Commentary
Strategic Implications of COVID-19: Considerations for Georgia’s Rural Health
Providers
Bettye A. Apenteng, PhD
1
, Linda Kimsey, PhD
1
, Charles Owens, MSA
1
, Samuel T. Opoku, PhD
1
, Angela Peden, MPH
1
, and
William A. Mase, DrPH
1
1
Center for Public Health Practice & Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro GA.
Corresponding Author: Dr. Linda Kimsey • Georgia Southern University • P.O BOX 8015, Statesboro, GA, 30460-8015 • Telephone: (912) 478-2008 • Email:
ABSTRACT
Whether rural hospitals and providers have seen a surge in COVID-19 cases or a reduction in patients seeking care since the
pandemic began, their financial condition has been negatively impacted. Many providers have now received some emergency
funding through the Coronavirus Aid, Relief, and Economic Security Act and the Payroll Protection Program but these are likely
only short-term fixes. For many, the crisis has exacerbated already existing problems. Notable among these problems are volume
declines, supply chain disruptions, and workforce concerns. While these problems require immediate action, two longer-term
systemic changes to rural healthcare delivery are needed to address them. Proactive adoption of telehealth is essential to stake a
value-added position in delivery of healthcare. Creating a regional ecosystem that both supports, and receives support from, local
businesses and potential workforce members is vital to building and maintaining a thriving organization. Rural healthcare
providers must consider these strategies to ensure that they are able to continue delivering their mission of improving the health of
the populations they serve.
Keywords: COVID-19, rural healthcare, strategic planning, telehealth, ecosystems.
HEALTH CARE PRACTICE POINTS
● COVID-19 has exacerbated problems of reduced patient
volumes, supply chain disruption, and workforce
inconsistencies for rural health providers.
● Participation in systems-based strategies focused on
creating value for patients, providers, and supporting
businesses could be a viable approach for rural health
providers.
● Proactive involvement in telehealth networks and
development of regional business ecosystems are two
strategies for rural health providers to consider.
INTRODUCTION
The COVID-19 pandemic has taxed the resources and
capacity of the nation’s healthcare system. Rural healthcare
providers, many of which were already struggling
financially prior to the pandemic, may be impacted even
more significantly. As of October 2020, 98.8% of rural
counties had reported at least one confirmed case of
COVID-19, and 79.5% of rural counties had reported at
least one death (Ullrich & Mueller, 2020). During the spring
of 2020, data indicated that the fastest rate of increase in
COVID-19 cases and deaths was occurring in rural counties
(Kaiser Family Foundation, 2020). While some rural
providers have been overtaxed in COVID-19 hotspots,
others have lost business as patients delayed non-COVID-19
care out of fear, and as providers paused elective services in
preparation for the unknown. Amid this uncertainty, experts
continue to worry about the long-term effects of COVID-19
on rural America, where residents on average are older, have
more chronic health concerns, and experience more
healthcare access-related issues (Centers for Disease
Control and Prevention, 2020).
IMPACT OF COVID-19 PANDEMIC ON RURAL
HEALTH PROVIDERS
Whether they saw a surge in COVID-19 cases or not, rural
hospitals and providers nationwide have been impacted
financially as a result of the pandemic (Arnos & Blavin,
2020). Many providers received some emergency funding
through the Coronavirus Aid, Relief, and Economic Security
(CARES) Act and the Payroll Protection Program but these
are likely only short-term fixes (U.S. Department of Health
and Human Services, 2020; Guelich & Majka, 2020). Amid
this crisis, several multi-faceted factors have arisen that are
increasing financial stress. Notable among them are volume
declines, supply chain disruptions, and workforce concerns
(Arnos & Blavin, 2020). While these problems require
immediate action, longer-term systemic changes to rural
healthcare delivery are also needed to fully address them.
