by Jane Winnick Thirtwell
Paradox of health care for rural women in North Carolina: Small and far-reaching hospitals cannot afford to continue delivering babies and provide other important OB/Gyn services, but their communities cannot afford to stop.
If there is hope to stop or reverse this trend, rural hospitals and healthcare professionals will need stronger accountability, incentives and support. The strengthened regulatory and legislative framework built and maintained by the North Carolina Legislature and its Department of Health and Human Services could help achieve this.
While these changes are dramatic for North Carolina, many other states are considering whether similar measures have already been implemented to address rural women’s health services.
“From a system perspective, there are plenty of opportunities for improvement,” said Dolly Presley Bird, chairman of the Department of Obstetrics and Gynecology at the Asheville-based Center for Mountain Regional Health Education. “There are several structural ways in which health care systems can be created that exacerbate inequality and increase disparity, whether geographically, socioeconomically, or racially.
“In an ideal situation, if we could serve women and provide the care they needed in the community they live in, they would not have to travel and they had support around them.
Standards of care that affect the health of rural women
In North Carolina, the state provides neonatal level care. This means that hospitals maintain pre-defined standards of care that are expected to be provided to infants.
If the hospital has committed to treating the baby at Level IV (the finest medical care possible), but it drops to Level III, the health services regulatory department will take action.
There is no similar system for maternal care in North Carolina. However, the other 16 states have standards for the level of maternal care provided by hospitals, including North Carolina’s neighbours, Tennessee, Georgia and South Carolina. And there’s the possibility of more people coming in.
Mississippi, very poor Maternal and infant mortality rates have built a system of standards for both maternal and infant care to solve the problems. It will be performing live later this year, according to Mississippi Health Officer Dan Edney.
“The statewide system will target highly vulnerable labor and childbirth windows, and postnatal immediately for both mothers and babies,” Edney told the CPP.
“Our goal is for high-risk pregnancy to provide the right level of care, so moms have everything they need.
North Carolina policymakers are also considering implementing maternal care levels. However, more regulations will also increase hospital costs, which requires a measured approach.
“We are a great place to go,” said Belinda Pettiford, chief of the Women, Children and Community Wellness Section of DHHS’ public health department.
“If we update newborn-level care, we’ve been digging deeper into what it looks like. We’re still having those conversations and trying to figure out what it takes to move that work forward.”
Data Collection and Other Accountability
DHHS currently does not collect rigorous or standardized data on maternal care in hospitals. A more robust data collection system can help agents identify and address issues. But lawmakers must pass laws requiring this oversight.
State Rep. Julie von Haefen (D. Rayleigh) said strengthening data collection at hospitals in North Carolina could be the first step to addressing the issue.
“(DHHS) needs more data,” Von Haefen told CPP. “If you don’t know what’s going on, how can you figure out how to solve it? An increase in data collection will help you understand where we target our efforts.”
The county’s health department also has no capacity to hold hospitals accountable. The department is expected to work with local hospitals to write health assessments for community needs, but public health officials have no way of enforcing hospitals to meet identified needs.
Giving these sectors more teeth and regulatory capabilities could prevent hospitals from eliminating or reducing rural women’s health services without facing formal pushback.
Financial solutions to promote rural women’s services
Because maternity services generally operate at economic losses, funding and payment reforms may encourage hospitals to maintain services. Hospital obstetric care is even less profitable in rural areas as many patients suffer from Medicaid.
And the proposed reduction in Medicaid could completely override the equation.
“The thing about the maternity unit is that they are not profit makers. They are the leaders of losses,” said Ami Goldstein, a certified nurse and associate professor at the UNC School of Medicine’s Faculty of Family Medicine. “So, if you have six births a month, the hospital still pays staff to be available for the entire time.”
A decrease in birth volume results in higher costs per patient and makes services financially unsustainable in many rural areas.
Increased Medicaid reimbursement rates for rural hospitals and doctors can help resolve the issue. State legislator Timothy Leader (R-Greenville), who is also a doctor, told the CPP he insisted on these enhanced refunds.
However, the future of Medicaid is not certain nationwide as Congressional Republicans recommend substantial cuts in the program.
Private insurers could also implement special payment models that take into account the higher per patient costs of rural healthcare, but most of them are not. Some states have initiatives that require insurance companies to better support rural hospitals, but North Carolina has not done this before.
Workforce solutions for hospitals
The decline in rural health workers is another urgent issue that requires solutions.
It is very important for professionals to create incentives for working in rural hospitals, according to Rebecca Bagley, director of ECU’s midwifery education program. Training college students and other members of the fast-growing workforce to practice in rural areas – a ball game that is different from urban practice, but equally important, she said.
“It’s better to provide care to patients near their homes,” the leader said.
“Therefore, it is important to provide support to rural hospitals and doctors. No community has been successful in rural areas without access to healthcare. Healthcare is essential for economic development and growth.
“I have successfully advocated several provisions to help support rural care, providing funding for rural settlements, repayment of loans for several health occupations, and expanding the expansion of medical training programs through local universities.
Rep. Von Haefen also supports incentives to bring healthcare workers back to rural North Carolina.
“We have to think outside the box when it comes to labor and delivery services, and OB/Gyn services in general, because we have such a disastrous workforce problem,” von Heffen said. “This is especially true in rural communities.”
Von Haefen recommends a “Yourself Grow” style program that encourages newly trained nurses and doctors to return to their hometown to practice. When expanding education In a North Carolina setting, the model encourages graduates of education programs and returns to their school district to work.
She also highlighted the importance of community colleges.
“More rural community colleges are trying to focus on health workforce issues,” von Heffen said. “Investing more in community college programs is really important because we bring in people living in those sectors to grow our healthcare workforce.”
Expanding the current workforce capacity is another strategy. Give family physicians and EMTs the opportunity to expand their scope of practice. And continue to train them.
State Rep. Allen Bouanci (D-Chapel Hill) likes this strategy.
“Universities and hospitals can do a better job ensuring that rural (WHO) general physicians continue to train in the basics of prenatal, childbirth and postnatal care,” Boonsi told the CPP.
“Business roles” of hospitals to ensure that local doctors in rural women’s healthcare desert areas are trained in the basics of OB/Gyn care,” Buansi explained.
Rural North Carolina communities risk losing remaining women’s health care services.
Through changes in regulations and incentives already under consideration, rural North Carolina communities can retain critical obstetric services through financial reform, targeted workforce development, increased accountability and saving the lives of women and children throughout the state.
The state could also see a recovery in rural women’s services programs where hospitals have declined or reduced in some areas if regulatory and incentive structures change.
Instead of growing the healthcare desert for rural women, oasis of care can expand and create new stories for rural North Carolina healthcare.
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