Williamston, North Carolina — One morning in mid-August, Christopher Harrison stood outside the shuttered Martin General Hospital, recalling the day a year earlier when he had taken photographs as workers covered the facility’s sign.
“Yes, sir. It was a sad day,” Harrison said of the financial collapse of the small rural hospital where his four children were born.
Quorum Health operated the 49-bed facility in the rural eastern North Carolina town of about 5,000 until it closed. The hospital was losing money for some time. The county’s population has declined slightly and is aging; it has experienced gradual economic downturns. Like many rural hospitals, these headwinds have caused managers to interrupt labor and delivery services and stopping intensive care over the past five years.
The prospects for reopening appear bleak.
Taylor Sisk for KFF Health News
But a new designation of hospitals by the Centers for Medicare & Medicaid Services that went into effect last year has provided some hope. Since August, hospitals in 32 communities across the country have become rural emergency hospitals to avoid closure. The new program provides a federal financial boost to struggling hospitals that continue to offer emergency and outpatient services but stop inpatient care.
The REH model “is not designed to replace existing, functioning rural hospitals,” said George Pink, a senior research scientist at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which has tracked 149 rural hospitals that have closed or no longer provide inpatient care since 2010. “It’s really intended for small, rural communities that are at imminent risk of hospital closure.”
The program has not yet been used to reopen a closed hospital.
With advice from health consultants, Martin County officials asked federal regulators to study the possibility of adopting the REH model and ultimately got the green light.
If successful, Martin County could become one of the first in the nation to convert a closed hospital to the new model.
Ask members of a community that has lost its hospital what they miss most, Pink said, and you almost invariably get emergency services. Count Harrison among them, especially after a medical crisis nearly took his life.
Harrison, who lives in a small community a few miles south of Williamston, began experiencing leg pain in February. Under normal circumstances, Harrison said, he would have gone to his primary care physician if his leg started hurting. This time, he couldn’t, because the office closed along with the hospital a few months earlier.
Taylor Sisk for KFF Health News
Then one morning, he woke up to find his foot had turned black. It took him 45 minutes to get to the nearest hospital in Washington, D.C. There, doctors discovered blood clots, and he was flown by helicopter to East Carolina University Medical Center. A doctor told him he had probably had blood clots for nearly a year and was lucky to be alive. The medical team was able to save his foot from amputation.
Harrison, like many others in the community, now had first-hand experience of the consequences of a hospital closure.
The state legislature’s decision last year to expand Medicaid has helped reduce the number of people without health insurance in North Carolina, meaning fewer hospital bills go unpaid. But health care is changing: Many procedures that once required hospital care are now done on an outpatient basis. Dawn Carter, founder and senior partner of Ascendient, a health care consulting firm that works with the county, said the number of patients hospitalized at Martin General in recent years has ranged from five or six a day to a dozen.
“So we’re talking about significant costs and significant infrastructure to support all of this,” she said.
With no emergency care within a half-hour radius, Martin County administrators believe a rural emergency hospital would be a good solution and a viable option. REH status allows a hospital to receive enhanced Medicare payments, an annual facility fee and technical assistance.
Carter said the team will present the state Department of Health and Human Services with a set of drawings of the portion of the building they intend to use to see if it complies with REH regulations.
“I hope that process plays out over the next few weeks,” she said, “and that will give us a better idea of whether we have a handful of really quick and easy things to do or whether it’s going to take a little bit more effort to reopen.”
The authorities will then accept proposals from companies interested in managing the hospital.
Carter said the facility is expected to initially be exclusively for emergency and imaging, “and then I think the question is, over time, where do we build beyond that?”
Rebuilding may prove difficult from the start. Many former staff have accepted jobs in nearby health facilities or have left the region. The effects of this exodus will be compounded by the widespread difficulty of recruiting health workers in rural areas.
It’s too early to gauge the success of the rural emergency hospital model, Pink said. “All we have are armchair anecdotes.” It appears the model is working well in some communities, while others “are struggling a little bit to make it work.”
Pink has a list of questions to assess the long-term performance of an emergency hospital:
Is the budget at least balanced? And if not, do the administrators plan a solution?
How does the community respond? If someone thinks they have a problem that might require hospital care, Pink suggests, maybe they’ll bypass the REH for a hospital that can admit them. And to what extent does bypassing their doors impact all services?
Are patients satisfied with the care they receive? Are clinical outcomes good?
The rate of rural hospital closures increased in 2020 and then declined significantly in 2021. Congress passed the CARES Act and the Healthcare Provider Relief Fund provided a financial lifeline, Pink said. That money has now been distributed, and the concern is that “many rural hospitals are going back to pre-COVID financial distress and unprofitability.”
If the trend continues, he said, more rural hospitals could turn to the REH model.
Ben Eisner is Martin County’s attorney and interim county executive. He recognizes that the health and well-being of this community requires much more than a hospital. He points, for example, to a new nonprofit organization whose mission is to address the social determinants of health.
Advancing Community Health Together was established in response to hospital closureMade up of community members, its goal is to address inadequate access to health care and poor health outcomes due to generational poverty, said Vickey Manning, director of the Martin-Tyrrell-Washington Health District.
“We can’t approach rural health care in a vacuum,” Carter said. His organization, Ascendient, is part of the Rural Healthcare Initiative, a nonprofit organization mandated by the North Carolina General Assembly to study sustainable models of health care for rural communities.
Like most rural areas in eastern North Carolina, Martin County is in transition, Eisner said. Family farms are shrinking, industry is shrinking. “So the question becomes,” he said, “What happens to all these communities? What happens next? And the answer isn’t fully written yet.”
Harrison, who still uses crutches, recently drove 45 minutes north on U.S. 13 to the town of Ahoskie to have his foot examined by a doctor. He said a hospital that offers basic emergency care isn’t a perfect solution, but he’ll have peace of mind once the sign is removed and his local hospital reopens.
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the main operational programs of KFF — the independent source of health policy research, polling and journalism.
