Perspectives

Geography should not be a determining factor for health status. Yet, in the US, the zip code you live in plays an outsized role in determining your health and life expectancy. It directly impacts whether one has access to preventative care, healthy foods, and good job opportunities. This is the unfortunate reality for the nearly 60M Americans who live in rural communities.

Across hundreds of small towns and farms today, we see a population that trends older, with greater health disparities, and often lacking both access to care as well as financial resources to address their health concerns. Despite advances in public health and medical treatments, rural residents are becoming more likely than their urban counterparts to die prematurely from the leading causes of death in the US. In 1999, the natural-cause mortality rate for working-age adults in rural areas was only 6% higher than for urban residents in the same age bracket. By 2019, the gap widened to 43%. These communities are also seeing an alarming rise in “deaths of despair,” which include deaths related to drug overdose, alcohol abuse, and suicide. Between 2000-2020, suicide rates increased 46% in rural areas compared to 27% in urban areas.

The issue becomes more dire when considering the unique set of economic, social, demographic, and logistical circumstances rural residents face today, all of which collectively contribute to the nation’s growing urban-rural divide. Compared with urban areas, rural populations have a 25% lower median household income, a 5% higher child poverty rate, and a 12% lower share of adults with college degrees. As a result, Americans in rural communities report more trouble affording quality care, lower levels of health literacy, and are more likely to delay or forgo care. 40% of rural Americans say their families have experienced problems affording medical bills, housing, or food, upwards of 56% have low health literacy levels, and 36% skipped needed care due to cost.

The lack of accessible care in rural communities places additional barriers on residents. Rural hospitals and health systems have been in a crisis for decades due to longstanding dynamics such as low reimbursement rates, staffing shortages, low patient volumes, and regulatory barriers, driving 50% of rural hospitals to report negative operating margins. These financial challenges have driven over 190 rural hospitals to close since 2005 and have placed an additional 360 hospitals at immediate risk of closing within the next three years. To improve financial viability and stave off closure, rural hospitals have been forced to reduce the services they offer. Between 2014 and 2022, 382 rural hospitals stopped providing chemotherapy and since 2011, 267 hospitals discontinued obstetric services. Further, rural counties are home to only 10% of physicians despite representing 20% of the population. As fewer providers chose to work in these communities, this dynamic is not expected to lessen. Physicians from rural backgrounds were more than twice as likely to practice in rural areas, however the number of medical school entrants from rural areas declined by 28% from 2002 to 2017. Limited provider availability in rural areas raises significant concerns about heightened transportation barriers, treatment delays, and adverse health outcomes. Studies have shown that rural closures have increased inpatient mortality by nearly 9%.

These challenges create an imperative for those seeking to improve population health and address health disparities in the US to embrace the use of healthcare technology in rural America. Stakeholders across the healthcare continuum are actively working to deploy new technologies to transform care delivery and consumer experiences. PBMs are supporting independent pharmacies in deploying digital health solutions to address SDOH needs. Employers are partnering with virtual care solutions to expand employee access to specialty and behavioral health care. Payers are implementing value-based care models that include in-home visits, community-based visits, and technology-enabled clinical services to meet rural residents where they are. Providers are adopting workflow automation tools to reduce clinician administrative burden. State governments are funding telehealth initiatives that expand preventative screenings and health education access to rural communities. These tech-forward strategies ultimately offer the promise of overcoming the healthcare supply shortfall and improving access to care for rural Americans.

Improving rural health requires a targeted approach that considers the variety of access barriers rural residents experience. To best outline care gaps among the population, 7wireVentures categorizes rural consumers into four distinct segments based on insurance coverage: Uninsured, Medicaid/CHIP, Employer/Individual Market, Medicare/Dual-Eligible.

The unique characteristics of these consumer segments highlight the population’s reliance on public insurance programs, an increasing aging population, and the varied approaches to care required to meet their health needs. With a more nuanced understanding of our rural communities and a focused commitment to solving their distinct needs, they no longer have to be an outlier in health and care.

Rural Health Landscape

From virtual specialty care to in-home care providers, investor interest in rural health solutions has grown. Between 2020 and 2023, total investment exceeded $8B, with 2022 alone seeing a staggering $5.6B in private investment.¹ We believe the rural health market landscape can be broken out into six different categories: Referral Management & SDOH, In-Home Care Providers, Rural Provider Enablement, Virtual Care Connectors, Virtual Specialty Care, and Virtual Substance Use Disorder (SUD) Treatment.

[1] Pitchbook

Referral Management & SDOH: While rural areas comprise less than two-thirds of all U.S. counties, they represent 9 out of 10 counties with the highest food insecurity rates and nearly 80% of the 664 high poverty counties in the U.S. are rural. These communities often have their own system in place for connecting individuals in need to local services and help. However, identifying, engaging, and connecting residents to these services presents a challenge for rural providers. Solutions that integrate SDOH into healthcare delivery by identifying gaps in care and partnering with Community-Based Organizations to provide comprehensive support can work to connect the unconnected. A 7wireVentures portfolio company, GroundGame.Health, manages the complex connections between health plans, members, and Community-Based Organizations to fulfill unmet social and care needs for the most difficult to engage populations. Another company, Soda Health, provides tools and resources to help individuals navigate and overcome barriers to care, such as transportation, food insecurity, and housing.

