Dissecting the Plight of Rural Hospitals: Part III

Rural health is in trouble.

EDITOR’S NOTE: In this final installment of a three-part series as to why rural health is in trouble, more of the reasons and potential solutions will be addressed. In Part 1, Dr. Zelem addressed financial reasons and staffing shortages. In Part 2, he talked about what life was like in a day of a rural/critical access hospital (CAH). In Part 3 Dr. Zelem will address the difficulty in finding physicians, especially specialists or surgeons such as those working in the fields of cardiology, neurology, orthopedics, ophthalmology, and more.

According to the Association of American Medical Colleges (AAMC), physician shortages across the country have left a growing number of communities desperate for care. Of the more than 7,200 federally designated health professional shortage areas, three out of five are in rural regions. And while 20 percent of the U.S. population lives in rural communities, only 11 percent of physicians practice in such areas. There are a plethora of reasons for this, some of which are not medically related:

• Lack of cultural resources in the area, and long distances to travel to find them;
• Difficulty in finding work opportunities for spouses, especially if they have a highly trained profession;
• Educational opportunities for children of physicians;
• Employed vs. private practice:
  • Increased malpractice rates for the specialties;
  • Both young and older established physicians may have a concern for earning less; and
  • This is the conundrum – especially if the physician is not hospital-employed, but if they are, an increased financial burden for the hospital that already has shrinking budgets.
• Hope that children from the area who become physicians will decide to return to the area of their roots to practice (but most of them are not in the specialty fields that are so needed);
• Lack of patient resources; and
• Inability to adequately respond to major trauma, except to stabilize for transfer to a higher level of care and the availability the services to transfer.

One may ask, OK, these are the reasons rural health is in trouble, but what are the solutions? Are they in force, or being thought of and planned? The challenges these facilities face are multifactorial, and can also be quite variable and different for every facility. Therefore, the solutions will be dissimilar.

Here are just some of the solutions in force now, and some thoughts for the future:

• CHQPR (Center for Healthcare Quality and Payment Reform) suggests:
  • Health insurance plans, especially private and advantage plans, reimburse hospitals appropriately for services provided and reduce the number of egregious denials;
  • But, on the other hand, rural hospitals must ensure that their processes are compliant and consistent; and
  • Adequately supporting and reimbursing emergency services.
• Community and industry support, especially in those rural communities where a major industry exists;
• Encouraging specialty physicians from surrounding urban areas to extend their practice to these rural areas, seeing requested consults in a timely manner, minimizing avoidable days, which increases the expenses (not insurance reimbursed) rural hospitals face;
  • This can also mean decreased observation stays that are greater than 48 hours, and many times not reimbursed by commercial payers
• There is no doubt that there will always be an appropriate need to transfer patients to higher levels of care for some of the above-mentioned specialties, and:
  • This does result in reducing census numbers and increases the need to board these patients until a bed or transportation is available – again, this all increases cost to the rural hospital;
  • When it comes to EMS systems in rural areas, most are composed of volunteers – there needs to be a way to find a greater source of this specialty; and
  • EMS is grossly underpaid by payers for the necessary services they provide – this needs to be addressed.
• The swing bed program has been a great boon to rural hospitals and their communities;
• On a lighter note, some residency programs are offering rural rotations and encouraging a sense of community; and
• Offering a greater sense of work-life balance.

In conclusion, while there is no end in sight to these problems, more effort needs to be exerted to save one of our most valuable healthcare resources.