Bob Haworth, fire chief of the volunteer
fire department in Belgrade, Missouri described the scene of the accident with
one word: blood.

A man working on a bulk feed truck at a
local feed store was caught in an auger, and it ripped off his leg just below the
knee. The man was able to climb out of the truck, and his co-worker used a belt
as a tourniquet and called 911.

When Haworth arrived, a trail of blood a
foot wide had spilled down the side of the truck, he said.

“I would not wish anyone to see that,”
Haworth said. “Because I honestly don’t know how much he had lost, but there
was blood everywhere.”

When the air ambulance arrived, the
helicopter did not even stop running. The man was loaded and flown to a
hospital in St. Louis — about 90 miles away. Miraculously, he survived and is
now a volunteer for the same fire department that saved his life, Haworth said.

Incidents like this don’t always have a
happy ending. Farm and agricultural work is a dangerous profession, especially
in rural areas where health care is sparse.

When a farmer experiences a traumatic
injury, every second it takes to get to a care facility is critical — and those
care facilities are becoming fewer and farther between as rural hospitals
close. According to Hospital Industry Data Institute
statistics, the average distance traveled by rural hospital
patients who did not survive illness or injury either on the way to a care
facility or at the facility was 32.1 miles, compared to 9.1 miles for non-rural
hospital fatalities.

The status of health care in rural parts
of Missouri paints a bleak picture for farmers who live and work in such a
dangerous profession. On top of working under constant risk of injury and
death, farmers have very few options when it comes to the types of care they
can receive. And, when and if that care is available, patients can be billed
exorbitant costs.

Farm accidents

According to the Centers
for Disease Control and Prevention, about 243
agricultural workers in the country suffer lost work time every day because of
injuries, and 5 percent of those injuries result in permanent impairment. The
CDC reports that 417 farmers and farm workers died in 2016 from a work-related
injury — a fatality rate of 21.4 deaths per 100,000 workers.

The CDC also estimates that every day,
about 100 agricultural workers suffer a lost-work-time injury.

Dave Dillon, Missouri Hospital
Association spokesman, who also served as the former deputy director of the
state Department of Agriculture, said the farming industry is, by nature,
extremely dangerous. There’s potential exposure to chemicals and burns.

Farmers who operate dangerous equipment
can get caught under tractors, suffocate in grain storage bins or get tangled
with an auger. In animal agriculture, particularly with the large amount of
cattle farms in Missouri, farmers can get trampled, kicked or stomped.

“For us, the real question is, if one of
these bad things happen, then it becomes ‘how quickly can we get to care?’”
Dillon said.

In rural Missouri, Dillon said, access to
most services — whether going to the grocery story or getting a diesel truck
filled up — takes longer compared to an urban area because of the geography.
But access to care is a life-or-death situation versus a trip to the grocery
store.

“What we find is that it’s more and more
difficult for emergency care, as we see some hospitals close, to have those
individuals have local access,” he said.

Hospital closures

The closure of a rural hospital can send
ripples through a community — particularly a community that relies on such a
dangerous industry like farming. Six rural hospitals have been shuttered in
Missouri over the last five years — with three closing between 2018 and 2019,
according to data from the Cecil
G. Sheps Center for Health Services Research at the
University of North Carolina at Chapel Hill.

The hospitals ranged in size from the
100-bed Twin Rivers Regional Medical Center in Kennett, which closed in 2018,
to the 15-bed I-70 Community Hospital in Sweet Springs, which closed this year.
With the closure of a hospital, an injured person would have to add more time
and distance to travel to the next closest center.

After the closure of Twin Rivers Regional
Medical Center, Kennett-area residents are expected to travel more than 1
million additional miles to receive hospital care, according to the Missouri
Hospital Association.

According to association, 37
percent of Missouri’s population is rural, approximately
2.2 million people. However, only 9 percent of licensed Missouri physicians
practiced in rural areas in 2014, and the number of rural physicians has
declined by 15
percent since 2011, according to Hospital Industry Data Institute
statistics.

From 2011-13, rural hospitals accounted
for 29 percent of all Missouri emergency department visits, including 36
percent of all treatments for poisonings and injuries, 29 percent of all
treatments for burns and 29 percent of all treatments for head injuries,
according to MHA data.

Dillon said he would like to see more
support for a system where small rural hospitals are the first point of care
for patients in rural Missouri. That way, patients can get stabilized before
they are transferred to a higher-level hospital.

“Even without closures, rural residents
travel farther to get care. You have to. It’s the way rural Missouri is built,”
Dillon said. “But, in an emergency, it makes a big difference.”

