THE RURAL
HOSPITAL DILEMA:
Will
Nevada’s Rural Hospital System Survive?
Prepared
by
Nancy L.
Anderson
University
of Nevada, Las Vegas
College of
Urban Affairs
Public
Administration Department
April 10,
2000
TABLE OF
CONTENTS
Abstract 3
Chapter 1 - Introduction 4
Figure
1 8
Figure
2 9
Chapter 2 - Literature Review 10
Chapter 3 - Methodology 18
Chapter 4 - Rural Hospitals of Nevada 19
Tables 29
Chapter 5 - Nevada Rural Hospital Project 31
Chapter 6 - Department of Taxation 36
Figure 3 38
Chapter 7 - Conclusion 44
References 49
Appendixes 53
Appendix
1 Survey 53
Appendix 2 NRHP Member List 54
Appendix 3
Nevada Revised Statutes:
Chapter
450 57
Appendix
4 Map Location of Hospitals 75
ABSTRACT
This
study, prepared for the Department of Public Administration, will review and
discuss the rural hospitals in the State of Nevada. By virtue of its size and population distribution, Nevada has a
need for rural hospitals. These
hospitals, which are of critical importance for Nevada residents, are
constantly struggling with how to build and support their limited health system
capacity and infrastructure.
To
survive, rural hospitals must offset the losses they have sustained as a result
of decreased federal funding. Some ways
these losses have been offset is by employing some of the programs created by
the Balanced Budget Act of 1997 such as the Medicare Rural Hospital Flexibility
Program. In addition, they have begun
to better serve their constituent population by their involvement in other
areas, such as becoming county hospital districts, developing telemedicine
capacity, implementing long term care options and working with the Nevada Rural
Hospital Project. It is the combination
of these factors and changes to their everyday functioning and continued ability
to accommodate changes in the health care environment that determine the ultimate
survival of Nevada’s rural hospital system.
CHAPTER
ONE
INTRODUCTION
Since
rural hospital closures became common in the 1980s, it has become increasingly
important to understand how and why rural hospitals must change to meet the
needs of the community and to keep their doors open.
The distinction between urban and
rural has particular significance for Nevada since 80% of the state’s land mass
has been categorized as rural by the federal government. Federal tax dollars, Medicare and Medicaid
reimbursements, awards of research funds and even the allocation of equipment
and medical staff, can be affected by the complex determination of whether a
given geographic area within the state is designated rural,(Figure 1) urban,
metropolitan or frontier (Figure 2).
There are
two principal federal government definitions of rural. The definitions derive from the Office of
Management and Budget’s (OMB)”Metropolitan-Nonmetropolitan” system and the
Bureau of the Census’ “Urban-Rural” classification of populations (Ricketts,
1998).
According
to the Census Bureau, urban and rural are “type-of-area concepts rather than
specific areas outlined on maps” (U.S. Department of Commerce, Bureau of the
Census, 1983a). The Bureau of the
Census defines urban as comprising
all territory, population, and housing units located in urbanized areas (UAS) and in places of 2,500 or more inhabitants
outside urbanized areas. Territory, population and housing units that
the Census Bureau does not classify as urban, comprise the rural population, that is, those living outside urbanized areas in
“places” with less than 2,500 residents and those living outside “places” in
the open countryside. In the 1990
census, 24.8 percent of the national population was classified as rural
(Ricketts, 1998). In addition, federal
funding through Health Care Finance Administration (HCFA) sources distinguish
between metropolitan and nonmetropolitan “rural” areas. Metropolitan and nonmetropolitan areas are
defined by the OMB on the basis of counties
Metropolitan Areas contain: (1) core counties with one or more central
cities of at least 50,000 residents or with a Census Bureau-defined urbanized
area and a total metro area population of 100,000 or more, and (2) fringe counties that are economically
tied to the core counties.
Nonmetropolitan counties are outside the boundaries of metro areas and
have no cities with more than 50,000 residents. In 1996, 2,522 of 3,139 counties or county-equivalents were
classified as nonmetropolitan. These
counties included 52,393,300 persons or 19.8 percent of the total 1996 national
population estimate of 264,100.960 (Ricketts, 1998).
Areas
with six or fewer persons per square mile are considered frontier counties or communities.
A total of 383 counties (excluding Alaska boroughs) met this criteria in
1995 (Ricketts,1998). Frontier counties
account for one-fifth of the population and 45 percent of the land mass in the
United States. In Nevada, 80% of the
land mass (a total of 94,835 square miles) is inhabited by only 321,000
people. This low density population, as
well as the fact that medical services for these residents is more than one
hundred miles away, dictates that most of Nevada falls within the frontier
county designation. As such, the
preservation of rural hospitals is critical for the health and well being of
these Nevada residents.
Clear
evidence exists that the characteristics which distinguish rural and frontier
places from urban communities have important effects on health service delivery
and access. Lillie-Blanton and
colleagues (1992) demonstrated that select characteristics of rural hospitals
such as small size, low occupancies, less-intensive service mix, and declining
or weak local economies almost ensure their closure.
In 1981, rural community hospitals
accounted for 23.8% of all
community hospital beds, but by 1991 this number had fallen
1.7% to 22.1%,
accounting for approximately 2421 rural community hospitals
in the
country. Between
1981-1991 the drop of 12.4% was due to closures, mergers,
or acquisitions by larger facilitates according to the
American Hospital
Association (1992).
By 1999, according to the American Hospital Association
rural hospitals had decreased by 216 hospitals.
U.S. Community Hospitals by Urban/Rural Status
|
Urban…………….2,852 |
|
Rural………….….2,205 |
|
Total……….…….5,057 |
The 1999, status of urban and rural
hospitals (American Hospital Association, 1999).
The
purpose of this paper is to determine what Nevada’s rural hospitals are doing
to remain viable. It will provide
background about Nevada’s rural hospitals including location, size, number of
staff, management structure and financial status. The paper also examines the Nevada Rural Hospital Project, a
consortium of Nevada rural hospitals to determine whether it has been an
effective mechanism to maintain facilities.
Finally, the paper will present what Nevada rural hospitals are doing to
survive and succeed.
CHAPTER
TWO
LITERATURE
REVIEW
A review of the literature
regarding the future of rural hospitals can be
divided into three major areas of concern: 1) history; 2) availability of funds;
and 3) potential solutions.
