COVID-19 Sparks Clarion Call To Improve Rural Healthcare

Rural healthcare woes put in spotlight by COVID-19 pandemic

Health disparities have been a longstanding struggle for people living in rural communities who represent 20% of all Americans. Compounding that history, COVID-19 has been killing rural Americans twice the rate of people living in urban areas. It's not unthinkable, considering that rural America encountered the perfect storm when COVID-19 arrived. 

The compromised state of rural healthcare pre-pandemic

Rural healthcare was already weakened before COVID-19 affected the nation. Since 2010, 138 hospitals have closed, including 20 just in 2020. Additionally, 47% of rural providers were already operating at a deficit before the pandemic. From 1999 to 2019, people living in rural areas saw all causes of death increase from 7% to 20% compared to urban areas. These death rates have risen in rural communities most months since March 2020." This level of lives lost and disparities in rural health impacts the entire country as rural populations provide the majority of the workforce for U.S. manufacturing, farming, and ranching . 

Rural health disparities & COVID risk

Rural health disparities put people at risk for more severe COVID. People living in "noncore" and "micropolitan," aka rural, communities have complicating factors that can lead to more severe COVID-19 symptoms. Rural counties have a larger number of adults over age 65, more prevalence of obesity and smoking, coupled with a higher percentage of adults living with multiple chronic health conditions like arthritis and diabetes. 

The pandemic has greatly exacerbated longstanding and persistent barriers to better rural healthcare. This is the clarion call to face the disparities and find innovative ways to provide care at a distance, tap into accessible technologies, and engage rural communities.

Rural COVID challenges that go beyond healthcare access issues

While 53% of people received vaccinations in urban areas, rural communities were much lower, around 41% in fall 2021. And due to the pandemic, 53% of rural residents surveyed had delayed or put off procedures and checkups. These decisions can reflect complex cultural, social, and economic factors that can compound existing geographic factors and disparities in age, income, and health status. 

Trust in healthcare is also an issue with rural healthcare outcomes. Recent research uncovered five social, cultural, and programmatic barriers to better rural healthcare: 

1. Friction exists between aspects of patients' rural identities and healthcare systems
2. Facilitating access to healthcare requires application of and respect for cultural differences
3. Communication between healthcare providers is systematically fragmented
4. Time and resource constraints disproportionately harm rural health systems
5. Profits are prioritized over addressing barriers to healthcare access in the U.S.

The authors noted, "In rural settings especially, level of trust and familiarity are common factors that affect service utilization."

Twofold impact on COVID death rates in diverse rural communities

Highly diverse rural communities are those where 33% or more of the population are Black, indigenous, and people of color (BIPOC). And while 14% of rural communities are comprised of people of color, more than 50% of American Indian and Alaska Native (AI/AN) people live in rural communities. AI/AN people have the highest COVID-19 death rate at 281 per 100,000 individuals. 

At the state level, death rates can be even higher. For example, AI/AN individuals living in New Mexico witness COVID-19 fatality rates of 437 per 100,000 people. Not only do people of color experience rural disparities, but they also face health inequities, significantly increasing negative experiences of care and outcomes. These highly diverse rural communities have witnessed 1.6 times more COVID-19 deaths per capita than other rural counties. Also, in rural counties where one BIPOC group comprises more than 33% of the population, death rates reach up to 2.1 times other groups.

What is being done to improve rural healthcare?

New Rural Emergency Hospital model

In late 2020, congress launched a new Rural Emergency Hospital (REH) model that offers rural communities a new option for providing care. Slated for 2023, the program focuses on smaller towns to ensure local access to 24-hour emergency services and outpatient care. The North Carolina Rural Health Research and Policy Analysis Center projected that about 68 rural hospitals may participate in this new model to avoid closure.

On June 30, 2022, CMS released the first proposed rule for the REH program, containing conditions for participation as a new Medicare provider type. Additional payment and enrollment rules are expected later summer 2022. 

COVID-19 funding for rural providers

The American Rescue Plan (ARP) established $7.5 billion in COVID-19 relief funds for rural providers who serve Medicaid, CHIP, and Medicare beneficiaries. The funding will go to over 40,000 rural providers across the U.S. and its six territories. Payments range from $170,000 up to $43 million. Additionally, the Biden Administration awarded $1.5B in healthcare workforce awards for rural and underserved communities. 

The US Department of Health and Human Services has committed more than $1 billion to rural health clinics and hospitals to support COVID-19 testing, vaccination rollout, and resources for inpatient care. Despite this investment, COVID-19 infections and mortality continue to affect rural populations significantly. Recent studies have shown that rural U.S. populations with COVID-19 infection have proportionally higher hospitalization and mortality rates than urban populations.  

