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HOW DO YOU DEFINE “RURAL”?


How many rural hospitals are there in Texas? Legally speaking, the term “rural” is surprisingly slippery. In 2014, the Texas Legislative Coun- cil identified 48 separate definitions of “rural” in Texas laws and codes. Various federal agencies also have their own definitions. That makes it hard to identify exactly how many rural hospitals exist nationally or statewide. According to the Texas Organization of Rural and Community Hospitals (TORCH), Medicaid defines a “rural hospital” as:


Hospital with a Critical Access Hospital (CAH), Sole Community Hospital (SCH), Rural Referral Center (RRC) designation from Medicare, or any other hospital in a county of 60,000 and less (according to the 2010 census)


Meanwhile, Medicare defines it this way:


Hospital in a non-Metropolitan Statistical Area or in a rural census tract of a MSA, a hospital designated by state law or regulation as rural, or an urban hospital that would meet all requirements of a RRC or a SCH if it was located in a rural area.


TORCH says under Medicaid’s definition, Texas has 159 rural


hospitals, and by Medicare’s definition, there are 153. All told, 163 Texas hospitals meet one or the other standard — or both.


Since 2013, 18 have closed permanent- ly or for a period of time, and dozens more are endangered. “It doesn’t sound like a lot,” Mr.


Pearson said. “But it’s about 10 per- cent of all the rural hospitals. Com- pared to other states, we’ve closed twice as many as the nearest state.” The prospect of more closures rais- es questions about how communities


y KXN K\OK ZRc]SMSKX] y MKX ROVZ VV the gaps in medical care left by a hos- pital’s departure. Last spring, the Tex- as A&M Rural and Community Health Institute (ARCHI), working with the Episcopal Health Foundation, issued a report titled What’s Next?: Practi- cal Suggestions for Rural Communities Facing a Hospital Closure. The idea behind the report was


to provide alternatives to traditional hospital care that could help rural patients, such as creating stand-alone emergency departments and relying more heavily on telemedicine, says Nancy Dickey, MD, executive director of ARCHI. Filling the void left by a ru- ral hospital is a community effort, but it is often led by physicians, she says. Ultimately, they will be the ones who will have to provide the services lost when a local hospital shuts its doors. “We had more than one provider come to us and ask, ‘Isn’t there any- thing anyone can do to help? What is my town supposed to do for health care?’” Dr. Dickey said.


LOSING COUNT


needs, Dr. Dimmick says. Some of the nearest large hospitals are in Bay City or the Houston suburbs, both about 40 or 50 minutes away. And recruiting new colleagues to the area has become WY\O NSP M_V^ K] aOVV “Most of us have been involved in


building and supporting that hospital for years,” Dr. Dimmick said. “I mean, that was our hospital. So I think, more ^RKX ^RO XKXMSKV SWZKM^ S^t] T_]^ RK\N to see.” The Wharton hospital’s passing is part of a much larger epidemic among


56 TEXAS MEDICINE November 2017


rural facilities. According to the North Carolina Rural Health Research Pro- gram, 82 rural hospitals have closed in the United States since 2010, and the Chartis Center for Rural Health re- ports that another 673 are in precari- Y_] XKXMSKV ]RKZO David Pearson is president and


chief executive officer of the Texas Organization of Rural and Community Hospitals (TORCH), which represents 163 rural facilities. He says Texas is in the unenviable position of leading the country in rural hospital closures.


Mr. Pearson says the crisis in rural hospitals starts with demographics. Those hospitals treat a relatively small share — about 3.1 million — of Texas’ 27.7 million residents. Those patients tend to be spread out over broad geo- graphic areas. Of Texas’ 254 counties, 172 are considered rural. The Texas Demographic Center says that if cur- rent trends hold, 95 percent of Texas’ growth will take place in metropolitan — not rural — areas in the foreseeable future. For these and other reasons, TORCH says rural hospitals face dif-


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