Rural America emerges into recovery Ill prepared for COVID-19's spread

While major cities remain the epicenter of the coronavirus pandemic in our country, COVID-19 cases are surging in rural states like Nebraska. Hall County, where 31 patients have died from coronavirus complications, now ranks in the nation’s top 100 counties for COVID-19 mortality.

Less than 50 miles down Interstate 80, Jillian and Brady Fickenscher treat outpatients, deliver babies and work in the emergency room at York General. While the small rural hospital has fewer COVID-19 patients, it has stepped up telehealth to supplement a limited workforce and stretched its face mask supply by treating them with ultraviolet light. The husband and wife couple wonder what impact COVID-19 spread would have on their ER and their practice.

By mid-April, about one-third of rural counties have reported at least one COVID-19 case. Rural cases tend to emerge later but can have a higher impact. In the two week period ending April 27, the Kaiser Family Foundation estimated that rural counties saw a 169% increase in COVID-related deaths, compared to 113 percent in urban counties.

Rural hospital and community preparedness requires rapid attention from policymakers, community organizations, and local and state governments. Among counties with at least 25% of residents who are 65 or older, 83% are rural. Their medical centers struggle with finances and capacity. Most are safety-net hospitals, obligated to serve uninsured patients and saddled with high uncompensated care costs in Medicaid non-expansion states. About half of rural hospitals had a negative operating margin in 2019. More than 400 rural hospitals are considered vulnerable to closure based on their financial health.

With a surge of COVID-19 patients, rural hospitals are more likely to run out of resources and become more financially vulnerable. To limit the spread of COVID-19 and conserve resources, all elective surgeries and non-essential surgeries have been canceled. Rural hospitals rely heavily on elective procedures, which may be up to half their cash flow.

Although the CARES Act has $100 billion in stimulus allocated for health care, large urban hospital systems may receive the majority of the funds, as they are treating the majority of the COVID-19 patients so far. Some executives believe rural hospitals may be left out. The legislation allows hospitals to bill Medicare for three months of “accelerated payments” (six months for critical access hospitals) based on reimbursements from the previous year. As these are loans that hospitals need to pay back, many rural hospitals are skeptical of using it.

Medical supplies and human resources also may fall short of the challenge. States and cities are engaged in bidding wars for medical supplies, including ventilators, masks, and other personal protective equipment. Most rural hospitals, working on tight budgets, will likely run short of such supplies. Rural hospitals also have weak supply chain networks or connections. The U.S. Food and Drug Administration (FDA) recently issued an Emergency Use Authorization (EUA) to help increase the availability of ventilators and respirators. States should give rural hospitals special consideration in allocating equipment and resources.

Maintaining an adequate workforce in rural hospitals has been a persistent challenge. Many rural communities struggle to recruit and retain healthcare providers. Some rural hospitals only have one respiratory therapist. Doctor shortages overburden the existing workforce, eventually leading to physician burnout, which becomes even more prevalent during a pandemic.

In the long run, rural healthcare system needs a significant overhaul. But right now, to address the pandemic, rural health systems may need to reassign staff members to different roles based on evolving medical needs. Traveling doctors and nurses can alleviate the shortage temporarily. Rural hospitals also can develop a plan for staffing support and exchange with other community hospitals in the area.

The stimulus package also expanded the reimbursement for telemedicine services that rural hospitals can leverage to manage outpatient and follow up care. Telehealth services through nearby larger hospitals could help rural hospitals with low staffing for specialized skills like managing ventilators. But patients without high-speed internet connections will still come to hospitals for their care.

The coronavirus presents a significant challenge in rural areas across the U.S. With luck, lower population densities, and a more home-based lifestyle should generally help tamp down the spread of the virus. On the other hand, rural health care systems are smaller and more isolated. Rural populations also tend to be poorer and more prone to some underlying conditions that make COVID-19 more lethal. Bottom line, we need to help these communities face their unique challenges and move through their case peaks successfully.

Jay Bhatt D.O. is an internal medicine practitioner in Chicago. Soumitra S. Bhuyan, PhD, MPH, is an assistant professor of health administration at Rutgers University. Aakanksha Deoli, BDS, is a Master of Health Administration student at Rutgers.

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