Richard Columbo is grateful that he only has to push a couple of miles to receive chemotherapy. UCHealth and Mt. San Rafael Clinic in Trinidad have teamed up to deliver treatment nearer to residence for patients in southern Colorado who need to have chemotherapy. Pictures: UCHealth.
The way Richard Columbo describes his journey with esophageal most cancers borrows from a popular tune by the Beatles.
“It’s been a extensive and winding road,’’ claims Columbo, an artist who life in Trinidad, Colorado, with his spouse, Debi Hoyle.
In the months since he discovered in May possibly 2020 that he had esophageal most cancers, Columbo has had a whirlwind of doctor’s appointments in Arizona, the place he lived aspect of the 12 months, and Colorado. Fortuitously, the street to his chemotherapy therapies is now only about 1.5 miles.
Access to cancer procedure in rural southern Colorado
In the springtime, UCHealth Memorial Medical center Central and Mt. San Rafael Hospital in Trinidad teamed up to give chemotherapy treatment method in Trinidad, removing a 129-mile, a person-way drive to Colorado Springs. UCHealth prepares chemotherapy in Colorado Springs, couriers the medicine to Trinidad, exactly where nurses at Mt. San Rafael infuse the treatment.
When Columbo comes at the Trinidad clinic, a staff members member opens the doorway for him and announces: “Here’s our VIP.’’
Dr. Robert Hoyer
Columbo appreciates the 5-star treatment. He’s expended a life time teaching artwork – drawing, painting and sculpting – to youngsters and university learners since he believes it’s critical to produce the creative mind. When he lived in California, Columbo worked with the Children’s Museum of San Diego to present a system titled: Option Components in Artwork. He taught kids how to turn recyclables into eye-catching art parts.
Columbo is happy of his get the job done, and he recognizes when individuals are excellent at that craft, even if it unfolds in a clinical environment.
“Our people today at this hospital have been incredible, so caring,’’ Columbo states.
The collaboration between the two hospitals started in the springtime. Dr. Robert Hoyer, an oncologist at UCHealth’s Most cancers Middle in Colorado Springs, goes to Trinidad two times a thirty day period and sees individuals from Trinidad, Walsenburg, the San Luis Valley and Raton, N.M. Hoyer also visits Lamar five occasions a thirty day period, caring for sufferers from the Arkansas Valley and western Kansas. The outreach, which contains quite a few specialties in Lamar, is part of UCHealth’s exertion to improve accessibility to health care for sufferers in rural Colorado.
“It’s the ideal issue for individuals,’’ Hoyer explained. “I really consider it is a exclusive detail.’’
Most cancers treatment shut to house lessens the burden of travel
Hoyer claimed that people coming from Trinidad to Colorado Springs for care could commit two to 3 hours driving one way, for a take a look at that could final 30 minutes.
A lifelong artist, Richard Columbo demonstrates some of his work. Columbo has esophageal cancer and does not have to push two hrs to Colorado Springs for chemotherapy treatment options.
“The time and cost genuinely add up quickly, and if a affected individual is not feeling properly right after a take a look at, to be in a vehicle for 2-3 several hours on the way home, from a quality-of-daily life standpoint, it can make a ton of perception to carry the clinic and the medicine to them,’’ Hoyer said.
Some regimens for chemotherapy can very last from two to 6 hours, and some of the regimens are Working day 1, Day 2 and Working day 3. You can see how this can rapidly include up,’’ Hoyer explained.
In his travels to Trinidad and Lamar, Hoyer has witnessed the problems for individuals in rural communities to obtain care.
“There is a enormous require throughout the state of Colorado and carrying out these outreach clinics has really opened my eyes to the scenario of rural drugs in our nation and our condition,’’ he explained. “There are pretty several most important treatment physicians in communities, so it is a really great matter for clients to have that access and to strengthen that obtain.
“When people can get the the vast majority of their treatment close to household it can help to increase high-quality of lifetime for the patient and for their families as effectively. They never have to consider extra time off do the job, they have extra time with loved ones, and less driving.’’
Most cancers prognosis when you live in a rural space
Columbo’s most cancers journey commenced with bouts of consuming problems. He’d swallow food stuff, but it would arrive appropriate back again up. Imaging showed he experienced a tumor at the junction of his esophagus and stomach. He has sought treatment method in Colorado and Arizona, and has integrated acupuncture, Chinese teas, and other substitute medications into his treatment. More than time, he’s shed about 50 pounds.
He has done five of seven classes of chemotherapy at the Trinidad medical center to stem the Phase IV cancer, which has unfold to his liver.
As Richard Columbo says, his journey with most cancers has been “a extended and winding street.’’ He is seated with his wife, Debi Hoyle.
“It normally takes me down,’’ he suggests of chemotherapy cure.
Hoyle is grateful for the care her spouse gets at their community medical center.
