Spring Parker Accelerating Health Care Performance

Beth O'Connor, Executive Director at Virginia Rural Health Association

Featured Guest: Beth O'Connor

What she does:  Beth is the Executive Director of the Virginia Rural Heath Association, immediate Past-President of the National Rural Health Association Board of Trustees, and past Chair of the National Rural Health Association Government Affairs Committee.

On risk: "If you said risk and rural to me, the first thing that would pop into my mind was the hospital closures we've had all over rural America.  Those hospital closures and the concern about our small rural facilities being able to stay financially viable is absolutely at the top of my mind when you say risk … Economics is a big factor. Can you financially keep the hospital open? Can you keep paying your staff? Can you stay in the black long term? That's very tricky for rural hospitals … Even if you can pay them (staff) a decent salary, can you attract people to work in your facility? … It's very hard to keep a physician in a rural community. It's especially hard to recruit and retain specialists in rural communities. So that's a major problem.  If you have a facility that doesn't mean you can provide all the services … Transportation is a barrier on so many levels.  Every corner of the country has different types of transportation barriers.  Transportation and the distance between services is absolutely a concern … People need to realize how many of our rural citizens and even our rural facilities, hospitals, clinics, still do not have sufficient access to the internet … The regulations that govern rural hospitals were created by Congress. And it takes a literal act of Congress to change them"


Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in.

Perceptions, perspectives, and even definitions of rural health and rural health care vary greatly based on the individual, the location, and the organization. All of those have a common thread. Each plays an important role in rural health care, risk in rural health care, and the performance and success of rural health care. A report from the Center for Healthcare Quality Payment Reform found that more than 600 rural hospitals - 30% of all rural hospitals - are at risk of closing. The report found two common contributing factors: persistent financial losses and low financial reserves with insufficient net assets to counter losses on patient services over a period of more than six years. The report goes on to say over 150 rural hospitals closed between 2005 and 2019. Since 2019, 37 rural hospitals closed, including nine in the first 10 months of 2023 - almost as many as in 2021 and 2022 combined. The number of closures during the pandemic were smaller because of the special financial assistance hospitals received during the pandemic. Pandemic aid has now ended so closures are likely to increase. A facility or department closure is typically the ultimate result of financial stress. The financial condition can be caused by issues such as staffing, but risk can enter a rural health care organization and community through numerous vulnerabilities. How can rural health care address and manage risk? How can individuals, groups, and organizations within a local community - but also outside a community - help strengthen risk vulnerabilities? Today I'm speaking with Beth O'Connor about risk in rural health care, including perceptions and perspectives. Beth is the Executive Director of the Virginia Rural Health Association, past Chair of the National Rural Health Association Government Affairs Committee, and the immediate past President of the National Rural Health Association Board of Trustees. Let's talk with Beth about risk in rural health care. 

Beth, welcome to the show.

Beth O'Connor  2:42  
Well, thank you.

Scott Nelson  2:44  
Before we begin talking about risk in health care, let's go back to the beginning. How did you get into health care and where you are today?

Beth O'Connor  2:49  
Oh, mercy. So once upon a time, I was an undergraduate student with great dreams of becoming a genetic engineer. And then I discovered you had to take chemistry. And that was, I loved biology, I was great at biology, chemistry, not so much. So I started looking at you know, what are my some of the other options that are in more of the biology world. And I discovered that the undergrad program I was at had a degree in health education, where you, most people in that field are working with various health centered nonprofits, such as the Virginia Rural Health Association, or people may be more familiar with like the American Heart Association, or the American Cancer Society and those types of organizations.

Scott Nelson  3:40  
I would have been in the same way with the chemistry as well, that would have gotten me in a different pathway.

Beth O'Connor  3:45  
It required studying I was just didn't get it.

Scott Nelson  3:48  
With me it would have required studying and a whole lot of probably luck and other stuff that I didn't have. But anyway, I'd like to start our conversation by framing and describing rural health. I grew up in a town in Ohio with a population of around 100,000 people at the time. My high school was surrounded on all four sides by cornfields and we thought we were in a small rural town. But now that I've lived and worked around the US I've come to see and understand there are many differences and variations created by many factors like geography, for example. HHS Health Resources and Services Administration's Federal Office of Rural Health Policy says that the United States Census Bureau and the Office of Management and Budget define rural areas, and that it uses those definitions and Rural-Urban Commuting Area Codes to create its own definition, but that the Census and OMB definitions present measurement challenges. Based on the 2010 US Census data, 19.7% of the population - 60.8 million people - and 86% of the land area of the country are considered rural. Locally for you in Virginia, Virginia has 2.5 million people and approximately 20% of Virginia's population. So, is there a simple way to understand what rural health is?  And what does it look like? And what is a rural health organization?

