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rural medicine

Rural Hospitals and Clinicians Await Washington’s Next Move

Posted on Thu, Nov 17, 2016
Rural Hospitals and Clinicians Await Washington’s Next Move

Healthcare facilities in rural areas have increasingly been under pressure. Access to care, physician shortages, shrinking reimbursement and gaps in insurance coverage have plagued patients in “Middle America.” On Election Day, rural Americans disproportionately voted for Donald Trump. Now, rural residents and the healthcare industry are anxious to see what direction the new administration will take to address the concerns of these citizens.

Twenty percent of the nation lives in rural America, and according to this year's exit polls, rural voters made up 17 percent of the electorate, according to the National Rural Health Association. Now that Rural Americans seemingly have Washington's ear, hospital administrators across the country trying to guess what impact Trump will have on the industry, particularly if he will work to repeal the controversial Affordable Care Act (ACA).

In a recent Modern Healthcare article, Kaiser Permanente CEO Bernard Tyson said that while Trump has said that he wants to repeal the ACA, the president-elect "seems to agree that everyone ought to have affordable, high-quality care and access.”

Dr. Rebecca Parker, president of the American College of Emergency Physicians (ACEP), said in a recent press release that emergency physicians are committed to working with the new Congress and President to address the critical issues facing patients. ACEP is focusing its efforts on putting pressure on the insurance industry to address gaps in coverage.

“State and federal policymakers need to ensure that health insurance plans provide adequate rosters of physicians, affordable deductibles and co-pays and fair payment for emergency services,” said Dr. Parker.

Emergency physicians represent only 4 percent of all doctors, but provide care for 28 percent of all acute care visits, 50 percent of all Medicaid and CHIP visits and 67 percent of acute care given to uninsured patients, according to ACEP.

Rick Pollack, President and CEO of the American Hospital Association, released a statement last week, reasserting his organization's goals: "Amid the changing political landscape, our priorities remain the same – advancing the transformation of healthcare, ensuring access to coverage, preserving adequate resources for healthcare, protecting patient access to care, enhancing the quality of care and patient safety, and making healthcare more affordable."

EmCare treats for more than 1.5 million patients in 170 rural hospitals around the country, requiring efficiency, alignment, creativity, targeted recruiting, and skilled resource management. Because of the unique climate at these client sites, the company has dedicated an entire division to managing rural, community and other small-volume hospitals and medical centers.


Rural Healthcare: What to Expect in 2016

Posted on Mon, Feb 22, 2016
Rural Healthcare: What to Expect in 2016

EmCare cares for more than 1.5 million patients in 170 rural hospitals around the country, and more than 2,000 clinicians dedicate their practice to this critical need. EmCare Physician Services (EPS) is the EmCare division which manages rural, community and other small-volume hospitals and medical centers. Bill Yarbrough, Chief Executive Officer of EmCare Physician Services, provides his insight on what rural hospitals and clinicians can expect this year.
What trends do you foresee in 2016 for healthcare in general and rural medicine specifically?

We’ll see the cost of coverage increase, affecting patients’ decisions on the affordability of coverage, and where and how they’ll seek care. The use of technology will increase to help address costs and barriers to access to care, particularly in rural and other underserved areas. In the healthcare in general, we’ll see even more consolidation and partnership among healthcare entities and an increased focus on post-acute care management.

Will the presidential election affect healthcare?

The election could have an impact on non-Medicaid expansion states in that there’s a significant difference in access to and affordability of coverage/care for patients, particularly in rural areas. From a national perspective, certain elements of the Accountable Care Act (ACA) may change depending on the composition of Congress or the White House.
What will be the top challenges for rural hospitals in 2016?

  • The ACA will continue to cause a negative financial impact in Medicare and Medicaid, which represents a large percent of rural hospitals’ of payor mix. We may see some regulatory fixes, such as removing the 96-hour conditional payment for critical access hospitals.
  • Rural hospitals will need to consolidate services, particularly for specialty care and referrals, to remain competitive. This may mean further horizontal integration of hospitals via mergers and partnering with systems.
  • And, rural hospitals will be challenged to expand the use of telemedicine for specialty consultation.

What will be the top challenges for rural physicians in 2016?
  • Declining reimbursement makes becoming employees of hospitals and healthcare entities more attractive. It’s expected that 75 percent of physicians will be employed by 2020.
  • Becoming proficient using the technology expected for documentation while trying to stay engaged with patients amidst the shift to pay for performance will be a noted challenge. 

