When rural hospitals close, access to critical health care is at risk

Half a dozen goldfinches greet patients with their chirping from a cage in the waiting room at Boone Health Primary Care Clinic in Mexico, Missouri. The birds belong to Dr. Peggy Barjenbruch, who together with Dr. Michael Quinlan has been serving the Mexican community for decades.

That looked like it might come to an end last fall when the hospital they were associated with, Audrain Community Hospital, suddenly closed.

Audrain Community Hospital has been a staple of the community since its inception in the 1980s, but in September it joined a growing list of hospital closures across the country. More than 130 rural hospitals in the US have closed in the past decade. Dozens of those closures have occurred in the Midwest, including 10 in Missouri, amid pressures from shrinking populations and lower reimbursements for care due to uninsured patients.

In many rural towns, local hospitals are community facilities. If they close, the entire community will feel the impact and access to critical healthcare is at risk. For Barjenbruch and Quinlan, the closure brought uncertainty.

“We always thought we were big enough to move on,” Quinlan said.

Hospital closures put patients in a difficult position

A native Mexican, Quinlan grew up with the hospital in the heart of the Mexican community. It closed shortly after changing ownership for the second time in two years. Kansas City, Missouri-based Noble Health Corporation acquired the hospital in 2021.

After increasing internal unrest within the company, Noble sold the hospital to Texas-based Platinum Team Management, which closed the facility. Quinlan said towards the end the staff worked without pay to continue to serve the community.

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After the closure, the Audrain County Health Department had to set up a phone line to answer patient questions, CEO Craig Brace said.

“We had a nurse dedicated to those questions, finding answers, and providing them,” Brace said.

But some of these questions did not have easy answers. The closure of the local hospital means the nearest option for emergency care and other inpatient services is 40 miles away in Columbia.

Quinlan said this put his patients in a difficult situation.

“Sometimes in the morning you hear, ‘Oh, I had a chest pain at 2 a.m. and I just wanted to see if I could see you guys,'” he said. “…we don’t want to risk that.”

Patients have also rescheduled important appointments like cancer screenings, Quinlan said, hoping the hospital will reopen.

There is no sign of this in the foreseeable future, but other providers have moved in. MU Health opened two clinics in Mexico this summer, including an emergency center. And Boone Health acquired Quinlan’s outpatient clinic in October.

Boone Health CEO Troy Greer saw benefits in the move for both his healthcare system and the community.

“It allows Boone to continue to grow in those areas to meet their needs, but also [creates] a more convenient place for those people to use Boone services,” Greer said.

But stepping in to run the hospital isn’t something Boone or any other entity is capable of, according to Greer.

Emergency care is difficult to replace

One emergency care option that has spread to other states is the standalone emergency room — an emergency room that is not attached to a hospital. Freestanding emergency rooms often provide faster care than traditional emergency rooms, but can also have higher prices.

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While much of the freestanding emergency room has occurred in suburban areas, they could also be an option for rural cities, said Dr. Cedric Dark, an assistant professor of emergency medicine at Baylor College of Medicine in Houston, who studies freestanding emergency rooms.

“If we’re talking about rural hospital closures, I think you should at least be able to keep the ER open as a freestanding ER because people in those communities still need access to emergency care,” Dark said.

Regulations in several states, including Missouri, effectively ban freestanding ERs. According to the Missouri Hospital Association, the state does not recognize or license freestanding emergency rooms.

That means communities like Mexico must find other ways to keep their hospitals running, whether through private equity firms or individual investors.

Quinlan and Brace were hoping for a potential investor who had expressed an interest in the hospital reopening. However, according to Quinlan, Platinum recently sold the property to another buyer.

Instead, Quinlan said the recently enacted federal rural emergency hospital designation was a consideration. This would allow the hospital to reopen its emergency department and offer outpatient care.

However, Quinlan said there are also plans to open a micro-hospital elsewhere – offering emergency services and some inpatient care – if the Audrain Community does not reopen.

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