Beth O'Connor  5:05  
Simple way? No, there is no simple way. You know, you referenced the Federal Office of Rural Health Policy and the Office of Management and Budget. But the reality is, every single department of the Federal Government has a different definition of rural. So how you define rural may depend on what agency you're working with, or what grant you're going after, or how the funding works out best for you. For us, we use the Federal Office of Rural Health Policy the most frequently but we also use the CDC. According to the CDC, any locality with less than a half million people is rural, which meant yes, your town in the cornfields of Ohio would have counted. Other folks that live in remote rural areas would have looked at you and said, you've got to be kidding me, that's not rural.

Scott Nelson  5:57  
Now, when thinking about like the organization's when we read and you hear about Critical Access Hospitals, FQHCs, or federally qualified health centers, rural health clinics, are there differences between each one of those? I'm assuming that there are but are those spread throughout an area? So in Virginia, do you have one or each of those, multiple of those, in terms of rural health care organizations? And then can people in rural health go to other types of organizations outside of just those three examples?

Beth O'Connor  6:28  
Absolutely. So you know, hospitals, obviously, are entities in and of themselves separate from the clinics. So Critical Access Hospitals, by federal definition are hospitals with 25 or fewer beds that are at least 35 miles from another hospital facility. Now, there's some exceptions for that, such as places where the 35 miles involves some very mountainous roads, steep terrain, you know, that could be shortened. So you know, there's the hospitals that are meant to be small, tertiary care facilities for their communities. Now, you mentioned federally qualified health centers, and people very often equate FQHCs with rural, but it's probably better to think of FQHCs as high need. There are federally qualified health centers in New York City. It just depends on what the need is for that community. So they are more focused on making sure everyone has access to care, regardless of the ability to pay. So there are FQHCs, very rural, very remote areas and their FQHCs in downtown Richmond. As opposed to rural health clinics, which must meet that federal definition of rural. Rural health clinics are a slightly different entity in of themselves. Some of them are independent, whereas others are what we call provider based, which means that they're a part of a larger hospital system. As opposed to the FQHCs, which are also they're always their own independent nonprofit organization, not part of another entity. And the rural health clinics, their primary purpose is to make sure that people on Medicare, which we know is a higher than average percentage of our rural population, have someplace to go to receive services. So they receive enhanced reimbursement for Medicare services, that you might not get in another type of clinic in an urban area.

Scott Nelson  8:27  
Taking that, kind of that background or that context, how do you think about risk in rural health, both locally in Virginia, but then also nationally, in your work as the Executive Director of the Virginia Rural Health Association, but also in your past role as the President of the National Rural Health Association?

Beth O'Connor  8:44  
Oh yeah. You know if you said risk and rural to me, the first thing that would pop into my mind was the hospital closures we've had all over rural America. Since 2010 there has been, and I would have to look up the exact number, but hundreds of small rural hospitals that have closed leaving people in the communities with no options. In Virginia alone we had two, one of those stunningly - Lee County - has been able to reopen, which is absolutely unheard of. Typically, once a hospital closes, it's gone forever. So you know, those hospital closures and the concern about our small rural facilities being able to stay financially viable is absolutely at the top of my mind when you say risk.

Scott Nelson  9:34  
How was that hospital able to open up again? 

Beth O'Connor  9:37  
Through sheer force of will of its local population. It was amazing. I have never seen anything like that before.

Scott Nelson  9:45  
During my work and conversations with health care professionals and organizations across the US I hear three consistent themes or barriers that affect and impact rural health. The first is economic, the second's geographic, and the third is sociocultural. These place populations and communities at risk, and can also affect and impact rural providers and organizations. Are these the only barriers? Or are they the three biggest barriers? Or are there others? So from your perspective, what areas of risk in rural health should be of concern to health care professionals and organizations?

Beth O'Connor  10:18  
There's so many different ways to look at that. As you mentioned, economics is a big factor. You know, can you financially keep the hospital open? Can you keep paying your staff? Can you, you know, stay in the black long term? That's very tricky for rural hospitals. There's so many other issues. One is staffing. Even if you can pay them a decent salary, can you attract people to work in your facility? We know that it's very hard to keep a physician in a rural community. It's especially hard to recruit and retain specialists in rural communities. So that's a major problem of, you know, if you have facility that doesn't mean you can provide all the services. One of the things we know is there's a huge number of rural hospitals, whether you're talking Virginia or throughout the nation, they no longer provide labor and delivery services. So if you show up to Giles County Hospital, which is just north of where I am now, in labor, they will stuff you in an ambulance and send you 35 miles down the road to the Montgomery hospital, because they don't provide that service, because they don't have a frequent enough birth rate in the area to be able to justify keeping the staff on board for that service. Obviously, that's a risky situation for mom, for baby, for the ambulance drivers. We have a frightening number of EMTs delivering babies on the side of a highway. Not the best situation for everybody. So that's absolutely a risk.

Scott Nelson  12:01  
And that goes right into what my next question was going to be in terms of what about services as a risk or as a barrier, such as dental, behavioral health, primary care, you just mentioned women's services, pediatrics. I hear about those as well in a lot of conversations in these rural communities and how do services create or address risk. I came across an article recently from Rural Health Information Pub, and it was published in The Daily Yonder, about the Department of Transportation to help rural and tribal communities access funding opportunities. And so the Department of Transportation was funding nearly $6 million for more than 60 rural and tribal communities with the goal of creating jobs, improving safety, and strengthening economies. So is that an opportunity where we talk about the the economic pieces, as well as when you were just talking about staffing, recruitment, retention, workforce, and infrastructure, for government or other entities to get involved and help out in those areas?

Beth O'Connor  12:59  
Transportation is a barrier on so many levels. You know, first of all, can your patients get to your facility to be seen? You know, last I checked, there's not a subway running around rural Virginia, or bus service, or anything like that. So you know, can people get to the service? Without transportation do they have a way to get to jobs that would pay them sufficient benefits to have health insurance to be able to use your services? There's so many things tied up in transportation that I think people don't realize, you know, when you're working with a community that has barriers to be able to own their own car, for whatever reason, there's just no other options.

Scott Nelson  13:41  
How do those barriers go into risk variations? Or are there risk variations? Meaning, are there differences based on geography or type of organization or type of community? So how are rural Virginia and rural California and rural Massachusetts and rural Florida, or any other state around the country, how are those different?

Beth O'Connor  14:02  
It's definitely the more different we are the more than we are the same. Every corner of the country has different types of transportation barriers. In Virginia, you know, we think of either the Appalachian Mountains on the west side, or you think of the eastern shore with, you know, the Chesapeake Bay is in the middle part of Virginia, how do you get around that? As opposed to the Great Plains states where you may have hundreds of miles between one hospital and the next so that it really depends on where you are. Either way, the transportation and the distance between services is absolutely a concern. You know, whether you're talking about, again, that the mother and the baby, whether you're talking about liability in terms of how you serve that population, so many different aspects.

Scott Nelson  14:52  
Do you see any types of areas where there can be solutions? Just last year, Ohio initiated a $500 million program for the Appalachian Community Grant Program. And what that does is provides planning development grants for communities located in Ohio's 32-county Appalachian Region. Are those kinds of opportunities giving these local communities the ability to come up with solutions, to think through new, and I know that Ohio's program there was to come up with a sustainable solution after giving seed funding, to get these programs up and running. Are those opportunities to help these local communities kind of put these efforts into motion and be successful?

Beth O'Connor  15:33  
Oh, absolutely. Anything that you can do to provide that infrastructure to allow projects to move forward are absolutely essential. I've heard some disparaging comments about oh, you know, it's just a handout. But there's different ways to structure those types of opportunities. Are you doing something to provide a ground floor that people can build upon? That's fabulous. There's so many things you can do once you have that initial foundation.

Scott Nelson  16:02  
And I had a conversation last year with a local community leader, after Ohio announced their program, and it really kind of hit home with me from that conversation when he said, you know, typically, they're trying to figure out how to put a plan together to put in a, you know, $500, or $1,000, you know, water main or water pipe into an area, you know, when you're looking at those types of opportunities these days, you know, that's like telling them, you know, how are they going to get to the moon. And just trying to think through those strategies and, and put those things down into bite-sized pieces that they can then act on. And I'm going to get to another question in terms of bite-sized pieces here in a second, but when we look at, we've touched on local communities, some of these providers, who are the stakeholders and actors involved in rural health care? And how do they or how can they address risk?

Beth O'Connor  16:50  
Well I would say there are the key community leaders that are involved, and there's the key community leaders that should be involved. So certainly the health care entity, whether that's a hospital or a clinic, you know, the people that work in and manage those facilities, your local health department very much is involved. But we need to see more involvement from other key community leaders, elected officials, people in the business community, people in the social service community. Anything that you can do to realize that health care is an integral part of the overall success of that community. People talk a lot about the need for economic development in our rural communities. Last I checked the paycheck and taxes from that paycheck of a physician look pretty dang good as opposed to most other jobs in a rural community. Why aren't we doing more to make sure that we're investing into those types of jobs?

