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112119159 November 21, 2019 The Randolph County Board of Commissioners met in special session at 6:00 p.m. in the 1909 Randolph County Historic Courthouse Meeting Room, 145 Worth Street, Asheboro, NC. Chairman Darrell Frye, Vice -Chairman David Allen, Commissioner Kenny Kidd, Commissioner Maxton McDowell and Commissioner Hope Haywood were present. Also present were County Manager Hal Johnson, Finance Officer Will Massie, County Attorney Ben Morgan, Clerk to the Board Dana Crisco, and Deputy Clerk to the Board Sarah Pack. Dr. John Rogers gave the invocation at the request of Commissioner Haywood. Chairman Frye introduced Senator Jerry Tillman, Representative Allen McNeill, and Representative Pat Hurley and thanked them for their tireless efforts in giving the County options for helping Randolph Health. He noted that he, County Manager Hal Johnson, City of Asheboro Mayor David Smith, and City of Asheboro Manager John Ogburn were all part of a restructuring committee at the hospital. He stated that this meeting was to discuss applying for a loan for the Rural Health Care Stabilization program in SB537 which aids a struggling hospital in a tier one county. This is only the beginning of the process. In order for the County to borrow the money, there must be a successor hospital. At the time of this meeting, there is no successor. The successor will not be part of Randolph Health but will create a long term solution for local health care. If a successor comes, the County will hold a hearing to borrow the money and, if approved, will remit it to Randolph Health on an as -needed basis. During the interim time for Randolph Health operations, there will be a new Board chosen. Evaluation of the application for the loan will be made by UNC Hospital to determine if the plan will be successful. Then the Local Government Commission must determine if the County is debt worthy and has the ability to repay the money. The County borrows the money and will be required to repay it; no hospital will be required to repay the debt. He stated it is the role of citizens to let the Board know if they are willing to repay the money as taxpayers. Application for the loan doesn't mean that the County must borrow it. Chairman Frye said the County has partnered with the City of Asheboro to retain attorneys from Nexsen Pruet. This firm does not represent Randolph Health so this keeps the process transparent and independent from that of the hospital during restructuring. Mayor David Smith came forward and read a proclamation* from the City Council in support of applying for the Rural Health Care Stabilization program. *Please note that all documents ofsupport presented at this meeting will follow these minutes in Attachment A. Chairman Frye next introduced Angie Orth, CEO of Randolph Health. Ms. Orth stated that the hospital restructuring was being done to preserve healthcare and move to a sustainable health care model. It does not emphasize protecting Randolph Health. She introduced Chairman Mack Pugh, Consultant Louis Robichaux, and Attorney Bob Wilson. She said the Randolph Health Board of Directors is requesting that the County apply for a loan on behalf of Randolph Health to transition to a modern, right -sized hospital. 11/21/19 160 Ms. Orth explained that local health care access is threatened by a potential closure of the county's only hospital. It will affect not only availability of care for citizens but will impact the community with lost jobs and wages. She spoke of the "Sustainable Health Plan" that will transition Randolph Health and allow for a successor hospital to be in place after three years. Randolph Health will file bankruptcy. The successor will buy outpatient facilities out of bankruptcy and build a new facility. In the meantime, Randolph Health will continue to operate the emergency room, inpatient beds, the lab, and the pharmacy at the current campus. In order for a planned, solvent closure in three years, Randolph Health would use the Rural Health Care Stabilization funds for capital needs, new equipment, and a deficiency account to pay employee salaries and vendors. Commissioner McDowell asked how much money would be in the deficiency account. Ms. Orth replied $5-6 million. Commissioner Allen inquired as to whether $20 million would be enough to accomplish this plan. Ms. Orth said she believes it will be enough. Commissioner McDowell asked if $13 million would be enough for the first year. Ms. Orth stated that Randolph Health would request $6 million out of bankruptcy and the additional money as needed. Chairman Frye clarified that the $20 million would be split over a two year period; $13.5 million the first year then $6.5 million the second year. Commissioner Kidd asked about a projection of losses over the three year restructuring period. Ms. Orth said it would be approximately $9 million. Commissioner Allen confirmed that $6 million out of bankruptcy would be used to buy the facility. Ms. Orth said yes. Chairman Frye addressed the issue of using the Rural Health Care Stabilization funds for capital purchases. He said the Local Government Commission may not agree with that use. Mr. Robichaux said Randolph Health is working with Nelson Mullins Attorneys on clarification of the wording in the Bill. Commissioner Haywood asked Ms. Orth to explain the newer health care model. Ms. Orth said traditional patient care was focused on the hospital. As technology progressed, outpatient services became more common. Now, specialists can be accessed through telemedicine. This has allowed health care to expand to rural communities where specialists can work with patients remotely. Another change has been helping patients control their chronic illnesses before they become emergent. There will still be a need for an emergency room and inpatient facilities but for a smaller number of patients. At 7:04 pm, Chairman Frye opened the Public Hearing and Attorney Ben Morgan read the rules. Citizens wishing to speak signed up on slips of paper prior to the meeting and those names were drawn at random from a box. 11/21/19 161 Cris Richardson, 781 Anns Ct., Asheboro, introduced himself as an Obstetrician Gynecologist (OBGYN) and the Chief of Staff at Randolph Health. He is also a Board Member of Randolph Health. His practice delivers around 700 babies per year and has approximately 14,000 office visits per year, 70% of which have Medicaid or Medicare. The ability to travel can be a difficulty for patients; some ride with friends or family, some walk to appointments, some use public transportation, and some come by ambulance. If this care is not available locally, these patients would have to go somewhere else and may not even seek care. Also, OBGYNs are required to live within 15 minutes of their hospital to be available to deliver babies. Without a local practice, he and his partners would have to move out of Asheboro. Tim Greene, 73 Sherwood Rd., Asheboro, said that we shouldn't repeat some of the mistakes made in the past. He said that a 200% increase of salaries each year is ridiculous. A local waitress he knows is also a phlebotomist making $10 per hour. He stated that "the laborer is worthy of their hire," and these people deserve a better wage. When looking at the people at the top, we need to remember those at the bottom. Linda Schumacher, 105 Cloverbrook Dr., Jamestown, has worked with the Randolph Health Community Foundation since 2011. Some nonprofits assisted by Foundation grants would lose funding and may not be able to operate. Some people may not be able to make the drive to Greensboro, High Point, or Troy for healthcare. "All it takes is for one very bad thing to happen to just one Randolph County citizen" and any Commissioner who votes "no" may have to answer to the citizens. Some citizens may not want property taxes raised. However, not applying will cause the hospital to close. Raising property taxes may be easier to defend. Mary Johnson, 1073 Woodside Pl., Asheboro, is a Pediatric Hospitalist. She believes that the City and County are "being taken for a ride." She asked why the taxpayer is involved at all and why Randolph Health is still talking to Cone after the way Cone has treated Randolph Health. Why can't Baptist or Atrium save Randolph Health and directly provide rural care? She concluded by saying "stop waiting for somebody to save you." Commissioner Haywood asked Ms. Johnson if she had a copy of the presentation she was reading. Ms. Johnson gave a copy to the Clerk (Attachment B following these minutes) and referenced her blog djshousecalls.blogspot.com . Mark Trollinger, 2407 Old Lexington Rd., Asheboro, said having access to local healthcare is vital to his construction business. Construction accidents occur. The emergency room is vital to provide care for those with a severed finger or broken bones. He said that his brother received excellent local daily treatment and continued his business while fighting cancer. The financial impact of not working could have resulted in the loss of his livelihood. The stigma of our city not having adequate healthcare would have a negative effect on our economy. Long standing property values will drop and the quality of life would be lost without local healthcare. He asked Commissioners to vote yes in what he said may be one of the most important votes of their careers. Matthew Smith, 316 S. Randolph Ave., Asheboro, is the Asheboro Randolph Chamber Board Chair. He believes that applying for the Rural Health Care Stabilization Program supports the least impact on residential and commercial property taxpayers, preserves jobs, local spending, the 11/21/19 162 local economy, and future opportunities of business and industrial growth. He asked for the economy and local healthcare to be preserved. His Board passed a resolution in support of applying. He provided a copy to the Clerk. Kathleen Riley, 1403 Willow Downs Ct., Asheboro, is a pediatrician at Randolph Health. She said that access to local healthcare is vital for patients, newborns, family and friends that support patients, and emergency deliveries. As a patient, she has received compassionate care; the nurses are kind to everyone. Her young child had trouble breathing and she appreciated that Randolph Health was close to home so she could miss less work. This hospital is a not for profit hospital offering care to any patients. She doesn't want a large corporation to take over and change the way medical providers practice. Tammy O'Kelley, 1061 Rockridge Rd., Asheboro, is the CEO of the Randolph County Tourism Development Authority (TDA). The TDA Board approved a resolution that fully supports the Board of Commissioners applying to receive funds from the Rural Health Care Stabilization program. She gave a copy of the resolution to the Clerk. With only a two mile ride to the hospital after an accident, she is able to walk today due to the care she received at Randolph Health. Dr. Heath McCoullogh, 7066 Toscana Ln., Summerfield, is an Interventional Radiologist who cares for patients in the Cone, Baptist, and Randolph Health systems. He has worked with Randolph Health for over six years. Randolph Health gives very compassionate care to the patients. The transportation issues that patients deal with are very real. He reminded the Commissioners that rural health care is struggling across the country. Randolph Health has a plan that, if successful, could become a model across the country. He suggested taking a risk in order to make things better. James Gouty, 261 N. Fayetteville St., Asheboro, is the Senior Vice President of BB&T Bank, a member of the Randolph Community College Board of Trustees, and a member of the Randolph Health Corporate Board. Recruiting new business to come to the County would be next to impossible without a hospital. He asked Commissioners to fully support the success of Randolph Health and apply for the loan. Kevin Franklin, 447 Parksfield Trl., Ramseur, President of the Economic Development Corporation (EDC), presented a resolution of support on behalf of the EDC Board. He asked that Commissioners retain local healthcare. Employers rely on local health care because employees are happier and more productive when they are healthy. Without a hospital, the bottom line of local businesses will be impacted and attracting new industry to the County without local healthcare will be difficult. Randolph Health has higher than average wages affecting taxes paid and local non-profit charity donations. Rev. Lynda Ferguson, 512 Cliff Rd., Asheboro, is a Reverend at the First United Methodist Church. She spoke of a young man who donated his organs and, with quick action by Randolph Health, seven lives were saved. She said she has numerous stories of the hospital saving citizens. She asked Commissioners to keep quality healthcare available locally. 