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Sustaining Rural Hospitals After COVID-19The Case for Global Budgets

Educational Objective
To understand financial and medical stresses rural hospitals are enduring during and after the COVID-19 pandemic
1 Credit CME

The coronavirus disease 2019 (COVID-19) pandemic is a financial stress test for US hospitals.1,2 Revenues have declined from the suspension of elective procedures and nonessential services, and many hospitals have experienced a surge of critically ill patients. These circumstances have created an unprecedented challenge for rural hospitals, many of which entered the crisis in poor financial condition due to the loss of patients to regional referral centers and rural depopulation.3 Of the 4663 acute care hospitals in the US, approximately 47% are located in rural areas across 49 states.4 The added financial strain of COVID-19 has the potential to accelerate the closure of rural hospitals, draining health care resources and jobs from rural communities that have lost 130 hospitals since 2010.5,6

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Article Information

Corresponding Author: Eric T. Roberts, PhD, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto St, A653 Crabtree Hall, Pittsburgh, PA 15261 (eric.roberts@pitt.edu).

Published Online: June 10, 2020. doi:10.1001/jama.2020.9744

Conflict of Interest Disclosures: Drs Fried and Liebers reported previously serving as consultants to the Pennsylvania Office of Rural Health. Dr Fried reported receiving personal fees from Pennsylvania Department of Health outside the submitted work. Dr Liebers reported receiving personal fees from the Pennsylvania Office of Rural Health outside the submitted work. Dr Roberts was supported by a grant from the Agency for Healthcare Research and Quality (K01HS026727).

Disclaimer: This content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality, the Pennsylvania Office of Rural Health, or the Pennsylvania Department of Health.

Additional Contributions: We thank Julie Donohue, PhD (Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health), and Derek Angus, MD, MPH (Department of Critical Care Medicine, University of Pittsburgh School of Medicine), for helpful comments on an earlier draft of this article. The authors also gratefully acknowledge the contribution of Mark Herzog, MD, MPP (1992-2020), in inspiring our writing.

References
1.
Khullar  D , Bond  AM , Schpero  WL .  COVID-19 and the financial health of US hospitals.   JAMA. Published online May 4, 2020. doi:10.1001/jama.2020.6269PubMedGoogle Scholar
2.
Glied  S , Levy  H .  The potential effects of coronavirus on national health expenditures.   JAMA. Published online April 27, 2020. doi:10.1001/jama.2020.6644PubMedGoogle Scholar
3.
Mosley  D , DeBehnke  D . 2020 Rural hospital sustainability index: trends in rural hospital financial viability, community essentiality, and patient outmigration. Guidehouse. April 8, 2020. Accessed May 8, 2020. https://guidehouse.com/insights/healthcare/2020/rural-hospital-sustainability-index
4.
U.S. hospital list. Cecil G. Sheps Center for Health Services Research website. Accessed May 17, 2020. https://www.shepscenter.unc.edu/programs-projects/rural-health/data/
5.
Diaz  A , Chhabra  KR , Scott  JW . The COVID-19 pandemic and rural hospitals—adding insult to injury. Health Affairs Blog. May 3, 2020. Accessed May 4, 2020. doi:10.1377/hblog20200429.583513
6.
Holmes  GM , Slifkin  RT , Randolph  RK , Poley  S .  The effect of rural hospital closures on community economic health.   Health Serv Res. 2006;41(2):467-485. doi:10.1111/j.1475-6773.2005.00497.xPubMedGoogle ScholarCrossref
7.
Health insurance providers respond to coronavirus (COVID-19). America’s Health Insurance Plans website. Updated May 7, 2020. Accessed May 8, 2020. https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/
8.
Murphy  KM , Hughes  LS , Conway  P .  A path to sustain rural hospitals.   JAMA. 2018;319(12):1193-1194. doi:10.1001/jama.2018.2967PubMedGoogle ScholarCrossref
9.
Haber  S , Bell  H , Morrison  M ,  et al. Evaluation of the Maryland All-Payer Model: Final Report. RTI International; 2019. Accessed May 8, 2020. https://downloads.cms.gov/files/md-allpayer-finalevalrpt.pdf
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