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News for CAHs and RHCs

Changing Hospitals' Not-For-Profit Status "Important Decision for a Community"
Posted: Oct 31 2021

KAWC NEWS Arizona Edition with Lou Gum | Oct 29, 2021

A proposed joint venture between Yuma Regional Medical Center and hospital management company, LifePoint Health, a holding of the Apollo Management Group, a private equity firm, would change the hospitals' not-for-profit status to a for-profit model. 

Today on Arizona Edition, host Lou Gum speaks to Dr. Daniel Derksen, Professor of Public Health, Medicine and Nursing at the University of Arizona's Mel and Enid Zuckerman College of Public Healthand Director of the University's Arizona Center for Public Health.  

Derksen discusses various hospital ownership and management models, including the fairly recent introduction of private equity firms into the ownership landscape. He says a lack of data makes it hard to assess whether a not-for-profit or non-profit hospital is better for a community than a private, or corporate-owned entity, in part due to mandated reporting and health metrics for one group and less transparency or required accountability for the other. 

Derksen suggests the "important decision" by a community to change its hospital's legal framework should be based on the transparency and accountability of hospital leadership, their commitment to addressing local health needs, and an on-going dialogue with community members. 

» Listen: https://cpa.ds.npr.org/kawc/audio/2021/10/azed_web_102921.mp3

 

Mt. Graham moving closer to critical access hospital designation
Posted: Oct 26 2020

EASTERN ARIZONA COURIER | By Kim Smith editor@eacourier.com | Oct 23, 2020

Gila Valley residents could soon see expanded cardiology, wound care and inpatient dialysis services if things go as planned for Mt. Graham Regional Medical Center.

The hospital is taking the final steps necessary to be designated a critical access hospital, which would allow it to be reimbursed differently by Medicare and Medicaid.

A public meeting was held Thursday night to inform Gila Valley residents about the effort and as part of the application process.

Hospital CEO Roland Knox and Jill Bullock from the Arizona Center for Rural Health, which is helping the hospital during the process, spoke to roughly a dozen people at Graham County’s general services building.

Right now, the hospital is reimbursed a lump sum of money based on a diagnosis code and it doesn’t matter if the patient takes a few days longer to recover in the hospital than anticipated, Knox said.

If the hospital receives the critical access designation, the reimbursements will become cost-based, he said.

The additional funding would allow the hospital to expand services, including cardiology, Knox said.

More than 200 rural hospitals closed in the 1990s because the payment system wasn’t working, Bullock said. As a result, lawmakers passed the Medicare Rural Hospital Flexibility Program in 1997 to make changes to the payment system and improve the health and wellness of people living in rural communities.

There are 15 critical access hospitals in Arizona right now and both Mt. Graham Regional Medical Center and San Carlos Apache Healthcare Corporation are seeking the designation, Bullock said. Nationally, 22 percent of all hospitals have the designation.

In order to become a critical access hospital, the hospital must be located in a rural area 35 miles or more from another hospital and provide 24/7 emergency care, she said. The hospital must also have no more than 25 acute care and swing beds.

Knox explained that Mt. Graham will be losing 23 medical/surgical beds and one bed in obstetrics, but adding 10 observation beds if it receives the CAH designation.

However, the CEO stressed that over the last four years, the medical/surgery unit usually only had five or six patients a day anyway. The obstetrics unit averaged three patients a day.

If the hospital had designated observation beds over the last four years, it would’ve averaged five or six patients a day.

Overall, the hospital only has a 33 percent occupancy rate right now, Knox said. Once the hospital is designated a critical access hospital, the occupancy rate will be around 46 percent.

Besides the cost-based reimbursements from Medicare, another benefit to being a critical access hospital is getting access to educational resources, technical assistance and funding for special projects, Bullock said.

Over the next couple of months, the hospital and Arizona Center for Rural Health will finish up the application, sent it to the Arizona Department of Health Services and then on to the Centers for Medicare and Medicaid Services.

If all goes well, Knox said the hospital will get the designation by spring.

On Native American Land, Contact Tracing is Saving Lives
Posted: Aug 14 2020

THE NEW YORK TIMES | By Gina Kolata | Photographs by Tomás Karmelo Amaya | Aug. 13, 2020

The coronavirus is raging through the White Mountain Apache tribe. Spread across a large reservation in eastern Arizona, the Apaches have been infected at more than 10 times the rate of people in the state as a whole.

Yet their death rate from Covid-19 is far lower, just 1.3 percent, as compared with 2.1 percent in Arizona. Epidemiologists have a hopeful theory about what led to this startling result: Intensive contact tracing on the reservation likely enabled teams that included doctors to find and treat gravely ill people before it was too late to save them.

A crucial tool has been a simple, inexpensive medical device: an oximeter that, clipped to a finger, detected dangerously low blood oxygen levels in people who often didn’t even realize they were seriously ill.

Contact tracing is generally used to identify and isolate the infected, and thereby to slow the spread of the coronavirus. Elsewhere in the United States, the strategy mostly is failing; the virus has spread too widely, and tracers are struggling to keep up.

But on the reservation, contact tracers have discovered effective new tactics as they trek from home to faraway home. They may not have been able to stop the virus, but they have managed to prevent it from causing so many deaths.

“This is really not about contact tracing cutting down spread,” said Dr. Arnold Monto, a professor of epidemiology and public health at the University of Michigan who was not involved in the project but reviewed the findings. “Do it right, and the mortality will be lower.”

“This could help with other hard-to-reach communities,” he added. “If we identify cases sooner, they won’t come in half dead with horrible lungs.”

This approach, which doctors at the Indian Health Service laid out recently in the New England Journal of Medicine, may offer a new strategy for reducing Covid-19 deaths in some of the hardest-hit communities, Dr. Monto and other experts suggested — especially among people of color who more often live in housing where multiple generations share space.

