The Future Of Rural Health
Where Nebraska Stands Now
The recent changes in the rural health care system have magnified some of the traditional challenges and created new ones. However, these changes are also creating new opportunities to strengthen and transform the rural health system.
The rural health system in Nebraska has been evaluated on both a regional and state level (Bipartisan Policy Center, 2017 and Office of Rural Health, 2016). These reports, taken together, provide a comprehensive analysis of both the strengths and weaknesses of the rural health system. However, it should be emphasized that these reports have all concluded that while the rural health system continues to be very resilient, the long-term survival of the system and its ability to meet the needs of future patients and improve health outcomes depends on making a series of strategic changes.
One of the strengths of the rural health system in Nebraska is the large number of rural health professionals who are committed to providing high-quality health care services. Another strength is that many rural health leaders are visionary and exploring new models of care. For example, there are several rural physician clinics, both independent and hospital-based, that have joined accountable care organizations (ACOs) and/or become patient-centered medical homes (PCMHs). Some health care providers are also working closely with other health organizations such as community mental health centers, rural dentists, long-term care services, and local health departments to improve care coordination and patient outcomes. In addition to stronger collaborative partnerships, most rural health care organizations are focused on high-quality patient-centric care and operational efficiency. Many have emphasized improving work processes (e.g., streamlining hospital admissions and discharges), reducing waste by applying lean management techniques, and enhancing the patient experience as evidenced by relatively high patient satisfactions scores. Another strength is that rural health organizations are both agile, adaptable and resourceful. In comparison to their large urban counterparts, rural organizations are quite flexible and can shift course more quickly. For example, rural clinics are more likely to allow physician assistants and nurse practitioners to provide care closer to their full scope of practice. Other examples include the effective use of telemedicine and sharing resources such as mobile CT scanners and MRIs.
Many of the challenges facing the rural health care system are related to the demographic and socioeconomic status of the population. The population is not only small but also spread out over a large geographic area. In addition, the population is declining and growing older in most areas. The net result is a smaller volume of services and a less healthy population. These problems are magnified by relatively low incomes and less adequate health insurance coverage. Furthermore, rural populations tend to be less healthy than urban populations for several conditions and risk factors. Although the mortality rates for some conditions (e.g., cancer) tend to be lower for rural populations as compared to their urban counterparts, the rates were higher for heart disease, unintentional injuries overall and motor vehicle crashes. Rural populations were also less likely to have had their cholesterol checked in the past five years, screened for colon and breast cancer and visited a dentist in the past year. They were more likely to be obese, use smokeless tobacco and report their health as fair or poor (Nebraska Department of Health and Human Services, 2016).
The shortage of health professionals has been a significant problem for many years. These shortages include virtually all types of health professionals, including physicians, dentists, behavioral health practitioners, nurses, physical therapists, lab technicians, and many others. The inadequate supply of health professionals has limited access to health care services as well as the number of services that can be provided.
Several reasons for these shortages, including lower reimbursement and a higher workload. Additionally, many younger professionals who are interested in moving to rural areas were unable to find acceptable day care services to meet the needs of their families. The shortage of adequate housing was also mentioned as a factor for not practicing in a small community.
Another issue that limits the supply of health care workers is related affordable health insurance coverage. Many employers in rural areas, including hospitals and clinics, have found that it is difficult to purchase health insurance coverage for their employees because they are simply too expensive. Unfortunately, most of the policies that are more affordable often provide inadequate coverage.
A major problem in some areas is the lack of obstetrical services. These “obstetrical deserts” have become larger because fewer family practice physicians now provide obstetrical care. As a result, some women are forced to drive an hour or more to deliver a baby, which is likely to limit the frequency of their prenatal care visits.
Unfortunately, this problem is likely to become more severe as older physicians retire. In 2015, almost 40% of family practice physicians were over 55 years of age. The retirement factor, coupled with a higher workload and – in some cases – lower compensation, will make it more difficult to recruit an adequate number of health practitioners to rural areas. Given these challenges, new strategies such as more team-based care and a greater use of technology such as telehealth services need to be implemented.
Although only one small hospital in Nebraska has closed its doors in the past four years, several critical access hospitals (CAHs) are experiencing severe financial pressures. In 2007, only four CAHs had a negative margin and five had margins between 0% and 2%. By 2016, nine CAHs had negative margins and 16 had margins between zero and two percent. There are many reasons for the declining profitability of CAHs, including the negative financial impact of sequestration and bad debt policies. According to a recent study, the average one-year loss due to sequestration for each rural hospital was $150,000 and it was estimated at $64,000 for bad debt (Michael Topchik, 2018). In addition, many rural hospitals are located in geographic areas that have small and declining populations, a high proportion of Medicare and Medicaid patients which have lower reimbursement rates, and high levels of uncompensated care, which is directly related to a higher number of uninsured and underinsured patients. Other factors may include a lack of consistent physician coverage and located in a non-expansion Medicaid state (G. Mark Holmes, Brystana Kaufman, and George Pink, 2017).
