Category: rural healthcare

The plain truth is that rural America has always had a market failure problem. 

In the 1930s, the problem manifests as woefully inadequate telephone and electrical service. The spaces were just too wide open, the potential customers too few, for companies to invest in America’s in-between places. 

In response to this market inefficiency, a federal government led by Franklin Roosevelt stepped in and created the Rural Electrification Administration (REA). Within 20 years, phone service was available to 65 percent of rural residents, and electricity extended to 96 percent. With the help of Washington, DC, modernity was extended to the heartland. 

And now, when market orthodoxy is almost an unassailable truth and the federal government is less trusted than ever, another market failure stares us in the face. This time the technology is fast internet service (broadband), which was a concern before Covid-19 and is now a need arguably on par with electricity in 1936. 

“The strength of High-Performance Broadband is that it will—if fully accessible to all in America—help solve some of our most critical challenges and help people overcome key barriers regardless of where they live and who they are,” reads an editorial published by the Benton Institute for Broadband and Society this past October. 

It’s not that the federal government has simply entrusted rural internet service to companies that don’t provide it, though there is some of that. Since 1995, the Rural Utilities Service (successor to the REA) and Federal Communications Commission have doled out billions in subsidies. What the feds have not done is replace stop-gap funding mechanisms with a comprehensive plan that solves particular problems associated with inadequate rural broadband almost all urban dwellers never have to face.  

At the time of the Benton Institute editorial, the most obvious critical challenge was Covid-19 and it remains so, even with the prospect of a vaccine on the horizon. It’s worth looking specifically at the ways Covid-19 has elevated the importance of broadband, particularly with regard to healthcare. 

Most obviously and importantly, the pandemic has boosted the importance of telehealth as a means of bringing clinicians and patients safely together. What was an industry experiencing modest growth is now a healthcare sector boosted by rocket fuel. 

“Between April 2019 and April 2020, national privately insured telehealth claims’ increased by 8,336 percent (as a proportion of total medical claims),” says the Health Affairs Blog. “While those ratios eventually tapered in the proceeding months as in-person visits rebounded, there’s no doubt that more patients and providers are relying on telehealth than ever before.” 

Of course, safety is only the most pressing concern when it comes to telehealth. Before the pandemic, remote patient visits were driven by the pursuit of lower costs and greater convenience—factors that will once again rise to the top when Covid-19 is managed. The difference, when we arrive at that longed-for future date, will be that telehealth will have proliferated and wormed its way more deeply into common clinical practice. 

All of that seems like progress, except that true progress doesn’t exclude millions of Americans. With limited broadband in rural areas, the blessings of telehealth will currently not fall on a large segment of the population. 

According to Health Affairs, “The lack of broadband in rural areas is one of the most striking inequalities in US society. Due to the lack of broadband availability, tens of millions of rural Americans aren’t able to ‘see’ their doctor over the internet in the same way urban Americans can. Making matters worse, financially strapped rural hospitals are being shuttered by the dozens.”

It would be a mistake to see the failure of rural hospitals as uniquely a healthcare issue on either the cause or effect side of the technology equation. On the one hand, slow internet makes telehealth visits more difficult and sometimes impossible. On the other, slow internet also makes living in rural areas and earning a decent living very challenging, which dramatically limits the rural hospital’s potential patient base. 

According to Alex Marre, a regional economist for the Federal Reserve, access to broadband improves wages, lowers unemployment, grows the population, and boosts home values, all of which creates a more stable base of support for local hospitals.

So, is there a market solution for what to date is a market failure? In a word, no. Well, not yet, at least. While the government may not be the broadband provider in the short or long term, some government involvement is probably a necessary component of the overall solution, especially with regard to money.

Another solution might be cooperatives, which helped extend the reach of electricity in the 1930s and have seen some broadband success in the modern era. 

