Such was the case when 63-year-old David Samuels stepped off a cross-country bus in St. Regis on the night of Jan. 24 and fainted into a snow bank near an on-ramp to Interstate 90. He wasn’t found until morning. Covered in a dusting of snow, the Wisconsin man’s body temperature had plummeted to 75 degrees.
Upon discovery, Samuels was transported to the nearest hospital, the small and struggling Mineral Community Hospital in Superior. Staff in Superior were able to stabilize the man, but a cardiopulmonary bypass machine was needed to warm his chilled internal organs. The closest such machine was 60 miles away, at St. Patrick Hospital in Missoula.
Life Flight, the quick bridge between rural and urban medicine, was grounded due to snow flurries. An ambulance from Missoula went to pick him up, and in the course of the ride Samuels’ heart stopped. Heeding their mantra—that a hypothermia victim is not dead until he’s “warm and dead”—paramedics performed CPR on Samuels for the 45-minute ride. Then, the advanced technology at St. Patrick saved his life again.
The story illustrates a trend that unfolds time and again in rural communities across America: lack of access to adequate medical care in rural regions. In Montana, a state in which 45 counties are still classified by the Montana Office of Rural Health as “frontier,” the trend can hit home hard.
In Mineral County, where Samuels spent the night in a snow bank, several factors contribute to the struggles of local health-care providers. Antiquated technologies force many patients to travel to nearby Missoula to use its state-of-the-art medical facilities. That, in turn, leads to low patient volumes and meager revenues for Mineral Community Hospital, which means less money to invest in technological improvements.
And while nursing shortages exist throughout the country, rural regions feel them most deeply because they have few attractions compared to urban areas, and nurses can make more money in cities. On top of that, doctors at rural facilities tend to be younger and less experienced, prompting a certain amount of wariness from locals.
Add these factors up and you have a hospital on the skids, even though it’s good at providing valuable services such as emergency care and outpatient procedures.
Mineral Community isn’t the only rural hospital in Montana suffering from such woes, according to Kip Smith, a program director for MHA, an Association of Montana Health Care Providers.
“Other facilities in Montana deal with similar issues,” Smith says. “As a general statement, rural hospitals are struggling. We have a number of facilities impacted by their geographic [proximity] to an urban facility. But the urban facilities are also an asset, so it’s a Catch-22.”
Though Superior is only 60 miles from Missoula, it’s a different world. It’s a place where an old man with a hand cannon strapped to his belt can shuffle down the icy streets with a ski pole for a cane. A place where four-wheelers zoom down the main drag and sooty-faced loggers undo their suspenders before sauntering into the local market. Nestled in a narrow valley of the Clark Fork River, it’s a town where an outsider will attract extended sideways stares.
Most nobody in Superior cares to spend too much time in Missoula, but more often than not their health care needs demand they travel the distance.
Three occupied overnight beds out of 10 is considered busy on the floor of Mineral Community Hospital. Oftentimes only one patient recuperates within the facility’s gray cinderblock walls.
The modular hospital mimics the architecture of Montana grade schools. Not only a hospital resides on the campus, but also a medical clinic, an assisted-living facility and a nursing home. Don’t be surprised to see old men spending their mornings chain-smoking and gazing at the fire-scarred hills across the way, marking the time with each passing train.
The hospital’s footprint has changed since 100 years ago, when it was a two-story wooden building on the side of the railroad tracks—an image depicted in paintings throughout town. The hospital grew with time and provided critical care for workers at the Diamond lumber mill, who helped to settle the town.
Since the mill shut down in 1994, so has the town’s economy.
The financial tailspin at Mineral Community Hospital led recently to the turn-of-the-year resignation of the hospital’s CEO of several years, Charlotte Lang.
“Everybody wants the shiny new buildings and the latest technology,” Lang says. “It puts Mineral at a disadvantage. We need capital improvements to stay competitive.”
Where to get that money is the million-dollar question. Lang wrote and received several grants over the years, but most of those were just tokeep the hospital up to federal code. So Lang was left with the tough task of cutting hours for receptionists, ward clerks and business office personnel—a move likely to cause hard feelings.