Declines in Volume
As hospitals and clinics halted elective procedures and
patients postponed seeking health services, healthcare
providers nationwide began experiencing significant
declines in volume. In June of 2020, the American Hospital
Association (AHA) estimated that by December 2020,
hospitals collectively lost over $323 billion as a result of the
pandemic (American Hospital Association, 2020), with
some hospitals reporting as much as 50-60% volume decline
(Dineen, 2020). A recent survey identified similar declines
in medical practice volume (Medical Group Management
Association, 2020). While many hospitals have experienced
spikes in COVID-19 related cases, hospital non-COVID-19
volumes continue to struggle to recover back to
pre-pandemic levels as patients continue to delay seeking
regular and elective care (Grimm, 2021), and these
challenges have been particularly hard for rural hospitals
over the course of the pandemic (The Duke Endowment,
2020).
The greatest declines in volume have been observed for
outpatient and emergency room visits, compared to inpatient
services, even in communities not significantly impacted by
the virus (Strata Decision Technology, 2020). In Georgia,
rural hospitals have also reported significant drops in
outpatient volume due to COVID-19 (Weber, 2020). While
hospitals (both rural and urban) have over time shifted to the
provision of more outpatient services, rural hospitals’
growing and disproportionate reliance on outpatient services
for revenue leave them particularly vulnerable to financial
distress in these times. In 2019, the median outpatient
revenue as a proportion of total hospital revenue was 76%
for rural hospitals, compared to 55% for urban hospitals
(Figure 1). While Georgia rural hospitals rely less on
outpatient services, relative to all US rural hospitals, the
median outpatient to total revenue for Georgia rural
hospitals still remains higher than urban hospitals in the
state and nationally (Figure 1). Thus, building outpatient
service volume back to pre-COVID-19 levels (and beyond)
would be imperative for sustainability of both Georgia and
national rural hospitals, and may require a concerted effort
by healthcare providers to build public confidence in the
safety of healthcare facilities.
Figure 1
Supply chain disruptions
The pandemic has also uncovered healthcare supply chain
vulnerabilities. Disruptions in the manufacturing of goods in
the wake of the pandemic, coupled with excessive demand,
resulted in shortages of medical supplies and subsequent
increases in the prices of medical supplies. One supply
category that took on added importance as a result of the
pandemic was personal protective equipment (PPE). Many
rural hospitals and providers, including those in Georgia,
struggled to obtain PPE and other similar items needed to
respond to the pandemic (Miller, 2020).
Responses to shortages of medical supplies have displayed
ingenuity. Nationally, several hospitals had to bypass their
group purchasing organizations (GPOs) and other
intermediaries and directly source their supply needs for the
first time (Kaste & Ruwitch, 2020). In Georgia, Pretoria
Fields Collective, an Albany-based brewery, converted its
factory line to produce medical supplies for their local
hospital and other rural hospitals (Carter, 2020). Early in the
pandemic, “outside of the box” strategies by rural hospitals
to shore up supplies of required equipment, like Homerville
Georgia-based Clinch Memorial Hospital’s use of staff with
sewing skills to make cloth masks (Weber, 2020), were
highlighted throughout the news.
Prior to COVID-19, hospitals had begun to embrace the
Lean operational improvement philosophy, and inventory
systems such as Just-in-Time (JIT), which minimize
inventories held, to reduce waste and lower costs (Snyder &
McDermont, 2020). However, the COVID-19-related
shortages suggest a need to advance these JIT efforts more
strategically - recognizing the importance of slack and
higher levels of “just in case” inventories (Sheffi, 2020).
Lessons learned pertaining to the need for supply chain
diversification, refined supply chain processes, and
enhanced innovation to improve resiliency will likely be
analyzed for years to come.
Workforce concerns
Maintaining a skilled healthcare workforce is a persistent
challenge nationally, and COVID-19, with its accompanying
surges and lulls in workload, has only heightened that
challenge. In preparation for potential surges in COVID-19
cases, and amidst existing shortages, many rural (and urban)
healthcare organizations had to develop creative approaches
for staffing. Some hospitals, for example, created a
workforce resource pool, including retirees, administrators,
and educators, to fall back on when the need arises (Muller,
2020). Yet other hospitals found themselves going through
periods of reduced workload. In rural healthcare
organizations that experienced financial losses due to low
volume in the early stages of the pandemic, and struggled to
make payroll, staff recruitment became a lower priority.
