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Penn Highlands Elk maternal care cuts highlight Pa.’s widening rural services gap

The end of Penn Highlands’ birth services marks another huge maternal care loss for Pennsylvania’s shrinking rural counties.

  • By Marley Parish of Spotlight PA State College
An aerial view of Penn Highlands Elk in St. Marys.

 Nate Smallwood / For Spotlight PA

An aerial view of Penn Highlands Elk in St. Marys.

This story was produced by the State College regional bureau of Spotlight PA, an independent, nonpartisan newsroom dedicated to investigative and public-service journalism for Pennsylvania.

As a maternity nurse, Jacki Nesbitt has teared up while helping strangers give birth and supported families through loss.

It’s her dream job. But when her 15th anniversary in the role at Penn Highlands Elk comes around this summer, labor and delivery services won’t exist. The hospital is ending them in May.

The 38-year-old could work in another department or at a Penn Highlands hospital roughly 35 miles away. But Nesbitt doesn’t want a new nursing job and is frustrated by the closure. She’s also “devastated” for the patients, who will be referred to Penn Highlands DuBois, a facility with 24-hour labor coverage and a 16-bed neonatal intensive care unit.

Penn Highlands Elk doesn’t have a NICU, so infants requiring specialized care would receive “a higher level” in DuBois, Nesbitt said. Still, the nurses in St. Marys are trained to transfer patients in emergencies, and as far as Nesbitt knows, transport has not caused a bad outcome during her time at the hospital.

“They have a great maternity unit over there. They have great people that work there,” Nesbitt said of DuBois. “But when it comes to labor and delivery, they can’t do anything that we can’t do here.”

In private meetings, Penn Highlands has told staff, local first responders, lawmakers, and community officials that the system needed three more OB-GYNs to alleviate the workload of Steven Koch, the only doctor with that specialty in Elk County. Plus, state data show the hospital’s 179 to 227 annual deliveries from 2011 to 2021 is low compared to DuBois’, which averaged 1,000 births a year in the same period.

The health system, which operates eight hospitals statewide, says patients will have access to “the highest quality of care and the most resources” at its Clearfield County facilities, said spokesperson Corinne Laboon.

“For Penn Highlands Healthcare, this transition is about quality and reducing risk and not finances,” Laboon told Spotlight PA in an email.

Community members who have watched services trickle out of the area say they are confused, frustrated, and worried by the news of the planned shutdown. Residents frantically called their elected leaders, who knew little more than their constituents about the decision.

Almost a decade ago, Penn Highlands Elk sought to become a critical access hospital — a Medicare designation that limits stays to four days — to improve its financial standing. The hospital later cut its generations unit, an inpatient program for older adults, and referred patients to DuBois instead. The health system is also closing a personal care facility in Ridgway this spring.

“It feels like it’s just one thing after another,” Nesbitt said.

Meanwhile, Penn Highlands is building a $70 million facility in Centre County, which already has a hospital.

Penn Highlands President and CEO Steve Fontaine, who made over $1.2 million in 2021, told state lawmakers during a February hearing on rural care challenges that inadequate payments from health insurance plans are the primary cause of hospital closures. He didn’t mention the expected labor and delivery shutdown in Elk County, but detailed how financial challenges, aging patients, and staffing shortages make it hard to sustain rural health facilities.

Tax documents show the health system reported $81.7 million in revenue in 2021 and $73.3 million in expenses. During the hearing, Fontaine said post-pandemic numbers show profit declines. He testified that Penn Highlands had one of its “greatest losses” in 2023: a negative 5% profit margin.

This year is “a little bit better,” he added.

Residents think money factored into Penn Highlands’ decision to cancel labor and delivery services in Elk County. But if finances weren’t an issue, they question whether the closure was necessary. Additionally, as shrinking population projections loom over Pennsylvania’s rural areas, officials fear these changes leave their communities without the infrastructure to survive long term.

“Everybody in rural Pennsylvania deserves access to the same services as urban and suburban residents,” Clearfield County Commissioner Dave Glass told Spotlight PA. “We aren’t lesser people here.”

How it happened

Penn Highlands has emphasized that the closure in Elk County applies only to labor and delivery. The hospital still plans to provide prenatal and postpartum care, exams, tests, and ultrasounds.

In late February, the health system hosted a private, invitation-only meeting at Penn Highlands Elk that brought out staff from the offices of U.S. Rep. Glenn Thompson (R., Pa.), state Sen. Cris Dush (R., Jefferson), and state Rep. Mike Armanini (R., Clearfield). County officials, municipal leaders, and community members also attended the meeting, according to several attendees.

