The challenging economics of providing care in rural communities contribute to gaps in access, according to a Jan. 25 report published by the American Hospital Association. Rural communities, by nature, have fewer people and do not generate the healthcare utilization to finance the full spectrum of healthcare services.
Rural healthcare can also be more costly on a per patient basis as those in rural communities tend to have more complex health needs, are more likely to be uninsured and more likely to rely on public programs when they do have coverage, according to the AHA.
With this in mind, it's unsurprising that many hospitals have struggled to keep their doors open, particularly with the macroeconomic and financial challenges that they were forced to deal with stemming from the pandemic.
Since 2020, 37 rural hospitals across the U.S. have closed, according to data compiled by the University of North Carolina's Cecil G. Sheps Center for Health Services Research. Many more are at risk of closing or filing bankruptcy this year as expenses continue to outpace revenue for many hospitals.
To address concerns that rural and critical access hospital closures are reducing access to care for people in rural areas, CMS established the rural emergency hospital designation last year. Few have converted to the new Medicare provider type, but hospital leaders are taking the designation more seriously this year as financial challenges drag on and stifle recovery efforts.
"The REH program is still very new, and just as it took time for the hospital community to warm up to the critical access hospital designation, this will be no different," Brooke Kensinger, CEO of MercyOne Elkader (Iowa) Medical Center, told Becker's. "Hospital leaders and community boards are learning more about the pros and cons of this option, and whether it is truly the best path at this time for their community."
Downsizing or discontinuing any service is a difficult decision for hospitals that are committed to providing high-quality care to their communities, but the current economic and workforce climate has forced many facilities to do so. However, much like the CAH designation, hospital leaders are grateful to have a new model in the REH designation from which to work.
"We expect that as healthcare leaders and board members across the country continue to evaluate this program, there will be improvements made — similar to the CAH program — to better ensure access to care," Ms. Kensinger said.
Staffing shortages, rising labor costs and the struggle to recruit and retain talent — particularly in rural communities — have exacerbated hospitals' financial challenges, but, in a 24/7 industry, it is critical to not inadvertently create inpatient deserts when considering facility closures or conversions, according to Ms. Kensinger.
Many critical access hospital challenges relate to the workforce and ensuring they can maintain access to care for patients 24/7. MercyOne Elkader, a 25-bed critical access hospital, has a tough time recruiting nurses; paramedics; radiology, ultrasound and lab technicians; and providers such as physicians, nurse practitioners, general surgeons and anesthesia specialists.
"Finding those that will take on-call and/or work shifts on nights/weekends prove to be the most challenging for us to recruit," Ms. Kensinger. "We have come up with innovative ways to combat these shortages by trying to grow our own team or recruiting new team members through scholarships, grants and partnerships."
A few ways MercyOne Elkader is combatting staff shortages include:
- Supporting employees who want to advance their careers (including CNA to LPN to RN, phlebotomist to lab tech, EMT to paramedic, first responder to EMT, ultrasound tech to echocardiogram tech)
- Hiring nurses and supporting them financially during their last year of school.
- Becoming a National Health Service Corps-certified site, which offers loan repayment options for providers who commit to working in a health professional shortage area.
- Partnering with local colleges to be clinical sites for training nurses and radiology techs and offer classes for the hospital staff to teach first responder and EMT courses.
- Supporting Gov. Kim Reynolds' provision of grant funding for healthcare apprenticeships in Iowa.
In addition to workforce, another key challenge for rural hospital leaders is ensuring long-term financial viability for their facilities while meeting the needs of their community.
"A program that has become very important to the financial viability of critical access hospitals is the 340B program," Ms. Kensinger said. "MercyOne Elkader is newer to this program than most, joining in 2018. It helps to subsidize our 911 ambulance response that is currently carved out of the critical access hospital reimbursement model and operates at a loss. If this program were to go away, it would be financially detrimental to rural hospitals."