November 13, 2019
Since 2005, roughly 106 rural hospitals across the United States have closed, removing a valuable source of employment and significantly extending the journey for patients requiring urgent care. In every year between 2011 and 2016, more hospitals closed than opened, and in 2016 alone 15 rural hospitals closed while only 2 opened.
The potential impact of this closure trend on individual patients should not be hard to imagine.
There is a state, however, with a lot of remote terrain—much of it breathtaking—where no rural hospitals have closed. How has Utah managed this feat when hospitals in so many other states have shuttered?
Perhaps area residents owe it to a religiously inspired ethic.
Specifically, in the mid-1970s the Church of Jesus Christ of Latter Day Saints (aka, the Mormons) divested of 15 hospitals in Utah, Idaho and Wyoming and donated them to the citizenry under the condition that they be run by a non-profit entity committed to the community. Within months, Intermountain Healthcare was born.
“Thanks to sacrifices made by urban hospitals and their willingness to work with their small town counterparts, rural hospitals in Utah were among the most profitable in the country from 2011 through 2017,” says a report on rural hospital closures by Gatehouse Media. “Only 14 percent lost money during the period and not one was forced to shut down.”
According to Utah Hospital Association Executive Vice President Dave Gessel, Utah’s success is the product of planning and an ethic that prioritizes hospital survival over individual facility profit.
“Twenty years ago, we instituted a policy where we would take a little money from urban hospitals and give it to rural hospitals. That’s provided a base for all our hospitals.” Gessel explains, before adding the church angle. “Rural Utah is pretty heavily Mormon. Because of those connections, those ties, local residents realized if they didn’t come together, things could get really bad.”
Bad, as in how they’ve gotten in other states—Texas has lost 17 hospitals; 27 counties have no licensed physicians, and 22 counties have just one—that apparently didn’t follow the Utah model.
To be fair, most closures—77 of 106—have occurred in states that chose not to expand Medicaid (Utah eventually did). This fact alone, however, does not fully explain the abysmal financial performance of rural facilities or the fact that some 700 rural hospitals nationwide are still struggling and 200 more are on the verge of financial collapse.
So, is a state’s commitment to all is residents the essential ingredient in keeping rural hospitals open? Arguably, yes. Utah has it. Other states, it would seem, do not.
And why not extoll the virtues of will, commitment, community and sacrifice when it comes to making sure acute care is locally available? At least we KNOW intent can endure and even succeed where treating healthcare as a consumer product seems largely inadequate to the challenge.
Indeed, uncertainty abounds for many aspects of the healthcare system. Take health policy, for example.
“Rigorous evaluations of health policy are exceedingly rare,” writes healthcare economist Austin Frakt in the Upshot healthcare blog for the NY Times. “The United States spends a tremendous amount on health care, but very little of it learning which health policies work and which don’t. In fact, less than 0.1 percent of total spending on American health care is devoted to evaluating them.”
This situation is disappointing, yes, but it also undermines the ability of anyone—policymakers, politicians, administrators, patients—to make decisions based on documented efficacy.
And what about various forms of treatment?
“The British Medical Journal sifted through the evidence for thousands of medical treatments to assess which are beneficial and which aren’t,” Frakt writes in the same blog. “According to the analysis, there is evidence of some benefit for just over 40 percent of them. Only 3 percent are ineffective or harmful; a further 6 percent are unlikely to be helpful. But a whopping 50 percent are of unknown effectiveness. We haven’t done the studies.”
Troubling. Again, how are patients to make treatment decisions with little or no knowledge about what actually works?
Meanwhile, healthcare costs in the United States approach 20 percent of GDP while healthcare waste is estimated at 20 to 35 percent of total expenditures.
“These are massive numbers,” writes Don Berwick, MD, a former CMS administrator and former president and CEO of the Institute for Healthcare Improvement. “With US health care expenditures exceeding $3.5 trillion annually, 25 percent of the total would amount to more than $800 billion per year of waste (more than the entire 2019 federal defense budget, and as much as all of Medicare and Medicaid combined). Even 5 percent of the total cost is more than $150 billion per year (almost 3 times the budget of the US Department of Education).”
Oh, and it also turns out that permitting hospitals to merge or gobble one another up neither improves care nor drives down the cost, regardless of what hospital administrators (some of whom are squirrelling away money in the Cayman Islands) tell us.
Which brings us back to ethics and commitment, and to the value of public health, which is consistently shown to be more beneficial to a greater number of people than expensive therapies and billion-dollar IT systems.
“… public health investments are often so valuable that they pay for themselves,” says Frakt again, this time writing with Aaron Carroll, MD. “There’s no reason not to make them. In contrast, very few medical interventions pay for themselves; we typically hope that they are at least cost-effective, not that they save more than they cost.”
This is what Utah hospitals understand—that providing care close to where people live is of greater collective value than groundbreaking medical interventions.
Which is not to say that we shouldn’t pursue breakthrough medical technology, where it works and helps. Utah hospitals have also effectively used telemedicine—a technology proven to improve care and reduce costs—to extend care from the population centers near Salt Lake to rural hospitals.
But so much evidence says we are wasting billions while still allowing hospitals to fail that it seems a commitment is in order—a commitment to finding a way for hospitals to stay open instead of blaming closures on financial failure and pretending that healthcare is a typical market-oriented industry and that patients are consumers. Neither is true.
The principle in play is minor individual sacrifice for the benefit of the whole, and most belief systems make it a fundamental ideal, so the question remains: Can American healthcare weave this ideal into all the other efforts to improve care? The choir is still out.