Health Care Hurdles Across Rural America: Symptoms and Solutions

Page 1



Joshua Kleinstreuer


Excutive summary

A variety of systemic issues contribute to health care complications in rural America, including a shortage of health care workers, continuing hospital closures, a high rate of elderly patients, poor and underinsured residents, as well as a high frequency of chronic illness. In this white paper, we examine the dilemmas faced by rural health care administrators, including patient access, the need for telemedicine and telehealth solutions, as well as the shortage of health care workers in rural America and its impact on facility operations and patient care.



Table of contents

Patient access Hospital closures Health care staffing shortages

4 5 6

Provider demographics: Changing times = Change in care


Health care administration requirements


Telehealth and telemedicine


How telehealth is beneficial for facilities


How telehealth is beneficial during a health crisis


Hurdles for telehealth in rural America


Solution: digital credentialing, enrollment, HIPAA-compliant messaging


Simplified application process


Pre-fill, store and reuse templates


Reduce errors, save time




HIPAA-compliant messaging






Some patients can’t access care at rural hospitals One of the primary goals of health care facilities is ensuring that care is easily accessible for all patients. Cost factors aside, physical access to care can be a major barrier for those that live in rural areas. These rural areas, which are classified by the U.S. Census Bureau, are based on population thresholds, density, distance, and land use, urban areas make up only 3 percent of the entire land area of the United States but are home to more than 80 percent of the population. On the other hand, 97 percent of the country’s land mass is rural, and occupied by 20 percent of the population — which equates to approximately 65 million people spread out across 3.6 million square miles3. This sparse population density creates a range of challenges in health care, with respect to care access for primary appointments, emergency treatment, preventative medicine, patient follow-up and even basic provider communication. When combined with a population that has a higher average age and elevated rate of chronic illness, these barriers to care access may have grave consequences.

Residents in rural areas who live on farms, reservations,

time off from work for an initial appointment or follow-

and frontiers are usually required to travel long distances

up. Since many people do not have the privilege of paid

to reach a health care provider. Patients who do not live

time off or paid sick leave at their disposal, this may cause

in close enough proximity to healthcare facilities may not

patients to delay or avoid care. Greater distances also result

want to spend the time, effort, and resources to attend

in longer wait times for emergency medical services (EMS),

in-person appointments, increasing the likelihood that

which can endanger patients requiring EMS treatment

symptoms will go undiagnosed and diseases will progress,

(Warshaw 2017). Hospital administrators must keep such

often past a critical tipping point. An extended travel time

determinants into consideration when evaluating how to

can have further negative consequences for patients

improve care access for patients.

beyond delays in medical treatment. It could entail taking


Rural hospitals are closing at an alarming rate Another issue that further limits patient access for residents of rural areas is hospital closures. According to a report conducted by the University of North Carolina at Chapel Hill (2020), 170 rural hospitals have closed since January of 2005: more than 120 of those closures occurred since 2010. The university’s report utilized the definition of a “closed hospital” as provided by the Office of Inspector General: “A facility that stopped providing general, short-term, acute inpatient care [….] We did not consider a hospital closed if it: merged with, or was sold to, another hospital but the physical plant continued to provide inpatient acute care, converted to critical access status, or both closed and reopened during the same calendar year and at the same physical location.” The report from the Office of Inspector General in the research conducted by the university found various factors that contributed to rural hospital closures. The study found the primary reasons to be business-related decisions, such as relocations, consolidations, or mergers. Other factors influencing business-related closure would include rising costs or lagging revenues, due to low patient numbers. Only a small number of rural hospitals reported Medicare and/or Medicaid reimbursements as the primary reasons for closure.




Health care staffing shortages Even if the difficulties surrounding patient access to health care are diminished and telehealth becomes more easily attainable through federal funding initiatives, a significant and continuous hurdle remains: a shortage of health care providers in rural areas of the country. There is a disparate allocation of health care workers and licensed medical providers across the United States, with urban areas having the highest concentration of health care industry workers. As of March 2020, nonmetropolitan areas accounted for 61 percent of Primary Medical Health Professional Shortage Areas, according to the Bureau of Health Workforce Health Resources and Services Administration (HRSA), which is part of the U.S. Department of Health & Human Services. The designations that indicate health care provider shortages in primary care, dental health; or mental health. There is a major shift taking place in the health care industry, and its effects are most notable in rural America. As doctors from the Baby Boomer generation begin retiring, there is an increase of closures impacting independent family practices, most notably in small towns across the United States. The patient-to-primary care physician ratio in rural areas is approximately 40 physicians per 100,000 people. In contrast, in urban areas the patientto-primary care physician ratio is approximately 53 physicians per 100,000 residents. This high percentage of health care provider deficiencies across a wide range of medical practices causes rural populations to be at risk for limited access to care, thus resulting in poorer health outcomes (Mock et al.).