“They put him in a mattress they give him ease and comfort. They look at him like a hawk, no matter whether it is a transfusion or chemo, they’re viewing him regularly,’’ Hoyle claimed.
Joe Vigil, a nurse at Mt. San Rafael who takes care of people, explained it is been a gift to present the remedies in Trinidad.
“It’s been actually great for the sufferers to be equipped to receive chemotherapy and immunotherapy, and to get to know them on a own foundation. We get to know their spouse and children and their tales, and they get to know ours,’’ Vigil claimed.
The infusion middle is in a newly transformed element of the medical center.
Bruce Livingston. Image: UCHealth
For Bruce Livingston, a resident of Trinidad, getting chemotherapy at San Rafael Healthcare facility, is a gift of benefit. Livingston has pancreatic most cancers and gets chemotherapy 2 times a week.
“Are you kidding me? It is key. I go from my home to San Rafael Hospital, it probably normally takes me 7 minutes,’’ Livingston stated. “And they have anything ready, it’s been requested from the doctors. They truly hold an eye on my platelet rely. It’s got to be above 100 ahead of they’ll do infusion.’’
Not obtaining to make the long travel to Colorado Springs makes his everyday living simpler.
“Chemo hits kind of difficult,’’ he explained.
Developing group in rural counties
Casey Peat, a nurse supervisor in the infusion unit at UCHealth Memorial Hospital Central, explained the collaboration amongst Mt. San Rafael and UCHealth has helped to develop group.
“This is bringing a service to that community that wasn’t there prior to,’’ Peat stated. “Patients really do not have to drive so considerably away to get providers, and the nurses at San Rafael have the aid of excellence. We are obtainable to them. If it is a new medication, or they require some aid or have questions, they can access out to us for that assist.
“We are also satisfied to make the trip there to be there in particular person. General, we’re aiding people today and we’re supporting in developing nursing, what they can do. It’s a terrific partnership that we have with them,’’ she said.
For sufferers like Columbo, it would make the long and winding street a tiny additional pleasant.
But while the money helped slow the pace of rural hospital closures and enabled these facilities to care for critically ill patients during COVID-19 surges, it did little to address the financial crises facing them before the pandemic. The temporary federal funding may in fact make many rural hospitals appear more financially stable than they really are, according to four different analyses of rural hospital finance data.
While the exact numbers differ, the latter three studies estimate that hundreds of rural hospitals nationwide could be at risk of closure once the federal dollars stop flowing and hospital balance sheets return to normal.
What solutions exist?
Some of the most common policy proposals offered to stem the tide of closures include expanding Medicaid, so hospitals care for fewer people without insurance, and eliminating Medicare sequestration — a payment policy whereby the federal government reimburses facilities either 98 or 99 percent of the actual cost of care, rather than the full 100 percent.
Many rural hospitals see more uninsured patients, more patients who are covered by Medicare or Medicaid, and fewer private insurance patients than urban hospitals do. Any changes to those federal programs can have a disproportionate impact on rural hospitals’ ability to stay financially afloat.
“There is a lot of evidence about if you’ve expanded Medicaid, that it becomes a bigger source of revenue for these hospitals and helps sustain them,” said Julia Harris, a policy analyst at the Bipartisan Policy Center and co-author of the organization’s analysis about how the pandemic impacted rural hospitals.
“We’ve heard that from states that had expanded and had a lot of hospitals in trouble before,” she said. “They really felt that [Medicaid expansion] was a way that got a lot of their rural small hospital sites out of trouble.”
Brock Slabach, the director of the National Rural Health Association, worked for 20 years as the CEO of a rural Mississippi hospital. He estimated that between 13 and 15 percent of the people at his hospital had private insurance plans, meaning the other 85 percent had either Medicare, Medicaid, or no other payer but themselves.
“In my facility, 65 percent of my business was due to one payer and that’s Medicare,” Slabach said. In 2013, because members of Congress couldn’t agree on the budget, the federal government implemented automatic cuts to Medicare reimbursements through a policy called sequestration. The cuts have never been permanently resolved.
“Any impact that decreases my payment from that source inhibits my ability to maintain solvency as a hospital. So, when you look at sequestration, that’s the prime example.”
The role of Medicare Advantage plans
But, some experts disagree on the level of impact these changes could really have.
Harold Miller, the director of the Center for Healthcare Quality and Payment Reform and a professor of public policy at Carnegie Mellon, argues that while expanding Medicaid and eliminating sequestration would both be good policy changes for rural hospitals, neither would generate enough new funding to impact a facility’s bottom line.
“The people who are newly getting Medicaid are only a very small proportion of the thing that’s causing the hospital the loss,” Miller said. “That’s not the problem. The problem is [rural hospitals] actually in many cases are losing money on their privately insured patients.”
Miller’s data show the situation in North Carolina is slightly more complicated than the nationwide trend. It is one of two states where small rural hospitals — meaning facilities with less than $30 million in annual expenses — did not see a decline in payments from private insurers between 2019 and 2020.
