Monday, October 29, 2018

NYT Shocked: Rural Means Not Big City

h/t Borepatch

Apparently the NYTimes has discovered that small-town means Small. Town.  And not Big City.

And that this has implications for medical care in Podunk.

"Hospitals are often thought of as the hubs of our health care system. But hospital closings are rising, particularly in some communities.
“Options are dwindling for many rural families, and remote communities are hardest hit,” said Katy Kozhimannil, an associate professor and health researcher at the University of Minnesota."

1) There is nothing wrong with the NYT story, per se.

2) They hit all the reasons.
 a) One-horse hospitals are being closed by ruinous malpractice premiums. Tort reform is long overdue.
 b) Indigent/uninsured care hits small potatoes hospitals a lot harder than conglomerates with multiple hospitals, because they have no way to spread that financial load.
 c) Care at small rural hospitals, compared to larger suburban and urban medical centers, is minimally adequate to borderline sub-standard. If anything "serious" needs Lifeflight to the city anyways, you aren't running a hospital, you're running a clinic, whether anyone told you or not.
 d) Expanding the Medicaid mandate costs states huge sums of money, which inevitably drives up taxes for everyone. If you kill jobs and tax people out of their homes, you won't just lose the hospitals, you'll lose the residents themselves.

What the NYT didn't tell you was that all of this was factored into ObozoCare, as it was intended to, in order to chain everyone to Big Daddy government, and push more people into cities, and out of more rural (and self-sufficient) living and lifestyles. That was known when they did it, but most of "flyover land" isn't having any, thankyouverymuch.

Good for them.

What you need in rural areas is primary care, not a mini-mart trying (poorly) to do Big City Care.
Trauma is even worse in rural areas because you never had trauma care there, and never will. One major case could break the hospital.

That's what medical evacuation is for.

Critical care (heart attacks & strokes) is essentially the same story: you can't have an ICU in Podunk, because it'll either be empty, or overflowing, and so even if you have it on paper, you don't in reality. So people will need transfer to Big City Hospital anyways. That's just how it goes.

More hospitals close than open because doing one right can no longer be done on a shoestring budget in Hooterville. Or even Pixley. You need the population of a city of a minimum of 100K people to do a small hospital, and 500K or more to do an actual decent primary facility that can offer everything.

By a strange coincidence, you don't have 97 dining choices in Ruraltopia either, or 3 mega-malls, or 5 multiplexes, and a professional sports team or 3.

But you also don't have multi-racial ghettoes, a gang problem, a crime problem, a homeless problem, and a host of other pestilential problems of the Big City.

Most folks who live there see that as a feature, not a bug.

So at the end of their pointless story, after paragraphs of pointless Chicken Little running around in circles, the lede is uncovered:
Not all closures are problematic. Some are in areas with sufficient hospital capacity. Moreover, in many cases hospitals that close offer relatively poorer quality care than nearby ones that remain open. This forces patients into higher-quality facilities and may offset negative effects associated with the additional distance they must travel. 
Perhaps for these reasons, one study published in Health Affairs found no effect of hospital closures on mortality for Medicare patients. Because it focused on older patients, the study may have missed adverse effects on those younger than 65. Nevertheless, the study found that hospital closings were associated with reduced readmission rates, which is regarded as a sign of increased quality. So it seems consolidating services at larger hospitals can sometimes help, not harm, patients.

No screaming eagle shirt, Cochise: Teeny Weeny Hospital is not your best choice for care, for the same reason Mr. Drucker's General Store is probably not the same retail experience that Mega-Mall or Amazon is going to be.

You want to b.s. over the stove about what's going on in Hooterville, hit up Mr. Drucker.
You want the Gee Whiz 2100, you go to MegaMall, or you have UPS or FedEx drop it off from Amazon.

In short, this is shocking to the NYTimes, but folks in the hinterboonies have been doing it for, oh, about 100 years.

They don't regard it as shocking.

