The death of rural hospitals could leave Mississippians ‘sick, sick, sick'

by Devna Bose, Mississippi Today
March 21, 2023

GREENWOOD – Only a few dozen cars sit in Greenwood Leflore Hospital's parking lot.

The hospital's windows, streaked with purple paint, read, “Stay strong!” Another one says, “We love our patients!” Behind the glass, magazines sit untouched on side tables —the lobby is vacant.

Greenwood Leflore is the community's only hospital, and it's months away from closing.

The COVID-19 pandemic drained the hospital, which was already financially vulnerable, dry. Costs went up, while profit did not. Doctors and nurses, burned out from the pandemic, left in droves. Now, the hospital is shutting down floor after floor, cutting costs to maintain operations.

Mississippians know this story.

Dozens of hospitals across the state, many the only in their communities, are struggling to stay open.

A report from the Center for Healthcare Quality and Payment Reform puts a third of Mississippi's rural hospitals at risk of closure, and half of those at risk of closure within the next few years. There are only three other states with worse prognoses.

But it's especially devastating in Mississippi, where life expectancy and health outcomes are consistently the worst in the country.

Hospital administrators are holding their breath, waiting on help from the state, but they could be getting less money this year than they need. And there's little to no chance that state leaders will expand Medicaid this year as 40 other states have done. Expanding Medicaid under the Affordable Care Act would bring more than $1 billion in federal funding to Mississippi in a year.

Ryan Kelly, executive director of the Mississippi Rural Health Association, said the situation is dire, and there's not a straightforward answer.

“I wish, for the sake of simplicity, I had one single thing I could point to and say this is the problem,” he said. “We have been saying this for a long time that this will get serious and it is now serious.

“We are in far more of a serious time now than we ever have been before.”

For the hospital CEOs, doctors and residents of rural Mississippi, this isn't just a statistic. It's a life-and-death reality.

‘Hospitals can close. Watch and see.'

Dr. John Lucas's office is at the end of a quiet hallway, past empty rooms with empty beds.

Though he's spent his entire professional life at Greenwood Leflore, Lucas, a longtime Greenwood resident and now chief of staff, remembers starting his career as a surgeon in a much different hospital than the one he sees today.

His late father, Dr. John Lucas Jr., practiced at Greenwood Leflore from 1963 until his retirement in 2011. Back in the hospital's heyday, Lucas said his father's patients overflowed into the hallways. At that time, the hospital was licensed for 250 beds, he said.

When Lucas joined his father at the hospital in 1988, he didn't experience that level of activity, but it was a far cry from the desolate hospital he serves today.

“It wasn't uncommon to have as close to 200 beds full when I first came here,” he said. “It's really sad to walk these empty halls and to see that we only have one part of one floor occupied with patients.”

In the past decade, Lucas has watched the hospital close unit after unit, tapering services in an effort to stay open.

First it was the neurosurgery department. Then, it was the urology department and inpatient dialysis. Now, the hospital doesn't have full coverage of its emergency room for orthopedics or general surgery. Most recently, it shuttered its labor and delivery department and intensive care units.

At a health affairs committee meeting in February, Nelson Weichold, chief financial officer at the University of Mississippi Medical Center, said the worst part about the looming hospital closures is the slow cessation of services.

“It's not just when the hospital closes,” he said. “It's the years building up to that when they're taking financial measures to do everything they can to try and keep the doors open.”

But it's not financially viable to keep all of those service lines open anymore, according to Greenwood Leflore's interim CEO Gary Marchand.

About 75% of the hospital's patients are uninsured or on Medicaid or Medicare, which underpay the hospital for its services, Marchand said.

So most of the time, that means the hospital is losing money caring for its patients. And for the quarter of patients who have commercial insurance, the hospital often has to fight with the company to get the claim paid, he said.

“Our challenge is we have to map the inadequacy of those payments to our cost structure,” Marchand said. “For years, systemically, they (Medicare, Medicaid and commercial insurance) have paid below real cost.”

Before 2020, the hospital was losing between $7 to $9 million a year, Marchand said. To satisfy the city and county, which partially own the hospital, Greenwood Leflore leaders came up with a plan to generate $7 million a year to break even.

Then COVID hit, and everything changed.

The hospital went into the pandemic with $20 million in cash reserves. With each wave of the virus, despite government relief, their reserves were depleted. By the end of 2021, half of the cash was gone.

It's a fallacy that hospitals made money during the pandemic, Marchand said. Because Medicaid and Medicare paid for patients by their diagnosis, not the length of their hospital stay, patients who were in the ICU for weeks ended up costing the hospital.

Greenwood Leflore hasn't been able to make the money back — it's not clear why, but fewer people are seeking care, and payments have remained stagnant.

For several months, the University of Mississippi Medical Center was entertaining a plan to lease the hospital, saving it from closure. However, in November, the deal abruptly fell through without explanation from UMMC.

