Three Models of a Rural Emergency Hospital
On December 21, 2020, Congress passed the Consolidated Appropriations Act of 2021, which established Rural Emergency Hospitals (REHs). Allowing hospitals to convert to an REH may assure continued access to emergency and outpatient services in many communities. However, REH is a new Medicare payment provision and, as such, there is no historical clinical or operational experience with this model. REHs will have to make many decisions about their service mix, patient volume, clinical staffing, and technology, but they will have little evidence to guide them because small rural emergency departments have not been widely studied. They are often left out of larger regional studies because of low volumes, lack of electronic health records, and limited staff available to conduct research. The evidence base is disjointed, with most information coming from descriptive studies of individual hospitals. The paucity of data and evidence to inform REH clinical and operational decisions as well as other proposed policies on quality measures, patient transfer, trauma center referral networks, and emergency medicine services is problematic. This lack of knowledge may impair the success of the REH: if an REH fails to provide adequate access to high quality emergency services, rural residents would be at increased risk of mortality and other adverse events. This could inadvertently drive disparities in emergency care outcomes for rural communities.
Furthermore, REHs will face many clinical and operational challenges. Access to high quality healthcare services for rural communities is reliant on an adequate supply of physicians. In a study of 2003 Medicare data, emergency physicians provided care for approximately 50% of rural Medicare emergency patients with 20% cared for by family physicians and the remainder a mix of other specialties and advanced practice providers. It is not known how this evolved in the last 20 years, but shortages of emergency medicine physicians continue to grow in rural America. According to the National Study of the Emergency Physician Workforce 2020, of the 48,835 clinically active emergency physicians in the U.S., 92 percent (44,908) practice in urban areas with just 8 percent (3,927) practicing in rural communities, down from 10 percent in 2008. Further, emergency physicians in rural communities tend to be older; the median age for an urban emergency physician is 50 years old, the median age in large rural communities is 58 years old and 62 years old in smaller rural communities. For REHs, this means that recruitment of emergency physicians will be a major challenge, and many will have to use clinical staffing models that incorporate family medicine physicians and advance practice providers such as physician assistants and nurse practitioners. We hypothesize that secondary data about small rural emergency departments and expert opinion can be used to develop three clinical and operational models of an REH.
Among rural hospitals considering conversion to an REH, there is extensive variation in their community sizes and needs. This suggests that as REHs roll out across rural America, different clinical and operational models will evolve that reflect local community need. The goal of this study is to develop three models of a REH based on case mix, service mix, patient volume, clinical staffing, and technology.