Status and Future of Health Care Delivery in Rural Wyoming

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´╗┐RUPRI Center for Rural Health Policy Analysis

Status and Future of Health Care Delivery in Rural Wyoming

June 2007

The mission of the RUPRI Center is to provide timely analysis to federal and state health policy makers, based on the best available research. The research of the RUPRI Center focuses on rural health care financing/system reform, rural systems building, and meeting the health care needs of special rural populations. Specific objectives include conducting original research and independent policy analysis that provides policy makers and others with a more complete understanding of the implications of health policy initiatives, and disseminating policy analysis that assures policy makers will consider the needs of rural health care delivery systems in the design and implementation of health policy.

The RUPRI Center is based at the University of Nebraska Medical Center, in the College of Public Health. For more information about the Center and its publications, please contact:

RUPRI Center for Rural Health Policy Analysis University of Nebraska Medical Center 984350 Nebraska Medical Center Omaha, NE 68198-4350 Phone: (402) 559-5260 Fax: (402) 559-7259 unmc.edu/ruprihealth

Table of Contents

Executive Summary ..................................................................................................................................1 Key Findings.........................................................................................................................................1 Recommendations.................................................................................................................................2

Introduction: Conceptual Framework .......................................................................................................7 Chapter 1. Wyoming Population and the Health Care Delivery System................................................11

Key Findings.......................................................................................................................................11 Analyzing the Characteristics of Wyoming's Population...................................................................11 Methods...............................................................................................................................................11 Findings...............................................................................................................................................12 Summary .............................................................................................................................................29 Health Care Delivery System in Wyoming ........................................................................................30 Summary .............................................................................................................................................57 Special Analysis: Physician Origin and Medical Education...............................................................58 Special Analysis: Hospitalizations for Ambulatory Care Sensitive Conditions in Wyoming............59 Special Analysis: Vulnerable Communities In Wyoming ..................................................................63 Chapter 2. Workforce Recruitment and Retention .................................................................................71 Key Findings.......................................................................................................................................71 Methods...............................................................................................................................................71 Needs, Programs, and Next Steps .......................................................................................................71 Summary .............................................................................................................................................76 Chapter 3. Delivery System Redesign ....................................................................................................77 Key Findings.......................................................................................................................................77 Methods...............................................................................................................................................77 Findings...............................................................................................................................................78 Summary .............................................................................................................................................84 Chapter 4. Community Case Studies ......................................................................................................85 Key Findings.......................................................................................................................................85 Methods...............................................................................................................................................85 Findings...............................................................................................................................................86 Summary .............................................................................................................................................94 Chapter 5. Economic Impact of the Health Care System .......................................................................95 Key Findings.......................................................................................................................................95 Methods...............................................................................................................................................95 Findings...............................................................................................................................................97 Summary ...........................................................................................................................................106 Chapter 6. Hospital Inpatient Out-migration ........................................................................................107 Key Findings.....................................................................................................................................107 Methods.............................................................................................................................................108 Findings.............................................................................................................................................110 Summary ...........................................................................................................................................146 Chapter 7. Other Systems as Models for Change .................................................................................151 Key Findings.....................................................................................................................................151 Methods.............................................................................................................................................151 Overall Health Care Systems Comparison .......................................................................................152

Initiatives to Improve Health Care Delivery.....................................................................................158 Summary ...........................................................................................................................................164 Chapter 8. Recommendations ...............................................................................................................167 Recommendation to Meet the Need for Health Professionals ..........................................................167 Recommendations to Improve Health Care in Communities ...........................................................168 Recommendations to Monitor and Analyze Trends In Health Care Delivery..................................171 Recommendations to Achieve Systemic Change in Health Care Delivery and Finance..................174 Recommendations for Specific Actions............................................................................................176

List of Figures and Tables

Figure 1.1. Wyoming Population Per Block Group, 2005......................................................................13 Figure 1.2. Population Census and Projections by Selected Counties, Wyoming 1980 to 2020............14 Figure 1.3 Working Age (15-54 years) Population Census and Projections by Selected Counties, Wyoming 1980 to 2020 ..........................................................................................................................16 Figure 1.4. Percent of Wyoming Population Aged 19 Years and Under Per County, 2005...................18 Figure 1.5. Percent of Wyoming Population Aged 65 Years and Older Per County, 2005 ...................19 Figure 1.6. Elderly (aged 65 years and over) and Youth (aged 19 years and under) Population Census and Projections by Selected Counties, Wyoming 1980 to 2020 ................................................20 Figure 1.7. Education Attainment, Residents Aged 25 Years and Older, Population Census by Select Counties, Wyoming 1980 to 2000 ...............................................................................................21 Figure 1.8. Wyoming Percent of Total Racial Minority* Population, any Ethnicity Per County, 2000.........................................................................................................................................................24 Figure 1.9. Wyoming Percent of Total Population of Hispanic Ethnicity, any Race Per County, 2000.........................................................................................................................................................25 Figure 1.10. Racial Minority and Hispanic Ethnicity (any race) Population Census, Teton County 1980 to 2009 ...........................................................................................................................................26 Figure 1.11. Residents below the Federal Poverty Level, Population Census by County, Wyoming 1980 to 2000 ..........................................................................................................................27 Figure 1.12. Unemployment, Civilian Labor Force, Population Census by County, Wyoming 1980 to 2000 ...........................................................................................................................................29 Figure 1.13. Location of Wyoming Hospitals and Service Areas ..........................................................32 Figure 1.14. Wyoming Hospitals' Referral Region ................................................................................33 Figure 1.15. Location of Wyoming Health Clinics.................................................................................34 Figure 1.16. Location of Wyoming Skilled Nursing Facilities...............................................................35 Figure 1.17. Federally Designated Primary Care Shortage Areas ..........................................................37 Figure 1.18. Federally Designated Dental Shortage Areas.....................................................................38 Figure 1.19. Distribution of Wyoming Physicians .................................................................................40 Figure 1.20. Distribution of Wyoming Primary Care Physicians...........................................................41 Figure 1.21. Distribution of Wyoming Emergency Medical Physicians ................................................42 Figure 1.22. Distribution of Wyoming Obstetricians-Gynecologists .....................................................43 Figure 1.23. Wyoming Obstetricians-Gynecologists per 100,000 Females Age 12-49 years................44 Figure 1.24. Distribution of Wyoming Dentists .....................................................................................45 Figure 1.25. Distribution of Wyoming Psychiatrists ..............................................................................46 Figure 1.26. Distribution of Wyoming Registered Pharmacists .............................................................47 Figure 1.27. Distribution of Wyoming Physician Assistants..................................................................48 Figure 1.28. Distribution of Wyoming Advanced Nurse Practitioners ..................................................49 Figure 1.29. Distribution of Wyoming Trauma Centers.........................................................................51 Figure 1.30. Distribution of Wyoming Authorized Ambulance Agencies .............................................53 Figure 1.31. Location and Status of Prehospital Emergency Medical Services Personnel ....................55 Table 1.1. Travel Distance Between Selected Cities in Wyoming and Surrounding States...................56 Table 1.2. Patient Characteristics Associated with ACSC Hospitalizations for Wyoming Residents, 2003 .......................................................................................................................................60 Figure 1.32. Proportion of ACSC Hospital Discharges by County, Children Aged 1?17 Years ...........61 Figure 1.33. Proportion of ACSC Hospital Discharges by County, Adults Aged 18?64 Years ............61

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