Last week, Jon Mark Hogg, candidate for U. S. Congress in Texas Congressional District 11, brought together four experts in rural healthcare for an eye-opening, non-partisan, online discussion of the challenges facing rural healthcare in Texas. 

John Henderson, Executive Director of the Texas Organization of Rural and Community Hospitals (TORCH), opened with, "Texas is ground zero of this rural healthcare crisis," and said that 27 rural Texas hospitals have closed since 2010, in a wave that started in East Texas and is now moving north and west. Around 60 percent of rural hospitals still operating cannot deliver babies except in a dire emergency. 

Retired physician Dr. Jane Rider, who practiced pediatrics in San Angelo, added that at least half of the mothers giving birth in San Angelo's hospital are on Medicaid or are uninsured. 

Adding to the challenge of under-insured patients, Dr. Bradly Bundrant, a physician in Ballinger, said that tight budgets at rural hospitals do not have the capacity to manage referrals and take care of people who cannot pay. Dr. Bundrant said, "It is critical [for physicians] in rural areas to work with a hospital." He said that rural hospitals rely on cost-based reimbursement, which requires operating differently from big city hospitals. 

Tim Jones, CEO of the Heart of Texas Health System, explained that cost-based reimbursement is "like a hospital's tax return." Critical-access rural hospitals receive periodic payments from Medicare and Medicaid to provide care to the patients covered by those programs. If a hospital provides more care than it received money for, it is refunded for the cost of care; if it provides less care, the hospital owes money to the government providers. Jones said that for a rural hospital to do well, it needs a mix of cost-based and private pay/insured patients.  

Hogg asked what realistic things can we do to address the rural healthcare crisis, and every panelist talked about telemedicine. Henderson said that up to February of this year, about one-tenth of one percent of doctor visits were conducted through telemedicine. When the novel coronavirus kept more and more people at home, telemedicine visits jumped to 44 percent of doctor visits. "It is great for rural hospitals," Henderson said, adding that the Texas legislature ruled that virtual medical visits are to be treated the same as in-person visits. 

Jones said that telemedicine helps hospitals financially, because they are able to charge for the service, and also charge a technology fee for referrals to specialists. Telemedicine has been around for a while, but "COVID forced it to be used better," said Jones. 

Dr. Rider recalled that doctors have been answering phone calls from patients for a long time without charging for it. "It's a valuable service," she said. "Once Medicare uses telemedicine, commercial insurance comes along behind." 

While many older patients do not care for telemedicine, Dr. Bundrant said that home health nurses sometimes take the step of connecting older folks with doctors or specialists through telemedicine. "The younger folks are fine with it," he said.  

Other practical considerations for improving healthcare, said Dr. Bundrant, include getting fast internet access for rural people. Hospitals have a government program that helps them pay for good internet, but patients need reliable internet service as well. He mentioned the decline in volunteering and our community organizations as a factor in some people being disconnected from society. He gave the example of how being socially disconnected can lead to drug abuse, which results in wasted lives and a drain on the rural healthcare system. Finally, he said that long term care is a big line item with Medicaid, and we have to find a way to address the shortfall in funding. 

Jones agreed that rural hospitals "have to keep clawing and scratching" to take advantage of federal and state programs to pay the bills. He said that rural hospitals do not have the population to support the services and specialties of big city hospitals, yet "we're still open 24 hours a day and the overhead doesn't stop." 

"Texas leaves a lot of federal money on the table," Henderson said. He lamented that every time Medicaid expansion comes up, the discussion tends to turn partisan. He noted that when Medicaid expansion is on a state ballot, voters usually approve the measure. Also, he said, "Seventy percent of national hospital closures were in non-expansion states." 

In addition, "Texas has not kept up its commitment to [medical school] graduates," Dr. Rider said, citing the lack of residencies in rural areas. Physicians often end up working wherever they do their residencies. A program to help doctors repay student loans by working in underserved areas has recently been cut by 25 percent. Furthermore, medical schools should offer a rural healthcare track, said Dr. Rider, because working in rural healthcare is "way different than a big city position." 

Dr. Rider said that the incredibly complex system of administering reimbursements and payments in healthcare in general, adds about 30% to the cost of care. Other panelists agreed that administrative procedures were unnecessarily complicated. 

Finally, Jon Mark Hogg asked what regular people could do to help their rural healthcare providers. Dr. Bundrant said to get involved in your community to strengthen relationships in society. Henderson said, "Get your care locally." Jones said, "Go see your doctor when you get sick. Don't go to the emergency room at 3 a.m. on a Sunday for something you've had for the last two weeks." 

 "Critical-access" is a federal designation that allows a rural hospital to use federal cost-based reimbursement programs. A county with fewer than 60,000 residents is considered "rural." Congressional District 11 serves 36 counties, including Comanche County. For more information about Jon Mark Hogg, visit www.jonmarkhogg.com

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