COLUMBIA -- As the nation's health care system moves to a variety of delivery systems, Missouri University Extension specialists warn the transformation could be even more dramatic in the state's rural areas -- with nearly four out of every 10 Missourians -- than in urban regions.

A lengthy study of what lies ahead for rural medicine in Missouri has been made by university specialists including Dr. Daryl Hobbs, a professor of rural sociology on the Columbia campus, and Dr. Charles Fluharty, director of the school's Rural Policy Research Institute.

Hobbs says his studies conclude that health care as it has long existed in rural Missouri is in the process of being "redefined" in terms of "what it consists of, who provides it and who pays for it."

Approaching the subject in a slightly different way, Fluharty believes outstate Missouri communities are sensitive to three critical factors: changes taking place in the health care marketplace; decisions in the public sector intended to address these marketplace changes; and the extent to which rural communities can determine their own futures.

Regarding his third point, Fluharty raises a question of whether communities can defend themselves by developing their own service-providing organizations. If not, much of rural medicine in the state will simply follow the path charted by other groups and outside profit-making corporations.

Both men agree the current health care system is being torn apart, with much of the "tearing" originating in the marketplace. But close behind are legislative changes in both Washington and Jefferson City, often aimed at reducing federal involvement as more responsibility is shifted to the states.

Hobbs, Fluharty and other university specialists say the overriding effort in health delivery services is cost saving. They note that costs have, indeed, been rising rapidly, with the result that savings have been sought through consolidation of providers, such as mergers among hospitals and other care facilities, and by reducing the extent and possibly the quality of care made available. As evidence, the experts point to the rapid rise of so-called managed care units as provided especially by health maintenance organizations but also by networking among providers.

Large hospital companies are regularly showing up in Missouri, frequently purchasing physician groups. A significant feature of the mergers is the frequency of for-profit institutions purchasing not-for-profit companies with long records of medical delivery services.

To date, the experts say, health care services have survived reasonably well in rural Missouri. HMOs, for example, have been largely confined to metropolitan areas, but the situation is far from secure as pressures build to envelop more rural care services into HMOs. That situation, they predict, will be more likely to materialize as Medicaid turns toward HMOs to provide the services it finances.

In Missouri, 600,000 residents are eligible for Medicaid, which serves especially the needs of low-income women and children and the elderly and disabled. Missouri's Medicaid budget is $3 billion, which represents 21 percent of the state's annual budget. These funds are divided among three groups: 40 percent to hospitals, 35 percent to nursing homes and 8 percent to physicians. It is widely believed that 50 percent of Missouri's Medicaid recipients will soon be served by HMOs.