11/21/19 163 Rodney Welch, 1807 Stallion Trl., Asheboro, is a disabled veteran. He said that local healthcare is very important to the community. He stated that the Board has the opportunity to create a better tomorrow for generations to come. He asked Commissioners to please let this pass. Trent Cockerham, 416 Vision Dr., Asheboro, is the Chief Operating Officer at Hospice of the Piedmont, which serves eight counties. Many patients reside in Randolph County. He believes in the need for acute care and ancillary services to be available locally. When care is further away, it is hard to imagine the impact until you need it. Randolph Health closing could increase the transportation costs for patients. He asked that the Commissioners apply for funds to preserve healthcare in Randolph County. Chip Owen, 634 Maple Ave., Asheboro, is a local retired pharmacist. He said it is imperative for local pharmacies to have a hospital. Without a hospital, pharmacists will not have work. Jimmy Roddy, 884 Mack Rd., Asheboro, said that it doesn't make sense that Randolph Health is hard -up for money because they have buildings all over the place. Alan Ferguson, 4794 Troy Smith Rd., Liberty, said the County should move forward to support Randolph Health. He said that a hospital is a symbol of civilization in a community and citizens have to pay for them. People need to be the focus, not money. A county that doesn't have enough thought to have a hospital will not be successful. He said that the Commissioners need to keep the hospital open to make this a first class county. Jonathan Thill, 815 Viewmont Dr., Asheboro, said he was speaking for the entrepreneurial community. Millennials are looking for more space and they believe in community. People won't be able to imagine coming here without a local hospital. More people are starting to move to rural communities. They need access to local care to sustain a quality of living. Gilbert Jacobs, 1473 Franklin Hills Ct., Randleman, said he has no connection to Randolph Health. He and his wife had searched and found land in Moore County. Upon realizing that the closest hospital was almost 30 miles away, they rescinded their offer and ended up moving to Randolph County. He has received care from Randolph Health in the past and found the staff to be professional and kind. He said that all of the citizens in attendance were here because Randolph Health needs them. Filmore York, 505 Dogwood Dr., Liberty, is the Mayor of Liberty. He said while most Liberty residents go to Greensboro or Siler City for their care, every one of them has ties to Asheboro. He said his Board met in support of Randolph Health. Without the hospital, there would be a loss of $55 million annually in payroll, property taxes would be effected, revenues would decline, and recruitment of new businesses and industry would be challenging. Randolph Health generates $209 million in economic value. Commissioner Haywood said that if the County were to borrow the money, the budget would be impacted for years to come. She urged the citizens to continue working together because funding availability for government services such as mental health care, Social Services, and public schools will be affected. 11/21/19 164 Kim Canter, 1628 Old Farmer Rd., Asheboro, said that local healthcare does matter. Through Randolph Health, in-home healthcare and mental health care can be provided for anyone that needs them. Nurses go to homes because patients can't always travel to the hospital. She said that Randolph Health offers a lot more than just the facility. David Jones, 1688 Sylvan Way, Asheboro, is the previous Director of the North Carolina Zoo. He said that attendance at the Zoo is approaching one million people per year. It has the potential to be the largest zoo in the world after the addition of three proposed new Continent exhibits. Telling visitors that the nearest hospital may be 40 miles away would impact Zoo attendance. Currently, the Zoo's economic impact is about $100 million and $2 million of that goes directly back to the County. The gross economic impact of the hospital equates to roughly $34 million dollars in taxes. Marcus Gentry, 583 Wellington Pl., Asheboro, is an Emergency Physician. He said many people would not survive their injuries and illnesses if they had to travel further than Randolph Health to receive healthcare. He is worried for his patients and his family if the hospital closes. He urged the Commissioners to find a way to "make it work." Art Martinez, 784 Anns Ct., Asheboro, is proud to be the father of a daughter who had leukemia and was treated by Randolph Health. People in Greensboro advised him not to purchase a business in a dying community. Over the last 14 years, the community has supported his business. Randolph County is a great place to live, work, and do business. Losing the hospital will result in a trickle-down effect with the loss of businesses and less economic development. Chris Harrington, 304 Trollinger St., Randleman, supports the County applying for a loan on behalf of the hospital. This issue involves good jobs, safety, and health in a good community. The drive to another hospital is a "big deal." Quick access to healthcare is important for his employees especially during an accident. Without healthcare, it will be hard to recruit new businesses. Talented people and viable businesses will leave. At 8:09 p.m., the Board took a brief recess and reconvened at 8:15 p.m. Mayor David Smith read a statement by Gene McMasters. Mr. McMasters wanted the Board to do what they could to help Randolph Hospital. Lilly Bossong, 1419 Westmont Cir., Asheboro, has lived in Randolph County for 18 years. She chose to have children and surgeries at Randolph Health. The care was excellent. She said healthcare is vital to the community. Cindy Schroder, 2623 Brassie Ct., Asheboro, said citizens deserve quality healthcare. It wasn't until her husband became sick and required chemo and radiation that she realized how difficult it was to take him out of town for treatment. She urged the Board to ensure quality healthcare locally. Dr. Robert Scott, 3097 Fiddlers Creek Rd., Asheboro, has had a family practice here for 37 years. He gave the Clerk an article from the Center for American Progress called Rural Hospital Closures Reduce Access to Emergency Care (Attachment C following these minutes). He and his 11/21/19 165 colleagues make public health decisions daily. Everyone in his practice asked to give a unanimous vote of support. He offered statistics from UNC that show urban hospitals closing have less effect on the community than if a rural hospital closes. The mortality rate rises by over 5%. He urged the Commissioners to keep health care here. Tim Saunders, 1402 E. Allred St., Asheboro, was raised in Randolph County. He was born at the hospital and he and his family have used it in emergencies. The care has always been good. He knew this was a complicated issue and he asked the Board do what has to be done to keep health care local. Rick Powell, 1058 Cable Creek Rd. Asheboro, owns PEMMCO Manufacturing. As a business owner, he recruits people from across the nation. That will be hard without a hospital and local healthcare. Stefanie Yelverton, 1898 Berkley Ln., Asheboro, has been a nurse at Randolph Health for 13 years. Local healthcare matters. Her family's health has been positively impacted by having a hospital here. Mark Hensley, 1326 Middleton Cir., Asheboro, is Executive Director of Randolph Senior Adults. Having a hospital is critical to senior adults, especially those who do not have transportation and use RCATS. Senior adults are the fasted growing demographic in Randolph County. Local health care is a vital for them. Losing local health care would be devastating. Duffy Johnson, 1184 Cedar Creek Dr., Asheboro, has been a resident for 30 years. He supports the Randolph Health request. He had a health episode that needed immediate care. He was not sure if he would be here without local access. Pam Smith, 5335 Reeder Rd., Asheboro, has been a registered nurse in the maternity unit for 29 years. Patients have changed. Newborns are addicted to drugs. Unwed mothers and children can't get to another facility. As a mother with a sick child, she was glad the hospital was close by. Rhonda Trollinger, 2407 Old Lexington Rd., Asheboro, said the bottom line is we have to have a hospital. As a business person, she understands how the economy is affected. She was impressed with the unity shown at this meeting and urged everyone to support Randolph Health. "It may have a different form but accept the changes and find the best situation." She asked the Board to vote for this application. Zac Beane, 1844 Pine Grove Dr., Asheboro, said Randolph Health is so important. He represents an age group that will fill the seats in the future. He has family here in town. He advocated for the Board to apply and take necessary steps to keep local health care. Mack Sherrill, 845 Newbern Ave., Asheboro, is on the RCC Board of Trustees. He said they passed a resolution of support. He mentioned that RCC is building a state of the art Allied Health Center and students will be looking for jobs. Micki Bare, 116 S. Elm St., Asheboro, said this is a difficult issue. As a member of the Asheboro Randolph Chamber, she understands the negative impact for local residents and businesses. As an employee of Partnership for Children, it is difficult for children born out of the 11/21/19 166 county to be reached for early childhood development programs. She was grateful for the hospital when she needed it. Local healthcare is important. She asked the Board to apply for the loan. The Public Hearing closed at 8:55 p.m. Chairman Frye thanked the speakers for their expressions and sentiments for a quality of life in Randolph County. He asked the Board how they wanted to proceed. Commissioner McDowell appreciated everyone's comments and stated that this had been a long meeting. He asked Finance Officer Will Massie how much a tax increase may be. Mr. Massie said that it depended on the interest rate and length to pay the loan back. It will possibly increase by 1-1 1/2 cents. Commissioner McDowell reminded the audience that the loan could last as long as 20 years. He recommended to Ms. Orth that the administrative salaries be addressed. He was the only Commissioner born at Randolph Hospital/Health and would agree to vote tonight due to the importance of the issue. Commissioner Allen said this is a process that has steps. He stated tonight's vote is easy but gets harder as the process goes on. He has concerns but those will come out in further discussions. It is a complicated process and the Board needs to be conscious of taxpayers and Randolph Health. Commissioner Kidd stated that his mother-in-law would not be here without Randolph Health. He does have concerns about the details of the plan. This is the first step in a long process. The community has proven it is a no-brainer and the Board needs to get the ball rolling. Commissioner Haywood agreed with things she heard. She understands citizen concerns about the process. The health care partner needs to be right for the county. She was disturbed that chronic disease was higher in Randolph County than the average in North Carolina. The County had invested in a Wellness Administrator who has made an impact across the county in businesses, schools, and municipalities. The County is ahead of the game in some areas but needs to work on others. Commissioner Kidd thanked Ms. Orth for doing a great job compiling the information. Commissioner Allen thanked Senator Tillman and Representatives Pat Hurley and Allen McNeill for their hard work on the Bill. On motion of Kidd, seconded by McDowell, the Board voted unanimously to apply for the Rural Health Care Stabilization program on behalf ofRandolph Health. Adjournment At 9:15 p.m., on motion ofAllen, seconded by Kidd, the Board voted unanimously to adjourn. Darrell Frye, Chairman David Allen 11/21/19 Kenny Kidd Hope Haywood Maxton McDowell Dana Crisco, Clerk to the Board 167 11/21/19 168 Attachment A RESOLUTION NUMBER 49 RES 11--19 CITY COUNCIL OF THE CITY OF ASHEBORO, NORTH CAROLINA A RESOLUTION SUPPORTING THE RANDOLPH COUNTY BOARD OF COMMISSIONERS' APPLICATION FOR, THE RURAL HEALTH STABILIZATION ACT WHEREAS, the City of Asheboro recognizes access to nearby healthcare is an essential service to have in order to sustain and grow jobs, and for the health of our citizens; and WHEREAS, access to local healthcare has been identified by the City of Asheboro Strategic Plan and The Randolph County Strategic Plan as key assets in our community's ability to grow and thrive; and WHEREAS, local hospital healthcare and its services in Randolph County employ 800 local residents with an annual payroll of $55 million and an overall economic impact to Randolph County of $209 million annually; and WHEREAS, local hospital services t-reat,38,000 emergency patients annually, hundreds of whom would not survive transport to an out -of -county emergency department; and WHEREAS, the loss of local hospital healthcare and services would severely impact the public health and safety operations of the City of Asheboro Fire and Police Departments; and WHEREAS, local hospital -owned physician practices treat 1.25,000 patients annually, and the local hospital -owned Cancer Center treats 10,000 patients close -to - home; and WHEREAS, loss of those jobs would have an immediate, negative and long- term impact on the overall local economy and on Randolph County's ability to attract new business and industry; and WHEREAS, loss of those services would have an immediate and negative impact on Randolph County citizens as they would have to travel away from home for basic and essential healthcare, and hundreds of lives will be lost clue to lack of nearby emergency services and care; and WHEREAS, the North Carolina legislature has adopted a Rural Health Stabilization Act that would allow Randolph County to apply for loan funds that Page 1 of 2 169 would sustain local, essential healthcare services while a healthcare successor constructs a new replacement facility; and WHEREAS, these loan funds would allow for the continuation of local jobs, local payroll. spending, and local healthcare services for Randolph County citizens. THEREFORE, BE IT RESOLVED, that the City Council of the City of Asheboro fully supports the Randolph County Board of Commissioners' application ,for the Rural Health Stabilization Act. This Resolution was adopted by the Asheboro City Council in open session during a regular meeting on November 7, 2019. n 1� 1�' , David H. Smith, Mayor A0 � pj'� 44 LU M Holly H. oerr, CMC, NCCMC, City Clerk Page 2 of 2 RESOLUTION Whereas, the Asheboro/Randolph Chamber is a voluntary organization of 835 business and professional members, representing