Standing room only for 24 hour emergency care discussion

During the Board of Commissioners "Committee of the Whole" meeting, held Monday, September 11th, several items were on the agenda.

The meeting opened with a moment of silence in remembrance of the events that took place on September 11, 2001, followed by prayer led by Mike Webb as well as the Pledge of Allegiance.

There was no public input, so the meeting flowed directly into the first item on the agenda: Group discussion regarding the major need for a small hospital and 24-hour emergency health care facility with the County Commission, health care professionals, and local, state and federal officials. In attendance were: Dr. Martin Chaney, CEO of Maury Regional Health, Rick Williams from Congressman Andy Ogles office, Brittany Montgomery from Senator Bill Hagerty's office, Jeff Parrish from Senator Marsha Blackburn's office, Susan Hensley, Linda Grimes, Todd Reed and Mike Webb of the Healthcare committee, Tri-Star Health Alliance Vice President Bill Jolley, State Representative Jody Barrett, State Senator Joey Hensley, Chief Administrative Officer of Ascension Saint Thomas Hickman Hospital Kevin Campbell, City Councilmen Scottie Bass and Chris Trull, City Mayor Danny McKnight, Chamber of Commerce Director Debbie Landers, and local business partners, Oliver Technologies COO Paul Cameron, and owner of Summertown Metals Matt Stoll.

The purpose of the meeting was two-sided. From the community standpoint, the commissioners were able to share what they are hoping to achieve, and those in attendance were able to share what has and hasn't worked in their experience. Commissioner Feichtinger began, "With the recent survey you all just had done, what do you foresee as maybe a solution for us as far as funding available for rural health?" Senator Hensley responded, "We've seen a lot of rural hospitals close. The main reason is because of Medicaid and Medicare rates are low. Rural areas have a high rate of those patients, so hospitals struggle financially in those areas. What happened here years ago is the company that owned the hospital went bankrupt and went out of business. Instead of allowing the hospital to close, Maury Regional bought it. The real problem is reimbursement rates. Tenncare rates are even lower than the already low Medicare rates. If the State could get those rates up, that would certainly help. There are grants available for emergency hospitals. You have to not only open the hospital, but then you have to run it. This is where the expensive undertaking of running a 24 hour facility really comes in."

Addressing the round table of officials, Committee Chair Kyle Bobo asked, "Something we've been discussing as of late is that after-hours care. It is our main concern. We do not have anything like that in our community, and unanimously, this is our focus. So, what are ways to navigate achieving emergency care and/or after hours care?" Jeff Parrish responded by asking how far away the closest hospital is. "35 miles on the money," responded Commissioner Pigg. "Most folks in this discussion about rural healthcare," continued Parrish, "run into this. There is a federal rule that says you cannot have a free standing emergency room within 35 miles of each other. Senator Blackburn and we are working feverishly to break down barriers and change rules that maybe made sense at the time but are not working for us anymore. We just ran into that in Perry County where an organization wanted to come in and reopen an old hospital, but that 35 mile rule came into play. Also, it is possible to obtain waivers at the federal level from an organization called CMS (enforcers of the Medicare rule and the 35 mile rule). They can issue a waiver if presented with great arguments and reasoning." He goes on, "I encourage everyone to look at Jamestown, Fentress County. After their hospital closed, they formed a partnership with UT Medical and petitioned the government, pled their case and begged for a waiver for the 35 mile rule. It is the first one we are aware of that has been granted. Selmer, Tennessee is on the same path and in the process of following the Jamestown experience." Mike Webb made the observation that if an ambulance is called from the Hampshire station, it is going to be longer than 35 miles to get to them and then on to the hospital. Feichtinger agreed, "35 miles as the crow flies is not 35 minutes for us in Lewis County, it is 45 minutes to an hour ambulance drive, depending on where in the county you're coming from. And that is the difference between life and death sometimes. If we had rural emergency care, like Dr. Hensley said, it would be beneficial." Parrish commended Feichtinger, "35 miles as the crow flies is part of the argument Jamestown made that got them the waiver. They did traffic studies and had ambulances drive the terrain. Providing their studies and research is what landed them this deal, and you're on the right path."

