Just off the historic U.S. Route 66 in eastern New Mexico, a 10-bed hospital has for decades provided emergency care for a steady flow of people injured in car crashes and ranching accidents.
It also has served as a close-to-home option for the occasional overnight patient, usually older residents with pneumonia or heart trouble. It’s the only hospital for the more than 4,500 people living on a swath of 3,000 square miles of high plains and lakes east of Albuquerque.
The interior of an emergency room at the Guadalupe County Hospital in Santa Rosa, New Mexico. Hospitals that convert into the new federal Rural Emergency Hospital designation will get a 5% increase in Medicare payments and an average annual facility fee payment of about $3.2 million in exchange for giving up inpatient beds and focusing solely on emergency and outpatient care.
“We want to be the facility that saves lives,” said Christina Campos, administrator of Guadalupe County Hospital in Santa Rosa. Its leaders have no desire to grow or be a big, profitable business, she said.
But even with a tax levy to help support the medical outpost, the facility lost more than $1 million in the past six months, Campos said. “For years, we’ve been anticipating kind of our own demise, praying that a program would come along and make us sustainable.”
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Guadalupe is one of the nation’s first to start the process of converting into a Rural Emergency Hospital. The designation was created as part of the first new federal payment program launched by the Centers for Medicare & Medicaid Services for rural providers in 25 years. And though it is not expected to be a permanent solution to pressures facing rural America, policymakers and hospital operators alike hope it will slow the financial hemorrhage that continues to shutter those communities’ hospitals.
More than 140 rural hospitals have closed nationwide since 2010, and health policy watchers aren’t sure how many of the more than 1,700 rural facilities eligible for the new designation will apply. CMS officials said late last month that seven have already filed applications. Dr. Lee Fleisher, director of the Center for Clinical Standards and Quality at CMS, said how long it will take to review the applications will vary. The agency declined to provide the names or locations of hospitals seeking the designation.
Facilities that convert will get a 5% increase in Medicare payments as well as an average annual facility fee payment of about $3.2 million in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds that closed after the law passed on Dec. 27, 2020, are eligible to apply for the new payment model if they reopen.
The new program “strikes me as the first time we are saying, you know, maybe we can just take the beds away,” said Dr. Paula Chatterjee, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine. Outpatient and emergency visits already make up about 66% of Medicare payments for rural hospitals that are eligible to convert, according to Chatterjee’s recent research.
Still, she found that many would likely need to scale up some outpatient services, such as telehealth and substance use care. Even then, the payment model might not be able to shift the “foundational pressures” of declining, aging and sicker populations that are making it hard to deliver care in rural America, she said.
“This feels like rearranging deck chairs on the Titanic,” Chatterjee said.
More than 50 hospitals and other organizations have expressed interest in the rural emergency designation, said Janice Walters, chief operating officer of programs for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to facilities interested in converting.
Most hospitals “are still trying to figure out, ‘Is the math going to work?’” Walters said.
Those showing immediate interest are very small, with three or fewer patients staying overnight any given day, and, generally, they long ago gave up maternity care to save on expenses. The federal law will need to be amended to help larger rural hospitals with more overnight stays, said Brock Slabach, chief operations officer for the National Rural Health Association.
“It’s enough for now,” Slabach said. “But is it going to be enough for the long term? I don’t think so.” Top priorities for the group include adding the ability for hospitals to participate in a federal drug discount program and allowing for longer patient stays.
At Stillwater Medical in Oklahoma, Chief Administrative Officer Steven Taylor said the switch already makes sense for two of the system’s smaller hospitals that “have struggled financially.” The small regional health system’s outpost in Perry, which rarely has more than two inpatients a day, has already filed an application, and its facility in Blackwell will likely do so soon, he said.
Keeping emergency services “is the most important thing” for the small communities, he said. The new model requires a 24-hour emergency department and a clinician on call. It also caps the average length of patient stays at 24 hours — which Taylor said is not a problem. One patient may need to be watched for 12 hours for chest pain while another, with pneumonia, may need to stay for 36 hours, but that will average out to less than 24 hours for the year, he said.
Assistant administrator and lab manager Frank Tenorio listens as administrator Christina Campos goes over legislation for rural hospital designations at Guadalupe County Hospital in Santa Rosa, New Mexico.
Plus, he said, anybody who needs more intense care can be transferred to their regional hospital in Stillwater. Oklahoma, like other states, is working to update state laws for licensing or regulations to ensure hospitals can be credentialed with the rural emergency designation quickly.
John Henderson, president and chief executive of the Texas Organization of Rural & Community Hospitals, agreed with other speakers at the National Rural Health Association’s February policy conference in Washington, D.C. The new rule “could be a relief valve” for very small rural hospitals, he said. A two-bed facility in Crosbyton confirmed for Henderson earlier that day that it was the first in Texas to be approved for the new payment mechanism.
Henderson said he knew of several more of the state’s 158 rural hospitals that are applying or have already applied, and others are considering it: “These are the folks that are just hanging on."
8 statistics that explain the rural doctor shortage
8 statistics that explain the rural doctor shortage
For Americans who live in cities or suburbs, going to the doctor is usually a simple errand. Even if they have trouble finding an appointment time that works for their schedule or getting their health insurance to cover it, their doctor's office or hospital is usually a manageable distance from their home or work.
