Courtesy of THINKSTOCK

AAOS Now

Published 5/1/2015
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K. William Kumler, MD, MBA; Craig Mahoney, MD; Michael Suk, MD, JD, MPH

Rural Orthopaedics: Not for the Faint of Heart

Rural hospitals are struggling, but innovative solutions can be found

Although hospital closures have been relatively uncommon in the United States, the rate of rural hospital closures has increased dramatically in the wake of the Affordable Care Act (ACA)—from 3 in 2010 to 16 in 2014. Of the nearly 50 rural hospitals that closed between 2010 and 2014, all but 8 had fewer than 50 beds. In many rural settings, patients lose their “golden hour”—that period when medical treatment after a traumatic injury may be lifesaving—simply getting to the closest facility.

Rural orthopaedists tend to be older (average age older than 50 years); have a general, rather than specialty-focused, practice; and are more likely to be employed than their urban counterparts. Nonetheless, rural hospitals have a difficult time recruiting orthopaedists, perhaps because most orthopaedic residents pursue fellowships, and a rural practice might not offer the opportunity to continue development of specialty training.

Physicians—regardless of specialty—choose to practice in a rural setting for many reasons. This means that each rural region will have a different mix of primary care and specialty physicians. As a result, rural facilities may have very different capabilities and limitations when caring for patients with multiple comorbidities. If no orthopaedist practices in the region, the musculoskeletal “expert” may be a primary provider interested in sports medicine, a physical therapist, a chiropractor, a podiatrist, or an athletic trainer—all of whom have varying degrees of knowledge of musculoskeletal conditions.

Having access to someone with a deep knowledge of musculoskeletal medicine is important for any rural system. The same is true for cardiology, critical care/pulmonology, pediatrics, general surgery, and urology, along with several other major specialties. Without the support of a knowledgeable team, an orthopaedist may not be able to care for patients who have certain comorbidities or risks for certain complications.

If an area has but a single orthopaedist, the burden of call is tremendous even if the volume is low. Two orthopaedists cut that burden in half, but it is still significant to take call, on average, every other night. Even when physicians are not on-call in a small community, they are visible and see patients everywhere they go. Patient satisfaction and “quality measures” spread quickly in rural communities.

The number of patients seen can sometimes be low, but in an emergency, volume can quickly pick up, overwhelming usually underused resources. Rural physicians may feel disconnected from their urban colleagues or frustrated by systems that do not allow them to provide the care they believe is appropriate. Rural regions with successful healthcare systems have good communication processes within their medical staffs and positive referral relationships with tertiary facilities.

Federal subsidies or grants may help offset a less favorable payer mix in rural areas. As part of the 1997 Balanced Budget Act, states can designate critical access hospitals, which are paid at 101 percent of reasonable costs for inpatient and outpatient services for Medicare recipients, and are not subject to the inpatient or outpatient prospective payment systems. To maintain critical access status, hospitals must meet the following criteria:

  • specific location in a defined rural area
  • a full-time emergency department with on-site and on-call staff
  • no more than 25 inpatient beds
  • average length of stay of less than 96 hours for acute care

Improving rural orthopaedic care
Some alternatives exist that could facilitate the delivery of orthopaedic services in a rural setting. One option would be to improve professional relationships between rural providers and their urban colleagues through better communication and patient care coordination. Providing a minimum level of governance that recognizes the needs and concerns of both parties would be advantageous in creating a more optimal delivery model for orthopaedic care.

A second option involves a more formal clinical and financial relationship between larger orthopaedic providers and critical access hospitals. Using a comanagement model, large orthopaedic groups can supply rural hospitals/health systems with multiple-specialty–trained orthopaedic surgeons in an organized, coordinated fashion. The effort expended and the expertise shared by the orthopaedic group can be fairly, legally, and financially recognized by the hospital.

