It will take creative solutions and sustained cooperation to meet the needs of our rural populations.
Between 2005 and 2023, nearly 150 rural U.S. hospitals either closed or stopped admitting patients. Of them, 81 shuttered completely. The Center for Healthcare Quality and Payment Reform has found that millions of Americans no longer have a hospital in their community, and one-third of all rural hospitals are at risk of closing because of serious financial problems they are facing.
I have seen the impact of rural hospital closures firsthand while working at academic medical centers in Iowa, Georgia and Virginia. Each state faces similar challenges in addressing rural health care. Rural populations are rapidly declining as older generations are dying, and younger people are choosing to live in more urban areas. It is increasingly difficult to attract providers to rural areas, and finding enough employees to staff a hospital has been exacerbated by a nationwide provider shortage.
Now more than ever, healthcare leaders must deeply prioritize rural healthcare sustainability — and there are key collaboration opportunities that can be explored today. Here’s what I’ve learned works.
Iowa as a case study
Iowa’s physician workforce shortage is one of the most serious in the nation, ranking 44th for number of physicians per capita. Iowa has 17% fewer physicians per capita in rural areas versus urban areas, impacting access to care and leading to reduced capabilities at rural hospitals. This is especially true for maternal health care in the state — Iowa’s shortage of OB-GYN providers is a contributing factor to the closure of 41 hospital labor and delivery departments in the state since 2000.
Though the statistics paint a bleak picture, Iowa has recently seen success in addressing these issues. Operating margins for hospitals in Iowa significantly improved from 2023 to 2024, with the number of hospitals reporting positive operating margins jumped from 30% to 58% in one year. What changed? The state began investing in the Medicaid managed care hospital directed payment program in 2023, which is providing substantial support for Iowa hospitals.
Additionally, despite facing the same challenges as other predominantly rural states, Iowa is highly ranked for its health systems based on cost, access and outcomes. This is largely thanks to the strong collaboration between rural hospitals, state government and University of Iowa Health Care — the state’s only comprehensive academic health system.
At UI Health Care, it is our mission to be a trusted health care partner for the entire state, providing resources to improve the health care of all Iowans, even if they never enter our doors. Here are just a few ways we are collaborating with others to develop innovative solutions for addressing rural health care’s most pressing problems:
- Workforce and training support programs: These programs take many forms, but one example is our UI Carver College of Medicine Rural Iowa Scholars Program (CRISP), a medical school rural track for students pursuing careers in primary care or other eligible specialties. Students are paired with mentors, engage in special programming and receive tuition repayment if they return to practice in Iowa. By collaborating with physicians who understand the unique challenges of rural practice, CRISP designs its program to equip participants with the comprehensive experience and knowledge needed to thrive in rural medicine.
While programs like CRISP are a helpful starting point, increasing the number of physicians who practice in Iowa requires both public and private investment. Thankfully, Iowa Gov. Kim Reynolds recently signed into law a legislative proposal to increase physician training options and rural healthcare accessibility. The law directs the Iowa Department of Health and Human Services to secure $150 million in federal funding to create 115 new residency slots at Iowa teaching hospitals.
- Community training and outreach: Our teams at UI Health Care regularly organize community training and outreach opportunities at rural locations. For example, the Iowa Perinatal Quality Care Collaborative is an initiative between Iowa HHS and UI Health Care to support quality improvement and safety training for Iowa’s hospitals. As part of the program, simulation-based educational training is offered to all birthing hospitals in Iowa, including their ER teams. Rural maternity units are often low-volume and inherently may see obstetrical emergencies less frequently. In many facilities, the patients present through the ER — rather than directly to the labor unit — so it is important for the ER team to be prepared to recognize evolving emergencies.
- Epic® Community Connect®: With this program, UI Health Care is providing smaller healthcare organizations with access to the Epic® HER system, gaining the benefits of using Epic® without incurring the cost and resource burden of a full-scale implementation of their own. An added benefit is streamlined communication when a patient transfer does need to happen, providing seamless continuity of care. Our partner hospitals are overwhelmingly positive about the benefits, and we are continuing to expand the program to more facilities over time.
- Roundtable discussions with critical access hospitals: We regularly bring together leaders of critical access hospitals from across the state to share best practices and discuss innovative solutions for improving health care in our rural communities. UI Health Care acts as the facilitator with the main goal of listening and learning from our rural partners. Together, we have developed solutions to streamline access to specialists, share patient medical records and leverage IT infrastructure to connect rural and urban clinicians.
These are just a few ways UI Health Care is collaborating with others to address rural care gaps in our state, but the problems facing rural health care are bigger than any of us can tackle alone. It requires collaboration and partnerships with other health systems, along with state and federal support.
As healthcare leaders, we know we can’t keep delivering care the same way we always have. By working together through connected networks, we can more effectively develop and implement innovative solutions that benefit the entire health system and patients.
Bradley Haws is CEO of clinical enterprise, UI Health Care, the state’s only comprehensive academic medical system, based in Iowa City. As CEO of the clinical enterprise, he oversees the operational, strategic and financial performance of Iowa’s only tertiary and quaternary medical center.
