Rural health-care experts suggest five creative ways the Biden administration can improve rural health care

The pandemic has pushed many rural hospitals and clinics to the brink of bankruptcy, or into it. To reverse the trend, say two doctors who study rural policy, the Biden administration must include rural advocates in policymaking and think more deeply about the root causes of rural health-care disparities.

"The solutions rural America needs aren’t just about expanding broadband or insurance coverage, both of which are critical to extend telehealth and health care access. Rural health care will have to transform to survive and then thrive," Lauren Hughes and Sameer Vohra write for The Conversation. Hughes is the state policy director at the Farley Health Policy Center and an associate professor of family medicine at the University of Colorado Anschutz Medical Campus. Vohra is a pediatrician and the chair of the Department of Population Science and Policy at Southern Illinois University.

Hughes and Vohra suggest five creative ways the Biden administration can improve rural health care:

1. Rethink how providers are paid. Normally hospitals bill patients per service, but a la carte billing encourages hospitals to focus on elective procedures and services that bring in more paying patients (and therefore profit). Pennsylvania launched a program in 2019 that pays participating hospitals a fixed annual fee that covers inpatient and outpatient service. "With a predictable budget, enrolled hospitals can focus on the care their communities need, such as treating addiction, increasing cancer screenings and improving the management of patients’ chronic diseases like diabetes to reduce the need for more expensive acute care. The goal is to reduce costs while improving care," Hughes and Vohra write. 

The Biden administration could help transform rural health care by encouraging creative solutions such as Pennsylvania's, they write. Specifically, the administration could create a division within the Center for Medicare and Medicaid Innovation dedicated to designing and testing solutions to rural problems.

2. Expand mental health and addiction services. Rural residents often have difficulty getting mental-health care. "Expanding mental health and addiction services for Medicare and Medicaid recipients and integrating those services with primary care could improve access and reduce stigma. And that could avoid wasteful spending on preventable hospitalizations and medical transfers to larger facilities," they  write. "One way to do that is to change Medicare’s lopsided billing rules for mental health care."

Clinics designated as Federally Qualified Health Centers or Rural Health Clinics already get higher payments for primary care services to Medicare and Medicaid patients, but FQHCs can bill for a wider array of mental-health and substance-use treatment services than RHCs. "Rural clinics could better address higher rates of behavioral illness and substance misuse if they could fully bill for these services," Hughes and Vohra write. "Changing how telemedicine visits are billed by making them equal to in-person visits would also help rural patients access needed services."

3. Build transformational leadership. Rural hospitals already train and recruit physicians through various incentive programs; such pipeline programs should be created or expanded to bring in innovative health-care administrators. Hughes and Vohra suggest employer-supported master's degree programs and expansion of the National Health Service Corps.

4. Bring back pregnancy and childbirth services and improve them. Fewer than half of rural counties in the U.S. have hospitals that deliver babies. Obstetrics, which has high malpractice-insurance costs, is among the first to be cut when hospitals tighten their belts. But the lack of such services has made it more difficult for rural women to access prenatal care or give birth and increased poor outcomes. 

"The new administration could offset costs necessary for critical access hospitals – small, 25-bed hospitals that exist only in rural areas – to deliver babies through special maternity care payments tied to quality outcomes such as increasing breastfeeding rates," Hughes and Vohra write. "These payments would prevent the temptation for small hospitals to grow expensive surgical service lines to cover financial losses commonly associated with offering maternity care. Such payments would also allow rural hospitals to hire dedicated obstetrics nurses." They also write that more grants through the Patient Centered Outcomes Research Institute could encourage university hospitals to partner with rural health-care providers.

5. Invest in health-promoting rural infrastructure. Crumbling rural infrastructure makes it harder for patients to get health care, and health-care workers to get to work. Though the Trump and Obama administrations improved transportation and telecommunication, "these investments were often viewed as solutions rather than tools for innovation. Rural towns would benefit from infrastructure investments that also encourage healthy behaviors," Hughes and Vohra write. They cite examples of communities that have expanded bike paths and built accessible playgrounds.