What changes do you foresee with the rural patient population?
  • More patients are transitioning back to self-pay due to affordability/usability of exchange healthcare coverage. There will be a continued shift toward higher deductible plans and copays. In fact, only 4 percent of healthcare consumers selected high-deductible plans in 2006, compared with 22 percent in 2014.
  • Telehealth will be used more by patients for routine, preventive, primary and psychiatric care.
  • Bundling of post-acute services will be more difficult for care coordination for rural patients.

Bill Yarbrough, Chief Executive Officer of EmCare Physician Services (EPS), joined the company in 1989 has had a dedicated focus on meeting the needs of community hospitals. He previously served as EmCare’s EPS Chief Operating Officer and Vice President of Client Services.  His prior experience includes leadership positions in Spectrum Healthcare and Professional Anesthesia Services.


National CRNA Week: Our Growing Role, Especially in Rural Hospitals

Posted on Mon, Jan 25, 2016
National CRNA Week: Our Growing Role, Especially in Rural Hospitals

During National CRNA Week – January 24-30, 2016 – We will recognize some of the amazing men and women providing care in this important clinical role. Visit EmCare’s Facebook page to learn more about our CRNA superstars.

By Linda Caccamo, CRNA, MS, MBA/MHA

America’s rural hospitals are struggling. It seems that I read news of a hospital closure nearly every week. One way that financially strapped hospitals are working to deliver quality care more economically is through the use of advanced practice registered nurses, specifically Certified Registered Nurse Anesthetists (CRNAs).

CRNAs, the primary providers of anesthesia services in rural America, provide the majority of anesthesia care in U.S. counties with lower-income populations and populations that are more likely to be uninsured or unemployed, according to Nursing Economic$.

About CRNAs

CRNAs administer approximately 40 million anesthetics each year in the United States, according to the AANA’s 2014 Practice Profile Survey. The industry began credentialing registered nurse anesthetists in 1956.

CRNAs provide anesthesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists and other qualified providers. They are responsible for patient safety before, during and after surgery. Nurse anesthetists administer every type of anesthesia to patients in a variety of healthcare settings. CRNAs provide continuous pain relief and sustain patients’ critical life functions during surgical, obstetrical and other medical procedures. CRNAs monitor and interpret diagnostic information throughout the course of a patient’s procedure.

Typically, the requirements to be a CRNA are:

  • A Bachelor of Science in Nursing (BSN) or other appropriate bachelor’s degree
  • A current license as a registered nurse
  • At least one year’s experience as a registered nurse in a critical care setting
  • Graduation with a minimum of a master’s degree from an accredited nurse anesthesia educational program
  • Pass the National Certification Examination following graduation.

To be recertified, CRNAs must obtain a minimum of 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice.

Job Outlook

Due to increased financial pressure on hospitals, there is a significant and growing need for CRNAs across the country. A 31 percent growth rate is predicted over the next decade, according to

EmCare employs CRNAs in facilities across the country. They are valued members of our clinical team, and our integrated care approach enables CRNAs to practice at the top of their licenses.

EmCare supports CRNAs in a variety of ways, including:
  • Leadership, teaching and mentoring opportunities
  • Flexible scheduling
  • Earn While You Learn, a program that provides a monthly stipend to providers completing a CRNA program

During National CRNA Week – January 24-30, 2016 – We will recognize some of the amazing men and women providing care in this important clinical role. Visit EmCare’s Facebook page to learn more about our CRNA superstars.

Linda Caccamo

Linda Caccamo, CRNA, MS, MBA/MHA, is Senior Vice President of Operations for EmCare Anesthesia Services. Caccamo received her master’s degree in anesthesiology from the Medical College of Pennsylvania and combined MBA/MHA from Wilmington University in Delaware. In her current role, she offers supervision and support for anesthesia site medical directors and professional staff. Before joining EmCare, she served as an executive director for a large anesthesia group practice at a Level 1 regional referral center. She is a former instructor for Advanced Cardiovascular Life Support (ACLS) and has earned a Black Belt Certification in Lean Methodology for Healthcare. She has served on numerous professional and state level committees and continues to practice anesthesia as an anesthetist in EmCare’s North Division.