First responders

When Steve Kimker slipped off his tractor
in 1996 and cracked his ribs and sternum, he had to drive himself to the
nearest hospital 18 miles away.

It was a snowy day on Kimker’s family
cattle farm in Bourbon, Missouri and he was riding a Ford 4000 tractor,
unrolling a hay bale to feed his cows. About 8 inches of snow covered the
ground.

The bale spun out of the tractor, and
Kimker moved his foot to the clutch to stop, but it slipped. The tire climbed
on top of the hay bale, and the tractor began to tip. Kimker tried to jump off,
he said, but since it was wet, he wasn’t able to get entirely off. The backside
of the tire landed on his side and back.

He was able to walk back to his house and
drive himself to the hospital in Sullivan.

Tractors are the leading cause of death
and injuries that lead to disabilities, according to a study by the U.S.
Department of Agriculture. Most deaths are caused by the tractor
tipping over on top of its operator.

Often, when an incident on a rural farm
occurs, volunteer firefighters are the first to arrive. In fact, the National
Fire Protection Association estimates that 65
percent of the nation’s fire departments are made up of volunteers.

• 

• 

Kraig Bone owns a company in Cadet,
Missouri that trains volunteer fire departments to respond to large machinery
accidents on farms.

The Midwest Center for Investigative
Reporting obtained and analyzed data to find agriculture-related incidents.

In Missouri’s case, after narrowing the
data down to focus on agricultural incidents, more than 700 incidents could be
considered farm-related in 2016. These incidents included vehicle injuries,
search and rescues and other medical assists.

Air evacuation

When an accident happens in a remote area
and an urgent response is needed, air evacuation is often the best option for
patients in time-critical situations.

Missouri has 13 providers of air
ambulance services with rotary aircraft scattered over 36 bases, according to a
report released in January by the Missouri
Department of Insurance, Financial Institutions and Professional Registration.

The largest of those companies is Air
Evac — an independent company founded in 1985 in West Plains with 141
helicopter air ambulance bases across 15 states; 13 are in Missouri.

The Missouri Hospital Association
partners with Air Evac, and the company was responsible for 3,570 air
evacuation transports in 2017, about a third of all air ambulance transports in
the state that year.

The company owns its own helicopters,
crew quarters and hangers and employs its own pilots and crew members.

Shelly Schneider, public relations
manager for Air Evac, said the first thing someone should do after an accident
is call 911. Air Evac promotes a practice of “early activation,” where EMS
service or medical professions call their company and lets them know of the
situation.

Although air ambulance services can
greatly reduce a patient’s time before receiving medical care, the cost can be
exorbitant.

Air ambulance companies billed
Missourians nearly $25.7 million billed for services in 2017 alone — an average
of nearly $20,000 per individual, according to the January report. The
Government Accountability Office reported in 2017 that the median cost for
helicopter air ambulance service doubled from around $15,000 to about $30,000
per transport between 2010 and 2014.

Because the air ambulance industry has
very high fixed-costs compared to “per trip” costs, patients are charged for
even short flights that can run to tens of thousands of dollars, the report
noted.

Air ambulance reimbursement rates are
fixed by Medicare and Medicaid, and providers that participate in these
programs have to accept these rates as payment in full — they cannot “balance
bill” patients for amounts charged over the reimbursement rates.

One of the ways companies like Air Evac
have tried to limit these high costs is through membership fees. Air Evac’s
parent company, Air Medical Group Holdings, also oversees the AirMedCare
Network. People can become members of the network for $85 a year per household,
and Air Evac flights are then covered by whatever the member’s insurance
company pays. 

According to the St. Louis Post-Dispatch,
air ambulance memberships are frequently advertised in rural areas, and the
126,000 members of the Missouri Farm Bureau get a discounted rate if they
choose to buy an Air Evac membership.

Independent companies like Air Evac have
become more popular in certain areas because they reduce the risk of paying high
fees, said Jaclyn Gatz, vice president of safety and preparedness. When an
uninsured patient is flown via medical evacuation, a number of air ambulance
providers will use aggressive collection strategies, such as placing liens on
homes or garnishing wages, according to the January report.

“Any time you’re on an aircraft, it’s going to be expensive,” Dillon said. “A big determining factor is how much your insurance covers. If you’ve got a fairly gold-plated insurance plan, it may cover a lot of or all of medical transport. If you don’t, then you may be exposed to significant costs for that medical transport.”

This
story was produced in cooperation with the Midwest Center for Investigative
Reporting by students in a spring 2019 Investigative Reporting class at the
University of Missouri School of Journalism taught by associate professor Sara
Shipley Hiles.

The post For rural Missourians, access to quality health care is a nightmare appeared first on Investigate Midwest.