During the listening sessions, participants also mentioned the negative impact of high deductible insurance plans, the reduction in swing bed usage due to bundled payments in some urban and regional hospitals, and the decreasing revenue associated with value-based plans such as ACOs, particularly if the hospital does not own the clinic. In addition, the proposed changes in some key federal policies such as the 340B medication assistance program could significantly reduce revenue for some hospitals.
Many hospitals and physician clinics are moving upstream and focusing on population health (keeping people healthy instead of waiting for them to become sick or injured). They are also partnering with other organizations such as behavioral health organizations, local health departments, and long-term care organizations to improve the coordination of care. Although the reimbursement system is in the process of transitioning from an emphasis on volume of services to the value of services provided, this transition is far from complete. As a result, many rural health providers are not appropriately reimbursed for their population health efforts.
Although many laws and regulations have been created to protect the health and safety of patients and in some cases to control costs, often these regulations negatively impact the operational efficiency of the hospital and/or are outdated or should be modified to reflect the changes in the health care environment. For example, all small hospitals in Nebraska now have operational electronic medical records (EMRs), but some of them cannot meet the federal meaningful use standards. During the listening sessions, participants agreed that EMRs were essential to high-quality patient care, but meeting the federal requirements was very costly, especially for small hospitals. To meet these requirements continual upgrades were needed, resulting in higher costs, lower revenue, low staff morale, and no appreciable improvement in patient care. If a hospital and/or clinic has a working EMR, it has been quite cumbersome and time-consuming to access information through the Nebraska Health Information Initiative.
To improve care coordination and encourage partnerships between hospitals, physicians, long-term care facilities, and other providers, the HIPAA and Stark laws needed to be modified. Effective care coordination requires health care providers to share confidential patient information, but these laws have created barriers to information sharing.
As previously mentioned, recent efforts by CMS and pharmaceutical companies to eliminate or significantly change the 340B program would be very detrimental to many CAHs in Nebraska and even force some of them to close their doors.
Regulatory and reimbursement policies related to the provision of home health and hospice services have limited the availability of these services in rural areas. For example, home health services are very costly to provide because of relatively low reimbursement rates and high operational costs. However, the home health fee schedule established by CMS is set very low and only allows providers in a high-volume market with a high concentration of patients to earn a small profit. In rural and frontier areas, where the volume of patients is low and operational costs are higher because of the longer travel distances to see patients, access to these services is severely limited.
To improve access to home health services for rural patients, CMS should adjust the fee schedule to reflect the lower volume of patients and higher operational costs. Access could also be improved by allowing reimbursement for home health telehealth visits. These changes would lead to an improvement in health outcomes and a reduction in long-term cost for Medicare.
During the listening sessions, there was considerable discussion about why the fragmentation of health care services resulted in major gaps in services. While the patient referral and coordination process between rural hospitals and physicians and urban hospitals and physician specialists is generally effective, this process does not work nearly as well for other types of services. For example, major problems occur if a patient has a physical health problem and behavioral health issues. In a recent survey of primary care physician clinics in Nebraska, only 37% of the PCMH clinics and 22% of the non-PCMH clinics had access to behavioral health professionals that can provide immediate care for clients who present for a behavioral health condition (David Palm, et al., 2017). These care coordination challenges are linked to the inadequate supply of behavioral health professionals, a lack of data sharing capabilities and reimbursement issues. However, this problem is also related to the fact that the behavioral and physical health systems have operated as separate systems of care. Although the new delivery models such as ACOs and PCMHs are working toward better care coordination models, progress has been relatively slow.
EMS services play a vital role in transporting patients to both urban and rural hospitals, but these services are generally not closely connected to small hospitals nor to other EMS units. A single county often has several ambulance services (e.g., eight in Thayer County with an estimated population of only 5,045 in 2015). Additionally, there is no central, regional or, in many cases, local control of volunteer EMS agencies, which makes it difficult to establish uniform policies and to link these units to other parts of the rural health care system.
Many local health departments are forming strong linkages with a few primary care clinics in their jurisdiction. These linkages involve sharing patients through the implementation of the National Diabetes Prevention Program, worksite wellness programs, and home visitation programs. These departments also assist nonprofit hospitals in developing their community health needs assessments and implementation plans. These plans can be used to identify local community health needs and help to better target resources to address these needs.
Studies have shown a strong association between oral health infections and several chronic illnesses such as heart disease, diabetes, and cancer. Despite this association, access to dental services for low-income children and adults, older populations residing in long-term care facilities, and individuals with mental or physical disabilities often have difficulty accessing oral health services. Many of these access challenges stem from an inadequate supply of dentists, lack of insurance coverage, and a limited number of dentists who participate in the Medicaid program. As a result, these population groups tend to have poorer health status and are more likely to receive treatment in a hospital emergency room. A recent study in Nebraska found that during the period 2011-2013 the average and total hospital room expenditures were estimated at $934 and $9.3 million respectively (Rampa, et al., 2017).