During the meeting, Penn Highlands leadership reiterated that the decision would offer “higher quality care” for patients, detailed Koch’s overextended workload, and mentioned declining birth numbers in Elk County. However, attendees questioned whether the health system had truly exhausted all options before deciding on a closure. A birth center that employed midwives overseen by physicians was one alternative floated by the group, which asked Penn Highlands to more proactively involve the community in big decisions in the future.

“I don’t think it’s such an outlandish idea,” Elk County Commissioner Matt Quesenberry said of a birth center. “I didn’t get the impression that was an idea they were considering.”

St. Marys Mayor Lyle Garner told Spotlight PA that while he somewhat understands why Penn Highlands plans to end labor and delivery, he thinks the hospital wasn’t open enough with residents.

“I don’t think we should be the middleman on this,” Garner said. “They put me in a bad situation, whether I like that or not. There’s a bad public opinion of our hospital, and they need to change that. This didn’t help things.”

Penn Highlands Elk didn’t invite some leaders in neighboring areas affected by the anticipated closure to the meeting, including Cameron County, where residents rely primarily on Penn Highlands Elk or UPMC Cole in Potter County for care. Though Cameron County has a health center, the nearest hospital is at least a 40-minute drive, Commissioner James Moate said.

“To me, that’s not putting patients first. That’s putting their bottom line first,” he told Spotlight PA, referring to the impact these closures have on patients in surrounding areas.

Though regular conversations between elected officials and health system leadership might not prevent closures like this, they could give local leaders a chance to ramp up advocacy for more state funding to fill service gaps, Cameron County Commissioner Jessica Herzing told Spotlight PA.

“It would certainly be nice to include the elected people that represent our constituents who make up their client base and utilize their services,” Herzing said. “So, not only are we aware of what’s coming down the line, but also so that we’re not blindsided by after-the-fact decisions, and then excluded from further discussions.”

Maternity care deserts

Jessie Larabee lives less than two miles from Penn Highlands Elk, but she and her partner face a roughly 45-minute drive to DuBois when the 30-year-old goes into labor with her fourth child, a girl due June 30.

The drive to Clearfield County isn’t her top concern though, as the couple did it with their second child. Instead, Larabee is worried about knowing the doctor who will be in the delivery room. If it were up to her, Larabee would choose Koch.

Larabee has spent years developing a bond with him as a patient. Koch — whose office said he couldn’t comment on the closure — has been her doctor since 2021. He was there when Larabee lost a pregnancy and had to deliver early at 21 weeks. He delivered her youngest son at Penn Highlands Elk in December of the following year.

By June, his working location will depend on a labor and delivery rotation at DuBois, so there’s only a chance he’ll be on hand when Larabee gives birth this time around. Penn Highlands did not provide additional details about the schedule.

“You build a relationship over nine months, and you trust that doctor,” she told Spotlight PA. “When the time comes, you just have to trust whoever’s there, but it just makes you more comfortable to know who’s taking care of you.”

Labor and delivery services shutting down in Elk County follows previous losses of maternal care in rural Pennsylvania.

March of Dimes, a national nonprofit that works to improve maternal and child health, considers five rural Pennsylvania counties “maternity care deserts,” which it defines as areas without a hospital or birth center that offers obstetric care, and those without obstetric providers, including OB-GYNs, family doctors, nurse midwives, or certified midwives.

report from the organization shows that 47.6% of women in rural Pennsylvania live more than 30 minutes from a birthing hospital. Farther travel can increase maternal morbidity risks and adverse outcomes.

State Sen. Judy Schwank (D., Berks) told Spotlight PA that the legislature and government agencies should reach a consensus on what qualifies as a “maternity care desert.” She prefers a broad definition with mileage buffers, so state spending can support health services, child care, transportation, and access to grocery stores.

The Center for Rural Pennsylvania sponsored a 2022 study that predicts 18 counties will be maternity care deserts by 2025. The report also anticipates that demand for maternity care in rural areas will decrease because the population is expected to decline, especially among people of childbearing age.

Once the closure takes effect, Elk County will be the sixth county in the region without a hospital or another facility delivering babies. The others are Cameron, Clarion, Clinton, Forest, and McKean Counties, which collectively contain more than 156,000 people.

For years, health care administrators and experts have said workforce shortages and increased operating costs have exacerbated financial problems, especially for hospitals in rural areas where residents are typically older and more reliant on Medicare and Medicaid.

