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Trump administration wants to ease regs for rural providers

“The Centers for Medicare and Medicaid Services (CMS) {has} released a vague rural health plan that vows to, among other things, advance telehealth and improve access to care through ‘provider engagement.’ But the most important line in the eight-page document, according to rural health advocates, says the federal government will ‘apply a rural lens to CMS programs and policies.”’

“That’s the most significant thing because that’s been the biggest issue for the past couple of decades,” Alan Morgan, CEO of the National Rural Health Association, told Governing. ”The [Feds] release a regulation, and nobody asked ‘what’s that going to mean for rural [areas]?'”

“This is the first time, according to Morgan, that CMS has said it will formally and consistently take into consideration how federal policies impact the nation’s smallest clinics and hospitals.”

To read the Governing article, please hit this link.

Senate GOP health bill seen as lethal for many rural hospitals

Some see the healthcare bill put together by the Senate Republican leadership as dooming some already cash-short rural hospitals mostly because the legislation would slash Medicaid funding.

“These hospitals are hanging on by their fingernails,” Maggie Elehwany, vice president for government affairs for the National Rural Health Association, told CNN. “If you leave this legislation as is, it’s a death sentence for individuals in rural America.”

Meanwhile a new report by the Chartis Center for Rural Health says the bill could lead to thousands of rural healthcare workers being thrown out of work.

The Senate leadership’s bill could cost rural hospitals $1.3 billion in lost revenue, Chartis estimates, and likely push nearly 150 more rural hospitals into the red.

To read more, please hit this link.


Rural hospitals create alliance to survive


By MICHAEL OLLOVE, for Stateline News Service


Ask Sam Lindsey about the importance of Northern Cochise Community Hospital and he’ll give you a wry grin. You might as well be asking the 77-year-old city councilman to choose between playing pickup basketball—as he still does most Fridays—and being planted six feet under the Arizona dust.

Lindsey believes he’s above ground, and still playing point guard down at the Mormon church, because of Northern Cochise. Last Christmas, he suffered a severe stroke in his home. He survived, he said, because his wife, Zenita, got him to the hospital within minutes. If it hadn’t been there, she would have had to drive him 85 miles to Tucson Medical Center.

There are about 2,300 rural hospitals in the U.S., most of them concentrated in the Midwest and the South. For a variety of reasons, many of them are struggling to survive. In the last five years, Congress has sharply  slowed spending on Medicare, the federal health-insurance program for the elderly, and the patients at rural hospitals tend to be older than those at urban or suburban ones. Rural hospitals in sparsely populated areas see fewer patients but still have to maintain emergency rooms and beds for acute care. They serve many people who are uninsured and can’t afford to pay for the services they receive.

Several months ago, Northern Cochise sought to strengthen its chances for survival by joining an alliance with Tucson Medical Center and three other rural hospitals in southwestern Arizona. Together, the Southern Arizona Hospital Alliance is negotiating better prices on supplies and services. And the Tucson hospital has promised to help its rural partners with medical training, information technology and doctor recruitment.

“We are committed to remaining autonomous for as long as we can,” said Jared Wilhelm, director of community relations at Northern Cochise. “We think this gives us the best leverage to do so.”

Northern Cochise and the other rural hospitals in the alliance, which is similar to ones in Kansas, Mississippi, Washington state and Wisconsin, hope that by joining they will avoid the fate of 56 rural hospitals that have closed since 2010. Another 283 rural hospitals are in danger of closing, according to the National Rural Health Association (NRHA).

Right now, some Arizonans in the region are learning what it’s like to lose a hospital. Cochise Regional Hospital, in Douglas, near the Mexican border, closed earlier this month, following Medicare’s decision to terminate payments because of repeated violations of federal health and safety rules. The hospital was part of a Chicago-based chain and its closing leaves Arizona residents in the far southeastern portion of the state up to 75 miles away from the closest hospital emergency room.

Sam Lindsey shudders to think what a long drive to Tucson would have meant for him last Christmas.

“If I’d have had to go 85 miles,” he said, “I don’t think I’d be here today.”

Multiple Advantages

The alliance offers the rural members multiple advantages. One of the most important is in purchasing. Their combined size will enable them to get discounts that are beyond them now. For example, instead of being a lone, 49-bed hospital with limited bargaining leverage, alliance member Mount Graham Regional Medical Center, in Safford, is suddenly part of a purchasing entity with more than 700 beds.