Maury Regional CEO Dr. Martin Chaney spoke up, "Just to add a little historical perspective, we have been in conversations with Wayne County as to what to do with Wayne Medical Center. We are averaging about one inpatient and 14 ER visits per day. Wayne is a similar size county to Lewis, and we have been looking at the options there as well. We are bound by the 35 mile rule and cannot turn that into a critical access hospital, because as I understand it from the CMS, you have to be in mountainous terrain or the predominant roads used to get to the closest hospital have to be considered secondary roads. Wayne County does not fall into either of these, and so we cannot convert that into a critical access facility. Critical Access is a designated hospital from CMS that allows you to get reimbursement from cost plus. Which the cost of caring for the patients plus about 2-3% in addition to make a positive margin to reinvest into your system. So, going through the exercise with Wayne County, the Wayne County Commission decided about two months ago to convert Wayne Medical Center into a Rural Emergency Hospital, which is somewhat like a free-standing ER, but it is allowed to be within 35 miles of other hospitals, and you can keep patients there on an observation status, but not an inpatient status." He goes on to make the statement, "The challenge with rural hospitals is that to be in inpatient these days usually requires specialists to be involved in your care. The old model of hospitals admitting inpatients is no longer the best model to care for patients. So, I think going to a hospital model here is probably not the wise thing to do in the long term. I don't think the volumes would support it, and I don't think the shift in care of patients would be challenging. Hohenwald would not qualify for a rural emergency hospital. That designation is only to convert an existing hospital that is either critical access or an acute care hospital. And that hospital has had to have been in operation in 2020. With the hospital model taken off the table, the other options become an emergency department presence or urgent care presence." The emergency department includes options such as a free-standing ER, where if you are sick enough to be admitted, you will be transported to a hospital that can care for you. The urgent care model involves care for lacerations or caring for a sick child at midnight. The difference between these and a full emergency room is that the full ER is typically supported by a 24/7 X-Ray or Imaging capabilities to support the ER's decision, and lab capacity where you could have blood drawn. The urgent care model would have a physician on site, maybe a nurse practitioner, but wouldn't always have the lab and imaging available all the time. "We, at Maury Regional," said Chaney, "had that model here for many years, and our numbers and volume in Lewis County had gotten so low, that the math didn't work for us either. But if we could make the math work better as far as staffing physicians and nurses 24/7, we are certainly willing to have that conversation." He went on to express, "I think an ER would require a new facility with new codes. In today's market, that would be millions and millions of dollars. I would estimate a minimum $20 million investment on top of the operational costs of keeping a lab and x-ray in an ER 24/7. That means that need-to-treat number would have to be at a certain level to get to even break even. That's where the community would have to subsidize, to some degree, the difference."

There has always been a discussion regarding Certificate of Need when conversing about opening a hospital. Certificate of Need (CON) is a permit for the establishment or modification of a health care institution, facility, or service at a designated location. Popular opinion in Lewis County says it has hindered medical facility advancements for our community for too many years. Senator Hensley addressed this saying, "We did pass a bill last year saying a rural county like Lewis that doesn't have a hospital no longer needs to go through the lengthy process of getting a CON."

"Dr. Chaney is correct," added Jolley. "For this community to qualify for a designated REH, it would require congressional action. Getting back to Senator Hensley's comment, our hope was, leading the nation as the state with the most per capita hospital closures, that Congress would work to come up with an alternative for these communities that don't have a medical presence. Is there an opportunity legislatively to change the program that would allow them to open an REH. As Chaney stated, currently that opportunity does not exist for Lewis County.

Commissioner Pigg asked Chaney, "What is the number of Lewis County patients seen at Maury County's facility each day?" To which Chaney replied, "Our mission and our vision is community healthcare, and all of our profits, all of our margins so to speak, go back into our health system to grow our community. We would have to look at what those numbers are and know that there would be some sacrifices to partner with you all, just like there would be some sacrifices on the county's side to have that 24/7 presence that you all really want."

To close, Commissioner Feichtinger stated, "It seems to me, to achieve our goal of 24 hour emergency services, we have two main obstacles to overcome. The 35 mile rule and the 2020 date of service regarding the conversion of an existing hospital are those two obstacles. I would like to look into the possibility, from a litigation perspective, of altering them both. Doing so would give us a chance of having an REH here locally. This is something that Lamar Alexander had championed back in 2018, and I believe it would greatly benefit this area."

Parrish agreed and encouraged the commission to start the research and gathering the data that will be needed for the task. "The federal rules are being looked at and evolving. There is hope."