A rural hospital in California closes after federal officials strip 'critical access' designation it has held since 2000

Glenn Medical Center in Willows, California 
(Glenn Medical Center photo)

After more than 70 years of serving its rural community in Willows, California, Glenn Medical Center closed its doors following the loss of its "critical access" designation, which had allowed the hospital to receive higher federal reimbursements that helped it remain open.

To qualify as a "critical access" hospital, a medical center needs to be at least 35 miles from the next closest hospital. Glenn Medical Center was 32 miles from "the nearest neighboring hospital under a route mapped by federal officials," reports Jessica Garrison of the L.A. Times. "Though that distance hasn’t changed, the federal government has now decided to enforce its rules." The hospital was awarded its critical access status in 2000.

The loss of Glenn Medical Center leaves the surrounding farming community without emergency care, "eliminates 150 jobs and puts rural residents at risk of preventable deaths," Garrison writes.

Rural hospitals across the state are already at risk of closure. Peggy Wheeler, vice president of policy of the California Hospital Association, told Garrison, "It’s like the beginning of a tidal wave. I’m concerned we will lose several rural hospitals, and then the whole system may be at risk.”

Before Glenn Medical Center's designation was stripped, Glenn County officials and hospital administrators worked for months to persuade federal officials to grant an exception.

Now that the hospital is closed, many community members fear what will happen to older residents in need of immediate care, injured farm workers or victims of car accidents along nearby Interstate 5. Glenn County Supervisor Monica Rossman told Garrison, "People are going to die."

Rural hospitals in Arkansas find different ways to stay open and still serve their communities

Rural hospitals, represented by green dots, stretch across mid- to southern Arkansas counties. 

Rural hospitals in Arkansas continue to explore the best ways to serve their communities despite severe financial struggles. Some medical centers have found success by ending inpatient care in exchange for more Medicare dollars, while others keep their doors open by opting for other designations to continue providing vital care, such as inpatient stays, reports Tess Vrbin of The Arkansas Advocate. According to a 2023 University of Arkansas review, roughly 41% of Arkansas residents live in rural areas.

Two years ago, DeWitt Hospital and Nursing Home was in financial straits and CEO Brian Miller chose to convert it into a "rural emergency hospital, which draws more federal funds to rural hospitals if they reduce or eliminate inpatient services and focus on emergency and outpatient treatment," Vrbin writes.

Beyond higher Medicare payments, the switch helped DeWitt lower costs while adding income from outpatient services, such as cardiology and wound care. The hospital is one of five Arkansas hospitals to sign up for the emergency rural designation.

But converting to an emergency triage-type care model doesn't work for every rural community. The Southwest Arkansas Regional Medical Center in Hope will not apply for rural emergency status because inpatient stays are needed for residents in surrounding counties. Its chief administrative officer, Shelby Brown, told Vrbin, "We want to be able to, if we need to admit someone, to put them in our hospital so they can stay home locally."

Instead of opting to convert to a rural emergency hospital, Southwest Arkansas Regional applied for and received approval to become "a critical access hospital, a federal designation for facilities located no fewer than 35 miles from other hospitals and maintaining no more than 25 beds," Vrbin explains. "Medicare subsidizes critical access hospitals for inpatient treatment of Medicare recipients."

For many rural hospitals in Arkansas, the choice between ending certain types of patient care or possible closure is difficult. Brown told the Advocate, "The big scheme of rural health in the state of Arkansas is in a crisis mode. . . . I would always think it’s better to have a rural emergency hospital versus no hospital.”

Emergency departments in some rural areas don't have 24/7 on-site physician coverage

A hospital in Ekalaka, Mont., sits at the intersection of two dirt roads. 
(Photo by Arielle Zionts, KFF Health News) 

Many rural emergency rooms are no longer run by attending physicians, but instead depend on care by nurse practitioners and physician assistants. "A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7," reports Arielle Zionts for KFF Health News. "More than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals."

The 2022 report represents "82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government," Zionts writes. "The study is the first of its kind, so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School."

The idea of an emergency department without a doctor on staff remains controversial, and not all states allow it. "Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them," Zionts explains. Indiana, Virginia, and South Carolina have passed laws that require all their EDs to have a 24/7 physician on-site.

Even when states require their EDs to staff a round-the-clock doctor, that doesn't make finding one easy. "In the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing," Zionts reports. In response to the regional shortage, Sioux Falls-based Sanford Health launched an emergency medicine residency to help increase its ED physician numbers.

Some rural health advocates say lawmakers need to be sure that employing full-time ED physicians 24/7 is feasible for their region before passing legislation that requires it. Zionts adds, "Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it."

New Hampshire's North Country uses collaboration and training to address labor and delivery unit closures

Eleven L&D  units have closed in New Hampshire
since 2002. (NHPR map, from N.H. Peri. Collab. data)

Health care stakeholders, planners and employees in New Hampshire are working to repair and "fill gaps in a maternity care system that’s been eroding for years," reports Paul Cuno-Booth of New Hampshire Public Radio. Part of their efforts are taking shape through the North Country Maternity Network, which is a "collaboration between hospitals, health workers, social service nonprofits and others," with supportive management through Dartmouth Health.

