The Transformation of Rural Health

Healthcare is changing.   I’m reminded of the old television show with Redd Foxx, grasping his chest and proclaiming “This is the big one!”

Politicians come and go, CMS programs, revisions and studies change on a moment’s notice, reimbursements are cut, and missions are altered. Above it all, are the relentless market forces that force us to rethink what we are doing and why we are doing it.

We are told that the healthcare industry must change from being a reactive episode-based system to a collaborative, proactive process that enhances wellness, provides health maintenance and reconnects the physician and the institution with the community. We cannot look to others to make this happen. It’s up to us.

Perhaps it is time to rethink our mission, define the basics of community wellbeing and structure our services too efficiently and effectively meet those needs. At the present time, our rural and community hospitals are too expensive and inflexible. They are too often built as a smaller version of a metropolitan hospital rather than that of a unique complimentary care provider.

But what does the face of rural health look like? Is it a hospital? What is different than its current state and what are the advantages of changing?


New wellness/rehab addition at Butler County Health Care Center, David City, Nebraska                         Daubman Photography

“Shifting healthcare from a point of service clinical model to an ongoing dialog between patients and providers is a profound societal and [technological] shift.” Robin Guenther, Fast Company

Think of a community wellness organization as an enhanced Dr. Welby. (If you can remember Redd Foxx you may remember Dr. Marcus Welby.) People don’t want more treatment, they want better health. Most of all, they want to associate and form relationships with people who genuinely care about them.

The people in mid-America are known for their self-reliance and ingenuity. The trend underway from governmental agencies is that rural healthcare will be squeezed either through reduced reimbursements or geographical restrictions or both. The future most likely holds the elimination of cost-based reimbursement with the adoption of value-base compensation taking its place. Vertically-integrated accountable care organizations, together with accompanying mergers and consolidations, are sweeping the country. It is time for rural America to exhibit the qualities that are its strengths. We must form our own future.

Healthcare in rural America can define its own destiny and fulfill its mission of service to the community by weaving itself into the fabric of the local culture. This can be accomplished by developing systems that respond directly to the health needs of the people both inside and outside of our walls.   In order to do so, we must position our organizations to take advantages of those services that we can provide better than anyone else, improve the services that are marginal and be willing to forego those services that we are not able to provide in a high quality, cost effective manner. In a value-based healthcare system, resources will flow to the highest quality lowest cost provider. It will be in the best interest of affiliated partners to maintain population health at the most basic level of care in the patient’s home and in the patient’s home communities.

We think the following statements ring true:

  • Healthy lifestyles make healthy communities. Healthy communities make high quality, efficient healthcare systems. Sponsorship of farmers markets and other nutrition programs build community interest in wellness and integrate individual responsibility for healthy choices. Wellness programs can become community social attractions to define the local healthcare center as the source of health and vitality.
  • Facilities must be easily accessible, flexible and reconfigurable. The facility must be re-envisioned to focus on the provision of services that will maintain health, enhance public participation and redefine the scope of care. These health centers will be a reflection of individual community needs and the mission of the providers.
  • Information concerning a patient’s health should be available to care providers anywhere at any time. Mobile health tracking devices should be used extensively within the parameters of patient privacy. Physicians and nonphysician providers should be freed from the confines of clinics and hospitals. Care coordinators, working with mobile care providers should visit the homes of those with chronic illnesses to find ways to improve their medical conditions.
  • The primary care physicians are critical to the success of rural health. Local health care facilities and physicians should work together to form strong collaborative arrangements. Collaborative organizations can simplify payment structures, realign physician/patient relationships, increase physician compensation and provide payment mechanisms for patient-centered medical home programs.