more than 20,000 employees, who have joined together for the purpose of promoting the civic and commercial progress of the City of Asheboro and Randolph County; and Whereas, the area's economic well-being is important to the Asheboro/Randolph Chamber as it has a major impact on the business, income, and future growth of the area; and Whereas, the Chamber recognizes access to nearby healthcare is an essential service to have in Randolph County in order to sustain and grow jobs, and for the wellbeing of our residents, and Whereas, access to local healthcare has been identified by the Chamber Advocacy Network as a top priority in making Asheboro and Randolph County a great place to live, work, and do business; and Whereas, local hospital healthcare and its services in Randolph County employ 800 local residents with an annual payroll of $55 million and an overall economic impact to Randolph County of $209 million annually; and Whereas, local hospital services treat 38,000 emergency patients annually, hundreds of whom would not survive transport to an out -of -county emergency department; and Whereas, local hospital -owned physician practices treat 125,000 patients annually, and the local hospital -owned Cancer Center treats 10,000 patients close -to -home; and Whereas, loss of those jobs would have an immediate, negative and long-term impact on the overall local economy and on Randolph County's ability to attract new business and industry; and Whereas, loss of those services would have an immediate and negative impact on Randolph County citizens as they would have to travel away from home for basic and essential healthcare, and hundreds of lives will be lost due to lack of nearby emergency services and care; and Whereas, the North Carolina legislature has adopted a Rural Health Stabilization Act that would allow Randolph County to apply for loan funds that would sustain local, essential healthcare services while a healthcare successor constructs a new replacement facility; and Whereas, these loan funds would allow for the continuation of local jobs, local payroll spending and local healthcare services for Randolph County citizens; THEREFORE BE IT RESOLVED, that the Board of Directors of the Asheboro/Randolph Chamber fully supports the Randolph County Board of Commissioners to apply for the Rural Health Stabilization Act funds and borrow the dollars necessary to the benefit of our local economy, and for the compassionate care and concern of our residents. ADOPTED, this 20tTda November 2019 Matth w Smith, Chairman of the Board Asheboro/Randolph Chamber 171 Randolph County, NC Economic Development 40 ' Corporation Expanding Opporrun?Ver to the Heart ofNorrh Carolina RESOLUTION WHEREAS, the Randolph County Economic Development Corporation is a non-profit organization tasked with supporting a growing healthy economy through both the attraction of new business and retention and expansion of existing business and industry in Randolph County; and WHEREAS, the area's economic well-being is important to the Randolph County EDC as it has a major impact on the business, income, and future growth of the area; and WHEREAS, the EDC recognizes access to nearby healthcare is an essential service to have in Randolph County in order to sustain and grow jobs, and for the wellbeing of our residents; and WHEREAS, access to local healthcare has been identified by the Chamber Advocacy Network, of which the EDC is a participant, as a top priority in making Asheboro and Randolph County a great place to live, work, and do business; and WHEREAS, local hospital healthcare and its services in Randolph County employ 800 local residents with an annual payroll of $55 million and an overall economic impact to Randolph County of $209 million annually; and WHEREAS, local hospital services treat 38,000 emergency patients annually, hundreds of whom would not survive transport to an out -of -county emergency department; and WHEREAS, local hospital -owned physician practices treat 125,000 patients annually, and the local hospital -owned Cancer Center treats 10,000 patients close -to -home; and WHEREAS, loss of those jobs would have an immediate, negative and long-term impact on the overall local economy and on Randolph County's ability to attract new business and industry; and WHEREAS, loss of those services would have an immediate and negative impact on Randolph County citizens and businesses requiring citizens and employees to travel outside of the community for basic and essential healthcare, and hundreds of lives will be lost due to lack of nearby emergency services and care; and WHEREAS, the North Carolina legislature has adopted a Rural Health Care Stabilization Act that would allow Randolph County to apply for loan funds that would sustain local, essential healthcare services while a healthcare successor constructs a new replacement facility; and WHEREAS, these loan funds would allow for the continuation of local jobs, local payroll spending, and local healthcare services for Randolph County citizens. THEREFORE, BE IT RESOLVED, that the Board of Directors of the Randolph County Economic Development Corporation fully supports the Randolph County Board of Commissioners to apply for the Rural Health Care Stabilization Act funds and borrow the dollars necessary to the benefit of our local economy, and for the compassionate care and concern of our residents. ADOPTED this 20th day of Novem/b6r 2019. f Bil ardin, Chairr6dn of the Board Randolph County Economic Development Corporation 172 RESOLUTION IN SUPPORT OF RANDOLPH COUNTY PURSUING FINANCING TO SUPPORT RANDOLPH HOSPITAL Resolution 20191.9 WHEREAS: Randolph Hospital provides necessary local healthcare; and WHEREAS: The highest average wage jobs will disappear; 800 of which are Randolph County residents; and WHEREAS: There will be a loss of $55 million annually in local payroll that will negatively impact the local economy; and WHEREAS: Property values and property tax revenue will decline; and WHEREAS: Recruiting efforts for new business and industry will be extremely challenging with no local healthcare; and WHEREAS: Randolph Hospital creates $209 million in local economic benefit; NOW THEREFORE, BE IT RESOLVED that the Liberty Town Council supports Randolph County pursuing financing to preserve Randolph Hospital and local healthcare. Adopted this 18 day of November , 2019, 46d moreY ark, (Mayor Gary Davis ayor Pro Tem kvson E. n J.R Beard Chris Compton LPry Coble A EST: r J Jes a Brown, Town Clerk Oliver Oliver Rubber Company 408 Telephone Avenue Asheboro, NC 27205 November 20, 2019 Randolph County Board of Commissioners 725 McDowell Rd, Asheboro, NC 27205 Dear Board of Commissioners, 173 I am writing this letter to express our support for Randolph Health, our community health care provider for the greater Randolph County Area. Randolph Health plays a vital role in our efforts to ensure the Randolph County area remains vibrant and growing. Nearly all of our employees utilize the health care services provided by Randolph Health inpatient, outpatient and emergency services. Our hospital is one of the key pillars in the community, specifically the availability of emergency services for our workforce and the community at large as the occasions arise. We are fortunate that our workforce has required emergency services only on limited occasions in recent years. Each and every time, Randolph Health is there to provide the appropriate medical services needed by our employees. Again, as part of the business and industry community in Randolph County, we support making the appropriate efforts to ensure Randolph Health remains a strong health care provider for our community and workforce during this transition period. Sincerely, Steve Scruggs, Plant Manager Oliver Rubber Oliver Rubber Company, LLC 408 Telephone Ave Asheboro, NC 27205 A RESOLUTION SUPPORTING APPLICATION FOR THE RURAL HEALTH CARE STABILIZATION ACT FUNDS WHEREAS, Randolph Community College helps Randolph County increase its competitive advantage by developing and training a quality workforce that is essential to the local and state economy; WHEREAS, Randolph Community College helps employers by closing the skills gap thereby creating opportunities forjob creation and retention; WHEREAS, Randolph Community College is constructing a new, state of the art, Allied Health Center to house our healthcare programs to train students in these specialized careers; WHEREAS, Randolph Community College partners with our local healthcare providers who offer our healthcare students with clinical opportunities and local jobs upon graduation; WHEREAS, loss of these jobs would have a negative and long-term impact on the overall economy of Randolph County and the ability to attract new business and industry; WHEREAS, the North Carolina legislature has adopted a Rural Health Care Stabilization Act that would allow Randolph County to apply for loan funds that would sustain local, essential health care services while a healthcare successor constructs a new replacement facility; and WHEREAS, these loan funds would allow for the continuation of local jobs, local payroll spending, and local healthcare services for Randolph County citizens; NOW, THEREFORE BE IT RESOLVED THAT THE RANDOLPH COMMUNITY COLLEGE BOARD OF TRUSTEES fully supports the Randolph County Board of Commissioners to apply for the Rural Health Care Stabilization Act funds and borrow the dollars necessary to the benefit of our local economy, and for the compassionate care and concern of our residents. Adopted by the Randolph Community College Board of Trustees November a1, 2019 175 RESOLUTION Rando p unty Tourism DevelopmentAuthority WHEREAS, the Randolph County Tourism Development Authority is a public authority governed by the terms of special legislation granted by the N.C. General Assembly on July 28, 1997 as House Bill 337, An Act to Authorize Randolph County to Levy a Room Occupancy and Tourism Development Tax under the Local Government Budget and Fiscal Control Act; and WHEREAS, the Authority operates the Heart of North Carolina Visitors Bureau, serving as the official destination marketing organization for Randolph County, and the 1-73/74 Visitor Centers serving travelers on both north and southbound lanes of interstate 73/74 and welcoming on average 65,000 visitors each year; and WHEREAS, the travel and hospitality industry's economic impact in Randolph County has increased by more than 99.9 percent since 2000, welcoming 1.4 million visitors and generating $153.58 million in 2018; and WHEREAS, Authority staff, Board members, and partners and stakeholders recognize that access to local area health care services for both citizens and visitors to Randolph County is essential for maintaining and continuing to grow local economies and increasing the economic impact of tourism; and WHEREAS, in the face of a medical emergency, access to health care services is vital to visitors who may become injured or fall ill and seek medical treatment; and WHEREAS, Randolph Health provides local health care access to a network of doctors and emergency assistance daily, around the clock, to visitors traveling through or making the county their destination; and WHEREAS, the North Carolina Zoo, the county's largest attraction with nearly 750 full- and part-time employees, 1,000 volunteers, and to date, 883,000 visitors in 2019, is located less than 15 minutes from and partners with Randolph Health in implementing disaster response and preparedness planning including storing the Zoo's inventory of antivenom at Randolph Health's pharmacy in Asheboro; and WHEREAS, North Carolina Zoo Park Ranger Emergency Medical Technicians requested 17 ambulances be dispatched for transport of visitor medical emergencies to Randolph Health in 2018 and to date have requested 16 ambulances be dispatched for transport of visitor medical emergencies to Randolph Health in 2019; and WHEREAS, the loss of local health care would have an immediate, negative, and long-term impact on both the citizens of Randolph County and the visitors we welcome each year, forcing them to travel further for basic and essential health care services and potentially resulting in the loss of life due to the lack of emergency services; and WHEREAS, the North Carolina legislature has adopted a Rural Health Care Stabilization Act that would allow Randolph County to apply for loan funds that would sustain local, essential health care services while a health care successor constructs a new replacement facility; and WHEREAS, these loan funds would allow for the continuation of local health care services for visitors to and citizens of Randolph County. THEREFORE, BE IT RESOLVED, that the Board of Directors of the Authority fully supports the Randolph County Board of Commissioners in making application to receive Rural Health Care Stabilization Act funds that will enable the continuation of local health care and emergency services to residents and visitors, alike. ADOPTED, this 20111 day of November 2019. �, c David Caughron, Chairman of the Board 176 Attachment B Thursday, November 29, 2099 Thank you, Commissioners, for this opportunity to share my opiniontexperience ... and pro -offer a solution that does not put the Asheboro/Randolph County taxpayer in debt for decades to come. I am going to deal in facts tonight - and paint a bigger picture than Randolph Health or the Courier Tribune usually delivers to the general populace. Some folks won't like what I have to say. I'm used to that. Truth often hurts feelings. But it should TRUMP them. As a few of you already know, Atrium Health (formerly Carolinas Healthcare System) in Charlotte, and North Carolina Baptist Hospital (in Winston-Salem) are in cahoots to start up an off -shoot of Wake Forest's medical school in Charlotte. 