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The Challenges of Rural Health · CareTalk: Healthcare. Unfiltered.

• 0:00
  David: Well, rural communities have fewer doctors, nurses, and medical facilities per person than the country as a whole, and some rural hospitals have closed, leaving large geographic areas without any local services.
• 0:12
  David: Plus the population is older, sicker, and more likely to have unhealthy habits like tobacco use and less likely to have access to reliable transportation to get their appointments.
• 0:22
  David: Rural healthcare is a challenge, but is it all doom and.
• 0:25
  David: Stay tuned to find out.
• 0:27
  David: Welcome to CareTalk America's home for incisive debate about healthcare, business and policy.
• 0:32
  David: I'm David Williams, president of Health Business Group.
• 0:35
  John: And I'm John Driscoll, the president of Walgreens Health.
• 0:38
  John: David, it is pretty much doom and gloom, but we should, we should, you should tell, tell our listeners about how we're doing in the, the league tables.
• 0:46
  John: They're, they're, they're, they're really helping us out here.
• 0:49
  David: No, no doom and gloom here.
• 0:50
  David: John.
• 0:50
  David: We have to say thank you to our listeners for making us number two on Apple Podcasts in healthcare.
• 0:55
  David: So I very much appreciate that, John, and I'm sure it's something that you said or I said, but really people must be listening and telling their friends.
• 1:02
  David: Please keep it up.
• 1:03
  David: And what I would say is if you want even more care talk, why not subscribe to our informative newsletter?
• 1:08
  David: It goes deeper into topics that we cover on the show.
• 1:11
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• 1:17
  John: Thank you listeners.
• 1:20
  John: So David, tell us, tell us a little bit more about, I mean, it, it ain't good news.
• 1:24
  John: I mean, you've had 130 plus hospitals close in the, in the relatively recent term, 20 and 2020.
• 1:33
  John: Um, the, the health statistics.
• 1:35
  John: Are kinda lousy.
• 1:37
  John: Uh, and yet, you know, depending on how you con how you counted 15 to 20% of America, 46 million Americans live in rural areas.
• 1:46
  John: W you know, what's, what's the nature of the challenge?
• 1:49
  John: And, and, and where do we stand?
• 1:51
  David: So John, you're right about the hospital closures and we'll come and talk about that a little bit down the road.
• 1:55
  David: I think the place to start is actually the so-called social determinants of health, cuz that represents about 80% of population health.
• 2:01
  John: That phrase, can you at least explain it in human talk as opposed to
• 2:08
  David: economics talk?
• 2:08
  David: Sure.
• 2:09
  David: John.
• 2:09
  David: So there's so-called, can I say socioeconomic factors or is that, is that, I'm gonna say it John.
• 2:14
  David: So, so that's about 40% of overall, you know, healthcare is explained by socioeconomic factors, and those are things like education level.
• 2:21
  David: So there tends to be lower education level that leads to less understanding about.
• 2:26
  David: Things like vaccine, hesitancy's, overall economic challenges, and an older population.
• 2:30
  David: Then there's the health behaviors.
• 2:32
  David: So you.
• 2:33
  David: Tobacco use.
• 2:34
  David: That's a big deal.
• 2:35
  David: John, if we just take a look at this, a lot of people start smoking when their teens are earlier, and that's a hard habit to break, and it's really a killer.
• 2:43
  David: Quite literally 11% of adolescents in rural areas smoke compared to 5% in urban areas.
• 2:49
  David: You've got alcohol, drugs, obesity, diet, and exercise.
• 2:52
  David: Then there's a physical environment.
• 2:54
  David: John, in some cases, people in rural areas have contaminated drinking water.
• 2:57
  David: In particular, they have non fluoridated water, and that leads to having a lot of dental problem.
• 3:02
  David: And broader health problems.
• 3:03
  David: And then you've got transportation issues, lack of public transport, lack reliable.
• 3:07
  John: Hey David.
• 3:07
  John: David, David.
• 3:08
  John: David, your, the list could go on forever.
• 3:10
  John: Let's just break down what the social determinants are.
• 3:14
  John: There are things that are I, I would think causative like tobacco use.
• 3:19
  John: There's no greater public health challenge because the return on the investment of people not smoking saves in cancer.
• 3:29
  John: Heart disease, C O P D, card pulmonary disease.
• 3:33
  John: You've got people in rural areas or, or in many cases, More food insecure and they don't have a social network to help them through things like transportation issues.
• 3:43
  John: And if you can't see the doctor, it's, it's a problem.