Instead, these organizations implemented layoffs and
furloughs to manage financial viability (Grimm, 2020).
The evidence further suggests that the multiple waves of the
pandemic have taken a significant physical and
psychological toll on healthcare workers. As of April 14th
2021, the Centers for Disease Control and Prevention
reported that over 463,000 health care workers had been
infected with COVID-19 and almost 1,200 died from the
disease (Centers for Disease Control and Prevention, 2021).
A recent study conducted by Kaiser Health News, in
partnership with the Guardian, estimated more than 3,600
healthcare worker deaths nationally as of April 7, 2021, a
majority of which occurred among individuals under 60
years, nurses, and people of color (KHN & The Guardian,
2021). For Georgia, the healthcare worker toll from
COVID-19 is estimated to be 38,881 cases (Georgia
Department of Health, 2021) and 74 deaths (KHN & The
Guardian, 2021) as of mid-April 2021. Recent studies also
indicate high levels of anxiety and depressive symptoms and
burnout among healthcare workers responding to the
pandemic, especially among those who have contracted the
virus or have had a coworker contract the virus (Firew et al.,
2020).
The workforce-related challenges brought on by COVID-19
have been especially difficult for Georgia hospitals. In
December 2020, Georgia hospital CEOs told Governor
Kemp that personnel shortages were their most significant
COVID-related problem (Miller, 2020b). Rural Georgia
hospitals that might have had physical bed capacity, often
found that they did not have the necessary personnel (in
particular, ICU nurses) to make those beds operational,
forcing patient transfers to other cities (Miller, 2020a).
However, these struggles merely exacerbated existing
workforce challenges for rural Georgia hospitals. Attracting
and retaining qualified personnel has been particularly
difficult for rural areas, even before the pandemic. Several
of Georgia’s rural counties have no physician providers
(Spelke et al., 2016; Sweeney, 2016) and shortages of
nursing professionals are projected to grow to 2,200 across
the state by 2030 (U.S Department of Health and Human
Services, 2017).
The full workforce impacts of the pandemic are yet to be
revealed. However, some potentialities include a worsening
of existing rural workforce shortages due to voluntary
retirement or turnover driven in part by burnout and safety
concerns, and attrition due to elevated mortality from
COVID-19 spikes that could occur within the workforce.
RELEVANT SYSTEMS LEVEL STRATEGIES
None of these issues will likely resolve any time soon;
long-term strategic implications post-COVID-19 should be
expected. The current overall economic downturn may
reshape the healthcare market considerably. Rural healthcare
organizations will need to be prepared to deal with these
potential long-term implications in order to remain viable.
What is certain is that thinking at a systems level - beyond
the organization, and in consideration of other actors that
share its goals - will be increasingly important as the
complex adaptive system of healthcare grows even more
complex, with or without COVID-19. While many rural
hospitals have become part of larger health systems, this
should not be assumed to be a panacea to the woes that
COVID-19 has accentuated: these health systems may have
little economic tolerance for supporting unprofitable
satellite members in a financially challenging environment
that the pandemic has created. Securing a position in other
systems or networks will be essential. Two systems-level
strategies that may be helpful for rural healthcare providers
seeking to thrive in the future are telehealth adoption and
building regional ecosystems.
Telehealth
The pandemic has created an environment that has opened
the door for many providers to adopt telehealth as a means
of providing essential healthcare in a way that significantly
reduces patient, provider, and staff exposure to the virus. A
system that allows for local healthcare to continue with
minimal disruption is vital for the health of the community
and the financial sustainability of an already fragile
healthcare system. Telehealth has proven to be an essential
tool for improving healthcare access, maintaining continuity
of care, and enhancing financial sustainability during the
pandemic. Analysis of telehealth usage from June 26 to Nov
6, 2020 indicates a direct correlation between the amount of
telehealth visits and the number of COVID-19 cases
(Demeke et al., 2021). Without telehealth, pandemic-driven
social distancing guidelines and public worry might have
limited health care providers’ capacity to provide timely and
accessible care, leaving massive gaps in healthcare access.