Nationally, though, Miller said small rural hospitals lose money caring for people with private insurance. This includes people who have Medicare Advantage plans.
“Medicare Advantage started many, many years ago because of the notion that private health plans could do a better job of managing people’s health care than the government could,” Miller explained. “A Medicare Advantage plan is required to cover everything that traditional Medicare covers but it has the ability to charge different cost sharing amounts. It has the ability to have networks. It has the ability to do prior authorization.”
A chart from the researchers at the Center for Healthcare Quality and Payment Reform shows the change in margins between the two years calculated. They found that in every state except North Carolina and Pennsylvania small rural hospitals lost more money caring for patients with private health insurance plans between 2019 and 2020. Their analysis includes Medicare Advantage plans. Credit: Center for Healthcare Quality and Payment Reform.
In other words, it looks and acts more like a private health insurance plan than traditional Medicare does.
Traditional Medicare covers 80 percent of costs for most services, potentially leaving a consumer on the hook for 20 percent. That 20 percent gets more expensive as people age and have more health problems. One way people on Medicare get around that cost is by purchasing a supplemental plan, which will cover the 20 percent. The supplemental plan comes with a monthly premium.
For seniors who don’t have any medical problems, any additional monthly cost can seem like an unnecessary expense, Miller explained. Instead, many will opt for Medicare Advantage plans that often don’t have any premium. But his analysis shows that in many states these plans — along with regular private insurance plans — don’t pay small rural hospitals enough to break even.
An analysis by the Center for Healthcare Quality and Payment Reform shows that during the pandemic small rural hospitals lost more money caring for patients who had private insurance plans — including Medicare Advantage plans – than they did prior to the pandemic. Credit: Center for Healthcare Quality and Payment Reform.
“One of the concerns that I have personally about small rural hospitals is that people in their communities may increasingly be signing up for Medicare Advantage plans because they think they’re paying less for that and not realizing that they’re putting their hospital out of business,” he said.
Miller argues that in order to keep rural hospitals financially afloat, Medicare Advantage plans must be required to pay these facilities at higher rates.
“It would be terrific to assume that we could require Medicare Advantage plans to pay providers more,” said Slabach, from the National Rural Health Association.
“But that’s a really complicated set of arrangements,” he said. “Congress could say that Medicare Advantage plans have to pay rural providers more. But I guess I’m not really sure if the government would ever do that because that implies that at some point, the government is going to have to pay more because eventually that’s where the money comes from.”
A new payment model
Even though the funds paid by private plans to rural hospitals look better on average in North Carolina than in the rest of the country, Miller argues that the financial systems supporting rural hospitals are so dysfunctional that they need to be fundamentally reimagined.
In his organization’s analysis, they propose a payment structure whereby rural hospitals would receive a fixed payment that would be used to keep critical services up and running, such as the emergency room or a maternity ward, regardless of how much those facilities are used. In addition, as they do now, hospitals would receive regular reimbursements from insurers for the care they provide to people.
“Emergencies vary from year to year: you have a COVID outbreak, you have a natural disaster, a hurricane, you have whatever. All of a sudden, a lot of people need the emergency room and it needs to be there,” Miller said. “In the years when you don’t have those disasters, it may not get enough revenue to cover its costs,” but still it needs to stay open.
Some say Miller’s model is similar to the new federally designated Rural Emergency Hospital policy, but he says it’s not quite the same. Under the proposal, Rural Emergency Hospitals would receive a fixed amount of funding to stay open and operate their emergency services, but they wouldn’t provide in-patient care, which Miller — and many others — feel are necessary services for community hospitals to offer.
Federal regulators are still working on rules and guidance that would govern Rural Emergency Hospital policy, which goes into effect in 2023.
Whatever you call it, said Mark Holmes, the director of the Sheps Center at UNC, a sustainable payment model for rural facilities will probably look something both like Miller’s proposal and the new Rural Emergency Hospital, with “some chunk of money paying for fixed costs and some chunk of money paying for variable costs.”
While it’s clear that a different payment model is needed, it’s not clear who will be responsible for coming up with the difference.
“Is it Medicare’s responsibility to underwrite the viability of a rural hospital or is it a shared responsibility?” Holmes asked. “Is that the state’s responsibility? A county’s responsibility?”
“At the end of the day, most of the challenges of rural health care come down to volume,” Holmes said, “That’s the cause of many of the ills.” The price that Medicare pays hospitals for services was designed for large urban facilities that see a constant churn of patients, Holmes explained. That’s a payment model that does not work for rural community hospitals that see far fewer people.
Slabach agreed.
“The real problem is volume. And when you have low volumes, it’s hard for any of these programs to cover the overhead that’s required,” he said. “If it were easy to solve, we would have probably solved it long ago.”
Correction: The caption of the first chart previously stated that small rural hospitals lost money caring for patients with private health insurance plans between 2019 and 2020. It has been updated to reflect that the chart shows the change in margin between those two years.