History
Health
care is big business in the United States, accounting for nearly 14 percent of
the nation’s gross domestic product (Smith, et al., 1998) Despite today’s cost containment rhetoric,
national heath care expenditures are almost certain to increase in the future
as income and population (especially the elderly population) increase, and as
new drugs and medical technologies come on-line. Smith and colleagues (1998) project national spending to double
between 1996 and 2007, passing the $2 trillion mark by 2007.
Rural
hospitals in the United States operate at a disadvantage compared to urban
hospitals because of their smaller size; because their clientele tends to be
poorer; because of competition from other health care providers and because of
their remote location. Between 1980 and
1987, 519 United States hospitals closed or ceased to provide in-patient
medical care. Of the hospitals that
closed 364 were community hospitals and 45% of those were rural hospitals. In addition, more than 70 percent of the
rural hospitals that closed between 1983 and 1991 had fewer than fifty beds
(American Hospital Association, 1994).
This statistic reinforces the premise that rural hospital survival is
contingent upon its ability to become specialty centers or to collaborate with
other rural or regional medical centers.
Another
area of financial concern with rural hospitals arises from the Prospective
Payment System, which differentially reimburses rural facilities at lower rates
than urban facilities (Egan, 1997).
This is one of the factors that indicates aftercare is poor due to
cost-conscious organizations in rural areas.
Rural hospitals are suffering the
consequences of high costs,
technological inadequacies, chronic staffing difficulties,
and dwindling Medicare
reimbursements.
According to Dale Bankston, senior vice-president and
executive officer of VHA Gulf
States in Baton Rouge, La., “It makes no sense to let rural hospitals fold,
because their long-term survival is in doubt.”
Rural
medical facilities and hospitals occupy important positions in their
communities. They are the focal points
of local health care delivery systems, serve as an important element in the
physician recruitment process, provide a source of civic self-esteem, and are
an important aspect of the local economy.
Rural hospitals provide jobs and
the steady flow of public and private funds brought in from payment for
services, act to stimulate local business and employment prospects.
Availability of Funding
The
passage of the Balanced Budget Act of 1997 created some important opportunities
for states trying to deliver and pay for health services in rural and frontier
communities by the creation of , the Medicare Rural Hospital Flexibility
Program and the State’s Children’s Health Insurance Program.
(1) The Medicare Rural Hospital Flexibility
Program helps states and rural communities improve access to essential
health care services by establishing limited service hospitals referred as
“critical access hospitals”(CAHs). The Medical Critical Access Hospital (CAH)
program, is a nationwide limited service hospital program that was built on the
Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) and
Medical Assistance Facility (MAF) demonstration programs. CAHs can provide outpatient, emergency and
limited inpatient services and receive reasonable cost-based reimbursement for
their services (Reif and Ricketts, 1999).
The CAH
program, a Medicare hospital reimbursement program, is a major component of the
Balanced Budget Act of 1997’s Medicare Rural Hospital Flexibility Program. The program allows states to designate rural
facilities as critical access hospitals if they are located a 35-mile distance
from other hospitals, provide 24 hour emergency care, maintain no more than 15
inpatient beds, and keep patients hospitalized no longer than 96 hours. Rural hospitals converting to critical
access hospital status do not have to meet all the Medicare staffing
requirements that apply to full-service hospitals. These hospitals are reimbursed on a reasonable-cost basis for
inpatient and outpatient services provided to Medicare beneficiaries.
In order
to participate in the program, states must submit a rural health plan to the
federal Health Care Financing Administration and establish a process for
designating local hospitals that meet specific program criteria as critical
access hospitals
The
Medicare Rural Hospital Flexibility Program also provides a grant program. The program, which began in 1998, authorized
up to $25 million annually over five years to support implementation of the CAH
program, improvement of rural emergency medical services and other activities
to strengthen rural health systems (Reif and Ricketts, 1999). States can also use the grant funds to provide
technical assistance and support for hospital CAH conversions to:
·
develop integrated networks of care;
·
examine the conversion to CAHs;
·
conduct a financial feasibility analysis;
·
develop information systems and telehealth activities;
·
improve quality assurance activities; and
·
improve rural EMS systems.
State
policymakers have the opportunity to develop creative and comprehensive CAH
models that can include the integration of network development, emergency
medical services, telehealth services, mental health services, and public
health, depending on the needs of each community. To expedite appropriate and successful CAH conversions, states
can encourage facilities considering conversions to:
·
conduct a financial feasibility study;
·
educate the physicians, the hospital staff and their
governing board, and the community about the conversion; and
·
partner with a fiscal intermediary that understands the
nuances of the CAH program so that claims processing is simplified.
(2) The State Children’s Health Insurance
Program was established by Title XXI of the 1997 budget legislation. It provides states with approximately $4.8
billion annually for five years to provide health insurance to uninsured
children. According to Medical
Expenditure panel Survey data for the first half of 1996, 27.9 percent of all
uninsured children live in rural and frontier areas and might be eligible for
this program.
Potential Solutions
(1) Telemedicine is the use of medical
information exchanged from one site to another via electronic communications
for the health and education of the patient or health care provider and for the
purpose of improving patient care (American Telemedicine Association,
1999). The information exchanged may
include medical images, live audio and video, patient medical records, output
data from medical devices and sound files.
Telemedical interaction between patients and health care professionals
may include patients monitoring data from the home and transmitting this data
to a clinic, or transmitting a patient’s medical file from a primary care
physician to a specialist.
Telemedicine
“began” in the 1960’s as a medical treatment rendered over the telephone and by
wire by physicians who were physically remote in relation to their
patients. Although the principles are
largely the same today, the technology is advanced and socio-economic and
legislative issues surrounding its use are vastly different. Prior to the Balanced Budget Act (BBB) of
1997, Medicare did not have an explicit policy to pay for Telemedicine
services. The passage of the BBA
required Medicare to pay for Telemedicine consultation services using
interactive video in rural “Health Professional Shortage Areas” (HPSA) by
January 1, 1999 signaled a major change in policy. The legislation limits coverage to rural HPSAs and prohibits
payment for line charges or facility fees.
Physicians are reimbursed at 75 percent of the rate for an in-person
consultation. The referring physician
is eligible for the remaining 25% of the allowable reimbursement. Reimbursement under Medicare is contingent
upon the type of provider that refers the patient. At present, rules are proposed to allow for payment for services
to physician assistants, nurse practitioners, social workers, mid-wives, and
clinical psychologists, to name a few (Kincade, 1998). According to HCFA, the BBA limits the scope
of coverage to a consultation for which payment may be made under the Medicare
program. These services include
initial, follow-up, or confirmatory consultations in the hospital, outpatient
facility or medical offices, using the Current Procedural Terminology (CPT)
codes.