Provider demographics: Changing times = Change in care The question remains as to how rural health care facilities can not only enroll providers, but consequently retain them as well. Merritt Hawkins conducted its 2019 Survey of Final-Year Medical Residents to showcase the “concerns and expectations of physicians who are about to complete their final year of training and enter the employment market.� The results of the survey revealed a troubling reality for health care in rural America. According to the survey, only 1 percent of doctors in their final year of medical school said that they want to live in communities with a population under 10,000 and only 2 percent of doctors wanted to live in towns of less than 25,000 residents. There are a couple of substantial factors that play into this decision, including the high cost of taking over a small-town practice as well as the time-intensive process of establishing a network that might be intimidating for younger physicians. Many doctors fresh out of medical training are choosing to work at urban hospitals, rather than opening their own practices.

Offering a cost-effective solution that would permit more doctors to easily open and maintain a private practice, or enable existing rural medical facilities to entice this new generation of doctors to be part of a small community, may be the ultimate answer to resolve the diminishing supply of doctors in rural America, and the increasing urban-rural divide (Siegler 2019). Health care compliance, credentialing, and enrolling providers are all essential procedures for medical facilities of any size that can be costly and time-consuming if not executed correctly. Streamlined, efficient, automated healthcare administrative processes make rural healthcare facilities attractive places for doctors to work, especially when paired with other telehealth solutions that elevate the level of care while maintaining the personally connected aspect of living in a small community.


Health care administration requirements One of the largest hurdles facing the rural health care industry involving staffing is the complexity of the administrative processes a provider and health care worker must complete before patients can begin receiving treatment. Whether a provider wants to join an existing medical practice or start their own, they first need to get credentialed. Credentialing is a long, slow process that can take anywhere from a few weeks to six months. The credentialing process must be redone every two years, in addition to fulfilling continuing medical education (CME) requirements. In combination with other non-clinical paperwork, this administrative burden takes up nearly nine hours a week for the average doctor, according to a study published in the International Journal of Health Services (Woolhandler & Himmelstein 2014). In addition to the time spent completing paperwork, there are costs associated with loss of potential patients and income prior to certification. Any delay in completing the credentialing process consequently delays the enrollment procedure. Enrollment refers to the process of a health care provider requesting participation in a health insurance plan network. It can also be the validation of a provider in a public health plan such as Medicare or Medicaid, and the approval to bill the agency for services rendered.

It can take anywhere from a few weeks to six months for a physician to get credentialed1

The average doctor spends

8.7 h urs per week on administration2

Enrollment in Medicare and Medicaid is especially important for rural health care facilities, due to the larger percentage of elderly and low-income residents that live in rural areas compared to urban areas. Since rural hospitals generally do not have budgets comparable to those of their urban counterparts, much of the administrative work is conducted manually which results in income loss for the facility and the provider. Delays cost providers thousands of dollars in lost income— the exact amount of which depends on how much they earn and how long it takes to get credentialed. For a physician making the average income of nearly $300,000 a year, waiting a few weeks would cost the provider around $25,000 in lost income. The worst-case scenario of waiting six months would cost the provider around $150,000 in lost income. If rural medical facilities are not able to efficiently credential and enroll providers in government health plans or insurance networks that fit the needs of the patients, the provider is likely to transfer to an urban facility.


