"When a rural hospital closes, seniors are spending an additional 14 minutes in an ambulance," said Sarah Gaskell, an associate director at Guidehouse, citing a 2019 University of Kentucky study. "In light of previous work, the more time people spend in an ambulance is associated with an increase in the likelihood of death."
Declining populations, decreasing employment rates and staffing shortages are making it hard for rural hospitals to stay open. Hundreds are at risk of closing.
The percentage of rural hospitals with a negative operating margin jumped from 40% in 2017 to 46% in 2019, according to Chartis' research. As a result, many hospitals cut service lines like obstetrics, creating service deserts in pockets of the country.
"Rural hospitals absolutely anchor the affiliated healthcare delivery system. When you lose a rural hospital, doctors aren't going to hang on much longer and you lose all those federated types of care—it is precipitous," Topchik said.
Advanced practice registered nurses and physician assistants helped fill the care gaps in rural counties that experienced hospital closures, the GAO noted. While they provided some of the care offered by primary care physicians, they could not take the place of surgeons, who were most likely to leave rural communities after their hospitals closed.
As a result, the share of hospitals that offered general medical and surgical care for adults in rural communities dropped from 81% in 2012 to 39.7% in 2017, according to the report. Emergency department access dropped at a similar rate. Outpatient surgery, intensive care and pediatric care experienced the next-biggest hits.
"The downturn when you lose a hospital and the impact on tax receipts on that town is profound. You're talking about the welfare of the entire community—the ability to support schools, the fire department, law enforcement," Topchik said. "The situation spirals."
Year-end COVID-19 relief legislation established higher reimbursement rates for rural emergency hospitals.
It allows struggling critical-access hospitals or rural hospitals with fewer than 50 beds convert to a new Medicare provider type for pared down facilities with emergency services, observation care and some outpatient services. They would not provide any acute-care inpatient services.
The legislation also extends payments to physicians in areas where labor costs are lower, dedicates funding to train new doctors at rural medical schools, expands mental health access through telehealth, allows physician assistants to directly bill Medicare and gives rural and urban hospitals more flexibility to collaborate to mitigate physician shortages.
Delaying 2% annual cuts to Medicare payments via sequestration has also helped, experts said, advocating for more permanent relief.
Rural hospital leaders need to address why residents are bypassing their local healthcare facilities for care, said Gaskell, noting a Guidehouse analysis that found that 3 out of 4 patients who live in rural areas with a hospital didn't seek care there.
"Outmigration remains a particular challenge," she said. "Rural facilities need to make investment in service lines that are of real interest to the community, and market to people who are going elsewhere for care."
For more context, check out Modern Healthcare's Next Up podcast on rural healthcare.