Patients receiving extra support were just as likely to return to the hospital within 180 days as those not receiving that help.

This article was first published on Wednesday, January 8, 2019 in Kaiser Health News.

By Dan Gorenstein and Leslie Walker

Improving health and lowering costs for the sickest and most expensive patients in America is a dream harder to realize than many health care leaders had hoped, according to a study published Wednesday by the New England Journal of Medicine.

Researchers tested whether pairing frequently hospitalized patients in Camden, New Jersey, with nurses and social workers could stop that costly cycle of readmissions. The study found no effect: Patients receiving extra support were just as likely to return to the hospital within 180 days as those not receiving that help.

The results are a blow to Dr. Jeffrey Brenner and the Camden Coalition of Healthcare Providers, the organization he founded nearly 20 years ago.

"It's my life's work. So, of course, you're upset and sad," said Brenner, who now does similar work with health insurance giant UnitedHealthcare.

The model of care, pioneered in part by Brenner and profiled in a widely read 2011 article in The New Yorker, has inspired dozens of similar projects across the country and attracted millions in philanthropic funding.

"This is the messy thing about science," said Brenner, who won a MacArthur Foundation "Genius Grant" for his efforts. "Sometimes things work the way you want them to do work and sometimes they don't."

The Hope

Many hospital and insurance executives have pinned their hopes on this work because it promised to solve a common problem: when patients lives are so complicated by social factors like poverty and addiction that their manageable medical conditions, like diabetes and asthma, lead to expensive, recurring hospital stays.

Writer and physician Atul Gawande introduced Brenner as a brash visionary crusading on behalf of the "worst-of-the-worst patients" in the New Yorker piece, titled "The Hot Spotters." (Gawande, who now heads Haven, a joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase, declined to be interviewed for this article.)

Brenner's prescription: Pair these people with front-line care workers who would shepherd them to the social and medical services they needed. Early evidence was promising, the anecdotes inspiring. Brenner boiled the model's potential down to four words and two tantalizing goals: better care, lower costs.

As word spread, breathless headlines popped up like "Health Care's Best Hope" and "Could Camden Coalition Save US Healthcare?"

"Lots of organizations make claims that their programs work and they've never been rigorously tested," Brenner said.

Instead, Brenner took the unusual step of inviting the scrutiny of respected researchers.

In 2014, Massachusetts Institute of Technology economist Amy Finkelstein began a randomized controlled trial, the same rigorous method used to evaluate new drugs. Over four years, the coalition enrolled 800 patients, all who had been recently hospitalized and struggled with social problems. Half received the usual care patients get when leaving the hospital. The other half got about 90 days of intensive social and medical assistance from the coalition.

And the result: The 400 patients who received the intensive help were just as likely to return to the hospital as the patients who didn't. In both groups, nearly two-thirds of people were readmitted within 180 days.

So why did the coalition fail? Why did the savings touted in their early data, which Gawande had declared "revolutionary" in The New Yorker nearly a decade ago, disappear when put to this rigorous test?

'My Daily Routine'

Larry Moore, who has hypertension, alcohol addiction, chronic seizures and difficulty walking, was one of the first people to enroll in the coalition's trial.

Moore's experience serves as a road map for understanding why the coalition missed its mark.

His first months were promising: prescriptions filled, medical appointments attended, Social Security benefits claim in process. The 47-year-old even started to trust the team with the details of his deep-seated addiction, confiding how he would consume mouthwash, vanilla extract and even hand sanitizer at times.

"You couldn't keep anything with alcohol in it" around him, Moore recalled. "That's addiction."

But all the progress suddenly stopped when Moore seemed to disappear from the coalition's radar.

"We didn't see Mr. Moore after November," said nurse Jeneen Skinner. "We went to the house. We sent text messages. We [made] phone calls."

The coalition has learned that for people living in poverty and with poor health, a small hiccup — in Moore's case, a missed rent payment — can spiral into a major setback.

Moore spent the next 2½ years mostly homeless, completely out of touch with the coalition.

"I was going from place to place. I sleep on a bench or a rock until the next day when the liquor store opens," remembered Moore. "That was my daily routine."

Seventy emergency room visits and six hospital admissions later, Skinner reconnected with Moore.

He told her the one thing that would keep him out of the hospital: housing.

The 'Camden Coalition'

Too many times, during the trial, people ended up back in the hospital despite the intervention. But the coalition is convinced it didn't fail as much as the larger social safety net did.