Voluntary Hospital Networks are emerging One study (Rhenquist 2003) examined whether or not hospital patients who bypass their local rural hospital to receive care in another hospital will base their decision on if the hospital is in a less competitive or a more competitive market. If the patient is price-sensitive and competitors have decreased hospital prices, the patient might choose a hospital in a more competitive market. If patients are concerned with issues that do not involve prices, such as facility amenities, the patient might choose a hospital in a less-competitive market. Due to the fact that most hospital care is paid for by third party payors and not out-of-pocket, the insured patient might be more motivated to bypass their local rural hospital to select another which is located in a less-competitive market with higher perceived levels of service, clinical outcomes, amenities, and service quality. When examining the correlation between individual factors and the likelihood that a patient would bypass their local hospital, the hospital network and the number of services provided were positive predictors of bypassing, while a public hospital affiliation and distance to the patient’s residence were negative predictors. Researchers found that rural patients were more inclined to visit hospitals that participated in a network with other hospitals. Overall, networked hospitals were preferred over non-networked hospitals by nearly 50 percent (Rhenquist 2003).) However, not all rural hospitals are quick to join a sizeable hospital network. In their research, Moscovice et al. (1995) found that the rate at which rural hospitals have been linked to large, multihospital systems has slowed. Aside from possible financial losses, there are concerns by rural hospitals that an affiliation with a large hospital system could result in a lack of attention to local needs and loss of hospital autonomy. Alternatively, an increasing number of rural hospitals have looked at establishing less structured, joint arrangements by participating in voluntary hospital networks.


Even a smaller, rural hospital network isn’t always easy to sustain. There are some network-sponsored programs that are relatively straightforward and inexpensive, such as educational programs or physician recruitment. Yet other network activities such as joint quality-assurance or credentialing programs need extensive cooperation, reliable and accessible communication tools, and a high level of trust among participating hospitals. There is no easy, one size fits all, solution to the myriad of issues surrounding patient access in rural health care. One possible solution that has been examined is telehealth and telemedicine. There are various benefits to integrating technology and health care within facilities, yet it is not always feasible, as there are many moving parts to successfully implementing telehealth in rural areas.


Telehealth offers answers for rural patient care As detailed above, one of the primary obstacles involving patient access to health care in rural America is distance to hospitals and travel times in the event of a medical emergency. A study conducted by the University of Iowa and published in the journal Telemedicine and e-Health (Mohr et al. 2018) focused on 14 rural hospitals in the Midwest with emergency department telehealth programs. Researchers found that the use of telehealth technology has helped reduce emergency room wait times for patients in rural hospitals by an average of six minutes. Another benefit of telehealth which emerged from the study was the finding that the length of stay for patients that were seen by telehealth providers prior to hospital admission was an average of 22 minutes shorter. Telehealth also has the potential to expand access to additional health care services which may not be accessible at a local, rural health care facility. Provider recruitment and retention, a low volume of patients, and inadequate resources are all factors that could prevent specialized health care services from being offered in rural America. Telehealth may also be especially important for providing care in disciplines that are not well represented in rural areas. In a recent analysis of rural Medicare beneficiaries, researchers found that nearly 80 percent of telehealth visits were related to mental health conditions. Medicare has increased its coverage of telehealth services for patients living in rural areas, and in 2018 Congress further expanded coverage to include telestroke care. An American Hospital Association report (Wagenen 2018) found that telehealth holds great potential to address some of the patient access issues and health disparities discussed earlier in this paper that have continuously existed in rural communities, such as geographic isolation and a geriatric demographic. In public health crises, such as the global COVID-19 pandemic, telehealth may become the safest option for treatment of non-life threatening conditions. As technology continues to improve and the notion of delivery of health care via virtual connections becomes more accepted in the general population, the utilization of telehealth services will increase.


Facilities that adopt telehealth gain advantages While improving patient care, access, and overall health and well-being are clearly the primary motivators for rural health care systems to implement the use of telehealth technologies, it can be economically advantageous for facilities and communities alike. The NTCA Rural Broadband Association describes themselves as the “premier association representing nearly 850 independent, community-based telecommunications companies that are leading innovation in rural and small-town America.� In their Anticipating Economic Returns on Rural Telehealth report (NRHA 2020), researchers stated that via telehealth solutions, hospitals could save more than $80,000 annually in states such as Texas, Oklahoma, Kansas, and Arkansas. The rural communities in these states could save an average of $40,000 a year by using telehealth technologies instead of traveling. The report stated that if residents in rural communities utilized physician services with telehealth, an average of $24,000 would be saved in travel costs and an average of $16,000 would be saved in lost wages associated with taking time off from work to travel a long distance to receive services from qualified physicians. Facilities implementing telehealth solutions not only create options for their existing patient base, they expand their potential pool of patients beyond existing geographic constraints. Further, their health care providers are more easily able to access continuing education, remote training, diagnostic assistance, and other means of expanding their services and developing provider expertise.