(2) Rural Utilities Service Nevada implemented the Rural Utilities
Services (RUS) project to connect rural communities and providers to training
opportunities, medical specialists, and other health professionals. RUS provides distance education, continuing
education, Internet access, teleradiology, and telemedicine services to nine
rural counties and two urban counties.
It uses a combination of funds to equip compressed-video systems,
Internet, teleradiology, and audio conferencing for the participating
counties. The project is responsible
for training, education, statewide meetings, telehealth, and other activities that
benefit rural residents, students, patients, and health professionals in
Nevada. RUS is a joint effort of the
University of Nevada School of Medicine, the Great Basin Community College, and
the Nevada Rural Hospital Project.
A second
grant awarded from the U.S. Department of Commerce’s Technology and
Information Infrastructure and Assistance Program has been used to add
equipment to the backbone of RUS. Six
rural hospital sites have been added to the RUS rural network through a
combination of compressed-video, high-speed modems for still-image capture and
store-forward technology for data, voice, and picture. Linkages connect rural Nevada hospitals to
urban specialists for consultations, to designated urban trauma centers for
emergency treatment support, and to the University of Nevada and the Great
Basin Community College system for Internet connection and educational support.
(3) Integration A survey of 223 rural CEOs by Hospital & Health Networks
showed that the respondents were aware of the need for integration of rural
hospitals with major health care systems.
The most significant reason for the surge in affiliations is the move to
managed care. Approximately half of the
survey participants have formal contractual affiliations with another hospital
or health system.
It is
questionable, however, whether or not integration will work in rural markets
since one hundred thousand participants are needed to make a managed care plan
financially viable and rural markets usually do not have sufficient population
to cover the financial risk associated with a managed care system. Rural areas are usually sparsely populated, therefore rural hospitals may
have to adapt the system to their
unique surroundings and fit their needs and service area (East, 1999).
If managed
care systems can develop a creative mechanism for financing
their programs on a smaller
population base, integration may work in rural
hospitals. Otherwise, each hospital may be left to
create its own unique process
for ensuring continued viability.
(4) Networking To help ensure the survival of rural hospitals, networking is
starting to play a crucial role. Rural hospitals are embracing networking as
one strategy to unify health care systems with minimal capitalization. Rural health care providers are being
offered affiliations with large health care organizations. Rural provider-initiated networks can assure
local representation when participating in the new market and improve the rural
health infrastructure
(Rosenthal,1997).
Rural hospitals need to affiliate with other groups such as
rural hospital projects or large health care systems to
provide management
services and access group purchasing programs, and to
concentrate on
providing the clinical services performed best. Other benefits of networks
include benchmarking and establishing best-of-practice
standards among similar
health care organizations in a region; access to new
technology; and attracting
and retaining primary care physicians and medical
staff. Another advantage of
networking with other facilities is that the rural hospitals
then have access to
specialists.
CHAPTER
THREE
METHODOLOGY
In light
of the stated purpose of this study, to determine whether and by what
mechanisms Nevada’s rural hospitals can overcome the environmental changes and
pressures that contribute to their financial vulnerability and potential
demise, survey research was conducted.
The
purpose of the survey was to establish baseline data from each of the 12 rural
hospitals in Nevada with regard to hospital size in terms of number of beds,
number of staff; amount of population served; distance from the closest urban
center; the facilities form of ownership; the age of the facility and whether
or not it operates at a profit. The
survey was conducted via interviews with hospital administrative staff
employing questions from the 1991 study,
“The Strategies and Environments of America’s Small Rural Hospitals: A
Survey of Strategic Approaches of Small, Rural Hospitals” by David E. Berry,
John W. Seavey and Richard J. Bogue.
Based upon
the baseline, data interviews were conducted with staff at the Nevada
Department of Taxation for the purpose of analyzing the financial structure of
rural hospitals; their assets and liabilities as well as operating revenues and
expenditures within the context of the Counties in which they are located. Finally, interviews were conducted with the
administrators; boards of directors and participants in the Nevada Rural
Hospital Project Consortium to determine whether participation in that project
was a viable mechanism for ensuring long-term financial health for Nevada’s
rural hospitals.
CHAPTER
FOUR
RURAL
HOSPITALS IN NEVADA
There
are presently a total of twelve rural hospitals in Nevada. The brief descriptions of each hospital
gives an insight into the differences between them and yet some of the
similarities that makes them each individually unique. The information contained in the following
chapter and illustrated in tables 1.1 through 1.4 was derived from a sample
survey (Appendix 1). The survey has a
100% response rate with respondents coming from either the human resource or
finance department of the surveyed facility.
Battle Mountain General Hospital
(Lander County)
Battle
Mountain General Hospital located in Lander County was founded in 1968 and
originally was organized as a public hospital.
In 1984 the taxpayers voted to approve Battle Mountain to become part of
the County Hospital District, serving a population of 7,500 and distanced 54 to
75 miles from another medical facility (Table 1.1). In 1968, the original structure that now houses the medical
clinical and administrative offices was built.
Three years ago in 1997 a county bond issue was approved for an
additional 18,000 square foot facility.
Information
from the Nevada Department of Taxation revealed that in 1999 Battle Mountain
General Hospital showed a $1.4 million loss (Table 1.4). Battle Mountain General Hospital bed size is
23 with 7 acute and 16 long term care and 75 employees of which ninety percent
are local residents (Table 1.2). An
average patient stay of 2.4 days the hospital maintains a clinic as well as
emergency room, and home health services.
The payor mix includes Medicare, Medicaid, government assistance,
insurance and private pay (Table 1.3).
The hospital has two full-time physicians and one nurse practitioner and
uses specialty physicians from Elko.
Boulder City Hospital (Clark
County)
Boulder
City Hospital located in Clark County was founded in 1931, owned by the
government for dam employees. Boulder City Hospital was restructured in 1954 as
a not-for profit, serving a population of approximately 16,000 and is only 27
miles from the nearest urban facility (Table 1.1). Boulder City Hospital today serves the areas of Boulder City,
Kingman, Searchlight, as well as Henderson and parts of Las Vegas. Boulder City Hospital is the only rural
hospital in Southern Nevada.
Information
from the Nevada Department of Taxation revealed that in 1999 Boulder City
Hospital showed a profit (Table 1.4).
