FORT SCOTT, Kan. — A slight drizzle had begun within the grey December sky outdoors Group Christian Church as Reta Baker, president of the native hospital, stepped via the doorways to hitch a weekly morning espresso organized by Fort Scott’s chamber of commerce.
The city supervisor was there, together with the franchisee of the native McDonald’s, an insurance coverage company proprietor and the receptionist from the large auto gross sales lot. Baker, who grew up on a farm south of city, knew all of them.
About ‘No Mercy’
KHN’s year-long collection, No Mercy, follows how the closure of 1 beloved rural hospital disrupts a group’s well being care, financial system and equilibrium.
Nonetheless, she paused within the doorway together with her chin up to absorb the scene. Then, decreasing her voice, she admitted: “No one talked to me after the announcement.”
Just some months earlier than, Baker — becoming a member of with the hospital’s proprietor, St. Louis-based Mercy — introduced the 132-year-old hospital would shut. Baker rigorously orchestrated face-to-face conferences with docs, nurses, metropolis leaders and employees members within the remaining days of September and on Oct. 1. Afterward, she despatched written notices to the employees and native newspaper.
For the 7,800 individuals of Fort Scott, about 90 miles south of Kansas Metropolis, the hospital’s closure was a loss they by no means imagined attainable, sparking anger and worry.
“Infants are going to be dying,” stated longtime resident Darlene Doherty, who was on the espresso. “This can be a catastrophe.”
Bourbon County Sheriff Invoice Martin stopped earlier than leaving the gathering to say the closure has “a darkish aspect.” And Dusty Drake, the lead minister at Group Christian Church, diplomatically stated individuals have “plenty of questions,” including that members of his congregation will lose their jobs.
But, whilst this city offers with the trauma of dropping a beloved establishment, deeper nationwide questions underlie the wrestle: Do small communities like this one want a standard hospital in any respect? And, if not, what well being care do they want?
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Sisters of Mercy nuns first opened Fort Scott’s 10-bed frontier hospital in 1886 — a time when touring 30 miles to see a physician was unfathomable and when most medical remedies have been so primitive they might be distributed virtually anyplace.
Now, driving the four-lane freeway north to Kansas Metropolis or crossing the state line to Joplin, Mo., is a day journey that features purchasing and a cease at your favourite restaurant. The larger hospitals there supply the newest refined remedies and gear.
And when sufferers right here get sick, many merely go elsewhere. A mean of 9 sufferers stayed in Mercy Hospital Fort Scott’s greater than 40 beds every day from July 2017 by way of June 2018. And these numbers are usually not unusual: Forty-five Kansas hospitals report a mean every day census of fewer than two sufferers.
James Cosgrove, who directed a current U.S. Authorities Accountability Workplace research about rural hospital closures, stated the nation wants a greater understanding of what the closures imply to the well being of individuals in rural America, the place the burden of illness — from diabetes to most cancers — is usually larger than in city areas.
What occurs when a 70-year-old grandfather falls on ice and should select between staying residence and driving to the closest emergency division, 30 miles away? The place does the sheriff’s deputy who picks up an injured suspect take his cost for medical clearance earlier than going to jail? And the way does a younger mom whose toddler fell towards the espresso desk and now has a gaping head wound cope?
There’s additionally the financial query of how the hospital closure will have an effect on the city’s demographic make-up since, as is usually the case in rural America, Fort Scott’s hospital is a main supply of well-paying jobs and attracts professionals to the group.
The GAO plans to finish a follow-up research later this yr on the fallout from rural hospital closures. “We need to know extra,” Cosgrove stated. The report was initially requested in 2017 by then-Sen. Claire McCaskill (D-Mo.) and then-Rep. Tim Walz (D-Minn.), and has been picked up by Sen. Gary Peters (D-Mich.). Right here in Fort Scott, the questions are being answered — painfully — in actual time.
On the finish of December, Mercy closed Fort Scott’s hospital however determined to maintain the constructing open to lease parts to deal with an emergency division, outpatient clinic and different providers.
Mercy Hospital Fort Scott joined a rising record of greater than 100 rural hospitals which have closed nationwide since 2010, in line with knowledge from the College of North Carolina’s Cecil G. Sheps Middle for Well being Providers Analysis. How the city copes is a window into what comes subsequent.
‘We Have been Naive’
Over time, Mercy turned a lot part of the group that oldsters anticipated to see the hospital’s ambulance standing guard at the highschool’s Friday night time soccer video games.