Payments from Medicare, Medicaid, and commercial insurance companies haven’t kept up with inflation, Nicole Stalling, president and CEO of the Hospital and Healthsystem Association of Pennsylvania, told lawmakers in February. Medicare and Medicaid reimburse Pennsylvania hospitals 84 and 81 cents on the dollar, respectively, Stalling testified.

Fontaine said Penn Highlands’ consolidation with other health systems — such as Mon Valley in Washington County and Connellsville in Fayette County — has helped facilities survive by mixing patient and insurance demographics. This strategy is why Penn Highlands expanded into Centre County, where resident numbers are expected to grow, he told lawmakers.

Jessie Larabee, who is pregnant, poses for a photograph outside her St. Marys home.

Nate Smallwood / For Spotlight PA

Jessie Larabee, who is pregnant, poses for a photograph outside her St. Marys home.

Residents turn to lawmakers

Although residents and officials who attended the private meeting with Penn Highlands think it’s unlikely that the system will reverse its decision to shutter birth services, a coalition of business owners is lobbying lawmakers and hospital leadership to find alternative solutions.

Twenty-eight people signed a letter urging their federal and state representatives to “explore options to prevent the closure.” They fear the decision will endanger people traveling to give birth and deter workers from moving to the area due to the service gap.

“Our frustrations reflect how much we value our families, community members, and businesses,” they wrote. “Our efforts are the result of an appreciation for what we already have. We hope future generations will have the same.”

U.S. Sens. Bob Casey (D., Pa.) and John Fetterman (D., Pa.), along with Thompson, Democratic Gov. Josh Shapiro, Dush, and Armanini — who declined to comment on the issue — received copies of the letter.

Manuel Bonder, a spokesperson for Shapiro, told Spotlight PA that senior administration officials met with residents and business leaders in Elk County to discuss the service closure and potential solutions. In his budget pitch, Shapiro proposed spending $2.6 million on maternal care and education and $4.3 million on increasing support for health providers, family planning, and reproductive care.

The Hospital and Healthsystem Association of Pennsylvania has voiced support for the governor’s proposed maternal health and other health care investments.

Thompson also requested a meeting with Fontaine earlier this month to discuss the closure and ways to expand health care access in Elk County. Through a spokesperson, Casey said pregnant people shouldn’t have to travel more than an hour to give birth “just because they live in a rural area” and cited his past proposals to support rural hospitals.

Dush argued the state should find ways to address staffing shortages and financial challenges, citing a law that took effect this year that ties Medicaid reimbursement to federal rates and pays whichever amount is higher. The law also reimburses emergency medical services organizations for 100% of the miles they travel with a patient.

Earlier this month, a state lawmaker also announced plans for legislation that would expand access to midwives in Pennsylvania.

Though more spending in rural areas might not stop anticipated population losses entirely, officials hope funding for health, housing, broadband, and education could help slow the decline.

The Pennsylvania Office of Rural Health is looking to conduct a statewide assessment to determine the feasibility of establishing a new birth center, Lisa Davis, the office’s director, told Spotlight PA. The northern part of the state could make sense for these affected counties, she added. Though it’s not “an inexpensive alternative,” a birth center could be less costly than having a full unit in the hospital, Davis said.

A view of St. Marys in Elk County.

Nate Smallwood / For Spotlight PA

A view of St. Marys in Elk County.

Filling the gap

Penn Highlands said emergency department staff can handle births if someone cannot make it to DuBois or another facility in time to deliver. Nesbitt cautioned against this, though, saying it takes at least two years to become “fully oriented” as a maternity unit nurse due to training and certification requirements.

Emergency room nurses started observing births at Penn Highlands Elk over the last month to prepare, Nesbitt added.

Plus, first responders have started to plan for Elk County to lose birth services and a brace for a possible uptick in pregnant patients needing transportation to a hospital farther away.

St. Marys Ambulance Service staff — which covers a portion of Elk County and all of Cameron County — is brushing up on labor and delivery skills, said manager Nicholas Burdick. While this training is standard for EMTs, they don’t typically deliver babies, so they want to be ready if a patient in labor requires transport.

As emergency response personnel face staffing shortages and financial challenges statewide, Burdick said he understands the tough decisions hospitals must make to survive. But this choice from Penn Highlands “feels like it’s not necessary,” he told Spotlight PA.

For Glass, the Clearfield County commissioner, this closure follows a larger trend of service cuts in rural Pennsylvania.

“We live like this every day, not just in health care,” he said.

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