The healthcare delivery system that supports rural America is chronically ill. It has quietly suffered for decades, declining despite various attempts to solve its many complicating factors. Given the systemic challenges already facing rural America, it is not surprising that the early part of the Covid-19 pandemic had a devastating impact on these communities that persists today, highlighting the need for solutions that will reverse the current situation and help drive better health outcomes.
Many of rural America’s health problems can be traced back to access to care. Rural Americans face environmental and economic access biases that are very different from their urban and suburban counterparts.
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The vast geographic dispersion of rural communities and a significant underinvestment into basic infrastructure such as electricity, transportation and telecommunications has created an environment that makes delivering consistent, high-quality care very difficult. These underlying environmental factors make it challenging for rural healthcare delivery systems to attract and retain providers – a challenge compounded by the fact that rural hospitals are closing at a rate of 10-15 per year.
The economic structures of American healthcare make delivering care in lower-populated areas very difficult for traditional provider organizations if they are to remain solvent. Ongoing labor force changes have impacted healthcare at all levels across the country, but the effect has been amplified in rural areas by a shortage of primary care physicians. More than 60% of the Primary Care Health Professional Shortage Areas (HPSAs) are in rural areas. It is increasingly clear that traditional brick-and-mortar professional services are unable to serve all of the clinical needs of rural Americans and lack the resources to address social determinants of health in these communities.
The result of rural America’s multifaceted lack of access is the involuntary exclusion of tens of millions of Americans from effective participation in the healthcare delivery system. It has led to a higher than average rate of chronic conditions among rural Americans – an extremely difficult public health problem even when there is easy and consistent access to high-quality care and social support.
While the pandemic has exposed many weaknesses in our healthcare delivery system, it has also generated a wave of healthcare policy innovation and the formation of private-sector businesses focused on solutions for underserved populations, including rural Americans. These new policy initiatives, combined with the availability of experts in remote care delivery, have the power to create a much more equitable approach, allowing both patients and providers access to specialized resources that can help support the CMS quadruple aim more effectively.
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The Affordable Connection Program (ACP) and enhancements to existing programs such as USDA ReConnect, are designed to support high-speed telecommunications infrastructure development and to help individuals afford access to services. Rate increases for CCM, expanded codes for Primary Care Management (PCM), and higher care management reimbursement for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) are all helping providers offer quality, targeted services to even more patients.
The physical infrastructure expansion for video conferencing and telephonic engagement removes much of the geographic burden facing rural Americans. It also creates a mechanism for Critical Access Hospitals (CAHs), RHCs, and other provider organizations to partner with companies that can deliver the social infrastructure necessary for consistent, patient-centric care of rural Americans.
Rural providers should leverage outsourced preventive services such as Behavioral Health Integration (BHI) and Chronic Care Management (CCM) to expand their reach, help them focus on managing rising-risk patients to avoid further decline, and build a strong social infrastructure that allows providers to to engage in consistent, trust-based interactions with patients between office visits – services often provided by care navigators.
Alternate means of engagement allows care navigators to work with providers to close non-clinical care gaps in a way that aligns with physician-driven care plans. They can alleviate the burden of many routine aspects of care (e.g. scheduling appointments, transportation to services, medication delivery, etc.), allowing providers to shift from a reactive model of care delivery to a more proactive and preventive model. Care navigators build trust with patients over time and are often more aware of the non-clinical factors that account for over 80% of individuals’ health status. Numerous studies show that their consistent, high-touch engagement helps individuals maintain better health and patients report higher satisfaction with the care they receive.
Now, with better alignment between policy and availability of support for patients and providers, there’s real opportunity to make change possible. Rural health providers now have access to the tools and organizations that will support the move toward a more comprehensive care delivery model focused on prevention and proactive management of clinical issues and the Social Determinants of Health (SDoH) challenges that cause or exacerbate the clinical issues. This whole-person approach to care provides better alignment with the CMS quadruple aim, and helps advance the move to value-based care. Research also shows it can materially reduce expenditures, particularly for those individuals living with multiple chronic conditions and unmet mental health and behavioral health needs.
Americans need drastic care delivery transformation. Delivering consistent, quality care is the one of the most difficult parts of our complex system and many of the solutions that work in a rural setting can also be effectively adopted by non-rural providers. Solving access issues specifically for rural Americans will go a long way in fixing access for Americans in general.
Photo: marekuliasz, Getty Images
Ryan Atwood joined the Engooden team after more than twelve years working with hospitals and physician groups to develop managed care strategy, negotiate contracts, and implement value-based care programs. During this time, Ryan worked closely with payer and provider leadership teams in support of strategic objectives for revenue enhancement, cost reduction, operational improvement and regulatory compliance. Ryan brings his deep understanding of care delivery operations and healthcare finance as well as his passion for innovation and health equity to Engooden Health.
