BONNE TERRE — In this former mining town 60 miles south of St. Louis, the city’s sole hospital has ended most overnight patient stays. But, in a rare situation in the world of underfunded rural hospitals, Parkland Health Center in Bonne Terre is about to get a financial boost.
As part of a new federal program, hospital officials agreed to end inpatient services. In exchange, they have added three beds to their ER, bringing its total to eight, and they will receive higher payments for emergency care.
Parkland officials made the case this week that the transition will work well in Bonne Terre, where they have seen inpatient beds go underused in recent years. They have a sister hospital just 12 miles down the road in Farmington, with inpatient beds and services Parkland is too small to offer.
The facility, which is part of the BJC HealthCare system, is the state’s first — and so far, only — Rural Emergency Hospital. The new type of license promises hospitals higher Medicare reimbursement for emergency room services, and establishes a new flat monthly payment of around $270,000.
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The Rural Emergency Hospital designation — established by Congress in 2021 and authorized in Missouri last year — was viewed as a method of preventing rural areas from losing emergency services altogether.
But experts are skeptical that many other rural hospitals can — or should — make a similar change. While it opens a new path forward for struggling facilities, it comes at a cost to inpatient care, and the financial model isn’t proven yet.
Policymakers and hospital leaders nationwide have spent decades working to bolster small-town medical facilities, which usually lack the lucrative specialty services that keep large, urban medical centers afloat. They also often care for higher portions of uninsured or underinsured patients.
Missouri has suffered its share of rural hospital closures — 10 in the past decade, according to the state hospital association — forcing patients to travel farther for care. And when the distance becomes burdensome or prohibitive, residents’ health problems go untreated or unnoticed.
The idea behind the new program was to ensure that care — especially emergency care — remains available in towns that can’t support a full-service hospital, said Brock Slabach, COO of the National Rural Health Association.
“They’re not intended to be a solution for every rural community in the United States,” Slabach said.
Eight ER beds
Bonne Terre, a city of 7,000, is well-positioned to make the change, officials said. Giving up their inpatient services allowed them to add needed capacity in the emergency room. The flat monthly payments have stabilized the hospital’s income.
“This is going to be a really good thing for the city,” said Bonne Terre Mayor Erik Schonhardt. “We know about the number of rural hospitals that have closed in the past several years. ... Increasing the size of the emergency department definitely outweighs the closing of a couple inpatient beds.”
The inpatient services at the hospital — used, for instance, by patients suffering from strokes, heart attacks or chronic conditions — were already somewhat limited, said Dr. Leo Hsu, the hospital’s ER and medical director.
“When you think about a patient who needs to be in the hospital for more than a day, usually that person would need some kind of advanced procedure or surgery, or other things like that that we didn’t have available,” Hsu said.
And the additional three beds were welcome in what was previously a five-bed ER. In such a small department, it doesn’t take much of an influx before patients are overflowing into the waiting room, Hsu said.
People who need inpatient care can be transferred to Farmington, about a 10-minute drive, and shorter with lights and sirens. Helicopters based in Farmington can bring patients from either facility into St. Louis for more complex procedures.
While the hospital in Bonne Terre may be well-suited for the new program, people in the industry said other hospitals considering the model will have to carefully weigh its trade-offs.
Rural Emergency Hospitals aren’t eligible for a federal drug discount program, known as “340B,” that provides reimbursements to hospitals and clinics in low-income communities. For some hospitals, including the one in Bonne Terre, the payments are marginal. For others, that financial hit would be prohibitive.
Multiple Rural Emergency Hospitals have weathered gaps in Medicare reimbursements transitioning to the new license.
Parkland is part of the BJC system. For independent hospitals, the new model might be more difficult, said Joshua Gilmore, the former CEO of Iron County Medical Center, who navigated the hospital through a Chapter 9 bankruptcy.
Emergency departments are often the top money-loser for rural hospitals. Gilmore said he fears some will view the designation as a “shiny, new, potential ‘save us’” button.
The first Rural Emergency Hospital was established in early 2023, and at least 27 others have made the transition since then, so the industry will soon have a financial track record to examine. But for now, Slabach said, “the jury is still out.”
‘We welcome change’
For most of the 20th century, Bonne Terre had a much larger hospital.
In 1911, with the support of the lead company, a 69-bed hospital opened at Church Street and Lake Drive.
It was absorbed in 1992 by Christian Health Services, which merged the following year with Barnes Hospital and Jewish Hospital of St. Louis, forming BJC HealthCare.
BJC replaced Bonne Terre Hospital with a three-bed facility that opened in 1995. The former hospital was converted into a nursing home, which still exists today, across from Bonne Terre Lake.
As locals learned of the changes at the hospital this week, they said that in an ideal world, Bonne Terre would have a full-service hospital with more specialty services. But expanding the emergency room should be an improvement. And indeed, inpatient services were probably underused.
“I don’t know anyone who’s been there more than six hours,” said Shari House, who has lived in St. Francois County for 42 years.
For specialty care, residents do usually have to go to Festus — or more likely, St. Louis, said Schonhardt, the mayor.
“That’s just one of the things that happens when you live in a smaller community,” he said.
But the city has its basic needs met. It has several primary care clinics and urgent cares.
To Saundra Cramp, who has lived in the area since 1983, the change sounded like a good idea.
Cramp lives in DeSoto, and with her husband owns the Cut and Sew Quilt Shop on West School Street in Bonne Terre. All of their doctors are in Farmington.
“Anything’s better than what we got,” Cramp said. “We welcome change.”
St. Louis Post-Dispatch photographers captured April 2024 in hundreds of images. Here are just some of those photos. Edited by Jenna Jones.