Bootheel hospital’s struggles raise concerns about access to health care [St. Louis Post-Dispatch]

Oct. 13--HEALTH CARE: CHANGES AND CHOICES

part ten

CARUTHERSVILLE, Mo. --Many of the customers at the Round House, a popular restaurant in this southeastern Missouri farming town, see health care access as a cut-and-dried issue.

"We have enough doctors and hospitals," said Earl Bullington, a frequent Round House patron.

The problem in Pemiscot County, said the retired farm credit manager and cotton farmer's son, is that "a large percentage of the local population is (on) Medicaid. We have a lot of people who abuse the (government) card they get. Lots of doctor visits are made for unnecessary things."

That view is typical in these parts, except among those who are unemployed, uninsured and broke.

Fact is, life expectancy in Pemiscot County is lower than in El Salvador -- and the lowest in the state of Missouri, the state's hospital association says. (Then again, the life expectancy within the city limits of St. Louis is only slightly better.)

This Missouri Bootheel county, with a population of about 18,200, is one of the state's poorest, a fact reflected in high rates of infant mortality, obesity and disease. Its poverty has been well-documented for decades -- the equivalent of a festering boil that's targeted occasionally by federal and state bureaucrats, health advocates and assorted do-gooders.

The county's only hospital, Pemiscot County Memorial, serves a large population of the poor and uninsured. Located in Hayti, nearly 200 miles south of St. Louis, the hospital has struggled financially for years. Area residents recognize its limitations.

"We have a good 'First Aid Station,'" said Harlin Crayne, a lifelong resident of Caruthersville. "It's a good place to get stabilized, and then they shoot you somewhere else."

Crayne, now in his 60s, knows. At 38, he suffered a heart attack and, once stabilized, was flown by helicopter to Memphis, Tenn., for follow-up care. A few years ago, he had heart trouble again, and was rushed out of the area for specialty care.

The local First Aid Station is now in jeopardy.

Without an expansion of the Medicaid program -- the government program that provides health care coverage for some of the poor and disabled -- the hospital likely will close, Kerry Noble, the hospital's chief financial officer and former CEO, told state lawmakers earlier this year.

At the time, Noble's warning was dismissed as fear-mongering by Missouri House Speaker Tim Jones, a Republican and a fierce opponent of the Affordable Care Act. And Missouri lawmakers subsequently refused to expand Medicaid.

Whether Noble's prediction proves prescient remains to be seen. Poverty-stricken rural areas, where health needs are great and resources few, may pose the ultimate test of President Barack Obama's signature health reform law as well as state Medicaid programs. In the end, will the nation's most neglected populations have greater access to health care or less?

PHYSICIAN SHORTAGE

The Bootheel's shortage of physicians cuts across the region's yawning chasm between the haves and have-nots, especially for those whose families have lived for generations in poverty in the Mississippi Delta region.

When Amber Ely, 33, of Kennett in nearby Dunklin County, needed medical attention, local providers referred her to a specialist in Cape Girardeau, a 90-minute drive.

Ely, who is partially blind and on Medicaid, was pregnant.

She had suffered a stroke a few years ago, and physicians wanted to be certain that her pregnancy and delivery would go smoothly. She recently gave birth at St. Francis Medical Center in Cape Girardeau, more than an hour's drive away.

"My daughter has been getting beautiful, beautiful care" in Cape Girardeau, said Ely's father, Frank Bailey, of Southaven, Miss.

Curtis Hicks, who is disabled and lives in Hayti, said that he walked into Pemiscot County Memorial Hospital's emergency room a few months ago around 11 p.m. He had chest pains, and waited for four hours without being seen.

"I finally walked out. I was the only one in the waiting room," Hicks said. "I had Medicaid. They wouldn't even take my information. They didn't act like they cared. ... If I had a car, I would've taken it to Kennett or the Cape."

Kennett, located 17 miles away in Dunklin County, is the home of Twin Rivers Regional Medical Center, a for-profit hospital. Cape Girardeau has two large nonprofit hospitals.

"Back in the day, Pemiscot was a good hospital," Hicks said. "Someone needs to buy (them) out."

