North Dakota oil boom overloading rural hospital emergency rooms and leaving them with unpaid bills

The Bakken oil boom in western North Dakota -- with its massive equipment and its young, transient oil workers -- is puting tremendous strain on the region’s small hospitals that are finding it hard to shoulder the increasing emergency trauma load and the unpaid bills left behind it. John McChesney reports in the Daily Yonder that if that weren't enough, "Nurse and staff recruitments have become much more difficult due to high housing prices and high competitive wages in the oil patch. And attracting physicians, always a problem for rural areas, has gotten tougher, even as needs soar."

Randall Pederson of Tioga Medical holds
piles of unpaid bills returned from
addresses for people long gone.
(Photo by John McChesney)

Randall Pederson, president and CEO of the 25-bed Tioga Medical Center and a regular ambulance volunteer, says his town has seen a dramatic leap in ambulance runs and emergency room patients this year. “In 2007 we would see 600 patients in ER per year,” Pederson told McChesney. “In 2012, we anticipate seeing over 2,000.” That means in a five-year period, Tioga’s emergency room visits have more than tripled. “We are seeing a lot more industrial accidents, major trauma, many of those involving car accidents, because there’s a lot more vehicles on the roads these days,” Pederson explains. Many accidents involve 40-ton tank trucks colliding with 5,000-pound passenger cars, writes McChesney, "incidents that can bring several patients with horrible injuries into the small ER at the same time. The one doctor on call has to scramble for help."

According to Darrold Bertsch, president of North Dakota’s Rural Health Association, private insurers pay less in North Dakota than in most other states. And many of these ER patients -- many who come from out-of-state for piecemeal work -- don’t pay their bills. Tioga's Pederson in Tioga says his hospital had to write off $270,000 in bad debt. Other area hospitals report similar collection problems. McChesney reports that North Dakota's McKenzie County Hospital will lose more than half a million dollars this year because of patients' unpaid bills. Likewise, Montrail County Medical Center in Stanley, has 25 to 30 percent of revenue written off to bad debt. In Williston, Mercy Hospital’s bad debt has sky rocketed from a pre-oil-boom $2 million a year to $7 million this year, hardly something rural hospitals can endure for long. Mercy's CEO Matt Grimshaw says most of those charges have been billed to people who have jobs and could afford to pay, but he just can’t find them. Could Obamacare help here, with its mandate that everyone have insurance? In this red state, no one wanted to answer that question, McChesney reports. (Read more)

Health reform said to hurt rural doctor recruitment

Recruiting doctors to rural hospitals will get harder in the next few years as the Patient Protection and Affordable Care Act reaches full implementation and the demand for healthcare services increases, a new report suggests. An Association of Staff Physician Recruiters report, "In-House Physician Recruitment Benchmarking," says interview-to-hire ratios in rural areas are much higher than in urban, and rural recruiting officers are often responsible for several things, not just hiring new doctors, making them overworked. Both factors make it harder for rural hospitals to recruit, the authors concluded. (University of Chicago photo)

ASPR Benchmarking Committee Chair Shelly Tudor told John Commins of HealthLeaders Media that the cost of recruitment is rising, making it hard for rural hospitals to compete with their urban counterparts. "In lots of respects, the process favors urban providers. Physicians are coming to urban areas and they are looking for jobs, whereas rural providers have to go out and target physicians that are likely to come to their area," Tudor said. Rural recruiters have to "filter through a lot of people to find the right one who is willing to come in and even look at the opportunity," she said. (Read more)

Feds want 1,000 rural hospitals to switch to electronic health records by 2014

The federal government wants 1,000 "critical access" and rural hospitals to adopt electronic health records by 2014, and is funneling about $30 million through its Regional Extension Center to make it happen. The money could help as many as 1,500 rural hospitals, or 90 percent of those covered by the Small Rural Hospital Improvement Program.

The Office of the National Coordinator for Health Information Technology has already secured $32 million in American Recovery and Reinvestment Act money for REC for IT improvement at critical access hospitals, which are classified as facilities with no more than 25 beds and an average of 10 patients a day, Neil Versel of Information Week reports.