"The bottom line is, we built a brilliant intervention to navigate people to nowhere," said Brenner.

Coalition staff and their patients usually knew what was needed — evidence-based addiction treatment, housing, mental health services — but resources were often in short supply.

Over the past three years, the coalition set out to fill in those gaps, undergoing a kind of metamorphosis.

"We think of ourselves now as the Camden Coalition" steering away from the "health care providers" part of the name, said Kathleen Noonan, who succeeded Brenner as head of the organization.

It has forged partnerships with jails, lawyers and legislators, and started its own housing program. Many of these efforts began as the clinical trial was ongoing — a sign the coalition had seen the writing on the wall.

'I Kid You Not'

"I would have never imagined this," said Moore, sweeping his arm around his one-bedroom apartment.

A green houseplant sits in the sunshine. A fluorescent-colored stuffed animal decorates the bed.

"When I first moved in here," Moore explained, "it took me about a month to even sleep in my bed. I slept on a couch."

Housing made it easier to face his other problem, choosing to try the drug naltrexone, a long-acting injection to treat alcohol addiction.

Moore is nearly two years sober today. He meets with a coalition support group on Wednesdays. He's becoming a deacon at his church. In the 22 months he has lived in the apartment, Moore's trips to the hospital have plummeted: just one admission and one ER visit.

"I kid you not, when I saw Mr. Moore probably a month ago, I was standing next to him and did not recognize him," said nurse Skinner. "He looked at me, and said, 'Jeneen, it's me. And I was like, 'My God, you look amazing!'"

Larry Moore's story is just that: one story.

Yet it represents a larger trend. Insurers — including UnitedHealthcare under Brenner's direction — hospitals and many state Medicaid agencies have begun spending millions to meet patients' social needs.

The new study, though, backs up the skepticism of other researchers that, when it comes to saving money at least, these approaches don't work well. For one, programs are expensive and hard to scale. The coalition's housing effort currently serves only 50 people and costs about $14,000 per person per year. Secondly, the data is lacking, cautioned Boston University economist Austin Frakt. "Despite what people would like to believe, there's not a lot of evidence you can reduce health spending by spending more in other areas."

Finkelstein said that as health care companies move further beyond the four walls of a hospital, the need for rigorous evaluation grows. "I think a lot of well-intentioned people in health care can't handle the truth," she said. "They're trying to do good, but they don't have the courage to say, 'Let's do a gut check on ourselves.'"

Dan Gorenstein is the creator and co-host of Tradeoffs podcast and Leslie Walker is a producer on the show, which features the study on the Camden Coalition in episode 7.

CMS administrator speaks on a range of issues in an interview with Kaiser Health News.

This article was first published on Friday, January 3, 2020 in Kaiser Health News.

By Sarah Varney January 3, 2020

Seema Verma, administrator for the Centers for Medicare & Medicaid Services, sat down for a rare one-on-one interview with Kaiser Health News senior correspondent Sarah Varney.

They discussed her views on President Donald Trump's plan for sustaining public health insurance programs, how the administration would respond if Obamacare is struck down by the courts in the future and her thoughts on how the latest "Medicare for All" proposals would affect innovation and access to care.

A portion of their conversation aired on PBS NewsHour on Dec. 23. A transcript follows, edited for length and clarity.

Sarah Varney: Thank you, Administrator Verma, for joining us. We really appreciate it. You spoke recently about this need to protect Medicaid as a lifeline, but also not to have people be entrapped, or trapped on, Medicaid and come to rely upon it too greatly. So, as I was mentioning, we were in Tennessee recently, and I know you can't speak to specific cases —

Seema Verma: Mmm, hmm.

Varney: But, we did find a number of families who had been disenrolled, and then found it quite difficult to get back on. And I just wondered if there is a danger in taking this approach where there's more frequent verification checks, a real focus on eligibility verification, that it could discourage some parents and kids who might be eligible for the program from signing up?

Verma: Well, our top priority is making sure that the beneficiaries in the Medicaid program have high-quality, accessible care, and we want to do everything that we can to improve the quality of their lives. In terms of the enrollment process, we also have an obligation to taxpayers to make sure that only the people that qualify for the programs are participating. And we also want to make sure that the programs are sustainable over the long term. I think there's a balance between making sure it's easy for people to apply, but we also have to make sure that we do the appropriate work to make sure that they qualify for the programs.

