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Bye-Bye, Bypass

Hospital bypass is a major problem for rural hospitals, with large numbers of patients opting to drive long distances for care that they could easily find close to home.

In a new report from the Center for Economic Analysis of Rural Health, Dr. Alison Davis takes a “meta” approach to understanding the bypass problem, synthesizing more than half a dozen recent studies that address the questions of who, how much, and why.

(Her 32-page report actually looks at trends in rural demographics, insurance, telehealth, and more. The whole thing is worth a download, but it was the hospital bypass issue that caught our eye.)

WHO: Studies show younger patients and those seeking elective or scheduled care are more likely to bypass their local hospital. That creates margin pressure for rural hospitals left with a higher percentage of older Medicare beneficiaries as well as uninsured individuals seeking emergency care – not an ideal payer mix.

HOW MUCH: In terms of numbers, quantitative studies say the bypass rate could be as high as 50%, while qualitative studies range as high as 70%. Either way, rural hospitals are losing large numbers of patients who are willing to drive further in search of an elusive something they perceive to be missing in their own community.

WHY: As Davis puts it, “Rural patients may choose not to seek care at their nearest rural hospital for many reasons. Patient perception of the local hospital, including the perception of quality and reputation of local services and providers, may affect a patient’s choice to seek care locally. Satisfaction with the local hospital is also associated with rural hospital bypass.”

Notice all the “squishy” words there: perception, reputation, satisfaction. Patients are making their bypass decisions using criteria that are very hard to quantify.

And this is where things get interesting. According to a 2020 study from CMS, rural residents said they based their opinions on word-of-mouth rather than more objective sources like the HHS Care Compare website.

So, it’s not that rural hospitals are getting passed over in favor of competitors with statistically better outcomes or better patient experience. Instead, relationships and rumors are a major driver of the hospital bypass problem.

But relationships cut both ways, and research shows that positive physician relationships may be one key to reducing hospital bypass.

"Participants noted the importance of the relationship between primary care providers and rural Medicare beneficiaries, particularly the loyalty that patients feel for their providers. These relationships often extend beyond the rural Medicare beneficiary to other members of the family, which contributes to rural Medicare beneficiaries choosing their home hospitals – there is a strong, long-lasting trust in the local health care system" (p. 13).

The CMS research involved Medicare beneficiaries, but there’s no reason to expect a significantly different view from patients with private insurance. The fact is, when patients trust their primary care providers, they are more loyal to their local hospital or health system.

For rural healthcare leaders, the takeaway might be that a familiar old face is more important than shiny new equipment when it comes to reducing hospital bypass. Yes, staffing is notoriously difficult in rural communities, but investing in your provider affiliation strategy can pay long-lasting dividends.

Here’s an important caveat, however: If trust is the goal, your provider strategy can’t ignore local demographics. In a recent study of 525 individuals who identify as Black, Hispanic, Asian, or Native American, about half the participants said they would “trade off access to convenient, in-person care with longer-distance travel or virtual visits to get a provider who looks like them/is culturally competent.”

If your rural hospital serves a market with a large non-White population, it’s worth looking for racial and ethnic patterns in your bypass data. You need to know exactly which patients you’re losing before deciding which providers you need to attract.

Provider alignment strategy and transforming primary care are just two of the areas in which RHI consultants have decades of experience. Please contact us if you’d like to know more.

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