Q&A: The Critical Condition of Rural Health Part 1

Over the past century across the United States, healthcare technology has quickly evolved stranding many small, rural, and community providers who are unable to afford these new developments.

Tim Putnam, who serves as the President of National Rural Health Association (NRHA) and President and CEO of Margaret Mary Health—a critical access hospital in Batesville, Indiana -shared a preview on some rural challenges he will address at NRHA’s Critical Access Hospital Conference in Kansas City September 18 -20.

The first part of our interview offers Putnam’s perspective on the state of rural healthcare in America as well as his take on creating payment models best suited for population health management in rural communities.

MEDHOST: Can you paint a broad picture of how you see rural healthcare fitting into the larger healthcare industry?

Tim: Routine checkups, regular physician office visits, screenings, those are the things that rural and community hospitals are good at. It’s not high-end open-heart surgery and neurosurgical procedures. We need to think about it from the perspective of population health—rural hospitals are perfectly aligned for that. Keeping people healthy, not high-end interventions.

About five years ago our hospital heard from a gentleman that offered us an analogy. He said, “The rural experience in the current healthcare system is like my grandmother. I loved playing with my grandmother, and it was so much fun. Then she got diabetes. Her diabetes was so bad the hospital had to cut off her toe. Now she is in a wheelchair. Next time I visited; she was in a bed because they had to cut off her leg.”

He explained that every step along the way, a hospital is getting paid for diagnosis and treatment, but is never incentivized to keep grandmother's diabetes under control. The gentleman looked at our board and said, "If we really care about the mission of improving the health of our rural communities, we will focus on keeping grandmother’s diabetes under control, much more than becoming the best amputation program in the country.

Rural healthcare providers have become aware that they cannot do everything. We're great at diagnostics, great at primary care, but major interventions—that's not what we do. The rural experience is just a piece in the continuum and those providers know what they can do and what they can't. Partnerships are what will help rural providers become successful and create good patient outcomes.

MEDHOST: Can you discuss patient outcomes from the perspective of population health and how that differs in the rural experience?

Tim: If you ask a group of healthcare leaders or community leaders what population health is, you'll get a variety of different answers. At its core, population health is about improving health of a well-defined population.

In places like Los Angeles or Seattle, one facility only sees a fraction of the healthcare delivery for the larger community. In smaller, rural communities across the country, there's often one hospital that covers the majority of that population's care.

Rural community hospitals do a good job of defining their population. It's easier to look at the 20,000 or 30,000 people in an area and establish yourself as a healthcare leader than it is for any large community. Rural providers have a clear need to do what they can to make a defined population healthier.

MEDHOST: What kind of unique challenges are rural hospitals facing when trying to do those things that make their defined population healthier?

Tim: At a high level, you see an older, poor, sicker population in rural America. In addition, slightly less than 20 percent of the population lives in rural areas, but far less than 10 percent of physicians practice in rural areas. You've got a high population need with a low percentage of providers. That's where some of the challenges start and it just builds from there.

MEDHOST:  Payment models often don’t account for the unique rural challenges. How can rural-specific payment models play a part in reducing pressure and help rural facilities remain profitable?

Tim: In a rural community you see patients in more places than just the hospital setting. You see them at the ballgame, at church, at the grocery store, and the farmer's market. You want that to continue. NRHA mission states that we should do all we can to improve the health of our communities. Current payment models don't align very well with helping rural providers achieve that. We'd love to be paid for prevention, but right now we're being paid for just the pounds of cure.

Think about where the dollars go in our healthcare system. It's always the high-end treatments—treating cardiac disease at the very last point. Studies have shown how much more is spent on healthcare in the last few months of life than what is spent on early prevention.

The things I mentioned earlier: routine checkups, physician office visits, things like that, those are the things that rural and community hospitals are good at. Thinking again about the definition of population health—rural hospitals are perfectly aligned for that. Keeping people healthy, not high-end interventions. We need a payment model that aligns with those strengths.

MEDHOST: Where are we in terms of getting closer to placing a larger emphasis on a payment model that aligns better with preventive care?

Tim: When you see what is invested in public health, screenings, and health and wellness, as opposed to investing in the high-end treatments, we're clearly going down that road. How to pay that, and how that model will work is interesting.

I look at examples like Maryland and Pennsylvania and their global payment models for rural areas. You define the population you're serving and analyze previous year expenses. Payers will give you that amount, plus a two or three percent increase. As a result, the facility can provide better healthcare the following year.

Now you start thinking more in-depth, like emergency department visits via an ambulance. How many of those 911 calls could have been prevented with better engagement 48 hours prior? How do we get other community organizations involved in prevention? How do we keep disease under control before it gets out of control? How many kids routinely miss school because of illness? Whose responsibility is it, beyond the parents, to help find a solution for what's going on with that child? If you start focusing on a community or a population and start looking at data from various sources, you can start finding answers.

For example, at our hospital we're partnering with local schools and a telehealth program that allows school nurses to call our physicians or nurse practitioners when a child is sick at school. We help them resolve issues, prescribe medications, and things of that nature. Schools are very interested in that type of thing. Getting nontraditional healthcare providers involved in population health is essential.

Check out Part 2 and learn about Putnam’s unique approach to integrating healthcare services within communities, plus other key topics he will cover at the conference.

If you’d like to learn more about the NRHA’s upcoming event visit www.ruralhealthweb.org/events.

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