• 3:46
  John: Then there are things that I think are more associative, like the fact that people are not as well educated.
• 3:51
  John: I don't really think that's a determinant.
• 3:54
  John: Of health.
• 3:54
  John: It may, it may be an input, but if you, if you can't get good food, and if you are, uh, if you're on opioids or you're smoking too much, that's more causative.
• 4:05
  John: The social determinants really tie to things like economic disparity, where again, if you are, if you're housing or food insecure, you're not gonna be taking care of.
• 4:16
  John: You're gonna be dealing with a lot more stress or specific behaviors.
• 4:20
  John: But again, this cluster term of social determinants of health is a word that is a, is a cluster phrase that only an economist would like.
• 4:28
  John: But let's, let's maybe unpack the specific rural challenges.
• 4:32
  John: You know, you touched on transportation in your ra, in your endless list Yeah.
• 4:37
  John: Of social determinants.
• 4:38
  John: Can you double click on that?
• 4:39
  John: Because I do think that's a, that is a genuine...
• 4:42
  David: it sure is.
• 4:42
  David: John.
• 4:42
  David: So I, I speak with, uh, people including, uh, my brother who's a rural physician.
• 4:46
  David: Ask him what are the big challenges and for transportation, you know, people can't get to their appointments.
• 4:51
  David: So if I live in an, I live in an urban area, I can actually walk, I can take the train, take the car a short distance.
• 4:57
  David: I could take a taxi, I could take an Uber or Lyft if you're in a rural area.
• 5:01
  David: Uh, the same patients, if you don't have your own, uh, reliable vehicle to drive yourself, you know, they don't have any of those other options, uh, that I just described.
• 5:10
  David: So it affects getting to your doctor's appointments for sure.
• 5:13
  David: Uh, but it also affects, you know, being able to go out and pick up your prescription.
• 5:17
  David: And it affects, uh, things like isolation because, you know, you can't go to see people.
• 5:23
  David: Uh, so that's actually usually the main problem.
• 5:25
  David: And it's hard to be, the distances are longer.
• 5:27
  David: So even when you're driving and gasoline is.
• 5:31
  David: Uh, it takes more money to go from one place to the other, so it's actually more expensive, even though the overall cost of living might be lower.
• 5:37
  David: That's what I mean on transportation.
• 5:38
  David: Well,
• 5:38
  John: and, and, and, and, and I think it's even made worse by the fact, I think it's roughly, um, uh, the ratio of doctors to population in urban areas is, is close to, I think 38 docks per hundred thousand residents, and it's north of 50.
• 5:57
  John: Um, uh, sorry.
• 5:58
  John: It's north of 54 docks per a hundred thousand residents in urban areas and 38 docks per every a hundred thousand residents in rural communities.
• 6:07
  John: And that number's actually going down.
• 6:10
  John: Recruiting for rural doctors is very hard.
• 6:13
  John: Most medical schools are in urban areas, uh, and rural health is, is much less of a thing.
• 6:20
  John: Then the super specialization that typically is the kind of career you'd have or wanna be associated with in more of an urban or a suburban area.
• 6:29
  John: You know, your career's gonna be different in a, in an urban area.
• 6:32
  John: And I think that that access to doc crisis is getting worse, which of course makes transportation even more, uh, of, of, of a, of a, of a challenge because that's the only bridge you have, uh, to a doctor that's farther and farther away.
• 6:46
  John: Now I, I'm, I'm very nervous.
• 6:48
  John: Uh, David about the rural health crisis.
• 6:51
  John: Cause I don't, I don't think it's one that's, that, that people think of as a, as a real priority, um, for kind of critical needs in the US healthcare system.
• 7:00
  David: Well, John, we were talking about social determinants, which is word you don't like, but you seem to say it a lot.
• 7:05
  David: Uh, and now let's talk about actually the healthcare delivery, which you started to, to get into when you talked about, you know, doctors and nurses.
• 7:11
  David: The facilities actually in rural areas, you know, there are not as many hospitals.
• 7:15
  David: They tend to be small.
• 7:16
  David: Of course, you're not gonna put a 500 bed, you know, hospital in the middle of, uh, farmland.
• 7:20
  David: A lot of 'em have under 25 beds.
• 7:22
  David: And that means, you know, it's very rare that you're gonna have a lot of specialists there because they're, they're not going to, you know, have enough to do.
• 7:29
  David: Um, and as you mentioned, the, there's a kind of a brain drain actually, because if you're a rural person, let's say you want to go and become a physician or become a nurse.