As CEO of Oklahoma Electric Cooperative, Patrick Grace leads an effort started in 2018 to extend fiber broadband to cooperative members. Working toward providing broadband to all 43,000 members, OK Fiber currently offers 100 Mbps speeds for $55 a month and 1 Gbps speeds for $85. 

But what was true of electricity access also holds for broadband. Absent sufficient dollars, fiber networks take a long time to implement, regardless of how well managed the cooperative. For rural areas, time is of the essence, and concerted action may create a rural renaissance where there is currently a steady decline.

Returning to the Health Affairs Blog: 

“Federal investment in rural electrification helped ignite investment across the country. Manufacturers didn’t have to locate near big cities, instead, they could build factories in rural areas where land was cheaper. Electric machinery and refrigeration made farms and ranches more productive. Today, in an era where remote work is increasingly common, rural and urban Americans alike need broadband to stay connected and productive.”

Again and again, we see that public health is an interrelated web of contributing factors. It’s education, and it’s housing, and it’s family support, and it’s job security. In the 1930s public health could undoubtedly be tied to electricity. In modern times, the equivalent is access to high-speed internet. The market has had sufficient time to provide a solution. Time for the public sector to come up with a comprehensive plan that includes private industry. 

So long as we could say, “Healthcare is a business,” we could continue to avoid the moral and ethical choices from which such statements shield us.

But then COVID-19 came into the picture and the bottom dropped out of healthcare as a business. Hospitals and health systems are hemorrhaging money; the American Hospital Association estimates total losses will exceed $300 billion by the end of the year.

“The growing number of cases is threatening the very survival of hospitals just when the country needs them most,” writes Bloomberg News. “Hundreds were already in shaky circumstances before the virus remade the world, and the impact of caring for COVID-19 patients has put hundreds more in jeopardy.”

Nowhere are these dire illustrations of American healthcare during COVID more impactful than in the country’s rural areas, most of which struggled mightily even before there was a pandemic. Predominantly white small towns and unincorporated areas are where so-called diseases of despair—alcoholism, drug addiction, suicide—are at their worst. To say the closing of a hospital in these areas adds insult to injury dramatically undersells the devastation.

Since 2005, more than 170 rural hospitals have closed in America; 18 of those shut down in 2019 alone and 14 closed by mid-August of this year. When a rural hospital closes, it doesn’t just make lifesaving care more difficult to get, but it certainly does that. According to a University of Washington study, rural hospital closures drive up mortality rates in the surrounding community by about 6 percent. Comparable urban closures have no discernable impact on mortality.

Immediate access to the care a full-service hospital with specialists provides may have made the difference for Robert Finley. A resident of Fort Scott, Kansas, which lost Mercy Hospital in February 2019, Finley fell and hit his head shoveling snow and then went to sleep with what turned out to be a brain hemorrhage. During a week in the hospital, he never regained consciousness.

“When this kind of trauma happens, time matters,” explains Sarah Jane Tribble on Kaiser Health News’s Where It Hurts podcast. “It takes time for the medevac operator to find a pilot to come for Robert. The pilot then has to get there. Once he’s arrived, he still has to transport Robert to Kansas City.”

Hospital closures also blow a sizeable hole in the surrounding community. These facilities are often one of the largest employers. The hospital itself and employees—well-paid physicians among them—are a crucial part of the tax base. Satellite facilities like clinics and dialysis centers, not to mention other local businesses with which the hospital contracted, often disappear shortly after the hospital shuts down.

The challenges a hospital closure creates are often placed before people who can least afford yet another obstacle.

“By one estimate, socioeconomic factors account for 47 percent of health outcomes,” write George Holmes and Sharita Thomas in the AMA Journal of Ethics. “Poverty and inadequate transportation are two important social factors that make rural residents particularly vulnerable to a hospital closure. Rural residents experience higher rates of poverty than do urban residents and can live in communities of ‘persistent poverty,’ where the poverty rate is at least 20 percent over approximately 30 years.”

