Clarksdale Press Register
Delta Council Addresses Rural Health Care
By Floyd Ingram
Small, out-patient hospitals are not the wave of the future – they are here.
One of the nation’s top healthcare experts told those gathered for the Delta Council’s annual meeting last week that big-box, multi-service hospitals with a range of specialty doctors are fading fast and will soon only be found in larger metropolitan areas.
Richard Cowart, a Nashville attorney specializing in rural healthcare, was hired by a group of Greenwood businesses to help Greenwood’s hospital pursue a federal designation that, if granted, could ensure its long-term viability. The Clarksdale hospital’s new board of trustees is seeking a similar designation.
“You cannot afford specialty care in every community in the Delta,” Cowart told the Delta Council audience. “There is not enough population.”
Depopulation is a factor across the Delta with Coahoma County losing 18-percent of its population as reported in the 2020 Census. The county’s population currently stands at 20,197 and falls by about 300 people every year.
Cowart was also hired to help the Delta develop a regional approach that will allow local medical facilities to not only survive, but figure out ways to improve the healthcare brought to town by local hospitals.
He said repeatedly the Delta needed a fresh approach to healthcare. He talked of micro-hospitals that have 10-to-20 beds, an emergency room, a small Intensive Care Unit, basic services and diagnostic equipment, telemedicine and doctors that visit the facility weekly rather than daily.
He said these regional micro-hospitals also serve surrounding counties. Cowart cited examples in Alabama and Tennessee as two states that decades ago developed successful regional models.
“The best way to survive when you are small and at risk is to play as a team,” he said.
Cowart also said Delta healthcare providers need to think carefully and plan wisely in the midst of what he called a national rural healthcare crisis.
“You can’t make long-term decisions in a crisis,” said Cowart. “You’ve got to stabilize the patient. We’re going to try and stabilize the patient, and then we’re trying to take the long view as to how you take a different view and a fresh view and a regional view to health care.”
He noted the latest estimate by the Center for Healthcare Quality and Payment Reform that nearly 30-percent of all rural hospitals in the country are at risk of closing. In the Delta, the problem has gotten especially severe, he said, with all five of its acute care hospitals, including hospitals in Clarksdale Cleveland, Greenville, Greenwood and Rolling Fork, operating at a loss or at least running low on cash.
Cowart noted a micro-hospital in Crittenden County, Ark., has bucked that trend and has seen emergency room traffic increase and that leads to follow-up visits with local doctors and clinics. That hospital is affiliated with Baptist Healthcare, is about 65,000-square-feet, has 11 beds and was built for about $40 million.
He said most rural hospitals were built at a time when inpatient care was more common, and they were designed with the physical space to accommodate it. Inpatient volumes, though, have dropped dramatically, a trend that was accelerated by COVID-19. Today, about 60-percent of health care is performed on an outpatient basis, and that is projected to grow to 80-percent, according to Cowart. That has left hospitals in rural areas, which were also impacted by population declines, operating at 15-percent capacity or less.
Cowart said he was hopeful that Greenwood Leflore will be granted a waiver on the distance rule that would normally disqualify its application for critical access status. But even if that endeavor is successful and, together with several short-term cash infusions, restores the hospital to financial stability, that won’t be “the end of the job,” he said. “That is just to get you in a position to start thinking about what do you do that is longer term and more sustainable.”
Clarksdale is also seeking a change in distance rules that affect its status.
Cowart said communities in the Delta need to start collaborating — similar to the concept that drives Delta Council’s agriculture, economic development and flood-control efforts — in developing a regional approach to health care. The broad outlines for that, he said, might be identifying those essential services — such as emergency and obstetrical care — that every county should have, but to be more strategic on where specialized treatment is provided.
Cowart only mentioned briefly in his first presentation — and not at all in his second — a topic that has been of considerable debate in Mississippi: expanding Medicaid to cover mostly the working poor, as provided under the federal Affordable Care Act. Expansion has been endorsed by Delta Council as well as the Mississippi Hospital Association, but it has gotten nowhere in the Republican-dominated state Legislature. Gov. Tate Reeves and outgoing House Speaker Philip Gunn, both of whom were on stage with a host of other state officials for Friday’s main gathering, have been unflinchingly opposed to expansion. Mississippi is one of only 10 non-expansion states.
