AHA's Advocate for Rural Health Names Top Concerns

The new head of the AHA's governing council representing small or rural hospitals discusses his most pressing challenges: addressing the shortage of health professionals, advancing population health, and preserving the critical access hospital designation.

Healthcare providers across the country will face a challenging environment in the coming year as ground-changing reforms take effect. For any number of reasons, however, meeting those challenges will be even harder for providers serving rural areas.

1. The patients they serve tend to be older, sicker, less educated, and poorer.
2. Access issues are far more challenging in rural areas, where the closest hospital or physician's office is more often miles away.
3. Every rural provider trying to recruit a physician, a nurse practitioner or any of a number of specialists understands the intense competition for clinicians.
4. Smaller and remote hospitals and other providers often cannot easily access the capital or the expertise for technology upgrades and interoperability mandates that can create economies of scale, improve care and reduce costs.
5. Many rural hospitals, through no fault of their own, over-rely on Medicare, Medicaid, and other government payers with lower reimbursements than private payers, which also makes it more difficult to offset the costs of charity care

I could go on, but you catch the drift.

Despite all of the challenges, Paul R. Bengtson, CEO of Northeastern Vermont Regional Hospital, a critical access hospital in St. Johnsbury, is upbeat about the work that rural providers accomplish.

"We are like many other critical access hospitals and the programs that we have here are very sophisticated and many are on the cutting edge of high quality," says Bengtson, who this month began a one-year term of office as chair of the American Hospital Association's Section for Small or Rural Hospitals in 2014.

"We have programs that are directed at improving the health of the populations we serve. I am excited just in general to pursue the Triple Aim: to improve care, to improve the health of the population, and to lower healthcare costs. We are a rural hospital, but we are working on all fronts."

The 21-person governing council represents small or rural hospitals in the AHA's policy process and member services initiatives, and through it, Bengtson says he's been exposed to "a large number of really smart and creative people working in rural healthcare settings all across the country."

'Crisis Mode'
"Having said that, many rural providers are in what I would call a crisis mode because the systems and many situations and the economy are rather fragile," he says.

Bengtson says in some rural areas "it is next to impossible to recruit qualified physicians."

"Just by way of statistical reminder, 20% of America's population is living in rural areas and we have probably less than 10% of America's physicians serving that population," he says. "That is true for a variety of reasons, but in some areas it is very difficult to recruit the kinds of physicians that are needed, particularly primary care physicians."

Bengtson sees that as "a real problem because we've got over 2,000 rural counties in America that are designated as health professional shortage areas. That does make the work really hard. One of the toughest jobs is going to be to replace the workforce we have now."

Bengtson says one of his priorities as leader of the AHA's Small or Rural Hospital's Section will be to advance population health.

"I want us to be learning from each other. I do see where the Small or Rural Governing Council has a think tank operation where we can figure out who's doing what that is going to be most effective to bring good programs to rural populations in the future, with the intent of improving care, with the intent of improving the health of the population and lowering costs," he says.

Emphasis on Population Health
"I would like to see a lot more emphasis on population health improvement; meaning hospitals in rural areas reaching outside of the walls, connecting with private practices, public agencies, departments of health, wherever possible to have a collective impact on the health of the populations they serve. Yes, we have to improve the quality of care in the hospitals themselves. But I am after improving the health of the population. That has always been important to me, and it will be this year too."

I asked Bengtson if he thought that the federal government, Congress, and other healthcare powerbrokers held a proper appreciation for the work of rural healthcare providers under challenging conditions.

"That varies greatly across the country. In the most rural of states like Vermont, the legislature, [and] the power brokers get it because they're in immediate contact with their constituents. Nobody runs around here anonymously doing things that are not good for the population," he says.

"But it is interesting across the country and there is a lot that I frankly don't understand. I don't know that people in powerful positions don't get it. I have to say I am not happy about the politics of healthcare when I think there is so much that can be served through the mission of healthcare. But politics and money make a difference. I am not sure that people don't get it, but I see a lot of action that would cause me to think they either don't get it or don't want to get it."

Preserving CAH Status
One of the best ways that the federal government can show its appreciation for the work of rural providers would be to outright reject or at least very carefully scrutinize any reconfiguration of critical-access status for small and isolated hospitals.

"If we lost our critical access hospital status that would have a very bad affect on the people we serve," Bengtson says "We have a primary service area of least 30,000 people, and there would be a lot of people around here who would automatically lose access to a lot of needed services. Would the hospital go out of existence all together? No. But it probably would have to morph into something that would be much less than what it is capable of doing now."

"Frankly, the benefit of what we have to offer the population would be much diminished and also the population would be very disappointed. When I ask people 'what do you need from us?' their answer is almost uniformly 'be there. Be there now. Be there in five years. Be there in 10 years. Be there in 20 years for my family.' That is what people are looking for."