Varney: So, are you concerned, though, that there were a number of people, after the eligibility process kicked in again in 2017, after the ACA sort of put things on hold for a while, that there might have been families, though, that have been lost? That just don't want to come back, or can't come back? Or are hearing worries about the public charge rule, as well, and so are concerned about giving the government their information?

Verma: You know, our top priority is making sure that we focus on improving quality of care, high-quality care, accessible care, and making sure that we're improving the quality of life for individuals. You know, when I think of the Medicaid program, and in every decision we make, I try to keep in mind the actual beneficiary. In my time spent on the Medicaid program, I've met a lot of Medicaid beneficiaries. I met a gentleman, Richard, who was in Indiana. He was a quadriplegic and literally requires 24-hour care. I met some parents of a child on the Medicaid program. This child had cerebral palsy and so severe that they require 24-hour care, and you can imagine the impact on the entire family. This is a child that will never be independent, will always require help. And so, when we're creating our eligibility policies, we keep those individuals in mind. We don't want to make it harder for them to apply for the program.

And so, we try to come up with policies that don't put a lot of onerous requirements on the beneficiary, but we can have requirements for states that require them to do back-end processes, and back-end checks that don't actually burden the actual recipient or their families, but that also ensure that we are putting the appropriate protections in place for taxpayers, so the program is sustainable over the long term. And we have only the people that qualify for the program participating.

Varney: We know that more health coverage leads to longer life expectancy; I think this has been well established. And I wonder if whether or not the administration should be emphasizing more finding those children who are not enrolled, who are eligible but not enrolled, and perhaps focusing on outreach, which we haven't really heard your administration talk about?

Verma: Well, again. Our focus is on making sure, especially children, that they have access to high-quality health care. As a mom, I've got two kids, so I can personally attest to the fact that having health insurance is very important for children. Something very little, like an ear infection, can lead to deafness if it's not, you know, treated appropriately. So having that access to high-quality health care is very, very important to their development. The Trump administration is very committed to the Children's Health Insurance Program; the president signed legislation around that. Additionally, we have spent over $48 million on outreach efforts. We're very focused on working with states, so that they can identify the best practices to make sure that those individuals, children that qualify, can enroll in the program, that they're aware that this program exists.

Varney: Have you found that the reduction in the Navigator grants has made it more difficult to reach those families?

Verma: We, actually, we have not. If you look, the Navigator programs are really aimed at the Affordable Care Act programs and the exchange programs. So those are not aimed at children. Those are aimed at our adult population. And we have seen very minimal impact. What we have done is try to increase our digital communication, of, to help enrollment. And we've seen a very minimal impact on enrollment.

I think the issue around enrollment really comes back to affordability. Obamacare has had a direct impact on increasing premiums. Across the nation, we've seen premiums go up by 100%, 200%. [Editor's note: PolitiFact rated this claim by the Trump administration "false." ACA premiums were down by about 4% in 2019 compared with 2018.] And so the issue around enrollment is that health insurance has become so unaffordable for families that that's why they can't afford their coverage.

Varney: So we did hear from a number of federally qualified health centers that although the Navigator grants really were focused on, you know, ideally they were focused on exchanges, people buying private health insurance, that, in fact, there were a lot of people who came in, who became eligible for Medicaid and discovered that they were eligible for Medicaid in that way. So I wonder if there is additional outreach that needs to be done to those families, not just virtually or online, but some other way to reach those families?

Verma: The real problem around making sure that people have access to affordable coverage is really addressing the high cost of health care. And that's what the president is focused on. His health care agenda isn't just about putting out more subsidies and having the government pay more and more and creating unaffordable programs. But it is about addressing the underlying cost drivers in health care. That's why he's focused on prescription drug pricing, he's focused on transparency, price transparency, so that there's more competition in the market. We're also focused on getting rid of burdensome regulations that we know drive up the cost of care.

I think by addressing that, that is going to result in decreased premiums, which will result in more people having access to affordable coverage.

Varney: But all those things that you just mentioned — they don't necessarily affect the Medicaid population directly. Now, they may affect them indirectly by increasing overall health care costs, but in terms of the Medicaid population, really reaching out, ensuring that every single child who's eligible for Medicaid is enrolled?

