June 12, 2019
As rural hospital closures become more common, many patients are left without sources of care, raising ethical questions about hospitals’ and clinicians’ responsibilities during and after closures.
In a new case study and commentary published online by the AMA Journal of Ethics, George “Mark” Holmes, PhD, professor of health policy and management at the UNC Gillings School of Global Public Health and director of the Cecil G. Sheps Center for Health Services Research, and Sharita R. Thomas, MPP, research associate at the Sheps Center, explore this question.
Often, hospitals have been economic hubs of communities for many years and are obliged to consider short-term and long-term consequences of closures on community life.
“N Health Network recently announced the closure of one of its institutions, S Medical Center,” begins Holmes’ and Thomas’ case. “In a rural location, the medical center is the area’s only full-service, inpatient hospital, providing primary, emergency and specialist care to more than 20,000 residents since its opening 40 years ago. Reasons given by N Health Network for the medical center’s closure include decreasing revenue, decreased patient volume, and burdensome building maintenance costs. The medical center’s patients and staff of local clinicians will be consolidated and transitioned to N Health Network’s main campus about 30 miles away.”
In the related commentary, the co-authors report that the rate of hospitals closures nearly doubled from 7.5 per year 2010-2013 to almost 13 per year 2014-2018. They also offer the context that socioeconomic factors have been estimated to account for 47 percent of health outcomes, meaning poverty and inadequate transportation make rural residents particularly vulnerable to local hospital closures. Rural residents experience higher rates of poverty than do urban residents, and they are faced with limited public transit options.
Holmes and Thomas’ commentary concludes with the statement that, “Hospitals need to be financially viable in order to fulfill their mission. […] The old maxim ‘no margin, no mission’ holds true.”
When a hospital that is financially struggling becomes simply unable to continue to operate —and the closure could have a devastating impact on the community in the near and long term — they suggest that health networks help communities transition to new service locations by actively partnering with community members to identify and respond to resulting gaps in access to and delivery of needed health care services.
“People across the country are worried about rural hospital closures and what it would mean to their community if it happens,” Holmes said. “These closure can be devastating from an economic as well as a health standpoint. We wanted to explore the issue from an ethical perspective to inform how best to help communities adapt when they face a closure.”
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