The network added additional training and drills for its doctors and staff, so they are prepared for stressful deliveries. Cuno-Booth writes, "More than a quarter of patients now live a half hour or more from the nearest birthing hospital – making it harder to access routine prenatal care and raising the risk of an unplanned birth at home or on the way to the hospital."

Ali Willard, a high-risk obstetrics nurse and care coordinator with Dartmouth Health, told Cuno-Booth, “If you were having a heart attack, would you want to have to drive three hours to receive medical care? No. And that's not a standard anywhere in our country to have to drive that far for that type of emergency. But obstetric emergencies are just as critical to somebody's life. But some women have to drive that far.”

The network's collaboration is also working to "give EMTs and ER doctors in the region more training on how to respond to obstetric emergencies, in case something happens far from the nearest birthing hospital," Cuno-Booth adds.

Natalie Valliere, who runs a labor and delivery unit in Coos County, is working with a team to address the many challenges North Country maternity services face. "[She] says there’s no single answer," Cuno-Booth reports. "But in a region where people and resources are spread out over a vast rural area. . . collaboration will be key."

As people "work to strengthen maternity care in the North Country, [many] say that mission is about more than supporting parents and newborns," Cuno-Booth writes. "It’s about whether communities here can survive and thrive." If a woman can't safely have children in a region, will a family want to move there?

Half of rural hospitals lose money; consultancy estimates 418 could close, citing Medicare Advantage as big issue

Map by Chartis Center for Rural Health, labeled by The Rural Blog

Rural hospitals are in more trouble than ever, and 418 of them are “vulnerable to closure,” according to a study of their finances by Chartis, a Chicago-based health-care consultancy that specializes in tracking the business of rural health. (Here's its list of top 100 rural and community hospitals.)

The Chartis Center for Rural Health says rural hospitals are entering "a startling new phase of this crisis as rural hospitals fall deeper into the red, 'care deserts' widen throughout rural communities, and the increasing penetration of Medicare Advantage could further disrupt rural hospital revenue."

The top warning signal cited in the study is that half of rural hospitals are losing money, up from 43 percent a year ago. That news is especially bad for independent rural hospitals, 55% of which are in the red, while only 42% of rural hospitals affiliated with groups are operating at a loss. "Nearly 60% of rural hospitals are now affiliated with a health system," Chartis reports.

Most people on Medicare now have Medicare Advantage, private insurance plans that get lump sums from Medicare to cover members and look for ways to attract customers while limiting claims. "Medicare Advantage now accounts for 35% of all Medicare-eligible patients in rural communities," Chartis reports, saying Advantage plans' share of rural residents has risen 48% since 2019. 

Chartis map, labeled by The Rural Blog; click to enlarge

That's a problem for rural hospitals designated as "critical access" because Medicare Advantage plans' net reimbursement to such hospitals "is often lower for similar services than that of traditional Medicare because Medicare Advantage does not follow cost-based reimbursement" as traditional Medicare does for such hospitals, Chartis reports. Insurance companies negotiate those rates with hospitals, and in many rural areas, hospitals are at a negotiating disadvantage because few insurers operate in their service areas.

Also, "Medicare Advantage may not cover all the services traditional Medicare does, including swing beds, which provide skilled nursing care for patients and are often a strong source of revenue stability for rural hospitals," Chartis notes. "Rural providers may not be equipped to efficiently navigate administrative requirements for payment introduced by Medicare Advantage, such as prior authorizations, which can lead to increased denials."

Since 2010, "167 rural hospitals have either closed or converted to a model that excludes inpatient care," Chartis says. The firm says its estimate that 418 are “vulnerable to closure” is based on "a new, expanded statistical analysis" of their finances, gleaned from cost reports they file with Medicare.

Medicare Advantage plans are growing in popularity, but their payment tactics hurt smaller hospitals

Photo via Mesa View Regional Hospital

Medicare Advantage plans have become increasingly popular with seniors, but for small, rural hospitals, the plans are too risky, which can leave local plan participants unable to go to their town's hospital. "Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare," reports Sarah Jane Tribble of KFF News. "The plans have become dubious payers for many large and small hospitals, which report that the insurers are often slow to pay or don't pay."

Enrollment in private Medicare plans "has increased fourfold in rural areas since 2010. Meanwhile, more than 150 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. States such as Texas, Tennessee and Georgia have had the most closures."

The slow or no-payment tactics of Advantage plans disproportionately hurt "small, rural hospitals that Medicare has designated as 'critical access," Tribble explains. "Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don't match those of traditional Medicare." 

Medical providers can face a no-win situation when rural residents enroll in Advantage plans. For example, Mesa View Regional Hospital, a rural hospital about 80 miles east of Las Vegas, has "a high percentage of patients enrolled in Medicare Advantage plans," Tribble reports. The hospital has "21 Medicare Advantage contracts with multiple insurance companies. . . . Mesa View's CEO, Kelly Adams, says he has trouble getting the plans to pay for care the hospital has provided. They are either 'slow pay or no pay, he said. . . . It would be a 'tough deal' to be forced to reject patients because they didn't have traditional Medicare."

