Q & A: Planting Seeds of Hope for Rural Healthcare-Part 1

Are we in the midst of rural healthcare crisis?

According to Maggie Elehwany, the Vice President of Government Affairs and Policy at National Rural Health Association (NRHA) , a healthcare desert is rapidly spreading across close to 95 percent of the American landscape.

Disproportionate opioid death rates, underdeveloped travel infrastructures, aging populations, and poverty are just a few of the issues making it quite difficult for rural hospitals to keep its doors open.

In a two-part Q & A full of expert insight from Elehwany, we discuss in detail how these issues, along with workforce shortages and shifting healthcare models, are impacting rural healthcare across the country.  We also take a close look at what the NRHA is doing to create more rural healthcare awareness on Capitol Hill and advocate for positive change.

MH: Tell us about your role at NRHA and what you are trying to achieve for rural healthcare in America.

Maggie: My name is Maggie Elehwany, and I'm the Vice President of Government Affairs and Policy for the National Rural Health Association. We are a national nonprofit organization that's dedicated to really one mission, improving access, and quality of care in rural America.

NRHA is made up of two arms. There's an education segment of our association that reaches out to our membership and provides them with continuing medical education and best practices. That side is mainly focused on helping hospitals improve what they do each and every day in rural America. Then there's my arm of the association. I advocate on behalf of our membership, which includes all different types of rural providers.

MH: You just closed out a big day of advocacy in Washington (DC) at your annual Policy Institute. What were your biggest takeaways from this year’s event?

Maggie: It was so exciting to see so many folks, so energized. I think it was one of the best policy institutes we've had, by both the quality of attendees and the quality of people from the administration and Capitol Hill. I really liked a lot of the panels we were able to put together.

The reason why I think this one was especially important, is because our message can be bleak, but what we try to focus on is how, with just a few resources, we can really turn things around in rural America.

What we see, and what recent reports from the CDC have shown us, is that the mortality gap between rural and urban America is growing, largely because of chronic diseases and also because of risky lifestyles.

At the policy institute we try really hard to focus on the bright spots. Some of the poorest, most health challenged areas in the country—like deep areas of Appalachia—we're really able to turn some of their population health issues around. This is a result from few extra resources made available in those areas, but also from complete buy in at the local community level. They really took a stand on working to change things.

We had a very powerful message. We had the data to show just how significant the problem is in rural America, and we had a great group come in to really attack the issue and educate members of Capitol Hill and we hope to see some good results.

MH:  What are some of those key messages you are trying to communicate to legislators and push forward when the topic of rural healthcare comes up?

Maggie: First of all, we want to make sure that everyone on Capitol Hill understands that what the federal government invests in rural America is very small. Yet, rural America does so much, and so they just have to stop cutting in and they have to stabilize the system.

They have to stop taking resources away from these rural providers. The reason we're seeing so many of these hospitals have to shutter their doors, is because Congress is taking away their reimbursement payments. A lot of larger hospitals can absorb these cuts. Smaller rural hospitals cannot.

Rural hospitals account for 46 percent of small hospitals operating at a financial loss across the country. That number has risen six percentage points in just the last two years. How can they overcome these things? How do we improve and secure access to care? That is a mission that really unites each and every one of our members—improving access to care. That probably always will be the greatest challenge in rural America.

You've got 20 percent of the population living in rural areas scattered over 90 to 95 percent of the landmass. You've got mountains, rivers, extreme weather, that often make it very difficult for those individuals to access care. When you layer that on top of workforce shortages—20 percent of the population lives in rural America, yet only 9 percent of the physicians actually practice in rural America.

MH: What kind of connections do you see between a trend in rural hospital closures and issues  like workforce shortages and poverty? Which areas need the most help?

Maggie: The hospital closure crisis has made workforce shortages even more extreme. There are tremendous shortages in all different types of healthcare providers: physicians, nurses, even anesthesiologist. If you look into any of those specialties—specifically mental and dental health—they can be virtually nonexistent in a lot of rural America.

These rural hospitals are closing in areas where access to health care is needed tremendously. What I mean is, that they're closing in areas of high poverty where chronic disease rates are equally high.

Studies show that in rural areas across the country over six percent of Medicare populations have chronic disease, in comparison to the typical one or two percent.

What we're seeing is a very challenging population health, but we're also seeing hospitals close in those areas, making access to healthcare even more difficult. When you lose a hospital, almost always in rural America, the physician often leaves the community, the nurses, the pharmacists—they all leave. You end up with these tremendous medical deserts and a tremendous strain on the EMS staff that is left behind.

MH: When you talk about specialists, you are referring to areas of care that may be unique, but are of critical importance to communities? Any specialty areas that are more vulnerable than others?

Maggie: Obstetrics departments are definitely a red flag when a hospital is financially hurting, because obstetrics is such an expensive department to maintain. You have to have physicians on call, you have to have an anesthesiologist, you have to have the right equipment, you have to have proper liability insurance. It's often something that we see cut, but it's becoming absolutely detrimental to so many women across the community.

We are getting a lot of interest from Capitol Hill in OB because they see it in their communities. It's really hard to keep a community robust if you don't have a place where babies can be born. Families won’t stay in a community if their local hospital can’t maintain obstetric services.

We are also incredibly concerned about infant mortality rates in rural communities. The most vulnerable communities are those that are losing their obstetrics.

We've had more than 200 obstetric departments close in the past 10 years. Rural counties with higher percentages of African American women, were more than four times as likely to have lost obstetric services. Even more importantly, they were 10 times as likely to never even have obstetric departments at their hospital.

NRHA is forming a coalition in Washington DC with ACOG (The American College of Obstetricians and Gynecologists) and with the American Academy of Family Physicians. We need to make sure Congress has the information they need to address this crisis.

MH: Can you point to any factors that have led to these workforce shortages? Is this a national crisis or is it something that is specific to rural America?

Maggie: Since there's been a rural America, there has been a rural America healthcare workforce shortage. There haven't been healthcare workforce shortage areas across the nation at all times. However, in the last several years we are seeing more and more members of the baby boom generation going into Medicare. This elevation is causing a tremendous physician shortage across the nation. A lot of physicians are in that baby boom generation, and they're retiring as well.

You've got an aging health care workforce and you've got a tremendously large population who are growing older and needing more access to healthcare more often. That's a national problem that's going on now. However, it's a problem that has always been there in rural areas, and those retirements and the population explosion just magnify the issue.

If you look at the health profession shortage areas (HPSAS) nationally, you've got 77 percent of rural counties across the country that are considered HPSAS.

Keep your eyes peeled for the second half of this Q&A which will continue to focus on takeaways from NRHA’s Policy Institute, switching to a discussion on new care delivery and payment models. Elehwany will discuss what needs to happen on Capitol Hill to help rural facilities struggling to adapt to these major shifts within the healthcare industry. She will also offer an inside look at what kind of partnerships the NRHA is forming to accomplish change at the federal level.

The conversation is just getting started, so don’s miss out!

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