Just off the historic U.S. Route 66 in eastern New Mexico, a 10-bed hospital has for decades provided emergency care for a steady flow of people injured in car crashes and ranching accidents.

It also has served as a close-to-home option for the occasional overnight patient, usually older residents with pneumonia or heart trouble. It’s the only hospital for the more than 4,500 people living on a swath of 3,000 square miles of high plains and lakes east of Albuquerque.

“We want to be the facility that saves lives,” said Christina Campos, administrator of Guadalupe County Hospital in Santa Rosa. Its leaders have no desire to grow or be a big, profitable business, she said.

But even with a tax levy to help support the medical outpost, the facility lost more than $1 million in the past six months, Campos said: “For years, we’ve been anticipating kind of our own demise, praying that a program would come along and make us sustainable.”

Guadalupe is one of the nation’s first to start the process of converting into a Rural Emergency Hospital. The designation was created as part of the first new federal payment program launched by the Centers for Medicare & Medicaid Services for rural providers in 25 years. And though it is not expected to be a permanent solution to pressures facing rural America, policymakers and hospital operators alike hope it will slow the financial hemorrhage that continues to shutter those communities’ hospitals.

More than 140 rural hospitals have closed nationwide since 2010, and health policy watchers aren’t sure how many of the more than 1,700 rural facilities eligible for the new designation will apply. CMS officials said late last month that seven have already filed applications. Dr. Lee Fleisher, director of the Center for Clinical Standards and Quality at CMS, said how long it will take to review the applications will vary. The agency declined to provide the names or locations of hospitals seeking the designation.

Facilities that convert will get a 5% increase in Medicare payments as well as an average annual facility fee payment of about $3.2 million in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds that closed after the law passed on Dec. 27, 2020, are eligible to apply for the new payment model if they reopen.

The new program “strikes me as the first time we are saying, you know, maybe we can just take the beds away,” said Dr. Paula Chatterjee, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine. Outpatient and emergency visits already make up about 66% of Medicare payments for rural hospitals that are eligible to convert, according to Chatterjee’s recent research.

Still, she found that many would likely need to scale up some outpatient services, such as telehealth and substance use care. Even then the payment model might not be able to shift the “foundational pressures” of declining, aging, and sicker populations that are making it hard to deliver care in rural America, she said.

“This feels like rearranging deck chairs on the Titanic,” Chatterjee said.

More than 50 hospitals and other organizations have expressed interest in the rural emergency designation, said Janice Walters, chief operating officer of programs for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to facilities interested in converting.

Most hospitals “are still trying to figure out, ‘Is the math going to work?’” Walters said.

Those showing immediate interest are very small, with three or fewer patients staying overnight any given day, and, generally, they long ago gave up maternity care to save on expenses. The federal law will need to be amended to help larger rural hospitals with more overnight stays, said Brock Slabach, chief operations officer for the National Rural Health Association.

“It’s enough for now,” Slabach said. “But is it going to be enough for the long term? I don’t think so.” Top priorities for the group include adding the ability for hospitals to participate in a federal drug discount program and allowing for longer patient stays.

At Stillwater Medical in Oklahoma, Chief Administrative Officer Steven Taylor said the switch already makes sense for two of the system’s smaller hospitals that “have struggled financially.” The small regional health system’s outpost in Perry, which rarely has more than two inpatients a day, has already filed an application, and its facility in Blackwell will likely do so soon, he said.

Keeping emergency services “is the most important thing” for the small communities, he said. The new model requires a 24-hour emergency department and a clinician on call. It also caps the average length of patient stays at 24 hours — which Taylor said is not a problem. One patient may need to be watched for 12 hours for chest pain while another, with pneumonia, may need to stay for 36 hours, but that will average out to less than 24 hours for the year, he said.

Plus, he said, anybody who needs more intense care can be transferred to their regional hospital in Stillwater. Oklahoma, like other states, is working to update state laws for licensing or regulations to ensure hospitals can be credentialed with the rural emergency designation quickly.

John Henderson, president and chief executive of the Texas Organization of Rural & Community Hospitals, agreed with other speakers at the National Rural Health Association’s February policy conference in Washington, D.C. The new rule “could be a relief valve” for very small rural hospitals, he said. A two-bed facility in Crosbyton confirmed for Henderson earlier that day that it was the first in Texas to be approved for the new payment mechanism.

Henderson said he knew of several more of the state’s 158 rural hospitals that are applying or have already applied, and others are considering it: “These are the folks that are just hanging on.”

Dr. Denise Brown, CEO of virtual care provider Fident, spoke up from the front row during Henderson’s presentation. Her company uses telehealth so doctors and other clinicians can work virtually with multiple hospitals in different states. Brown said she was concerned that hospitals that convert won’t have enough ambulances available to transport or a place to send sicker patients, especially if they aren’t part of a larger health system.

Heads began to nod throughout the crowded room. Many rural hospitals needed every bed they had during the worst of the covid-19 pandemic, and to give up those beds now seems counterintuitive.

Those same rural hospitals often find that larger facilities refuse to take their patients who need specialized care, Brown said.

“How do I know that I can guarantee somebody a bed?” Brown said, adding that she prefers rural hospitals keep patients longer. How would she explain to concerned family members that their loved one was “two or three hours from home”?