Verma: So, our focus is also on addressing the economy. Under the president's leadership, we have a booming economy. We have one of the lowest unemployment rates. We have more people that are earning more money, and we have fewer people living in poverty. There's been a reduction in the number of people living in poverty by 1.4 million people. And so, we are seeing people coming out of the Medicaid program, and because the economy's doing so well. The issue is, though, they can't afford coverage. And so, even as we increase our outreach efforts, we spent over $48 million on outreach, the issue is around affordability. Obamacare has impacted the market in such a way that it's become unaffordable for people that don't have subsidies.

Varney: So, we're at this moment in our country and our national conversation where we're talking about how do we ensure that more and more people are insured? And I wonder what the administration is doing to move the needle, to stop the growth in the uninsured, particularly among children?

Verma: I think our focus has been about addressing affordability of health care. The underlying issue in people not being able to afford their health insurance is that it's too expensive. And the solution is not trying to throw more government money around subsidies, because that's just going to increase taxes for everybody. Our approach is to address the underlying issues. President Trump is addressing long-standing issues in health care that haven't been addressed by any administration. The blueprint that he put out on drug pricing was very historic. The work that he's done on price transparency. And the work that we're trying to do around the regulatory burden, getting rid of all kinds of unnecessary regulations that are actually increasing the cost of health care for providers. We spend over $200 billion on administrative costs every year. So what we're trying to do is address the cost of health care, but also make sure that we continue to have the high-quality, innovative health care system that Americans are used to.

Varney: So there are some people who are advocating for a Medicare for All type of solution to this, to say that much of those costs are because the marketplace, in a sense, doesn't work in health care. And I wonder what you say to people who are proposing that? Who are saying, this is all just, that the market doesn't work when it comes to health care?

Verma: So, when it comes to health care and it comes to the solutions around Medicare for All. … Medicare for All would strip Americans, 180 million Americans, of their private health insurance and put them on a government-run, bureaucratic program. If we look at the programs that we have today, our government-run programs, our Medicare program is not affordable. The Medicare Trustees have indicated in the next seven years they're gonna run out of money, they're gonna have trouble paying their bills. The Medicaid program is the No. 1, No. 2 budget item for many states. And you're hearing states every day — look at the situation in New York, where they can't afford their Medicaid programs. And so, our track record on government-run programs isn't strong. And I think our focus is on trying to unleash competition to drive down costs, but keep the innovation in the system. Our concern is that a government-run or more government is going to thwart innovation.

As the head of the Medicare program, I see every day that government regulations kind of stand in the way, that there are delays in our beneficiaries being able to access treatments. That's why the president put out the Medicare Executive Order, which was focused on making sure we can do better with this. But I think, you know, putting more people on a government program is actually going to threaten the sustainability of the programs that we have in place today.

Varney: And do you think through the measures that you're talking about, that you could reduce costs — 15%, 20% — in the health care system of the United States?

Verma: I think our goal is to try to reduce cost, and to make it more unaffordable [sic]. And we've had great success with this under President Trump's leadership. If we look at the Medicare Advantage Program, for example, under his leadership, premiums have gone down by over 23% since he came into office. In the Part D program, premiums are down by 13%, the lowest level in seven years. Going back to Medicare Advantage, that's the lowest level in 13 years. So, I think the president's policies are working, because we demonstrated that we can lower premiums.

Same thing on the individual exchanges. For the very first time, the individual market has been stabilized and premiums went down last year by a percent, this year by 4%, and they're still too high, there's a new class of uninsured being created by Obamacare, but President Trump's policies have actually resulted in more Americans, more seniors having money back in their pockets.

Varney: Now we're waiting for a ruling from the courts on the future of the Affordable Care Act. If it's struck down, what is your plan to replace it?

Verma: Well, the president's been very clear that he wants to make sure that individuals with preexisting conditions have protections. And we have prepared for a variety of scenarios, and we want to make sure that there's no disruption in coverage. And we'll work with Congress to make sure that Americans have access to high-quality, affordable coverage. That is not what they have today. People with preexisting conditions do not have those protections. Individuals that don't get subsidies and can't afford coverage really don't have those protections. And so the president wants to make sure that we're addressing those individuals, and that people with preexisting conditions have the appropriate protections that they don't have today.

Varney: But how do you guarantee those protections, also reduce costs and not lead to widespread uninsurance rates going up?

Verma: I think our focus is not just on costs, but it's also making sure that we preserve quality and innovation in the system. One of the initiatives that we've had is around trying to pay our providers differently. Right now, we're paying in a system where we just pay for people to get things done. And we want to change that paradigm, where we're holding providers accountable for providing quality care, improving the quality of life, preventing disease and keeping people healthy.

