A Crisis for Rural Hospitals

The last baby, an urgent arrival, was delivered in 1995. The last surgery was performed a dozen years earlier. Now, even the emergency room at Southern Inyo Hospital is usually locked, its only doctor on call.

Here in the giant shadows of the eastern Sierras, a little hospital, buffeted by the changing winds that roil U.S. health care, is struggling to survive.

The story of Southern Inyo and of Lone Pine’s desire to save it reflects similar sagas across the state. More than a third of California’s hospitals are losing money, but the condition of the state’s rural hospitals is far worse: An overwhelming majority are hemorrhaging dollars, merging with chains, declaring bankruptcy or closing outright. One in five has gone out of business or into bankruptcy since 1996.

At a time when medical mysteries are being unraveled at breakneck speed, the withering of the rural hospital network threatens to leave millions of Californians protected by only a minimum of health care service--or none at all.

And the trend has broader implications for many small towns, where the medical center, as it does here, serves as both health care and economic hub.

In Lone Pine, a one-stoplight community between Bishop and Ridgecrest in the Owens Valley, the 37-bed district hospital provides the largest source of employment, and the only emergency or acute care for 60 miles in one direction and 80 miles in the other along heavily traveled U.S. 395.

Residents note that Southern Inyo, which filed for bankruptcy protection in 1999, is important to thousands of travelers, many from Southern California, who pass through this remote, starkly beautiful region on their way to resorts in Mammoth, Lake Tahoe and Reno.

“This hospital saves lives,” said Michael Dillon, an emergency room physician whose company is on contract at Southern Inyo. “It just needs to be here.”

Without a surgeon or other specialists on staff, the hospital must send severely injured patients to more sophisticated facilities. But Southern Inyo’s ability to stabilize them first is essential. Otherwise, doctors say, many patients would not get treatment within the “golden hour,” that crucial period after a trauma when lives can more easily be saved and aftereffects reduced.

“You would exhaust that just with the transportation time to the next hospital,” said Tom Kozak, a San Diego-based family practice and emergency physician who spends eight days a month at Southern Inyo.

Many of those treated in the hospital’s emergency room are victims of high-speed collisions on U.S. 395, which runs through town. Others have suffered heart attacks, and can be treated with clot-busting drugs before enduring the helicopter ride to a cardiac care facility in Los Angeles, 230 miles away.

In a town with just two resident doctors--one retired, the other part-time--losing the hospital and adjacent rural clinic “would be a disaster,” said Herb Hawley, Lone Pine’s funeral director. His mother survived a heart attack two years ago after she was stabilized at Southern Inyo before being flown to a Los Angeles cardiac care center.

The hospital is striving to cut costs, find funding and reinvent itself as a sort of medical steppingstone to more advanced care somewhere else.

“We just can’t do everything anymore,” administrator Donna Donald said recently. “I’d rather try to do a few things well.”

But hospital officials and other experts in rural health care say that Southern Inyo is fighting an uphill battle. Among the pressures: declining public and private reimbursements, a remote location that drives up the cost of health care, and a small, aging population with few options for insurance coverage.

“The state has just not recognized the crucial need that rural communities have for these facilities,” said Assemblywoman Virginia Strom-Martin, who sponsored unsuccessful legislation last year aimed at increasing funding to some of the smallest and most isolated hospitals.

Other measures in the works might help. One is a federal Critical Access Hospital designation, which allows hospitals in key locations to recoup more of their costs not covered by insurance. Consultants to Southern Inyo estimate that the program, which is just being launched in California, could eventually bring it as much as $175,000 to $200,000 a year. The hospital’s annual budget is $6 million.

Another is the advent of telemedicine--video medical conferences with outside experts--which advocates say may help small, limited hospitals compensate for their lack of specialists.

But more is needed, say experts such as Stephen Lewis, the former executive director of the nonprofit California State Rural Health Assn. “A major problem is that the health care market is structured and designed around an urban reality that just doesn’t match the reality in rural communities, where there may be one provider,” Lewis said.

In January, for example, a two-week contract dispute between the only hospital in the remote community of Crescent City and the town’s primary insurance carrier left residents temporarily in a bind. Frightened at the prospect of paying higher costs for a hospital stay in town or driving at least 80 miles to reach a fully covered provider, some residents postponed surgeries. Others quickly bought air ambulance insurance.

Rural hospitals have been especially hard hit by recent cuts in Medicare, said Sharon Avery of the California Healthcare Assn., a hospital trade group.

The immediate future looks bleak, said Avery, executive director of the association’s rural health care center.

She points to these realities:

* Six of the state’s rural hospitals have closed since 1996. The most recent, Lindsay District Hospital near Fresno, shut its doors in November.

* Ten more--including Southern Inyo--are in bankruptcy proceedings, have recently emerged from it or are in the initial stages of filing.

* Nearly 75% of the state’s 71 rural hospitals are losing money. Even for the rest, the situation is precarious.

“I’ve had more than one sleepless night,” said Joyce Gysin, administrator of Surprise Valley District Hospital in tiny Cedarville, in the state’s northeast corner. In 1993, Surprise Valley made national news when a young family, including a 5-month-old baby, was rushed there after being lost in a blizzard for eight days.

* Others are reducing services. Healdsburg General Hospital in Sonoma County has announced it will close maternity and intensive care units, reduce its beds from 43 to 15 and drastically cut staff.

Southern Inyo, a low-slung, wood-framed complex just off Lone Pine’s main street, filed for bankruptcy protection in 1999, nearly $1 million in debt. Two years later, with a reduced staff and a bare-bones budget, it is still struggling, turning a small profit one month, falling back into the red the next.

“We’re not really out of the woods yet,” said administrator Donald, 75, who came out of semiretirement to lead the hospital. Donald has helped garner a grant for a new air-conditioner and recently received a bequest for a new roof. But she said more funding is needed--for X-ray equipment, beds, furniture and even gurneys.

Like many other rural health care centers, Southern Inyo combines an acute-care hospital with a long-term nursing facility, a rural clinic and a standby emergency room, which is unlocked as needed, usually once or twice a day.

Staff members, such as nursing director Sandy Manning, say they sometimes miss the old, more active days, when the hospital had many more acute-care patients and the demand for nursing skills was greater.

“We were busy constantly,” said Manning, who began working at the hospital in 1984.

Lone Pine residents grow wistful, too, as they remember the days when babies were born at the hospital and surgeries could be performed there. Many wish those facilities still existed, but appear largely resigned to the limited service that remains.

Even those who sound almost dismissive of what Southern Inyo has become nonetheless argue strongly for its continued presence in Lone Pine.

“It’s not really a hospital anymore--it’s nothing more than a health care facility, without its acute care,” said Helen Hoffman, a former board member. “Some people say let’s close it. But of course we need to keep it--we need that emergency room and we need the long-term care.”

Along the community’s tiny main street one recent day, nearly everyone had a story to tell about the hospital and Lone Pine’s need for it.

Cable company operator Bruce Branson said he broke his shoulder and suffered hypothermia and facial cuts in January after sliding hundreds of feet down a local peak. Branson, 52, was treated at the hospital before he was flown out from the helipad just a few steps out the back door.

Frances Gardner, 72, whose family owns the local hardware store, said her condition was stabilized at Southern Inyo after a 1998 heart attack; she was transported out two hours later for quadruple bypass surgery.

At the Totem Cafe, owner Jody Winchester, who also owns a packhorse business, recalled the many times tourists on Mt. Whitney, which looms above the town, have been carried down, victims of altitude sickness.

“They come down blue and head right to that hospital,” she said.

Several people said the hospital, with 67 full- or part-time workers, is vital to the community’s fragile economy--and to its identity.

“There’s something about being in a place big enough to have a hospital,” said Manning, the nursing director. If the facility were to close, many residents, especially Lone Pine’s numerous retirees, might worry about the prospect of no emergency care and decide to move, she said.

“This whole town would just dry up and blow away,” Manning said.

Alarmed by the bankruptcy protection filing, many Lone Pine residents are rallying to support the hospital.

One group, emboldened by a recent initiative in Orange County, is considering a similar measure to require Inyo County supervisors to use the county’s share of tobacco settlement funds for Southern Inyo and its healthier sister hospital, Northern Inyo, in Bishop, 60 miles north.

Other residents are trying to help in smaller ways--taking up collections to buy needed medical equipment, donating their used home computers and even earmarking the proceeds from Lone Pine’s weekly bingo night for the hospital.

“If you’re well, you never really think much about it,” said Gwen Gardner, Frances’ husband, as he called bingo numbers for 13 eager players in Lone Pine’s community center one recent night.

“But if your mother or your wife needs help, the way mine did, you sure get to know that it’s just vital to have it here,” he said. “I think we all recognize that now.”