Revitalizing Healthcare Reimbursement in Rural Communities
Adam S. Edwards III, NFL Alumni, MBA, PACS, ACHE
May 14, 2025
7 minutes read
Revitalizing Healthcare Reimbursement in Rural Communities
Access to quality medical care and prescriptions is a fundamental right, yet rural communities often face significant barriers and find it more challenging to achieve equitable and fair medical services in the community where they work, live, and play. An aggressive revitalization of rural healthcare is critical to address the unique challenges these areas encounter daily. This reality makes navigating these reimbursement challenges essential. As such, overcoming obstacles and disadvantages in rural communities is vital for the healthcare ecosystem to create favorable patient outcomes that remove access barriers for patients in our rural communities.
This article will provide a snackable overview of the vital balance of increasing equitable healthcare access, the critical and essential role of reimbursement in sustaining rural health services, and the burgeoning need for forward-thinking solutions to close the chasm in care delivery. The solution is evident, and an effort this important must be a public-private partnership with the urgency of ensuring equitable healthcare access for all. We can hope, dream, and work towards a healthier, more inclusive society by addressing these issues.
The US Healthcare System
The US healthcare reimbursement system is a complex and complicated mix of public and private payers. Even our elected leaders admit there is so much about the healthcare system's archaic function that it is challenging to create broad legislative agendas that solve the most equitable healthcare issues. To highlight this, let's review the primary types of US insurance coverage. They include:
- Medicare: A federal program providing health coverage if you are 65 or older or have a severe disability, no matter your income.
- Medicaid: A state and federal program that provides health coverage if you have a very low income.
- Private Insurance: Coverage is provided by private companies, often through employers, but is also available for individual purchase.
- Independent Physician Associations: A network of independent doctors who collaborate to negotiate contracts with insurance companies and provide coordinated care to patients.
Collectively, the picture becomes clearer on why navigating the reimbursement processes for multiple payers (Medicare, Medicaid, private insurance) can be particularly challenging for smaller rural providers.
Impact of Rural Healthcare Providers
Reimbursement issues can severely affect the financial stability of rural healthcare facilities (See Figure 1). Many rural hospitals operate on thin margins and rely heavily on reimbursements from Medicare and Medicaid, which often pay lower rates than private insurance. According to the American Hospital Association, nearly half of rural hospitals are operating at a loss, and hundreds are at risk of closure. The recent decrease in Medicare payments and the current reconciliation budget discussions in Congress will undoubtedly further strain these facilities, making it difficult for them to maintain their crucial financial stability (AHA, 2023).
Smaller rural providers are dedicated to navigating complex reimbursement processes across multiple payers. Rural healthcare facilities often have limited resources, including fewer healthcare professionals and outdated infrastructure. For example, Independent Physician Associations in rural communities usually face challenges such as limited access to resources and difficulties in securing appropriate reimbursement rates, which can impact the sustainability of their practices. This frequently requires additional administrative staff, which increases operational costs. However, the dedication of these professionals is unwavering, ensuring that quality care is always a priority (AHA, 2022).
Sustainable Solutions
Telemedicine for rural healthcare allows providers to offer consultations and follow-up care remotely, dramatically reducing the need for patients to rely on transportation for healthcare visits. Additionally, the emergence of mobile clinics tends to curate community faith-base and other influential partnerships that reduce non-scientific theories on preventative healthcare screenings. Such options have undoubtedly shown that meeting patients where they are in rural communities has the promising potential to reduce significant disparities.
The notion that Americans should be left to their resources to access quality care is not a healthy solution for our complex care system, particularly in rural communities. It truly takes a concerted effort to ensure a healthy and vibrant community. For this reason, consistent care delivery can sometimes be understated. Health workers help bridge gaps in care and provide culturally relevant support to patients. These innovative solutions offer hope for the future of rural healthcare.
Case Summary
A Texas Rural Accountable Care Organization case study highlights how sharing patient-specific Medicare claims data and discussing high-utilization patients with providers increased care coordination referrals, reimbursement, and patient participation in care coordination activities. This approach led to better outreach and improved healthcare delivery in rural areas. Although silos will persist, sharable data creates an inclusive care ecosystem that enables efficient deliverables within an extremely complex environment (Rural Health Innovations, 2015).
Conclusion
The patient remains at the center. Payers and providers must remember that it takes a collective approach to reduce disparities and enhance the overall healthcare infrastructure in rural communities. In regions where complex plan designs exist, such as Independent Physician Associations, education and training updates for healthcare workers can address insufficiencies and improve value-based healthcare. After all, every American has a fundamental right to access quality healthcare and providers deserve appropriate reimbursement for this delivery of care.
Bio
Adam Edwards, MBA, PACS, CMAA
With over 20 years of executive nonprofit and healthcare leadership, Adam is Sanofi’s Head Vaccine Reimbursement Education Liaison for the Southwest Region. He holds a master’s in business administration and several credentials as a healthcare executive, Prior Authorization Certified Specialist (PACS), and mergers and acquisitions.
Connect with Adam on Linkedin>>
References
- https://www.aha.org/2022-09-07-rural-hospital-closures-threaten-access
- https://www.aha.org/guidesreports/2024-05-01-2023-costs-caring
- https://www.azaleahealth.com/blog/cms-final-rule-2025-rural-health-clinics/
- https://www.ruralcenter.org/sites/default/files/Case%20Study-Final.pdf
- https://www.aha.org/fact-sheets/2022-12-05-workforce-shortages-delay-patient-discharges-and-exacerbate-providers-severe-financial-challenges
- https://www.aha.org/guidesreports/2024-05-01-2023-costs-caring#figure1
- Wazeer, A. (2022). Medicaid And Medicare Savings Programs. Muslim Journal, 47(36), 5.
(n.d.). Rural-health-revitalization-challenges-solutions.
