Expiring drugs, staff turnover and more and more regulations

Health care costs keep going up, and the future of health coverage is anyone’s guess. And in rural areas, the challenges are even tougher.

We love open spaces and small communities. But if we get bit by a rattlesnake, we also love having the antidote nearby, and a skilled professional to inject it without accidentally killing us. And that’s not cheap.

That’s the kind of thing smaller rural hospitals have to consider.

Rob Brandt, CEO of Mountainview Medical Center in White Sulphur Springs elaborated on some other challenges for Montana’s 50 or so critical-access hospitals before a legislative panel Tuesday.

• A hospital needs a wide range of expensive medications on hand. But those meds often expire and are never used, so thousands of dollars worth of drugs sit on hospital shelves and then end up in the waste bin. “Those types of things are things that we have to have, because we’re here when our patients need us most, but we don’t always use them,” Brandt said.

• Electronic Medical Records are now the standard across the industry. It’s great to show up in an emergency room and have the staff already know your history; but it causes new burdens. When records were on paper, often transcribed from a doctor’s dictation, a family practitioner could see as many as 30 to 40 patients in a day. Now, it’s a good day if they see about 18, Brandt said, and the industry is saddled with “hundreds of quality reporting metrics.” It’s complex enough that doctors often have to leave town for training on all the requirements. In White Sulphur Springs, the facility needs IT professionals who cost about $60,000 per year, and must be available 24 hours a day. The IT budget at that hospital is about $400,000 annually, out of a total budget of about $5.5 million.

• Government payers — like Medicare, Medicaid, Indian Health Services and VA-connected programs — don’t pay their fair share, with Medicaid reimbursement not even coming close. That’s especially straining smaller hospitals, where the government payers are often a bigger part of the mix than at larger hospitals.

• Attracting and retaining quality physicians in rural areas is tough. “We have to pay them, otherwise they’ll go to a place like Billings or Bozeman, or they’ll leave our state,” Brandt said. The same thing applies to nurses and other professionals.

And then of course is the presence of the larger, better-equipped hospitals in the cities.

Brandt and a representative of Billings Clinic both told the panel that they see themselves as partners, not competitors, serving different needs. Montana’s rural hospitals provide primary care, outpatient services, physical therapy and 24-hour emergency rooms, leaving more complex care to the cities. Hospitals like Mountainview Medical Center have also added CT scanners and other diagnostic devices, keeping patients and their health-care dollars close home.

“The critical word here is access,” Brandt said. “We’re here 24/7/365.”

Big Horn County Memorial Hospital rural Montana healthcare

Big Horn County Memorial Hospital in Hardin

Still, the rural hospitals are very aware that the bigger facilities are often just an hour or two away.

“Our patients have the ability to drive right past our hospital and go someplace else for those same services,” Brandt said. “So we have to hire and and retain … quality physicians, quality nursing staff, and have the equipment in-house to be able to service our patients.”

Brandt said the rural facilities are doing what they can to reduce costs: renegotiating contracts, cross-training staff and leaving positions empty, and banding together with other hospitals to buy supplies in bulk.

In White Sulphur, private donations have helped with major investments, including the CT scanner. Brandt noted that his hospital takes no local tax dollars.

But they still deal with a world where costs keep going up — most notably in prescription drugs, and also in things like health insurance for their own employees.

There’s one area with virtually no competition between the rural and urban hospitals: mental health. Billings Clinic, the panel heard, loses $6 million annually in psychiatric services — more than the entire annual budget of the hospital at White Sulphur Springs.

That’s an area that needs serious attention, a representative of the Billings Clinic said, echoing what advocates have been saying for years.

The legislative panel’s actual business was to discuss the issue of transparency in health care pricing for consumers, and Tuesday’s hearing what just the first step in that discussion. The thinking is that we know the price on just about everything we buy, from broccoli to pickup trucks, but generally not the price of our upcoming doctor’s visit or open-heart surgery.

rural montana healthcare hospitals So the panel might look at legislation from last session and from around the country, like this California bill for pharmaceutical transparency, which passed the California House Monday over passionate and well-funded opposition from the drug industry.

But as many at the hearing pointed out, it’s not that simple in health care: Patients aren’t the ones actually paying most of the bills; health care and its billing is complex, with different rates for different payers and a wide range of copayments and deductibles; and the care you receive isn’t always the care you planned on getting when you showed up.

The panel will continue to meet this year and next, and possibly bring recommendations to the 2019 Legislature.

–Sanjay Talwani


Featured image by August Schield Photography

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