Leveling the Playing Field for Rural Health Providers

What will it take? Rural health executives share their solutions to healthcare desert challenges.

Editor’s note: This article appears in the July-September 2023 edition of HealthLeaders magazine.

Virtually every problem that exists in healthcare today is exacerbated for rural providers due to lack of resources and funding, a smaller talent pool, and fewer points of access. What can be done? Can the problems facing rural healthcare be solved? Rural healthcare executives share ways that can help alleviate specialty care access, staffing issues, and financial challenges.

Telehealth can conquer rural access challenges for both patients and specialists

Access to primary care in rural and remote parts of the country is tough enough, but what about when someone needs to see a specialist?

According to the National Rural Health Association (NRHA), there are roughly 30 specialists available per 100,000 people in rural parts of the country, compared to 263 per 100,000 people in urban regions. Simply put, specialists tend to live and work in well-populated areas, where they can work near large health systems and have access to a large patient base. The only time you'll likely find a gastroenterologist or neurologist in rural America is if they've retired there.

Rural communities and health systems are addressing this challenge through telehealth and digital health tools and platforms. They're using platforms that enable rural residents to meet with specialists online, either from their homes or from telemedicine stations set up at local hospitals, health clinics, or doctor's offices. In addition, these platforms enable specialists to live in rural regions and build their own patient base.

Organizations like the MAVEN Project are contributing as well by forming virtual networks of specialists to help remote health clinics access specialists for mentoring and support. The MAVEN Project is a nonprofit organization that has built a network of retired and active providers and specialists to virtually mentor and support providers in rural areas and those who work with underserved populations.

"We want to be in an environment where everybody can have access to health services when they need them, and that includes specialists," says Suzan Bast, service excellence manager at Fairbanks Memorial Hospital in Fairbanks, Alaska, a city of roughly 100,000 that's closer to the Arctic Circle than the nearest major metropolitan center.

To facilitate access to specialty care, Fairbanks Memorial has a partnership with Troy Medical, a Texas-based telehealth company that provides virtual specialist services. Local residents who are referred to a hepatologist, rheumatologist, or gastroenterologist, or who need to see a neurologist or dermatologist and can't wait for the region's one specialist to clear time on the calendar, can visit the hospital's Tanana Valley Clinic to see a doctor located thousands of miles away.

"It's six hours to Anchorage," says Bast. "So if you need to see [a specialist], you're traveling a lot." That's time-consuming, costly, and exhausting to patients and their families, she says.

Standing up telehealth

Troy Medical was, in fact, launched by an Alaskan to meet that need for specialist services. Kara Hartl, MD, an ophthalmologist who'd spent roughly 15 years in Fairbanks, launched the company after struggling to find care for a patient who was living with a debilitating medical condition and needed to be seen by three specialists.

"I couldn't get them the access to care they needed," says Hartl, who named the company after that patient. "COVID made it a lot worse, but it also helped to validate telehealth as a way to provide that access."

Hartl says Troy Medical saw great success in its first year of operation in Alaska, at which point she decided to extend the company's reach to another state with similar rural health issues: Texas. She set up shop in Austin, began working with the Texas Organization of Rural and Community Hospitals, and launched a second site in Sulphur Springs, a city of 15,000 in the northeast corner of the state, about 80 miles east of Dallas.

Rural Texas faces many of the same healthcare access issues as Alaska. With smaller populations and a troubled economy, it's difficult to sustain a health system at all, never mind one with its own specialty services. Twenty-one hospitals in Texas have shut down over the last decade, more than any other state, and roughly a quarter of those still open are at risk of closure, notes the Texas Hospital Association on its website.

Hartl's business model is to establish relationships with local hospitals and communities, rather than just setting up a telemedicine platform and letting the chips fall where they may. As with Fairbanks, Troy Medical built a clinic in Sulphur Springs where residents can go for appointments. The hospitals have a role in selecting which specialists are needed, and the clinic is staffed with support personnel to handle administrative tasks and help patients with virtual visits.

"You need to have the presence on the ground," Hartl says. "Keeping it local is so important to those community hospitals."

That's because many specialist consults lead to more consults and care management, as well as treatments and other services that can be coordinated with local providers. The idea is to make sure care remains in the community.

