Unlike some other Kansas hospital managers, Mercy may have done everything right in Fort Scott — except for predicting the future of medicine

FORT SCOTT — Sisters of Mercy, a Catholic women’s organization founded in Ireland in the 19th century, began providing healthcare in Southeast Kansas with its establishment of the original 10-bed hospital in Fort Scott in 1886. One century and three decades later, by then officially managed by Mercy Health Foundation, Mercy Hospital Fort Scott had expanded to a 46-bed acute care facility serving not only Fort Scott but surrounding areas as well.

Then, late last year, Mercy announced the hospital would be closing at the beginning of February. For many in the community, the news was devastating.

"Babies are going to be dying," one longtime resident reportedly said late last year at an event organized by the local chamber of commerce. "This is a disaster."

For now, at least, because of an agreement between two Pittsburg organizations — Ascension Via Christi and Community Health Center of Southeast Kansas (CHC/SEK), which are temporarily operating an emergency room and clinic, respectively, at the former Mercy Hospital Fort Scott — no babies are dying as a result of the closure. In fact, they continue to be born.

“We’ve delivered two babies in the emergency room here since we’ve been here,” said Jason Wesco, executive vice president of CHC/SEK in a recent interview.

While healthcare privacy law prevents providers from disclosing personal information on patients, one of those babies appears to be the daughter recently born to Kristen Juarez of Fort Scott, who was in the clinic lobby the same day Wesco spoke to the Morning Sun, waiting for a checkup on her one-week-old daughter. Juarez previously gave birth to another daughter who is now two years old when the hospital was still a Mercy facility.

“I think it’s very comfortable still, like being here, everybody’s still really nice,” Juarez said. “I think their services, they try to do what they can with what they’ve got, because I know it’s not as big as what it was and everybody really works together on that, so that’s really good.”

According to Wesco, “maybe a third” of the 177,000 square foot former Mercy hospital in Fort Scott is now being put to use. A large parking lot on the west side of the building is entirely vacant, and many services once offered are not any longer, though a few are now available that Mercy was unable to provide.

The future of healthcare in Fort Scott will be even more uncertain after the end of 2020, when the temporary arrangement between Ascension Via Christi and CHC/SEK is set to expire.

If the hospital is not bought by another healthcare provider — “and I think the chances of that are highly unlikely,” Wesco said — it will probably be demolished, although Mercy has generously offered CHC/SEK approximately 7.5 acres of land at the facility to build a new clinic.

“We’re grateful for that, because we’ll be able to operate in that space more efficiently at a lower cost than we can in this current environment, which was built to be a hospital, not just a clinic,” Wesco said.

“On the face of it it seems silly that a building like this would be knocked down and the people who are in it, us, would have to go and build another building while they’re knocking one down behind it,” he said, but the reality of the situation is that constructing a new facility will ultimately be cheaper for CHC/SEK than operating in a much larger building than it can fully utilize.

CHC/SEK is “committed to being in Fort Scott” long-term, Wesco said. Making the ER financially viable, however, is a more difficult task.

“We don’t know exactly what the future of the emergency room is,” Wesco said, adding that he couldn’t speak for Ascension Via Christi. “In that world, as I understand it, stand-alone emergency rooms don’t really pay for themselves. And so I think that’s a reality that I know they’re investigating very closely, and I know they want to be here. I have no doubt that Ascension Via Christi wants to operate an emergency room, the question is can they afford to do it?”

PUTTING POLITICS ASIDE

Few would argue that there was a silver lining in the Fort Scott hospital closure — but for politicians, at least, it provided an opening for a debate on broader healthcare issues.

“This should not have happened,” Gov. Laura Kelly said at the time of the Fort Scott hospital’s closure. “Simply put: if Kansas had expanded Medicaid, Fort Scott would still have a hospital.”

According to data compiled by GateHouse Media, the Morning Sun’s parent company, Kansas is the least profitable state in the nation for rural hospitals, with 64 percent of hospitals statewide losing money. 16 of the 20 least profitable rural hospitals in the country are located in just three states – Kansas, Oklahoma and Texas – none of which have expanded Medicaid following the passage of the Affordable Care Act in 2010.

