Improving Rural Intensive Care Infrastructure in the United States: A Strategy to Avoid Further ICU Closures

Over the past two decades, the United States (U.S.) has made improving rural health a priority. For example, the 2010 Affordable Care Act (ACA) expanded access to insurance coverage and funneled additional funding towards rural hospitals, which serve a disproportionate fraction of the uninsured population compared to their urban counterparts.^1,2 Despite this attention, more and more rural hospitals are closing each year, restricting rural residents’ access to both regular hospital care and intensive care.³ Here, we describe the landscape of rural intensive care infrastructure and detail how policymakers can better support rural intensive care by leveraging advances in health care delivery and learning insights and policies from other countries.

Intensive care unit (ICU) capacity was decreasing in rural America even before the COVID-19 pandemic, but changes wrought by the pandemic accelerated this trend. ICU capacity has decreased by 28.6% in rural counties with hospital closures versus 7.3% in rural counties without hospital closures.⁴ Rural communities now have almost half as many ICU beds compared to their urban counterparts (1.7 vs 2.8 per 10,000 people).⁵ The lack of community critical care services has been associated with higher mortality rates and exacerbates geographic disparities in care.⁶ Coupled with rural communities’ higher prevalence of co-morbidities, lower socioeconomic levels, lower levels of insurance coverage, and greater percentage of adults over age 65, rural ICUs face increasing demand with fewer resources to provide services.

This crisis is multifaceted and requires a comprehensive solution. For example, reducing uninsured populations though the ACA Medicaid expansion and increasing health workforce are well-studied solutions for sustainable care provision in rural areas. Additional policies could exploit recent advances in technological applications, new delivery models, and lessons internationally to bolster rural critical care infrastructure while equipping providers with cost-effective tools to deliver high quality care more efficiently and reduce ICU transfer time, a key predictor for both patient mortality and length of hospital stay.

Remote patient monitoring (RPM) is proving to be a cost-effective way to provide patient monitoring and expert guidance at a distance. Current RPM devices can accurately measure and transmit real-time information to both internal and external providers including integrated telemetry data and ventilator settings. This allows coordination with specialized providers both in the community and at larger tertiary care hospitals to more robustly support telehealth consultations and tele-ICU services. For hospitals without board-certified intensivists, the expansion of RPM and tele-ICU services could help preserve critical care capacity and mitigate provider shortages. In a hybrid ICU model, a virtual care team comprised of nurses and intensivists would monitor and evaluate the patient, adjust therapies, and coordinate specialty telehealth consultations. This would free the in-person team to focus on medication administration and other needed interventions. The flexibility of a remote nursing team could also alleviate potential quality compromises driven by the nurse shortage in rural hospitals. Furthermore, integrating RPM data with the medical record could automate entry of vitals further freeing up in-person providers to better respond to acute situations and cover more patients.

Prior studies have affirmed the benefits of these technological solutions. A recent systematic review and meta-analysis found that tele-ICU implementation was associated with significant reductions in both mortality and length of stay.⁷ Since the pandemic, tele-ICU interventions have also increased staff comfort with treating complicated critical conditions, improved adherence rates to ICU best practices, and benefited hospital financial performance.⁸

However, a hybrid ICU model has a high upfront equipment cost, and both maintenance and ongoing operations are expensive. To help pay for the equipment cost, funding should be earmarked for rural hospitals to establish or update their ICUs with remote monitoring technologies. In terms of operation and maintenance costs, the inpatient prospective payment system in the U.S. offers inconsistent revenue for rural hospitals due to more variable fluctuations in occupancy rates and patient volume compared to urban hospitals. Instead, federal and state agencies may consider global budgeting to allow rural hospitals to use a population-adjusted cash flow as they see fit for services important to their local community, an approach that has reduced Medicare expenditures in Maryland.⁹ Additionally, payment parity for tele-ICU services is set to sunset in the coming months. Further legislation should make the payment parity permanent for rural hospitals to promote ongoing tele-ICU implementation in rural areas. Tele-ICU should be a complement to rather than a substitute for in-person services. Policies should also target rural hospitals for preserving in-person critical care capacity in shortage areas to reduce ICU transfer times and the transfer-related risk on patients.

The problem of rural hospital closure is not unique to the U.S. Other developed countries face similar issues. In Demark, rural hospital closures have led to rural physician efflux, dramatically increasing distance to primary care for rural patients.¹⁰ Canadian rural emergency department closures have led to worse health care access and outcomes for patients needing cardiovascular care. Officials in France have described ‘medical deserts’ in rural areas, where emergency departments have closed due to staff shortages. Initiatives launched in these countries to mitigate the adverse effects of rural hospital closure may offer lessons for the U.S. For example, France has focused on reducing administrative burdens in rural areas through investment in dedicated care coordinators for patient disposition and discharge, freeing up the limited physician workforce to prioritize patient care and complex medical needs, particularly in ICUs.¹¹ The National Health Service in the United Kingdom has worked towards creating rural health “care networks” where several small community hospitals come together to share resources, technical knowledge, and infrastructure to provide distinct clinical services that would be expensive to provide at all locations.¹² Under this scheme, one hospital focuses on obstetric emergencies and deliveries for the region while another serves as the primary stroke center.

Rural hospital closure is a persistent challenge facing the U.S. The latest federal action to address this challenge, the Consolidated Appropriations Act of 2021, helps preserve an essential lifeline to emergency care access in rural areas through a new rural emergency hospital designation. However, it does not comprehensively address the burgeoning intensive care crisis in rural America. The work of improving rural critical care infrastructure is unfinished. Policymakers can make further advances in supporting rural intensive care by adopting hybrid ICU models and alternative payment strategies and learning lessons from other countries to better equip rural hospitals and improve critical care in rural communities.