By Taylor Sisk for KFF Health News.
Broadcast version by Shanteya Hudson for North Carolina News Service reporting for the KFF Health News-Public News Service Collaboration
On a mid-August morning, Christopher Harrison stood in front of the shuttered Martin General Hospital recalling the day a year earlier when he snapped pictures as workers covered the facility’s sign.
“Yes, sir. It was a sad day,” Harrison said of the financial collapse of the small rural hospital, where all four of his children were born.
Quorum Health operated the 49-bed facility in this rural eastern North Carolina town of about 5,000 residents until it closed. The hospital had been losing money for some time. The county’s population has slightly declined and is aging; it has experienced incremental economic downturns. Like many rural hospitals, those headwinds drove managers to discontinue labor and delivery services and halt intensive care during the past five years.
Prospects for reopening seemed dim.
But a new hospital designation by the Centers for Medicare & Medicaid Services that took effect last year offered hope. As of August, hospitals in 32 communities around the country have converted to the rural emergency hospital designation to prevent closure. The new program provides a federal financial boost for struggling hospitals that keep offering emergency and outpatient services but halt inpatient care.
The REH model “is not designed to replace existing, well-functioning rural hospitals,” said George Pink, a senior research fellow at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which has documented 149 rural hospitals that have either closed or no longer provide inpatient care since 2010. “It really is targeted at small rural communities that are at imminent risk of a hospital closing.”
The program hasn’t yet been used to reopen a closed hospital.
With guidance from health consultants, Martin County officials asked federal regulators to explore the possibility of adopting the REH model and were ultimately given the go-ahead.
If successful, Martin County could become one of the first in the nation to convert a shuttered hospital to this new model.
Ask members of a community that has lost its hospital what they miss most, Pink said, and it’s almost invariably emergency services. Count Harrison among them, especially after a medical crisis nearly killed him.
Harrison, who lives in a smaller crossroads community a few miles south of Williamston, began experiencing leg pain in February. Under normal circumstances, Harrison said, he would have gone to his primary care doctor if his leg began to hurt. This time he couldn’t, because the practice closed when the hospital folded months earlier.
Then, one morning he awoke to find his foot turning black. It took him 45 minutes to drive to the closest hospital, in the town of Washington. There, doctors found blood clots and he was flown by helicopter to East Carolina University Health Medical Center. A doctor there told him that he’d probably had the blood clots for close to a year and that he was lucky to be alive. The medical team was able to save his foot from amputation.
Harrison, like many other community members, now had firsthand experience with the consequences of a shuttered hospital.
The state legislature’s decision last year to expand Medicaid has meant fewer North Carolinians are uninsured, which means fewer hospital bills go unpaid. But health care is evolving: Many procedures that once required inpatient care are now performed as outpatient services. Dawn Carter, the founder and a senior partner of Ascendient, a health care consulting firm working with the county, said the inpatient census at Martin General in its last few years ranged from five or six a day to a dozen.
“So you’re talking about a lot of cost, a lot of infrastructure to support that,” she said.
With no emergency care within a half-hour radius, Martin County administrators believe a rural emergency hospital would be a good fit and a viable option. REH status allows a hospital to collect enhanced Medicare payments, an annual facility payment, and technical assistance.
Carter said the team will present to the state Department of Health and Human Services a set of drawings of the portion of the building they intend to use to see if it meets REH regulations.
“I’m hoping that process is happening in the next several weeks,” she said, “and that will give us a better idea of whether we have a handful of really quick and easy things to do or if it’s going to take a little more effort to reopen.”
Officials then will take proposals from companies interested in running the hospital.
Carter said the expectation is that, initially, the facility will be strictly the emergency room and imaging department, “and then I think the question is, over time, where do you build beyond that?”
And the rebuilding could prove a challenge from the start. Many former staff members have taken positions at nearby health care facilities or left the area. The effects of that exodus will be compounded by the widespread difficulty in recruiting health workers to rural areas.
It’s early yet, Pink said, to assess the success of the rural emergency hospital model. “All we have are armchair anecdotes.” It seems to be working well in some communities, while others “are struggling a little to make it work.”
Pink has a list of questions to assess how an emergency hospital is faring in the long run:
- Is it at least breaking even? And if not, do administrators foresee a solution?
- How is the community responding? If someone believes they have an issue that might require inpatient care, Pink suggested, perhaps they’ll bypass the REH for a hospital that can admit them. And to what extent does bypassing their doors carry over to all services?
- Are patients happy with the care they’re receiving? Are the clinical outcomes good?
