Like so many small-town hospitals, this one in Kansas is struggling to stay alive

May 14--Last Wednesday, it was the cleaning supply guys.

"I had to figure out how to cut a $2,500 check. It wasn't easy," said Les Dean, the president and CEO of Sumner Regional Medical Center. "We have to make decisions every day, every day, on which bills to pay. I mean that literally."

Seemingly everything conspires against keeping the Wellington facility, like so many other rural hospitals, open for another day.

People in small towns are older and sicker than those in cities and suburbs.

They're more likely than their counterparts in metro areas to rely on Medicaid or Medicare -- meaning less reimbursement to a hospital than private insurance.

They also are more likely to have no insurance coverage at all.

It doesn't help that Kansas decided not to play the Obamacare game and expand Medicaid coverage. That alone, Dean estimates, costs the hospital $750,000 a year out of a budget that struggles to line up revenue and expenses of about $32 million.

Wellington's hospital is just rural enough to carry small-town problems and just close enough to Wichita -- a little more than 20 miles up the turnpike -- to see patients referred to bigger hospitals for the most complicated and money-generating care. That means empty beds and sometimes idle staff, more factors that push its ledger toward the red.

Voters here have repeatedly voted to tax themselves to save the hospital, most recently adding a 1 percent sales tax. Still, the two-story facility nearly missed payroll early this year, saw nearly 10 percent of its staff sacked and limps by on 12-year-old computers.

Dean, who took the helm less than two months ago, has an uneasy hope about keeping the operation afloat by putting a budget-cutter's eye to everything that goes on.

But it wouldn't take much -- some unexpected expense, an unanticipated loss of revenue -- and Wellington would see a shuttered hospital sitting across from the Just Junk shop.

If Wellington's hospital goes down, people in town worry about what doctors might follow, what business might not come to town, or which might leave.

"We're in true survival mode, constantly," Dean said. "If we're going to go down, we're going to go down swinging."

Yet he sees potential haymakers from the vast, and vastly complicated, American medical system that subsidizes the particular costs of rural health care even as market forces make the finances of medical services in remote places increasingly untenable.

The latest, evolving version of the American Health Care Act, or "Trumpcare," that would repeal and replace the Affordable Care Act, or "Obamacare," could easily disrupt the already fragile equation that holds the Wellington hospital budget together.

If people with pre-existing conditions were put in high-risk insurance pools, for instance, some could expect to see unaffordable premiums. If they, in turn, started showing up at the Wellington emergency room without insurance, that's money out the door.

If existing Affordable Care Act subsidies for insurance went away, leaving some poor and middle-income patients unable to afford insurance, that would be another tough blow.

"If they pull that subsidy," Dean said, "the impact is obvious."

Remotely troubled

In April, Missouri Sen. Claire McCaskill pressed the General Accountability Office for a study documenting the rate at which rural hospitals are closing and what's driving the trend.

A study released this year by iVantage Health Analytics counted at least 80 rural hospital closings this decade, most of them grouped across the country's lightly populated midsection. Roughly two in five small hospitals, the study said, lose money.

The same report noted that states that didn't expand their Medicaid rolls -- heavily subsidized by the federal government in its early stages, with growing state obligations in later years -- saw their rural hospitals suffer more.

Neither Kansas nor Missouri expanded Medicaid eligibility to get those Obama-era dollars. One study found that in states that expanded Medicaid, uninsured hospital stays dropped by half in 2014. There was no drop in the other states.

Other changes in the industry push health care dollars to large city hospitals. Small facilities, like the Wellington hospital, struggle to compete on price because they don't benefit from economies of scale.

At the same time, private insurance policies carry ever higher deductibles. That means patients feel the direct cost, and choose urban hospitals that often charge less.

"Rural patients with high-deductible plans are becoming more price sensitive and showing a willingness to travel greater distances to reduce their healthcare costs," the iVantage report said.

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When the federal government imposed cuts in 2013 on Medicare spending, they hit rural hospitals with large elderly populations particularly hard. The Congressional Budget Office estimated that rural hospitals would lose $3.5 billion over 10 years, their communities' economies would see $18 billion in activity vanish and 153,000 jobs would go away.

Part of Obamacare also slashed federal payments to hospitals to compensate them for unpaid patient bills. The Affordable Care Act aimed to balance that out by putting more people on Medicaid, which would mean that the hospitals would care for fewer uninsured patients.

In states such as Missouri and Kansas, where lawmakers didn't expand Medicaid, that money never arrived. That meant the loss of an additional $1.4 billion nationwide to rural hospitals, $7.3 billion in lost economic activity in their communities and 62,000 disappearing jobs, the CBO calculated.

"These things start to add up," said Robert Moser, a physician who operated a practice in small-town western Kansas for decades and later headed the Kansas Department of Health and Environment. He's now executive director of the Kansas Heart and Stroke Collaborative at the University of Kansas Health System. "They all make it harder for rural hospitals."

When the century-old Mercy Hospital closed in Independence, Kan., in late 2015, pressure built on Gov. Sam Brownback and the Kansas Legislature to expand Medicaid. The pressure was renewed this year with news reports about the possible closing of St. Francis Health Center in Topeka. A new partnership appears to have spared the hospital for now, but the debate goes on.

