May 8, 2020 | Hometown health
Rural health care is deeply personal for Ashley Thompson. Her great-grandmother, Irma Bergeson, was a nurse in a rural hospital in northwest Iowa and was the first district vice president of the Iowa Nurses Association. Thompson’s husband, Nate, grew up in rural Iowa and is CEO of the Story County Medical Center in Nevada. Many of her immediate and extended family members work in the field.
Thompson works in health care as well — as the director of government and external affairs for UnityPoint Health — and plays a key role in shaping the rural health system. Thompson supports advocacy, legislative and policy efforts that affect patients and health care providers in Iowa, particularly UnityPoint’s critical access and rural hospitals, rural health clinics and community mental health centers. She sees firsthand the challenges and opportunities these areas face.
“While our health care providers and professionals are needed now more than ever, and they are delivering high-quality essential services to our rural communities, the challenges we face are significant and increasingly so,” Thompson said. “Delivering health care in our rural communities is distinct from how we provide care in our metro areas and in other parts of the country.”
From physician recruitment to a precarious financial situation and the unprecedented COVID-19 pandemic, the rural health care system does face daunting challenges. But there are opportunities as well. Seizing them will help provide critical services for our state’s rural areas, where about 1 in 3 Iowans live.
Iowa doesn’t have the grand allure of mountains, oceans, big sports or large cities. The large majority of the state is considered rural. Those factors can make it hard to recruit high-quality and talented doctors to practice in the state. Iowa ranks 42nd in the nation for the number of physicians per 100,000 people, according to a January 2020 report from the University of Iowa Carver College of Medicine.
But there are many other factors beyond geography that hinder Iowa.
“We struggled to get doctors to come to Iowa to begin with, and, yes, the rural areas even struggle more than Des Moines, Iowa City, Cedar Rapids and more,” said Dr. Christina Taylor, chief quality officer at The Iowa Clinic. “And now with Iowa being so incredibly far behind all of the other states, even our own ‘sons and daughters of Iowa’ that are going off to medical school are not easily returning because of the malpractice [insurance] and inability to afford it and make a living.”
Iowa’s reimbursement for Medicare payments is extremely poor. The state ranks 51st among states and territories for Medicare reimbursement, falling behind Puerto Rico. That can make it harder for physicians to practice and take care of the large elderly population in rural areas. It’s a big part of why Iowa’s rural hospitals are struggling — both financially and in recruiting physicians.
Steve Cassabaum of 21st Century Rehab knows that story all too well. His organization provides physical, occupational and speech therapies in addition to sports medicine and occupational health services. It operates several clinics, but also provides services to rural hospitals across Iowa.
He has noticed reimbursements from all types of providers — Medicare, Medicaid and private insurances — declining across the board. That puts hospitals in a precarious spot.
“It’s a big part of [the financial hardships],” Cassabaum said. “I think the health care system in general is not well run. I think they give incentives for the wrong reasons, but most of the problems come from reimbursement. It’s had a big impact on rural hospitals.”
Another big challenge in recruiting workforce has been the continuing divide between Iowa’s urban and rural areas. Many skilled workers are moving to the state’s most populated areas, which creates a shortage in rural hospitals.
There’s work being done to address this shortage, from the state all the way to the local levels. Thompson said the key will be helping rejuvenate rural towns and areas to help make them a more attractive place to live and work.
“Oftentimes, when we are recruiting a new health care professional to one of our rural hospitals or clinics, they have a spouse who is also looking for employment opportunities in our towns and children who would be enrolling in our local schools,” Thompson said. “So having a vibrant, family-friendly community with housing options, a good job market, excellent schools and social opportunities is essential to growing our rural workforce.”
There is also a push for Iowa to grow its own generation of doctors and health care providers, which would help bolster workforce over the long term, Thompson said.
DAMAGES ADD UP
The tough financial situation for rural health care is exacerbated by Iowa’s outdated malpractice laws. The Iowa Medical Society, a statewide professional association representing Iowa physicians, residents and medical students, goes so far as calling it a crisis.
According to figures from the Iowa Medical Society, Iowa has seen a substantial jump in high-dollar malpractice awards against physicians and facilities. In the past three years, five cases alone have resulted in $85 million in damages. Many of the surrounding Midwest states put a cap on noneconomic damages — damages associated with pain, suffering, inconvenience, physical impairment, mental anguish and more nontangible effects. These damages can often push up the reward of lawsuits into the tens of millions of dollars.
Iowa hospitals have felt the blow, said Jodi Schweiger, employer health services director at The Iowa Clinic.