Varney: So, just my final question. There have been these reports of a rift, a growing rift between you and Department of Health and Human Services Secretary Alex Azar. And I wonder if people should be concerned about whether or not that's going to get in the way of the very ambitious slate of initiatives that you and President Trump have planned?

Verma: Well, Secretary Azar and I are both committed and have a shared goal around delivering on the president's agenda.

This story also ran on PBS NewsHour

Sarah Varney: svarney@kff.org, @SarahVarney4

The AHA has issued few guidelines on hospitals' aggressive collection practices or the limited financial assistance policies that often trigger them.

This article was first published on Saturday, December 28, 2019 in Kaiser Health News.

By Jay Hancock

The American Hospital Association, the biggest hospital trade group, says it promotes "best practices" among medical systems to treat patients more effectively and improve community health.

But the powerful association has stayed largely silent about hospitals suing thousands of patients for overdue bills, seizing homes or wages and even forcing families into bankruptcy.

Atlantic Health System, whose CEO is the AHA's chairman, Brian Gragnolati, has sued patients for unpaid bills thousands of times this year, court records show, including a family struggling to pay bills for three children with cystic fibrosis.

AHA, which represents nearly 5,000, mostly nonprofit hospitals and medical systems, has issued few guidelines on such aggressive practices or the limited financial assistance policies that often trigger them.

In a year when multiple health systems have come under fire for suing patients, from giants UVA Health System and VCU Health to community hospitals in Oklahoma, it has made no concrete move to develop an industry standard.

"There could be a broader message coming out of hospital leadership" about harsh collections, said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. "It seems unconscionable if they are claiming to serve the community and then saddling patients with these financial obligations that are ruinous."

Nonprofit hospitals are required to provide "community benefit," including charity care in return for billions of dollars in government subsidies they get through tax exemptions. But the rules are lax and vague, experts say, especially for bill forgiveness and collections.

The Affordable Care Act requires nonprofit hospitals to have a financial assistance policy for needy patients but offers no guidance about its terms.

"There is no requirement" for minimum hospital charity under federal law, said Ge Bai a health policy professor at Johns Hopkins. "You design your own policy. And you can make it extremely hard to qualify."

Practices vary sharply, a review of hospital policies and data from IRS filings show. Some hospitals write off the entire bill for a patient from a family of four making up to $77,000 a year. Others give free care only if that family makes less than $26,000.

The law does not substantially limit harsh collections, either. IRS regulations require only that nonprofit hospitals make "reasonable efforts" to determine if patients qualify for financial assistance before suing them, garnishing their wages and putting liens on their homes.

Gaping differences in both collections and financial assistance show up in the policies of health systems represented on AHA's board of trustees.

This year, AHA board chairman Gragnolati's Atlantic Health System, in northern New Jersey, sued patients for unpaid bills more than 8,000 times, court records show.

Atlantic Health sued Robert and Tricia Mechan of Maywood, N.J., to recover $7,982 in unpaid bills for treatment of their son Jonathan at the system's Morristown Medical Center.

Three of the Mechans' four children have cystic fibrosis, a chronic lung disease, including Jonathan, 18. Tricia Mechan works two jobs — full time as a manager at Gary's Wine & Marketplace and part time at Lowe's — to try to pay doctor and hospital bills that pile up even with insurance.

"I have bill collectors call me all the time," Tricia Mechan said. "You're asking me for more, and all I'm doing is trying to get the best care for my children. I didn't ask to have sick children."

She closed a savings account and borrowed money to settle Jonathan's bill for $6,000. Another son with cystic fibrosis, Matthew, owes Atlantic Health $4,200 and is paying it off at $25 a month, she said.

Marna Borgstrom, CEO of Yale New Haven Health, also sits on AHA's board. Yale almost never sues families like the Mechans.

"I have not signed off on a legal action since 2015" against a patient, Patrick McCabe, the system's senior vice president of finance, said in an interview. "People are coming to us when they are at their most vulnerable, and we truly believe we need to work with them and not create any additional stress that can be avoided."

Yale has treated Nicholas Ruschmeyer, 30, a Vermont ski mountain manager, for recurring cancer. He has been careful to maintain insurance, but a few years ago the hospital performed a $12,000 genetic test that wasn't covered.

"Yale completely absorbed the cost," said his mother, Sherrie Ruschmeyer. Yale is "wonderful to work with, not at all aggressive," she said.