Marchand said the hospital has six months to figure out a plan or it'll be forced to close.

“The struggle is to get the community and the legislators and others to understand a hospital is a business,” he said. “I think a lot of people think, ‘Oh, you need hospitals. They're never going to go away.'

“Hospitals can close. Watch and see.”

A quick scroll on the hospital's Facebook page shows that Greenwood residents know that closure is a real possibility.

Lucas said he hears the same refrain over and over again when he's out in the community: “How's the hospital doing?”

“Whenever I go to a social outing, it's the first thing I get asked,” Lucas said. “Everybody's concerned.”

Pie Fincher and her family are products of Greenwood Leflore Hospital.

Fincher, who is 89 years old, has only gone to another hospital for treatment one time in her life. Both of Fincher's children were born at Greenwood Leflore, and the hospital has saved her life several times, she said, including once when she had a major brain bleed.

“It's just been a lifeline for our family,” Fincher said.

But the neurology department doesn't exist anymore. Neither does labor and delivery. Those doctors that delivered her kids and saved her life are long gone.

“I vividly remember how proud we were of that hospital to be built (in its current location in 1952),” Fincher said. “It was just state of the art everything. As time has gone on, we've been so fortunate to have so many wonderful doctors.

“That's what's so heartbreaking about it, is we have all these wonderful doctors that are willing to work in Greenwood — this little small, nondescript, tiny town — and we let them go.”

DeWitt Kimble was born in Greenwood 72 years ago. In the past few years, because of problems with his prostate, he's increasingly relied on the hospital for emergency care.

Kimble first heard the hospital might shutter about a decade ago. Now that its closure is imminent, he's worried.

“If you really close this hospital down, we're going to have to go to Jackson,” he said. “We're going to have to go to Grenada. We're going to have to go to Cleveland, and a lot of people don't have transportation, like me.”

The motor gave out on Kimble's Suburban about a month ago, and he's not been able to afford its repair.

If the hospital closes, residents such as Kimble will be forced to travel a half hour or more for care. In the Delta, where much of the population struggles with reliable transportation, the lack of a nearby hospital could be fatal.

Between a quarter and a third of Lucas' surgeries are canceled, largely because of transportation issues, he said.

Kimble had a surgery scheduled on Monday to remove his catheter. His primary care physician at a private practice said he'd arrange for Kimble's transportation, but Kimble said he's called the office repeatedly, and no one has answered.

No one from his doctor's office could be reached for comment by press time.

Kimble never made it to his procedure.

“I'm just sitting here, so frustrated,” he told Mississippi Today on Monday afternoon.

That means Kimble will still have to rely on his doctor in Greenwood and the hospital for continuing care.

“If the hospital closes, there will be a lot of walking dead,” he said. “Folks will be sick, sick, sick.”

Marchand's Plan A is getting Greenwood Leflore designated as a critical access hospital. That means the hospital would have to give up almost all of its 200 beds, but it would get more money for services that it provides. Critical access hospitals are typically reimbursed by Medicare at a rate of 101%, theoretically allowing a 1% profit.

State Health Officer Dr. Dan Edney said closing service lines and applying for different hospital designations are solutions he's seen increasingly across the state, but especially in the Delta. Though they might keep hospitals open, it's still a loss for the community, he said.

“You take what was a vibrant hospital in the Delta, pre-pandemic, and now it's a shell of its former self, post-pandemic,” Edney said. “Their only road to survivability is to downgrade.”

But to qualify for the designation, Greenwood Leflore would have to be 35 miles from the nearest hospital.

They're just short —South Sunflower County Hospital in Indianola is 28 miles away.

Marchand is hoping for a waiver from the Centers for Medicaid and Medicare regarding the distance requirement. His argument is that because of transportation challenges for the hospital's population, the hospital should be an exception.

If that doesn't work, the hospital will go up for sale again.

The survival of Delta's largest health care system will be ‘touch and go' after this year

If you ask Iris Stacker, interim CEO of Delta Health System in Greenville, how long the hospital system has before it's forced to close, perplexingly, she smiles.

“I intend to be here forever,” Stacker says.

But Chief Nursing Officer Amy Walker raises an eyebrow.

“We'll be here through the end of the year,” Walker deadpans. “It's really touch and go after that.”

The duo head up the largest health care system in the Mississippi Delta. And together, they're trying to keep it from closing.

Walker's cynicism is often balanced out by Stacker's cheeriness, but they do agree on one thing: The hospital is losing money.

“Even Positive Polly over there can't deny that,” Walker said.

Despite being licensed for over 300 beds, the hospital's census hovers around 80 patients. And most of the patients are uninsured or on Medicaid or Medicare.

Last year, Delta Health spent about $26 million on uncompensated care. That amounts to about 15% of its total operating expenses.

