The fragility of health care in rural communities is clearly seen by the economic forces battering rural hospitals, but officials says there is hope for the future.
The Bamberg County Hospital closed its doors in 2012, with the Barnwell County Hospital closing in 2016. This created what many officials had called a "health care desert" in the area, with barriers to access and affordability for residents of both counties.
Regional Medical Center officials announced health care was coming back to Bamberg, Barnwell and surrounding counties when they cut the ribbon for a 20,500-square-foot emergency medical center earlier this year, but the process has not been without challenges.
"We have to do something because in many different health situations, time is tissue, be it a stroke or heart attack. I applaud our legislative individuals. ... All of them working together to make that (medical center) a realization was big, and also working with our state to understand the importance of rural health care," RMC President and Chief Executive Officer Charles E. Williams said.
Williams also thanked the Southern Carolina Alliance -- a Barnwell-based economic development group that has Bamberg, Barnwell and Allendale among the seven counties it serves -- for helping make the emergency medical center a reality.
Williams said RMC has worked closely with the South Carolina Hospital Association in meeting the needs of rural areas, which tend to have a higher concentration of uninsured and underinsured individuals lacking adequate access to care.
“We work really close with them kind of on policy and how we can build effective rural health care. It’s hard when resources are as strapped as they are,” said Schipp Ames, SCHA vice president of communications, education and members services.
Ames said the hospital is the only place some individuals, particularly in the rural areas, can get care.
“It’s going to take out-of-the-box solutions to save rural areas because they are very unique places in the challenges that they face. We’re having to think of new ways to get providers there, maintain services and protect access because making sure we have a strong safety net for everyone to access care if they need it is the biggest issue for our rural hospitals.”
Ames added, “It’s the rural areas that tend to have a higher concentration of folks who are sicker because they tend to delay medical care, whether it is because of cost or access. ... So you have sick people with less resources and that trickles down to the hospital.”
Williams said, “One of the things that we're working toward is increasing our status in funding to what's called 80% persistent poverty. One of the things I'm working hard with the state on is that we truly need to have the full 100% rural designation," he said.
"When you look at this market, while we might be closer to Columbia than Allendale, we are rural," Williams said. "When you look at the individuals we serve in Calhoun, Orangeburg and Bamberg, we are rural. So that's about a 20% reimbursement that we don't get.
"And we need to look at that. Why is that? When you look at our payer mix, it is different. We are 56% Medicare, 18% Medicaid and 8% self pay. In an economy like this, 8% self pay in reality and in many cases is no pay," Williams said.
He said RMC is also not subsidized by any taxes.
"So while we are an asset of the county, we receive no money from the county. That's not a bad thing, that's not a good thing, that's just a fact. If we're not receiving any subsidy from any taxes, but we are taking care of all, there's a gap.
"So that's why it's so important that we have a registration and a processing and a payment system that is appropriate. ... Some would say, 'Well, it shouldn't be about money,'" but staff and water and electricity bills must be paid, Williams said.
"So we have to continue to put in front of our legislative bodies, our local community leaders and businesses, the importance of ensuring that there is an economic flow to ensure that we continue to not just pay, but reinvest. Technology is continuously evolving, and we all deserve the latest technology," he said.
Ames said the SCHA has been supportive of the state’s Rural Health Initiative.
“It’s a part of the state budget that prioritizes projects around rural care, trying to get more providers in underserved communities and incentivizing MUSC and USC to do that by trying to create different training opportunities. ... Rural flight is a real issue,” he said.
The SCHA and the S.C. Technical College System have teamed up to provide a Path to Provide scholarship program to expand the health care workforce in the state. Orangeburg-Calhoun Technical College is one of 13 technical colleges participating.
“How can we build that bridge from Orangeburg-Calhoun Technical College directly into the hospital? That’s kind of what Path to Provide does. RMC will match part of the scholarship for students to attend the college, and that student gets to do kind of a work-study program where they go to the hospital, learn a trade” and hopefully remain in their communities to serve, Ames said.
‘Education ... a bigger piece’
Dr. Alexandra Proctor is chairperson of the Department of Science, Technology and Health and Human Sciences at Denmark’s Voorhees College, which is home to a Center of Excellence in Rural and Minority Health.
Proctor said collaboration is key in providing health care in rural areas.
"We are in a South Carolina Promise Zone. So we reach out to the community here and try to inform them of resources. This is kind of a laboratory for our faculty and students in public health. We're uniquely situated here at Voorhees because of our rural health center and because of our public health program to be part of this collaboration that is looked for," Proctor said.
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Bamberg County is one of six Promise Zones, or high-poverty communities, where the federal government partners with local leaders to address priorities.
Dr. Kendall Williams, an assistant professor of public health and program coordinator of public health at Voorhees, said, "I'm currently establishing contacts with the Bamberg County Health Coalition ... and will hopefully provide them with another avenue for resources from an educational standpoint."