1 am an alumna of Baptist's medical school (then Bowman Gray), and Brenner's Pediatric residency program. As a physician, I am familiar with all of the players by virtue of my professional associations over the years. Charlotte lost out on a medical school to East Carolina University a little over fifty years ago, and has NEVER gotten over it. if this "strategic combination" (everybody is downplaying the word, "merger") is approved by state and Federal regulatory bodies, the state of North Carolina would then have six medical schools (Wake Forest, Duke, UNC, ECU - with MD programs, and Campbell with a DO program - plus the new school in Charlotte). Some states don't even have one medical school. More medical schools, putting out more doctors, basically allows NC hospital executives to continue their long-standing, finely -honed tradition of devaluing the services of physicians and treating them very badly... as i was treated... after coming back to Asheboro to start a Pediatric practice, for Randolph Hospital, from scratch in 9995 ... fulfilling a public-service obligation to the state and Federal governments in the process. The goal of the taxpayer's investment in repaying my medical school debt was to recruit and retain my services in a rural area - in this case, my hometown. But after almost three years of very hard work, Randolph executives fired me "without cause"just two weeks after reporting a "bad baby" case (involving a "Cone -owned" Family Practitioner) to Peer Review... at approximately the same time I completed my service obligations. The "without -cause" termination of duly privileged/credentialed physicians by hospitals is one of medicine's dirtiest secrets. No due -process or review is afforded the doctor. Executives can do whatever they want - especially in "fight -to -work" states. If you've ever wondered why your doctor just "disappeared", wonder no more. By ALL accounts 1 saved the child's life (defying the written threats of Randolph executives to do it), and she is studying to be a nurse today. This is what motivates me most tonight - because this young woman ... whose life was almost snuffed out by a doctor's arrogance and incompetence ... but whose life was saved by a brave charge nurse who, in the middle of the night, dared to think outside the box and call a 177 Pediatrician (me) in ... deserves SO MUCH BETTER than what I am seeing doctors and nurses endure today at the hands of our post Obamacare medical oligarchy. And 1 am compelled to be the voice of CHANGE - even if I stand alone. Again, I'm used to it. Over an utterly demoralizing thee year period, I fought back against what Randolph's executives did to me (again, without ANY due process exercised by my peers - or genuine oversight on the part of their rubber-stamping Board). 1 found myself mired in what amounted to taxpayer -funded litigation (with the taxpayer being kept utterly in the dark). This included being unsuccessfully sued for "libel".. . ironically because I responded to requests for feedback, and told the governments I served the truth about what had happened - and how the stated mission of their programs had been undermined/thwarted. Ultimately, the cases were settled in my favor. But I was swindled at settlement... of approximately $550,000 (a conservative estimate based on the value of the practice that was stolen absorbed by the hospital ... or alternatively, the salaries paid out to remaining doctors after l was sidelined and muzzled). For Randolph Hospital executives lied repeatedly during discovery about the "confidentiality" of their not-for-profit books and salaries ... and withheld IRS 990's ... which are public records, and have been made so readily available now... when THEY WANT SOMETHING. Let's talk about accountability to the taxpayer. When I discovered the ruse, I bled complaints with every oversight agency under the sun. 1 and my family even appeared at an Asheboro City Council meeting begging for help. 1 vividly remember one Council member (who 1 will not name here only because he is dead and I am Southern) literally sneering at me and my late Father in that meeting. State and Federal officials (including our Governor- then Attorney General) stonewalled and dodged and refused to investigate my complaints, or conduct a forensic audit - because (Randolph County DA) Garland Yates exercised his discretion not to make a referral to the SBI - effectively burying the case. i was a whistle -blower who signed my name (as whistle -blowers desiring protection should). 1 fought for years for some kind of justice ... including turning to Greensboro - based `journalist'; Edward Cone (now on the Cone Board of Trustees), and "his" Greensboro blogosphere for help ... forced there because local newspapers and TV stations buried their heads in the piles of advertising dollars that hospitals executives doled out. The citizens of Asheboro might as well have been reading Pravda. I never got any help. 1 did get routinely libeled (let's just say, I'm not a political progressive) and even cyber -stalked: Eventually, 1 gave up. And I just continue now. The supreme irony is that exposing administrative malfeasance then (15-20 years ago) just might have prevented what is happening now. 178 I was literally told to my face by Federal agents that my life and career and dreams of a practice in my hometown did not matter in the great SCHEME (key word) of things. Good Pediatricians were "a dime a dozen" according to my then -boss ... the future, very -well- paid CEO who would ultimately run Randolph aground ... and walk away unscathed. Randolph Hospital was a public charity too big to fail. Except that it has. I subsequently watched the CitylCounty pour even more taxpayer dollars into the hospital's endeavors. A total of one million dollars was pledged in 2006 to fund the Armfield Cancer Center... which, for all practical purposes, Cone Health now basically controls ... and Randolph Hospital now identifies as the foundation of their current financial woes. A lot of people are worried now about losing their jobs and paying their mortgages. Given the history just cited, i totally get that. I was cast out -- told 1 did not "fit in" my own hometown - and was forced "on the road" to make my living. But 1 still own a home here ...and my elderly Mother (who taught in the Asheboro City school system for over thirty years - kindergarten, first grade and special Ed) increasingly relies upon local services for medical care. I stand here to tell you that I've already been bled dry "at the office'; and that, as a taxpayer, I am sick and tired of giving and giving and giving, only to have the people who run this hospital LIE and TAKE. I suffered two botched surgeries at Randolph - which required major revision somewhere else. When my Mother began acting strangely one morning last year (a prelude to a T1A and the diagnosis of a prior stroke), my sister-in-law put her in the car and took her home with her - diverting to Alamance Medical Center on the way - because NONE of us wanted to deal with Randolph. Two months ago, I had a limb - threatening emergency. At two AM in the morning, I drove past both the Randolph and Cone ED's to get to Baptist. Our medical experiences are just as valid as Annette Jordan's - who can liberally pontificate to the deliberately-kept--in-the-dark masses from her soapbox at the Courier Tribune. 1 have digressed. Atrium and Baptist collaborating to build a medical school in Charlotte could be considered a "merger" and✓or the monopolization of medical resources across a large swathe of North Carolina. That is WHY the Federal Trade Commission is now involved. In fact, 1 spent a close -to -an -hour on the phone with an FTC Attorney last week Cone Health is in the last quarter of a ten-year medical management deal with Atrium. There is little doubt they will want to be "picked up" and swaddled again by their bigger, apparently very fiscally -stable corporate "parent". But will they? For you see, Cone competes directly with Baptist. 179 Again, THINK MONOPOLY. The FTC doesn't like monopolies. Atrium would do ANYTHING to finally get that medical school... including dropping Cone like a stone if that relationship interfered with the "collaborative" agreement with Baptist. Randolph could be ponying up to Cone now, only for both hospitals to be dumped from the bigger corporate parents to appease the Federal government's concerns about a monopoly. But (it's a BIG but): Part of the deal with Baptist is (the old/tired/really worn-out) argument that, in producing more doctors Atrium will somehow magically improve rural care - never mind that most doctors these days are eschewing small towns for the big city - and better incomes (because working for a small hospital in the sticks does not pay as it should pay). Inpatient Pediatrics is, in fact, dying on the vine in smaller/rural communities everywhere. Mother -Baby services ultimately suffer as EVERYTHING gets labeled "high risk" and "shipped" up the road- across oftentimes scary distances when time matters. Just today, it was announced that yet another Mother -Baby unit in far western North Carolina is closing its doors. I have seen Asheboro's future - for in my travels, I've rescued and navigated hospital & service meltdowns (when other Pediatricians threw up their hands and walked away) .... and dealt with money-grubbing administrators who would lie to their Mothers for a fast buck ... over and over again. It's what I do. 1 know what's coming unless this community wakes up. So my question to the Randolph County Commissioners, very respectfully, is this: WHY go with the middle -man? WHY doesn't Atrium and/or Baptist pony up to "save" Randolph. RIGHT NOW ... and directly provide rural care as a part of their medical school proposal? Saving Randolph (before or after bankruptcy) is chump change to Atrium. In 2098, they listed $6 billion in revenue and $9 billion in assets. They don't have to go to Georgia (as they have done) to buy and shore up systems there. They could do it (as they have done it) in their own North Carolina backyard. And considering Atrium's need to make their case (to the FTC/state) that another medical school will help rural care ... and that the benefits to rural care outweigh the effects of what is effectively a monopoly... Randolph Hospital is MORE than a pawn in this game - no matter how "hard to get" Atrium's "baby" (Cone) is playing right now. In recent days, after months of talking about bankruptcy as part of their "strategic plan", Randolph Hospital CEO, Angie Orth has indicated that if the County fronts the money to keep the hospital open, she is not inclined to file bankruptcy. Wait. Whut? It is NOT the County/City's job to clear Bank of America's bad corporate debt. The bank made its bed by backing Bob Morrison & Steve Eblin's less -than -smooth "world-class" moves ... much like former hospital board member Mike Miller took First National down. Barring a solid plan that guarantees more than just a few years of stability for BOTH Cone and Randolph, 1 implore you -all to look beyond Cone. For Randolph Hospital has been Cone's "biOtch" FOREVER ... feeding and referring millions of dollars of medical "business" across a county line for literally decades ... only to get dumped a year ago like a bad date. They finally saw Randolph's books. And they RAN. From the boardroom. Screaming. Those books are something we ALL should be seeing now - as taxpayers being asked to mop up the mess. i would argue we need to see IRS 990's at least back to 2006. But we're a County of dumb hicks and Republican rednecks to Terry Aiken/Cone ... an easy mark. Desperate bumpkins. That is the hand that Randolph Health's leadership has always played to. Commissioners,) say to you ... and to my fellow citizens/healthcare colleagues assembled here tonight (front lines people ... in all reality, MY people ... many of whom were told to show up in the scrubs and plead to save the hospital): STOP waiting for someone to "save" you. Make the calls yourselves to Atrium, to Baptist, AND to the FTC. The "big boys" want another medical school in North Carolina. Okay. FINE. What are they willing to do and/or prove to get it? Are THEY willing to put real skin in this game? To coin a phrase, QUID PRO QUO. I would LOVE to be able to finally come back home to a "mission" that did something besides feed the pocketbooks of the entrenched MBA's with the multi -million -dollar salaries running these hospitals. I want to finally see a hospital that SERVES the entire community - not just the folks on the west side of Asheboro that can afford to "dine around". After a decade of denial, everyone seems to concur that we need a smaller hospital ... with streamlined basic services ... plugged into nursing and medical educational centers ... as well as referral networks that actually work for doctors and patients. In other words, it's way past the time Randolph Health was proud of being a very good "Band Aid Station". Applying to participate in the "Rural Health Care Stabilization" program ... if a viable plan can be articulated... is one thing. It's kind of a "duh" decision. It makes sense to at least open the door, and keep it open as other things play out. I am not here tonight to protest that. But actually applying for the funds (which would be the subject of another hearing down the road) is quite another matter. 