The caption on the second chart previously stated small rural hospitals lost more money caring for patients who had private insurance plans than they did caring for those on Medicare and Medicaid. Small rural hospitals lost more money caring for patients who had private insurance plans than they did prior to the pandemic.
Republish our articles for free, online or in print, under a Creative Commons license.
X
Republish this article
As of late 2019, we’re changing our policy about reprinting our content.
You are free to use NC Health News content under the following conditions:
You can copy and paste this html tracking code into articles of ours that you use, this little snippet of code allows us to track how many people read our story.
Please do not reprint our stories without our bylines, and please include a live link to NC Health News under the byline, like this:
By Jane Doe
North Carolina Health News
Finally, at the bottom of the story (whether web or print), please include the text:
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org. (on the web, this can be hyperlinked)
by Clarissa Donnelly-DeRoven, North Carolina Health News May 17, 2022
About 40 percent of rural hospitals are losing money on their obstetrics programs, but many continue to provide the service because of its importance for community health, a new study shows.
Losing childbirth services can also be a harbinger of hard times for a rural hospital, oftentimes serving as a precursor to closure.
In large part, researcher Julia Interrante said, rural hospitals that close their obstetrics units are more likely to close their doors for good.
“Usually the obstetrics unit will close, and then other services will start to close before the entire hospital closes,” she said. “It’s not always the case – sometimes we see things where hospitals will enter into mergers or move those services to another hospital location… But often when they end up closing OB services, then it usually kind of leads toward the hospital closing.”
A survey of obstetric unit managers or administrators at nearly 300 rural hospitals found that whether the program was in the black wasn’t as important to these leaders as how much the community needed it.
Hospitals reported they needed 200 births per year to maintain safety standards and to remain financially viable. More than 40 percent said they had fewer births than needed to sustain operations financially.
“I think that’s really striking,” Interrante said. “But so many of them also reported understanding the need and importance of having those services in rural communities, because people are still giving birth, and they have to have somewhere to go.”
The survey respondents said it was important to keep the obstetrics units open because of the complications patients could encounter if they had to drive long distances to give birth.
About two-thirds of survey respondents said meeting their community’s needs was the most important factor in keeping their obstetrics units open, even if there weren’t enough births in the area to warrant it financially. Only 16.5 percent said their top priority in making that decision was the financial aspect. Nearly 13 percent said their top priority was staffing.
Nationally, birth rates have been falling since 2008, according to the U.S. Census Bureau. Birth rates tend to be higher in rural areas, around 1,900 births per every 1,000 women, compared to 1,600 births for 1,000 women in urban areas. However, because there are fewer women of child-bearing age in rural areas, hospitals tend to see fewer births per year.
“Many hospital administrators in rural communities care deeply about the health of pregnant rural residents,” Katy Backes Kozhimannil, director of the Rural Health Research Center and lead author of the study, said. “Rural hospital administrators prioritized local community needs over finances and staffing, keeping obstetric units open because local pregnant patients need care. Policy investments are needed to help rural hospitals and communities support safe, healthy pregnancies and births.”
Interrante said insurance reimbursement is one issue rural hospitals face in keeping the obstetrics units open. Rural areas tend to have more patients on Medicaid, she said, which only reimburses a percentage of what it costs hospitals to provide those services. According to the CDC, half of the women who give birth in rural areas are on Medicaid, compared to 41.9 percent in urban areas.
Medicaid’s role in financing maternity care: Number and share of births, by payer source, rural vs. urban 2018. Table source: MACPAC; Data source: CDC
More than a quarter of those responding to the survey said they were not sure if they would continue providing obstetrics. Or they said they expected to stop offering the service, indicating a continued downward trend in health care access, researchers said.
“The responses from the rural hospital administrators strongly highlight the fact that they provide obstetric services because they are so necessary and important for the health of rural communities they serve,” Bridget Basile Ibrahim, a co-author of the study, said. “For many of the patients who give birth at these hospitals, it would be a huge burden for them to travel to the next nearest hospital to give birth.”
Researchers concluded that any policies to improve rural obstetrics care should take into account community needs, clinical safety, and rural hospital finances. How low-volume, rural hospitals are reimbursed should be investigated to ensure those hospitals’ financial viability, they said.
Republish our articles for free, online or in print, under a Creative Commons license.
X
Republish this article
As of late 2019, we’re changing our policy about reprinting our content.
You are free to use NC Health News content under the following conditions:
You can copy and paste this html tracking code into articles of ours that you use, this little snippet of code allows us to track how many people read our story.