"At Mesa View, patients must drive to Utah to find nursing homes and rehabilitation facilities covered by their Medicare Advantage plans," Tribble reports. Adams told her: "Our local nursing homes are not taking Medicare Advantage patients because they don't get paid. But if you're straight Medicare, they'd be happy to take that patient."

What is being done? "In June, a bipartisan group of Congress members, led by Sen. Sherrod Brown, D-Ohio, sent a letter urging federal agencies to do more to force Medicare Advantage insurers to pay health systems what they owe for patient care. . . . In an August response, CMS Administrator Chiquita Brooks-LaSure wrote that a final rule issued in April made 'impactful changes' to speed up care and address concerns about prior authorization — when a hospital and patient must get advance permission for care to ensure it will be covered by an insurer," Tribble reports. Brooks-LaSure noted another proposed rule that, once finalized, "could mandate that insurers provide specific reasons for denying care within seven days."

New study reviews eight centers that are working to improve rural postpartum care through innovation and collaboration

A new case study highlights eight community-focused postpartum care centers working to address the unique challenges of postpartum health for rural women. The review from the University of Minnesota looked at programs serving rural communities in Colorado, Maine, Minnesota, Montana, Oregon, South Carolina and Washington.

The goal of each center is to reduce maternal mortality rates, which are disproportionally high in rural areas. Each organization reviewed provides support to rural women and their families through access to obstetric care, mental health services, logistical support and social services during pregnancy and after childbirth.

Researchers cite one of their key findings: "Despite challenges related to transportation, stigma, isolation, and affordability, the organizations profiled here innovate, including in their program offerings and finance models, and collaborate with local and national partners to provide a variety of critical resources to postpartum families in their rural communities. . . . Each organization expressed the importance of stable, secure funding for their work."

In the study, each center is reviewed for rural community context. The Postpartum Resource Group in Whitefish, Montana, is an example. The area "is a mountainous community located near Glacier National Park in northwest Montana. The town is one of only three in the [Flathead] county, which occupies 5,098 square miles and is home to about 108,000 people. . . . ."

Each center in the study is reviewed by discussing its services. In Whitefish, researchers spoke with Brooke Jaszczak, the Network Director of Postpartum Resource Group who gave a program overview: "The Postpartum Resource Group is a non-hospital-affiliated, community-based postpartum mental health support group that was founded in 2016 by a midwife who created a support group with her patients. She recognized the need for such support based on both professional and personal experience, as she was also experiencing postpartum mental health challenges at the time."

The researchers write, "Their mission is two-fold: to provide support, education, and resources for mothers and their families who are experiencing postpartum mood disorders, and to educate and inform the community and providers about postpartum mood disorders."

A discussion of each center's challenges is also shared. "In the Flathead Valley, many local residents struggle to afford basics like housing, food, childcare, and health care due to rising costs. Located near Glacier National Park, the region experienced a population increase during the Covid-19 pandemic, as people moved there to work remotely. The service industry workers were priced out of housing and health care, and a rationing of care and preventive services resulted due to their limited resources. Furthermore, the population is very spread out. Between winter weather and poor driving conditions through the mountain passes, it can be difficult to access areas of the community, its resources, and clinicians."

Researchers hope their analysis will inform and encourage other communities looking to bridge the gaps in rural postpartum health. 

Opinion: The loss of rural labor and delivery departments means lower-quality health care for mothers and babies

Photo by Jill Sauve, Unsplash

When fewer than half of rural hospitals offer labor and delivery services, what does that mean for rural pregnancies and deliveries? It means less prenatal, postnatal, and postpartum care – and more risk – for moms and babies, Anna Thompson Hajdik writes in an opinion piece for The Daily Yonder. The reasons we got here are complex, but there are solutions to consider. Here's a gently edited version:

"The accelerated closure of rural hospitals has touched every part of the country, and even if the hospitals themselves stay open because of a Critical Access designation, their labor and delivery units are disappearing. Multiple media outlets have reported on the dire situation. Families driving over four hours in blizzard conditions in the middle of the night because their local hospital ceased delivering babies 18 months earlier. A mom in rural Illinois was forced to deliver a baby on an Interstate 55 off-ramp a month after the labor and delivery unit in the small town of Lincoln, Illinois, closed. A soon-to-be mom in labor who navigated an isolated mountain pass in rural Washington on her way to the hospital with barely enough gas to get there.

At the same time, maternal mortality rates across the United States have increased significantly. In 2021, the rate of maternal deaths that occurred while pregnant or within 42 days of being pregnant was 32.9 per 100,000 live births, 10 times the rate for countries of comparable high income. The proliferation of "maternity care deserts" in rural America is an adjacent issue to overall maternal mortality; the March of Dimes defines maternity deserts as counties where there are no hospitals providing obstetric care, no birth centers, no ob/gyn and no certified nurse midwives.

Three major factors seem to drive closurs of maternity units: Labor and delivery departments are expensive to operate, risk and liability to doctors and medical staff have become untenable in a much more litigious environment, and it is challenging to recruit new obstetricians and other reproductive professionals like certified nurse midwives to rural areas.