While expanding KanCare, the state’s program for administering Medicaid, may seem like a simple solution, however, not everyone agrees that it would have saved Fort Scott’s hospital. Even Gov. Kelly has more recently revised her position somewhat.

“The governor has consistently stated that while expanding Medicaid won’t save rural hospitals, it gives them more time to develop a new and sustainable business model. Medicaid expansion will not solve all problems for struggling hospitals. However, expansion does help hospitals’ bottom lines and is the best path forward for Kansas,” Lauren Fitzgerald, communications coordinator for Gov. Kelly’s office wrote in an emailed response Friday to an inquiry from the Morning Sun. “This has been studied from every possible angle. There have been over 300 published studies and reports on the positive impact of Medicaid expansion in other states, including: a reduced poverty rate, a growth in the number of healthcare related jobs spurring economic growth, a healthier insured population, and a significantly lower level of uncompensated care for health facilities. It’s absolutely the right thing for Kansas.”

For Kansas, perhaps, but expanding Medicaid — the federal healthcare program for low-income people — “would have a minimal impact in Fort Scott,” the Kansas City Star has reported.

“I think the general consensus of rural health experts is that Medicaid expansion is not a silver bullet,” Brock Slabach, vice president for member services at the Kansas Rural Health Association, told the newspaper.

“In Fort Scott the figure that was given to me was around $14 million that the hospital had lost and that expansion of Medicaid would have only brought in around two million,” State Rep. Ken Collins (R-Mulberry) wrote in an emailed response to questions from the Morning Sun in April. “That would not have saved that hospital.”

Earlier this year, members of the Kansas House of Representatives “put politics aside and came together to pass a Medicaid expansion compromise,” in Gov. Kelly’s words. To do so, they used the controversial “gut and go” procedure, which is allowed in Kansas and some, but not all, other states and involves replacing the text of a bill with something entirely different shortly before voting on it. The bill did not pass in the State Senate, however, where Republican leadership blocked a vote on it, prior to the end of the legislative session, effectively killing the chances of KanCare being expanded in 2019.

Rep. Monica Murnan (D-Pittsburg) was among supporters of the bill to expand Medicaid in Kansas.

“I believe that we are long past due in Kansas for taking advantage of the dollars that are available from the federal government to expand Medicaid, that’s why I voted for it,” Murnan told the Morning Sun in April. “I believe that it is not only a compassionate and humane thing to do, to cover 150,000 Kansans with basic health insurance, but I also believe it’s an economic development issue. We have heard loud and clear from our hospitals and our community health providers, our mental health providers, that expanding Medicaid would allow them to continue to do what they do.”

The 150,000 figure cited by Murnan and other Medicaid expansion supporters appears to come from the group Alliance for a Healthy Kansas. A separate study released by the Kansas Health Institute in March, however, had somewhat different findings.

“Nearly 130,000 Kansans (including 90,000 adults and 40,000 children) are estimated to newly enroll in KanCare if Medicaid is expanded, an increase of 31 percent in the number of program enrollees,” according to that study. “Of the projected new enrollees, about 75,000 were previously uninsured, while about 55,000 were already insured and expected to switch to KanCare.”

In April, Gov. Kelly accused opponents of her Medicaid expansion plan of “preventing action on this critical issue while rural hospitals struggle and in some cases close.”

Kelly is not the only Kansas officeholder whose position on Medicaid expansion as a cure-all for problems afflicting rural hospitals seems to have since softened.

“We have to continue to look at Medicaid expansion as one of many things that can shore up our health care infrastructure,” Murnan wrote Friday in an email to the Morning Sun. “While not the only solution, it is indeed one strategy that would have a positive impact on hospitals, mental health providers and other health care providers. The most positive things [sic] about Medicaid expansion is that it benefits both the working poor and our health care systems.”

