By Mariah Muhammad and Laura Dyrda of Becker's Hospital Review
Rural hospitals and healthcare facilities face amplified financial challenges amid persisting workforce shortages, rising costs and leveling reimbursement. Reserves are dwindling and without urgent action, hundreds of facilities face closure.
But it's not too late. Mobile health, partnerships, new payment methods and government support can make a big difference to rural hospitals across the U.S. Becker's asked 33 healthcare executives to share their best ideas to save rural healthcare, and here they are. The executives featured in this article are all speaking at the Becker's Healthcare CEO+CFO Roundtable on Nov. 13-16, 2023 in Chicago.
Question: What is your best idea to save rural healthcare?
President and CEO
Johnese Spisso. President of UCLA Health, CEO of UCLA Hospital System and Associate Vice Chancellor of UCLA Health Sciences: While some progress has been made in improving access to primary care in rural areas, access to specialty care remains a challenge. One of the opportunities to increase access is through the use of telemedicine and video visits with highly trained specialists who are available at academic medical centers and other large health systems. One of the ways we have expanded access at UCLA Health is through telemedicine. Additionally, through operating an interfacility transfer center, we serve as a resource to rural hospitals in our region, which rely on us to accept transfers of complex patients that have needs that exceed the level of care that can be provided in the rural facilities.
David Lubarsky, MD. CEO and Vice Chancellor of Human Health Sciences at UC Davis Health (Sacramento, Calif.): Around one in five Americans live in rural areas, but only 5 percent of physicians practice in these same areas. UC Davis has made it a priority to help close this gap in rural healthcare by incentivizing medical school graduates to practice in rural communities. We have built a number of clinical and education partnerships to both increase providers in these communities and bring in, via virtual technologies, advanced and specialty practices from regional academic medical centers.
We need new models of place-based medical provider recruitment, education and training to include far greater numbers of individuals from rural communities, as they are much more likely to ultimately practice in these communities. Our COMPADRE program is an example of a cross-state effort funded by American Medical Association, UC Davis and Oregon Health & Science University to partner with dozens of graduate medical education programs and tribal communities in Southern Oregon and Northern California to address this crisis.
Bill Gassen. President and CEO of Sanford Health (Sioux Falls, S.D.): Protecting rural health care starts with reimagining how we deliver care for the 1.5 million patients we have the privilege of serving at Sanford Health, two-thirds of whom live in rural communities. Sanford’s landmark $350 million virtual care initiative aims to expand access to convenient, high-quality care regardless of zip code, improve the patient experience, advance innovation through new research and attract and train a new generation of clinicians.
The past few years have tested our nation’s health systems as never before. Sanford Health is committed to seeking new ways to provide more affordable, accessible and equitable care, which is why we’re excited about our proposed merger with Fairview Health Services. Together, we will strengthen care for our patients, offer expanded career growth opportunities for our employees and serve as a destination for top clinical talent. By combining our respective strengths and expertise in rural and urban health care, we will expand access to high-quality care for more people across our region, drive innovative care solutions, invest in the well-being and quality of life of our communities and ensure we can continue to deliver world-class care for all those who place their trust in us long into the future
Donna Lynne. CEO of Denver Health (Colo.): My best ideas for rural healthcare are partnering with urban hospitals, particularly safety nets, and using telehealth with those hospitals that are truly partners. Lastly, another good idea is to use some form of "gainsharing" when patients are transferred.
Brian Peters. CEO of Michigan Health Hospital Association (Okemos): I am a big believer in technology as a game-changer for the future of healthcare delivery. In particular, it can serve as a force multiplier in the realm of healthcare staffing. When combined with the significant traction gained by telehealth since the start of the pandemic, this means that technology — if thoughtfully deployed — can help to stabilize the rural health infrastructure. One imperative: we need regulatory and reimbursement policies that incentivize and support this concept.
Jeff Thompson, MD. CEO Emeritus at Gundersen Health System (La Crosse, Wis.): Although more rapidly changing the payment system away from fee-for-service will help, the best hope and most progress is to change the behavior of the large systems and universities to view rural areas not as referral pipelines but as citizens and providers that need real population healthcare partners.
Not closing, but re-focusing the work of rural providers and rural hospitals that have already been shifting to outpatient work [will help]. Systems can connect the EHR , provide quality and HR systems improvements, focus on cancer screening and mental health services as well as those other needed procedures that can be done well locally like cataracts, mammograms, and colonoscopies. Those systems that are truly partners will most likely improve referrals, but the connection is built on the value of improving health.