In-Home Care Providers: Physical distance to care and transportation difficulties in rural areas compromise patient outcomes, particularly for the elderly, disabled, and children who have limited access to cars. In some states, rural patients are required to travel 3 to 4 times farther than urban patients to receive care and 7% of rural adults missed their appointments due to transportation difficulties. By bringing healthcare and other resources directly to the patient in an accessible, comfortable environment, in-home care providers are well-suited to increase access to preventive and urgent care and improve patient adherence to treatment. EasyHealth works with value-based care providers and health plans to close gaps in care and reach underserved populations by sending nurses and medical assistants to the home, both in-person and virtually. DispatchHealth provides high-quality care and on-site diagnostics to members’ homes with services that range from same-day specialty care to 30-day acute care.

Rural Provider Enablement:  In 2023, 65% of rural areas had a shortage of primary care physicians and there is a projected 25% decline in PCPs in rural areas by 2030. Staff shortages and increasing administration requirements make it difficult for rural primary care practices to provide the level of care they desire while sustaining their practice financially. Provider enablement solutions can promote value-based care, streamline administrative processes, and extend practices’ ability to deliver supplemental and non-clinical care. Homeward focuses on providing comprehensive healthcare services to rural communities, including managing chronic conditions, preventive care, and coordination of healthcare through local teams that work alongside patients’ existing doctors. The company also offers assistance with medications, insurance benefits, and connecting patients to local support services. Main Street Health provides primary care services to seniors living in rural areas. The company’s model focuses on in-home visits, telehealth, and partnerships with local providers to ensure comprehensive and continuous care.

Virtual Care Connectors: In rural areas specialists are few and far between, requiring patients to travel long distances for in-person visits. Consequently, PCP referrals to specialty care are less common in rural areas. Virtual care connectors enable primary care providers and frontline physicians located in rural areas to receive real-time support from specialists, increasing their ability to make better diagnoses and develop appropriate care plans. AristaMD empowers PCPs with 200+ evidence-based clinical work-up checklists, the ability to conduct eConsults with a national panel of specialists, as well as analytics to optimize care collaboration and specialty referral triage. Hippo offers specialist consults by equipping providers with video-enabled headsets that livestream patient exams for real-time diagnosis and treatment.

Virtual Specialty Care: Rural residence is associated with a 40% higher preventable hospitalization rate and a 23% higher mortality rate. Access to specialists account for 55% and 40% of the rural-urban difference in preventable hospitalizations and mortality, respectively. Virtual specialty, chronic condition, and maternity-focused solutions can expand access to key specialty areas. Companies like Wildflower Health are pioneering mobile maternity programs using self-reported data to identify high-risk pregnancies for timely intervention. Another notable company is Heartbeat Health — a virtual-first platform that offers a comprehensive suite of cardiac care solutions including telemedicine, diagnostic services, medication management, and lifestyle guidance.

Virtual SUD Treatment: Disparities related to addiction in rural America range from poor treatment infrastructure, low health literacy, and a lack of providers trained in delivering substance use treatment. Ultimately, less than 20% of rural residents with OUD receive necessary treatment. The disproportionate need for SUD care in rural areas presents a meaningful opportunity for digital health solutions to increase treatment capacity. Workit Health combines telemedicine with personalized care plans, including medication-assisted treatment and counseling for opioid and alcohol addiction. Eleanor Health focuses on a whole-person approach, addressing not only substance use but also underlying mental health conditions and social determinants of health.

7wireVentures Predictions

PREDICTION 1: Value-based care models and care enablers will continue to gain traction in rural communities for Medicare populations.

Rural residents are older, sicker, and poorer than their urban counterparts. The complexity and comorbidities also drive higher costs, especially when using a standard fee-for-service model. As a result, both patients and health plans may be better served through a whole-person model of care, rather than focusing on each condition as a standalone issue. Advanced primary care models, either as standalone operations or in partnership with local providers, will be the central node for care coordination to manage the complex needs of the population. To enable this, health plans will look to models that take a holistic approach and are accountable for clinical and financial outcomes.

PREDICTION 2: Health plans will emphasize solutions that can shift utilization toward preventive care and other cost-effective interventions.

Rural residents often delay necessary medical care due to barriers to accessing care, such as transportation and cost, leading to higher rates of preventable hospitalizations. Health plans will seek partnerships with organizations that can identify and close these critical care gaps. Digital health solutions that can effectively direct members to preventive care services, such as screenings and regular check-ups, will become increasingly valuable. eConsult services, same-site diagnosis and medication access, and mobile care units can lower the threshold to receiving care. These solutions not only improve health outcomes but also reduce overall healthcare costs by preventing more serious health issues.

PREDICTION 3:  Virtual specialty access will be a primary focus for payers and health systems, driven by the shortage in physicians for specialty conditions.

Rural hospitals often lack the patient volume needed to support in-person specialty care, however the shortage of specialists in rural areas, such as neurologists and oncologists, creates significant gaps in care. Virtual specialty services can help bridge these gaps by providing rural patients with access to expert care without the need for long-distance travel. These solutions can leverage existing care access points, such as primary care sites, rural clinics, and pharmacies, to mitigate broadband access challenges and provide necessary specialty care. Further, implementing virtual care solutions can decrease staffing costs and increase revenue for financially struggling rural hospitals by reducing patient transfers to other hospitals. By utilizing telehealth and digital consultation platforms, healthcare providers can ensure that rural patients receive timely and specialized care, addressing both acute and chronic conditions effectively.

Ultimately, these trends will drive improvements in health outcomes and healthcare equity for rural populations, ensuring that they receive the high-quality care they need and deserve. We have conviction that digital health solutions can be deployed to transform the end-to-end consumer care journey for those living in rural communities. By embracing these innovations, we can make significant strides in closing the healthcare gap between rural and urban areas.