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The Census Bureau divides Americans as living in one of three areas:

  • Urbanized Areas (UAs): 50,000 or more people
  • Urban Clusters (UCs): at least 2,500 and less than 50,000 people
  • Rural: encompasses all population, housing and territory not included within an urban area

According to most recent census, almost 21% of Americans live in rural areas, down from 1990 when it was 22%. 1 However, this still accounts for over 59 million people. An additional 10% live in population clusters of 2,500 - 50,000. In ten states, over 40% of the population lives in rural areas. In 2007, before the recession began, 15.8% of those living in rural counties fell under the poverty line. Three years later, that rate in rural counties had increased to 17.8%.

As technology improves, fewer and fewer jobs are in rural areas. Think of the agricultural industry. The Bureau of Labor Statistics expects the need for agricultural workers to decrease 3% between 2010 and 2020 in part due to technological advancements which raises the output per farm worker. This trend forces the younger labor force to leave an aging population behind with increased medical needs and higher cancer rates. These patients are cared for by the 1,980 rural hospitals (as defined by the American Hospital Association) as opposed to the 3,019 urban hospitals. 2

What does this mean for oncology care?

A recent study discussed the trend in cancer patients foregoing healthcare after cancer treatment due to costs. The report suggested that cancer survivors in rural areas over the age of 65 were more likely than their urban counterparts to forgo follow-up cancer care because of cost. The author of this article hears often from physicians in rural or small communities that they frequently have to convince patients to travel for cancer care due to the cost. It is not unusual for the closest cancer center offering standard chemotherapy and radiation therapy to be 90 - 250 miles away. 3

When the patients want the best and greatest at home and agree to raise the funds to do so, hospital administrators jump at the chance. The desire from the hospital and the community, no matter how well founded, is not sufficient to move forward. The start-up costs are just the beginning when it comes to cancer care and, in fact, other specialty medical care. Before a hospital decides to move forward with any new program, and in particular any aspect of cancer care including radiation oncology or infusion program for cancer patients, it is critical to do a thorough assessment.

Support for the program from the existing medical staff is critical. If the existing staff will not support the program, it will fail as they will continue to send patients elsewhere. Other components of the assessment include the following elements:

  • Market analysis
    • What is the region from which the program will draw patients?
    • How many potential patients are in the defined region who could benefit from cancer care (the cancer pool)?
    • Of that pool, how many could be treated locally and how many need sophisticated care (for example, treatment utilizing radiosurgery techniques or a subspecialty surgeon such as a patient with pancreatic cancer) and need to go to a tertiary center?
  • Do we have capabilities to support the program?
    • Operations: can the hospital recruit the appropriate credentialed staff needed to provide the services?
    • Medical Needs: what physician support is necessary either through regulations or national standards, such as those related to medical supervision for radiation oncology and chemotherapy? What are the chances that recruitment will be successful?
    • Quality Requirements: can our services meet the quality measures required for oncology including minimal volumes suggested by professional organizations?
  • Reimbursement
    • Will reimbursement cover the costs of providing the service or will additional resources be required (philanthropy, grants, federal funds)?

There is a continuum of choices to provide the needed services for cancer patients diagnosed at rural hospitals–from partnerships with other providers, transportation options and development of the services locally, if supported, There are many options and models and it can be a complicated process to determine the correct mix of services and programs.

To learn more about the expertise of The Oncology Group and how we can help with the development of programs to support your cancer patients, please contact Marsha Fountain, President of The Oncology Group, at 512.583.8815 or by email at [email protected].

3. Nynikka R. A. Palmer, et al; Research Articles: Impact of Rural Residence on Forgoing Healthcare after Cancer Because of Cost, Cancer Epidemiology Biomarkers and Prevention. October 2013 22:10 1668-1676;