MONTGOMERY-Alabama currently has eight counties (Chilton, Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and
Perry) with no hospital. Over the past six years, Alabama has had five rural hospitals close. This is tied
with Georgia for the second highest number of rural hospital closings among all 50 states. Texas, with
nine, has had the most rural hospital closings. Unfortunately, the fact that more rural Alabama hospitals
are experiencing threatening financial difficulties is well known.
Many rural residents and others interested in rural health care are asking if there is a model of health care
facility that can provide care similar to that received in a hospital in counties with no hospital. This need is
being studied by the Alabama Hospital Association and widely discussed by many others, including the
Alabama Rural Health Association.
One possibility is the Freestanding Emergency Department which is a new type of health care facility that
is now authorized in Alabama. This is basically a hospital emergency department that is not attached to
the hospital. Two requirements for this facility limit its possibilities in meeting the needs in rural counties.
It cannot be located more than 35 miles from the parent hospital and must be directed by an Emergency
Medicine physician.
A second possibility is the Critical Access Hospital (CAH) which was first authorized under federal law in
1997. A CAH is certified under Medicare conditions that differ from those for acute care hospitals. A CAH
cannot have more than 25 inpatient beds; must maintain an annual average length of stay of no more than
96 hours for acute inpatient care; must offer 24-hour, 7-day-a-week emergency care; and must be located
in a federally-recognized rural area.
Critical Access Hospitals are encouraged to focus on providing care for common conditions and outpatient
care, while referring patients with other conditions to larger hospitals. In return, this type of hospital
receives cost-based reimbursement from Medicare, instead of standard fixed reimbursement rates. This
can enhance the financial status of many rural hospitals with larger percentages of Medicare patients.
Critical Access Hospitals have not been as financially feasible in Alabama as in many other states.
Alabama currently has only four critical access hospitals: Red Bay Hospital in Red Bay, Choctaw General
Hospital in Butler, Washington County Hospital in Chatom, and St. Vincent’s Blount in Oneonta. There are
30 Critical Access Hospitals in Georgia and 32 in Mississippi.
Currently, there is a state requirement in Alabama that acute care hospitals must have a minimum of 15
beds. Given current restrictions on inpatient stays, many rural hospitals do not have a daily census of
patients that would require 15 inpatient beds. The federal requirement for critical access hospitals is that
there be 25 or fewer authorized beds. There is no required minimum number of beds.
There is a federal requirement that a critical access hospital must first be an acute care hospital and then
convert to a critical access hospital. A new hospital cannot be opened as a critical access hospital. With
Alabama’s requirement that acute care hospitals must have 15 or more authorized beds, a new hospital
must be constructed with a minimum of 15 beds, even if there is no need for so many beds.
The current financial crisis among many of Alabama’s rural hospitals may make the time right for Alabama
to take a look at our regulatory requirements for acute care hospitals to consider allowing our rural areas
to have hospitals with fewer than 15 beds. These facilities could operate as acute care hospitals or
convert to critical access hospitals without being required to have more beds than they can realistically
expect to need. This could be done as a change in regulatory requirements for acute care hospitals or by
authorizing a new type of hospital – the Small Rural Hospital. Either of these approaches would require
approximately a year to complete the legal procedure if there is no opposition, possibly more time if there
is opposition.
Several states already have rural hospitals with small numbers of authorized beds, including Tennessee
and Mississippi. The Johnson County Community Hospital in Mountain City, Tennessee is a 2-bed critical
access hospital with 78 employees that operates at a profit when the annual critical access hospital
payment is received. The emergency department at this facility treats patients with minor conditions and
sends then home, stabilizes patients with more serious conditions for transfer to a larger hospital, or keeps
those who should be observed overnight. The emergency department utilizes tele-medicine and an
emergency department staffing service. There is a certified rural health clinic affiliated with this hospital.
Major services such as radiology, other scanning, laboratory, and therapy is provided. This small hospital
even provides obstetrical service.
The Greene County Hospital in Leakesville, Mississippi is currently a 3-bed critical access hospital that is
being expanded to seven beds in a county that does not have a single physician, like Coosa County here
in Alabama. This hospital has 55 employees and is also operating at a profit. There is a 60-bed nursing
home attached to this hospital and it has a certified rural health clinic. The services provided at this
hospital are quite similar to those in Mountain City except that tele-medicine is not being utilized and the
emergency department is staffed by four advanced practice nurses (Certified Registered Nurse
Practitioners) who commute from Mobile, Alabama to provide this coverage. Advanced practice nurses
cannot provide this coverage in Alabama, though there is some discussion about considering this
coverage to hold down costs during early morning hours when patient traffic is light.
Can small rural hospitals like these provide part of the solution to our rural hospital crisis in Alabama?
One thing for certain is that continuing to allow rural hospitals to close is not part of the solution.
MEDIA RELEASE/ALABAMA RURAL HEALTH ASSOCIATION/DALE E. QUINNEY
