Magazine October 2019

Condition Critical: Arkansas’ Rural Hospitals Face Complicated Future

condition

by Dwain Hebda

Every community in America has local institutions that define its identity. For many, it’s a high school and the pride it engenders. For some, it’s a local attraction, business or natural resource, from ducks to diamonds. For still others, it’s the connection to famous residents and the companies or institutions they founded. 

None the least of these, particularly in the rural reaches of our state, is the community hospital, the harbinger of hope and a symbol of local prosperity. Ask any town that has one and they’ll point to it with pride; talk to a community that doesn’t — or worse, lost theirs — and the tone turns grim.  

From Arkansas’ State Capitol to Main Street, from the Boston Mountains to the Delta, hospitals are as universally valued as they are challenged in the current health care climate. 

“I’m impressed with the level of commitment that we have within our state from those organizations that are administering our hospitals, particularly our rural hospitals,” says Sen. Missy Irvin, R-Mountain View. “They understand the importance that a hospital plays for their community, and not just in taking care of the health needs of those communities. They also understand they are really the cornerstone of that local economy. 

“[A local hospital provides] not just jobs but serves a basic need. It makes it attractive for people to want to move there, to want to raise their kids in that community. A viable health care community is absolutely the cornerstone of any growing, thriving local economy.” 

Yet for as much as hospitals are valued within a community, it’s an industry that’s been subject to regulatory and financial strafing unlike any other over the past decade or so. From discordant federal health care reform to local health care personnel shortages to patient populations swollen with the ranks of the uninsured, hospitals operate on a business model that’s a universe apart from other industries. 

“At the Arkansas Hospital Association, they told me that if a hospital made 1-percent-a-year profit, they were doing well,” says Sen. Eddie Cheatham, D-Crossett. “Of course, they’re not there to make money; it’s just keeping their head above water. But show me another business that could do that and survive. 

“In my senate district in the southeast corner of the state, I’ve got seven hospitals. If things got real tight, we’d probably lose two.” 

In 2019, two hospitals in Arkansas have closed shop: DeQueen Medical Center, a rural hospital, and North Metro Medical Center in Jacksonville. Unfortunate though that statistic is, it’s a far cry from industry watchers predicting wholesale closings. In fact, compared to neighboring states, Arkansas is in much better shape.  

“I will tell you first of all, that we haven’t seen the closures that they’ve seen in other states — Texas, Missouri, Oklahoma, Tennessee, Mississippi,” says Bo Ryall, president and CEO of the Arkansas Hospital Association. “There have been 44 closures in the last 10 years. We have not seen those closures here in Arkansas.”  

Ryall has a simple explanation for that, too — Arkansas Works, the Medicaid expansion compromise hammered out over the last couple of legislative sessions — and industry watchers agree. Governing.com reported in August the three Southern states that had expanded Medicaid coverage through 2017 — Kentucky, Louisiana and Arkansas — had suffered far fewer of the nation’s 113 rural hospital closings since 2010 than those that didn’t.  

The site noted Texas led the nation with 20 rural hospital closings during that timeframe, followed by Tennessee with 12 and Oklahoma and Georgia with seven each. Mississippi Today reported in February that almost half of that state’s 64 rural hospitals were at risk of going under. 

“The expansion of Medicaid has been significant for Arkansas hospitals, decreasing the uninsured rate and the uncompensated care for hospitals. That has saved a number of hospitals,” Ryall says. “So certainly, the legislature and the governor have done a great thing by hospitals by passing that piece of legislation and funding it and keeping that going since 2013. That has been very successful.” 

“I was here when we passed the Affordable Care Act, and we thought that was going to be the answer to the charity care that Arkansas was providing.” — Rep. Fred Love

Ryall says there was more work to be done legislatively to help hospitals regain their vigor and noted one committee had already been revived to do just that. The Arkansas Legislative Council Subcommittee on Medicaid and Hospitals, which had laid dormant for some time, was resuscitated by Rep. Fred Love, D-Little Rock. He co-chairs the committee with Cheatham. 

“We did not focus any [legislation] on rural hospitals this legislative session, so that was a concern of mine,” Love says. “Then we had the hospital in DeQueen close, and we also had some that were on the brink of closure, but through some other initiatives they were saved. 

“I really wanted to reengage this committee because we need to look at the health of our rural hospitals. I was here when we passed the Affordable Care Act, and we thought that was going to be the answer to the charity care that Arkansas was providing. While that did assist the hospitals, there is still an issue, and it’s a combination of the health of Arkansans and the health of our systems.” 

The committee has scheduled a series of town hall meetings to get input from community and hospital officials in rural areas to gain best practices to share and discuss ways the legislature can get involved. Love says the overall intent is to get a firsthand grasp on the issues these facilities face. 

“I want to go into the rural areas where the hospitals are and look at these facilities,” he says. “It’s not really the legislature’s job per se to go and judge the facilities of a hospital. However, we should be concerned. I want to go and visit these rural hospitals, these critical access hospitals, so that we can see what is going on to ensure the care Arkansans are receiving is what it should be.” 

Irvin, vice chair of the Arkansas Legislative Council’s Hospital and Medicaid Study Subcommittee, also sees a role for lawmakers to play in helping increase the number of health care professionals headed to rural areas after graduating medical or nursing school. She cited a statistic that medical personnel tend to stay within 60 miles of where they serve their residency, so creating more residency programs in small hospitals is key. 

“Under our current administration with UAMS, [Chancellor] Dr. Cam Patterson has a holistic vision for the health care of the state,” she says. “He is working really hard to reestablish rural residency programs and more of them. That to me is the number one challenge and need that we have. 

“[U.S.] Sen. John Boozman [R-Arkansas] has a bill in front of Congress right now to increase the funding for more residencies. We need them, or we’re going to be in a state of emergency, in my opinion. Medicare partially pays for these residency spots, but there was a cap put on that funding in 1996. That was a mistake.” 

Medical technology is another way smaller hospitals are staying competitive. This technology helps smaller health centers stay connected with needed medical specialties in other places, enabling them to treat more patients closer to home. Dr. T. Glenn Pait of UAMS and Dr. Carolina Cruz-Neira of UA Little Rock are collaborating on health care applications for virtual reality.  

“We have a completely virtual training system that is not targeted to medical students, it’s actually targeted to physicians,” Cruz-Neira says. “Like all of us, when we become professionals we specialize sometimes very narrowly into something we do all the time. But once in a while, we might encounter something that is within our discipline, but something we haven’t done in a while, so we need a bit of a refresher.  

“Maybe a doctor is always focusing on the first three vertebraes of the spine and now he has a patient that is actually vertebrae number five. It’s not something that the doctor sees very often. We are working on a project that helps keep doctors more current on their early medical school materials.” 

Cruz-Neira says another application for virtual reality is to create digital environments which professionals in different locations can experience at the same time, expanding upon the progress made by telemedicine over the past few years.  

“Telemedicine is mostly video-based, and we are talking more about a 3-dimensional space that looks like maybe the operating room or the examination room and brings in [all doctors and specialists] as if they were all in the same space.” 

Pait says it’s not a question of if the physicians of tomorrow will have to be technologically savvy, but how quickly they can get there. Ultimately, he says, the overwhelming patient benefits of such technology will make it the new competitive reality for all hospitals to invest in some sort of next-generation hardware and software.  

“Telemedicine, virtual reality and artificial intelligence gives us the ability to take the health care providers and specialists into a rural environment,” he says. “You have to get everything worked out, including the HIPAA regulations. You need a whole team. You’ve got to  have a technician, your experts in dealing with computers. Initially, it is a financial commitment but once you get that, you simply download it in your lab.” 

“The benefit here is that the patient doesn’t have to travel long distance. We can try all the nonsurgical things first, and you can do it at a distance. The hospital there will participate in preparing the patient to get everything done as an outpatient, so the patient doesn’t have to travel back and forth. In this way, the rural hospital or clinic can continue to play an incredibly important role.”