The rate of rural hospital closures rose through 2020, then dropped considerably in 2021. Congress had passed the CARES Act, and the Provider Relief Fund offered a financial lifeline, Pink said. That money has now been distributed, and the concern is that “many rural hospitals are returning to pre-covid financial stresses and unprofitability.”
If the trend continues, he said, more rural hospitals may turn to the REH model.
Ben Eisner serves as Martin County’s attorney and interim manager. He acknowledges that the health and well-being of this community require a lot more than a hospital. He cites, for example, a new nonprofit with a mission to address the
social determinants of health.
Advancing Community Health Together was created in response to the hospital closure. Composed of community members, its focus is addressing inadequate health care access and poor health outcomes as a consequence of generational poverty, said Vickey Manning, director of Martin-Tyrrell-Washington District Health.
“We can’t address rural health care in a vacuum,” Carter said. Her organization, Ascendient, is part of the
Rural Healthcare Initiative, a nonprofit commissioned by the North Carolina General Assembly to study sustainable models of health care for rural communities.
Like most of rural eastern North Carolina, Martin County is in transition, Eisner said. Diminishing family farms, less industry. “And so the question becomes,” he said, “‘What happens for all these communities? What happens next?’ And it’s an answer that is not yet fully written.”
Harrison, still relying on crutches to get around, recently drove 45 minutes north on U.S. 13 to the town of Ahoskie to have a doctor examine his foot. He said a hospital that offers basic emergency care isn’t a perfect solution, but he’ll have some peace of mind once the cover is peeled from that sign and his local hospital reopens.
Taylor Sisk wrote this story for KFF Health News.
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By Madelyn Beck for WyoFile and Rae Ellen Bichell for KFF Health News.
Broadcast version by Kathleen Shannon for Wyoming News Service reporting for the KFF Health News-Public News Service Collaboration
William Lopez remembers clearly the day in June 2017 when he says he was asked to call the spouse of a college friend who had just died and ask for her eyes.
The spouse hadn’t responded to calls from other employees at the Rocky Mountain Lions Eye Bank, he said. As Lopez recalled, his supervisor thought a friend’s personal number would have more success.
Lopez refused. “I went for a walk,” he said.
Even without Lopez’s help, the eye bank that procures corneas from deceased donors in Wyoming and Colorado eventually collected his friend’s corneas, Lopez said. Lopez, who had entered the field to help people, became increasingly disillusioned during his three years working with the eye bank, despite rising from a technician to the distribution manager, and ultimately quit.
Checking the “donor” box on a driver’s license application, people may picture their heart, kidneys, or other organs saving another person’s life should the worst happen.
They are less likely to consider that tissues — corneas, tendons, bone marrow, skin, bone — are also covered by that checked box. In fact, donated tissues are collected much more frequently than organs, and corneas are the most commonly transplanted body part in the U.S., with nearly 51,000 transplants last year, according to the Eye Bank Association of America.
Organ and tissue donations are guided by different rules, with less transparency and what critics identify as more self-policing in the tissue donation industry. In Wyoming and Colorado, where the Rocky Mountain Lions Eye Bank estimates it collects eye tissue from about 2,500 deceased donors a year, that has contributed to a tense work environment resulting in damaged or wasted tissues due to accidents, four former eye bank employees say.
“I think there’s an urgent need for stricter oversight of the donation process in general, particularly for eye and tissue banks,” said Janell Lewis, who worked at the Rocky Mountain Lions Eye Bank for 12 years, managing public relations and overseeing fundraising before she quit in February 2023.
John Lohmeier, executive director of the Rocky Mountain Lions Eye Bank, declined to be interviewed for this article. In a prepared statement, he said he couldn’t comment on personnel matters or specific incidents raised by the former employees.
But generally, he wrote, “there are internal procedures that have been in place and continue to be followed to investigate and/or report any incident that would impact health and safety concerns.”
Lewis, Lopez, and two other former eye bank employees recalled one or more of the following problems during their time at Rocky Mountain Lions Eye Bank:
- Removal of eye tissue from the wrong body
- Damage or destruction of corneas due to improper removal
- Removal of corneas from a donor with a high-risk family history that could endanger a transplant recipient
- Lack of transparency about whether errors were being reported to federal agencies
- Pressuring and bullying of technicians
- High turnover and brief training of low-paid and inexperienced technicians
The Windshield of the Eye
The cornea is considered the
windshield of the eye. It is a clear dome that protects the eye from contaminants, maintains fluid balance, and filters light. Recipients of cornea donations typically need transplants because of trauma, infection, or
other conditions that cause blindness or blurred or cloudy vision.
