Overall, the system was designed for an urban setting where you've got a demographic of Medicare versus private insurers, and that pay base really determines your viability. When you move to the rural area and flip those ratios, so you have a high percentage of Medicare and Medicaid, the numbers just don't work, and then you build in a set of quality metrics that don't fit the rural environment.
In a larger hospital, you have whole bodies of people to deal with this. In a rural hospital, you may have one person doing six different jobs to be able to take care of.
Richard Watson is an emergency medicine physician.
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