Rural hospitals close when they don't have enough paying patients to care for, but they're also now penalized when the same patients show up over and over again. That puts rural hospitals in a precarious position of occasionally needing to keep people away from their care.
Under the Affordable Care Act, Medicare began to punish hospitals if too many patients showed up in a hospital again within 30 days. Many consider the measure imperfect, but it's meant to incentivize hospitals to get it right the first time.
That's affected the way Charlotte Potts of Livingston deals with her health problems. Potts spends much of her day in a recliner, tethered to a pulsing oxygen machine listening to the radio in her apartment.
"I've only had five heart attacks," she says with a laugh. "I've had carotid artery surgery. Shall we go on? Just a few minor things." She jokes that she's "a walking stent."
Fortunately, this Texas native lives a short distance of the Livingston Regional Hospital — a 114-bed facility large enough to have a cardiac unit. But the hospital doesn't want to see her every time she's got a question about her heart. So last time she was in, they linked her up with a few companies that could provide care at home.
"If I'm going to have certain things going on here in my chest, I call for help, and they're there," Potts says.
A New Era In Hospitals Management
There were days when a home health agency might have been viewed as a competitor. Not anymore.
Hospitals used to run on the fee-for-service model — the more service a hospital provided, the more money it made. But that's transitioning to a model in which hospitals are rewarded for safety and efficiency.
"When I started this almost 40 years ago, the mission was different," says Tim McGill, CEO of Livingston Regional. "We wanted patients in the hospital. That was the incentive. We were paid for it. Now you're not."
In this town of 4,000 people on Tennessee's Cumberland Plateau, the hospital operates on the thinnest of margins — just 0.2 percent in the most recent figures. And so-called readmissions have been a persistent sore spot.
At Livingston Regional, for example, one in five patients with heart failure, was back within the month. The hospital has paid the maximum penalty recently, nearly $200,000 a year. So leaders started asking a basic, unifying question of other providers in town.
"What can we do together so they'll stay out of the hospital and stay healthier in their home setting?" McGill says. "That's where the work is."
Mary Ann Stockton is a nurse who leads quarterly meetings at the Livingston Public Library. She invites all the home health agencies as well as hospice providers, even nursing home leaders.
At the October meeting, she applauded agencies for increasingly meeting patients inside the hospital before they're discharged. She said it helps with acceptance.
"We know in our area, people don't like to have a total stranger come into their home," she said.
The group brainstorms how to generate the same kind of acceptance for hospice care, which, as one doctor in the meeting puts it, some families view as assisted suicide.
And on this day, they spend much of their time reviewing the value of flu shots, especially for people who work at nursing homes. Stockton says elderly patients with bad lungs become "frequent fliers."
"Flu starts off, goes into pneumonia, COPD exacerbation, and they are a revolving door in our hospital," Stockton says. "They're hitting that ER a couple of times a week."
Advance directives are on the agenda for next time — another way to keep people near the end of life from becoming repeat customers.
Livingston's parent company is launching this community approach in many of its 80-or-so markets, which are almost all rural. LifePoint Health's Cindy Chamness helps hospitals find willing partners.
"We were very frustrated for many years," Chamness says, "because we weren't able to impact readmissions just working on it by ourselves as a hospital."
Admissions And Readmissions
In one Arizona town, paramedics now visit discharged patients to make sure they're following doctors' orders. It's working.
The house calls also cut down on government-funded ambulance rides.
Broadly speaking, rural hospitals are finding themselves taking on these new roles. But administrators are having trouble seeing where it ends.
"[A] CEO from Montana said to me, 'The problem is, when we do the right thing, are we saving ourselves right out of business?' " says Michael Topchik of the Chartis Center for Rural Health.
The focus on reducing readmissions — by definition — reduces overall admissions too.
"So this is the real inherent tension and challenge, which is hospitals get reimbursed for doing sick care," Topchik says. "But more and more they're being asked to do population health and really focus on wellness."
To make up the volume, the Livingston hospital is expanding its maternity ward and general surgery offerings.
But there is also some immediate financial upside: The hospital has cut readmissions more than any other rural hospital in Tennessee, according to data compiled by Chartis. As a result, its Medicare penalty in the coming year will be reduced to 0.3 percent of its reimbursements, down from the maximum of 3 percent.
All because patients like Charlotte Potts stay home.
"I got a real bad tightness in the chest," she recalls about a recent episode. She questioned whether to call an ambulance. "I was very uncertain about what was going on."
But she phoned her home health agency, took a nitroglycerin pill, and instead of going to the ER, she went back to sleep.