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Annals of Emergency Medicine

Shuttered Rural Hospitals Strain Safety Net

In the wake of 75 rural hospital closures since 2010, what’s been the impact on emergency treatment? (2016)


By Charlotte Huff

After Cochise Regional Hospital in Douglas, AZ, closed down last summer, it didn’t take long for the emergency department (ED) to start filling up at the nearest hospital, some 25 miles away in the remote southeast corner of the state.

Copper Queen Community Hospital, which had been accustomed to treating 600 to 700 patients a month in its ED, saw its volume shoot much higher, to as many as 1,100 monthly during flu season, said James Dickson, MBA, chief executive officer of the 14-bed hospital in Bisbee, AZ. Moreover, the ambulances have to navigate the twists and turns of a 2-lane road through the Mule Mountains to reach Copper Queen, he said. “You can’t rip-roar in an ambulance at full speed.”

So early next year, Copper Queen plans to open a $5.5 million freestanding emergency facility in Douglas, one of a number of innovative efforts around the country to address widening gaps in access to rural emergency care.

By early June, 75 rural hospitals had closed their doors since January of 2010, according to the North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill. And that pace of closures, according to hospital performance research by iVantage Health Analytics, is anticipated to accelerate, with 673 more rural facilities classified as vulnerable to shutting down.

“When you look at polling and you look at community health needs assessments, it’s clear that one of the highest-value services a rural hospital provides is its emergency department,” said Brock Slabach, MPH, a senior vice president at the National Rural Health Association, noting that rural areas must cope with agricultural and other injuries along with the more typical heart problems and motor vehicle crashes.

Slabach is among those rural advocates, hospital leaders, and first responders who are trying to fill emergency care gaps with everything from community initiatives to legislative proposals. Some hospitals, such as Copper Queen in Bisbee, are establishing emergency facilities in nearby rural communities that have shuttered their hospital, a step that’s made feasible by billing under the home hospital’s license. Legislation and policy proposals also are trying to create an option for rural communities to open an independent, continuously open, freestanding, emergency facility that can bill Medicare and Medicaid without piggybacking on an existing hospital’s license.

In other cases, communities are beefing up the role of their ambulance services, such as using paramedics to help patients stay healthier at home and—it is hoped—reducing the number of medical crises. When city leaders in Independence, KS, realized that century-old Mercy Hospital was teetering on the brink of closure, they decided to upgrade their technology and approach. They expanded their fleet of city ambulances from 3 to 5 and added equipment, including telemetry, to relay heart rhythms to the physicians en route.

Particularly for time-sensitive medical crises, skipping the brief stop that was previously made at Mercy’s ED before proceeding onward likely has saved some lives, said David Cowan, public safety director for the community of nearly 10,000 residents.

“Going into this, I had no idea what to expect the outcomes would be, losing the local hospital,” he said. “I firmly believe our patients get better care now, especially our critically ill and sick people. People who may have not made it are now having great outcomes.”

Legislative Proposals

Rural hospitals around the country have encountered increasing financial strain, buffeted by a combination of cuts in public reimbursement and the “uneven adoption” of Medicaid expansion in the wake of the Patient Protection and Affordable Care Act, according to the analysis by iVantage, released earlier this year. Critical-access hospitals compose two thirds of rural facilities classified as vulnerable. Southern states are poised to be the hardest hit.

In Oklahoma, 3 rural hospitals had already closed by June of this year, according to Andy Fosmire, MS, vice president for rural health at the Oklahoma Hospital Association.

“There are 2 other [rural] hospitals in the state that we really don’t think are going to make it through the calendar year,” he said.

The Oklahoma Hospital Association is looking at ways to support keeping emergency care open by updating some state rules that already allow emergency-only facilities.

Retaining emergency services in a community after a rural hospital closes down, though, is complicated by the underlying finances, Slabach said. EDs are one of the more costly areas of a hospital to operate. Plus, in rural regions, they can expect a relatively low number of patients, given the less populated regions where they are based, he said.

“The combination of that makes solutions following closure rather dismal,” he said.

To retain a freestanding ED, there are primarily 2 options. The one most frequently used is to roll the new emergency facility under a nearby hospital’s license, essentially creating an outpatient hospital department that would allow billing for services, according to Slabach. That’s what Arizona’s Copper Queen is doing with its nearly 8,400-square-foot emergency facility now under construction.

Immediately after Cochise Regional’s closure, Copper Queen had opened up what Dickson describes as a quick care clinic with expanded hours care, including laboratory services. But the lack of an emergency facility meant loss of that service not only for that border town of Douglas but also a broader region extending east to the New Mexico line, Dickson said. (Cochise County, which includes both Bisbee and Douglas, is more than 6,000 square miles, roughly the area of Connecticut and Rhode Island combined.)

Rolling the new Douglas ED under Copper Queen’s license for billing purposes makes the new construction feasible, Dickson said.

“It’s doable. Will it decrease our bottom line? Absolutely. It’s a mission-driven thing, not a financially driven thing.”

