by Ben Jenson, Matt Holman and Gavin Boileau

Our intention with this post is to imagine what a better future for rural health care could look like, including the key elements or building blocks most critical to making the transition. We also consider the sustainability of proposed future models and the potential impact on rural communities.

KEY BOUNDARY CONDITIONS

The pace of innovation in healthcare is constrained by a complex web of existing regulatory and incentive mechanisms that collectively reinforce the status quo. While these forces remain significant, we believe the disruptions created by the COVID-19 pandemic offer an unprecedented opportunity for systems-level change.

Many of the regulatory adjustments associated with COVID-19 are supportive to transforming rural healthcare, including CMS Section 1135 Waver and Section 3704 of the CARES act, which (in some cases temporarily) enable: (i) a meaningful removal of barriers to inter-state telehealth regulations, (ii) non-HIPAA compliant platforms, and (iii) “rural-to-rural” telemedicine by allowing rural sites to serve patients at other rural sites (including their own place of residence). The continuation of these practices, particularly the first and last, are instrumental towards enabling the telehealth component of the system we propose.

While current conditions provide some tailwinds, transforming rural health also requires trade-offs that current reimbursement models strongly disincentivize. In general, delivery of high-quality and cost-effective care will require a significant shift away from delivery of elective surgeries and specialty care on-site at rural facilities. These procedures tend to be major revenue drivers for rural facilities and systems, and thus will require that payers, particularly Medicare/Medicaid, increase reimbursement for primary care and behavioral health services or otherwise redesign incentives to compensate for this shift.

THE NEW MODEL

Modernizing our rural health care delivery system will require changes across three broad dimensions, in ways unique to individual community needs, in shifting away from the current paradigm of rural health as a full-service one-stop shop to one that is more fit for context and purpose given our current available technology and resource constraints:  

Shifting Site of Care Paradigms: Quality outcomes in healthcare tend to favor volume and comparative advantage, and for most complex specialty care the level of procedural volume and expertise is lower in rural communities than in regional or urban hubs.  This does not mean that rural residents should settle for poor care or outcomes, just as lacking a high-end department store does not mean they cannot have high-end merchandize delivered to their doors within a few days.  The rural retail experience has been thoroughly reordered over the past decade, and rural health can produce better outcomes at lower costs by applying a bit of modern technology to evolve the current supply chain and logistics of care delivery.  In an ideal future, the majority of rural healthcare resources would focus on delivering comprehensive primary care that addresses a range of physical, behavioral and chronic care needs (including ancillary preventive care such as vision and oral health). Low-volume specialty care services and procedures should largely be provided via regional or urban centers of excellence, via telehealth-based models for visits or consultations or via stabilization and transport for more urgent procedures. Depending upon regionally-specific specialty needs a smaller and more targeted set of specialty services could continue to be delivered within rural communities. Emergency services would continue to be provided but be further focused toward a stabilization, triage, and transport model which limits required local hospital bed capacity. All of these changes would require rural health systems and payers to adopt more sophisticated referral mechanisms and networks as well as fundamental changes to incentive mechanisms to achieve buy-in from providers and patients alike.

Re-Architecting Infrastructure: In practice, shifting specialty and procedural volume out of rural communities may look less like a downsizing and more like a repurposing of existing space and shared resources. Hospitals and their affiliated clinics are often the economic engines of the rural areas they serve and provide considerable high-quality and multi-purpose space. Repurposing space could allow rural health systems to serve as a flexible center of holistic, community health. Operating rooms, intensive care units and other spaces no longer needed could be retrofitted into a space for community groups, civic gatherings, and seminars tailored toward physical health as well as social determinants of health. Private or mission-driven enterprises, including nutritional counselors, private retail pharmacies, or charitable groups, could leverage excess space.

Evolving the Rural Health Workforce: The proposed model of care would also require adjustments to the workforce of rural hospitals: namely an expansion of primary care and behavioral health providers as well as supporting resources to manage the enhanced logistics related to referrals, transport and case management necessary to provide an integrated patient experience. This should be buttressed by the expansion of education programs tailored toward rural health needs, including advance practice providers (e.g., NP/PA) that can play broad roles within the primary care-driven model. While specialty care delivered at individual rural hospitals will be downsized, COVID-19 presents a significant opportunity. In the past, rural health systems have struggled to hire specialists due to low patient volumes. However, recent telehealth regulation changes have allowed for rural-to-rural telehealth consults. This means that certain medical specialists can be located in rural areas and fill their time with regional service provision via a combination of telehealth consults and in-person care. Lastly, supplemental workforce adjustment is needed to adapt to a response, stabilization, triage, and transport model for acute situations. This could include additional EMTs and individuals able to staff the vehicles (e.g., helicopters, autos) needed for patient transport.