Katrina Robertson, an intake specialist at the nonprofit Bootheel Area Independent Living Services, or BAILS, in Kennett, said that primary care physicians and surgeons who practice in the Bootheel area tend to stay only a few years. Many doctors become frustrated with their patients' lack of compliance with their instructions.

Patients with chronic diseases such as diabetes, she said, will "be warming up TV dinners in the microwave, which is going to cause their blood sugar to go up and land them back in the ER."

BAILS, a community-based nonprofit organization that serves Dunklin, Pemiscot, New Madrid and Stoddard counties, helps residents apply for Medicaid and arranges transportation and in-home services for the disabled.

Robertson said about 90 percent of referrals by local providers for specialty care are to specialists based outside the Bootheel, including for patients who need dialysis, cardiology and neurology services.

Her 17-year-old son Will, for instance, made several trips this year to see a hand surgeon in Little Rock, Ark., after he suffered an injury playing basketball.

The Delta Regional Authority, a federal-state partnership focused on development in the Mississippi Delta, has a visa waiver program that allows foreign doctors who are trained in the United States to work in medically underserved areas for at least three years. But the shortage of Bootheel physicians persists.

A TRAIL OF STATISTICS

In the last two decades, Missouri's overall health care rating has eroded.

In 1990, the UnitedHealthcare Foundation ranked Missouri 24th in the nation. Today, the state ranks 45th -- and the Bootheel has some of the worst chronic disease rates in the state.

Pemiscot County's sickly population spends a lot of time in the hospital.

Residents are hospitalized more than twice as often as the average Missouri resident, according to the Delta Regional Authority. Hospital inpatient days per 1,000 residents in Pemiscot County is 1,858; the Missouri average is 719 days; the U.S. average is 643 days.

Academics point to socioeconomic factors:

--Less than 60 percent of the county's adults ages 25 or older has a high school degree; nearly 20 percent of these adults have less than nine years of public education.

--The percentage of Pemiscot County residents living in poverty is more than twice as high as the state average, Missouri officials say.

--According to the U.S. Census, the county's unemployment rates are also significantly higher than the state average.

But there's no escaping the region's shortage of doctors. Pemiscot County, on a per capita basis, has about one-fifth the number of doctors and dentists than the state average.

"I've had numerous patients who have died because of lack of access to primary care," said Dr. Abdullah Arshad, who provides emergency care at the hospital. "I had two patients who lost their legs because they did not have Medicaid and could not afford their medication. I had a patient with the HIV virus who died of HIV because she did not have Medicaid or insurance."

He said that one of his patients -- a young woman with nodules in her lungs -- died of metastatic lung cancer in August because she could not afford an X-ray.

FINANCIAL WOES

Pemiscot County Memorial Hospital, the county's second-largest employer, opened in 1951 -- when the county's population exceeded 45,000, more than twice its current level. In subsequent decades, as agriculture changed and machines replaced farm workers, people left the region. Now, the 49-bed hospital is in trouble.

The hospital had total revenue last year of $94 million and a net loss of $759,000, according to the American Hospital Directory.

The county's annual contribution to the hospital is about $634,000, said Ben Baker, a county commissioner who also oversees a NAPA auto parts store in Caruthersville.

"The county's broke as hell," Baker said. "We had people on the hospital board with conflicts of interest. We have a new board now."

According to the Caruthersville-Hayti Democrat Argus newspaper, the hospital's board of directors resigned recently after allegations surfaced that the panel had awarded a lucrative hospital contract for billing services to then-board chairman Glen Haynes.

In August, state officials agreed to release $1 million in emergency funds to the hospital, which began to lay off or furlough some of its workers to reduce its payroll. And the county's primary care clinic increased its prices by 20 percent.

Jack Pennington, the hospital's chief executive officer, declined to comment about the hospital's finances, plans or the recent scandal.

The county's hospital system "almost went through a bankruptcy proceeding. There's just no money there," Arshad said. "We need somehow for the government to support us when we care for an uninsured patient."

Under new federal rules, the hospital is being penalized for its higher than average readmission rates. If a discharged patient fails to take prescribed drugs or to show up at doctor's appointments and becomes sick again, the hospital has no choice but to readmit the patient -- and is penalized for it.

"We need help with our equipment," Arshad said, stressing that the hospital's key technology is more than 20 years old. "Our MRI machine has been down for two weeks. Our cardiac stress machine has been down for a month."

