Everything Old is New Again-with a Twist for Rural Health Care Providers
As rural health care providers cut back on services--or close altogether—RHCs face pressures to provide expanded care and “old fashioned” approaches, including doulas and promotoras, gain popularity when any facility to simply too far away.
Consolidation hurts access to care, especially in rural communities. That, frankly, is a no-brainer for anyone who works in a rural or any other underserved community. Large health systems acquire small rural hospitals and either shutter them or close several service lines, usually including obstetrics.
The result: decreased access for those in rural areas. But this realization has done nothing to slow the pace of mergers and acquisitions.
Here’s the real kicker: Consolidation continues to gain steam because of the belief that consolidation creates economies of scale that lead to better care. But in many instances, it’s a mistaken belief; in fact, many experts report just the opposite. These “economies of scale” often don’t control costs.
In fact, multiple studies have focused on how hospital consolidation is driving up the cost of care. So not only are there severe unintended consequences, but the intended benefits aren’t being realized
Of course, it’s not always that cut and dried. Many acquisitions occur when a small independent hospital can’t keep its doors opened. Without the acquisition, it would have gone under. But once acquired, it can be shuttered. Either way, patients lose.
With the hospitals gone, rural clinics providing outpatient care face even more pressure. They often end up taking on more--and sicker patients--and they often have to do it with fewer clinicians. Providers, understandably, leave the community once the rural hospital closes. As we know all too well, rural communities already face staffing challenges. Recruiting and retaining providers is exponentially more difficult after a closure.
(For an in-depth look at the problem of closures, download our whitepaper, A fraying safety net: Rural hospitals continue to close, leaving patients and community clinics in the lurch
Rural Health Care Providers: Birthing a Trend
Consolidation has spawned another trend that makes it harder to obtain care: increased specialization. As Modern Healthcare recently observed, services such as obstetrics and cardiology are being centralized in high-traffic hospitals.
Obstetrics is especially problematic, given that pregnant women in the U.S. are dying at higher rates than ever; we have one of the highest maternal mortality rates in the industrialized world. Decreasing access probably isn’t the best response to the crisis.
And yet…The Chartis Center for Rural Health reports that, between 2010-2018, 134 rural hospitals--or 12% of all rural hospitals--that offered obstetric services stopped providing them. An additional 18 hospitals with OB departments totally shut down. The upshot? Only 46% of rural hospitals offer labor and delivery care. Meanwhile, an estimated 108 rural hospitals closed between January 2010 – July 2019, according to the North Carolina Rural Health Research Program.
Another factor is contributing to the dismal state of maternal and child care: Medicaid cuts. Medicaid pays for half of all births in the U.S., a number that rises to 59% in rural areas, according to Rural Health Research Center. But that’s a topic for another day.
As families look for other options, it’s no surprise we’re seeing an increase in the number of doulas.
Doulas to the Rural Health Care Provider Rescue?
A study published in Birth found that when mothers received help from a doula (a person trained to provide advice, information, emotional support, and physical comfort to a mother before, during, and just after childbirth) they--and their babies--had fewer complications, and the rates of preterm births and Cesarean delivery dropped. Across the 12 states in the study, access to doulas among Medicaid beneficiaries could save $58.4 million and eliminate 3,288 preterm births annually.
Doulas can be a great help for expectant mothers lacking a traditional medical support system. Like midwives, doulas have been around for centuries. A newer, related, trend, community-based maternal care models, offers enhanced care and support, including doula and midwife services, to women in underserved communities. Ideally, they can reduce disparities in outcomes.
Even when access to pre- and post-natal care improves, there’s still a problem: having to drive hours for delivery--either to a hospital or birth center--constitutes a serious access problem. Doulas can deliver babies at home, but that’s generally less than optimal--especially when the nearest critical care center is far away.
From No-tech to High-tech: Looking for Alternatives
With hospitals disappearing and the physician workforce shrinking, another traditional caregiver--the community health workers (CHW)--is also playing a larger role.
These lay health workers conduct outreach and health education in homes, community centers, schools, worksites, etc. Many focus on serving the needs of specific ethnic groups. In Hispanic communities, a promotora is both an advocate and a guide--and atrusted member of the community.
Formally trained community health workers have been around for decades, but the wise woman (or man) who supports the health of the community is ageless.
Today, we know using CHWs reduces healthcare costs. While CHWs do not typically serve in clinical roles, as intermediaries, they link clinical services to community-based services and organizations.
On one hand, we have the traditional, holistic approaches to care, such as the midwives, the doulas and the community health workers. Even house calls are having a resurgence.
On the other, we have sophisticated technology to help bridge the gaps. Telehealth continues to gain traction in rural communities--especially as more communities have access to high-speed internet. It typically results in improved quality and cost savings.From e-consults to e-ICUs to virtual hospitals, telehealth has proven particularly useful in terms of triage and post-acute care.
But no matter how good the prenatal care, no matter how supported the mother is, many births need to take place in a hospital. Likewise, no matter how connected a rural clinic is to the big-city hospital, it isn’t going to be able to provide bypass surgery or emergency care. There’s no alternative to a hospital.
No Alternative, but Some Paths Forward
Robert Kirkpatrick, Milam County (Texas) Health Department director, discussed the dilemma in an interview with the Austin American-Statesman. He’s exploring new ways to improve rural access to urgent care--but now, the burden falls on clinics.
“Hospitals should be for emergent care, not necessarily for chronic disease medical attention. We need to get the population to become healthier as a whole so that chronic problems aren’t there and we are able to focus on medical emergencies in hospitals,” he said.
Even that’s a tough order for rural health care providers, who treat sicker and older populations. We can help. We can’t stop consolidation or change federal policy. What we can do is provide tools that make rural hospitals and clinics more resilient and viable--and we do it on contingency. If you are interested in learning more, click here for a free 30-minute advisory services session.