Rural reckoning: COVID-19 highlights long-standing challenges facing rural hospitals. Will it create momentum for change?

For a small, rural hospital in Louisiana, the COVID-19 pandemic brought new strains on the workforce. With the delta wave, clinicians intubated patients sometimes two or three times per week or even per day, said Mary Ellen Pratt, CEO of St. James Parish Hospital, a critical-access hospital in Lutcher, Louisiana, about 35 miles from New Orleans. Before the pandemic, maybe one person per month needed intubation.

Medical professionals have decided to retire early, take breaks from the field or leave the business completely as the stresses of the past 19 months weighed on them. That in turn puts pressure on the employees who remain, who are already working long hours to deal with a surge driven in large part by people who aren’t vaccinated. Her hospital is about 20% short on nursing staff, Pratt said.

St. James Parish Hospital tried basically everything to raise morale and make clinicians feel appreciated, from increasing pay for nurses and providing incentives to providing mental health services and massages, Pratt said.

“People are committed, and I know they’re committed, but they’ve been doing this now for 19 months, and a lot of people are like, ‘Once I get the hospital through this, then I’m going to be done,’ ” Pratt said. “The situation is pushing people to make those decisions as to whether or not they want to keep working in this environment.”

Read more: Is it time to change how the U.S. pays rural hospitals?

Almost 600 miles away, it’s a similar story at the Effingham Health System, a critical-access hospital in Springfield, Georgia, about 25 miles from Savannah. Some staff have retired early, become sick with COVID-19 or taken other jobs. Money that was initially supposed to go toward recruitment was redirected to personal protective equipment or patient care.

“This has certainly been a game changer for healthcare,” said Effingham Health CEO Fran Witt. “Strategically and creatively designing some recruitment strategies are going to be critical, and funding should come from the state and federal government to support those efforts, particularly in those areas where the populations are at high risk.”

Nationwide, thousands of hospitals and health systems are facing the same issues. But those challenges are more acute in rural settings. For decades, the lack of specialists, nurses and other healthcare professionals played a role in poorer health outcomes for rural citizens.

Long-term solutions to these chronic shortages must focus on overhauling how the U.S. trains providers while improving retention policies, experts say. Some hospitals are trying to “grow their own” workforce, recruiting students from their communities following research that shows clinicians are more likely to practice in the areas where they are educated. Policymakers should also look to revise rural payment models and be more innovative about retaining and recruiting medical personnel, experts say.

COVID is killing rural Americans at twice the rate of urbanites

“The good news is I really firmly believe that federal and state authorities and the academic institutions recognize there’s a potential to address this, but we’re going to have to keep focusing on this,” said National Rural Health Association CEO Alan Morgan. “COVID has really cleared the heads of policymakers.”

Solutions to long-running problems

Before COVID-19 hit, about 60% of areas designated by the federal government as health professional shortage areas were in rural counties.

There are many reasons for this, including rural hospital closures, high rates of uninsured people and uncompensated care, the refusal of some states to expand Medicaid under the Affordable Care Act, the fact that the vast majority of physicians and nurses are not trained in rural areas, and a population that tends to be older and sicker.

“The safety net was extremely strained from a workforce point of view before COVID,” said Michael Topchik, national leader for the Chartis Center for Rural Health. “COVID is the proverbial straw breaking the camel’s back. It’s the one more thing on top of an already fragile system that is overloaded and under-resourced.”

All of the trends are pointing in the direction of the problem continuing, Topchik said. “It’s going to get more challenging, not less challenging. We’ve seen an unprecedented number of physicians and nurses decide to call it quits.”

There is some movement from rural hospitals and federal and state governments to build up their workforces.

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Golden Plains Community Hospital, a critical-access hospital with 25 staffed beds in Borger, Texas, about 40 miles from Amarillo, is one of them. The facility developed an accelerated nursing training program with two local colleges, partnering and splitting costs with five regional hospitals. Students can train to become licensed vocational nurses in one year, after which they become eligible to transition into registered nurse training. The first cohort of RNs graduates in the spring.

“We’re excited about where we can take this,” said Don Bates, the hospital’s CEO. “I’m hopeful that part of our problem will be solved once we graduate our first class.”

Other universities have started offering rural tracks for medical students.

The Health Resources and Services Administration awarded about $28 million in grants to 38 organizations in 2019 and 2020 to start rural residency programs in family medicine, general internal medicine and other needed specialties.

“That is one of the goals of this program—to recruit right out of residency,” said Rob Schmitt, CEO of Gibson Area Hospital and Health Services, a critical-access hospital in Gibson City, Illinois, about 30 miles north of Champaign.

Burnout 

It’s not yet clear what long-term effects the pandemic will have on the rural health workforce, but surveys and anecdotal accounts raise concerns.

In rural hospitals, where clinicians often wear many hats and have close relationships with their communities, having even one unexpected departure can pose major challenges.

“The pressure, I would argue, is much greater in rural communities,” said Erin Fraher, director of the Carolina Health Workforce Research Center at the University of North Carolina, citing the lack of resources, workloads and financial pressures, all of which the pandemic exacerbated.

“Will the healthcare workforce there bounce back? I worry very much about that,” Fraher said.

As the nation inches toward year three of the pandemic, there’s no end in sight. Vaccinations were seen as the clearest path to controlling the coronavirus outbreak, but healthcare workers, especially in rural areas, are increasingly frustrated when their hospitals become full of COVID-19 patients who didn’t get the shot, taking away resources from patients who need other types of care and denying caregivers the reprieve they expected when vaccines became available.