“If I’m just Mount Graham and I’m going to buy one MRI every seven years, the sales people will say, ‘Oh, that’s very nice,’ ” said Keith Bryce, Mount Graham’s chief financial officer. “But as part of this alliance that they want to do regular business with, they are going to give us a much better price.”

Bryce said that he expects the added purchasing power alone will save Mount Graham “in the six figures” every year.

Similarly, the hospitals expect the combined size of the alliance to result in lower costs for employee benefits, workers’ compensation and medical malpractice insurance.

The alliance also helps the rural hospitals recruit doctors and other medical providers, many of whom are reluctant to work, let alone live, in isolated areas. Rural hospitals rarely have the contacts and relationships that help urban hospitals find doctors. “We’ve been trying to recruit another primary care doctor to this community for the last year with no success,” said Rich Polheber, CEO of Benson Hospital, another alliance member.

Tucson Medical Center has pledged to use its own recruiting muscle to help its rural partners find providers who are willing to live in rural areas, or at least regularly see patients there. As an incentive, Tucson will offer interested doctors help in managing the business aspects of their practices.

The rural alliance members also want Tucson’s help with medical training and IT. Some have dipped into telemedicine, which is particularly valuable for rural hospitals underserved by specialists, and are looking to expand those efforts. Copper Queen Community Hospital, in Bisbee, the fourth rural member of the alliance and probably the rural hospital in the best financial shape, is the most advanced user of telemedicine. Its networks in cardiology, neurology, pulmonology and radiology can connect doctors and their patients to specialists at major institutions such as the Mayo Clinic and St. Luke’s Medical Center, in Phoenix.

The alliance also will make it easier for patients who have surgery in Tucson to be transferred back to their home hospitals for recovery and rehabilitation, saving them and their families from traveling long distances.

A Defensive Strategy 

Despite the numerous advantages for the rural partners, the idea for the alliance began with the Tucson hospital, which approached the others with the proposal last spring. At the outset, some of the rural hospitals were skeptical.

“At first, we were like, ‘OK, so why are they doing this? What’s in it for them? Do they want to absorb us?’ ” said Bryce, the Mount Graham CFO.

But after a series of meetings, the suspicions disappeared and the rural hospitals eagerly signed on.

The Tucson hospital was frank about its motivation: to remain independent in an industry moving toward consolidation. As a result of acquisitions in the last few years, it is the last locally owned, independent hospital in Tucson.

“All of a sudden, we were in a situation where [Tucson Medical Center] found itself isolated and facing its own competitive market pressures because the environment had so dramatically changed,” said Susan Willis, executive director of market development at the hospital and president of the new alliance.

Nearly a quarter of Tucson’s patients come from outside the city, many from the areas served by the rural hospitals in the new alliance. Cementing the relationship with those hospitals, Willis said, will help Tucson maintain a flow of patients who need medical services that are beyond the capabilities of the rural hospitals. The rural members have laboratories, diagnostic equipment and therapeutic services, but some have little or no surgical or obstetrical services. Not one is equipped to perform complicated surgeries.

“Certainly you could describe it as a defensive strategy,” Willis said.

Medicare payment cuts imperil many rural hospitals



The Great Plains.

Some 30 rural hospitals in Kansas and Kentucky may close soon because of changing reimbursement procedures and declining populations.

One big challenge has been the effects of the  Medicare Prescription Drug, Improvement, and Modernization Act of 2003, in which critical-access hospitals received 101 percent of reasonable costs.  Since  sequestration — a 2 percent across-the-board cut in Medicare provider payments — took effect in April 2013 such hospitals are receiving 99 percent of their allowable costs.

Jodi Schmidt, president of the National Rural Health Association, elaborated on High Plains Public Radio:

“There are some basic things you would expect to have in a hospital, like television sets and telephones, that Medicare does not consider allowable costs. And then there are a number of physician costs outside of the emergency room and other sorts of operational overhead expense that the government doesn’t consider allowable.”



Rural hospitals face big new challenges

By GUY GUGLIOTTA, for Kaiser Health News



Despite residents’ concerns and a continuing need for services, the 25-bed hospital that served this small East Texas town for more than 25 years closed its doors at the end of 2014, joining the ranks of dozens of other small rural hospitals that have been unable to weather the punishment of a changing national healthcare environment.

