Rural healthcare is at a breaking point | Dartmouth Health CEO Joanne Conroy

Joanne Conroy, president and CEO of Dartmouth Health

American healthcare was in crisis before the pandemic. However, based on what we are now seeing, especially in rural hospitals and health systems, the worst may be yet to come.

Our rural hospitals and healthcare systems continue to lose money. Many think the pandemic is over – that we are out of the woods and can get back to normal. Current data shows that new cases, hospitalizations and deaths from COVID continue to decline, but are still a threat. An early flu season and high rates of respiratory syncytial virus (RSV) infection among our children late last year added strain on healthcare.

In addition to the increased demand caused by this “tripledemic,” we have ongoing workforce challenges, inflation, and supply chain issues that may cause even more economic stress than the first three years of the pandemic …. and the challenge is even more significant for rural facilities.

Last fall, a report from the American Hospital Association showed that 136 rural hospitals closed from 2010 to 2021 – 19 in 2020 alone. The Texas Hospital Association has warned that 1 in 10 hospitals in that state is at risk of closure, with nearly half of that state’s hospitals projecting negative operating margins.

Much of the discussion about the healthcare workforce has focused on the shortage of nurses and doctors, as the “Great Resignation” continues to impact hospitals and clinics.

Healthcare systems are also deeply impacted by the downstream impacts of similar staffing crises at skilled nursing facilities, rehabilitation centers and other facilities, beds dedicated to caring for patients after a stay at a hospital where they received care for a severe illness or injury. Hospitals rely on these post-acute care facilities for safe patient discharges when they no longer need hospital-level care. And here in New Hampshire, 30% of the state’s limited number of post-acute care beds are closed because of staffing.

At my hospital alone, we average 350-400 denials of requests for critical transfers each month. We are fully staffing every bed we have, but on average we have 75 patients ready to be discharged but with no post-acute care setting that will accept them. This situation is far worse in rural areas, where the workforce shortages are greater and the options are fewer compared to urban centers.

So much for being out of the woods.

All hospitals, but especially those in rural communities like mine, have been developing innovative solutions to address these critical needs.

In 2014 – years before “SARS-CoV-2” was known to most of us – Dartmouth Health created a Workforce Readiness Institute to help fill our needs for allied health positions like pharmacy technicians, surgical techs, medical assistants and phlebotomists. We have strengthened our relationship with the nursing program at New Hampshire-based Colby Sawyer College, making significant investments and widening our pipeline for new nurses.

And last month we introduced our Center for Advancing Rural Health Equity, partnering with communities and community organizations to address social determinants of health, giving our communities – mainly rural – a stronger foundation of well-being to better navigate this and future public health crises.

However, much more needs to be done to strengthen our healthcare infrastructure. You all experience the symptoms of a system under stress when you can’t find a primary care provider, you have to wait more than 8 hours to get prescriptions filled, you stay in the emergency room for hours for a bed to become available in the hospital or you have to delay getting necessary surgery because of operating room closures.

When our communities experience natural disasters, we lament the shortcomings of our infrastructure, propose ways to make it more durable and resilient, and then, ultimately, do little or nothing. However, this storm-battering healthcare is different: We simply do not have the luxury of crossing our fingers and hoping for the best next time. Our inactivity has real-time implications for patients who are your parents, children, and neighbors.

These unprecedented times also present an opportunity to reimagine the training models for physicians and other healthcare professionals. We still train our physicians as we did 100 years ago, and modernizing our approaches could help us train providers faster and more efficiently.

In its final days, the 117th Congress passed legislation that extends, among other things, programs and financial support that will benefit hospitals and service providers in rural areas, as well as telehealth benefits for Medicare beneficiaries first expanded during COVID that proved so valuable to patients and providers everywhere. These are steps – although small ones – in the right direction.

The American Hospital Association continues to advocate for solutions including lifting the cap on Medicare-funded physician residencies, boosting support for nursing schools and faculty, providing scholarships and loan forgiveness, and expediting visas for all highly trained foreign healthcare workers. These are important initiatives, and help from measures like these cannot get here soon enough.

The pandemic, and the issues it created and magnified, are not in our rear-view mirror. They are still right on top of us, and we need solutions to keep our rural healthcare systems solvent and working.

We – and our patients – cannot wait.

Joanne M. Conroy, MD, is chair-elect of the American Hospital Association’s Board of Trustees, and CEO & President of Dartmouth Health, based in Lebanon, New Hampshire.