Dr. Vincent Marconi, director of infectious diseases research at Emory University in Atlanta, said it was “incredible” that contact tracing could have such an effect on a population so disadvantaged and at such high risk.

» Continue reading and view photographs at link below:

UArizona Health Sciences awarded $1.35M in COVID-19 relief funds for rural hospitals in Arizona
Posted: May 13 2020

DAILY INDEPENDENT | May 12, 2020

Rural hospitals have struggled with a unique set of challenges long before the coronavirus pandemic, which has placed even more burdens on these much-stressed health care providers.

To assist Arizona’s rural hospitals, the U.S. Health Resources and Services Administration has awarded the University of Arizona Health Sciences $1.35 million to support the Small Rural Hospital Improvement Program at the Center for Rural Health in the UArizona Mel and Enid Zuckerman College of Public Health.

The source of the funding is the Coronavirus Aid, Relief, and Economic Security Act, which allocated $150 million for SHIP-eligible hospitals in the United States. In Arizona, 16 rural hospitals are eligible to receive as much as $71,500 over the next 18 months to prevent, prepare for and respond to COVID-19, according to a release.

“This funding is a much-needed source of good news for rural hospitals,” Leila Barraza, JD, MPH, assistant professor and public health lawyer at the Mel and Enid Zuckerman College of Public Health, said in the release. “These rural facilities continue to serve Arizonans traveling long distances for primary, preventive, emergency and inpatient care.” She is principal investigator of the HRSA initiative.

The SHIP program allows the Center for Rural Health to assist with the following:

  • Ensure patient and hospital personnel safety to minimize COVID-19 exposure.
  • Address emergent COVID-19 issues, including testing, lab, patient and community education.
  • Restore, sustain and strengthen hospital capacity and staffing levels by reinstating and reassigning providers, hiring new providers or contractors and/or increasing staff time to respond to coronavirus and continue hospital operations.
  • Complete minor alteration and renovation to maximize isolation precautions and facilitate telehealth.
  • Purchase equipment, including health information technology and telehealth equipment, vehicles, triage tents and mobile medical units.
  • Purchase supplies, including COVID-19 therapeutics and vaccines, when available.

“As we adjust to the COVID-19 pandemic, rural hospitals in Arizona face greater challenges with fewer resources,” University of Arizona President Robert C. Robbins, MD, said in the release. “The funding from HRSA will give rural hospitals critical support to build capacity to mitigate this pandemic in the communities they serve. The CARES Act provides much-needed support to rural hospitals, and I am proud the University of Arizona can assist those in need.”

“The HRSA award to support our University of Arizona Center for Rural Health’s Small Rural Hospital Improvement Program illustrates how academic medicine-community partnerships align with our land-grant university mission and underscores our commitment to the health providers and facilities so critical to Arizonans living in rural areas,” Michael D. Dake, MD, senior vice president of UArizona Health Sciences, said in the release.

“Combined with our other HRSA and state-supported initiatives, like the State Office of Rural Health and the Medicare Rural Hospital Flexibility Program, we are able to quickly leverage this new HRSA funding to address unmet rural health needs during the COVID-19 pandemic in 16 rural Arizona hospitals,” Daniel Derksen, MD, health policy expert, said in the release. He is director of the Center for Rural Health and associate vice president at UArizona Health Sciences.

For information about current activities in the five health sciences colleges, go to the UArizona Health Sciences COVID-19 Resources webpage.

For the latest on the University of Arizona response to the novel coronavirus, go to the university's COVID-19 webpage.

‘The worst is yet to come.’ How COVID-19 could wipe out many rural hospitals
Posted: Apr 17 2020

PBS NEWS HOUR | April 16, 2020 | By Laura Santhanam

Rural hospitals in Texas have been bracing for COVID-19’s ominous arrival in their communities, only to be hit with another potential killer: a lack of patients and revenue to keep essential services operating on slim margins. 

Compared to urban coronavirus hot spots like New York, where hospitals have raced to meet the onslaught of infections, the spread in more remote communities has been mostly slow, thanks to social distancing efforts and a widespread lack of public transportation — for once, a benefit. But the measures have also slowed the flow of normal patients to a trickle, with potentially dire, long-term consequences for everyone who lives miles around.

In Dimmitt, Texas, a place known for family farms that raise cattle, cotton, corn and wheat, a rural 17-bed critical access hospital — one of 1,300 nationwide — serves the entire county’s 8,000 residents, who are spread across 900 square miles. Castro County Hospital District has seen times of financial trouble before, but for the past 17 years, it has been on a steadier course. Outpatient services, such as physical therapy for hip- and knee-replacement patients, have helped the hospital climb out of the red. Up until a month ago, the hospital’s staff “weren’t rich by any means, but we weren’t having issues making payroll,” CEO Linda Rasor said.

“The worst is yet to come. The rural health safety net is truly unraveling.”

Then COVID-19 arrived. After passing through larger cities like Dallas, Houston and San Antonio, Rasor said, the virus hit Dimmitt and “our revenue has just tanked.” 

Compared to three months ago, the number of patients coming daily to Rasor’s hospital and primary care clinic has dropped from 100 to 10, she said. Older patients who underwent recent hip- and knee-replacement surgeries (and stand at a higher risk for more severe health outcomes if infected with the virus) are “rehabbing at home” rather than coming in for physical therapy, Rasor said, after Texas issued shelter-in-place orders last month. Emergency 911 calls and rehabilitation services are down. 

“Nobody’s going anywhere, and they’re not utilizing health care,” Rasor said. “They’re just treating themselves at home.” 

