2019 has been a difficult year for rural Maine hospitals. Calais Regional Hospital recently filed for bankruptcy and just a few months ago Penobscot Valley Hospital did the same. And more hospitals in our state and across the country are imperiled. Over 100 rural hospitals in the US have closed since 2010 and it is estimated that 430 more are at risk of closing, the two mentioned here and others in Maine among them. This is nothing new. I recall meetings in Lincoln in the early 1990s aimed at addressing the real risk of closure of that small hospital, and strategizing to address its viability. Underpayment by public payers, providing care for the uninsured, predatory negotiating by private payers, inefficiencies of small scale operations, declining populations, and recruiting challenges all underlie the destabilization of these vital community resources. Maine’s delay in expanding MaineCare exacerbated the problem – between 2008 and 2016 states that did not expand Medicaid saw more hospital closures than those who did not and uninsured rates dropped 36% to 16% in expansion states but only 38% to 32% in non-expansion states.
Hospital leadership teams, community healthcare partners and public policy leaders have failed to collaborate, innovate and address these longstanding threats, and far too often have accelerated their competition for diminishing resources. All of this comes at an alarming cost and it is not just about convenience. When rural hospitals close the consequences are dire. Ambulances have to travel greater distances to get to critically ill or injured people, and then transport them long distances for care. Critical and basic skill sets, like obstetrical care, are lost. Following a hospital closure there is typically a rapid exodus of doctors and other healthcare professionals and jobs in the community are lost. Most alarmingly a new study has shown that when a rural hospital closes the mortality rate in the areas served by that hospital rises by nearly 6%.
Our country does not have a strategy to address the health care needs of people who live in rural areas and there is not even a meaningful discussion of a comprehensive approach to this challenge. In that vacuum there is some local innovation occurring. In rural NY state there is a proposal for a full collaboration between all health care entities and the people they serve to build a “Total Cost of Care” model in which the insurers, Medicare and Medicaid agree to a lump sum payment to cover the cost of care of everyone in the region and the healthcare and social service organizations work together and in partnership with the people they serve to determine the best use of that money. New models for the roles of paramedics and community health workers also hold promise, and pharmacists can be very important members of a primary care team. Federally Qualified Health Centers are natural partners in this work and if FQHCs and community hospitals can break through the barriers of their historical competition and recognize the highly complementary nature of their roles in rural areas there is much that can be accomplished. It will require a new perspective from the leaders of our hospitals, medical practices and community leaders and that is a big undertaking. But therein lies our hope.