The Emergence of Rural Emergency Hospitals

In response to growing concerns about rural hospital closures, the Consolidated Appropriations Act of 2021 established a new hospital type: the rural emergency hospital.¹ As of January 1, 2023, hospitals that adopt this new designation will close their inpatient units and provide exclusively outpatient and emergency services. In exchange, each rural emergency hospital will receive an additional monthly facility payment totaling more than $3.2 million in 2023, as well as a 5% increase in payments for certain outpatient services. There are more than1500 rural hospitals eligible to obtain the rural emergency hospital designation, with recent projections anticipating as many as 681 hospitals to be potential early adopters.^2,3

The rural emergency hospital represents an important mechanism to preserve vital access to health care services at rural hospitals vulnerable to closure. Maintaining outpatient and emergency services at the expense of inpatient care redefines the rural hospital and represents a fundamental shift for rural health care delivery. Safely implementing this new model of care will inevitably confront important tradeoffs. This View-point describes key domains where this new model of care may benefit patients in rural communities and recommends potential safeguards to monitor and minimize unintended consequences (Table).

Table.

Monitoring for Unintended Consequences of the Rural Emergency Hospital Care Model

Domain	Anticipated benefit	Potential unintended consequences	Early signs of unintended consequences
Ensuring access	Preserve outpatient and emergency services	Greater travel burden for patients to obtain inpatient care Delays in patients receiving inpatient care	Changes in patient travel distance to care Rates of emergency presentations for access-sensitive conditions
Facilitating transfers	Align patient care needs with facility resources	Difficulty for rural hospitals to identify an accepting hospital with inpatient services Overburden nonrural hospitals with increased inpatient volume	Increased rates of delayed or rejected transfers Limited bed capacity at receiving hospitals
Strengthening continuity of care	Strengthen relationships and disseminate expertise	Fragmented care across multiple sites and multiple clinicians Redundant care leading to higher care utilization	Patients with care across sites without interoperable electronic health records Duplicate testing across sites of care
Maintaining a rural workforce	Maintain outpatient and emergency workforce	Difficulty recruiting outpatient clinicians who also need inpatient resources Less overall infrastructure to recruit outpatient clinicians	Loss of clinicians who provide inpatient and outpatient services Increase vacancies for outpatient clinicians

Ensuring Access

The underlying goal of transitioning to rural emergency hospitals is to ensure health care access in rural communities. Hospitals may avoid closure by streamlining financial resources to only outpatient and emergency services. And while less than the previous number of services would be offered, it would result in more services than if the hospital closed entirely. Preserving a core set of outpatient services, such as primary care, maternal care, and mental health, improves health outcomes. There may also be opportunities for hospitals to use the additional payments to expand access to previously unavailable outpatient services such as preventive screening mammography or colonoscopy.

Despite the potential of rural emergency hospitals to maintain access to some essential services, they may also worsen access for others. For example, surgical procedures requiring inpatient care will no longer be available. Patients requiring hospital admission, even for common conditions that can be safely managed in rural settings,⁴ will need to be expeditiously transferred or take on a greater travel burden themselves. In doing so, they may become less likely to receive timely care. As such, safeguards should exist to monitor excessive patient travel burden and delays in care. For example, policymakers could use existing administrative claims data to measure changes in patient travel distance and rates of emergency presentations for access-sensitive conditions.⁵

Facilitating Transfers

As hospitals transition to a rural emergency hospital model, they will transfer patients requiring inpatient hospital services to other larger centers. In doing so, patients may benefit by having their care provide data specialized center with more dedicated expertise. For example, for complex cancer conditions, this may lead to an overall improvement in the quality of care patients receive. In fact, many of the hospitals eligible for this new care delivery model are critical access hospitals that already maintain transfer agreements with nearby hospitals. Stronger regional relationships may improve referral and transfer processes from rural emergency hospitals and streamline rural patient access to specialty care.

Despite the promise of rural emergency hospitals to transfer patients to optimal inpatient care settings, capacity constraints may be confronted. Urban hospitals that would accept transfers on average experience nearly twice the occupancy rates of their rural counterparts.⁶ As such, rural emergency hospitals, now without their inpatient resources, may find it more difficult to identify an accepting hospital with sufficient capacity. As hospitals transition to this new care model, the number of rejected transfers and delays in care will need to be evaluated. In some scenarios, receiving hospitals may need additional resources to increase their capacity in anticipation of rural hospitals no longer providing inpatient services.

Strengthening Continuity of Care

With rural patients receiving care more often at larger hospitals, regional care delivery models will be needed. This includes an opportunity for greater collaboration between specialty and primary care clinicians. Interfacility partnerships that disseminate expertise across multiple sites of care should be encouraged. For example, telehealth has successfully extended specialist expertise at academic medical centers to primary care clinicians in underserved areas.⁷

Despite opportunities for collaboration, more patients receiving care at distant sites may result in greater care fragmentation and ultimately worse outcomes.⁸ As an example, rural emergency hospitals will need to transfer patients to another hospital before they can qualify for admission to a local skilled nursing facility. To mitigate these risks, rural emergency hospitals and their larger referral hospitals will need robust processes for coordinating care. Strategies to strengthen transitions of care, such as integrated electronic medical record access and telehealth follow-up visits, should be a focus for safely implementing this new model. Duplicate testing should be monitored as a reflection of redundant and fragmented care.

Maintaining a Rural Workforce

The emergence of rural emergency hospitals may provide important resources to maintain an adequate rural clinician workforce. If rural emergency hospitals aid in averting hospital closure, it would importantly preserve jobs for local health care workers and the broader community. Additionally, increased reimbursement for outpatient services may also maintain, and even expand, practices for outpatient clinicians. For example, supporting rotating specialty clinics at rural emergency hospitals, a practice that some rural clinics already implement.

Despite their vital role, recruiting rural clinicians remains a persistent challenge. With the elimination of inpatient care, it may become more difficult to recruit and retain clinicians who importantly provide the broad range of services needed in rural communities. For example, general surgeons who can perform a broad range of common, outpatient procedures needed in rural communities (eg, colonoscopy, inguinal hernia repair) may be more difficult to recruit without available inpatient services typically needed in their practice. Paradoxically, the focus of rural emergency hospitals on emergency and outpatient services may weaken the workforce of physicians working across inpatient and outpatient settings and, in turn, decrease the outpatient workforce. As hospitals transition to a rural emergency hospital model, workforce changes will need to be monitored for unintended losses across all service lines.

Conclusions

Despite the potential for rural emergency hospitals to preserve health care access to rural communities, the policy may also have unintended consequences. Safe adoption of this policy will require lessons learned from its earliest adopters. Specifically, it will require proactive monitoring for unintended consequences and, when needed, ample resources for rural communities to reestablish full-service hospitals. Doing so would reaffirm health care as a necessary infrastructure for rural communities.