For the high percentages of elderly and uninsured patients who live in rural areas, closures mean longer trips for treatment and uncertainty during times of crisis. “I came to the emergency room when I had panic attacks,” said George Taylor, 60, a retired federal government employee. “It was very soothing and the staff was great. I can’t imagine Mount Vernon without a hospital.”

The Kansas-based National Rural Health Association, which represents around 2,000 small hospitals throughout the country and other rural care providers, says that 48 rural hospitals have closed since 2010, the majority in Southern states, and 283 others are in trouble. In Texas along, 10 have changed. 

“If there was one particular policy causing the trouble, it would be easy to understand,” said health economist Mark Holmes, from the University of North Carolina, whose rural health research program studies national trends in rural healthcare. “But there are a lot of things going on.”

Experts and practitioners cite declining federal reimbursements for hospitals under the Affordable Care Act as the principal reason for the recent closures. Besides cutting back on Medicare, the law reduced payments to hospitals for the uninsured, a decision based on the assumption that states would expand their Medicaid programs. However, almost two dozen states have refused to do so. In addition, other Medicare cuts caused by a budget disagreement in Congress have also hurt hospitals’ bottom lines.

But rural hospitals also suffer from multiple endemic disadvantages that drive down profit margins and make it virtually impossible to achieve economies of scale.

These include declining populations; disproportionate numbers of elderly and uninsured patients; the frequent need to pay doctors better than top dollar to get them to work in the hinterlands; the cost of expensive equipment that is necessary but frequently underused; the inability to provide lucrative specialty services and treatments; and an emphasis on emergency and urgent care, chronic money-losers.

‘Another Disaster’ 

Rural healthcare experts caution that national and state officials need to address the problems for rural hospitals or they could face a repeat of the catastrophic closings that followed changes in the Medicare payment system 30 years ago. That 1983 change, called the “prospective payment system,” established fixed reimbursements for care instead of payments based on a hospital’s reported costs. That change rewarded large, efficient providers, but 440 small hospitals closed before the system was adjusted in 1997 to help them. Those adjustments created the designation of critical-access hospitals for some small, isolated facilities, which are exempted from the fixed payment system.

“And now, beginning in 2010, we’ve had another series of cuts that are all combining to create another expansion of closures just like we saw in the ‘90s,” said Brock Slabach, senior vice president of the Rural Health Association. “We don’t want to wake up with another disaster.”

The current surge in closures means federal officials need to come up with new legislation to halt the recent cuts to small hospitals in order to “buy time” to figure out how rural hospitals should effectively operate in the future, said the association’s chief lobbyist, Maggie Elehwany. “It is important to stop the bleeding right now.”

In Mount Vernon, a town of 2,678 people nestled in grassland and dairy country about two hours east of Dallas, family practitioner Jean Latortue has taken out a lease on the now-vacant hospital building to convert it into an outpatient and urgent care clinic at his own expense. Reopening may be a risky move, he acknowledged, but the need is there.

“The community went into panic mode,” he said. “I figured I had to step up.”

The non-profit ETMC Regional Healthcare System, based in Tyler, Texas, closed the Mount Vernon hospital and two others of its then-12 rural hospital affiliates because it could no longer sustain operating losses that had persisted for five years.

“There was no ill will,” Franklin County Judge Scott Lee said in an interview from his Mount Vernon office. “They were losing money. We had a good working relationship for years, and they had a business decision to make.”

Mount Vernon’s Issues 

Perry Henderson, senior vice president of affiliate hospitals for ETMC, a major healthcare provider in East Texas, noted that rural hospitals have many uninsured patients, and Medicare accounts for “60 to 70 percent of the business,” while in “Dallas or Houston it’s a fraction of that.”

Mount Vernon, with lakefront properties that are attractive to retirees, has its share of elderly patients. Henderson also noted that many rural hospitals also have to deal with large numbers of agricultural accidents. Farming, another Mount Vernon staple, is one of the country’s most dangerous occupations. Finally, he added, country roads bring many traffic accidents. When there’s no hospital, emergencies mean longer trips to get help.

