It's common knowledge that Americans living in rural areas have poorer health outcomes than their urban counterparts. But, despite policy efforts to ameliorate disparities, the gap is not getting any better, according to several new studies published in Health Affairs this week.
Rural residents have a 23% higher mortality rate, according to one of the studies, along with more preventable hospitalizations and emergency room visits. Rural outcomes are especially dire for chronic and behavioral health, with deaths related to chronic obstructive pulmonary disease, diabetes and suicide exponentially increasing over the past few years.
But despite the statistics, the population, which is also more likely to be low-income and with high-cost chronic conditions, is experiencing a paucity of care.
CMS has tried to address the higher mortality rate through several recent initiatives, like expanding Medicare reimbursement for virtual care visits, allowing non-physician providers to offer some key primary care services and increasing the wage index of rural hospitals, allowing the facilities to recruit more staff and invest in more resources.
But larger structural forces have so far stymied efforts to move the needle on healthcare for the 62 million people living in rural America.
"The game is rigged," Janice Probst, a professor at the University of South Carolina's Arnold School of Public Health said Wednesday at a Health Affairs event in Washington. "If we don't change the game, we never win."
Rural provider M&A helps finances, not care quality
Rural areas face unique struggles in accessing high-quality medical care driven by innate factors like geographic size and distance, along with a market bias toward population-heavy metropolitan areas, experts say. And those inherent barriers are exacerbated by the financial motives of healthcare providers themselves.
More than 100 rural hospitals have closed since 2010, and one in five are at risk of closing, especially in southern and midwestern states. In an effort to strengthen their bottom lines and avoid shuttering their doors, many rural facilities have merged or affiliated with larger health systems.
"Ultimately, market forces in rural healthcare are really challenging," Claire O'Hanlon, an advanced fellow in the Veterans Affairs Center for the Study of Healthcare Innovation, said. "When you're running a hospital, whether nonprofit or for-profit, the margins have to work."
Mergers and acquisitions among rural hospitals have increased, from 10 to 30 per year in the 2000s to roughly 30 to 70 per year in the 2010s, according to the North Carolina Rural Health Research Program.
Though powerful provider lobbies like the American Hospital Association argue M&A actually lowers prices for consumers, their evidence is shaky. Previous studies show prices tend to be higher in more consolidated markets.
One of the Health Affairs studies tracking the affiliation status of rural hospitals nationwide between 2008 and 2017 found those that affiliated with a larger system had fewer onsite diagnostic imaging technologies and fewer obstetric and primary care services.
For those facilities, operating margins increased significantly with no corresponding improvement in patient experience, readmissions and emergency room visits, all metrics of care quality, leading researchers to conclude "joining health systems may improve rural hospitals' financial performance" but "affiliation may reduce access to services."
Disparities start in physician pipeline
Currently, only 11% of the physician workforce practices in rural communities, although roughly one in five people in the U.S. are rural residents, according to the Census Bureau.
Evidence shows that medical students who grow up in a rural setting are more likely to eventually practice in a rural area, yet rural students represented less than 5% of all incoming medical students in 2017.
That number would need to quadruple to become proportionate to the number of rural residents in the U.S. population, researchers found, suggesting medical schools have a part to play to stymie the 15-year decline in the number of rural students.
Medical schools could consider a rural background as a component of diversity in their incoming class, experts suggested. Additionally, communities could bolster pipeline programs giving incentives to younger students to become doctors.
Increasing staffing, especially for specialty care, would also go far to increase access, experts said.
One study found access to specialty care, not primary care, had an outside impact on care quality — accounting for 55% and 40% of the rural-urban difference in preventable hospitalizations and mortality, respectively.
The finding caused researchers to decry current HHS policies as "misguided and unlikely to reduce disparities." Instead, the Trump administration should consider interventions like expanding telemedicine reimbursement in specialty areas, like cardiology — and CMS has previously said it is considering more flexibility around virtual care payments.
Additionally, rural residents are more likely to be uninsured or on Medicaid or Medicare, forcing hospitals to shell out more uncompensated care. States that have not yet expanded Medicaid under the Affordable Care Act like Texas, Alabama and Mississippi could do so for an influx of cash to those facilities, and would particularly help small towns in rural areas, according to the Georgetown University Health Policy Institute.
To date, 14 states have not yet expanded Medicaid.
However, academic researchers say such policies may be stopgap measures without meaningful, systemwide change to level the socioeconomic and healthcare playing fields countrywide, regardless of geographic location.
"Take a step back and tear it down and rebuild it in a different way," Kevin Bennett, director of the Research Center for Transforming Healthcare, said. "Where are we going to be in 20 years, and how can we position rural [healthcare] to get where we're going?"