If policymakers care about fostering a vibrant and resilient future for rural America, they would safeguard rural hospitals by creatively and sustainably funding labor and delivery departments in rural places. And while many rural health-care stakeholders advocate increased reliance on technology like telehealth and mobile health clinics, expectant mothers shouldn't have to deliver their babies over Zoom or drive more than two hours to receive care. A recent study demonstrates that the closure of labor and delivery units in rural areas is linked to the reduced quality of prenatal care, even if health-care institutions are providing it.

States like Texas (where rural hospitals more broadly are in especially dire circumstances) that have opted not to expand Medicaid should reconsider that decision as the rate of rural hospitals at risk of closure steadily increases each year. But a simple federal solution exists as well – significantly increasing Medicare and Medicaid reimbursement rates that actually reflect the skyrocketing costs of healthcare and maternity care in particular in a post-pandemic America. The American Hospital Association supports this action, among many other initiatives, in their call for Congress to pass the Rural Hospital Support Act, which is a piece of legislation that has broad bipartisan backing.

Ultimately, a national reckoning is playing out across the country when it comes to rural healthcare, exposing so much that is broken. . . . Unless policymakers (regardless of their political affiliations) and civic leaders take action to solve this crisis, rural people are left with limited options, while the future of the nation's rural communities more broadly is one of precarity and accelerated population loss.

Anna Thompson Hajdik is a senior lecturer at the University of Wisconsin-Whitewater in the Languages and Literatures department. Her rural background and continued interest in agriculture inform her research and writing, as well as her "extracurriculars," including serving as vice president of the Wisconsin Dairy Goat Association.

With hospital closures and need for reliable funding, rural America's emergency medical services seek new solutions

Rural ambulance in Sweetwater, Wyoming
(Photo by Kim Raff, The New York Times)

You can call 911, but in some rural places, no one can come immediately, no matter your emergency. "Nearly 4.5 million people across the U.S. live in an 'ambulance desert' – 25 minutes or more from an ambulance station – and more than half of those are residents of rural counties," reports Nada Hassanein of USA Today, citing a study by the Maine Rural Health Research Center and the Rural Health Research Centers. "As rural hospitals shutter across the nation, dwindling emergency medical services also must travel far to the nearest hospital or trauma center. Experts and those in the field say Emergency Medical Services need a more systematic funding model to support rural and poorer urban communities."

Lead study author Yvonne Jonk, deputy director of the center, told Hassanein, "This is a really extreme problem, and we need to figure out solutions. People think that when you call 911, that someone's coming in. Most people don't realize that their communities don't actually have adequate coverage." Hassanein reports, "Four of 5 counties across the nation have at least one ambulance desert, according to Jonk's analysis of 41 states and data from 2021 and 2022."

The inability of many rural areas to have and staff an emergency response team has several reasons. From the truck to the equipment to professional dispatchers and emergency medical technicians, an ambulance service is an expense most areas are expected to cover but can't. Hassanein writes, "The McDermitt Paiute-Shoshone Tribe reservation stretches along the Nevada-Oregon border near Idaho and has no ambulance or hospital. . . . Tribal chairwoman Maxine Redstar said the community used to have an ambulance service, but it couldn't afford to keep it going. . . . Weather, wildlife and long, dark winding gravel roads make getting to the scene difficult." Redstar told Hassanein: "When you call an ambulance, it comes from Winnemucca, which is an hour away."

For many rural areas, funding an ambulance service can be a major obstacle. "Few states designate EMS as an essential service. In the U.S., EMS are mainly funded by local governments, and not all states allocate supplemental funds toward the services,"Hassanein reports. "Amid patchwork funding, communities rely on varied revenue sources to fund ambulance services, said Lindsey Narloch, project manager at Rural EMS Counts, a North Dakota EMS improvement project. That often doesn't cover expensive equipment, medication and staff salaries. Counties end up having to pay most of the cost."

Having and staffing an EMS services may require a new model. Hassanein explains, "Gary Wingrove, president of The Paramedic Foundation, noted that critical access hospitals, which are medical centers in rural, underserved communities often with a high number of uninsured residents, are paid more than other hospitals if their care delivery cost is higher than the standard Medicare payment."  Wingrove told Hussanein: "We have to take a hard look at our financing of rural ambulance services. And to me, it just makes a lot of sense if we create a system like the critical access hospitals have for the rural ambulance services."

Country life may not mean a happier life, study suggests; mental health is no different, but access to treatment is

Photo via the University of Houston

With its fresh outdoors, flora, fauna and open spaces, country life suggests a healthier life. But that is not always the case. "A study from the University of Houston found that those living in the country were not more satisfied with their lives than people who lived in urban areas," reports Cara Murez of HealthDay. "Rural U.S. residents didn't feel like their lives were more meaningful, and they also tended to be more anxious, depressed and neurotic. . . . Almost 85% of all rural counties have a mental health professional shortage, even though rural residents appear to need more psychological services, according to the study. Among the reasons for the shortage of mental health professionals is the surge in rural hospital closures since 2010."

