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During a Jan. 6 virtual conversation hosted by the Leonard Davis Institute of Health Economics at the University of Pennsylvania, experts discussed how well the initial funding announcements from the $50 billion Rural Health Transformation Program (RHTP) align with the healthcare needs of rural communities.
Paula Chatterjee, M.D., M.P.H., director of health equity research at Penn LDI and an assistant professor of medicine at the Perelman School of Medicine, said that there may be a mismatch between rural health needs and where the funds are targeted.
“The Rural Health Transformation Program has these clearly stated goals: improve access, improve rural population health, right? So if we can benchmark those goals to what the state of the world is in rural communities, can we say that funding is aligned with need or is it not aligned with need? And unfortunately, we're seeing that in a lot of ways, it perhaps is not well aligned with the needs.”
Chatterjee explained that the RHTP is very clear that it's not meant to be a bailout for rural hospitals’ financial circumstances. But she added that if one of the goals is to improve rural health access, it would make sense for funds to be targeted to places that have had greater access challenges.
She and colleagues looked at states that have lost the greatest share of their rural hospital beds from 2018 to 2023 and whether funding from the program is going to those places where a greater share of rural hospital beds were lost.
“What we can say is that maybe states that have lost a greater share of their rural hospitals get a little bit more total funding, but when you adjust for rural population, that potential benefit goes away almost entirely,” Chatterjee said. “When you look at where funding per rural resident goes under this program, which I think is the right measure, it's not going to states that have the highest rural mortality rates. It's not going to states that are projected to have the greatest reductions in federal Medicaid spending. It's not going to places that are losing the most hospital beds. The only thing that we have found that is weakly, weakly correlated with where money is going is a state's administrative capacity.
She explained that there was a very short time frame for states to prepare proposals to get at this pool of money, and “unless you're a state that has the administrative capacity to do this, it was probably really hard for you to put this together.”
Kevin Bennett, Ph.D., director of the Center for Rural & Primary Healthcare; and professor in family and preventive medicine in the School of Medicine at the University of South Carolina, agreed that the 52 days that states had to pull their grant applications together created a limitation. “And there are a lot of parameters around this program that make it hard to stick your neck out and be truly innovative, because if it doesn't work, then future funding is in jeopardy,” he explained. “There are a lot of great things in these proposals, but I think if we really wanted to transform, they would have gone a lot further. And I would imagine folks wanted to go further, but wanted to stick within the parameters of the program to keep it going.”
The panelists were asked which types of rural health workforce efforts announced are evidence-based and therefore more likely to have staying power.
Chatterjee said there is a reasonable body of evidence about what works. Rural pipeline programs have some strong evidence, she added. “We know that if you recruit folks specifically in the healthcare workforce who come from rural backgrounds, or if you provide people with extended rural training, that that is consistently associated with higher rural retention in the workforce. Education-focused strategies — if you integrate rural placements, rural training pathways and clinical medicine. Where I trained, we had Indian Health Service rotations that folks would go on, and then several of my good friends ended up practicing in the Indian Health Service for their career choice. Offering these training opportunities can also be important and help with workforce challenges.”
Less effective, she said, are things like return of service requirements that can sometimes drive initial recruitment of a workforce, but they often fail to sustain retention after people's obligations under those programs end. The same with stand-alone financial incentives, where they pay you this much extra money to come work in a place. “The evidence for that, I would say, is weak and inconsistent, especially if you don't combine those types of initiatives with community resources, with educational resources.”
Chatterjee cited a study in Health Affairs looking at the 50-year retrospective history of the Health Professional Shortage Area Program, which was designed to get at this workforce challenge in rural communities from a variety of different levers — loan forgiveness, higher Medicare reimbursements, etc. The program costs about a billion dollars a year to administer, she added, and the researchers found no significant changes in mortality or physician density. “This is dating from 1970 to 2018. That’s a long time for us to be able to say this is a great effort, but perhaps not achieving the outcomes that we had hoped.”
Bennett agreed that a lot of the workforce proposals in these state programs are tried and true methods — pipeline development, incentive programs, and loan repayments, “but they're not the answer, as we know, because, as Paula indicated, we still have a long ways to go as far as keeping workforce there.”
He suggested that you have to follow the money. Medical students, for example, have a tremendous debt burden when they graduate. “It's really difficult for rural kids, who tend to be less resourced, to carry that debt, and then you want them working in rural settings, where they might earn less. And the way our payment system is set up is very volume-based, fee-for-service. Without very innovative ways of changing the payment system, I think we're always going to have this issue of trying to get rural folks to practice in rural areas.”
Bennett added that he believes there are a tremendous number of providers who want to practice in rural areas, but the finances just don't work out. “There are some alternative payment models or value-based purchasing in some of these plans,” he said. “But I have colleagues who have worked on this and talked about how we need capacity payments. We need a bonus of money to rural primary care, for example, just to keep your doors open and just maintain services, and then payment on top of that. Without that kind of change, I think we're always going to struggle with recruitment and retention.
“In our state of South Carolina, we have a lot of trouble with OB/GYN access. I don't think that's uncommon anywhere. I think these types of programs could make a large improvement with workforce such as community health workers, doulas and these kind of wrap-around provider types that do tremendous work, that improve outcomes and deliver great care, to supplement what physicians are able or unable to do because of location and payment. The key is how do we pay for CHWs in this type of environment? And value-based care could get us to that point, and that would be very valuable, but it's going to take some time.”
The conversation then turned to the fact that the funding from this program has to be weighed against the huge expected negative impact of all the Medicaid cuts enacted last year.
“My colleagues at the National Rural Health Association said this program would have been great as a stand-alone, transformational investment program in changing rural healthcare,” Bennett said. “With the cuts, you’ve got facilities that are going to be struggling to keep their doors open, and it's really hard to think about transformation if you're trying to keep your doors open and employees employed and patient served. How do you ask a rural hospital to change your payment program and create a new workforce and train them if they're worried about making payroll next month or they might have to cut OB services?”
Bennett said we should explicitly acknowledge that this is politically based legislation, not necessarily healthcare legislation. It's not planned out by health policy wonks to create a better healthcare system, he said. “This was a a way to bring other Republicans on board to get the legislation passed, and that's the way the game’s played. So now that it's here and now that they're awarded, what can we do with it? What can we maximize with it, to try to do something positive with it, at least in the environment that we're in, and that’s the best we can do.”
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