All system-wide changes come with tradeoffs. The adjustments we propose prioritize improving quality of care, increasing the sustainability of health care delivery in rural areas, and ensuring a breadth of access to care (understanding that much of this care will be delivered remotely). These steps reflect, at the highest level, a shift from profitability to sustainability of rural health care delivery. Without adjustments like these, we believe it is unlikely that the current model of rural health care delivery will be able to sustain itself.

While the model described will require major shifts to reimbursement, patient behavior, existing infrastructure, and likely policy to implement at scale, there are established cases where similar models currently exist and work very effectively.  One such model is Southcentral Foundation’s Nuka System of Care in Alaska, which focuses on the physical, mental, emotional, and spiritual wellness of its “customer owners”. (for more information, see this case study developed by their former CEO, Katherine Gottlieb). 

IMPACTS ON SUSTAINABILITY, QUALITY AND ACCESS

Rural health system sustainability is a complicated balance of cost and revenue considerations. On the cost side, patients will face competing out of pocket considerations, with the possibility of additional travel for acute cases, that may be offset fully or in part by reduced travel required given an increased use of telehealth care delivery. For health systems, the fixed costs related to providers, equipment and real estate oriented toward specialty care will be reduced, but costs related to transportation (e.g., ambulances & helicopters as well as their associated emergency personnel) will increase. The corresponding reimbursement mechanisms and regulatory framework will need to adjust to accommodate and sustainably compensate for these changes (e.g., reimbursement for primary care, referrals resulting in lower total cost of care, and coverage of emergency transport within an overall episode of care). It is likely that bundled payment or partial capitation models will be critical to adequately align incentives within this new model.

The challenge in making the case for improving quality in rural communities is that many patients do not perceive that they are receiving “low quality” care, and that the changes proposed here would in fact reduce the care available within their communities. In reality, what we are proposing would, if implemented well, result in far more comprehensive care and improved outcomes for most patients.  By focusing on primary care, acute care stabilization and triage, and specialty care referrals, rural health systems will be able to continue managing the vast majority of needs within the community while more rapidly connecting patients to care they need outside the community when they need it.

By focusing on lower-acuity care and leveraging telehealth to increase entry points into the health system, access can be expanded in the future model without any additional brick and mortar infrastructure being required. While this can be seen in some ways as a net neutral, the increased focus on supporting expanded (e.g., dental, behavioral health, etc.) service provision should provide a boost to primary care and public health resources in ways that makes preventive care more accessible and sustainable in the future.

CONSIDERING THE BIG PICTURE

Transforming rural healthcare will require many years and changes to incentives, regulations, infrastructure, and workforce. These changes themselves do not exist in a vacuum. This may require seemingly non-healthcare investments such as improvement of roads and airports, attracting new talent and retraining existing talent. It will require creativity in re-purposing current infrastructure and tough decisions in eliminating services and providers that community members are attached to.  It will require thinking very differently about hospital finances and likely absorbing some turbulence and losses during the transition. It will require both payers and providers to take more risks, literally and figuratively, in testing and transitioning toward new incentive models. It will also require new sources of government and private philanthropic funding to help fill the investment gap in expanding the pipeline of providers offering primary care and supporting services in rural areas and enabling critical technology and infrastructure investments.

Rural health care delivery in the US is built on an old model, one that is propped up by federal funding structures and business practices that do not adequately address concerns of long-term sustainability nor the true health needs of their communities. The COVID-19 pandemic has revealed the imperative and created the conditions for broad systemic change in a way we have not seen in a generation. While we often think of healthcare innovations as emerging from urban health-tech hubs, perhaps the most exciting systemic changes to improve access and outcomes exist far to the periphery of traditional funding and focus within our rural communities.

The post Envisioning the Future of Rural Health appeared first on Camber Collective.

by Ben Jenson, Matt Holman and Gavin Boileau

Even before COVID-19 struck the United States in February 2020, the traditional hospital-centric rural health model was a failing business proposition that delivered sub-optimal patient outcomes. Well over one hundred rural hospitals have closed in the past decade with more closing in 2019 than ever beforeᵢ. For rural residents with diminishing options, higher rates of chronic conditions and hospitalizations for common ailments are a tangible leading indicator of the persistent and possibly growing lack of regular high-quality primary care utilization compared to urban areas. The threat of rural closures has increased dramatically as COVID-19 temporarily eliminated and continues to disrupt the flow of elective surgeries and other fee for service (FFS) volume that are critical to balancing the tenuous financial equation for most rural health systems. In the short-term, there is a clear imperative for ongoing state & federal flexibility and funding to reinforce the ability of existing rural institutions to continue to serve their patients during the pandemic. At the same time, we believe it is worth asking if the prevailing, failing model for rural health delivery is worth saving in the long term, or if we should use this moment as an inflection point for architecting a new paradigm.