In its latest "Hospital Strength Index," iVantage estimated that 673 hospitals across the country stood "vulnerable or at risk" for closure. Those hospitals treat patients 11.7 million times a year and employ 99,000 people.

In Kansas, 34 hospitals are vulnerable to closing, according to the Chartis Center for Rural Health. Missouri has 29 vulnerable hospitals.

Kansas has seen two hospital closures this decade, in Independence and Great Bend. Since 2010, Missouri saw hospitals shuttered in Osceola, Farmington and Ellington.

Part of the problem comes from an exodus of patients. The emptying out of rural America has moved steadily for more than a century. Its hospitals are emptying at a faster clip.

The Wellington hospital, for instance, is equipped for a range of care. You can get a colonoscopy there. Surgeons can remove your gall bladder.

Increasingly, that business goes to Wichita. The hospital is licensed for 80 beds and actually has 65 available, but those numbers don't mean much. Ten years ago, it was common for the hospital to have 10 or so patients admitted at any one time. But now, on a typical night, it hospitalizes just one to five patients. Instead, its care is dominated by out-patient care that pays less than in-patient services.

Imagine you're a 60-year-old guy with chest pains, said Tamara McCue, a Wellington physician and a member of the hospital's board of directors. If a doctor at Sumner Regional Medical Center initially diagnoses you as not having a heart attack, the hospital is fully equipped to monitor you for a night. But there's no cardiac surgeon if things turn south.

"The expectation of the medical consumer has changed," McCue said. "Everybody wants to see a specialist."

That drives patients north on Interstate 35 to Wichita. Often, as well, it's the physicians in Wellington who refer patients out of town. Dean, the hospital CEO, wants the clinicians at a six-physician practice in town to send more patients to him. He's thinking of expanding the hospital's own clinic as a way to drive more admissions.

"It's tricky. There's politics," he said. "It could very easily be perceived as threatening" the local doctors' practice.

Larry Anderson, a physician who has practiced in the area for more than 40 years, said there was a day when he admitted heart attack patients in Wellington. No more.

"You don't take care of heart attacks in small hospitals anymore," he said. "The larger centers are big enough that they can afford all the high-stakes stuff."

If patients come to expect the highest level of specialty -- whether it's needed or a wise use of insurance dollars -- what's a doctor to do? Being just close enough to Wichita to be practical, Anderson said, makes it hard to keep those patients near home.

"We're rural, but we're not frontier," he said. "An admission to a rural hospital today requires that the patient be sick enough to truly need hospital care, but not so sick as to require highly technical/specialized care, which is likely not available in the rural hospital."

A community without

Would it be so awful if a place like Wellington lost its hospital, if patients took all of their business up the road?

The Henry J. Kaiser Family Foundation looked at what happened after the closure of three rural hospitals -- one in Kentucky, another in South Carolina and the Independence, Kan., facility. It found that some doctors left the towns. The poor and elderly, in particular, struggled to find rides to out-of-town care.

Emergency care posed the biggest hole to fill. Communities had to buy more ambulances to speed patients to bigger cities. Folks in Wellington estimate they'd need to spend at least $1 million on new ambulances if their hospital closed. But the Kaiser paper also noted that most emergency room visits involve "common ailments that do not require emergency care."

A study led by a Harvard researcher looked at 195 hospital closures between 2003 and 2011 found "no significant difference" in death rates among people who lived in areas where a hospital had closed and those who lived elsewhere. An older study looking at data from rural areas the 1980s "did not detect significant effects of hospital closures on mortality."

Dean, the Wellington hospital boss, insists people could die if his emergency room shut its doors. McCue, the physician on the hospital board, wonders how many Wellington folks might not survive the dash to Wichita when they have a stroke, get hit by a peanut allergy or fall into cardiac arrest.

Anderson, the physician who's practiced there for decades, said: "Will there be more deaths? Not many. But some people might not survive the ride."

Quality of life would deteriorate, he said. Go to Wichita for a three-day hospital stay, Anderson said, and family might not be able to visit. Follow-up care could be more complicated.

"It's a whole lot easier," he said, "to be admitted in your home town."

The hospital also is part of what makes Wellington a community.

"The public belief is that we need health care locally and available," said Wellington City Manager Shane Shields. "If we didn't have a hospital, some of the companies are going to leave."

He wonders whether the town could hold on to Tect and GKN, its two aerospace manufacturers.

"It would make it harder to recruit more businesses like that," said J.C. Long, the president and CEO of Bank of Commerce & Trust Co. "What if somebody gets hurt on the job, or on the highway?"

With more than 130 workers, the hospital is one of the biggest employers in town. Those workers might move, or at least commute, to Wichita.

"That's more people we could lose," said Terry Deschaine, a retiree and member of the hospital board. "How would we recruit new physicians or hold on to the ones we have?"

That's one reason voters, by more than two-to-one, voted in 2015 for a new hospital sales tax. That subsidy helps, but it's barely more than a rounding error in the facility's budget.

Meanwhile, surgical nurse Marsha Dugan recalls just a few years ago when a surgeon worked regularly out of the hospital. Now, surgeries are limited mostly to one day a week.

"We've got the equipment here, and it's sitting here doing nothing," she said.

Dugan worries about what might happen to the community if everyone had to go to Wichita for care.

"These are our friends and neighbors," she said. "They count on us."

Scott Canon: 816-234-4754, @ScottCanon

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