• 7:39
  David: That means you're going to an urban area for medical school, you're more likely to stay where you train.
• 7:43
  David: Cause that's where the, that's where the jobs are.
• 7:45
  David: So there's a, there's kind of a migration even on the healthcare side.
• 7:49
  David: There's another factor, John, which has to do with payments.
• 7:53
  David: And in the rural areas you've got, uh, people that are mostly Medicare and Medicaid.
• 7:58
  David: And so that means the payments are lower typically than, uh, what you'd get in, in other areas where there's more commercial payments because they tend to have higher rates.
• 8:06
  David: Having said that, Uh, some of the rural systems are more monopolies, and so if there are commercial payers, they can actually charge high rates, uh, when they're there.
• 8:15
  David: But those are some of the things on the healthcare, uh, delivery side
• 8:18
  John: But it, but it's, but I mean, it's a, it's a, again, if you're thinking about it from a career perspective, you know, a hospital with a thousand beds versus, versus, um, you know, 25, I mean, half of rural hospitals have, uh, 25 ish ki beds.
• 8:35
  John: And even there, the occupancy.
• 8:38
  John: Is I think closer under 40%.
• 8:40
  John: Yeah.
• 8:40
  John: Versus over 60% in urban areas.
• 8:44
  John: And so if we're gonna solve the rural healthcare access crisis, we're gonna have to really work, almost engineer a career path for docs who wanna be kind of traditional primary care providers in rural communities.
• 8:57
  John: Cuz there's definitely a constituency for that.
• 8:59
  John: But we've gotta.
• 9:00
  John: Provide that career path and, and pay 'em.
• 9:02
  John: Because if we don't, I, I, I, I just think the, the, the rural healthcare crisis, because you've got, um, higher use of opioids, you've got increased, uh, rates of obesity, um, heart disease, um, cancer, it, the, the numbers are really, you know, really, yeah.
• 9:20
  John: Devastating when you think, when you start to add that up and when you talk about isolation, and we should probably do a podcast on this isolation, you know, true loneliness, um, is, uh, from a, from the arc of your health, uh, you know, you, you is, is as dangerous, uh, in some studies as smoking a pack of cigarettes a day.
• 9:42
  John: Now I don't that, that seems like a dramatic.
• 9:45
  John: In arch point, but the, the, the numbers seem to support it.
• 9:49
  John: And I think it's not just the loneliness itself, but all of the health, the bad health behaviors that follow from not having any social connection.
• 9:58
  John: Um, and I think that those are, those are, these are, these are, you know, the, I don't think the rural healthcare crisis and the specific needs of rural.
• 10:08
  John: Uh, of, of, of rural communities are really a major, uh, item of agenda because again, most of the, most of the healthcare wonk and policy people live in the city.
• 10:17
  David: So, John, I think I'm, instead of calling you John Driscoll, I'm gonna call you John Doomy gloomy.
• 10:21
  David: I don't think it's all doom and gloom.
• 10:22
  David: John, let's talk about some advantages of rural communities.
• 10:25
  David: One is they tend to have close-knit communities In a city people might not know their next door neighbor in their apartment building in a rural area, more likely to know one another.
• 10:32
  David: Have informal caregiving options.
• 10:34
  David: You've got interventions with people from, you know, Families and people are used to kind of, you know, sticking up for one another.
• 10:40
  David: The cost of living is lower.
• 10:42
  David: We talked about the problems with the environment, like, uh, pesticides and so on.
• 10:45
  David: But you can have also, you know, fresh air, uh, in the rural areas, uh, as well.
• 10:49
  David: You've also got access.
• 10:51
  John: You're, you're struggling here, dude.
• 10:52
  John: I'm not struggling.
• 10:53
  John: So, so you're, so, you're like, you're telling me that the, the water, the water's gonna make my teeth fall out.
• 10:58
  John: Yeah.
• 10:58
  John: And I can't drink.
• 10:59
  John: And I can't drink and I can't.
• 11:01
  John: And I, and, and that, and that's when it's not contam.
• 11:03
  John: But heck, I can, I can breathe as much as I'd like.
• 11:06
  John: So, so John, no, no, no.
• 11:07
  David: That's not a very good trade, David.
• 11:09
  David: Yeah.
• 11:09
  David: Well, you can drink beer, John, but there's, you have good access to nature and out outdoor recreation a lot of times, and there's are opportunities for healthy lifestyle choices as well.
• 11:17
  David: And you know, there's less bureaucracy you, so you can, you can test out something new.
