California Rural Health Advocate, Winter 2010



<Back	Urban versus Rural – What’s Important for Rural Health Clinics Written by: William Deane Over the years, many misconceptions have developed about the definition of the terms “urban” and “rural” and how they apply to rural health clinics. Federal and State programs use different terminology to explain the location and service area characteristics of clinics. With the arrival of the results of the 2010 census, we will become aware of these terms again. Why is it necessary to understand? Urbanized versus non-urbanized definitions are used to establish criteria for swing beds in a hospital and rural health clinic eligibility. Several Federal agencies, including HRSA, rely on the U.S. Census Bureau’s definition of these terms to establish eligibility. What are the eligibility requirements for a rural health clinic? In order to establish and maintain an RHC, its location must be in a service area designated as a “HPSA” or a “MUA” and must be classified as “non-urbanized”. Since RHC certification is a Federal program, we must use their definitions. What does urbanized mean? By U.S Census Bureau definition as published in the Federal Register on March 15, 2002, an urbanized area has more than 1,000 people per square mile, surrounding census blocks have at least 500 people per square mile and together they encompass a population of at least 50,000 people. The State of California Office of Statewide Planning and Development (OSHPD) also has urban and rural definitions, but these have nothing to do with RHC eligibility. In addition, Medicare has definitions to classify urban and rural hospital locations, which again are a different definition. So what’s the problem? There are a multiple problems in understanding and applying these definitions: California has unique characteristics in that some of its counties can be urban and rural at the same time. For example, Fresno County features one of the largest cities in the state, yet vast portions of the county are largely agricultural, sparsely populated and very rural. Federal programs frequently do not understand our state geography and lump areas together. Not all Federal programs adhere to the same definitions. HRSA does not use what the U.S. Dept. of Housing & Urban Development uses, nor what the U.S. Department of Transportation uses. The Census Bureau definitions are highly specialized. There is terminology confusion. The words “non-urbanized”, “urban area”, “rural”, “urban cluster” are used interchangeably, yet they are defined differently. For example, the U.S. Census Bureau uses the term “urban cluster”. This term means nothing for RHC eligibility. The State agencies (DHCS and CDPH) rely on CMS Region IX to review RHC eligibility issues and make a determination of whether an area is urban or rural. However, the software program which CMS utilizes for this determination does not distinguish service areas below the county-wide level. In other words, they cannot distinguish non-urbanized areas within an urbanized county. Past experience has shown CMS making an incorrect determination in at least a dozen cases, which were subsequently corrected by our efforts. How can I determine whether my RHC is located in an urban or rural area? Well, it’s difficult to do. The U.S. Census Bureau maintains a list of urbanized area outline maps based on the 2000 census which you can download. But there is no clear cut method of reviewing a map to determine your clinic location – it takes a little guesswork and an understanding of the boundary delineations. The 2000 census shifted several communities from rural to urbanized, including Atascadero/Paso Robles, Hanford, Madera, Manteca, Porterville, Petaluma, Tracy and Turlock. The upcoming 2010 census will also increase the number of urbanized areas in California as the population continued to grow in the past decade and more census blocks will be added. In 2008, CMS proposed changes in conditions of participation for the RHC program covering a variety of topics including eligibility criteria. If these regulations are proposed and adopted in the future, you will need a better understanding of the impact of urbanized and non-urbanized areas on your clinic location. What can I do to ensure my RHC maintains certification? Renew your HPSA (“Health Professional Shortage Area”) designation every three years when it comes up for renewal. Maintaining a current designation is a key component for eligibility. Review the demographics of your local community. Is the population growing? How close is your clinic to a major metropolitan area? Understand the population and income trends of your community. Hire a healthcare consultant to assist you in the above steps. Contact: Mr. William Deane has 15 years experience in primary care clinic licensure and development. Mr. Deane has management skills, experience in rural health needs and rural health clinics (RHCs), federally qualified health clinics (FQHCs), licensing and regulatory issues, regulatory issues relating to health professional shortage designation (HPSAs), medically underserved areas and populations (MUAs/MUPs) and HRSA New Access Point grant writing. In addition, Mr. Deane has worked as a CFO for an FQHC, handling all finance related projects and accounting. William Deane Manager, Clinic Development HFS Consultants Inc. bdeane@hfsconsultants.com Comments or feedback? Email us at advocate@csrha.org.

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