The Rocky Mountain Lions Eye Bank is one of about 60 eye banks operating in the U.S.,
which leads the world in corneal transplants. New technicians often arrive at the eye bank untrained, sometimes with only a high school diploma, to perform the grim job of removing corneas from recently deceased corpses for about the same wages many fast-food workers earn.
But what eye bank technicians may lack in education and training, they generally make up for with a strong belief in the mission, according to the former employees. They said they joined the Rocky Mountain Lions Eye Bank because they wanted to help restore people’s sight.
The nonprofit employs about 70 people across Colorado and Wyoming, according to a
tax filing submitted in 2023. Those records also show a net income of less than $1 million and more than $16 million in assets. Lohmeier was paid about $142,000.
Organs vs. Tissue
Organ donations fall under the purview of the Health Resources and Services Administration, and
public data details performance and
financial transaction records of organ procurement groups. Tissue donation is regulated by the Food and Drug Administration, as well as national industry groups, and tissue bank transactions, performance, and outcomes are not available to the public.
There’s no reason tissues and organs should be treated differently, said Robert Dickson, medical director for the Washtenaw County Tuberculosis Clinic in Michigan. A patient in his county died from a bone graft contaminated with tuberculosis just a couple of years after a contaminated bone graft
killed eight other patients.
He
compared the tissue regulatory environment to the Wild West and called it a major public health concern.
“It’s fundamentally no different from an organ transplant. You’re taking tissue from one deceased patient and putting it into a living recipient. But it is not regulated and not tested as rigorously,” he said.
Marc Pearce, president and CEO of the American Association of Tissue Banks, said such cases are very rare.
“We don’t believe that we’ve proven ourselves to be not capable of regulating ourselves,” he said.
FDA officials disagree that the tissue industry is largely self-regulated, pointing to
federal rules that require certain organizations to register with the agency and provide a list of human cells or tissues they recover, store, or distribute.
The rules set donor eligibility requirements, and the agency inspects tissue establishments, including eye banks, said spokesperson Carly Pflaum.
“The FDA has implemented a tiered risk-based approach for the regulation of human cell, tissue and cellular and tissue-based products,” Pflaum wrote.
KFF Health News and WyoFile months ago requested reports of adverse events associated with the Rocky Mountain Lions Eye Bank, but the FDA has yet to provide them. FDA dashboards show the eye bank
has not issued a recall since 2017, and inspections since at least 2009
have not resulted in any official action.
The tissue industry is largely self-monitored and the performance of eye banks is tracked internally, whereas the federal government publishes
annual performance reports for organ procurement groups. Health care providers are not required to report to the FDA adverse events resulting from tissue transplants.
Organ transplant providers are required to report safety events in recipients within 72 hours to the Organ Procurement and Transplantation Network, which operates under contract with the U.S. Department of Health and Human Services. That includes an organ going unused because it was delivered to the wrong location. They have 24 hours if, for example, the recipient gets an infection or disease that may have been from the new organ.
Other countries have public registries detailing the outcomes of corneal transplants, including Australia, the United Kingdom, and Sweden. A similar registry in the U.S. could help monitor outcomes for patients and identify adverse events from transplant procedures, eye doctors and researchers wrote in
the journal Ophthalmology Science.
Tissue bank industry groups are responsible for much of the oversight of their dues-paying members. Transplanting surgeons may report adverse reactions to the tissue bank, which generally then conducts a review and submits a report to the FDA and the Eye Bank Association of America or the American Association of Tissue Banks.
Nearly all eye banks in the U.S. are members of the Eye Bank Association of America, which inspects member banks at least every three years as part of its accreditation process, but such inspection reports aren’t publicly available. Safety is paramount, association president Kevin Corcoran said, and the association’s medical standards require eye banks to request patient outcome information from transplanting surgeons a few months after surgery.
“We want to make sure we don’t have an eye bank that is slipping in their performance or failing to recover tissue,” he said. He declined to comment on any individual eye bank’s performance or release quality or transplantation data, complaints filed, or investigations undertaken.
No investigations have resulted in corrective action, he said, in the 13 years he has been at the association. The Rocky Mountain Lions Eye Bank is an accredited member of the association.
Balancing Mission and Stress
Several of the former employees were hesitant to speak about the Rocky Mountain Lions Eye Bank because they didn’t want to sully the reputation of an industry they believe is essential for improving people’s lives and honoring the wishes of the dead.
But they described a high-pressure environment that they said led to many of their colleagues leaving and errors that reduced the number of successful retrievals.
Mackenzie Urban started recovering corneas as a technician for the eye bank in 2019 after finishing her bachelor’s degree. She saw it as a temporary job as she applied for medical school. But within a year of recovering her first cornea, she said, enough employees had left that she became the senior recovery technician and was training others.
