Rural Healthcare

Want to improve public health? Start with housing.

A well-worn axiom says that “hope is not a plan.” Indeed, hope alone is such a hands-up abdication of planning that editor Thomas Mowle was inspired to use the phrase as the title of his 2007 book of essays on the war in Iraq, which says something.

Still, if we play with syntax and add a few words, we can say that every successful plan should offer a measure of hope—hope for success, an improved reality, greater opportunity.

With the twin American scourges of homelessness and addiction, hope starts with a plan that includes housing—a refuge, even if it’s just a 50-square-foot wooden box.

“Housing is one of the best-researched social determinants of health, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs,” writes Lauren Taylor in Health Affairs.

Perhaps, then, housing is a key component in the overall explanation for why health and life expectancy have been declining in America the last few years. When workers making minimum wage—more than 20 million people and roughly 30 percent of all hourly, non-self-employed workers over 18—can afford a modest one bedroom home in only twelve counties in the country, it’s near impossible to argue that the gap between wages and housing costs does not create profound desperation and instability.

That despair, in turn, worsens public health in myriad ways. People with no hope turn to drugs and alcohol, battle depression, eat poorly, work three jobs to exhaustion and injury, battle chronic pain with no viable options, sleep too little, etc. And in worst case scenarios, they end up on the street with few if any possible good outcomes.

Is it the housing as an end that creates better public health outcomes? Not really. No one who lacks adequate housing or has to move frequently is clamoring for a 7,000-square-foot home.

Instead, it’s the benefits housing provides that support a healthier, more sustainable life. As an essential social determinant of health, well-built and well-conceived housing is one corner of foundation supporting four interconnected quality of life pathways: stability, quality and safety, affordability, and community. If any of these pathways are lacking in the housing options available, housing potentially becomes a negative social determinant of health.

For example, consider the tiny homes many cities are now building to try and grapple with the problem of homelessness. Initially, it seems like any kind of lockable structure is an improvement on doorways, park benches and even shelters. But in some cities, tiny houses don’t come with heat, electricity and plumbing, effectively making clusters of houses a small step up from homeless encampments. As social determinants of health, they still register a negative, leaving America far from realizing the goal of housing as net positive for all citizens.

Of course, housing is only one social determinant of health, which collectively are generally lumped as social and environmental factors (20 percent), genetic fortune or misfortune (30 percent), and individual behavioral choices (40 percent).

The final 10 percent is healthcare, and maybe that percentage seems a little light, given how much attention we pay to the healthcare system. Still, think about the ability of healthcare to balance all other social determinants—diet, housings situation, employment status, mental status—when they’re decidedly or even predominantly negative.

It’s not hard to see why clinicians resent being held responsible for the fire after the house is engulfed in flame.

And what, if anything, can healthcare do about these social determinants over which they have no control? In short, look for solutions and shortcuts.

Comprehensive medical records, interoperable systems, healthcare data exchanges and the like can together enable hospitals and clinicians to circumvent the complications created by a transient life. But healthcare providers and organizations can also address social determinants of health more directly.

“The health care sector should continue to explore the extent to which home interventions, such as the well-studied community asthma initiatives, can make financial sense among other patient populations,” says Health Affairs writer Taylor. “Given the shift toward accountable care models and other value-based payments, the financial incentives for health care systems to take broader responsibility for social determinants of health (including housing) are likely to increase.”

And that’s the added factor that may motivate healthcare organizations as much as anything else. Housing makes communication with patients more reliable, which cuts down on the costs of care and lends stability that enables accountable care. Really, all social determinants on the positive side of the ledger decrease healthcare costs, but stable housing makes the others that much more likely.

The social determinants of health are also lurking in the national discussion of universal healthcare. At times, the nation and the industry seem caught up in discussions of payment models, insurance deductibles and technological advancements. Maybe we miss the fact that having affordable healthcare is better than not having it in the same way that having a 200 square-foot house with locks is better than living on the streets, even if we can agree that such basic standards are not enough.

Using social determinants, we could improve the health of many Americans without ever specifically addressing a medical record or length of stay. And until we do see patients as a complex amalgamation of influences, we can’t be surprised that specific therapies out of context have negligible impact on overall public health.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Can healthcare IT save rural hospitals?