However, for 46 million Americans living in rural areas, accessing healthcare isn't as easy. According to a 2018 survey by the Pew Research Center, nearly a quarter of rural Americans say access to good-quality hospitals and doctors is a challenge for their community. Making things worse, these rural residents tend to be older, less wealthy, and less likely to have health insurance than their urban and suburban counterparts.
The challenges preventing rural Americans from accessing medical care will likely worsen. The Association of American Medical Colleges projects a shortage of 54,100 to 139,000 doctors in the United States by 2033. Residents of rural communities will see their travel times to doctors and hospitals increase even more.
Of course, not every doctor's visit requires in-person care: Telehealth is becoming more popular, thanks in part to government agencies offering grants and training programs promoting telehealth and the uptick in virtual visits during the COVID-19 pandemic in 2020 and 2021. However, many people in rural areas also lack access to a stable broadband internet connection—which renders telehealth visits nearly impossible.
To understand the effects of the rural doctor shortage in the United States, Incredible Health compiled data from government entities and research institutions. Here's what you need to know about the current lack of medical care in rural communities, the effects the shortage has on patients, and the outlook for health care in rural areas.
Nearly 4 in 5 rural U.S. communities are short on medical staff
According to data from the Health Resources and Service Administration, 60% of the areas in the United States that are designated as "medically underserved"—meaning they face a shortage of primary care providers—are rural. Even more troubling, the average age of rural physicians is older, which means almost a quarter will likely retire by 2030. There has also been a decline in the number of medical school graduates who grew up in rural areas, who historically are more likely than their urban- and suburban-raised peers to practice medicine in rural areas as adults.
There are fewer health care providers per capita in nonmetropolitan areas
Although nearly 20% of the U.S. population lives in rural areas, less than 10% of U.S. doctors practice in rural areas. According to data from 2018 and 2019 that was released in 2021 by the Department of Health and Human Services, nonmetropolitan areas have fewer than half as many physicians per 10,000 people as metropolitan areas. Primary care providers and behavioral health care providers are in particularly short supply. For nursing shortages, the gap is slightly better, but there are still only seven nurse practitioners per 10,000 people in rural areas.
1 in 4 rural teens—and 1 in 5 rural adults—don't have a primary care doctor who they see regularly
The lack of primary care physicians in rural populations is particularly troubling. Patients who regularly see a primary care physician tend to spend less time in the hospital and have lower health care costs over their lifetimes. Additionally, many Americans consider a primary care doctor a trusted source of advice: A 2022 survey reported that rural adults said that their health care provider was the most trustworthy source of information about the COVID-19 vaccine. Four percent of unvaccinated adults said that the reason they weren't vaccinated is that they didn't have a primary care provider.
Compared to metropolitan areas, there are more than twice as many rural counties in health professional shortage areas
Data released in 2022 by the Department of Agriculture shows that rural counties are more likely to face shortages of primary care doctors, dentists, mental health care providers, and even hospitals.
Rural residents are also more likely to have to travel farther to access medical care. A 2018 report from the Pew Research Center found that rural residents drive 17 minutes on average to the nearest hospital—more than five minutes longer than the average driving times for suburban and urban residents. An extra five minutes might not sound like much, but it can make a big difference in a medical emergency.
Medical practices in the most rural locations treat four times as many Medicare patients as metropolitan practices
When a community has only a few health care providers, those practices end up with a much heavier workload. Research released in 2022 found that more isolated practices with fewer physicians cared for greater numbers of patients on Medicare. Practices in urban and suburban settings typically offer more flexible schedules, lighter workloads, and shorter shifts—an attractive proposition for new doctors.
142 rural hospitals have closed since 2010
Out of 185 rural hospitals that have closed since 2005, 76% closed after 2010. A 2022 study found that lower profits, shrinking patient volume, and staffing challenges contributed to most of these closures. Because rural hospitals typically treat more patients on Medicare and Medicaid, they often receive lower reimbursements than they would for patients with private insurance.
The patient mix in rural hospitals is also frequently older, poorer, and sicker than hospitals in urban or suburban settings. Making matters worse, when a rural hospital closes, it doesn't just make it more difficult for residents of that community to get medical care—it can also harm the local economy by cutting physician and nursing jobs, as well as dozens of related jobs in the community ranging from food services to cleaning and transportation.
1 in 5 medical schools ran a formal rural program in 2019
Attracting recent medical school graduates to rural areas is crucial to reducing the rural doctor shortage. However, although most medical schools offered some rural clinical experience, only 21% of medical schools operated a formal rural program in 2019.
Rural training programs offer medical students hands-on experience in communities where a primary care doctor might be the only physician for miles, forcing them to expand their scope of practice to cover specialties like obstetrics. That expanded workload doesn't translate into additional stress: One 2019 study found that rural physicians in South Dakota experienced lower rates of burnout than their peers in cities or suburbs.
Hundreds of millions of dollars are going toward mitigation efforts and solutions for this shortage
Addressing the rural doctor shortage will likely require a combination of several different approaches. Building on the existing rural training programs, the Department of Health and Human Services announced it would award more than $155 million to teaching health centers that focus on providing primary care and mental health care to underserved rural communities.
Creating pre-medical pipeline programs in rural communities can also help high school and college students see themselves entering medicine, which could bolster the rural applicant pool. The Office for the Advancement of Telehealth within the HRSA also runs several projects aimed at providing better access to telehealth services for rural communities.
This story originally appeared on Incredible Health and was produced and distributed in partnership with Stacker Studio.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
