Barry Gibbs is an independent, enterprising Down Easter who hasn’t asked for a lot of help in 61 years of living. He figures he’ll die without getting any aid, too, since the hospital nearest his home was shuttered last year, and it’s now at least an hour’s drive to the closest emergency room.
“You just get it in your head that if something happens, you’re going to die,” Gibbs said. “You make peace with it. The only thing I can hope for is that it happens quick.”
It was quick for Gibbs’ wife, Portia, whose death from an apparent heart attack a week after the closure of Vidant Pungo Hospital in Belhaven has become a rallying call for residents of two counties who relied on the small hospital for emergency care. Her story is seen as a worst-case scenario by experts who say other rural hospitals in the state – and hundreds across the country – are at risk of shutting down. When they go, they take away some of the best-paying and most reliable jobs in their community, make it difficult for towns and counties to recruit new business and residents, and leave some of the poorest and sickest populations with no quick access to critical care.
Other industry experts and Vidant Health, the Greenville-based corporation that acquired the Belhaven hospital in 2011 from the community that had owned and operated it since 1949, say the situation in Belhaven shows that the nature of rural health care must change. The busiest parts of most rural hospitals are the emergency departments, which often are used by uninsured and underinsured patients as the first line of treatment for any ailment, because they know they will not be turned away when they can’t pay. It’s an inefficient system, experts say, using the most expensive way to deliver care for what are often chronic illnesses that could be inexpensively managed through regular visits to primary care doctors and nurses.
Fifty-seven rural hospitals have closed across the U.S. since 2010, including at least two others in North Carolina, according to UNC’s Cecil G. Sheps Center for Health Services Research. But the closure of the hospital in Belhaven – an institution as dear to its residents as any of its schools or churches – so rankled the town mayor that he has worn the soles off his hiking boots walking to Washington, D.C., and to Raleigh to seek attention for the hospital’s plight and legislative help in his battle to reopen it. The NAACP has filed a lawsuit over the closure, on the grounds that it disproportionately affects people of color, given that about 55 percent of Belhaven’s population is black, along with about 25 percent of surrounding Beaufort County’s. The hospital fight was a centerpiece in recent municipal elections that were surprisingly bitter for a town of 1,612 residents.
“People are dying,” said Adam O’Neal, 46, who won Tuesday’s election to secure a sixth term as mayor. “What am I supposed to do, just sit down? What if it’s one of my kids who dies because there’s no emergency room?
“We’re going to open a hospital in Belhaven,” O’Neal said. “And don’t tell me we don’t need it.”
O’Neal has made significant progress toward his goal. Keeping it open – if he succeeds – may be even harder.
Built in time of need
The building that opened on the peaceful harbor of Pungo Creek in 1949 came at another time of need.
Hospital construction across the country, most of it done by charities, churches or municipalities, had come to a halt with the Great Depression, and hundreds of hospitals closed. In 1941, the federal government formed a commission to study the problem, and in 1947 Congress passed the Hospital Survey and Construction Act, referred to as the Hill-Burton Act for its principal sponsors, that would provide matching funds to build and improve hospitals in underserved areas, including rural communities.
The Pungo District Hospital was an early Hill-Burton project. The single-story brick building opened on a waterfront site a couple of blocks from the center of Belhaven with 20 beds, later expanding to 49 beds.
Through its history, the nonprofit hospital relied on Medicaid and Medicare payments, grants and support from the local community. Dr. Charles Boyette, who has practiced medicine in Belhaven for more than 50 years, said that for its size, the hospital was unusually well-equipped, with a CT scanner, ultrasound and bone density imaging machines. Doctors could perform heart catheterizations and gastro-endoscopies there, and the hospital ran outpatient cardiology, nephrology and pulmonary clinics.
In 2010, The Duke Endowment gave the hospital $150,000 for digital mammography equipment. A local family set up an endowed scholarship that would help one second-year medical technology student at Beaufort County Community College each year if the student promised to work at the hospital in Belhaven for a year after graduation.
The community was kind of built around this hospital.
Adam Linker, co-director of the N.C. Justice Center’s Health Access Coalition.
“The community was kind of built around this hospital,” said Adam Linker, co-director of the N.C. Justice Center’s Health Access Coalition.
In 1997, when the hospital had 175 employees, it sold bonds to finance two additions and a major renovation.
But in 2001, it filed for bankruptcy, and though it stayed open, it struggled financially, as Linker says most rural hospitals have done. In its service area – primarily Beaufort and Hyde counties, which have a combined population of just over 53,000 – people are older and poorer than state averages. With age and poverty come costly medical problems: cardiovascular disease, hypertension, asthma, diabetes. In rural areas, residents also tend to be involved in more serious accidents; in Beaufort and Hyde counties, people get hurt while hunting, farming, commercial fishing, logging, or driving on country roads.