“It’s really placing these small rural facilities in a financial pitfall,” Schweiger said. “We’re seeing that it’s causing a lot of problems for Iowans, especially when they’re out in these rural areas. They don’t have a lot of options. We’re trying to come together as a state and as a health system to bring awareness to the need for tort reform.”
The problem extends to recruitment as well. Without a cap on malpractice damages, physicians might be wary of practicing in the state.
“We’re also seeing that this makes it even more difficult to actually recruit physicians in Iowa because it has astronomically increased liability insurance,” Schweiger said.
In February, a bill that would put a cap on the amount of damages awarded in medical malpractice lawsuits was proposed at the subcommittee level. The bill would make $250,000 the maximum amount a jury could award for non-economic damages. The cap would not affect economic damages awarded for lost wages or health care costs. But due to COVID-19, the bill has been put on pause.
PANDEMIC BRINGS ISSUES TO LIGHT
COVID-19 has brought to light many of the problems stated above, particularly the workforce shortage. Front-line health care workers are essential in the fight against the pandemic, but Iowa was already facing a problem before the illness swept the nation in early spring.
In a study released in January, the University of Iowa Carver College of Medicine found Iowa is short 361 physicians across eight different specialties. More than 8,000 job vacancies are estimated in the health care and social assistance spaces, according to a 2019 workforce needs assessment by Iowa Workforce Development.
Cassabaum said many urban hospitals are bracing for an influx of COVID-19 patients, meaning many people are being referred to places outside of the metro area for care. That means rural hospitals are busier than normal, putting a strain on the workforce.
“Some rural hospitals have become very busy on the inpatient side because other beds in some hospitals are being held for COVID-19 patients,” he said.
For the most part, people have stayed away from hospitals unless it’s a dire emergency. Many elective surgeries have been canceled. And that’s helped capacity, but it has also put a burden on patients who might be afraid to seek help in this time of crisis.
“In general, patients across Iowa are staying home like they are told to do, but patients are also neglecting their health, which is not good,” Taylor said. “Patients with chronic conditions need to continue to have their follow-up appointments with their doctors. If they don’t, their conditions could worsen, and that could land them in the emergency room, which is the last place we want them going right now.”
Taylor said many patients are taking advantage of virtual visits via video chat. But in rural areas, access to internet can be spotty, making it difficult to do an audio or visual visit. The Iowa Clinic has been forced to shut down almost 20 outreach clinics — located outside of Iowa’s most-populated areas — to focus on COVID-19 capacity.
UnityPoint Health said it was working in cooperation with other organizations to monitor the effect of COVID-19 on rural hospitals.
“UnityPoint Health and our fellow health systems across the state are working closely with the governor’s office, Iowa Department of Public Health and important state association partners like the Iowa Hospital Association and the Iowa Rural Health Association to monitor the impact of COVID-19 on rural hospitals in Iowa and advocate for funding to ensure sustainability during the unprecedented crisis,” Thompson said.
THE PATH FORWARD
Amid the hardships Iowa’s rural health care system faces, there are opportunities to grow.
Thompson believes one of the biggest areas of improvement is technology. Broadband can be hard to access in many rural areas, which makes in-person treatment a necessity. But if the state could better tap into video or phone services, people may be able to get care remotely.
“Technology is a tool that can help many of us with our health care needs while addressing barriers such as lack of transportation, lack of health care providers in a community or taking time off work,” Thompson said. “Supporting full telehealth parity — meaning our doctors and health care providers are paid the same for providing care whether they are doing so in person or through telehealth — will help ensure access to care for all Iowans, no matter where we live.”
Cassabaum sees an opportunity in changing the way the health system looks at care. As a physical therapist, he said preventive and conservative care provides enormous benefits and can actually reduce the amount of surgeries and testing needed after an injury.
The problem is that type of care isn’t financially lucrative enough, meaning hospitals, which may already be struggling, usually choose other types of services.
“The savings are astronomical,” he said. “The way it’s set up now sets up the system for more failure for spending more money than they should. There needs to be incentives in place so we can have that type of care for all patients.”
Schweiger emphasized the need for tort reform, and limiting the amount of damages allowed in a malpractice lawsuit. She said that affects everything from the financial viability of hospitals to the ability to recruit physicians to Iowa.
“Tort reform is a huge, huge issue,” Schweiger said. “It really does affect the whole state.”
Iowa’s health care system is full of innovative people who are passionate about improving patient care. Ultimately, they will help lead the path forward, Thompson said.
“We have so many passionate health care providers, advocates, leaders and everyday Iowans who are working to pave the way for Iowa to improve our overall health and health care,” she said.