Greenwood Commonwealth
GLH Critical-Access Bid May Be Long Shot
By Tim Kalich, Editor
A month ago, two Leflore County supervisors created a stir when they expressed skepticism that Greenwood Leflore Hospital would be successful in securing what has been depicted as a life-saving designation as a critical access hospital.
Reginald Moore, president of the county board, and Robert Collins, its vice president, said that once turned down at the regional level by federal regulators, an application for the critical-access designation has never been approved.
At the time, the two supervisors were part of a majority that balked at providing the hospital, which is jointly owned by Leflore County and the city of Greenwood, with additional emergency funding to keep it afloat. They had suggested that the application was doomed, after being rejected by the Atlanta office of the Centers for Medicare and Medicaid Services on the grounds that Greenwood’s hospital was too close geographically to other hospitals.
Less than two weeks later, the county board, under pressure from worried hospital employees and other constituents, relented, approving a $3 million draw on a line of credit that the supervisors anticipate should cover any shortfalls at the hospital until it hears later this year about its appeal to higher-ups at CMS.
It turns out, however, that Moore and Collins could be right. Based on information provided by CMS itself, the CAH designation appears to be a long shot.
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The critical access hospital program was created by Congress in 1997 as a way to ensure medical services would be available in rural parts of the country. Until COVID-19 compounded the Greenwood hospital’s already mounting financial problems, it did not demonstrate any interest in pursuing the designation.
Although it enviously eyed the higher Medicare reimbursements being received by critical access hospitals with which it competed for patients, most notably the rejuvenated North Sunflower Medical Center in Ruleville, the Greenwood hospital had too much inpatient volume to qualify.
In order to get a CAH designation, a rural hospital must limit itself to no more than 25 inpatient beds. Although it had been years, if not decades, since Greenwood Leflore had needed anywhere near the 208 beds for which it had been licensed, its census still put it well over the 25-bed limit.
But the negative impact on patient volumes created by COVID and years of multimillion-dollar losses had necessitated cutbacks in services. With the elimination of the hospital’s maternity ward, its intensive care unit and other unprofitable or hard-to-staff specialties, the hospital was down to using only a dozen to two dozen beds a day.
Still, pursuing CAH status remained only a potential consideration until the University of Mississippi Medical Center in early November 2022 backed away from a long-term lease during the final stages of negotiation.
What had been a backup plan quickly became not just Plan A but in the opinion of the hospital’s administration the last realistic hope to keep the 117-year-old hospital in operation.
A critical-access hospital is reimbursed at 99% of its cost for treating Medicare patients. That compares to an estimated 84% that acute care hospitals, such as Greenwood Leflore, receive.
With half of its patients on Medicare, the Greenwood hospital has estimated that converting to a CAH would generate between $10 million and $14 million more a year in revenue — enough to cover all of its present operating deficit and then some.
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From the start, it has been understood that Greenwood Leflore Hospital’s main obstacle to obtaining the critical-access designation is the program’s distance rule.
In order to become a CAH, the applicant must be located more than 35 miles away from another CAH or hospital if the distance is covered by primary (four-lane) roads, or more than 15 miles if the distance is covered by secondary (two-lane) roads. If the drive involves both primary and secondary roads, more than 15 of the total miles must consist of areas in which only secondary roads are available.
Greenwood Leflore Hospital is 28.3 miles from Tyler Holmes Memorial Hospital in Winona and 28.1 miles from South Sunflower County Hospital in Indianola, with both of the distances covered mostly by a four-lane highway, U.S. 82.
North Sunflower Medical Center is also less than 35 miles away, but because most of that distance is on secondary roads, it does not factor into the Greenwood hospital’s application.
Before 2006, Mississippi hospitals could be granted waivers from the distance rule by the state Department of Health if they were designated as a “necessary provider.” That’s how both North Sunflower (located 10 miles from Bolivar Medical Center in Cleveland) and Tyler Holmes got their distance waivers and received their CAH status.
According to a list provided by the Department of Health, at the first of this year, there were 32 critical access hospitals in Mississippi.
A handful of these, due to their own financial struggles, have since converted or are trying to convert to a new federal designation, “rural emergency hospital,” which requires them to end all in-patient services in exchange for a monthly stipend as well as higher Medicare reimbursements.
Of the 32 CAHs on the list, though, 20 had been designated as necessary providers by the Department of Health. This was before Congress, in a cost-cutting move, removed the authority of the states to grant waivers to the distance rule. The law, which took effect on Jan. 1, 2006, grandfathered in any facilities that had been designated as necessary provider CAHs prior to that date.
Nevertheless, Greenwood Leflore Hospital officials have been led to believe by outside attorneys and U.S. Rep. Bennie Thompson that waivers from the distance rule are still available.
Speaking in November 2022 to a gathering of local government and hospital officials at the Leflore County Courthouse, the longtime Democratic congressman encouraged the hospital to apply for the critical-access designation with the Centers for Medicare and Medicaid Services.
