Obstacles Persist for Rural Patients to Access Hospice

Demand for hospice and palliative care is rising in rural areas as they are for the rest of the country, but patients in those regions often lack access to care. Hospices trying to reach them often contend with lower patient volume and long travel times between home visits. While recent legislative action could make a dent, hospices themselves are finding a need to innovate to meet patient needs and sustain their businesses.

About 82% of hospices operated in urban or suburban areas in 2019, according to the Medicare Payment Advisory Commission (MEDPAC). Only 18% work in rural areas. MEDPAC notes that this is not necessarily an indicator of access, as these data do not account for the size of those providers or their capacity to serve patients. Nevertheless, the commission indicated that the proportion of Medicare decedents who elect hospice is rising, and the number of provided available to serve them is shrinking.

The limited options for rural patients who need hospice care reflects the broader issue of health care disparities throughout the continuum, according to Brian Mistler. chief clinical operations & people officer for Vynca, Inc.

“There are millions of people who should be receiving hospice but aren’t,” Mistler said. “Too often people are underserved across the health care spectrum – this includes rural, as well as race and ethnicity, income level — overall we need to be doing better everywhere.” 

Mistler is the former president chief operating officer of Resolution Care, a Eureka, Calif., palliative care provider whose service region includes large rural areas. The company was known for its successful integration of telehealth to supplement in-person care. Advance care planning company Vynca acquired Resolution in June.

Despite the relatively low population density, rural America has a high concentration of seniors. About 1-in-5 adults age 65 or older dwell in a rural area, according to the U.S. Census Bureau. This represents more than 17% of the total rural U.S. population. In some states, such as Vermont and Maine, rural seniors accounted for 65.3% and 62.7%.

Challenges related to delivering care for rural populations include geography, resources, and staff education and retention. Geographical challenges in rural areas consist of unpredictable access to patient homes due to weather, topographical features, poorly maintained roads, and long distances between homes.

Rural hospices also tend to see smaller margins than those in urban centers, according to MEDPAC. The 2019 aggregate Medicare margin for urban hospices was 12.6%, compared to 10.3% for rural providers.

Poverty tends to be higher in rural areas than urban centers. This means that rural seniors have significant needs in relation to social determinants of health.

“Health care in rural communities highlight certain problems, but they’re the same problems faced across the country — not enough providers, not enough community resources, the need for better communication and technologies that meet patients where they’re at,” Mistler said. “The biggest challenge of rural communities is access to other resources and groups that can effectively manage care coordination via telehealth and an extensive network of partners on the ground.”

Many rural patients nearing the end of life are admitted to critical access hospitals, small facilities that offer a limited number of inpatient or outpatient services. Most of these facilities are in rural communities. They place these patients in swing beds, which are patient rooms that can be used for either acute care or skilled nursing services.

These patients are not enrolled in the Medicare Hospice Benefit. Rather, they are receiving what the facilities call end-of-life comfort care, for which they bills traditional Medicare, according to Sandy Kuhlman, executive director of Hospice Services and Palliative Care of Northwest Kansas. Critical access hospitals are located in 15 of the 16 counties in which Hospice Services provides care.

“It’s really tough, because that’s also what keeps our local hospitals open. I think they’re really dependent upon patients in skilled swing beds,” Kuhlman told Hospice News. “But it’s really challenging for hospices. That’s probably the reason we are not serving a larger percentage.”

Recent legislative action has the potential to boost access in these types of locales, but may create additional competition for hospice providers. Congress earlier this year approved the Rural Access to Hospice Act, allowing doctors in Rural Health Centers and Federal Qualified Health Centers to serve as attending physicians for hospice patients. Both types of centers for the first time would be able to bill Medicare for hospice attending physicians services.

Though the new law could slow hospices’ ability to gain market share, many providers and industry organizations supported the bill.

“We support expanded patient access to high-quality, person-centered hospice care including greater access for rural and urban families in medically underserved areas,” said National Hospice & Palliative Care Organization President and CEO Edo Banach in a statement. “This statutory oversight has kept too many patients from choosing hospice care for fear of losing their preferred attending physician.”

Also interfering with rural patients’ ability to receive hospice at home is a lack of family caregiver support. Their children or other family may live long distances away. While social isolation plagues the senior community nationwide, rural patients may be more vulnerable since they may be far from neighbors or support services. More than 22% of rural seniors live alone, the U.S. Census Bureau reports.

The isolation problem has only gotten worse during the COVID-19 pandemic due to the need for social distancing, restrictions on entry to nursing homes and other factors.

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.

During the pandemic, hospices have been able to provide interdisciplinary services via telemedicine or audio as long as the patient is receiving routine home care level of care and those telemedicine services which are audio-only services are capable of meeting the patient and caregiver needs.

The $2.2 trillion CARES Act, designed to help the economy and essential industries weather the impact of the pandemic, also contained provisions related to hospice telehealth, including permitting practitioners to recertify patients via telemedicine appointments rather than face-to-face encounters.

The U.S. Centers for Medicare & Medicaid Services (CMS) is reviewing the temporary flexibility to determine which can be made permanent. It stands to reason that expanded telehealth will become a permanent feature in the health care system, but the number of provisions that will pertain to hospice in particular remains to be seen.

“We’re not quite sure what the future looks like and what CMS will allow post-pandemic. We’re hoping we can still do the face-to-face [recertification],” Kuhlman said. “Putting a medical director on the road for an hour or two hours is not a good use of that resource. I think we are all finding telehealth very helpful.”

Despite the benefits, telehealth is not a cure-all. A 2020 study found that seniors in rural households were nearly 30% less likely to have internet access than their urban counterparts. They were also more likely to have an unfavorable perception of technology.

Rural hospices, and the industry at large, face another looming threat — a diminishing workforce.

More than 35% of hospice leaders surveyed by Hospice News earlier this year cited staffing shortages as a top concern for their organizations, along with regaining access to patients in facilities. The shortage is occurring across a range of disciplines, including nurses, licensed independent practitioners, case managers and aides.

COVID isn’t helping. Many hospice providers have seen staff turnover rise during the pandemic, as have organizations in other health care settings. Slightly more than 20% of health care workers have considered leaving the field due to stress brought on by the pandemic, and 30% have considered reducing their hours, according to a recent study published in JAMA Network Open.

This has put pressure on rural providers who often have a smaller pool of potential new hires that hospices in more heavily populated areas.

“There’s only so many nurses, so many aides, so many social workers,” Kevin Stock, vice president of Moments Hospice. “If you have a few hospices in your area, you’re not only fighting with each other over staff, but you’re also competing with other health care providers: hospitals, home health companies and skilled nursing.”