This situation enables the delivery of high-level specialty care in a rural setting. The transfer of emergency orthopaedic cases is facilitated by the relationship between the orthopaedic group and the critical access hospital. Both parties are accountable for the effort, expertise, and financial outlay expended in this situation.

The challenges with this option can be getting orthopaedic specialists to travel long distances to satellite clinics or getting patients from the rural setting to the specialists. Creating a coordinated system with open communication may minimize travel and allow for follow-up care in the rural community using technology such as telemedicine.

A third option—more challenging to replicate—is to develop a fully integrated health system, exemplified by Pennsylvania’s Geisinger Health System. Founded in 1915 by Abigail A. Geisinger in memory of her husband, the 63-bed George F. Geisinger Memorial Hospital was designed to offer comprehensive, specialized medical care to people in the rural areas of central and northeastern Pennsylvania. Unlike many hospital-focused environments, Geisinger’s tradition has always been physician-led and physician-driven.

Today, as the nation’s largest rural health services organization, the Geisinger Health System serves more than 3 million residents in 48 counties. This not-for-profit, fully integrated health services organization includes a 1,200 member multidisciplinary physician group practice with system-wide aligned goals, 9 hospital campuses, 2 research centers, and a 467,000-member health plan (Geisinger Health Plan).

Geisinger has made heavy investments in information technology (IT), relying on email, Web technologies, and digital image capabilities to facilitate care delivery in its rural environment. Its electronic medical record (EMR) is considered one of the most sophisticated in the country, linking physicians and patients to information that can improve quality and save time.

In orthopaedics, for example, Geisinger Medical Center in Danville, Pa., is the region’s only Level One Trauma Center, home to a highly respected orthopaedic residency training program, and the hub for tertiary and quaternary care. With one of the nation’s most mature health IT platforms, Geisinger orthopaedics has been able to develop “warranty programs” known as ProvenCare Acute® for total hip and total knee arthroplasty, hip fracture, and lumbar spine treatment. These programs represent advancements in care delivery leveraging evidence-based medical protocols, lean processes, and continuous surveillance to ensure the “right care at the right time for the right reason.”

Matching community expectations with the economies of a fully integrated health system has not been easy. Recruiting physicians to rural areas continues to be a challenge, despite the opportunity for orthopaedic surgeons to join a larger academic collaborative. Work-life balance, the practice safety net of belonging to a financially sound, integrated health system, and the availability of network providers in every specialty are also helpful in recruiting.

Changing attitudes to promote chronic care management rather than high-return, procedure-based care is still a difficult task, even in a physician-led organization. To address this need, Geisinger dedicates a portion of operating revenue to experiment with pay-for-performance initiatives, enabling orthopaedic surgeons to lead change and affect the total cost of care.

Although the community expectation for a full-service orthopaedic program at each rural location is often unrealistic, effective use of midlevel providers and seamless transfer protocols can ensure operational success. Transitioning local providers to a new IT platform with dashboards, objective quality metrics, and cost containment strategies can lead to a sense of loss for the “artistry and autonomy” of orthopaedic practice.

Balancing access and care
Orthopaedic care in a rural setting remains a challenge. However, uncoordinated, isolated care unsupported by effective communication is not only costly but also technically difficult. Physicians cannot allow the pendulum to swing back to a time when access to care was limited access and patients were unable or unwilling to obtain treatment for small, preventable problems until they became big, tragic, and costly. The first step is to recognize what physicians and patients want from a rural health system and how it might look. Only then can the journey to creating such a system begin.

The current challenges in rural health delivery offer the orthopaedic community an opportunity to lead the way by creating a more connected, highly integrated system with shared goals and aligned incentives. This is not an easy undertaking, nor is it without risk, but it is the right thing to do for our communities, our practices, and, most importantly, our patients.

K. William Kumler, MD, MBA (Maysville, Ky.); Craig Mahoney, MD (Des Moines, Iowa); and Michael Suk, MD, JD, MPH (Danville, Pa.), all practice in rural areas.