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Rural
hospitals face birthing pains
Related
story:
- Hospital investment roundup
by
Marjolijn Bijlefeld
Virginia Business
November
2004
Last
summer a former patient of obstetrician James Hamilton
on Virginia’s Northern Neck showed up at a family
physician’s office in premature labor. Because
the obstetrics unit of Rappahannock General Hospital
in Kilmarnock had closed in February, she was referred
to one hospital, which referred her to another in Richmond.
The baby died. “No one will know if we could have
saved that child, but early intervention might have
helped,” says Dr. Hamilton. “[Before the
unit closed] we delivered three patients who had acute
bleeding at the end of the pregnancy. In all three cases,
mom and baby were fine,” he says.
The
loss of the woman’s baby is a tragic example of
what can happen when maternity care is not available
in rural communities, a growing problem in Virginia.
Rappahannock General was one of at least five hospitals
in Virginia that closed their maternity units last year.
Many rural communities can’t support a maternity
unit because of their low volume of births. Practitioners
have trouble getting or paying for malpractice insurance.
And the state’s Medicaid program covers only 60
percent of the cost of a delivery, leaving hospitals
to swallow the rest or make painful decisions about
cutting services.
Rappahannock General’s maternity unit had been
operating in the red for years. After the hospital shuttered
the unit, Dr. Hamilton and his partner, Dr. Matthew
Vogel — the only obstetricians in the area —
were unable to renew their malpractice insurance for
obstetrics. Only four insurance companies, down from
nearly two dozen a few years ago, now underwrite the
high-risk specialty. The doctors have scaled back their
practice to gynecology and prenatal care. Before the
closing of the maternity unit, they had delivered about
275 babies a year at the hospital. Now women going into
labor gear up for a long haul — to Richmond or
Fredericksburg, both at least an hour away. For the
majority of women, it’s a nuisance. For some,
that hour delay can be catastrophic. Dr. Hamilton hasn’t
given up. He and other health care professionals are
trying to bring back maternity services on the Northern
Neck by opening a birthing center with the help of a
special government program.
Meanwhile, other rural hospitals are struggling with
the same problems that closed the obstetrics unit in
Kilmarnock. At Bon Secours St. Mary’s Hospital
in Norton, the obstetrics unit typically saw fewer than
100 deliveries a year, says Barbara Hale, the hospital’s
chief financial officer. Not only is it difficult to
staff a unit for such low volume, but also “the
nurses are not as trained or experienced as nurses in
another facility where they have more volume,”
Hale says. That unit closed last November.
Southern Virginia Regional Medical Center in Emporia
also closed its maternity unit last year for about a
month until the city council and the Greensville Memorial
Foundation provided $250,000 to keep the unit open for
a year. Lou Kauffman, the hospital’s CEO, says
the money will be used to cover the gap between payments
and the costs of operating a unit with one obstetrician
delivering about 150 babies a year. The hospital is
now trying to determine whether it can keep the services
next year.
Russell County Medical Center in Lebanon and Alleghany
Regional Hospital in Low Moor have also closed their
obstetrics units. Buchanan General Hospital in Grundy,
where about 85 percent of the delivering moms are covered
by Medicaid, closed its maternity unit in July. “It’s
a miracle the service lasted as long as it did,”
says Laurens Sartoris, president of the Virginia Hospital
and Healthcare Association. “If you’re losing
40 percent on 85 percent of your business, how do you
stay open?”
The problem is getting some attention at the state level.
In September, Gov. Mark R. Warner raised Medicaid payments
to practitioners for obstetrical services for the first
time in 10 years. Even with a 34 percent increase, the
current payment is at about 80 percent of what private
insurers pay. The increase helps in communities with
large Medicaid populations. The governor made his announcement
at Rockingham Memorial Hospital in Harrisonburg, where
disgruntled obstetricians were leaving the area or the
specialty. Sartoris says the crisis in Rockingham put
the issue front and center by showing it wasn’t
just a rural, remote-access problem. Rockingham had
debated closing its obstetrics unit, a move that would
force about 1,900 women a year to find an alternative,
but the hospital has decided to keep the unit open for
now.
