Rural Hospitals in Critical Condition

A recent USA Today article highlighted the struggles facing rural hospitals.  Authors Jayne O’Donnell and Laura Ungar report that since 2010 43 rural hospitals have closed—with the number of closures seeming to increase every year, and still more currently in danger of closure.

“The Affordable Care Act,” the authors write, “was designed to improve access to health care for all
Americans…But critics say the ACA is also accelerating the demise of rural outposts that cater to many of society’s most vulnerable….Hospital officials contend that the law’s penalties for having to re-admit patients soon after they’re released are impossible to avoid and create a crushing burden.”

O’Donnell and Ungar also point to low Medicare and Medicaid reimbursements and high costs of EHR implementation as further blows to rural hospitals.  Rural hospital closures, the article explains, harm not just patients, who must now resort to long commutes to the closest hospital, often at times when every minute counts, but also the rural community in which the closure occurs, as rural hospitals are often an integral part of the local economy.

The authors note that struggling rural hospitals tend to face one of two options: either they must try to partner with larger, more financially-solvent health systems, or they must hope that local councils will implement increased taxes to provide the funds to keep the lights on.  Neither of these options, as O’Donnell and Ungar explain, has proven to be a satisfactory solution across the board.

While the article maintains that Medicaid expansion to all states would help, they also note that such expansion will not solve all of the problems facing rural hospitals, and the authors pass on this advice from stakeholders: “[A]dvocates say government can do more; state legislatures can adopt policies that bolster small hospitals, and the federal government can pay Medicare and Medicaid providers at least their costs and revamp the critical access program in light of the ACA.”

Characteristics, Utilization Patterns, and Expenditures of Rural Dual Eligible Medicare Beneficiaries

The SCRHRC released another report today, focusing upon rural Medicare beneficiaries also enrolled in Medicaid (a.k.a. dual eligible beneficiaries).  The graphic below highlights our major findings.

People living with HIV/AIDs in the Rural South

A recent article in the The Washington Post describes the difficulties faced by people living with HIV/AIDS (PLWHA) in the South. While nonprofit organizations, such as the Southern Aids Coalition, continue to advocate for increased awareness and funding, budget cuts threaten the availability of medical care and prescription drugs for PLWHA in the South.

The author, Teresa Wiltz, points to “social factors such as poverty, persistent anti-gay attitudes and a lack of transportation in rural areas” as leading factors that result in the higher rates of HIV in the South. A report released in 2013 by the SCRHRC on HIV/AIDS in Rural America found that in 2008, the South had the highest prevalence rate of PLWHA of the 28 states analyzed. 

Using 2010 data obtained by AIDSvu.org, we were able to map the rate of persons living with an HIV diagnosis by rurality (below). The dark shades of green (urban) and red (rural) indicate an above median rate of persons living with HIV. 

Map created by South Carolina Rural Health Research Center
Source: AIDSvu.org 2010 data

The map illustrates that Southern states are concentrated with high levels of HIV prevalence. As pointed out in the Washington Post article, an additional obstacle faced by Southern states is the decision to not implement Medicaid Expansion. This disproportionately impacts uninsured individuals, many of whom are minorities, as described in an infographic published by the Kaiser Family Foundation in JAMA. 

Access to care and the availability of discounted or free prescription drugs for PLWHA in the South continues to be of concern. Rural areas in the South are faced with the added barriers of lack of transportation, low awareness/education, and poverty.

Rural Medicare Advantage Enrollment--yet another disparity

Recently, Medpac released a statement debunking the thought that up to one-half of all new Medicare enrollees were choosing Advantage plans.  Their analysis indicates that this percentage is only 24%, with 28% of the overall Medicare population enrolled in Advantage plans.

This enrollment is much lower, however, among Rural populations  The RUPRI Center for Rural Health Policy Analysis estimate that less than 18% of rural beneficiaries are enrolled in Advantage plans, a majority of which are actually PPO plans.

Why is this lower percentage significant?  Advantage plans often offer additional benefits (such as dental or vision), care coordination, and lower out of pocket costs for their enrollees.  These benefits do come with a tradeoff in more restrictive networks and services, but it is one often beneficial to the individual.

Rural residents, much like everything else in health care, have a reduced access to Advantage plans.  An insurance industry analysis indicates that rural residents have fewer Advantage options, the premiums are higher, and have fewer benefits than those offered in urban areas.

While this may explain the lower enrollment proportion, it also indicates yet another area in which rural residents may be left behind.

Safety Net Hospitals and EHR Adoption

A new study published in Health Affairs details EHR adoption rates and meaningful use attestation in hospitals across the United States.  While adoption has increased steadily over the years, safety net hospitals continue to lag behind other hospitals in the types of EHR system implemented.

Specifically:

• In 2013, Critical Access Hospitals had similar rates of basic EHR systems as other hospitals, but were much less likely to have comprehensive systems
• A similar trend is seen among rural hospitals in general, as well as those with high DSH payments.
• Rural, Critical Access, and high DSH payment hospitals were all more likely to not have adopted any EHR system
• Very few hospitals met all 15 criteria for Meaningful Use Stage 2 attestation, but this was not presented by hospital type.