Still, he voices optimism about the hospital's future. "The hospital will find a way to be viable. The hospital will stay open," he said. "But I fear that the hospital will be in the same situation two or three years from now."

A DOCTOR'S PERSPECTIVE

Arshad, whose specialty is internal medicine, also provides primary care and ad hoc specialty services at a county-run clinic across the street from the hospital. He sees 30 to 50 patients a day.

"I do everything from cardiology to neurology and pulmonology and oncology," Arshad said. "City physicians don't want to do that. They don't want to accept the responsibility."

He said the Medicaid program has a long waiting list of Bootheel patients who need to see specialists. "The number of uninsured has increased. The number of sub-specialists has decreased," he said, referring in particular to doctors who specialize in heart, lung, eye and cancer care.

"Of course there is a shortage of doctors," Arshad said, "but the real problem in this area is the patients' inability to access what we have."

He said that several factors conspire to limit health access for the poor, beginning with a lack of insurance. About 15 percent of Pemiscot County adults younger than 65 are uninsured, a level that is roughly in line with the state.

Pemiscot County's primary care clinics in Hayti, Caruthersville and Steele offer sliding-scale rates for doctor appointments, but no discounts for medications, resulting in many patients not filling their prescriptions and getting sicker.

A lack of education among the poor is also a big factor.

"The patients just don't realize that they should care about their health," he said, adding that it's not uncommon for 10 people and three pets to be living in a small trailer. "Even if they don't smoke, they get secondhand smoke."

Another key factor is limited public transportation. Buses run along the Bootheel's main arteries, but not along the smaller veins including gravel roads where many people live -- often without cars or phones.

Some of Arshad's patients walk to his clinic in Hayti from the town of Holcomb -- population 631 -- in Dunklin County, a distance of 10 miles.

"These patients can't go anywhere," Arshad said. "They don't have cars. They don't have the gas money."

He recalled an elderly woman who showed up at the hospital two weeks after suffering a stroke. The left side of her body was paralyzed.

HEALTHY SOLUTIONS

It's difficult to identify potential solutions to problems that seem intractable, experts say. But the region's ongoing economic troubles, including its dearth of jobs and health disparities, have drawn the focus of academics.

Since the 1990s, researchers from St. Louis University have explored ways to address the high rates of heart disease among African-Americans in Pemiscot County, which are about 60 percent above the state average. The researchers cite the apparent correlation between the county's few economic opportunities with some residents' loss of hope, depression, low self-esteem and high stress levels.

The Bootheel's fertile, black delta soil has long yielded cotton, soybeans, wheat, corn and rice crops. More recently, a novel partnership has blossomed there between SLU researchers and community health advocates.

"It's not enough for us to go out into the community and encourage people to eat right and exercise," said Freda Motton, the project's community liaison. "These people are poverty-stricken. They don't even know where their next meal is coming from, let alone have time to think about eating high-priced fruits and vegetables. They can't yet hear that message.

"The thinking was that people going to the grocery store are reaching for all the wrong things," she said, citing the need to eat more healthy foods with less salt and less fat. "What good is it to take a person's blood pressure if they can't even afford to go to the doctor? If they have high blood pressure, what's the next step?"

Inspired by a village garden that had sprung up years ago in Caruthersville, the city of Hayti and two private landowners donated plots of land. To lower the risk of heart disease, they would grow their own food.

A dozen unemployed men, including felons, who had participated in "Men on the Move" job-readiness workshops were hired to work part time in three community gardens. They planted cucumbers, squash, tomatoes, greens, watermelon, peas and eggplant. They set up a produce stand in Hayti to sell fresh produce at dirt-cheap prices.

Recipes, nutrition-education materials and cooking demonstrations were developed to echo the harvest. Similar gardens were established in Dunklin, Scott and Mississippi counties.

But not long after the program's launch, its grant through the National Institutes of Health recently ended -- leaving researchers and community health advocates scrambling to find new funding streams.

"We did have some successes," said Motton, explaining that men who worked in the gardens moved on to other local jobs. "It gave them a step up. It ignited hope in them. They learned communication skills, teamwork and decision-making. ... Just because the grant ends, doesn't mean the work ends."

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