It’s not just in Dimmit. With health officials across the country telling the public to stay home unless they need immediate medical care, rural hospitals have seen demand for services — and revenue — plummet. That’s problematic, because like so many other industries hit by this pandemic, hospitals are businesses, too. The national median amount of cash-on-hand for such institutions — the amount of money they have to make payroll and cover expenses — is enough to last just 33 days, according to recent research from the Chartis Center for Rural Health. Many facilities are approaching that turning point.

In Eastern Kentucky, Stephanie Courtwright Moore oversees White House Clinics, a regional network of nine clinics that offers primary and pediatric health care, dental services and behavioral therapy and treatment to 31,000 patients per year.

But since COVID-19, patient visits have nosedived by 90 percent, thanks to a statewide stay-at-home order (which she supports as good public health policy).

“If we need to do this for a month, or two months, I probably wouldn’t be as concerned,” she said. “The thought of this lasting four months, or six months, I just shudder at thinking what the financials will look like.”

The financial fragility of U.S. rural hospitals long predates the COVID-19 crisis. One out of five Americans lives in rural communities, but 453 rural hospitals are perched on the verge of closure, the report also found.

» Continue reading at link below:

Hospitals near ‘financial extinction’ from limits to prep for COVID-19
Posted: Apr 15 2020

CRONKITE NEWS - ARIZONA PBS | By Christopher Scragg

WASHINGTON – Arizona hospitals are facing “dire financial consequences” and furloughing staff, as cutbacks meant to prepare for COVID-19 cases have instead cost them as much as $575 million a month, about 30-40% of normal revenues statewide.

The cancellation of elective procedures meant to free up beds for potential coronavirus patients, combined with a drop in emergency room visits, has deprived hospitals of the “cash cows” they need to stay afloat in an industry that otherwise has margins of only 3-4%, advocates said.

The result is health care centers in financial distress, at risk of closing or reducing staff, said Dr. Daniel Derksen, director of the Arizona Center for Rural Health at the University of Arizona.

“If you don’t have the revenues to support paying your nurses and physicians and staff and transport, lab, imaging, X-rays, those types of things, it creates just an untenable situation,” Derksen said.

Advocate said Congress included $30 billion for hospitals when it passed the $2 trillion Coronavirus, Aid, Relief and Economic Security, or CARES Act, last month. Arizona hospitals have already seen $220 million in assistance from the bill.

Arizona Hospital and Healthcare Association President Ann-Marie Alameddin said the money helps – some – but she called it “insufficient” at a time when state hospitals are seeing losses twice that amount every month.

Gov. Doug Ducey last month issued two executive orders directing hospitals to simultaneously increase capacity while cutting non-essential surgeries like knee replacements and minor cancers. Hospitals complied, but it was not without cost, said Arizona Public Health Association Executive Director Will Humble.

“Revenue is down and expenses are up,” Humble said. “If you don’t have the cash reserves to carry yourself through, you’re in big trouble fast even meeting payrolls.”

Derksen said rural hospitals serving smaller areas are facing a particularly tough challenge.

“Some of these hospitals in these smaller areas … the number of days they could stay open if their revenue completely stops can be as little as 30 days,” Derksen said.

Alameddin said hospitals across the state often operate in a precarious situation and are susceptible to drops in cash flow.

“Financially, hospitals typically have fairly small margins, maybe 3-4% so they simply do not have the margins to absorb those losses,” she said.

Advocates said one way hospitals might recover is by loosening restrictions on elective surgeries, within reason. Humble posed a hypothetical change under which hospitals would allow elective surgeries until a specified capacity percentage is reached that still leaves room for COVID-19 patients.

“That would be a policy change that wouldn’t cost the state any money but would allow the hospitals to bring in more revenue and at the same time allow patients to get some procedures that they’ve been waiting for,” Humble said.

Alameddin said the goals of Ducey’s executive orders are laudable but that, based on new recommendations from the federal Centers for Medicare and Medicaid Services, it may be time to reassess the restrictions on hospital services.

“I think it was the right call at the time but now we have better data,” she said. “It would be appropriate to allow those hospitals to be making that determination according to CMS guidance.”

Another possible source of help would be more federal funding. House and Senate leaders are currently negotiating on a proposal to add $250 billion to a small-business relief fund, but some Democrats are pushing for other industries to be added.

“I think many are hoping that this CARES II Act that they’re working on in Congress now would specifically address the acute needs in our rural and urban and underserved sites that are really on the brink of fiscal extinction right now because of this loss in revenue,” said Derksen.

He agreed with Alameddin that the $30 billion in hospital aid in the first CARES Act is “certainly not enough.”

In the meantime, Alameddin said that while precautions need to be taken for hospitals to be prepared for COVID-19 cases, the survival of hospital networks as the pandemic continues is of utmost importance.

“We’re going to be dealing with this potentially a year to 18 months out and the hospital infrastructure needs to be strong to meet that challenge,” she said. “We need finances to do that.”

» See more at link below:

AZ PBS - Arizona Horizon: The Impact of Corona Virus on Already Struggling Rural Hospitals
Posted: Apr 14 2020

Watch the April 13 Arizona Horizon episode from Dan Derksen's interview with Ted Simons (from 2min:20sec to 9min:10sec).

 

Navajo Nation and Arizona's Rural North Bear the Brunt of Its COVID-19 Deaths
Posted: Apr 10 2020

PHOENIX NEW TIMES | ELIZABETH WHITMAN | APRIL 10, 2020

COVID-19 is striking Arizona's rural areas harder than urban ones, exacting a disproportionate toll on communities thin on medical care and basic infrastructure, an analysis of Arizona's positive cases and deaths shows.