“I’ve worked and got two other hospitals that were within the 35-mile radius, we’ve gotten a waiver, but it’s an individual-by-individual basis,” he said. “So we need to just make the application with CMS, and we’ll fight that battle.”
Subsequent requests by the Commonwealth to Thompson’s Washington office to identify the two hospitals have not been successful. Instead, a congressional aide issued earlier this month a general statement of support, saying, “Congressman Thompson stands with and continues to champion the cause of Greenwood Leflore Hospital. He is actively engaged with those dedicated to ensuring the hospital stays open.”
The hospital also has Mississippi’s two U.S. senators, Roger Wicker and Cindy Hyde-Smith, lobbying on its behalf. The two Republicans and Thompson have requested a meeting with the head of CMS, Chiquita Brooks-LaSure, as well as her boss, Health and Human Services Secretary Xavier Becerra, according to Gary Marchand, the hospital’s interim CEO.
CMS says, however, that neither it nor HHS has the legal authority to grant a waiver.
“The requirement for critical access hospitals (CAHs) to not be located within a certain distance of another hospital or CAH is a statutory requirement and, therefore, there is no discretion under this statute for either CMS or HHS to grant a waiver to this requirement,” a CMS spokesperson in Washington said in a prepared statement to the Commonwealth.
Curiously, though, there are at least two critical access hospitals in Mississippi that were seemingly able to get past the 35-mile rule even after the law changed in 2006.
Franklin County Memorial Hospital in Meadville was certified as a CAH in 2009, and Pearl River County Hospital in Poplarville received the designation in 2010. Neither was designated as a necessary provider by the state. According to Google Maps, the Meadville Hospital is 32 miles, by mostly four-lane highway, from Kings Daughters Medical Center in Brookhaven. The Poplarville hospital is a 27-mile drive, mostly along an interstate highway, to Highland Community Hospital in Picayune.
It is not immediately clear how those two CAHs were not tripped up by the distance criteria.
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In its 11-page appeal to the Centers for Medicare and Medicaid Services, Greenwood Leflore Hospital offers several reasons why it should be granted an exception to the 35-mile rule.
It argues that a fairer standard would be the 15-mile requirement because of the poverty in the region that impacts both health care and transportation availability. It claims that 12.6% of the households in Leflore County do not have access to a vehicle.
“We respectfully submit that lack of transportation by a large segment of the medically underserved population, as uniquely exists in Leflore County and the Delta, is as significant a barrier to hospital access as driving distances between facilities,” the appeal states.
The hospital says that a waiver would also be in keeping with President Joe Biden’s executive orders on advancing racial equity and supporting underserved communities. If the hospital closes, which the appeal says will happen if CAH status is not granted, Leflore County would become the largest county in Mississippi without a hospital. The impact, the hospital says, would be “catastrophic” for the area’s economy and contribute to already glaring health disparities based on race and income levels. “There is no doubt that closure of GLH will have a disproportionate impact on minority and low-income communities,” the appeal states.
Lastly, the Greenwood hospital argues that for the purposes of evaluating its CAH application, regulators should disregard the two hospitals that caused, because of their proximity to Greenwood, the initial denial by CMS.
Tyler Holmes Memorial Hospital in Winona and South Sunflower County Hospital in Indianola operate more like rural emergency hospitals because of their limited services and capacity, the appeal says. REHs are not considered when CMS is determining whether an applicant for CAH status meets the distance requirement.
According to a chart comparing the three hospitals, Greenwood Leflore has an active medical staff of 50, whereas the other two hospitals have only three medical staff members each. Greenwood’s hospital has an average daily inpatient census that is at least double either of the other two, and it has more than three times the number of employees. The appeal says that the Winona and Indianola hospitals would not be able to handle the volume of patients if Greenwood’s hospital went out of business.
“In the last fiscal year,” the appeal says, “GLH had over 22,000 Emergency Room visits. If GLH is forced to close, it would be literally impossible for Tyler Holmes and South Sunflower to serve those patients, assuming that the patients would have the means to travel to the hospitals in the first place. Tyler Holmes and South Sunflower ‘serve a distinct purpose in the community,’ but it does not include serving as an alternative and accessible inpatient facility for the residents of Greenwood and surrounding communities.”
To support its case for reconsideration, the Greenwood hospital provided CMS with a letter from Dr. Daniel Edney, the state health officer, who pleads for help in dealing with the escalating health crisis in the Mississippi Delta. “If a person has a heart attack, stroke, farm accident or severe trauma, it is dire circumstances to be able to access appropriate health care in the Delta. Even one of the largest hospitals in the region only has the capacity to take care of a heart attack victim three days a week,” Edney writes.
“In this environment, it is vitally important for Greenwood Leflore Hospital to survive.”
The success of these pleas and arguments, though, relies on CMS using its discretion, something the federal agency claims it does not have.