By Matt Skoufalos
Although rural America accounts for about 14 percent of the United States, or some 46 million people, it’s a population that’s always been difficult to reach with services, be they transportation, electricity, broadband Internet or health care. As emergent demographic trends now suggest that it’s shrinking even further in the wake of the novel coronavirus (COVID-19) pandemic, the challenges of delivering access to the same level of care that Americans in more densely populated areas can reach are growing further complicated.
According to Kenneth M. Johnson, senior demographer at the Carsey School of Public Policy and a professor of sociology at the University of New Hampshire, more than two-thirds of all non-metropolitan counties throughout America shed residents from 2010 through 2020, contributing to an overall population loss in those areas for the first time in U.S. history. Johnson attributed the thrust of that decline to “the economic turbulence of the Great Recession and its aftermath” in the earlier part of the decade prior, noting also that “low fertility and higher mortality among the aging rural population” might further compound this downturn.
He further predicts that the outsized impact of COVID-19 in rural communities “may foster even more widespread population loss in the future.” According to the Rural Policy Research Institute (RUPRI) at the University of Iowa, the pandemic has claimed more lives per capita in rural America (379.8 deaths per 100,000 people) than in urban counties of the United States (286.2 per 100,000) from April 2020 to April 2022.
“This will increase the incidence of rural depopulation, a downward demographic spiral that is already occurring in 35 percent of rural counties,” Johnson wrote. “Such depopulating rural counties face significant challenges maintaining critical infrastructure needed to provide quality health care, education, and a viable economy for the remaining residents.”
Whitney Zahnd, Ph.D., assistant professor in the department of health management and policy at the University of Iowa College of Public Health, points out that rural Americans “have persistently faced lower access to health care services, including fewer primary care providers and specialists, and longer travel times to hospitals.” The lack of access “often manifests itself in less utilization of preventive care,” Zahnd said – notably, in cancer screenings, which can leave people in farther-flung regions of the country in worse overall health when they do fall ill.
Moreover, in the past decade, as rural populations have declined, 138 hospitals in those same areas of the country have closed; between 2005 and 2016, 300 others merged or were acquired outright. Zahnd points to a December 2019 study from Health Affairs showing that those mergers have frequently resulted in “a significant reduction in on-site diagnostic imaging technologies,” among other services, including obstetrics, primary care and outpatient nonemergency visits.
“Health care systems, particularly those in rural areas, have to consider the financial balance of maintaining a service line, such as radiology, to ensure the viability of their facility,” Zahnd said. “This may be particularly true in states that have not expanded Medicaid. Hospitals in these areas provide more uncompensated care, which makes these hospitals more vulnerable to closure or mergers and acquisitions, which has a domino effect on service lines.”
Lisa Davis, director and outreach associate professor of health policy and administration at the Pennsylvania Office of Rural Health in University Park, Pennsylvania, said that delivering high-quality health care in community health systems “so that they can keep these services and keep those patients in their communities” has been an ongoing challenge for at least the past 15 years.
“We try to keep patients local because it’s important to the local economy and the local hospital,” Davis said. “Once that care starts to be provided at a tertiary care facility, there’s a greater likelihood that patients will go to those providers for all types of services than using their local facility.”
As local health care delivery systems are among the top three employers in every county in America, weakening them produces an economic effect that Davis said, “is much more visible in rural counties.” Conversely, a strong health care delivery system makes it easier for other local employers to recruit and retain talent “because they want to be able to show prospective workers that there is a place for people to get really good health care,” she said.
“It’s also a great way to be able to attract providers,” Davis said. “If you are coming to a vibrant health care delivery system, even if it is a small community, that is a way to really see an impact of what you’re doing.”
But for decades, rural hospitals have been challenged in general to recruit physicians, who are necessary not only for their skills, but also for the clinical oversight they provide to support staff, like radiology technicians, as well as specialists and sub-specialists who can perform complicated procedures from image-guided surgeries to oncological treatment planning.
“If you look at the quality indicators across all of the range of services, rural hospitals tend to do quite well on many of the traditional types of services,” Davis said. “Their outcomes are not as good or nonexistent for specialized care because they don’t provide those types of services. Workforce is an intractable issue, and it always has been.”
Dr. Mina Makary, an interventional radiologist at the Ohio State University Wexner Medical Center in Columbus, Ohio, concurred that the challenges rural hospitals face nowadays less commonly revolve around access to imaging technology as compared to shortfalls in staffing.
This trend was identified as late as October 2015, when a study in the journal Radiology illustrated that just 8.1 percent of all practicing radiologists in the United States work in a rural setting. In four low-population states (Alaska, Montana and the Dakotas) no radiologist was reported to be practicing in any rural setting, and in three others (Nevada, Wyoming and Idaho) two or fewer radiologists were working in a rural setting. According to physician staffing service Locum Tenens, radiology programs are only growing at 2 percent annually, with 30 percent of new radiologists pursuing sub-specialties that are less likely to be located in rural environments. Radiology also has a high mobility rate, as indicated in a November 2020 report from the Journal of the American College of Radiology, which showed that more than 40 percent of all radiologists in the country have changed practices at least once within the four-year period sampled between 2014 and 2018.
All these underlying circumstances were exacerbated by the COVID-19 pandemic, during which federal reimbursement policies helped accelerate adoption of teleradiology services that somewhat addressed this shortfall in rural environments. However, the months-long shutdown in non-essential imaging services that accompanied the teleradiology expansion also created a backlog of diagnostic exams that even nighthawking can’t resolve on its own.
