Alabama Rural Health Conference
Friday, March 18 and Saturday March 19, 2016
Includes an Organizational Meeting for Establishing an Association for Alabama's Rural Health Clinics
Past President of ARHA Quoted in New York Times Story on Marion Tuberculosis Outbreak
Marion is in the throes of a tuberculosis outbreak so severe that it has posted an incidence rate about 100 times greater than the state’s and worse than in many developing countries. Residents, local officials and medical experts said the struggle against the outbreak could be traced to generations of limited health care access, endemic poverty and mistrust — problems that are common across the rural South.
“There’s not a culture of care-seeking behavior unless you’re really sick,” said Dr. R. Allen Perkins, a former president of the Alabama Rural Health Association. “There’s not support for local medical care, so when something like this happens, you have a health delivery system that’s unprepared.”
Small Rural Hospitals – Can These Provide Part Of The Solution In Rural Alabama?
Alabama currently has eight counties (Chilton, Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and Perry) with no hospital. Over the past six years, Alabama has had five rural hospitals close. This is tied with Georgia for the second highest number of rural hospital closings among all 50 states. Texas, with nine, has had the most rural hospital closings. Unfortunately, the fact that more rural Alabama hospitals are experiencing threatening financial difficulties is well known.
Many rural residents and others interested in rural health care are asking if there is a model of health care facility that can provide care similar to that received in a hospital in counties with no hospital. This need is being studied by the Alabama Hospital Association and widely discussed by many others, including the Alabama Rural Health Association.
One possibility is the Freestanding Emergency Department which is a new type of health care facility that is now authorized in Alabama. This is basically a hospital emergency department that is not attached to the hospital. Two requirements for this facility limit its possibilities in meeting the needs in rural counties. It cannot be located more than 35 miles from the parent hospital and must be directed by an Emergency Medicine physician.
A second possibility is the Critical Access Hospital (CAH) which was first authorized under federal law in 1997. A CAH is certified under Medicare conditions that differ from those for acute care hospitals. A CAH cannot have more than 25 inpatient beds; must maintain an annual average length of stay of no more than 96 hours for acute inpatient care; must offer 24-hour, 7-day-a-week emergency care; and must be located in a federally-recognized rural area.
Critical Access Hospitals are encouraged to focus on providing care for common conditions and outpatient care, while referring patients with other conditions to larger hospitals. In return, this type of hospital receives cost-based reimbursement from Medicare, instead of standard fixed reimbursement rates. This can enhance the financial status of many rural hospitals with larger percentages of Medicare patients.
Critical Access Hospitals have not been as financially feasible in Alabama as in many other states. Alabama currently has only four critical access hospitals: Red Bay Hospital in Red Bay, Choctaw General Hospital in Butler, Washington County Hospital in Chatom, and St. Vincent’s Blount in Oneonta. There are 30 Critical Access Hospitals in Georgia and 32 in Mississippi.
Currently, there is a state requirement in Alabama that acute care hospitals must have a minimum of 15 beds. Given current restrictions on inpatient stays, many rural hospitals do not have a daily census of patients that would require 15 inpatient beds. The federal requirement for critical access hospitals is that there be 25 or fewer authorized beds. There is no required minimum number of beds.
There is a federal requirement that a critical access hospital must first be an acute care hospital and then convert to a critical access hospital. A new hospital cannot be opened as a critical access hospital. With Alabama’s requirement that acute care hospitals must have 15 or more authorized beds, a new hospital must be constructed with a minimum of 15 beds, even if there is no need for so many beds.
The current financial crisis among many of Alabama’s rural hospitals may make the time right for Alabama to take a look at our regulatory requirements for acute care hospitals to consider allowing our rural areas to have hospitals with fewer than 15 beds. These facilities could operate as acute care hospitals or convert to critical access hospitals without being required to have more beds than they can realistically expect to need. This could be done as a change in regulatory requirements for acute care hospitals or by authorizing a new type of hospital – the Small Rural Hospital. Either of these approaches would require approximately a year to complete the legal procedure if there is no opposition, possibly more time if there is opposition.
