Understanding the Health Challenges Facing Rural Communities

Rural communities continue to face health challenges and disparities, with higher percentages of preventable deaths, higher rates of Medicare and Medicaid populations, and much fewer providers, according to a panel discussion at AcademyHealth National Health Policy Conference, being held February 4-5 in Washington, DC.

In 1999, there was a 6% gap in mortality rates between rural and metropolitan areas, but by 2016, that rate tripled to 18%, explained Mark Holmes, PhD, professor of health policy and management at the University of North Carolina Gillings School of Global Public Health. From 1999 to 2010, there was a 50% quicker decrease in mortality rates compared with prior years for both metropolitan and nonmetropolitan areas. However, from 2010 to 2016, nonmetropolitan mortality remained flat while metropolitan mortality continued to decline, albeit at a slower rate.

The reasons behind this trend can largely be explained by higher deaths from motor vehicle accidents, heart attacks, other types of accidents, and suicide by firearms, according to Holmes.

At the same time, rural hospitals have been facing shrinking inpatient volume while outpatient volume increases, with 3 of 4 hospitals having more than 60% of their revenue coming from outpatient care. Other challenges facing these hospitals include having trouble recruiting and retaining providers; having greater Medicaid, Medicare, and self-pay populations; having smaller populations that are sicker, older, lower-income, and unemployed; and having less access to technology, such as electronic health records and telehealth.

These hospitals also face a lack of physician coverage, patient safety concerns, and poor management, as well as negative profit margins.

As a result, rural hospitals are closing across the country, with higher concentrations of closures in the South, said Holmes. While some convert to outpatient, primary, or urgent care centers, more than half are being abandoned.

And it’s not just closures of whole units that are an issue, explained Holmes. It’s also the closure of service lines. For example, 9% of rural counties lost their obstetrician services between 2004 and 2014.

As healthcare stakeholders continue to search for answers to the problem, Holmes explained that a possible solution could come from rural freestanding emergency departments that offer 24/7 care. However, he said, there is no current good mechanism for reimbursing them.

Rural health clinics (RHCs)—primary care clinics in underserved rural areas—are also facing significant shifts from these challenges, explained Bill Finerfrock, executive director for the National Association of Rural Health Clinics.

The rural health community has seen a dramatic shift from independent of physician-owned RHCs to provider-based or hospital-owned RHCs, he said. In 2012, 49% of visits were at independent or physician-owned RHCs and 51% were at provider-based or hospital-owned RHCs. Just 4 years later, in 2016, provider-based and hospital-owned RHCs accounted for 63% of visits.

And while the total number of RHCs increased from 4226 in 2014 to 4428 in 2018, the news is not all good, explained Finerfrock. Since 2012, 388 RHCs have closed, 64% of which were independent or physician-owned. He noted that 65% of these closures were in states that did not expand Medicaid.

At the same time, 312 independent RHCs have converted to provider-based RHCs. According to Finerfrock, they are often converted to small hospitals because they get special reimbursement under the Rural Health Clinic program. While the per-visit reimbursement rate for Medicare is capped at $84.70 for independent or physician-owned RHCs in 2019, the rate is uncapped for small hospitals, with the rate per visit in 2018 averaging $206.

Shifting gears, Thomas Morris, MPA, from the Health Resources & Services Administration (HRSA) of HHS, explained that, historically, rural health policy has typically focused on the financial and workforce aspects of rural clinics and hospitals, which is a proxy for the larger concern: access to care.

“While the focus on finance and workforce is important, I’m not sure all of the tweaks in the world to how we reimburse providers or train them is necessarily going to get at addressing these disparities,” said Morris, referencing the higher rates of heart disease, cancer, unintentional injuries, and chronic lower respiratory disease among rural Americans.

He emphasized the importance of supporting access and capacity building through enhanced payments through Medicare and Medicaid; workforce training and clinician placement programs; investments in public, community, and mental health; investments in technology; and key federal resources beyond HHS.

As an example, he cited the rural opioid challenge. Opioid-related overdose deaths in rural areas increased by more than 10% from 2015 to 2016, and research has shown that rural residents are the most likely to be prescribed, and overdose on, prescription painkillers. However, more than 60% of rural communities lack a single physician who can prescribe buprenorphine, and less than 10% of opioid treatment programs are in rural counties.

Responding to this rural epidemic, the 2018 President’s Budget and the 2018 Final Budget both included a targeted focus for HRSA to address the crisis, said Morris. In addition, HRSA has targeted key populations, including the rural underserved, people with HIV, and pregnant women, as well as implemented a multipronged approach that works on prevention, treatment, recovery, capacity building, and workforce.

He added that different parts of HHS have recognized the opportunities for addressing rural health challenges, with CMS implementing a Rural Health Strategy, CDC running a 12-part rural health series in its Mortality and Morbidity Weekly Report, and the National Cancer Institute working on a tailored approach to rural cancer control.