“We tried to think as creatively as possible,” Lang says. “When I left, we couldn’t wring out any more money. The hospital needed to generate new revenue. I decided to leave and I hope they’re focusing on the issues instead of personalities. I did as much as I know how to do. Hopefully someone new will have a magic answer.”
One move Lang made toward covering more of the hospital’s costs was to land federal designation as a Critical Access Hospital (CAH). The program funnels money to hospitals that provide invaluable medical service to rural communities. It also provides larger Medicare and Medicaid reimbursements to such facilities. The catch is that a Critical Access Hospital can’t have more than 15 beds, and must have an average patient stay of 96 hours. The CAH designation is designed to stabilize and maintain local health-care access in rural communities.
But Lang’s magic answer ultimately needs to come from the community, she says. To date, no market research has been done to answer the fundamental question: What kind of service is Mineral County willing to pay for?
The hospital does good outpatient business in diagnostic procedures like colonoscopies. Several procedures and examinations are done each day, but rarely does anybody stay overnight, and if anything complicated—compound fractures and heart surgeries, for example—comes through the door, the patient is quickly shipped to St. Pat’s or Community in Missoula.
The question of whether Mineral County can support an effective hospital is one that nobody feels comfortable answering.
“The jury is still out on that one,” former CEO Lang says. If the hospital were to close, the effect would be devastating on the local economy and on 24-hour emergency health care, MHA’s Smith says.
“In a rural community, the hospital is one of the top two employers in the community. Once you eliminate those jobs, a lot of money stops coming into the community. You also lose critical emergency care and a loss of access to general care. It’s critical in my mind that these health-care systems be in the community. But, that’s up to the community.”
John Rohrer, Mineral Community Hospital’s interim CEO, takes a stab at the question of what sort of facilities are needed in Mineral County.
“The town will tell us that by [its] utilization of this place,” Rohrer says. “It’s not for me to say whether there is to be a hospital in Superior, Mont. Our customers will tell us that. They’ve been saying that there’s needed to be a hospital in Superior for 100 years. Arguably this is never going to be a particularly robust operation. If you look at the financial statements since the beginning of time, it’s never been super-healthy. But it’s always had a way of getting through, a resilience that seems to be evident in a lot of rural facilities.”
Smith weighs in on the advantages of maintaining a hospital versus the most likely alternative—a partial-services clinic in town and a 60-mile drive for specialized care.
“Emergency care is a major service that is beyond a physician’s clinic. In order to sustain those services you need the rest of the hospital. It is extremely difficult to bring medical providers to a community without a hospital,” Smith says.
Rural facilities are inherently hard to manage. Customers want the top-of-the-line technologies, but often there aren’t enough consumers to justify investment in those items, Rohrer says. “Small rural hospitals bring to the table some real challenges. Challenges that relate to patient volumes given the array of services you provide and the relatively high cost of providing those services. So you can get yourself in a bind,” Rohrer says.
A year and a half ago, Lang says, “We bought a CAT scan machine. It costs as much for us to buy one as if Missoula bought one [$130,000], but we don’t have the same volume to get the returns.”
Rohrer is an interim management specialist. He travels to different hospitals and helps them recover when they lose a CEO.
“Sometimes the departure leaves behind a number of management issues that need to be answered in relatively short order,” Rohrer says. “Some of those issues have dollar-and-cent tags attached to them. I do what I can to improve the situation.”
At the top of Rohrer’s agenda is to hire a new CEO, lessen Mineral Community’s dependence on traveling nurses and learn what the community wants from its health-care facilities.
“We need to get out into the community so they can hear the hospital’s story and so we can listen to what the community is telling us,” Rohrer says. “In any community there is a segment that are strong hospital supporters, a segment that feels the opposite way, and the majority of the people in the middle.”
To pick Superior’s brain you need go no further than the IGA parking lot, the primary hub of human traffic in town.
Sheryl Stapleton used to work at the assisted-living facility. “I worked there for three days and quit. I had 13 people to take care of for $6 per hour. It was too much,” Stapleton says.
These days Stapleton goes to Missoula for health care, mainly because she thinks the physicians here are better-trained.
