Within the past few months, there have been articles in both The Washington Post and The New York Times that detail the desperate state of maternity wards in rural hospitals.
The Post notes that "financial and staffing problems are cited as the main factors affecting the availability of hospital-based [obstetric] care in rural areas," according to an October 2022 report by the U.S. Government Accountability Office. And the Times makes the case that the closing of these facilities adds to "maternity care deserts" in sparsely populated, low-income regions across America.
We believe that there are creative fixes that can help maternity units in rural hospitals to reduce their costs, offer high quality care and continue serving families in their regions. These solutions include:
1. Adjust Medicaid payments. Over the past decade, more than 130 small hospitals in rural America have closed, and over 600 additional rural hospitals — more than 30 percent of all rural hospitals in the country — are at risk of closing soon. The primary reason for this dilemma is the fees that small rural hospitals are paid by Medicaid for medical services to low-income patients are less than the cost of delivering these services. To turn this crisis around and help small rural hospitals survive, the rate of Medicaid payments that rural hospitals receive must be increased to the same level as the Medicaid payments that are made to hospitals in major metro regions.
Recalibrating the Medicaid fees that rural hospitals are paid for services provided would dramatically improve their solvency as well as their ability to deliver quality maternity care to their communities — the majority of which are living below the poverty line.
2. Base Medicaid payments on an economic diversity index. An equitable way to remedy the challenge of inequitable Medicaid reimbursement rates that rural hospitals receive would be to base them on an economic diversity index that reflects the income level of the populace: the lower the index, the greater the reimbursements that hospitals in these areas should be paid for services rendered. Payments based on an EDI figure would properly recognize the importance of rural hospitals and allow them to offer sustainable maternity care to their patients.
3. Allow advanced practice registered nurses to staff maternity wards. Most hospitals in rural markets don't have the budget to pay new physicians to practice there. The reason for this is because new physicians are saddled with tremendous medical school debt and must seek higher paying opportunities in urban and suburban regions. To get around this impediment, more states must allow the maternal units in rural hospitals to be staffed by advanced practice registered nurses.
APRNs have training and experience beyond that of registered nurses, and they're much less expensive to retain than physicians, as they aren't encumbered with the immense debt that physicians have. APRNs with backgrounds in obstetrics could handle low-risk births and an on-staff physicians could oversee cases that are more challenging.
Here in Missouri, bills in the state Senate and its House counterpart have been introduced to grant full practice authority to APRNs. If passed, maternity wards in rural hospitals would instantly benefit from the cost savings that these capable medical professionals can bring to their communities.
The movement to staff rural hospitals with Advanced Practice Registered Nurses, which is a fix that can be quickly implemented via legislative order, is growing: Utah just became the 27th state in the country to pass a law that allows APRNs to work as fully independent primary care practitioners.
4. Pursue CAH designation. Rural hospitals that are fiscally challenged should establish themselves as critical access hospitals. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities.
CAH facilities, which were created with the Balanced Budget Act of 1997 and must adhere to several operational guidelines, represent more than two-thirds of all rural hospitals and are paid higher Medicaid reimbursement rates than traditional hospitals. This recategorization would allow the CAHs' maternity units — as well as their other care areas — to ramp up their efficiency and fiscal viability.
The cure to assist struggling maternity wards and prevent "maternity care deserts" in rural locales is not impossible to achieve. It requires bold fiscal and staffing fixes at the state and federal level that will give rural communities — which are composed of all races and nationalities — continued access to birthing centers, obstetrician-gynecologists, certified nurse midwives, prenatal care and postpartum checkups. Such essential obstetric care can be available and sustainable in rural America if inventive solutions are pursued.
Dr. David Lenihan is President of Ponce Health Sciences University, a medical school with campuses in St. Louis and Ponce, Puerto Rico. Jamey Murphy is secretary of the Missouri Republican Party State Committee.