— Policy solutions can help preserve access to care
by Logan Cho October 6, 2023
I was traveling to my hometown in Central Pennsylvania when I read this fantastic investigative piece by MedPage Today’s Kristina Fiore on Bucktail Medical Center, a hospital in the rural town of Renovo that solicited GoFundMe donations in order to keep the community hospital open. Located just over an hour drive from my hometown, Renovo is by all indications a classic rural Pennsylvania town. As a multi-generation descendant of the region, these types of communities mean a great deal to me. These are the same communities my father — and his father before him — have treated for decades as primary care physicians.
There are always fears that hospital closures will impact a community’s ability to receive care in the future. These fears, as mentioned in the MedPage Today piece, could very well be realized given that the next closest inpatient hospital is more than 40 miles away, a 50-minute drive down a winding two-lane road. If Bucktail closes, Renovo residents are at risk of not having guaranteed access to care — potentially life-saving care.
Herein lies the macabre, existential question with which I’ve been contending. Do communities really have the right to emergency care?
The “right to healthcare” has been a third rail in American health policy. There’s no agreed upon definition for the “right to healthcare” in the U.S., let alone a consensus on whether it’s an enumerated right or not. This term is somewhat of a misnomer, as it is often used in reference to government-funded or universal healthcare coverage rather than the actual delivery of care. Coverage serves as a serviceable proxy for the delivery of care because of our high healthcare costs, but fundamentally, the “right to healthcare” in modern parlance fails to capture situations where access isn’t guaranteed. Paying for care is a non-issue if there is no care to be had.
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, requires Medicare-participating hospitals to offer emergency services and, if necessary, stabilization and transfer, regardless of a patient’s ability to pay. In a sense, this provision guaranteed a “right to emergency care.” As highlighted in the Bucktail case, emergency care options are a requisite for the application of EMTALA. The offering of care is guaranteed, but access to this care is not necessary.
This background raises several corollary philosophical questions. Should the “right to healthcare” fundamentally be about “access to care” before “coverage of care?” Should access to healthcare, or at least emergency care, be guaranteed in practice? How can this be reconciled while simultaneously ensuring we don’t turn our backs on the issue of ensuring affordable healthcare coverage?
The factors financially straining rural hospitals like Bucktail are deeply rooted in decades of health policy, embedded in our largest institutions, and entangled among a complexity of additional financial pressures currently facing hospitals nationwide. Pragmatically speaking, it is impossible to meaningfully resolve this situation (i.e., making rural hospitals profitable) in any short-term timeline. Acknowledging this reality, I advocate for public funding to be directed at preventing the loss of further rural community hospitals until the systems are changed to ensure sustainable emergency care options. If keeping the community emergency department open isn’t of public interest, then what is?
While many have hoped for telemedicine to play a role in rural communities, it is no panacea. True emergency care requires a trained individual to be present with the patient to perform an examination, obtain vascular access, and perform basic life supporting measures such as resuscitation or hemostasis when necessary. Fortunately, there may be creative solutions that help relieve the financial burden of running a 24/7, fully equipped emergency facility for a small population.
One option involves paying rural community physicians in the area to be “on-call.” This is predicated on physicians living in the area near the hospital and being willing to take on this additional responsibility. Provided the compensation is set appropriately, it could be appealing for rural office-based physicians (primary care or specialty) to be compensated while also being able to maintain the benefits of not giving up too much of their office-based practice. In rural areas like Renovo that may see only a single-digit number of patients at their emergency department each day, office-based providers could essentially keep a portion of their schedule open to attend to any emergencies that occur while on-call, while simultaneously providing flexibility to minimize the disruption to scheduled outpatient visits. Hospitals would save on physician salaries, even if they aren’t fully staffed by these office-based physicians.
There are natural concerns regarding non-emergency trained physicians providing emergency care in a setting away from their office. Such a proposal would have to include provisions for periodic training where providers refresh and hone clinical skills. Telemedicine interactions with a remote emergency-trained practitioner, potentially funded by state or federal government and assigned to several rural hospitals, could also assist in the triage process by determining whether a case requires calling in the on-call physician versus transferring the patient.
Other cost-saving measures could involve the state or federal government assuming the costs of stocking emergency supplies at hospitals. In the event that hospitals are still too unprofitable, subsidies could help establish urgent care centers with less overhead. Critical Access Hospital is a designation that already exists to improve the viability of some hospitals, but clearly some are still slipping through the cracks. Adequately equipped urgent care centers may represent a more efficient model. Here again, these satellite urgent care centers can tap into local physicians, trained personnel like EMTs, and telemedicine to triage and treat or transfer appropriately.
To be clear, inadequate access to care is an issue that has plagued rural communities for a long time. Versions of some of these proposals already exist, but a combination of more funding and more efficient models are needed to prevent continued closures. Scarce emergency departments shouldn’t need a GoFundMe to keep the lights on. The story of Bucktail’s fundraising campaign was a reminder that it could be my neighbors who have to drive 50 minutes down winding roads to get emergency care. By re-considering the “right to healthcare” and how the interpretation of this right impacts our patients, we can begin to do these communities justice.
Logan Choo is a fourth-year medical student at the Icahn School of Medicine in New York City, and an advisory board member of MedPage Today’s “The Lab.