Missouri Primary Care Needs Assessment (PCNA) 2020 Missouri Department of Health and Senior Services Office of Rural Health and Primary Care [email protected] www.health.mo.gov/living/families/primarycare/ https://health.mo.gov/living/families/primarycare/publications.php 1 | P age Thank You, Missouri Department of Health & Senior Services staff who contributed to this report: Office of Rural Health and Primary Care Sara Davenport, Chief Laura Hart, Primary Care Office Manager Aleesha Jones, Primary Care Office Grant Manager Sandy Srivastava, Associate Research/Data Analyst Office of Health Care Analysis and Data Dissemination Andrew Hunter, Chief Haley Stuckmeyer, Associate Research/Data Analyst 2 | P age Table of Contents Executive Summary ............................................................................................................................................. 6 Summary of Findings ........................................................................................................................................... 7 Introduction ...................................................................................................................................................... 11 Purpose of the Primary Care Needs Assessment .......................................................................................... 11 The State of Missouri ........................................................................................................................................ 11 Population ..................................................................................................................................................... 11 Population Age Groups ............................................................................................................................. 14 Race and Ethnicity ..................................................................................................................................... 15 Geographic Highlights – Contiguous States .............................................................................................. 18 The Office of Rural Health and Primary Care .................................................................................................... 19 The Missouri Primary Care Office ................................................................................................................. 20 The Conrad 30 State J-1 Visa Wavier Program.......................................................................................... 21 National Interest Waiver Program ............................................................................................................ 22 Health Professional Student Loan and Loan Repayment Programs ......................................................... 22 Health Professional Shortage Area Designation ............................................................................................... 34 Missouri Primary Care Providers ................................................................................................................... 36 Methodology ..................................................................................................................................................... 42 Health Indicator Selection ............................................................................................................................. 42 Health Status Indicators ............................................................................................................................ 42 Health Care Access Indicators ................................................................................................................... 43 Ranking of Indicators................................................................................................................................. 44 Health Status Indicators .................................................................................................................................... 44 Life Expectancy .............................................................................................................................................. 45 Years of Potential Life Lost ............................................................................................................................ 45 Self-Reported Health Status .......................................................................................................................... 46 Ever Breastfed ............................................................................................................................................... 47 Total Mortality .............................................................................................................................................. 48 Infant Mortality ............................................................................................................................................. 48 Heart Disease Mortality ................................................................................................................................ 49 Cancer Mortality ........................................................................................................................................... 50 Chronic Lower Respiratory Disease (CLRD) Mortality ................................................................................... 51 Stroke Mortality ............................................................................................................................................ 51 HIV/AIDS Health Indicator ............................................................................................................................. 52 Asthma .......................................................................................................................................................... 53 Obesity .......................................................................................................................................................... 53 3 | P age Diabetes ........................................................................................................................................................ 54 Hypertension ................................................................................................................................................. 55 High Cholesterol ............................................................................................................................................ 56 Depressive Disorders..................................................................................................................................... 