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Patient Migration Suggests Big Changes Await Rural Hospitals

 |  By John Commins  
   September 12, 2012

Nearly half of Tennesseans living in rural areas who seek healthcare drive past the hospitals closest to their homes to look for care in more urban settings, even when their local hospitals offer the same services, a study shows.

The study, Patterns of Care in Tennessee: Use of rural vs. non-rural facilities, from the BlueCross BlueShield of Tennessee Health Institute, explains in great detail the sourcing and methodology used to cull the 2009 data and how it was parsed to get "apples-to-apples" comparisons. For expediency's sake read the original report.

Steven L. Coulter, MD, president of the Health Institute told me the data clearly shows that rural patients are migrating to more urban settings for their healthcare. Coulter also readily concedes that the data can't say why.

"That actually is the question of the hour," says Coulter, an internist. "My speculation is that they perceive, whether true or not, that the services are better elsewhere. We really can't make a policy-level judgment based on the data we have found. All we can say is people are mobile and they are moving. What we can't say is whether that is a good thing or a bad thing, because we haven't looked at clinical outcomes or the economic impact on the communities that these small hospitals serve."

These findings suggest that profound changes are underway for rural hospitals in Tennessee. If nearly half of the potential patient base is driving past the door to get the same services farther from home—for whatever reason—that challenges financial viability. Hospitals that don't attempt to understand that migration and that don't adapt to that migration will shutter.

"These hospitals are going to find themselves forced to either go it alone or sell to a for-profit or somebody like that who knows how to do it, because the reality is a lot of these places are not financially viable," Coulter says.

Maybe it's time for rural hospitals to wave the white flag for elective procedures and instead focus on services that take advantage of their proximity to patients: Trauma and chronic care.

"Trauma is 'every minute counts,' but there are diseases like myocardial infarction and pneumonia where minutes really do count as well," Coulter says.

"It has also been shown that the most appropriate and best intervention for myocardial infarction is on-the-spot angioplasty and not the clot busters that for so long we thought were the equivalent. In other words, if you don't have a cardiac cath lab, you aren't serving the people in your community. If anything, you may be just slowing them down from getting where they need to go."

Coulter suggests that many rural hospitals could convert into emergency stabilization centers.  "Instead of having inpatient beds, put in a cath unit in, put in a trauma unit. Have a trauma surgeon and a cardiologist in the house or on call 24 hours a day," he says.

"My bias is that many of these facilities could be converted to much more effective facilities for not really a whole heck of a lot of money."  

The Affordable Care Act will place a renewed emphasis, and money, on chronic care treatment. Coulter believes that rural hospitals are a perfect source point. Instead of traveling longer distances for their more-frequent chronic care consultations, patients could drive to the hospital down the street.

"The emphasis is going to come particularly through the (Accountable Care Organization) concept. It's going to come from the perspective of case management," Coulter says. "There is finally some literature coming out showing that intensive case management really does prolong life. It is not necessarily cheaper in the aggregate, but it does improve quality of life."

This change in care models and emphases for rural hospitals will likely accelerate the consolidations that the sector has seen over the past five or six years. "We are going to see a lot of CHS and HCA and Tenet-type organizations are going to take over these small hospitals and they are going to figure out what the most profitable means to make the viable," Coulter says. "Then you have to ask is the most profitable the right thing to do?"

There is no way to determine if the patient migration patterns identified in Tennessee apply in the same measure to other states. Geographically, Tennessee is long and narrow and surrounded by eight states with lots of potential for patient migration. And while Tennessee is mostly rural, the state's highway system is among the best in the nation. As a result, access to quality care in more-urban settings, both instate and across state lines, is readily available.

Still, it would not be unreasonable to suggest that the findings in Tennessee are somewhat applicable to rural hospitals in other states. After all, these migratory patterns are a function of consumer behavior and consumer behavior is not restricted to state lines.

In other words, if consumers have a choice and can go elsewhere, a certain percentage of them will exercise that choice.

Rural hospitals across the country would be wise to understand why patients in their service areas drive past the doors. Once the reasons for patient migration are understood, rural hospitals can determine which services best play to their home-field advantage.

When cost-effective point-of-service options are identified, a rural hospital can turn its remote location into a distinct competitive advantage.  

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John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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