In addition to Fort Scott, hospitals have closed this year in Oswego in Labette County, Hillsboro, located north of Wichita, and in Horton, northwest of Kansas City. Other closures in recent years include the former Mercy hospital in Independence, which shut its doors in 2015.

Not all of these were Mercy hospitals. In fact all of them besides Independence were once operated by a single company, EmpowerHMS, which has developed a much different reputation than Mercy, and has all but disappeared since its former hospitals closed and filed for bankruptcy protection.

Shortly before its Kansas hospitals closed, EmpowerHMS announced a deal with the company iHealthcare — once known as “Opulent Acquisition, Inc.” — where EmpowerHMS CEO Jorge Perez apparently resigned as a director just one week before the two companies announced their agreement.

The Kansas Attorney General’s Office is now investigating the former EmpowerHMS hospital closures, and in April it emerged that EmpowerHMS, along with other entities involved in Perez’s “web of companies,” was under federal criminal investigation.

“But that company was important to Horton,” Rep. Murnan said when asked about the apparently corrupt management of the EmpowerHMS hospital chain just days after the criminal investigation of the company was first reported. She also urged the Morning Sun to investigate the closures of hospitals besides Horton.

“It’s a different situation,” Murnan said. “You need to look into Fort Scott and Oswego. It’s a different situation, specifically Fort Scott.”

The Morning Sun and GateHouse Media have looked into — and written extensively about — the closure of Oswego Community Hospital.

In Fort Scott —where the closure of the local hospital did not involve criminality, but rather Mercy’s inability to make the facility financially viable — questions and anxiety about the impact of the closure on the community remain widespread.

IT STARTS TO FEEL REALLY UNCERTAIN

Rural hospital closures, including some of those in Kansas, have received considerable media coverage. When Mercy Hospital Independence shut down in 2015, the New York Times even published an article.

“Mercy’s problems attracted notice in Topeka,” the Times noted, “as some lawmakers renewed calls on the state to expand Medicaid under the Affordable Care Act, a move that would have pumped an estimated $1.6 million a year into the hospital’s coffers.”

Then-governor Sam Brownback, however, opposed Medicaid expansion.

“Medicaid expansion would primarily benefit a small number of big city hospitals, not smaller rural hospitals like Mercy,” Melika Willoughby, deputy communications director for Brownback at the time, wrote in 2015. "Those who say Medicaid expansion would save the Independence hospital are lying. It wouldn't.”

Willoughby went on to describe the expansion plan as an “Obamacare ruse” that “funnels money to big city hospitals, creates a new entitlement class and fails to rightly prioritize service for disabled citizens."

The Times noted that Mercy Hospital Independence officials said expanding Medicaid “would have helped significantly but probably would not have ensured Mercy’s long-term survival.”

Medicaid expansion would help a hospital like the former Independence facility to pay its bills, Robert St. Peter, president of the Topeka-based Kansas Health Institute, told the Kansas City Star, but said it was oversimplifying the situation to claim it would have saved the hospital.

“And I’d be skeptical about pointing to it as the only factor or main factor in any particular hospital’s survival,” he reportedly said.

“Certainly, Medicaid expansion would have been a big deal for us,” Mercy spokeswoman Joanne Smith told the Star. “But it was clearly not the only factor.”

Medicaid expansion might not have saved Mercy’s Fort Scott hospital, but possibly could have helped the healthcare system retain some employees. Last week, Mercy announced a round of layoffs as it “continues to be challenged by reduced reimbursement for the services we provide, especially from Medicare and Medicaid which do not fully cover the costs of care,” the healthcare provider said in a statement Thursday.

Last year, however, David Cowan, Independence’s emergency medical services director, told another publication, the Kansas Leadership Center Journal, “without hesitation” that the city, which also lost a major employer in the area with the closure of an Amazon distribution center the same year the hospital shut down, was still getting by without its hospital.

“At the end of the day, the community survived,” Cowan said. “And we’re even more resilient.”

Robert Uhler, Fort Scott’s community development director, made a similar comment to the Star about the situation there.

“We got punched,” he said. “But I think actually, we’ll be stronger in the end.”