The study report noted that mental illness is not more common in rural areas, but the difference is lack of access to treatment. Researcher Olivia Atherton, a professor at UH, told Murez, "It will be critical to improve access to psychological services in remote areas, and to identify how characteristics and values of rural communities can be leveraged to promote positive psychological health."

Researcher Olivia Atherton
(University of Houston photo)

Murez explains, "Atherton and her colleagues analyzed data from two large longitudinal studies of Americans, the Midlife in the United States and the Health and Retirement Study. . . .They looked at whether there were different levels and changes in extraversion, agreeableness, openness, conscientiousness and neuroticism. They also examined whether there were differences or changes in psychological well-being and life satisfaction across adulthood."

"The study fills important gaps in the literature by showing that where people live can impact personality and well-being in adulthood," writes UH's Laurie Fickman. Atherton told her, "Given the far-reaching consequences of rural health disparities for individuals, families and communities, there is a pressing need to identify the psychological, social and structural mechanisms responsible for disparities and the ways in which to intervene upon those mechanisms to improve the health of rural Americans."

Rural hospitals' financial data show a significant advantage for them if their state has expanded its Medicaid program

Kaiser Family Foundation graph, adapted by The Rural Blog, based on KFF analysis of hospital data from 527 short-term general and/or critical access rural hospitals. Expansion status is as of July 2017 and excludes states that expanded Medicaid during the period, as well as Wisconsin (the only non-expansion state without a coverage gap), leaving 438 facilities. Margins reflect profit earned on patient care and other operations such as gift shops, parking, and cafeterias.

Just how big an advantage is Medicaid expansion for rural hospitals? It's significant, according to hospital finalcial data that the Kaiser Family Foundation compiled from Medicare cost reports.

"Median operating margins among the rural hospitals in our analysis increased earlier in the Covid-19 pandemic, likely as a result of government relief funds, but that these facilities face renewed financial challenges, especially in states that have not expanded Medicaid," Kaiser reports. "Among rural hospitals in non-expansion states, median operating margins were 2.1 percent during the July 2021-June 2022 period and were -0.7 percent when excluding documented relief funds. In Medicaid expansion states, median operating margins dropped, but remained positive even after excluding documented relief funds."

Now that the pandemic funds are going away, rural hospitals "face renewed financial challenges," Kaiser reports. "After increasing substantially earlier in pandemic, median operating margins among the rural hospitals in our analysis fell from 7.7% in July 2019-June 2022 to 3.3% in the July 2021-June 2022 period. When subtracting out relief funds documented in hospital cost reports, median operating margins were slightly lower than pre-pandemic levels during the July 2021-June 2022 period and would likely have been even lower if accounting for relief funds that were not specifically documented by hospitals. Industry reports suggest that the outlook for hospitals and health systems deteriorated in 2022, which is only partially reflected in our analysis of July 2021-June 2022 data. In this context, it is not clear whether hospital closures may reemerge as an issue facing rural communities. There were seven hospital closures in 2022, which was greater than the number in 2021 (two closures), but still less than the average number from 2005-2022 (10.3)."

Rural areas are finding new ways to overcome shortages of doctors and nurses; stories from Maine and Montana

Dr. Kaycee Gardner in Miles City, Mont. (Photo by Amy Lynn Nelson)

Rural America is set to have one of the largest physician shortages by 2030, and nurses are likewise in short supply in rural areas.

Montana is already feeling the pinch and has been looking for ways to recruit and retain young physicians. "The greatest predictors for who will become a rural physician boils down to specialty and background," reports Emily Schabacker of the Billings Gazette. "Family medicine physicians are better positioned to serve rural populations than those who opt for more specialized training. And physicians raised in rural places are more likely to return to rural places to practice, making rural recruitment more important than ever."

One challenge facing Montana has been the lack of student interaction with medical professionals and very limited opportunities for high-school students to shadow doctors. Dr. KayCee Gardner, who practices in Miles City, Mont., "grew up 35 miles south of Broadus, where only a physician’s assistant and a nurse cared for the community," Shacbacker writes. "Not knowing any doctors growing up, Gardner never thought she’d end up in the medical field. No recruitment programs or career summer camps came to her corner of Montana."

To encourage their rural physician development, RiverStone Health created the RiverStone Health MedStart camp, which "aims to expose high schoolers from rural communities to careers in medicine," Schabacker reports. Camp organizer Nikole Bakko told her, "Every county in the state has been represented at one of the five participating health centers since the camp began in 2010. . . . Rural students aren’t being exposed to (careers in medicine). With MedStart we’re able to show them opportunities they don’t typically see."

The medical-provider shortage is not limited to physicians. "Rural hospitals have endured physician shortages for decades, but the staffing dearth that followed the pandemic has made staffing challenges even worse. As a result, critical access hospitals are relying more on traveling nurses," reports Schabaker. Rich Rasmussen, CEO of Montana Hospital Association, said the high cost of traveling nurses are and expense that has threatened to sink the state’s larger hospital systems.