Rural hospitals and clinics, too, must embrace telehealth as
a means of extending the workforce and retaining higher
acuity patients within the community by facilitating
connections to specialists in neighboring communities.
COVID-19 has positioned telehealth as a cornerstone of
health care delivery and has strengthened rural and urban
hospitals working together to meet the needs of their
communities wherever they live. Just before COVID-19
appeared in Georgia, rural Wills Memorial Hospital
implemented telehealth as part of a program with Augusta
University (AU) to leverage AU physicians to support their
patients in need of care beyond what is available locally.
Patients connect virtually allowing the patient and physician
provider to communicate directly with one another to
evaluate and determine the most appropriate care needed.
Patients are treated without unnecessary transport (55 miles
each way), additional costs or stress occurring from having
to be transported to Augusta. AU, like most urban hospitals,
has been operating at or near capacity since COVID-19
appeared. Telehealth allows AU physicians to evaluate and
treat patients at Wills Memorial virtually. This, in turn,
allows the patient to receive the appropriate care close to
home and saves critically low bed space for those in greatest
need. Additionally, it allows the rural hospital that is
providing care to earn revenue that might have otherwise
been lost (The Augusta Chronicle, 2020).
Wills Memorial Hospital’s pre-pandemic telehealth focus is
an illustration of an increasing trend in the uptake of
telehealth by Georgia’s rural hospitals. Between 2017 and
2019, the proportion of Georgia's rural hospitals utilizing
telehealth for consultations and office visits tripled from
approximately 15% to 46%, surpassing rural hospitals in
other states (Figure 2). The pandemic-driven increase in
provider adoption and patient willingness to use telehealth is
likely to be sustained in the post-pandemic era (Thomas et
al., 2020).
Figure 2
To aid in encouraging telehealth within the healthcare
system, the CARES Act expanded coverage of telehealth
services for Medicare patients and among safety net
providers including Rural Health Clinics, Federally
Qualified Health Centers, among others (Centers for
Medicare and Medicaid Services, 2020a; Centers for
Medicare and Medicaid Services, 2020b). On December 1st
2020, the Centers for Medicare and Medicaid Services
announced that it was making permanent coverage for over
60 out of the 144 telehealth services that were newly
covered in response to the pandemic (Centers for Medicare
and Medicaid Services, 2020c).
Although telehealth brings with it increased privacy
concerns, it is likely the new normal. Proactively adopting
telehealth will be essential for rural healthcare providers as
they address declining patient volumes and workforces that
have been stretched thin. However, the success of telehealth
in effectively expanding healthcare access, especially in
rural areas, will depend on the existence of robust
infrastructure to support its implementation, such as
broadband internet services, the willingness of rural
residents and providers to use telehealth services, and an
alignment of reimbursement models (Haque, 2021).
Telehealth usage in both the south and in rural areas of the
U.S. was found to lag that of the rest of the country during
the pandemic (Demeke et al., 2021), indicating that the
south, including Georgia, may find it more challenging to
embrace virtually-delivered healthcare.
Ecosystems
Supply chains that run from China to rural America have
now become common in many business sectors, including
rural healthcare. Likewise, the use of more costly per diem,
travel, and locum tenens healthcare personnel has increased
and is forecast to increase even more in the post-COVID-19
era (Staffing Industry Analysts, 2020). Given the supply
chain and workforce issues discussed above that have been
exacerbated by COVID-19, an overreliance on these
strategies now seems possibly shortsighted. Providing
support for local and regional businesses and potential
workforce members is a long-term, systems-based strategy
that aligns with healthcare’s overarching mission to support
its community and could also serve to enhance
organizational resilience.
The AHA’s Healthcare Innovation blog, pre-COVID-19,
discussed the possibility of “ecosystem” becoming the new
healthcare buzzword (Shin, 2019). A service ecosystem is a
“relatively self-contained, self-adjusting system of
resource-integrating actors connected by shared institutional
arrangements and mutual value creation through service
exchange” (Vargo & Lusch, 2016, p.11). In a service
ecosystem, value is achieved at a system level through
exchange among its actors, and improved system viability is
one way to improve value (Ng & Vargo, 2018). Essentially,
ecosystems are about integrating internal and external
stakeholders to facilitate innovative and responsive
organizational growth (Shin, 2019).
