Facilitating Change. Preserving Access.

Crisis: Access

In the midst of the most active hurricane season in the last 60 years, there are additional, metaphorical hurricanes impacting the future of the United States in ways that will have a much more lasting impact on our Country. I will not begin to opine about the metaphorical hurricane that surrounds this election season although it carries an infectious agent that sickens me on a daily basis. Neither will I comment on the specifics of the pandemic that has exacerbated the healthcare paradigm.

I will, rather, try to focus your attention on the metaphorical hurricane that is the constantly deteriorating ability of our fellow citizens to access critical healthcare services. Approximately 60 years ago, the government began to formulate Title XVIII and XIX of the Social Security Act of 1965; Medicare and Medicaid. This landmark legislation guaranteed access to healthcare services for the aged, infirmed, and indigent American citizens. In addition, it created important financial resources for healthcare providers to be able to effectively care for these folks and expand programs and services to maintain health status and expand long term care in their communities.

While certainly not perfect and replete with ‘tweaks’ to coverage and payment mechanisms over the subsequent 55 years, these programs have had a monumental impact on health status indexes as is reflected in average longevity increasing from the 60s in 1960 to the 80s in 2020. The legislation has also fueled technological innovation and exploded the physical presence of healthcare venues to add convenience and timeliness to disease intervention.

Fast forward to 2020 and our infrastructure is crumbling. Mega proprietary healthcare companies dominate the landscape on the payor and provider sides of the equation; publicly traded and generating billions of dollars in profits. HHS has abdicated and outsourced the management of Medicare and Medicaid to private insurance companies through the creation of Managed Care Organization (MCO) contracts which, in turn, generate huge profits for these companies in the name of “efficient contract management”.

Healthcare in the United States is approaching twenty percent (20%) of our Gross Domestic Product (GDP). To put that in perspective, all other developed, first world countries do not approach ten percent (10%). If 20% of our economy is dependent upon healthcare enterprises, is it approaching the banking industry of 2008 being “too big to fail”? The problem is: It is failing!! Just like diabetes causes neuropathy as it progresses over time, healthcare is failing in the extremities of its infrastructure. The growing “numbness” in its fingers and toes is reflected in the continuing closure of rural and community hospitals across the country who are no longer able to survive with declining reimbursement rates, shrinking procedure and admission volumes, and deteriorating, costly-to-maintain, physical plants.

In reality, there is no money (smart money) to turn this around in its current form. Trying to maintain the status quo in any facet of healthcare delivery going forward is foolhardy, at best. Current delivery models are evolving, in part, due to the impact of the pandemic. However, as long as the reimbursement and delivery models are based upon cure rather than prevention, our system of healthcare is unsustainable and will collapse in the next ten years.

Am I prognosticating Armageddon? In fact, I am. There is no appetite, currently, for radical change. Healthcare is like an aircraft carrier that requires nautical miles to turn around. We do not have time for that kind of navigational change. However, the healthcare landscape can begin to be impacted in a positive way by crafting a proactive plan based upon preserving access to critical healthcare services in rural America.
As hospitals close or enter bankruptcy protection, efforts must be undertaken to re-imagine the mission of that healthcare organization to the community it serves. Clearly, the “failure to thrive” for healthcare facilities in rural America is multi-factorial, as described, above. In large measure, it results from three factors:
Increasing overhead costs due to deteriorating physical plants and required staffing levels for regulatory compliance.    
Declining reimbursements per encounter.    
Declining volumes (visits/procedures/stays) due to loss of providers/specialists and general out-migration.

This downward spiral usually includes negative press from patient complaints, general concern about quality of care, and efforts by competing healthcare providers to erode market share through the development of clinics and urgent care centers in that community where the failing hospital resides. With no resources to fight back, the downward spiral accelerates.

When this happens, access to critical services is lost. The emergency department, diagnostic services, therapies, and primary care intervention can only be accessed through significant travel time to a neighboring community; valuable time that could mean the difference between life and death. Continuity is lost and, one of the important legs of the economic development stool, is fractured.

Rural and community hospitals, whether traditional acute care or Critical Access, cannot be all things to all people and provide a comprehensive compendium of services to their respective communities going forward. It is cost-prohibitive and egocentric!! Moving to a proactive, population health management model must focus on those critical services mentioned in the previous paragraph, referral relationships with larger health centers, telehealth, and an effective EMS and transportation infrastructure.