"We're creating relationships and helping these patients navigate the healthcare system," she says. "The only thing we request of community hospitals is promotion."

State licensure rules often hinder telehealth expansion

Texas is proving an easier place to establish this platform, Hartl says, because the state has a lot of doctors. That means it's easy to find specialists in state and set up the virtual care network. Alaska doesn't have many doctors, so Hartl must expand her network into other states to fill the ranks.

That's one of the biggest challenges to this type of program. Each state licenses and regulates its own providers through state medical boards, and not everyone is comfortable treating a patient in another state through telehealth. The pandemic did make the healthcare industry aware that telehealth could be used to practice across state lines, and many states relaxed their rules during the public health emergency to allow certain telehealth services. But licensure is still a complex process, and doctors must apply for a license in every state in which they want to practice. This means telehealth platforms like Troy Medical must ensure the specialists they're providing can treat a patient in a certain state.

Hartl says she prefers to work with states that are part of the Interstate Medical Licensure Compact (IMLC), a network of states that have adopted a streamlined licensure process to allow providers to practice in other states (ironically, Alaska isn't in the IMLC).

That said, with successes in Alaska and Texas, Troy Medical is poised to expand to other states.

"The technology for this is straightforward," she says, referencing technology partners that include athenahealth and Logitech, among others. Troy Medical will spend roughly $100,000–$150,000 to stand up a clinic, then work with local hospitals and providers to bring in specialists virtually.

"Sometimes you feel like a rock star," she says, talking of providing access to a specialist in a rural area—which can save a patient and family thousands of dollars in travel costs, reduce stress, and uncover pathways to stronger care management, better clinical outcomes, and improved health and wellness. "It's what we want medicine to be like."

Back in Fairbanks, Suzan Bast says the platform can work both ways. While it gives residents access to the experts, it also gives her hope that the region can attract more providers.

"The benefits of Alaska don't necessarily appeal to everyone," the native Alaskan admits. But not everyone wants to live in a big city or densely populated state. Thanks to the technology now available, a doctor can think of moving to a rural area and develop a patient base that spans the country.

"The work-life balance isn't bad," she adds.

Why nurse practitioners are a solution to rural healthcare

With more than 100 million Americans lacking access to primary care, employing more nurse practitioners (NP) and allowing them to practice at the top of their license is critical to making healthcare more accessible in rural areas, NP leaders say.

NPs could ease "care deserts" created by physician shortages and rural hospital closings. Nearly 80% of rural U.S. counties are medical deserts, according to the NRHA. About 35% of all U.S. counties are "total maternity deserts"—no access to prenatal or delivery services—and another 54% are considered partial deserts, which equates to 7 million women without access to maternity care, according to the March of Dimes.

"There are many people who don't see a doctor or get healthcare on a regular basis, and when they are really sick, they go to the emergency room for their care," says April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, immediate past president of the American Association of Nurse Practitioners (AANP).

"It is definitely a need in rural health that we get providers out in every community," Kapu says.

Growing in number

The demand for NPs is growing and their role is expanding, thanks in part to an aging U.S. population, increasing infectious diseases, rising chronic diseases, and fewer physicians, the AANP says.

The percentage of rural physicians has declined—12.8% from 2008 to 2016. But the percentage of NPs increased 17.6% during that same time period, according to a 2020 study.

"We're growing at a rate of about 9% a year," Kapu says. "We are up to more than 355,000 nurse practitioners across the U.S. today, and we are estimated to grow by 46% by the year 2031."

Nearly 90% of NPs are certified in an area of primary care and 70.3% of all NPs deliver primary care, according to the AANP, with 83.2% of full-time NPs seeing Medicare patients and 82% seeing Medicaid patients. Additionally, nearly half of all rural primary care practices have at least one NP, according to the NRHA.

A well-rounded approach to healthcare

NPs' holistic, wellness-centered approach to primary healthcare—health promotion, prevention, and chronic disease management—is particularly beneficial to rural patients who must travel long distances when illness requires acute care.

"One really valuable thing they bring to rural health is the approach to healthcare, which differs a bit from the medical model," says Michele Reisinger, DNP, APRN, FNPC, a working NP and assistant professor of doctoral nursing at Washburn University in Topeka, Kansas. "Nurse practitioners are trained to look comprehensively at the individual."

