James Riser, MD, didn’t open a family medicine practice in rural Mississippi because he thought success would come easily. Still, he says, it’s been more difficult than he anticipated — and the challenges keep coming, year after year.

Right now, Riser notes, his independent, certified, freestanding rural health clinic (RHC) in Picayune, a city in southwest Mississippi with a population that just barely breaks 10,000, is vying for work from the same patient population as two provider-based RHCs associated with a community hospital. The competition is one thing, he says, but then there’s also the matter of the reimbursements he receives for Medicare and Medicaid services, which are just a fraction of what the other RHCs get. (Medicare- and Medicaid-managed care insurance companies are obligated by law to pay higher rates to provider-based RHCs.) “They’re billing somewhere around $225 to $250 per visit, whereas I’m capped at about $86,” explains Riser. That’s often below his cost for providing care. “You can see the dilemma for a free-standing. It really is getting tough.”

Rough ride for rural healthcare

When it comes to the issues surrounding rural healthcare, most of the attention in recent years has focused on the plight of underserved patients. But at least one reason many communities lack the health services they need has to do with the economics of rural practice. There are independent clinics, like Riser Medical Associates, that have found innovative ways to survive in rural settings, but it’s not easy to get by.

One of the biggest problems involves reimbursement, according to the National Association of Rural Health Clinics. Independent RHCs, NARHC has predicted, will cease to exist within the next 10 years if the payments they receive on a per-visit basis aren’t raised substantially. While the total number of RHCs in the United States has been growing steadily year over year (there were 4,428 n the 2018 calendar year compared to 4,349 in 2017), at least 700 freestanding RHCs have either closed their doors or converted to provider-based status since 2012, the organization notes.

Compounding the issue of low payments from CMS (for RHCs in particular, but also for any practice) is the fact that for many rural providers, Medicare and Medicaid patients account for a significant portion of their business. Rural residents, according to the National Rural Health Association, tend to be older and have lower incomes than their urban counterparts. They also often have less education, are less likely to have high-speed Internet, and they may lack reliable transportation. Rural Americans, overall, are more likely than those living in urban areas to die from heart disease, cancer, and other chronic conditions. They require more care, but may have difficulty accessing it. They’re more often un- or under-insured, and yet the care they need is often more expensive — and for many rural residents, unaffordable.

Today, the NRHA reports, there are about 40 primary care providers per 100,000 residents in rural areas compared to 53 per 100,000 in urban areas. But because relatively few new-grad doctors are opting to take jobs in small-town clinics, and many of the physicians already serving rural areas are now approaching retirement age, it’s predicted this discrepancy is going to get worse, making it harder for rural patients and providers alike.

Survival solutions

There is some good news, though: The strategies that practices like Riser Medical Associates are using can also provide a roadmap to success for others.

At his clinic, Riser says, they’re doing everything they can to get patients in the door for preventive care. “With healthcare reform, this is the way forward. We’re being proactive with our patients instead of just seeing them when they get sick.”

Riser explains that in the past, a patient with diabetes who had control of their condition might have been seen once a year for a regular checkup. But using the clinic’s new approach — a kind of “intensive primary care” — that same patient would be encouraged to come in at least every three months. “We want to get them on a care plan and engage them in their healthcare, and not only when they’re in the clinic with us.”

That diabetic patient might be seen in Riser’s office for dietary consults, weight checks, blood-sugar testing, and other services. Staff might reach out to the patient with monthly phone calls and receive updates on his or her exercise via text message. And with every service they provided, Riser’s clinic is compensated for its work. “It’s not taking advantage of or gaming the system; this is what the new system wants. So it’s better for us, but it’s also much better for our patients because it allows us to provide care that can really make a difference.”

Like most other successful rural practices, Riser Medical Associates has also updated how it markets to new and returning patients. For example: Outreach gets a boost from the practice’s website, which includes a patient portal link where clients can update their insurance information, view lab results, make payments, and request prescription refills. Medical-release and patient-information forms are also available online, so anyone with a scheduled appointment can minimize the time they have to spend in the waiting room. And finally, the practice offers urgent-care services through a walk-in clinic open during regular business hours.

Looking ahead, Riser believes there’s room to further expand his business by offering rural-friendly services like telehealth, and he envisions leveraging the practice’s success in preventive care to pursue potentially lucrative contracts with insurance companies. “We can save them a lot of money compared to the provider-based RHCs, especially when it comes to managed-care plans,” Riser explains. He sees a future where clinics like his market services not only to patients, but also directly to the payers—to “partner with the person paying the bills.”

Rural practices that hope to survive and thrive have to get creative and look for ways to provide value beyond what’s been expected of traditional healthcare, Riser explains. Medicine is evolving, he says, and as it does, providers will find many opportunities to care for their patients in ways that they couldn’t before. “We’re just in our infancy of trying to figure this out.”

Chris Hayhurst is a frequent contributor to athenahealth's Knowledge Hub.