1 may not be able to attend that hearing - because 1 am 181 a front lines Pediatrician who spends half -her life "on-call" somewhere else (while Randolph Health pays people who donT live here big bucks to cover call). So I am saying my peace tonight. If you move forward, this is a LOAN, not a grant (the term I hear a lot of people using). Someone has to pay it back. The County and City actually risk meeting the same fate as the hospital -they -would -like -to -save -from -itself What happens to all of the services that Cities and Counties are supposed to provide, if you pour everything into bailing out a hospital that "died" largely by virtue of fiscal irresponsibility, administrative arrogance and just pure greed? What has thus far been proposed by Randolph Health is really, Really, REALLY sparse on details, says nothing about checks or balances, and offers nothing more to City/County leaders for the taxpayer's dimes (in terms of local input/influence%versight) than the status quo of the last twenty years. . That status quo has ALWAYS catered to Cone - who as of the time 1 composed the bulk of this statement (on Wednesday evening) remains non -committal to mounting their white horse. Recently, Cone took an idea (regarding mental health services) that 1 proposed well over a year ago (as a means to save Randolph) and ran with it on their own terms in Guilford County. The way Cone has played Randolph over the last year - expecting you-all/the taxpayer to pick up their tab even as they dangle a "rescue" Is just OFFENSIVE. If you follow blindly because you fear that no one will rebuild in Randolph's ashes, then you just don't understand the medical corporate word. For if there is business here (and there is), one or more of the "big boys" will come - to direct it where they want it to go - or to use it to serve their purposes (like secure a medical school in Charlotte). In that sense, Randolph County IS prime medical real estate. It's time we acted like it. DO NOT follow blindly. DO NOT trust these "suits" the way 1 once trusted them when 1 was young and very naive and still believed that non-profit hospitals existed to serve the public good. They don't. Everything they do is ALL and ONLY about MONEY... the next conquest and market domination. Sadly, as I have moved on and on and on from Asheboro - looking for greener grass and never finding it, i have endued variations of that lesson over and over again. It has been my experience that healthcare executives LOVE to abuse doctors/nurses and bully them into wholesale submission. 1 am convinced it must be a class they take in "evil business school". If you do take the money, cross the is and dot the is of any agreement. Leave NOTHING to chance or interpretation. Demand accountability and change. Insist that the private not-for-profit companies involved.... that do not pay taxes ...pay you back once things are stabilized. DO NOT leave the taxpayers of Asheboro and Randolph County holding a very expensive empty bag - paying the bills that kill. My sainted Mother could not attend tonight to help cede the extra minutes that might have allowed me to deliver this statement in its entirety. Her blood pressure is up, and i A given our track record appearing at these kinds of things, l did not want her unduly stressed. But 1 know she stands with me -and is just as disgusted and put OUT with this red hot mess. On a final note, in deference to someone who Is no longer with us, l do want to thank the executives and directors of our local hospital for one thing: Years ago, l protested in front of Randolph - hoping it would bring attention to my plight. To exercise my free speech, I had to procure a parade permit and was only allowed to march up and down the sidewalk, in front of the old entrance. I could not sit down - or plant flags or signs. The Courier, as per usual, did not show up -and the hospital/April Thornton were ITCHING to see me arrested for stepping out-of-bounds. The hospital had called the police as a measure of intimidation - on the pretense of "protecting" the public. All in all, it was a humiliating and largely unproductive experience in how civics really works In small mill towns when you're not "right people". But my Father showed up - dressed in his ever-present dungaree jacket and railroad hat. He parked his big Red Ford truck... got out and stood silently... with his clenched fists crammed deeply in his pockets ... directly across the street... between me and the police. NOBODY was going to mess with his little girl. On that day, my Pops was EVERYTHING 1 ever needed him to be. And for that memory/moment, I am profoundly grateful to the men running my hometown hospital who separated me from my parents and the life I had chosen .... and who fashioned a good portion of my professional life into a living HILL. At some point in February, l may very well stand in the same spot where my Daddy stood, to watch the doors of Randolph Health close. While neither the citizens of Asheboro/Randolph County - nor the front lines clinical/ancillary staff - deserve that outcome... the executives and directors of this hospital, past and present, most certainly do. Thank you for your time and attention. I hope what I have suggested tonight leads to something productive for the future. As a citizen and Pediatrician, 1 would like to be a part of that future. ®hrf"son, M.D., FAAP , N.C. and Phone# redacted for publication) *As of 3 PM on 99/27/2099, this statement has been posted online ... on my mostly - archived bldg, "Dr. J's Housecalls". It will also be posted publicly on my Facebook page. 183 Progress HEALTH CARE Attachment C Rural Hospital Closures Reduce Access to Emergency Care By Tarun Ramesh and Emily Gee Posted can September 9, 2019, 5.00 am Getty/Michael S, Williamson Biilir g envelopes. litter the floor of tl'ie shuttered Southeast; Health Center In Ellington, Missouri, July 2019. OVERVIEW • Rural hospitals struggle financially with lower patient volumes, higher rates of uncompensated care, and physician shortages. PRESSCONTACT RELATED SERIES � Introduction and summary The number of rural hospital closures in the United States has increased over the past decade.1 Since 2010, 113 rural hospitals,2 predominantly in Southern states, have closed. This is a concerning trend, since hospital closures reduce rural communities' access to inpatient services and emergency cares In addition, hospitals that are at risk financially are more likely to serve rural communities with higher proportions of vulnerable populations.' Understanding the financial pressures facing rural hospitals is imperative to ensuring that America's 60 million rural residents have access to emergency cares Rural hospitals are generally less profitable than urban ones, and those with the lowest operating margins maintain fewer beds and have lower occupancy rates. Low -margin rura hospitals are also more likely to be in GET THE LATEST ON HEALTH CARE �%mall....�...��...m_wWm�..�.._,_.,..,........._.,,... �.v.,....,,..,.,_..,...� states that have not expanded Medicaid under the Affordable Care Act (ACA). According to new analysis by the Center for American Progress, future hospital closures would reduce rural Americans' proximity to emergency treatment. Among low -margin, rural hospitals—those most likely to close—the majority of those with emergency departments are at least 20 miles away from the next -closest emergency department. 185 This report first discusses the role that hospitals and emergency care play in rural health care as well as trends in hospital closures, It then uses federal data to examine differences in the financial viability of rural and urban hospitals and the availability of hospital-based emergency care in rural areas. The final section of this report offers policy recommendations to improve health care access and emergency care for rural residents. Rural hospitals have been closing at an unprecedented rate From 2013 to 2017, rural hospitals closed at a rate nearly double that of the previous five years,6 (See Figure 1) According to the Government Accountability Office (GAO), recent rural hospital closures have disproportionately occurred among for-profit and Southern hospitals. Southern states accounted for 77 percent of rural hospital closures over that time period but only 38 percent of all rural hospitals in 20137 FIGUR 1 Bumf hospitals closures have increased Nationwide rural hospital closures, 2008-2017 2000 2409 2010 21111 2012 2013 2014 21115 2016 2017 S wrmUS.GmmmentkcmurublFtyOffiiw.,"1lumIHOSPRE11CiceurenNum.berandChRmd8r:I srf dad WipaitabandCunlrlbutlhUfaactorx' ' asfilnq =Wl Bl aveMa We at F�ti s �Yw�w+� gam gav sset is 4°6� 1 pdb Hospital closures may deepen existing disparities in access to emergency care. Closures are more likely to affect communities that are rural, low income, and home to more racial/ethnic minority residents.s Although about half of acute care hospitals are located in rural communities and the other half are located in urban areas,s rural residents live 10,5 miles from the nearest acute care hospital on average, compared with 4,4 miles for those in urban areas,' q According to a poll by the Pew Research Center, about one- quarter (23 percent) of rural residents said that "access to good doctors and hospitals" is a problem in their community, while only 18 percent of urban residents and 9 percent of suburban residents said it was a problem," A variety of factors influence hospitals' sustainability. Thanks to medical and technological advances, conditions that once required hospitalization can now be treated in an ambulatory care center or a physician's office, University of Pennsylvania professor and CAP nonresident senior fellow Ezekiel Emanuel has argued that one reason hospitals are closing is that "more complex care can safely and effectively be provided elsewhere, and that's good news,"12 As a whole, the hospital industry remains highly profitable, and hospital margins are at their highest in decades.13 Evidence on the relationship between hospital closures and health outcomes is mixed, A 2015 study of nearly 200 hospital closures in Health Affairs found no significant changes in hospitalization rates or mortality in the affected communities, whether rural or urban.", More recent studies have found an association between rural hospital closures and increased mortality. Harvard researcher Caitlin Carroll showed that rural hospital closures led to an overall increase in mortality rates for time -sensitive health conditions,ls and Kritee Gujral and Anirban Basu of the University of Washington found that rural hospital closures in California were followed by increases in mortality for inpatient stays,16 In rural areas, hospitals face additional challenges to their viability, including lower patient volumes; higher rates of uncompensated care; and physician shortages,' 7 In addition, rural patients tend to be older and lower income,'$ Rural hospitals tend to be smaller, serve a higher share of Medicare patients, and have lower occupancy rates than urban hospitals.19 Rural hospitals commonly offer obstetrics, imaging and diagnostic services, emergency departments, as well as hospice and home care,20 but patients 187 needing more complicated treatment are often referred to tertiary or specialized hospitals, In fact, rural patients are more likely to be transferred to another hospital than patients at urban hospitals.21 Most urban hospitals are reimbursed under the prospective payment systems (PPS) for Parts A and B of Medicare, Through both the inpatient and outpatient PPS, the Centers for Medicare and Medicaid Services (CMS) reimburse hospitals at a predetermined amount based on diagnoses, with adjustments ----including those for local input costs and patient characteristics.22 However, rural hospitals often face higher costs due to lower occupancy rates and provide care to a higher percentage of patients covered by Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Such hospitals may be eligible to receive higher payments from Medicare if they qualify as a Sole Community Hospital (SCH) or Medicare -Dependent Hospital (MDH).23 Another form of financial relief for rural hospitals is obtaining designation as a Critical Access Hospital (CAH), which Medicare reimburses based on cost rather than on the PPS ,24 To qualify as a CAH, a hospital must provide 24/7 emergency services; maintain no more than 25 beds; and serve a rural area that is 3.5 miles from another hospitaI.25 Medicare reimburses CAHs at 101 percent of reasonable costs, rather than through the inpatient and outpatient PPS structures.26 As of 2018, there were 1,380 CAHs nationwide,27 accounting for about two-thirds of all rural hospitals.28 Even with cost -based reimbursement, however, some CAHs are unable to sustain the costs required to maintain inpatient beds,29 The 25 -bed limit for CAHs prevent participating hospitals from eliminating inpatient services and restrict their ability to expand in response to fluctuations in community populations or care volumes. Other challenges facing rural hospitals include lacking sufficient patient volume to maintain high-quality performance for certain procedures and pressure to drop high-value but poorly reimbursed services such as obstetrics while maintaining low-volume, high profit services such asjoint replacement procedures, 30 A key way that states can support struggling rural hospitals is by expanding Medicaid under the ACA. Expanding Medicaid increases coverage among low-income adults, 31 which in turn reduces uncompensated care costs for hospitals32 and allows financially vulnerable hospitals to improve their viability.33 Consistent with other recent studies,34 the GAO concluded in a 2018 report on rural hospitals that those "located in states that increased Medicaid eligibility and enrollment experienced fewer closures."35 Rural hospitals are cutting back on services Rural hospitals in different states have responded to financial pressures in a variety of ways, trying to balance community needs with financial viability, For many hospitals this has meant cutting inpatient obstetric services, leaving more than half of rural counties without hospital obstetric services.36 For instance, in Wisconsin, falling birth rates led to 12 hospitals in the state closing their obstetric services in the past decade,37 In Grantsburg, Wisconsin, lower birth rates and an older community population led Burnett Medical Center to shut down its obstetrics services. 