Holmes and Thomas, acknowledging that healthcare is a business, suggest that the ethical approach to closing a hospital is to engage the community as a partner throughout the process. Will emergency services still be provided after the hospital is gone? Can transportation challenges be mitigated? What will the closure do to the job base?

These and many other questions are valid. With COVID-19, however, there emerges another question that was less frequently discussed pre-pandemic: To what extent is a hospital a public good more than it is a business?

“Coronavirus is definitely a reminder that health care is, in fact, a public good,” says Dan Mendelson, founder of healthcare advisory consultancy Avalere Health. “We all have a vested interest in making sure that everybody around us is seeking appropriate medical care at the right time.”

That public good, Mendelson explains further, is not limited to the current COVID-19-fueled scenario. When people don’t have insurance or access to care, they tend to wait until their health gets much worse before seeking treatment, which guarantees either very expensive treatment or mortality. Regular exams enable early treatment, which gives clinicians the opportunity to manage illness more efficiently, effectively, and affordably.

Still, nothing illustrates the idea of healthcare as a public good quite so elegantly as a pandemic. And while many people initially thought COVID-19 would mercifully avoid adding to the struggles of rural Americans, it’s become clear that the virus does not discriminate based on geography.

The current scenario in rural America hastens the country’s reckoning with a fractured healthcare system that leaves too many sick or bankrupt or both. This day was always coming, after all.

What’s necessary to ensure the availability of care in America’s rural areas is the resolve to ensure it exists. Calling it a public good may help sell it, but ultimately what it’s called matters less than that it’s there. In many ways, the fate of rural hospitals is a test of America’s commitment to rural life as more than an exercise in economic viability. Certainly, the food produced in rural areas is a public good we’re willing to subsidize. Is not healthcare also?

The good news is that many of the ideas bandied about as solutions for the broader healthcare crisis will lift up both urban and rural hospitals and providers.

As former National Coordinator for HIT David Blumenthal and others write in a recent New England Journal of Medicine article, capitation is one payment approach that may help chronically underfunded facilities improve financial viability.

Beyond creative payment schemes, resolve manifests as public policy.

“If reduced prepayments nevertheless threaten the availability of critical services, additional public policies may be necessary to subsidize providers whose losses might jeopardize the health of communities,” Blumenthal, et al, write.

If what matters in economics is the numbers, what will ultimately matter in moving away from a predominantly economic approach to healthcare is also the numbers, but in terms of casualties. The economic approach couldn’t keep tens of thousands from dying of COVID-19 in hospital-rich urban areas, so it’s a bad argument for letting the rural poor expire because the local hospital can’t break even.

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Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

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The COVID-19 virus is ravaging the planet at a scale not seen since the infamous Spanish Flu of the early 1900s, inflicting immense devastation as the U.S. loses more than 200,000 lives and counting. According to CDC statistics, 94% of patient mortalities associated with COVID-19 were simultaneously suffering from preexisting conditions, leaving a mere 6% of victims with COVID-19 as their sole cause of death. However, while immediate prospects for a mass vaccine might not be until 2021, there is some hope among rural hospital health information technology consultants where the pandemic has hit the hardest. 

The fact that four in ten U.S. adults have two or more chronic conditions indicates that our most vulnerable members of the population are also the ones at the greatest risk of succumbing to the pandemic. From consultants laboring alongside healthcare administrators and providers, all must pay close attention to patients harboring 1 of 13 chronic conditions believed to play major roles in COVID-19 mortality, particularly chronic kidney disease, hypertension, diabetes, and COPD.

Vulnerable rural populations must be supervised due to their unique challenges. The CDC indicates 80% of older adults in remote regions have at least one chronic disease with 77% having at least two chronic diseases, significantly increasing COVID-19 mortality rates compared to their urban counterparts.

Health behaviors also play a role in rural patients who have decreased access to healthy food and physical activity while simultaneously suffering high incidences of smoking. These lifestyle choices compound with one another, leading to increased obesity, hypertension, and many other chronic illnesses. Overall, rural patients that fall ill to COVID-19 are more likely to suffer worsened prognosis compared to urban hubs, a problem only bolstered by their inability to properly access healthcare. 