The National Rural Health Association is enthusiastic about the funding, but still sees obstacles to implementation, Versel reports. "To realize this goal, we need all hands on deck. We need everyone rowing in sync, including leadership and staff in every critical access and rural hospital, electronic health records vendors, hospital associations and state offices of rural health in every state, Rural Health IT Network Development grantees, Office of the National Coordinator grantees, and many more public and private, federal and local partners," ONC Office of Provider Adoption Support director Mat Kendall, and ONC rural health IT coordinator at Leila Samy said. (Read more)

Study: Rural residents have equal access to health care -- if they have insurance and like the drive

A health-care study in Tennessee, which started with the premise that people in rural areas have less access to care than urban dwellers, ended with a rather surprising conclusion: They don't. Not if they have health insurance. "When it comes to commercially insured patients, there’s little disparity in access to health care between residents of rural communities and urban areas in Tennessee," said Dr. Steven L. Counter, president of the BlueCross BlueShield of Tennessee Health Institute.

How can this be? The study found that almost half of rural residents pass up the hospitals closest to their homes to go to larger urban hospitals, even if the same services are available locally, writes Getahn Ward of The Tenneseean. "The conclusion we came to is that we’re living in a very mobile society, and the distance is not necessarily a determinant factor in whether people get care or not," said Coulter.

Because the survey did not include consumers, it's only a guess about why they chose to take the time and trouble to go to the big town, but experts says it's a combination of services not being available or a perception that they aren't, even if they are. This raises, again, age-old questions about the viability of rural hospitals, some of which often don’t have the money for capital-intensive technology and services. However, Coulter told the Tennessean that "a recent increase in alliances between rural hospitals and larger hospitals and urban health systems raises hopes that non-urban hospitals may be able to expand their menus of services."

Such partnerships between non-profits and for-profit chains are becoming more common, reports Ward, and some say those efforts will change the perception of those in far-flung regions that great medicine is being practiced close-by. This could be especially important, said Wes Littrell, chief strategy officer and president of Nashville-based Saint Thomas Health, in the new world of health reform. “We expect that when you get more into population management that you need to take care of the patient closer to home in the lower-cost setting,” he said. (Read more)

South Dakota starts program to get health workers, not just doctors, to work in rural areas

Mindy Jagerson, left and Julie Crick at
work at the Freeman Regional Health
Services Hospital (Argus-Leader photo)

Incentives to get doctors in rural areas, like this one in Missouri, are common. Now a program will put $10,000 bonuses into the hands of newly hired health-care employees if they promise to keep working in rural South Dakota for three years. The money comes from the state with a matching share from the worker's employer, reports Jon Walker of the Argus Leader in Sioux Falls. The South Dakota legislature approved the arrangement this year to protect towns where hospitals and nursing homes struggle to find employees.

The jobs include nurses, dietitians, nutritionists, lab technicians, pharmacists, paramedics, X-ray technologists and occupational, physical and respiratory therapists. "It's a no-brainer for the staff person," said Dan Gran, CEO at Freeman Regional Health Services. "They get their $10,000. All they've got to do is show up and maintain their employment. We benefit because we've retained them."  The program is limited to communities with less than 10,000 people.  If the town is smaller than 2,500, the state will pay 75 percent.

The new program bypasses federal involvement, notes Walker. It would use about $300,000 a year from the state general fund. A companion program sets up bonuses for rural health professionals with more training. They range from $35,000 for midlevel professionals to $100,000 for doctors starting new jobs and promising to stay three years in towns smaller than 10,000. The state again covers up to 75 percent of costs. Annual cost is $515,000 for the state. Deputy State Health Secretary Tom Martinec said it's reasonable to use public money to assist private business. "The fact of the matter is we need health care workers in rural areas. They're competing against larger towns. That's why we needed to step in."
 

Rural hospitals urge Congress to save two Medicare programs that help them

A coalition of rural hospitals are lobbying Congress to keep two Medicare programs that the National Rural Health Association says are vital to keep hundreds of smaller hospitals going. The Medicare Dependent Hospital designation and the Low-Volume Hospital Adjuster, which date to the 1980s, help keep low-volume rural hospitals' doors open with the Medicare payment adjustments they provide, according to the NRHA.