Nowhere is that more evident than on the Navajo Nation, which on Thursday confirmed it had 405 cases in Arizona, out of 558 across the entire reservation, which spans portions of Arizona, Utah, and New Mexico. That means that the Nation is home to 1.4 percent of Arizona's population but now has slightly more than 13 percent of the state's current COVID-19 cases.

Twenty-two people have died on the Nation, where an evangelical church rally in Chilchinbeto on March 7 is believed to be a source of the outbreak. At the end of March, the Navajo Nation implemented a curfew, from 8 p.m. to 5 a.m., in an effort to stop the spread. Acknowledging the severity of the pandemic for the Navajo Nation, Arizona Governor Doug Ducey on Thursday called the COVID-19 crisis on the Navajo Nation "top of my mind."

State and county data also show that the heavy coronavirus toll on the Nation makes the toll in each of the northern Arizona counties it spans — Coconino, Navajo, and Apache — also disproportionate to their populations.

Just over 143,000 people live in Coconino County, which stretches over 18,600 square miles of northern Arizona. The county is home to less than 2 percent of the state's population, yet it currently comprises nearly 14 percent of the state's deaths from COVID-19, the illness caused by the new coronavirus. 

As of Friday, Coconino County data showed that of its 206 cases, 61 percent are in tribal communities. According to the U.S. Census Bureau, 27.6 percent of people Coconino County identify as American Indian. 

The remaining cases are in Flagstaff (20 percent), Page (18 percent), or other cities (1 percent). Nearly half of cases are people 55 years and older. 

The county is not publishing a breakdown of data on the locations of deaths out of concern that people could be identified, county epidemiologist Matthew Maurer said during a press call on Thursday, although that could change as the cases and deaths rise in number.

Figures from the two other northern counties that overlap with the Navajo Nation similarly show the concentration of cases. 

Just under 1 percent of Arizonans live in Apache County, in the northeast corner of the state. Yet 1.8 percent of the state's COVID-19 cases and 3.2 percent of deaths from the virus are there. 

"Right now, all of our positive cases in Apache County have been on the Navajo Nation," county health department Director Preston Raban told Phoenix New Times. "All of our deaths have been on the Navajo Nation."

Areas of the county outside of the reservation have no positive cases so far, Raban said, adding, “Nothing yet has gone south of I-40 in our county.”

Navajo County, the band of nearly 10,000 square miles between Apache and Coconino County, has 1.5 percent of Arizona's population and 7.5 percent of its COVID-19 deaths.

The county doesn't publish a detailed breakdown of cases or deaths, but Brian Layton, the assistant county manager, said most of them are on the Navajo Nation.

“We have seen some cases here, off tribal land, but not nearly as many” as on the Nation, Layton told New Times.

A voicemail and email to a spokesperson for the Navajo Nation were not returned.

So far, the COVID-19 pandemic has drawn attention to metropolitan areas, where the absolute numbers of cases are "eye-popping," said Dr. Dan Derksen, the director of the Arizona Center for Rural Health at the University of Arizona in Tucson.

Maricopa County, for example, had 1,741 cases of COVID-19 as of Friday — nearly 56 percent of cases in the state. But it is also home to nearly 4.5 million people, or just under 62 percent of the state's population, meaning that the proportion of the state's cases is lower than its proportion of the state's population.

In Arizona's vast, sparsely populated areas, including on reservations, not only do people have less access to medical care than their rural counterparts, but they also tend to have risk factors that heighten their risk of being hospitalized and put on a ventilator — or dying — because of COVID-19, Derksen said.

"There tend to be more low-income elderly who live in rural areas," Derksen said. And those elderly tend to have underlying conditions, such as asthma, emphysema, diabetes, or high blood pressure, that make them more prone to the ravages of COVID-19. 

Lack of running water also presents challenges with hand-washing to prevent spread of the virus.

The only other county as disproportionately affected by COVID-19 is Pima County, which is home to 14.3 percent of the population but has nearly 28 percent of its COVID-19 deaths. 

If people in rural areas can reach them — if they have working cars, if the road is good enough — Arizona has 15 critical access hospitals, which are designated by the federal government for having a maximum of 25 beds and being at least 35 miles away from other health care facilities.

» Continue reading at link below:

 

AHCCCS to Provide Funding to Critical Access Hospitals
Posted: Apr 8 2020

The Arizona Health Care Cost Containment System (AHCCCS) Wednesday announced it would make more than $50 million in accelerated hospital payments and advances and extend an additional $5 million in new COVID-19 related funding to Critical Access Hospitals throughout the state.

The Arizona Hospital and Healthcare Association, representing over 80 hospitals and healthcare members in Arizona, applauds the quick action on behalf of AHCCCS and Governor Doug Ducey to provide this critical funding to our hospitals working on the front lines of this COVID-19 pandemic response.

“On behalf of AzHHA member hospitals across the state, I would like to thank Governor Ducey and AHCCCS Director Snyder for making these funds available,” said AzHHA President and CEO Ann-Marie Alameddin. “We hope they will leverage new and existing funds to help offset the $430 million to $575 million in monthly losses hospitals are reporting. Healthcare providers are facing severe cash shortages NOW. Cash reserves are being depleted drastically and many facilities will have no cushion to pay salaries and purchase needed supplies to respond to the disaster.”

AzHHA analyzed data from the 2018 Uniform Accounting Report to calculate the revenue loss to Arizona hospitals. Member hospitals report revenues are down 30-40% due to the cancellation of elective procedures and a reduction in emergency department visits. On a statewide basis that would equate to a revenue reduction of $430 million to $575 million per month.

