The rural health care facility infrastructure described in this section includes the managed care system, primary care health facilities (e.g., community health centers, rural health clinics, school-based health centers, public health facilities and clinics), hospitals, mental health facilities, pharmacies, and telemedicine sites.
Managed Care System: Arizona has become one of the most aggressive and competitive health care marketplaces in the United States. Much of the development of managed care delivery systems can be traced back to Arizona’s successful efforts during the past two decades to implement the state’s Medicaid demonstration, Arizona Health Care Cost Containment System (AHCCCS). In 1982, Arizona incorporated the philosophies of managed care into a publicly funded health program, becoming the first state in the country to provide care to indigent, Medicaid eligible populations through primary care gatekeepers working under the auspices of organized networks of hospitals and physicians coordinating care to patients.
While managed care products were available in the state in the early 1980s, market penetration was limited. In the years 1994 to 1999, the percentage of Americans with employment-based coverage slowly increased. This was also the situation in Arizona. Most of the increases in private health insurance coverage during this time period could be explained by increased employment, rising wages and incomes, shifts to full-time employment, and increased education. In addition to the increase of employer-sponsored managed care (MC) plans, the expansion of commercial MC products that targeted seniors (Medicare HMOs), small employers, and rural residents contributed to the increase in managed care enrollments. As a result of these changes in the private health care marketplace, Arizona placed among the top states in terms of the number of persons who received health care coverage through managed care plans.
The dominance of commercial and public managed care plans (e.g., AHCCCS and KidsCare) in the Arizona health care market has resulted in the formation of numerous organized networks of physicians (e.g., Physician Group Practices and Individual Practice Associations) in the state. Most of these occur in the urban areas, but there are both formal and informal networks of physicians in rural areas. There are still a few rural physicians whose practices are not 100 percent contracted managed care plans.
In spite of changes in the health care marketplace, such as a reduction in the number of MC plans and products offered and the rise and fall of Medicare HMOs, Arizona remains one of the top managed care penetrated states in the country. Most of the managed care products are offered in the urban centers, where the majority of the state’s physician offices and group practices, medical facilities, and hospitals are located. Managed care plan options are very limited in the rural areas of the state; thus, it’s not unusual for rural physicians to contract with multiple MC plans.
Community Health Centers: One of the federal government’s major initiatives to increase access to health care is the expansion of Federally Qualified Community Health Centers (FQCHCs). The Arizona Association of Community Health Centers (AACHC) has developed a five-year plan to expand the number of FQCHCs in the state. Additional information about the plan can be found at the AACHC website: http://www.aachc.org/community.html. Community health centers (CHCs) provide care for low-income individuals in medically underserved areas. CHCs are public or private non-profit organizations that provide primary and preventive health care services. Unlike CHCs, FQCHCs receive federal grant funding under section 330 of the Public Health Service Act in which they are required to provide a sliding-fee-scale for their services and must provide care to everyone, regardless of their ability to pay. In addition, FQCHCs receive higher Medicaid and Medicare reimbursement levels for heath care provided. In 2002, there were several Arizona counties that did not have a FQCHC. These included Apache, Gila, Graham, Greenlee, La Paz, and Yavapai counties – each of which is a rural-rural county. Map 1 (below) shows the locations of the FQCHC main facilities and their satellites in 2003. Table 1 provides a listing of the FQCHC main facilities and community satellite locations in Arizona in 2002.
Map 1. Federally Qualified Community Health Center Locations in 2003
Rural Health Clinics: In 2002, there were only six Rural Health Clinics (RHCs) in Arizona. Five were located in Apache County and the sixth one was located in Gila County (see Table 2). These clinics were located in an area designated as a health professional shortage area (HPSA) or a medically underserved area (MUA). Unlike FQCHCs, RHCs are not eligible to receive federal grant funding under section 330 of the Public Health Service Act, but they are eligible for various federal grants such as the Rural Health Outreach Grant Program. RHCs are not required to provide services on a sliding-fee-scale, but are required to provide outpatient primary medical care services. They receive higher reimbursement levels from Medicaid and Medicare for health care services rendered. Additional information about RHCs can be found at the Arizona Rural Health Office Rural Health Clinic website.
