Understanding Why Rural Health is in Trouble

EDITOR’S NOTE: This is the first writing in a three-part series by Dr. John Zelem about the unique and daunting challenges currently faced by rural healthcare providers.

It has been stated that approximately 61 million Americans live in rural, tribal, and geographically isolated communities. Rural areas tend to have unique economic and social dynamics, and, more often than not, land-based industries such as farming and forestry, with economics very different from those of cities and urban areas. These communities often experience significant health inequities, including heart disease, stroke, cancer, unintentional injuries, suicide risk, and chronic lung disease.

Death rates tend to be higher for many reasons, and that difference has grown over the last two decades, as all of the 10 leading causes of death among Americans in 2019 saw higher rates in rural areas, as opposed to urban areas.

According to the Center for Healthcare Quality and Payment Reform (CHQPR), more than 600 rural hospitals, roughly 30 percent, are at risk of closing in the near future. If one looks at causes, the COVID-19 pandemic is often blamed, but the reality is that this is not the true reason. Over 150 rural hospitals closed between 2005 and 2019, with an additional 19 in 2020. The real cause was losses from patient services. Even though, during the pandemic, special financial assistance was given, six more hospitals closed in 2021 and 2022. Now that the COVID public health emergency (PHE) will end May, the financial risk will be even more apparent.

It costs more to deliver services, as limited as they may be, because of lower populations, increased cost of staffing, and inability to attract professional and non-professional staff. These hospitals are not inefficient, and many operate on a shoestring of executive and managerial staff. In addition, there is a common misconception that there is a higher ratio of Medicare and Medicaid patients in such facilities, but more than half of these patients have private insurance, resulting in low margins – and there are more losses due to poor Medicaid reimbursement and the uninsured. These rural hospitals also seem to be targeted by vultures of commercial insurance, with excessive, egregious denials.

It is hard to determine an etiology for this: is it poor processes, such as in the utilization review arena, poor physician documentation, or a combination of multiple factors? 

The challenges faced by all hospitals, especially rural hospitals, are multifactorial, and not just financial in nature, often due to lack of adequate reimbursement for services provided. Here are just some of the other reasons:

• Staffing shortages across all levels, not just nursing, with some of the reasons including:
  • Aging populations – with the advances in modern medicine, people are living longer. The current life expectancy for the world in 2023 is 73.16 years, a 0.24-percent increase from 2022, while for the U.S., it was 77.28 as of 2020. More people are requiring hospitalization as they grow older, and staffing is lacking as census numbers rise.
  • Nursing shortage – the nursing profession continues to face shortages, due to a lack of educators, high turnover, and inequitable workforce distribution. The causes related to the nursing shortage are numerous, and all issues of concern, of which two key ones are burnout and increased violence in the workplace. Both of these issues have been present for a while, but were brought to higher levels as secondary results of the pandemic.
    • Burnout is a widespread phenomenon characterized by a reduction in nurses’ energy that manifests in emotional exhaustion, lack of motivation, and feelings of frustration, and this may lead to reductions in work efficacy or just leaving the profession. The pandemic had an overwhelming influence on this.
    • Violence at work refers to acts or threats of violence directed against employees, either inside or outside the workplace, as well as verbal abuse, bullying, harassment, and physical assaults, even at times escalating to homicide. Even though workplace violence has become a worrying trend worldwide, the true magnitude of the problem is uncertain, owing to limited surveillance and lack of awareness of the issue.
• Workforce problems in U.S. hospitals are troublesome enough, as the American College of Healthcare Executives selected a new category as the No. 1 listing in its annual survey of hospital CEOs’ concerns. In the survey, executives identified “workforce challenges” for the second year in a row. Workplace violence to healthcare workers accounted for 73 percent of all nonfatal workplace injuries and illnesses in 2018. According to the World Health Organization (WHO), it is estimated that between 8 and 38 percent of health workers suffer physical violence at some point in their careers.
• Financial challenges, which consistently held the top spot for 16 years in a row until 2021, were listed as the second-most pressing concern in the survey. Most CEOs (90 percent) ranked shortages of registered nurses as the most pressing issue within the category of workforce challenges, followed by shortages of technicians (83 percent) and burnout among non-physician staff (80 percent).

There are many other factors demonstrating that rural health is in trouble. In Part 2 of this series, more of these challenges will be discussed.