However, Slabach said, “some communities don’t want to affiliate [with another hospital] until it’s way too late, and then nobody wants them.” Another option is for the community to open an independent emergency facility, but such facilities run into a billing hurdle. Because the Centers for Medicare & Medicaid Services doesn’t recognize those facilities as EDs, they generally can’t accept Medicaid or Medicare payments, according to the American College of Emergency Physicians (ACEP).

Several legislative and policy proposals are attempting to forge a more supportive financial framework. The Rural Emergency Acute Care Hospital Act, introduced in 2015, proposes giving critical-access hospitals and those with fewer than 50 beds the option to convert to a freestanding rural emergency hospital and be reimbursed by Medicare at 110% of reasonable costs. The hospital wouldn’t include any inpatient beds but could include some other outpatient services, such as skilled nursing, infusion services, and telemedicine.

ACEP wrote a letter in support of the legislation, Senate Bill 1648. “I think that [approach] would be very beneficial for those hospitals that are struggling to stay open,” said Hans House, MD, an ACEP board member. “You are maintaining that safety net through this process.”

Although the Rural Emergency Acute Care Hospital Act is a good start, the National Rural Health Association believes that its scope doesn’t go far enough, according to Slabach. The association backs legislation, also introduced in 2015, called the Save Rural Hospitals Act, which would create what it describes as a community outpatient hospital with the flexibility to add other vital community services, such as clinics and ambulatory surgery, he said.

The Medicare Payment Advisory Commission also has gotten involved, noting that the current payment models are built around maintaining inpatient beds even as the number of those patients has dwindled. The commission outlined 2 potential options for converting a critical-access hospital, with related reimbursement structures, in a June report to Congress. The first approach would allow critical-access hospitals to convert to a continuously open ED model. The second option, for communities too small to support such an ED, would involve turning the inpatient facility into an extended-hours primary care clinic with an attached ambulance service.

A few states hard hit by rural hospital closures, such as Georgia, have attempted another route, making changes to state regulations to allow the opening of independent emergency facilities. But that move doesn’t address the issue of receiving federal reimbursement.

Dr. House, with ACEP, also pointed out that some states like Georgia with a higher percentage of struggling rural facilities also opted not to expand Medicaid coverage under the Affordable Care Act.

“It’s very clear that the states that have expanded Medicaid, those are less likely to have problems with their critical-access hospitals,” he said. “Because those patients that do show up to the [ED]—they have some reimbursement, they have some source of funding and the hospital gets paid for their work.”

Community Innovation

Once leaders in Independence realized that they might have to cope without a local ED, they conducted an analysis of staff time and equipment with the help of outside consultants, according to Cowan. At that point, they were operating 2 fully equipped ambulances, with a third primarily used for patient transfers.

Typically, an ambulance would be tied up for 30 to 45 minutes before it would be available for another call. But city leaders knew that window could be easily doubled by additional travel to another hospital if Mercy closed.

The city ended up spending nearly $400,000 for 2 more ambulances and the equipment to ensure that all 5 were transformed into what Cowan dubbed a medical “hot spot,” self-sufficient without pulling equipment from another ambulance. Routine equipment includes intravenous pumps, ventilators, handheld Doppler devices, telemetry monitoring, and even the capability to have video consultations with physicians on their way to that hospital.

Before Mercy’s closure, the ambulances carried ECG equipment on board. But the ambulance would still make a stop at Mercy for the physician’s evaluation before driving to a larger hospital with a catheterization laboratory.

“Now we pass that middle step,” he said.

In other rural communities, first responders have been implementing an approach called community paramedicine, including home visits and closer monitoring after hospital discharge, in the hope of easing the pressure on the local ED. Since 2007, Mike Wilcox, MD, has been training paramedics in some of the most rural areas of Minnesota. His first class of graduates numbered 8, and now the state has more than 200 trained community paramedics statewide, he said.

Each rural area with community paramedicine will adopt a somewhat different approach, depending on their region’s needs, said Dr. Wilcox, a family practice physician. Some of the services they provide might include medication reconciliation, addressing nutritional needs, and checking home safety issues.

“One of the hopes we have is that it will prevent the need for bounce-backs in the emergency department for patients in crisis,” said Dr. Wilcox, who is in the process of compiling data.

Dr. House, who practices at the University of Iowa, said community paramedicine holds potential to prevent lower-level crises in rural areas. Another strategy that’s proven to be helpful, one that’s used in rural parts of Iowa, is telemedicine. A significant portion of the EDs in rural Iowa hospitals are staffed only by nurse practitioners or physician assistants, he said. So when they encounter a medical situation beyond their capabilities, they can consult by video connection with a physician in a larger city.

But ultimately none of these supportive measures replace the loss of a community’s ED, Dr. House stressed. In southeast Arizona, Dickson looks forward to filling one of those fissures in the rural landscape within the next several months. The new facility in Douglas will also include a helipad for patients who need to be flown straight to Tucson.

“We are not aware of any incident that has occurred where patients have been harmed during this transition,” Dickson said in early summer. “And when we put the emergency department in, there will be none.”