Boulder City Hospital bed size is 67 with 20 acute and 47 long term care
and over 200 employees (Table 1.2). An
average patient stay of 5.8 days the hospital maintains long term care as well
as full medical, surgical and outpatient services. The payor mix includes Medicare, Medicaid, insurance and private
pay (Table 1.3). The hospital has no
full time physicians on staff, but grants privileges to local physicians.
Carson-Tahoe Hospital
(Carson-Tahoe County)
Carson-Tahoe
Hospital located in Carson-Tahoe County was founded in 1949, as a
not-for-profit community hospital.
Carson-Tahoe Hospital serves a population of a 100,000 and distanced 32
miles from another urban medical facility (Table 1.1). Today Carson-Tahoe Hospital is the process
of funding a Cancer Resource Center with grants for research.
Information
from the Nevada Department of Taxation revealed that in 1999 Carson-Tahoe
Hospital showed a profit before non-operating income (Table 1.4). Carson-Tahoe Hospital bed size is 128 acute
and 658 employees making it the second largest employer in the area (Table
1.2). An average patient stay of 3.0
days the hospital maintains a staffed emergency room and clinic
facilities. The payor mix includes
Medicare, Medicaid, insurance and private pay (Table 1.3). The hospital has no salaried physicians, but
contracts the emergency room physicians.
Churchill Community Hospital (Churchill County)
Churchill
Community Hospital located in Churchill County was founded in 1958, as a not-for-profit hospital. In 1990 Banner Health Systems of Fargo,
North Dakota, started managing the facility and sometime between 1994 and 1996
they became part of the Banner Health Systems. Churchill Community Hospital serves a population of 45,000 and
distanced 60 miles from another medical facility (Table 1.1).
Information
from the parent company Banner Health Systems revealed that in 1998-1999, the hospital broke even and is
currently making a slight profit.
Churchill Community Hospital bed size is a 40 bed acute facility and
employs a staff of 416 full and part-time (Table 1.2). An average patient stay of 3-4 days the
hospital maintains surgical and outpatient services. The payor mix includes Medicare, Medicaid, insurance and private
pay (Table 1.3). The hospital has two
full-time salaried physicians and one relief physician as well as private
physicians with privileges.
Grover C. Dils Medical Center
(Lincoln County)
Grover C.
Dils Medical Center located in Lincoln County was originally founded in 1943 as
a non-for profit hospital. In 1974 the
taxpayers voted to approve Grover C. Dils medical Center to become part of the
County Hospital District., serving a population of 4,800 and distanced of over
a 100 miles from another medical facility (Table 1.1).
Information
from the Nevada Department of Taxation revealed that in 1999 Grover C. Dils
Medical Center even with non-operating funds showed a loss (Table 1.4). Grover C. Dils Medical Center bed size is 20
and has 54 employees (Table 1.2). An
average patient stay of 1.2 days the hospital maintains outpatient
services. The payor mix includes
Medicare, Medicaid, government assistance, insurance and private pay (Table
1.3). The hospital contracts the
physicians.
Humboldt General Hospital
(Humboldt County)
Humboldt
General Hospital located in Humboldt County was originally built in 1908, as a
public hospital and has undergone several renovations. The taxpayers voted to approve Humboldt
General Hospital as part of the County Hospital District, serving a population of
16,000 and distanced 164 miles from another medical facility (Table 1.1). In 1994 the clinic building was demolished
to allow for the construction of a new Skilled Nursing Facility. The Skilled Nursing Facility was completed
in April 1995; includes 30 beds, a large solarium, activity area, cosmetology
room, and staff lounge. A new surgery
suite was completed in April 1995 which consists of a special procedure room,
two operating suites and four recovery beds.
A new administration building was completed in July, 1995 along with the
new Radiology and Laboratory wings. The
radiology department includes mammography, ultrasound, fluoroscopy, and C.T. Remodeling of the 22 bed acute care wing was
finished in November, 1995. Acute care
services includes a two bed fully equipped intensive care unit.
The
emergency department at Humboldt General Hospital has 24 hour-a- day coverage
by rotating in-house emergency physicians and nurses. Construction of the new emergency room was completed in January,
1996. This facility is fully equipped
with a trauma room to care for major trauma or life threatening cardiac
problems the obstetrics department completed in early 1996, and includes a
labor/treatment room, two birthing rooms, four postpartum rooms, and a nursery.
In March,
1997, an ambulance facility was completed, supporting the volunteer ambulance
corps. There is a full time paramedic
as coordinator/liaison for pre-hospital services as well as four paramedics in
addition to the EMTS. This is one of
the busiest services in the State.
Information
from the Nevada Department of Taxation revealed that in 1999 Humboldt General
Hospital showed a profit after non-operating income (Table 1.4). Humboldt General Hospital bed size is 52
with 22 acute and 30 long term care and 158 employees (Table 1.2). An average patient stay is 6.07 days the
maintains a fully equipped facility.
The payor mix includes Medicare, Medicaid, government assistance,
insurance and private pay (Table 1.3). Medical
staff consists of two family-practice physicians, two internists, a general
surgeon, and two pediatricians. In
1994, a medical office building was constructed, which presently houses three
physicians. A pathologist and
radiologist are on the associate staff. Consultant physicians offer specialty
services on a regular basis. The
emergency room staff is provided by contract physicians on a rotational
basis.
Mt. Grant General Hospital
(Mineral County)
Mt. Grant
General Hospital located in Mineral County was founded originally in the 1900s
as a not-for-profit hospital. In 1964
the taxpayers voted to approve Mt. Grant General Hospital to become part of
part of County Hospital District, serving a population of 5,000 and distanced
60 miles from another medical facility (Table 1.1).
Information
from the Nevada Department of Taxation revealed that in 1999 Mt. Grant General
Hospital showed a profit after non-operating income (Table 1.4). Mt. Grant General Hospital bed size is 35
with 11 acute and 24 long term care and employ 100 people making them the
second major employer in Hawthrone (Table 1.2). No information available on average patient stay the hospital
maintains emergency services and a clinic.
The payor mix includes Medicare, Medicaid, government assistance,
insurance and private pay with statistics available (Table 1.3).
Pershing General Hospital
(Pershing County)
Pershing
General Hospital located in Pershing County was founded in 1962 as a
not-for-profit hospital. The taxpayers
voted to approve Pershing General Hospital to become part of the County
Hospital District, serving a population of approximately 4,000 and distanced
over 60 miles from another medical facility (Table 1.1).. This year they have initiated a
rehabilitation facility to better serve the community.
