‘There ought to be options, other than just close or the status quo, to help them transform to best meet community needs’
WHEN THE ONLY HOSPITAL serving the southeast corner of Arizona closed three years ago, Jim Dickson, CEO of the nearest hospital, had an idea for preserving healthcare access in the area. He proposed building a free-standing emergency department with radiology and a lab, plus a clinic for visiting specialists and physical therapy office.
Cochise Regional Hospital, a critical-access hospital in Douglas, Ariz., 100 yards from the U.S.-Mexico border, had shut down due to problems with finances and quality of care, leaving the 17,000 residents of Douglas—plus thousands more people living just over the state line in New Mexico and across the Mexican border—without a nearby hospital or emergency room.
Dickson’s facility, Copper Queen Community Hospital, also a critical-access hospital, was 25 miles northwest in Bisbee, Ariz., over mountainous two-lane roads. It already operated an urgent-care center in Douglas.
But Dickson’s plan faced a payment policy roadblock. Arizona’s Medicaid program, seeing a flood of new free-standing EDs opening in Phoenix and Tucson, had lowered the basic visit fee it paid to such facilities from $750 to $500. That would make his proposed rural ED non-viable financially.
So he pleaded with state Medicaid officials to make an exception for rural providers that open free-standing EDs to replace shuttered hospitals. They granted his request last spring and Copper Queen opened its new
“If you focus a rural hospital on inpatients, you are dead in the water. If you focus on outpatient and primary care, you will be successful.”
JIM DICK SON CEO COPPER QUEEN COMMUNITY HOSPITAL
facility in April 2017.
With 83 rural hospitals having closed nationwide since 2010 and hundreds more in jeopardy, many rural healthcare experts and some policymakers want to see more rural communities with struggling or closed hospitals do what Douglas did. Nearly 20% of U.S. residents live in rural areas, according to the Census Bureau.
But state and federal policy changes are urgently needed to make these new models possible, analysts say. That includes paying for telehealth and facilitating full use of nurse practitioners and other mid-level providers. Expanding Medicaid to low-income adults in the 18 states that haven’t yet done so also would help rural providers.
Today, the Douglas ED, staffed by an emergency physician and a nurse practitioner, is seeing as many as 1,100 patients a month, twice as many as projected, while Copper Queen’s ED in Bisbee has seen no fall-off in traffic. Two to three babies are delivered at the Douglas facility each month. The visiting physician clinic, featuring a cardiologist, urologist, and nephrologist, is busy with patients who can’t drive to see specialists in Tucson, 118 miles away.
Dickson said Copper Queen is doing well financially with its Douglas outpost. “If you focus a rural hospital on inpatients, you are dead in the water,” he said. “If you focus on outpatient and primary care, you will be successful.”
Communities, experts say, must consider alternative models for providing healthcare for their residents, including replacing inpatient care with emergency and/or outpatient services and using telehealth to connect with specialty services. Community health centers and other providers in these areas need to be part of a coordinated solution.
“There ought to be options, other than just close or the status quo, to help them transform to best meet commu-
nity needs,” said Dr. Anand Parekh, chief medical adviser at the Bipartisan Policy Center, which issued a report on reinventing rural healthcare in January.
Bills are pending in Congress to ease the way for these new models and provide financial support for rural hospitals while they make the transformation. And in an experiment that will be closely watched, Pennsylvania is partnering with the CMS’ Center for Medicare and Medicaid Innovation to test a new payment system based on all-payer global budgets for rural hospitals, starting next January (See story, p. 21)..
The CMS last month issued a rural health strategy framework, including general statements about expanding telehealth, improving patient transportation, promoting interoperable data systems, and offering providers technical assistance so they can fully participate in agency programs such as accountable care organizations.
But the strategy is short on specifics. Parekh was particularly disappointed it did not address how the CMS would help rural communities retarget and rightsize services. That may be because CMMI, which would test new rural models, did not have its new director, Adam Boehler, in place until April.
“Communities want choices, so I hope there will be more to come there,” he said.
Policy differences within the administration, resistance from rural providers and communities, or disagreements between the administration and Democrats over Medicaid policy and new spending for rural needs also could slow progress. “I’m hoping this won’t be as divisive as some other healthcare issues,” Parekh added.
Maggie Elehwany, vice president of government affairs and policy at the National Rural Health Association, warned there’s an urgent need for action, given that the percentage of rural hospitals operating at a loss ticked up from 41% to 44% just in the past year.
“We are jumping up and down yelling that when a rural community loses a hospital, that’s a death sentence,” she said. “We need Congress to do something now and look at new models. But it’s an election year, and I can’t name any legislative vehicle for this.”
Back in Arizona, Copper Queen’s Dickson said rural hospital leaders and residents need to get realistic and act fast to serve local patients. “Hospitals are obsolete unless they change, like we did,” he said. “People in rural areas are running scared. They need to have the vision to do what’s
● necessary to keep people alive.”