The covid-19 crisis is going to get much worse when it hits rural areas
Posted: Apr 6 2020

THE WASHINGTON POST | By Michelle A. Williams, Bizu Gelaye and Emily M. Broad Leib  | April 6, 2020 at 7:00 a.m. MDT

Michelle A. Williams is dean of the Harvard T.H. Chan School of Public Health. Bizu Gelaye is an assistant professor at Harvard and Massachusetts General Hospital. Emily M. Broad Leib is a law professor, director of the Harvard Law School Food Law and Policy Clinic and deputy director of the Harvard Law School Center for Health Law and Policy Innovation.

Over the past few weeks, our urban centers have scrambled to mobilize in response to the mounting covid-19 cases. But be forewarned: It’s only a matter of time before the virus attacks small, often forgotten towns and rural counties. And that’s where this disease will hit hardest.

Covid-19 is infiltrating more of the country with each passing day. Colorado, Utah and Idaho are grappling with sudden clusters in counties popular with out-of-state tourists. Cases are also skyrocketing in Southern states such as Georgia, Florida and Louisiana. So far, sparsely populated communities have been better insulated from the spread. But since no place in the United States is truly isolated, there’s simply no outrunning this virus. Every community is at imminent risk.

Rural communities could fare far worse than their urban and suburban counterparts. Rural populations are older on average, with more than 20 percent above the age of 65. Rural populations also tend to have poorer overall health, suffering from higher rates of chronic illnesses such as heart disease, diabetes and lung conditions, all of which put them at greater risk of becoming severely ill — or even dying — should they become infected.

Rural areas also already suffer from a rural mortality penalty, with a disparity in mortality rates between urban and rural areas that has been climbing since the 1980s. Chronic financial strain and the erosion of opportunity have contributed to “deaths of despair” as well as a rise in conditions such as heart disease, Type 2 diabetes and stroke. Add in prolonged social distancing and the economic downturn, and these trends will surely worsen.

Long before the novel coronavirus emerged as a threat, America’s rural hospitals were already in dire financial straits. About 1 in 4 are vulnerable to being shuttered, with 120 having closed in the past decade. With the pandemic looming, many of these health systems have been forced to cancel elective procedures and non-urgent services such as physical therapy and lab tests, which in some cases account for half of their revenue. As cash flow wanes, the American Hospital Association warns that even more hospitals could be forced to shut their doors exactly when patients need them most.

Rural counties have just 5,600 intensive care beds total, compared with more than 50,000 in urban counties. In fact, half of U.S. counties do not have any ICU beds at all. And even if these counties are somehow able to scale up their infrastructure, experts are afraid there will not be enough health-care workers to staff them. The time to prepare rural America is now. Fortunately, rural health systems will get some relief from the stimulus bill, which allocated $100 billion to health-care providers. But it is critical that we find additional ways to alleviate the burden on these health systems to the greatest extent possible.

One way to do that is by expanding telemedicine capabilities, which will allow millions of Americans to be seen by care providers even if there’s no room for them in hospitals. The Centers for Medicare & Medicaid Services recently issued guidelines that expand access to telemedicine for Americans on Medicare. That directive now includes federally qualified health centers, rural health clinics and hospices, so they, too, can be reimbursed for serving patients remotely.

Of course, telemedicine is far from a panacea, as broadband access remains limited in so much of rural America. The stimulus included an additional $100 million for rural broadband access, but this will not be enough. In the long term, policymakers must continue to close the “digital divide,” recognizing that Internet access is both an economic and health necessity. In the short term, Internet service providers should consider rolling out mobile Internet units and providing WiFi hotspot access to temporarily increase connectivity.

More importantly, we must expand the social safety net, especially the Supplemental Nutrition Assistance Program, child nutrition programs, Supplemental Security Income, housing assistance and Medicaid. Lawmakers must also ensure the availability of these programs to rural residents. For example, unlike their urban counterparts, many rural children cannot come to schools each day to pick up meals. The Agriculture Department launched a pilot program to deliver meals to rural children in some regions, but initiatives such as this should be more widespread.

It is clear the battle against covid-19 will look vastly different in the heartland than in our cities. The U.S. Navy won’t be docking a floating hospital in Nuckolls County, Neb. But if what’s happened in America’s coastal cities can teach us anything, it’s that the coming weeks will determine the trajectory of this virus. And we don’t have a moment to waste.

Rural areas fear spread of virus as more hospitals close
Posted: Apr 2 2020

THE WASHINGTON POST | April 1, 2020 | By Jay Reeves | AP

CARROLLTON, Ala. — As the coronavirus spread across the United States, workers at the lone hospital in one Alabama county turned off beeping monitors for good and padlocked the doors, making it one of the latest in a string of nearly 200 rural hospitals to close nationwide.

Now Joe Cunningham is more worried than ever about getting care for his wife, Polly, a dialysis patient whose health is fragile. The nearest hospital is about 30 miles away, he said, and that’s too far since COVID-19 already has been confirmed in sparsely populated Pickens County, on the Mississippi state line.

Cunningham is trusting God, but he’s also worried the virus will worsen in his community, endangering his wife without a hospital nearby.

“It can still find its way here,” said Cunningham, 73.

The pandemic erupted at an awful time for communities trying to fill health care gaps following the closure of 170 rural hospitals across the nation in the last 15 years. 2019 was the worst year yet, with 19 closures, and eight more have shut down since Jan. 1, according to the Sheps Center for Health Services Research at the University of North Carolina.

While the nation’s coronavirus hot spots so far have been big cities like New York and New Orleans, officials fear inadequate testing and the lack of medical resources linked to hospital failures will catch up with smaller population centers.

The reasons for the closures vary, but experts and administrators cite factors including declining rural populations, rising medical costs, insufficient Medicare reimbursements, large numbers of uninsured patients, state decisions against Medicaid expansion and mismanagement. About 60% of the counties and towns that have lost hospitals are in the South, an analysis by the Sheps Center showed.

