News for CAHs and RHCs

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.

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.”

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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.

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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.

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.

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.

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National Rural Health Association | Rural Health Voices 
Author: Angela Shultis | Monday, Jun. 24, 2019

In 2002, Meeker Memorial Hospital in Litchfield, Minn. – population 6,500 – was at risk of joining the growing number of rural hospitals in the U.S. unable to maintain positive profit margins. Eighty-one rural hospitals closed between 2010 and August 2017, according to University of North Carolina’s Cecil G. Sheps Center for Health Services Research, and many others are vulnerable. About 41 percent of rural facilities operated with negative margins in 2016, a Chartis Group and iVantage study of 2,100 hospitals revealed. Hospital closures in small towns like Litchfield mean patients lose access to their closest emergency room, and local economies suffer devastating blows.

A single phone call may have changed Litchfield’s fate. A hospital board member called Mark Madden, an old friend who had grown up in the small community. He knew Madden had become a search consultant, helping health care organizations find qualified executives to fill vacant leadership roles. Madden, whose 86-year-old mother still lives in Litchfield, happily accepted the challenge.

Battling the currents of health care change
Meeker Memorial was a century-old pillar of the community Madden loved, but for nearly a decade the facility had weathered shrinking health care margins. As a result, certain structures, equipment, and technology required modernization, and the small facility was unable to accommodate additional patient volume. These factors, among others, hampered both patient and physician attraction.

Madden’s first priority was to meet with the hospital’s board members, physicians, and direct reports to understand what it would take to turn things around.

“Mark had a way of getting to the heart of things and really helped us hone in on the precise competencies and profile we needed in our next CEO,” says former Meeker Memorial Board Member Mike Huberty, who worked with Madden on subsequent searches.

A pivotal moment in Meeker Memorial’s journey
It was time for Meeker Memorial to make some big changes. The hospital was on the verge of losing money, the board had developed a strained relationship with the exiting CEO, and relationships with local providers were poor. Madden set out to find qualified leadership candidates and educate the board on how they would need to change their working relationship with the incumbent, if he or she were to be successful.

The priority was to identify health care leaders with the following attributes:

• A firm grasp on the future of health care and a vision for how Meeker Memorial could develop a strategy to provide the community with high-quality, sustainable care.
• The ability to collaborate with board members, government and community leaders, physicians, and the greater medical community on a common vision.
• Strong financial and operational experience to ensure financial viability.

In May 2002, Mike Schramm was hired as CEO. He had turned around a smaller hospital and clinic system in Sibley County, Minn., about 50 miles from Litchfield. Meeker Memorial was a larger hospital with a strong medical staff, which appealed to Schramm.

“Mark has very good political instincts, he had a good read on the operational challenges, and his insights prepared me well for the role,” Schramm says of his experience working with Madden. “I knew exactly what I was getting into, which is a tremendous benefit when you’re entering a new organization.”

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