I just finished serving 15 months on a national hospital task force charged with studying vulnerable rural and urban communities and their health care needs. We found big differences between them, of course, but also surprising overlaps in health problems, needs, and possible solutions.

The task force findings are interesting in light of the presidential election and its stark red/blue, rural/urban voting patterns. Here are my most important takeaways, as well as a few surprises, about this divide and its implications for health and health care.

3 key facts

Our task force studied the demographics of rural and urban communities and the financial status of their hospitals, summarizing findings in rural and urban chart packs.

Compared to national averages and suburban communities, rural and inner city households:

  1. Have a harder time (for inner cities, a much harder time) making ends meet
  2. Likely need more health care services
  3. Rely on hospitals that are struggling financially

The impact on rural communities and inner cities

Here's how income levels, health care needs, and hospitals' financial sustainability in rural and inner city communities stack up to national trends.


 

Compared to national averages and trends

In rural counties

In inner cities

Making ends meet for households
  • 15.9% adult poverty compared to 13.6% nationwide
  • For 1 in 5 counties, more than 20% of the adult population is below the federal poverty level (FPL)
  • Businesses move or close as populations dwindle, leading to job and income loss—and the failure to attract new businesses
    • More than twice the national poverty rate
    • For more than 80% of census tracts, more than 20% of the adult population is below the FPL
  • More than twice the national poverty rate
For more than 80% of census tracts, more than 20% of the adult population is below the FPL

Populations need more health care because …
  • Proportion of elderly is more than 20% higher that U.S. average
    • Lack of basic life needs (food, safe shelter), higher disease burden due to socioeconomics
  • Lack of basic life needs (food, safe shelter), higher disease burden due to socioeconomics

Hospitals that are struggling financially
  • Nearly 30% have total margins in the red
  • 1 in 3 lose money on operations
  • Average operating margin for rural hospitals is 4.9% compared to 5.7% for all U.S. hospitals
    • Nearly 20% have total margins in the red
    • 1 in 4 lose money on operations
    • Average operating margin for inner city hospitals is 4.4% compared to 5.7% for all U.S. hospitals
  • Nearly 20% have total margins in the red
  • 1 in 4 lose money on operations
Average operating margin for inner city hospitals is 4.4% compared to 5.7% for all U.S. hospitals

3 somewhat surprising findings

We also studied the care provided by rural and urban hospitals. Some of these findings challenge common generalizations.

1.  Outpatient care makes up a bigger chunk of rural hospital revenues. In the aggregate, outpatient care accounts for nearly 17 percent more of rural hospital revenues as compared to urban hospital revenues (61% of rural hospitals' revenue versus 44% of urban hospitals').

But the shift toward outpatient care is moving at about the same pace—increasing about 30 percent since 2000—in both rural and urban hospitals.

2.  Rural hospitals provide more non-acute care. As compared to their inner city counterparts, 60 percent more rural hospitals offer home health, two times as many provide skilled nursing, and nearly five times as many provide assisted living.

3.  Rural hospitals are more dependent on Medicare. Rural hospitals are more dependent on Medicare than their inner city counterparts. About 46 percent of rural hospital revenue comes from Medicare. In inner city hospitals, only 38 percent comes from Medicare.

Even more surprises in task force recommendations

In determining how to apply our findings, we identified the essential health care services needed in vulnerable communities, and some forward-looking ways to provide those services.

You many find some of our suggestions, summarized in this report, surprising. They include:

  • Patient screening and referrals for socioeconomic factors like food insecurity
  • Global budget payments—hospitals are given a fixed payment for a fixed period of time for a defined community or population, freeing up resources to address health needs more proactively
  • Inpatient/outpatient transformation—hospitals reduce their inpatient beds to reflect current community needs, shifting those resources to outpatient and primary care

Pennsylvania is both very rural and very urban—and renowned for this split personality. So you can imagine how fascinating and important I found my work on the task force, given my role as leader of our state's hospital association.

My biggest takeaway from this experience? The health and health care of vulnerable rural and urban communities have a lot more in common than voting habits might suggest.

Surely we can find a way to bridge the divide and foster better health for all Pennsylvanians

-----

Have a health care question or frustration? Share your story »

Read more of Health Cents »