Atlantic Health bars families from receiving financial assistance if they have more than $15,000 in savings or other assets. Yale never asks about savings. Even families who own homes without a mortgage qualify if their income is low enough.

Atlantic Health's policies including seizing patient wages and bank accounts through court orders to recoup overdue bills. Yale says it does not do this.

In some ways, Atlantic Health's policies are more generous than those of other systems.

It forgives bills exceeding 30% of a family's income in many cases, the kind of "catastrophic" assistance some hospitals lack. It also bills many uninsured patients only slightly more than Medicare rates. That's far less than rates charged by other hospitals in the same situation that are substantially higher than the cost of treatment.

"Atlantic Health System's billing policy complies with all state and federal guidelines," said spokesman Luke Margolis. "While we are willing to assist patients no matter their financial situation, those who can pay should do so."

After a reporter inquired about its practices, Atlantic Health said it "is actively engaged in refining our policies to reflect our patients' realities."

AHA also is considering changing its position on billing in the wake of recent reports on aggressive and ruinous hospital practices.

Previously AHA said billing offices should "assist patients who cannot pay," without giving specifics, and treat them with "dignity and respect." Queried this month, association CEO Rick Pollack said, "We are reevaluating the guidelines [for collections and financial assistance] to ensure they best serve the needs of patients."

Kaiser Health News found that the University of Virginia Health System sued patients 36,000 times over six years, taking tax refunds, wages and property and billing the uninsured at rates far higher than the cost of care. Richmond-based VCU Health's physicians group sued patients 56,000 times over seven years, KHN also found.

In Memphis, Methodist Le Bonheur Healthcare sued patients for unpaid bills more than 8,000 times over five years, ProPublica reported. In South Carolina, hospitals have been taking millions in tax refunds from patients and their families, an examination by The Post and Courier showed.

In response, VCU pledged to stop suing all patients. UVA promised to "drastically" reduce lawsuits, increase financial assistance and consider further steps. Methodist erased debt for 6,500 patients and said it would overhaul its collections rules.

Yale's less aggressive policies also came in response to journalism — a 2003 Wall Street Journal report on how the system hounded one family. Yale still sends overdue bills to collections, McCabe said. But it balks at the last, drastic step of asking a court to approve seizing income and assets.

For patients with unpaid bills, he said, "if you're willing to play a game of chicken, you will win."

Hospitals say they see more and more patients who can't pay, even with insurance, as medical costs rise, family incomes plateau and out-of-pocket health expenses increase. In particular, they blame widespread high-deductible coverage, which requires patients to pay thousands before the insurance takes over.

"More consumers pay far more with fewer benefits," Pollack said.

Some states go beyond federal rules for charity care and collections. In California, patients with an income of less than $90,000 for a family of four must be eligible for free or discounted care. New Jersey requires Atlantic Health and other systems to give free care to patients from families of four with income less than $51,000.

The National Consumer Law Center, a nonprofit advocacy group, suggests all states adopt that standard for large medical facilities. Its model medical debt law also would require substantial discounts for families of four with income below $103,000 and relief for patients with even higher incomes facing catastrophic bills.

The AHA should consider similar changes in its own guidelines, NCLC attorney Jenifer Bosco said.

"I would be interested in seeing them taking a more active role in creating some standard for hospitals about what's too much," she said. "What's going too far? Given that this is a helping profession, what would be some appropriate industry standards?"

KHN senior correspondent Jordan Rau contributed to this report.

Jay Hancock: jhancock@kff.org, @JayHancock1

It's been about a year since the hospital in Fort Scott, Kan., closed. The lessons for this community about meeting its residents' health needs could provide insights for the rest of the country.

This article was first published on Tuesday, December 24, 2019 in Kaiser Health News.

By Sarah Jane Tribble

 FORT SCOTT, Kan. ― Dr. Max Self grabbed a sanitary wipe and cleaned off the small flashlight in his hands. More than 20 years as a family doctor in rural Fort Scott, Kan., has taught him a few tricks: "I've got my flashlight. See? Look, you want to hold it?"

Two-year-old Taelyn's brown eyes grow round and her tiny hand reaches out. But, first, Self makes sure she opens her mouth wide and he peers down. Behind him sits another staff member ― a medical scribe. Self's scribe gives him the ability to "focus on people," rather than toggling between a computer screen and the patient. It's a new perk he didn't have when he worked at Mercy Hospital.