Rural response to health crises improves with telehealth Due to the coronavirus pandemic, health care facilities across the United States and around the globe are overwhelmed. Many are facing supply shortages, staffing shortages, and health care administration is overwhelmed. Consequently, the advantages of telehealth and telemedicine are moving even more rapidly to the forefront. Congress included $500 million for the use of telehealth services in its emergency COVID-19 aid package passed toward the beginning of March. The legislation gives $200 million to the Federal Communications Commission to help it expand telehealth services during the pandemic. The FCC Chairperson proposed part of the funding to allow eligible health care providers to purchase devices to assist with broadband connectivity. To reduce the in-patient burden on health care facilities, the federal government lifted restrictions on Medicare reimbursement for telehealth services. This immediately allowed telephone and videoconferencing between doctors and patients. Practical applications of the new, more lenient regulations regarding telehealth and telemedicine have already been put into place for health care services treating coronavirus and COVID-19 patients. One such example is at Robert Wood Johnson University Hospital in New Jersey. According to the online publication NJ Spotlight, the facility has installed “video robots� in its pop-up tents. The devices are able to transmit a video of the patient in the tent to a physician inside the emergency room. The device is also equipped with an electronic stethoscope to monitor the patient’s breathing. After the consultation, the physician recommends whether the patient should be admitted to the emergency room or if the patient should simply self-quarantine at home. Telehealth is rapidly transforming the face of medicine in America, not only for rural communities but across health care as a whole, especially during a time of crisis that necessitates physical distancing.


Hurdles for telehealth in rural America Despite the proven benefits of telehealth throughout the past decade, industry experts say that the tool has not reached the critical point of widespread acceptance in the health care industry. However, telehealth access among patients continues to increase, and it is shown to be safe and effective. At the same time, the integration of digital health tools has grown significantly among physicians in recent years. However, progress needs to be made in certain areas before telehealth is accepted as a standard form of health care. First and foremost, an increase in patient awareness needs to occur. The J.D. Power Telehealth Satisfaction Study (2019) found that lack of access to and awareness of telehealth options is the primary hurdle to adoption. The survey traced telehealth user experience, hurdles to adoption and real-world patient concerns. The report found that while nearly 10% of Americans have used telehealth services, nearly 75% said they either don’t have access or are unaware of telehealth options available to them. The awareness of telehealth is lowest in rural areas, despite the fact that telehealth is shown to increase health care access and outcomes. The study found that approximately 9% of rural residents have adopted the service, compared with approximately 12% of suburban residents and 11% of urban residents.

Other hurdles that telehealth faces in rural America include • Restrictions on how Medicare covers and pays for telehealth •L ack of internet connectivity and adequate connection speeds •L icensure compliance for health care providers across state-lines • Equipment costs

While these are not trivial hurdles to overcome, rapid and widespread applications of telehealth and telemedicine services in response to the coronavirus pandemic in recent weeks shows that it is an achievable reality. Medical facilities in urban areas are experiencing an unprecedented reality that has been commonplace for rural health care systems for years: a shortage of health care providers and medical staff, and a concomitant need to protect those who are able to work.


Solution: Digital credentialing, enrollment, HIPAA-compliant messaging Rural health care currently needs more attention than ever, especially considering the massive burden caused by the COVID-19 pandemic and the need for healthcare solutions to other non-critical issues that uphold physical distancing measures and slow viral spread. Both in the short-term, and especially the long-term, patients need improved access to medical facilities. The usage of telehealth and telemedicine needs to become more widespread and accepted by patients and providers alike, and medical facility administrators need to take the appropriate steps to ensure that health care providers are able and willing to become long-term members of their care team. Many rural health care facilities still utilize manual credentialing methods with paper spreadsheets. Oftentimes the initial cost of credentialing software is the determining factor, despite the overall positive economic impact on the facility and the provider outlined in the previous section. It is common for health care administrators in both urban and rural areas to be unaware of alternative options, or simply institutionalized in using outdated methods such as spreadsheets. Intiva Health has built a revolutionary proprietary telehealth platform offering a variety of tools which exponentially reduce the time it takes to complete burdensome credential management and administrative tasks. Ready Doc™ utilizes blockchain technology to immutably and securely digitize both the credentials of a provider and the verification of the credentials – i.e., creating a digital notarization – which drastically reduces the credential verification timeline. After a health care professional’s credentials are uploaded and verified in Ready Doc, they can share their digital documents with any medical facility and obtain near-instant privileges at that facility. Ready Doc also facilitates compliance by automatically monitoring the expiration of credentials and alerting medical professional and facilities in advance. This solution allows all credential compliance to occur on the same platform, dramatically increasing efficiency and reducing the risk of lapses in compliance.


