The challenges of rural health care

November 1, 2017

The College of Community Health Sciences hosted a panel discussion focused on rural health care challenges in Alabama during its October Board of Visitors meeting to share perspectives, brainstorm ideas and build collaborations. Panel members included: James Cowan, administrator of Choctaw General Hospital in Butler; W.O. Buddy Kirk, a retired district judge from Pickens County; Don Lilly, senior vice president of UAB Health System in Birmingham; Nisa Miranda, director of The University of Alabama Center for Economic Development; Wallace Strickland, CEO of Rush Health System in Meridian, Miss.; and R.B. Walker, director of Government Relations for UA. The panel discussion was moderated by Pat Duggins, news director at Alabama Public Radio. The Board of Visitors is made up of volunteers, including alumni, donors, community physicians and other friends of CCHS who help the College develop relationships and partnerships with Alabama communities and with organizations at the state and national levels. “Alabama is more rural than most of the US and the concern for sustaining rural communities and their health and economies is great. So are the challenges,” said Dr. Richard Streiffer, dean of CCHS, as he provided a framework for the panel discussion. “Rural communities have populations that are older, sicker and poorer. They have difficulty attracting and retaining young people and families because of a lack of jobs, inadequate education and few services and amenities. Rural communities struggle to attract and retain physicians and other health-care professionals, and to support hospitals and health-care services.” In Alabama, 55 of its 67 counties are considered rural. There’s a critical shortage of doctors and other health-care professionals in rural counties, and eight counties have no hospital at all. Over the last eight years, seven rural hospitals have closed in the state, placing Alabama near the top of the list for rural hospital closures nationwide. A key recurring theme during the panel discuss was the need for the state to include health care and rural hospitals in economic development efforts. “A hospital is an industry unto itself and should be recognized as that,” Strickland said. Lilly added: “Hospitals are good economic development for the state. When an industry comes, the state rolls out the red carpet.” Walker noted that larger employers in rural areas are generally school systems and hospitals. Cowan pointed out that a single physician in a rural community can potentially create 23 additional jobs and $1 million in economic benefit for the local community. “It’s economic development worthy of the state’s attention,” he said. “It’s hard to recruit industry if you don’t have health care or a hospital,” Walker added. “The state needs to look at health care as part of the economy. That’s the way to make it important to the Legislature.” Miranda said it might be difficult for officials to know how to bring hospitals, including rural hospitals, into the economic development equation because of the complex way that health care is financed, and because hospitals are often recognized not as an industry but as a public service. She also said industrial recruitment is easier “because that structure is in place.” Strickland said better planning is needed to match health-care resources with health-care needs. “No health planning exists in this country, whether it’s a rural area or an urban area. Right now, we’re scatter shooting.” Lilly said there is likely duplication of services from one rural area to the next “so it’s not sustainable because there’s not the volume. It’s like rural hospitals exist on an island.” Panel members stressed the importance of considering creative solutions. Walker said more programs are needed like one currently being launched by the College and Tuscaloosa Fire and Rescue Services that treats low-emergency conditions at the scene, reducing costly emergency room transports. Cowen suggested telemedicine could bring needed health care to areas. Strickland explained that Rush Health System has, when building rural hospitals, placed admissions and cafeteria sections in space separate from traditional hospital space. The reason – $110 per square foot in construction costs as compared to $300-plus per square foot typically required for in-patient space. In addition, Strickland said Choctaw General Hospital in Butler, which is owned by Rush Health System, has “swing beds” that can switch from acute care status to skilled care status, something that Medicare provides coverage for and that particularly serves the needs of smaller hospitals and communities. Lilly said some rural hospitals might need to provide emergency care only “so they can get the reimbursement they need to stay open.” Cowan said it’s important for rural hospitals to be an active part of a community. He said Choctaw General Hospital provides space for town hall meetings, and the cafeteria also operates as a place for the public to eat. “You have to engage with the community and keep it fresh and new. You can’t just build it and they keep coming back. You have to work at it.” Kirk agreed, adding that it is important to get local citizens involved well before a rural hospital faces possible closure. “That speaks volumes to the Legislature and elected officials.”