Rethinking rural hospitals
Via Journel of American Medical Association (JAMA) is an invitation us to keep looking at the plight of rural hospitals in light of decreasing rural population. Dr. Diana Mason writes:
But other rural communities, home to nearly 20% of the US population, are not so fortunate. Since 2010, 78 of the more than 2150 rural nonspecialty US hospitals have closed. While the closure rate has recently declined, the proportion of financially struggling rural hospitals has increased. When a rural hospital closes, the economic losses can devastate an already stressed community through loss of health care workers, emergency services, and primary care capacity, as well as higher unemployment and lower per-capita income, a drop in housing values, poorer health, and increasing health disparities.
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Why are rural hospitals at higher risk of closure than urban hospitals? George Pink, PhD, Deputy Director of the North Carolina Rural Health Research Program, sees 3 main contributors:
- Market factors. Rural areas tend to have poorer population health, higher unemployment rates, and stiffer competition from other hospitals
- Hospital factors. These include low occupancy rates, lack of physician coverage, deteriorating facilities, and patient safety concerns
- Financial factors. From 2012 to 2014, for example, rural hospitals averaged a 2% operating margin, compared with 5.9% for urban hospitals
I did not see it in this post, but a major factor in funding for rural hospitals, especially in poorer areas, is Medicaid funding. In almost every state, hospital groups have been among the strongest advocates of expanding Medicaid. I know that in Virginia several have closed that might have stayed open if the state had seen to expand Medicaid, which it did not. Without doubt, an increase in rural hospital closures would be an outcome if indeed Congress and Trump succeed in eliminating the ACA expansion of Medicaid or even cut it back further than that, which there seems to be talk of.
Barkley:
Just to add to your comment. The ACA started to cut back on reimbursing hospitals (starts at >15% of cost) for the uninsured because people would have Medicaid to pay for it. As you know, many states did not expand Medicaid and the process for cutting back still went on. The average bill is ~$2,000 of which 60% is usually paid by the patient and other sources. 40% left over is still a big hit in states without Medicaid.
The real question is how far to the next hospital? 10 miles versus 100 miles is a big difference. since many studies show that the more a procedure is performed in a hospital the better the hospital is the agruement for small hospital is not there. Now for level 1 trauma centers your likley to have to go 100 miles in most rural areas for example. You also see this in that towns on the modern frontier (Edwards and Real counties in Tx) there are no Ob/Gyn services so most folk go to San Antonio or San Angelo for these services. It does mean that helicopter evac is more often needed however.
My parents lived in a relatively rural part of West Virginia. The local hospital was called Greenbrier Valley Hospital. The locals renamed it “Death Valley Hospital” because pretty much if you checked in, you didn’t check out. This is a major reason why they left that area and moved to a more urban area.
Smaller hospitals are good in emergency (stitches, broken bones, etc.). Moving to a larger hospital can be better. My kids would have pushed me to Cleveland except for the fact Mansfield was top 5% in the nation for the surgery I was to have. They had Cleveland Clinic doctors. I liked that mid-sized hospital and it was a lower cost. U of M, I tried to keep away from as they are “huge” and make mistakes. Cutting a nerve in your back does help afterwards.
My aunt was admitted to Greenbrier Valley (a.k.a. Death Valley) Hospital. I happened to be in town that day so went an visited her. She was unconscious and the doctors did not know what was wrong with her…. “they were running tests.”
My dad (her brother) kept pleading with my uncle to take her to Charleston, a much bigger, better hospital. He refused, trusting the Death Valley doctors. She died, of a treatable Staph infection. My dad never forgave my uncle, and I don’t think he forgave himself as she was his world to him.
Small rural towns if not the county seat (because it has government as a major employer) are going to fade away anyway. In most cases if you have a severe injury you will be helicoptered to the nearest level 1 trauma center anyway. As noted in the posts above small hospitals don’t do enough work to keep their skills current also. The community will more need emt’s with no local hospital, to prep folks for transport. (actually emts are a form of telemedicine already). The small town will be eventually reduced to a few churches since they are the last institutions in a settlement to go away.
They can not afford helicopters. The best you will do is an ambulance or a car.
You do see a lot of medivac flights after car accidents. If the case is not in that class an ambulance is used. But major trauma tends to helicopters, in particular in truly rural areas, when the level 1 trauma center is 100 to 200 miles away. (Such as I 10 in Tx in the Junction area) Also you find fewer and fewer OB/GYNs in the small town, thus fewer births at the local hospital, and the hospital is not equipped for much beyond routine births.
I’ve read several comments here mentioning air ambulance services for rural areas. Right now, even under the ACA , air ambulance is not covered by most insurance policies.
“Of all the complaints we have received in our office, not one person was uninsured,” said Jesse Laslovich, the legal counsel for Montana’s insurance commissioner. “They’re all insured. And they are frustrated as heck that they’re still getting $50,000 balance bills.”
https://www.theatlantic.com/health/archive/2016/01/air-ambulance-helicopter-cost/425061/
John:
Welcome to AB. 1st comments go to moderation. Your comment of helicopters are welcome. I believe as the article said, the parents appealed the billing and were able to get the insurance company to pay. One of the aspects of the ACA is appeal ability to get the right treatment. I am guessing this falls in the same category as it was an emergency. There was no where else to go and no alternatives. I had a similar issue just not a chopper ride. The doctor/supplier agreed to the rate.
Believe me. I support much of the protections that the ACA finally accorded to the patient especially in rural America. This AHCA however, is really going to strangle critical care in rural America as hospitals shutter their doors and ambulance services have to pick up the demand. The AHCA allows state governments to waive insurance coverage for ambulance service so rural residents are going to taken to the cleaners when it comes to access to critical medical care.