Both programs could end Oct. 1 without Congressional action. "Rural facilities do not have the financial background to weather all of these cuts," said Lance Keilers, NRHA president and administrator of Ballinger Memorial Hospital in San Angelo, Tex., told Brendon Nafziger of DOTmed News, an online magazine serving the medical and medical equipment industry.

More than 200 hospitals have the Medicare Dependent designation. To qualify, a hospital must have fewer than 100 beds and Medicare patients must make up 60 percent of its inpatient days or discharges. Low-volume hospitals must be at least 15 miles from another hospital and provide care for fewer than 1,600 Medicare beneficiaries a year. (Read more)

Time to check your local hospital's credit rating

What is your local hospital's credit rating? Did you even know it had a credit rating? It might be a good time to check it, since many hospitals are getting lower ratings these days.

Nick Tabor, senior staff writer for the Kentucky New Era in Hopkinsville, found that Jennie Stuart Medical Center's rating dropped, meaning that "The hospital may have to pay a higher interest rate if it needs to borrow money in the near future." Tabor wrote.

Fitch Ratings, one of the global agencies whose ratings guide investors, said uncertainty about the expansion of Kentucky's Medicaid system and how federal health reform will affect the hospital's finances were other reasons for the downgrade. The hospital has lost money in two of the last four years. Last year, it had a 1.9 percent loss.

Tabor explains there are eight ratings above the BBB level. If the facility's rating "were to slip two levels lower, to BB+, it would be on the level of 'junk bonds,' no longer considered investment grade," he reports.

There are three major rating companies in the U.S.: Fitch, Moody's and Standard and Poor's. Moody's expects downgrades of nonprofit hospitals to outnumber upgrades by the end of 2012, reports Jeffrey Young for The Huffington Post. Fitch expects the same will happen, said Senior Director Emily Wong. Smaller hospitals will especially feel the pinch since they "don't have as much ability to offset expense, inflation or reimbursement reductions," Wong said.

AA- and A-rated facilities are reviewed every two years. BBB and BBs are reviewed once a year, and B- and below-rated facilities are reviewed every six months. The easiest way to check ratings for hospitals is to get an account at each of the three major rating companies. "These accounts are free and easy to set up," Tabor tells us. (Read more)

Safety-net hospitals could get hit hardest when Medicare reimbursement changes in October

When hospitals start getting paid based on the quality of care they provide to their Medicare patients, so-called "safety net" hospitals, a last resort for the poor, could be the losers in the equation. That's because a main way of measuring quality will be patient experience ratings, and safety-net hospitals tend to get poorer marks from patients, according ta new study published in the Archives of Internal Medicine.

Since hospitals have had to publicly report their patient experience ratings, the gap between how patients rated these facilities and the scores that other hospitals got widened. "We found that [safety-net hospitals] performed more poorly than other hospitals on nearly every measure of patient experience and that gaps in performance were sizeable and persistent over time," the authors write.

When the Centers for Medicare and Medicaid Services agency starts using the scores to hand out bonuses and penalties, safety-net hospitals could be at a disadvantage, especially since penalties could mean a 2 percent cut on regular Medicare payments. Starting in October, patient experience scores will determine 30 percent of a facility's bonus. "The hospitals that perform best will gain money, while those that lag in scores and improvement over time will end up with less," reports Jordan Rau for Kaiser Health News. (Read more)

Rural health advocates object to federal report that suggested ending special payments to rural hospitals

The National Rural Health Association and a coalition of Medicare-dependent rural hospitals say a recent report that found payments to rural doctors are "at least as adequate as those made to urban physicians"and "some special payments to rural hospitals should not be continued" is inaccurate and "harmful to rural Americans," the Daily Yonder reports.

The report came from the Medicare Payment Advisory Commission, "an independent congressional agency given the job of reporting on functioning of Medicare." The groups say 77 percent of rural counties are defined by the Rural Health Research Center as having a shortage of health professionals, and 164 counties have no primary-care physician. And they point to a 2011 federal report which found that “Rural areas have higher rates of poverty, chronic disease, and uninsurance, and millions of rural Americans have limited access to a primary health care provider.” Moreover, the groups say that a recent study found that 35 percent of all rural hospitals lose money.

Alan Morgan, CEO of NRHA, said “Rural patients and providers will ultimately pay the price as rural hospitals will be forced to eliminate services or close their doors if this report is enacted." (Read more)