Mercy’s identify was seemingly all over the place, actively selling inhabitants well being initiatives by working with the varsity district to decrease youngsters’s weight problems charges in addition to native employers on diabetes prevention and wholesome consuming packages — worthy however, typically, not income turbines for the hospital.
“You can’t take as a right that your hospital is as dedicated to your group as you’re,” stated Fort Scott Metropolis Supervisor Dave Martin. “We have been naive.”
Certainly, in 2002 when Mercy determined to construct the then-69-bed hospital, residents raised $1 million out of their very own pockets for development. One other million was given by residents to the hospital’s basis for upgrading and changing the hospital’s gear.
“No one donated to Mercy only for it to be Mercy’s,” stated Invoice Brittain, a former metropolis and county commissioner. The purpose was to have a hospital for Fort Scott.
Right now Mercy is a serious well being care conglomerate, with greater than 40 acute care and specialty hospitals, in addition to 900 doctor practices and outpatient amenities. Fort Scott is the second Kansas hospital Mercy has closed.
Tom Mathews, vice chairman of finance for Mercy’s southwestern Missouri and Kansas area, stated Fort Scott’s regular decline in sufferers, mixed with lack of reimbursement — in addition to the growing value of bills comparable to medicine and salaries — “created an unsustainable state of affairs for the ministry.”
However Fort Scott is a spot that wants well being care: One out of each 4 youngsters in Bourbon County reside in poverty. Individuals die a lot youthful right here than the remainder of the state and charges for teen births, grownup smoking, unemployment and violent crime are all larger in Bourbon County than the state common, based on knowledge collected by the Kansas Well being Institute and the Robert Wooden Johnson Basis. Ten % of Bourbon County’s greater than 14,000 residents, about half of whom reside in Fort Scott, lack medical insurance. Kansas is considered one of 14 states that haven’t expanded Medicaid underneath the Reasonably priced Care Act and, whereas many elements trigger a rural closing, the GAO report discovered states that had expanded Medicaid had fewer closures.
The GAO report additionally discovered that residents of rural areas usually have decrease family incomes than their counterparts in greater cities, and usually tend to have limitations due to persistent well being circumstances, like hypertension, diabetes or weight problems, that have an effect on their every day actions.
The county’s untimely start price can also be greater than the 9.9% nationwide, a quantity that worries Dr. Katrina Burke, an area household care physician who additionally delivers infants. “A few of my sufferers don’t have automobiles,” she stated, “or they’ve one automotive and their husband or boyfriend is out working with the automotive.”
By almost any social and financial measure, southeastern Kansas is “arguably probably the most troubled a part of the complete state,” stated Dr. Gianfranco Pezzino, senior fellow on the Kansas Well being Institute. Whereas the well being wants are nice, it’s not clear the way to pay for them.
Well being Care’s ‘Very Startling’ Evolution
Reta Baker describes the farm she grew up on, south of city, as “a bit large place within the street.” She utilized to the Mercy faculty of nursing in 1974, left after getting married and got here again in 1981 to take a job as employees nurse on the hospital. She has “been right here ever since,” 37 years — the previous decade because the hospital president.
It has been “very startling” to observe the best way well being care has advanced, Baker stated. Sufferers as soon as stayed within the hospital for weeks after surgical procedure and now, she stated, “they arrive in they usually have their gallbladder out and go house the identical day.”
With that, funds and reimbursement practices from authorities and well being insurers modified too, valuing procedures fairly than time spent within the hospital. Rural hospitals nationwide have struggled underneath that components, the GAO report discovered.
Acknowledging the problem, the federal authorities established some packages to assist hospitals that serve poorer populations survive: By means of a program referred to as 340B, some hospitals get decreased costs on costly medicine. Rural hospitals that certified for a “crucial entry” designation due to their distant places received larger funds for some lengthy stays. About three,000 hospitals nationwide get federal “disproportionate share funds” to mirror the truth that their sufferers are likely to have poor or no insurance coverage.
Fort Scott took half within the 340B low cost drug program in addition to the disproportionate share funds. However, although Baker tried, it couldn’t achieve crucial entry standing.
When Medicare reimbursement dropped 2% due to sequestration after the Finances Management Act of 2011, it proved traumatic, because the federal insurer was a serious supply of revenue and, for a lot of rural hospitals, one of the best payer.
Then, in 2013, when the federal authorities started financially penalizing most hospitals for having too many sufferers returning inside 30 days, hospitals like Fort Scott’s misplaced hundreds of dollars in a single yr. It contributed to Fort Scott’s “monetary fall,” Baker stated.