Other communities are trying to keep hundreds of endangered hospitals afloat as resources are stretched thinner than ever and moneymaking services like elective surgeries are curtailed during the outbreak.

“It’s a scary time to be thinking about losing a hospital when you’ve got a pandemic going on,” said Scott Graham, chief executive officer of Three Rivers and North Valley Hospitals in central Washington. The hospitals serve about 26,000 people in a wide-open area that Graham describes as so remote it’s more frontier than rural.

In North Conway, New Hampshire, a physician at the 25-bed Memorial Hospital already is among the county’s seven confirmed cases of coronavirus, said CEO Art Mathisen. The hospital is preparing for the worst as it tries to triple the number of beds and spends upward of $100,000 on rooms with air flow aimed at limiting the spread of contagions, he said.

About 15% of the U.S. population, or more than 46 million people, lives in rural areas, according to the Census Bureau. They are more likely than urban dwellers to die from chronic respiratory illnesses, heart disease and other problems that put people more at risk for COVID-19, the illness caused by the virus, according to the Centers for Disease Control and Prevention.

For most people, the coronavirus causes mild or moderate symptoms, such as fever and cough that clear up in two to three weeks. For some, especially older adults and people with existing health problems, it can cause more severe illness, including pneumonia, and death.

In West Virginia, where no city has a population of more than 50,000 and 20% of residents are senior citizens, frustration has mounted over two recent hospital closings that forced patients to seek help farther away. A tentative purchase deal was announced Wednesday for a third hospital that had said it would shut down sometime in April. There has been talk but no immediate action to open new facilities to deal with coronavirus cases in one of the unhealthiest states.

“We certainly need our local hospital. We need the beds. We need the equipment, and we need it locally,” said Michael Angelucci, a state lawmaker who operates an ambulance service in rural Fairmont, West Virginia, where a hospital closed this month.

» Continued at link below:

Study: Arizona hospitals could be overwhelmed by COVID-19 case surge
Posted: Mar 20 2020

By Christopher Scragg | Cronkite News | Thursday, March 19, 2020

WASHINGTON – A surge in coronavirus patients could overwhelm Arizona hospitals in the coming months if action is not taken now to expand hospital capacity and curb infections, according to a new study by the Harvard Global Health Institute.

And the state is not alone.

The study, published Tuesday with ProPublica and the New York Times, says American hospitals face a “daunting” future that other parts of the world have seen, said one of the report’s authors.

“Without seeing the numbers, the risk seems theoretical,” said Thomas Tsai, a surgeon and one of the project leads at Harvard. “But looking at the numbers it really breaks through the notion that somehow we’re different from the rest of the world.”

Arizona health experts said they are well aware of the potential danger and doing all they can to prepare. But they also warned that the numbers in the report “paint a worst-case scenario” and worry it will cause more alarm than necessary.

“It’s something that we need to take with caution because if you look at their modeling, the way they did the numbers, it’s based on assumptions that may or may not happen,” said Holly Ward, a spokeswoman for the Arizona Hospital and Healthcare Association.

The report looked at the average number of available hospital beds in each of 305 designated hospital “referral regions” in the country. It compared that to the number of patients that could be expected to flood hospitals under nine different scenarios: When 20%, 40% or 60% of adults were infected with the coronavirus over a span of six, 12 or 18 months.

In most of the scenarios, the report said, “the sheer number of patients at risk for COVID-19 may overwhelm the system if preparations are not taken.”

Arizona has four such regions, the largest being Phoenix and Tucson, which respectively have 2,567 hospital beds and 1,184 beds available on average. The two smallest, Mesa and Sun City, average 648 and 364 unoccupied beds.

In all but the most-mild scenarios, capacity in each of Arizona’s four regions was quickly reached or exceeded. In more dire predictions, hospitals would end up with just a fraction of the beds needed to treat the influx of patients.

If, for example, 40% of the population got sick over six months, the Mesa-Chandler region would need to increase its capacity by 971%, the report said. The Phoenix region – which stretches to include Flagstaff and Yuma – would need to increase its beds by 598%.

Mark Coleman, a registered nurse in Phoenix, said as coronavirus patients begin to increase, he fears shortages of beds and other supplies will lead Arizona to experience issues similar to what New York is facing.

“They are quickly running out of ventilators and attaching multiple people to a single ventilator,” he said of New York hospitals. “We could probably look forward to that in the near future when there is a surge.”

But state hospitals said they are actively planning for the oncoming waves of cases and working with local and state governments to prepare.

“Hospitals prepare every day, every month, every year for emergency preparedness,” Ward said. “This is not new to Arizona hospitals.”

Daniel Derksen, a University of Arizona professor of public health, agreed with Ward that the numbers in the report need to be considered carefully, pointing to the many unknowns with COVID-19, partially due to the lack of testing and slow results in the U.S. He said in an email that studies like Harvard’s “can paint a worse-case scenario that alarms a lay public.”

“Until we get the testing kits more widely available and the more rapid turnaround of those results it’s hard to really comment on how reflective this would be in the near or longer term for our state or for our country,” Derksen said in a telephone interview. “The math can get pretty complicated and the further you get down into the subsets on a set of assumptions I think the less certain you can be.”

Tsai recognizes that his study paints an extreme scenario, but said it’s important information for doctors and decision makers to understand the gravity of the pandemic.

“I think there’s still room for optimism, and the goal of putting our data out into the public sphere is to not incite panic but to instill collective action,” Tsai said.

Derksen agreed that whether the report reflects “reality or not, I think in a pandemic it’s always better to prepare for the worst case scenario.”