6 Reasons to Consider a Career in Rural Medicine

Posted on Mon, Aug 10, 2015
6 Reasons to Consider a Career in Rural Medicine

By Andy Scoggins

Nearly 25 percent of the U.S. population lives in a rural area, yet only 10 percent of the nation’s physicians practice there. There’s a shortage of qualified clinicians throughout the country, but in America’s least-populated areas, this dearth of doctors can mean the difference between life and death.

As medical professionals we’re hard-wired to go where we’re needed to serve our patients, yet for some, rural America is akin to Siberia. Here are six reasons you may want to reconsider a career in a “fly-over” state.

  1. Better Quality of Life: While practicing in larger cities may pay more, living in rural areas often costs less. You may be able to afford a larger home and more property, and you will probably sit in a lot less traffic! If you are nature-lover, most rural areas offer incredible hiking, fishing and biking opportunities, and who doesn’t love farm-fresh produce?

  2. Options to Lower Your Loans: Many states encourage physicians to practice in rural communities by offering financial incentives, including federal or state-funded student loan reimbursement or repayment programs. The amount of loan forgiveness usually increases each year that the physician continues to practice in the rural community.

  3. Ways to Expand Your Experience: Ever seen a snake bite or scorpion sting? Work in a rural area and you just might! Physicians in these areas often see cases that they might not normally come across in medical school or residency. Because a rural EM physician also serves as PCP, dentist, OB/GYN and more, they see a broader scope of chief complaints, and that’s experience you just can’t buy.

  4. Emphasis is on Technique, Not Technology: In many rural areas, access to high-tech diagnostic equipment and cutting-edge treatments isn’t readily possible. Rural EM doctors will need to rely on their more low-tech skills – palpation, data collection and H&P interviewing skills, including asking questions that might not seem common: interaction with livestock, access to dental services, access to preventive care. Your initial clinical evaluation and examination will be even more important when you don’t have access to the technologies that can hasten diagnosis.

  5. You Get to Be the Decider: In rural settings, it’s often a one-person show. You will need to be decisive, autonomous and authoritative. These are skills best learned through repetition and experience, and a rural post will offer you the ability to hone them. Of course, if you are fortunate to have a lot of clinician support, be collegial and collaborative, but odds are you won’t have residents, advanced practice providers or scribes to help with the work load. It may be all you, so be bold.

  6. You Become a Part of a Community: Yeah, urban trauma centers see a lot of action, but in a rural ED, you’ll interact with patients in a way you may never see in a larger city. Critical access hospitals are, as the name suggests, critical to the overall health of the community’s population. Your facility may be the only option for medical care for 100 miles. Your patients will appreciate you. They will trust you. And they will need your expertise and teaching skills to avoid another illness or injury. The need is real, but the reward is enormous. It can – and probably will – change the way you deliver care for the rest of your career.

Nearly 30 percent of EmCare’s clients serve patients in rural areas. Recruiting and retaining competent, committed physicians for these communities is one of our top goals. In fact, we’ve dedicated an entire division to this mission. For more information about a career in a rural hospital, including a Cost of Living Calculator, visit

Andy Scoggins is Chief Operating Officer of EmCare Physician Services.


The Critical Role of Rural Hospitals

Posted on Tue, Jun 23, 2015
The Critical Role of Rural Hospitals

Rural hospitals play a critical role in the overall healthcare system. 

Rural hospitals face ongoing challenges with recruiting of physicians and staff, the lack of easily accessible onsite training and development programs; inaccurate community perceptions often leading to patient migration to larger hospitals for care of even basic medical problems; and in some cases a more challenging patient population due to the lack of primary care resources, advanced age and undiagnosed chronic conditions. Financially, with tight budgets and lower ability for revenue & service line growth than their more urban counterparts, these hospitals face greater threats from reimbursement and regulatory changes and uncertainty associated with value-based purchasing.

According to the National Rural Health Association (NRHA), rural hospitals serve an estimated 62 million Americans, representing approximately 20 percent of the 318 million people in the U.S. Often rural communities have a disproportionate share of the elderly, uninsured and patients with significant health challenges. While not always easy,  rural hospitals find a way to provide these Americans quality care close to home.

The following article features a number of common questions about the state of rural healthcare answered by an EmCare clinical leader. Dr. Jeff Slepin, Executive Vice President and Regional Medical Director for EmCare’s community hospital division. 

