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Opinion: To Reinvent Rural Health Care, Ditch the ‘One-Size-Fits-All’ Model

Geography shouldn’t be an impediment to quality care

A man waits at a mobile clinic in Olean, New York, in June 2017. Rural communities should be given the flexibility to figure out a health care delivery system that works for them, Dorgan and Krutsick write. (Spencer Platt/Getty Images file photo)
A man waits at a mobile clinic in Olean, New York, in June 2017. Rural communities should be given the flexibility to figure out a health care delivery system that works for them, Dorgan and Krutsick write. (Spencer Platt/Getty Images file photo)

As policymakers grapple over how to best deliver quality, affordable health care, they cannot ignore the unique challenges faced by the 46 million Americans living in rural areas.

Not only do rural residents rank worse than their urban counterparts on many health metrics such as obesity, tobacco usage and suicides, their communities also face shortages of health care workers and geographic challenges that make it more difficult to address these concerns.

In recent decades, strengthening the financial viability of their health care systems has been a top priority for rural communities and lawmakers. The broader health care system, meanwhile, focused on moving toward a payment system based on value and quality rather than volume.

Policymakers made improvements to how Medicare reimburses for rural services, but ultimately decided that rural communities are not ready to fully participate in new delivery models or programs focused on value. The mentality to “stabilize first and innovate later” has dominated the legislative and regulatory efforts of recent years and continues to affect the rural health policy outlook in Congress and the administration.

Last year, the Bipartisan Policy Center launched a six-month effort with the Helmsley Charitable Trust, speaking with over 100 experts to better understand the implications of existing federal policies and the health care challenges facing rural communities. BPC hosted three roundtable discussions with stakeholders from seven Upper Midwest states (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming) and worked with the Center for Outcomes Research and Education to conduct interviews nationwide with thought leaders in rural health care from across the political spectrum.

Our survey findings were released in BPC’s recent report and revealed four areas that require policy attention:

(1) allowing rural communities to define their own needs and services;

(2) creating funding mechanisms that account for rural realities and allow for innovation;

(3) optimizing the full array of health professionals to support a sustainable and diverse workforce;

(4) providing health professionals with the tools and technology for success, such as access to telehealth.

The report’s main message is that rural communities have unique strengths and challenges, and should be given the flexibility to figure out how to right-size their local care delivery systems. While Critical Access Hospitals, or CAHs, have been the leading model in rural areas, stakeholders generally agreed that a full-service hospital may not be appropriate for every community. Rural residents must be able to adjust the CAH model to meet their specific needs and ensure they have access to sustainable, quality services.

Current efforts to reform reimbursement using pay-for-performance models are designed for high-volume areas, precluding most rural health care organizations from participating. What rural communities need are funding mechanisms that account for their low patient volumes and reliance on Medicare and Medicaid. Rural-specific quality metrics and some protection against downside risk will be necessary to include these communities in the larger movement toward value-based care.

Geographic and professional isolation, combined with a lack of exposure to rural practice during training and residency programs, make it difficult to recruit and retain health care staff. Connecting providers to a peer network through telemedicine can help prevent burnout but will require updated reimbursement standards and improved broadband infrastructure. Broadening the roles of nontraditional providers such as community health workers and expanding pipeline programs to recruit future providers from local schools can help address staff shortage issues.

Our conversations converged on one fundamental point: Delivering health care in rural communities is distinct from delivering health care in other parts of the country. This tends to go unacknowledged in health policy conversations and puts rural areas at a disadvantage. The piecemeal approach of previous legislative and regulatory efforts has undermined the rural health care system while largely ignoring significant interdependencies among factors such as CAHs, the rural health workforce and telemedicine.

Comprehensive policies that consider these relationships and identify opportunities for change will lead to more effective results. Ensuring that geography isn’t an impediment to quality health care will require a coordinated, bipartisan effort from federal, state and local officials in all 50 states.

Byron L. Dorgan is a former Democratic senator and congressman from North Dakota and a senior fellow at the Bipartisan Policy Center. Caitlin Krutsick is the project manager for the Bipartisan Policy Center’s rural health care initiative.

The Bipartisan Policy Center is a D.C.-based think tank that actively promotes bipartisanship. BPC works to address the key challenges facing the nation through policy solutions that are the product of informed deliberations by former elected and appointed officials, business and labor leaders, and academics and advocates from both ends of the political spectrum. BPC is currently focused on health, energy, national security, the economy, financial regulatory reform, housing, immigration, infrastructure, and governance. Follow BPC on Twitter or Facebook.

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