Henderson and other experts cite three reasons for the rash of closures nationally. Sequestration, the across-the-board federal budget cut that arose out of the legislative impasse between the Obama administration and congressional Republicans, has resulted in a 2 percent reduction in Medicare reimbursements since 2013.

“If Medicare is 50 percent of your revenue and you lose two points,” North Carolina’s Holmes said, “it can be a killer.”

Rural hospitals took a second hit from the federal health law’s reductions in “disproportionate share hospital” payments to hospitals with large numbers of indigent and uninsured patients. Federal officials made the cuts assuming that the law would assure that more patients had insurance.

It hasn’t worked well in rural areas, the Rural Health Association’s Elehwany said, because annual deductibles for the new insurance plans, which come out of consumers’ pockets, “are running between $2,500 and $5,000,” and people can’t pay them.

And in communities such as Mount Vernon, this problem is exacerbated because Texas, along with 22 other states, has refused to expand Medicaid, a key provision of the Affordable Care Act.

“That’s a big deal,” ETMC’s Henderson said. “That’s when we had the hurt.”

Latortue, who came to Mount Vernon as an ETMC hospital doctor in 2008, appears undaunted by the challenges of reinventing the hospital, which was treating an average of eight inpatients a week when it closed. Still, he said, “I’m very busy, and patients need to be seen—we’ll be all right.”

He intends to provide both outpatient services, including lab work, at the new clinic, and emergency care, stabilizing patients until they can be transferred to the Titus Regional Medical Center, in Mt. Pleasant, 16 miles away, or to a smaller facility in Winfield, eight miles away. He also plans a wellness clinic to treat obesity and will offer Botox and laser cosmetic services. A cardiologist and a gastroenterologist will make weekly visits, and he is also looking for an ob-gyn.

Latortue got a favorable lease from the town of Mount Vernon and inherited an X-ray machine and other equipment from ETMC, but he still took out $150,000 in loans for remodeling and needs another $60,000 to $70,000 for equipment.

Still, none of this will replace the hospital, and his patients know it. “I live right behind the building,” said Mary Hunter, a very fit grandmother of 73. “I’ve had very good health until my blood pressure spiked last week,” she said. “We retired in 2006 and moved here, partly because of the hospital. And now it’s gone.”

Rural hospitals’ lucrative rehab business


The Associated Press reports that federal investigators have found that a law lets rural hospitals bill Medicare for rehabilitation services for seniors at higher rates than nursing homes and other facilities and cost billions of dollars in extra government spending.

Yet more reasons why Medicare spending is out of control.

Most patients could have been moved to a skilled-nursing facility within 35 miles of the hospital at about one-fourth the cost, the U.S. Department of Health and Human Services’ inspector general said.

The AP reported that hospitals ”juggling tough balance sheets have come to view such ‘swing-bed’ patients as lucrative, fueling a steady rise in the number of people getting such care and costing Medicare an additional $4.1 billion over six years.”

”Legislation passed by Congress in 1997 created the designation of ‘critical-access hospitals’ to help small facilities in remote areas survive. Rather than paying set rates for services as throughout the rest of the Medicare system, the federal government reimburses the hospitals for 101 percent of their costs. They also often receive state funding and grants.”

Congress, as now, was controlled by Republicans in 1997. Many represent rural areas in the South and West with many such “critical-access hospitals.”

The AP said that Alan Morgan,  chief executive of the National Rural Health Association, agreed  that Medicare could save money by modifying the system. But he told the AP that  dozens of rural hospitals have closed in the past five years, and nearly 300 others are very financially fragile. The Obama administration has already proposed  cutting all reimbursements  to critical-access hospitals, which  Morgan said would further accelerate the closures.

”Some hospitals received critical access designation under old rules and were grandfathered in. A previous report from the inspector general’s office found the vast majority would not meet the requirements if forced to requalify,” the news service reported.



When healthcare, if not beauty, is far away


The Trinity Alps, in the northern California region discussed here.

By DANIELA HERNANDEZ, for Kaiser Health News

HAYFORK, Calif. — It’s Tuesday morning, half past eight and already hot, when the small bus pulls up to the community clinic. Most of the passengers are waiting in front — an old man with a cane, two mothers with four kids between them, packed lunches in hand.

