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ferent challenges than their urban counterparts. Because populations are smaller, the volume of patients can swing wildly from one day to the next. Rural populations also tend to be older and poorer, so people often have more serious chronic health problems, such as heart disease and diabetes. That also means rural hospitals deal with more Medicare, Medicaid, and unin- sured patients than do urban facilities. Many of the recent Texas closures


were caused in part by congressional Medicare cuts totaling more than $50 million a year for Texas rural hospitals, Mr. Pearson says. The closures also were fueled by underpayments in the Texas Medicaid program to rural hos- pitals approaching $60 million a year. Texas’ refusal to expand Medicaid un- der the Affordable Care Act also hurt rural hospitals, he says. “If you couple the shrinking reim- bursements with the ever-increasing costs of running a small, isolated, low- volume hospital in a rural area, what cY_ ^OXN ^Y QO^ O`OX^_KVVc S] K XKX- cial scenario that doesn’t balance costs and revenues,” he said.


“The one complaint I hear from my patients is that if there is an emergency, there’s no easy place to get to.”


According to the 2017 Rural Hospi-


tal Environmental Impact Study pre- pared by TORCH and the Episcopal Health Foundation, a rural hospital’s departure can badly damage a rural area’s economy. Rural hospitals often are a region’s largest employer, and closing down a hospital can eliminate anywhere from 75 to 150 high-wage jobs.


Any hospital closure causes eco- nomic ripples for years because busi-


Many small-town hospitals, like the one in Wharton, convert to being a stand-alone emergency department..


nesses shy away from towns without hospitals — and so do physicians, Dr. Dickey says. “In a recent closure [in Texas], a


surgeon left approximately the same day the facility closed,” she said. “And another physician was out looking for other opportunities, saying, ‘I’d love to stay and take care of my patients, but the reality is that what I do is tied to the capacity to have an in-patient facility.’” The physicians who do stay often


are left with poor choices when it comes to helping their patients. Pris- cilla Metcalf, MD, an ophthalmologist in Wharton, says the hospital closure was an inconvenience for her person- ally. Instead of doing eye surgeries in Wharton, she now has to travel to Matagorda Regional Medical Center in Bay City, about 40 minutes away. But many of her patients are el- derly and low-income, so making that drive can be an ordeal, given their vi- sion and other health problems. “It’s tougher to get families to take off [to drive patients to their surger- ies],” she said. “And the one complaint I hear from my patients is that if there is an emergency, there’s no easy place to get to.”


WHAT TO DO?


The ARCHI report lists several sug- gestions for physicians and commu- nities looking for alternatives after a RY]ZS^KV MVY]O] >RO \]^ YX S^] VS]^ S] working to establish a stand-alone emergency department. Communities need to be realistic about their needs, and local physicians can help others understand what those needs are, Dr. Dickey says. “If [your town] happens to be near a major road system and you have a lot of accidents, or if you’re a big farming community and you have a moderate amount of trauma coming out of farm machinery, you may need a much more sophisticated emergency depart- ment that is prepared to stabilize and maintain a patient while you’re in the process of trying to find transporta- tion,” she said. The ARCHI report also encourages


local physicians to make greater use of telemedicine. With TMA’s backing, the Texas Legislature this year passed Senate Bill 1107, which updated and clarified the rules concerning tele- medicine. (See “Clearer and Simpler,” August 2017 Texas Medicine, pages 38– 39, or visit www.texmed.org/SB1107.) The University of Texas and Texas


November 2017 TEXAS MEDICINE 57


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