Rural healthcare providers in the U.S. have been under tremendous strain for a long time. The pandemic has only exacerbated some of those challenges. We spoke to Eric Friedberg, the American College of Radiology’s chair for the General, Small, Emergency, Rural Practices Commission Network Planning Committee to find out what the situation looks like today, and what’s being done to fix it.

HCB News: We know that rural providers have been struggling for years. What was the situation like prior to the pandemic?
Eric Friedberg: Prior to the pandemic, rural America — which comprises nearly 20% of the U.S. population (> 60 million people) — was facing a crisis in care due, in large part, to rural hospital closures. Per Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, over 130 rural hospitals have closed since 2010, and 174 have shuttered since 2005. Prior to the pandemic, even those rural hospitals that remained viable were experiencing high rates of financial distress, and many of them (some estimated as many as 20%) were near bankruptcy.

In particular, the economics of providing diagnostic imaging and interventional services to rural patients at a level of care on par with that provided in urban areas have always been challenging. Imaging centers require capital-intensive investment and ongoing operations costs to provide the necessary equipment, technology, staff, and facilities to the patient population they serve. Rural populations are dispersed over larger geographic areas than urban populations. Smaller numbers of patients who are more commonly uninsured or underinsured are primarily served by rural imaging centers. These centers do not have offsetting reductions in costs to make up for the differences in revenue the higher volume urban imaging centers tend to generate for similar services. Because of these challenges, many critical access and rural hospitals are unable either to obtain or maintain higher-end imaging equipment, such as CTs and MRs, or to meet demand for interventional services. Historically, funding from outside sources, both government and private, has been inadequate to overcome the financial impact of falling reimbursements and increasing costs driven by regulatory, legislative, socioeconomic, and other factors.

HCB News: How has the COVID-19 pandemic impacted access to imaging in rural areas?
EF: The pandemic has only exacerbated the already substantial challenges of providing high- quality health care in rural areas. The implementation of precautionary measures by imaging facilities in response to the pandemic significantly drove costs up, while concurrently decreasing patient throughput. Rising costs and falling revenues, superimposed upon diminished cash reserves, precipitously increased financial pressure on these centers. Those fortunate enough to receive loans/grants have fared better than those that did not. Nevertheless, 15 rural hospital closures have occurred to date in 2020.

Additionally, factors that disproportionately affect access to imaging in rural areas during this pandemic, to name a few, include: small staff size, which leaves little redundancy to compensate for sudden absences; fewer available public and/or affordable transportation options for communities that generally are less affluent and have to travel longer distances to receive their care; greater challenges in communicating important and timely care-related community and health matters due to (at times) inaccessible internet services or the inability to afford such services.

HCB News: Does it make sense to draw a line between X-ray and advanced imaging access? Is it fair to say that the challenges are primarily concerning exams like MR or PET/CT, for example?
EF: It's important to address the access-related issues related to all imaging modalities, as well as access to image-guided, minimally-invasive procedures — both emergent and non-emergent — ranging from vascular-related procedures to biopsies and drainages. All of these are important when considering the high impact they have been demonstrated to have on identifying and treating both disease and injuries. The "line" you refer to usually gets drawn because many more centers can provide x-ray and ultrasound services, but either cannot afford or cannot justify the more expensive and sophisticated technologies of MR, CT, PET, etc. Additionally, the more sophisticated capabilities require highly-trained staff and maintenance resources that may be hard to come by in rural America. The diminished access our rural communities have to these services tends to amplify the already long-standing systemic health and social inequities that exist in these communities.

HCB News: I know you're a big advocate for teleradiology. How is it helping rural patients now, and how might it be able to do more?
EF: Teleradiology has proven to be a great benefit not only to our rural communities, but also to metropolitan, suburban, academic, and VA/military practice environments. Teleradiology provides both internal and external medical support, which can be efficiently and economically leveraged to provide high-quality imaging interpretation and improved, comprehensive care around the clock. The hardships that some rural practices have recruiting and retaining radiologists during times in which demand for radiologists is historically strong, also factors in to why teleradiology can be beneficial. Teleradiology complements on-site radiologists' skills, and, in turn, enhances patient care, by providing access to specialized expertise without increasing the time or cost to obtain such expertise. When uncommonly challenging cases arise, teleradiology offers a way for smaller groups to obtain a second opinion from off-site group members who may have a greater focus or fellowship training related to the case at hand, or to obtain the same type of consultation from a contracted teleradiology service. The ability to aggregate imaging studies onto shared radiologist work lists also allows radiologists who are at smaller, lower patient volume facilities to stay busy by supporting other busier facilities in the practice. These economies and efficiencies are emerging as critically necessary capabilities to offset falling reimbursements, increasing costs, and the ever-dynamic regulatory and legislative requirements that all face, but at times disproportionately impact rural practices.

HCB News: Are you familiar with the federal government's new rural telehealth task force? And if so, are you willing to share a few thoughts and comments on your reaction to it?
EF: I am only familiar with how it was created and its purpose as described by the government's released memorandum of understanding. I have no informed comment to make at this time, since the task force is still in its infancy.

HCB News: As we look ahead to the future, are there any fundamental changes you would like to see that would improve the state of rural radiology in the U.S., post-pandemic?
EF: Leveraging telehealth, including teleradiology, as well as other emerging technologies such as AI applications, offer potential approaches to achieve more standardized levels of high quality care for our patients in under-resourced, socioeconomically-challenged, and geographically-dispersed communities commonly found in rural America.

To succeed we will need to develop national policies that provide appropriate reimbursement levels and financial incentives that enable the practical implementation of emerging technologies and care services. Additional strategies that promote local investment in these efforts would also be beneficial.

HCB News: Is there anything else important to mention about rural imaging that we haven't already discussed?
EF: I have tried to emphasize that radiologists provide critically important diagnostic and interventional services that are needed in rural communities. Radiologists and the services they provide form a critical link in the healthcare delivery chain required to provide high-quality, comprehensive care. Deficiencies in the availability and accessibility of diagnostic imaging and image-guided services in our rural communities leads to delays in diagnoses, and in many instances, significantly higher care costs. It is in everyone's interest to address these deficiencies. Rural communities are critically important to sustaining our country's access to our most basic and essential needs: affordable energy, clean water, food production, and outdoor recreation. We need to invest in the resources necessary to provide high-quality, accessible, and affordable healthcare services to the rural communities that support these essentials.