Rural Hospices, Patients Encounter Higher Needs, Fewer Options

Hospices that serve rural communities encounter unique challenges to bring care to a geographically dispersed population while contending with a smaller labor pool and higher costs for clinician travel.

Demand for hospice and palliative care is rising in rural areas as the population ages with the rest of the country. But those patients often find themselves in greater need for services with fewer options than their counterparts in more densely populated communities.

Studies show that, compared to urban residents, rural populations tend to be older, have higher mortality rates, are more likely to have a serious illness and often have fewer financial resources. They may also lack caregiver support, with their adult children or other family living further away.

These considerations can put providers and patients in a bind.

“Many rural communities wanting to offer palliative care face barriers associated with a lack of clinical training, resources, or dedicated palliative care staff,” a 2015 policy brief from the Rural Health Reform Policy Research Center indicated. “In addition, rural communities often do not have access to hospice or palliative care specialists, and payment mechanisms are inadequate to support programs where patient volume is low.”

Hospices operating in rural regions encounter obstacles that make it difficult to access patients and maintain a healthy bottom line.

Some of these obstacles are literal. Some rural communities have poorly maintained roads and topography that can slow travel, particularly in bad weather. Clinicians also have to travel longer distances for home visits.

The COVID-19 telehealth boom may be a bright spot of an otherwise dark couple of years for rural hospices. Telehealth has enabled rural hospice providers to stay in contact with far-flung or isolated patients with greater frequency, reducing the need for clinicians to travel long distances unnecessarily.

But hospices operating in those regions also tend to see higher costs, slimmer margins, as well as lower reimbursement due to geographic adjustments to Medicare payments.

Case in point, the 2019 aggregate Medicare margin for urban hospices was 12.6%, compared to 10.3% for rural providers, MedPAC reported.

Contributing to this are geographic and wage index adjustments that the US Centers for Medicare & Medicaid Services (CMS) applies to hospice payments, according to Christy Whitney, CEO of Colorado-based hospice provider HopeWest.

This in turn can complicate providers’ ability to counter the industry’s meanest headwind — the labor shortage.

“Our program has been significantly impacted by the wage index methodology and how it’s applied to hospice,” Whitney told Hospice News. “We’ve also had this disparity in that our wages are high because our competition for nurses is with a regional referral center that is a disproportionate-share hospital or sole community provider.”

Compounding these concerns, hospice providers are scarce in some rural areas.

As of 2020, 83% of hospices were operating in urban areas compared to 17% in rural communities, the Medicare Payment Advisory Commission (MedPAC) reported earlier this year. The number of rural hospices actually fell about 1% between 2019 and 2020.

MedPAC notes that this decline does not necessarily mean that access to hospice also dropped. This totally doesn’t account for the size of the providers or their service care, or their capacity to bring on patients.

Nevertheless, the commission indicated that the proportion of Medicare decedents who elect hospice is rising, and the number of providers available to serve them is shrinking.

Consequently, many terminally ill rural patients lack the option of passing away in their homes.

They often receive end-of-life care in critical access hospitals, small facilities that offer a limited number of inpatient or outpatient services. These patients are typically placed in “swing beds,” which are patient rooms that can be used for either acute care or skilled nursing services.

While critical access hospitals provide much-needed services to rural patients, including the terminally ill. Those patients do not receive the full range of care that hospice offers, including the choice to die at home.

These limitations can be painful for patients and families.

“People remember their family members’ end-of-life experience forever, and not just the exquisite care of the patient — but what happened with that family,” Whitney said. “[Hospice] is a model of care that really changed the world, and I feel like the current policy environment puts that in danger.”

Many policymakers from both ends of the political spectrum have acknowledged the challenges that exist in rural health care and have taken some steps towards leveling the playing field. But to date the initiatives and resources directed towards rural health care have fallen short of the tremendous need, and only a few of those policies specifically address hospice.

For example, the Consolidated Appropriations Act of 2021, folded in language from the previously proposed Rural Access to Hospice Act, which allows rural health clinics (RHCs) and federally qualified health centers (FQHCs) to receive payment for services to hospice patients.

​Not long after, the American Rescue Plan of 2021, a $1.9 trillion stimulus package, contained $8.5 billion in aid targeted at rural providers, including hospices. Those funds were intended to help offset financial losses stemming from COVID, similar to the Provider Relief Fund.

More recently, the Build Back Better Act floated by the Biden Administration included dollars to support scholarships and investments in additional medical residencies, designed to incentivize rural students to pursue careers in health care and practice in their home communities.

That bill also contained funds to expand access to broadband internet in rural areas, which could enable more patients to access telehealth.

But according to most observers that legislative package is unlikely to move forward.

While actions like these may help to some extent, the bulk of challenges that rural hospices encounter remain unchanged.

“Somebody needs to take a hold of the public policy and get it fixed. Whether that’s a legislative fix or a regulatory fix or both,” Whitney said. “I really think that the hospice benefit needs updating. Its methodology needs updating and the regulation needs updating.”

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