Two more arrive. A gray-bearded man with a pirate bandana steps from the shelter of his Subaru. A sunken-cheeked woman rushes up on her bike.

“Woohoo! We have a full car!” the driver says brightly after they’ve all climbed aboard. The riders smile back, some with a hint of resignation. It’s time for the weekly trip to the clinic in Mad River, about 30 miles down a winding mountain road near the Trinity Alps. The tight twists and turns are hard on the stomach, but even harder on the joints — especially if you have chronic Lyme disease, as more than a few of these riders do.

Jeff Clarke, the 58-year-old in the black bandana, has Lyme, acquired long ago from deer ticks that dwell in the region’s sprawling forests. But today he’s going to ask about a lump that’s been growing in his left breast. It’s starting to hurt, and he’s worried. His fellow riders list their own ailments matter-of-factly: asthma, dental decay, diabetes, drug addiction, heart disease and much more.
Like so many isolated American towns, Hayfork has lost its vitality and much of its youth to bigger places.

For all its tree-lined ridges and breathtaking views, Hayfork is well beyond the tourists’ byways — more than an hour from the city of Eureka on the west and Redding on the east. It’s a 45-minute drive just to Weaverville, the tiny Trinity County seat.They wouldn’t be making this trip if they didn’t have to. In Hayfork, “we’re down to the remnants of the medical personnel,” says Clarke, a well-spoken musician with a love for science, cats and NPR. “It just came to the point where if I needed to deal with anything important I just felt much more comfortable going over to Mad River.”

Whether they’re too poor to leave or charmed by the star-filled skies, Hayforkers have mostly made their peace with isolation: No retail stores, theaters, museums, fancy restaurants – and Internet access that is iffy at best.

“We were always 20 years behind everything,” says Shannon Barnett, a 41-year-old a former school teacher who grew up here. “We were all just fine with that. Now it’s different.”

She’s referring to the exodus of basic health services.

For decades, Hayfork had been fortunate. Well after the rise of urban health systems and their intricate business models, it had a tight-knit local “system” founded on the simple, generous commitment of two people: a general practitioner and a pharmacist.

“He was everybody’s doctor,” Barnett says of Dr. Earl Mercill, a GP who moved up from the Central Valley almost 50 years ago. “You never thought about going to anyone else.”

But it’s been years since Mercill retired. Now his clinic is staffed by doctors who rotate in from Weaverville once or twice a week, and otherwise it’s run by physician’s assistants. There are no hospitals for miles, though helicopters swoop in for emergencies when needed.

In these tiny towns of California’s  far north, lacking insurance is not the biggest obstacle to care. Even before Obamacare took effect, about four of five people were insured, roughly the same as in the rest of the state. A good number are on Medi-Cal. The Mad River clinic isn’t an ideal alternative.  It’s bigger than Hayfork’s and offers a wider array of services but it’s still staffed mostly by physician’s assistants and about an hour away by bus. It’s so backed up with patients it can take weeks to get an appointment, Clarke says.

What’s ailing these people is geography – that, and poverty. The median household income in Hayfork is about $34,000 a year, well below the statewide figure of about $60,000, according to the American Community Survey.  Unemployment is extraordinarily high – estimates range between 9 and 26 percent. Many people lack a sturdy car to drive, or even money for gas.

In the federal government’s parlance, Hayfork is a “medically underserved” community – one of roughly 3,500 in the country and 170 in California, according to the federal government’s latest numbers. By definition, these areas have too few primary care providers, high infant mortality, pervasive poverty or a significant elderly population. Some are islands of deprivation within otherwise well-stocked urban areas. Others are dots on the map like Hayfork, far from where doctors and medical services are clustered. According to the National Rural Health Association, only about 10 percent of physicians practice in rural America, where nearly a quarter of the population lives.

healthcare is available on the other side of the mountain, says Greg Schneider, a 65-year-old writer and band mate of Clarke’s. “The problem,” he says, “is getting there.”

Lumberjacks and Janes

In 1967, long after its rise and fall as a gold-mining town, Hayfork struck it rich. That’s when a friend told Mercill, then practicing in tiny Arvin, Calif., that an even tinier town south of Oregon badly needed a doctor.