Though a provider may have the proper credentials to work at a facility and been granted privileges, they still cannot be paid until the enrollment process is complete. As detailed above, the enrollment process can be just as time intensive as traditional credential management methods. However, with the digital notarization of verified documents, electronic signature capabilities, OIG exclusion database access, and CAQH monitoring available within Ready Doc, the platform can be used to expedite provider enrollment as well. There is no need to duplicate any data collection, verification, or entry efforts into the array of forms involved with enrollment. Once all of the provider data and credentialing documents have been uploaded into Ready Doc, the credential management process and enrollment process can each be completed hassle-free, in a fraction of the time.

Features SIMPLIFIED APPLICATION PROCESS: Traditionally the application process is the most time consuming and paper-intensive process for the medical staff office. Digital Forms are designed to eliminate manual processes by allowing the providers to fill out essential application data online via computer, phone, or tablet. PRE-FILL, STORE AND REUSE TEMPLATES: Pre-fill custom templates, send and store any provider application, letter or custom templates unique to your organization in a very easy to use interface. Digital Forms eliminates the costly process of printing, mailing, and entering data for initial or reappointment applications. Providers can login, modify, and submit applications online from anywhere. SIMPLIFY ON-BOARDING: Business rules can be enforced to make sure the application is complete before it can be submitted. Medical staff office members can view the progress of applications as they are completed. Applicants can view the progress of the credentialing process once the medical staff office begins processing the application. REDUCE ERRORS, SAVE TIME: Providers can fill out the application at their convenience, with the entire application and supporting documents available to view and sign digitally. For each unique user, MD-App includes built-in lookup tables and reference addresses, minimizing the time needed to fill out the application, while expediting the application process and reducing errors. E-SIGNATURE: Cost effective, gathering signatures on complicated legal contracts is made simple when a recipient can sign electronically with our e-signature solution. You can either upload a contract or use an existing one from your library, attach a signature block and send.

HIPAA-compliant Messaging Ready Doc™ Messaging is a secure and encrypted application that protects patient information and meets HIPAA guidelines. It helps health care administrators and providers save time and improve communication efficiency by alleviating phone tag, unanswered pages, and disruption to patients and care team members—all while maintaining compliance. It is available for iOS mobile devices, Android mobile devices, and desktop workstations.





Keep messages private with a fully encrypted, end-to-end, secure texting solution.

Send high-priority messages that apply a unique label for instant differentiation. Pin high-prioirty conversations directly in your inbox.

Forward messages directly to another colleague.




Have open and ongoing forum discussions with colleagues on specif ic topics. Join or leave a channel anytime.

Know instantly when messages have been sent and read.

Recall a message and attachments. Resend messages as an instant reminder.



Create groups to improve collaboration and see who has read your message and when.

Securely attach any media directly to the conversation in real-time.


Conclusion As rural health care facilities, along with their urban counterparts, continue to navigate through uncharted waters in the face of a global pandemic, their pre-existing hurdles have created an untenable situation. Rural health care administrators and providers need to implement cutting-edge operating strategies and sustainable solutions that yield value innovation, in order to survive and, ideally, to thrive. Ready Doc provides key tools and frameworks to aid in eliminating the trade-off between differentiation and cost reduction within a company. By utilizing the features of digital credentialing, automated enrollment, online continuing medical education, and HIPAA-compliant messaging services available within Ready Doc, rural facilities have an opportunity to increase telehealth services for patients, diminish administrative burden for their staff, provide a more appealing opportunity for providers at any stage in their career, and maintain and expand their operations with reduced operating expenses and increased revenue. Intiva Health offers modern telehealth solutions for common administrative applications to streamline and improve the healthcare experience.



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