That beloved hospital closed one year ago and, in the passing months, the small town's anger and fear evolved into grief, nervousness and ― lately ― pragmatic hope. Most of the handful of physicians in town stayed, taking jobs at a regional federally qualified health care center that took over much of the clinic work from Mercy. The emergency department, after closing for 18 days, was reopened temporarily ― run by a hospital 30 miles south.

It's not "all gloom and doom, although we all wish we had a hospital ― no doubt about it," insurance agent Don Doherty said during the town's weekly Chamber of Commerce coffee on D

Nationwide, death rates have been higher in rural America compared with urban areas since the 1980s, and the gap continues to widen. More rural residents live with chronic conditions, like diabetes, that affect their daily lives, and there is a higher percentage of older residents. Rates of smoking and premature births are relatively high, and people often die younger here than the national average.

Since 2010, 120 rural hospitals have closed across the country ― 19 in this year alone, according to data from the University of North Carolina's Cecil G. Sheps Center for Health Services Research. A national analysis of Medicare cost reports found that 21% of the nation's remaining rural hospitals are at high risk of closing.

"Frankly, it's not getting better," said Dr. Daniel DeBehnke, study co-author and a managing director with Navigant's health care practice.

A year ago, after Mercy gave a 90-day notice that it would close, City Manager Dave Martin said the betrayal felt by city leaders led to lawyers and calls with other health care systems about taking over the facility. Now, Martin has realized "we will not have ― or do we need ― a hospital."

But, if not a hospital to care for rural communities like Fort Scott with its 7,800 residents, what is needed? The answers to that question play out every day here and could hold lessons for the rest of the country.

'You Will Be Taken Care Of'

Self has cared for his share of struggling patients in this town, where 1 in 4 children live in poverty, and its main corridor ― U.S. 69 ― is lined with fast-food restaurants. But Fort Scott is "not far off" from what it needs to be healthy. Sure, residents have to travel south 30 miles to Pittsburg, Kan., or north 90 miles to the Kansas City, Kan., area to be hospitalized, but "you will be taken care of," he said.

Self's new employer is Community Health Center of Southeast Kansas, which as a federally qualified health center gets a higher level of government reimbursement for Medicare and Medicaid patients than Mercy did, said Jason Wesco, executive vice president at CHC.

The center can also gain grants to take care of the uninsured, which is important in states like Kansas that did not expand Medicaid, though Wesco said it has not received any for Fort Scott.

Wesco estimates 90-95% of the health care offered before the hospital closed is still available locally. And services have been added, including a much-needed therapist on-site for behavioral health and telehealth access to a psychiatrist and substance abuse services.

"Drive up there, go into the parking lot, you're like 'There's a lot of people here,'" Wesco said. CHC's Fort Scott facilities have filled more prescriptions and done more mammograms in a month than the hospital "ever did," he said.

Local residents like 28-year-old Eliza Oliver, whose daughter, Taelyn, easily passed her annual wellness check with Dr. Self, said it's much less expensive to get care and prescriptions at the new health center. That part is great, Oliver said, but she still worries about the future of emergency care in town and where people can deliver babies.

Another Catholic hospital chain, Ascension Via Christi, which has a facility 30 miles away in Pittsburg, Kan., stepped in at the last minute to operate Mercy's old emergency room, signing a two-year agreement. This was vital: While much of the rest of Mercy Hospital Fort Scott had been underused and patient rooms sat empty, the ER handled nearly 9,000 people the year before it closed.

Mercy Hospital delivered more than 230 babies between July 2017 and June 2018. A few months ago ― after the hospital closed ― Oliver drove a friend who was in labor across the Missouri border more than 20 miles to deliver. "We had to jet over there and even though we made it in time, it's nerve-wracking," Oliver said.

Another Catholic hospital chain, Ascension Via Christi, stepped in at the last minute   

Not having a community hospital does require a new mindset. The community still has an obstetrician, but doctors send patients out of town to have their babies. By June this year, Ascension's Fort Scott ER staff had delivered three babies for expectant mothers who didn't leave enough time.

Randy Cason, president at Ascension's Pittsburg hospital, drove to Fort Scott to tell the weekly chamber coffee that doctors needed to "counsel and educate" mothers that it's no longer a 10-minute drive to the hospital.

Sherise Beckham, a former Mercy dietitian, was anxious on bed rest this spring while awaiting a baby. "You're on a two-lane highway; a lot of times you get behind a semi, behind a tractor," Beckham laughed. "Sometimes, you are lucky if you have cell service."

Beckham's delivery did not go as planned. After driving to Ascension's Pittsburg hospital to meet her family doctor, she had an unexpected cesarean section, and the baby, whose heart rate dropped dramatically, was transferred to a neonatal intensive care unit an hour away from home in Joplin, Mo. Now, eight months later, the baby is healthy though he continues to see a physical therapist who monitors his developmental progress.

Recent research by Katy Backes Kozhimannil, an associate professor at the University of Minnesota School of Public Health found that rural residents have a 9% greater chance of dying or suffering complications such as heart failure, stroke and the need for blood transfusions during childbirth compared with non-rural residents.

Federal policymakers have said they want to do better. President Donald Trump's administration this year set new Medicare payment policies that included more telehealth services and changed some payments for rural hospitals. Seema Verma, the administrator for the Centers for Medicare & Medicaid Services, also promised a new rural health payment model and "a lot of people are waiting with bated breath," said George Pink, a senior research fellow at UNC's Sheps Center.

CMS declined to comment on the timing of the proposal.

Congress, too, has made overtures to passing legislation. Maggie Elehwany, lead federal lobbyist for the National Rural Health Association, said the Affordable Care Act's promise that hospitals would have more insured patients and less bad debt "never really unfolded in rural America." The 14 states that have not adopted Medicaid expansion are largely rural and many are in the South, where the greatest number of hospitals have closed.

Catholic nuns founded the Fort Scott hospital more than a century ago and 89-year-old Fred Campbell still recalls a mantra etched in stone over the entrance of one old Mercy hospital building: "Dedicated to suffering humanity."

"We always felt that, man, come hell or high water, you're gonna be with us and you're not going to abandon us," Campbell said.

But exactly a year ago, its then-owner, St. Louis-based Mercy, a major health care conglomerate with more than 40 hospitals, declared it no longer financially viable.

Within weeks of Mercy closing, a newly built $9 million grocery store closed. A few weeks later, the cancer center closed and, by October, the town's dialysis center had closed, too. John Leatherman, professor for the department of agricultural economics at Kansas State University, said there's no doubt Bourbon County took "a big hit" when the hospital was shuttered.

Roxine Poznich lost her income when her job at Mercy ended. After more than 20 years at the hospital, the 73-year-old said she now finds herself paying for groceries with her credit card ― even though she is unsure whether she can pay the bill at the end of the month. "I'm scared," Poznich said.

But Fort Scott economic development director Rachel Pruitt said the loss of the hospital has not affected the city's sales tax revenue. Manufacturers like the community's largest employer, Peerless Architectural Windows and Doors, with its 400 jobs, continue to expand ― just down the road from where Mercy's 177,000-square-foot hospital building still stands.

City leaders say ideally the community would "right-size" its health care. That would include keeping the current outpatient clinics that provide primary care and an emergency department but also adding some inpatient beds, allowing residents with short-term hospitalization to stay local. Pruitt said there has even been talk of adding a wound center that could treat injuries among the town's industrial workers.

And, though the mostly empty Mercy Hospital building feels like a white elephant, that too may soon change: Mercy recently announced it would donate land in a repurposed corner of its property to Community Health Center. Health center leaders have hired an architect for a new building that will probably be about 30,000 square feet. Wellness, imaging, walk-in care, a women's health center, dental care and expanded primary and specialty care would be available.

ER operator Ascension declined requests for interviews, but spokeswoman Michelle Kennedy said the Pittsburg leadership team is "working on plans related to our presence in Fort Scott in the near future" but could not release details. City leaders say they are confident an ER will remain.

In the background, there is Reta Baker. Residents here denounced the former president of Mercy Hospital Fort Scott at the time of the closure. She sold her house and moved closer to her new job with CHC, at its headquarters in Pittsburg, Kan.

Baker, who started her career as a nurse at Fort Scott's hospital in 1981 and grew up nearby, said she continues to "be engaged in a lot of conversations" about the community's future. The next year will have growing pains, she said, but she believes the health care needed for residents is there.

"Now, we need to cement it," she said.

This is the fifth installment in KHN's year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community's health care, economy and equilibrium. Coming in 2020, a podcast from KHN with more voices and stories from Fort Scott, Kansas.

Sarah Jane Tribble: sjtribble@kff.org, @SJTribble