Please do not reprint our stories without our bylines, and please include a live link to NC Health News under the byline, like this:
By Jane Doe
North Carolina Health News
Finally, at the bottom of the story (whether web or print), please include the text:
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org. (on the web, this can be hyperlinked)
by Daily Yonder, North Carolina Health News April 22, 2022
In the past decade, rural hospitals that shuttered tended to be in rural counties with lower incomes, higher levels of unemployment, and higher proportions of Black and Latino residents. That finding comes from a recent study conducted by researchers at the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill. The 141 rural hospitals that closed nationwide between 2010 and 2020 were also often located in counties adjacent to metropolitan areas.
Federal hospital finance data show that the rural hospitals in North Carolina that had the weakest financial outlook in 2019 — the most recent year for which data are available — are in counties that share many of the characteristics of the communities that suffered closures in the last decade, according to an analysis by NC Health News.
The numbers come from before the pandemic, which turned health care on its head. But even as COVID-19 strained rural hospitals, the federal government pushed out millions of dollars to help keep them afloat to care for affected patients.
Under these abnormal circumstances, the financial status of these hospitals could be even more uncertain.
“It won’t show what happened in 2021 for most hospitals until early 2023,” said Harold Miller, the president and CEO of the CHQPR, which created the database. The organization is a national policy center that advocates for improvements to the delivery and payment models used in health care.
“The data come from the hospitals themselves — they fill out the cost reports — so they can’t be totally unfamiliar with it, but they may not have made the same calculations using the data that we have,” Miller said.
What do these numbers mean?
The hospitals that might be in the riskiest financial position are those with negative net assets and negative margins, Miller explained. This means, essentially, their bills and their debt are higher than the amount they bring in. To think of it in terms of personal finance, Miller said, imagine net assets to be your savings minus your debt.
“You can have more debt than you have savings, but at some point, the debt has to be paid off,” he said. “If you don’t have enough money to do that, you’ll be bankrupt.”
In order to analyze a hospital’s net assets, CHQPR adds up all of a hospital’s sources of income — bank accounts, investments, accounts receivable — but excludes the value of the hospital’s actual building, equipment and land.
“Many hospitals will show positive net assets because of the asset value assigned to the hospital building itself,” Miller explained. “The only way the hospital could use that asset to pay staff or loans would be to sell the hospital building, which would mean it would no longer be a hospital.”
A hospital’s margins refer to their profit — or lack thereof. If a hospital makes more money than it spends, it has a positive margin. If it spends more than it makes, it has a negative margin.
For a lay person, he says, it’s the equivalent of expenses being higher than earnings.
“If you’re not earning enough to pay your bills, you’re in trouble. If you have savings, you can withdraw some of that money to cover the extra expenses, but if you have to keep doing that, at some point, the savings will run out, and then you won’t be able to pay the bills.”
Though CHQPR analyzes the hospital finance data, the organization itself does not label specific hospitals as “safe” or “at-risk.” Miller explained that the hospital could have a recovery plan in place, which the database wouldn’t reflect. On the other hand, a hospital could be at-risk but the data released by CMS could be too old to show it.
Which hospitals might be in trouble?
According to the calculations made by CHQPR, six rural North Carolina hospitals had both negative net assets and negative margins — meaning, essentially, that they’re spending more money than they’re bringing in — in late 2019, or early 2020.
Those hospitals were Washington Regional Medical Center, Swain County Hospital, Person Memorial Hospital, Granville Medical Center, Bladen County Hospital, and Charles Cannon Memorial Hospital in Avery County.
The data collected and analyzed by the CHQPR shows these six rural hospitals had negative net assets and negative margins according to fiscal data from either late 2019, or early 2020.
Frank Avignone, the CEO of Affinity Health Partners which owns Washington County Hospital, said the data are “very old” and do not reflect the hospital’s current financial status. Avignone said he would speak to NC Health News about the hospital’s status only with his attorney present, and didn’t respond to follow-up requests for an interview.
Swain County Hospital and Person Memorial are both owned by Duke LifePoint.
“Both hospitals play critical roles in supporting an important regional network of local care through relationships with peer facilities,” said Michelle Augusty, the senior VP of communications at Duke LifePoint. “These hospitals are also part of a strong national healthcare system in LifePoint Health that is committed to their longevity and understands the critical role both Person and Swain play in our communities.”
Granville Medical Center is owned by that county. Alfred Leach, a spokesperson for Granville Health Systems, said that the hospital is “in solid financial operation.” Notably, in the most recent state budget, the hospital was awarded $10 million to improve its infrastructure.
The vice president of marketing and communications at Bladen County Hospital, Chaka Jordan, said the hospital has reported a profit for the last two fiscal years and is not in danger of closing. She said the hospital reported a loss in 2019/20 after experiencing “catastrophic damage from Hurricane Florence,” which could explain why the data show the hospital operating at a loss.
“Also, the Bladen County Hospital is part of the larger Cape Fear Valley Health System, which includes eight hospitals in the region. Discussing any individual hospitals’ financial statistics in this context gives an incomplete picture of the health system as a whole,” she said.
Cannon Memorial is owned and operated by Appalachian Regional Healthcare System. Officials at the hospital did not respond to requests for comment.