Robert Corona. CEO of SUNY Upstate Medical University (Syracuse, N.Y.): It will be solved by technological and process innovations. We serve one-third of the geography of New York State, so rural healthcare is key for us. We have a rural medicine training program for physicians and they need special tools. Rural healthcare is best served through use of advanced computing and communications technology, autonomous machines like drones and robots for supply logistics and other operations.
We now have established an autonomous machines division and a mobile medical unit. We have a hospital at home program and an influenza-like illness program that both use body-worn sensors on remotely located patients for vital signs and other parameters. This is all part of the distribution of healthcare services beyond bricks and mortar healthcare facilities.
Mark McPherson. President and CEO of Trinity Health At Home (Livonia, Mich.): Enact legislation to pay for telehealth in a home health nursing environment. During the pandemic, telehealth was shown to be highly effective as a way to provide care. It's reimbursable for physicians, but not for nursing care. Reimbursing telehealth in-home care would allow home care agencies to leverage already scarce nursing resources across an unlimited geography, mitigating many of the logistical issues of providing home care in a rural environment.
Charles A. Powell, MD. CEO of Mount Sinai-National Jewish Health Respiratory Institute; Medical Director of Mount Sinai Hospital Respiratory Care Services (New York City): In the respiratory disease space, a key point of emphasis on providing access to specialty services in remote or rural regions. We are able to address potential gaps in access by leveraging technology to connect rural clinics and to connect with patients at home. For example, multidisciplinary tumor boards and multidisciplinary interstitial lung disease management programs can provide access to clinicians in practice locations that are distant from the tertiary facility hosting the discussion. We have deployed remote patient monitoring solutions to patients and home sleep study patients by direct shipping that allow us to connect with COPD patients across the continuum of care and to diagnose patients with symptoms of obstructive sleep apnea.
Helen Johnson. CEO of Sparrow Eaton Hospital (Charlotte, Mich.): The expansion of broadband internet services has helped level the playing field for rural communities. While not yet complete, in those areas where access to high-speed internet is available, those communities are leveraging this basic utility for healthcare, education and economic development.
Donald Lloyd, II. President and CEO of St. Claire Healthcare (Morehead, Ky.): In my view, we cannot perpetuate a stable rural health infrastructure until we address three significant issues critical to achieve rural health sustainability. First, we must develop and attract a rural-centric pipeline of talent to meet our clinical and workforce needs. Second, we must realize that it is not economically possible to sustain a full service acute care hospital in every rural community. Such a realization takes great political courage but also clinical creativity to meet the community's needs. Third, CMS and state Medicaid agencies must establish payment methodologies that sustain institutions in low volume and safety-net environments
Mark Gridley. President and CEO of FHN Memorial Hospital (Freeport, Ill.): My thought is a deep focus by federal and state legislators that are truly seeking to understand the barriers to healthcare in rural communities. Many of these barriers are driven by inadequate reimbursement methodologies for noncritical access providers, which creates difficulty in staffing and, ultimately, in providing access to care that is sustainable, consistent and close to small communities. This would include innovative technological program funding in addition to stabilizing declining reimbursement amidst increasing costs.
Michael Canady, MD. CEO of Holzer Health System (Gallipolis, Ohio): The solution to saving rural healthcare lies in solving the payer mix issue. Rural HCOs have such a high percentage of Medicare/Medicaid/self-pay that it is becoming a challenging revenue issue. Closely related to this is the 20 percent initial denial rate across the board. Fix these two problems and rural healthcare can survive.
Thomas Siemers. CEO of Wilbarger General Hospital (Vernon, Texas): Collaboration and diversification are the key strategies for future success. We should look for ways we can collaborate with other organizations and providers to expand and diversify our services. Rural hospitals will have to try new strategies, start new services, adapt to the changing needs of patients. The key is to keep our patients local so they don't have to travel for care. Rural hospitals will have to share revenue and/or pay for the services provided by other organizations/providers. But it's worth it. We've got to grow.