It all starts in the Home:

Since 75% of medical costs in the United States can be traced to chronic diseases, significant economies can result from proactive interventions including proper nutrition and monitoring of medications together with social support services. The patient care coordinator becomes an emerging profession in a value-based care model. This critical position becomes the focal point that connects and monitors the relationships formed between physician and nonphysician providers and members of the community. Patient care coordinators use information gleaned from a broad base of data to form courses of action based on predictive modeling. Through consultation with physicians and nonphysician providers, a broad spectrum of support services can be deployed to improve health outcomes within the service area of the providers.

direct care model

New technologies including digital communication devices (such as smart phones and digital tablets) hold the promise of closely monitoring patient conditions, providing a remote personal interface with care providers, scheduling appointments and delivering test results. It is important to note that nothing can replace the personal contact and relationship formed between the patient and the care provider. When an electronic interaction is appropriate, a mobile care provider should be present in the patient’s home and facilitate that interaction. The mission of the mobile care provider is to use their personal communication skills and the mind of a detective to ferret out any impediments to good health regardless of the source. This integrated collaborative team, focusing on the individual, is the key to the success of an improved national healthcare system.

“Healthcare provision is specialized down to the patient, who is treated as individually as a snowflake.” Pierce Story


The Creation of Wellness Districts:

The transition of our present fee for service compensation model to a value-based compensation model is no small task, but it is an imperative in the quest to reduce costs while, and at the same time, improving safety and enhancing outcomes. It is envisioned that the immediate future of rural healthcare may take on the following features:

Rural community, county and critical access hospitals will become components of Wellness Districts composed of Life Enhancement Centers coupled with physicians and physicians groups. These Life Enhancement Centers (LEC) are flexible and agile facilities containing a variety of services meeting the needs of the population. The LECs could contain: patient-centered medical home physicians’ offices, wellness and rehabilitation centers, specialty clinics, diagnostic centers, wound care centers, nutrition and cooking classes, outpatient treatment centers and urgent care facilities. LECs may include related services including dental offices, eye care specialists and retail functions including: durable medical equipment, opticians, retail pharmacies, food services etc.

Wellness Districts will receive payments for maintaining the health of the people in the service area.   The Wellness District would receive a prepayment from the state for Medicaid participants, the Centers for Medicaid and Medicare Services (CMS) for Medicare participants. They would also receive prepayments from local employers and from private citizens to provide for the individuals unique health needs. This value-based compensation would include funds for catastrophic wrap-around insurance coverage for major life threatening events such as heart failure, cancer, trauma or other services not provided by the Wellness District. The Wellness District would have the incentive to keep the people in its service area healthy to reduce its costs and increase its margin.

The advantages of this system are multiple and profound:

  • The system can redefine and realign the relationship between the care provider and the care recipient. This is particularly effective when the recipient has some investment in the process such as through a private payment or a health savings account. Employer sponsors may also contribute to a realigned emphasis on wellness. Through whatever means available and appropriate, an effort should be made to incentivize good health, wellness and participation by all parties.
  • Contracted direct primary care provides an efficient payment mechanism to allow care givers to customize and to tailor wellness programs to meet the specific needs of the recipient. The goal of caregivers, under a properly designed value-based program, is to maintain and/or improve the health of the covered population through lower cost proactive interventions. It will be in the best interest of the providers to offer wellness programs, nutrition programs, dependent chemical dependency cessation assistance, and group health education programs to the recipients.
  • By elimination of small claim processing costs, collection of unpaid accounts, co-pays, unnecessary clinic visits and overhead costs can be dramatically reduced. Patient-centered medical home practices are shown to reduce emergency room visits, emergency medical services, costs associated with readmissions, etc.
  • Resources in a vertically-integrated system will flow to the highest quality, lowest cost provider. It will be in the best economic interest of large hospitals to enhance the quality and extent of services offered by wellness districts. Therefore, larger hospitals and hospital systems will extend specialty physicians and services to rural areas and will provide assistance for technical support related to electronic health records, data mining and in-home health monitoring systems.
  • When rural health facilities focus on community involvement based on good health, it can spawn economic development. Evidence of this may be a simple as a wellness district’s support of a farmers market encouraging the use of high quality locally-grown food products coupled with nutrition education programs. An LEC may also become a hub for not-for-profit entities and retail stores supporting sports and wellness activities within mixed-use developments.

“Create an agenda that goes beyond healing that would be appropriate, unique and perhaps life changing for your patient population.” David Rockwell


Douglas Elting

January, 2014

Edited: Oct 2015