Rural Communities Risk Losing Hometown Healthcare
At the end of April, Franklin, Tenn.-based Community Health Systems (CHS) announced plans to turn Haywood Park Community Hospital, located in Brownsville in the western part of the state, into an urgent care clinic. Plans call for the county’s only hospital to cease inpatient admissions and emergency services at 11:59 p.m. on July 31.
According to a release from the hospital, inpatient admissions had dropped from 1,300 in 2009 to less than 250 in 2013. Additionally, the Emergency Room had also seen a sharp decline with 15 or fewer patients per day over the past several months. The release went on to cite changes in guidelines for inpatient admissions and federal reimbursement cuts under the Affordable Care Act that have not been offset by Medicaid expansion in Tennessee as contributing factors to the hospital’s demise. In light of the new reality, Haywood Park CEO Joel Southern said maintaining a full-service hospital was simply not sustainable. Residents of the agricultural community must now drive close to 30 minutes to hospitals in Covington, Ripley or Jackson for inpatient and emergency care.
Although the latest to make a news splash, Haywood Park isn’t the only hospital that has closed in Tennessee or been reassigned as an outpatient clinic in recent months. Craig Becker, president of the Tennessee Hospital Association, noted two others have closed in West Tennessee and that Scott County in East Tennessee has recently reopened without obstetric care after being shuttered for several months.
Humboldt General Hospital and Gibson General Hospital both closed earlier this year. Humboldt now offers an Emergency Department plus outpatient clinical and rehabilitation services. Gibson General has been rechristened Trenton Medical Center and offers urgent care, primary care, lab and X-ray services, behavioral health and physical rehab. Another hospital in Upper East Tennessee is currently on life support.
A common theme among the recently departed inpatient facilities and the more than 50 others that have been deemed ‘in danger of closing’ is their rural location. Becker said, “These rural areas are the most vulnerable. We’re going to have to figure out how to keep a medical presence in these communities, and right now it’s hard to envision how that’s going to happen.”
Joellen Edwards, PhD, RN, FAAN, president of the Rural Health Association of Tennessee (RHAT), concurred, noting hospital closures have a ripple effect. “You lose your prenatal care. You lose your primary care because they just can’t make it when the hospital closes.”
Edwards, whose research focuses on rural populations, is a professor and associate dean at East Tennessee State University’s College of Nursing. Looking at a number of the threatened hospitals in the state, she said, “Some of these are critical access hospitals, which means there is not another hospital for a minimum of 30 miles – or it could be even further away ... and probably is.”
She continued, “In East Tennessee, if you live in our mountains, 30 miles is not an easy drive. Not having a hospital available in minutes … rather than an hour or more away … makes a difference literally to life and death.”
In addition to losing access to care, Becker said the economic impact of losing a hospital is a topic that has been glossed over. “These are often some of the best paying jobs in these communities,” he said.
Edwards pointed out hospitals are frequently the economic driver in rural communities and are sometimes one of the few jobs in the county that come with health benefits. Losing those jobs only exacerbates the problem of uninsured and under-insured rural populations.
“I can guarantee you Brownsville is hurting right now because of losing those jobs,” Becker said. He added CHS couldn’t be blamed for their decision to cease emergency and inpatient services … it’s simply an economic reality. “It certainly isn’t that the community doesn’t deserve to have a hospital. The reality is now you can’t afford to have one.”
Even in communities that don’t close hospitals, Becker said he anticipated seeing service lines that are not typically profitable … such as oncology and obstetrics … cut loose. “Cutting services isn’t much of a strategy, but we’re going to see a lot of that,” he predicted.
When the Supreme Court struck down the ACA’s state mandate to expand Medicaid, hospitals were left with severe cuts and the loss of a significant source of offsetting reimbursement. The funding cuts, such as DSH payments, are back loaded. Becker said Tennessee hospitals face $1 billion in cuts in the year 2019 alone.
“Even with (Medicaid) expansion, it’s going to be difficult,” he said of the financial stressors hospitals face. “But without expansion, we’ll lose even more hospitals and definitely see more services cut.”
He added lawmakers have, at times, accused the THA of ‘crying wolf’ as the association leaders have discussed the imminent danger to numerous hospitals in the state. “This is the kind of thing we’ve been predicting,” Becker said of the recent closures, adding he wasn’t happy to be proven right.
The current closures, however, are feared to be the tip of the iceberg. Without expansion of the Medicaid rolls (TennCare), Becker doesn’t foresee a happy ending for a lot of other hospitals. “One-third of the hospitals in the state are losing money,” Becker said, adding they couldn’t indefinitely continue to operate in the red. “I see other hospitals on the border … on the brink,” he noted.
The Tennessee Plan proposed by Gov. Bill Haslam as an alternative to the Medicaid expansion program rolled out by the federal government and accepted by 26 states plus the District of Columbia so far, is still stalled … although not yet dead. During the 108th General Assembly, however, state lawmakers added another hurdle to getting funding to Tennessee hospitals by passing a bill requiring Haslam to obtain legislative approval before accepting any expansion dollars.
Under the federal Medicaid expansion plan, states would receive 100 percent of the cost to ensure individuals with incomes up to 138 percent of the federal poverty line for three years from 2014 through 2016. Beginning in 2017, funding phases down over the next four years to a permanent match rate of 90 percent by 2020 … significantly higher than the 65 percent provided for current TennCare enrollees.
Becker, who called himself an eternal optimist, said he still believes the Tennessee Plan could pass. Unfortunately, he said it might take having more hospitals close to drive the message home. “Maybe there is going to be some pressure on some of these rural legislators when they realize they are losing part of the social fabric of their communities,” he said.
If a deal is struck soon, Tennessee still has a chance to receive one full year at the 100 percent match rate. “I think there’s definitely a possibility … we’re not going to give up,” Becker stressed.
From RHAT’s standpoint, Edwards said, “We have a stance that uninsured people in Tennessee should have an opportunity to be covered just like in Maryland where they chose to expand Medicaid.”
Although she said the association doesn’t take a political stance as to which expansion plan is implemented, Edwards concluded, “We in the Rural Health Association do want to see a reasonable expansion of services to people in this state … it’s what they deserve.”
From the Release Announcing Haywood Park’s Closing:
Rural hospitals such as Haywood Park are particularly impacted by new cuts in federal program reimbursement as part of the Affordable Care Act. These cuts were based on more people having insurance, whether through Medicaid expansion or the insurance exchanges. Tennessee has forgone the option to cover more individuals with Medicaid, leaving many of the state’s most vulnerable citizens without access to health insurance, and with no means to address the unsustainable burden of uncompensated care.
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