This last week, John Gale and his colleagues at Maine Rural Health Research Center, supported by the Rural Health Research and Policy Center, presented an important national analysis of the state of Rural Health Clinics (RHCs) across the country. It provides the most comprehensive analysis of RHCs since 2013. The review included key RHCs characteristics, provided services, staffing, and costs/efficiency looking at services by geographic region and RHC clinic type.  It is well worth a read. But to those who may not have the time, here is a quick summary, followed by actions you can take to improve your RHC.
The Rural Health Clinic Program is one of the nation’s oldest rural health support programs, established in 1977 to address geographic primary care access barriers experienced by Medicare and Medicaid populations living in rural underserved areas. To be certified as an RHC, the RHC must be located in a non-urbanized area that is designated as a health professional shortage area (HPSA) or medically underserved area (MUA) and must employ a nurse practitioner (NP) or physician assistant (PA) at least half of the time that the clinic is providing care.
From 2017 data, the authors observed continued growth of rural care with almost 5,000 RHCs providing more than 40 million visits in 45 states. 9 million of those visits are provided to more than 2 million Medicare beneficiaries, accounting for 25% of all RHC visits. The Midwest and South regions account for almost 80% of all RHCs, with the largest number of provider-based clinics in MO, TX, IA, CA, IL and KS.
60% of Critical Access Hospitals (CAHs) manage an RHC. 2/3 of RHCs were provider-based and 85% of those provider-based RHCs were owned by CAHs. 2/3 of provider-based RHCs were non-profit, 1/4 were publicly owned, and 11% were for-profit. Of the independent RHCs, 74% were for-profit entities.
Behavioral Health Services
Shortages of mental health services are a longstanding problem for rural areas. With recent changes in Medicare reimbursement for behavioral health services, RHCs can play an important role in meeting these needs.
The percentage of CAH-based RHCs offering MH services was relatively small at 9 percent of all CAH-based RHCs, with the majority being a single LCSW. Average visits were 950 visits/FTE. (50th percentile external benchmarks for LCSWs visits/FTE average is 1450 visits/FTE).
RHCs receive Medicare cost-based reimbursement for a defined package of services including those provided by doctoral-level clinical psychologists (CPs) and licensed clinical social workers (LCSWs) who can offer short-term individual counseling and psychotherapy for episodic concerns. Despite enhanced payment under Medicare and Medicaid and the significant need in rural communities, relatively few RHCs provide mental health services, with highest percentages of behavioral health services offered in the West.
Behavioral health services have been shown to address community needs and contribute to increased access to necessary services, improved the efficiency of their PCPs, reduced demands on PCP’s time, increased referrals to the hospitals, greater use of ancillary services, and reduced clinic repeat visits, inpatient admissions, and emergency department use.
To increase service access to their communities, 15% of RHCs provided weekend coverage hours.
When comparing provider-based vs independent RHCs, the average staffing patterns were similar. Physicians saw approximately 3,500 visits/year. Fewer provider-based clinic physicians met productivity standards of 4,200 patient visits/FTE compared to independent RHCs (51% vs 38%). NPs met their productivity standards > ¾ of time in both clinic types.
There was no information on staffing vacancy rates, since it is not an included data element in the cost reports.
Provider-based RHCs owned by hospitals with less than 50 beds are exempt from Medicare payment limits, with 85% of that group being CAH-based RHCs. Their costs were higher than independent RHCs ($223 vs $151). Interestingly, most of the cost difference between the two types of RHCs centered around physician compensation which was 50% higher (average difference of $80K more) in the provider-based clinics.
Why Is This Important?
While not covered directly in the article, let’s first acknowledge the obstacles we currently face with increased staffing salaries costs and recruitment difficulties, which are creating very real challenges for our facilities’ survival. But since it was not covered in this article, let’s move on.
Behavioral Health Service have been long recognized as a key missing ingredient to the care of rural communities. Less than 10% of RHCs provide behavioral services, despite 100% of the rural communities having the need. And that average service staffing in those 10% of RHCs is generally one licensed social worker who has 65% productivity compared to benchmarks. For Rural Health Clinics, our largest clinical gap is behavioral services.
For Medicare patients, Behavioral Healthcare Coordination Programs are now reimbursable and can serve as the foundation to introduce robust mental health programs. With a focus on a team approach aimed at relieving the Primary Care Providers (PCPs) from this patient population who tend require more intensive resources, these Care Coordination Programs can finally address this rural service gap. The program reimbursement includes a behavioral care manager, psychiatrist, weekly team meeting reviews for Psychiatric Collaborative Care Management (CoCM) and Substance Abuse Disorder Programs management.
This study also indicated where the largest gap is for both efficiency and costs - provider efficiency. Compared to independent RHCs, CAH’s provider-based RHCs annual provider pay is substantially higher ($80K more) and a subsequent higher cost/visit (50%). To address higher costs/visit for physicians, hospital and clinic leaders should evaluate ways to improve provider productivity, but not by asking providers to just see more patients. Clinic Optimization Programs have been shown to improve provider ability to see patients by removing obstacles that do not add overall care value and slow providers down. One of the largest opportunities is reducing provider documentation time through increasing the number of supporting Medical Assistants (MA) and increasing their responsibility for documentation.
How Rural Health Solutions Can Help
RHS’s sole focus is helping unaffiliated Critical Access Hospitals improve their financial viability so they can better serve their local communities.
Behavioral Health: RHS can introduce rapidly an integrated behavioral health service programs that can provide behavioral health services, Psychiatric Collaborative Care, and 24/7 hotline for acute mental distress with therapists, psychologists, and psychiatrists. In addition, RHS provides a weekly RHC/behavioral health team with providers to review difficult cases. These programs can help both your providers and your community address mental health and substance abuse disorders more effectively.
Clinic Productivity: As a physician-led consulting organization, we have years of experience in creating a more efficient provider-friendly clinic operation, while also increasing clinic volume. Our Clinic Optimization Program is an integrated product focusing on increased community awareness of clinic capability, patient self-scheduling capability, improved patient access, and higher PCP productivity by creating an aligned organization which supports timely provider evaluation and care.
 Community Characteristics and Financial and Operational Performance of Rural Health Clinics in the United States - John Gale, et al, Maine Rural Health Research Center – May 2022 and Rural Health Research and Policy Center. https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1016&context=clinics  Provision of Mental Health Services by Critical Access Hospital-Based Rural Health Clinics Flex Monitoring Team Briefing Paper #45 June 2020. John Gale, et al. Maine Rural Health Research Center Muskie School of Public Service University of Southern Maine. https://digitalcommons.usm.maine.edu/clinics/14/