To get to Johnson County Community Hospital, 30 miles southeast of Bristol, TN, you must drive straight through the mountains. From Blacksburg, VA, you drive the switchbacks of Route 91 where it snakes alongside Laurel Creek and crosses the Virginia-Tennessee state line. Logging truck drivers ride their "jake brakes." Towering among the dark pine trees is a billboard reading, “Meth Kills.”
Mountain City, where Johnson County is located, is one of many isolated enclaves across the country where health care is limited to a single critical access hospital. Budgets are tight and services are limited — most lack any complex care, like obstetrics. Yet despite the paucity of resources, most rural hospitals are a paean to efficiency and quality of care. Behind the tight, two-bed facility, a helicopter pad acts as a kind of contingency plan, but it’s one that Chief Medical Officer Mark Wilkinson says is used only once a week at most. The hospital has both processes and infrastructure in place to deal with whatever arises.
"Nearly everyone is cross trained and capable of doing multiple jobs," said JCCH CEO Dwayne Taylor. "We try to be everything we possibly can for the community, so that they can get everything they need within reason here, and not have to travel."
While one could say that receiving complex care at Johnson County is “discouraged,” it’s certainly possible in emergencies, and perfectly safe. In fact overall, despite what many experts consider to be an ongoing crisis for rural health facilities, outcomes, care quality and patient safety are equal between rural and urban hospitals, according to a rural relevance study done by iVantage Health Analytics. Not only that, but costs are lower as well. According to the report, rural EDs are cheaper and more efficient than urban EDs, with inpatient admissions less than half the national rate.
Healthcare Dive took a trip down to Mountain City, TN to visit Johnson County and discover both the challenges that rural hospitals face and what those hospitals are doing right.
The rural health crisis
In the U.S. today, more than 46 million people, or about 15% of residents, live in rural areas and depend on their local hospital as their primary source of care. Johnson County Hospital, a designated Critical Access Hospital, cares for 17,000 lives and offers both primary and emergent care. Recent investment in telehealth infrastructure has broadened the specialty services the hospital is able to provide.
Despite the fact that many of these hospitals put the “critical” in “critical access," there have been rural closures in Georgia, Texas, Louisiana, North Carolina, Virginia, California and Tennessee in recent years. According to Modern Healthcare, 10 hospitals have closed in the last three years in Alabama alone. In Georgia, Gov. Nathan Deal last month proposed that rural hospitals be allowed to maintain licensure while offering fewer medical services than the requirement.
Closures are generally attributed to patient volumes too low to support operations, and the high proportion of Medicare and Medicaid beneficiaries in rural populations — care administered at the approximately 2,000 rural hospitals across the country accounts for 25% of Medicare’s annual spending. Johnson County bills 53.3% of its care to Medicare recipients and 14.6% to Tennessee’s Medicaid program, TennCare.
At the recent National Rural Health Association annual meeting in Las Vegas, CEO Alan Morgan ascribed the closures to reimbursement cuts and state-level refusal to expand Medicaid under Obamacare. The AHA’s 2013 Annual Report on Small or Rural Hospitals echoes the same sentiments: "Rural hospitals' low-patient volumes make it difficult for these organizations to manage the high-fixed costs associated with operating a hospital," states AHA's 2013 Annual Report on Small or Rural Hospitals. "This in turn makes them particularly vulnerable to policy and market changes, and to Medicare and Medicaid payment cuts."
Tennessee is one of the states that refused to expand Medicaid, a move Taylor called a “big negative” for the hospital.
“About 10% of patients that we deliver care to have no form of coverage at all,” Taylor said. “Because the state of Tennessee decided not to expand Medicaid, we haven’t seen any pick-up in access of coverage.”
There’s also some other regulatory concerns at work. In mid-August, HHS’ Office of the Inspector General recommended that CMS decertify some two-thirds of CAHs that don’t meet current location requirements. The AHA strongly criticized the HHS for showing “an unfortunate lack of understanding of how health care is delivered in rural America,” FierceHealthcare reported.
In response to these challenges, many small, rural hospitals are considering mergers with larger systems in order to survive. “Every one of the small, rural hospitals is talking to somebody, because they have to,” Kenneth L. Oakley, CEO of the Western New York Rural Area Health Education Center, told The Buffalo News.
Yet if you ask Taylor, none of these are Johnson County’s biggest challenge.
Obstetricians, telehealth and a good back-up plan
Recruitment, according to Taylor, is Johnson County’s biggest challenge — particularly recruitment of physicians and support staff. Taylor says he has to sell the community appeal to attract potential physicians because there’s no two ways around it: Mountain City, Tennessee is isolated and, for those unaccustomed to reading excerpts from the Book of Revelation on roadside signs, a culture shock.