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How can a physician trained in dermatology, pediatrics, obstetrics, podiatry, or orthopedic surgery suddenly be pulled into life-saving, gut-wrenching work as an emergency medicine physician? What prepared them for this, and how can they perform adequately when no one has a few minutes to prepare them for the next emergency patient who needs ventilation? How do they handle the dreadful death toll of this virus? What about their medical ethical mandates when triage is indicated?

The practice of medicine for many of these out-of-specialty physicians will be and is dramatically different during the present and future pandemics. Once working in private offices, group practices, or standing in state-of-the-art operating rooms, these physicians will find themselves propelled from 20th-century medicine into new standards of 21st-century medicine within months. New-normal medicine will be uncharted territory and will tax many of their beliefs about healthcare.

Work may, at times, be in field hospitals set up by the military or in settings that formally were used for other purposes, including hotels, convention centers, factories, warehouses, tents, and even ships. Their former, somewhat predictable, daily routine will no longer be the routine that continues. How will it affect them?

Suicide Statistics Provide a Small Window

The consequences are far-reaching not only for the physicians but for their families and their fortunes. Physicians are not immune to emotion, and we know that by the statistics that lay out, in an eye-opening fashion, the suicide data relative to physicians.

“Suicide is the second most common cause of death for 10-to 34-year-olds in the United States. The average age of matriculating medical students in 2017–2018 was 24. Thus, it should come as no surprise that medical students, residents, and attendings — like other Americans — are affected by suicide and mental illness.” An estimated 300 physicians commit suicide each year, but that statistic is old and doesn’t factor in a pandemic with all of its increased stress and potential burnout in addition to PTSD (post-traumatic stress disorder).

Out of Specialty Work

Graduating medical students take the Hippocratic Oath, which sets their career course in terms of ethics and morals. The newly-minted physicians expect to undergo grueling years of advanced training. Each specialty has been carefully evaluated for their interest and their skill-level.

Personalities, too, were included in the search for their future career goals. Once the COVID-19 hit, the best-laid plans of new docs went awry in directions no one could predict.

Not all physicians are “people” people but now their choices would be limited by a pandemic. Some would have preferred the solitude of a lab or the absolute authority of the operating room rather than the M.A.S.H environments into which they were thrown.

Challenging is one of the words most often used by physicians and nurses who were placed into unfamiliar circumstances where they needed to refresh or learn new medical protocols. The main concern, now for all, was how to protect themselves and their families, once they were off shift. They knew they were dealing with an incredibly deadly, contagious virus, and it clung to clothing, cardboard, metal, and several other materials and hours if not days.

The virus was also resistant to heat, presenting an additional difficulty in labs and treatment rooms. It wasn’t easily killed or removed.

Even the protective materials that were to be used required special procedures for removal. An additional concern was whether or not there would be adequate masks and gowns on the next shift. If the work didn’t demand yeoman-like skills, the anxiety of not having PPEs (Personal Effective Equipment) available heightened the stress.

Whoever thought needed supplies or machines wouldn’t be there when needed for treatment or to save a life? It was out of the realm in which they had trained.

Ethical Concerns Arise

The difficulty which presented itself was whether or not to refuse reassignment to an ED (emergency department) or chance catching the virus while working in the ED. Did physicians come to their work as a “calling” or a profession that made difficult ethical choices a part of the bargain?

Some in healthcare would refuse to work if PPEs weren’t in adequate supply. Was ethics involved at all here? Is it mandatory that physicians and other healthcare workers put themselves in situations of extreme risk and death to satisfy their oath to serve? What does a physician do in situations of scarcity where staff or equipment is at a premium?

One article has addressed this situation in a forward-thinking manner. “Educators should begin to teach “scarcity thinking” in medical schools, residencies, and other training situations, with a focus on practical guidance for contingency planning and a deep understanding of the ethical principles of implementing crisis standards of care.” We can put this under “lessons learned” during a pandemic.

Is working in an area in which the MD is not a specialist an ethical issue? A medical license does not indicate a need to be a specialist and often states the person is qualified to practice medicine and surgery. But a license is poor protection.

The duty to treat has come up against new ethical issues outside areas of specialization. And the situation is not contained in one area of the country or the world or to one specialty. “We’re hearing a lot of anxieties from specialists who don’t know what the right thing to do is for their patients,” said Dr. Megan Ranney, an emergency physician in Rhode Island. “Dermatologists, ophthalmologists, we’re even hearing from dentists.”

As a result of the difficulty of the pandemic, “U.S. medical professionals on the front line of the coronavirus pandemic are lobbying policymakers for protection from potential malpractice lawsuits as hospital triage care and physicians take on roles outside their specialties.”

For any physician or healthcare professional, COVID-19 difficulties can be daunting. In the case of physicians wishing to volunteer or to come out of retirement, the American Medical Association has provided a series of guides.

For employed physicians, the AMA has another bit of assistance in “a guide that concisely covers key strategic, legal, and contractual considerations. The information is not to be construed as legal or financial advice, but it is meant to help physicians understand their rights and the opportunities available to them.”

In the greater scheme of things, a physician, NP (nurse practitioner), PA (physician’s assistant), or another licensed medical professional has to weigh the moral/ethical issues as well as the legal ones. Guides may provide some valuable information, but the law isn’t always so clear-cut on many matters, and medicine is one of them.

The swirl of a pandemic created in 2020 will change all of us and the world in which we live, the hospitals in which we work and the labs where advances are made to name a few. Many other changes may come as surprises or welcomed advances but that’s not for us to know today. We await a better tomorrow after this dark night in which we now find ourselves.

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