Rural Hospitals and the overlooked fight against COVID-19
What Big Data Can Tell Us About Vulnerability In Rural Areas
April 16, 2020 // Romano Nickerson
Dr. Neil Nickerson, Dr. Roger Nickerson, and Dr. Harold Williamson
My grandfather was an internist in a small town in rural Minnesota. In the 1950s, he formed a practice with his brother, a general surgeon, and his cousin, a general practitioner. Together, they bought out a physician named Dr. Hunt, who owned a building called the Lakeside Clinic which contained his clinic on the first floor and a second floor that housed a nursing ward with multiple rooms that could hold 2-3 patients; essentially a small hospital. In the basement was a kitchen connected to the other floors by a dumbwaiter and a small apartment where a nurse lived.
At the time, there were 8,500 people in our town. My grandfather’s hospital was one of two, small, physician-owned hospitals that supplemented the larger city hospital. In the mid-1960s, my grandfather spearheaded the formation of a medical group that unified the doctors around the same time as the construction of the current 40-bed hospital. He also established a coronary care unit (CCU), one of the first in the country, which was part of a strategy of creating a practice environment that would help with recruiting physicians.
The story of my grandfather is meaningful in my hometown and certainly to me, but it is hardly unique among the more than 16,000 towns in the United States with fewer than 10,000 residents, where unsung heroes worked to build and sustain medical services. More recent efforts to provide rural care culminated in the Critical Access Hospital program, which was established in 1998 to provide funding for small hospitals in rural areas. To qualify, a facility may have no more than 25 beds, an average length of stay under 96 hours, and be separated from another hospital by more than 35 miles. As of January 2020, there are more than 1,800 critical access hospitals in 45 states.
Unfortunately, the 60 million people who live in rural areas of the country have seen a disturbing trend in the past decades. According to a recent study of rural hospitals by the Chartis Center for Rural Health cited by Forbes, 120 rural hospitals closed from 2010 to 2020. Of particular risk are rural hospitals in states that did not adopt Medicaid expansion. Becker’s Hospital Review lists the following chief reasons driving pressure to close critical access hospitals.
- Revenue pressure. Rural areas have fewer commercial payers than more urban markets, which means these hospitals have a higher volume of state-funded healthcare with lower reimbursement rates.
- Patient population complexity. As the U.S. population ages and struggles with chronic conditions, these issues are more extreme in rural areas. For example, studies show 18% of people are aged 65 and older in rural communities, compared with 14% in urban areas, and 18% have limitations due to chronic conditions, compared with 13% in urban communities. These patients require more services and more specialties than younger, healthier patients.
- Provider recruitment and retention. Remote locations have a harder time recruiting full-time physicians, especially in specialties such as orthopedics or neurology. While rural patients still need these services, rural hospitals are often only able to offer them once a week or once a month with alternating coverage for subspecialties. It leads to lack of access to care for patients, burned out physicians and loss of revenue for organizations.
And now the COVID-19 situation looms over this landscape of reduced capacity. Daily briefings from Federal and State–level government fill the airwaves and social media while many of us follow online counters that track the inexorable growth of cases and deaths from the virus. And while every death will be tragic, I fear that those who are vulnerable will suffer more than most. The focus of COVID-19 coverage naturally falls on places like New York City, where the Tri-State Area has half of all reported cases in the United States, as of April 14th. But what about places like Blaine County, Idaho?
Counties with highest per capita rates of COVID-19 cases
New York County (the island of Manhattan) has the highest rate of positive COVID-19 cases with nearly seven percent of the population infected. Surrounding areas comprise three of the most stricken counties, along with Blaine County, Idaho with 21.5 cases per 1,000 residents. Most people have never heard of Blaine County and would struggle to point to it on a map if I didn’t note that it is a county in Idaho. In no way do I wish to diminish what is going on in and around New York City, but as of today, the rate of infection in Blaine County is significantly more troubling because of the current state of rural medicine.
Counties with fewer than 25,000 residents and more than two COVID-19 cases per thousand residents. Blaine County is shown in dark orange.
Blaine County is not the only place of concern in Rural America. The highlighted areas in the map above shows counties with a population of fewer than 25,000 residents and more than two COVID-19 cases per thousand residents. Those counties are shown over top of population density by county, with darker areas representing greater density. Of more specific concern is the rapid growth in number of counties that fall in this range. One county met the criteria on March 25th, ten counties on April 2nd, and now 62 counties as of April 14th.
Healthcare is challenging in rural areas, even in the best of times. Bed counts are lower than the national average. Travel distance to medical facilities can exceed 50 miles. Visits with clinical specialties are often only achieved through rotation and may only be available one day a week. These conditions make the spread of the virus concerning, especially when number of cases significantly exceed the number of available beds. Ironically, one of the likely outcomes of COVID-19 will be a shift to telemedicine for health services like primary care, something that critical access already uses. Our rural providers will surely have lessons to share with the rest of the country!
As healthcare architects, we have described a concept that we call Community-Based Step Down, which focuses on using existing community assets like ambulatory surgery centers and hotels to add capacity to existing hospitals. Although surgery centers are even more rare than hospitals in rural America, there are hotels and other suitable spaces for flexing care, including school gymnasiums and American Legion Halls. Recent changes from CMS have waived requirements for beds, length of stay, and distance to the nearest hospital to allow surge sites. However, also needed will be supplies, personal protective equipment, and medical equipment rerouted from urban areas.
The spread of the Coronavirus has exposed numerous vulnerable populations around the world and in our nation. My hope is that we will be able to use data to guide our response in this pandemic crisis and I hope it will give places like Blaine County a chance before it is too late. While I assure you that the providers who live in rural America are as well trained as anyone anywhere, they will most certainly have a harder time marshalling the resources they need to treat COVID-19 patients and telling their stories. I, for one, would love to be able to assist our rural health providers in quickly processing data, developing, and deploying strategies and solutions to help them and their communities get through this. I’m pretty sure my grandfather would want me to.
Feel free to contact me at firstname.lastname@example.org.