But it does make me wonder something:

Do those ignorant boobs in NYFC get reruns of Green Acres and Petticoat Junction?
It would probably help to explain the facts of life to hipster yuppie millenials who think anything out of walking distance is Outer Mongolia.


RandyGC said...

Realize we're talking decades ago, but my experience with rural hospitals (county seat of 10,000 people) was that it was good for "routine" emergencies and basically stabilized anything serious for transport to the U of Iowa hospital an hour away by road or 20 minutes by helo.

I was lucky, born there, in once for minor surgery and once for a few stitches to the foot, and to get an infected ear lanced and cleaned at 0 god thirty once.

Little brother, unfortunately, got the benefit of their stabilized and into the helo care after a nasty car accident. Almost 40 years later he's still annoying me ;-)

Can't complain about the care in either case. Which, if I read you right, is the model you are laying out. Seemed to work then.

Old NFO said...

Agreed! And yet when 'they' move to the 'country', they expect ALL of those things they have in the big city! Sigh...

RJ said...

I'd bet new yawk city hasn't thought much about flyover country and hicks since the urban television execs did the rural purge in the early '70s.

Anonymous said...

Our county has around 4800 people as of last census. Our county hospital has driven itself into dire financial straits for a few reasons most self inflicted. First was the inept leadership of a CEO who had no medical background or any sort of relevant background for that matter. She wasted huge sums of money on cosmetics and trying to make the hospital into something it isn't, wasn't and never would be. You're not going to have a major surgery there by choice. You're not going to have a baby there by choice. Nobody is impressed with the 25,000 dollar light fixture in the lobby, in fact they're horrified when they find out what it cost them as taxpayers. It's a bandaid station, the clinic your specialist rotates to a few days a month to see his local patients, the place you go to see your family doctor, the place you go for physical therapy so you don't have to drive 2 hours. If you need to have any sort of major surgery or serious medical issues you go to one of the two regional hospitals or the big league hospitals which are usually university hospitals in larger metro areas. Hell, they're not even getting the bandaid station thing right. People were calling the ER before going to see who was working. If a certain physician was on duty people drove an hour to somewhere else. If someone who has tangled with a chainsaw and lost, calls first to see if Dr. Asshole is on duty and upon finding he is, drives 90 minutes to another ER you have a staffing issue.

RCPete said...

Klamath county in south central Oregon has one hospital in a city of 20,000. It had a horrible reputation ("Merle West" turned into Murder West.) It seems to be a bit better as Sky Lakes (Sky Flakes) for basic stuff, with cardiac care up through pacemakers. Our population is pretty old; we're where the not-so wealthy Californians do a CalExit. Medium bad trauma is a 100-150 mile flight to Medford or Bend, with really bad stuff getting triage/stabilization, then the survivors flying to the OHSU teaching hospital in Portland.

Oregon Tech is now doing nursing instruction, so there's a pool of semi-trained people. OHSU is in a partnership with Sky Lakes and its clinic for teaching. They're building a good sized clinic--won't be much smaller than the hospital when its done. We'll see how its set up, but my primary care doc is teaching at the pilot program. I have hopes.

We don't get the specialists. Eye procedures stop at cataract surgery and basic diagnostics, so if you need retina or cornea work, it's a trip over the Cascades. Medford has some decent facilities and doctors for that stuff.

Eaton Rapids Joe said...

My next door neighbor had a bout of kidney stones. The first bout had him sitting in the Sparrow Hospital waiting room as it filled up with homeless people with "chest pains" on that cold night. It was eight hours before he triaged to the top.

The next time he had kidney stones passing, admittedly not a high mortality event, he went to the small town hospital. In five minutes he was in a private room. In fifteen he had an IV and was in happy-land.

His words were "I would rather die in the Eaton Rapids hospital than spend another minute in Sparrow's emergency room."

ERHC and Hayes-Green-Beech in Charlotte cannot do heart surgery but they can diagnose and smack you with drain-o-for-the-brain-o, box you up and ship you out. Your survival for cardio events is probably far more dependent upon the time that spins off the clock between first symptoms noticed and first molecules of anticoagulant in the blood stream than it is dependent on how many ICU beds are under the roof.

It is an additional bonus that the bacteria in the drains are naive, the nurses are young and pretty and the floor staff will allow your wife to bring your dog to visit you.

Mike_C said...

>you can't have an ICU in Podunk, because it'll either be empty, or overflowing

And let's generalize this a little more to not just ICUs but cardiac catheterization labs and the like: Another problem is that if volume is low, a local practionner may not have enough cases to keep his skill level high. If you're getting a complex coronary procedure done, you want the guy who does 3-5 tough cases a day, not the guy who does three run-of-the-mill cases a week. Or a month.

> If a certain physician was on duty people drove an hour to somewhere else

Oh yes. And it's not just the ER. Same with inpatient attendings, only most people don't have access to the info, and can't influence how the system works. Example: when my mom was seriously sick and admitted to hospital via Emergency (at the place where I did my Medicine residency so I knew folks) my question to the ER attending (with whom I was on good terms) was, "Who's on for Gen Med?"
ER Doc: Lemme see ... Oh, it's McBraggart's team.
MC: Shit.
ERD: Yeah, shit. Good ol' Florid McBraggart, bless his useless ass. Hmmm. It's 1430, when does Medicine switch from short to long call again?
MC: Three PM.
ERD: Tell you what, I'm gonna hold off on putting through the admission order for about 31 minutes.
And so it went.

>Your survival for cardio events is probably far more dependent upon the time that spins off the clock between first symptoms noticed and first molecules of anticoagulant in the blood stream

Yeah, mostly. On the other hand, there is an alternative to having to use TPA ("clot buster") because of remoteness. In places such as where I'm sitting right now, we have 24/7 interventional teams (that will go in and open up that coronary artery and stent the fucker) at literally 4 hospitals within 2 miles of here. NOT the usual state of the country I admit, but I'd point to the Minnesota system as an example. In MN ANY rural hospital in the state can "activate the cath lab" at the main University Hospital in Minneapolis. As they're bringing in the interventional cardiologist and his team in Minneapolis, in Bumfuck the patient is being put in ambulance, on helicopter, or on fixed-wing craft (depending on distance to Minneapolis) emergently to the Univ Hosp. This is effective because it prevents the problem of complex and expensive labs and equipment that will mostly be underutilized at Rural Clinic (and not having it there prevents it from being used unnecessarily). It also allows each patient to be treated by doctors who have HIGH case volume and expertise. The key is that Univ Hosp has to trust that Rural ER is not sending them false alarms.

The Gray Man said...

As a RN splitting my time between a Level II trauma center in a city of 55k, and a rural hospital in a town of about 300 (where I live), I agree with all of your points, except maybe your estimate of requisite population numbers in order to support a hospital that can offer "everything".

As far as rural ERs, a LOT of what we can and can not receive hinges on whether or not we have a CT available 24/7 (we do) and whether we can administer tPA (we can).

All I can say is thank God for LifeFlight and ShandsCair.

The Gray Man said...

Is a city of 10k really considered "rural"? Just wondering.

The Gray Man said...

I assure you that the vast majority of people calling to see who the doc on call is, are not calling because they have a legitimate issue. 98% of them are calling because they want to make sure that the right doc is on, the one who'll give them 2mg of Dilaudid and 50mg of Phenergan for their chronic body aches.

Ask me how I know.

Actually, don't. You either already understand, or you're one of them.

The Gray Man said...

I notice commenters referencing "rural" hospitals in towns of 10k and 20k. Damn. If that's rural, I must be on the damn moon.

Anonymous said...

Saw a story during the weekend, talking of drones delivering medical supplies to remote areas faster than standard vehicles. No where near the quantity of course (Story mentioned 10 pounds with the current drones used) were the norm. Flyzipline is one such service.

No idea on what their range is but that is a good idea, I think.

Anonymous said...

Uh....that's my hometown mainstreet in the picture, Bardstown, KY. We have an excellent community hospital, Flaget Memorial. And, if needed, its about 35 miles from Louisville, and about 50 from Lexington. I think Bardstown is now about 20K. When I grew up there it was about 6K.

Aesop said...

Yes, it is indeed Bardstown.
I grabbed that pic because it's photogenic small-town America.

10K-20K is rural.
Smaller than that, is, in fact, Beyond The Black Stump, aka BFEgypt.

Anonymous said...

I live smack dab in between two rural towns of about 14k population a piece. Both of them have hospitals. One of them has an ER with a CT scan available, I know that much from being through it. Neither hospital is like where I grew up, but I also like the fact that neither hospital has waiting rooms in the ER jam-packed with 50 people at any given moment (see: Stanford).

One of the rural communities is a well-known place for fairly wealthy retirees, so they have an excellent stroke and cardiac unit. In worst cases, a flight to Sacramento (Mercy General, etc.) is about 15 minutes. I still have a couple of specialists in the Bay that I see twice a year, and one of them is nearly convinced to move up here (same health care system, and it's better up here in terms of lifestyle). I do NOT miss living in an urban environment, I never will.

Hell, if I croak on my patio from a heart attack, it'll be while while listening to the frogs in my pond, the crickets chirping, looking at the gorgeous scenery, and feeling content (minus the chest pain for a bit). MUCH worse ways to go. If they want me moving back to the Bay or some other hellhole, they can think again. A life well-lived and content, even if somewhat shortened, is better to me than a long life filled with sirens, crime, assholes, traffic, craptastic water, and scenery composed of nothing but buildings that look like someone shat out a Lego. Quality over quantity, any day, any time.

elysianfield said...

"Quality over quantity, any day, any time. "

Yes, well said. I would expect that, once reaching the 7th decade of life, our chief occupation should be to prepare for our certain demise, and to understand the event should be with a bit of dignity and acceptance...and avoidance of heroic and very expensive attempts at maintenance.

Anonymous said...

@ Gray Man
In many instances of people calling the ER elsewhere you may be right but here it wasn't the case. The ER physician in question was incompetent, incredibly rude to patients and families bordering on abusive. The other staff detested him and he treated nurses and the EMT crews like they were beneath contempt. In a small rural area word spreads fast. Everybody either had a story about him or could tell you several they'd heard. My experience with him was certainly consistent with the stories going around about him.

Anonymous said...


"10K-20K is rural.
Smaller than that, is, in fact, Beyond The Black Stump, aka BFEgypt."

Until recently, for 20+ years we lived in a 1500 sq mile county with 3,000. And you could have barely accumulated 10k by adding the next two contiguous counties. And that is not an anomaly in this neck o'.

Even now our environment is just barely 10-12k except when the Communist FOB (college) is in session.

After I wrote this I had to hit the reCaptcha thing, and it had me identify all the traffic lights. That reminded me that the first county I mentioned had Not. Even. One.

TiredPoorHuddled Masses said...

A NY Times article that gets the facts straight? What is the world coming to?

Aesop said...

But cleverly still manages to draw most of the wrong conclusions.

TiredPoorHuddled Masses said...

Ah, staying true to form. Good to hear!

Anonymous said...

25 years ago, I was reading stories about small rural hospitals along the US/Mexico border closing due to foreigners (read illegal aliens) coming across the border for their medical needs, then boogieing back across without paying their bill (who knew THAT would happen). So this isn't new news, except that now the "problem" is being recognized because it's happening all over the country, as illegals and other foreigners (refugees) are being spread all over the country in resettlement programs funded by our tax dollars and other non-government do-gooder programs.


Anonymous said...

Here is another issue, back in the 70's Hospitals starting changing from non-profits and Insurance companies from mutual formats. Local control and focus on providing service instead of profits sent to Wall Street was lost. For that thank the lobby people (lawyers) and their supporters. At that point the only things big enough to fight back was state and federal governments. We all know the result of that. The rural hospital has to be a primary care facility with the ability to call upon and integrate with the larger center city facility as several above have mentioned.