Several states already have rural hospitals with small numbers of authorized beds, including Tennessee and Mississippi. The Johnson County Community Hospital in Mountain City, Tennessee is a 2-bed critical access hospital with 78 employees that operates at a profit when the annual critical access hospital payment is received. The emergency department at this facility treats patients with minor conditions and sends then home, stabilizes patients with more serious conditions for transfer to a larger hospital, or keeps those who should be observed overnight. The emergency department utilizes tele-medicine and an emergency department staffing service. There is a certified rural health clinic affiliated with this hospital. Major services such as radiology, other scanning, laboratory, and therapy is provided. This small hospital even provides obstetrical service.
The Greene County Hospital in Leakesville, Mississippi is currently a 3-bed critical access hospital that is being expanded to seven beds in a county that does not have a single physician, like Coosa County here in Alabama. This hospital has 55 employees and is also operating at a profit. There is a 60-bed nursing home attached to this hospital and it has a certified rural health clinic. The services provided at this hospital are quite similar to those in Mountain City except that tele-medicine is not being utilized and the emergency department is staffed by four advanced practice nurses (Certified Registered Nurse Practitioners) who commute from Mobile, Alabama to provide this coverage. Advanced practice nurses cannot provide this coverage in Alabama, though there is some discussion about considering this coverage to hold down costs during early morning hours when patient traffic is light.
Can small rural hospitals like these provide part of the solution to our rural hospital crisis in Alabama? One thing for certain is that continuing to allow rural hospitals to close is not part of the solution.
Telemedicine: Ready or Not, Here It Comes!
The provision of health care is constantly changing to meet the varying needs of those it serves and to take advantage of ever changing technology. Another dramatic change in the provision of and receiving of health care may be on the horizon in Alabama, especially in rural areas. This involves the availability of telemedicine.
What is telemedicine? There are currently three major types of telemedicine: store and forward, remote (or high-risk) patient monitoring, and live video. Store and forward technology has been available and widely used for some time. An example of this technology is having technicians in many of Alabama’s rural hospitals complete x-rays, various types of scans, etc. and transmit these electronically to services staffed by radiologists and other professionals, some even in other countries, where there is a rapid analysis and reporting of findings.
Remote or high-risk patient monitoring has been tested in rural Alabama and is in current use. An example of this technology is the current monitoring of vital signs for over 700 home care consumers by the Alabama’s Department of Public Health’s Bureau of Home and Community Services. Regularly scheduled telephone calls are made to or received from these consumers with special needs. They have selected vitals monitored using special equipment and the telephone to identify whether special attention is needed or not. This can help in avoiding unnecessary travel for patients in remote areas or with difficult transportation concerns. This can also identify potentially serious conditions requiring fast intervention or treatment.
Live video is an emerging and rapidly advancing technology that involves a health care provider in one location examining or providing other care for a patient in another location – possibly thousands of miles away. This is done through the use of special equipment, sometimes located on a cart, including a screen and phone connection allowing the provider and patient to see and communicate with each other. There are numerous attachments such as a digital stethoscope, otoscope, etc., depending upon the specialty or sub-specialty of care that is being provided, that can be used with this equipment in examining patients or specific conditions.
With the use of high quality broadband connectivity, the services of another health care provider who is with the patient to follow the provider’s instructions in using the equipment, and high technology medical instrument attachments, a health care provider can examine the patient and offer instruction on the required treatment. The special attachments allow the provider to see images that can sometimes provide much greater detail than is seen in face-to-face visits. This explanation of telemedicine is very basic and offers limited detail in comparison to all services which are currently possible using this technology.