It is interesting, that despite the findings above, that the authors conclude:

Despite early concerns about a digital divide¹⁵ in which hospitals serving poor patients would struggle to adopt EHRs to a greater extent than better resourced hospitals, we found no evidence of such a gap. The lack of a digital divide between safety-net institutions and other hospitals is remarkable, given that safety-net hospitals usually struggle with expensive and complex changes. Policy makers were concerned about this early on and created a separate incentive structure for these institutions.

While the data demonstrate similar rates of basic EHR adoption, they clearly show higher rates of no adoption and lower rates of comprehensive adoption among rural safety net providers.  These data suggest a digital divide does indeed exist-- one of functionality that would lead to a lower rates of Meaningful Use attestation among these rural providers, not to mention the non-adopters without any EHR system at all.  The factors associated with some of the safety net hospitals--teaching status and urban location--are simply not available in these rural areas.

Racial differences in life expectancy, rural edition

A new article in Health Affairs examines the life expectancy gap between whites and blacks in the US, over a 20 year time period.  They found positive results, namely:

Nationally, the black-white difference in life expectancy at birth shrank during the period by 2.7 years for males (from 8.1 to 5.4 years) and by 1.7 years for females (from 5.5 to 3.8 years). 

 However, they also found considerable variations by census region and state, with some areas experiencing a much smaller decrease in life expectancy gap.  The good news is that virtually all areas saw a decrease in the gap, driven by an increase in life expectancy within black populations.

These data do not tell the full story, however.  Dr. Probst published a study in Health Affairs describing mortality differences among rural populations:

In an analysis controlling only for sex and age at interview, we found that rural whites and both rural and urban blacks were at greater risk of death by 2006 than were similar urban whites. 

And further:

When personal characteristics and circumstances were held statistically equal, only urban blacks had a higher risk of death than urban whites, while urban Hispanics were at a reduced risk of death (Exhibit 2). This suggests that much of the increased risk of death among rural whites and blacks is associated with personal characteristics more prevalent in the rural population, such as low education, poorer health, and lack of private insurance. 

These results show how important it is to not lose sight of individual characteristics in regards to studies in disparities.  While Harper et al found important and good news regarding life expectancy, small populations (e.g. rural minorities) may not experience such an improvement.  State-based studies are not discrete enough to measure the experiences of these subgroups, and should not be taken as positive results for all.

Rural ACA Marketplaces

The Robert Wood Johnson Foundation recently released a report detailing the insurance plan choices and premiums available to rural residents.  Many rural advocates have feared that rural residents will face higher premiums or fewer choices in these marketplaces, and appears that these fears are valid, at least to a degree.

Some key takeaways from the report include:

• Rural residents have, on average, 1.2 fewer providers, 2.8 fewer plan choices, and 0.4 fewer plan types than urban residents
• Premiums were, on average, $18 more expensive (for the second most expensive silver plan) for rural residents
• HMOs and EPOs were less available, and POS more available, to rural residents
• States with a higher proportion of marketplace eligible residents living in rural counties were more likely to have higher premiums and fewer insurers, choices, and plan types than more urban states.

There was considerable state by state variation in premiums, with the range being $201 higher in Nevada to $72 cheaper in Mississippi.  

These results highlight the need to continue to monitor rural resident's enrollment options, and its relationship to actual enrollment proportions.  Higher premiums, particularly in more rural states, could potentially lead to a lower uptake in coverage, furthering an already existing gap in rural healthcare delivery.

Insurance Instability and Rural Residence

An interesting article was published this week in the Journal of Rural Health; "The Impact of Insurance Instability on Health Service Utilization: Does Non metropolitan Residence Make a Difference?"

The authors explored how discontinuous insurance coverage affect actual utilization of services, subset by rural residence. From the abstract:

"Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas."

In short, living in a rural area meant lower utilization, particularly among those discontinuously insured. Hopefully, full implementation of the ACA will help to reduce this discontinuity; Adriana McIntyre over at Vox describes how the ACA has shown evidence of reduced churn. If the ACA truly does reduce those who drop (or are dropped from) insurance coverage, then these impacts will be mitigated. However, given evidence of rural residents falling trhough the cracks of ACA implementation (see the Kaiser Family Foundation's report here), it is clear more work needs to be done to ensure rural residents have adequate access to health care.

Loss of a public health champion

It is with deep sorrow that the South Carolina Rural Health Research Center announces the passing of its founding Director, Dr. Michael E. Samuels.

Dr. Samuels, subsequent to service with the US Navy, had an outstanding public health career and a pronounced effect on rural health across the US. Early in his career with the US Department of Health and Human Services, he obtained the legislative authority and implemented the Health Underserved Rural Areas Research Program in the Health Resources and Services Administration (HRSA), predecessor to the current Office of Rural Health Policy. In recent years, Dr. Samuels received both the Distinguished Research Award (2002) and the Distinguished Educator Award (2010) of the National Rural Health Association, as well as the C. Everett Koop Medal of Appreciation from the Koop Institute (2005).

Dr. Samuels’ passion for social justice motivated a long career in public health administration and public health education. Throughout that time, he never stopped fighting for equitable health care for rural poor, underserved and minority populations. We honor his memory and are inspired further to continue his work.

Dr. Samuels' personal obituary is available at the Winston-Salem Journal.

Health Care Providers In Rural America

Our own Jan Probst appears, once again, in Health Affairs to rebut an article published in the Fall of 2013 regarding service utilization comparison across Urban and Rural medicare beneficiaries.  Give it a read!
http://content.healthaffairs.org/content/33/2/346.1.extract?etoc