American Epidemic: Rural Clinics Are Closing At An Unprecedented Rate. What Can Be Done?

Rural health clinics are in big trouble.

Over the last seven years, the US has experienced an epidemic of rural health clinic closures - with no end in sight. Over 70 rural clinics have closed in the US since 2010, with a majority of these clinics located in the southern states. Last year, the nonprofit National Rural Health Association estimated that 673 out of over 2,000 rural facilities are at risk of closure. What does this mean for these communities? And what can be done to reinstate safe, effective health care in affected rural areas in the face of increasingly limited access? 

The total health of a community's population is at risk.

Community clinic closures result in increasing risks in childbirth and senior health. Pregnant women in particular have difficulty receiving care; in fact, results of a recent study that found that 179 rural counties lost hospital obstetric services between 2004 and 2014 - rural communities adjacent to urban areas lost 103 hospital-based obstetric services while non-adjacent rural communities lost 76. The study also found that preterm births and births outside of the hospital increased after obstetric services were lost in rural counties. According to the CDC, preterm births are the most frequent single cause for infant mortality. Another vulnerable population, seniors, often experience mobility issues; with care centers located further away, there's a good chance older adults won't get the care they need. 

Why are rural health clinics closing?

The reasons are complex. But southeastern regions - Georgia and Arkansas, for example - experience higher rates of closures than other parts of the country. Generally speaking, there are more cases of obesity and hypertension in the South, as well as higher rates of uninsured people. The result? People who have the highest need have fewer options. This also results in longer waits to see a doctor in the hospitals that remain open, sometimes waiting months for an opening in a physician's schedule.  

Rural Clinic closures are also connected to cost-saving efforts. Many rural hospitals were built decades ago and can't afford the upgrades that make regional hospitals more attractive, particularly to those with private insurance (which pays better than government insurance, i.e. Medicaid and Medicare). Those without insurance have become increasingly dependent on emergency care services in Emergency Rooms or Urgent Care centers, both of hold their own set of issues; primarily, that ERs are expensive to operate - particularly between the hours of midnight and 7am, when patient traffic slows. Unpaid ER charges are ballooning as this type of clinic serves the chronically uninsured. 

Changes to Medicaid could also affect closures.  Expanding Medicaid would have meant greater access to insurance for low-income patients and more reimbursement for hospitals, thus helping their bottom lines. But rural states leadership often rejects expansion of programs such as Medicaid, and the non-expansion of Medicaid has hurt all rural county hospitals. (Case-in-point: Georgia, which did not expand Medicaid and where over half of the state's 73 rural hospitals are in danger of closing. Six have closed since 2010.) 

Michael King's 2018 Law Review article "Telemedicine: Game Changer or Costly Gimmick?*" touches on rural health's ongoing struggle:

What is driving this epidemic in rural health care? Although the ACA’s Medicaid
expansion helped reduce the uninsured population in states that adopted it, the ACA created
additional challenges for rural facilities, including reduced support for the uninsured, lower
reimbursement rates for Medicare and Medicaid, increased regulatory costs and electronic health
records requirements, and penalties when patients must be re-admitted soon after they are
released. Together with lingering effects of the economic recession, tight state and local
government budgets, and payors permitting fewer patients to stay overnight, rural hospitals often
find themselves trapped in a perfect storm that could force many more closures in the years

The solution: either operate differently, or stop operating.  

So how do we prevent loss of care in rural communities? One solution is glaringly obvious: to operate differently, more efficiently, and more effectively; by embracing digital health platforms not only in rural areas, but in healthcare as a whole. We have a responsibility to introduce these communities to the convenience and efficiency of technology-based solutions. Platforms in the digital health space offer a variety of services: some allow patients to self-monitor conditions such as diabetes and hypertension; others provide access to consult with doctors via text or call, such as in the fast-growing telemedicine sector. On-demand platforms offer an effective way for patients to consult a physician via text, call or video chat to receive diagnosis, prescriptions, and care plans without leaving home. At a federal level, The Veterans Affairs department has successfully implemented a telehealth program to assist its nationwide network of veterans. How do we replicate these programs in our private systems?

What is obvious is that the healthcare industry needs to change the way it thinks about and manages patient care, eliminating the notoriously archaic operational layers. What is less obvious is how to usher in the next generation of tech-based digital health solutions to do so.



*"Telemedicine: Game Changer or Costly Gimmick?”, by Michael King. For more information on telemedicine reform, please see “Telemedicine: Game Changer or Costly Gimmick?” by Michael W. King as published in this month’s Denver Law Review (95 Denv. L. Rev. 289 (2018), available here).

Kevin McGarvey