COVID-19's Current Impact on Rural Healthcare Delivery: Q&A with Brock Slabach

by Kay Miller Temple, MD

Brock Slabach is the National Rural Health Association's Senior Vice President for Member Services, joining the organization's executive team in 2008 after serving as a rural hospital administrator for more than 21 years. He discusses the impact of COVID-19 on rural America's healthcare organizations.

When did you first realize that COVID-19 was an unprecedented public health crisis?

In late February, I started to see general hygiene measure advice directed to the general population in order to reduce the spread of this virus. By early March, I started noticing some disconnect in the messaging between public health officials and individuals providing projections around the disease, so on a personal level, I began to reconcile those differences.

I was in the office on March 13th when the president issued the public health emergency message. That immediately triggered a cascade of reactions and I suddenly found myself completely immersed. But it was the Centers for Medicare and Medicaid Services (CMS) waivers — a first-time occurrence for what I thought was a series of stunning waivers for providers in all parts of the country, including rural areas — that made me fully understand the seriousness of the situation.

What has been the most impactful policy change for the rural providers to date?

The first was the rapid succession of the number of 1135 waivers that were made to existing regulations in order to respond to COVID-19.

With projections at the time of those original waivers, many of us were assuming that every hospital in the United States was going to be overrun with COVID-19 patients. I was thinking, now they can have more than 25 beds and increase the average length of stay to more than four days. And as I reflected back on my days in Mississippi during Hurricane Katrina, I knew we'd be trying to figure out how today's rural providers were going to handle the surge of patients.

The second was the CMS-issued advisory that hospitals and clinics needed to suspend elective and non-emergent services in order to care for the anticipated surge of infected patients and prevent spread within those same facilities.

We suddenly had to shift gears and paradoxically both continue to prepare for a surge yet assist all these rural providers hemorrhaging cash with routine work having all but stopped.

In the following week, hospital hallways were empty; clinic exam rooms, empty. I suddenly recognized that we were dealing with what I've referred to as the COVID-19 paradox: in the midst of a worldwide pandemic, instead of dealing with a surge we were dealing with empty hospitals and clinics. With only several exceptions, this was a phenomenon all across the country. We suddenly had to shift gears and paradoxically both continue to prepare for a surge yet assist all these rural providers hemorrhaging cash with routine work having all but stopped.

What has been the major key to making sure that rural healthcare providers were not left behind with new policy changes?

The major key is definitely that Washington is actually hearing the rural voice. To our surprise and relief, since the emergency's been declared, we have been very well received in Washington. We believe that reception is due to our membership's work over the years — especially in the most recent years. Thousands of people over the last several years have written their congressional representatives, talked to them about rural hospital and clinic issues, expressed concerns about the future of rural health. We now see more sensitivity to rural issues.

Because our voice comes from our membership and our leadership — who is elected from that membership that represents healthcare organizations across rural America — we were able to raise rural concerns to both regulators and legislators.

From your perspective, what has been the important behind-the-scenes collaborative work that has contributed to managing the public health emergency in rural areas?

Again, the work of our members and our elected leadership. There is also significant collaboration happening on the membership's NRHA Connect listserv with real-time information exchange. This exchange represents the pulse of what is happening in rural communities and also provided additional key information that we shared with policymakers.

On March 14th, we had an entry into the listserv sharing the public health emergency announcement information about the Critical Access Hospital restriction and requirement waivers. The listserv just blew up at that point. For many of those questions, we at NRHA didn't have answers. But, rural people are collaborators by nature and the purpose of a protected networking site like our listserv is that it provides user-generated answers to user-generated problems and issues.

This behind-the-scenes work has shown me that when we are in uncharted territory where there are no answers, people set aside the risk that comes with not knowing and work together to get answers.

What was so brilliant about the listserv community was that many facilities around the country had already thought through many of the issues, dove right in, started fixing problems, and then shared those fixes with colleagues. The listserv provided a rapid spread of important information. This behind-the-scenes work has shown me that when we are in uncharted territory where there are no answers, people set aside the risk that comes with not knowing and work together to get answers.

Information exchange was happening between those who were experiencing no volume and those who were experiencing surges — for example, Batesville, Indiana; Lutcher, Louisiana; and Blaine County, Idaho. This provided "contrasting" collaborators, if you will, in terms of what was going on out in rural America.

