Rural hospitals are in crisis. How did this Alabama hospital beat the odds?

Bibb Medical Center in rural Bibb County, Alabama, has figured out a way not only to keep its emergency room open, but to transform itself into a thriving healthcare system. Their success comes at a time when rural hospitals are closing or in trouble across the country. Bibb may be a blueprint for other rural hospitals that could play an even bigger role in keeping their communities healthy. In this episode of the Health of America podcast, learn how Bibb Medical Center is beating the odds.

Bibb County, Alabama, population 22,572 is just about in the middle of the state. And along the banks of the Cahaba River here, you can find one of the only remaining fields of the endangered Cahaba lily. They’re a big deal here – there’s a Cahaba Lily festival, the crowning of the Cahaba lily queen. Cahaba lily tourists. A few lush crops of these fragrant flowers only bloom between mid-May to early June. And each individual bloom–which looks like an exploding white star–lasts only a day.

It's a metaphor for another endangered species: rural hospitals. In the last 10 years, more than 163 hospitals have closed across the country. 11 in Alabama alone. Nationwide, hundreds more are at risk.

During the COVID-19 pandemic, rural hospitals have been swamped. And if they don’t have an intensive care unit, they’ve had to scramble to find open beds elsewhere.

Even when there’s no pandemic, the Federal Office of Rural Health Policy says that, when a rural hospital closes, thousands of people, many of them poorer and less healthy, are affected in other ways. For example, some residents may lack reliable transportation to hospitals farther away. And when it comes to emergencies, like a stroke, traveling 30 to 60 minutes could mean life or death. That could even be a problem for lesser emergencies, when there's nowhere close to go.

Take, for example, a young child's ear infection, the kind that wakes her up and needs immediate attention. If it's past regular pediatrician hours, people often go to the ER, especially if options in the area are limited for urgent care. But instead of being shown to an exam room to wait, what if the hospital also had an urgent care clinic–a much less expensive option?

"What we've created," says Joseph Marchant, president and CEO of Bibb Medical Center, "is really just one point of registration that allows you to send the patient to the correct, most appropriate place."

Bibb has created kind of a one-stop-shop in a place that used to have only one expensive option – the emergency room – which you might not need, for example, for an ear infection.

"It really has created an opportunity, from a business standpoint," says Marchant, "for us to really compete with and manage an urgent care within the hospital."

But hospitals aren’t always able to make this new kind of business model work. Blue Cross and Blue Shield of Alabama's Amy Ellison, who works with hospitals to negotiate the rates they'll pay for patients in the facility, knows rural hospitals are on the frontlines for rural members. She says that during the COVID-19 pandemic, they've been more important than ever.

And of course when there’s no pandemic, rural hospitals are still a critical link to care for members. But if hospitals can’t afford to stay open, or don’t have a range of levels of care, there goes that critical link. Hospitals could be attracting more patients, while maintaining or strengthening the quality of care. But they can’t do it on their own. Bibb Medical Center has partnered with Blue Cross and Blue Shield of Alabama to implement a new program called Enhanced Patient Care. It gives rural hospitals like Bibb the opportunity to do more for patients, and get paid for it.

“And what we do," says Ellison, "is we say 'find something in your community we could partner with you on,' such as a health problem that needs addressing in their community, like diabetes or nutrition."

“Give us a strategy related to that," says Ellison, "and help us support you through that process.”

With Bibb Medical Center, Ellison says the strategy was to identify members who didn’t have a primary care doctor and connect them to that preventive care. She’s talking about patients who end up in the emergency room or admitted to the hospital a lot, often because they need more support controlling a chronic condition. 

Ellison says she asked the hospital to do the outreach and see if it could make a difference in managing those conditions and providing preventive care. "Can you help them reduce their readmissions? Can you help them close the gaps in care, make sure they're getting the medications that they need and really trying to service that patient as a whole?”

BCBS Alabama would provide a financial incentive for closing those gaps in care. And Bibb said yes.

“We are paying for that service," says Ellison. "So as they were staffing up their facility we worked with them to say, ‘here's the number of patients that we're looking at for you and here's the potential incentive that we can give you per patient that you're working with.’ And they're able to do things that they never were able to do before because they weren't compensated for that.”

For example, instead of waiting for someone to come into the emergency room in a diabetic crisis, a hospital case manager could call patients who hadn’t been seen in a while and set up an appointment. Maybe they could call and offer diabetes education. Maybe they could help a patient find a food bank that could package up diabetes-friendly meals. That’s not what you think of when you think of what hospitals do. But Ellison says the arrangement is great for patients who need the care. It’s great for the hospital, which needs to diversify its offerings and enough funding to stay open. And it helps keep health insurance costs down because healthier people tend to have lower medical costs.

The hospital launched the program and took it even further. "We built a clinic within the hospital," says Marchant, Bibb's head. "And we've just been designated as the only Blue Cross Choice Urgent Care in our community.”

Marchant says the hospital is making sure residents know about what the hospital has to offer. They’re seeing more patients. And that’s given the community hope at a time when rural hospitals are struggling. The North Carolina Rural Health Research Program at the University of North Carolina has found that many rural hospitals are losing patients, and the revenue they bring in, for a few key reasons. One is that local residents don’t know what their hospital has to offer besides an emergency room, or they think it isn’t high quality, so they bypass it for a bigger hospital.

Bibb’s chief of staff, Dr. John Meggs, says the hospital is doing more than surviving: it’s thriving. And that’s something that can’t be said for some surrounding communities.

“I know the county south of us, the county east of us," says Meggs, "those hospitals are both closed. Rural hospitals in Alabama have had a struggle.

Meggs says that’s a problem because residents in rural areas—including here in Bibb county—face a lot of health challenges. “We have an abundance of obesity, diabetes. Physical fitness and exercise is not an ingrained habit in this part of the world as it is in other places and so it leads to more chronic disease more long term issues that we have to deal with .”

That's inspired one more Bibb Medical Center investment: a wellness center. And they’ve started hosting a farmer’s market--a first for the community, "where," says Meggs, "we hope we'll have services to encourage patients to be active and to be more involved in their health.”

Preventive care, outpatient offerings, wellness: Meggs says that’s where rural hospitals need to go. "That's what's going to save rural hospitals and save this country, too, from going broke paying for escalating healthcare costs. We're great at treating disease," says Meggs. "We need to get better at preventing disease.”

Wrapping up the conversation, Meggs leads a tour of the hospital and stops by a painting on the wall. “Have you heard of the cahaba lily? They only bloom for about 2 weeks in the spring," he says.

That endangered lily, still hanging on, is clearly a source of pride, much like this hospital that's positioned to keep a rural community healthy for years to come.

The Health of America podcast is brought to you by the Blue Cross Blue Shield Association.

Blue Cross and Blue Shield of Alabama is a licensee of the Blue Cross Blue Shield Association, an association of independent, locally operated Blue Cross and Blue Shield companies.

The programs mentioned in this podcast are in no way associated or affiliated with, or endorsed by, the Blue Cross Blue Shield Association.