Safety-net hospitals in the nation’s rural areas are strained and busier than their counterparts in urban areas, a new JAMA study reveals. This problem is further exacerbated by fewer physicians serving patients in these areas and generally worse health for rural residents.

Rural hospitals also are constrained financially with "operating margins often too narrow to invest in upgrades to optimize care delivery." According to the JAMA study authors, emergency department use patterns provide a lens into the status of healthcare delivery in the communities they serve.

Traditional office-based care settings require significant resource investment and a robust physician pool, which may be lacking in rural communities. These factors raise the possibility that rural EDs are increasingly serving as a source of care for rural patients in ways that are distinct from their urban counterparts.

From 2005 to 2016, estimated rural ED visits increased from 16.7 million to 28.4 million and estimated urban visits rose from 98.6 million to 117.2 million. Additionally, Medicaid beneficiaries rose from 4.4 million to 9.7 million; those aged 18 to 64 years 9.6 million to 16.7 million; and patients without insurance 2.7 million to 3.4 million in rural areas.

Rural ED visit rates increased by more than 50 percent, from 36.5 to 64.5 per 100 persons between 2005 and 2016. This increase outpaced urban ED visit rates, which were generally flat, increasing from 40.2 to 42.8 visits per 100 persons.

The study results follow recent data from the Centers for Disease Control and Prevention that showed ED visits increased by nearly 10 million patients in 2016 compared to the previous year.

"Rural EDs are experiencing important changes in utilization rates, increasingly serving a larger proportion of traditionally disadvantaged groups and with greater pressure as safety-net hospitals," the researchers wrote in their brief.

An alternative study released in 2018 found that challenges persist among rural emergency departments that face physician shortages. The study in the Annals of Emergency Medicine found that almost 64 percent of emergency physicians were in urban counties, while nearly 45 percent were in rural counties, according to the study. More than 27 percent of counties did not have emergency medicine clinicians and 41.4 percent of counties did not have any emergency physicians reimbursed by Medicare fee-for-service Part B.

The JAMA study provides one possible option for fixing the disparity (a solution that is often thrown around) — more telehealth! The use of televisits, which could keep patients at home to receive appropriate care, may reduce the burden on emergency departments.

The JAMA report also suggests that safety net hospitals need some help and are struggling to keep up with uncompensated and charity care. Per Healthcare Dive, America's Essential Hospitals (AEH) said pending disproportionate share hospital cuts slated for Oct. 1 will push those facilities to a "breaking point."

AEH hospitals operated with an average margin of 1.6 percent in 2017, about half of what they had the previous year and well below the 7.8 percent average of other hospitals.