NPs are well positioned for primary care roles because of their education and training, says Reisinger, who has helped obtain an advanced educational nursing workforce grant centered on educating nurse practitioners for rural practice.

"When we train them as nurse practitioners, we train them to manage chronic disease states; we train them to be experts in promoting health and wellness [as opposed] to an urban setting where they may work only in urgent care … or have a very targeted education in cardiology or neurology," Reisinger says.

Instead, rural nurses treat the spectrum of pregnant women, infants, children, adults, and geriatric patients, along with entire families, she says.

"Nurse practitioners in rural areas wear many hats," she says. "They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So we try to prepare them in a way that it's global in that manner."

Working closely with patients allows NPs to create collaborative prevention plans to help patients make lifestyle changes and health choices that can stave off chronic disease and keep them out of the emergency department, Kapu says.

"We know that timely access to care, particularly preventative care, is crucial to the early detection of health issues," Kapu says. "It has a huge impact on the mitigation of healthcare cost, and so important to health and well-being overall, and whenever that care is delayed, we know that individuals face a greater risk for complications for not following up on chronic diseases."

Such preventive care makes a difference to rural patients, Kapu says. "Many large-scale reliable studies have shown that we have a tremendous impact on the reduction of unnecessary emergency department visits," she says.

Breaking down barriers

Despite the advantages that NPs can bring to rural, underserved areas, barriers continue to limit them from working at the top of their license, Kapu says.

For example, even though more than half of U.S. states have granted NPs full practice authority (FPA)—which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—nearly as many states make it illegal for NPs to practice their profession without a collaborative agreement with a physician.

The American Medical Association (AMA) and other physician groups accuse FPA of "scope creep"and charge that nonphysicians practicing medicine is a threat to patient safety. At its annual meeting in June, the AMA passed a policy amendment calling for advanced practice RNs (APRN) to be licensed and regulated jointly by the state medical and nursing boards. Nursing groups denounced the policy amendment.

States that have embraced FPA have increased their nursing workforce and helped ease care deserts, Kapu says. When Arizona enacted FPA in 2001, the NP workforce doubled across that state within five years and grew by 70% in rural areas, and North Dakota's adoption in 2011 saw its nursing workforce grow by 83% within six years, she says.

Some barriers are being reconsidered. The Improving Care and Access to Nurses Act (ICAN) was reintroduced in the U.S. Senate in April and would allow NPs, physician assistants, and other APRNs to provide particular services under Medicare and Medicaid. ICAN would, among other things, authorize NPs to order and supervise cardiac and pulmonary rehabilitation, certify when patients with diabetes need therapeutic shoes, and certify and recertify a patient's terminal illness for hospice eligibility.

"These are substantial barriers that, if they were removed," Kapu says, "we will be able to provide much-needed, timely care, and [for] our elderly and Medicare beneficiaries who live in these rural communities."

Financial stability in rural health

According to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, 136 rural hospitals closed between 2010 and 2021. The Sheps Center says 19 rural hospitals closed in 2020, the most closures in a single year in the past decade.

A pair of top healthcare executives told HealthLeaders that four factors pose significant financial difficulties for rural hospitals:

1. Declining and stagnant populations in rural areas
2. An unattractive payer mix dominated by Medicare and Medicaid patients
3. Sicker patients in rural areas compared to urban areas
4. Financial challenges related to workforce shortages
    

"Declining and stagnant populations in rural areas are a challenge. About 80% of rural counties nationally have declining populations. Traditionally, rural hospitals had sufficient patient volumes, and they were able to provide care to most patients. That is just not the case anymore," says Brian Shockney, MHA, president of Indiana University (IU) Health South Central Region.

To address the impact that declining and stagnant populations are having on its rural hospitals, IU Health is careful about the kinds of services its facilities provide and it reviews the services relative to the population’s needs, he says. "Every three years, we do a community health needs assessment, and every year we reassess our services based upon that community health needs assessment."

Grants play a crucial role in providing services at rural hospitals with low patient volumes, Shockney says. For example, IU Health received a U.S. Health Resources and Services Administration grant to provide dementia and Alzheimer's disease care in Lawrence County, Indiana. "We are able to provide that care for patients through those grant dollars," he says.

