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Despite Rural Hospital Crisis, Wyoming System Plows Ahead

By Jack O'Brien  
   May 14, 2018

Jeremy Davis, CEO of Evanston Regional Hospital, talks about how the system is pursuing growth, staying financially solvent, and providing quality care. 

Across America, rural communities have fallen into economic decline, negatively impacting the financial stability of the hospitals and health systems servicing them.

Since 2010, 83 rural hospitals have closed, according to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, while 673 rural hospitals remain vulnerable to closure according to a 2016 study commissioned by the National Rural Hospital Association.

In Wyoming, the rural hospital crisis is top of mind. The state is serviced by 25 rural providers according to the Chartis Center for Rural Health, a healthcare analytics firm, with 11 rural hospitals operating on negative margins. Additionally, between 2007 and 2017, Wyoming hospitals lost $51,761,497 in revenue, 2,087 jobs, and $245,391,405 in gross domestic product.

Amidst these challenges, one hospital is implementing a series of policies to grow operations, reduce bad debt on the front-end, and embrace telemedicine. 

Evanston Regional Hospital (ERH) in Evanston, Wyoming, is a 42-bed hospital located in the southwestern corner of the state, about an hour-and-a-half from Salt Lake City, Utah. Last year, ERH recorded a total revenue of $66,749,559, with a net income of $8,288,804.

ERH services Uinta County and its population of almost 20,500, where 12.6% of people under the age of 65 do not have health insurance and 10.6% live in poverty, according to the United States Census Bureau. Wyoming did not adopt Medicaid expansion under the Affordable Care Act.

Strategy to maintain and grow

Jeremy Davis, CEO of Evanston Regional, told HealthLeaders Media that rural hospitals face multifactorial challenges to their business, requiring an equally diversified approach to stability.

Davis said growth is the biggest imperative for rural hospitals, noting that maintaining and expanding service lines is a strong indicator of satisfying the needs of the community and ensuring local care options remain available.

While growth is the cornerstone of ERH's strategy for the future, Davis added that the level of uncertainty on the federal level regarding healthcare, including multiple attempts to repeal the Affordable Care Act, remind hospital executives that there is no solid footing in healthcare. 

To sustain and build upon success, Davis has advised other systems to focus on community outreach and maintain open lines of dialogue with local leaders. Since 2016, ERH has held a key community leaders breakfast once a month to share updates regarding the hospital while also soliciting feedback and concerns to improve operations. 

Davis said this approach, coupled with engaging medical staff in the hospital's decision-making process, has been vital to ensuring ERH is not subject to the financial pressures that have shuttered so many other rural hospitals.

"My biggest concern is not only the public health impact, but also the economic impact [closure] could have on the community," Davis said. "It's tough sledding out there; rural communities have unique challenges, but at the same time if [a hospital] really partners with the community, medical staff, and employees, it can come up with solutions and creative strategies that will help address short-term and long-term issues to ensure viability."

Revenue cycle improvements for bad debt operations

Improving revenue cycle operations and reducing bad debt from vulnerable populations is a concern shared by hospitals, especially rural systems.

ERH has implemented revised payment plans to help its patients, culminating in a partnership with MDSave, an online tool that matches uninsured patients with providers who offer prepay discounts for medical procedures. Over 175 procedures are offered on the organization's website, which are discounted by 60% when patients prepay with ERH.

Related: Rural Medical Suppliers Spared, Temporarily, from Rate Adjustment

Davis compared this arrangement to Groupon, stressing the importance of developing effective payment options on the front end to make it easier for patients to access services at an affordable cost rather than attempting to collect on bad debt on the back end.

Telemedicine and tech improvements

Another major concern for rural hospitals is ensuring that patients can receive quality care locally and avoid long-distance rides to larger systems.

To achieve this, ERH has explored telemedicine opportunities, most notably partnering with Salt Lake City–based University of Utah Health for tele-critical care support. This partnership allowed ERH to reopen its ICU and have an ally to bolster work in the emergency room.

Davis acknowledges there are plenty of patients who want the physical presence of a physician as opposed to telemedicine options, which is why ERH has scheduled twice monthly visits from urologists in Salt Lake City to Evanston to meet with patients.

ERH has also shifted most of its investment dollars in the last year to improving the facility and medical equipment, according to Davis. This includes upgrades to its MRI, installing new patient monitoring technology, and purchasing new surgical equipment.

Recruiting and maintaining physicians

Perhaps the most significant challenge facing ERH is recruiting physicians to work there and buy into the organizational culture, according to Davis. Working in Evanston, which Davis said is "rural but not isolated," has drawn hesitation from prospective physicians even in the hyper-connected age of digital communication.

"If I had to summarize rural hospitals in one word, it would be creativity," Davis said. "A lot of times with specialists, a full-time urologist might need a service area of 40,000-50,000 [people]. We don't have that population base here, so we have to find someone who can work part-time or get creative and partner with doctors out of these larger urban markets and get them to come up [to Evanston.]"

However, ERH has seen its patient volume rise, resulting in the addition of new hires and more than a dozen providers since 2016, which Davis called an anomaly for rural systems.

This uptick also coincided with the decision by Community Health Systems Inc. to spin off ERH and 37 other hospitals as part of the newly formed Quorum Health Corp. However, due to declining revenues, Quorum has sold off several hospitals since then, with its network shrinking to 28 hospitals, while retaining ERH.

Related: Hospital Closures Deepen Quorum's Q1 Losses

To better recruitment efforts, Davis focused on investing in staff support and market adjustments for more competitive salary and compensation packages. This strategy applies not only to physicians but nurses and laboratory staff as well.

The hospital’s work has drawn recognition, says Davis, with ERH earning a Performance Leadership Award in Quality from the National Organization of State Offices of Rural Health and the Chartis Center last year.

Jack O'Brien is the finance editor at HealthLeaders, a Simplify Compliance brand.

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