Experts agree that the best strategy to prepare for the pandemic is two-fold. The first strategy is to slow down the rate of infections through practices like social distancing and hand-washing to “flatten the curve” in the growth of confirmed cases. The second is to increase hospital capacity.

But Tsai said you can’t do one strategy without the other.

“The importance of the ‘flatten the curve’ concept is that it basically buys time for the second approach, which is, hospitals increase the capacity of their hospital beds,” Tsai said.

That’s easier said than done, Coleman said.

“There’s a lot of regulation infrastructure behind opening up a hospital room,” he said. “I wish it were as simple as slapping a cot on the floor.”

Despite the obstacles, Coleman said he was optimistic that with the government assistance, hospitals and healthcare workers would be ready to meet the challenge.

“We have to be, there’s not another choice right now,” he said.

Arizona Could Face Hospital Bed Shortage in Worst-Case Coronavirus Spread
Posted: Mar 17 2020

PHOENIX NEW TIMES | Steven Hsieh | March 16, 2020

Could Arizona handle a widespread coronavirus outbreak, such as those seen in Italy and China?

It doesn't appear so. At least, not with how things stand now.

The state has one of the lowest number of hospital beds in the country, according to a 2018 analysis from the Kaiser Family Foundation. With about 1.9 beds for every 1,000 people, Arizona ranks among the bottom 10 states.

There are 14,790 available hospital beds in Arizona as of Monday, according to Holly Ward, a spokesperson for the Arizona Hospital and Healthcare Association (AZHHA). That's out of a total of roughly 16,000 licensed beds in the state.

The CDC estimates that between 2.4 million to 21 million Americans could require hospitalization for COVID-19, the disease caused by the coronavirus. Do the math in Arizona, a state of about 7.1 million people, and that's about 50,000 hospitalizations for a conservatively estimated outbreak, and 460,000 in the worst-case scenario.

USA Today's own nationwide analysis found that Arizona would only have one bed available for every 22 to 24 severely ill patients amid a serious coronavirus spike.

It's unclear how many of those beds are located in intensive care units equipped to treat severe cases of COVID-19. Neither Arizona health officials nor the AZHHA could provide that information by deadline.

Also unclear is Arizona's supply of ventilators, which have been necessary in some cases to keep coronavirus patients alive. Neither Arizona health officials nor the AZHHA could provide that information by deadline. Banner Health also did not have the number of ventilators in their system offhand. 

Public health experts have warned that ventilator shortages could become a problem nationwide if large outbreaks of coronavirus happen in the United States. 

During a press conference on Monday, Banner Health Chief Medical Officer Dr. Marjorie Bessel said there is no current shortage of beds or ventilators. "I want to be clear about this," Bessel said. 

But she could not answer a question from a reporter asking whether Banner — the largest health care system in Arizona — could handle a large surge of coronavirus cases.

"At this time it is a very fluid situation," Bessel said. "We are taking absolutely every planning step we can, working very closely with the county, the state and other federal agencies to put ourselves in the best possible position to rise to the occasion and take care of everybody in the state of Arizona who is going to need us."

Bessel added that Banner has "plans for alternatives sites of care," should the network reach bed capacity, but did not elaborate on what those sites may be. 

During the press conference, Bessel repeatedly emphasized the importance of "social distancing" and personal hygiene (washing hands, avoiding face-touching) to prevent the spread of the coronavirus. Known as "flattening the curve," the concept aims to slow down the virus so as not to overwhelm hospitals.

"It’s very important that gatherings of more than 200 people stop," Bessel said. "Gatherings of more than 50 people should stop. Individuals over the age of 60 should not be in a gathering of more than 10."

To prevent the spread of coronavirus within its own facilities, Banner has implemented visitor restrictions. Patients will only be allowed one visitor a day, and Banner will conduct temperature screenings on everyone who comes into a hospital. Those who show symptoms of illness will not be allowed to visit patients.

Bessel said that Banner is also considering a moratorium or a significant reduction in elective surgeries to free up space in case of a coronavirus case surge.

Just as critical as beds and medical equipment will be adequate hospital staffing, said Dr. Daniel Derksen, associate vice president for Health Equity, Outreach and Interprofessional Activities at University of Arizona Health Services. The Arizona State Department of Health Services has not answered a question on whether it has assessed the state's current medical workforce.

"Hospitals generally try to be lean and efficient and not have redundancies," Derksen said. "Measures will have to address how many people need those tertiary levels of care and how we build redundancies in our system as this goes along."

Critical to keeping staffing levels up will be ensuring that medical workers do not become infected, Derksen added. And keeping nurses and doctors healthy will require an adequate supply of protective gear, like masks and gloves.

At the press conference, Bessel said Banner does not currently have a shortage of protective equipment.

"If we begin to run short, we will work with state and federal agencies to secure supplies," she said.

 

‘We’ll improvise’: A resource-starved rural hospital steels itself for coronavirus’s arrival
Posted: Mar 15 2020

The WASHING POST | By Eli Saslow | March 14, 2020 at 6:51 p.m. MDT

DAYTON, Wash. — The hospital was still waiting on a test result for its first possible case of the novel coronavirus when the staff crowded into a meeting room late last week to finalize plans for a potential outbreak. Employees at tiny Dayton General Hospital had spent the past month marshaling what few resources they could as they watched the virus spread from China to Italy to Seattle and finally toward them in rural America, which they worried was the most vulnerable place of all.

“How are we on masks and protective gear?” asked Shane McGuire, the hospital’s CEO.

“Getting low,” the supply manager said. “I can’t buy anything. Everything’s out of stock.”

“How about our staffing?” McGuire asked. “We need to make contingency plans in case some of us get exposed and need backup.”

