Shaky Prognosis

Featured in the November issue of our magazine.

By Candace Krebs

Rural hospitals and clinics struggle to provide care to a generally older and poorer population where a lack of practitioners is a growing concern.

Randall Dauby is chief executive officer of a community hospital
in Pinckneyville, Ill., population 5,000, built three years ago
with a USDA Rural Development loan. The on-site emergency
room and adjacent health clinic have two telehealth computers
with high definition TV screens, which allow specialists, such as
dermatologists, to diagnose and treat conditions through video
conferencing.

Pinckneyville is considered a “Critical Access Hospital” (CAH), a
designation that reduces financial vulnerability of rural hospitals
and improves access to healthcare by keeping essential services in
rural communities.

The set-up sounds nearly ideal. But Dauby, who was named Rural
Health Administrator of the Year this past summer by the Illinois
Rural Health Association (IRHA), can also point to all the ways the
state’s rural healthcare system is ailing.

According to a recent report by the Illinois Health and
Hospital Association, nearly half of the state’s small, rural
hospitals operate on slim to negative profit margins.
Compared to urban settings, rural populations are
older, poorer, more often uninsured and more dependent on Medicare or Medicaid.

Lack of rural practitioners is a glaring problem. Dauby has spent
the past two years trying to recruit a family physician, with no luck.
Working at a rural hospital usually requires doing rotations and being
on call, which isn’t popular with applicants. Attracting specialists,
such as psychiatrists or obstetricians, is even more difficult.

The Association of American Medical Colleges predicts the
shortage of physicians will reach 120,000 by 2030. In Illinois
specifically, 25 percent of the state’s population reside in rural
areas, but only 10 percent of physicians practice there, which means
roughly three-quarters of the state’s rural counties are primary
care deficient. The Illinois Health and Hospital Association finds
rural areas have 45.5 primary care physicians for every 100,000
residents, compared to the statewide average of 80.7.

The area of care that causes Dauby the biggest headache, however,
is mental, behavioral and psychiatric health. While such patients
account for only 15 to 20 percent of emergency room traffic, they
often create logjams due to insufficient treatment options.
“We had a patient the other day who waited six hours for a
therapist to show up,” he says. “Tele-psych is something that is
needed in every community, because there’s just not enough
availability of those services, and that’s as big, or bigger, than the
opioid crisis.”

That perspective comes as no surprise to Kim Saunders,
executive director of the Center for Rural Health at Southern
Illinois University Carbondale.

“Every small community hospital has to do a community needs
assessment every three years, and in Illinois I can’t imagine mental
health not being one of the top five priorities for most of them,
right up there with diabetes,” she says.

In rural areas, there are 1.6 psychiatrists for every 100,000
people, according to the Illinois Health and Hospital Association.
The statewide average is 10.5. In almost every case, earlier intervention leads to better
outcomes. Saunders says the state is starting to make progress on
better integration of mental and physical health.
Margaret Vaughn, executive director of the Illinois Rural Health
Association, agrees a shortage in any one area of care often has a
cascading effect. Sixty-six Illinois counties are “dental shortage”
areas, for example, and many dentists won’t take Medicare
patients.

“Some of our rural counties have just one ambulance, and they
might not have a single dentist. So, let’s say someone has a toothache
that becomes so severe they end up calling the ambulance,” she
explains. “That means the county’s only ambulance is tied up,
and in the meantime, what if there’s an accident or someone has a
heart attack? In a lot of rural areas, it might take 30 minutes just
for the ambulance to get to the patient.”

Lack of transportation worries Dauby, too. As patients age, they
have a harder time driving to see specialists in distant cities.
“People in nursing homes or assisted living facilities can typically
get transportation to our local hospital but not all the way to the
urban areas where the specialized care is. Ambulance transport is just not very ideal for that. A lot of these are volunteer services, and it’s already a challenge for them to keep going,” he says.
Telemedicine looks like the obvious remedy for solving many
of these challenges. Doug Wilson, the state’s USDA Rural
Development director, says the most popular way for rural
hospitals and clinics to use the agency’s facility assistance program
is by expanding telehealth capabilities.

“We really are seeing more consultation between small and large
hospitals, and telemedicine is how they connect,” he explains.
“It can even involve online diagnostics that give live reviews of a
patient’s condition in real time. If they are in an ambulance, for
example, specialists can monitor what’s going on, and advise the
paramedics so they can go straight to where they need to go.”
But telemedicine relies on broadband service, which can be a
barrier in remote areas.

Wilson, who lives on a fourth-generation grain farm seven miles
from town, says while most communities have baseline services,
they aren’t always adequate for commercial use. “On my farm in
southwest Livingston County, on a good day we get five megabytes
download speed whereas in larger communities it may be 100
megs, so there’s quite a chasm between the two,” he says.
It’s not a situation unique to rural Illinois. Nationwide an
estimated 39 percent of the population lives in areas where
broadband is substandard, he says, though federal agencies are
working to address the discrepancy.

Shaky Prognosis



Broadband capabilities aren’t the biggest problem holding back
adoption of telemedicine at Dauby’s hospital, however. “The federal reimbursement rate right now is so miniscule that I can’t afford to offer those services,” Dauby says. “Everybody is
pushing the idea, but the payments are not matching what the IT
infrastructure has the ability to do.” That’s a sore spot with the rural health association, which is
pushing government payers and private insurance companies
to treat remotely accessed services as equivalent to in-person
care. Outpatient services, which are becoming increasingly
common in rural areas, also get reimbursed at lower rates than
inpatient treatment.

Without advances in telemedicine, Dauby worries it will be
impossible to keep pace with regulations. “Many of the new laws
are good, but being able to comply is burdensome for a small
hospital,” he says. “For example, Illinois passed a law requiring
hospitals to have a trained sexual assault nurse examiner on
staff. Our hospital may have only one or two cases a year, which
is a good thing, but it’s impossible for any nurse to maintain
certification. The law requires several hours of actual experience
to satisfy the mandate.”

Instead, Dauby is being forced to look at contracting expensive
outside services — if he can find them.

Shaky Prognosis