Midwestern health providers and stakeholders are speaking out, and what they have to say is surprising. Could fewer hospitals bridge the widening urban-rural health gap?
A new report highlighting the challenges and opportunities in rural health care across Iowa and six other Midwestern states says small communities need more flexibility to customize health care services, workforces and facilities to meet individual needs — even if, in some communities, it results in the loss of a full-service hospital.
The Bipartisan Policy Center and the Center for Outcomes Research and Education spoke with more than 90 thought leaders and key stakeholders in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming to compile the report, which was released this month.
Although the group recommends a broad and holistic approach to address all the interdependent factors stifling rural health care advancement, their top recommendation is “rightsizing health care services” by setting aside the current “one-size-fits-all” public policy approach and meeting the distinct needs of each community.
“Not every rural community needs to have a Critical Access Hospital; communities should tailor available services to the needs of the community, which for many rural areas are driven by changing demographics.”
If the idea spreads, the impact in Iowa could be monumental. Of the state’s studied, Iowa led the pack with 82 CAHs — four more than neighboring Minnesota, which boasts 2.4 million more state residents.
Because of current regulations and available reimbursement, CAHs are the most common service model in rural areas — and it’s been that way for several years. The name and most rules that govern the facilities were set in motion by the 1997 Balanced Budget Act, which was a response to a string of hospital closures in the 1980s and 1990s.
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In order to be classified as a CAH (and benefit from funding formulas tied to the designation) hospitals must meet certain standards. For instance, a CAH must have 25 or fewer acute care inpatient beds, be located more than 35 miles (by primary roads) from another hospital, maintain an annual average length of stay of 96 hours or less for acute care patients, and provide 24/7 emergency services.
Report authors noted that while many participants recognized CAHs were no longer the most effective health delivery option, participants also grappled with what facility closure means to area residents and the local economy. So most opt, in places where a full-service hospital isn’t necessary, for a new model of care that is somewhere between a traditional hospital and primary care. Exactly what that looks like, depends on community needs, determined by various assessments.
In this area, the report highlights the work of two members of Iowa’s Congressional delegation — Republican Sen. Chuck Grassley and Democrat Rep. Dave Loebsack — as advancing policies that could help shift the landscape.
The Rural Emergency Acute Care Hospital Act, introduced by Grassley, would allow certain CAHs to transform into rural emergency centers. The bipartisan Save Rural Hospitals Act, sponsored by Loebsack and Missouri Republican Sam Graves, provides permanent extension of rural ambulance add-on payments and establishes a new hospital designation for CAHs that would allow more focus on emergency and outpatient care.
But even if these or other bills are successful, rural communities have two more complex problem areas to overcome: funding and workforce. While the federal lawmakers are largely responsible for the first, state and local policies can nudge more doctors, first responders, nurses and psychiatrists to consider practicing in rural communities.
As Gov. Kim Reynolds showed in her condition of the state address this month, carving a better path forward can be as simple as public investment in new learning tracks at existing schools. Des Moines University, which leads in the nation in producing primary care physicians, has partnered with the National Alliance on Mental Illness to ensure every graduate receives training to identify and treat patients experiencing mental illness. Reynolds’ proposed budget offers public money for this initiative, which addresses a long-standing need.
Report authors also highlight the rural “grow your own” approach that I’ve favored. It involves local communities working with school districts to identify students as young as middle schoolers who have interest in a health field. From doctors to nurses to radiologists, the community then makes a commitment to these students to pay for higher education in exchange for a commitment to return to the community and work for a certain length of time.
This is an important pipeline of health care professionals because what studies have shown is that young people raised in rural communities are more likely to return and stay if there are job and housing opportunities. In other words, these workers not only fulfill their original commitment, but are more likely to stay beyond the predetermined time frame and be more satisfied in doing so.
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Like most studies on what ails rural America, this report has little trouble identifying and naming problems. But it also goes a step further by highlighting what is working and why, and what people in those communities would like an opportunity to explore.
Maybe a traditional hospital isn’t what is needed to better address rural health care. But, scary as it is, we won’t know unless we try.
• Comments: @LyndaIowa, (319) 368-8513, firstname.lastname@example.org