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The rural health care challenge

Published on 8/15/2018

This content originally appeared in Perspectives, a Cerner publication that features the leading voices, insights and industry analysis of some of the most innovative minds in health IT today. Download Cerner’s Perspectives for exclusive content from leaders in health care.

When you imagine thousands of sick and hurt people lined up in the pre-dawn hours, asleep in cars and traveling hundreds of miles to receive medical help, you probably recall images from post-Katrina, New Orleans or the Kapartu camp in northern Iraq. But that scene played out just this summer in rural southwest Virginia. More than 2,000 people traveled to receive care from a Remote Area Medical (RAM) pop-up clinic, an organization that provides free medical care to people in remote, underserved locations. Originally founded to provide care to remote regions in Central America, RAM now travels across the United States hosting clinics for people in rural areas where, increasingly, hospitals are closing and access to health care can be hard to find.

Rural hospitals provide essential health care services to nearly 57 million people across the country and are often an integral part of the local economy, providing jobs and a tax base for the community. According to the North Carolina Rural Health Research Program, 80 rural hospitals have closed since 2010 across 27 states, and in 2016 there were another 673 rural facilities at risk for closure, according to an iVantage Health Analytics report. In addition, iVantage’s 2017 Rural Relevance Study reports that 41 percent of rural hospitals operate at a negative margin. Rural hospitals across the country are struggling to survive, but why?

Rural hospitals more vulnerable to federal funding changes

Because rural populations tend to include elderly and lower income individuals, hospitals in these areas collect more of their revenue from Medicare and Medicaid reimbursements than hospitals within a city. This leaves them more vulnerable to policy changes that affect government reimbursement. The Rural Health Policy project reports that from 2014 to 2015 Medicaid provided coverage for 45 percent of children and 16 percent of adults in small towns and rural areas. Because of this dependence on federal funds, any changes to policy or law can acutely affect rural hospitals already in precarious financial positions.

For states that expanded Medicaid coverage under the Affordable Care Act, the increased number of people getting coverage in rural areas had a positive effect on the bottom line for rural hospitals. The Center on Budget Policy and Priorities reported that since 2013, rural hospitals in Medicaid expansion states saw their share of Medicaid revenue as a share of total revenue rise by 33 percent, as opposed to the 1.1 percent seen in non-expansion states. 

The 2013 federal funding cuts known as sequestration are projected by the Chartis group to have a significant impact on rural hospitals over the next 10 years. The Congressional Budget Office predicts that the two percent cuts would result in $3.5 billion in lost Medicare reimbursement among rural hospitals and 153,000 lost jobs among rural hospitals. For hospitals already operating on tight margins, these types of policy changes can mean the difference between staying open and shuttering.

Health disparities in rural populations

Differences in the health needs of rural and urban populations contribute to the struggle of rural hospitals. Rural areas serve a higher proportion of elderly adults, veterans and poor people than urban areas. These are populations that often have more frequent and complex health needs. Rural populations also have a higher incidence of disease, including diabetes, the seventh-leading cause of death in the country. These health needs can strain rural hospitals that may already be short on resources. The large geographic distances of rural areas can also make it more difficult for individuals with chronic conditions to access care, which can compound the severity of these health issues. 

What happens to the patient experience when rural hospitals disappear or cut services?

The challenges facing rural hospitals and the increased rate of hospital closures are having a serious health and economic impact on rural communities. A Kaiser Family Foundation study that studied the impact of hospital closures in three rural communities found that not only do hospital closures negatively affect access to emergency care, they also impacted other kinds of specialized care. Since rural hospitals are often one of the few or only health care providers in rural communities, they may act as primary care or specialty care providers. One hospital in the study estimated that up to 90 percent of emergency department cases were for non-emergency situations. Without the rural hospital, many individuals simply forgo the care they need if they are unable to travel to other locations.

Sometimes rural hospitals find ways to remain open, but that may mean cutting services, and often those cuts begin with maternity services. According to the latest American Congress of Obstetricians and Gynecologists, only 6 percent of the nation’s ob-gyns work in rural areas.  For the millions of women who live in these maternity deserts, this means driving up to an hour for prenatal care. 

For many patients in rural locations, the availability of a rural hospital is the foundation of the patient experience. Rural hospitals and the services they provide are an important health care lifeline, and one that needs to be supported to continue to provide care to millions of individuals who aren’t near metropolitan areas.

Supportive models to rural patient care

Recognizing that technology and efficiency are two key factors to remaining open, organizations such as the Great Plains Health Alliance (GPHA) seek to help rural hospitals close the resource gap of larger, urban hospitals and keep medical care local by providing hospital management, financial and billing services and IT offerings for rural community hospitals at a subsidized cost. These services help rural hospitals manage the administrative, regulatory and financial issues that they may not have the staff or expertise to handle on their own.

A not-for-profit organization of hospitals in Kansas and Nebraska, GPHA was originally established in the 1950s to offer administrative support to the nurses of these facilities. Now, GPHA partners with Critical Access hospitals in the heart of rural America, providing billing and payment services, information security, human resources, information technology and a range of additional management and technology offerings though a leased, managed or resource sharing relationship – allowing our partners to remain viable members of their communities.

Keeping resources affordable creates an efficient patient experience that benefits all community members, patients and providers alike. Physicians and caregivers expect state-of-the-art medical records and platforms to provide the same high-quality, accessible care as larger metropolitan facilities. In a nine-month turn after partnering with an EHR vendor, GPHA launched an EHR for 16 hospitals and plans to have another nine live by early fourth quarter of this year. This provides a more comprehensive, up-to-date patient view in these rural communities – something these organizations likely wouldn’t have been able to afford or execute independently.

But keeping a rural hospital’s doors open to ensure the community has access to care is just the first component of the patient experience. Caregivers showing genuine concern and compassion, providing their undivided attention, and demonstrating expertise when asked questions are among the many variables that factor into the patient experience equation. Utilizing the tools and efficiencies made available through collaboration and partnership allow all facets of the care team to more effectively provide care and improve the health outcomes of their community.

Rural America is an integral part of this country’s fabric — it’s where our food is grown, our livestock is raised and our coal is mined. Geography shouldn’t be a factor in the quality of a person’s health care — when rural hospitals can stay open, these communities not only survive, they and the rest of the country benefit.

CommunityWorks brings innovative health care solutions and services beyond the highly populated metropolitan areas and into the rural and community hospital market. Learn more here.