Information
from the Nevada Department of Taxation revealed that in 1999 Pershing General
Hospital showed a $304,883 loss (Table 1.4)
Pershing General Hospital bed size 37 with 5 acute and 32 long term care
and 100 full and part time employees (Table 1.2). An average patient stay of 2 .5 days the hospital maintains
outpatient services and nursing home.
The payor mix includes Medicare, Medicaid, government assistance,
insurance and private pay (Table 1.3).
The hospital has a staff of three physicians.
Nye Regional Medical Center (Nye County)
Nye
Regional Medical Center located in Nye County was established in the early
1960s as a not-for-profit hospital. In
August of 1999, Nye Regional Medical Center was purchased by Mina Medical Group
and leased back to Prime Care Nevada.
Nye Regional Medical Center has also applied for admission to the
Critical Access Hospitals program run by the Health Care Financing
Administration (HCFA). If Nye Regional
Medical Center is accepted into the program, the designation will allow it to
acquire the funds necessary to remain open.
Nye Regional Medical Center serves a population of 3,616 and distanced
over 300 miles from another medical facility (Table 1.1).
Information
from the Nevada Department of taxation revealed that since April, 1997 until
August of 1999, the Nevada Department of State Taxation had managed the
facility, due to it losing 100,000 to 150,000 dollars per month. In February, 1999, the Nye County
Commissioners, voted 4 to 1 to expend an additional 350,000 dollars to allow
operations to continue until March, 1999.
Nye Regional Medical Center is one
of those rural hospitals that has
less than 50 beds, employs 60 people, and is one of the
largest employers in
Tonopah (Table 1.2).
The payor mix includes Medicare, Medicaid and
government assistance (Table 1.3).
South Lyon Medical Center (Lyon
County)
South Lyon
Medical Center located in Lyon County was founded in the 1953 as public owned
hospital. In 1998, Taxpayers voted to
became part of the County Hospital District, serving a population of 11,300 and
distanced 81 miles from another medical facility (Table 1.1). In 1998 a long term facility was completed.
Information
from the Nevada Department of taxation revealed that in 1999 South Lyon Medical
Center had a loss. South Lyon Medical
Center bed size is 63 with 14 acute and 49 long term care and employs
approximately 100 people including both staffed physicians and “contract”
emergency room physicians Table 1.2).
An average patient stay is 3 days the hospital maintains long term as
well as clinic serves. The payor mix
includes Medicare, Medicaid, government assistance, and insurance (Table 1.3).
William Bee Ririe Hospital (White
Pine County)
William
Bee Ririe Hospital located in White Pine County was founded in 1969 as a
not-for-profit hospital. The taxpayers
voted to approve William Bee Ririe Hospital to become part of the County
Hospital District, serving a population of 13,000 distanced 300 miles from
another medical facility (Table 1.1).
Additions to the original structure include a clinic adjacent to the
hospital that was completed in February of 2000.
Information
from the Nevada Department of taxation revealed that in 1999 that William Bee
Ririe Hospital showed a profit after non-operating income (Table 1.4). William Bee Ririe Hospital bed size is 40
beds and 98 employees with both staff and “contract” physicians (Table
1.2). An average patient stay of 2.3
days the hospital maintains a clinic as well as long term care facility. The payor mix includes Medicare, Medicaid,
government assistance, and insurance (Table 1.3).
Elko General Hospital (Elko
County)
Elko
General Hospital located in Elko County was established in 1921 and was
originally organized as a public hospital. June, 1998, became a private
hospital when purchased by Province Healthcare, serving a population of 50,000
and distanced over a 180 miles from another medical facility (Table 1.1).
According
to Province Healthcare in 1999, Elko General Hospital showed a profit, but the
figures were not available for review.
Elko General Hospital bed size is 50 with 300 employee (Table 1.2). The average patient stay information was no
available for review. The payor mix
includes Medicare, Medicaid, and insurance (table 1.3). The hospital employs two full time salaried
physicians.
|
|
|
|
|
|
CHAPTER
FIVE
NEVADA
RURAL HOSPITAL PROJECT
The Nevada
Rural Hospital Project (NRHP) is a voluntary consortium of ten of the twelve
Nevada small rural and frontier hospitals with Elko General Hospital and Nye
Regional Medical Center (Appendix 2).
Consortium hospitals are
community, county and/or district not-for-profit hospitals, with each hospital
represented with an equal vote on the NRHP Board of Directors. Definition of county hospital districts is
found in (Appendix 3).
The
consortium has a history (1978) of working together as members of the Rural
Council of the Nevada Hospital Association.
In 1988, the consortium received a grant from The Robert Wood Johnson
Foundation (TRWJF) as one of thirteen grantees in the “Hospital-Based Health
Care Program.” The goals for that
program were to improve the viability of rural hospitals, access to health care
by rural residents and the quality of health services in rural areas. These goals continue to be the mission of
NRHP.
The
mission of NRHP is to strengthen member hospitals through the development of
public policy, which supports the viability of Nevada’s rural facilities. Generally, NRHP resources are used to
address issues which impact all member hospitals, although NRHP is also
responsive to a hospital’s specific needs and problems.
Services Provided to Members
Since the
original grant, there have been many other vital projects and programs
undertaken and accomplished by NRHP.
The following describes many of these projects and programs.
·
Group Health Insurance Program: Member hospitals are able to benefit from a
group health insurance program negotiated at a discount rate. The member hospitals are able to control
health insurance costs for their employees through this program. NRHP was instrumental in getting legislation
passed that would allow public, not-for-profit hospitals to pool their monies
for an insurance program.
·
Distant Learning Program: NRHP has worked with Nevada educators, the
rural Directors of Nursing and the School of Medicine’s Area Health Education
Center (AHEC) to develop a distant learning program to deliver an LPN/AND
Degree in Nursing to three rural communities via compressed video. Over 30 students have graduated from the
program. Additionally, baccalaureate
nursing and continuing education courses are delivered through this network.
·
Teleradiology:
Recognizing the need for access by rural residents to basic diagnostic
services, NRHP has implemented a teleradiology network in ten communities
(those with limited radiologist services).
The network allows rural physicians and patients access to radiologic
consultation around the clock. This
program is coordinated and administrated by NRHP on behalf of its members.