Along with work to ensure adequate personal protective equipment, another collaboration is happening with rural long-term care facilities. Rural hospitals can potentially serve as infection control resources for those organizations and help to reduce the spread of infection. I think hospitals are a lot more involved in their communities now, helping to mitigate the COVID-19 spread. To the extent to which that chain is fortified by a hospital's involvement in long-term care units, that collaboration can really help decrease community spread.

COVID-19 has brought about a very rapid adoption of telehealth. What might be the resulting long-term impact on the provision of rural primary care and other key healthcare services?

When the clinics cleared out and began hemorrhaging cash and patients who needed to be seen weren't being seen, something had to change for rural health facilities. One of the first policy changes was the expansion of distant site designation. I guess you could say that all rural providers pretty much took to that like ducks on water. With the modifications of telehealth regulations, they've been able to use telehealth effectively. The waiver around secure video communications was also very important.

Telehealth has now become so important for rural providers that at the end of this public health emergency, it will be very difficult to stop since it's become such an integral part of their operations.

Telehealth has now become so important for rural providers that at the end of this public health emergency, it will be very difficult to stop since it's become such an integral part of their operations. With that in mind, we need to be really careful about what we do next because telehealth may not be effective as a total replacement for robust and effective in-person primary care.

With that perspective, I would like to see the regulations for the face-to-face visit that establishes the doctor-patient relationship remain in place after the public health emergency ends. I'm concerned about how large corporate medicine organizations may start to market telehealth services to patients nationwide. Yes, it's been critical for this emergency, but there may be significant unintended consequences if that personal relationship with a provider at the local level is totally replaced by telehealth. The importance of personal face-to-face contact that is core to creating a medical home needs to be considered. We will need to make sure any future policies are set in context and that we don't rush into something that would be harmful in the long term to our rural systems of care.

When considering the multiple integrated elements that comprise healthcare delivery, what causes you the most concern for providing healthcare in rural America as the nation moves forward to what is being referred to as "the new normal"?

We don't have a clue yet about just how much our world has changed since March 13th and we can only speculate at what the new normal will be. I believe that the impact of telehealth won't be dismissed and that virtual meetings may continue to replace in-person gatherings. We are now even looking at how much different we will likely behave in public. But, one of my biggest concerns is the financial structure associated with delivering rural healthcare.

Looking ahead, the question is: How will our rural systems and our rural communities withstand the COVID-19-related decrease in volumes for 12 to 24 months?

First, consider the pre-COVID-19 issues for rural hospitals: on average 33 days cash-on-hand and 130 rural hospitals closing since 2010; four since the COVID-19 public health emergency. Next, consider rural funding allocations: the CARES Act with $10 billion in targeted rural funds, the Paycheck Protection Program, and CMS's Advanced Accelerated Payment Program. Looking ahead, the question is: How will our rural systems and our rural communities withstand the COVID-19-related decrease in volumes for 12 to 24 months?

This look into the next 12 to 24 months is part of current conversations. One question being raised concerns the amount of financial support that's been allocated to date. Many are wondering if we got too much support. Perhaps this is another irony, another COVID-19 paradox. I'm making the case that we need to be talking with policymakers about these allocations in terms of time. If you are thinking only about the next two or three weeks, then maybe it is a lot of money. But if this was going to be money that needs to last for a period of 12 to 18 months, anticipate that there are some really lean times coming up. I don't think we can be looking to Congress for repeated allocations. We need to find a way to monitor our cash flow projections for the long term. This money that we're getting now might need to be "saved and stored forward".

Looking away from the urgently implemented regulatory changes, the financial needs and monetary support for rural healthcare organizations, and looking instead to the issues around the humanity associated with this public health emergency, what has most inspired you about how rural providers, facilities, and communities have responded to this national emergency?

Though I'm not surprised because I was in Mississippi during Hurricane Katrina and saw similar activities, I'm still just absolutely awestruck by the work of rural providers. Now, I'm not talking about management. I'm talking about the frontline workers who have stepped up and performed with great skill and empathy in taking care of sick patients, both with COVID-19 and without. They put themselves at risk. In the areas where there have been surges, like Batesville, Indiana; Lutcher, Louisiana; and Blaine, Idaho, they stepped up and they did what needed to be done. I know there are many other individuals doing important work and while I don't intend to leave them out, I'm amazed and inspired by the dedication of these rural frontline clinical teams.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.