In remote Idaho, a tiny facility lights the way for stressed rural hospitals

Provider's exit will leave thousands without insurance
Provider's exit will leave thousands without insurance

One evening in early March, Mimi Rosenkrance set to work on her spacious cattle ranch to vaccinate a calf. But the mother cow charged, all 1,000 pounds of her, knocking Rosenkrance over and repeatedly stomping on her.

"That cow was trying to push me to China," Rosenkrance, 58, recalls.

Dizzy and nauseated, Rosenkrance nearly passed out. Her son called 911 and an ambulance staffed by volunteers drove her to Lost Rivers Medical Center, a tiny brick hospital nestled on the snowy hills above this remote town in central Idaho.

Lost Rivers has only one full-time doctor, and its emergency room has just three beds -- not much bigger than a summer camp infirmary. But within 90 minutes, hospital staff gave Rosenkrance a CT scan to check for a brain injury, took X-rays to look for broken bones and sewed her ear back together. The next morning, although the hospital has no pharmacist, she got a prescription for painkillers filled through a remote pharmacy service.

It was the kind of full-service medical treatment that might be expected of a hospital in a much larger town.

rural hospital patient pharmacy
Shane Rosenkrance fills a prescription for his wife, Mimi, after she was discharged from Lost Rivers Medical Center following a cow-related injury.

Not so long ago, providing such high-level care seemed impossible at Lost Rivers. In fact, it looked as if there wouldn't be a Lost Rivers at all. The 14-bed hospital serves all of Butte County, whose population of 2,501 is spread over a territory half the size of Connecticut.

"Bears outnumber people out here," is how hospital CEO Brad Huerta puts it.

The medical center nearly shut its doors in 2013, due in large part to the declining population of the area it serves.

But then the hospital got a dramatic reboot with new management, led by Huerta, who secured financing to help pay for more advanced technology, upgraded facilities and expanded services. If Lost Rivers had closed, the alternative would have been hospitals in Idaho Falls or Pocatello, each more than an hour away.

Rural hospitals are facing one of the great slow-moving crises in American health care. Across the U.S., they've been closing at a rate of about one per month since 2010 -- a total of 78 closures, or about 6%.

About 14% of the U.S. population lives in rural counties, a proportion that has dropped as the number of urban dwellers grows. Declining populations mean a smaller base of patients and less revenue. And because many patients in the countryside are older and sicker, they require more intensive and often more expensive care.

Related: High-cost Alaska sits in the eye of health care reform storm

Faced with these dramatic economic and demographic pressures, however, some hospitals are surviving -- even thriving -- by taking advantage of cutting-edge trends in health care. They are experimenting with telemedicine, using remote monitors to track patients and purchasing high-tech equipment to perform scans and other types of exams. And because many face physician shortages, they are partnering with universities and increasingly relying on nurse practitioners and others to deliver care.

At Lost Rivers, Huerta's strategy was to use technology and innovation to offer the kind of high-quality medical care that would keep patients like Rosenkrance coming back.

"Necessity is the mother of invention," Huerta said. "Small hospitals like mine are always going to be under the gun. You have to get really creative."

In the decades to come, America's heartland and hinterlands will continue to be home to the people who run the country's farms, forests and fisheries, and to visitors who crave nature and recreation. And those people will need medical care. As a result, rural health researchers say hospitals like Lost Rivers are important test cases. They show that, despite daunting obstacles, rural America need not be left behind when it comes to health care.

"Being in a rural place does not preclude high-quality medicine," said Tom Ricketts, senior policy fellow at the Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill. "They are under a lot of pressure, but there are rural places you can point to as places you would say, 'This is how things ought to be done.'"

When Huerta, the CEO, arrived four years ago, he found the hospital in disarray -- dilapidated facilities, fearful employees, reluctant patients and a financial mess left behind by the former CEO. The hospital's bank account held just $7,000 and morale was at an all-time low.

"We were the poster child for everything that was wrong with rural health care," he said. "It had been a slow, steady decline from neglect."

After borrowing money to pay his employees, Huerta campaigned to pass a $5.5 million bond for Lost Rivers. Then he set his sights on overhauling the badly outmoded facilities. He also instituted a new philosophy: If it doesn't happen at a "real" hospital, it doesn't happen at Lost Rivers. That meant ending some local practices, like allowing people to bring their horses in for X-rays.

"I said, 'I have no problem doing this, but you tell me what insurance the horse has,'" he recalled. "The practice stopped immediately."

He also started to provide services to ensure that his patients didn't have to travel. Those services included telemedicine. The Bengal Pharmacy, on the bottom floor of Lost Rivers Medical Center, looks like any other pharmacy. But it has no pharmacist on site; instead, technicians and students from Idaho State University in Pocatello fill prescriptions, their work supervised by a pharmacist 80 miles away. Patients who want to talk to him go to a small private room with a phone and video link.

For rural hospitals, telehealth can make otherwise faraway services accessible to people where they live, said Keith Mueller, director of the Center for Rural Health Policy Analysis at the University of Iowa. "We can, in effect, bring the provider to the community without physically doing so," Mueller said.

Related: Obamacare's impact on this Alaska town with only one doctor's office

At Lost Rivers, patients also can have telemedicine appointments with a psychiatrist. And doctors can get virtual guidance from specialists in trauma, emergency care and burns.

But new technologies sometimes take getting used to. Leon Coon, 83, said the concept is a bit foreign to him. "I just don't do that stuff," said Coon, who works loading hay. "I'm a little old-fashioned."

rural hospital patient phone
A patient uses a telephone in a private room to talk to a pharmacist at Idaho State University after receiving his medication at Lost Rivers Medical Center.

Telemedicine is hardly a panacea. The projects often depend on grants or government awards, and they require high-speed internet, which isn't always reliable or cost-effective in rural areas.

Orie Browne, who took over as Lost Rivers' medical director in 2015, said he was drawn to the variety of rural health care. He spends his days bouncing between the emergency room, the hospital inpatient beds and the primary care clinic. "That's good for a person who gets bored easily," he said.

Many doctors, however, don't feel the same pull. Rural hospitals and clinics have long struggled to recruit doctors. In rural areas, there are roughly 13 physicians -- of any kind -- per 100,000 people, compared with 31 in urban areas, according to the National Rural Health Association.

In addition to Browne, the medical center has four part-time primary care physicians, some who live hours away and come in once a week. The hospital also relies on nurse practitioners and physician assistants. Various specialists, including a cardiologist and an orthopedist, also rotate into the medical center about once a month.

Rosenkrance, the cattle farmer, has been coming to the hospital since she was a child. Now her husband teases her about having a standing reservation in the emergency room.

"This hospital is a big deal," she said. "It's saved a lot of lives."

Editor's note: This story was a collaboration between Kaiser Health News and POLITICO. The original version of this story cited Kaiser Health News as the primary contributor to this article. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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