In order to consider what needs to change in rural health it is helpful to consider how we got here. As with most aspects of the US health care system, our current rural care delivery infrastructure reflects the incentives in place as they emerged. These incentives date back to 1946 when the Hill-Burton Act began providing federal construction grants and loans for building hospitals, ultimately helping finance construction of over 6,800 facilities before being phased out in 1997. In addition, rural health has for decades operated under FFS reimbursement agreements with commercial insurers that were designed around urban area utilization patterns and based on high volume and efficiency that look very different in small communities. The Critical Access Hospital (CAH) program, enacted in 1997 and replacing Hill-Burton, further accelerated this trend by improving the incentives for hospital-based care of Medicare patients that tend to make up a large portion of rural hospital visits, as well as subsidizing capital improvements to rural hospitals. It is no accident that the “big blue H” typically stands as the largest employer, largest building, and community anchor point for small towns and cities across the country. By and large, federal and state incentives for nearly 75 years have focused on rural areas building health care “factories” in a scaled down mirror image of their urban counterparts. That model made sense in a time when rural areas needed to be self-reliant in managing a full range of medical needs. However, this model is inefficient and costly in an era where technology, telecommunications and transportation have evolved to a point where rural communities can and should leverage connectivity and comparative advantage to design a lighter and more unique footprint that better meets local needs.

While less than 20% of the US population is deemed to live in “rural” areas, the rural areas in which they live make up 97% of the country’s landmass. Rural populations skew older, less wealthy and less healthy than urban areas on a whole. Even so, rural communities are not monolithic, and the health care needs and issues facing America’s rural expanse are remarkably heterogeneous. Most major US cities have enough density that, while rates may vary, there is a minimum efficient scale of heart attacks, head injuries, cancer of most types, behavioral health conditions, etc., to justify the expansive generalist model of the US hospital. The health needs of rural communities can vary greatly, from a remote fishing community in Alaska to a retirement enclave in New Mexico to an industrial town in eastern Michigan. For each of these places there are common imperatives, such as emergency response, triage, stabilization and transport for acute care needs, as well as in delivering high-quality primary care and chronic care management. Where rural needs begin to diverge is across higher-level acute, specialty, and surgical care. As a result, the future rural health operating model likely has a core that is similar across communities, but very different from today, and a tertiary layer that is far more specialized to specific local conditions and needs.

So, what should the rural health care system of the future look like? Among the many models our Medicare financing model has incentivized, the path forward likely looks less like the traditional Critical Access Hospital and more like the more nimble Rural Health Center (RHC) and Federally Qualified Health Center (FQHC), models that were created to support primary care rather than acute episodic needs. If you were to re-architect these centers to be patient centered care delivery hubs, absent existing regulations and incentives, they would likely take on a broader mandate as medical home for primary care and overseeing acute care triage and specialty referrals (including hosting tele-specialty visits). Ideally they would address a wide range of health and social needs would incorporate case management to ensure an integrative approach across patient needs. They would leverage technology to bridge the miles between patients’ homes and their care teams. If done well, they could close the current health outcomes gap and provide flex capacity for serving a community as it grows.

COVID-19 and the related economic and social upheaval are creating generational tailwinds for health care transformation. In addition to the practical imperative for rural health care delivery to change by merit of financial crisis, many regulatory barriers have temporarily come down in ways that reflect the needs and demand for delivering care differently in rural areas. This includes provisions within the CARES Act and a CMS 1135 Waiver that temporarily removed interstate telehealth restrictions, expanded the range of platforms that can be used to deliver telehealth, and enable rural clinics to be deemed “distant sites” for originating telehealth visits to patients as well as for provider-to-provider consultations. The FCC, for its part, has added nearly $200 million to its rural health care program which focuses on increasing broadband and telecommunications capabilities in support of patient care. Some of these temporary changes will revert, but momentum is clearly with the trend toward greater flexibility by CMS and commercial insurers.

The starting point in transforming rural health must be grounded in a clear-eyed consideration of trade-offs. Is the priority to deliver all care in the community? Or is it to deliver the highest-quality care? Or to achieve lowest cost? In our current model we have chosen community-based delivery at the expense of quality and cost. In our second post on this topic, we’ll further tease out these tradeoffs, and put forward a specific vision for what a rural healthcare delivery system of the future could look like. We welcome your perspectives and feedback as we continue this important conversation.

This is a two-part series. Part 1 provides an overview of the challenge and opportunity. Part 2 articulates a specific vision for the future of rural health.

The post Rural Health Needs a Reboot appeared first on Camber Collective.