Scott Nelson  17:52  
Now thinking about the work of rural health care professionals and organizations and the process of putting everything together. What resources have you found helpful and possibly even essential? So for example, we touched on the Rural Health Information Hub, you mentioned federal, state and local government resources, HHS, Health Resources Services Administration. Where are some pieces and resources that you think organizations and professionals should be utilizing?

Beth O'Connor  18:18  
Well certainly you mentioned the Rural Health Information Hub, that is absolutely key. They have so much information to help folks find the resources that they need. Any of your big national health related organizations or rural related organizations, the National Rural Health Association, the National Association of Rural Health Clinics, the folks over at USDA, all of those entities have fantastic resources that people should be checking out. And make sure that you are talking to your elected officials. Who is your member of Congress, who is your Senator, do they know who you are and what you do in your rural community? Make sure you contact them.

Scott Nelson  19:01  
Getting back to that point that I made in terms of bite-sized pieces and some of the barriers and obstacles that are in front of some of these groups. We touched on staffing, recruitment and retention, bringing some of these people into these communities and having the resources available. Mentioning the Rural Health Care Information Hub again, and an article that was published in Fierce Healthcare about a rural Illinois hospital. It says that in 2021 a ransomware attack was partially to blame for its closure, again, talking about another hospital closure that you had mentioned earlier. What can and should be done to address risk in rural health care. So what practices or solutions do you believe are successful to avoid or manage or mitigate risk? So if I was a doctor or a provider or an administrator in a rural health care organization, what one, two, or three actions should I be doing to decrease vulnerabilities and become stronger?

Beth O'Connor  19:55  
So I'm gonna go back to talk to your elected officials. The regulations that govern rural hospitals were created by Congress. And it takes a literal act of Congress to change them. Make sure you know who the staff members are in your representatives office, in your Senators office, that deal with health and health care issues. Be in contact with them, make sure they understand what you are dealing with on a day to day basis, and understand how federal policies help or hurt what you are doing.

Scott Nelson  20:28  
Looking back through recent history, from a risk standpoint, what was expected versus unexpected, from your perspective and where you sit? What could have been done differently over the last year or so?

Beth O'Connor  20:39  
So this isn't really the question you asked, but I think this is the direction to go. People need to realize how many of our rural citizens and even our rural facilities, hospitals, clinics, still do not have sufficient access to the internet. I just got internet in my house in February of this year. So looking back, you know, during COVID, we talked about working remotely and telehealth and all those types of things. That was not an option for me unless I went to the office. And for so many, for so many things that can be done these days to help rural communities if they don't have that infrastructure it's hard to communicate with the people who are paying the bills, in terms of insurance companies and CMS. It's hard to research and apply for grant opportunities. It is hard to recruit physicians and other types of clinicians. It's impossible to run telehealth if you don't have adequate internet at your facility.

Scott Nelson  21:49  
That's a perfect direction to go in. And now even, actually thinking about this, the flip side of that, looking forward during this year, maybe even beyond and maybe the infrastructure piece of this in terms of the broadband and technology requirements may be part of this, but what do you see as potential issues? And how to anticipate and be prepared in the future?

Beth O'Connor  22:09  
Well certainly you know, the Farm Bill is up for reauthorization at the federal level. I encourage people to look into that. Again, talk to their elected officials about why that's important. Not just for big ag. People look at the Farm Bill and think it's just agriculture. There's millions of dollars in the USDA dedicated to rural health, so make sure that you know what's going on there. The other thing I think we can do better in the future is understand how to recruit and retain our rural health care providers. You know, one of the things in our rural communities we know is that you can recruit somebody from the outside to come in but they probably only stay for so long. We really need to change our focus to encouraging our local kids to consider health care careers so that they can come back to our communities and be embedded in our communities and stay there long term.

Scott Nelson  23:07  
You know, that's an interesting point because I think what I've been finding when I have conversations, whether or not it's with dental care or with with physicians in medical care, a lot of these rural communities, there have been is local kids that have grown up there have gone away to school and gone away to either medical school or dental school or veterinary school, then they'll practice for a time period, and then at some point time some of these do go back to their local communities and want to go back and raise their families in the area in the community where they were raised. And I think that that not only helps those families, it helps the community, and it helps just the greater area as well.

Beth O'Connor  23:46  
Absolutely. We see stories of kids leaving their current rural communities and going off to college to be able to go get a good job.  Healthcare is a good job. You can do that in your rural community unlike some other jobs that you have to go to a big city to get.

Scott Nelson  24:03  
That's a great point. And that's a great point to conclude our conversation on. Beth, thank you very much for your time and your sharing your thoughts today and your experiences. I really appreciate it.

Beth O'Connor  24:11  
Thank you.

Scott Nelson  24:14  
Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.

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