What are the demographic characteristics of the communities these hospitals are in?
Using data from the U.S. Census, the North Carolina Rural Center, and the Health Policy Institute at Georgetown University, NC Health News found that the counties with the most financially troubled hospitals all share some of the same characteristics — proximity to a metro area, higher population of residents of color compared to the median for rural areas, low incomes, etc. — that researchers at the Sheps Center found among rural communities that suffered a hospital closure in the last decade.
A fact sheet put together by the NC Rural Center reported that the 2019 racial and ethnic makeup of rural North Carolina was 67 percent white, 19 percent Black, 8 percent Latino, and 2 percent Indigenous, while the median household income was about $50,000.
Just one of the six hospitals — Washington County Hospital — isn’t in a county that’s adjacent to a metro area. But, nearly 50 percent of Washington County residents are Black and nearly 50 percent of households live on less than $35,000 a year.
Avery County, where Cannon Memorial Hospital sits, is whiter than the average rural N.C. county, but nearly 45 percent of households make less than $35,000, the kind of reality that can result in trouble for a rural hospital. Bladen County is 32 percent Black with nearly 50 percent of households making less than $35,000. In Granville County, about 30 percent of residents are Black, 10 percent are Latino, and around 30 percent of the population reports a household income under $35,000.
Similar income levels are seen in Person County, where about 36 percent of households make less than $35,000 in yearly income and about a quarter of residents are Black. There are fewer Black and Latino people in Swain County than in the average rural North Carolina county, but as the center of the Cherokee Nation in North Carolina, nearly 30 percent of county residents are Indigenous. About 44 percent of households report making less than $35,000.
While it wasn’t included as an analytical point in the Sheps Center study, two-thirds of these hospitals sit in counties where the uninsured rate — particularly the uninsured rate among non-elderly workers — is much higher than the average rate among rural North Carolina counties. The Rural Center reported that about 460,000 non-elderly rural North Carolinians are uninsured, about 11 percent of the state’s 4 million rural residents.
In Avery County, the uninsured rate for non-elderly workers is 27 percent — the highest of any county in the state. In Bladen County, it’s 18 percent. In Swain County, it’s almost 23 percent. And in Washington County, it’s nearly 20 percent.
The Sheps study did find that many of the most recent rural hospital closures happened in southern states, particularly in those that did not expand Medicaid, such as North Carolina.
Advocates and researchers have long argued that non-expansion can contribute to rural hospital closures because it leads to higher rates of uninsured people in the community, compared to expansion states. When people don’t have insurance, a hospital will still care for them, but they are unlikely to get reimbursed for that care, which can hurt their margins.
What meaning should be made out of these shared characteristics?
“I would not call [these findings] a coincidence,” said Arrianna Planey, a co-author of the Sheps Center study and assistant professor at the UNC Gillings School of Public Health.
The patterns the authors found fit well within existing research about what access to health care looks like for low-income people and people of color in other areas across the country, she said.
Washington Regional Medical Center in 2005. Photo source: Washington County tax records.
“It’s fair to suggest that rural providers — rural hospitals — have been facing generations of payment disparities,” said Brock Slabach, the COO at the National Rural Health Association. “These inequities between rural and urban providers have been systemic over time, and they have created the forces that are putting tremendous pressures on rural hospitals to be able to satisfy their requirements in serving their communities.”
Some of the racial patterns in the data, though, are seen in both urban and rural environments.
“In urban service areas, we can observe hospitals pulling away from neighborhoods with high shares of Black and Latinx residents,” Planey said. “Or, if they are in those neighborhoods, they engage in what is called medical gentrification.”
She defined medical gentrification as the process by which hospital expansion — both for medical and retail services — pushes long-term residents out of the area, especially residents of color.
“The research on the health impacts of rural hospital closures has largely focused on mortality,” Planey said. Most of that research has not found that rural hospital closures lead to higher rates of mortality, she said, but has instead found evidence that hospital closures disrupt access to care for some patients more than others, namely those who are pregnant, Latino, and people on Medicaid and Medicare.
Granville Medical Center in Oxford. Photo credit: Taylor Sisk
One theory the researchers have for why rural hospitals near metro centers are closing more than rural hospitals that are farther out is that they must compete with the facilities in the nearby metro areas — facilities that are often better-resourced.
“Rural hospitals generally have fewer days cash on hand, less capital, and more uncompensated care,” Planey said. Uncompensated care refers to services the hospital provides to uninsured people who can’t pay and to care provided to people who have Medicare and Medicaid, which generally reimburse hospitals at lower rates than private insurance.
“They are less likely to have dedicated personnel for grant-writing — and this is in contrast with larger academic medical centers who register each facility as a separate hospital and were thus able to secure grants for each facility within their system,” she said.
