Greenwood-Ericksen MB, D’Andrea S, Findley S. Transforming the Rural Health Care Paradigm. JAMA Health Forum. Published online September 2, 2020. doi:10.1001/jamahealthforum.2020.0987
The coronavirus disease 2019 (COVID-19) pandemic is exposing the fragility of health care in rural areas of the US. The pandemic-related hospital financial crisis may exacerbate the long-standing rural hospital closure crisis, worsening preexisting rural health disparities.1 COVID-19 is spreading in a “checkerboard” pattern through hot spots in rural areas. Rural health care facilities have undergone significant and costly preparations for potential surges of patients with COVID-19. Yet they may still be overwhelmed by a local outbreak, facing intractable clinician shortages and lack of regional planning for patient transfers.2
Thus, COVID-19 highlights a wicked problem for rural hospitals—they are repeatedly forced into a reactionary pattern regarding finances, staffing, and transfer/coordination networks that hinders their ability to optimize care delivery and quality. The consequences to communities experiencing rural hospital closures are tragic, starting with loss of health care access and ending with community decline. It is time for a new paradigm.
The current financial and delivery model for rural hospitals is untenable. The US health system’s basis in volume and profit is at the heart of the problem for rural hospitals, which disproportionately rely on outpatient and surgical volume for revenue.3 With surgical patients increasingly referred to urban centers, rural hospitals survive on revenue from nonsurgical conditions. Critical access hospitals, the dominant rural care model operating on cost-based payment, are plagued by closures and quality concerns. The latter drives rural hospital bypass and the cyclical process of declining volume, declining revenue, and low-volume quality issues. Subspecialization and advanced technology available in urban centers can prevent rural hospitals from competing in quality. To adapt, rural hospitals increasingly affiliate or merge with other hospitals or health care systems, which can diminish access to technology and primary care. Furthermore, rural populations are older, sicker, and poorer and thus have significant health care needs.
We propose a new model for rural health care in which states and the federal government financially invest in rural facilities as a public good and policies are advanced to improve access and quality through regional networks, coordination, telemedicine, and workforce innovation. To address the challenges to rural health highlighted by the COVID-19 pandemic, we propose the following 5 policies to support rural hospitals and clinicians in improving clinical care:
Expand collaboration with academic medical centers. During the COVID-19 pandemic, academic medical centers (AMCs) in states with large rural populations are rapidly engaging with regional partners through telemedicine for education and clinical care for rural communities.4 This collaboration is critical because patients with COVID-19 treated at smaller hospitals may experience triple the risk of dying compared with those treated at larger centers. Some rural and tribal communities have developed academic-community partnerships for contact tracing, staffing, and peer-to-peer education in hard-hit areas, such as the Navajo Nation. These collaborations may facilitate improved treatment and early transfer to AMCs. Beyond COVID-19, AMCs have collaborated with rural hospitals through surgical coaching to reduce complications and through peer education to improve quality measures for chronic conditions.5
Invest in regionalized care. This approach has been key to improving trauma care6 and cardiac care.7 However, no regional planning mechanism exists to link rural facilities consistently with tertiary care centers. Reliable transfer networks coupled with quality improvement initiatives can optimize transfers and reduce mortality. The COVID-19 pandemic highlights the need for planned transfer networks based on capacity and the use of back-transfer from urban centers to rural hospitals for recovery and rehabilitation. Centralized planning can be transformational. For example, New Mexico established a statewide call center to facilitate transfer of critically ill, rural patients based on hospital capacity. As a result, New Mexico hospitals are now accepting hospital transfers from overwhelmed neighboring states.
Expand telemedicine to improve rural patient access and care quality. Telemedicine is well received by patients, improves access to neurologic and trauma care, and facilitates specialist input for rural clinicians. Historically, limited rural telemedicine penetration has been related to payment, infrastructure, and broadband availability. However, COVID-19–related policy and funding opportunities have rapidly reduced these barriers for outpatient care, and rural clinicians are increasingly engaging with telemedicine. We recommend that this care be expanded to include hospital-based telemedicine services in emergency departments, which play outsized roles in rural health care delivery,8 and in intensive care units. These telemedicine services improve outcomes in the critically ill and help coordinate rural patient transfers to large AMCs.
Innovate in workforce development to address rural care needs. While telemedicine is key to a specialty workforce, in-person primary care is the backbone of rural health care. Data-driven approaches to expand and support the rural primary care workforce include successful academic training programs and advanced emergency skill training partnerships between primary care and emergency medicine.9
Adopt a new financial and delivery model. The federal government and states need to directly invest in rural hospitals to ensure their financial stability. Global budgets10 and guaranteed federal support would implicitly consider rural hospitals as a public good, bringing predictable funding streams. COVID-19–related federal rural hospital support should extend into permanent funding. These policies would optimize rural care quality and referral of complex cases through engagement with AMCs, telemedicine, and transfer networks. For example, rural hospitals and AMCs can collaborate in telemedicine-linked networks providing educational platforms such as Project ECHO to improve care quality, along with acute care consults and transfer coordination for critically ill patients or those with complex care needs. Loss of volume related to transfer and referral can then be offset by additional payments for meeting rural-specific quality metrics (education, transfer, referral, acute care quality). Finally, physicians could be dually employed by both AMCs and rural hospitals to support their salaries—one of the largest costs for rural hospitals.
Our proposed policies provide a framework to transform rural health care. They can be combined to support the finances, delivery, and quality of rural care. What is needed now and in the postpandemic period is a stable, high-quality rural system of care that can shift its focus from economic survival to health care innovation.
Corresponding Author: Margaret B. Greenwood-Ericksen, MD, MSc, Department of Emergency Medicine, University of New Mexico, 700 Camino de Salud, Albuquerque, NM 87109 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr D’Andrea reported being a staff physician and employee of Fort Defiance Indian Health Board Incorporated, a 638 health care entity. No other disclosures were reported.
Additional Contributions: We thank David Sklar, MD (Arizona State University), Cameron Crandall, MD (University of New Mexico), and Joseph Minardi, MD (University of West Virginia), for helpful comments on an earlier draft of the article.
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