In business, disruption is often seen as a good thing, e.g., digital photography disrupting Eastman Kodak’s business so significantly that the company has scrambled in recent years just to stay afloat, the thing they once did better than anyone now largely irrelevant.

So, disruption is a negative for employees of old technology companies, but it’s a boon for workers in cutting-edge businesses and generally for consumers as well. Those who benefit greatly outnumber those who don’t.

And disruption isn’t limited to photography, of course, but in other industries it’s more difficult to blithely nod to the gods of commerce and light another candle on the shrine of economic casualties.

The best example of this scenario we have right now is American hospitals, where Morgan Stanley says nearly 20 percent are either teetering on the edge of insolvency or are “weak.” Of the roughly 6,000 hospitals in the United States, more than 1,000 exist on shifting financial sands. In recent years, an average of 30 hospitals have closed each year, according to the American Hospital Association, and that seems likely to continue.

Among those threatened hospitals, the threat hangs disproportionately over rural areas.

“Since 2010, 86 rural hospitals have closed and 673 others — a third of all rural hospitals in the U.S. — are vulnerable and could shutter their doors,” says Healthcare Dive. “And currently, 44 percent of rural hospitals are operating at a loss, up from 40 percent last year.”

What factors are making it so hard to function outside America’s urban zones?

  • Shrinking reimbursements
  • Higher costs
  • Fewer inpatient admissions
  • Many Medicare/Medicaid patients and few with private insurance
  • Competition from alternative care sites

And let’s be clear about the impact of these hospital closures. When a hospital is shuttered in an urban environment, it creates an inconvenience and a slightly longer car/ambulance ride. When hospitals close in rural areas, towns lose jobs, a source of civic pride and community engagement, and often lives as well.

But the current hospital closure rate need not continue. As healthcare moves through dramatic changes, re-imagined processes and sparkling new tools can empower key preservation strategies:

Establish Telehealth Partnerships: When Plains, Georgia, the home of former President Jimmy Carter, lost its only clinic in March, the Mercer University School of Medicine stepped in and opened Mercer Medicine Plains. Offering both onsite and telehealth services, Mercer Medicine Plains is just the most recent project managed by Jean Sumner, dean of the School of Medicine, who has managed similar efforts in other rural parts of Georgia.

“It’s a way to bring some healthcare to people who don’t often see it, but who do need it,” Sumner said. “In these areas, you need to figure out what you have, and then work with it.”

Telehealth also offers the potential to simplify revenue cycle through enhanced billing and collections. As direct payments by patients have become a larger segment of hospital revenue, organizations must now collect as many outstanding dollars as they can. With telehealth, patients are often willing to pay upfront for convenience and ease.

If we want other communities to benefit as Plains, Georgia, has, we must make sure sufficient infrastructure is in place. In recent testimony, the American Hospital Association encouraged Congress to make sure broadband networks proliferate more widely to the areas where telehealth can have a dramatic impact.

Use the Cloud: In northern Kansas, rural Republic County Hospital used to have an expensive relationship with a radiology organization that read images for the hospital. With the current cloud-based, vendor neutral PACS system in place today, Republic cut their imaging costs in half and can now give clinicians access to patient images through any internet connection. The update to an internal fiber optic network opened a new world of possibilities that the hospital is now starting to maximize.

Beyond PACS, how else might Republic use the cloud to further cut costs and improve revenue?

A cloud-based storage and healthcare IT platform would empower Republic to save money on servers and other local infrastructure, provide better access to patient data beyond just imaging, access solid backup and disaster recovery options, scale for expanded storage without having to buy hardware, and run analytics on patient and organization data to identify opportunities for greater efficiency.

Increase Reimbursements: Hospitals are reimbursed by the federal government, in part, based on a formula that uses a national average and local factors like cost of living and level of competition. This wage indexing of reimbursement, not to mention other regulations, makes profitability more of a challenge for rural hospitals than it arguably is for their city cousins.

“Rural is experiencing death by a thousand cuts,” said one rural hospital CEO.

The issue here is that while cost of living in rural areas may be less, the cost of providing care is not. Members of Congress have asked why CMS has not yet fixed this problem, and the agency may have to come up with a different reimbursement scheme or decide in the interim that rural healthcare is a public good the government must preserve while financial viability is worked out.

Reduce Regulation: Yes, telehealth shows strong early promise, but many of those providing care in rural areas believe it could have more of an immediate impact with fewer shackles. Currently, Medicare’s telehealth limitations include geography, setting and type of service provided.  

Rural healthcare is also subject to policies and regulations that may work perfectly well in city hospitals but are much more difficult to comply with where resources are scarce. Rural hospital administrators argue that what they need is the flexibility to solve problems in a manner that makes sense locally. In essence, these same administrators are making the argument for the freedom to remain viable, which seems like a clear-cut public good on the face of it.

Amid the ongoing turmoil, many clinicians and administrators lament the way technology is turning the traditional hospital environment upside down. It’s a completely understandable response to upheaval. But technological change would not be possible in an environment that was not already ripe for disruption. And the good news is that technological change does not just plow through an industry like a tornado through a Kansas trailer park. It leaves a different, usually more flexible order in its path.

So, to revisit the original question, can technology save the rural component of American healthcare from destitution? Not alone, but many of the policy changes necessary to save rural care are enabled by advances in technology. We’re better served by an integrated, collaborative approach regardless of which healthcare sector we work in.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

The viability of rural healthcare relies on evolution

Choice can be a double-edged sword—we all want more of it, but with too many choices paralysis can set in. Choosing a physician or hospital, for example, in an urban or suburban area without some kind of recommendation can truly be a daunting task.

But it beats having few or no choices. Increasingly, that’s the situation rural Americans find themselves in as the number of hospitals decreases and specialists stay in the cities.

While this may have been the trend in rural healthcare over the past 10 or 15 years, the current advance of technology in healthcare and the introduction of new care models offers rural hospitals much-needed opportunity. Heartland hospitals have the ability now to revamp and re-envision care in the essential areas where America produces energy and food.

What strategies and adaptions available now can ensure affordable and efficient rural care for the foreseeable future?

Strategy 1 - Forge relationships. As with all hospitals, Winona Health (99 beds, Minnesota) had more than a few patients using the ER for chronic but manageable health conditions. To get ahead of and maybe prevent ER visits, Winona Health established relationships with organizations that included a nearby senior center, the state health department and Winona State University to provide support for the chronically ill. This led to the formation of the Community Care Network in 2012, through which Winona Health trained Winona State University students as health coaches.

By providing basic emotional support and performing a few tasks like grocery shopping, the Community Care Network reduced ER visits by 91 percent and hospital readmissions by 94 percent in the first 90 days of the program.

Are there organizations in your community that can contribute to managing the health of those who need support and preventing health emergencies in the ER?

Strategy 2 – Innovate around care. Even where there are sufficient providers in a rural area, there are seldom enough specialists, which means patients sometimes have to travel long distances for specialized care. The University of New Mexico’s Project ECHO works to address this need through educational innovation by connecting specialists with physicians in rural areas, giving them the understanding they require to meet particular patient needs.

For more than 20 years, Stanford University has organized the Chronic Disease Self-Management Program (CDSMP). The program trains patients with chronic illnesses to manage their own emotions and behaviors—eating well, taking medications appropriately, communicating with friends and family, getting enough rest. Results demonstrate that the CDSMP improves the lives and satisfaction of chronically ill patients, and it saves money on reduced hospitalizations and readmissions.

Are there cost-saving care innovations your organization is not yet utilizing? How can you implement proven programs to keep costs down and bring patients deeper into the provision of care?

Strategy 3 – Focus on what you do well. Most doctors willing to live in rural areas are not specialists.

“Specialty has a powerful effect on physician location choice …” according to a study on physicians and rural America published in the Western Journal of Medicine.  “Family physicians distribute themselves in proportion to the population in both rural and urban locations and are the largest single source of physicians in rural areas. All other specialties are much more likely to settle in urban areas.”

Specialized care is not and probably never will be the strong suit of rural physicians. But this perceived weakness gives rural hospitals the opportunity to focus on natural strengths.

“A rural environment lends itself to population health and wellness,” says Jennifer Lundblad, CEO of Stratis Health, a Bloomington, Minnesota, nonprofit that promotes innovation and collaboration. “Providers probably know the patient and their family, they may go to church with them, they see them at the grocery store. If rural communities can figure out how to harness those assets, they will be well-positioned for the future.”

Of course, rural health providers remain the most important interface with patients, making them primarily responsible for creating access to specialists by forging relationships and innovating around care (above), and by maximizing the use of technology (below).

Are the wellness and population health efforts in your organization robust enough to create lead time when your patients have to utilize your relationships with specialists?

Strategy 4 - Use technology. Much has been written about the potential of telehealth to alter the rural healthcare landscape.

In South Carolina, the state Department of Mental Health worked with the University of South Carolina School of Medicine and 18 hospitals, mostly rural, to provide telepsychiatry services. Most of the hospitals had no psychiatrist in the ER when mentally ill patients arrived, and the program provided that resource 16 hours a day, 7 days a week.

The telepsychiatry services have reduced both wait times in the ER and inpatient admissions, and it has lowered costs. Patients are going to their scheduled outpatient appointments more often, and levels of satisfaction are up for both patients and physicians.

Telehealth services, while not the only approach to technological innovation, are now seen as the most promising technical cure for what ails rural hospitals.

“There are two kinds of healthcare innovation: more-for-more and more-for-less,” write Nathan Washburn and Karen Brown in the Harvard Business Review. “The American healthcare system exemplifies the first kind, offering more and more value at higher and higher costs … Virtual consultations … are at the heart of a reconceptualization of rural hospitals (and eventually urban clinics and hospitals as well) because they provide access to higher-quality care at much lower costs.”

Of course, rural hospitals cannot provide effective population health and wellness services without effective, affordable, interoperable healthcare IT systems; the technology is a prerequisite. While rural health organizations currently lag behind their urban and suburban cousins in terms of adoption, government initiatives are helping to close the gap.  

Is your organization maximizing affordable technologies, including telehealth and electronic health records, that improve the bottom line without busting the budget?

Strategy 5 - Merge. Wafer-thin profit margins (if they exist at all) and threats of insolvency would cause any rural hospital executive to consider merging or being acquired. Predictably, activity in the hospital M and A sector has been brisk over the last several years as rural facilities sign on with larger, more financially stable urban and suburban health networks. 

So, is independence even realistic, let alone desirable, for rural facilities? The answer is yes, though with caveats.

“The trick to staying local and ‘going it alone’ is often through configuring creative but limited partnerships with larger systems,” writes Beth Nelson in Hospitals and Health Networks. Complete independence may be completely historical, but that doesn’t mean rural hospitals can’t maintain a semblance of self-determination.

Have you explored the alliances available to you that may enable your hospital to survive and provide for the needs of the surrounding community?

A piece of good news: At least one study shows that rural hospital closures have not had a measurable impact on local mortality. The not-so-good news: rural residents are generally less healthy than urbanites, so having no local hospital and healthcare organization eliminates the opportunity to improve care through various wellness and population health programs.

Just as they always have, rural hospital executives and clinical leaders are doing all they can with the resources available. The difference in our current technological age is that so many more cost-saving tools exist than just ten years ago. By employing strategy and technology, rural healthcare organizations finally have the tools to move beyond survival and become catalysts for healthier communities. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

America has a rural healthcare crisis. Technology can help.

As 2017 begins, around 81 percent of Americans live in urban areas, up from 79 percent in 2000. At the same time, urban and suburban areas where vacant land exists (so, not you, San Francisco) have been expanding, redefining what used to be rural. With this demographic shift comes a transition of resources and tax bases that leave rural areas and rural services, including healthcare, struggling to survive.

Indeed, we can learn a lot about the state of rural healthcare from several access-related statistics:

  • As of last year, more than 70 rural hospitals had closed since 2010 and 673 were vulnerable to closure, of which 68 percent were critical access.
  • The distance to hospitals in rural America is often much further than in urban areas, sometimes meaning the difference between life and death.
  • The number of doctors per 10,000 residents is 13.1 in rural areas and 31.2 in urban environments, simply making care harder to get. With regard to specialists per 100,000 residents, the average is 30 in rural areas and 263 in urban.
  • More than half the counties in the country have no practicing psychiatrist, psychologist or social worker to deal with mental health and addiction issues.

More generally, America’s rural population is older, makes less money, smokes more, is less healthy and uses Medicaid more frequently. All these factors dramatically complicate access issues and yield predictable results.

Opioid-related addiction and overdoses, for example, are disproportionately higher in rural areas than in urban. Improvements in the death rate for rural residents have evaporated. For rural white women, death rates have increased as much as 30 percent in recent years, a stunning reversal of previous trends.

Why this is happening is complex and not easily fixed—certainly lack of economic opportunity is a factor, as demonstrated in the recent election—but in many ways technology can make a discernable difference.

Opiate Addiction and Treatment

“While my city patients are well aware of the fact that most physicians consider opiates high risk for addiction, this fact may totally elude my rural patients,” writes Dr. Leonard Sowah in a recent KevinMD post. “I had a few experiences with individuals who were clearly addicted to opiates but would constantly state they were not addicts since they received opiates only from licensed prescribers.”

Certainly, increased awareness and better educational materials will help this situation, but the responsibility will ultimately fall to physicians. Without the Prescription Drug Monitoring Program (PDMP), this would be a near impossible task. The PDMP—a database of electronically prescribed medications and patients that functions in 49 states—makes it possible for doctors to see a patient’s prescription history and identify potential “doctor shopping” and addictive behaviors.

Behavioral Health Treatment

If the National Health Service Corps, which uses loan repayment as incentive for doctors to work in high-demand areas, isn’t doing the trick, what’s next on the list of ideas?

Right now, almost all bets are on telehealth, which has proven effective thus far in treating depression and PTSD. Congress made funding for telehealth a significant part of the recently passed 21st Century Cures Act and is requiring CMS to periodically report back on how telehealth is being used in Medicare and whether or not it is working.

Telehealth may also provide relief on the cost side of the equation for rural hospitals. According to a 2012 Institute of Medicine report, telehealth increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. To make it really effective, all insurers need to embrace telehealth and all providers need to implement the technology.

Hospital Closures and Access to Care

Telehealth is also one solution to hospital closures, even if it’s not ideal or even effective for every scenario where a hospital would improve or save lives.

Electronic health records (EHRs) and participation in health information exchanges (HIEs) and accountable care organizations (ACOs) offer benefits in terms of streamlining patient care and improving efficiencies, as well as having ready access to best practices and specialists when referrals are necessary.

“The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare,” said CMS Acting Administrator Andy Slavitt. “In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.”

No, the ACO Investment program is not a technology, but it is almost completely hamstrung if rural providers don’t adopt technology to make improvements.

Non-technological Factors

Of course, technology alone won’t fix the issues that plague rural healthcare. It’s not magic, after all. Economics and public policy will also come into play.

For example, the slim profit margins, if they exist at all, that rural hospitals create necessitate an affordable EHR system that doesn’t require a huge pile of cash up front to implement. Most hospitals have used Meaningful Use to help pay for those systems, but the unique financial challenges of rural healthcare might necessitate a Stage 3, even though CMS has signaled that the program is about done.

Using policy to assist rural providers is the focus of the recently formed CMS Rural Health Council, which operates with an all-encompassing agenda:

  • Improve access to care for all Americans in rural settings
  • Support the unique economics of providing healthcare in rural America
  • Make sure the health care innovation agenda appropriately fits rural health care markets

A solution that meets all three of those objectives will have to be creative, flexible and effective.

The ongoing changes to American healthcare occur in a time of social and political upheaval, and it will take some time to know whether or not past legislation and upcoming changes to those laws have had a positive impact. If not, the nation may have a difficult decision to make about rural care. If the economics don’t improve and technology can’t make a significant financial difference, what are the alternatives? Can acquisitions by larger hospitals keep facilities alive AND keep costs down?

It’s an important conversation, and solutions will be difficult to hammer out, but what hangs in the balance for the people that grow our food and harvest our energy is essential to the entire nation. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Subscribe to Rural Healthcare