We must make rural health care a high priority

Health Progress, Sep/Oct 2001 by Place, Michael D

Rural areas certainly need their hospitals. In Illinois, rural death rates from all causes in the period 1992-1996 were 1,106.7 deaths for every 100,000 people, compared with 853.8 for those in urban areas. Rural deaths from vehicular accidents in the same period were 21.4 per 100,000, compared with only 12.4 for those in urban areas.4 Michigan residents living in the area served by the Cadillac and Grayling hospitals reveal a level of obesity higher than the state average, which is itself higher than the national average. Deaths in the area from diabetes are higher than the state average-15 percent higher in Grayling, 21 percent higher in Cadillac-- which, again, is higher than the national average.5

Unfortunately, rural hospitals were hit hard by the Balanced Budget Act (BBA) of 1997. It has been estimated that, of the $118 billion to be cut over a five-year period, $16.8 billion was cut from Medicare funds intended for rural areas.6 Legislation in 1999 restored only some $1.8 billion of this money, which is certainly not enough. The BBA also established the Medicare Rural Flexibility Program and other enhancements. These enhancements, which include the "Critical Access" designation for some small rural hospitals, along with maintenance of counterpart rural hospital designations (e.g., "Sole Community Provider," "Medicare Dependent," and "Rural Referral") are vital to the preservation of rural health care, a generally low-cost mission.

However, despite these incentives, rural health care continues to bear a significant burden because of the Medicare wage index. This index adjusts Medicare inpatient and outpatient payments to account for the varying wages paid by hospitals in different market areas across the nation. Although the adjustment makes some sense, it disregards the fact that a tightened national market for health care professionals has served to increase labor costs in rural (and smaller urban) communities. The data on which the wage index is based is out of date. It simply adds to the problems rural hospitals already face in recruiting and retaining highly skilled professionals.

NOTES ON THE RURAL CHALLENGE

The following are random observations based on my encounters with caregivers in the rural ministry. Rural Hospitals Can Provide a Continuum of Care Some urban people have an unfortunate bias against rural primary health care: They think it cannot be as good as primary care provided in an urban setting. However, if you believe that periodic accreditation agency scores are an accurate measure of quality, you will find-as I have in my visits to rural areas-that rural facilities score just as high as their urban counterparts. True, they usually do not offer the range of services that urban hospitals do. But they often have unique (and sometimes creative) arrangements with tertiary and specialty care providers, so that even if some services must be delivered away from the "hometown" facility, follow-up care can be given at that facility. In this way, rural hospitals do provide the full continuum of care.