56 Smoking ......................................................................................................................................................... 57 Health Access Indicators ................................................................................................................................... 58 Medicaid Enrollment ..................................................................................................................................... 58 Medicare Enrollment .................................................................................................................................... 60 Uninsured ...................................................................................................................................................... 60 Population Living in Poverty.......................................................................................................................... 61 Population-to-Provider Ratios ...................................................................................................................... 63 Population to Primary Care Provider Ratio ................................................................................................... 63 Population to Mental Health Provider Ratio ................................................................................................ 64 Population to Dentist Ratio ........................................................................................................................... 64 Mammogram, Pap Smear, and Sigmoidoscopy/Colonoscopy Screenings.................................................... 65 Preventable Hospitalizations ........................................................................................................................ 66 Dental Visits in the Last Year ......................................................................................................................... 67 Dental-Related Emergency Room (ER) Visits ................................................................................................ 68 Inadequate Prenatal Care ............................................................................................................................. 68 Low Birth Weight .......................................................................................................................................... 69 Additional Barriers ............................................................................................................................................ 69 Hospital Closures ........................................................................................................................................... 69 Health Literacy .............................................................................................................................................. 71 Education ...................................................................................................................................................... 71 Transportation .............................................................................................................................................. 72 Internet and Telehealth ................................................................................................................................ 73 Unemployment ............................................................................................................................................. 73 Coronavirus Disease 2019 (COVID-19) .......................................................................................................... 73 Missouri Population .................................................................................................................................. 73 Economy .................................................................................................................................................... 74 Hospital Operations .................................................................................................................................. 75 Local Public Health Agencies ..................................................................................................................... 75 Missouri Primary Care Office Efforts................................................................................................................. 75 Workforce Recruitment and Retention ........................................................................................................ 75 Collaboration and Partnerships ................................................................................................................ 75 Health Professional Student Loan and Loan Repayment Programs ......................................................... 76 National Health Service Corps ................................................................................................................... 77 4 | P age Code of State Regulations (CSR) ............................................................................................................... 77 COVID-19 Efforts ....................................................................................................................................... 78 Next Steps ......................................................................................................................................................... 78 Data Collection .............................................................................................................................................. 78 Conclusion ......................................................................................................................................................... 79 Appendix A: Glossary of Terms ..................................................................................................................... 80 Appendix B: Greatest Unmet Need Ranking by County – Rank Order ......................................................... 83 Appendix C: Greatest Unmet Need Ranking by County – Alphabetical List ................................................. 86 Appendix D: MICA (Missouri Information for Community Assessment) System .......................................... 89 Appendix E: Health Status Quintile Points and Rankings by County ............................................................ 91 Appendix G .................................................................................................................................................... 98 Appendix G: Endnotes/References ............................................................................................................. 