Q: How would you describe the role of rural hospitals in providing critical services to the community?

A: Rural hospitals deliver high-quality services efficiently and affordably, and help keep patients close to loved ones during episodes of care.  They provide competent, compassionate community-based care for the general medical and surgical needs of their patient populations. Often, in small communities, the caregivers in the hospital  are neighbors helping neighbors.  As in larger hospitals, providers focus on patient-centered care with continuous quality improvement and strive to create an outstanding patient experience.

Q: How has the role of rural hospitals changed over the past decade?

A: Rural hospitals face many of the same challenges as their urban, tertiary, and academic center counterparts, including population health concerns, new laws and regulations and reimbursement.  Over the past 15 years of working directly with rural hospitals, I have seen a more sharpened focus on how these facilities address the needs of their communities

While rural hospitals are prepared to manage most emergent and urgent care needs, they have also become very competent at managing the traditional scope of general medical and surgical problems, and have become a focal point of entry of patient who require more advanced services by forming relationships that efficiently and seamlessly connect patients with higher level treatment facilities that can deliver specialized care.    These referral relationships are symmetrical and strive to assure that upon their return to the rural community their ongoing relationships with local primary care physicians and the hospital are preserved.
Q: What market forces most impact the direction your hospital must take to keep up with the healthcare needs of this community?

A: Hospitals are in a constant battle to keep up with health trends including the aging population, acute exacerbations of chronic conditions (including diabetes, cancer, respiratory, and cardiovascular disease) changing demographics, decreasing reimbursement, increasing costs, physician shortage, and aging infrastructure.  To maintain their viability, rural hospitals strive to recruit new providers and improve current or establish new service lines (such as medical or surgical subspecialties),

Q: How do rural hospitals compare to larger urban hospitals for service?

A: Service excellence and positive patient experiences are key benefits of lower-volume rural facilities. They are often better positioned to provide more personalized service because nursing and ancillary staff have more time to spend with patients thereby improving the patient experience.  Satisfaction scores and performance on the HCAHPS survey are in line with those of  larger hospitals. Patient safety and clinical outcomes are also keeping pace with larger facilities, including comparable rates of readmission and hospital-acquired conditions.

Q: What are the advantages for patient and families?

A: In terms of convenience, compassion, personal attention and communication, rural hospitals provide patients and families a competent and desirable alternative to care at venues that requires even 20 or 30 miles or more of travel.

Q: What do you think is the most common misconception about rural hospitals?

A: The most common mistaken belief about rural hospital that they are little more than first aid stations and unable to care for more complicated patients.  Based on analysis of transfer rates in our client base, most rural hospitals are able to handle more than 90% of the patients who present to the Emergency Department.

Indeed many rural hospitals provide the full spectrum of family medicine, internal medicine, general surgery, pediatrics and obstetrics/gynecology service lines.

Transfers are arranged only when requested by the patient or medically necessary, i.e. the patient has a condition for which the hospital does not have the capacity, capability, or resources to manage the patient and any reasonably foreseeable complications that may develop.

Q: What should a patient expect if they must go to a larger urban health system?

A: While at times this is necessary to get the specific services and treatments at higher level facilities, the disadvantages, including travel time and expense (fuel, hotel, meals), potential of lost wages, and the emotional challenges of  leaving a family member alone for extended periods of time, and perhaps  less access to the medical staff for the patient’s family, are outweighed by the benefits of tertiary care when indicated.

Q: In addition to improving access to immediate and convenient care, what are the other benefits of rural hospitals?

A: Like their urban counterparts, rural hospitals provide a community education and outreach, often more focused to the specific needs of a smaller population.  Rural hospitals are often among the largest employers in the area.  Having a dedicated community hospital in the local area is one of the elements that improve the likelihood of more people and businesses in considering relocation to a rural area.

Nearly 30% of EmCare’s clients are rural, lower-volume or critical access hospitals. Supporting rural hospitals by bringing competent and committed physicians into these communities is one of EmCare’s greatest achievements.

Dr. Jeff Slepin

References and related articles for further reading:

Healthland. (n.d.). Fighting for Rural Hospitals. Retrieved from Healthland

Health Research & Educational Trust. (2013, June). The role of small and rural hospitals and care systems in effective population health partnerships. Chicago, IL: Health Research &Educational Trust.