Unfinished Business

Iowa's Rural Rx is a Band-Aid

Photo by Possessed Photography on Unsplash

On October 1, 2022, Blessing Health Keokuk Hospital, a 49-bed nonprofit facility, closed its doors. One hundred fifty-one employees in this town of 9,900 lost their jobs, and residents were sent to the nearest emergency room 17-18 miles away.

More than 140 rural hospitals across the U.S. have shuttered since 2010. It should be good news that the Iowa legislature recently passed legislation addressing this issue, and Gov. Reynolds has signed it. Yes, . . . but it may be more of a relief valve than a lifeline.

Financially struggling hospitals with 50 or fewer beds now have two alternatives: (1) Close completely (2) Downsize to a 24-hour emergency department with a clinician on call, and a 24-hour cap on the average length of patient stay. Sicker patients would be transported to a larger facility.

This new alternative, the Rural Emergency Hospital (REH) is a bipartisan legislative effort, co-sponsored by Sen. Charles Grassley, and signed into law on December 27, 2020. It creates a new federal payment program by the Centers for Medicare & Medicaid Services, providing a 5% increase in Medicare payments, along with an average annual facility fee payment of about $3.2 million.

Iowa joins Kansas, Nebraska, Arkansas, and South Dakota in its passage of authorizing legislation.

Hospitals that closed after passage of the federal legislation, like Blessing Health Keokuk Hospital, are eligible to apply and re-open as an REH. Blessing Health averaged 1.5 in-patients and 22-24 ER patients daily. (A third-party review estimated the hospital needs $20 million in repairs.)

Outpatient and emergency visits currently make up about 66% of Medicare payments at the rural hospitals eligible to convert to an REH, according to research by Paula Chatterje, an assistant professor at the University of Pennsylvania's Perelman School of Medicine. But she cautions that hospitals still will need to calculate if the math will work.

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Beyond financial considerations, broader questions loom. For instance, during the worst of Covid-19, many rural residents across the U.S. were left without a bed because their hospital was one of the 150 that closed their doors between 2005 and 2019. What happens during the next pandemic? Converting to an REH also means that a community loses access to preventive care, lab work and x-rays, and other essential services. As a result, patients may delay care, causing more serious health consequences and more costly care.

The REH isn't a panacea, Chatterje says. "This feels like rearranging the deck chairs on the Titanic," she told The Daily Yonder.

Intensive Care Needed

More is needed. An October 2022 report by the Center for Healthcare Quality & Payment Reform revealed that almost 30% of rural hospitals across the U.S. (600) are at risk of permanent closure in the near future; 24% of rural hospitals in Iowa (22) fall into this category. Clearly, the federal REH law would have to be expanded to assist larger rural hospitals averaging more overnight stays.

The pandemic didn't cause the current financial distress. In fact, federal grants provided temporary relief, helping to limit hospital closures to six in 2021-22. (19 closed in 2020.) Once the Covid-19 public health emergency funding ends in May, hospitals will be even more vulnerable to the impact of inflation and workforce shortages, as well as uninsured patients who also will lose Covid-19 Medicaid coverage.

Rural hospitals aren't closing because of inefficiency. The National Rural Health Association argues that rural hospitals aren't paid enough to cover the cost of delivering services. Rural hospitals have lower patient volumes, and as a result, higher per unit costs.  It's not hard to figure out why: Rural America's population is declining, aging, and has more chronic conditions.

Yet health insurance reimbursements are based on the number of patients treated, not on the costs of maintaining a minimum staff. One could compare this to paying fire or police departments based on the number of fires extinguished or crimes solved. A Better Way to Pay Rural Hospitals at www. chqpr.org.

Many rural patients are covered by Medicare or Medicaid, or they're uninsured. The growth in Medicare Advantage plans exacerbates the problem by paying rural hospitals less than traditional Medicare. Some employer-sponsored insurance plans also underpay. Eleven states still have not expanded Medicaid coverage through the Affordable Care Act.

Abandoned: Mothers and Babies

What else is our Iowa legislature doing to help the majority of rural hospitals? One growing problem in Iowa and many other rural areas is Maternity Care Deserts. More than 40 Iowa hospitals have eliminated maternal care in the last two decades. A total of 66 of 99 Iowa counties do not offer labor and delivery. In fact, Iowa comes in dead last in the U.S. in OB-GYNs per capita (American College of Obstetrics and Gynecology).

During this session, SF #324 (HF #427), would create a new state-sponsored Family Medicine Obstetrical Fellowship program to support maternal health services for rural and underserved areas. Iowa would invest $560,000 to fund four one-year obstetrics fellowships for family medicine physicians who commit to practicing in rural and underserved communities for no less than five years after completing the program. This specialized training would focus on managing pre- and post-natal health care, including for women with complex medical conditions and performing surgical procedures.

It's a step in the right direction, but it's only a band aid for a gaping wound.

Rural Iowa is not alone. In 2018, more than half of U.S. hospitals had no labor and delivery units. A total of seven million women in the U.S. live in areas with minimal or no access to maternal care, according to a 2022 March of Dimes study.

That translates into higher maternal mortality rates. The U.S. averages 23.8 deaths per 100,000 live births-- the highest of all industrial nations. Two women die every day from complications of pregnancy and childbirth, according to the CDC. These include mental health, excessive bleeding, cardiac conditions, infection, blood clots, and high blood pressure. The CDC states that 80% of these deaths are preventable.