Furthermore, the impact of the multi-sector Great Resignation – another key hallmark of the pandemic – on medical imaging has yet to be fully calculated; at least initially, the U.S. Bureau of Labor Statistics has shown that nearly 20 percent of health care workers have left their jobs in the past two years. Even if the bulk of these displacements are not to be found among medical imaging professionals, let alone those in the rural setting, it’s another potential shortfall to address in making sure that patients in these locations have access to high-quality health care services.
“Between all these factors good and not as good, it’s stressing our system,” Makary said. “Telework in general, inflation, real estate costs – the resources of the trained radiologist may not be able to catch up with that extra demand. All these things have accelerated because of COVID, and it’s a huge thing. It might affect how we think about health care policy nationally, but the specific trends, the intended or unintended outcomes on health care overall, remain to be seen.
“We don’t want to get into a situation where these health care disparities get aggravated any more than they need to,” he said. “There’s a moral standard to strive to achieve. Somebody in a community hospital deserves a high quality of care like anybody else.”
Makary remains bullish on the prospects of teleradiology as a solution to the regional disparities in availability of diagnostic imaging professionals, especially in the context of a group practice setting. Despite the observation that affiliations and mergers can have the unintended effect of reducing local access to imaging services, partnerships among regional health centers, community hospitals and the like can make it easy to get patients to the services they need.
“A lot of private-practice physicians are affected by the economics of managed care – smaller margins, reimbursement cuts, limited resources to achieve highest level of care,” Makary said. “How do we bridge it? Local centers of excellence, transport, a team managing that patient.”
“Cleveland Clinic might be headquartered in Cleveland, but it also maintains smaller centers throughout the state,” he said. “There’s University of Pittsburgh Medical Center (UPMC) in Pittsburgh, but they also have a presence in smaller towns, like Altoona, Pennsylvania. Those help bridge that gap; and even if a rural center is not ready, it’s easier to transport a patient within the same system.”
Makary described these agreements as among the most significant byproducts of the persistent, industry-wide consolidation of health care institutions that’s been ongoing for the better part of two decades. He also believes that after the extensive mergers, acquisitions and partner agreements have reached a theoretical limit in densely populated urban environments, competition for community and rural hospitals in more remote settings may be “the last frontier.”
“We can use these relationships to benefit our communities and provide services in rural areas,” Makary said. “It’s the same thing with private-practice groups that go out there: when you partner with a bigger player, you get help with practice-building, resources, partnerships, and being able to ultimately be able to provide those services to regions that are underserved.”
Another persistent health equity issue in rural settings involves addressing the shortfall in access to screening services for certain types of diseases, like breast and lung cancers, outcomes for which improve dramatically with early detection.
Jamie Studts, Ph.D., is a behavioral scientist who co-leads the cancer prevention and control program at the University of Colorado Cancer Center. He’s also the scientific director of the behavioral oncology program at the University of Colorado School of Medicine, where he teaches. In Studts’ experience, “the disproportionate burden of people who are eligible for lung cancer screening are rural-residing individuals, and we are at a very low level of public awareness about lung cancer screening.”
“We need regional to local access to lung cancer screening where they do suffer the disproportionate burden, or else we will never leverage lung cancer screening to its potential,” he said.
To date, many of the solutions that have been engineered to overcome this screening deficit have been technological in origin. Demonstration projects have funded the retrofitting of vehicles with breast and lung imaging equipment; they’re then driven into rural communities themselves, effectively bringing the technology into the areas where it’s needed. Studts argues, however, that the same funds that paid for those imaging devices could deliver greater results if they were used instead to build high-quality cancer screening programs in community hospitals.
“A mobile, low-dose CT can only be in one place at a time, and maybe you get hundreds of scans done a year, at best,” he said. “Leverage the brick-and-mortar facilities we have at hospitals and train a navigator; those tools are under-utilized. There’s skill involved, but it’s within the wheelhouse of every radiology service. It’s helping them enhance the skills they already have and building the trusted relationships with the community around this modality.”
Beyond overcoming the same personnel deficit that impedes the delivery of care throughout rural American communities, Studts argues that the institution of American health care itself must address the feelings of nihilism and fatalism that have made it easier for those at high risk for lung cancer to embrace rather than facing the practical logistical and economic difficulties of getting a screening.
“Tobacco use is a stigmatized condition,” he said. “That has caused not just a rift between the folks we’re trying to serve and these systems, but between clinicians and patients.”
“If you don’t approach tobacco use in an empathic, supportive, compassionate way, why would they trust us to offer them lung cancer screening?” Studts said. “These people have traditionally not been our favorite constituent in our health care system. They don’t have the right insurances, they don’t have the best insurances, they don’t quit smoking, and we’ve been badgering them to do that for 50 years. They want to live as long as they can without knowing that they have lung cancer and die quickly.”
The solution, he argues, is to build approaches that are created around the patients themselves.
“So many folks want to put that CT scanner at the center; even the ones that are more understanding put the navigator at the center,” Studts said. “The solution is putting the patient at the center of the process to leverage the tools of a CT scanner and the connections we built to make sure we have a workflow for how people get into our screening program, and how we get them the care afterwards.”
In constructing that kind of approach, Davis suggests that the role of the health care community navigator is a potential low-cost way to embrace locals with a knowledge of rural areas and their populations to reach people in “venues that are not health-related,” including churches, service-based organizations like Kiwanis and Rotary Clubs, and other, more informal ways of gathering.
“It is really trying to help the patient care for themselves in their totality,” she said, “and it is absolutely a distinct issue of equity. Communities that have been traditionally underfunded and under-resourced, communities that have been redlined, have had specific difficulties.”
“It takes incremental steps,” Davis said. “We can’t give up.”