• 11:21
  David: So I'm not, I'm not so deeply David and gloomy like you, John.
• 11:23
  David: David,
• 11:23
  John: David.
• 11:24
  John: You can drink beer in urban areas too.
• 11:26
  John: And by the way, one of the interesting health num things about beer is that nothing bad can grow in.
• 11:31
  John: And so it actually is a healthy alternative for particularly in a low or zeroed low alcoholic content.
• 11:37
  John: So, David, thanks for bringing up that point.
• 11:39
  John: Maybe we could bring on Sam Adams as a sponsor.
• 11:42
  David: It's a good place, uh, John to, you know, beer, you could snuff out your cigarette in there and then it makes it even healthier.
• 11:48
  David: So gimme a minute here, John, because I'm pleased to announce that we are now offering opportunities for organizations to support our work here at Caretalk.
• 11:55
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• 12:01
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• 12:06
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• 12:12
  John: What could make you more popular in your community socially than being a sponsor for CareTalk david.
• 12:18
  John: We should just be recruiting people everywhere.
• 12:21
  John: Um,
• 12:21
  David: but you like, you like to talk about rural hospital closures.
• 12:24
  David: That's sort of like your little trope there that, that, and the 10,000 people are turning 65 every hour, but is that really what we should be measuring and what's actually going on with rural hospital closures and, and who care?
• 12:36
  John: Well, I care, David because I've got friends who live in rural communities.
• 12:40
  John: No, I mean rural hospitals.
• 12:42
  John: They may be small.
• 12:44
  John: They may be struggling, but they're really the center of the healthcare system for folks who are, you know, who are in extreme need in rural areas.
• 12:53
  John: I mean, being real sick in a rural area before we started to develop a, uh, an exte, a more extensive rural healthcare system in the early 19th century, you know, you people were dying of, of absolutely preventable accidents and illnesses, and so that crisis is real.
• 13:10
  John: You've got about 200 hospitals right now.
• 13:13
  John: That are on the bubble that are probably in the verge of closing, that the feds are very focused on keeping open.
• 13:20
  John: It's a broader problem than just having, you know, buildings with docks in it.
• 13:25
  John: But that is, that's the foundation around which I think that rural healthcare, you know, could be, uh, could be supported.
• 13:32
  John: And you do see politically, it's one of the few areas of genuine opportunity for bipartisan support.
• 13:39
  John: I just think it can't be a stop gap.
• 13:43
  John: Subsidizing those hospitals.
• 13:46
  John: We need to, we need a kind of a plan to deal with communities in, in rural areas.
• 13:50
  David: So John, there are some things that are, that are happening and have been happening over time, as you say, opportunity for bipartisanship because.
• 13:56
  David: You know, this liberal, uh, conservative divide is often an urban rural divide.
• 14:00
  David: So if you, you can need to address, uh, both things.
• 14:03
  David: Uh, healthcare affects rural areas and, and urban areas as well.
• 14:06
  David: There are some special programs, so there are some, uh, what they call critical access hospitals.
• 14:11
  David: Um, and those hospitals are in these underserved, you know, rural areas.
• 14:15
  David: And they have certain, um, advantages and get more, get more payment in order to help to keep them open.
• 14:20
  David: There's also the National Health Service Corps, uh, which my, actually my brother was in, which pays for medical school as somebody go to support, uh, uh, less, you know, healthcare shortage area.
• 14:30
  David: Not all of which are rural, but many, uh, many are.
• 14:34
  David: Uh, there are loan forgiveness programs, including at the state level.
• 14:37
  David: So there are things that are, that are actually there to help and those can have a big impact, uh, especially for those that actually, you know, want to go and make their career.
• 14:45
  David: Uh, in a rural area.
• 14:46
  David: So that I think is the, is the case, John, when, uh, a hospital closes on the rural side.
• 14:52
  David: I was kidding.
• 14:53
  David: Of course you care about the rural hospital, John, and not just cuz your friends live there, but cuz other people do too.
• 14:58
  David: If you think about what happens in an urban area when a hospital closes, because frankly hospitals close at about the same rate in urban areas as rural areas.
• 15:06
  David: The difference is, is there's an urban area.
• 15:07
  David: Okay, well you probably weren't going to that hospital anyway.
• 15:09
  David: There's always another hospital.
• 15:10
  David: There's always.
• 15:11
  David: But in a rural area, if you uh, don't have the opportunity, uh, to have a hospital in your town, you may be driving two, three hours or something.
• 15:21
  David: And sometimes that doesn't matter.