Increasingly over the past 10 to 15 years, rural hospitals have seen their service areas split into two kinds of patients: those who can’t pay for hospital care, and those who can. Those who can’t pay tend to go to the small rural hospital, where the cost of their care will end up being paid at a reduced rate by Medicaid or Medicare, if it gets paid at all. Those who have private insurance or pay out of pocket bypass the rural hospital and go to the closest bigger one.
A hospital that takes patients who can’t pay needs paying patients to help offset that cost.
“That’s why rural hospitals are suffering,” said Julie Henry, spokeswoman for the N.C. Hospital Association, an industry trade group. “Nobody is choosing to go there. It’s happening all over the country.”
In fiscal 2009-2010, Pungo District Hospital had $10.6 million in revenues, and $11 million in expenses, according to annual tax filings. In fiscal 2010-11, it had $9.7 million in revenues and $10.9 million in expenses.
That year – 2011 – the large community board that governed the hospital voted to approach Vidant Health, then known as University Health Systems, about taking over the hospital. The not-for-profit company is the largest health care provider in Eastern North Carolina and runs eight hospitals in the region, with its flagship, Vidant Medical Center, at East Carolina University in Greenville.
Its hospitals include Vidant Beaufort Hospital, which sits in the town of Washington, about 30 miles across Beaufort County from Belhaven, and Outer Banks Hospital in Nags Head, which sits in Dare County, just east of Hyde County.
The hospital board and Vidant agreed that Vidant would “maintain and strengthen Pungo’s commitment to the community in providing health care services without regard to ability to pay; utilize the clinical components of each party to their best advantage; and enhance the delivery of high quality, cost-effective care to patients” in the hospital’s service area. Vidant would pay off the hospital’s $1.6 million construction debt and agreed to invest $2.5 million in capital improvements.
Vidant took over the hospital in September 2011.
In September 2013, Vidant announced it would close the hospital in 2014. Vidant’s then-CEO David Herman said North Carolina’s decision not to expand Medicaid under the Affordable Care Act was partly to blame. The state is one of 19 in which Republican governors or legislatures have rejected the expansion, which extends benefits to anyone earning 133 percent or less of the federal poverty-level income.
Hospitals favor the expansion because more patients get help paying for hospital care.
Herman also said the building’s age and waterfront location had made it increasingly costly to maintain.
A 2007 FEMA report on managing hospital risks in earthquakes, floods and high winds said the hospital had to be evacuated in September 2003 as Hurricane Isabel approached but that, “Isabel’s storm surge produced the highest flooding on record in Belhaven, yet the hospital weathered the storm without damage.” It noted that the hospital also had stood through decades of hurricanes without sustaining major wind damage.
Once they learned of the plan to close the hospital, activists rose up to try to save it. The town, along with the state and local chapters of the NAACP, filed a legal claim alleging unfair trade practices, breach of fiduciary duty, breach of contract, and fraud. After a circuitous route through the court system which the plaintiffs say suggested additional racial bias, the claim was dismissed in October. The group plans to appeal.
O’Neal, the mayor, has said he now believes Vidant always intended to close the hospital because it competed with its hospitals in Washington and Nags Head. Vidant officials say they acted in good faith.
The hospital closed July 1, 2014.
‘Could they have saved her?’
On July 7, Portia Gibbs was doing yard work with her husband at their house near Lake Mattamuskeet when she told him her chest hurt, and she took a seat on the porch.
In 27 years of marriage, Barry Gibbs had learned to help his wife, a nearly lifelong diabetic, control her blood sugar. He fetched a blood-sugar monitor, and when it read low, he brought Portia a drink and a snack. Still, she told him, “My chest really hurts.”
“I told her, ‘Get in the car. Let’s go,’ ” Gibbs said. They started toward the rescue squad station at Swan Quarter. Before they reached the road that crosses the lake, Portia began vomiting. Even with the Buick hitting 100 mph, it took 15 minutes to get to the station, and by then, Portia had stopped breathing. As Gibbs roared into the parking lot, an emergency crew pulled Portia out of the car and got to work.
If the hospital at Belhaven had been open, they would have taken Portia Gibbs to the emergency room there, working on her in the ambulance during the 30-mile trip. With that hospital closed, their options were to drive to Washington, 50 miles away, or call for a helicopter to be sent from there or Greenville.
In 30 minutes, they could have been at the hospital in Belhaven. Could they have saved her? I don’t know. The good Lord is the only one who can answer that.
Barry Gibbs, whose wife, Portia, died of an apparent heart attack
They called for the helicopter and kept working on her. Medics later told Barry Gibbs that they revived her and lost her several times. Nearly an hour after he got his wife to the station, Gibbs said, he saw the helicopter coming in. But before it could land, a member of the rescue team told him Portia was dead.
“In 30 minutes, they could have been at the hospital in Belhaven,” Gibbs said. “Could they have saved her? I don’t know. The good Lord is the only one who can answer that.”
Local residents cite other incidents in the 16 months since the hospital closed in which they say patients died while awaiting delivery to an emergency room, or got sicker after they delayed going for treatment because they couldn’t afford to travel an hour to a hospital or didn’t feel comfortable going to a new place.