Jeremiah Hodshire. President and CEO of Hillsdale (Mich.) Hospital Administration: Ultimately, rural healthcare suffers from the reality that we are often paid less than what it costs us to provide patient care. No other business or industry would be expected to survive under those conditions, and rural hospitals shouldn't have to scramble to find other revenue sources like grants, cash-only services, etc., in order to be financially sustainable. Achieving health equity for rural Americans requires us to sustain rural hospitals so we can continue innovating, investing in technology, pioneering access to care initiatives and more. Payment reform is not just the best way to save rural healthcare long-term — it is the ONLY way.
Kenneth Rose. President and CEO of Texas Health Hospital Mansfield: The plight of rural healthcare in our country is one that will not be solved by hospitals and healthcare systems alone. Rural communities would be benefited by the collaboration of community services offered by other not-for-profit organizations along with hospitals. The issues in rural communities many times are more than just acute care related and have other social/societal components, which calls for more than the expertise of community hospitals. An issue as large as this brings the old saying to mind: many hands make light work.
Christopher Bjornberg, CEO of Mayers Memorial Healthcare District (Fall River Mills, Calif.): The best way to save rural healthcare is to treat it as rural healthcare. Urban health is not the same as rural health but it is mostly treated the same way. Currently, Medicare is the only payer that has a program specific for rural health that takes a critical access hospital designation while Medicaid and commercial payers like Blue Cross, UnitedHealthcare and the like generally do not. Coupled with the poor reimbursement rates, are the rising administrative costs for providing healthcare. According to an article from CNN in February 2022, “Administrative costs alone make up more than a quarter of U.S. healthcare spending.” If we want to save rural healthcare we have to change the reimbursement across all payers not just one and then ease the administrative burdens that go along with that. Just like it shouldn't be difficult for people to obtain good quality healthcare, it should not be difficult to get paid to provide good quality healthcare.
CFO and Strategic Leaders
Marty Hutson. CFO of St. Mary's Health Care System (Bayside, N.Y.): The first step to 'save' rural healthcare is to accept that the one-size-fits-none model of Medicare does not work. Rural hospitals face more difficulty in recruiting and retaining staff. Given your location, access to goods and services is also more expensive. CAH based on bed size is not effective when some facilities are too big to be considered critical access but remain just as remote and important as those with that designation.
Nate Shinagawa. COO of UCI Health (Orange County, Calif.): One of America's strengths, compared to anywhere in the world, is our recognition that immigrants add value to the culture and success of our country. Nowhere is this more evident than in healthcare, where 25 percent of all physicians are international medical graduates. Many of these physicians came to America through the H1-B visa program, a critical pathway that's provided talented physicians to underserved areas, including much of rural America.
For example, in places like North Dakota, H1-B applicants represent almost 5 percent of all physicians. We can turn around the healthcare access problem in rural America with progressive immigration policies. Expand H1-B visas, fast-track the green card process for physicians and nurses, expand the J-1 visa waiver program and make it easier to attain state licensures. In a year, we'd see the impact of these changes to the great benefit of rural America.
Cristen Page, MD. Executive Dean of the UNC School of Medicine (Chapel Hill, N.C.): We should address this issue with humility. Our neighbors living in rural areas need to be listened to and supported as they know best what is needed in their communities. I have dedicated much of my career to rural workforce development and creating sustainable programs that introduce future providers to the impacts that they can make and the joys that they can find in rural service. We need more providers in rural service – not just physicians, but nurses, APPs, and others. We need to support the expansion of rural residency and other training programs and to continue building strong networks so that success stories and knowledge can be shared. And we need to leverage technology to support our rural providers as well as new models of care to better serve our rural patients.
Arianne Dowdell, JD. Vice President and Chief Diversity, Equity, and Inclusion Officer of Houston Methodist (Texas): Equitable access to healthcare may not just mean a brick-and-mortar location but also working closely with community partners to support people with chronic health conditions through prevention, education and access. Looking at data to learn more about the communities we serve or those we have the potential to serve and knowing more about incidence rates of certain diseases is helpful when meeting the healthcare needs of patients, particularly those in rural communities.
At Houston Methodist, we often talk about meeting people where they are and that includes supporting people with varying education levels, limited knowledge about their own healthcare, or those who have little to no access to technology. We learned a lot during the pandemic about how we can support people who may fall into these areas of their healthcare journey, and we're continuing to use those lessons learned to create quality healthcare experiences for people despite where they live.
Nick Stefanizzi. CEO of Northwell Direct (New Hyde Park, N.Y.): 'Saving' rural healthcare will be predicated on solving for the unique challenges experienced by these populations – primarily, addressing access and social determinants of health, which in the context of rural health, are synergistic strategies.
