Doing Without Hospitals : Rural Towns Suffer but Cope Without Care

In this tranquil farm town, folks are accustomed to life without a movie house. Now, they will have to cope without a more precious commodity--a hospital.

White Hall Hospital, a Main Street fixture for nearly eight decades, is out of business. A “gone fishing” sign is tacked above the entrance.

“Everybody’s scared to death,” said businessman Jim Ballard. “What if a kid is run over? Or someone has a heart attack? You’re pretty much left alone. It’s a great loss.”

“It’s like you’re losing your identity,” said Dr. Ludwig Dech, a silver-haired physician who was on White Hall’s staff 30 years. “Who in the medical community is going to locate where you don’t have a hospital?”

White Hall has joined the growing list of farm towns that have struggled throughout this decade, losing people, businesses and, finally, a life-and-death resource: the hospital.

“The question is not whether hospitals will close, but which ones are going to close, who’s going to make the decision . . . and what’s going to be left,” said Robert van Hook, executive director of the National Rural Health Assn.

The number of rural hospital closings has jumped from seven in 1983 to 40 in 1987, Van Hook said. Forty percent of last year’s closings, he said, were in Texas, Arkansas and Louisiana.

From 1981 to 1986, admissions to rural community hospitals fell 24%--from 8.4 million to 6.4 million, the American Hospital Assn. says.

In 1986, the group reports, occupancy averaged 55%; it was less than 40% among hospitals in Texas and those with fewer than 50 beds.

“The whole system is going into shock,” said Glenn Klein, a consultant hired this year as White Hall’s administrator. “There’s not enough money in the system to cover the people.”

He should know. White Hall Hospital averaged 40% occupancy and lost almost $500,000 last year. It provided $911,000 in care for which it wasn’t reimbursed.

What’s ailing America’s rural hospitals is similar to what’s crippling urban ones: declining demand and money. But in small towns, the major obstacle seems to be Medicare, which serves the elderly, a large chunk of rural hospital patients.

Under federal rules, rural hospitals receive less per Medicare patient than urban ones. The rural-urban difference is, on average, 36%-37%, Van Hook said.

Medicare pays by diagnosis, so a city hospital treating a stroke victim would receive $4,055, while a rural hospital would receive $2,990, said Tim Size, executive director of the Rural Wisconsin Hospital Cooperative.

The dual scale, established in 1983, assumes that treatment costs are lower in small-town hospitals. Although rural hospitals are somewhat cheaper, Van Hook acknowledged, the difference shrivels as cases become more complex and the patient load drops.

“Being underpaid each of the last 6 years, it’s taken its toll,” Van Hook said. “You can’t buy new equipment. You can’t raises nurses’ salaries. You can’t make the improvements.”

The White Hall area, like many that have witnessed the steady exodus of their young people, has a large elderly population. Almost 1 in 5 Greene County residents is 65 or older; nearly 10% of all county residents receive public aid.

Those factors helped sink the 30-bed hospital. Last year, 85% of hospital patients were Medicare or Medicaid recipients or indigent, Klein said.

“When your reimbursement is primarily Medicare and Medicaid, you have a rope around your neck,” Klein said, explaining that White Hall last year received 49 cents for every dollar of services provided.

The rural health association filed suit in Washington early in November, claiming the dual-scale differential was too large and rural hospitals were being forced to subsidize Medicare.

A similar suit was filed in February by 28 rural Missouri hospitals, which alleged the federal system was arbitrary, capricious and discriminatory, said Jerry Sill, legal counsel for the Missouri Hospital Assn.

Already, the loss of rural hospitals has people worried about treatment delays.

“When you have to have to go 50, 60, 70 miles, things get very difficult if you’re about to deliver a baby. . . . If you’re bleeding or if something’s wrong . . . you don’t need an hour- or 2-hour ride,” Van Hook said.

Fewer Amenities

And when a small town loses its hospital, it also loses doctors and nurses and struggles to replace them, hampered by having less money to offer and fewer amenities. “We don’t have opera every Saturday night,” Van Hook said. “We often don’t have theater. Many times we don’t even have McDonald’s.”

To combat their financial problems, rural hospitals are diversifying. Some in Iowa are offering adult day care or turning cafeterias into catering services.

For the 3,000 residents of White Hall, there wasn’t time to diversify.

“We did not realize the need to change until it was too late,” Klein said, noting that local hospitals have been losing patients for years to regional hospitals with more services and specialists.

Still, the hospital didn’t give up easily.

Bought Building for Clinic

In the late 1970s, it remodeled to meet government standards. A few years ago, it recruited three doctors, Klein said, reopened an obstetrics unit at their request and purchased a building 3 miles away in Roodhouse for a clinic.

“We guaranteed them a good living,” Klein said. “We helped them in recruiting their patients. . . . People thought this would be something they could use to build and expand on.”

But the doctors notified the hospital board in December that they had decided to stop delivering babies. “It was almost a stab in the back,” Klein said.

Two of the doctors still have hours at the Roodhouse clinic. The remaining doctor working full-time in White Hall said it would be too stressful to handle deliveries alone and be on call 24 hours a day.

Even then, the hospital kept trying. It cut staff. It reduced inventory. It failed.

Affected Economically

“This not only affects us emotionally and sentimentally,” said Bob Moulton, hospital board president. “It also affects us economically. We lost a payroll of $864,000.”

That will hurt Main Street. But the impact could go well beyond.

The town no longer has a medical center to stabilize emergency patients. The nearest hospital is 10 miles away, and the ambulances making the trip are staffed by county medical technicians, untrained in such critical tasks as inserting intravenous tubes.

“Ten miles without primary care services are darn dangerous miles,” Klein said. The nearest trauma center is 27 miles distant, and Klein said a 40-minute ride is potentially fatal for an accident or heart-attack victim.

When White Hall closed in early September and filed for bankruptcy, Klein said, many couldn’t believe it.

“The community, for many years, had a wait-and-see attitude. The community could have saved the hospital and kept it open,” he said, but “there was no point in doing that. We didn’t have the patients.”