·
Telemedicine:
The Nevada Rural Hospital Project was successful in obtaining a grant
from the U.S. Department of Commerce’s National Telecommunications and
Information Administration’s Telecommunications and Information Infrastructure
Assistance Program (TIIAP). This grant
program has provided five rural hospitals with compressed video telemedicine
equipment. The hospitals are now part
of an eight-site network that includes the University of Nevada’s School of
Medicine and an urban tertiary hospital.
Rural citizens now have access to cardiology, ENT and dermatology
consultations without leaving their community.
The hospitals are: Battle Mountain General Hospital; Grover C. Dils
Medical Center; Humboldt General Hospital; Mt. Grant General Hospital; Nye
Regional Medical Center; Pershing General Hospital; South Lyon Medical Center;
and William Bee Ririe Hospital.
·
Loan Pool Fund: NRHP has developed a $900,000 capital pool through grants and a
low interest rate loan from The Robert Wood Johnson Foundation (TRWJF). Each member hospital has access to low cost
(5.7%) loans for equipment and capital improvement.
·
Shared Financial Management Services: This program provides financial support and
education to participating hospitals.
By sharing the cost of a financial manager, the hospitals are able to
reduce costs while benefiting from expertise to which they would not otherwise
have access. These services include the
development and implementation of financial analysis tools as well as the
training and education of hospital staff.
The financial manager evaluates the hospitals’ financial information and
assists with the implementation of any appropriate corrective action.
·
Board Development: Rural Hospital Board members are often overwhelmed by the
complexity of hospital governance. NRHP
has sought to support these voluntary hospital board members by providing educational
opportunities in rural settings. These
seminars are offered free or for a very modest registration fee.
·
Technical Assistance: Technical assistance to individual hospitals
is a service provided by NRHP. Resources have been used for strategic
planning, licensure issues, the development of alternatives to ownership and
service delivery methods, community education and financial management. One strength of the consortium is its
ability to draw on expertise available in one facility to help another.
·
Group Purchasing: NRHP negotiates group discount rates on capital purchases. To date, this has included copy machines,
computers and interactive communication equipment.
·
Reference Laboratory Services: NRHP negotiated group discount for specialty
lab work, saving ten participating hospitals 50% over previous costs.
·
Quality Assurance: NRHP developed a model Quality Assurance (QA) plan for members
and also developed a step-by-step implementation manual for hospital department
heads. NRHP has served as a resource
for the hospital QA Coordinators.
·
Information Source: NRHP serves as a clearinghouse and resource center for its member
rural hospitals and other rural Nevada health care providers. Questions about any issue relating to rural
facilities may be directed to NRHP and NRHP staff will assist its member in
anyway it can.
·
Improve Rural Hospital Credibility: The greatest accomplishment of
NRHP has been the improved credibility of member hospitals, both within the
state and nationally. While this
benefit is not always tangible, it allows hospitals to influence rules, regulations,
and laws to improve hospitals’ ability to operate. On the state level, NRHP has been called upon regularly to act as
a resource or to perform special health related projects. At the federal level, NRHP has been invited
to participate in many nationwide committees and organizations as an expert of
rural healthcare.
NRHP has become an important
element in the prosperity of the small, rural and frontier hospitals in
Nevada. NRHP’s intent is to maintain
current programs, as well as create and implement many more. When looking for new programs, the three
main qualifications to consider, in respect to the member hospitals, are:
1.
Improve quality of care;
2.
Increase access to quality care; and
3.
Improve financial viability.
CHAPTER
SIX
DEPARTMENT
OF TAXATION: State of Nevada
Given the
downward financial trend in some of the Nevada rural counties and the problems
faced by those hospitals this report prepared on February 7, 2000, Jack W.
Moore, Supervisor - Local Government Finance, explains and analyze the ratios,
financial statements and graphs.
Ratio Analysis of Nevada Hospitals
This
analysis is designed to give the reader a “feel” for a particular facility’s
financial position and operation based upon what is occurring in the other
facilities along with a comparison to some subjective ratios as a standard. This analysis is presented as follows:
1.
A summary of each entity’s audited financial statement. The financial statement comparison (Figure
3) explains for the counties of White Pine, Humboldt, Lincoln, Lander Pershing,
Mineral, and Carson-Tahoe the current, fixed and other assets; current and
long-term liabilities; and fund balances.
Then operating revenue from patients through reimbursements from
Medicare, Medicaid, private insurances and private cash pay less operating
expenses. Shows the operating
income(loss) and then the net income(loss) after the nonoperating revenue which
comes from property tax allocations, interest and other nonoperating revenues. These summaries reports each entity’s
assets, liabilities and fund balance, along with a summary of the operations
for the fiscal year ended by the balance sheet date.
The
information presented is based upon the audited financial statements received
by the Nevada Department of Taxation for the fiscal years ended June 30, 1999
and 1998. The Nevada Department of
Taxation in an over view with these figures shows that the hospitals with
exception of Carson-Tahoe showed a loss before government assistance. That being part of the County Hospital
Districts helps offset the losses except for Grover C. Dils Medical Center in
Lincoln County and Pershing General Hospital in Pershing County. These two facilities even after taxpayer
dollars still show losses.
CHAPTER
SEVEN
CONCLUSION
This study
presented just tipped the iceberg regarding the factors and problems facing
Nevada rural hospitals. Findings
regarding the financial condition of rural hospitals, their involvement in the
Nevada Rural Hospital Project and a review of each rural hospital was
presented.
Nevada
rural hospitals perform many critically important functions in their
communities. They provide an array of
health services, even though they do not always include more intensive
services. They employee people and
sometimes will be the biggest employer in the community. They also give back to the community because
as the biggest employer they indirectly support other businesses and even help
attract businesses because of their accessibility.
Given the
sparse population of Nevada, rural hospitals are a necessity to ensure the
delivery of quality care to all citizens.
The viability of rural hospitals in Nevada will be determined in the
first instance by whether these hospitals can reduce costs without reducing the
quality of medical care that rural residents need and deserve and in the second
instance by whether these hospitals can provide these services in a manner that
still makes the hospital economically viable.
RECOMMENDATIONS
Recommendations
for future studies regarding Nevada rural hospitals are as follows:
The
payment changes included in the Balanced Budget Act are predicated on the
assumption that health care providers and delivery systems can adjust to lower
federal funding (Medicare reimbursement payments) by operational cost-cutting. Cost cutting may be realized through further
development of local and regional networks.
Another mechanism for finding costs savings is to increase the volume of
service per provider such that economies of scale yield savings. Two other possibilities exist: large rural
networks or consolidation of providers.