She used limes for the training, guiding her students on how to use a scalpel to remove the peel without nicking the fruit beneath. Success meant lifting the peel off the lime without any juice spilling out.
“If you’re stressed, you’re going to shake,” Urban said.
Outside factors can compound the challenges of performing the delicate procedure. Maybe the coroner had drawn fluid from beneath the cornea, making collection much trickier, she said. After a person has been dead for about 24 hours, the eyes tend to deflate to the point of uselessness, adding time pressure to collecting donations, Urban said.
Sometimes, Urban said, another technician would be working on a body simultaneously, so that the entire body was moving around while she was trying to do the delicate procedure.
Interactions with grieving families could be intense, too. Sometimes, families would hug her, thankful that something good would come of their loss. Other times, they were hostile, such as the time one relative of a potential donor told her to “Cut your own f****** eyes out, you b****,” she recalled.
Urban appreciates the work the eye bank performs and doesn’t regret her time there. She said she respected that “they had a real commitment to serving the community and keeping prices low.” (It’s illegal to sell human body parts for transplant, but companies get reimbursed varying amounts for the expenses of harvesting, preparing, and shipping tissues.)
But the workplace culture made it untenable for her, she said. For example, Urban said, she was reprimanded and told that she needed to “buck up or get out” because she declined to harvest corneas from a person who died from an unknown cause. The body was purple from the neck down, covered in oozing blisters and with opaque flecks in the eyes, Urban said.
When Irish Eyes Are Smiling
The Rocky Mountain Lions Eye Bank has international contracts and ships corneas to Japan and the U.K., among other destinations. It became the exclusive eye tissue provider for Ireland when that country stopped collecting corneas over fears of transmitting mad cow disease. That means anyone who has received
a cornea transplant in Ireland in the past two decades likely now sees thanks to a person who died in Colorado or Wyoming, according to the Irish Blood Transfusion Service.
Lohmeier, the eye bank CEO, said local needs are prioritized for donations, while international shipments help fulfill the eye bank’s mission and “ensure that all viable corneas are transplanted, giving the gift of restored sight.”
The U.S. is one of the few nations with a
cornea surplus. FDA inspection reports confirmed that the Rocky Mountain Lions Eye Bank procures more tissue than its geographic area can use.
The demand for international orders contributed to the high-pressure environment, Lopez said.
Employee turnover and the stress of the job resulted in the collection of corneas of poor quality, Lewis said. Local hospitals inquired about why so many corneas weren’t being transplanted, she added.
The leading reason was recovery errors that damaged the tissue, Lewis said.
Lohmeier disagreed that there was a significant decline in corneas being placed. “We do not believe this description accurately reflects the state of corneal recovery and transplants,” he said.
Internal records showed that about half of recovered corneas in November 2022 had moderate to heavy stress. The Eye Bank Association of America does not have comparable national data. The closest figure it tracks is the proportion, among tissues that were prepared but not transplanted, that were unable to be transplanted because of damage during processing; in 2022, it was a quarter.
Ashi Moore, who used to lead the Rocky Mountain Lions Eye Bank’s quality assurance department, said she once filed a report to the FDA after a donor’s eye tissues were removed despite a family history indicating a high risk of Creutzfeldt-Jakob disease. The disease, which should have been disqualifying for donation purposes, is a fatal brain disorder that
can be transmitted through infected tissue.
The issue was caught before the corneas could be placed in someone else’s eyes, but it should never have gotten to the point that the corneas were removed from the body, Moore said.
At least once, a technician retrieved corneas from the wrong body, according to Moore and other former employees. (The FDA was unable to provide records to confirm that report by publication.) Moore said she should have been told about the case of mistaken identity immediately but said she wasn’t made aware of it until after the eye bank’s leaders handled the situation themselves.
She said she couldn’t find evidence that the eye bank had reported the error to the FDA. It was one of the major reasons she decided to leave the organization, though she had derived a strong sense of purpose from working at the eye bank, she said.
When Lewis resigned, officials at the nonprofit eye bank offered her $5,000 to sign a severance agreement with a nondisparagement provision. She declined.
Lewis said she would like to see states hold tissue recovery agencies to the same standards as other organizations that handle corpses, such as hospitals, coroners, and funeral homes. And if they fail to meet those standards, they need to be held accountable to build public trust, she said.
Lewis’ and Lopez’s negative experiences with the eye bank had another consequence. Each decided they no longer wanted to be an organ or tissue donor.
“After witnessing and experiencing so many issues, I no longer feel comfortable with the potential of my family having to go through that when the time comes,” Lewis said.
Madelyn Beck and Rae Ellen Bichell wrote this story for KFF Health News.
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