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Rural hospitals across the country have been going out of business at an unprecedented pace. Residents are leaving rural areas, and the people who stay don't always have health coverage. These hospitals are struggling to attract insured patients, and they're also facing penalties if the same people show up over and over. Blake Farmer of member station WPLN reports on the readmission conundrum.
BLAKE FARMER, BYLINE: Livingston is a town of 4,000 that's tucked in the rolling Tennessee hills that has attracted a lot of retirees, like Charlotte Potts. She spends much of her day in a recliner, tethered to a pulsing oxygen machine in her cramped apartment.
CHARLOTTE POTTS: I've only had five heart attacks (laughter). I've had carotid artery surgery - just a few minor things.
FARMER: Potts lives within spitting distance of Livingston Regional Hospital, which has a small cardiac unit. But they really don't want to see Potts every time her heart flutters. So last time she landed in the ER, hospital staff linked her up with a home health agency.
POTTS: If I go to have certain things going on here in my chest, I call for help. And they're there.
FARMER: There were days when home health aides might be viewed as a competitor to the hospital - not anymore.
TIM MCGILL: It is ironic.
FARMER: Tim McGill is CEO of Livingston Regional.
MCGILL: When I started this almost 40 years ago, the mission was different. We wanted patients in the hospital. That was the incentive. We were paid for it. Now you're not.
FARMER: This hundred-bed hospital operates on the thinnest of margins, and so-called readmissions have been a sore spot. Under the Affordable Care Act, Medicare began to ding hospitals if too many patients end up back in a hospital within 30 days. In some years, Livingston Regional has lost 3 percent of its Medicare revenue, the maximum penalty. The punishment forced Livingston's leaders to start cooperating with other medical providers in town.
MARY ANN STOCKTON: Hello. Come on in.
FARMER: Hospital nurse Mary Ann Stockton is at the local library where she holds quarterly lunch meetings. She invites home health operators, hospice caregivers, even nursing home leaders. They've cared for the same patients forever but rarely coordinated until now.
STOCKTON: Home health and hospice, we've definitely seen an increase in y'all coming into the hospital, meeting the patients before they go home.
FARMER: On this day, they talk about how all their workers need flu shots. Otherwise, elderly patients can become what Stockton calls frequent fliers.
STOCKTON: Flu starts off and goes into pneumonia, COPD exacerbation, and they are a revolving door at our hospital. They're hitting that ER a couple of times a week.
FARMER: Livingston's parent company has more than 80 rural hospitals and has been experimenting with the co-operative approach. In one Arizona town, for instance, paramedics now check in on discharged patients. It's not just rural hospitals. All hospitals can be penalized for readmissions now, and it's worked. Readmissions are down nationwide. But the smaller, rural hospitals wonder if they'll have enough patients to survive says researcher Michael Topchik.
MICHAEL TOPCHIK: The CEO from Montana said to me - you know, the problem is, when we do the right thing, are we saving ourselves right out of business?
FARMER: The focus on cutting readmissions, by definition, cuts admissions, too.
TOPCHIK: And so this is the real inherent tension and challenge, which is, hospitals get reimbursed for doing sick care. But more and more, they are being asked to do population health and really focus on wellness.
FARMER: And wellness doesn't pay much at the moment. But in the short term, things have improved at Livingston Regional. It's cut readmissions more than any rural hospital in the country. Its latest penalty has dropped from $200,000 to practically zero, all because patients like Charlotte Potts stay home.
POTTS: I've got a real bed tightness in the chest.
FARMER: The last time that happened, she pondered whether to call an ambulance. This time, she phoned her home health agency, took a nitroglycerin pill and went back to sleep.
For NPR News, I'm Blake Farmer in Livingston, Tenn.
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