Rural health care centers need autonomy, fresh talent, report says

Jan. 18--Rural health care centers should have more flexibility to build and fund services, a new report suggests.

The Bipartisan Policy Center's report released Wednesday aimed to identify ways to better manage funding, personnel and services as assets for rural health care providers. The report focused on how policy could be directed differently for more sparsely populated areas.

"This distinction tends to go unacknowledged in health policy, which often puts rural areas at a disadvantage," the report said.

Researchers focused on seven states to model rural health care -- Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming. They contain just 4 percent of the country's population but have a quarter of the rural-based critical-access hospitals.

People in those states tend to be older, more at-risk for certain ailments and more reliant on publicly funded health insurance, the report said.

Montana stood out among the states for having the highest percentage of Medicaid and Children's Health Insurance Program enrollees -- 21 percent -- and the second-lowest number of primary care physicians per 100,000 people.

"The geography -- the space between communities -- really forces us to be creative," said Heidi Duncan, physician director of health policy at Billings Clinic, during a panel discussion of the report in Washington, D.C.

One of the study's main points was "right-sizing" services for communities. While critical-access hospitals are common providers in rural areas, researchers said that a full-service facility might not be needed in all those places.

Still, policymakers have a line to walk between creating efficiency and losing access. The line sits somewhere "on the spectrum between hospital and primary care," the report said.

Restrictions to right-sizing are systemic, according to the report. But they're financial as well, as the health care sector is often the biggest private employer in those regions.

The report pointed to telemedicine as one way to maintain care in rural areas with fewer doctors.

Panelist Darrold Bertsch, CEO of Sakakawea Medical Center in Hazen, North Dakota, said that a grant-funded telemedicine program allowed family medicine providers to take emergency patients. An emergency physician would be available via video call to oversee the patient.

But some areas do need physicians, and those talent pipelines often lead to urban sites.

Duncan said that finding a solution could mean shifting some financial support of medical residencies from urban to rural hospitals, which sometimes lose money hosting graduate residents -- "Where people do residency or where they're most likely to practice," she said. "Getting physicians exposed in residency to rural medicine is going to definitely help workforce in rural areas."

The report highlighted other financial challenges faced by rural providers with fewer patients than their urban counterparts. Some revenue-sharing models calculate payouts based on performance metrics that could be skewed in low-volume hospitals, where one patient with a poor health outcome could drag down the average, for example.

The relationship between private providers and public agencies received scrutiny in the report. Participants in the study complained of poor coordination with the Indian Health Service and Veterans Affairs clinics with things like referrals and records-sharing.

Another issue researchers pointed to is that there are fewer insurance payers in rural areas. More often the insurance payer there is the federal government.

Many rural hospitals receive a large chunk, as much as 80 percent by some estimates, of reimbursements from Medicaid or Medicare and other public sources, the report said. That makes an isolated health system vulnerable to swings in government funding decisions.

That drama could play out this week amid a budget battle in Congress.

"The answers are out there," said Sen. Mike Rounds, R-South Dakota, during the panel discussion. "But it's going to take some agreement among people with different points of view. And we start by actually passing a budget."

The report pointed to multiple draft policies currently circulating in Congress, most aimed at creating more autonomy for rural providers and support for telemedicine programs.

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