The challenge for rural providers will be how to cooperate across a
sufficient number of service locations to generate the number of patients
needed to use new techniques of medical and administrative management, without
sacrificing local autonomy.
Policy
makers examining the Medicare program are obligated to be fiscally prudent in
setting payment policies, but they are also charged with the responsibility of
doing what they can to assure that services are available to the beneficiaries. These twin responsibilities pose what has
become a core dilemma in recent years - meeting an obligation to finance
services without spending more than is affordable in the context of the
Medicare Trust Fund and the General Fund of the federal budget. The unavoidable obligation to constrain
Medicare spending cannot be met by simply imposing continuing and significant
payment reductions on small rural providers since to do so jeopardizes access
to care for rural beneficiaries.
Providers should be able to cut costs in a manner that contributes to
savings deemed necessary for the future of Medicare, albeit not at the same
levels as larger providers.
Consequently, public policy changes will need to be implemented. For example:
·
Changes in payment policies should include a “rural
differential,” accounting for different impacts on providers as a function of
size and location,
·
Policies designed to encourage change in the organization of
health care services should include resources and suggested models that
encourage rural providers to participate in the changes (Mueller & McBride,
1999).
Both of
these public policy examples are founded upon a market position analysis. The possibility that hospitals can avoid
direct competition by establishing a distinct market position has significant
implications for the competitive dynamics among rural hospitals. Failure to consider a hospital’s market
position may overestimate the competitive pressure the hospital experiences in
a given market (McKay, 1998).
The market
position framework employs three service domains to evaluate the market
position of a local hospital in a given market area. The attributes are geographic distance, size and service
configuration.
(1) Geographic Distance: Likely to
affect the competitive dynamics among rural hospitals. Hospitals at a distance from other hospitals
may avoid direct competition for patients and physicians and have better
prospects for survival.
(2) Relative Size: The
relative size of a hospital may determine where patients and physicians go,
therefore if rural hospitals are adequate in size to meet the needs of the
population they serve, they will have
better prospects for survival.
(3) Service Configuration: The
relationship between market position and hospital closure is explored by
considering the effects of service configuration within three service domains:
basic, high-tech, and outpatient/outreach.
Basic services are defined as primary acute medical services that are
generally associated with “traditional” hospital inpatient activity (e.g.,
respiratory therapy, general medical/surgical care). High-tech services are specialized clinical services involving
the use of advanced technological facilities (e.g., cardiac catheterization
lab). Outpatient/outreach services are
those nonacute services that are often used to supplement or replace acute care
services (e.g., ambulatory surgery, hospice) (McKay, 1998).
Using the
market position framework, it is important to consider a rural hospital’s
position in these service domains relative to other hospitals in the
market. The focus, therefore, is not on
the absolute number of services provided in a particular service domain, but
the relative number as it relates to the market area.
The role of
the hospital in the American health care system is changing
rapidly, just as there has been a
dramatic change in the access to rural health care services in Nevada in the
last five years. The number of
physicians and physician assistants has more than doubled and the rural communities
are receiving new or improved services.
While recruitment of health care personnel continues, the main concern
becomes maintenance of these basic primary health care services as well as
building on the recent growth to insure a stable health care delivery system
for rural Nevadans.
A rural
health care system is only as strong as its weakest link. The interconnected links which constitute a
rural health care system include the hospital and its separate components, such
as buildings and equipment; management; health care personnel; the community
support structure for health care services-health insurance programs, county
subsidy programs, public health programs, pharmacy services, physicians, and
the patients.
If any
portion of this complex set of interrelationships does not function, the entire
system has the potential for collapse.
In a rural setting, this stability is much more at risk because of the
relatively small size of the system.
Any loss could have critical consequences in a rural setting.
Each area
of the health care system must maintain its own individual competence while
supporting and maintaining faith in the balance of the system. Therefore, health care systems must keep
communication between the various units open and supportive. To keep costs down, the administrations of
rural hospitals must always look for ways to reduce costs and maintain a high
quality of care.
Finally in
an age of increasing economic pressures the survival of any rural health care
system is dependent upon a combination of hospital administrators with the
expertise and vision to recognize the need to maximize relationships with
larger urban medical facilities and community residents who use, albeit do not
abuse, the services provided by the rural hospitals.
REFERENCES
American
Telemedicine Association (1999). Telemedicine: A Brief Overview (Online)
Available: http://www.atemeda.org.html.
Berry, David E.; Beaulieu, Joyce E.; (1994). Hospitals and Long -Term
Care. Rural
Health Services. 111-124.
Campion, D.M. (1995). The Next
Generation of Limited-Service Rural
Hospitals. Washington, DC: Alpha Center.
Campion, D.M.; Dickey, D.F.
(1995). Lessons from the Essential
Access
Community Hospital program for rural network
development. Journal of Rural
Health, 11(1). 32-39.
Center for Health Care Leadership,
AHAs., (1997). A Profile of
Nonmetropolitan Hospitals 1991-1995.
[On-line]. Available: http://pso.
Aha.org/memberserv/smallrhreports.html.
Cordes,
S., Van der Sluis, E., Lamphear, C., and Jerry Hoffman, (1999). Rural
Hospitals and the Local Economy: A Needed Extension and Refinement of Existing
Empirical Research Rural Health Research. 189-201.
Department
of Taxation, State of Nevada, 1550 E. College Parkway, Carson City, Nevada.
Doeksen,
GA, Loewen, RA, and Strawn, DA, (1990). A rural hospital’s impact on a
community’s economic health. The Journal of Rural Health, 6(1), 53-64.
East, Robert G., (1999). Rural
Hospitals See Need for Integration.
Houston, Texas: The ProHealth Group.
Egan, M; Kadushin, G. (1997).
Rural hospital social work: views of
physicians and social workers. Social Work Health Care, 26:1. 1-23.
Fasciano, N.J., Felt-Lisk, S.,
Ricketts, T.C., and B. Popkin, (1999).
Preparing Rural Communities for Managed care: Lessons
Learned. The Journal
of Rural Health, 15(1), 78-86.
Furlow, Leslie. (1999). Rural
hospitals: Getting the short straw.
Higman Healthcare Highlights, Volume 7, Number 1.
Kincade,
K., (1998). New law makes reimbursement mandatory. Telemedicine and Telehealth Networks.
4(2), 23.
Kuz, Martin; (February 14,1999).
Prognosis grim for rural hospitals.
Las Vegas Sun.
