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Big Fish Eats Little Fish- Warning for Rural Hospitals

The views expressed are those of the author and are not necessarily those of Scientific American.


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St. Andrews Hospital, Boothbay Harbor, Maine update.

In my previous post, I outlined the looming menace to tiny St. Andrews hospital in Boothbay Harbor, Maine.

I’ve met with one Lincoln County Healthcare (LCH) executive, Dr. Mark Fourre, Director of Emergency Services at Miles Memorial Hospital and St Andrews Hospital and a Trustee of the Board of Lincoln County Healthcare. Their public premise is that the issue is not so much about economics, but rather about “quality of care.” I requested demographic and utilization information to evaluate LCH’s comments about the sustainability of the small community hospital, and was rebuffed, being told that data is “private.” Just trust them…

Residents and town officials of the Boothbay peninsula—Southport Island, Boothbay Harbor, Boothbay, and Edgecomb—are outraged at the announcement that they will lose their emergency room and hospital and that this was presented by LCH as a fait accompli, with no discussion with the community. The selectmen from the towns and state Representative Bruce MacDonald have put together a task force to explore alternatives to closing the region’s emergency room. They are committed to seeking alternatives that would address the utilization and quality issues raised by LCH. Their efforts are being stymied by the lack of transparency from LCH, with their withholding data from the community task force as well as recommendations from their consultants, but especially by time constraints.

$old Out

Unfortunately, pleas for LCH to have a meaningful discussion with the community and time to explore alternatives have fallen on deaf ears. LCH and its parent, MaineHealth, have refused to extend the deadline to close the ER that they arbitrarily set for April 2013.

In addition to the work of other taskforce members, I am undertaking a review of how some other tiny Critical Access Hospitals (CAH) have sustained themselves. Boothbay’s St. Andrews is one of 1327 hospitals nationally named a “Critical Access Hospital.” The CAH designation means the hospital is certified to receive special cost-based reimbursement from Medicare, which is extended to small, rural hospitals to help stabilize them financially and thereby reduce hospital closures. All of these CAH hospitals have less than 25 beds. Out of a total of 39 hospitals in Maine, 16 are CAH hospitals. Each CAH facility is required to maintain an Emergency Department, but there is no requirement for 24/7 staffing in the ED.  Providers, who may be physicians, physician assistants or nurse practitioners, may be “on call” if they are able to met the mandated response time of around 15 minutes.

With a brief Google search, I was promptly able to identify a number of successful CAH hospitals. For example, many small rural hospitals use physician assistants/nurse practitioners to provide most care. Some use temporary physicians, e.g., locum tenens. One strategy many of them use is to utilize telemedicine to provide quality, state-of the art care to their patients.

I was surprised not to have heard telemedicine proposed by LCH as an obvious solution for their proclaimed quest for quality. After all, telemedicine is not new to Maine, and has been used by a number of Maine hospitals. In fact Maine Medical Center, part of the MaineHealth consortium that includes St. Andrews, has also used an e-ICU since at least 2005.

Benefits of e-ICU (Maine VitalNetwork TeleHealth Conference)

Maine Medical touts the benefits both in clinical outcomes for patients—decreased complications and mortality—and in financial benefits for the hospital. Central Maine Health Care partners with Massachusetts General Hospital in Boston to provide emergency neurological consults for patients with strokes, seizures, or other neurologic emergencies via video-streaming.

To find out more about telemedicine for CAH, I spoke with Kristi Henderson, DNP, NP-C, FAEN and Director of Telehealth, University of Mississippi Health System. She provided a number of insights. Dr. Henderson has been involved with coordinating the care between Mississippi’s 30 CAH and the University of Mississippi’s emergency room. Through this consortium, she notes that the quality of care at the CAH is now comparable to that of the bigger hospital. Patients are now better stabilized prior to transfer, and patients who did not really require transfer are able to be identified and treated locally.

With such a collaborative telemedicine arrangement, both the receiving and transferring hospitals benefit financially, according to Dr. Henderson. The local hospital keeps revenues generated locally, improving their financial viability. The tertiary referral hospital benefits by receiving appropriate patients, who can receive the specialized care they need and then be transferred back to the community CAH for continued care. This frees up their beds for the more sophisticated and profitable high-tech care, and reduces their length of stay (LOS), critical to financial success. The CAH generates local revenue by providing the skilled nursing/rehab through use of their “swing” beds.

So how much does this telemedicine system cost?

You would be surprised. Costs of video conferencing and computer systems are steadily decreasing. Three emergency rooms can be set up, each with telemedicine capabilities, for ~$45,000—less than the bonus St. Andrews CEO received in just one year! Portable units are similarly ~$15,000 each. What’s more, Dr. Henderson informs me that the CAH is  typically reimbursed for the set up costs.

So telemedicine seems a low risk, “no-brainer” for the peninsula and other similarly isolated rural hospitals. If I found a viable model with a few hours of research, why hasn’t LCH and MaineHealth proposed this?