119 5 | P age Executive Summary Health Resources and Services Administration (HRSA) was created in 1982 and subsequently began working with state and territorial officials to improve access to quality health care services. This collaboration resulted in HRSA awarding grants to state and territorial governments to fund their state Primary Care Office (PCO).1 HRSA continues to collaborate with states to complete a Primary Care Needs Assessment (PCNA), every five years. The PCNA is a methodical technique used to identify unmet health and healthcare needs in Missouri and thus recommends changes to meet those unmet needs. The Missouri Statewide PCNA 2020 analyzes Missouri’s unmet needs, lack of access to health care services, and evaluates resources and services necessary to overcome disparities in Missouri. The Missouri Department of Health and Senior Services (DHSS), Office of Rural Health and Primary Care (ORHPC), Primary Care Office (PCO) conducted a Missouri Statewide PCNA 2020 to identify communities with the greatest unmet health care needs, disparities, and health workforce shortages, and the key barriers to accessing primary health care services. The Missouri PCNA 2020 examines 33 primary care health indicators subdivided into two groups:  18 Health Status Indicators examine the current state of health in Missouri by incorporating the following indicators:  General population health, such as life expectancy and years of potential life lost;  Health-promoting practices, such as breastfeeding;  Prevalence of several notable diseases/health conditions; and  Mortality rates for the total population, infants, and several leading causes of death.  15 Health Care Access Indicators examine Missouri residents’ access to various health care services by considering the following indicators:  Socioeconomic factors, such as poverty and lack of health insurance;  Measures that may indicate a lack of access to preventive health care services, such as dental-related emergency room (ER) visits and low birth weight;  Usage of various types of health screenings; and  Availability of several types of health care providers. The health status and health access indicators explore factors influencing the current state of Missourians’ health and barriers associated with accessing primary health care services in Missouri. The health status and health care access indicators also provide information about the relative health of each Missouri County. The PCO utilized the health indicators to identify where additional and necessary health resources are needed most to meet the health care needs for underserved and high- risk populations. 6 | P age Summary of Findings The Missouri PCNA 2020 report key findings include:  HRSA has designated most of Missouri as a Primary Care Health Professional Shortage Area (HPSA) in medical, dental, and mental health disciplines.  Rural counties were consistently identified as the counties ranked with the greatest unmet needs in all but one health indicator.  The HIV/AIDS health indicator demonstrated that urban counties were ranked with the greatest unmet needs but comparatively four of the ten counties were rural.  The southeastern region of the state, which is predominantly rural, was identified as having a greater instance of unmet needs, as compared to all other Missouri regions.  Based on the analysis of health indicators, the areas with greatest unmet health needs identified were primarily clustered in the southern part of Missouri, particularly in the southeast and south central areas.  Moreover, 22 of the 23 Missouri counties with the greatest unmet health care needs were located south of the Missouri River.  Only one county (Linn) was located north of the Missouri River, in the northeastern region, as shown in Figure 1 and Figure 2 below.  Furthermore, this is consistent with the findings of the 2015 Missouri PCNA,2 demonstrating nominal changes since 2015.  Refer to Appendix B for a comprehensive list of counties in rank order, associated with greatest unmet needs overall.  For alphabetical order, refer to Appendix C.  Figure 1 provides a list of the 23 counties that demonstrate the greatest overall unmet needs.  Figure 2 illustrates the Missouri counties with the greatest overall unmet health care needs. Figure 1: Counties with the Greatest Unmet Needs Overall Health Combined Overall Health Care County Status Rank Primary Care BRFSS Region Access Rank Rank Score Needs Rank Pemiscot 115 109 224 115 Southeastern Region Iron 114 109 223 114 Southeastern Region Ripley 104 115 219 113 Southeastern Region Dunklin 113 99 212 112 Southeastern Region Mississippi 110 99 209 111 Southeastern Region Oregon 94 114 208 110 Southeastern Region Wayne 98 109 207 109 Southeastern Region Wright 97 107 204 108 Southeastern Region New Madrid 110 93 203 107 Southeastern Region Reynolds 101 99 200 106 Southeastern Region 7 | P age Carter 101 98 199 105 Southeastern Region Dent 91 107 198 103 Central Region Shannon 89 109 198 103 Southeastern Region Washington 108 89 197 102 Central Region McDonald 91 99 190 100 Southwestern Region Stoddard 109 81 190 100 Southeastern Region Benton 94 93 187 98 Southwestern Region Butler 112 75 187 98 Southeastern Region Texas 85 99 184 97 Southeastern Region St. Clair 85 97 182 96 Southwestern Region Linn 104 75 179 94 Northeastern Region Madison 98 81 179 94 Southeastern Region Morgan 79 96 175 93 Central Region Figure 2: Areas with Greatest Overall Unmet Health Care Needs – County Map D Lowest Need Quintile 2nd Quintile - 3rd Quintile - 4th Quintile - Highest Need Quintile 8 | P age Figure 3 and Figure 4 demonstrate the Missouri counties with the greatest need for improvement in the health status indicators. Figure 3: Table of Counties with Greatest Unmet Need – Health Status Indicators – Top Quintile County Health Status Rank Pemiscot 115 Iron 114 Dunklin 113 Butler 112 Mississippi, New Madrid 110 Stoddard 109 Washington 108 Ripley, Linn, Laclede, Henry 104 St. Francois 103 Reynolds, Carter 101 Wayne, Madison, Scott 98 Wright 97 Oregon, Benton, Randolph 94 Buchanan 93 Figure 4: Health Status Indicators: Areas with Greatest Unmet Health Care Needs - County Map [==i Lowest INeed Quinrne LJ 2nd Quintile LJ 3rd Qu1i11ti1le 4th Quintile - Hi:gh.est INeed Qulntile 9 | P age Figure 5 and Figure 6 demonstrate the greatest challenges with health care access. Figure 5: Table of Counties with Greatest Unmet Need – Health Access Indicators – Top Quintile County Health Care Access Rank Ripley 115 Oregon 114 Pemiscot, Iron, Wayne, Shannon, Ozark 109 Wright, Dent 107 Douglas 106 Dunklin, Mississippi, Reynolds, McDonald, 99 Texas, Sullivan, Dallas Carter 98 St. Clair 97 Morgan 96 New Madrid, Benton, Stone 93 Figure 6: Health Status Indicators: Areas with Greatest Unmet Health Care Needs - County Map LJ Lowest Need Quintile D 2nd Quintile - 3rd Quintile - 4th Quintile - Highest Need Quintile 10 | P age