Georgia is a leader in adopting the use of telemedicine. Patients in Georgia can currently receive care involving more than 40 specialties or sub-specialties through telemedicine. Primary care is available in many retirement facilities, often avoiding unnecessary transport by ambulance for basic care. Children who may rarely or even never see a physician have the ability to receive care through school based clinics.
Georgia, Tennessee, and Mississippi have all passed legislation mandating that private insurance companies reimburse for telemedicine services. Private insurance reimbursement is not being mandated through legislation in Alabama. This has been a major barrier to the use of this promising technology. A second barrier is the need for high quality broadband access throughout Alabama. High quality broadband access is a critical need for the expansion of remote patient monitoring.
The lack of reimbursement by private insurance companies in Alabama is being decreased as a barrier. Alabama’s largest private insurance company, Blue Cross and Blue Shield, has announced that it will voluntarily start reimbursing for selected services involving cardiac care, neurological care or stroke, dermatology, infectious diseases, and behavioral health on December 1. Medicare already reimburses for telemedicine services nationally. Alabama’s Medicaid program currently provides reimbursement for some telemedicine services.
Even without private insurance reimbursement, several types of telemedicine are already being practiced in Alabama. Alabama currently has tele-stroke care available in several rural emergency departments where patients are examined by a distant neurologist with local providers being instructed in what time-sensitive care should be administered. Tele-wound care is being provided at the Washington County Hospital in Chatom to help local patients possibly avoid having to travel more than 70 miles one-way for this care. Tele-anesthesiology, tele-cardiology, tele-HIV medicine, tele-psychiatry, and tele-child psychology are all being utilized in Alabama.
The Alabama Department of Corrections is utilizing telemedicine in several prison clinics to avoid transporting expenses for general care. The Alabama Department of Public Health is providing strong support for the expansion of telemedicine by placing telemedicine carts in nine county public health departments that can be used by local providers. Tele-HIV medicine is being provided in some of these locations. Others locations are being considered for telehealth applications such as tele-prenatal care.
Positive potential abounds for all involved parties. This technology can allow health care providers to be more like other businesses by exporting their health care services. Insurers have the potential to reimburse for earlier and lower cost care administered through telemedicine, possibly avoiding greater expenses for treatment received later. Consumers have the option of receiving care more conveniently and earlier.
What the future of telehealth and telemedicine will become is yet to be seen. However, the current utilization is very exciting and promising, especially for such needs as providing specialty and sub-specialty care to patients in our rural areas. Talk with your health care providers and encourage them to utilize this very promising technology.
Alabama's Obstetrical Crisis
More Bad News
East Alabama Medical Center - Lanier in Valley (Chambers County) ended the providing of obstetrical service as of the end of December 2015. This unfortunate loss in obstetrical service leaves only 16 of the 54 counties considered rural by the Alabama Rural Health Association with hospitals providing this most basic and important health care service. In 1980, 45 of the 54 counties currently considered rural had hospitals that provided obstetrical service. This loss has been much greater in the Black Belt Region counties. In 1980, 10 of the 12 Black Belt Region counties had hospitals that provided obstetrical service. Today, only one of the 12 Black Belt Region counties has a hospital providing this service.
Bibb Medical Center in Centreville (Bibb County) has returned obstetrical service to this medical center. Being able to absorb the financial loss of offering obstetrical service to the residents in its service area is being accomplished by enhancing financial stability in other service areas.
With the returning of this service to the residents in the Bibb Medical Center service area, a disturbing trend has been interrupted. ARHA has researched as far back as 1970 and has found only a short time in Pickens County during the 1990s where a county lost this service and had it later return. Bibb Medical Center administrator, Joseph Marchant; John Waits, M.D.; and Lacy Smith, M.D. are to be applauded for their leadership roles in returning this service. Mr. Marchant is a former Director of ARHA. Drs. Waits and Smith are members of ARHA.
