From the WebMD Archives

May 4, 2020 -- Rural communities are facing their first wave of coronavirus cases, lagging behind many cities that have hit their peak. Rural residents are often older, sicker, and poorer than urban residents and have less access to medical care, making them particularly vulnerable to COVID-19.

About 8 in 10 rural counties have confirmed cases, with 52,480 -- representing 5.2% of the total cases -- and 1,965 deaths -- representing 4% of all U.S. fatalities -- as of April 27, according to the University of Iowa's Rural Policy Research Institute.

The coronavirus has spread in South Dakota via an outbreak at a Sioux Falls meatpacking plant that infected more than 300 workers. In Idaho and Colorado, the virus spread from popular ski resorts. In rural southwest Georgia, a large funeral started an outbreak. A religious revival event in early March in a western town in the Navajo Nation that shares borders with Arizona, New Mexico, and Utah appears to have been a “super spreader” event, responsible for many infections.

Many rural communities were already facing problems of access to health care and greater rates of health care problems. Add the coronavirus pandemic, and America’s rural areas are suffering.

Rural Hospitals Dwindling

People in rural areas who get sick with COVID-19 have fewer hospitals to treat them. Since 2005, 170 rural hospitals have closed, including 10 this year alone, according to the University of South Carolina Rural Health Research Program.

The Centers for Medicare and Medicaid Services (CMS) has designated at least 1,350 of the estimated 2,000 rural hospitals nationwide as “critical access hospitals” that have 25 or fewer beds and are more than 35 miles, or 15 miles by mountainous terrain or secondary roads, from the next nearest hospital.

“These hospitals are designed for primary care and surgery, not pandemics. Most of the care is outpatient -- people are coming for diagnostic testing, broken bones, and immunizations. If they need intensive care, they are transferred to larger facilities,” says Alan Morgan, CEO of the National Rural Health Association (NRHA) in Washington, D.C.

The critical access hospitals are trying not to ventilate sicker patients until they can transfer them to the larger regional hospitals with intensive care units and more ventilators, says Morgan. In addition, in rural counties, there are regional shortages of nasal swab test kits and a lack of personal protection equipment in reserve.

One in five U.S. rural hospitals are at a high risk of closing unless their financial situation improves, according to a 2019 analysis of publicly available data.

In addition, rural hospitals rely on Medicare and Medicaid patients, who make up 60% to 70% of their patients, compared to 30% in urban hospitals, says Morgan. “Rural hospitals have been providing too much uncompensated care. That is why we’ve seen so many close in the Southeast and more recently in the Midwest and Plains. They were in a precarious financial position before the pandemic.”

When county hospitals close, there are ripple effects in the community. Patients have to travel farther to get to the nearest hospital, which is a barrier to routine primary care as well as emergency room and inpatient care, says Carrie Henning-Smith, PhD, deputy director of the Rural Health Research Center at the University of Minnesota in Minneapolis.

When a rural hospital closes, mortality rates increase by 6%, according to a paper published last year by the National Bureau of Economic Research.

There is also the economic impact -- rural hospitals are often the biggest employers in town. “When they close, jobs disappear and workers leave town and take their tax dollars with them. That means fewer people supporting the town financially,” says Henning-Smith.

Revenue Lost to Pandemic

The pandemic has pushed some cash-strapped hospitals out of business. Two that closed last month -- one in Tennessee and another in West Virginia -- cited COVID-19 as a key factor. “They report that they were losing money when revenue from elective surgeries and routine procedures stopped coming in the door,” says Morgan.

Most hospitals followed the White House coronavirus task force recommendations on March 18 to postpone elective surgeries and routine health procedures to make room and supplies available for the expected surge in COVID-19 patients. But those surgeries and procedures can account for up to 80% of hospital revenue, according to Morgan.

To save money, more than half of rural hospitals nationally have furloughed or laid off staff, including Margaret Mary Hospital in Batesville, IN; St. James Parish in New Orleans; and Lexington Hospital in Lexington, NE, says Morgan.

San Luis Valley Health in rural Alamosa, CO, in the southern central part of the state, has not seen the expected surge of COVID-19 patients. The regional hospital, which serves about 55,000 residents, had seen only 11 confirmed COVID-19 cases and two deaths by April 28, says SLV Health Chief Medical Officer Carmelo A. Hernandez, MD.

The hospital prepared for the pandemic in mid-March by expanding its 49-bed capacity, increasing the number of ventilators, and training providers to work in different areas. The providers canceled all elective surgeries, procedures, and imaging, which has taken a heavy financial toll, he says.