Cannon Memorial Hospital in Linville. Courtesy of Appalachian Regional Healthcare
As a first step, Planey said, the U.S. needs to think about how to allocate resources to rural hospitals in a way that is “less burdensome.”
One piece of federal legislation sitting in the U.S. Senate could start that process, according to Slabach: the Save Rural Hospitals Act of 2021. Two provisions in the bill could dramatically improve the finances of rural hospitals. Both deal with Medicare.
One portion would increase the amount hospitals receive to care for people on Medicare, and another would enable hospitals to collect 100 percent of a debt that wasn’t paid by a patient on Medicare. Right now, they can only get reimbursed for 65 percent of the cost of the bill.
“Rural populations are subjected to other disparities — they’re older, poorer and sicker generally. And these contribute to the issues that the UNC study pointed out,” Slabach said. “This all combines to make a pretty toxic mix, in terms of the ability for rural hospitals to be able to serve their communities.”
More than anything, Planey said, “We need to prioritize equity as an outcome.”
Republish our articles for free, online or in print, under a Creative Commons license.
X
Republish this article
As of late 2019, we’re changing our policy about reprinting our content.
You are free to use NC Health News content under the following conditions:
You can copy and paste this html tracking code into articles of ours that you use, this little snippet of code allows us to track how many people read our story.
Please do not reprint our stories without our bylines, and please include a live link to NC Health News under the byline, like this:
By Jane Doe
North Carolina Health News
Finally, at the bottom of the story (whether web or print), please include the text:
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org. (on the web, this can be hyperlinked)
by Clarissa Donnelly-DeRoven, North Carolina Health News March 30, 2022
Jan. 27, 2022 — SAN FRANCISCO and SIOUX FALLS, S.D. — KFF is expanding its KHN (Kaiser Wellbeing Information) operation by creating a rural overall health reporting desk supported by a $3.9 million grant from The Leona M. and Harry B. Helmsley Charitable Belief.
KFF will increase KHN’s editorial team and build a workforce of journalists and social media professionals in the states of Iowa, Minnesota, Montana, Nebraska, Nevada, North Dakota, South Dakota, and Wyoming. Whole-time reporters and freelancers from these states and KHN’s nationwide newsroom will produce and distribute explanatory, business, and investigative stories on well being treatment challenges applicable to rural communities.
The group of journalists will deliver unbiased, precise, and trustworthy reporting on a huge variety of elaborate issues, which includes the ongoing pandemic, access to well being protection and treatment, the stress of health and fitness treatment prices on shoppers, housing and schooling, the opioid epidemic, mental wellness, medical center closures, the lack of crucial lifesaving tools, and burgeoning improvements in telehealth and medication. KHN will lover with neighborhood media in the course of the region to generate deeply sourced tales that shed light on underreported concerns.
As with all its journalism, KHN stories produced by the Rural Well being Desk will be made freely accessible for publication by media outlets across the country, released on khn.org and dispersed by way of KHN’s social media platforms.
“Rural America’s small populace density gives sizeable challenges in the supply of wellbeing care providers, nonetheless at the identical time devoted providers are providing major-notch treatment via progressive methods, like state-of-the-art telemedicine,” explained Walter Panzirer, a Trustee for the Helmsley Charitable Have faith in. “KHN’s new rural health and fitness reporting desk will dive deep into these issues and spotlight initiatives that guarantee a person’s ZIP code doesn’t establish their health care results.”
“Rural wellbeing demands much more focus, and with this grant we can deliver that,” claimed KFF President and CEO Drew Altman, who is also KHN’s founding publisher. “We are thrilled to develop our work in this crucial spot, and we are grateful for the help of the Helmsley Charitable Belief.”
The institution of the Rural Health Desk follows information past summertime that KHN is opening an Atlanta-dependent Southern Bureau to deliver extra journalism centered on wellbeing, race, fairness, and poverty in the region. KHN also operates regional bureaus in California, the Midwest, and the Mountain States.
Media corporations fascinated in functioning with KHN should really make contact with us at [email protected] and individuals fascinated in becoming a member of our initiatives to increase and make improvements to health journalism in rural The us and further than should really make contact with KFF at [email protected]. Employment opportunities for the Rural Health Desk will be posted quickly listed here.
About KFF and KHN
KHN (Kaiser Wellbeing Information) is a countrywide newsroom that creates in-depth journalism about well being concerns. Alongside one another with Policy Assessment and Polling, KHN is just one of the a few major operating courses at KFF (Kaiser Relatives Foundation). KFF is an endowed nonprofit firm offering information on wellbeing troubles to the country.
About the Helmsley Charitable Have faith in
The Leona M. and Harry B. Helmsley Charitable Have faith in aspires to improve lives by supporting remarkable endeavours in the U.S. and all over the planet in health and fitness and choose spot-based initiatives. Given that beginning active grantmaking in 2008, Helmsley has fully commited a lot more than $3 billion for a large selection of charitable uses. Helmsley’s Rural Health care Application resources ground breaking jobs that use info technologies to join rural patients to crisis health care care, provide the most recent medical therapies to patients in distant spots, and give point out-of-the-art training for rural hospitals and EMS staff. To date, this application has awarded additional than $500 million to organizations and initiatives in the states of North Dakota, South Dakota, Nebraska, Wyoming, Minnesota, Iowa, Montana, and Nevada. For a lot more information and facts, take a look at below.