“There’s a lot of workers who are just exhausted and increasingly frustrated that the friends and neighbors they care about and take care of aren’t doing their part,” said John Henderson, president and CEO of the Texas Organization of Rural and Community Hospitals. “People who have done their part and worked on the front lines are kind of tired of waiting on everyone.” 

Healthcare employers to date have focused more on individual interventions rather than tackling institutional or professional factors that contribute to fatigue, said Tania Jenkins, an assistant professor at the University of North Carolina who studies burnout among physicians.

“One of the things that is critical is really hearing and listening to what doctors are experiencing right now,” Jenkins said. “I would encourage C-suite executives to spend more time in clinics and hospitals to see what their providers are going through.”

There are systemic problems leading to burnout, Jenkins said. Providers are pressured to see as many patients as possible while hospitals only hire the bare minimum to get the job done, she said. 

Some rural hospitals have tried finding creative solutions to this problem, absent the ability to recruit enough clinicians or compete with larger facilities for staff.

More rural hospitals are sharing specialists, for example, said Patricia Schou, executive director of the Illinois Critical Access Hospital Network.

Hospitals are also looking at wage scales and offering incentives, daycare and time off to workers, as well as relaxation rooms, Schou said. They’re also working to recruit students from rural areas to train as clinicians.

COVID-19 has driven home the underlying problems, Schou said. “We’d been dealing with shortages in our rural communities and all of these issues aggravated it. We don’t want to lose any more hospitals.”

Nursing shortage

Hospital leaders are especially concerned about nurses due to a long-running shortage that has become more severe during the pandemic.

“We were already faced with a nursing shortage in our nation before COVID. Especially if you’re in the (Texas) panhandle, it’s harder to recruit,” said Golden Plains Community Hospital’s Bates.

In rural areas, hospitals find it difficult to compete with wages offered by urban centers or traveling nurse agencies, which are offering higher pay as demand spikes. Nurses have also left to take early retirements, or because of burnout or concerns about safety.

“Since COVID, many nurses have left the profession because they simply can’t stand the loss anymore and then you’ve got many who leave to take the bucks. You can’t find staff,” Bates said.

Policymakers and health systems should focus more on retaining their current workers rather than looking for replacements when people leave, UNC’s Fraher said. For one thing, there aren’t enough educators to train new nurses or the capacity to churn out enough graduates to meet the growing need.

“We can no longer assume that nurses grow on trees or physicians grow on trees,” Fraher said.

In a McKinsey survey, nurses reported needing more support from their employers, including access to mental health resources, time off and more appreciation for their work. Among the 22% who said they might leave their jobs, more than half cited the insufficient staffing, workload and the emotional toll of the pandemic, and 43% said they would seek higher-paid positions.

Rethinking recruitment and residencies

One of the biggest ways to drive more clinicians to rural areas is to reform the $14 billion Medicare Graduate Medical Education program, which primarily benefits schools in the Northeast, experts say. 

Some rural health advocates for years have sought changes to the program to make it more equitable for rural areas.

“While other smaller-scale programs like the new HRSA program are a good start, that doesn’t change the fact that we still invest about $14 billion nationally in GME and still only 1% goes to rural,” Fraher said. “Until we figure out how to change that system or at least reallocate some money to rural, we’re just going to be in this bind for a long time to come.”

Medical residents are disproportionately trained in Northeastern metro areas, which not only creates geographic disparities but inflates healthcare spending, according to a report issued last month by the Niskanen Center, a policy-focused think tank. For example, there are about 92 medical residents per 100,000 people in New York, compared with 32 per 100,000 people in Texas, a state with almost 10 million more residents and a high number of health professional shortage areas.

“That’s the worst possible system we could possibly construct,” the NRHA’s Morgan said.

Congress capped the number of Medicare-funded residency slots in 1997, essentially freezing the geographic distribution of residency slots for 20 years, according to the Niskanen Center.

“There has to be both an increase in funding, an increase in slots, and a focus on rural,” Morgan said. “Just adding to the current maldistribution of clinicians is not an acceptable path forward.”

That would take congressional action. A proposal from Sens. Jon Tester (D-Montana) and John Barrasso (R-Wyoming) would lift GME caps at rural hospitals, provide incentives for urban hospitals to increase the number of residents in rural tracks and help rural hospitals to start residency programs. The NRHA has asked Congress to include these providers in the Senate version of the domestic policy package Democrats are attempting to advance through Congress.

Currently, hospitals starting new GME programs don’t get funding from the program until residents start training, posing financial obstacles to under-resourced hospitals, according to a report the Government Accountability Office published in May.

Because of those obstacles, critical-access hospitals—most of which are in rural areas—are unlikely to participate in residency programs.

“We need more rural residencies for physicians, and it needs to be not just an elective, but a requirement,” said Pratt of St. James Parish Hospital.

Another proposal, included in the House version of the Democratic bill, would award 1,000 scholarships per year for students from underserved or rural areas to attend medical school if they agree to practice in those communities after graduating. It would also allocate an additional 1,000 residency slots per year for hospitals with a record of training medical students in medically underserved areas.

Anything that increases the number of clinicians in rural areas is good, said Topchik of the Chartis Center. Eventually, smaller rural providers are going to have to affiliate with larger health systems, he said.

About 56% of rural hospitals have these relationships and they tend to do better financially, and have better access to specialists. “I think independent hospitals operating as islands are the single greatest challenge. They just can’t compete,” he said.