Nobody answered, and McGuire looked around the room at his pharmacy department of one, at his 70-year-old doctor, who was working alone in the emergency room, and at his lab director, who was now also in charge of infection control. Most people on his staff were already working multiple jobs to keep the hospital functioning. “I know we’re stretched thin as it is,” McGuire said. “We’ll improvise and make it work however we can.”

They had been doing exactly that for the past several years, somehow keeping the doors open even as America’s rural health-care system collapsed all around them, with 125 other rural hospitals around the country closing for budget reasons and doctor shortages spreading across 85 percent of rural counties. Dayton General could no longer afford to offer obstetrics, endoscopy or surgery of any kind. Its emergency room and nursing home were both losing more than $1 million per year. But the hospital remained the final lifeline for an aging community of about 5,000 people in a rugged corner of southeast Washington state, isolated from all other medical care by 35 miles of barley and wheat.

The employees in the meeting room took turns reviewing what they knew about the novel coronavirus. The Centers for Disease Control and Prevention said it was deadliest for the elderly, and Dayton residents were an average of 13 years older than people in the rest of the state. The virus was worse for people with underlying health issues, and, like most rural communities, Dayton had high rates of COPD, obesity, diabetes and heart disease. Experts estimated that as many as 1 million of the most vulnerable Americans might need to rely on lifesaving ventilators, and Dayton General had none.

“This is a virus that can take over and expose your weaknesses,” McGuire said, and he feared that was true for both rural residents and the beleaguered hospitals left to care for them.

» Continue reading at the link below:

The Health Care Worker/Hospital Shortage in Rural America
Posted: Jan 10 2020

National Conference of State Legislatures | By Mark Wolf | Dec 18, 2019

Phoenix—America’s rural hospitals are ailing; underpaid and squeezed by a population that is older, poorer, less insured and sicker than the nation at large.

And they're closing at a rate that alarms health officials, who are witnessing the emptying of the health infrastructure for a wide swath of rural America.

Rural hospital closures (118 since 2010, including 17 this year alone) are escalating, panelists told a session on “Health Care Access in Rural America” during NCSL’s Capitol Forum.

The closures contribute to a growing lack of health care coverage in rural America, said Dr. Dan Derksen, a family physician, rural health care expert and associate vice president for health equity, outreach and interprofessional activities at the University of Arizona.

“Once a critical access hospital (25 beds with a 24/7 emergency department and at least 35 miles from another facility) closes, they almost never come back,” he said.

Before Arizona expanded Medicaid under the Affordable Care Act, it ranked in the bottom five states for uninsured residents at 19%. Last year, the uninsured rate was 10.9%.

“We almost halved it but that’s still unacceptably high; 750,000 people don’t have ready access to care because they can’t get coverage,” Derksen said. “Half of those would be eligible for Medicaid or marketplace subsidy, but for a host of reasons, a significant portion doesn’t take advantage of it.

“Medicaid expansion stabilized the rural health situation. Administrators don’t like what Medicaid pays but it beats trying to get money out of folks who don’t have it.”

Legislation passed last year in Arizona will provide more than $18 million for Medicaid Graduate Medical Education (with a $10 million federal match), expanding medical students in primary care and tuition remission, rural broadband, rural prenatal telemedicine equipment and state loan repayment.

“We need to move the training pipeline closer to the area of need,” he said, citing the need for more residencies in rural areas. “The more likely you are to get them in a residency program, the more likely they are to stay.”

John Supplitt, a senior director (“I’m the rural guy”) at the American Hospital Association, said occupancy rates at rural hospitals average 40% and those with fewer than 50 beds have the lowest rate (33%) since 2015.

“They have a challenging payer mix that makes them more vulnerable to federal payer changes,” he said, adding that 56% of their revenue comes from Medicaid and Medicare. The broader trend of more outpatient procedures also hurts rural hospitals, where the increase in outpatients doesn’t offset the loss of inpatient volume.

Compounding the dependence on Medicaid and Medicare, rural residents are more likely to have high-deductible policies than city-dwellers, which means they may be unable to afford care.

On a hopeful note, Supplitt cited communities in Vermont and Georgia who worked with state agencies to add facilities to small towns.

“Not every community can maintain a hospital, but every community needs a medical presence,” he said. “It takes a lot of mobilization from both policymakers and health care providers to make that happen.”

Hawaii Senator Roslyn Baker (D) said her state, which expanded Medicaid in 2014, is facing a shortage of 800 primary care providers, which is most acute on the less-populated islands and exacerbated by the high cost of living and an aging population.

The state provides loan repayments for nurse practitioners, doctors and physician assistants and is expanding its telehealth capacities.

Only 49% of Kansas’ needs for health professionals are being met, said Senator Elaine Bowers (R) and five rural hospitals have closed in the state since 2010. Nearly three-quarters of rural Kansas hospitals are operating at a loss.

A visa waiver program eliminates the two-year home country residency requirement for non-citizen physicians who are international medical graduates if they commit to practicing in a health professional shortage area.

Kansas has not expanded Medicaid. Proponents fell one vote short of adding expansion to the legislative calendar this year.

An intriguing program is the University of Kansas Medical School campus in Salina (population under 50,000), which admits eight students per year and is the smallest medical school in the nation. The aim is to train students who will work in rural areas.

Haley Nicholson, a senior committee director in NCSL’s State-Federal Relations Division, briefed the session on Disproportionate Share Hospital (DSH) Payments, which states are required to make to hospitals serving a high number of Medicaid and other low-income patients and the Rural Health Demonstration funding through the Centers for Medicare & Medicaid Services.

The program would give rural areas seed money to help redesign their health care systems and encourage providers in those areas to participate in value-based care. The money could be spent on telehealth development or hub and spoke models. Details are pending.

Mark Wolf is editor of the NCSL Blog.

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