• 15:22
  David: Although the transportation problems before that we described are, are a problem.
• 15:25
  David: But for time, sense of things like a heart attack, a stroke, Sepsis, uh, an asthma attack.
• 15:31
  David: You know, these are things that you really do have an impact on mortality, and that's born out, um, in the figures.
• 15:37
  David: There's an interesting, um, twist here, John also, which is, if you think about emergency medical services, you know, calling 9 1 1, there's an opportunity for, uh, some innovation here because.
• 15:49
  David: The paramedics that we usually go out and then transport somebody to the hospital, but there's changing where you've got more of a community paramedicine program, send the ambulance out, but try to work with the, uh, the individual there rather than having to transport them.
• 16:02
  David: That's actually an innovation that can be done in a rural area.
• 16:05
  David: That actually may be useful, uh, to bring to urban areas.
• 16:07
  David: Yeah, so just to
• 16:08
  John: unpack that a little bit, there are a lot of paraprofessionals, not necessarily nurses and doctors who, particularly with supervision and the right equipment, could be doing a lot more than stabilize and move, uh, uh, the, you've got the ability to, I think, diagnose quickly and, uh, potentially titrate some drugs and, and, and actually provide some basic.
• 16:31
  John: Wound care.
• 16:32
  John: I mean, there's a whole series of things that, um, if you had a trained EMS core that was up trained, if you will, under supervision and leveraging telemedicine and access to expert oversight, you could actually do a lot more.
• 16:48
  John: Uh, there, there that really hasn't been explored, you know, to a large degree.
• 16:52
  John: The skill sets are kind of locked in by level and by background, as opposed to leveraging, you know, access and reach and, and helping people, almost upskilling them above even where their licensure is and testing that because there's certain areas where we're just not, we, we can't, we're not going to.
• 17:10
  John: And one of the areas is a, a, a, an emergency where you don't have people available if you've.
• 17:17
  John: We don't, you don't have necessarily the perfectly skilled person available.
• 17:20
  John: Well, how do you take the, the, the skills of, uh, everything from caregiver to uh, uh, an EMS paraprofessional and train them with support on how to actually solve, solve some of the healthcare problems, or improve the likelihood that someone's gonna survive.
• 17:36
  John: The transport.
• 17:37
  John: I mean, I think that's, that's, that's a really, really interesting area.
• 17:41
  David: So, John, last question to you is about something that you just raised in passing, which is telemedicine.
• 17:46
  David: How much of an opportunity does telemedicine provide to address rural healthcare crisis as you've described it?
• 17:53
  John: Well, I, I, I, I, I think it's a really exciting, because suddenly for the first time, you've got, you know, um, a high quality video, real-time contact with docs and, and, and, You know, pretty much any specialist you'd want available via telemedicine.
• 18:11
  John: I think telemedicine would be helpful in terms of follow up, chronic care, some basic monitoring and connection.
• 18:18
  John: I just don't wanna oversell the value of technology.
• 18:21
  John: I think a lot of the, there's a lot of medicine where you either need to be in person to do a scan, a study, take a sample, or just.
• 18:32
  John: And then, and then I think there's a lot that you lose if you're not actually someone who's trying to counsel or work with a patient or a family isn't in front of them.
• 18:41
  John: So I think it can be a critical infrastructure support and extender, but I don't think it's a replacement.
• 18:46
  John: What's, say
• 18:47
  David: you.
• 18:48
  David: Well, John, I, I, I, I, I'm, I'm, I'm sticking with your doom and gloom moniker.
• 18:53
  David: I think it's a, it gives a lot of opportunity and we can help to even out some of these things.
• 18:58
  David: You know, in cities you have too many specialists in rural areas, not enough, and telemedicine is actually a good way to link them.
• 19:03
  David: And you've seen some good efforts like Project Echo, uh, in New Mexico, which saves, uh, people the trouble of having to come all the way into Albuquerque.
• 19:11
  David: By having specialist level care, uh, where they come from, that that, you know, goes back a few years.
• 19:16
  David: So I think it has a lot of potential.
• 19:18
  David: I'm gonna end it up right there, John, before you have any doomy, gloomy, more things to add.
• 19:23
  David: That's it for yet another episode of CareTalk.
• 19:25
  David: We've been talking about rural healthcare challenges and opportunities.
• 19:28
  David: I'm David Williams, president of Health Business Group,
• 19:32
  John: and I'm John Driscoll, the president of Walgreens Health.
• 19:34
  John: If you like what you heard or you didn't, please subscribe on your favorite service, and thank you so much listeners.