Baker did her greatest to set issues proper. To scale back the variety of bounce-back admissions, sufferers would get a name from the doctor’s workplace inside 72 hours of their hospital keep to schedule an workplace go to inside two weeks. “We labored actually, actually arduous,” Baker stated. 5 years in the past, the variety of sufferers returning to Fort Scott’s hospital was 21%; in 2018 it was 5.5%.
In the meantime, sufferers have been additionally “out-migrating” and selecting to go to Ascension By way of Christi in Pittsburg — which is 2 occasions bigger than Fort Scott — as a result of it provided cardiology and orthopedic providers, Baker stated. Sufferers additionally incessantly drove 90 miles north to the Kansas Metropolis space for specialty care and the youngsters’s hospital.
“Anyone who’s having an enormous surgical procedure carried out, a bowel resection or a mastectomy, they need to go the place individuals do it on a regular basis,” Baker stated. Mercy’s Fort Scott hospital had no cardiologists and solely two surgeons doing simpler procedures, comparable to hernia restore or eradicating an appendix.
Final yr, solely 13% of the individuals in Bourbon County and the encompassing space who wanted hospital care selected to remain in Fort Scott, in response to business knowledge shared by Baker.
There have been no sufferers within the hospital’s beds throughout one weekend in December, Baker stated, including: “I take a look at the report day by day. It bounces between zero and 7.” The hospital employed 500 to 600 individuals a decade in the past, however by the point the closure was introduced fewer than 300 have been left.
That logic — the monetary want — for the closing didn’t sit nicely with residents, and Mercy executives knew it. They knew in June they might be closing Fort Scott however waited till October to announce it to the employees and the town. Metropolis Supervisor Martin responded by shortly assembling a well being process pressure, insisting it was “essential” to ship the correct message concerning the closure.
Relations between Mercy and the town grew so tense that attorneys have been wanted simply to speak to Mercy. In all, Fort Scott had spent greater than $7,500 on Mercy Closure Undertaking authorized charges by the top of 2018, in line with metropolis data.
Will Fort Scott Sink With No Mercy?
When Darlene Doherty graduated from Fort Scott Excessive Faculty in 1962, there have been two issues to do on the town: “Work at Mercy or work at Western Insurance coverage.” The insurance coverage firm, although, was bought within the 1980s, and the employer disappeared, together with almost a thousand jobs.
But, even because the group’s inhabitants slowly declined, Martin and different group leaders have stored Fort Scott vibrant. There’s the brand new Smallville CrossFit studio, which Martin attends; a brand new microbrewery; two new fuel stations; a Sleep Inn lodge, an assisted dwelling middle; and a Dairy Queen franchise. And the McDonald’s that opened in 2012 simply accomplished renovation.
The city’s largest employer, Peerless Architectural Home windows and Doorways, which supplies about 400 jobs, purchased 25 extra acres and plans to increase. There’s state cash promised to increase native highways, and Fort Scott has utilized for federal grants to broaden its airport.
Baker and a number of the physicians on Mercy’s employees have been busy making an attempt to make sure that important well being care providers survive, too.
Baker discovered consumers for the hospital’s hospice, house well being providers and first care clinics so they might proceed working.
Burke, the household care physician, signed on to be a part of the Group Well being Middle of Southeast Kansas, a federally certified nonprofit that’s taking up 4 well being clinics operated by Mercy Hospital Fort Scott. She should ship infants in Pittsburg, which is almost 30 miles away on a principally two-lane freeway that has development staff slowing visitors as they work to broaden it to 4 lanes.
Burke stated her follow is full, and she or he needs her sufferers to be taken care of: “If we don’t do it, who’s going to?”
Mercy donated its ambulances and transferred emergency medical employees to the county and metropolis.
And, in a tense, last-minute save, Baker negotiated a two-year cope with Ascension By way of Christi hospital in Pittsburg to function the emergency division — which was closed for 2 weeks in February earlier than reopening underneath the brand new administration.
However she is aware of that too could also be only a patch. If no purchaser is discovered, Mercy will shut the constructing by 2021.
That is the primary installment in KHN’s year-long collection, No Mercy, which follows how the closure of 1 beloved rural hospital disrupts a group’s well being care, financial system and equilibrium.
Sarah Jane Tribble:
Public Well being
Hospitals Kansas No Mercy Rural Drugs