Over the last few years, a new idea has emerged to help rural communities threatened by hospital closures, one that would allow those facilities to keep their emergency rooms open to ensure people still have access to critical urgent care.
But that model is running into a problem just as it's getting off the ground: Will there be enough doctors to staff these emergency-only hospitals?
Expect to hear a lot more about Rural Emergency Hospitals in the months and years to come. Congress created this new designation in 2021 as a way to try to stem the loss of health care access in rural communities given the growing number of hospital closures.
The North Carolina Rural Health Research Program reported this month that six more rural hospitals have closed in the United States, adding to the nearly 200 rural hospitals that have shuttered across the country since 2005. But one of these closures — Crosbyton Clinical Hospital in Crosbyton, Texas, a town of 1,500 about four and a half hours west of Dallas — was different.
That facility will not close entirely, but will instead be converted to a Rural Emergency Hospital, the first of its kind.
As a Rural Emergency Hospital, hospitals can continue to operate an emergency department in their areas, providing that critical care closer to home for patients. But they can no longer admit patients for longer-term stays nor perform the other medical services that hospitals typically offer, such as surgeries, childbirth, or cancer treatment. Medicare will pay these facilities differently than it does conventional hospitals, with the end result likely being a slight pay cut, experts say. But the idea is they should have less overhead now that they have more limited operations.
The reality may prove more complicated. As Margaret Greenwood-Ericksen, an emergency physician and researcher at the University of New Mexico, pointed out to me, these are still legacy facilities that were built to be full-service hospitals. Keeping overhead low may be harder than it sounds if, for example, you still need to run the HVAC for the entire building.
Nevertheless, this looks like the way of the future for rural hospitals struggling to keep the doors open. Two of the other rural hospitals that closed in the past few months are considering a conversion. The NC researchers project that as many as 73 hospitals across the country could already be candidates for converting to a Rural Emergency Hospital. If the economic situation for rural hospitals continues to worsen, that number may grow.
If it does, these hospitals will need staff who can perform emergency medical care. Rural ERs are more likely than major trauma centers to be staffed by nurse practitioners or physician assistants, rather than MDs specializing in emergency medicine, because they tend to see less serious medical situations. But as these facilities concentrate more exclusively on emergency care, it follows they may seek out emergency-trained doctors to strengthen their practice.
But there could be a problem: What if there aren't enough ER doctors?
That was the subject of a big news story this week: the sizable drop-off in medical students applying for residencies in emergency care. The number of those applicants dropped by a quarter from 2021 to 2023 and more than 550 residency slots were left unfilled for this year, according to a trio of emergency physicians who wrote on the trend for STAT.
The mechanics of residency matching are complex, but, suffice to say, this is a worrying sign that fewer doctors coming into the workforce are interested in emergency medicine.
"All specialties are suffering from the crumbling health care system. The decline in students' interest in emergency medicine does not only affect the workforce — it also affects our patients," the ER doctors wrote in STAT. "Emergency medicine is the safety net for all patients at all hours of the day."
The reasons for the decline are likely multifaceted. One culprit may be the burnout of the pandemic, when emergency rooms were slammed with patients and clinicians often found themselves overwhelmed. That may be making emergency medicine less attractive to students who can instead choose more lucrative specialties (orthopedics, for example) with better working conditions. A previous report that the US could have an oversupply of ER docs was another commonly cited factor because it may have motivated students to look elsewhere lest they not have a job when they're done with their education.
The truth is, we don't know whether this drop in student interest in emergency medicine is permanent or not. Perhaps it will correct itself. But the number of unfilled residencies grew from 2022 to 2023 so for now, things are moving in the wrong direction.
And this is especially concerning given the expected trend toward rural hospitals narrowing their operations exclusively to emergency care. Those hospitals have already had trouble attracting talent because students tend to take full-time positions near where they perform their residency, which is typically at a larger academic center. Various policy attempts to encourage new doctors to take jobs in rural communities, such as loan repayment, have not fixed the problem, according to Greenwood-Erickson.
Now the pool of potential clinicians to hire may shrink even further if this disinterest in emergency medicine proves to be a more permanent shift.
"Historically, these facilities had a lot of trouble getting people in. This uncertainty only makes that more concerning," she said. "If these rural emergency hospitals move toward staffing with more emergency physicians, this will only make things more challenging."
In other words, even as Congress attempts to throw rural hospitals a lifeline, changes in the medical workforce may leave it just out of reach.
