Hospitals or hybrid clinics? Report looks at what best serves rural areas
How rural hospitals survive in today’s healthcare economy is a tense policy debate, both in Washington, D.C., and remote areas. A new report adds another twist, suggesting that not all rural communities need critical-access hospitals.
Those hospitals can maintain up to 25 inpatient beds, but researchers with the Bipartisan Policy Center and the Center for Outcomes Research and Education found that, on average, only three to five of those beds were occupied in seven states they studied, a costly proposition for those facilities.
That presents a complicated question for communities, some of which, researchers argued, would be better served by facilities that mix primary care and emergency services.
“I think it was the realization that the volume being so low in many of these places coupled with the high fixed-operating costs makes it, from a long-term perspective, not necessarily financially sustainable,” said Dr. Anand Parekh, an author of the report and BPC’s chief medical adviser.
For the report, researchers talked to more than 90 thought leaders and stakeholders in seven states last year to learn about the ongoing challenges rural healthcare providers face, the implications of federal policies and what could be improved.
The states included in the study— Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming—have some of the lowest population densities in the country. Of the nation’s nearly
1,340 critical-access hospitals, one-quarter are located in these states, according to the report.
Local providers told BPC their patients are older and spread out, and that the lack of access to the care they need can have “devastating consequences,” the report said. Shortages in behavioral health and obstetrics providers, nursing homes, ambulance services and non-emergent care were highlighted as rising concerns.
Critical-access hospitals are a touchy subject for stakeholders in the states studied. They’re typically an important economic component of their community, but in some cases aren’t financially sustainable because of low occupancy. Critical-access hospitals in South Dakota, for example, see an average of five patients per day, the report found.
How to reinvent critical-access hospitals to better serve communities is undecided, Parekh said, but it would likely combine primary care with acute services.
A number of different formats have been floated. Sen. Chuck Grassley (R-Iowa) is championing the Rural Emergency Acute Care Hospital Act, which would create a new Medicare classification to allow rural hospitals to limit themselves to providing emergency and outpatient services. The bill doesn’t have a House companion.
The National Rural Health Association supports the REACH Act, but prefers its own plan, the Save Rural Hospitals Act. That would allow for the creation of “community outpatient hospitals,” but also includes increased Medicare funding and other provisions. “We’re willing to work with anybody on working toward a new model,” said Brock Slabach, NRHA’s senior vice president.
Another resounding take-home message that emerged: There’s no onesize-fits-all policy that will tackle the challenges in every rural community. Solutions will have to be flexible.
Most delivery system reforms under the Affordable Care Act either excluded rural providers or allowed them to participate with little financial risk.
The NRHA has developed a proposal to help critical-access hospitals dip their toes into value-based purchasing. It would increase hospitals’ Medicare reimbursement by 2% if they submit quality data, which they’re currently not required to do, and agree to join Medicare managed-care groups.
There are also efforts to expand the use of telemedicine and to allow nurses and physician assistants to practice to the highest level of their licensure. Rural areas are also embracing the use of community health workers, case managers and care coordinators who travel to patients and help arrange their care.