In Maine, the most rural state in the country, is addressing its nursing shortage and the additional costs with a "Grow Your Own" model. Eastern Maine Community College in Bangor "partners with rural hospitals to provide nursing education close to home for students who would rather not come into the city," reports Nichole Dobo of The Hechinger Report, which covers education. "Now in its sixth year, the program is helping the community college increase enrollment in a job that’s in great demand. And it is reaching students who might otherwise struggle with transportation costs (especially during a period of epically high gas prices), family responsibilities or just a preference for staying close to home."

Maine is also reaching out to more non-traditional students. Emily Thompson, "then 47, had recently re-entered the workforce as a cashier after raising her child. A woman came into the store, worried about getting gas into her car because she had forgotten her wallet. As she helped the woman with the electronic payment app on her smartphone, she noticed her name tag: Pilar Burmeister, director of the nursing program" at the college, Dobo writes. "Now, she’s looking forward to May when she plans to graduate as an R.N. and leave her cashier days behind."

The program "partners with rural hospitals to provide nursing education close to home for students who would rather not come into the city," Dobo reports. "Now in its sixth year, the program is helping the community college increase enrollment in a job that’s in great demand. And it is reaching students who might otherwise struggle with transportation costs (especially during a period of epically high gas prices), family responsibilities or just a preference for staying close to home."

Pilar Burmeister, director of the program, told Dobo, “It’s a win-win for everybody. We get to increase our rolls. Hospitals win because they get nurses. Students win on saving time and money.”

Also, "This rural focus helps community colleges train more people who are likely to stick around in the rural hospital after they graduate," Dobo notes. Thompson told her, “It is going to be a bit of a new lease on life for me. I wasn’t making a bunch of money at the store. I liked working there. But this is a real career for me.”

Program leans on paramedics from across Maine to maintain round-the-clock treatment at a remote rural clinic

Jackman Community Health Center
(Photo from Rural Health Information Hub)

Staffing challenges put a small clinic in rural northwestern Maine at risk of being unable to offer urgent care outside of regular business hours to the Moose River Valley's roughly 1,500 residents, reports Gretel Kauffman for the Rural Health Information Hub. To close the gap, local healthcare leaders opted to try out a new program that would allow paramedics from across the state to staff the Jackman Community Health Center after regular hours and on weekends. 

"The program, which was designed and developed through a series of community meetings and discussions, allows the paramedics to perform basic urgent care procedures and connect with emergency department physicians" at a hospital in Bangor, Kauffman writes. 

Without the initiative, dubbed the Critical Access Integrated Paramedics program, residents of the Moose River Valley who needed urgent treatment would have to travel nearly an hour to Bangor. For nearly two decades the town of Jackman had been unable to retain a new doctor for more than a year and a half, Kauffman reports. Now specially trained paramedics can sign up to provide emergency medical services to residents who need it. 

"I think of EMS as the spackle of healthcare: If there’s a crack, you can use EMS ability,” said Dr. Jonnathan Busko, one of the lead organizers of the CAIP initiative. “This is a big crack being filled by EMS, but now all of these other small cracks are being identified — we can also do this, and this, and this.” Kauffman reports that new CAIP initiative is being used as a pilot project that could be adapted to communities across Maine, should the program prove itself effective to the state's EMS board. 

Hospital industry analysis: Problems that triggered 136 rural hospital closures in 2010-21 appear to be getting worse

"Low reimbursement, staffing shortages, low patient volumes, regulatory barriers, and Covid-19 disruptions all played a role in the shuttering of 136 rural hospitals between 2010 and 2021, including a record 19 closures in 2020," John Commins reports for HealthLeaders, citing a report from the American Hospital Association, And, the report says, "Those problems appear to be worsening as rural hospitals contend with rising costs for labor, drugs, supplies and equipment, threatening care access for rural Americans." Key takeaways from the report include:

• 35 percent of all U.S. hospitals are rural. That includes critical-access hospitals, frontier hospitals, and sole community hospitals.
• Rural hospitals are often their community's largest employer, and drive the local economy.
• Rural hospitals support 1 in 12 rural jobs nationwide.
• AHA wants Congress to extend subsidies under the Medicare-Dependent Hospital and Enhanced Low-volume Adjustment programs. Both programs are set to expire Sept. 30.

Struggling rural hospitals can go emergency-only, starting next year; new Medicare agency rule lays out the process

"The Biden administration released a proposed rule that grants more regulatory flexibility for small, rural hospitals in a bid to curb a worrying trend of facility closures," Robert King reports for Fierce Healthcare. "The Centers for Medicare and Medicaid Services’ proposed rule released Thursday outlines the conditions of participation for a facility to become a Rural Emergency Hospital, which enables a facility to offer emergency care, observation and other outpatient services."

In December 2020 Congress created the rural emergency hospital as a new type of Medicare provider. The model, which takes effect in 2023, aims to mitigate the loss of emergency services in rural areas where hospitals have closed. Some small rural hospitals or critical-access hospitals can convert to REHs, facilities that provide 24-hour emergency services but no inpatient care. The new classification matters because rural hospitals rely on Medicare reimbursements, but in order to receive it they must maintain expensive inpatient beds so they can still be classified as hospitals. (This webinar had a good overview.)