The governor’s action raised the payment to practitioners
to $1,502 for non-surgical births and $1,702 for Cesarean
sections, up from $1,121 and $1,270 respectively. The
cost to the state is $7.2 million. For an obstetrician
who delivers 100 babies a year — with half of
the patients covered by Medicaid — that’s
$20,000 more. However, most obstetricians have seen
their malpractice premiums double or triple recently.
Their premiums average $65,000 per year in Virginia.
In late September, a task force convened by the governor
presented a set of recommendations for Medicaid payments
for pregnant women and newborns. These include a 33
percent increase to hospitals for obstetrics patients,
a nearly 50 percent increase in payments to pediatricians
who take over an infant’s care after birth, an
expansion of Medicaid coverage to include more pregnant
women and a $1 million medical malpractice premium subsidy
program for practitioners who provide obstetrical services
and see a certain percentage of uninsured and Medicaid
patients.
The new formula may not change the equation for hospitals
that have already closed obstetrics units. That’s
why in Kilmarnock there’s an unusual drive led
by Dr. Hamilton and others to bring back maternity services.
“Prenatal care is not a 9-to-4 job,” says
Dr. Hamilton. “The function is to identify a problem
so you can intervene before the mother or baby is injured.”
He and a group of doctors and nurses formed the Family
Birthing Center of the Northern Neck, which hopes to
lease the maternity unit from the hospital or to open
a birthing center nearby. The group is approaching a
variety of government agencies to see if state and federal
programs can help. The group hopes to open a birthing
center as a “critical access hospital,”
a federal designation for a hospital with fewer than
25 beds in a rural area providing essential medical
services.
There are six such hospitals in Virginia, says Margot
K. Fritts, a senior policy analyst at the state Department
of Health. By gaining the federal designation, the Dickenson
Community Hospital in Clintwood was able to reopen late
last year after having been closed for nearly a year.
Medicare payments to these critical access hospitals
reflect the actual costs of care, which improves the
chance that they’ll stay in the black. “It’s
intended to benefit rural communities, not just the
critical access hospitals,” Fritts says. For example,
in communities where hospitals were closing, some emergency
medical technicians were reluctant to volunteer because
bringing a patient to the nearest hospital could mean
a commitment of several hours, if not the entire day.
Medicare, the federal program for elderly and disabled,
doesn’t generally cover obstetrical care, but
Dr. Hamilton is hoping that if the unit gains the federal
designation, the state’s Medicaid program would
also opt to pay the actual costs. He says costs would
be lower for a birthing unit than for a general hospital.
“There would be no ER or radiographic facilities
that drive up the cost of patient care in other units.”
Drs. Hamilton and Vogel are also looking at ways to
reduce the cost of malpractice insurance — even
if it means giving up their independent practice. They’re
talking with Roderick Manifold, executive director of
Central Virginia Health Services, a 10-site Community
Health Center, another federal designation for nonprofit,
private corporations located in a medically underserved
area. These centers provide health care to anyone seeking
care, regardless of ability to pay. Manifold’s
group also administers an obstetrical practice in Farmville.
The Kilmarnock doctors are looking at this health care
model because the federal government covers the providers’
malpractice coverage. “[Other practitioners] are
paying $50,000 to $100,000 or more per person that we
don’t have to pay,” Manifold says.
Dr. Hamilton says if the Kilmarnock group could reduce
costs by entering a federal program like Manifold’s
and get higher reimbursements through the critical access
hospital designation, that model could be replicated.
That’s important, says Dr. Mitchell Miller, president
of the Medical Society of Virginia, because today’s
crisis in obstetrics is the tip of the iceberg. Dr.
Miller is a family physician in Virginia Beach. Even
in his relatively low-risk specialty, his malpractice
premiums quadrupled in the past two years. Because payment
rates are set by insurers and the government, “there’s
no way to recover that,” he said. Dr. Miller hopes
that the current focus on obstetrics soon spreads to
other primary care providers. As long as Medicaid reimbursements
are so far below the cost of providing care, more physicians
could decide to close their practices to Medicaid patients.
While most people would agree that access to health
care for low-income residents is important, the public
funding hasn’t kept up. “Do we as a society
decide that we’re going to ante up more for health
care? I think we don’t have any choice,”
he says.
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