Twenty percent of Americans live in rural communities. I am one person in that twenty percent. Since the pandemic began in 2020, the number of people moving out of urban areas has increased substantially, and our little town of 10,000 has grown. However, our healthcare systems have not. We still only have one hospital within an hour's drive and we still struggle to find local primary care providers. I feel lucky to have a 140 bed acute care hospital, including an emergency room, within 15 minutes of my home. But, I know that if I have a serious emergency, it will require a helicopter to transport me to the nearest trauma unit over an hour away.
Since 2010, 138 rural hospitals have closed throughout the United States - 180 since 2005, with many more at risk of closing. These include critical access hospitals and hospitals paid under the prospective payment system (Medicare reimbursement payment based on a predetermined, fixed amount). Because of the higher incidents of accidents in rural communities, the majority of these hospitals see their highest utilization from their emergency departments (ED). In 2018, 25 million Americans received care in a rural emergency department. Closing a facility means it takes longer to get an accident victim the critical care they need - sometimes making a difference between life and death. Mortality rates and health disparities increase in communities where a rural hospital has closed. And, the impact of these closures is not solely related to healthcare. The hospital is often one of the largest employers in the area. Closure means medical staff leave the area to find work or, unfortunately, go into another line of work. The economic impacts cannot be ignored.
In February, 2022, I traveled to Arizona and attended the AHA Rural Healthcare Leadership Conference. The contract I work on at Bellese Technologies, Hospital Quality Reporting, is implementing some changes related to rural emergency hospitals and I wanted to hear about the struggles from people in other rural communities. I spent a week listening to presentations outlining the challenges of rural healthcare as well as the passion of those providers trying to make a difference.
I discovered that, while my community is considered rural, it is not nearly as remote as other places. We heard a presentation from a 12 bed hospital where patients come from as far as 150+ miles to get care. We heard from hospitals who not only had the challenge of being remote but also had to earn the trust of their patients who mostly belonged to Native American communities.
I learned that rural hospitals depend on community partnerships to help address the social determinants that often drive poor outcomes in rural communities. Health disparities are magnified because of things like lack of public transportation. There is no Uber in these communities. So rural hospitals are getting creative and connecting patients to community resources that can make a difference.
But, these hospitals have a hard time keeping up with their urban counterparts. I heard presentations from hospitals who said they would have “huddles” at the height of the pandemic where the attending physician would get on a call with an infectious disease doctor to ask if what they were doing was appropriate. The infectious disease doctor responded with “your guess is as good as mine, because I’m just seeing this for the first time as well”.
And, many of the presenters indicated that the workforce will be their biggest challenge in the coming years. Healthcare workers are burnt out after the height of COVID.
So, CMS is starting to focus on helping these rural hospitals. They have created a new hospital designation for “rural emergency hospitals” (REH) where a critical access hospital or any rural hospital with fewer than 50 beds can change their designation to REH. There are some other criteria that must be met like the facility cannot provide acute care and the state agency must approve the licensure. The average annual length of stay per patient must be less than 24 hours and they must have a transfer agreement in place with a Level I or Level II trauma center. The REHs will receive higher Medicare outpatient reimbursement rates than acute care prospective payment system hospital rates. The goal of this program is to provide rural hospitals an opportunity to remain open to serve their communities.
It remains to be seen how many rural hospitals will convert to this new designation. A study published in July, 2021 predicted that only 68 rural hospitals would convert. It indicated that only government owned or critical access hospitals would convert - hospital systems were less likely to take advantage of the new designation where the additional payment may not make financial sense. Almost half of the predicted converters would be located in four states - Kansas, Texas, Nebraska, and Oklahoma. The converted hospitals would most likely be from areas of higher unemployment and lower population density. The study also indicated that some hospitals would be burdened by the cost, time, and resources associated with the certification process.
Several other concerns could affect the decision to convert, including the ability to support the needs of the community. What if the trauma unit they have an agreement with doesn’t have beds available? How can they support the skilled nursing facility needs of their community without post acute beds? Can we maintain a staffed emergency department including staffing 24 hours a day by a physician, nurse practitioner, clinical nurse specialist or physician assistant?
Hospitals can convert to the new REH designation starting in January, 2023. CMS is hopeful that the additional five percent payment, along with the additional facility payments, will be enough to save our rural hospitals. However, there are conflicting views as to whether or not it will be enough. Bottom line; this is only the beginning.
For more information on the unfolding state of healthcare within our rural communities, check out the resources below: