Elective Surgeries May Resume, Finances At Rural Hospitals Still Threatened By COVID-19

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ATHENS, Ohio (WOUB)On Wednesday, Ohio Governor Mike DeWine signaled that restrictions on elective medical procedures may ease soon. Still, it may take time for hospitals to catch up financially. 

Amy Acton, Director of the Ohio Department of Health, ordered all hospitals to postpone elective surgeries and medical procedures in March. This measure was to preserve personal protective equipment, keep enough beds open for COVID-19 patients, and keep doctors from coming in contact with a large number of people. 

‘Just trying to preserve’

One of the main concerns for hospitals, particularly in rural areas, is the loss of revenue from these procedures.

Dr. Michael Sarap, chair of the department of surgery at the Southeast Ohio Regional Medical Center, chair of the American College of Surgeons Advisory Council for Rural Surgery and the chair of the Commission on Cancer Program in Ohio .
Dr. Michael Sarap, chair of the department of surgery at the Southeast Ohio Regional Medical Center, chair of the American College of Surgeons Advisory Council for Rural Surgery and the chair of the Commission on Cancer Program in Ohio. (Photo via SEORMC)

Dr. Michael Sarap, chair of the department of surgery at Southeast Ohio Regional Medical Center in Cambridge, emphasized that elective procedures help rural hospitals pay the bills. 

“Outpatient surgeries and X-rays and things are the lifeblood of the income for small community practices like mine; I’m a private practitioner, but more importantly for the hospitals,” he said. “And without that income, many of these hospitals have less than 90 days cash on hand, which means that they haven’t saved up or couldn’t save up for a long stretch where they couldn’t get income.”

Stacey Gabriel, CEO of Hocking Valley Community Hospital, said the hospital had a 50 percent drop in revenue in March.

Gabriel said part of this loss in revenue is because elective procedures were postponed, but also because people are not coming to the hospital because they are afraid of getting sick. She said the hospital has made some adjustments to preserve money and resources.

“We’ve closed down a few of our urgent care beds, which sounds so counterintuitive to what you would think would be happening, but we’re just trying to preserve,” Gabriel said. 

Gabriel said 75 to 80 percent of the patients at HVCH have Medicare or Medicaid, meaning the hospital does not get reimbursed as much for the services it provides these patients as it would with private insurance. 

Sarap said the situation is similar at SEORMC and in other rural areas. 

“A lot of folks don’t have insurance, other ones have Medicare and Medicaid,” he explained. “And that’s a problem with supporting local hospitals, because the reimbursement rates from these governmental entities are much lower in many cases than the cost of providing that care. And so, hospitals depend on people with third-party insurance to kind of make up the difference.” 

Stacey Gabriel, CEO of Hocking Valley Community Hospital
Stacey Gabriel, CEO of Hocking Valley Community Hospital (Photo from HVCH).

Both Hocking and Guernsey counties have a low number of confirmed COVID-19 cases compared to some urban counties in Ohio. Gabriel and Sarap said their hospitals are prepared for an influx of patients if it comes and have ventilators on hand to treat severe respiratory systems. 

Sarap said the lower number of cases may be because sick people in rural areas are staying home instead of driving to the hospital. He added rural hospitals are “at the end of the supply line” for COVID-19 tests and other supplies.

“In the rural counties, where we usually practice social distancing…we’ll be the last ones affected and our surge capacity will be the lowest as well,” Sarap said. 

Gabriel added hospitals in the United States have been working on surge plans since the September 11, 2001 terrorist attacks.

Potential impact on rural hospitals nationwide

Sarap said the pandemic could be a “death knell” for rural hospitals in southeast Ohio and across the nation.

He is also the chair of the American College of Surgeons Advisory Council for Rural Surgery and the chair of the Commission on Cancer Program in Ohio.

“It’s just been an absolute crisis in the last 3 to 5 years,” Sarap said. “Every single week we hear about another rural or small community hospital that has closed, has gone bankrupt or their larger institution has closed, and this is just going to make the situation much, much worse.”

Before the pandemic, a number of hospitals in rural areas had already closed. Data from the University of North Carolina’s Rural Health Research Program shows 170 rural hospitals have closed in the United States since 2005. Many of these are in the Midwest and in the South; there are higher rates of closure in states that did not expand Medicaid. 

Ten rural hospitals have shut their doors already in 2020, including two in West Virginia.

Sarap says there are several reasons rural hospitals close, including declining rural populations, poorer patients, the inability to recruit and retain physicians, increasing bad debt, and the increasing cost of business.

Both he and Gabriel said when rural hospitals close, it is devastating for the local community.

“Something like this could force that closure,” Gabriel said, “and then it leaves a huge healthcare void in areas where they’re poorer, they’re sicker, (and with) less access to transportation so then the health of that community just declines drastically.” 

“Folks (in Hocking County) don’t really even like to drive to Lancaster if they don’t have to, let alone to drive to Columbus or even further to get care.”

‘I’ve never felt this way’

Sarap said there is now a “palpable fear of going to work” among surgeons and healthcare professionals that he has never experienced in over 30 years as a doctor. 

He said rural doctors are often older, and thus at a higher risk for contracting COVID-19. 

“We’re very fearful that we will catch something and not be able to get back to work or worse,” he said. 

Sarap said there are not “young backups” for many doctors in rural communities. A study in the Annals of Family Medicine shows physicians under 45 are more likely to move out of rural areas than physicians aged 45 to 65. 

“This could have potential ill effects for access to care for the next 20 years,” Sarap said. “I’ve never felt this way before about going to work and many of my colleagues are feeling very much the same way.”

“But, people are still going to work and still caring for people and we will continue to do that.” 

Gabriel said some staff at HVCH have been worried about having enough PPE to protect themselves.

“People say, ‘you went into healthcare, you should expect to be exposed,’” she said. “We all chose to go into healthcare but we also want the understanding that we have the equipment we need to protect ourselves and our family.” 

Gabriel said there needs to be an understanding of how important rural hospitals are in the “wheel of healthcare.” She said she hopes there will be more funding and opportunities for rural hospitals in the future. 

“I’m hoping that in an odd sort of way, perhaps this has brought more to light the importance of rural hospitals.”