On a larger scale, the Coronavirus State and Local Fiscal Recovery Funds (SLFRF) part of ARP established a federal pool of $350B that states can use for healthcare-specific grants to improve rural healthcare. Three of the four categories of approved use of funds include:

• Respond to the far-reaching public health and negative economic impacts of the pandemic, by supporting the health of communities, and helping households, small businesses, impacted industries, nonprofits, and the public sector recover from economic impacts
• Provide premium pay for essential workers, offering additional support to those who have and will bear the greatest health risks because of their service in critical sectors
• Invest in water, sewer, and broadband infrastructure, making necessary investments to improve access to clean drinking water, to support vital wastewater and stormwater infrastructure, and to expand affordable access to broadband internet

This one-time funding program gives state, local, territorial, and Tribal governments resources to address underlying rural healthcare challenges exacerbated by the COVID-19 public health emergency.

Extending telemedicine's reach and potential 

The pandemic accelerated telemedicine in all its forms – telehealth, virtual care, telemedicine, and remote patient monitoring. It allowed patients to continue to receive a level of care and decreased patient and provider exposure to COVID-19 and helped preserve personal protective equipment (PPE) supplies.  

Before the pandemic, telemedicine visits for rural Medicare beneficiaries had grown 28% annually from 2004 to 2013. In 2019, the American Hospital Association (AHA) reported a "consistent positive trend in the number of hospitals using telehealth services before the rapid expansion of telehealth services during the COVID-19 pandemic." Even as far back as 2012, the National Academies of Science, Engineering, and Medicine published about how telemedicine "can drive volume, increase the quality of healthcare, and reduce overall costs by reducing readmissions and avoidable emergency department visits for rural communities." It benefits rural residents because they don't have to travel long distances to access specialty care as often, as well as delivers expertise that might not be readily available even at considerable cost and distance. 

During the summer and fall of 2020, research showed that 52% of people with Medicare insurance who lived in rural areas had a provider that offered virtual appointments, and 65% of rural telemedicine visits were conducted by telephone only. Approximately 30% of patients said they preferred telemedicine over seeing their providers in the office. Thirty-seven percent used telemedicine as a workaround for longer wait times for office appointments two years into the pandemic. For rural physicians, 86.5% had been using telemedicine for six or fewer months since mid-2020. And while 27% felt that telemedicine did not improve work satisfaction, "45% felt satisfied with the care they delivered via telehealth."

A study published in the “Journal of the American Board of Family Medicine found that telemedicine is an effective alternative to in-person care for rural residents, helping to drive up appointment completion rates.” The study revealed that telehealth can improve appointment completion rates by about 20%. 

Telemedicine challenges as part of a rural healthcare improvement strategy

However, telemedicine has challenges to adoption and scalable use. There are often policy barriers, infrastructure limitations, and concerns over the effectiveness of engaging with clinicians by phone or video technology.  Forty percent of people who hadn't used telemedicine appointments during the pandemic are uncertain "whether their doctor's office offers telehealth services and whether insurance covers telehealth appointments." 

Rural healthcare barrier to entry – poor Internet connectivity 

Poor broadband access and Internet connectivity have been the greatest hindrance to telemedicine's adoption. Twenty percent of people living in rural communities over 40 say lack of high-speed Internet is a barrier for them. However, in May 2022, the Biden Administration announced a $45 billion 'Internet for All (IFA)' initiative. Drawing on resources from the Infrastructure Investment and Jobs Act, IFA comprises several programs that will build high-speed broadband infrastructure, teach digital skills, and provide technology to make the Internet accessible to every American. The announcement followed that the administration had partnered with 20 broadband providers to improve subsidized high-speed internet plans made available to low-income Americans through the Affordable Connectivity Program. Additionally, the SLFRF part of the American Rescue Plan has funds to support Internet connectivity.

Attracting more physicians to rural communities

Warnings of a primary care physician shortage have been touted for many years. For rural communities, it's a reality. While 20% of the U.S. population lives in rural communities, only 11% of physicians practice there. This compounds the challenges with healthcare access. The director of a rural community health center shared, "There's no doctor in the county. No psychiatrist. No dentist." And "of the more than 7,200 federally designated health professional shortage areas, 3 out of 5 are in rural regions." But some programs are trying to change this trend, knowing that "research shows that Medical students who grow up in small communities far from urban centers are much more likely to return to them to practice…" 

The Oregon Health & Science University (OHSU) School of Medicine, for example, identifies potential candidates from rural communities and encourages students to pursue a career in medicine. They also provide support and guidance through medical school, linking medical students with residency programs. Residents can pursue rotations in rural communities, providing hands-on experience, as well as an understanding of the "scope of practice required of a primary care physician in a community where there may be no OB/GYN or general surgeon."

Next steps for improving rural healthcare

While innovative approaches to improving rural healthcare abound, commitment to policies and funding that provide the critical resources, training, and technology is needed to ensure that rural residents can receive more accessible, approachable, and equitable care no matter where they live.

Build better rural partnerships and telemedicine opportunities

The needs of rural providers, communities, and residents offer a challenge and an opportunity for urban and suburban provider organizations to bridge gaps in care while increasing revenue through new or expanded services. Learn more about RTI Health Advance services that can support rural healthcare initiatives, including Population Health, Quality Improvement, Patient Experience, and Digital Health.