November 7, 2022
Is that headline a bit hyperbolic? I certainly hope so. Even while rural hospitals have been steadily closing over the past 20 years, I’ve avoided considering that perhaps this was an inexorable decline.
But there’s little choice now but to ask the question: Is the rural health business model sustainable?
“Rural hospitals and their communities are facing a crisis that can’t be ignored, one that could significantly worsen with a pandemic like COVID-19 or any downturn in the economy,” says the 2020 Rural Hospital Sustainability Index published by the consultancy firm Guidehouse. “Through legislative action, affiliation, and engagement, local hospitals can once again become and remain facilities that their communities can embrace, utilize, and sustain.”
So, where do rural hospitals stand now that both the dreaded pandemic and economic disruption have occurred? In short, the challenges remain the same, even if they are now more pronounced than they were just a few years ago. As Guidehouse notes, there is an indispensable role for government on both the local and national level to play in the preservation of rural healthcare, but the combined use of other strategies they also suggest would help avoid making rural care something like an economically one-dimensional government program.
“We have witnessed a veritable digital health revolution …,” write Eric Larsen and Tommy Ibrahim in The Health Care Blog. “From telemedicine to remote diagnostics to the delivery of medications directly to a patient’s home, it seems that for every health care access need there is a digital solution.”
And maybe there is when it comes to “health care access,” but that’s not the sum total of what plagues rural healthcare. That a technological solution exists for a particular problem is no guarantee that it will be implemented effectively and used reliably. So many other facts are in play.
And, to their credit, neither Guidehouse nor Larsen and Ibrahim make the argument for technology as a magic panacea for what ails rural care.
“We see myriad factors impeding the successful adoption of these [digital] solutions,” write Larsen, president of The Advisory Board, and Ibrahim, president and CEO of Bassett Healthcare.
The myriad factors will be familiar to anyone who’s tried to implement healthcare technology. They include the following:
These complicating factors are exactly why Guidehouse includes political leaders in the group that actually has the influence necessary to protect rural health. Indeed, the complexity of factors that pose a threat to rural care make government on different levels an essential participant. These include a degraded payer mix, a misalignment of patient needs and hospital services, a shortage of clinicians, revenue challenges, and an inability to leverage innovation.
“Many already budget-strapped rural hospitals have been unable to keep up with technological trends,” Guidehouse says, “as they lack the capital to invest in updated, innovative technology, such as electronic health records (EHRs), telehealth, and advanced imaging platforms.”
Even if you build it, the rural hospitals will not come … without sufficient funding.
The Final Recommendations of the American Hospital Association’s Future of Rural Health Care Task Force make quite clear that saving rural healthcare requires a full cocktail of solutions that expand well beyond the boundaries of healthcare technology, and everything is on the table.
Perhaps public-private funding is a key element, per the AHA report. Maybe flexible funding options to transform infrastructure can be effective. What about a rural design center for payment and delivery models? Such a program already exists, but rural hospitals rarely meet the basic requirements of the program. How about linking hospitals with professional grant writers for help with pursuing available funds? Maybe, and wouldn’t it be disappointing to learn that the key to helping rural hospitals is just someone to guide them through an applications process.
Beyond these ideas, the AHA document focuses on eight (8) “promising practices” they think should be tested more broadly. Among these are telemedicine, the expansion of broadband technology, an “investment in transformational leadership,” and the integration of rural philanthropy in rural hospitals’ long-term budgets.
In combination, these and other strategies would go a long way toward shoring up rural healthcare so that the closures of the past 20 years become a trend that ends.
So, to the original question: Can technology save rural healthcare?
By itself? Absolutely not. It would be dangerous and myopic to follow the well-trodden path of treating technical innovation like it is magic and failing to see that it also creates unforeseen complications.
And, honestly, no one actively engaged in rural healthcare is making the argument that technology alone will solve existing problems. That perspective only emanates occasionally from marketing departments in health IT firms, and it usually falls on rather skeptical ears.
The benefits health IT offers are, however, necessary, even if they never will be sufficient. Also necessary is a coordinating entity that sees the bigger picture and is able to coalesce all the players. That grand coordinator may be a hospital system, as is the case with Ibrahim’s Bassett Healthcare in central New York, or it may be a visionary hospital administrator, which is what the AHA seems to be hoping for in the organization’s report on rural care.
Or, though it may bring a shudder to some spines, it may be a government agency, especially when it comes to isolated safety-net hospitals in rural areas that aren’t attractive acquisition targets. In those cases, government is the only organization with the mandate to coordinate the continuation of care.
So, let’s not go down the path of trying to find solutions to the rural healthcare crisis the don’t involve local and federal governments. Quite simply, there seldom are any. Rather, proactively making government a participant in the process brings in an entity with the most reliable source of revenue, taxes, and gives other stakeholders the opportunity to influence policies in ways that are not always available.
Fixing rural healthcare is the kind of team effort that free market orthodoxy says cannot succeed, but orthodoxy puts the kinds of limits on creative thinking that rural healthcare cannot suffer for much longer. What works is more important than dogma.