Cowart was retained in late 2022 by the B.F. Smith Foundation of Delta Council to assist the region in navigating the increasingly more complex world of rural health care.
Cowart is a recognized authority in advising senior management regarding policy, regulatory and business issues related to health care. He serves as strategic counsel to health care companies (both for profit and not-for-profit) and counsels providers on business, policy and governance issues, with an emphasis on business transactions.
Delta Health System (DHS), out of Greenville, formally handed over the reins of the Clarksdale hospital to a five member local board of trustees on May 1.
Paperwork signed May 1 included what is being called a “bill of sale” where the equipment at the hospital was turned over to Coahoma County, an intangibles agreement that turns over accounts receivable and payable accounts, contracts and insurance, the lease turning the DHS Clarksdale facility back over to the county and an agreement to release DHS from their lease once all terms of the dissolution are satisfied.
Hospital board of trustees attorney Ted Connell said at that time the board of trustees and the interim leadership team, headed up by Stroudwater consultants, were busy and had been meeting regularly to prepare for this transition. He pointed out the process of the transition will take from 60- to 90-days, but Coahoma County now manages the community’s hospital.
Supervisors signed a resolution in mid-April to sever ties with Delta Health System of Greenville, establish a local board of trustees and develop a plan to move the local hospital forward.
Supervisors also agreed to commit up to $15 million from the county $30 million Hospital Reserve Fund to help the fledgling board operate, create a budget, buy items, make changes in the physical plant and – if needed – make payroll.
The new hospital board of trustees has asked for $10.6 million at this point.
Having this line of credit will allow trustees and Stroudwater to plan for improvements at the hospital. Items that have been discusses with supervisors are new computers and software, immediate repairs, paying vendors, recruiting doctors and nurses and payroll.
The hospital’s new board of trustees is made up of: Bowen Flowers, President; Donnell Harrell, Vice-President; Tripp Hayes, Secretary; Lela Keys; and Alan Byrd.
The hospital is applying for a “critical access” designation that is being evaluated by the Mississippi State Department of Health, who must sign off on the application before it goes to federal regulators. As a critical access hospital, the Clarksdale hospital would be eligible for a larger annual Medicare reimbursement.
The main hurdle to that application is a regulation that would disqualify the Clarksdale hospital because it is located within 35 miles of other hospitals, specifically in West Helena and Marks.
Connell and Flowers made a trip to Washington D.C. to meet with Senators Roger Wicker and Cindy Hyde Smith and Congressman Bennie Thompson to explain the hospital’s situation and seek help at the federal level.
DHS Greenville announced in August it was having cash flow problems and that Clarksdale’s hospital was part of their problem. Greenwood-Leflore Hospital has reduced services and is also seeking ways to increase revenue.
Coahoma County Supervisors met with leaders of Delta Health System in a special called meeting Aug. 30, to discuss concerns at the Greenville hospital. The board then hired Stroudwater to gather data on the local hospital and offer solutions to revamping services at the local facility.
While the county has hired Stroudwater as a consultant, Stroudwater will actually be working for and with trustees. In Mississippi, hospital trustees are governed by state law.
Healthcare is a major industry in Coahoma County and a factor in attracting industry and jobs to a community. It is a key component to a community’s Quality of Life.
The COVID-19 pandemic, rising costs due to inflation and the shortage of nurses and doctors to staff hospitals have hit rural hospitals hard. Indigent care has also been a problem with emergency rooms required to treat a patient, but no guarantee of payment.
The complexity of the issue means there are no quick fixes and Stroudwater will work with the county for at least 18 months to see if there is a solution and way to make the Clarksdale hospital profitable.
Supervisors have asked the hospital board of trustees to provide a report through Connell every 30-days for at least the next three months. Hospital trustees are meeting regularly and – like county supervisor meetings – they are open to the public.