“We started out in a good financial situation -- we had 124 days of cash reserve -- but the impact has been pretty dramatic. The patient volume has dropped by at least half in both the ER and outpatient clinics, from 50 to 20-25 patients daily in the ER, with the lowest count of 13 daily patients, and from 325 visits daily to about 150 visits in the outpatient clinics,” says Hernandez.

But hospitals don’t get paid for their services until about 60 days later, says Hernandez. He anticipates the revenue losses will show up in late May and early June. In the meantime, the hospital has put cost-saving measures in place, such as reducing full-time staff hours and asking staff to take leave without pay.

The expected surge of COVID-19 patients also hasn’t hit Ferry County Memorial Hospital in Republic, WA, a critical access hospital that serves about 7,500 people in the northern part of the state. The county has only one positive case and no deaths.

Still, the hospital had to prepare by buying extra ventilators, personal protective equipment (PPE), and medicines for intubation. Meanwhile, the hospital canceled all elective surgeries, procedures, and imaging, which has taken a huge financial toll.

“Our revenue is down 38% in late April, compared to where we were a year ago. To run the hospital costs us $38,000 daily,” says Richard Garcia, DO, the hospital’s medical director and chief of staff.

To keep patients safe, the staff ramped up telehealth visits. “We get compensated $95 per telehealth visit compared to $180 for regular visits -- it’s a fraction of the previous provider payment,” says Garcia.

States Resume Elective Surgeries

The Trump administration is now calling on states to resume elective surgeries, which were largely suspended as health systems sought to boost capacity for an expected surge of COVID-19 patients. Twenty-four states have announced easing of restrictions or allowing surgeries to resume once their stay-at-home orders expire, according to Becker’s Hospital Review.

The federal Opening Up America Again plan, which President Donald Trump unveiled in late April, proposes that states meet certain criteria first, including a 14-day decline in documented COVID-19 cases or in positive tests as a percentage of total tests within a 14-day period.

The reopening plan also proposes that hospitals “treat all patients without crisis care and have a robust testing program in place for at-risk healthcare workers, including emerging antibody testing.”

Colorado Gov. Jared Polis announced last Sunday that facilities could do these elective surgeries and procedures if they develop a plan to reduce or stop them if there’s a surge of COVID-19 infections in their county or municipality. The state’s health department will determine the conditions that constitute a surge.

San Luis Valley’s regional hospital has reopened its outpatient clinics and started to phase in outpatient elective surgeries and procedures this week. “We will test patients a few days beforehand to minimize transmission and also protect our supplies of PPE,” says Hernandez. The hospital sends the tests to Denver, so the turnaround can take up to 36 hours, he explains.

“We are rolling out elective procedures gradually -- I don’t even expect a 75% increase next month -- we may need to request more tests as we go along.”

The hospital is also reassuring patients, worried about contracting the virus, that it is a safe place for them to be. “We’re trying to best to protect patients. When they come, the staff will be wearing masks, and we will give patients masks to wear and ask them to social distance. Once people check in, we will take them straight to the appropriate clinical area and avoid the waiting room,” says Hernandez.

Washington Gov. Jay Inslee announced April 21 that he would like the return of some elective surgeries when a stay-at-home order is scheduled to lift on May 4. But the plan would only move forward, he says, once cases of the new coronavirus have fallen enough that the state is able to manage future outbreaks.

“We’re talking that now so that as soon as we get the green light from the state, we will be able to open. But, we want to make sure that we can do that safely and still be prepared if an outbreak occurs. There is no playbook for how to close down and open back up,” says Garcia.

Federal Financial Relief

Rural hospitals were excluded from the Coronavirus Aid, Relief, and Economic Security (CARES) Act -- the first economic relief package, according to Morgan. But the $30 billion CARES Provider Relief Fund is providing some aid to rural Medicare providers through “accelerated payments.” Critical access hospitals can receive 6 months of Medicare payments based on what they billed last year. But these are loans, not grants, that must start to be repaid in 120 days.

“This relief allowed the majority of rural providers to meet immediate payroll and cash needs and was helpful to get them through May and early June,” says Morgan.

But “we’re not sure we will be back to normal in 120 days, so the loan is a potential burden as we continue to move forward,” says Hernandez.

Garcia received $375,000 from a state grant through the CARES Act that doesn’t need to be repaid. “That is enough to last us about 10 days.”

Rural hospitals were included in the $10 billion rural COVID-19 relief fund announced last week. “This funding will offer critical and rapid assistance to rural hospitals and health clinics that have been struggling to keep their doors open. The money will be distributed as early as this week,” Morgan says in an April 22 statement from the National Rural Health Association.