31 In order to offer these services, Burnett Medical Center would have needed to keep a general surgeon on call to perform caesarean sections, and with just 40 deliveries in 2017, the hospital could not justify the expense.39 White the hospital will continue providing prenatal and postnatal care, it will refer patients to a facility in Minnesota for deliveries ----a facility is almost 40 minutes away,40 In other communities, hospitals have been replaced by other types of health care facilities. For example, Appalachian Regional Healthcare System closed Blowing Rock Hospital in North Carolina in 2013. Three years later, it opened a 112 -bed post -acute care center in Blowing Rock in response to demand for rehabilitation services and the aging population in the surrounding area.41 • Financial data shows that rural hospitals are more likely to struggle To compare the financial situations of rural and urban hospitals and examine how future rural hospital closures could affect the availability of emergency care, CAP analyzed data from the CMS Healthcare Cost Report Information System (HCRIS). The CMS requires all Medicare -certified hospitals to report their financial information annually. CAP used the HCRIS to examine the financial margins and other characteristics of 4,147 acute care hospitals for fiscal year 2017. Of these, 1,954 hospitals (47 percent) were in rural areas, while the remaining were in urban areas. Hospitals self-report their status in the HCRIS as either urban or rural, which the CMS defines as either inside or outside of a metropolitan statistical area, respectively.42 Further information about CAP's hospital sample can be found in the Methodological appendix. Hospital operating margins, which measure excess patient -related revenues relative to patient -related expenses, are often used as an indicator of financial health,43 A 2011 study by Harvard researchers Dan Ly, Ashish Jha, and Arnold Epstein found that the lowest 10 percent of hospitals by operating margin were 9.5 times more likely to close within two years compared to all others. 44 The same study concluded that hospitals with low operating margins were also more likely to be acquired or merge.41 7 In CAP's hospital sample, the median operating margin was negative 2.5 percent among all hospitals, negative 0.1 percent for urban hospitals, and negative 4.9 percent for rural hospitals.115 Public hospitals and MDHs in the sample were more likely to have negative operating margins, consistent with what other studies have found.17 To analyze hospitals' relative financial health across geographic areas, CAP ranked hospitals in the HCRIS sample based on operating margin, splitting them into three groups; the lowest 10 percent, the middle 80 percent, and the highest 10 percent. The range of operating margins for each group is shown in Table 1. 190 TABLE I Rural hospitals are less profit bl Athan urban hospital's Hospitals, byoperating mar lfl Group, by p raling margin Dural hospitals Urban hospitals Total hospitals Note: Haspleal couras sfiewarrn the tabre are fortlte subset 4h aspdtalsin CWsdata immp[e laat hadlacftn InformasimvaAd formaWkV. urccC "autfrw%afl iscfCwOrsfix MedfcareandMadicaldSvry%r,� CostRepurts, waliabiea 4tW ans>9D''iResearh-5tntlsthL Data,andPyrstemsi7<3avadable-W lrese-FiWosk�&pnrbOnde ttrntests ee dFuly lJlB laumetalBureauREcanemFdRes , e °Hurthcare Gust Repadlri armatlan5!�. rn HMIS) meter"avallable aifinpsrfWwww ber rgfiWaftwintmi 0astawmad July 301!9), 19 Rural hospitals are less likely to be financially healthy than urban hospitals, In 2017, rural hospitals comprised only 27,9 percent of the hospitals with operating margins in the highest decile but comprised 59.7 percent of the hospitals in the lowest decile. Southern and Midwestern states had the greatest proportion of rural hospitals with low operating margins, mimicking the geographic patterns in hospital closures that the GAO report identified. CAP finds that from 2015 through 2017, rural hospitals were consistently more likely than urban hospitals to fall in the bottom 10 percent of operating margins, CAP`s analysis also confirms that rural hospitals in states that expanded Medicaid had a higher median operating margin (negative 3A percent) than those in states that have not expanded Medicaid (negative 5.7 percent), 191 Struggling rural hospitals are concentrated in the South and .Midwest Percentage of states' rural hospitals that are to u-mwglin fiffi NIA 10 0.9 10.19x, 9 30%+ Now -This anW#; deft e�s.lew-margh haspltaV as those in the hattom 9 Uper epa of A l aspitals by opiamilag margin In 7077Jn the dataset sw es with na rural hasi3 tars are osegarlud as 4dJW Sburm&Fauthar'aana[ slsofCinwrsfaeMadlcaraand Modic MSerulces,'CvLstF§Rpans,"awlableat:hitpr;(Iw rmsgov/Ressaf&Statistics-na- ta-aa�dS tamstdcmwroieatl ileP€iia{is-t eFiles cat-liepartspintle�cltEtiel(rastaceessedjulyzai9;;Wicinartiumauo EeanamicResearcllvKmlthcara Ccea5tFtepartlnfbmra0Gn5lis m(HCIIIS�Oata,`avallitblaathttpEliuw,vow.nbermrWdaWhcria,h'tmIClast.aacessedJuF 301R. To examine commonalities among the hospitals most vulnerable to closure, CAP analyzed characteristics of the hospitals with law margins, defined as having an operating margin in the lowest 10 percent among all hospitals. Smaller, low -occupancy rural hospitals were most likely to struggle financially; nearly 1 in 6 (1 S percent) of hospitals with 25 or fewer beds had low margins, and nearly one-fifth (17 percent) of hospitals with low -occupancy rates had low margins. (See Figure 3) 192 FIGURE 3 Rural, smalls and low-occua y hospi Is are more Ilkely to trug le nanciat y Share of hospitals in each category avith operating margins In lowest 10 parent among all hospitals Red size 8 Urban Rufal occupancy rate an 49 Iteral tw a M I to.25 z to 10 to 299 300 ortr M KO W M Low Pdledlunt High N teOUS analysisincludes 246 rural and 1ti6wban htispitaisthat had ©perating marglars Fn bpm 14 percent afalI Etcona care hosp#16in 2100 f0vronCAP aut1iar`sAnalysisofC®ntersforMedicareand Medicaid servicea,'CastBepo ,"awfbibie.athttpiVfw+r ,c,,msgrvfflesear&stawts-Da- t a:nd�a i rri�aclah9e P ails-ii'sa-pt4as asti3ep�ar��dind in 1$Iaaxactoned July 20119j,lUtIonalMureau afEta harnk Pmsea*"Hea thcate ' Cast ReWrtnformationSystern(faq%lata,'available atlttpsufrw nbero4dat*hKr1s.Mmi(lastaeeessed 2919). Emergency departments are on the front lines for rural health In some emergency situations, hospital closures can be life-threatening, increasing the time and distance patients travel to receive care. Studies show that the probability of dying from a heart attack increases with distance from emergency care,41 and traumatic njuries are more likely to be fatal for rural residents than for urban ones.49 i Rural residents are more likely than urban residents to visit the emergency department.'° A shortage of primary care providers; lack of public transportation infrastructure; shortages in preventive care; higher rates of smoking and obesity; and greater prevalence of chronic disease in rural areas all contribute to the greater utilization of emergency room care." As a result, emergency departments often stand in as the main source of care for vulnerable and low-income populations, especially for communities that face a shortage of primary care. 52 Among the dozens of rural hospitals that have closed in recent years, some served as the only emergency department in a community, according to MedPAC13 193 While freestanding emergency departments have proliferated,54 they are not filling the gap for rural emergency care. MedPAC found that, as of 2016, nearly all the country's 566 stand-alone emergency departments were in urban areas and tended to be located in more affluent communities." Researchers at the North Carolina Rural Health Research Program found that the freestanding emergency department model was generally not viable in rural areas of the state due to low patient volumes, high rates of uninsured patients, and provider shortages.56 One limit on the growth of independent freestanding emergency centers is that they are not recognized in Medicare law and are therefore unable to bill the program, unlike hospital -affiliated off -campus emergency departments. 57 Future rural hospital closures would increase the distances that patients travel for emergencies To better understand how future rural hospital closures could affect access to emergency care, CAP calculated hospitals' distance to the next -closest hospital-based emergency department. CAP restricted its 2017 HCRIS data sample to the 5,616 acute care hospitals that provide 24-hour emergency services.58 Using addresses or coordinates provided in the HCRIS, CAP mapped each low -margin rural hospital to the next -closest hospital emergency department. Mapping strategies are detailed in the Methodological appendix. Among the 222 low -margin rural hospitals, more than half (55 percent) were more than 20 miles away from the next -closest hospital-based emergency department, and one- tenth were more than 35 miles away. (See Figure 4). The average distance to the next - closest emergency department was 22 miles. 194 FIGU SA Rural hospital closures would reduce access to emergency care Distance from hospital to next -closest hospital-based emergency department, by hospital category W li k v-mafgPn rural other mraf 19 Urban 5 s -to ZQ 20 to 3S 35 to so 30+ tote. This, arra4yAslnd rdes246ruraland1456urbanhospHa'Isthathadaperatingmarginshabottom14percentofallacutecarehospkalsIn.2G17. Sourm CAP aut'taar's analysis of Centersfor.Medlcgrg4nd fitEWOMId $eevice� ^�esCFtepcxrts,"a�a�a�tle atC�ttps +fv+wase enas.�arvlF3esasaeFi Stati3skicrrLia- ta and 6y Eamsll en rrd d ale•Pt Eic-iJse�Fides r R'Wepnr€s r dearfi erd (lantatoessed July2019), Natia real Bureau ofEcaryDrnk R�eseareh� "Heahhcare i C ReWrtlrafn€matRmSysrv3rrr(MC#iI:S�i)a "as IlahCeatht€pslew+w�svarrberxrr daE F� 4shtrrdC astamcessedJ iy�i9'I9�, The disappearance of rural, low -margin hospitals would greatly increase patients'travel distances for emergency care. Without other resources to fill the gap, some patients might forgo care they need and others would be forced to undertake an even longer journey to receive medical attention. Policies to improve rural emergency and nonemergency care 4r`h As rural hospitals continue to close, it is crucial to preserve access to emergency care for rural Americans, The following section details a series of policy recommendations to support adequate emergency care and address care shortages in rural communities. 195 Expand Medicaid 3 Experience to date suggests that rural hospitals in those states that have riot yet expanded their Medicaid programs under the ACA would benefit from Medicaid expansion through lower levels of uncompensated care and increased financial sustainability. Medicaid expansion is associated with improvements in health and a wide variety of other outcomes, including lower mortality, less uncompensated care, and lower rates of medical debt.59 According to the Kaiser Family Foundation, about 4,4 million adults would gain Medicaid eligibility if the remaining 14 nonexpansion states expanded their programs.60 a Policymakers can also support rural communities and their hospitals by opposing efforts to repeal the ACA. If the Trump administration -backed lawsuit against the ACA were to succeed, 20 million Americans would lose health insurance coverage, and uncompensated care would rise by $50 billion, according to the Urban Institute.61 Create a greater number of rural emergency centers To preserve access to emergency care, Congress could allow rural hospitals like CAHs to downsize to an emergency department and eliminate inpatient beds without giving up special Medicare reimbursement arrangements. Qualifying hospitals could transfer patients requiring inpatient admission to other hospitals, while continuing to offer some diagnostic imaging and other outpatient services. One such proposal is the Rural Emergency Acute Care Hospital Act (REACH Act), bipartisan legislation proposed by Sen. Amy Klobuchar (D -MN) and Sen. Chuck Grassley (R -IA) that would create rural emergency centers.62 This designation would allow hospitals to provide only emergency care in rural communities and receive Medicare reimbursement at 110 percent of operating costs. Separately, MedPAC has recommended that rural hospitals located more than 35 miles from the nearest emergency department be allowed to convert to freestanding emergency departments while still being reimbursed at hospital rates,63 196 Institute global budgeting for rural hospitals Under global budgeting, hospitals are paid a fixed amount rather than having their reimbursements based on the volume and types of services they provide.14 Global budgeting can reduce small, rural hospitals' financial risk by providing them with a more predictable stream of revenue. In addition, payment reforms that include both hospital and nonhospital care can encourage communities to invest in services that are typically less generously reimbursed, such as preventive caress For example, in 2014, Maryland transitioned its acute hospitals from fee-for-service payments to a global budget .66 An evaluation of the global budget program showed that it reduced hospital expenditures relative to trend without transferring costs to other parts of the health care system.07 Future global budgets should emphasize improvements in population health and primary care, 61 including ensuring that patients receive care in appropriate settings and reducing the number of avoidable hospital visits. The Pennsylvania Rural Health Model is the first Medicare demonstration project to test the financial viability and community effects of