Texas slow to adopt potential solutions to keep rural hospitals open
In many rural parts of the state, there are no hospitals, and few – if any – emergency medical services. Texas Tech Public Media spent the past year examining the problem, and some of the potential solutions to the state’s health care drought.
The halls of Stamford Memorial Hospital are a lot quieter than they used to be. A wall at the front of the hospital was once filled with photos of the healthcare workers, but is now blank. The doors to old patient rooms are shut. Patients can now only get treated for minor conditions during limited hours.
The hospital closed in 2018, making it one of the 24 rural hospitals to close in Texas since 2005. This closure left nearly 3,000 residents without immediate access to healthcare.
“Any time you lose a hospital, the impact emotionally is really significant because you know, whether you need it or not, the hospital is always there,” said Nancy Clark, the hospital’s financial controller. “But just knowing there’s no hospital out here makes the community uneasy. I would probably say at least 50 percent of the impact is the emotional distress people have just knowing that they don’t have an ER to come to.”
Rural hospital closures are a problem nationally too, as data from the American Public Media Research Lab show that while Texas has had the most closures of any state, the U.S. has had 135 closures total in the last decade. According to health experts, this is largely due to financial problems, declining populations and healthcare worker shortages.
“Unfortunately there’s not one thing you can say ‘This is the reason this happened,’” Clark explained. “There’s no telling how many factors come into play and they all combine to make some of the hospitals have to close. As much as we wish it wouldn’t have, we were just informed it was going to and so we do the best we can.”
According to Stamford’s mayor, James Decker, the hospital closed because of finances - specifically, lower reimbursement rates to hospitals by the federal government. The reimbursements are meant to cover care and treatment of uninsured and Medicaid patients, and without them, the hospital could be stuck with debt.
“It’s one thing to say we don’t have a great doctor in town,” Decker said. “It’s another to say you don’t even have an ER now. This is not a problem we’ve developed. It’s a problem everybody has and we’re just one of the foremost victims.”
Decker was voted mayor of the Jones County town a few months after the hospital closed. He said residents were shocked, but that any serious illness or injury has been going to larger hospitals in Lubbock and Abilene for several years now, so Stamford’s hospital was facing a lack of patients.
“So, why are you paying to keep an in-patient hospital open that has a half a patient a day average?” Decker asked. “So you look at that and wonder what we actually need, and that’s emergency care.”
Just like Stamford’s healthcare, the population has been on the decline. Data from APM show the town’s population has declined by 3.4 percent since 2000.
“If you want other folks to move to town, if you want to reverse that decline and improve it, you have to have a certain level of quality of life,” Decker said. “Retirees are reluctant to move back if they don’t have access to a doctor. Families are going to be reluctant as well because what if something happens to their kids? It’s a vital sales pitch to the future of Stamford.”
However, there may be some ways to avoid more closures.
“Instead of death by 1,000 cuts, we need to be talking about survival by 1000 incremental improvements,” said John Henderson, CEO of the Texas Organization of Rural and Community Hospitals. “I think if you get a little bit of help from the federal and state programs, if you have some incentives for innovation around Telehealth, if you have initiatives or grant funded projects in rural Texas, all these things together add up to making a better outcome and story for all of rural Texas and the rural Texans we serve.”
Part of those improvements include new legislation that helps hospitals change their designation. Henderson said rural hospitals are often in tough financial situations from simple expenses, such as overhead costs. There is a lack of patients in many cases, but hospitals still have to pay the staff to be there and still have to keep in-patient services open in order to receive federal funding.
“There’s federal legislation that won’t take effect until 2023 that allows for a new designation of hospital,” explained Henderson. “Rather than having in-patient services and overnight stays, it’s built around the concept of having an emergency room and 24-hour observation.”
One key thing, according to Henderson, is Medicaid expansion in Texas. The government covers treatment and services to lower-income residents or those who can’t afford it at all through Medicaid, and expanding it would cover more Texans, increase funds to hospitals, and increase the services provided.
According to APM, Texas has the highest uninsured rates in the country and is one of 12 states that have not adopted Medicaid expansion. However, Henderson does not think that will change soon.
“It’s 100 percent political - we continue to be a very conservative state,” said Henderson. “It’s Medicaid expansion as part of the Affordable Care Act, and our statewide officials have been against that publicly for a decade now.”
Henderson said if Medicaid was expanded in Texas, rural hospitals could gain $4 billion a year and about a million Texans could be insured. But with the future of expansion in doubt, Henderson said there are other ways to get rural hospitals in stable condition, especially Telehealth and improved rural broadband access.
“I see momentum around Telehealth and broadband, and those are big deals to our hospitals and the communities they serve,” Henderson said. “Then if the federal and state government and the Medicare and Medicaid programs would simply say a Telehealth visit is recognized and paid as a face-to-face visit would be, then you would see a lot more of that activity and that’s a game changer for rural primary care.”
Project ECHO–Extension for Community Healthcare Outcomes–is an organization in New Mexico that has found a lot of success through Telehealth. In 2003, Dr. Sanjeev Arora was one of the few Hepatitis C specialists in the state and had patients driving hours for treatment.
Some of his patients couldn’t get to him in time though, so he founded Project ECHO in an effort to help create a global network of healthcare providers to pass along information, treatment advice and collaborate.
“Let’s say we have a doctor in rural West Texas who’s a primary care physician,” said Ben Cloutier, director of communications for Project ECHO. “They can join an ECHO program wherever it might be, and they can learn how to do a specific kind of screening or treatment or care, in their own setting.”
Cloutier explained that they saw a 450 percent traffic increase in 2020, as physicians were looking for ways to treat COVID-19. The organization also worked with the U.S. Agency for Healthcare Research and Quality on training over 9,000 nursing homes on the best practices, prevention and infection control.
The organization’s goal is to help spread knowledge and create a healthier community, so Cloutier said the service is available for any healthcare provider that signs up.
“If a medical provider takes part in ECHO and learns how to do that particular kind of treatment or care, their patients don’t have to go anywhere or they may get screened earlier,” Cloutier explained. “Anyone who gets involved is committing to that value of giving away all of their expertise for free, at no cost to anyone, for the benefit of everyone.”
By utilizing Telehealth, Project ECHO could increase access to healthcare in some remote places. In order to do that though, there needs to be a strong internet connection. Back in Stamford, Mayor James Decker knows that’s an issue they have, and he is still trying to bridge the gap for his community.
“You have to be an expert at Google searches to try and figure out what’s available out there,” explained Decker. “The federal government pretends to have a website that has all the options available, but it’s impossible to use. There’s 75 different places to get grants, but you have to ask 75 different people to figure out how to get that."
Last March, Jones County joined the Technology Action Plan, a program run by Connection Nation - a national nonprofit that helps to improve high-speed internet access to rural communities. Through this program, it could create a safety net for Stamford.
“I think people are very open-minded to telemedicine, but that’s going to be difficult until you have reliable internet access,” Decker said. “We just want to be able to provide the same minimum quality of life that you have throughout Texas.”
This story is part of a collaboration with The Texas Newsroom through FRONTLINE’s Local Journalism Initiative, which is funded by the John S. and James L. Knight Foundation and the Corporation for Public Broadcasting."