The high percentage of Medicare and Medicaid patients at Lebanon, New Hampshire–based Dartmouth Health is a payer mix challenge, says Wendy Fielding, MBA, chief financial officer of Dartmouth Hitchcock and system vice president of finance of Dartmouth Health.

"For us, governmental payers are about 60% of our revenue mix. Medicare is about 46% and Medicaid is about 14%. Northern New England has an aging demographic, so we expect that percentage of Medicare to increase year over year. In our 2024 budget, we have a $15 million to $20 million expected erosion in our net patient revenue as a result of the ongoing growth of Medicare in our payer mix," she says.

New Hampshire has among the lowest-reimbursed Medicaid programs in the country. Dartmouth Health is dependent upon commercial payers to overcome the low reimbursement rates of Medicare and Medicaid, Fielding says. "We struggle to overcome the low payment rates. Ultimately, we are shifting the burden of these low governmental payment rates onto our commercial payers."

Other efforts to address the unattractive payer mix have generated limited results, she says. "We are always advocating for ourselves with our representatives in Washington, and though we work internally to become more efficient, we are still taking it on the chin."

IU Health sees sicker patients at its rural hospitals compared to the health system's urban hospitals, Shockney says. "Our rural citizens are not as healthy, and many are living in poverty. When we look at our rural populations and the death rates in rural areas, it outpaces urban areas in the top 10 causes of death, including heart disease, cancer, stroke, and Alzheimer's disease. They are expensive patients to care for. So, that raises the cost of care."

Medical home models of care have been effective in treating patients with high medical needs, he says. "At all of our practice sites, we have telemedicine for behavioral health, and we embed pharmacists, social workers, and dietitians where there is a need to address high diabetes rates and care for those patients. We provide a team of caregivers who surround the patient. In a rural clinic, we may not be able to provide a full-time pharmacist or a full-time dietitian, but we have the telemedicine capability to connect patients with behavioral health services, or a consultation with a dietitian, or something of that nature. That reduces the cost of having to have a physician, and it manages the care of the patient holistically."

Fielding says Dartmouth Health's biggest financial challenge is related to the health system's workforce. "Even though we are located in a rural environment, we are close enough to Boston that we do need to compete with that marketplace, so our workforce is more expensive than what you might think of for a rural setting. Like other healthcare organizations across the country, we have been dealing with an increased reliance on contract labor such as agency nurses. That is having a significant financial impact on us."

To make Dartmouth Health more competitive with the Boston labor market, the health system has been working with local real estate developers to boost affordable housing, she says. The health system has also been looking for ways to increase childcare options for its workforce, Fielding says. "We have explored investing in childcare centers and building up the workforce in those facilities."

She says keeping contract labor costs under control has been difficult. "In the short term, we have gone back to our payers to reopen contracts to negotiate higher payment rates for our health system members to reflect the labor cost inflation that we are experiencing. In the long term, the situation requires us to do things like work redesign to make sure if we are going to be using very expensive labor, we better be using those folks at the top of their license."

The purchasing power and economies of scale at health systems are pivotal in stabilizing the finances of their rural hospitals, Shockney says. "There is no doubt about it. That is why the hospitals in Bedford and Paoli came to IU Health. From a financial perspective, we knew we could improve those hospitals overnight. We could improve their purchasing power, reduce their costs, and spread those factors across the health system."

Healthcare remains a challenging commodity for both residents and care providers living in rural and remote parts of the country. Sparse populations, geographical challenges, and a dearth of financial resources all play a part in hindering access to care. But new ideas and technologies can change that paradigm, and in some places those innovative strategies are taking root and showing results. Telehealth and digital health tools and platforms, new collaborations, workforce initiatives, and innovative funding programs are all helping rural healthcare organizations provide access and improved health outcomes for their residents and communities.

Eric Wicklund is an associate managing editor and the innovation and technology editor at HealthLeaders. He can be contacted at ewicklund@healthleadersmedia.com. Carol Davis is the nursing and post-acute editor at HealthLeaders. She can be contacted at cdavis@healthleadersmedia.com. Christopher Cheney is the clinical care editor at HealthLeaders. He can be contacted at ccheney@healthleadersmedia.com.