ARHA Announces Drive to Establish Student Chapters
First Community College Chapter of ASRHA Being Established at Northeast
Alabama Community College in Rainsville
Initial UAB Chapter Meeting Requires Larger Room to Accomodate Attendance
Additional Student Chapter Information To Follow
Your Alabama Rural Health Association has initiated an aggressive campaign to establish student chapters of the Alabama Student Rural Health Association (ASRHA) on all 54 public and private university, college, and community college campuses in Alabama. A partnership proposal has been submitted to another Alabama organization to assist in funding this promising program.
Student membership in ASRHA is a bargain at a cost of only $25 per school year. Included in this membership is annual membership in the campus ASRHA chapter (on campuses with ASRHA chapters), a full annual membership in the Alabama Rural Health Association, and a school year student membership in the National Rural Health Association. For additional information on student memberships and benefits, select "Join ARHA".
Student members can also seek election as an officer in their campus chapter or seek election to the student position on the ARHA Board of Directors.
Campus ASRHA chapters will have regular meetings during which information of value to students pursuing health related careers will be provided. A listing of possible program topics and speakers is currently being developed. Chapters will also conduct health related community projects. Each campus chapter must have a faculty/staff sponsor to oversee the chapter activities.
To assist in establishing campus chapters of ASRHA, the following are being sought:
Students with an interest in helping to establish a chapter at their school.
Faculty/staff at Alabama schools interested in serving as a campus sponsor.
Potential speakers on topics of interest to health related program students.
Please contact ARHA to assist with this program or if you have questions or recommendations.
2015 Alabama Rural Health Facts and Figures
Alabama’s rural county residents had a per capita income level that was 21% less than that for our urban residents. (2012 data)
Eight rural counties (Bullock, Coosa, Bibb, Sumter, Wilcox, Winston, DeKalb, and Randolph) are among the 250 U.S. counties with the lowest per capita incomes among all 3,113 counties. Marion County was ranked # 251. (2012 data)
More than one in every five rural residents is eligible for Medicaid.
Nearly one half (47 %) of all rural children are eligible for Medicaid.
14 rural counties have between 10 and 16 percent of all households with no vehicle.
Only two of Alabama’s 54 rural counties (Coffee and Pike) are not entirely or partially classified as primary care shortage areas. (May 2015)
Alabama’s primary care physician workforce is aging. The average age of all actively practicing primary care physicians in Alabama today is 51.4 years. This is a considerable increase from an average age of 50.1 in 2006.
All of Alabama’s 54 rural counties are classified as dental shortage areas for the Medicaid population. Only Shelby County and a portion of Madison County are not currently classified as dental care shortage areas. (May 2015)
Alabama currently has three counties (Coosa, Greene, and Lowndes) with no dentists in the entire county.
All of Alabama’s 54 rural counties are classified as mental health care shortage areas for providing mental health care to the entire or low-income populations. Only Madison County is not currently classified as mental health care shortage areas. (July 2013)
In 1980, 45 of Alabama’s 54 rural counties had hospitals performing obstetrics. Today only 16 of the 54 offer this basic service. In 1980, 10 of the 12 Black Belt Region counties had hospitals performing obstetrics. Today only one still offers this service.
12.2 percent of all adult Alabamians have been told that they have diabetes. This is the 3rd highest percentage among all 50 states.
Obesity is a major risk factor for numerous serious health conditions. 33 % of all adult Alabamians are currently obese. This is the 5th highest percentage among all 50 states. There are 10 rural Alabama counties with between 40 and 49 % of the adult population being obese.
13 rural Alabama counties do not have a dialysis clinic.
The cancer mortality rate for rural Alabama residents is over 16 percent higher than that for urban residents.
The heart disease mortality rate for rural Alabama residents is over 37 percent higher than that for urban residents.
The motor vehicle accident mortality rate for rural Alabama residents is nearly 56 percent higher than that for urban residents and more than double the national rate.
The 25 Alabama counties with the highest current unemployment rates are all rural and four of these have double-digit unemployment. (March 2015)