Mercill was intrigued. He visited a few times with his large and growing family (he and his wife Marianne eventually raised eight kids, four of them adopted).
After praying on the decision, the family moved up north, built a house and settled on 40 acres outside town. A few months afterward, Mercill opened his clinic downtown. Hayfork was still a mill town then, filled with lumberjacks and janes, as the women were known. It had restaurants, shops and even a thriving art and music scene.

He was beloved almost from the beginning. He made house calls in the middle of the night — sometimes walking over precariously narrow log bridges or shuttling to his patients’ homes by snowmobile.

He delivered babies by flashlight after storms knocked down power and waited by his patients’ bedsides for hours until they felt better, sometimes charging little more than a slice of cake.

“If they didn’t have any money, I saw them,” Mercill recalls, frail now, but with a keen long-term memory. “If they could pay later, fine. If they didn’t, they didn’t. I never went hungry.”

Mercill couldn’t do everything, of course. If a patient needed a specialist or surgery he sent them to colleagues in Redding or Weaverville. Sometimes he drove along with them and assisted in the operating room.

In 1982, pharmacist Gerry Reichelderfer came to Hayfork, also on a friend’s recommendation. He fell in love with mountain life, and took over the drug store next to Mercill’s clinic.

Reichelderfer lived just seven minutes and a single stop sign away from his shop. He’d drive over and open up anytime people needed a prescription. If they couldn’t pay right then, he’d put it on an I.O.U. or let it slide.

The men joined forces, talking daily by intercom. The partnership would last nearly two decades.

A Turn of Fortune

In the late 1980s, the logging industry started to crumble. Under pressure from conservation groups, the mills in Northern California dominoed shut. By the time Hayfork’s mill closed in the mid-1990s, the population had dwindled to the low thousands.

“When all the workers left, they took all the families and young children,” says Rick Simmons of the Trinity County Historical Society.  “What was left over was people unable to go anywhere.”

Homelessness, poverty and drug addiction took hold. An underground market began to sprout around marijuana — bringing drifters, seasonal trimmers and unofficial security forces to town. The forests became a dangerous place to wander.
He wanted to get sober for her, if not himself. Seeing no hope for professional help locally, he drove to a clinic in Weaverville. His first need, he told the counselor at the desk, was housing — a roof over his head.Clarke, a runaway and hitchhiker in his youth, was in some ways typical of Hayfork’s new generation. He arrived in the 1980s, in the clutches of methamphetamine addiction, a habit he picked up in the bars where he played guitar. For years, he landed jobs and lost them — working as a wood chopper, sandwich maker and cabinet craftsman. He started seeing a woman he met in rehab, then split with her, but not before they had a daughter. They named her Stormy Brooke. He gained custody and lost it more than once.

“He repeatedly said that’s not my job,” Clarke says.

Clarke stopped trying to seek addiction treatment after that. “Most of the progress I’ve made in the last few years has been behind the 12-step stuff I do,” he says.

The meetings at Hayfork’s Solid Rock Church saved his life, he says. He goes every Monday and has been sober 10 years.

His health is ok, considering.  He lost his teeth. His bottom denture wore out long ago and his top one is breaking. He has high blood pressure, a detached bicep and hepatitis C from a jailhouse tattoo. He developed chronic Lyme disease because he wasn’t treated right away with antibiotics.

Nowadays, Clarke lives behind the Trinity County Fairgrounds, in a two-room trailer next to the town cemetery. Supported by $889 a month in disability insurance, he spends his time organizing 12-step meetings, reading library books and science magazines, and volunteering as a sound engineer for gigs at a local coffee shop. On good nights, he gets paid a little. Most important to him, he says, is staying as healthy as possible so he can look after 23-year-old Stormy and her 2-year-old son, Tony, who lives with his dad.

Stormy, a tall beauty too insecure to know it, cuts herself and has made several attempts at suicide. Her porcelain arms bear the scars.

“She has no self-esteem,” Clarke says. “She has no faith in love, or trust for any other human beings. She has some real darkness inside her, you know? I’m sure I’m responsible for a majority of that.”
After three hours, her doctors released her with a prescription for klonopin to control her seizures and panic attacks, and told her to follow-up with her primary care physician.In June, during a fight with her father, she had what Jeff thought was a stroke. En route to Redding in an ambulance, she started seizing so they put her on a chopper. At the hospital, the doctors said she’d had a stress-induced seizure.

