Rural U.S. residents have a 30 percent higher rate of risk for stroke mortality than urban residents. In a “call to action,” the American Heart Association (AHA) has published a presidential advisory recommending several steps to address the widening disparities between urban and rural communities’ cardiovascular health.
The advisory calls on the AHA and other stakeholders to make rural populations a priority in programming, research and policy.
Published Feb. 10 in the journal Circulation, the report points out several alarming trends, including:
• Rural emergency department (ED) visits increased by more than 50 percent from 2005 to 2016);
• Rural areas have significantly higher rates of uncontrolled traditional cardiovascular risk factors compared with urban areas; and
• Rural areas also have higher rates of diabetes mellitus, obesity and hypertension.
The report highlights many of the societal roots of the problem, as well as the healthcare system challenges, including the shortage of rural healthcare professionals and the financial pressure and closure of many rural critical access hospitals. “Policy interventions are needed to promote the formation of partnerships between urban and rural facilities, the report notes.
The advisory suggests changes in funding models could help. “Partnerships in which urban facilities could send patients who need ongoing lower-acuity care to rural facilities would serve the dual purpose of freeing up high-demand urban beds while helping maintain adequate volumes in rural ones. This requires, in part, attention to reimbursement policies for transfers between hospitals for various levels of care.”
The report also recommends expansion of telehealth and other digital health models already in use. “Organizational models such as the hub-and-spoke model, which virtually connects specialists in urban centers (hubs) with clinicians in rural hospitals or clinics (spokes), as well as forming connections between regional rural centers and more remote rural locations, for education, consultation, and treatment, can be expanded to deepen systems of care in rural areas. Many states have already developed telestroke systems of care to improve stroke care in rural areas, and these programs can be spread to other states and to other conditions.”
Funding models and global payment systems could address disparities, the report says. “New payment models could also serve to better tie rural and urban facilities together. For example, if rural populations were attributed to urban centers according to partnerships through Accountable Care Organizations (ACOs), bundled payment for tertiary/quaternary care, or other similar payment mechanisms, there would be greater incentive to form partnerships. However, incentive payments must be constructed to ensure that they benefit both the rural and urban facilities in the partnerships.
The Pennsylvania Rural Health Model, recently launched by the Center for Medicare and Medicaid Innovation, is an example of a global payment model to watch.
Finally, on the payment landscape front, the report notes that many states with large rural populations have elected not to expand Medicaid. “This has likely had a significant impact on widening disparities in urban and rural health and a negative effect on rural communities and the hospitals that serve them.”
Discussing the report on Twitter, Rob Califf, M.D., head of medical strategy for the Google Health and Verily enterprises and one of the report’s authors, notes that wealth, education, race and where people live are driving a growing disparity in life expectancy and health life years. “Rural Americans are particularly disadvantaged. The differences are enormous and demand action. The first half of report is depressing, exhaustive and represents the best of information synthesis by AHA team, he wrote. “The second half gives concrete suggestions for strategies and policies. Medicaid expansion is a critical lynchpin. I’ve been involved in many "calls to action" in the past; This is one of the most important. I hope this report will signal a nadir from which we will ascend to a much more healthy and improved quality of life for our rural people.”
