ALBUQUERQUE, N.M. — New Mexico’s rural hospitals – which is to say, most of our hospitals – say they need $36 million more in public funds to care for people who don’t, or can’t, pay their medical bills. Absent those funds, according to several local experts, anywhere from four to seven hospitals could very well close.
The New Mexico Hospital Association and the state Human Services Department fought for a bill during the just-concluded legislative session that would have required 31 counties to come up with a portion of that money. The rest would come from a federal match.
The counties, which are sympathetic to the hospitals but dealing with financial and sovereignty issues of their own, successfully pushed through a bill that cut their contribution in half, which also cuts the federal match.
Nobody has been willing to identify on the record which hospitals are in jeopardy, but they are spread out around the state, most of them have, at most, a couple of dozen beds, and they are all a long way from Albuquerque.
Hospital management is a tough business. All hospitals face the same difficulties: ever-declining payments from government programs, ever-increasing regulation, costly equipment and people.
Changes in the way care is delivered mean hospitalization is required for fewer conditions, which means that in some hospitals there are fewer heads in the beds generating revenue to cover high fixed costs. The shortage of qualified medical providers means hospitals have to compete hard for the same scarce supply of people.
Rural hospitals have special problems. Many providers simply don’t want to live in remote areas. Profitable hospital services, like oncology and orthopedics, require highly specialized and expensive medical professionals and a lot of expensive equipment. Rural hospitals can’t afford to offer those services, even if they could lure the people it takes to deliver them, so they are stuck with providing a lot of unprofitable services.
A huge rural problem stems from what is known as the payer mix. The best payments for health care are usually made by private insurers. Hospitals overcome shortages in public payment by collecting more from private insurers for the same services, but in many rural counties around 30 percent of patients have no insurance at all, and many of the rest have coverage from Medicare or Medicaid, not from private insurers.
The hope is the rural-hospital funding problem disappears as the Affordable Care Act takes off. Eventually, the thinking goes, everyone has coverage in one form or another, so special funding for indigent and uncompensated care will no longer be necessary.
It could happen, but even if it does, attracting medical professionals and building profitable in-patient services will remain problems, and that doesn’t even begin to address a continuous erosion in government payments for hospital work.
Therefore, perhaps it’s time to imagine what health care would be like absent some of the marginal hospitals in rural New Mexico. If we were given a clean slate and a mandate to deliver adequate rural health care, would we even think about building hospitals in some of the places where we have them?
Perhaps we could take the money we spend on hospitals and install good urgent care clinics and a really good emergency response system. Rather than trying to provide hospital care everywhere, perhaps we should pay for good, fast, efficient transport to a few good, well-equipped regional hospitals. Harding County, for one, has a nice little clinic in Roy, staffed by a physician’s assistant and a nurse practitioner, a good emergency medical response system, and access to a 54-bed regional hospital in Las Vegas.
Instead of hospital investment, perhaps we should consider technology investment. Internet technologies are available to extend sophisticated care from the University of New Mexico to rural areas through telemedicine. Specialists in Albuquerque get on a video link to review cases and offer advice to practitioners in remote locations statewide.
Telemedicine has gotten to the point that soon a surgeon wearing Google glasses and a headset will have an experienced surgeon remotely looking over his shoulder and guiding procedures in real time. It won’t be long before an artificial intelligence system can oversee the surgery.
Patients can be hospitalized at home these days while doctors and nurses at a central location monitor their condition with remote sensors. Johns Hopkins University has developed tools that allow in-home hospitalizations that are working well at Presbyterian Healthcare Services in Albuquerque.
Obviously, few communities will volunteer to ax their hospitals. There are jobs and prestige at stake, among other things.
A bigger impediment is that New Mexico doesn’t think about health care systemically. Each hospital operates as best it can with what it has. There is little in the way of rigorous statewide thought given to ways to optimize acute care treatment through a rational system of hospitals, clinics, home health workers, emergency technicians, etc.
It will be tough to come up with a systemic fix. State government has offered no plan for one and lacks the authority to impose one. Hospital administrators who might like to devise a solution together could find themselves on the wrong side of federal anti-trust laws in no time.