A case for a paradigm shift in rural health care

One hundred eighteen rural hospitals in the United States have closed since 2005, and almost 700 more are in danger of closing, according to a recent health policy article published in The Journal of the American Osteopathic Association. The author, Brandon Isaacs, DO, says the decrease in available health care has been detrimental to the health outcomes of people living in rural areas.

The two main factors cited for hospital closures are economics and workforce shortages.

In the past, the majority of the U.S. population lived in rural America and hospital stays were much longer. Large institutions were built to meet local health care needs. Over time, the rural population decreased and shifted more toward urban areas. With improved technology and more efficient outpatient management, lengths of stay also decreased. These changes have resulted in decreased revenue for hospitals, which is the most common reason for closure.

The other factor causing hospital closures, workforce shortages, is due in part because of a ratio mismatch: 20% of the U.S. population lives in rural areas, while only 10% of physicians practice in those same areas. In 2015, Dr. Isaacs spoke with the CEO of a hospital in rural Oregon who reported his hospital was operating at 23% of the necessary manpower and that the majority of the hospital’s physicians were over 60. In a 2018 follow-up interview, the CEO said the situation was worse and his workforce had dwindled further.

To provide better health care access to rural communities and increase workforce numbers, Dr. Isaacs proposes implementing the following strategies as short- and long-term solutions:

• Change the Health Professional Shortage Area (HPSA) scoring system to improve access to loan repayment and make the “Travel Time to Nearest Source of Care Outside of the Region” answer more heavily weighted to enable remote communities to offer physician HPSA incentives.
• Increase physician retention by increasing rural health care pipeline programs that provide exposure to medical professions. Participating students are more likely to choose a health care career and return to rural areas to work.
• Support the community outpatient hospital model to lower overhead expenses for rural communities.
• Update Medicare’s hospital guidelines and rules, which are limiting because they are based on maintaining current infrastructure and crisis management. The updated guidelines should allow rural outpatient hospitals to focus on wellness, prevention, long-term care and acute-care interventions.

Dr. Isaacs writes that by implementing these proposed strategies, “rural communities would ‘grow their own’ health care professionals to administer emergency, preventive, and long-term care in financially sustainable outpatient hospitals.”