Since the outset of the pandemic, rural areas have seemed somewhat insulated from COVID-19 as cases surged in densely populated areas like New York City. Not anymore.
As novel coronavirus cases across the U.S. edge closer to 5 million, rural areas are now experiencing similar rates of spread — but they also face a serious dearth of medical resources to handle it.
Rural hospitals are disappearing. The Centers for Disease Control and Prevention (CDC) says 170 hospitals have closed since 2005 with 700 more currently at risk of closure. When rural residents do get sick, many must travel long distances to reach hospitals and other healthcare facilities. Among rural hospitals that do exist, most lack the critical care equipment and staff to treat COVID-19 patients. These facilities have a severely limited number of hospital beds, ICU beds, or ventilators. Some have no ICUs at all.
In many cases, the only way to give patients the care they need is to transfer them to a hospital that can — and that is not easy.
Evans Memorial Hospital in southeast Georgia, for example, recently had to search long and hard to find another hospital that would accept the transfer of a very sick COVID-19 patient, reported Georgia Health News
. With no ICU or critical care beds, they reached out to 14 other hospitals before finally finding one that would accept the patient, only it was two states and 500 miles away in Bowling Green, Kentucky.
The Georgian county population is about 10,000, and saw an increase in cases from 79 two weeks ago to more than 200 today. “We are seeing quite a spike, through the ED [emergency department] and for those who are being admitted," said Evans Memorial Hospital CEO Bill Lee.
About 46 million people live in rural areas across the country, and they may also be at higher risk of severe illness from COVID-19 because they tend to be older and have underlying chronic illnesses and disability, according to the CDC.
Yesterday, President Trump signed an executive order to improve rural health and telehealth access which includes upgrades to infrastructure, steps to improve the health of rural Americans, reducing some regulatory burdens and other developments but not much to attenuate the existing shortage of critical care facilities and clinical staff. Although the president did note the scarcity while signing the order at the White House, he pointed to reimbursement hurdles, stating that they have led to reduced patient volume and hospital closures.
“Since 2010, the year the Affordable Care Act was passed, 129 rural hospitals in the United States have closed,” Trump said. “Predictably, financial distress is the strongest driver for risk of closure, and many rural hospitals lack sufficient patient volume to be sustainable under traditional healthcare reimbursement mechanisms. From 2015 to 2017, the average occupancy rate of a hospital that closed was only 22 percent. When hospitals close, the patient population around them carries an increased risk of mortality due to increased travel time and decreased access.”
New research featured in Health Affairs
also examined the disparities in community ICU beds by median household income. Not surprisingly, 49% of the lowest-income communities had no ICU beds in their communities compared to only 3% of the highest-income communities. Furthermore, income disparities in the availability of community ICU beds were more acute in rural areas than in urban areas.
Research shows telehealth is an important tool for rural hospitals in treating COVID-19, and with the help of government funding, rural hospitals, including those in Oklahoma, have already been using it to manage difficult-to-staff environments.
"Prior to the outbreak of COVID-19, many rural hospitals in Oklahoma were already under serious financial strain, dealing with a very fragile financial outlook," said Rhett Stover, MHA, FACHE, and CEO of Oklahoma State University OSU Medicine, in a statement. "Through the availability of COVID-19 stimulus funding, many rural facilities have benefited from the receipt of additional resources, better positioning each to respond to the increased pressures caused by the novel coronavirus pandemic."
And surgeons at a rural healthcare system on both sides of the New York-Pennsylvania border have reported on their preparedness response plan
for dealing with the COVID-19 surge in an article published in the Journal of the American College of Surgeons. The plan includes greater utilization of telehealth, and coordination of resources and communications at affiliated centers spread over a large geographic area.
"We have an older patient population, and they have more comorbid conditions than what you might find in an urban area," said Jean Miner, a general surgeon at Guthrie Clinic/Robert Packer Hospital in Sayre, Pennsylvania. "Our population is also very spread out, with about 77 people per square mile, and some of the research shows that up to 35 percent of the people in rural areas don't have Internet access. Some of our staff doesn't even have Internet access." By comparison, New York City has about 27,500 people per square mile.