February 28, 20183:14 PM ET
ADRIENNE
ST. CLAIR
Heidi Schultz grew up traveling from one end of South Dakota to
the other, tagging along as her sister saw doctors and specialists in the
"big cities" to treat her diabetes.
Schultz thought she knew rural America well when she took a
position with the Helmsley Charitable Trust overseeing their rural health program in
seven western states, including Montana and Wyoming.
But even she has been surprised by how she can drive hours on
country highways seeing few cars and just "a handful of gravel driveways
going somewhere you can't see."
"It's almost scary," Schultz says.
"You're thinking, 'If something happened to me here on this road now, how
long would it take for someone to get to me? An ambulance? And where would they
take me for care?' "
Now part of her job is to help organizations apply for grants to
provide care in rural areas. She understands that people living in these places
must come up with creative solutions to deal with their health care needs —
whether it's getting help in an emergency, receiving treatment for ongoing
illnesses or softening the natural consequences of old age.
It's a quickly changing landscape as more rural hospitals close,
and some health policy analysts say it's time communities made some hard
decisions — starting with completely changing the health care structure in
small towns.
For example, says a recent report by
the Bipartisan Policy Center, instead of making sure each rural resident can
easily get to a full-service hospital, some communities should consider what
kind of primary care and more specialized care they could offer at a facility
instead — short of having a full-service hospital.
Hospitals tend to be cornerstone institutions in rural
communities. They provide jobs and contribute to a town's economy. For many
citizens in small-town America, losing the local hospital would threaten the
livelihood of the town and its people, says Patrick Roche, chief
operating officer at Faith Regional Health Services based in Norfolk, Neb.
"There are two things they don't want to lose. The first
one is their school, the second one is their hospital," says Roche.
But there are big challenges to keeping these hospitals open.
They cost money and it's difficult to find a qualified workforce.
There are other concerns, including limited funding, regulatory
restrictions, problems with transportation, broadband internet accessibility
and the unique characteristics of the population, according to Dr. Anand Parekh,
chief medical advisor with the Bipartisan Policy Center and one of the report's
authors.
"Rural America," Parekh says, "is a little bit
older, a little bit sicker, a little bit poorer."
In 2016, the Census Bureau reported that
19.3 percent of the U.S. population lived in rural areas, which cover 97
percent of the country. Up to this point, the medical needs of that group have
been addressed by a system that has medical facilities, many of which do
receive some federal support, including about 1,300 small
hospitals known as critical access hospitals.
A hospital is designated as critical access by the Centers for
Medicare and Medicaid Services if has 25 beds or fewer, is more than 35 miles
from another hospital and provides 24-hour emergency services.
The National Rural Health Association says 673 rural hospitals
are at risk to close, and 210 of those are at "extreme risk"— 60
rural hospitals closed between
2010 and February 2016.
One of the main reasons for the significant rural hospital
closures is that the average number of in-patients is low, says Schultz.
"Running a full hospital is very expensive — the overhead,
24/7 staffing, the facilities," she says. "Think of a 25-bed
hospital, and you're only using four of your beds and how expensive that
is."
Residents of Tilden, Neb. — a town of less than 1,000 — know
what happens when the town hospital can't make ends meet. They lost their critical
access hospital in 2014 and had to find a different solution for their medical
care.
Roche explains that Faith Regional Health Services in Norfolk,
just 22 miles away from Tilden, worked out an agreement to lease the hospital
and clinic from the little town; Faith Regional then provided the medical
operations—staffing, providers and equipment.
"The operations are, in effect, owned by Faith Regional and
are operated just like any other clinic that is owned and operated by our
system," Roche says. But the facility in Tilden is no longer a full
hospital.
"There's been a fear in the air and you read a lot, and you
hear a lot about hospitals closing," says Schultz, who travels often to
rural communities. "And that's rightfully so. But if you look at the communities
that are losing their hospitals, you need to look at, 'What do they still
have?' "
The Bipartisan Policy Center and Helmsley Charitable Trust
partnered to propose a possible solution for communities struggling to keep
facilities afloat and provide quality care miles away from city and suburban
hospitals and clinics.
Their January 2018 report, which surveyed health care
professionals in seven states in the upper Midwest, says that the whole rural
health care system needs to be addressed. Each community should determine the
best health care structure, the report suggests, not the other way around. And
that difficult analysis may lead to closing a small town hospital.
Darrold Bertsch, chief executive officer of Sakakawea Medical Center in Hazen, N.D., says he agrees
with the idea of catering health care facilities to the population — whether
it's with an outpatient clinic, urgent care center, a hospital or something
else.
"If communities had a little bit more flexibility," he
says, "then they could adapt a health care delivery system in their area
that is more relevant to the needs that they have, rather than trying to make a
hospital fit in a community where it might not be able to be supported anymore."
The critical access hospital in Cody, Wyo., has stayed open —
partially because of this idea of flexibility, says Jeanine Brus,
who works as the laboratory director for the hospital.
Cody sits outside the eastern edge of Yellowstone National Park
and is a town of about 10,000 people. Cody Regional Health, which includes the
hospital and other health care facilities, such as a surgical center, a cancer
center and a dialysis center, serves the town and the farms and ranches in a
200-mile radius, as well as tourists from the park.
Brus says that the key to adapting has been collaboration
between the different facilities. And that's been good for the health care
workers, as well as the community, she says.
Bertsch from the North Dakota hospital says federal regulations
and the way hospitals are reimbursed mean there's no one-size-fits-all fix for
every community.
Still, Parekh underscores his hope for the possibilities that
can come when communities are open to new kinds of solutions.
"You know, you don't have to close your hospital," he
says. "You can transform the hospital to meet your community needs,
improve health and still continue to improve your local economy. Rural America
can thrive as health care transforms."
This
story is part of NPR's reporting partnership with Kaiser Health News.
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