Health care in the United States has seen tremendous change in the last 2-3 decades, stemming from a dramatic push to contain spending, a call to action to improve quality and safety, and a boom in technology and medical advancement.
While the specialty of hospital medicine in the United States matured in response to these calls to action, it mostly flourished amidst – and as a result of – market consolidation, cost containment, the rise in the underinsured, and the flight of primary care from hospitals.
Changes in the health care industry have paralleled other parts of our society. Health care organizations, like schools, churches, theaters, parks, and sports teams, are part of the social fabric of communities. They provide stability to communities as employers, educators, social supporters, and the provision of services. It is no wonder then, that smaller communities, rural areas in particular, flourish or wither when one or more of these institutions, especially health care, fail them.
Health disparities result from any number of factors but particularly when communities are destabilized. The Robert Wood Johnson Foundation has studied this across the United States. For example, in the Twin Cities of Minneapolis–St. Paul, Minn., where I live, life expectancy varies by over 10 years along the interstate highway that runs through the metro area. Similarly, this disparity is seen between urban and rural Kentucky.
To be sure, the confounding social determinants of health and the mitigating strategies for the communities are different in urban Minneapolis than in Wolfe County, Kentucky. However, much of the work around health care reform (and therefore, hospital medicine) has centered around urban populations such as Minneapolis rather than rural populations such as Wolfe County. While 80% of the U.S. population lives in urban centers, that still means that 1 in 5 people live in rural America – spread across 97% of the U.S. land mass. These rural populations are exceedingly diverse, and warrant exceedingly diverse solutions.
Eighteen years ago, when I started my career in hospital medicine, I would never have thought I would be a spokesman for rural care. I identified as an urban academic hospitalist at a safety net hospital known for serving the urban poor and diverse refugee populations. But I had not anticipated mergers involving urban and rural hospitals, nor our resulting responsibility for staffing several critical access hospitals in another state.
It was hard in the beginning to recruit hospitalists to rural areas, so I worked in those areas myself, and experienced the rich practice in nonurban centers. As our partners also joined in our efforts to staff these hospitals, they had similar experiences. Now we can’t keep physicians away. That is not to say that the challenges are over.
Since 2010, 26 states lost rural hospitals – over 80 hospitals in total. High premiums in the individual health insurance market have driven healthy people out of risk pools, pushed payers out of the market, driving premiums higher still, resulting in coverage deserts. Consolidation and alignment with urban and national health care organizations initially brought hope to cash-strapped rural hospitals. Instead of improving local access, however, referrals to urban centers drained rural hospitals of their sources of income.
Economic instability has further destabilized communities. Rural America is exceptionally diverse, and has higher rates of poverty and the working poor, a shrinking job market that still hasn’t recovered from the 2008 recession, and higher rates of disability when compared to urban America. Do I even need to mention the rural opioid epidemic? Or the rural physician crisis, with a dwindling 12% of primary care and 8% of specialty care in these communities?
There is hope. During a late-night text conversation with a millennial nocturnist who splits his time between large and small hospitals, I received this message at 11:42 p.m.: “I think I feel more appreciated/valued/respected out here. You know how it is at the smaller hospitals.”
This was a comment the young hospitalist made after he shared with me that, lately, he had been in a “funk.” Innovations such as telemedicine have brought balance to overworked rural family doctors and excitement to young, tech savvy hospitalists. Opportunities to educate rural nurses and increase the level of care, keeping patients local, have excited academic hospitalists and rural CFOs alike. For a physician in a high burnout specialty, a long peaceful drive through the country might be just what’s needed to encourage a few moments of mindfulness.
Many of our urban health systems have combined with rural ones. It’s time to embrace it. Ignoring the health disparities in rural America divides us and diminishes essential parts of our health care system. Calling the hospitals our patients are referred from “OSH” (Outside Hospitals) will only perpetuate that.
Hospitalists have an opportunity to play an important role in stabilizing rural communities, reviving rural health systems, and providing local access to health care. Let’s embrace this opportunity to make a lasting impact on this frontier in hospital medicine.
Dr. Siy is chair of the department of hospital medicine at HealthPartners in Minneapolis–St. Paul, Minn., and a member of the SHM board of directors.