Virus Helping Push New Technologies

COVID-19 has shown the cracks in the U.S. healthcare technology system that must be addressed for the future. As the pandemic unfolds, it’s worth noting that not all lasting effects will be negative. Just as the adoption of the Affordable Care Act a decade ago spurred healthcare organizations to digitize their records, the COVID-19 pandemic is accelerating overdue technological shifts crucial to providing better care.

Perhaps the most prominent change has been the widespread adoption of telehealth services and technologies that connect patients with both urgent and preventive care without their having to leave home. Perhaps the most prominent change has been the widespread adoption of telehealth services and technologies that use video to connect patients with both urgent and preventive care without their having to leave home.

Even if COVID-19 were to fade away on its own, the next pandemic may not. Furthermore, seasonal influenza serves as a reminder that healthcare is not a skirmish, but a prolonged war against disease. Rather than doom future generations to suffer the same plight our generation has with the pandemic, now is the time to develop innovative IT strategies that focus on protecting our most vulnerable citizens by leveraging existing healthcare initiatives to focus on proactive responses instead of reactive responses.

On the Right Road

While some of the most vulnerable people are the elderly, rural residents, and the poor, the good news for them is that CMS has long advocated the use of preventive care initiatives such as Chronic Care Management (CCM) and Remote Physiologic Monitoring (RPM) to track these geriatric patients. To encourage innovation in this sector, CMS preventive care initiatives provide generous financial incentives to healthcare providers willing to shift from conventional reactive care strategies to a more proactive approach focused on prevention and protection. This should attract rural hospital CEOs who have been struggling even more than usual because of the virus.

These factors led to the creation of numerous patient CCM programs, allowing healthcare executives and providers to remotely track the health status of geriatric patients suffering from numerous chronic conditions. The tracking is at a rate and scope unseen previously through the use of electronic media. Interestingly enough, the patients already being monitored by CCM programs overlap heavily with populations susceptible to COVID-19. To adapt existing infrastructure for the COVID-19 pandemic is a relatively simple task for hospital CIOs. 

As noted earlier, one growing CCM program that could be retrofitted to deal with the COVID-19 pandemic are the use of telehealth services in rural locations. Prior to the pandemic, telehealth services were one of the many strategies advocated by the CDC to address the overtaxed healthcare systems found in rural locations. 

Better Access, Funding and User Experience for Telehealth

Today, telehealth is about creating digital touchpoints when no other contact is possible or safe. It offers the potential to expand care to people in remote areas who might have limited or nonexistent access, and it could let other health workers handle patient screening and post-care follow-up when a local facility is overwhelmed. As a study published last year in The American Journal of Emergency Medicine affirms, virtual care can cut the cost of healthcare delivery and relieve strain on busy clinicians.

Telehealth has also gotten a boost from the $2 trillion CARES Act stimulus fund, which provides $130 billion to healthcare organizations fighting the pandemic. The effort also makes it easier for providers to bill for remote services.

The reason for the CDC and hospital administrators’ interest in telehealth was that telehealth meetings could outright remove the need for patients to travel and allow healthcare providers to monitor patients at a fraction of the time. By simply coupling existing telehealth services with CMS preventive care initiatives focused on COVID-19, rural healthcare providers could detect early warning signs of COVID-19. 

Integration Key to Preemptive Detection

This integration at a faster and far greater scale could mean much greater preemptive virus detection through routine telehealth meetings. The effect of telehealth would be twofold on hospitals serving rural and urban health communities. It could slow the spread of COVID-19 to a crawl due to decreased patient travel and improved patient prognosis through early and intensive treatment for vulnerable populations with two or more chronic health conditions.

