Rural Health and COVID-19 - 2

Financially Challenged Before COVID-19, Rural Hospitals Face Uncertain Future

Todd Neeley
By  Todd Neeley , DTN Environmental Editor
Connect with Todd:
As COVID-19 began to spread in other parts of the world earlier this year, staff at St. Anthony Regional Hospital in Carroll, Iowa, prepared. Pictured from left: Bailee Schleisman, registered nurse and infection preventionist at St. Anthony; CEO Ed Smith; Sara Roth, registered nurse and director of the emergency department and critical care unit at St. Anthony; Chief Medical Officer Dr. Kyle Ulveling; and Trish Roberts, St. Anthony Foundation development director. (DTN photo by Chris Clayton)

OMAHA (DTN) -- As soon as staff at St. Anthony Regional Hospital in Carroll, Iowa, first heard in January of a dangerous new coronavirus spreading in China, they watched the situation closely and began to plan.

Their goals included to protect the health of current longer-term patients, prepare for future COVID-19 patients, and help their rural health care system to survive one of its toughest financial years.

At the start of the pandemic, more hospital staff were trained to use heart monitors and ventilators. St. Anthony converted a fourth-floor storage area into an overflow ward. The hospital typically has four ventilators for any department to use -- it expanded that to now 10.

St. Anthony staff also realized they couldn't do this alone. The Iowa hospital reached out early in the year to other rural hospitals within its health region and state, as well as medical experts in other states, including the Nebraska Medical Center. They also accessed federal money when they could.

Together, these rural facilities weathered the initial COVID-19 storm by pooling resources and innovating.

In the second of a two-story special package on how COVID-19 is affecting the rural health system, DTN looks at how a rural hospital in Iowa prepared to handle COVID-19 and the possible impact of COVID-19 on the bottom line on rural health care.


Early on, St. Anthony staff began meeting weekly to prepare for a potential surge. Staff from critical-access hospitals were invited to join hospital staff meetings, drawing 50 to 60 medical personnel in Zoom calls weekly.

The critical-access hospital designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare. The designation is given to rural hospitals that meet criteria such as having 25 or fewer acute care in-patient beds and being located more than 35 miles from another hospital. It helps with such things as cost reimbursement for Medicare services.

"Flashing back to February/March, we didn't have governor's press conferences every day," to share more information with medical staff about the spread of the virus and dealing with it, explained Dr. Kyle Ulveling, cardiologist and chief medical officer at St. Anthony.

"We didn't have the experience of New York, Washington and California, so the idea behind the medical staff meetings was honestly to get as much information out to all of us in our various clinics and hospitals in an organized manner, but allow us to learn from each other, as well as learn from centers in other states," Ulveling said.


Bailee Schleisman, a registered nurse and infection preventionist at St. Anthony, said the hospital is flexible in how it uses facilities, supplies and personnel.

At the beginning of the pandemic, the hospital started by managing COVID-19 patients in the emergency department. The hospital then established a separate COVID treatment unit in order to isolate patients from the general population.

From early on in the COVID-19 fight, St. Anthony began monitoring its personal protective equipment, or PPE, supplies; the state requires hospitals to report inventory as part of reopening.

However, rural hospitals by-and-large are cash-strapped and lack storage to stockpile PPE. They have been performing a delicate balancing act throughout the pandemic. At St. Anthony, they talked to suppliers before the virus hit the region to make sure they could readily access as much PPE as possible.

"There is close to a week or less of supply, but in general we've been able to maintain more than a week's supply to continue the reopening and trying to get to a typical operation," Ulveling said.


St. Anthony learned from University of Iowa hospitals and clinics the importance of setting up a COVID-19 home team for patients who don't need hospitalization. This helps conserve PPE, Ulveling said.

"I can tell you we worried about it when we saw it get less than a week (of PPE supply), but that's nothing like what some of the hospitals saw where it was less than days' worth," he said. "We prepared for the worst."

But, so far, the worst hasn't happened with COVID-19 in Carroll.