“I had to laugh,” Clarke says. “We’re in Hayfork!”
Dr. Mercill hung onto his clinic as long as he could, finally selling it to a doctor based in Weaverville. That doctor recently sold it to Trinity Hospital, part of the Mountain Communities Healthcare District, also based in the city.

Like losing a limb

The saddened community dedicated a clock to him in the town center.  “It was like a limb being cut off,” Barnett says. ”I know at first I didn’t have another doctor for a long time. Other people didn’t either. They bounced around for a long time.”

Every once in a while, Mercill treated people who asked, but he’s 91 now, and hasn’t done that in years.

Two of Mercill’s kids grew up to be medical professionals – one a dentist, another a physical therapist–but they live and practice in bigger towns. The other children also moved away. One son, Steve, moved back from Southern California 21 years ago to care for his mother before she died. Now he’s caring for his dad.

Reichelderfer carried on at his pharmacy after Mercill retired, lending credit to Clarke and others when he could. But the economics of healthcare shifted under his feet. His business began to struggle. The reimbursements from insurers were too low, he said, and the clinic next door — a long time ally — began referring patients to bigger stores in Weaverville.

In Trinity County, where Hayfork is located, medical services overall became hard to find. In 2012, according to the Office of Statewide Health Planning and Development, there were 11 medical doctors currently practicing, roughly one per 1,200 residents. Statewide, the ratio is roughly 1 per 300.
A county behavioral office offers counseling in Hayfork, but a counselor isn’t there every day and in-person visits are by appointment only. Sometimes the most expedient treatment comes in jail — Clarke calls it the “nudge from the judge.”Specialists like dentists and psychiatrists are nearly non-existent here.

That lack of specialty care – particularly in mental health – wears on some residents. Stormy Clarke says that when she feels a panic attack or depression coming on, she simply tries to breathe deeply and distract herself by keeping busy. She also has a medical marijuana card and smokes regularly.

He mentions an acquaintance named Robbie, who suffers from paranoid schizophrenia. Since being released from jail, he’s been off his meds, Clarke says. He walks up and down Hayfork’s main strip along Highway 3, muttering to passers-by about the many people who are after him.

“In cities, you have places like outpatient programs for these types of people to go to, every single day,” said Julie Bussman, a psychologist at the Mad River clinic. “It’s a real hardship for people who are severely mentally ill to live out here because there’s not a lot of resources.”

In August, Bussman quit and moved back to Minnesota, leaving no psychologist for miles.

Back on the Bus
Everybody has to be seen before the bus can head back.After the bus pulls into the Mad River clinic — a remodeled blue cottage that used to serve as a the local forest service office — the riders start their wait. They are used to it by now: The kids pull out games and books; the adults chat in the waiting room or by a weathered picnic table on the back lawn.

On this day, Clarke is among the first in line. The physician’s assistant on duty examines his chest lump and advises against a biopsy, an invasive procedure, because he wants to run more tests. Clarke takes the news with some concern.

“I was pretty freaked out. I went in there with the agenda of the biopsy. They wanted to explore other options,” he says afterward.

By the time the bus gets back to Hayfork, it’s mid-afternoon. He drives back to his trailer, frustrated and spent.

A few Tuesdays later, he takes the bus back to Mad River and is referred to a specialist in Weaverville.

It is another two months before he learns the lump is a side effect of the medications he’s taking — a hypothesis he’d mentioned earlier to physicians and their assistants in Hayfork and Mad River.

Now he has to start thinking about replacing those dentures, which means another bus trip — or several – around the mountain.

Reichelderfer, 82 and in failing health, began looking earlier this year for someone to buy his store. He looked for months. Even the independents weren’t interested, in part because pharmacists’ family members weren’t keen on moving to Hayfork.

The Final Loss

With great sadness, he shut his doors on Sept. 18.

“I wish I could have been able to sell it to somebody,” he said, “for the convenience of the people.”

From now on, Hayforkers will have to get a ride to Owens Pharmacy in Weaverville or to Walmart or CVS in Redding.

It took only a few days to board up a drug store open for 32 years.

It’s a relic now, standing just yards from the clock the town dedicated to Dr. Mercill, with his years of service gratefully memorialized on a plaque.

Heidi de Marco and Carol Eisenberg contributed reporting.

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