Over the past decade many rural hospitals have had to close their doors. Reasons cited have included the lack of physicians serving rural communities, high costs of providing care, lower rates of Medicare reimbursement for rural hospitals, issues with Medicaid, cut backs in funds from local and county governments, smallness and the related lack of “economies of scale”, and difficulties in keeping the patient census at a break-even level.
Since many rural residents are old and poor, the issues related to reimbursement by Medicare and by Medicaid appear to be particularly critical. Generally, the rules for reimbursement reflect the situation of metropolitan hospitals. Citing higher salaries and infrastructure expenses, city hospitals are reimbursed at a higher level for the same services. The added costs related to maintaining medical services in rural areas are not factored into the equation.
Recently, the Health and Human Services Department of the federal government published a document, “One Department Serving Rural America,” calling for revision of policies related to this and other rural health care needs. It contains very interesting information and proposals. It is accessible on-line. Perhaps, there is hope that this problem will be addressed soon. (Interestingly, one of the pictures on the Web page is that of a rural church house.)
Meanwhile, problems in providing good health care in rural settings continue. A current example of this comes from rural Nebraska. Last fall Medicare decided to lower reimbursement for laboratory services not provided at a hospital. This hit home health care, even those offered by hospitals, doctors’ clinics, and assisted living centers hard. It was also a blow to rural persons who live long distances from hospitals. Nebraska Sens. Ben Nelson and Chuck Hagel have protested.
The unfortunate truth is that here, as in almost all areas, public policy is driven by the lobbying of special interest groups, rather than by a vision of what would be a comprehensive system of well-ness and health-care delivery. The United States needs a system that takes into account the unique needs and situations of all peoples and areas of the nation.
Those of us who live in rural areas cannot expect to have ready access to all of the medical specialities and newest technologies. We realized that these require high concentrations of population. But we do need to have access to what is called primary level care.
This month Pickens County Medical Center, our local rural hospital, celebrated 25 years of service to a poor rural West Alabama County. Next to the public schools it is the largest employer in the county.
After a couple of years of income shortfalls, its future is looking brighter now. Two year ago it contracted with the much larger hospital in Tuscaloosa to provide oversight and management. A new administrator was hired. Some difficult changes in staffing and operations were instituted. As a consequence it made money this past year.
One of the most significant changes was the closing of the maternity ward and nursery. They were replaced by a unit for geriatric dementia patients. In most instances these patients are sick because of having been over-medicated. This saved money on the one hand and generated money on the other. For some reason, Medicare and Medicare reimburse well for these services.
But there is an important ethical issue here, I believe. Today, expectant mothers must travel 25 to 50 miles to Tuscaloosa, Ala., or Columbus, Miss., for prenatal care and to deliver their babies. Since many of these nearly 300 expectant mothers are poor, they simply do not get pre-natal care. I am told that the average birth weight of newborns has dropped since the change.
In the decade prior to the closing of the maternity service at the county hospital, the birth weight rates had risen and the incidents of still births and infant death had dropped significantly. It appears that these gains will be lost.
To my mind this story is illustrative of a major ethical dilemma in modern life. An institution in order to survive seems to have departed from an important facet of its original mission. We have seen this happen to colleges, hospitals, churches and even denominational bodies.
Granted changing situations call for change in institutions. But here the needs continue. A central mission of origin for the hospital continues–the care of poor pregnant women and the healthy delivery of babies. This change is driven by economic considerations brought on by ill-devised public policies.
Certainly the hospital continues to serve important functions for the residents of the county. The support it receives from a portion of the sales tax collected in the county is well spent. But it is a shame that in order to survive it has had to abandon its ministry to “the least of these”. Hopefully, the policies related to reimbursement will change and rural hospitals will be able to reorganize and refocus upon the basic needs of all the residents of their service areas.