"CMS’ goal for the new designation is to enable small facilities in rural areas and critical access hospitals to “right-size their service footprint and avoid potential closure,” according to a fact sheet on the rule," King reports. "Overall, the conditions of participation closely align with current conditions for critical access hospitals. However, CMS is seeking comments on specific standards for the rural facilities, such as whether the agency should require a facility to also provide outpatient surgery services if surgical labor is necessary. "

New report offers short- and long-term solutions to help rural hospitals survive as they move out of the pandemic

Federal pandemic money shored up rural hospitals as they worked to care for increased volumes of critically ill patients, but many of them were at risk of closure before Covid-19 hit, and the financial challenges creating that risk have not gone away, so "Rural hospitals that were struggling before the pandemic will once again be at risk of closure unless additional action is taken to shore up these facilities," says a new report from the Bipartisan Policy Center.

The report, The Impact of COVID-19 on the Rural Health Care Landscape, examines the ongoing financial and workforce-related challenges facing rural hospitals through the lens of eight states: Iowa, Minnesota, Montana, Nebraska, Nevada, North Dakota, South Dakota and Wyoming. It lays out short- and long-term policy recommendations to strengthen rural care, as well as ones to serve as a bridge as health-care systems exit the pandemic.

The pace of rural hospital closures slowed during the pandemic, due in large part to the federal relief provided to hospitals nationwide. "In 2021, only two hospitals closed, down from 19 in 2020, marking a significant reduction from the 138 closures between 2010 and 2020," the report says. 

George Pink, deputy director of North Carolina Rural Health Research Program at the University of North Carolina Chapel Hill, said in a June 29 webinar, "This funding really allowed many hospitals to survive during the pandemic, and probably prevented many rural hospitals from closing," reports Melissa Patrick of Kentucky Health News.

Pink ticked off a list of challenges rural hospitals face. First, they serve small populations that are typically older, sicker, under-insured or uninsured. Also, they have low patient numbers that don't create enough revenue to cover the fixed cost of a 24-hour emergency department; high percentages of patients on Medicare, programs that often don't cover the cost of care; and struggles with recruiting health-care providers.

With the last pandemic funds soon to be distributed, Pink said he expects rural hospitals to fall to pre-pandemic levels of profitability. "In fact, profitability can decline even faster because of what hospitals are now having to pay for labor, particularly nursing," he said.

Bipartisan Policy Center graphic; for a larger version, click on it. 

Of the eight states the Bipartisan Policy Center reviewed for this report, the percentage of hospitals experiencing at least three consecutive years of negative total operating margins ranged from 6% in Nevada to a high of 38% in Wyoming. 

The BPC also assessed the financial vulnerability of 2,176 rural hospitals between 2017 and 2020. It found that 909 had two or more concurrent financial risk factors that put them at risk of service reduction or closure; 441 of them faced three or more risk factors; and 173 of them had four or more. The factors included negative operating margins (total and on patient services alone), negative current net assets, and negative total net assets.

Asked if their hospitals would survive without the federal relief money, Joan Hall, president of Nevada Rural Hospital Partners, a consortium of Nevada's 13 critical-access hospitals, said the hope is that there will be more money coming, but they are not sure there will be, Patrick reports.

"I think that is a something we're very worried about," said Hall. "We're seeing still sicker patients, patients with different kinds of of needs that typically we've not had to provide care for in rural areas." 

Joe Schindler, vice-president of finance policy and analytics at the Minnesota Hospital Association, added that it would be "disastrous" for hospitals that have depended on money from programs like the Medicare Dependent Hospital Program, which assists smaller hospitals that are heavily dependent on Medicare patients and is set to expire on Sept. 30, to lose this funding.

"This is the worst time probably to pull the rug out on programs that have helped support rural access for many of those hospitals that need those supports," he said.

The report offers several short-term proposals to help shore up rural health systems, largely measures to stabilize payment models and delaying until two years after the federal public health emergency for Covid-19 ends Medicare's scheduled payment reductions of 2%, Patrick reports.

The report also offers what it calls "evidence-based, viable solutions to the health care crisis in rural America" that seek to "stabilize rural health-care systems, strengthen the newly created Rural Emergency Hospital model, ensure an adequate workforce, and broaden access to virtual care in rural America."

Health-care roundup: Providers in N.D. discuss challenges; regulations boosting telehealth expansion will expire soon

Here's a trio of stories about rural health care:

At a roundtable discussion Monday, rural health-care providers in North Dakota spoke to state and federal officials about the difficulties they face. Participants "cited workforce issues, regulations and rising costs as three challenges to provide services in rural areas," Masaki Ova reports for The Jamestown Sun. Officials in attendance included Sen. John Hoeven, R-N.D.; Xochitl Torres Small, the Agriculture Department’s undersecretary for Rural Development; and Erin Oban, her North Dakota director.

Rural hospitals had to adapt to survive during the pandemic, aided by federal funding. Some hospitals hope to keep some of those new capabilities, but may not be able to when the federal public-health emergency order expires—drying up funding with it.