“I tend to shy away from local health care,” Stapleton says. Two of her chief concerns are anonymity amidst the rumor mills of a small town and access to specialized doctors. “The doctors that we have in town are working off their school loans. Some are good. Some are so-so. I think I had the last two babies in that hospital. I was the only one in there at the time, so it was kind of like a home birth.”
Physician trust is a topic that pops up more than once in the IGA parking lot.
“For basic needs I go to Mineral. Anything other than that and I go to Missoula. I think the doctors are better,” says Lee Scholzen, 68. “I have a niece who is a nurse at St. Pat’s. She tells me [who] the best doctors [are]. We have a cardiologist come out, but if anything needs to be done you have to go to Missoula. I might as well start there.”
Scholzen does likes one local specialist, who runs a private practice in town.
“I do go to the soft-tissue therapist in town. He’s really good. He’s got me walking like I couldn’t before. People come out from Missoula to see him. He’s talented at loosening muscles,” Scholzen says.
Robert Ireland is exceptionally fond of Dr. Park, one of the hospital’s physicians, but feels less trusting of the rest of the doctors on staff.
“If it’s life and death, and he’s not there, I’ll go to Missoula. I wish there were more doctors like him,” Ireland says.
But patient trust isn’t the only problem; Mineral Community Hospital also has trouble recruiting nurses. Poor pay and a lack of job availability for spouses doesn’t help. Neither do Superior’s sparse restaurants, entertainment venues or sometimes stand-offish attitudes toward outsiders. Scholzen’s niece was raised in Superior, for instance, but now works as a nurse in Missoula, instead of her home town.
To get nurses, Mineral Community has had to hire staff from national agencies who travel to different destinations around the country where they are needed, and who tend to boost their asking price for hospitals in need.
One exception to that rule is Shawn Harper, a former St. Patrick nurse who now works part-time in Superior. Her husband is the district ranger for the Forest Service, which is what originally brought her to the region.
“There aren’t enough nurses who want to work at the hospital, so they’ve had to bring travelers in,” Harper says. “I’m impressed they’ve been able to keep this hospital open. It’s a great stop-gap for trauma. Especially with all of the wrecks on the [Lookout] Pass. Sometimes Life Flight can’t get in there.”
Harper says that without a rural emergency room to immediately save a life, it wouldn’t matter what kind of technologies are available in urban facilities.
“Some of those people may not have lived if a one-horse-town emergency room couldn’t stabilize them before a larger hospital could respond,” Harper says.
Further woes for the hospital include the high numbers of uninsured. According to St. Patrick CFO Joel Langford, 22 percent of Western Montanans don’t have health coverage. Caring for those people costs St. Patrick $13 million annually.
“To cover those costs in Mineral County has to be an astronomical part of the budget,” Langford says. Indeed, Rohrer says, bad debt costs Superior $200,000 annually.
Sometimes those costs are pushed onto the hospital. Other times, uninsured patients don’t seek needed care, thus a potential customer is lost.
“If you have to make a choice between getting health care or paying monthly living expenses, people tend to put off health care until something drastic happens,” Lang says.
Will Superior’s hospital be able to keep its doors open in the face of so many challenges?
“Yes,” says one of the only people qualified to give a definite answer, board member Tate Kreitinger. “There’s no serious discussion to shut the hospital down. We’re in the process of looking for a new administrator. I think that’s a sign that we want to move forward. That person will evaluate the situation for us.”
No specific plans to nurture the hospital back into good health have been developed yet, but the project, Kreitinger says, will require “strong community support, an excellent medical staff and positive physician relations.
“Getting creative is essential to the future,” Kreitinger says. “But no formal plans have been laid out.”
MHA’s Smith saw a similar hospital in Malta rebound, although it still has problems like any rural facility, and probably always will.
“The administrator recruited medical providers that have stayed for several years in the community. The stability of the primary care offered is there,” Smith says. “They’ve converted to a Critical Access Hospital. And it is an extremely supportive community. They’ve done annual fundraising in the community and have built the support of the hospital. Much of the success of that hospital is driven by the unique nature of the community and the board and administration.”
Nurse Harper hopes to see a similar turnaround in Superior.
“The hospital needs to be here. There are people who can’t afford to go to Missoula. We’ll be here, we really need to be here.”
Contact the reporter: jmahan@ missoulanews.com