To start, given that the National Rural Health Association has described that of the more than 7,200 federally designated health professional shortage areas, 3 out of 5 are in rural regions, access is a clear structural barrier. The fix here can't just be brick and mortar facilities and providers. Rather, solving for this will require a combination of in-person and virtual treatment modalities to expand the pool of providers available for critical services. It will also require an investment in digital tools and resources that enable individuals to better engage and manage their own health. All must be highly integrated and easy to navigate if we expect widespread adoption and utilization.
Further, a population health approach to addressing the social determinants of health and the underlying factors that can adversely influence the health of populations living in rural communities will similarly help to address root causes. An individual's zip code often has more impact on health than any other factor, and in order to raise the health of rural populations, the focus needs to expand beyond traditional medical care. Through innovative and proactive interventions, we can enable health professionals and individuals to better engage and manage chronic and other conditions that exacerbate the challenges associated with the lack of access to local care providers.
Taken together, addressing access and social determinants will go a long way in solving the rural healthcare crisis.
Kerry Mackey. Vice President of Hospital Operations, Women and Children's Services at NYU Langone Health (New York City): Telemedicine/telehealth services can be utilized to expand access to care in rural areas. We learned this from COVID-19 when we had to extend healthcare outside the hospital’s doors/walls. Also, implementing a home hospital service can complement telehealth/telemedicine by bringing that day-to-day nursing care to the applicable patient's home. In addition, utilizing data and outcomes to negotiate reimbursement rates for Medicare services is how we can overcome the challenge around service or provider restrictions.
Scott Polenz, CPA, MBA, FACHE. Vice President of Physician and Advanced Practice Clinician Relations of Marshfield Clinic Health System (Wis.): Saving rural healthcare is about as ambitious an undertaking as you can aspire to because of the complex, interwoven challenges that must be addressed. Fixing rural health care requires fixing our national health care system and a societal-level shift with regard to how we view health and health care. On a national level, we have to commit to the systemic changes required to truly move to a value-based system. On a more rural-specific level, we need massive investments to upgrade our overall public health infrastructure. Rural communities lag behind metropolitan counterparts in areas like access to transportation, availability of internet, distance from sites of care, access to healthy food and many other community-based resources. This basic infrastructure is fundamental to accessing quality health care, and it is going to take systemic, sustained investment to equip rural health care with the tools we need.
Chad Dilley. COO of IU Health Saxony (Fishers, Ind.): IU Health is proud to serve many rural Indiana communities in places like Tipton, Bedford and Frankfort. There are really two inherent challenges: the geography of small populations spread over large areas, and provider recruitment to live and work away from urban centers and the specialty and subspecialty support that affords. We are continuing to lean into virtual care, virtual consults and telehealth to make care more accessible for patients close to home (or at home), and support our teams with the expertise and collaboration they need to provide excellent care in rural settings.
Kira Carter-Robertson. Senior Vice President of Regional Hospitals at Sparrow Health System (Lansing, Mich.): I would love to say there is a magic bullet to save rural healthcare, but I don't think the answer is one-size-fits-all. While rural hospitals may face similar pressures, rural communities are not all the same. In the short-term, rural healthcare providers will have to continue blocking, tackling, and juggling service needs with volume, managing staffing and provider challenges, assessing the right operation models, and exploring partnerships and mergers. Finances are the key driver behind closures and financial challenges for rural hospitals, so the long-term answer is a drastic payment overhaul. In the meantime, the secret sauce for rural healthcare is more complex and several levers will need to be pulled both regulatory and operationally to sustain the future of rural healthcare.
Rashid Syed. Managing Partner of North Houston Surgical Hospitals: In my opinion, the best approach towards improving rural healthcare is to segregate the patient care services from one large hospital system to nimbler healthcare facilities, making it more approachable and personable for both, the patients and the providers, by creating urgent care centers, surgery centers, specialty microhospitals for mild to moderate complexity elective and nonelective treatments and keeping larger hospitals for higher complexity, longer complicated treatments. It's about taking healthcare to the patients rather than patients in need seeking healthcare.
Andy Anderson, MD. Chief Medical and Quality Officer of RWJBarnabas Health (West Orange, N.J.): Rural healthcare is essential to address the health and healthcare needs of patients and families who live in rural communities. My best idea to save rural healthcare is to provide robust virtual access (through telemedicine and remote patient monitoring devices) to triage and address acute care needs, to better manage chronic conditions, and to provide access to the best specialists to diagnose and treat complex medical conditions.
