Rural/Critical Access hospitals can maintain up to 25 inpatient beds, but researchers with the Bipartisan Policy Center and the Center for Outcomes Research and Education found only three to five of those beds were occupied on average in the seven states they studied, a costly proposition for those facilities.

For the report, researchers talked to more than 90 thought leaders and stakeholders in seven states last year to learn about the ongoing challenges rural healthcare providers face and the implications of federal policies and areas for improvement.

The states included in the study—Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming—have some of the lowest population densities in the country. Of the nation’s nearly 1,340 critical-access hospitals, one-quarter are located in these states, according to the report. All seven states have obesity rates exceeding 31%, and North Dakota and Wyoming have some of the highest smoking rates in the country, at 19.8% and 18.9%, respectively.

Local providers told BPC their patients are older and spread out, and that the lack of access to the care they need can have “devastating consequences,” the report says. Shortages in behavioral health and obstetrics providers, nursing homes, ambulance services and non-emergent care were highlighted as rising concerns.

Critical-access hospitals are a touchy subject for stakeholders in the states studied, as they’re typically an important economic component of rural communities, but in some cases aren’t financially sustainable because of low occupancy. Critical-access hospitals in South Dakota, for example, see an average of five patients per day, the report found.

“Participants in this project struggled to reconcile their opinions that CAHs are no longer the most efficient way of delivering care in rural areas with concerns that closing the hospitals would still create access issues for communities and would have a negative effect on local economies,” the report said.

How to reinvent critical-access hospitals to better serve communities is undecided, Parekh said, but it would likely combine primary care with acute services.

A number of different formats have been floated.

“At the end of the day, a transformed entity is better than a closed entity for both the community health and the local economy,” he said.

U.S. Sen. Chuck Grassley is championing a proposal before Congress called the Rural Emergency Acute Care Hospital Act, which would create a new Medicare classification to allow rural hospitals to limit themselves to providing emergency and outpatient services. The bill doesn’t have a House companion.

“The goal of the REACH Act is also to help rural hospitals stay open while meeting the needs of rural residents for emergency room care and outpatient services,” Grassley said in a statement.

The National Rural Health Association, which represents rural hospitals, supports the REACH Act, but prefers its own proposal, the Save Rural Hospitals Act. That would allow for the creation of “community outpatient hospitals,” but also includes increased Medicare funding and other provisions.

Nonetheless, Brock Slabach, NRHA’s senior vice president, said, “We’re willing to work with anybody on working towards a new model.”

Another resounding take-home message that emerged: There’s no one-size-fits-all policy that will tackle the challenges in every rural community. Solutions will have to be flexible.

Congress and the current presidential administration have largely left rural communities out of value-based payment initiatives, focusing instead on strengthening those systems’ financial viability and access to healthcare in those areas, according to the report. Most delivery system reforms under the Affordable Care Act either outright excluded rural healthcare providers or allowed them to participate with little financial risk.

The NRHA has developed a proposal to help critical-access hospitals to dip their toes into value-based purchasing. It would increase hospitals’ Medicare reimbursement by 2% if they submit quality data, which they’re currently not required to do, and agree to join Medicare managed-care groups. Slabach said the proposal will likely be introduced in Congress next month.

While the ACA didn’t address telehealth and other remote-monitoring technologies in rural areas, the new report said it’s becoming increasingly important for rural communities. Significant barriers exist, however, including continued discomfort with the technology among providers and staff in the states studied. Local providers said both private and public payers have limits around what types of telemedicine they’ll reimburse for, and it’s not always the same as an in-person visit.

All states studied have changed laws to allow nurse practitioners to practice independently without direct supervision by a physician. Other states are considering allowing pharmacists to perform medication management for patients, although various provider associations oppose such measures, the report said.

Rural communities are also embracing the use of community health workers, case managers and care coordinators that travel to patients and help arrange their care. In-home care workers who visit several patients a day are also becoming increasingly important in rural areas with aging populations