Rural health needs big, transformative bets, not small pilots

More than 150 rural communities have lost access to inpatient hospital care since 2010. Only 41% of rural hospitals still provide maternity services, and an estimated 43 million Americans live in rural areas that are federally designated primary care health professional shortage areas. Access is shrinking, workforce shortages persist, and the pressure on rural providers continues to grow.

The consequences are increasingly visible across the healthcare system. Rural markets account for just 20% of the U.S. population, yet they generate more than half of all patient transfers, according to data from the Vizient Clinical Data Base. Nearly half of those transfers travel more than 50 miles to reach a higher level of care.

These statistics point to a multilayered challenge. Many rural hospitals are attempting to sustain a broad range of services despite low patient volumes, workforce shortages, and rising financial pressure. As volumes decline, maintaining clinical expertise and supporting specialty services become more difficult. More patients must be transferred elsewhere for care, creating additional strain on already-fragile delivery systems. The result is a model that has become difficult to sustain—for hospitals, and for the communities that depend on them.

This is what makes the current moment significant. The recently unveiled Rural Health Transformation Program (RHTP) will make up to $50 billion available over five years to help states and providers redesign care delivery, but the timeline is shorter than it appears. New care models often require 12 to 18 months to design, implement, and scale. Organizations will be expected to demonstrate measurable progress well before the funding period ends. Those that hesitate may find themselves running short on time before meaningful transformation has taken hold.

The moment calls for urgency. Rural providers have identified the problems. Now they must decide which solutions merit large-scale investment and move quickly enough to make them work. Organizations that spread resources across too many initiatives may find themselves with little to show for the investment. Conversely, those that achieve meaningful transformation will be those that focus on a few priorities that matter most and pursue them at a scale large enough to produce lasting change. In our experience, the biggest opportunities typically fall into three areas: chronic disease management, behavioral health, and workforce transformation. Every market is different, but these challenges sit at the intersection of access, outcomes, and sustainability for many rural providers.

Transformation will require a different approach than many healthcare funding programs of the past. Historically, funding initiatives have focused on facilities, equipment, and technology. Those investments remain important, but the RHTP is designed to achieve something different: to help rural providers build a new model, not incrementally improve an unsustainable model.

Rural healthcare cannot overcome its challenges by doing more of what it has always done. Long-term sustainability will require new care models, new workforce approaches, and new ways of connecting patients with services. RHTP funding cannot solve every challenge nor support every worthwhile idea. Leaders will need to make difficult choices, directing resources toward initiatives most likely to improve access and outcomes. Success will be gauged by whether meaningful transformation occurs.

Focus on the problems that matter most

As organizations begin working on RHTP projects, one pattern is already emerging: many are trying to do too much at once. Every department and service line can make a compelling case for investment, but spreading resources across dozens of initiatives rarely produces results. We have seen this dynamic before. Funding is divided among multiple pilots, each addressing a worthwhile problem, but none receives the scale needed to change outcomes.

The organizations gaining the most traction are making fewer, bigger bets. They are concentrating resources on a small number of priorities with the potential to improve access, outcomes and long-term sustainability. For some, that may mean redesigning primary care. Others may focus on chronic disease management or behavioral health access. The priorities will vary by market; what matters is the discipline to focus. Organizations that achieve meaningful transformation will be those that commit resources at scale and resist the temptation to do everything at once.

Making it stick

The hardest part of transformation is building the future while operating the present. You have to keep the lights on today while simultaneously transforming the business for tomorrow. So for a period of time, organizations will need to continue delivering care through existing models while redesigning workflows, developing new capabilities, and proving that new models can produce better outcomes.

This creates operational strain, particularly in organizations already facing workforce shortages and resource constraints. Many rural providers simply have not managed transformation at this scale before. We have seen organizations struggle when accountability is unclear or the capacity needed to manage change does not exist. New care models require clear governance, rigorous performance measurement, and operational discipline; otherwise, promising initiatives lose momentum. That will matter under the RHTP, because the Centers for Medicare & Medicaid Services, which oversees the program, is looking for outcomes, not activity. Organizations will need to demonstrate that investments are improving access, strengthening care delivery, and producing measurable impact.

While the funding may be initially generous, successful transformation depends on more than that. It requires an integrated set of capabilities—including data and analytics, strategic planning, operational improvement, clinical leadership, governance, and sustained execution, all of which must work together over time. Organizations that can bring those capabilities together are better positioned to achieve durable change.

The program spans five years, but the practical window for transformation is considerably shorter. The clock is already ticking, and organizations that wait for perfect clarity may run short on time. Those that spread resources across a long list of incremental initiatives may struggle to demonstrate meaningful results. Real transformation will require states and providers to move in the same direction, concentrating resources on a few carefully chosen priorities and building the accountability needed to deliver measurable results.

Trevor DaRin, Madeline McDowell, and Jason Spring contributed to this article.