A view from the trenches
Rural hospitals are facing some tough times nationally and West Tennessee facilities are not immune to the trend. Many facilities are struggling amid a confluence of factors ranging from reimbursement challenges, to the cost of technology, to recruiting physicians. Several hospitals have closed or drastically reduced services leaving pockets of the population with a lack of emergency care or a hospital within a reasonable distance. In addition to the care these facilities provide, they also play an important role in the community since many are often among the largest employers in their area. According to the Tennessee Hospital Association, rural hospitals account for $994.7 million in economic impact and provide 15,654 jobs.
Many residents in West Tennessee rely on rural healthcare and its plight needs addressing. While legislators have varying opinions on reforming the healthcare system in general, visiting those on the frontline of the issues provides greater insight on the plight or promise rural healthcare holds for the future.
On those issues, West Tennessee Healthcare's CEO, James Ross, finds they are basically the same as those facing all hospitals, they just impact rural facilities more. "Being able to recruit and retain quality physicians, who want to practice medicine under the current fluctuations in reimbursement. Physicians have to understand the growing complexities of healthcare under the funding methodologies that office practices and hospitals are moving to, such as volume-based to value-based payments and care delivery models. Whether it is the ACA, CPC+, MACRA, or Chronic Care Management and/or Patient Centered Medical Homes, the landscape is changing and doing so with such variance that it is difficult to navigate when you are striving for best practices and consistency in provision to quality care," he said. "This has many physicians finding being a part of a health system more appealing because they find they have a larger voice in the leadership, direction, and control."
Serving as the Chief Financial Officer for Henry County Medical Center, one of the most successful standalone rural facilities in West Tennessee, Lisa Casteel is fully aware of what rural hospitals face as she changes job title to CEO. "There are several issues. An explosion has occurred with who provides healthcare and where. The growth in technology and treatments in healthcare; the growth of consumerism in healthcare and the various facets of payment in healthcare," she said. "These fundamental plans in healthcare steer our strategies for funding physician recruitment, nursing and other clinical recruitment, renovations and equipment purchases, as well as providing care for everyone who presents in any of our facilities. In today's rural healthcare environment, the various facets of payment certainly dictate how we fund any of these."
As the Co-Chair of the University of Tennessee Health Sciences Family Practice Residency Program and Emergency Medicine Fellowship in Jackson, Gregg Mitchell, MD, has seen firsthand and dealt with the issues of rural healthcare in West Tennessee. As the head of one of the major sources of primary care physicians for the area, he knows the affect hospital closures can have. "West Tennessee has experienced closure of several of our rural hospital systems which have resulted in a shift of patients to the remaining systems in West Tennessee," he said. "These facilities closed under the ACA and a repeal would not improve the situation for the remaining open hospitals."
Gregg Mitchell, MD
In terms of the effect healthcare reform can have on these issues, Ross says help or hurt are very distinct yet vague terms in healthcare. "It could help certain disease entities with certain coverage, yet hurt others who are in different situations. The great thing about the various models being presented are the opportunities for health systems to choose what is right for the populations of patients it serves. When federal regulations go into effect across the nation it has to have flexibility for the unique populations we all serve. That is a positive in my opinion," he said. "But in arenas where we are geographically dispersed like we are in West Tennessee, it can also be problematic because 'one or two styles of shoes' don't work for all."
"Across the healthcare industry as a whole - the most significant financial issue is that costs of care are increasing faster than reimbursement. More resources are available and needed to support care - but clinical technology such as MRIs and robotics are expensive items. Access to new self-care as well as administrative tools including electronic health records and patient portals to increase patient engagement are complex technologies to implement and maintain," said Lance Beus, CEO, Tennova Healthcare -Regional Jackson. "All hospitals are challenged to recruit and retain clinical talent because the number of individuals entering the physician and nursing ranks isn't growing fast enough to meet demand. The concentration of clinical resources and physicians in urban markets makes them more attractive and makes it difficult to recruit physicians and nurses, particularly specialists, into smaller communities."
The helpfulness or hurt from healthcare reform will really depend on how reformers see healthcare, as a commodity to be purchased or as a basic need to be met according to Casteel.
"I think we truly never answer this question and only dangle pieces to try and solve parts of the puzzle. We currently exist inside a health system that needs reform. This reform should also include participation from the consumer," said Casteel.
Collaboration with other providers to extend their resources out into rural areas, such as specialists is critical, said Beus. In addition, rural facilities will have to leverage the available technology, such as telemedicine to support and expand services.
"Technology is costly and does not always lead to a gain in efficiency. It may at times lead to additional costs," said Casteel. "But, it is necessary with the growing need of data requirements, reporting, and analytics."
Technology has made improvements to the exchange and access of information opined Mitchell. However, the burden of electronic medical records has significantly increased the amount of time physicians spend in non-direct patient care. Nurse Practitioners and Physician Assistants help physicians extend services to communities. They are a key component of physician led team-based care to help with patient volume and access Mitchell continued.
"The use of and incorporation of Advanced Practice Providers, (Nurse Practitioners and Physician Assistants) as well as Behavioral Health providers into the rural community in a more progressive means has to be a component of the solution," said Ross. "Primary Care Physicians are becoming a scarcity, particularly in rural areas, so that we have to work to utilize the available providers. In my opinion, we have an antiquated regulatory system on medical schools that prohibits the means for more students to go to medical school that also does not encourage pursuing primary care roles."
According to Mitchell, "There are many obstacles to the reform of healthcare. The healthcare system is extremely complicated and there is no single answer that will resolve all of the issues. Our lawmakers are typically not involved in the healthcare industry and thus lack a grasp of some important concepts. Studies have shown that healthcare costs decrease, and healthcare quality improves with access to a family medicine physician. Studies have also shown there will be a primary care physician shortage by 2025. The greatest shortage will be in rural areas. If we cannot find solutions to the growing need for physicians, then access to care will be increasingly difficult. There is currently no major discussion about increasing the number of medical schools or increasing the number of residency positions. There should be incentives for medical students who choose rural primary care and they should also be able to enter into loan forgiveness programs in exchange for their commitment to the communities," said Mitchell.
"Many issues are being addressed in Washington without frontline providers having input. No one is educating the patient to the different changes and facts regarding coverages that they have or don't have and subsequent requirements of the plans," said Ross. "It is an injustice to all who are uneducated in the components and understanding of the terminology, coverage, requirements and steps to navigate the future of healthcare."
"Continuation of the existing challenges that face us today - rising expenses, decreasing reimbursement, recruitment/retention of physicians and nurses - is the biggest threat to all hospitals," said Beus.
"We are currently waiting for decisions that extend programs such as Medicare Dependent status and drug purchasing programs, and the development of a rural wage index," said Casteel. We will soon face issues concerning pricing for hospital based services versus free standing services. These are all reimbursement related. But the next issue is, how do we excite the next generation to return to rural communities, thereby waving off extreme healthcare work shortages? Some decisions are made by extending funding for programs," she said. "For other issues, communities as well as lawmakers will need to better understand the impact of losing rural healthcare. Many communities have lost industry. Will healthcare now be another lost industry in rural areas or will we find the opportunities through blending types of providers, joining partnerships, and better understanding consumers? In healthcare, it seems our next big issues will remain around the changing environment of reimbursement and the challenges of sustaining a work force."