Looking through the COVID-19 lens, a service ecosystem
strategy, in which hospitals serve as anchor institutions for
the community, seems to be a possibly fruitful strategy.
Anchor institutions seek to merge mission and margin,
acknowledging their leadership role in the local community
in which they operate. In urban areas, these hospitals are
often located near the communities of greatest need, serving
to motivate a focus on improving social determinants of
health (Koh et al., 2020). These hospitals are also typically
one of the five largest employers in their community, and
they have substantial budgets for supplies and services. For
example, Cleveland Clinic’s commitment to buy local has
been attributed to the founding of several successful
worker-owned cooperative businesses (Koh et al., 2020).
Brigham and Women’s hospital is committed to training
local residents for employment within their health system
(Zuckerman, 2013). Similarly, Kaiser Permanente and
Promedica are also undertaking anchoring initiatives in the
areas they serve (Koh et al., 2020). While scaling this type
of ecosystem down to small hospitals and communities is
yet unproven, regional collaboratives of hospitals, clinics
and communities, all seeking these same goals of reliable
supply chains, an available, qualified workforce, and a
thriving community in which to provide healthcare, might
be possible. A newly formed cooperative arrangement,
connecting small rural hospitals and Georgia farmers to
provide locally-farmed produce and meat in hospital
cafeterias, is one example of this type of ecosystem strategic
approach now underway in Georgia (Gibson, 2020).
Systems Focus
What telehealth and ecosystems-focused strategies have in
common is a requirement for healthcare providers to secure
their position within developing systems. Developing a
strong value proposition for local residents to ensure that
they continue seeking care locally will be important. With
in-home telehealth encounters now covered by insurance,
there could be a risk of losing patients to providers in nearby
large cities, since specialist appointments can be provided
directly, bypassing local providers. Maximizing other
opportunities of telehealth through things like robust use of
shared grand rounds and other employee training will also
be important. An active educational network of providers
who face similar clinical issues on which to learn from, can
increase the benefits reaped from telehealth capabilities.
Similarly, for ecosystem development, staking a position
within a healthy ecosystem will be important. Creating a
vibrant marketplace that supports co-production of health by
training and maintaining a qualified workforce and by
supporting companies that provide supplies, equipment, and
services can cure the fragility that comes with
10,000-mile-long supply chains and markets for graduates
of distant schools. In return, local and regional residents
gain financial security and career advancement, improving
the chances of a thriving ecosystem. Finally, development of
regional networks and systems may offer small, rural
hospitals and healthcare facilities the potential for achieving
meaningful operational economies of scale in maintaining
productive workforces and procuring needed supplies and
services.
CONCLUSION
COVID-19 may come to be known as a black swan event
like no other, due to its global, enduring impact. As we
recover from this unprecedented event, rural healthcare
administrators must move forward strategically to tackle
volume, supply chain, and workforce issues laid bare by
COVID-19. Establishing an environment where telehealth is
deployed across the continuum of care for financial stability
and care continuity and creating supportive local and
regional ecosystems are two systems-level strategies worth
considering as rural providers strive to address these issues
and secure their future.
Methodology for Supporting Figures
Data from Figures 1 and 2 were obtained from the Centers
for Medicare and Medicaid Services Cost Reports
(2014-2019) and the American Hospital Association’s
Annual Hospital Survey (2017 and 2019), respectively.
Descriptive statistics (medians and proportions,
respectively) are used to assess trends in hospital
dependence on outpatient services (Figure 1) and telehealth
use (Figure 2). Aggregate data were obtained for Georgia,
and the United States as well as for rural and urban counties.
Hospitals located in Metropolitan Statistical Areas (MSAs)
were classified as urban. Hospitals located in counties not
part of an MSA were classified as rural.
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