School-Based Health Centers: During the 2000-01 school year, School-Based Health Centers (SBHCs) delivered over 27,000 medical visits to over 14,000 Arizona children.[1] These visits included comprehensive, low-cost services such as well childcare, immunizations, medical care for acute and chronic illness and injury, and dental services. In 2002, most of the School-Based Health Centers were located in the two urban counties (Maricopa – 76 and Pima – 7). There were five SBHCs in the two rural-urban counties (Cococino – 2 and Yuma – 3). Of the 11 rural-rural counties, 4 counties had at least one SBHC (9). Table 3 provides a listing of all the School-Based Health Centers and their primary sponsor agencies in 2002. The Arizona School-Based Health Care Council website (http://www.azschoolhealthcouncil.org) provides detailed information on the state’s School-Based Health Centers.
Public Health Facilities and Clinics: There is a county health department in each of Arizona’s 15 counties (see Table 4). County health departments and clinics provide a variety of health services to the public (e.g., immunizations, family planning, prenatal care, nutrition education, WIC, child well visits, and oral health) as part of the state’s medical safety net. In addition to the main public health facility, 11 of the county health departments had clinic extensions in 2002. The ADHS website (http://www.azdhs.gov/phs/local_health/health_depts.htm) provides a link to each of the 15 county health departments.
Hospitals: In 2002, there were 74 acute care hospitals in Arizona (see Table 5). These included the federal hospitals (IHS, VA, and military) in the state. As expected, the majority of the hospitals and beds were located in the two urban counties (Maricopa – 31 and Pima – 10). There were five hospitals located in the rural-urban counties (Coconino – 3 and Yuma – 2).
One of the major challenges for small rural hospitals is maintaining financial stability. The Medicare Rural Hospital Flexibility (Flex) Program was created by Congress (authorized under section 4201 of the Balanced Budget Act of 1997 (BBA), Public Law 105-33, and its amendment, the Balanced Budget Refinement Act of 1999) to assist small rural hospitals in improving their financial viability and stability. A key aspect of this program was the creation of a new designation for rural hospitals called Critical Access Hospitals (CAHs). Under the Flex Program, CAHs receive a cost-based reimbursement for services provided to Medicare beneficiaries. In Arizona, an additional reimbursement is provided for serving Medicaid (AHCCCS) patients. In 2002, there were six CAHs in Arizona and this increased to 12 CAHs in 2005. The Arizona Rural Hospital Flexibility Program website provides a detailed description of the Arizona Flex Program and its 12 CAHs (http://azflexprogram.publichealth.arizona.edu).
Mental Health and Behavioral Health Facilities: In rural areas, the behavioral health facility infrastructure is very limited. For many families, access to behavioral health services in rural communities is major challenge. In 2002, 78 percent of all the behavioral health facilities in Arizona (678) were located in the two urban counties. The facilities included outpatient clinics, behavioral health residential treatment centers, psychiatric acute hospitals, rural treatment centers, sub-acute agencies, transitional agencies, rural substance abuse transitional centers, adult foster homes, and others (see Table 6). Five percent of the facilities were in the two rural-urban counties, and 17 percent of the facilities were in the remaining 11 rural-rural counties.
Pharmacies: In 2001, there were 901 pharmacies in the state (Table 7). While there was an increase of 372 pharmacies (70%) from 1997 to 2001, 311 of the new pharmacies (84%) were located in the two urban counties. Figure 18 shows the major disparity gap between the number of pharmacies in the two urban counties and 13 rural counties during the five-year period.
Figure 18. Pharmacies Profile for Arizona and Its Counties: 1997 – 2001
Telemedicine/Telehealth Sites: The Arizona Telemedicine Program is a statewide program designed with the intention of increasing access to healthcare to all residents in Arizona by using telemedicine technologies. The use of telemedicine reduces the need for rural patients and their families to travel to urban centers for health services and enhances the rural health infrastructure. The program’s telecommunications network spans the entire state and serves as a hub for linking all the telemedicine networks in Arizona, including the state prison’s telemedicine network (for details refer to Map 2). Arizona’s telemedicine network serves three functions: (1) health care delivery, (2) education and training, and (3) videoconference administrative meetings. Table 8 shows the type and location of the telemedicine sites in 2002. The Arizona Telemedicine Program website (http://www.telemedicine.arizona.edu) provides information about the statewide system.
Map 2. Arizona Telemedicine Network System in 2003
Medically Underserved Areas: Map 3 shows the location of each Arizona Medically Underserved Area (AzMUA) in the state. The AzMUA is a geographical designation that identifies areas as having a need for medical services on the basis of selected demographic data. These designations are important in determining funding eligibility for various rural programs.
Map 3. Medically Underserved Area Locations in 2003
Source: Arizona Department of Health Services
Reference
1. Arizona School-Based Health Care Council (2002). Retrieved on December 5, 2002, from the World Wide Web: http://www.azschoolhealthcouncil.org/sbhc_locations.html.
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