“We don't turn people away,” Stacker said. “Instead of trying to go to a doctor and pay for that visit, they wait until 5 p.m. and come to our emergency room.”

But the decline in hospital patients isn't because care isn't needed in the Delta, which has some of the worst health disparities in Mississippi.

“It's not because the patients aren't here,” Walker said. “It's because we don't have the nurses to take care of them.”

Walker said the hospital has long struggled to recruit nurses to Mississippi, much less the Delta.

“We've always had that problem,” Walker said. “And if you look at our salaries, we usually have to pay more than Memphis and Jackson to get nurses here. We were already used to doing that.”

The problem worsened during the pandemic, as nurses were offered more money to travel or work elsewhere. Others got so burned out that they went ahead and retired. Statewide, nurse vacancies and turnover rates are at a 10-year high.

Since the pandemic, the hospital's nurse workforce has nearly halved.

The exodus' effects have rippled throughout the hospital: emergency wait time has quadrupled, the largest medical surgery unit is closed, and half of the hospital's ICU beds are not in use.

“You would think that now three years out, things would have normalized, but they haven't, and I don't think we're ever going to get back to normal,” Walker said. “We've lost so much of our volume at this point. I can't really predict if it will come back.”

During the pandemic, supply and labor costs shot up. While prices aren't as high as they were then, they haven't returned to pre-pandemic levels.

The way Walker explains it, if the price of eggs goes up, a grocery store can make up for the inflation by passing the cost down to the consumer. But that can't happen in a hospital setting.

Delta Health has to keep serving its patients, no matter if it's losing money or not.

“We're pretty much living on grant money right now,” Stacker said.

Stacker knows that Medicaid expansion is unlikely to pass this legislative session, though it's what she thinks would help the most.

Without systemic changes, Stacker admits that the hospital's fate is uncertain.

And if the Delta loses the hospital system, it's going to affect the entire region.

“We save people's lives every day here,” Walker said. “Once hospitals start closing, those patients aren't just going to go away.”

Staying afloat, for now

Winston Medical Center's CEO Paul Black is a numbers guy.

Black's hesitant to say it, but he admits that his background has helped keep the hospital afloat.

Before taking the helm of the hospital, Black did consulting work for hospitals around the state and made use of his accounting degree as an auditor for the Medicare program.

“This reimbursement stuff is what I grew up doing,” he said. “So when I got started, I had already been on that side of the fence.”

Something his financial background did not prepare him for, though, was a disaster in his first week of work in April 2014.

Six days into his tenure, Louisville was hit by a devastating EF-4 tornado.

“I don't remember a whole lot about what took place the first six months,” Black said. “I won't say that I walked around in a fog, but there was just so much going on. And there's no manual for it.”

During that time, funding was coming from various sources — disaster relief, cash reserves, community loans —which is why, years later, Black said the hospital's finances don't look as dire as many other hospitals in the state.

Winston lost money caring for patients during the pandemic, and Black said expenses have gone up while payments have not increased. The nursing home's population has also been depleted because so many elderly Winston County residents died during the pandemic.

However, Black fought back with changes of his own.

The hospital raised nurse salaries, which convinced many to stay. Additionally, he's made sure the hospital offers a diverse array of services —from a nursing home to mental health needs — to protect them from financial collapse.

“That keeps a lot of people coming here,” he said. “We've been very efficient with what we're doing.”

But he warned that Winston Medical Center, while not in the red, isn't in the green either.

Black's predecessor, Lee McCall, now heads up Neshoba County General Hospital in Philadelphia, less than an hour from Louisville.

Neshoba County was similarly impacted by COVID —McCall said hospitalizations are down by about half, in part because many of the hospital's chronically ill and elderly patients who regularly sought care or were in the nursing home died during the pandemic.

When McCall took the CEO job in 2014, the hospital averaged 1,500 annual admissions. Last year, they had 750.

Because of the drop in census, the hospital closed one of its acute floor wings in October to cut costs.

Additionally, more people are visiting the emergency room, where they know the hospital will provide care, whether or not they're insured.

“Our ER visits have definitely gone up,” said Dr. Jon Boyles, the hospital's emergency department director. “We're seeing it seems more and more people who basically use the ER as a clinic.”

The hospital also lost staff during the pandemic — staff they can't afford to hire back. McCall said he's trying to do everything he can to prevent layoffs.

“To be honest, there's just not anywhere to really lay off unless we just shut down a service line completely, which we're trying to avoid at all costs,” he said.

McCall has kept a close eye on the Capitol the past few months. Like Stacker in Greenville, McCall knows Medicaid expansion isn't going to happen this session, but he'll keep advocating for it.

He doesn't deny that hospitals need the grant money making its way through the Legislature, but said hospitals need a sustainable solution — not a temporary one.

“That's one-time money,” McCall said. “That doesn't fix the ongoing problem. So we're going to be right back where we are now next year.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.