[ozone1]

How about development of regional care.
Local centers with Nurse Practioners/PA that take care of basics: physicals, blood draws/ sore throats/ stitches,(get a waver from the state for MD oversight)(could be any house, old church in area, even a stripped mobile home, requires no expensive equipment (there are auction sites for used hospital equipment) referal to local hospital for XRAYs, more complicated cases requiring MD input. Mobile CAT, MRI, PET scans are available (once a week, month they drive up to the hospital and plug in). Hospital only cares for less sick patients, obstetrics, anything requiring specialist gets referred/transferred to regional hospital (some people call this dumping, but if you don't have the quality care, don't offer it). Sign up with Tertiary care center for referrals and you can usually get specialists to see outpatients a day or 2 a month. Recognize you can't do everything and only offer basic quality services. Emphasis on ER/elderly care.

[ozone1]

You can also probably do an infusion clinic, Chemo, antibiotics. This way you don't need an oncologist and patients can still receive some treatment locally. All this can be based on prescriptions from specialists at regional/tertiary center, Oversight is through ER physicians, Faxes/phone calls to specialists. Reimbursement is still profitable.

[ozone1]

While your at it you can contract out pharmacy services to another hospital and they can use pyxis machines and a decent hospital computer system. You can also contract out physical therapy, speech therapy services. Or you can integrate these services with your home health care subsidiary (usually not profitable). PA's and Nurse Practitioners can also usually do most of the inpatient care. But the M.D.s usually want the money for services so your going to have to fight them. Other things you can do is convert some of your inpatient beds to skilled nursing beds/ long term care. Metal space buildings are fairly cheap and they do have standard designs available.

[liberallarry]

That's exactly where we're heading now - with one problem; the emergency room. We must have one to be called a hospital - and one is needed. Without ours a 200 mile stretch of an important highway would be uncovered. Also, we provide basic stabilization for locals and tourists (big recreation area). Because of this need we are labeled a critical access hospital and get some breaks from the federal government.

Our "hospital" has 37 beds. 33 are devoted to acute care - and are profitable (more or less). The other four are to service the ER - and are terribly costly. We also provide X-ray and some lab services. We can't keep a doctor in town. But we must have one on call to staff the ER. So we have a costly contract which brings doctors up here on a rotating basis. Not a great solution. Often people don't like what we get.

Not sure about mobile services. If we have them I'm not aware. The regional hospital is 65 miles away and is good enough to deliver most - but not all - services. The nearest full service hospital is 300 miles away.

There's an additional problem: We don't really get paid for the services we provide. Medicare, Medical, the insurance companies, the HMO's...none of them pay the real cost. We have to negociate for everything. AND we must take everyone - including complete indigents. If we could charge fair price for our services we wouldn't have a problem. But then virtually no one would have any medical care.

Barring some dramatic and unforeseen change in technology, the law, and/or organization the future is as you describe. Regional hospitals in the biggest towns in the counties. Smaller towns losing services and gradually drying up.

[liberallarry]

Ozone, my administrator found your suggestions very interesting. It turns out she had either heard of or tried them all. Ditto, my explorations of alternative medicine.

The problem remains; small rural hospitals simply do not have the volume to support most hospital services.

However, help has come from an unexpected quarter. The Federal government has designated us a critical care hospital which means the government considers emergency medical services at regular intervals to be an integral part of the national highway system. So they'll help us pay for the emergency room - solving our most pressing financial problem.

We are going to continue developing clinic services - which are appropriate for small communities.

Thanks to both of you for your help and encouragement. Perhaps some of this will be helpful to someone else next time around.