FULTON (AP) - The impending closure of the Fulton Medical Center startled the local community. In the days leading to when the hospital's doors were supposed to close, residents faced the reality of living without nearby emergency care.
A week before it was to close, EmpowerHMS, a Kansas City-based health management company, announced it purchased the hospital, preventing its closure. But the Fulton hospital story has become all too common in America's rural communities.
A study last year sponsored by the National Rural Health Association found 673 rural hospitals were at risk of closure and 210 are considered to be at an extreme risk for closing, the Columbia Daily Tribune reported.
Since the Affordable Care Act was passed by Congress in 2010, 82 rural hospitals in the United States have closed, according to the North Carolina Rural Research Program. The research program considers rural hospitals to be acute care, nonfederal hospitals not located in a metropolitan county or qualified as critical-access hospitals.
Of the rural hospitals the research program identified, three hospitals were in Missouri - Sac-Osage Hospital in Osceola, SoutheastHEALTH Center of Reynolds County in Ellington and Parkland Health Center-Weber Road in Farmington. All these hospitals struggled financially, according to the Missouri Hospital Association.
Information from the association shows three other rural hospitals that go beyond the research program's definition also have closed in the state since 2010 - the Southeast Missouri Mental Health Center, Southwest Missouri Psychiatric Rehabilitation Center and Ozarks Community Hospital in Springfield. A fourth, Missouri Rehabilitation Center in Mount Vernon, closed in 2014.
The Osceola community suffered a blow when the Sac-Osage Hospital closed in September 2014 after 45 years of operation, said James Naylor, former chair of the hospital's board. He was off the board when it voted to stop ambulance, emergency room and ancillary services, which he called a mistake.
Now, the closest hospitals to Osceola are a 30-minute drive away. If the Fulton Medical Center had closed, patients in that community would have been in a similar situation, having to travel to Columbia, Jefferson City or Mexico for hospital services.
"The public needs to be aware how vital their rural hospitals are," Naylor said. "It's vitally important to have personal service and personal experiences."
A town of about 900 people, Osceola doesn't have a McDonald's or other common fast-food staples found in most towns in America. The town has a grocery store, school system and a Casey's Gas Station and General store - not much to attract doctors and nurses, Naylor said.
While he was on the hospital board, Naylor said the hospital offered doctors $10,000 to $15,000 above the typical annual salary to try and compete with larger markets. A national nursing shortage also made it difficult for the hospital to find nurses.
"It was just difficult to recruit physicians," he said.
Attracting physicians always has been a struggle for hospitals in rural towns, considered as workforce shortage areas, said Rick Royer, chief executive officer of Primaris Healthcare Business Solutions, a Columbia-based health care consulting company.
Like the Sac-Osage Hospital, rural hospitals tend to offer bonuses and payment incentives to attract physicians. Though the offerings can be attractive, sometimes it's not enough, Royer said.
Telemedicine and partnering with larger health systems are helping rural hospitals, he said. Rural hospitals have started affiliating with urban hospital systems and created a telemedicine system allowing physicians to manage units in rural hospitals remotely, he said.
"Telemedicine is offering some real chances," Royer said. "Telemedicine is finally coming into its own."
Keith Mueller, interim dean of the University of Iowa College of Public Health, said rural hospitals have been using telemedicine to support their pharmaceutical, emergency and radiological services. Telemedicine allows patients to access health care near where they live. Many in rural areas cannot travel long distances for care, he said.
While telemedicine enhances its services, rural hospitals cannot always afford the technology, Royer said.
Under its previous owners, NueHealth and the University of Missouri Health Care, the Fulton Medical Center racked up $1 million in losses from January to May. Losses in 2015 and 2016 combined were more than $5.5 million.
Uncompensated care or care provided the hospital but not paid for was largely to blame for the Fulton hospital's poor financial situation. This issue has become all too common for rural hospitals that are located in communities with higher rates of Medicare and Medicaid patients, poverty and people in worse health, said Dave Dillon, spokesman with the Missouri Hospital Association.
Rural communities typically have fewer people with employer-sponsored health insurance, which lowers their ability to pay out of pocket, he said.
Rural area populations are declining, too. Lower-patient volumes - another struggle for the Fulton Medical Center - equate to less revenue.
Because rural communities tend to have patients with less employer-based insurance, those hospitals aren't serving enough of these patients to cost shift and compensate for lower-income patients, Dillon said.
"There's not a large enough pool to make services profitable," he said.
States that did not expand Medicaid under the Affordable Care Act tend to have rural areas with higher rates of poverty compared to their urban centers, Mueller said. Medicaid expansion increased the health coverage for residents up to 138 percent of the federal poverty level, but Missouri lawmakers have not opted to expand Medicaid.
Fulton officials have said the lack of Medicaid expansion in Missouri was a reason for the hospital's struggling finances. A map of rural hospitals closed since the ACA was passed in 2010 by the North Carolina Rural Research Program shows the most have closed in states without Medicaid expansion.
As a researcher, Mueller said he can't give a clear answer whether lack of Medicaid expansion has been a cause of rural hospitals' closure because he hasn't seen empirical work to answer the question.
"But if you look at the maps of where they've closed, intuitively it looks like Medicaid non-expansion is a contributing factor," he said.
Rural hospitals designated as critical-access hospitals by the Centers for Medicare and Medicaid Services typically experience more success because they receive larger Medicare reimbursements.
To qualify as a critical-access hospital, a hospital must provide 24-hour emergency services, maintain no more than 25 inpatient beds and be more than 35 miles away from another hospital.
In Missouri, 36 hospitals operate as critical-access hospitals. The Fulton Medical Center is not considered critical-access.
Before the ACA, critical-access hospitals were reimbursed 101 percent of costs of services provided to Medicare patients. The reimbursement rate dropped to 99 percent.
Royer said critical-access hospitals have a better chance of survival, but the Fulton hospital is too close to hospitals in Columbia and Jefferson City to fit in that category.
The Fulton Medical Center has lost patients to nearby hospitals. And Fulton and Callaway County leaders have reached out to the public to use the Fulton hospital.
EmpowerHMS executives made a pledge during a public meet-and-greet earlier this month to restore the community's trust in the hospital.
"The community using a hospital can be a determining factor of success, as well as if the hospital is in a hospital district or gets a small tax," Dillon said.
Before NueHealth announced the closure of the Fulton hospital, local officials mulled the idea of proposing a tax or hospital district, a political subdivision where a special tax is imposed, for voters.
Mueller said rural hospitals must find attract more patients with employer-based insurance and adequate coverage to improve their payer mix and gain financial sustainability.
"They must provide services in a way and market them in a way so" patients "don't want to make the drive" to another hospital, he said.
Despite financial issues, Dillon said some rural hospitals have found a way to expand services, which helps increase patient volumes.
Many rural hospitals also have switched to a nonprofit model or become supported by a charitable foundation, Mueller said, but rural hospitals run by for-profit companies still can succeed by finding ways to lower fixed costs.
"If they're able to engage in more effective contracting for durable medical equipment and other things hospitals have to purchase, they can affect their fixed costs and make the hospitals more profitable."
Mueller said new research studies are trying to pinpoint the effects of rural hospitals' closure on local communities.
"The problem now of trying to get services, something replaces the hospital that is a level of care the community needs, like an urgent care or a freestanding emergency department," he said.
"The effects are a full spectrum of anything from complete loss of all services - and that's a problem - to a change of service mix in the community, and it maybe the appropriate mix."