The opportunity for a general practitioner to ply his trade, however, is broad. As a physician at Johnson County, according to Wilkinson, you’re caring for everything. Specialists are not only difficult to attract, but out of the budget. They’re also risky: According to a 2007 Walsh Center for Rural Health Analysis paper on the decline of delivery services, “health care providers often identify medical malpractice pressure as an important factor influencing decisions about whether to provide certain high-risk services.”
For example, only one CAH in the state of Tennessee has an obstetric department. And while Johnson County is part of a regional system that allows them to leverage specialists at other locations, many patients are unwilling to make the drive through the mountains.
So the hospital has gotten creative with how they offer services. Johnson County has worked with East Tennessee State University to implement telehealth infrastructure, and expects to expand on the remote services they already offer (like diagnostic mammograms). They leverage diagnostic tools to determine whether a patient can be treated in-house or needs to be transferred to another facility to receive care.
The obstetric question is a good example of how JCCH handles patients in need of complex care. Primary care physicians offer OB care in Mountain City up until delivery, including an extended hours clinic with a NP who provides women’s health. The hospital can deliver patients in the ED — and does so on average twice a year — but only if the patient presents with imminent delivery. Johnson County uses a screening tool and transfers the patient to delivery suite at another facility if time permits.
And the helicopter pad is always waiting behind the hospital if something goes awry.
“The efficiency model”
The numbers back up the image of smooth and efficient care that Johnson County projects. The iVantage study found that CAHs consistently outperformed their non-CAH counterparts: Looking at common DRGs, the average charge per case ($13,374) was 63% less than the average charge per case for non-CAHs.
Taylor is quick to point out that Johnson County does less inpatient work than the average CAH in the study — JCCH has fewer than 50 admissions per year — but that his hospital stands up to the standard of efficiency. He cites operating expense per adjusted admission as the metric he is most proud of: JCCH runs $2,605 per adjusted admission, as compared to a general acute hospital rate of $4,000 to $5,000, according to Taylor.
The implications for other institutions are huge, insists iVantage executive vice president John Morrow, although the study doesn’t provide measurable evidence as to why rural hospitals are consistently outperforming their urban counterparts. Morrow has a few ideas, though.
“I can’t tell you empirically that it’s absolutely because [rural hospitals] manage tighter budgets but I can tell you anecdotally that they are doing it,” Morrow told Healthcare Dive. “They tend to be well run because they don’t have a whole lot of options -- they are forced to manage on much smaller budgets.”
The secret, according to Morrow, is a focus on providing the right care in the right setting — like Johnson County’s infant delivery screening tool.
“When the cases get tough, they transfer them to the appropriate tertiary care referral center,” Morrow said. “That is an appropriate use of resources.”
Maintaining that efficient flow, according to Morrow, is primarily a question of management. He points out that rural hospitals can’t rely on the economies of scale that larger systems can, and that their management has developed accordingly. He characterizes CAH management teams as leaner, like any small business, and by necessity more likely to adhere to budget-driven strategies that serve their community.
Morrow also credits telehealth as part of an overall lean strategy, although there is currently no metric to value its impact. He points to per-beneficiary spend as the area of study that manifests a telehealth reading. In 2012, the average cost per rural beneficiary was 2.5% lower than the average cost per urban beneficiary. (In fact, if average cost per urban beneficiary were equal to the average cost per rural beneficiary, Medicare alone would realize over $5 billion in annual savings.) Morrow suggests anecdotally that leveraging telehealth has had a significant impact on reducing that bottom line.
“When you compare rural against non-rural, rural does a pretty good job,” Morrow said. “They have lower prices, their costs and outcomes are in line. They treat less acute patients, they treat them during business hours, and they treat them much faster than urban communities.”
Why rural care matters
When asked about his response to CMS’ recent Medicare data dump, Dwayne Taylor had to shrug — he hadn’t heard about it yet. For Taylor, as for most small, rural hospitals, the focus is by necessity narrowed to the enclave of his own population. Taylor oversees two hospitals in the Mountain States Health Alliance, and the word “community” is the word he uses the most frequently, perhaps because the challenges each rural hospital faces are as distinct as the regions they serve. Drive through Shady Valley and back into Virginia, and you are in a different world.
“Rural care is not the biggest part of our economy but most states have some rural community, and as long as there will be two US senators from every state, [rural care will continue to matter],” said Morrow. “The conclusion in my study is that perhaps there is something to be learned here by all hospitals. If good value, manageable costs and good outcomes can be done in widely-spread, disparate rural communities, then the argument would be that it can be done anywhere.”