As TX Hospital Closes, Baffled Mayor Mulls Options

Unlike many rural hospital closures that occur despite public outcry and angst, the people of Bowie, Texas had the opportunity to save their hospital. They literally elected not to.

Nearly 50 years after it opened, the doors have finally closed for good at Bowie Memorial Hospital, a 51-bed independent community hospital serving Bowie, TX.

Employees gathered Monday morning for a brief closing ceremony that included lowering and folding the flags at the entranceway, goodbye hugs and handshakes for colleagues, and locking the doors to the emergency room that since 1966 had provided this community of about 5,100 souls 24/7/365 access to care. A handful of administrators will spend the next two weeks in the empty building clearing up paperwork before the lights flicker off one last time.

The closing means that many of the hospital's 138 employees will have to find jobs elsewhere, and many are expected to leave this town located midway between Fort Worth and Wichita Falls. Other town residents who require easier access to care are also likely to uproot to leave.

The Bowie residents who stay and require hospital or emergency care must now travel either 19 miles northeast to Nocona General Hospital or 28 miles southeast to Wise Regional Health System. Hospital closings have become far too common in non-urban America these days. Researchers at the University of North Carolina report that at least 59 rural hospitals have closed since 2010, almost all under financial duress. Bowie Memorial reported that it had lost $900,000 last year.

Unlike many of these rural hospital closures that occur despite public outcry and angst, however, the people of Bowie had the opportunity to save their hospital.

They literally elected not to.

A Nov. 3 referendum to create a hospital taxing district that would have raised property taxes by 17 cents (about $150 a year on a $100,000 house) was defeated by 53% of the voters.

Local media reported that Bowie residents who opposed the tax hike feared that there were no guarantees that the hospital wouldn't come back in future years with demands for more.

Bowie Mayor Larry Stack says he remains "totally baffled" that town residents did not support the tax increase, even though town and Bowie Hospital Authority officials made it clear that the hospital would shutter without the new revenue stream.

"We were one of two rural hospitals in Texas that did not receive tax support," Stack says. "Really, it's pretty amazing that the hospital was able to remain operational for as long as it did. It's hard to get that point across to people about how the payment system works, especially when you have a high Medicare census that's nearing 80%."

Mayor Stack spoke with HealthLeaders Media about the closing and its effect on the community. The following is an edited transcript.

HLM: What do you do now?
Stack: That's a good question! We have only one choice currently and that is to transport our citizens to Nonona or Decatur. Our city medical director has told us to continue to use the same medical directives that he had provided previously, which is to take the patients to the closest adequate facility.

Now as far as what we do with the hospital, the hospital board is working on that. I don't know what is possible at this time. Our hospital is needed here because of the large amount of Medicare patients and uncompensated care we have.

The long-term fix was tax support to generate the revenue to keep the hospital viable, and of course that did not happen. My suspicion is that an urgent care clinic at some point will come to Bowie, but I don't know how that business model will fit in here. It's my understanding that urgent care clinics' emergency rooms are not recognized by Medicare. Only emergency rooms associated with hospitals are recognized by Medicare.

And when the hospital was open, the Medicare census was nearing 80%. I don't see how that would be viable for an urgent care center here. I know they do that in urban areas where the population is younger and you have a higher percentage of private insurance."

HLM: How did Bowie Memorial find itself in financial straits?
Stack: I served on the hospital board for 16 years until 1996. This hospital opened in '66. It was chartered as a non-taxing entity. So the hospital always operated close to the vest and kept costs real conservative. We cash-funded our depreciation. It was very financially successful.

In 1993 when the government passed the Medicare Reform Act, the board knew at some point it was going to greatly affect the revenue of the hospital because we didn't have any room to cut costs. In '94 we told our administrator to set up a hospital taxing district. We weren't going to have a vote right then, but we wanted it in place because at that time you had to go to the state legislature to get that set up and our legislature meets every other year.

We didn't know when we needed to have that vote but we wanted it taken care of. The mistake we made then was not to have a referendum right then for a very small tax increase.

We decided to come up with all other ways to generate revenues. We started a physical therapy program. We started a home healthcare program. We started durable medical equipment rental. We built an assisted living center that was very profitable that offset our loss of revenues and it all worked pretty good. But as time went on, the payments got less and less and the Medicare census grew. So, that was a problem.

HLM: Why did voters reject the tax increase?
Stack: We had our first vote four years ago and it didn't pass. So the hospital really struggled to get to this point. In addition to all that stuff, our economy is heavily oil field related. Over the past six to nine months, there is one large employer here who had 600 people and now it's down to 300 and that was spread to a lot of other people who were doing oil field-related activities.

So, a lot of people didn't have jobs, or had their hours cut way back. It was hard for those people to support the tax increase because honestly, they didn't have the money.

And then the opposition bunch, which was basically citizens that lived outside the city limits, ran a hard campaign against it. A lot of the information they put out was not entirely accurate and the bunch here that was running the 'for' campaign tried to combat it as best they could.

But sometimes it's difficult to change people's minds. If you take all that into consideration, it's the perfect story type deal. But for the life of me, I cannot understand why people in a town this size of over 5,000 would not want to have a hospital. I don't know if people just thought it wouldn't close, but I am baffled. I am totally baffled.

HLM: How will local government respond to the closure?
Stack: This will have to be paid back in some other way. There is no free lunch. One of the things we had done, if you are a citizen of Bowie proper and our ambulance picks you up to takes you to the city hospital and let's say that trip is $1,500 and your insurance only pays $500 we accept that as full and final payment. We don't hassle you for the difference. That is a benefit you get for paying your taxes. Or if you don't have insurance we do the same thing. We don't hassle you. We let it go.

Well, that costs us about $350,000 to $400,000 a year and you can kind of justify that by the fact that you are taking those patients to your hospital. That is going to go away. Now we cannot afford to create a deficit to take people to places further away. The city council is considering an ordinance change that says you have to pay your own tab when you go to the hospital, and we will file liens. That's a perfect example of what is going to happen.

Montague County only pays us $18,000 a year to provide ambulance service for the southern half of the county. Well, we are going to have to take a hard look at that. That doesn't even begin to cover the associated costs.

HLM: How do you think not having a hospital will affect Bowie's ability to recruit new businesses?

Stack: It's going to be difficult. Available medical care is one of the top things people look for.   My first line of defense is to look at every possible avenue. I am writing letters to our state and federal elected officials to see if there are programs they can help us with and get this thing put back together as some sort of hospital of some size. I don't know at this point, but it is a definite negative.

Unfortunately most of those people who worked at the hospital with their specialties will not be able to find work here if they decide to stay in that same field, so we are going to lose population too. It's a gut punch.

HLM: Is there anything else you'd like to mention?
Stack: Only that if anybody has any suggestions about what we might do I'd be more than happy to listen to them.