Quality concerns

One concern that was raised by LCH is how doctors maintain competency for high-risk, low volume procedures. There are two readily available solutions. One is to rotate staff through (as from other hospitals in the MaineHealth consortium) or to hire experienced locum tenens (substitute) physicians. The other is to rely on telemedicine and periodic, hands on training with medical simulation.

But we also need to look at the loss of quality due to delays in care caused by transfers to Damariscotta. Analyzing the data reported by Sue Mello in the Boothbay Harbor Register a bit differently, I found that 390-542 patients with true emergencies (Level 1-3, defined as needing care in less than 1 hour) would need to be transferred out annually, just during hours the proposed urgent care center would be closed. The trip from St. Andrews to Damariscotta takes ~1/2 hour in good weather and no traffic—who knows how much longer from Southport Island, for example, or in the winter, or in summer tourist traffic).

Current standards are for patients with strokes or heart attacks to receive treatment with an hour if they are to avoid permanent damage—“the golden hour.” With elimination of the peninsula’s emergency room, many local people will actually risk much worse health outcomes by the delays of transfer, rather than initiating treatment in Boothbay and then, if necessary, transferring them to another center.

St. Andrews Hospital has it's own dock and access by land, sea, air.

While the trend is towards “hospitalists” (including in Damariscotta), I am not a fan of this system—they too often seem to be shift workers providing limited continuity, whose main incentive is to reduce the length of stay and cost, rather than to provide care. And there are quality concerns when patients are transferred away from their family physicians and their home community supports. How does being separated from your family physician community and being cared for only by a strangers fit with compassionate, holistic care?

Economics

Dr. Fourre states that the region must “look ahead,” as healthcare funding is likely to experience further cuts. But there is reason to believe that funding for CAH will not be cut, as providing care close to home will be more cost effective. Instead of occupying a bed in a more expensive referral center, the CAHs can provide lower costs via their “swing” beds, which can be used either for acute care or skilled nursing.

While the immediate discussion is over closing the ER and instead having an urgent care center, with limited hours, I have no doubt that urgent care is also on the chopping block. In a year, or two years, the administrators will decide that the “numbers” don’t justify maintaining those services either. I’ve seen this pattern before.

Also note, as Jim Donovan, Lincoln County Healthcare CEO, told town officials, Sen. Chris Johnson and private citizens, “Essentially there are no savings (from the changes)…We are shoring up quality and safety. Savings from expense reductions are wiped out by the loss of (St. Andrews) critical access hospital designation.”

While administrators understandably focuses on their bottom line, another unmentioned aspect is that when local rural hospital systems close, this will increase the burden and costs for the patients and their families, due to the need to travel to visit or stay with their loved ones, now hospitalized some distance away, and from lost work time. This was quite evident in Cumberland, as many patients have left to receive care in Winchester, Morgantown, or Washington.

Local citizens are justifiably concerned about what the loss of the emergency room and hospital will mean to the region economically. As I noted previously, the loss of 50 jobs in a town of 3120/region of 6000 is going to be a major blow to the economy of this tiny community, and will likely have a domino effect throughout, impacting local merchants, housing, and tax revenues, resulting in a downward spiral.

Dr. Henderson concurs with the community’s concerns, concluding that “a hospital is critical to the economic viability of the community.” If Mississippi, a state facing severe economic struggles like Maine, has chosen to support a vibrant network of small critical access hospitals and telemedicine, why hasn’t MaineHealth and Lincoln County Healthcare?

Conclusion

Medicine shouldn’t just be about numbers or the “comfort” level of the health care workers in providing care. It should be focused on the patient and on the community. And instead of throwing away a community’s hospital because there are some problems, a dedicated management team should be looking for solutions, as the Task Force and I have been feverishly doing. We care deeply about our community–enough to look for creative solutions to meet the community’s needs.

By their intransigence and unwillingness to explore alternatives nor extend their deadline for closing St. Andrew’s Emergency Room, Lincoln County Healthcare and MaineHealth they have demonstrated that they are not acting in good faith and that they are not truly committed to the needs of the peninsula. There is still time for them to reconsider.

One can only wonder how often this pattern is being repeated in rural communities across the country, and what the results of these administrative decisions to close local hospitals will do—likely poorer patient outcomes, due to increased travel times for emergency care and to huge economic losses for the affected communities. I hope that others will heed the warning signs of lessons painfully learned.

To learn more:

Boothbay Register

Boothbay Region Community Television

St. Andrews Task Force

Credits

Molecules to Medicine banner © Michelle Banks

No Problems, Only Challenges – Frits Ahlefeldt

$old Out at Newagen dock – Judy Stone

St. Andrews from Wottan’s Wharf – Mark Skinner

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Judy Stone About the Author: Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.

The views expressed are those of the author and are not necessarily those of Scientific American.





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