a global budget for strictly rural hospitals.69 This six-year program aims to smooth out cash flow for 30 rural Pennsylvania hospitals on a monthly basis with the goal of enabling hospitals to meet community needs, especially for substance -use disorder and mental health services.70 With global budgets based on the previous year's revenues, participating hospitals will have a more predicable stream of revenue. Importantly, the program allows hospitals to share in the savings that result from avoidable utilization.71 Improve transportation for rural residents ;Ma The lack of transportation infrastructure can lead rural residents to rely on ambulances and emergency rooms for nonemergency care. In nonemergency situations, patients often cite the lack of affordable transportation as a major barrier to care access.77 In order to fill the gap, payers and policymakers should consider efforts to utilize existing community transit resources for medical transportation or reimburse patients who use 197 ride -sharing services in areas that lack public transit or taxi services, 73 Another option would be to formalize volunteer services for medical transit. Oregon offers a tax credit for volunteer rural emergency medical services (EMS) providers, who provide medical and transportation services analogous to those of volunteer firefighter programs,74 The CMS should also consider policies to better reimburse and expand the use of telehealth in remote areas to reduce patients' burden of transportation.75 Finally, the CMS should stop approving states' requests to waive coverage of nonemergency medical transportation (NEMT) requirements under Medicaid.76 NEMT is vital to eligible beneficiaries` access to care, including appointments for preventive care, chronic disease management, and substance -use disorder treatment. Strengthen the rural healthcare workforce :} Rural health care provider shortages contribute to poorer access to care and poorer quality of care in rural communities. While 20 percent of the U.S, population lives in rural areas, only 9 percent of primary care physicians practice in rural areas.71 Greater access to primary care providers in rural areas would improve quality of care and health outcomes while also reducing unnecessary emergency department visits.78 One way to assist rural areas would be to encourage health professionals to train and work in underserved communities, Federal funding for physician training should include reimbursements for community-based sites so that medical residents can rotate through nonhospital settings.79 Expanding the National Health Service Corps --which provides scholarships and student loan repayment for professionals who work in federally designated health professional shortage areas ---could also help bolster the rural workforce, In addition, changes to immigration policy ---such as expanding the Conrad 30 program that funnels immigrant doctors into rural and underserved communities, reforming H-1 B visas to benefit high -need communities—could help alleviate rural areas' shortage of medical professionals.s° • Conclusion f Mounting closures of rural hospitals across the country are exacerbating the disparity in health care access between rural and urban areas. The financial vulnerability of the remaining rural hospitals suggests that the trend may continue, leaving shortages in emergency care and other hospital services. Policymakers should support initiatives that allow remaining rural hospitals the flexibility to tailor their services to meet community needs and improve access to care for rural Americans. About the authors T,arun Ramesh was an intern for Health Policy at the Center for American Progress. He is an undergraduate at the University of Georgia studying economics and genetics, Emily Gee is the health economist of Health Policy at the Center. Prior to that, she worked at U.S. Department of Health and Human Services and at the Council of Economic Advisers at the White House. She holds a Ph.D. in economics from Boston University, ri: - p! fir' CAP analyzed data from the CMS HCRIS data using Stata 15 statistical software. Data were from EY 2017, the most recent year for which the CMS has a complete set of hospital cost filings. CAP downloaded HCRIS databases formatted for Stata from the National Bureau of Economic Research and matched the data with Medicare's hospital general information database.81 HCRIS reports contain a variable indicating whether the hospital is rural or urban; the CMS defines any hospital outside a metropolitan statistical area as rural,g? 199 CAP used the most recent report filed for each hospital. Although hospitals are required to file annual cost reports, some reports contain more or fewer than 12 months of data, The analysis is restricted to reports that have between 10 and 14 months of data, the "full year" definition that the CMS suggests for analysis.83 CAP then excluded hospitals with data containing missing or apparently erroneous values as well as hospitals with operating margins below the fifth percentile or above the 95th percentile in order to eliminate unreasonable values before identifying the decile with the lowest operating margins. Lastly, CAP restricted its analytic sample to hospitals that had location data valid for mapping in the cost report. ,3 To map hospital-based emergency departments, CAP further restricted the sample to the 3,616 hospitals that had all -hours emergency services. The CMS's Hospital General Information database indicates whether hospitals provide emergency services.$4 CAP then used nearest -neighbor analysis to compute the distance between hospitals.,, Although the computed distances are underestimates, as they do not account for roads, obstructions, or alternate routes, these differences are negligible for the purposes of this analysis.86 1. Jessica Seigel, "Rural Hospital Closures rise to 98," NRHA, February 20, 2019, available at https://www.ruralhealthweb,org/blogs/ruralhealthvoices/february-2019/rural- hospital,closures-rise-to-ninety-seven. El 2. Sheps Center, "11.3 Rural Hospital Closures: January 2010 -- Present" (2019), available at https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital- closures/. fil 3. Jane Wishner and others, "A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies," (Washington: Kaiser Family Foundation, 2.016), 200 available at http://files.kff.org/attachment/issue-brief-a-look-at-rural-hospital- closures-and-implications-for-access-to-care. El 4. Erica Richman and George Pink, "Characteristics of Communities Served by Hospitals at High Risk of Financial Distress" (Chapel Hill, NC: Sheps Center, 2017), available at "http://www.shepscenter.unc.edu/download/15784/. 19 5. U,S. Census Bureau, "One in Five Americans Live in Rural Areas" (2017), available at https://www.census.goWlibrary/stories/2017/08/rural-america,html. El 6. Government Accountability Office, "Rural Hospital Closures: Number and Characteristics of Affected Hospitals and Contributing Factors" (2018), available at https://www,gao.gov/assets/700/694125,pdf, 19 7, Government Accountability Office, "Rural Hospital Closures." 19 8. Health Resources & Services Administration, "Hospital Closings Likely to Increase," available at https://www.hrsa.gov/enews/past-issues/2017/october-19/hospitals- closing-increase,html (last accessed August 2019), 9. Sheps Center, "Rural and Urban Hospitals in the United States" (2017), available at https://www,shepscenter.unc.edu/product/rural-urban-hospitals-united-states/. 19 10. Onyi Lam and others, "How far Americans live from the closest hospital differs by community type" (Washington: Pew Research Center, 2018), available at https://www,pewresearch.org/fact-tank/2018/12/12/how-far-americans-live-from-the- closest-hospital-differs-by-commun ity-type/. El 11. Kim Parker and others, "Views of problems facing urban, suburban and rural communities" (Washington: Pew Research Center, 2018), available at https://www,pewsocialtrends.org/2018/05/22/views-of-problems-facing-urban- suburban-and-rural-communities/, 12. Ezekiel J. Emanuel, "Are Hospitals Becoming Obsolete?", The New York Times, February 25, 2015, available at https://www.nytimes.com/2018/02/25/opinion/hospitals- becoming-obsolete.html. El 201 13. Emily Gee, "The High Price of Hospital Care" (Washington: Center for American Progress, 2019), available at https://www,americanprogress.org/issues/healthcare/reports/20l 9/06/26/471464/hig h -price -hospital -care/. El 14. Karen E. Joynt and others, "Hospital Closures Had No Measurable Impact on Local Hospitalization Rates Or Mortality Rates, 2003-11," Health Affairs 34 (5) (2015), available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2-014.1352.19 15. Caitlin Carroll, "Impeding Access or Promoting Efficiency? Effects of Rural Hospital Closure on the Cost and Quality of Care," (Cambridge, MA: Harvard University, 2019), available at https://scholar.harvard.edu/files/ccarroll/files/carrolljmp.pdf. El 16. Kritee Gujral and Anirban Basu, "Impact of Rural and Urban Hospital Closures on Inpatient Mortality," National Bureau of Economic Research working paper no. 26182, July 22, 2019, available at https://www.nber.org/papers/w26182, El 17. Eli Saslow, "'Who's going to take care of these people?", The Washington Post, May 11, 2019, available at https://www.wash1ngtonpost.com/news/nationaI/wp/2019/05/11 /feature/whos-going- to-take-care-of-these-people/?utm-term=.3d17d36c3461; Sarah Tribble, "Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?" Kaiser Health News, May 14, 2019, available at https://khn.org/news/dealing-with-hospital-closure- pi oneer-l<ansas-town-asks-what-com es -next/. 18. Rural Health information Hub, "Social Determinants of Health for Rural People," available at https://www.ruraIhealthinfo,org/topics/social-determinants-of-health (last accessed August 2019). 19. James Hatten and Rose Connerton, "Urban and rural hospitals: How do they differ?" Health Care Finance Review 8 (2) (1986): 77-85, available at https://www.ncbi.nim.nih.gov/pmc/articles/PMC4191541/. 20. Rural Health Information Hub, "Rural Hospitals," available at https://www,ruraIhealthinfo.org/topics/hospitals#rural-vs-urban (last accessed August ,2019). 11 202 21. George Holmes and others, "Trends in the Provision of Surgery by Rural Hospitals" (Chapel Hill, NC: NC Rural Health Research and Policy Analysis Center, 2011), available at https://www.shepscenter.unc.edu/wp-content/uploads/2014/10/FB10l ,pdf, Margaret jean Hall and Maria Owings, "Rural and Urban Hospitals' Role in Providing Inpatient Care, 2010" (Atlanta, GA: Center for Disease Control and Prevention, 2014), available at https://www.cdc.gov/nchs/products/databriefs/dbl47,htm#ref9. 19 22. Centers for Medicare and Medicaid Services, "Prospective Payment Systems - General Information," available at https://www.cros.gov/medicare/medicare-fee-for-service- payment/prospmedicarefeesvcpmtgen/index.html (last accessed August 2019). El 23. In addition, CMS has provided supplemental payments low-volume hospitals, a program funded through fiscal year 2019. See: Jacqueline LaPointe, "Rural Hospitals Get Low -Volume, Medicare -Dependent Funds Extended," Revcycle Intelligence, April 26, 2018, available at https://revcycleintelligence.com/news/rural-hospitals-get-low- volume-medicare-dependent-funds-extended. El 24. Centers for Medicare and Medicaid Services, "Critical Access Hospitals" (Baltimore, MD: Center for Medicare and Medicaid Services, 2017), available at https://www.cros.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf. 19 25. Balanced Budget Act of 1997, H.R. 2015, 105th Cong., 1 st sess (August 5, 1997), available at https://www.govinfo.gov/content/pkg/PLAW-105publ33/pdf/PI-AW- 105publ33,pdf. El 26. Centers for Medicare and Medicaid Services, "Critical Access Hospitals." El 27. joint Commission, "Facts about Critical Access Hospital Accreditation," The joint Commission, December 11, 2018, available at https://www,jointcommission.org/facts,about_critical,access_hospital_accreditation/. 28. Alex Kacik, "Nearly a quarter of rural hospitals are on the brink of closure," Modern Healthcare, February 20, 2019, available at 203 https://www. modernhealthcare.com/article/20190220/NEWS/190229999/nearly-a- quarter-of-rural-hospitals-are-on-the-brink-of-closure. 29. Dave Mosley, 1 in 5 rural hospitals are at risk of imminent closure. Lawmakers could help some stay open," STAT News, February 21, 2019, available at https://www,statnews.com/2019/02/21 /lawmakers -act -prevent -rural -hospitals - closing/. El 30. Les Masterson, "BRIEF Nonprofit hospitals'on an unsustainable path,' Moody's says," Healthcare Dive, August 30, 2018, available at https://www.healthcaredive.com/news/nonprofit-hospitals-on-an-unsustainable-path- moodys-says/531245/; Patrick Molt, "Rural surgery and the volume dilemma," Bulletin of the American College of Surgeons, October 1, 2016, available at http://buIlet!n.facs.org/2016/10/rural-surgery-and-the-volume-dilemma/; Peiyin Hung and others, "Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004-14," Health Affairs 36( 9) (2017), available at https://www.healthaffairs,org/dol/abs/10.1377/hlthaff.2017,0338; Christopher Weaver and others, "New Risks at Rural Hospitals," The Wall Streetjournal, December 25, 2015, available at https://www,wsj.com/articies/new-risks-at-rural-hospitals- 1451088096.El 31, jack Hoadley and others, "Health Insurance Coverage in Small Towns and Rural America: The Role of Medicaid Expansion" (Washington: Georgetown University Health Policy Institute, 2018), available at https://ccf.georgetown.edu/2018/09/25/health-insurance-coverage-in-smal I-towns- and-rural-america-the-role-of-medicaid-expansion/. Ej 32. David Dranove and others, "The Impact of the ACA's Medicaid Expansion on Hospitals' Uncompensated Care Burden and the Potential Effects of Repeal" (New York: The Commonwealth Fund, 2017), available at https://www,commonwealthfund.org/publications/issue-briefs/2017/may/impact- acas-medicaid-expansion-hospitals-uncompensated-care. 204 33, Dhruv Khullar and others, "Safety -Net Health Systems At Risk: Who Bears The Burden Of Uncompensated Care?", Health Affairs Blog, May 10, 2018, available at https://www.healthaffairs.org/do/l 0.1377/h blog20180503.138516/full/. 