Many rural hospitals in the United States trace their origins to 1946, when Congress passed the HillBurton Act.
The legislation funded the construction of some 6,800 nonprofit hospitals in rural America
and required that the facilities serve everyone in the community, no matter their race, income, or
national origin.
Currently 20% of the population of the United States lives in Rural areas of the country. Approximately
10% of the nation’s doctors practice in Rural areas. In many rural communities the Hospitals and Health
Care Services are the cornerstone of these communities. Hospitals in rural locations are often the largest
local employer and help attract other businesses to the area, which can improve economic stability.
Having a hospital in the community is seen as a sign of vitality in a regional area. In 2020, rural hospitals
supported one in every twelve rural jobs in the U.S. as well as an estimated $220 billion in economic
activity in rural communities.
The Rural Healthcare Landscape
According to the National Organization of State Offices of Rural Health (NOSORH) there are
approximately 1,300 Critical Access Hospitals (CAH’s) and 900 other Hospitals providing acute care to
rural communities. The true backbone of the Healthcare delivery system in rural America are the Rural
Health Clinics (RHC’s), Federally Qualified Health Centers (FQHC’s) and FQHC Look-Alikes. There are
currently more than 5,000 RHC’s and over 3.600 FQHC’s or Look-Alikes serving rural communities.
Even with the numbers cited above regarding the number of facilities delivering Healthcare into Rural
communities, many rural areas of the country are deemed to be “healthcare deserts”. This description
of available healthcare services in some areas of the country as being “healthcare deserts” was defined
within a Good Rx Research white paper, published in 2021. According to the white paper a healthcare
desert is defined by assessing six key dimensions of available services needed to provide adequate
patient care:
1. Pharmacies
2. Primary Care Providers
3. Hospitals
4. Hospital Beds
5. Trauma Centers
6. Low-Cost Health Centers
Not surprisingly rural communities are significantly more likely to be within a healthcare desert. In
assessing access to Pharmacies, the Good Rx White Paper found that South Dakota, Montana, Nebraska,
and Kansas have the largest number of counties that lack sufficient access to a pharmacy. In much of
these states, residents have to drive more than 15 minutes to access a pharmacy. The further a person
lives from pharmacies, the less access they have to in-stock medications and different options for price
shopping (since prices for the same medication often vary across pharmacies).
When looking at Primary Care Providers, which are delivering basic services such as immunizations,
check-ups and screenings; the HRSA targets having at least 1 full-time primary care provider for every 3,000 people.
In primary care deserts it is common to have 1 full-time primary care provider for every 10,449 people — a potential
patient caseload over three times the recommended level.
These larger patient caseloads create longer wait times for patients to get an appointment and in turn
makes it much more difficult to receive timely, quality care. When this happens, patients will often end
up relying on urgent care and the emergency room for their primary health issues, often after it’s too
late for preventive care and causing overcrowding of Hospital Emergency Rooms.
A significant amount of the primary care deserts are concentrated in the rural Southern and Western
United States. As an example, in Mississippi, over 58% of counties — most of them rural — don’t have
enough primary care providers for the majority of local residents. Mississippi ranks 49th out of 50 in
terms of access to primary clinical care.
As with primary healthcare provider deserts, many hospital deserts are located in rural communities.
Vermont, Alaska, Arkansas, Alabama, and Maine have the largest share of the state population living in a
hospital desert, many of which are concentrated in rural areas.
Surprisingly Trauma Deserts are a problem in the United States. Trauma centers, are usually associated
with the emergency room of a hospital, and exist to treat the most severe and life-threatening cases.
These include gunshot wounds, blunt trauma, traumatic car crash injuries, and/or major burns. There
are currently 2,020 Level I through Level V trauma centers scattered throughout the U.S. however; these
facilities are unevenly distributed throughout the country. According to the Good Rx white paper 49
million Americans live over an hour away from a hospital equipped to handle major traumatic injuries.
Having access to a trauma center is a matter of every second that counts due to the significant
conditions the patient is in. Doctors refer to the “golden hour” concept – that trauma patients need to
receive definitive care within an hour of injury to increase their chances of survival. Rural communities
throughout the nation live within Trauma Deserts.
Access to low-cost health care such as an FQHC (Federally Qualified Health Center) FQHC Look-Alike, or
Rural Health Clinic (RHC) can also be difficult for rural communities. 78 million Americans currently do
not have a low-cost health center within a 20-minute drive of their home. Twenty minutes may not
seem like a lot, however, 20 minutes can mean skipping a checkup, a screening, or a refill. Lack of access to
affordable healthcare can then result in relying on the emergency room to diagnose and treat issues,
and ultimately experiencing worse health outcomes.
It is well known that patient income plays a significant role in the healthcare access equation. 1 in 3
Americans reported skipping some form of healthcare due to cost factors. The relationship between
income and lack of access to low-cost healthcare facilities is alarming since rural areas have lower
income levels and these are precisely the people low-cost healthcare is designed to support.
The Healthcare Delivery Model Struggling to Stay Open in Rural America
While the value of having a Hospital in a Rural area is obvious both for the patients and the communities
they serve, many of these Hospitals are facing severe challenges in keeping their doors open. According
to the UNC Cecil G. Sheps Center for Health Services Research, during the period of 2010 to 2021 there
were 136 rural hospital and healthcare system closures. In addition to actual Hospital closures, many more
are at risk of closure. According to the Center for Healthcare Quality and Payment Reform
(CHQPR), 800 hospitals — 40% of all rural hospitals in the country — are either at immediate or high risk
of closure. The more than 300 hospitals at high risk closure either have low financial reserves or high
dependence on nonpatient service revenues such as local taxes or state subsidies, according to
the report.
