Rural hospital CEOs are hitting a breaking point. Inpatient volumes are shrinking, workforce costs are climbing, and the fee-for-service model that once anchored community hospitals offers diminishing returns.
But rather than waiting for the margin pressure to resolve itself, a growing number of rural CEOs are reconfiguring how their organizations generate and capture revenue, building models that look less like traditional hospitals and more like integrated health platforms serving entire regions.
Becker’s asked rural hospital leaders to describe the revenue streams and care delivery shifts they believe will define viability by 2030. Their answers reveal a sector in active transformation.
One of the common themes executives mentioned was the direct-to-employer model, which represents a genuine inflection point. Wyatt Brieser, CEO of Hammond-Henry Hospital in Geneseo, Ill., said it was the best model positioned to simultaneously stabilize revenue and shift care toward prevention.
“Employer-contracted care models will continue to gain traction as both employers and health systems look for ways around rising premiums, administrative friction and misaligned incentives,” Mr. Brieser said. “Direct partnerships can create shared accountability for cost, access and outcomes while establishing more sustainable revenue frameworks for hospitals and businesses alike.”
The opportunity runs deeper than contracting mechanics. Direct-to-employer arrangements could become the on-ramp to a more prevention-oriented system, something the industry has long promised but rarely delivered.
“If the system can find a way to capitalize off of keeping people healthy, we could finally realize a real paradigm shift in health trends in America,” he said.
Rick E. Smith, CEO of Troy Regional Medical Center in Alabama, is already operationalizing this logic. Troy Regional is “partnering with some of the community industries to provide on-site occupational medicine services, so their employees never leave the business site,” Mr. Smith said.
For many, the near-term revenue opportunity lies in identifying the services that competitors aren’t offering and building expertise around them. Troy Regional has added geriatric psych and medication addiction programs to fill gaps in the community. Mr. Smith is focused on thinking differently as inpatient volumes decline to provide outpatient services such as same-day surgery, imaging and infusion centers.
“In rural facilities, we can’t always hire the specialists that we need so we look to telehealth services to assist,” he said. “We are currently evaluating tele-nephrology so we can potentially avoid the 100-plus transfers per year we currently experience. We also recognize that primary care is the foundation of everything we do in the rural community setting. By expanding the footprint of our primary care clinics to surrounding communities, we are keeping healthcare close to home.”
The same logic applies to swing bed programs, behavioral health expansion, and chronic disease management, services flagged by multiple leaders as both clinically essential and financially underutilized in rural markets. Victoria Hanson, PhD, regional president and CEO of Avera Sacred Heart in Yankton, S.D., sees scalable behavioral health and advanced pharmacy and infusion programs as core components of future planning for rural healthcare.
“The next generation of rural CEOs will lead regional health enterprises built around predictable population-based revenue, digitally enabled care, scalable behavioral health, advanced pharmacy and infusion programs, mobile and EMS-based care, and monetized non-clinical assets,” Ms. Hanson said. “In the coming decade, sustainability will not be driven by where care is delivered, but by who owns the revenue model behind it — those who keep care increasingly virtual, distributed, and community-based while maintaining margin discipline across the enterprise will define the future of rural healthcare.”
The $50 billion Rural Healthcare Transformation Program will kickstart additional services and revenue streams at many hospitals across the U.S. The federal government allocated the funds to states for disbursement over multiple years, and rural healthcare executives are vying for their portions, which aren’t guaranteed. Several leaders made clear that grant dollars and supplemental funding must be treated as catalysts, not operating revenue.
Michael Hassell, CEO of Melissa Memorial Hospital in Holyoke, Colo., sees transformation program dollars — including those flowing through Colorado Medicaid’s Rural Healthcare Transformation Program — as the seed capital for structural change.
“The future of critical access hospitals will be defined less by volume and more by how effectively we convert transformation funding into durable, recurring revenue,” Mr. Hassell said. “Rural Healthcare Transformation Program dollars flowing through Colorado Medicaid are catalytic — but they reward measurable outcomes, partnerships, and infrastructure, not traditional encounters. By 2030, sustainability will hinge on building and participating in regional, distributed networks that monetize access, care coordination and downstream services across multi-county footprints.”
Partnerships will become invaluable to the future of rural healthcare facilities. Many hospitals will see growth coming from rural-relevant services like behavioral health, swing bed utilization and chronic disease management as ongoing care models instead of episodic care delivery.
“The hospitals that endure will look less like standalone facilities and more like integrated rural health platforms — designed to coordinate care, extend reach, and sustain access in the communities that depend on us,” said Mr. Hassell.
Kurt Barwis, president and CEO of Bristol Health in Orem, Utah, sees another change brewing that could influence the current healthcare revenue model.
“Price transparency for at least high volume services will be more ‘consumer usable’ while a combination of IA/affordability drives consumers to actually use the information to make decisions,” Mr. Barwis said. “While I’m not sure this supports a shift from fee for service to value-based care in a big way, at least a greater share of purchase decisions will be based on affordability. Patient convenience, provider shortage and the need for flexible work schedules versus in office costs will surely drive telehealth / virtual care.”
Mr. Barwis also sees targeted genetic and genome testing becoming more prevalent than traditional diagnostics. He anticipates cancer recurrence blood tests for solid tumor cancers will replace the annual surveillance PET scans, in addition to other disruptions.
The proliferation of wellness and preventative services could also be a boon for rural healthcare.
“I believe that larger investment into wellness will help define survival,” said Marc Augsburger, BSN, president and CEO of Edgerton (Wis.) Hospital and Health Services. “This revenue stream is largely based upon cash purchase and you get paid nearly 100% of reasonable charges for the services. The practice of marrying traditional western medicine and eastern medicine can go a long way to keeping people healthier for longer periods of time.”
The shape of a sustainable rural hospital in 2030 remains contested. But the leaders closest to the problem share a conviction: it will not look like the hospitals of the past decade.
“Eastern medicine also has a way of being less stressful and more relaxing, which tends to lengthen one’s life,” said Mr. Augsburger. “These types of wellness care are often ongoing, creating a regular stream of income.”
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