34. Richard Lindrooth and others, „Understanding the Relationship Between Medicaid Expansions And Hospital Closures," Health Affairs, 37(1) (2018), available at https://www,healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0976; Michael Braga and others, "Leaving billions of dollars on the table," Gatehouse News, July 28, 2019, available at http://gatehousenews.com/ruralhospitals/financialtroubles/. El 35. Government Accountability Office, "Number and Characteristics of Affected Hospitals and Contributing Factors," (Washington: Government Accountability Office, 2018), available at https://www.gao.gov/assets/700/694123.pdf. 36. Peiyin Huang and others, "Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004-14," Health Affairs, 36 (9) (2017), available at https://www,healthaffairs.org/doi/l 0.1377/hlthaff.2017.0338 37. Shamane Mills, "Number Of Babies Born In Wisconsin declines To Lowest Point In 44 Years," Wisconsin Public Radio, February 25, 2019, available at https://www.wpr.org/number-babies-born-wisconsin-declines-lowest-point-44-years, Wisconsin Office of Rural Health, "Report Examines Obstetric Delivery Services in Rural Wisconsin," (Wisconsin: Wisconsin Office of Rural Health, 2019), available at http://worh.org/rural-reporter/report-examines-obstetric-delivery-services-rural- wisconsin. 38. Shamane Mills, "Report: 11 Rural Wisconsin Hospitals Are Delivering Fewer Babies," Wisconsin Public Radio, July 18, 2019, available at https://www.wpr.or,g/report-ll- rural-Wisconsin-hospitals-are-delivering-fewer-babies. El 41. Nathan Ham, "Appalachian Regional Healthcare System Takes Next Step to Building Senior Living Community in Blowing Rock," High Country Press, June 7, 2019, available 205 at https://www.hcpress.com/news/appalachian-regional-healthcare-system-takes- next-step-to-building-senior-living-community-in-blowing-rock.html; Jeff Eason, "New Blowing Rock health center opens," Watauga Democrat, September 16, 2016, available at https://www.wataugademocrat.com/watauga/new-blowing-rock-health-center- opens/article_8573052a-c8ae-57a6-9bl e -509c11 e2f972,html. El 42. Medicare Payment Advisory Commission, "Serving rural Medicare beneficiaries," in Report to the Congress: Medicare and the Health Care Delivery System (Washington: 2012), available at http://www.medpac.gov/docs/default-source/reports/chapterW5- serving-rural-medicare-beneficiaries-june-2012-report-.pdf, 43. Dan Ly and others, "The Association Between Hospital Margins, Quality of Care, and Closure or Other Change in Operating Status,"Journal of General Internal Medicine 26 (11) (2011): 1291-1296, available at https://www.ncbi.nim.nih.gov/pmc/articies/PMC3208470/; Gloria Bazzoli and others, "Hospital financial condition and the quality of patient care," Health Economics 17 (8) (2008): 977-995, available at https://www,ncbi.nim.nih.gov/pubmed/38157911. 19 44. Ly and others, "The Association Between Hospital Margins, Quality of Care, and Closure or Other Change in Operating Status," 46, The median total margin, a profitability metric that accounts for both patient and nonpatient revenue and expenses, was higher for all categories: 3.4 percent for all acute care hospitals, 2.1 percent for rural hospitals, and 4,9 percent for urban hospitals, El 47. Masterson, "BRIEF Nonprofit hospitals'on an unsustainable path,' Moody's says." 19 48. Yu -Chu Shen and Renee Hsia,'The Association Between Emergency Department Closure and Treatment, Access, and Health Outcomes Among Patients with Acute Myocardial Infarction," Circulation 134 (20) (2016): 1595-1597, available at https://www,ncbi.nim.nih.gov/pmc/articles/PMC5297408/; Liam O'Neill, "Estimating Out -of -Hospital Mortality Due to Myocardial Infarction," Health Care Management Science 6 (3) (2003): 147-154, available at 206 https://link,springer.corn/article/l0.1023/A:1024463418429, Anika Hines, Taressa Fraze, and Carol Stocks, „Emergency Department Visits in Rural and Non -Rural Community Hospitals, 2008" (Rockville, MD: Healthcare Cost and Utilization Project, 2011), available at https://www.hcup-us.ahrq.goWreports/statbriefs/sbl 16.pdf, f El 49. Molly P. Jarman and others, „Rural risk: geographic disparities in trauma mortality," Surgery 160 (6) (2016), available at https://www.ncbi,nlm,nih.gov/pmc/articies/PMC5118091/. El 50. Hines, Fraze, and Stocks, "Emergency Department Visits in Rural and Non -Rural Community Hospitals, 2008"; Health Policy Institute, "Rural and Urban Health," (Washington: Georgetown University Health Policy Institute), available at https:Hhpi.georgetown,edu/rural/. 19 51. Ibid., Marcozzf and others, "Trends in the Contribution of Emergency Departments to the Provision of Hospital -Associated Health Care in the USA," Intern ation alJournal of Health Services 48 (2) (2018): 267--288, available at https://www,ncbi.nlm.nih.gov/pubrned/29039720, Fj 52. Brian Chen and others,'Travel distance and sociodemographic correlates of potentially avoidable emergency department visits in California, 2006-2010: an observational study," Intern ationalJoumal of health .Equity 14 (30) (2015), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4391132/; Marcozzi and others, "Trends in the Contribution of Emergency Departments to the Provision of Hospital - Associated Health Care in the USA`; Robert Steinbrook, "The Rale of the Emergency Department," New England Journal of Medicine 334 (1996): 657-658, available at https://www.nejm.org/doi/full/10.1056/NEJM 199603073341010; Chen and others, "Travel distance and sociodemographic correlates of potentially avoidable emergency department visits in California, 2006--2010: an observational study." El 53. MedPAC, "Models for preserving access to emergency care in rural areas," MedPAC Blog, November, 2015, available at http://medpac.gov/- blog-/medpacblog/2015/11 /24/models-for-preserving-access-to-emergency-care-in- rural-areas . fil 207 54. MedPAC, "Stand-alone emergency rooms" (2017), available at http://www.medpac.gov/docs/default-source/reports/junl 7_ch8.pdf. El 56. J. Dunc Williams and others, "Estimated Costs of Rural Freestanding Emergency Departments," (Chapel Hill, NC: NC Rural Health Research Program, 2015), available at https://www.shepscenter.unc.edu/product/estimated-costs-of rural -freestanding - emergency -departments/. 19 57. MedPAC, "Stand-alone emergency rooms." 19 58. Emergency service information is based on a Medicare registration designation. More details are in the methodological appendix. FS 59. 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Francis Boscoe, "A Nationwide Comparison of Driving Distance Versus Straight -Line Distance to Hospitals," the Professional Geographer 64 (2) (2012), available at https://www.ncbi,nlm,nih.gov/pmc/articles/PMC3835347/, 19 Center for American Progress O 2019 - Center for American Progress 212 This website uses a variety of cookies, which you consent to if you continue to use this site. You can read our privacy policy (http;//www.xtelligentmedia.com/privacy-policy) for details about how these cookies are used, and to grant or withdraw your consent for certain types of cookies, Consent and dismiss this banner by �� clicking agree. Topic REVCYCLE E N CIN! I ELLI; (https.//revcycleintelligence.com/) v Expanded Hospital Price Transparency Rules Worry Half of Providers (https://reveyeleinteIIigence.com/news/ hospital-price-transparency-rules- worry-half-of-providers) ospital-parice-transpareacy-rules- worry-half-ofproviders) 213 Rural Hospital Closures Boost Mortality Rates by Nearly 6% New research shows that patients are more likely to die following a rural hospital closure, whereas urban closures had no measurable impact on mortality. Source: Thinlcstoek 19 By Jacqueline LaPointe(mailto.jbelliveau@xtelligentmedia.com) September og, 2019 - Rural hospital closures"'Increase mo a r y a ou 5. percent overall, while urban hospital closures had nom 1Rnage ent mortality, according to a recently published National BurcaLwbUftdw"gspital Price Research working paper (https://www.nber.olFgAp worry Half of Providers The paper clears up questions about the impac"Ril} I&WrffnMPORdL49 /news/ outcomes, researchers from the University of Washi)4ftUpWcwj i-hajay..rules- study of 92 hospital closures in California from 1995 to 2011 thhwlffPt+aMders) 214 adjusted inpatient mortality for time -sensitive conditions, including sepsis, stroke, asthma/chronic obstructive pulmonary disease (COPD), and acute myocardial infarction (AMI). "With the rise in hospital closures, and especially with increasing rates of rural closures, lack of studies on the impact of closures on patient outcomes and the lack of consensus across existing studies pose barriers to policy implementation," they wrote in the paper. "This paper attempts to reduce the aforementioned gaps and reconcile differences across prior studies." Dig Deeper - Overcoming Rural Hospital Revenue Cycle Management Challenges (https://revcycleintel ligence.com/features/overcoming-rural-hospital-revenue-cycle- management-challenges) GAO Finds Uptick in Rural Hospital Closures as Inpatient Use Falls (https://revcycleintelligence.com/news/gao-finds-uptick-in-rural-hospital-closures-as- inpatient-use-falls) How a Rural Hospital Used Health IT, EHR to Stay Independent (https:I/revcycleintelligence.com/news/how-a-rural-hospital-used-health-it-ehr-to-stay- independent) Their study of hospital closures in California examined the impact of closures on Medicare and non -Medicare patients, and is therrs pa er o ana yze e lmpac i fr on patient mortality following the closure of hospitals i,cia nt high number of hospital closures, they explained, Expanded Hospital Price Transparency Rules Worry Half of The study revealed significant differences between patient outcomes f0ll0w*96Wers urban and rural hospital closure. (https://reveycleintelligence,com/news/ hospital-price-transparency-rules- worry-half-of-providers) ospital-price-transparency-rules- worry-halfof-providers) 215 Like many other studies, researchers found no measurable impact on mortality when they did not differentiate between urban and rural hospital closures. However, when comparing the impact by type of hospital, they found that patients are more likely to die following a rural hospital closure. The impact on mortality rates also varied by condition. Rural hospital closures increased mortality for sepsis patients by g.o percent, while urban closures boosted mortality for AMI patients by 4.1 percent. Urban hospital closures also decreased mortality for asthma/COPD patients by 6.3 percent, researchers reported. "[T]hese results demonstrate the extent to which negative effects of rural closures are masked when no distinction is made between treatment groups. As such, these results offer a crucial potential explanation for the lack of consensus among scholars regarding the impact of hospital (and ED) closures; rural hospital closures have a differential impact on patient mortality than urban closures," they stated in the paper. How rural hospital closures impact patient outcomes is a conversation at the tip of the healthcare industry's tongue. Since January 2o1o,113 rural hospitals have closed their doors permanently, according to research (https : //www. shepscenter. unc. edu/programs-projects/rural- health/rural-hospital-closures/) from the North Carolina Rural health Research Program. More rural hospitals are also on their way to closing. Consulting firm Navigant recently reported(https://revcycleintelligence.com/news/2i-of-rural- hospitals-at-high-financial-risk-of closing) that one in five rural hospitals is on the verge of closing based on the organization's total operating margins, cash on hand days, and debt -to -capitalization ratios, The at -risk hospitals represent 21,500 staffed beds and 707,000 annual discharges. Recent economic downturns and job losses are putting rural hospitals in crisis mode, researchers from the University of Washington explained. Outmigration and shrinking populations are leaving behind patients who are older, sicker, and more reliant on Medicare and Medicaid, which significantly underpay (https://revcycleintelIigence.com/news me scare -me icai - reimbursement -76.8b -under -hospital -costs) hosMgtin PracticeManagement Expanded Hospital Price Aging facilities, outdated payment models, grcaterpdA4 WWdgt rW - Half of decision by corporate owners or operations are also contributing to rural hOPp ders closures, they added.(https://reveyeleintelligence.com/news/ hospital-price-transparency-rules- worry-half-of-providers) ospital-price-transparency-rules- worry-half-ofproviders) 216 Patient access to care suffers when a rural hospital closes its doors for good, and consequently, patient outcomes can deteriorate. Research like theirs should have a significant impact on policies that aim to address access to care following a hospital closure, the authors stated. "Overburdening of the health care system post -closure and rural closures are particularly concerning, they wrote in the paper. "While policy instruments that tackle root causes for closures and macroeconomic effects of rural closures appear less straightforward, there seems to be a clear need to ensure emergency transportation post -closures, especially for vulnerable populations, and to identify strategies that help surrounding hospitals manage increased and potentially differential health care demands post -closures." 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