There has been a fair amount of media coverage lately about “medical deserts.”1 What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”2 There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.
Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.3 However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.1
Here is some evidence:
— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).4
— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.1
— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.1 This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.
But the list of hospital closures in the past year goes on:
- Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
- Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
- Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
- Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
- Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
- The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).
As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”5
Staff, Service Reductions
These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.1
These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.
In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.