The Times noted in its 2015 report that many rural hospitals were at risk of closing “because of declining reimbursements” but also because of “growing regulatory burdens and shrinking rural populations that result in an older, sicker pool of patients.”

In the early 1980s, Mercy Hospital Independence had more than 90 beds, but was staffing less than half that number by the time it closed. A shrinking patient population is certainly one factor behind the more recent Mercy closure in Fort Scott as well.

Mercy Hospital Fort Scott “was built at a different time when the hospital was much busier and more people were getting their healthcare, their hospital care here in Fort Scott and I think over time what happened is more people chose to go other places,” Wesco said. “I mean, it’s not that far to Kansas City from here. [...] I think the market just changed.”

While changes in how healthcare is provided have led more people to seek treatment at more distant specialized medical facilities, other factors such as easier access to Kansas City with the expansion of Highway 69 have also come into play. A decreased number of patients, however, can be both a cause and a result of rural hospital closures, creating a snowball effect.

“It’s about losing a hospital but it’s also about a lot more than that,” Wesco said. “I mean Mercy kind of started [in Kansas] here in Fort Scott, was completely interwoven in everything about this community, so it’s about community identity too, and about fear in the future, because many communities in Southeast Kansas are experiencing dramatic population loss.”

Wesco said CHC/SEK recently met with the Bourbon County Commission, which estimated the county could see its population drop by 9 or 10 percent as a result of losing the hospital “which happened in Montgomery County, you know, with Mercy in Independence, and if you have 13,000 people in a county and you lose 9 or 10 percent you’re talking more than 1,000 people, and so it starts to feel really uncertain and scary.”

Because of that uncertainty, Wesco said, CHC/SEK is anxious to get its new clinic built in Fort Scott, into which they will be investing about $4 million. Patients, of course, also experience uncertainty and anxiety as a result of rural hospital closures.

Christy Roberts is a mother of two young boys who has lived about 20 miles west of Fort Scott in a rural area of Bourbon County for the last five years. In early June she visited the CHC/SEK clinic to follow up after seeking treatment for a hairline fracture to her 3-year-old son Owen’s collarbone at the ER the previous week.

“You don’t want to think about having to take your kids to an ER for something major, you know, it’s just a collarbone, but if it was life-threatening, not having an ER around is definitely kind of scary for me as a mom,” Roberts said. “And you think about if you don’t have a hospital or an ER or whatever, what does that mean for your community, you know, will it close it down eventually? You don’t know how that will affect it long term.”

If she couldn’t take her sons to Fort Scott for treatment, Roberts said, she’d probably have to go to Iola, which could take twice as long. While she hasn’t noticed a change in the care available at the former Mercy facility in Fort Scott, Roberts said she expects hospital closures will affect people’s decisions —and particularly families’ decisions— about where they can live.

“They’re not going to want to live where there’s not going to be a hospital close by,” she said. “I think they’d rather be somewhere where there’s going to be, you know, a medical facility.”

Juarez, who recently gave birth at the former Mercy facility, and who has been moving back and forth between Fort Scott and Iowa over the past six years, said if the hospital closes entirely her whole family will likely move to accommodate her mother-in-law, whose health conditions could become significantly more life-threatening without a hospital nearby.

“She’s thinking about moving straight out of Kansas, so I don’t know, it’s up to her, wherever grandma feels like going, that’s where we’ll end up.” she said. “So that’s like, I don’t know, 8 or 9 people here that live in Fort Scott that will be up and moving to another city.”

In terms of impact on the community as a whole, Juarez is not optimistic.

“I think Fort Scott is pretty much going to be getting smaller, because it’s already getting smaller and smaller and then the hospital’s going,” she said. “There’s a lot of elderly people that live here, you know, and I think with the elderly you don’t have time to go 20 or 30 minutes. Some of the elderly people can’t even travel, you know, like they’re not in that position to travel to go to a different hospital, so I think everything’s going to be — Fort Scott’s just going downhill from now if they don’t open up another hospital.”