Comprised of a wide array of stakeholders from across the care continuum, "mega boards," with members trained in thinking about the health of the community as opposed to the financial performance of a hospital, could change rural healthcare delivery.
Rural healthcare delivery doesn't need to be tweaked. It needs an overhaul.
Even after years of talk and studies and calls for reform, most healthcare delivery in rural American remains overly reliant upon small hospitals with limited resources that provide fee-for-service inpatient sick care.
Care coordination, community outreach, and wellness and prevention programs often don't get the money or the emphasis they deserve because hospital leaders with immediate budgetary concerns aren't reimbursed for them.
This happens even though almost every rural provider and hospital leader I've spoken with understands that cost-effective care delivery must extend beyond the walls of the hospital.
We have well-intentioned rural hospital leaders and other providers who are ready and willing to act, but who are constrained by lack of money and other resources and must continue operating under an antiquated care delivery system.
A. Clinton MacKinney, MD, MS, a clinical assistant professor at the University of Iowa, and a family physician in rural Minnesota, says rural providers "are hamstrung on a payment system that is focused on hospital and illness and we are hamstrung by a small scale that tends to leave us out."
"The Centers for Medicare & Medicaid Innovation has a $10 billion budget. They tend to look to places to implement projects that have large scale to begin with. That automatically excludes rural," he says.
Blueprint for Change
"We can put together some scale and we can develop opportunities for learning that can be expanded. But if CMMI says off the bat that a particular demonstration project must have 50,000 or 100,000 lives to be considered, then we are already behind the eight ball. Therefore 25% of the population and provider workforce gets left out."
MacKinney is a coauthor of a new report from the University of Iowa's Rural Policy Research Institute that offers a blueprint for changing rural healthcare delivery.
"We are really trying to move past this antiquated concept of a hospital providing inpatient care," MacKinney says. "In reality, the locus of human and other resources in rural communities is often focused at the hospital. Whether that is good or bad, it just is. Thoughtful rural hospital leaders are saying we cannot be insulated inpatient-four-wall institutions any longer. They're thinking about how we can make our community a healthier place to live and raise children and retire rather than treating sick people in inpatient beds. But when the payment system doesn't reward you for doing that work, we have a challenge on our hands."
Seeking a 'Glide Path'
MacKinney says rural providers need a "glide path" to value-based care.
"We are now stuck in a fee-for-service environment, especially in rural, that is counter-productive to delivering value," he says.
"Making the switch, like flipping a light switch to a population-based healthcare payment system would be so disruptive it would be impossible. So our suggestions are glide paths from the current broken system to one that makes more sense but also along the way doesn't destroy rural infrastructure."
MacKinney says rural providers who buy into the concept need to convince other stakeholders to tear down the institutional silos that block care coordination.
"How do we start helping people understand that this isn't a traditional hospital way of thinking?" he says. "I've been working with one community where the hospital leadership is trying to do that, but the people they are reaching out to—public health, the agency for aging, human social services—don't get it."
"They are in the same kind of silos that the hospital has been in," he says. "It was frustrating for the hospital leadership because usually they are the ones who get blasted for simply thinking about making money and treating patient who are sick."
'Mega Boards'
Among its many recommendations, the study suggests that rural providers and community leaders create "mega boards" comprised of a wide array of stakeholders from across the care continuum who would identify patient service areas and their needs, and build a coordinated care network in that space.
"This isn't a hospital board in the old sense of the word," MacKinney says. "It is going to require education. We just can't have the board members who show up for the free dinners but never read the material who [are] participating in something that is as important as the health and welfare of the community."
Mega board members will need to understand how care delivery works outside of the hospital.
"Individuals who have all of their experience and focus around the old definition of hospital need to be trained in thinking about the health of the community as opposed to simply the financial performance of a hospital which is dependent upon beds being filled and patients through the door," MacKinney says. "That is a very different mindset."
The existing mindset, he says, is failing the people it is supposed to serve.
"We are sitting here with about 1,330 critical access hospitals, some of which aren't serving their communities as well as they can," MacKinney says. "They don't have a system yet to get to what thoughtful rural healthcare leaders know they need to be—which is more responsive to preventive health issues, playing a role in the social determinants of health, expanding beyond inpatient units, thinking of how we connect in real time clinically with care partners in the local community, and also connect regionally."
John Commins is the news editor for HealthLeaders.