When it closed the hospital, Vidant opened a 24-hour clinic in Belhaven that operates alongside three primary-care doctors’ offices the company has in town. The clinic is not an emergency room and can’t receive ambulances but can handle the kind of illnesses and injuries – flu, a strep infection, a broken arm – any urgent-care facility can treat.
Vidant says the clinic is seeing about 16 patients a day, the same number the company’s doctors were seeing at the emergency room in Belhaven in the last full fiscal year it ran the hospital, according to documents filled with the state Department of Health and Human Services.
Vidant has begun construction on a new $5.5 million medical building in Belhaven where it will consolidate the three doctors’ offices and the 24-hour clinic, which it promised to run for at least three years after the hospital closed.
Joan Wynn, Vidant’s chief quality officer, said that once the new building opens next year, the company hopes to add services, such as rotating clinics that will offer treatment for chronic diseases, and educational programs that will help patients take more control over their own well-being. Wynn said the clinic might have “health coaches” who could work with patients during office visits and monitor them between visits using telemedicine technologies such as weight monitors that could indicate a heart patient was suddenly retaining water.
The goal of such innovations, said Roger Robertson, president of community hospitals for Vidant, is precisely to keep people from needing emergency rooms.
“We’re not in the hospital business,” Robertson said. “We’re in the health care business.”
Since the hospital’s closure, Vidant has given $500,000 to Beaufort County Emergency Medical Services, which will be used to purchase two new sport utility vehicles whose crews will be able to provide quick, intermediate care, and a new ambulance that will provide full paramedic care, according to the county’s EMS director, John Flemming. Vidant has given Hyde County $250,000 to upgrade and expand its emergency medical coverage.
Health experts say it is too early to tell whether the loss of the emergency room in Belhaven will have an effect on morbidity rates or on Beaufort and Hyde counties’ infant mortality rates, which for African-Americans already exceed state averages.
O’Neal, the Belhaven mayor, hopes to have the hospital open again before the statistics can change.
After the closure, Vidant removed the equipment and supplies from the hospital, returning leased items to their owners and distributing the rest to its other facilities. The building sits nearly empty on Water Street. Through a rear window, a walker can be seen in a hallway propping open a door.
Ownership of the hospital was handed back to Pantego Creek LLC, the community board charged with protecting the community’s interest in the hospital. The group’s leadership, listed as four or five managers on different legal documents, does not share the mayor’s enthusiasm for reopening the hospital. Manager Brantley Tillman referred questions to New Bern lawyer Arey Grady.
Asked what relationship Vidant has with Pantego Creek LLC or its members, Chris Mackey, spokeswoman for Vidant, said, “Vidant has no affiliation with Pantego Creek or with its individual members.”
Supporters of the hospital have a business plan that says Beaufort and Hyde counties can support a hospital in Belhaven with 50 to 60 employees that has an emergency room and a reduced number of inpatient beds. Part of the building might be used for complementary medical services such as mental health care.
O’Neal succeeded during the legislative session in getting lawmakers to approve a special provision that would allow the hospital to reopen without having to apply for a new certificate of need. Typically, health care providers must show need and get approval from the Department of Health and Human Services to open or expand their facilities. The town has established a new nonprofit entity, Pungo Medical Center, to operate the hospital, and has just begun trying to purchase the property from Pantego Creek LLC through eminent domain.
O’Neal says he has the promise of $6 million in U.S. Department of Agriculture rural development loans to get the hospital up and running again. It could be done in a matter of months, he said.
If you have a rural hospital, you have to use the rural hospital.
Alan Morgan, CEO of the Kansas-based National Rural Health Association
Industry experts say it’s rare for a closed hospital to reopen, but those who have met O’Neal or read about his tenacity won’t bet against him and his supporters.
If the hospital in Belhaven does reopen, Alan Morgan, chief executive officer of the Kansas-based National Rural Health Association, said it will take determination by more than a few activists to keep it in business.
“If you have a rural hospital, you have to use the rural hospital,” Morgan said. “Otherwise, it’s not sustainable. And once it closes, the town usually follows.”
CORRECTED: This article has been corrected. The original article inccorectly said that New Bern lawyer Arey Grady represented Vidant Health in a lawsuit filed by the town of Belhaven and the N.C. NAACP. Grady represented only Pantego Creek LLC, the community board, which also was a defendant in the lawsuit. Vidant was represented by attorneys from K&L Gates.
Rural hospitals provide essential health care services to nearly 51 million U.S. residents.
Three rural hospitals have closed in North Carolina since 2010:
▪ Blowing Rock Hospital, Blowing Rock, in 2013.
▪ Vidant Pungo Hospital, Belhaven, in 2014.
▪ Yadkin Valley Community Hospital, Yadkinville, in 2015.
Franklin Regional Medical Center in Louisburg also closed in 2015, but it was not considered a rural hospital.
Source: The American Hospital Association