This integrated combination would shift standard reactive care to patient infections to a new monitoring methodology that proactively seeks out infected patients and rapidly administers treatment to those most at risk of mortality. This new combination of preventive care and telehealth services would not only improve patient and community health but would relieve the financial burden incurred from the pandemic due to the existing CMS initiatives subsidizing such undertakings.

In conclusion, preventative care targeting patients with pre-conditions in rural locations are severely lacking in the context of the COVID-19 pandemic. By leveraging CMS preventive care initiatives along with telehealth services, healthcare providers can achieve the following core objectives.

First, there are financial incentives with preventive care services that will relieve the burden on healthcare systems. Second, COVID-19 vulnerable populations will receive the attention and focus from healthcare providers that they deserve to slow the spread through the use of early detection systems and alerts to their primary health provider. Third, by combining with telehealth service, healthcare providers can efficiently and effectively reach out to rural populations that were once inaccessible to standard healthcare practices.

Rural hospitals are grappling with high rates of chronic disease, lack of broadband access, and workforce shortages that are exacerbated by the low pay and professional isolation that are characteristic of rural settings. It is from within this digital divide that rural hospitals have learned so much they can pass along to their urban peers.

What You Should Know:

– Cerner announced a new offering, CommunityWorks
Foundations aimed at reducing costs and speeding up the implementation process
for Rural and Critical Access Hospitals.

– This much-needed offering caters to small rural healthcare providers, who often face challenges such as geographic isolation, workforce shortages, educational disparities, and diminishing resources that can make it harder to deliver high-quality care.

– Rural hospitals serve about 20% of all Americans, and
Cerner is committed to providing technology and services to help individuals in
all communities get access to quality comprehensive healthcare.

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Cerner Corporation®,
today announced a new tailored cloud-based technology offering, CommunityWorks Foundations, created to help
Critical Access Hospitals across the U.S. reduce financial burdens. This new
technology, geared toward smaller and rural hospitals, offers a fixed-fee
payment structure with no up-front capital spend to help reduce costs and
lengthy implementation processes.

Rapid Cloud-based Deployment

CommunityWorks Foundations, a cloud-based
version of the Cerner Millennium® electronic health record
(EHR), is designed to expedite implementation with a six-month kick-off to
go-live timeline and will make it easier for small hospitals to better serve their
patients.

As with all hospitals deploying CommunityWorks, those using CommunityWorks Foundations will also leverage Cerner’s solutions and services designed to help improve clinical and business outcomes, the patient and provider experience and satisfaction while reducing physician burnout. CommunityWorks clients have seen success, with more than 70% of new clients beating baseline accounts receivable by 180 days post-implementation. These hospitals averaged a 5.5% improvement in this area.

Why It Matters

Healthcare providers in small communities often face challenges such as geographic isolation, workforce shortages, educational disparities, and diminishing resources that can make it harder to deliver high-quality care. The National Rural Health Association found COVID-19 has exacerbated these trends, with significant financial impact on these specialty hospitals – half of which were operating at a financial loss prior to the pandemic. Rural hospitals serve about 20% of all Americans, and Cerner is committed to providing technology and services to help individuals in all communities get access to quality comprehensive health care.

“Working with this segment of clients for more than a decade, we have evolved this cloud-based model to meet the various challenges community and rural health care organizations face,” said Mitchell Clark, president, CommunityWorks, Cerner. “CommunityWorks Foundations is the next evolution based on what we’ve learned from our more than 200 rural and critical access clients and the broader industry. It is built to help reduce financial barriers and better support communities that sometimes face challenges accessing the most innovative health care technology.”

Early Adoption

With the successful early adoption of CommunityWorks Foundations
at organizations like Macon
Community Hospital, Cerner continues to demonstrate value to clients.
Johnson County Hospital (JCH), an 18-bed Critical Access Hospital with two
clinics located in southeast Nebraska, recently signed for CommunityWorks Foundations.
Hospital leaders cite cost, ease of implementation and vendor support as top
drivers behind the switch to Cerner.