My father, who is now retired, chose to spend most of his long career as a certified registered nurse anesthetist working in smaller, rural hospitals because he preferred a small-town quality of life as well as being a part of a close-knit clinical team serving patients at a local community level.
Like many other rural healthcare professionals, he is acutely aware of the challenges—social, economic and cultural—that rural communities face that directly impacts the quality of healthcare and the health outcomes for people in those communities. In fact, at least one small hospital where my father previously worked, a medical center in Wharton, Texas, outside of Houston, closed its doors just last year. That 159-bed facility had, at one time, served as a regional hospital and a healthcare hub for the surrounding community.
Hospital closings are just one challenge that rural communities face even as the disparity in health status between rural and urban Americans continues to grow. Recent data from the Centers for Disease Control and Prevention (CDC) indicates rural Americans are more likely to die from the five leading causes of death—heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke—than residents in urban regions and that a greater percentage of rural deaths may be preventable.
During a recent webinar presented by the Commonwealth Fund, several rural healthcare leaders offered a more hopeful outlook for the future of rural health within the larger picture of the transformation of healthcare to value-based care. Titled “Banding Together for Population Health: New Business Model for Rural Hospitals,” the webinar first focused on the significant challenges facing rural healthcare—a higher percentage of elderly patients, a higher concentration of uninsured patients, as well as a higher poverty rate. Rural populations have less access to care with 39.8 physicians per 100,000 people compared to 53.5 physicians per 100,000 people in urban areas.
Looking at health status and behaviors, there is a higher percentage of smokers in rural areas as well as a higher prevalence of diabetes and coronary heart disease. The suicide rate among young men is also significantly higher in rural communities.
“Rural America presents a unique healthcare delivery environment—we have elderly populations, a sicker population, and a higher concentration with those at lower incomes, yet it seems that we have the fewest options available when it comes to seeking care. It’s a perfect storm,” Brock Slabach, senior vice president, member services at the National Rural Health Association, said during the webinar.
While this paints a dire picture, what was fascinating to me, and what the webinar really zeroed in on, was that despite these challenges, there are a number of rural healthcare systems that have become incubators for health system innovation. The webinar focused on how accountable care contracts and other value-based payment approaches can strengthen rural hospitals and enable them to innovate.
Slabach noted during the webinar, “Despite challenges, rural communities have begun to innovate, adopting the use of alternative payment models, and initiating delivery system reforms that help to address many long-standing issues that have plagued rural America: the workforce shortages, hospital closures, and a daunting reimbursement challenge for services that impact every rural provider of care.” With regard to alternative payment models and population health, he added, “Rural can lead in this effort; we have small, nimble facilities, with communities that are eager to rally behind change, and with the right leadership and technical assistance, we can be the leaders in this movement, showing urban areas how this movement can really make a difference in not only improving the quality of care but improving the population’s health.”
The National Rural Accountable Care Consortium (NRACC) is supporting rural health systems and hospitals in their journey toward accountable care. The first National Rural ACO was formed in 2013, and today the network organizes 6,000 providers in 164 hospitals in 23 Medicare Shared Savings Program (MSSP) ACOs [as part of the Centers for Medicare & Medicaid Services (CMS) MSSP ACO program], according to Lynn Barr, CEO and founder of Caravan Health and chief transformation officer at NRACC, who was also a speaker during the webinar.
“We’re in the process of signing up our 2018 cohort and are going to about double the number of rural hospitals, as we think 17.5 percent of rural hospitals are going to be in ACO programs next year, which I think is tremendous,” Barr said. “It’s been a very exciting process. In 2015, only 6 percent of our Medicare beneficiaries received annual wellness visits. In 2016, 24 percent of our Medicare beneficiaries received annual wellness visits. That’s the kind of change that really makes a difference.”
She added, “We’ve seen that every one of our sites have begun bending the cost curve—two-thirds have lower costs than the prior year, and one-third appear to be prepared for shared savings.”
During the webinar, two CEOs at rural hospitals, including a critical access hospital, shared their organizations' journeys into accountable care contracts and value-based payment approaches to improve care and population health.