As the founder and CEO of Horizon Professional Services, Ryan Kelly helps to provide leadership to a wide variety of nonprofits and membership organizations – including rural health associations in Alabama, Arkansas, and Mississippi. Given his unique purview, we thought he would be the perfect subject to kick off our recurring blog series, "5 Questions with..."
RHI: You lead rural healthcare associations in three different states, so this is clearly an important mission for you. How did you get involved?
RK: I originally became involved with the Mississippi Rural Health Association as a ‘volunteer executive director’ back in 2010. As we grew the association, it became more of a need for me to dedicate more time toward the association and our volunteers. I created my company, Horizon, in 2014, in order to better serve the MRHA as well as other organizations. In 2016, the Alabama Rural Health Association had a need for an executive director to continue the work of the previous director. In 2020, the new Rural Health Association of Arkansas was formed and needed assistance with its formation. By my staff and I serving in leadership with these organizations, we are able to make substantial improvements to the rural communities of these states.
RHI: A lot of people might assume rural healthcare is monolithic – do you see distinct needs and opportunities among the three states you know best? How is Mississippi different from Arkansas, for instance?
RK: There are indeed many similarities between rural communities in the nation. Many of our rural communities have a higher level of poverty and are less educated in comparison with urban and semi-urban counterparts. In addition, rural populations are less likely to have adequate health insurance coverage and often have less reliable transportation. Of course, this is a generality and does not reflect all populations or all groups within those populations. These conditions often come up within the inpatient and outpatient settings, as patients have vulnerabilities to these “social determinants of health.” These are generally the same for all states that have rural communities.
What may be different between the three states is the specific areas of vulnerability. In Arkansas and Mississippi, the greatest areas of struggle are in the Mississippi Delta Region. In Alabama, it is the Blackbelt region. You will also see subtle political differences in the three states. Although all three would fall into a typical Conservative political spectrum, the desires and focal points of the politicians are varied. In addition, the organizations supporting funding and allocation of resources will vary on the programs and projects that they find to be of greatest need.
All three states have similar issues of obesity, diabetes, and social determinant conditions. However, each state ranks differently when it comes to both positive and negative factors. For instance, Mississippi is a national leader in telehealth, Arkansas has expanded its Medicaid program, and Alabama is focusing attention on needs to wastewater and other public health concerns.
RHI: Covid is top of mind for everyone right now, but most of the news reports are coming out of urban areas. How has the pandemic affected the rural healthcare system in the areas where your members work?
RK: The struggles of workforce (primarily nursing) and burnout are the same everywhere. Rural areas have always struggled to hire and retain an adequate workforce, and COVID has presented tangible challenges to this from a workforce standpoint. Right now, rural hospitals are desperate for doctors and nurses to fill shifts and staff beds. Other than this, the pandemic and treatment of COVID patients is about the same in both urban and rural areas. It’s a rollercoaster with an unknown end point.
RHI: What’s the biggest overall trend you’ve seen in rural healthcare – whether positive or negative?
RK: Before the pandemic, I would have said that the strong move toward digital health and data management was the biggest trend. This trend has certainly not gone away, but the pandemic has altered the course toward data collection around public health. Specifically, the efforts toward messaging, contact tracing, and vaccine uptake have grown through necessity over the last year. My thoughts on this are twofold. On the surface, I believe that the more data that we have, the better the decisions are for both the provider and the patient / consumer. Data is good, especially when it can be used to solve a problem. However, I fear that the personal privacy issues surrounding the increase in health data will have effects that are not yet predicted or anticipated by researchers and clinicians, including a rejection of such care by patients due to concerns over privacy. Data and messaging around vaccines have best illustrated this of late.
I personally believe that telehealth is the greatest evolution and tool of healthcare in the past decade. Although telehealth in some form has existed for several decades, the growth of consumer driven telehealth technology is absolutely the future of healthcare, and it is one that empowers patients to take their healthcare into their own hands and use providers that best fit their needs and desires. Our challenge with this is to adapt our laws and policies to keep up with the growing demand and evolution of the technology.
RHI: Finally, if you could change one law or policy that would make rural healthcare stronger and more effective, what would it be?
RK: There are many policies that I would love to change, but if I could narrow one, it would be the reimbursement strategy for emergency departments. Currently, emergency departments are funded based on insurance claims, with a small number of quality-based metrics thrown in. This means that emergency departments are funded on sick people, and this presents a huge conflict of interest, or even better, conflict of design.
Emergency departments are structured much more like a public utility than a capitalistic provider of choice. Rarely do you have an opportunity to decide what emergency room to visit when you have a serious situation unfold…you simply go to the once closest. Like police and fire departments, an emergency department is there for all patients regardless of where they live or how they pay. But unlike police and fire, emergency departments are funded on claims from insurance or private pay. Plus, they are the highest cost of care for every hospital, with few breaking even on cost.
If emergency departments were 100% cost-base funded by taxpayer dollars, they would more evenly serve populations with the capacity needed for differing populations. Quality would not necessarily increase (as we rarely see a quality issue as it is), but the hospital could run these departments without a monetary loss as they do now. This single funding difference could allow hospitals to maintain a profitable budget versus an annual budgetary loss. And, it would provide greater sustainability for emergency care in our rural communities.
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'5 Questions with...' is a recurring series featuring a wide variety of leaders in rural healthcare. All answers reflect the views of the subject and should not be taken as the position of RHI or its principals.