By James X Stobinski, Ph.D, RN, CNOR, CSSM(E), CNAMB(E)
King Henry, in the play “Henry V” by William Shakespeare, exhorts his followers to return to the fray once again with the phrase, “Once more unto the breach …”1 Building on previous columns, I would like to return to the topic of rural health care.
Hospital closures and reorganizations continue in rural facilities with regular announcements in the industry press.², ³ Health care facility realignments are increasingly common and typically involve discontinuation of service lines such as emergency care and maternal services. Short of closure some rural facilities may attempt a transition to a smaller, more efficient organization such as a critical access hospital. Rural facilities continue to be challenged in the post pandemic recovery.
Dyrda reports that while some larger health care organizations are reporting record profits many rural facilities continue to struggle.² The American Hospital Association reports, “…continued significant financial pressures for hospitals nationwide.”² The most pressing issue is that inflation continues to outpace the growth of Medicare inpatient reimbursement rates. In addition, labor costs continue to rise and some facilities struggle to successfully transition to value-based care models. The closure or downgrades of facilities have special significance in rural communities. Patients and families incur significant expenses for travel and resources when care is not available in the community. There are also patient safety concerns with emergency care for cases such as obstetrical emergencies.
The rural health care dilemma is part of a larger picture of consolidations and mergers in American health care. This trend makes it increasingly difficult for rural facilities to remain independent and offer a wide range of services. Survival in any form may require joining a larger system with an eventual downgrade or elimination of services as complex, technologically intensive care is moved to a larger, centrally located care site. But these changes in service levels have larger, downstream implications.
The lack of health care facilities also translates into a lack of clinical sites for the education and training of health care professionals to include nurses. Often in rural communities the only pre-licensure program is a community college which are dependent on local clinical sites. Ultimately, the lack of health care facilities degrades the education experience for students and also lessens the ability to deliver culturally competent care for rural patients. A critical source of staffing for rural facilities is the local population. It is difficult to recruit staff to rural sites. The lack of clinical sites will worsen the already considerable staffing challenges for these facilities and limit the employment opportunities for nurses.
For those of us approaching retirement the availability of health care services is an important consideration. The lack of locally available health care then becomes a quality of life issue which impacts housing and relocation choices. The same impact is possible for younger families needing obstetrical and pediatric services. This leads to a spiraling effect. The lack of local health care may keep retirees and early career families from living in rural areas but also cause an out migration to areas with better access to health care. The lack of patients and resources then makes it increasingly difficult to maintain health care services leading to more closures or downgrades in rural areas.
The impact of rural health care challenges are wide-ranging to include workforce issues and population shifts. The lack of comprehensive local health care may influence who can live in a region. Viable solutions will require an investment of resources, political consensus and changes in reimbursement processes. Access issues for rural populations may continue to worsen on the near horizon until this issue comes to the forefront and there is political will for meaningful solutions and investment.
References
Poetry Foundation (2024). Speech: “Once more unto the breach, dear friends, once more” https://www.poetryfoundation.org/poems/56972/speech-once-more-unto-the-breach-dear-friends-once-more
Ashley, M. (August 11, 2024). 17 hospital closures in 2024. https://www.beckershospitalreview.com/finance/5-hospital-closures-in-2024.html
Gamble, M. (August 5, 2024). 703 hospitals at risk of closure, state by state. https://www.beckershospitalreview.com/finance/703-hospitals-at-risk-of-closure-state-by-state.html
Dydra, L. (August 9, 2024). The truth about hospital profitability. https://www.beckershospitalreview.com/finance/the-truth-about-hospital-profitability.html
