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Q & A: Planting Seeds of Hope for Rural Healthcare-Part 2

Q & A: Planting Seeds of Hope for Rural Healthcare Growth Part 2 EHR

In the first part of our discussion with Maggie Elehwany, Vice President of Government Affairs and Policy at National Rural Health Association(NRHA), we covered some of the most pressing issues facing rural healthcare today.

The discussion focused mainly some of the healthcare disparities in rural areas and key takeaways from this year’s recent NRHA Policy Institute.

Let’s turn our focus on solving for shortages in the rural healthcare workforce to updating care delivery and payment models for rural providers.

MH: In the first part of our discussion we talked in detail about workforce shortages. What are some other key issues your membership focused on at the Policy Institute?

Maggie: What we think is also important, and what we hear that the hill is interested in looking at, is trying to figure out a new healthcare provider model that makes sense in rural America. We haven't really created a new model in rural America since 1997, back when they did the Balanced Budget Act. That's when they created the critical access hospital, which was great and stabilized healthcare delivery for a long time. There are rigid rules to be a critical access hospital though, and Congress has cut those payments significantly.

So much changed since 1997. People don't stay in the hospital as long as they used to. So many things are outpatient. The critical access hospital was really built around people being in hospitals longer.

We’d love to see them look at some of these new payment models. That's an issue that Congress is hopefully going to move on. That's really what we're trying to advance during this congressional year.

MH: When we talk about changes to the rural healthcare delivery model, we often hear a lot about transitioning from critical access to community outpatient hospitals. How does that change occur?

Maggie: The critical access hospital is still important. It is absolutely the safety net provider in over a thousand rural communities across the country.

In some communities, where they don't have the population base that they may have had earlier in their inpatient census—maybe they need to go to that community outpatient hospital model. That was one of the original models that we were advancing to Capitol Hill. We still think that that's a very important. Congress hasn't acted on it so far, but we are encouraged that there that more and more folks on Capitol Hill interested in talking about a new rural model.

MH: Is there a timeliness factor when trying to adopt new rural hospital models? What if things progress in the wrong direction? What recourse then?

Maggie: Here is our big concern. When we created that critical access hospital in 1997, it took 10 years before it really got off the ground. Congress had to debate it, study it, do a demo, and then report back to Congress. It had to pass and get reported out of committee. It had to pass the Senate. It had to go out of the House committee and pass there. Then they'd go through conference—10 years.

At the rate that we're losing hospitals, we don’t have 10 years. There is such an urgency to this and it's great to look at new models, but our biggest push is saying: “Yay, new models, we love it, but first you need to stabilize, you need to stop some of the bleeding and you need to stop this trajectory of where, in just a two year span of time, an additional 6 percent of hospitals are operating at a negative loss.” Stabilize things and then we can look for a new model.

That's really our biggest ask this year, when it comes to developing that new model, is the system has to be stabilized first. Otherwise, we're going to lose so many hospitals, there's not going to be a hospital left to transition to that new model, as good of an idea as it may be.

MH: Do new payment models receive the same treatment as new care delivery models? Like shifts in Medicaid and Medicare that can sometimes marginalize the rural hospital? How can rural hospitals get more leverage in the discussion over payment models?

Maggie: We've got to remember that a lot of these small hospitals have very small staffs who may be wearing different hats. People are working and doing so much with so little. They see the regulatory burdens. They see patients that may have been insured but weren't because their state didn't expand Medicaid. They see patients that have insurance, maybe through one of the new exchanges, yet still can't afford their insurance. Unfortunately, those patients still get sick, and they show up in the emergency room.

In rural America more often than not, rural patients are buying high deductible plans and not realizing they still cannot afford their insurance.

Say I live in a rural area and suffer a heart attack. I go to my local hospital. They save my life, stabilize me. Being a rural hospital, part of the stringent rules the operate under, they can't hold me there. They have to transport me to an urban facility. I've got a high deductible. I can't pay the bill, so the rural facility doesn’t get paid.

Here's the irony. According to my insurance company, my deductible has been met even though I haven't been able to pay it. When I'm transferred, insurance kicks in. That's why we're seeing over 50 percent of rural hospitals’ bad debt dramatically increase since The Affordable Care Act went into effect. That's what's frustrating, this was an unintended consequence that is causing magnified harm on rural hospitals.

There are a lot of hospitals struggling out there. What we're trying to do is work the quickest way possible to get them help. We've been able to work through the USDA (United States Department of Agriculture) and through a new line of loan programs to specifically target rural hospitals that are struggling. It sounds like HHS (Health and Human Services) may make an announcement of some new grant awards going out to do something very similar-and those are pure grant dollars, not loans to rural hospitals.

Is that a good start? Absolutely. Is it enough? No.

What we need, are legislative changes. The frustrating thing is these hospitals are in areas of high poverty, where the population's really sick. The hospitals are just doing everything they can to tread water. They don't have time to write their congressman and say: “When are you going to hurry up and pass a law to help me?”

We're worried that people don't understand that this crisis is going on because these hospitals are struggling so much, they can't really get the word out. That's why we really feel our job is important, and really has an urgent factor to it.

MH: Thank you for sharing this insightful information for rural hospitals who make up a large portion of our customers. We hope this goes a long way in helping spread such an important message and does a bit more to educate our leaders on how they can work with NRHA to stabilize and sustain rural healthcare in America.

Maggie: Thank you for your support! We face some big challenges, but with such a diverse membership united under a shared mission, we can make some serious headway improving access to care in rural America and helping boost overall population health.

With so many facing such hardships, looking out to the horizon, what today’s rural healthcare facilities need most from the government is stability through immediate action. As a partner with NRHA, we help support their efforts to improve health in rural America and find solutions for the many challenges facing our rural hospitals.

Healthcare is better when we partner together. Learn more about how MEDHOST is working with rural healthcare providers. Call 1.800.383.6278 or email us

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