Sara Roth, registered nurse and director of the emergency department and critical care unit at St. Anthony, said the hospital hasn't seen a large increase of in-patients with COVID-19, despite having created additional intensive care unit, or ICU, beds in another hospital wing.

"We have been able to maintain at home with follow-up and are doing very well," Roth told DTN in June. "The positive cases that we've had definitely have been very manageable."


While the use of telehealth has been a key tool to help rural counties manage health resources during the pandemic, Ulveling said it has limitations.

Prior to the pandemic, there were doctors who "were absolutely sure they would never do telehealth," he said.

However, during the pandemic, both patients and providers have found a way to expand its use, despite a lack of widely available rural broadband.

"I can absolutely say that I've had patients drive to their local town libraries and sit in the parking lot to get on the Wi-Fi at the library to attend their health care visit," Ulveling said.


While the rural health system may have found ways to continue helping patients and keep them off the limited number of ventilators, rural hospital are reaching for financial lifelines to survive 2020.

Alan Morgan, CEO of the National Rural Health Association, said, as of Feb. 1, 2020, 47% of rural hospitals were operating at a loss -- this was prior to the COVID-19 outbreak in the United States.

Prior to COVID-19, on average, rural hospitals had about one month of cash on hand, Morgan told DTN.

And there were just more than 6,300 dedicated ICU beds in all of rural America at the time -- and much more needed if the pandemic spread as projected, especially in rural COVID-19 hotspots.

The Chartis Center for Rural Health said 25%, or 453 rural hospitals, were vulnerable to closure prior to COVID-19, as of April 2020.

Twelve rural hospitals have closed already this year. According to the University of North Carolina, by the end of June, there were 129 rural hospitals in the U.S. that have closed since 2010.

As grim projections were being made about how hard the pandemic could hit the country, there were calls for federal help.

The Coronavirus Aid, Relief, and Economic Security, or CARES, Act provided some relief.

Congress approved more than $2 trillion in relief to help families and the economy affected by COVID-19.

That included creating a $100 billion fund to help hospitals and other health care providers. Morgan said $30 billion was distributed to providers based on their Medicare patient volumes across the country, and another $10 billion targeted rural hospitals and clinics.

The CARES Act funding has helped rural hospitals to rise to the COVID-19 challenge, yet long-term financial viability is and always has been a major concern.

Despite money from CARES act helping the bottom line, the Iowa Hospital Association projects state hospitals will still lose about $1.4 billion by September as a result of the COVID-19 shutdown.


Most rural hospitals are privately owned and depend on income from Medicare and health insurance reimbursements. In states that haven't expanded Medicare, hospitals depend on revenue from elective and other procedures to stay financially viable.

Ed Smith, St. Anthony's CEO, said at the peak of the shutdown of elective procedures, the number of surgeries was at 10% of normal capacity at St. Anthony. Revenues declined by 50% in the first half of March on through April.

"Now, it looks like June we're tracking about 25% decline from normal," he said. "That's still pretty significant. This is having a devastating impact on the rural economy. And we're just a portion of that rural economy."

The Center for Agricultural and Rural Development at Iowa State University estimates Iowa farmers could see up to $3.6 billion in losses in the corn, soybean and ethanol markets in 2020 as a result of COVID-19 and other market factors.

Because rural hospitals have struggled financially for years, there is widespread concern the effects of COVID-19 could push the rural health system closer to extinction.

"The concern is we may have saved rural hospitals today to close them down this fall," Morgan said.

Despite concern about a rising number of cases in rural areas, Smith said he believes health care professionals have learned a lot during the pandemic and are better prepared.

"One of the things I think as a health care industry we've proven to the rest of society that we can be able to take care of an infectious disease epidemic, pandemic and be able to do other things as long as we have adequate PPE," Smith said.

"I think one thing that this has done is that we have doctors and nurses and hospitals in general, (who) have regained their rightful position as being respected within our communities and the nation.

"We are important."


Editor's Note:

This is the second of the two-story special package called Rural Health and COVID-19. To see the first story, you can find it at:…

Todd Neeley can be reached at

Follow him on Twitter @toddneeleyDTN

Todd Neeley

Todd Neeley
Connect with Todd: