No OB
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with OR available in situ
Staff it.
ACOG guidelines say that for a c-section. You gotta move fast.
"15 minutes from decision (to operate) to incision" is the standard.
When I worked in a small place in rural illinois (we were there for only about 8 years), when I got called for an epidural, or a section, the nurse told me that she's noting the time of the call in the patient's chart.
Half-hour delay? Gonna have a bunch of bad babies.
This is why, even on 2nd or 3rd call at our "bigger" place, I had to be within 15 minutes of the hospital. Got to be a drag when you're on 2nd call 5 times a month, and 3rd call 5 times a month.
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Scale is fine, if you have the population density. Maybe draw a 20 mile circle that encompasses 200k population?
Awful lot of the country won't fit that economy of scale.
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Seems like there is no choice. People in rural areas are going to have to travel far to have a baby.
(Unless there is some rich guy willing to pay a bunch of doctors to do nothing most of the day.)
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Pinedale’s residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining populations have spurred decades of downsizing and closures. Yet a few communities in Wyoming and others in Kansas and Georgia are defying the trend.
“To be honest with you, it even seems strange to me,” said Wyoming Hospital Association President Eric Boley. Small rural hospitals "are really struggling all across the country,” he said.
There is no official tally of new hospitals being built in rural America, but industry experts such as Boley said they’re rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.
About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.
To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1,700 eligible rural hospitals − from Georgia to New Mexico − have joined the program, according to data from the Centers for Medicare & Medicaid Services.
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Some care is better than no care. Stabilize and transport.
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Problem is how do you staff an ER in a rural setting? Years ago, I've worked 25-30 bed rural hospitals with one "trauma room" and a couple of exam rooms. Local docs (all three of them) would take call, often sleeping in the hospital. You'd have one nurse assigned to the ER at night, with the ability to pull another nurse and an aide from the floor if things got really hairy.
Doctors won't work like that anymore. I'm not sure nurses will. And you've got to have enough ancillary staff to support an ER, so I guess those guys would pull call. I guess you can cross-train a lab guy to do xray ( doesn't work well the other way, high complexity testing can get way beyond a xray guy) and the physician can do the basic respiratory stuff.
If you hire your ER doc, rather than having a local doc pull call, it's $200/hr (more on holidays, I've seen $500/hr on Christmas) if you can get one.
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So then how did this used to be done and these places stay open? The small hospital in my town, had a birthing center for decades. Over a 12 year span, all 5 of our kids were born there. A couple births, a day, was the norm there since...forever.
Did something change to make the couple births a day model unsustainable?
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Doctors and reimbursement.
Surprisingly, even Medicaid reimbursement for a vaginal delivery is pretty good. I'm not sure about a C-section.
Problem is the today's OB docs will simply not live the job. They want a life outside the practice.
And at the risk of being PC incorrect, I think it's because we have a lot more female OB/GYN docs. More women than men, won't live the job.
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When I went into private practice, our small place was doing about 1000 deliveries a year - that's 3 a day. It was sustainable.
When I retired, it was down to about 450 a year.
They closed the unit about a year after that.
As @jolly said, it's a staffing issue.
You're going to need 2-3 nurses per shift per day. The OB has to be within 15 minutes, 24/7. If you're delivering babies, you gotta be prepared to do a c-section within 30 minutes. Now you need a gas-passer and a neonatologist.
Gets pricey - fast. Neonatologist and gas-passer are gonna cost $600K a year - or more. Nurses get, what, $40 an hour? That's $120 an hour for 365 days. You're looking at another $1.75 million in salaries.
The OB docs? No way you're going to have only 2-3 now. No one wants to be on call every third night with every other if someone goes on vacation. Granted OB docs supplement their income by doing GYNE surgery, and that alone can sustain a nice lifestyle. So, why do the hard work of OB? I know three guys that quit delivering babies in their late forties, and they're happier for it - and better rested.
Equipment - OB beds are not regular hospital beds. Fetal monitors cost money, and maintenance of hospital-grade electronics needs to be considered. Gotta have an ultrasound machine handy too. Gotta have a fully-equipped OR available at all times. OR tables and anesthesia machines are pricey AF. Ive seen situations where the C-section is done in the main OR, but if your main OR is in use, gotta have one free.
Then, there's the liability. I'm just guessing that a hospital that doesn't do OB has a lower malpractice premium that one that does. But, if the insurance biz for hospitals is like it is for docs, I'd say I'm probably right.
Looks like at least $2.5 million in salaries, probably another million for equipment and maintenance (though that's a one-time cost other than PM) and insurance.
How many deliveries do you need to do to clear $2.5 million?
