additional code 6.1 Secondary flow 10% to 30% to a UA 6 Micropolitan low commuting: primary flow 10% to 30% to a large UC 6.0 No additional code 6.1 Secondary flow 10% to 30% to a UA 7 Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small UC) 7.0 No additional code 7.1 Secondary flow 30% to 50% to a UA 7.2 Secondary flow 30% to 50% to a large UC 7.3 Secondary flow 10% to 30% to a UA 7.4 Secondary flow 10% to 30% to a large UC 7 Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small UC) 7.0 No additional code 7.1 Secondary flow 30% to 50% to a UA 7.2 Secondary flow 30% to 50% to a large UC 7.3 Secondary flow 10% to 30% to a UA 7.4 Secondary flow 10% to 30% to a large UC UA=Urbanized Area UC=Urban Cluster UA=Urbanized Area UC=Urban Cluster

37. Rural - Urban Commuting Areas 8 Small town high commuting: primary flow 30% or more to a small UC 8.0 No additional code 8.1 Secondary flow 30% to 50% to a UA 8.2 Secondary flow 30% to 50% to a large UC 8.3 Secondary flow 10% to 30% to a UA 8.4 Secondary flow 10% to 30% to a large UC 8 Small town high commuting: primary flow 30% or more to a small UC 8.0 No additional code 8.1 Secondary flow 30% to 50% to a UA 8.2 Secondary flow 30% to 50% to a large UC 8.3 Secondary flow 10% to 30% to a UA 8.4 Secondary flow 10% to 30% to a large UC 9 Small town low commuting: primary flow 10% to 30% to a small UC 9.0 No additional code 9.1 Secondary flow 10% to 30% to a UA 9.2 Secondary flow 10% to 30% to a large UC 9 Small town low commuting: primary flow 10% to 30% to a small UC 9.0 No additional code 9.1 Secondary flow 10% to 30% to a UA 9.2 Secondary flow 10% to 30% to a large UC 10 Rural areas: primary flow to a tract outside a UA or UC 10.0 No additional code 10.1 Secondary flow 30% to 50% to a UA 10.2 Secondary flow 30% to 50% to a large U 10.3 Secondary flow 30% to 50% to a small UC 10.4 Secondary flow 10% to 30% to a UA 10.5 Secondary flow 10% to 30% to a large UC 10.6 Secondary flow 10% to 30% to a small UC 10 Rural areas: primary flow to a tract outside a UA or UC 10.0 No additional code 10.1 Secondary flow 30% to 50% to a UA 10.2 Secondary flow 30% to 50% to a large U 10.3 Secondary flow 30% to 50% to a small UC 10.4 Secondary flow 10% to 30% to a UA 10.5 Secondary flow 10% to 30% to a large UC 10.6 Secondary flow 10% to 30% to a small UC UA=Urbanized Area UC=Urban Cluster UA=Urbanized Area UC=Urban Cluster

38. Rural - Urban Commuting Areas The RUCA codes can be used in many different ways in various types of health related research and program development and implementation. The RUCA codes can be used in many different ways in various types of health related research and program development and implementation. There are 30 codes. The large number of codes facilitate the aggregation of the codes to fit specific needs of those using them for health, demographic, geographic, and other types of uses. There are 30 codes. The large number of codes facilitate the aggregation of the codes to fit specific needs of those using them for health, demographic, geographic, and other types of uses.

39. Rural - Urban Commuting Areas In almost all cases, the RUCA codes should be aggregated for use. In almost all cases, the RUCA codes should be aggregated for use. For instance, it may be appropriate to aggregate them into two groups: rural and urban.For instance, it may be appropriate to aggregate them into two groups: rural and urban. In other instances, it may be appropriate to create a specific group for the purposes of targeting a program (e.g., limiting a telehealth subsidy program to codes 7.0, 7.4, 8.0, 8.4, 9.0, 9.2, 10.0, 10.3, and 10.5 – the smaller and less functionally related to urban and large rural places).In other instances, it may be appropriate to create a specific group for the purposes of targeting a program (e.g., limiting a telehealth subsidy program to codes 7.0, 7.4, 8.0, 8.4, 9.0, 9.2, 10.0, 10.3, and 10.5 – the smaller and less functionally related to urban and large rural places).

40. Rural - Urban Commuting Areas The way in which they have been used most is to aggregate the codes into four categories. This is a generally useful aggregation that is useful for most health related work. The way in which they have been used most is to aggregate the codes into four categories. This is a generally useful aggregation that is useful for most health related work. Urban focused: 1.0, 1.1, 2.0, 2.1, 2.2, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1Urban focused: 1.0, 1.1, 2.0, 2.1, 2.2, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1 Large Rural City/Town focused: 4.0, 5.0, and 6.0Large Rural City/Town focused: 4.0, 5.0, and 6.0 Small Rural Town focused: 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.2Small Rural Town focused: 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.2 Isolated Small Rural Town focused: 10.0, 10.2, 10.3, 10.4, 10.5Isolated Small Rural Town focused: 10.0, 10.2, 10.3, 10.4, 10.5

41. Rural - Urban Commuting Areas The percentages of the estimated 1998 US population for these groupings are: The percentages of the estimated 1998 US population for these groupings are: Urban, 77.6%Urban, 77.6% Large rural, 9.3%Large rural, 9.3% Small rural, 6.9%Small rural, 6.9% Isolated, 6.1%.Isolated, 6.1%. The advantage of this definition is that it splits urban and rural in approximately the same way as does the OMB Metro definition but at the sub county level and it divides rural into three relevant and useful categories. In many studies and programs, it makes sense to separate the large rural cities/towns (say a place of 30,000 population with many medical providers) from those places that have 1000 population and are isolated from urban places. It is clear that under most circumstances these two types of places differ greatly and should be considered separately.The advantage of this definition is that it splits urban and rural in approximately the same way as does the OMB Metro definition but at the sub county level and it divides rural into three relevant and useful categories. In many studies and programs, it makes sense to separate the large rural cities/towns (say a place of 30,000 population with many medical providers) from those places that have 1000 population and are isolated from urban places. It is clear that under most circumstances these two types of places differ greatly and should be considered separately.

42. Rural - Urban Commuting Areas Coming Updates It is likely that investigators will be provided with the means to divide the 4 coded places and their associated places (e.g., 5s) into those of varying population (e.g., less than 25,000 population). It is likely that investigators will be provided with the means to divide the 4 coded places and their associated places (e.g., 5s) into those of varying population (e.g., less than 25,000 population).

43. Rural - Urban Commuting Areas Coming Updates It is likely that a "remoteness" tool will be created that shows the road distance and travel time between non "1" and "2" coded places and all other coded places (e.g., road distance from small rural towns to the nearest edge of an urbanized area). Likewise, the shortest road distance to large rural cities (code 4) and all other places will also be provided. It is likely that a "remoteness" tool will be created that shows the road distance and travel time between non "1" and "2" coded places and all other coded places (e.g., road distance from small rural towns to the nearest edge of an urbanized area). Likewise, the shortest road distance to large rural cities (code 4) and all other places will also be provided. This will allow a user of the codes to subset the RUCA codes based on their remoteness as measured by road distance. The travel data are now available for version 1.11 of the RUCAsThis will allow a user of the codes to subset the RUCA codes based on their remoteness as measured by road distance. The travel data are now available for version 1.11 of the RUCAs see the "Travel Distances to Urbanized Areas and Larger Rural Towns“ see the "Travel Distances to Urbanized Areas and Larger Rural Towns“ http://www.fammed.washington.edu/wwamirhrc/rucas/modifier.htmlhttp://www.fammed.washington.edu/wwamirhrc/rucas/modifier.html

44. Rural - Urban Commuting Areas Coming Updates It is likely that a version of the RUCA codes will be available that allows the codes to be used in work that involves aspects of regionalization. It is likely that a version of the RUCA codes will be available that allows the codes to be used in work that involves aspects of regionalization. For example, identifiers would be available so that code 5 places could be linked to their large rural cities (code 4 places) and in the case of 5.1 codes be linked to their secondary commuting urbanized areas (code 1 places). For example, identifiers would be available so that code 5 places could be linked to their large rural cities (code 4 places) and in the case of 5.1 codes be linked to their secondary commuting urbanized areas (code 1 places).

45. Nebraska Center for Rural Health Research Funding Organizations Federal Office of Rural Health Policy – Health Resources and Services Administration Federal Office of Rural Health Policy – Health Resources and Services Administration www.ruralhealth.hrsa.gov/www.ruralhealth.hrsa.gov/www.ruralhealth.hrsa.gov/ Rural Policy Research Institute Rural Policy Research Institute www.rupri.org/healthpolicy/www.rupri.org/healthpolicy/ Nebraska Center for Rural Health Research. Nebraska Center for Rural Health Research. www.unmc.edu/ruralwww.unmc.edu/ruralwww.unmc.edu/rural University of Nebraska Medical Center University of Nebraska Medical Center www.unmc.eduwww.unmc.edu