Donald Lloyd, CEO of St. Claire Regional HealthCare system in Morehead, Ky., said the shift to telehealth is likely here to stay. "Before the pandemic, telehealth visits weren’t common at his hospital. Now telehealth visits account for nearly 20% of hospital visits," Liz Carey reports for The Daily Yonder. That goes especially for behavioral health, he said, since more than 80% of such visits to the hospital are via telehealth these days.

Speaking of telehealth: Relaxed regulations during the pandemic allowed health-care providers to more easily prescribe buprenorphine for opioid-abuse disorder. Studies have shown that telehealth prescription visits are at least as effective as in-person visits in keeping patients on their medication, but those regulations will expire along with the federal public-health emergency order. "That could come as soon as October, and the Drug Enforcement Agency, which has sought to clamp down on buprenorphine’s misuse, has already missed deadlines to facilitate virtual access," Krista Mahr and Ben Leonard report for Politico. "The expansion across sectors has been critical in rural areas, where access to licensed clinicians is scarce and social stigma runs high."

Rural and critical-access hospitals rated in new rankings

How is your local hospital performing? Check out these new rankings and see.

The Leapfrog Group, a national heath-care safety watchdog group, has released its Spring 2022 Leapfrog Hospital Safety Grades, which assigns a letter grade to every hospital in the U.S. based on more than 30 measures of patient safety, including preventable errors, accidents, injuries, and infections. The newest rankings show that the pandemic has caused significant declines in several measures among many hospitals; Leapfrog explores worsening inpatient hospital experiences during the pandemic in a supplementary report. Some rural hospitals say they're having a hard time serving patients adequately because they're not able to fully access federal pandemic relief. Look up your local hospital's safety grade here.

Meanwhile, the Chartis Center for Rural Health, operated by the Chartis Group, has released its newest ranking of the top 20 and top 100 Critical Access Hospitals in the U.S., as well as the top 100 rural and community hospitals. The rankings are based on Chartis' Hospital Strength Index, which considers performance based on 50 rural-relevant factors in eight broad market-, value-, and finance-based categories. Chartis also named the top 20 hospitals for quality (based on its percentile rank of rural-relevant process of care measures), and another top 20 for patient satisfaction ratings. The National Rural Health Association will recognize the top 20 critical access hospitals during its Critical Access Hospital Conference in September.

Rural health-care systems in the South are crumbling from the pressures of the pandemic, Politico reports

Health-care systems in rural America, especially in the South, are crumbling amid the pressures of the coronavirus pandemic. Daniel Payne of Politico reports in a wide-ranging story.

"Of the 50 counties with the highest Covid deaths per capita, 24 are within 40 miles of a hospital that has closed, according to a Politico analysis in late January. Nearly all 50 counties were in rural areas." That doesn't prove the closure of hospitals led to higher death rates, because rural counties generally have higher infection rates, lower vaccination rates and lower health status than urban and suburban counties. But Payne raises the possibility that the closure of 181 rural hospitals since 2005 has discouraged vaccination and other preventive measures: "In the communities where health resources disappear, so too does confidence in the medical system. Trusted sources of information go elsewhere."

And the list of closures "may be just the beginning," Payne writes. "Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health-care advisory firms."

In pandemic surges, rural residents with a local hospital couldn't always access treatment. The nationwide bed shortage led to long waits in rural emergency rooms and critical patients left waiting for transfers to larger hospitals, Payne reports. "The entire system clogged up," Claude Brunson, executive director of the Mississippi State Medical Association, told him. "Without a doubt, there are some patients who died because we did get bottlenecked and couldn’t establish a very good flow of care across the system — because we had lost the numbers of beds that we truly did need."

Payne's object example is Haywood County, Tennessee, which "had its health care system ground down in the years leading up to the pandemic: Ever since the 84-year-old Haywood County Community Hospital closed its doors in 2014, the numbers of doctors and other health care professionals dwindled. Residents who once were on a first-name basis with their care professionals were left to book appointments at facilities miles from where they’d raised their families and grown older."

One factor Payne doesn't note: the lack of Medicaid expansion under the Affordable Care Act in Tennessee and most other Southern states.

Kaiser Health News opening a rural reporting desk for Midwest and Mountain West, supported by $3.9 million grant

Kaiser Health News is establishing a rural health reporting desk to cover the Midwest and Mountain West, planning to hire journalists and social-media experts to cover Iowa, Minnesota, Montana, Nebraska, Nevada, North Dakota, South Dakota, and Wyoming.

KHN's parent organization, the Kaiser Family Foundation, is able to fund the expansion through a $3.9 million grant from the Leona M. and Harry B. Helmsley Charitable Trust., which aims to improve lives by promoting health- and place-based initiatives.

"The team of journalists will provide unbiased, accurate, and trusted reporting on a wide range of complex issues, including the ongoing pandemic, access to health coverage and care, the burden of health care costs on consumers, housing and education, the opioid epidemic, mental health, hospital closures, the lack of critical lifesaving equipment, and burgeoning changes in telehealth and medicine. KHN will partner with local media throughout the region to produce deeply sourced stories that shed light on underreported issues," according to the press release. "As with all its journalism, KHN stories produced by the Rural Health Desk will be made freely available for publication by media outlets across the country, published on khn.org and distributed through KHN’s social media platforms."