William Morice, MD, PhD. President of Mayo Clinic Laboratories and Chair of the Department of Laboratory Medicine & Pathology at Mayo Clinic (Rochester, Minn.): From my perspective, to save rural healthcare, one must tackle one of the greatest challenges facing rural hospitals and healthcare providers, which is maintaining sufficient patient volumes in their facilities while also developing next-generation tools and capabilities. These tools and capabilities, such as at-home testing and digital diagnostics, will allow them to reach their patients in their homes spread across large areas. So, my idea is to invest in rural healthcare's ability to interact with patients remotely while also designing practice and social service models that bring them into facilities for care when needed. Done correctly, this will enable rural healthcare to sustain and grow their services while also increasing their reach and convenience for patients.
Phil Schaefer. Senior Vice President, Ambulatory Services and Chief Care Network Development Officer of Southern Illinois Healthcare (Carbondale): For rural hospitals to survive, the economics of reimbursement must change along with the hospitals' approach to their cost structures. With almost all major payers having record profits last year and with declining utilization and reimbursement, the current model of paying hospitals is not sustainable. Given this, it's imperative for rural hospitals to reevaluate their service portfolio and bend their cost curve downward.
Steve Lipshultz, MD. Goodyear Professor and Chair, Department of Pediatrics of University at Buffalo Jacobs School of Medicine and Biomedical Sciences (Buffalo, N.Y.); Pediatric Chief-of-Service of Kaleida Health (Buffalo, N.Y.); President of UBMD Pediatrics (Buffalo, N.Y.): Improving rural healthcare finances is one of several key elements to sustaining rural healthcare and coming closer to a single standard of US healthcare. Below I list 14 areas where opportunities exist and are needed. Utilizing technology such as:
3. ub-and-spoke health system networking and infrastructures to allow most care in the local community but having the backup;
Ongoing physician and other healthcare provider and staff training;
Workforce shortages with pipeline programs and others;
QA/QI oversight and feedback as drivers of decisions based on the quality of care in rural places;
Enhanced rural public health;
Focused patient management on unique needs in rural settings;
Other necessary infrastructures to increase both revenues from payments and reimbursements and other efficiencies and outcomes are key;
The transition to value-based care will be very sensitive for rural healthcare with reduced reserves and with unique needs and solutions.;
Having a national agenda to reduce disparities by states for funders of rural healthcare around the U.S. will help level the playing field. The differences in reimbursements and uncompensated care for the same services around the U.S. widely vary based on local rules and regulations and (both state and federal) often cause essential services in rural communities to no longer be sustained.; and
Adequate payments and better payment systems are needed with a level playing field.
Anuj Vohra, DO. Chairman and Medical Director of the Department of Emergency Medicine of Charlotte Hungerford Hospital (Torrington, Conn.): My best idea to save rural healthcare is advancing access to care by means of telemedicine, home visits and increasing preventative care.
Charles Emerman, MD. Chair, Emergency Medicine and Medical Director, Service Line of MetroHealth Medical Center (Cleveland, Ohio): Smaller rural hospitals would do well to form more robust clinical programs that leverage the resources of the larger urban hospitals. For example, we have trauma surgeons who take calls at two smaller rural hospitals. The local surgeons are happy not to take overnight ED calls. The trauma surgeons operate locally when appropriate and then transfer the more complex patients. It works out well for the patients, the local medical staff, and both systems.
Andy Anderson, MD. Chief Medical and Quality Officer of RWJBarnabas Health Medical Group (West Orange, N.J.): Rural healthcare is essential to address the health and healthcare needs of patients and families who live in rural communities. My best idea to save rural healthcare is to provide robust virtual access (through telemedicine and remote patient monitoring devices) to triage and address acute care needs, manage chronic conditions better, and provide access to the best specialists to diagnose and treat complex medical conditions.
Nisha Mehta, MD. Founder of Physician Side Gigs: Maintaining the quality of care in rural areas will become increasingly challenging as healthcare personnel shortages continue to amplify. Employers will need to place a real focus on retention and recruitment of clinicians, and systemically, threats to compensation by CMS and other payers need to be addressed. Medicare cuts are short sighted and will only exacerbate existing issues with access to care.