The Local Hospital Closed. These Doctors Didn't Give Up.

Larry Beresford

Disclosures

September 23, 2019

The Scope of the Rural Crisis

A total of 113 out of 1875 rural hospitals have closed in the United States since 2010. According to the Rural Health Research Program at the University of North Carolina . the hardest-hit states include Texas, Georgia, Tennessee, Alabama, Oklahoma, Kansas, and Mississippi. All opted not to participate in Medicaid expansion under the Affordable Care Act. The largest percentage of hospitals determined to be at highest risk of financial distress are in these same states.

A number of factors contribute to rural hospital closures. These include a population that is trending older and poorer, declines in inpatient volume and revenues, and poor management. Some communities highly value the independence of their local hospital. Others feel the imperative to merge with neighboring hospitals, larger regional health systems, or hospital corporations. A recent study found that 12% of rural hospitals chose to merge between 2005 and 2006. But these mergers are not a panacea. A distant company administrator could well decide to close a local hospital that is not meeting its revenue targets.

Closed hospitals may find a second life as an urgent care or emergency facility, a skilled nursing or rehabilitation facility, or an outpatient or primary care clinic. But about two thirds simply cease to function as a hospital, though the building may find another purpose.

Emergency services are typically the first service to go with loss of access to a hospital, says George Pink, PhD, of the Rural Health Research and Policy Center at the University of North Carolina. Other healthcare services not directly managed by the hospital, including physical or occupational therapy, home care, hospice, nutritional clinics, and the like, may be next to go.

"The hospital is typically the largest employer in the community, so there's a huge economic impact," Pink says. Recruitment of teachers and other important occupations is more difficult if there is no hospital. Other large employers will be more reluctant to build new plants there. The health and well-being of the entire community decreases, with per capita income down by 4% and unemployment up by 1.6%.[4]

While rural hospital closures have received the most attention, the scheduled shuttering of Hahnemann University Hospital, an institution in downtown Philadelphia for 171 years, clearly illustrates that urban hospitals can also be affected.

Patient outcomes in communities affected by hospital closures vary. One study examining the relationship between all US hospital closures and mortality found that patients living in closure areas experienced no increase in mortality rates.[5] The story may be different for rural patients. Another study assessing effect of hospital closures on mortality rates in Medicare patients in rural markets concluded that the increased travel time required to access care for a critical condition did affect mortality. While closures of rural hospitals, which often operated at about 40% capacity, did translate to a 5% decrease in Medicare spending, the tradeoff was a 5% increase in mortality in patients with time-sensitive health conditions such as stroke or myocardial infarction.[6]

Are Rural Docs an Overworked, Dying Breed?

Tom Dean is a family physician in Wessington Springs, South Dakota, population 1000, and part of a two-doctor group that employs several advanced practitioners. Dean says the common stereotype of the overworked, underpaid primary care physician, who is on call 24/7 and never sleeps, is not his experience on the ground. "The medical system has finally figured out the desperate need for primary care, and I'd say physician incomes have gone up substantially in the last 2 years. Opportunities for new graduates in family medicine have also increased. Our struggles more reflect the stresses of modern medicine, with its complications, difficulty, and loss of autonomy in medical practice," he says.

"I have practiced here for 40-plus years. Our local critical-access hospital is, for the most part, successful and financially stable. But what we do there has changed dramatically over the years I have practiced, with much less inpatient activity and majority of the income now coming from outpatient services, including physical therapy, infusion, the emergency room, and a whole variety of other services," he says.

A recent study published in South Dakota Medicine surveyed 300 graduates of a Midwest family medicine residency program to assess their rates of burnout.[7] A smaller percentage of family docs practicing in rural areas reported burnout: 25% compared with 37.5% of those practicing in medium-sized towns, and 51.4% of those in metropolitan areas. This statistically significant result suggests that a rural practice setting can have a positive effect on physician well-being, offering greater autonomy and perhaps better work-life balance.

How Are Rural Docs Adapting?

Providing New Services

Jason Lofton has been a solo family doctor with Lofton Family Clinic in De Queen, Arkansas, population 6500, for the past 12 years. The local De Queen Hospital, which lost its obstetric services around the time he arrived in town, was bought out by new owners 2 years ago. "For us, it's about adjusting to the ways medicine has changed," Lofton says. His practice includes a nurse and a care coordinator, and they are trying to implement new services. "My nurse is getting certified in wound care, and we're starting to change catheters. I'm taking classes in medical office emergencies. It has me thinking about Advanced Life Trauma Support certification," he reports.

"How can I extend my hours and be prepared for after-hours needs? I give my cell phone number to my patients, and they don't abuse it. I try to head off emergency visits, call them, tell them to come see me. If somebody walks in with a heart attack, we don't really have the necessary equipment, but I can use my AED (automated external defibrillator) until the ambulance arrives."

Sharing Care With the Hospital

Cullen in Alaska is one of six private family medicine physicians in his group. "We have an excellent relationship with our hospital at the moment, although it hasn't always been that way. We are both active partners in the care of the community. We need a place to practice, and we need their nurses. But it's a complicated relationship. In some respects we're a client, in others we're a collaborator, and in others a competitor. We're pretty enmeshed," he says.

"We could, as a private clinic, have our own ultrasound and lab diagnostics. We decided to let the hospital have that. Conversely, the hospital could have PAs or NPs cover the emergency department, but they wanted to make sure we have the shifts to support a robust medical practice. We've tried to figure out other shared models." One of the responsibilities of a rural hospital is having staff capable of responding to emergencies—heart attacks, strokes, gunshot wounds, he says.

Obstetrics or Not

Sometimes struggling hospitals opt to close their inpatient obstetric services because of low volume and high expenses. But when a hospital lets go of its obstetric services, that can be one of the steps in a downward spiral. "If you take away OB, you start losing everything else," Cullen contends. "Families won't be able to stay in town for their pregnancy. This adds to the flight of younger people out of the community, leaving an increasingly older population," he says.

If OB services closed in Valdez and people had to drive 300 miles to Anchorage, some wouldn't go. "We realized early on that even if we decided not to have obstetric services here, we'd still be doing obstetrics. So we decided to do it well."

Relying on Telemedicine

Dean, the family physician in South Dakota, says that telemedicine has helped his practice to survive. "It allows us to rely on advanced practitioners to run our ER, which helps with our biggest problem: that we can't get physicians to move here." The local hospital is part of the larger Avera Health, whose hub is in Sioux Falls. It is staffed with medical specialists, and the hospital in Dean's community, Weskota, is able to establish two-way video access with the push of a button.

"They are our back-ups and consultants, and they handle much of the administrative work, such as arranging transport. They can see our lab work and x-rays and cardiograms. In the middle of the night, our nurses in the hospital are not spending all of their time on the phone," Dean says. Instead, they are at the patient's bedside, talking with the remote consultant via the telemedicine video link.

Utilizing a Team

Duchicela points to "a policy that if you are our patient, you can just come in if you need to be seen" as one plank in his continued success. "We have developed a workflow method that intensively utilizes medical assistants."

Duchicela sees 50 to 60 patients in a typical day, taking advantage of his practice's large staff, who call patients into the office rooms, conduct histories and medical reconciliation, perform as medical scribes, and make follow-up phone calls.

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