Rural Outmigration and Access to Healthcare
One in five Americans – almost 60 million people – live in rural America, and rural communities cover over 97% of the country according to the U.S. Census Bureau. Despite their prevalence, many Americans living in rural areas have lower access to healthcare than their suburban or urban counterparts due to limited transportation, low access to health insurance, economic status and age.
“Rural hospitals are essential to care in rural populations and play a momentous role in improving access to care for at-risk populations,” said Susan Longfield, VP, Growth Strategy and Development at Intellimed. “They also form a critical component of the local economy.”
Despite their importance, 25 percent of rural hospitals are currently at a high risk of closing due to financial issues according to Guidehouse’s 2020 Annual Rural Hospital Sustainability Index. Of these at-risk hospitals, over 80 percent are considered to be essential to their communities.
COVID-19 has made the plight of rural hospitals increasingly dire, as elective surgery volumes continue to stay low. Despite this, one of the toughest long-term challenges facing rural providers continues to be rising rates of outmigration from rural areas to large cities and suburbs.
Leaving for Care
There are a number of factors that lead patients to seek care outside their communities, including previous relationships with providers, need for higher levels of care, or negative perceptions of the local facility. This paired with the migration of younger people to cities, difficulty with physician recruitment and lack of funds to invest in new services means that rural hospitals are facing an uphill battle trying to stay afloat.
While rural hospitals are able to keep some lower-acuity cases for which the hospital provides associated services, over 68% of patients still traveled to a non-local facility to receive this care. This directly impacts the hospital and overall local economy, as that is revenue that could be staying closer to home. As patient volumes go down and more people travel to get care, this can lead to intense financial strain and eventually hospital closures.
“Often, rural hospitals are one of the largest county employers and vital to the economic health of that community,” Longfield said. “Without these lynchpins, outmigration increases and the community loses key services.”
A 2006 Health Services Research study found that when the sole hospital in a community closures, per-capita income decreases by 4 percent and the unemployment rate increases by 1.6 percentage points.
More importantly, it also impacts mortality rates. Proximity to care is vital, and if a local hospital has shuttered its doors, residents have to wait longer for critical care after a heart attack, car accident or other emergency. This can have a profound impact on health outcomes.
A 2019 study from the University of Washington found that rural hospital closures cause average inpatient mortality to increase by 8.7 percent for time-sensitive conditions like stoke, sepsis and asthma/chronic obstructive pulmonary disease (COPD). Impacts on Medicaid patients and racial minorities were worse at an increase in mortality by 11.3 percent and 12.6 percent, respectively.
Case Study: Northern Nevada
Tracking outmigration can be tricky for hospitals. One of the easiest ways to do this is by examining patient origin data and market share by service line, but even this has its limits. Many hospitals, if they have access to data, only have it for their own facility which makes it virtually impossible to measure outmigration.
Others may purchase state datasets or MEDPAR data, but it can quickly get overwhelming to clean and process all of the information, and it only shows intrastate outmigration. If a provider is located nearby a state boarder, they will need access to data from their neighbor get a full picture. Many hospitals face issues getting and processing data from other states, as some states bar access from outside use.
For example, counties in Northern Nevada see a lot of outmigration to nearby states like Utah and Idaho. In 2019, the entire state of Nevada had 366,995 inpatient cases. However, looking closer at Elko, White Pine, Eureka and Lander Counties, 7,755 inpatient cases were forecasted – but only 3,678 cases were reported – a difference of 3,877 cases or almost half of the expected rate.
This shows a significant amount of outmigration from this region – and, paired with their geographic location in the northeast part of the state, much of these cases are traveling out of Nevada entirely. Looking at 2019 Utah data, we can confirm that 2,048 cases from those four counties traveled to Utah providers. To see outmigration to other states, we’d have to look at it from a state-by-state basis. When looking at outmigration, the more data the better. We suggest those measuring it utilize multiple datasets to confirm their findings.
This crisis has been approaching for decades, and as local health care leaders act to preserve and protect their rural hospitals and communities, groups like the NRHA and AHA have been working to develop solutions. They have helped stem the tide of outmigration and worked to bring care back into communities by partnering with state and federal leaders to change rules, pass laws and develop Medicare waivers.
In the meantime, rural hospitals can take other steps to address outmigration including:
- Partnering with other hospitals, health systems, payors, ACOs or others.
- Develop bilateral referring relationships in order to encourage return referrals for local diagnostic and follow-up care.
- Identify and work with local community leaders to build trust and promote local services
- Leveraging data and other resources to monitor outmigration and determine why people are leaving.
- Prioritize and invest in services from a community need and revenue-generating perspective.
If you are interested in learning more about how to use healthcare data to combat rural outmigration, reach out to us today to see if you qualify for our Community Blueprint solution. Specifically designed to be accessible and affordable for independent community hospitals, it draws on a combination of inpatient, outpatient, demographic and claims data to give you a complete view of your market in a customizable package.
Since 1983, Intellimed has been at the forefront of healthcare analytics, providing services and solutions that give healthcare providers the tools they need to make data-driven decisions. Led by a team with decades of experience in healthcare management, data analysis and market research, Intellimed offers clients actionable intelligence and unparalleled support. Headquartered in Phoenix, Arizona, Intellimed serves leading healthcare companies across the U.S., including hospitals, healthcare providers, payors and more. To learn more, visit us at Intellimed.com or call us at (888) 214-1415.
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