"I'm hoping within the next year or so to reach out more to not only the Denmark area community, but the county at large to offer services to them," he said.
While the Center of Excellence is without an executive director, Proctor said work continues.
"Because this is actually a business startup, the first thing is to, of course, maintain our activities, certain grant partnerships, our annual community health fair, seek external funding and then recruit an executive director with a vision that will lead us into the future. We definitely want the Center of Excellence to have a greater presence in the community and that is part of the college's strategic plan," she said.
Dr. Williams said while many rural hospitals are closing, they are crucial.
"There is a lack of funding that is offered to keep them afloat and sustainable. They are crucial from the public health standpoint as being the first response, or first line of prevention, in the area of disease. So we not only need them to be our surveillance to let us know what's going on in the community, but they also need to be the first stop for individuals to seek care at an early stage or onset of disease."
The hospital president said RMC’s Disproportionate Share-Medicaid funding, along with benefits provided through a 340B Drug Discount Program, are crucial and help ensure its sustainability.
The disproportionate share money pays hospitals that care for a disproportionately large number of indigent patients and has been reported to make up approximately 81% of RMC's non-operating revenues. The federal 340B Drug Discount Program requires drug manufacturers to provide outpatient drugs to eligible health care organizations at reduced prices.
"When you're listening to the political talk -- I don't care what side you sit on -- pay attention to that. There's always a discussion of cutting those programs. Those are the needed programs that we must have," Williams said.
The RMC president said the new emergency center was especially needed.
"We had projected to see a certain amount, but we've surpassed that every day. So we're in the right place. And what we're doing now as a team is we've had 1,900 square feet that we kept vacant. We didn't finish it because we wanted to ensure we had the time to assess the needs.
"Do we have more primary care coming in there? Rehab needs? Behavioral health? What is it that we see? … We're assessing now so that we can plan the right thing there so the people can get what they need," Williams said.
The hospital administrator said community input will be needed to ensure maximum care in the area. He urges individuals to come out to community forums that the hospital periodically holds.
"Please come out. One of the things we hope to get launched by September is our Patient and Family Advisory Committee. We are reaching out and trying to put together a team of about 10 people, with representatives from all three counties. They are people that can become ambassadors and ... tell us what their experiences are -- good and bad-- to help us become better," Williams said.
What is in the future for rural health care? Officials say a greater emphasis on education.
"Education is going to be a bigger piece," Williams said.
The RMC president added, "It must be a bigger piece because of broadband and because as money becomes more scarce, I believe you're going to see the 60-something academic medical centers we have in the nation one day could become 40 because graduate medical education funds are drying up.
"So the community hospitals will have to be stronger because everyone can't go and bombard the big academic medical center. ... It makes sense to be educated on coming to your local hospital to get what you need because that stabilization is a big deal."
Proctor said, "South Carolina is unique because we have a community health worker certification. So training and informing the population in order to be able to have more people that are educated in and working in public health is another strategy when you don't have these physical (building) spaces."
‘You can’t educate if you don’t have access’
Proctor said the public health field is growing.
"The fact that our state is one of nine states in the nation that has a certified health worker curriculum is also a part of the future and collaboration. More collaboration is the direction what we need to go in as we inform the population and train them," Proctor said.
Dr. Williams said, "Another part of the technology we're kind of looking at is the expansion of telemedicine to the rural community. ... A lot of times individuals don’t have the means to go see a doctor. So their socioeconomic status can cause a barrier to them seeking health care on so many levels.
"So hopefully through the community health workers and telemedicine, we will be able to get more information into the rural community and basically more feet on the ground as far as the information, knowledge and education that’s extended to them."
The RMC president said he is proud of the work that the Tri-County Health Care Network is doing. The nonprofit network was formed in 2013 to improve the health of residents in Orangeburg, Bamberg and Calhoun counties.
With the network's collaboration with everything from local churches to the Orangeburg County YMCA, Williams said a community effort is needed to make its initiatives run successfully.
"If you go back and look at the health assessment that has been put out by South Carolina, we tend to focus on the six urban counties in South Carolina, but 40 of the counties are rural. So often with a Community Health Needs Assessment ... we forget the first word.
"So we've been trying to bring all of the organizations, churches, YMCAs and all of us in to say, 'OK, what part of this can we play? Where can we plant gardens? Where can we impact transportation?' ... If we have a large percentage of rural America without broadband, how do we combat that to get the education to the people where they need it?" he said.
Sixth District Congressman Jim Clyburn has been working to increase broadband access in rural South Carolina and is an advocate of it being a big part of the nation's next infrastructure package.
Williams said, "That's the great work being done by Mr. Clyburn and his infrastructure plan. Think about it. You can't educate if you don't have access."