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‘The worst is yet to come.’ How COVID-19 could wipe out many rural hospitals

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.

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.

Before the pandemic, outpatient services such as X-rays and diagnostic tests accounted for 76 percent of rural hospital dollars and kept many financially afloat, the center reported, unlike urban hospitals, which often rely on endowments or more stable sources of funding to stay open.

Also, nearly half of rural hospitals were already operating at a loss before the virus emerged, up from a third of hospitals five years ago, said Michael Topchik, national leader for the Chartis Center.

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

Since 2010, 128 rural hospitals have closed nationwide, according to Cecil G. Sheps Center for Health Services Research at the University of North Carolina. These hospitals were not run by the federal government or deemed critical access hospitals. They were located more than 35 miles from the next-closest hospital and offered 25 or fewer acute care beds. But these facilities, though not as robust, are often vital to small communities, and their closures can be devastating. In many cases, the health care systems served as the primary local economic engine. When rural hospitals shut down, people not only lost vital access to doctors and nurses but also jobs. During the last decade, 22 rural hospitals have closed in Texas alone — more than any other state, according to the center’s data.

There are concerns about how the virus will affect the long-term health of rural areas, too. For months, Moore said her staff had worked to encourage patients to make a habit of coming to the clinic for preventative care, a key part of catching potential health problems but one that can fall by the wayside when access and costs are an issue. She said they had started to make progress, putting themselves in a position to improve patient outcomes and lower costs all around. But the pandemic put a stop to those steps forward.

Walking through an empty parking lot, day in and day out “does eat at your gut,” Moore said.

Under the CARES Act that President Donald Trump signed on March 27, Congress released $30 billion from a $100 billion hospital relief fund and accelerated Medicare payments to rural hospitals to help buoy them. Rasor’s hospital in Texas already received its $331,000 stimulus check on April 10, but she said the cash she has on hand remains low as she tries to keep staff with virtually no other money coming in.

How has the virus already compromised rural health care?

More than two-thirds of Texas’ 254 counties have confirmed cases of COVID-19, according to the state Department of Health and Human Services. And many Texas facilities are “on the ropes,” said John Henderson, who once ran a rural hospital and is now CEO for the Texas Organization of Rural and Community Hospitals. Health care leaders across the state have told Henderson they have maxed out their lines of credit with local banks or had vendors place them on hold for supplies. Of the 157 Texas hospitals serving a county population of 60,000 residents or fewer, Henderson said 64 reported having less than 30 days of cash on hand. That was in December.

With social distancing creating a dramatic reduction of hospital services, Rasor has furloughed some of the hospital’s 192 staff, she said. On April 10, she cut another 20 employees’ hours. She’s allowed many who remain to take time off without pay or put them on shifts at the nursing home she also runs where staff are “temp’d” — have their temperature checked for fever — twice a shift.

To save face masks at Castro County Hospital District, physicians and nurses cycle through using the same four masks they have been given. They wear one per day. At the end of their shift, they place the mask in a brown paper bag, labeled with their name and the day. Operating under guidance from the Centers for Disease Control and Prevention that the virus lives on surfaces for up to 72 hours, an employee waits four days before reusing that mask, a process that has “worked well,” Rasor said. But best practices in health care safety measures may still change rapidly, as so many basic facets of life have seemed to do during this pandemic.

In Rasor’s county, 11 people have so far tested positive for COVID-19, several of whom were tested in the hospital’s emergency department, she said. In March, a regional basketball tournament sparked an outbreak cluster of eight cases. The first county resident diagnosed was a man in his late 60s who showed up at Rasor’s hospital with a fever, cough and body aches.

Like nearly two-thirds of rural hospitals in the United States, Rasor’s facility offers no intensive care services, so her staff transferred the man to Amarillo, nearly 70 miles away, where he ended up on a ventilator and was treated for almost three weeks. He is now undergoing physical therapy and recovering back in Dimmitt.

More than 460 miles away in Medina County, Janice Simons serves as CEO for Medina Regional Hospital in Hondo.

With three rural health centers and five specialty clinics, Simons said her hospital operates on “very, very tight margins with very little cash on hand” and is the only hospital in the county.

Since COVID-19 started, patient visits have dropped by 50 percent, according to Simons. “We have had little revenue coming in, but are having to maintain the same expenses,” she said. The hospital chose to keep all staff at the same hours, in part because “recruiting for staff in rural Texas is unbelievably difficult” and the hospital will need health care workers after the pandemic ends — whenever that happens.

Out of a population of more than 51,000 people spread across 1,335 square miles, at least eight people in Medina County have tested positive for the virus. One person has died. If a patient suspects they have COVID-19 and gets tested at her hospital, Simons said they must wait for as long as 14 days to receive their test results.

Simons’ hospital has no ICU beds — meaning there are none in the entire county. If a person is diagnosed with the disease and needs intensive medical care, they must go to San Antonio, which is 45 miles away. If someone is in really bad shape, Simons said the hospital offers a single isolation room. If they are in relatively good health, staff tell them to recover at home.

Even caring for one COVID-19 patient could stretch a facility’s resources.

The Delta Regional Medical Center in Greenville, Mississippi, treated its first case in mid-March, said Dr. Ammar Dulli, a pulmonologist and critical care medicine physician at the hospital. To stay alive, she required lots of oxygen and staff used a large amount of personal protective equipment — a resource already in short supply. She now needs extensive physical therapy to recover. Since then, many more COVID-19 patients have passed through the hospital, he said. Right now, Dulli said the hospital has what it needs to treat patients, but “if we have 10 more patients like this (all at once), this is a big, big problem.”

Dr. Ken Kingdon, who oversees the emergency department in Medina County, has been preparing for that kind of worst case scenario. A Texan born and raised, the U.S. Navy-trained Kingdon used to be a combat surgeon. He put those skills to use while deployed in Afghanistan and when treating church goers shot during the 2017 mass shooting in Sutherland Springs, 75 miles to the east. He said he suspects the mindset that came with his training in the military could come in handy if COVID-19 cases begin to mount locally.

The staff in Kingdon’s department have implemented the paper bag method — same as Rasor’s workers — to save masks. They have put backup schedules into place, based on Italian health care worker numbers projecting that as many as 20 percent of his staff could catch the virus. They screen patients outside the hospital to prevent exposing patients and staff inside waiting rooms or during exams.

In addition to the changes in protocol, Kingdon has seen a shift at the hospital in people’s moods lately. He said it reminds him of the general feeling of fear and not knowing what’s next that he saw in soldiers’ expressions, “an uncertainty that Americans haven’t had to face.”

“You’re not going to get around it. You’re not going to get away from it. You have to focus and work through it,” he said. “You do what you can do. We’re all in this together.”

Health producer Jason Kane contributed to this report.