There are five key issues threatening rural hospitals:
1. population,
2. payment,
3. practice,
4. policy, and
5. profitability.
Rural healthcare is impacted by population from the standpoint of fewer patients and patients who are
older, sicker and less insured. A larger patient population in Urban healthcare allows for more highly
insured patients to help cover the financial load of operating a hospital. This means that it is more
difficult for rural health institutions to generate revenue. The issue of population has a secondary
impact to providing rural health due to a lack of qualified healthcare providers, these are the doctors,
nurses, clinicians, and radiologists who delivery care to their patients. 70% of Health Professional
Shortage Areas (HPSA’s) in America are located in rural communities.
Recruitment and retention of health professionals has long been a persistent challenge for rural
providers. Acute workforce shortages and increasing labor expenses have placed additional pressure on
rural hospitals
The majority of patients within the rural health market, primarily pay for service via Medicare and
Medicaid. These Government payers often reimburse at a rate which is less than the actual cost of
providing these services. It is estimated that in 2020 rural hospitals incurred $5.8 billion in Medicare
underpayments and $1.2 billion in Medicaid underpayments.
Government Policies and Practices are typically focused towards outpatient treatment options, rather
than inpatient care which provide for higher reimbursement rates. While this is helpful in patient care it
limits the access to higher reimbursement revenue streams.
Pathways for Rural Health’s Survival and Growth
The combinations of limited population, lower reimbursement rates, and government policies are all
working against Rural Hospitals being able to be profitable. Healthcare in rural communities is
multidimensional and includes an array of healthcare services. In order to stay healthy, a community
needs providers, hospitals, trauma centers, pharmacies, and community health centers. And just as
important to having the services available, patients need to be able to access these facilities.
While the above-mentioned challenges are significant, the Rural Healthcare community does have
various pathways that can help to not only stabilize the industry, but can actually attribute to growing
Rural Healthcare in underserved regions.
1. According to the American Hospital Association (AHA) Medicaid expansion is one policy that has
helped rural hospitals remain viable. The majority (74%) of rural closures happened in states
where Medicaid expansion was not in place or had been in place for less than a year. Research
has found that Medicaid expansion has been associated with improved hospital financial
performance and lower likelihood of closure, especially in rural areas that had many uninsured
adults prior to expansion.
2. Recruitment and retention of health professionals. Existing federal programs, such as the
National Health Service Corps, work to incentivize clinicians to work in rural areas. Other
programs, such as the Rural Public Health Workforce Training Network Program, help rural
hospitals and community organizations expand public health capacity through health care job
development, training and placement. Additional and continued support to help recruit and
retain health care professionals in rural areas is needed from state and federal governments.
3. Research suggests that, by expanding scopes of practice for non-physician primary care
providers such as physician assistants and nurse practitioners, access to primary care services
can be improved and the quality of those services will be comparable to that provided by
physicians. Expanded scope of practice for non-physician practitioners also could potentially
result in decreased costs.
4. Rural hospitals face a number of regulatory burdens that impact their ability to provide care.
According to a 2017 AHA study, the nation’s hospitals, health systems and post-acute care
providers spend $39 billion each year on non-clinical regulatory requirements. Rural hospitals
can protect their communities’ access to health care by receiving relief from outdated and
unnecessary regulations.
How USC Supports Rural Healthcare Communities
At Ultrasound Solutions we recognize the challenges facing healthcare delivery providers in rural
communities. When Ultrasound Solutions acquired Hi-Tech Medical Imaging Inc. in Olive Branch,
Mississippi we found ourselves dealing with many existing customers that were using older, outdated
imaging equipment. In some instances, we found that our radiography customers were still buying film
and chemicals from us for their radiology departments. Recognizing the environment that many of
these customers operate within, USC / Hi-Tech has made it a point to offer equipment retro-fit and
upgrading. Reimbursement rates for diagnostic studies performed with DR (Direct Radiography)
technology are higher than older technologies such as film. These higher reimbursement rates can help
rural healthcare providers in generating additional revenue for the same services performed. This is also
the case in Mammography where 2D studies using older equipment are reimbursed at a lower rate than
newer 3D Mammography systems. USC offers rural customers the option of providing new 2D or 3D
mammography solutions.
USC has also established field service engineers and sales personnel in rural parts of the country such as
Morgantown West Virginia, Olive Branch Mississippi, San Bernadino California, Springfield Tennessee
and Las Vegas Nevada to support throughout the rural southwestern United States. Often equipment
OEM’s and Distributors are not interested in serving these markets but rather focus their efforts on
larger urban centers such as New York, San Fransisco, Chicago, and Los Angeles. USC saw a need in rural
America and has tried to support these communities by establishing sales and service in rural areas of
the country.
USC provides CME (Continuous Medical Education) courses for sonographers. The majority of these
CME events are free. The ability for sonographers to maintain their credentialing to remain as practicing
sonographers, helps to retain these people in their current roles within the healthcare delivery system.
USC provides equipment and services to a number of University Medical programs and sonography
schools. We are proud of our relationships with these institutions as they continue to provide new
sonographers to the healthcare community.
USC works to provide awareness and recognition of the Rural Healthcare community and the challenges
they face. We look forward to continuing to provide outstanding products, services and solutions to our
customers and partners in the rural health community.
