Just what the doctor ordered

GRAND COULEE, Wash. – On a hill above the biggest hydropower dam in the country, local residents are building another ambitious project to better lives and bolster the economy.

At a cost of $25 million, the new Coulee Medical Center is expected to be a showpiece of what’s right with rural health care. Patients for miles around will use the hospital’s 25 beds. They will come for minor surgeries and to deliver babies. People badly hurt in car crashes and boating accidents on nearby Lake Roosevelt will visit its new emergency room.

Doctors will have access to a CT scanner, women can receive mammograms, and people can check in to a larger outpatient clinic for wellness visits, diabetes consultations and lab tests.

The new hospital is on schedule to open in the fall, replacing a decades-old facility where closets have been converted into cramped work stations and patient rooms are woefully dated.

“Everyone is just buzzing about what it will do for our ability to deliver the best possible quality care,” said Greg Hanoff, the hospital’s chief facilities officer who was hired in large part to shepherd the project for the hospital.

It’s a bold project, but it comes with a bit of risk. Small-town hospitals are often supported by local taxes and have struggled during the economic downtown. Profitable procedures such as knee replacements have migrated to larger health centers in cities, and the hospitals find themselves relying on Medicare payments, as the bulk of patients are over 65.

Many rural hospital executives say they’re cautiously optimistic about what national health care reform might do for them – but say they’ll just have to wait and see.

‘Part of the identity of communities’

In some rural areas, the collision of high costs and nonpaying patients points to tough decisions.

“There’s no question it’s difficult,” said Gary Smith, an economist with Washington State University’s Area Health Education Center. “These hospitals … are part of the identity of communities, and their survival is a really big thing.”

Serving large groups of patients whose care is paid by Medicare doesn’t give rural hospitals the luxury of submitting higher bills to rich insurance companies because many people living in rural areas don’t have employer-sponsored insurance coverage and can’t afford to insure themselves. Consequently, those without Medicare in many cases avoid going to the doctor until it’s too late and hospitalization is required.

To survive, hospital districts, like many rural school districts, have had to consolidate.

Such decisions are made more difficult because the rural hospitals, just as they are in cities, are major employers.

Tom Martin, the chief executive of Lincoln Hospital in Davenport, says rural hospitals must seek collaborations with neighboring communities as well as strengthen ties with larger hospitals such as Providence Sacred Heart Medical Center or Deaconess Medical Center in Spokane.

“We must look at our capacities to provide the right kinds of care for our patients respective to the expenses and volumes we have,” he said, anticipating that consolidations will inevitably occur.

The hospital in Davenport is tied to three clinics – in Davenport, Wilbur and Reardan – as part of a district that tries to fund day-to-day business activities with operating revenues and use tax collections for capital improvements.

The recession, Martin said, put the brakes on plans to build another clinic along Lake Roosevelt north of Davenport, where housing developments and recreationists are creating demand.

The hospital has given up some services to larger hospitals over the years, including profit-makers such as joint replacements, because it couldn’t keep pace with advancements.

It’s an ongoing struggle, Martin said. “Some years we’re up. Some we’re down.”

Rural hospitals could dodge reimbursement cuts

How federal health care reform will specifically affect small hospitals is not known, said Brenda Suiter, vice president of rural and public health for the Washington State Hospital Association.

Reform is not expected to deliver big reimbursement cuts to rural hospitals, as it could to larger health care centers. Many of the reforms, especially those slated to begin in 2014, will be partially funded by reducing payments to hospitals. In Washington it is estimated that hospitals will receive $3 billion less in federal funding.

But it’s not supposed to affect rural hospitals, which are called critical access hospitals. For hospitals in small towns with fewer than 25 beds, the government’s Medicare program reimburses for the cost of treating patients older than 65, plus gives the hospital 1 percent to provide the hospitals with a razor-thin profit margin. Larger hospitals don’t enjoy such a reimbursement schedule.

Suiter said some rural hospitals see reform as a way to bring more insurance coverage to rural communities, which in turn will ultimately mean more money for wellness checkups and hospitalizations.

“This could really help the rural communities if indeed everyone is covered with insurance,” said Smith, the economist, “because sometimes rurals give away a considerable chunk” in charity care.

He also said rural hospitals may benefit from the idea of creating accountable care organizations – basically health systems involving at least 5,000 people that would allow smaller hospitals to join larger hospitals.

The benefit may be that bundled payments made by the federal government to the organization would be split among the participating care providers, ranging from the large hospitals that perhaps provided most of the treatment, to the rural hospitals which may have provided the initial care before referring the patient.

“The reforms can be positive,” Smith said, “but not knowing exactly what’s going to be required is the biggest issue.”

Tom Jensen, chief executive officer of Coulee Medical Center, said the new hospital will be ready to serve patients whether health care reform brings relief or not.

“We will have a hospital ready to deliver the best care to our patients regardless,” Jensen said.

Technology helping small hospitals adapt

Martin, at Lincoln Hospital, said the staff there have been adopting technology that helps bring Spokane medical expertise to Davenport to keep patients in the local hospital.

A robot will soon be installed and operated by a physicians group in Spokane as part of a pilot project.

Othello Community Hospital has been recognized for its adoption of technology related to patient records, which is expected to improve patient treatment by making care histories more accessible to physicians.

The hospitals have also strengthened ties to larger hospitals to improve patients’ chances when they suffer heart attacks and strokes.

Lincoln Hospital, for example, has the ability to stabilize and begin treating a patient as Northwest Med Star helicopters are en route.

The closer cooperation has reduced the time from onset of heart attack in Davenport to treatment in a Spokane catheter lab to less than 90 minutes.

“All of this can help hospitals like ours participate in delivering the best care for the people in our communities,” Martin said. “And really, that’s what our focus is on.”