Rural America and Urban America can seem like two different worlds. Just look at the political map, or the disparity in wealth between ‘country folks’ and ‘city slickers’. Perhaps the most alarming difference, however, is the availability of basic healthcare services.
If you live in rural America, you could be 2- or 3-hours’ drive away from the closest renal dialysis center, or radiotherapy and chemotherapy clinic. You may also be several hours away from the nearest stroke or trauma center which in an emergency, could mean the difference between life and death.
As for many other medical services, rural Americans must make do with what is available in their community - a local midwife rather than a maternity hospital or ‘new life center’ staffed with neonatal experts and incubators in case they are needed. Go into labor early or present as a high-risk pregnancy and be prepared to be ambulanced or worse, air-ambulanced at huge expense, to a city hospital where you and your infant can be cared for. Today, anything other than basic medical services usually means a long drive to the nearest city.
The trouble is, that what remains of rural health services is rapidly declining. Rural hospitals and entire rural health systems are closing, and those that remain open, are continuously reducing their specialist services, which may not be used enough to remain profitable or cover costs.
A new report from the American Hospital Association (AHA) states that 136 rural hospital closures have occurred between 2010 and 2021, and a record 19 closures in 2020 alone. Beckers, in a recent article reviewed a larger period claiming that nearly 200 rural hospitals have closed since 2005. What’s even more alarming is the pace of closure is accelerating. Eight rural hospitals closed in 2023, as many as in 2022 and 2021 combined, according to the Center for Healthcare Quality and Payment Reform's latest report.
As recently as this month, the Eastern Plains Healthcare Consortium (EPHC) stated during its annual conference that 20% of rural hospitals in Colorado are at risk of closing. They require a 4% operating margin to replace equipment and maintain existing services, however, nearly all are currently running in the red, some as much as -17%. EPHC estimates that some 30 rural Colorado hospitals will be forced to convert to emergency only services as Emergency Rural Health Hospitals to save closing altogether.
Some of these hospital closures are the result of cyber-attack and in particular, one recent Illinois hospital closure is blamed upon a 2021 ransomware attack that prevented it from submitting claims to payers for months, killing its cashflow and financial viability. Another small hospital had its entire payroll stolen in a cyberattack preventing it from paying any of its staff and placing it in financial peril.
The Change Healthcare cyberattack earlier this year has exacerbated the plight of small providers and in particular rural clinics and physician practices. Many physicians are struggling to keep their practices afloat according to the American Medical Association (AMA) and even though UHG, the owner of Change Healthcare, has publicly said it will provide relief in the form of Temporary Funding Assistance to impacted providers, this is very selective, one-sided and fraught with caveats according to Richard Pollack of the AHA in a letter to UHG.
Challenges for Rural Healthcare Providers
Rural providers face many challenges: finances, through rural depopulation and a disproportionate number of rural patients on Medicare and Medicaid, general resource constraints, and huge difficulty attracting and retaining nursing, physician, and other staff. Most notable of these is the lack of trained and experienced cybersecurity staff to protect rural providers from an increasing volume of cyberattacks.These hospitals run on a small number of IT generalists and often find it difficult to patch systems in a timely manner, let along obtain the budget or expertise to implement the latest security tools and services. Many operate on end-of-life computer hardware and medical devices no longer supported by vendors. Compared to urban providers these hospitals are an easy target for criminals and are frequent victims of PHI breaches, ransomware, and other attacks.
Like their urban cousins, rural hospitals are undergoing a digital transformation to new clinical and IT systems. This involves the addition of more medical and other IoT systems including connected building management systems for HVAC, elevators, proximity door locks, CCTV cameras, and Pyxis drug cabinets. These systems dramatically expand the cyber threat surface and unless secured and maintained, can significantly elevate the risks of attack. But rural providers often lack the specialist skills to safely manage these systems. That is perhaps why, many are turning to a combination of Managed Services Providers (MSPs) and Managed Security Services Providers (MSSPs) to effectively outsource security and much of IT.
MSPs and MSSPs will manage a large number of hospitals at the same time and through a leveraged model can provide point expertise as needed in more or less any technology or vendor system. They can also implement advanced SaaS tools from Cylera and others to identify the growing number of connected assets and evaluate and prioritize risk remediation. Indeed, the incorporation of SaaS services is rapidly helping to drive improvements in rural provider cybersecurity, especially in medical device security, a growing problem for all healthcare providers.
The advent of managed services has become particularly important given a new assistance program for rural hospitals orchestrated by the White House and the AHA in June of this year. Microsoft and Oracle have agreed to provide free and heavily discounted cybersecurity resources to assist rural hospitals with access to many of their security tools and technologies. However, so far, relatively few rural hospitals are taking advantage of a free program designed to thwart ransomware attacks according to the White House this week. Only 350 of the 1,800 small and rural US hospitals are currently leveraging this assistance program.
It appears that without MSP or MSSP help, many rural providers are simply unable to accept or implement these discounted tools or utilize the free security assessments because they don’t have the manpower bandwidth to do so. This is the Catch22 of providing security assistance to rural health providers. Thankfully, for some, the MSP/MSSP buffer is helping to facilitate this today.
While near term improvements to rural hospital cybersecurity will be of great assistance in helping to reduce cyberattacks, there are still long-term structural problems of maintaining the continued presence of rural providers and access to healthcare services for rural communities. The healthcare industry faces many problems, not least of which is unmitigated cybersecurity risk. While urban providers can rely upon numbers to maintain services and a plentiful supply of cybersecurity talent nearby to avoid the worst of the attacks, rural providers face almost insurmountable challenges. This is undoubtedly a larger political question of healthcare reform that the next administration will need to prioritize.
