Report outlines challenges to rural health care

A new report by the American Hospital Association provides a comprehensive look at challenges to rural health care. It divides the 19 challenges into three temporal groups: emergent, recent, and persistent.

The "emergent" category includes:

• The opioid epidemic. Overdose death rates in rural areas outpace those in suburban and urban areas, but it's harder to find treatment options in rural areas.
• Violence in communities. Hospitals have to conduct drills to prepare for mass shootings, which are expensive and time-consuming for rural hospitals. Also, human trafficking is increasing in rural communities.
• Medical surge capacity. Rural hospitals often don't have the resources to effectively handle a disaster. 
• Cyber threats. Hospitals are frequent targets for hackers, but rural hospitals often don't have the training or resources to stave off such attacks.

The "recent" category includes:

• Changes in health care delivery. Across the U.S., many health care services that were once only available to inpatients are now available on an outpatient basis. Since outpatient visits cost less, rural hospitals are getting less money for medical services. 
• Coverage. People with no or inadequate health insurance often can't pay for emergency health services, which means rural hospitals must absorb those costs.
• Medicaid expansion. The 14 states that have not expanded Medicaid under the Patient Protection and Affordable Care Act have more uninsured people, which means rural hospitals often have to eat the costs of emergency health care when patients can't pay.
• Health plan design. "Skinny" health plans, which have higher deductibles and cover fewer services, have become increasingly popular. That can result in scenarios mentioned above, in which hospitals must absorb the costs of care when patients can't pay.
• Behavioral health trends. Recent studies suggest that mental illness, emotional distress and substance-abuse disorders disproportionately affect rural communities. Rural hospitals often don't have the staff and funding to effectively treat such patients.
• Economic, population and social changes. For example, higher unemployment means fewer patients can pay for care, forcing hospitals to absorb the cost of emergency treatment.
• Increased regulatory burden. Rural hospitals have to spend the same amount of time and money on regulatory requirements, but have less money and staff to do so.
• High cost of prescription drugs. Pharmaceutical spending has skyrocketed in recent years; hospitals often can't afford to keep expensive drugs in stock, and rural residents often can't afford to fill prescriptions.

The "persistent" category includes:

• Low patient volume. Because of low population density, rural hospitals don't have enough patients to cover high fixed expenses. 
• Challenging payer mix. Rural residents are more likely to rely on Medicare and Medicaid, but both programs reimburse hospitals at lower rates than private insurers. That makes rural hospitals more vulnerable to policy changes that could hamper payment for services. 
• Challenging patient mix. Rural residents are more likely to be sicker, older and poorer than national averages, meaning rural hospitals tend to have more to do. 
• Geographic isolation. Rural residents often have to travel farther to reach health-care facilities, and many don't have reliable transportation. 
• Workforce shortages. It's difficult to recruit and retain health care professionals to work in rural hospitals. 
• Limited access to essential services. Fewer health care services are available in rural areas for all the reasons listed above and more. 
• Aging infrastructure and access to capital. Many rural hospitals need updating but don't have the funds to do it.