It’s no secret that rural hospitals have been struggling. According to online data from the University of North Carolina, 137 rural hospitals have closed in the U.S. since 2010.
In Appalachia, the rural hospital where I work, which is staffed by a single hospitalist, has been “in the crosshairs” since I arrived in 2016 and has been limping along with subsidies from our regional health system. Over the years, we have repeatedly and fruitlessly discussed how to increase patient volume, increase case-mix index, avoid patient transfers to referral hospitals, etc., so that the “mothership” wouldn’t decide to shut us down.
Since COVID-19 has arrived, however, our ICU and medical floor have filled up. High-value, ventilated COVID-19 patients have boosted revenue. Due to a lack of beds at nearby referral centers, many of the non-COVID patients who normally would have been sent “down the road” for specialty consultations or services have remained in our hospital: one with a subdural bleed after an inpatient fall, one with septic arthritis, one with fulminant liver failure from a Tylenol overdose, one with a creatinine of 8+, and another with platelets of less than 3,000 and hemoptysis. These sicker patients have certainly increased our daily census, case-mix index, and diagnosis-based revenue.
So, I wasn’t too surprised when, at our last medical staff meeting, our leadership team reported that our little hospital was “in the black” and “not just because of the CARES Act funds,” they specified. We were making it work on our own. Well, more precisely, in my opinion, COVID-19 had saved us, with an honorable mention to the high proportion of unvaccinated patients in our area, who were without question the predominant ones in the hospital and on ventilators.
Payments to hospitals for ventilated patients are high. References to Medicare reimbursement for COVID cases estimate a payment of about $13,000 for a respiratory infection with major comorbidities and over $40,000 for those requiring ventilator support for greater than 96 hours. The coronavirus relief legislation also created a 20 percent premium for COVID-19 Medicare patients. From the perspective of a rural county with a median household annual income of less than $27,000 in 2010, those are big numbers.
So, for a short moment in time, our small hospital has been feeling pretty good: financially, that is, whereas the staff has been exhausted. Actually, my conclusion was premature: Other leaders reminded me that our little hospital needs to “pay back” the subsidies from previous years before any kind of “celebration” could take place.
Well, I wasn’t thinking of a celebration. What would we, in fact, be celebrating: The fact that the sick and dying residents of our community made us profitable for once? I don’t feel too good about that idea.
There is a bottom-line lesson that just seems to keep popping up like a bad penny in the domain of U.S. health care; that is, our health care system is built around sickness, not health. When people in our communities are sick, we prosper. And that, in and of itself, is sick, because if we had saved lives with a more successful vaccination campaign in our community, we might very well still be staring blankly at each other in the boardroom and shamefully accepting more subsidies, or shutting down for good.
So, COVID-19 may simply be a tsunami of profitability that fills our coffers for a short time before slinking back into the sea, leaving behind death, destruction, and the same uncertain future.
Thank you, COVID-19, and the unvaccinated, for these brief days of financial glory.
David M. Mitchell is a hospitalist.
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