Just this week, we learned that by 2021 Covid-19 had caused a major spike in maternal deaths across the U.S.: 32.9 deaths per 100,000 live births. Iowa's maternal mortality rate more than doubled from 2017 to 2020. By 2015, Iowa had jumped by 55%: 22.8 deaths per 100,000 live births, up from 14.7 deaths in 2007.

Many OB-GYN units have been abandoned to keep rural hospitals afloat. It's a similar story: low volume, high per unit costs. In many states, Medicaid pays providers less than half what it costs to give birth. Iowa's privatized Medicaid doesn't cover the full cost of delivering babies. If men could give birth, I'd wager that labor and delivery at rural hospitals would be fully supported.

Many OB-GYN providers also are close to retirement. OB-GYNs train for more years than other specialists; yet their income is lower. What impact would a potential Iowa abortion ban have on our state's capacity to compete for a limited pool of OB-GYNs? Would they think twice about the legal risks of treating women who miscarry, or require abortion care for an ectopic pregnancy?

Last fall, Sen. Charles Grassley introduced the Healthy Moms and Babies Act (SF2062) to address the national maternal mortality rate. It would provide greater telehealth access for pregnant and postpartum women, and improve maternal health coverage under Medicaid and the Children's Health Program (CHIP).

State incentives, such as loan forgiveness or expansion of the graduate medical education system, are long-term strategies. Other efforts include:

·      Rural Iowa Primary Care Loan Repayment Program, supported by state appropriations and private donations;

·      The University of Iowa's Rural Iowa Scholars Program (CRISP);

·      The University of Iowa also offers telemedicine as an option for prenatal and postpartum care; do insurers reimburse at the same in-person rate?

·      The University of Iowa is conducting its first nurse midwife training this year. It offers a master's degree, with emphasis on rural service, training RNs to be midwives.

·      Some Iowa hospitals are using grants to offer satellite OB clinics.

·      Iowa Specialty Hospital-Clarion received $1 million to renovate and expand the labor, deliver, recovery and postpartum rooms, thanks to the USDA's Emergency Rural Health Care Grant Program in the American Rescue Plan Act.

Prioritizing a Healthy Future

I've seen many rural Rx prescriptions play out. In the 1980s and 1990s, 400 rural hospitals closed across the U.S., largely because Medicare was paying rural hospitals less than urban hospitals on the premise that rural costs were lower. In 1997, I wrote about a new Critical Access Hospital designation (CAH). It helped CAHs (fewer than 25 acute care inpatient beds and located more than 35 miles from another hospital) receive cost-based reimbursement for Medicare services. Illinois launched its Rural Medical Education (RMED) program in 1993 to encourage medical students to practice in rural areas, and it has continued.

There's no single solution to the issue of rural health care. In the 1980s, I wrote in Successful Farming magazine that rural health care was an economic development issue. After all, when a company or a business considers locating or re-locating in a community, health care is a top concern for its prospective employees. Health care generates jobs, revenue, and taxes. According to the U.S. Dept. of Labor, a single primary care physician's practice supports about six jobs and has an economic impact on the community of more than $930,000 annually. I could be wrong, but I don't see much evidence that Iowa embraces this model.

In her Annual Condition of the State address, Governor Reynolds promoted the REHs and OB-GYN Fellowships. She blamed hospital closures on "out-of-control" verdicts and medical malpractice costs, suggesting a $1 million cap for non-economic damages, including pain and suffering. She proposed $2 million for More Options for Maternal Support (MOMS), a program modeled after Texas. None of these nonprofits are staffed by medical doctors or licensed health care providers.

Gov. Reynolds made no effort to connect rural health care to broader issues, including rural economic development and the challenges of retaining college graduates. Yet, to bolster rural health care, Iowa must bolster rural communities in a holistic way. After a baby is born at a rural hospital, it follows that its parents will need adequate rural childcare. Iowa only offers paid maternity leave to eligible state employees. The parents of this new baby also will value good, well-funded rural public schools that don't require an hour-long bus ride.

I've lived in rural Iowa most of my life. Within only a few miles of our farm over the past 12 years, three young women have buried stillborn babies. I'll never forget the death of a woman, pregnant with her first child, who stepped into the path of a freight train in a nearby town. Could these deaths have been prevented with more pre-natal visits and tests, or a greater awareness of mental health and depression?

Ibn Khaldun, a political philosopher born in Tunisia in 1332, is credited with the quote: "Geography is destiny." Would he be correct today, regarding essential health care services? Or, is health care a human right? Shouldn't our legislators be more concerned by the lack of OB-GYNs in 66 of our 99 counties? Why aren't they troubled by Iowa's increasing rate of maternal mortality? What about the 24% of rural hospitals at risk of closure in the near future? But, in the last few years, Planned Parenthood Clinics providing health care services to women have been shut down, and Iowa taxpayers now are funding MOMS, a thinly veiled anti-abortion initiative aimed at forcing women to give birth.

Yet our legislators are preoccupied with proposing 30+ bills aimed at trans and LGBTQ children in our schools. They're focused on statewide censorship of school library books, and intimidation of teachers from exercising their professional skills. These are their priorities. The message to rural Iowans regarding health care? Here's another box of band aids.

Photo by Erik Mclean on Unsplash

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