How Missouri is reimagining rural healthcare: 5 questions with Missouri Hospital Association President Herb Kuhn

Rural healthcare, in many ways, is in crisis. Many rural areas have a critically low supply of providers, particularly in specialties like psychiatry and obstetrics and gynecology. Rural hospitals face low patient volumes, treat an older patient population and have a payer mix that tips more heavily toward Medicare and Medicaid. These financial challenges have led many facilities to close their doors. 

While these issues loom large, the story of rural healthcare is more nuanced than a closure count, according to Missouri Hospital Association President and CEO Herb Kuhn. 

"Let me tell you, when you close one of these hospitals in a rural community, it really brings out a lot of grief and loss," Mr. Kuhn said. "Those five stages of grief — where there's denial, anger, bargaining, depression and then acceptance — you see all those things on full display when you close a rural hospital. It is remarkable. I don't think people fully understand and grasp how important they are in these communities."

Missouri has seen six hospitals shutter since 2014, according to data from the University of North Carolina's Cecil G. Sheps Center for Health Services Research, which has tracked hospital closures from 2005 to today.

Research has shown that Medicaid expansion would help buoy rural hospitals. Missouri is one of 14 states that has yet to expand Medicaid, and its rural hospitals stand to significantly benefit. It is also one of four non-expansion states with the biggest disparity in insurance coverage between metro areas and rural areas and small towns, according to Georgetown University's Health Policy Institute. If the state expanded Medicaid, 219,000 Missourians would gain health insurance coverage, reducing the population of uninsured nonelderly adults by 47 percent, according to the Kaiser Family Foundation. Mr. Kuhn and the MHA are actively advocating to expand this coverage. The MHA is part of a coalition of healthcare stakeholders, called Healthcare for Missouri, that launched a campaign Sept. 4 to get Medicaid expansion on the ballot in 2020.

But changing rural healthcare for the better will require more than Medicaid expansion, Mr. Kuhn told Becker's in an interview. The solution for rural healthcare will need to be just as nuanced as the problem. Becker's checked in with Mr. Kuhn to hear about Reimagine Rural Health, an MHA initiative launched in January to promote rural healthcare investment. Here Mr. Kuhn discusses how the initiative has changed rural health advocacy in Missouri and what he sees as the key elements to strengthening rural healthcare.

Editor's note: Responses have been edited lightly for length and clarity.

Question: MHA launched the Reimagine Rural Health initiative in January. What is the primary goal of that initiative?

Herb Kuhn: We wanted to focus messages about rural health for a number of different audiences, instead of doing a bunch of one-off initiatives. We, like other states, have seen a number of hospitals declare bankruptcy. In the last five years, six rural hospitals in the state of Missouri have closed. We needed to have a conversation about that with a number of stakeholders across the state. We needed a platform to help us advance policy options and tell the story — highlight the good things going on in rural healthcare and the challenges.

The second thing that helped us launch the initiative was our new governor [Mike Parson] held a rural healthcare summit last December. We thought, there's no better time for this. Part of it was designed to support his effort.

Q: What kinds of stakeholders are you working with? 

HK: One would be the Missouri Farm Bureau. We've been involved with them for years on a variety of different issues, but this gave us a new way to communicate with them and their members. Two really interesting outcomes came from that. One [outcome] was we had a really good opportunity to present to their policy committee this year, and they have continued to expand their platform of rural healthcare issues. The other thing we were able to do with them was on National Agriculture Day. The president of the Farm Bureau gave us a video to push out on the Reimagine platform that talked about the importance of rural healthcare, what the Farm Bureau can do to support that, and the intersection of agriculture and healthcare in rural communities across the state.Through their network, we were invited to submit an op-ed, which we then produced and sent across the state with them. It's been really interesting sharing policy ideas and advocacy messages. 

Beyond them, we've had chances to have further interaction with the Rural Electric Cooperative; the Farm Credit Association; with a lot of the education community, particularly in rural areas as we talk about workforce shortages; chambers of commerce, both urban and rural, but predominantly rural; and finally with the Cooperative Extension Services.

Q: What progress have you made so far with the initiative?

HK: This has created an opportunity to tell the story of what's going on in rural healthcare and in rural communities across the state of Missouri. Down in the southeast part of the state, a rural hospital closed. We looked at the care that hospital provided to the people in approximately nine different zip codes and compared it to how far those people now have to travel for the same inpatient and outpatient services. For the size of the population and the services they used, those people are now going to be traveling over 1 million miles a year to get that same level of service at another hospital. That's basically 42 times the circumference of the Earth. We took pictures of the Earth with a ring around it and the mileage and put it out in the community. It just visually tells a story differently than we have in the past, so we think that's a big accomplishment.

This has also been a chance to educate the community on not only the legislative and regulatory issues, but also to let them know not one solution will fix the problem. If it was that simple, people would've fixed rural healthcare long ago. There's a multitude of legislative and regulatory issues that need to be addressed, and what we've let people know is it's not a one-year initiative.

Q: Missouri is not alone in the challenge of sustaining rural health services. In addition to Medicaid expansion, what do you think states need to do to preserve healthcare for rural communities?

HK: Medicaid expansion is a key one, but I think there are some other investments states can look at. First is workforce. What we need to do in rural areas is invest in career paths. Tomorrow's nurse might be a lab tech in the hospital today. The fact that we think we're going to get someone and transplant them to a rural area is a bit naïve. We really need to think about how we take people that are currently in the healthcare system and help them lift their game through education. The other thing we need to do for the workforce is "grow-your-own" initiatives. We can reach into grade schools, junior high and high schools and help mentor young men and women to show them there is a wonderful opportunity for a career in healthcare. The likelihood they will come back to their home community is far greater.

Another thing states can do is look to CMS for waivers and opportunities for new payment models. Within rural healthcare, one of the biggest challenges is they are low-volume providers. That means there really needs to be a different set of rules and engagement for them. Rural areas also have a much higher payer mix of Medicare and Medicaid patients, and less commercial. Those programs really need to step up to the plate.

The third thing states can really look at is strengthening behavioral health. It's a problem everywhere, but in rural areas we have massive behavioral health deserts. What you find in many rural hospitals, seeing people boarded in emergency departments — they just shouldn't be there, and we can do differently.

And then finally, we need to continue to look at how to best use technology to support rural areas. Telehealth is great, but we know many rural areas don't have the broadband systems to really support it. If you think about the partners I talked about earlier, whether it's the Rural Electric Cooperative or Farm Bureau, they are behind the whole notion of broadband. Broadband can help so many different aspects of life in rural communities. Then taking it to the next stage, what states need to look at more aggressively are these multistate licensure compacts to permit clinicians to practice across state lines.  

Q: What's something commonly misunderstood about rural healthcare at the national level?

HK: I don't think a lot of people realize how truly innovative rural healthcare can be. You can get great quality of care. With the aging baby boomers and the "silver tsunami" that's upon us, we have a higher proportion of elderly in rural communities, and you see wonderful memory care programs, programs to make sure the elderly are not isolated in their communities. You know, it goes on and on in terms of the innovation that's out there.

Rural healthcare suffers from a lot of stereotypes and stigma, and I think that needs to be blown away. 


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