McBride, T.D. and K. Mueller,
(1999). Tracking the Response to the
Balanced Budget Act of 1997: Impact on Medicare managed Care
Enrollment in
Rural Counties. The Journal of Rural Health, 1591),
67-77.
McKay, N.J., (1998). Rural
Hospitals: Organizational Alignments for
Managed Care Contracting. Journal of Healthcare
Management, 43(2) 169.
Mueller,
K., (1997). Rural implications of the balanced Budget Act of 1997: A rural
analysis of the health policy provisions P97-10). Columbia, MO: Rural
Policy Research Institute.
Mueller,
K., & T. McBride, (1999). Taking Medicare into the 21st Century:
Realities of a Post BBA World and Implications for Rural Health Care.
[On-line]: http://www.rupri.org/pubs/archive/old/health/p99-102/index.html.
Nevada
Rural Hospital Project, 4600 Kietzke lane, Suite 0-269, Reno, Nevada,
89502. Phone 775-827-4770.
O’Shaughnessy, J; Clark, L; Dye,
N; Holmes, G; Raffin, E; Rector, S;
Zhu, x. (1997). Success factors for the future survival of
rural hospitals.
Best Practice Benchmarking Healthcare, Jan 2:1. 1-19.
Reif,
Susan S., and Thomas C. Ricketts, (1999). The Medicare Critical Access
Hospital Program: The First Year. The Health Care Manager, December, 1999.
61-66.
Reif,
S.S., Desharnais, S., and S. Bernard, (1999). Community Perceptions of the
Effects of Rural Hospital Closure on Access to Care. The Journal of Rural
Hospitals, 15(2), 202-209.
Ricketts,
T.C., (1999). Rural Communities and Rural Hospitals, The Journal of Rural
Hospitals, 15(2), 168-169.
Ricketts,
T.C., Johnson-Webb, K.D., and Patricia Taylor, (1998).
Definitions of Rural: A Handbook for Health Policy Makers
and Researchers,
Bethesda, MD, 1-23.
Rosenthal, TC; James, P; Fox, C; Wysong; FitzPatrick,
PG. (1997).
Rural physicians, rural networks, and free market health
care in the 1990s.
(Arch Fam Med, 1997 Jul, 6:4, 319-23).
Smith, S.,
Freeland, M., Heffler, S., McKusick, D., & The Health Expenditures
Projection Team, (1998). The next ten years of health spending: What does the
future hold? Health Affairs, 17(5), 128-140.
Succi, MJ;
Lee, SY; Alexander, JA. (1997) Effects of market position
and competition on rural hospital
closures. Health Services Research,
Feb, 31:6. 679-99.
State Challenges and Opportunities
in Rural and Frontier Health Care
Deliver, 1998. [On-line].
Available:http://www.naga.org/Pubs/IssueBriefs/1998/980929RuralHealth.asp.
The Medicare Rural Hospital
Flexibility Program (Critical Access
Hospitals). [On-line].
Available:http://pso.aha.org/MemberServ/critacceshosp.html.
U.S. Community Hospitals by
Urban/Rural Status. Hospital
Statistics.
1999 edition.
APPENDIX 1
SURVEY
1.
Name of the rural medical
facility:__________________________________
2. What year
was the hospital founded?_______________________________
3. How was
the hospital originally organized (for example, not-for-profit, public,
physician-owned)?______________________________________________
4. In what
year was the hospital last organizationally restructured?__________
5. What
organizations associated with for support?______________________
6.
How hospital compensates the
physicians?__________________________
7.
How many employees?__________________________________________
8.
Number of nurses
employed:______________________________________
9.
What geographic areas are included in the hospital’s service
area?________
10.
County:______________________________________________________
11.
The population estimates for your
county:___________________________
12.
Average patient
days:___________________________________________
13.
Profit or Loss as of last budget
year:________________________________
14.
Things doing to keep the doors
open:_______________________________
15.
Sources of
funds:_______________________________________________
16.
Number of
bed:________________________________________________
APPENDIX 2
MEMBERS OF
NEVADA RURAL HOSPITAL PROJECT
Battle Mountain General Hospital
Kathy
Ancho, Administrator
535
South Humboldt, Battle Mountain, Nevada
89820
Phone:
(775) 635-2550 Fax: (775) 635-8844
Boulder City Hospital
Kim
O. Crandell, Administrator
901
Adams Boulevard, Boulder City, Nevada
89005
Phone:
(775) 293-4111 Fax: (775) 293-0430
Carson-Tahoe Hospital
Steve
Smith, CEO
775
Fleischmann Way, P.O. Box 2168, Carson City, Nevada 89702-2168
Phone:
(775) 882-1361 Fax: (775) 885-4477
Churchill Community Hospital
Jeffrey
Feike, Administrator
801
east Williams Avenue, Fallon, Nevada 89406
Phone:
(775) 423-3151 Fax: (775) 423-3365
Grover C. Dils Medical Center
Shawn
Wiscombe, Administrator
U.S.
Hwy. 93 North, P.O. Box 38, Caliente, Nevada
89008
Phone:
(775) 726-5222 Fax: (775) 726-3797
Humboldt General Hospital
Byron
Quinton, Administrator
118
East Haskell Street, Winnemucca, Nevada 89455
Phone:
(775) 623-5222 Fax: (775) 623-5904
Mt. Grant General Hospital
Richard
Munger, Administrator
First
and “A” Streets, P.O. Box 1510, Hawthrone, Nevada 89415
Phone:
(775) 945-2461 FaxL775) 945-2359
Pershing General Hospital
Jon
Smith, Interim Administrator
855
6th Street, P.O. Box 661, Lovelock, Nevada 89419
Phone:
(775) 273-2621 Fax: (775) 273-3215
South Lyon Medical Center
Joan
Hall, Administrator
Surprise
& Whitacre, P.O. Box 940, Yerington, Nevada 89447
Phone:
(775) 463-2301 Fax: (775) 463-4300
William Bee Ririe Hospital
Robert
Morasko, Administrator/CEO
1500
Avenue H, Ely, Nevada 89301
Phone:
(775) 289-3001 Fax: (775) 289-8244
Rural
Hospital - Nonmember
Elko General Hospital
Fred
Hodges, CEO
1297
College Ave., Elko, Nevada 89801
Phone:
(775) 738-5151 Fax: (775) 738-1979
Nye Regional Medical Center
Debra
Pearson, President
825
Erie main Street, P.O. Box 391, Tonopah, Nevada 89049
Phone:
(775) 482-6233 Fax: (775) 482-6155