The answer they found was a resounding yes. In the year before their closure, most of the now-closed rural hospitals nationwide had low cash on hand, negative operating margins, and negative total margins, compared to rural hospitals that stayed open.
George Pink, one of the authors, says the study is the first he’s seen to analyze a hospital’s finances in the immediate years before its closure.
“We just wanted to get a handle on the hospitals that did close, compared to hospitals that did not close,” he said. “How were they different?”
Of the 56 hospitals that closed, 47 had less than a month’s cash on hand in the year before it closed. “Cash on hand” is a critical financial indicator that measures how many days a hospital could pay for its operating expenses with the money it has immediately available. Having little or no cash on hand indicates that an organization can’t really absorb some unexpected financial shock, in the case of a hospital that could be a surge of patients or an essential repair.
The other two measures — operating margin and total margin — can be a bit more complicated.
“When we talk sources of revenue to hospitals, we generally talk about two pots of money: operating revenue and non-operating revenue,” Pink said. “Operating revenue is revenue received for patient care — inpatient, outpatient, whatever the source. Whatever payers give you for patient care, that is called operating revenue.
Researchers at the Sheps Center keep the most comprehensive nationwide data on rural hospital closures. The bottom graph shows the numbers of rural hospitals that have closed each year since 2005. Credit: UNC — Cecil G. Sheps Center for Health Services Research.
“Non-operating revenue is revenue for activities that are not related to patient care, so, for example, the largest source of non-operating revenue is typically investment income.”
Among the hospitals that closed, 49 had negative operating margins in their final year of operation and 50 had negative total margins (which includes both operating and non-operating revenue).
“There’s a lot of commentary out there as to why these rural hospitals are closing,” Pink said. Many pin the blame for closures on large health systems, which buy up these smaller facilities and then close the hospitals when they consolidate services.
Something like that could be to blame for the closure in those facilities that are outliers in the data, the researchers didn’t look at those facilities specifically.
But, “By far, those are very small numbers,” Pink said. “The overwhelming percentage of the majority of them closed for financial reasons.”
The hope is that officials from state rural health offices could make it a practice to look at these financial indicators, which would enable them to identify hospitals that are at high risk of closure and implement measures to prevent the closure.
This particular study didn’t examine the role Medicaid expansion might play in preventing rural hospital closures, but a 2018 Health Affairs study by Colorado researchers — which relies on data from the Sheps Center — found that the program makes a significant difference.
Because Medicaid expansion increases the number of people with insurance coverage — thereby decreasing the amount of uncompensated care hospitals provide — those institutions perform better financially and are less likely to close, “especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion,” the authors wrote.
North Carolina remains one of 12 states to not expand Medicaid, though the state budget created a new 18-member committee in the general assembly to study health care access and Medicaid expansion.
Some federal relief could be coming for rural hospitals in states such as North Carolina. In December 2020, Congress passed the Consolidated Appropriations Act of 2021. The law creates the “Rural Emergency Hospital,” a new type of facility that will not provide inpatient services but will offer 24-hour emergency care. The law passed in response to the rate of rural hospital closures, and the negative impacts the closures have had on the health of communities.
“During the past decade, policymakers have recognized that rural communities need options other than full-service hospitals, to ensure access to essential services,” wrote staff members from the National Advisory Committee on Rural Health and Human Services in an October 2021 policy brief on the new designation of care facility. “The [new law] created the [rural emergency hospital] provider type to give rural communities with struggling rural hospitals an option between a traditional acute-care hospital and complete closure.”
The details of the new system are still being worked out. The federal Centers for Medicare and Medicaid Services are expected to have finalized the model by 2023, which is when hospitals can begin converting.
Pink, who provided his expertise to the committee, argues that his study “reinforces the need for a new model of rural health care, such as the proposed rural emergency hospital.”
“It’s just an example of a new model that probably is long overdue,” he said.
Republish our articles for free, online or in print, under a Creative Commons license.
X
Republish this article
As of late 2019, we’re changing our policy about reprinting our content.
You are free to use NC Health News content under the following conditions:
You can copy and paste this html tracking code into articles of ours that you use, this little snippet of code allows us to track how many people read our story.
Please do not reprint our stories without our bylines, and please include a live link to NC Health News under the byline, like this:
By Jane Doe
North Carolina Health News
Finally, at the bottom of the story (whether web or print), please include the text:
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org. (on the web, this can be hyperlinked)
by Clarissa Donnelly-DeRoven, North Carolina Health News January 24, 2022
