Tonopah rallied to recover from its hospital’s closure four years ago, but daunting gaps remain. It’s a case study in the healthcare crisis facing rural communities
“I was born there.”
Talk to a dozen people about the Nye Regional Medical Center in Tonopah, Nevada, and you’ll hear that from half of them. The other half will either tell you they worked there, or about the time a nurse there saved their life, or the life of a loved one. It’s the nature of small-town hospitals. Like churches and schools, they do more than provide an essential service. They’re woven into the fabric of individual and collective histories.
That’s why it was so painful when, following years of mismanagement by an unscrupulous administrator, the hospital closed in August 2015. Beyond the loss of a critical need, it was a betrayal of community trust.
But the administrator in question, Vincent Scoccia, was from out of town. After running the hospital into the ground, he retreated to his Texas ranch. He was never charged with a crime, despite compelling evidence, brought to light by the Dallas Morning News, that he’d siphoned millions of dollars off the business before filing bankruptcy in 2013. Tonopah became the poster child for the nation’s rural healthcare crisis, with the likes of CBS news and CNN doing specials on it.
Locals were no more inclined to bask in this celebrity than they were to wallow in anger at Scoccia. They didn’t have time. Between Tonopah proper and the surrounding small towns, such as Gabbs, Goldfield, and Round Mountain, the hospital’s closure left around 5,300 people with no hospital for 100 miles in any direction. If anyone were ever again to say, “I was born there,” the community would have to act fast. And it did.
“After the hospital closed, we went to Las Vegas and Reno,” says Jessica Thompson, director of Renown Medical Group’s Tonopah clinic. “We talked to all the big hospital companies. A couple came out and visited, but the one that stuck with us was Renown.”
[Pictured right, Jessica Thompson demonstrates a telehealth unit.]
Thompson checks two of the history-with-Tonopah-hospital boxes: both born and worked there — for more than two decades. A registered nurse, she was one of the last staff remaining when the place closed, and she was the first person hired by Renown after the Reno-based nonprofit hospital operator opened a clinic in June 2016. It would meet the community’s most urgent need, which was determined to be primary care, the basic and preventive services that keep people healthy and out of emergency rooms.
Tonopah Primary Care
That clinic now operates under a contract with the local government, an arrangement made possible by Nye County’s quick action. In 2015, it passed a law creating the Northern Nye County Hospital District, which started collecting taxes the following year. The resulting revenues funded the Renown clinic, as well as a community paramedic program through the Regional Emergency Medical Services Authority, or REMSA. In 2018, the district collected $1.1 million, according to Secretary-Treasurer Justin Zimmerman (another Tonopah native, born in the hospital). About $590,000 of it comes from property taxes, and the rest from net proceeds (such as mineral taxes), the state, and investments.
“Renown’s contract is capped at half a million dollars a year,” Zimmerman says. “And REMSA’s is capped at $440,000. So, that doesn’t leave a whole lot of extra.”
Walking around the clinic today, Thompson seems proud of what she and her staff of three have accomplished with such limited funds. They’re set up a stone’s throw from the shuttered hospital building in a barracks-like structure that functioned as the walk-in clinic when the medical center was open.
“Most of the stuff that’s here was left over from the hospital and the clinic when it closed,” she says, walking down the hall between a telemedicine exam room and the physician assistant’s office. “Except the computers and telehealth carts, obviously.”
These two carts and the physician assistant, or PA, Lisa Logan, are the linchpins of the operation, providing the clinic’s primary care 7 a.m. to 5 p.m. weekdays. Logan sees patients in person part-time, and M.D. Suzanne Zsikla sees patients from her home office in Reno via the telehealth units, also part-time.
This arrangement combines two things that many healthcare experts have long touted as key solutions to the rural healthcare crisis: advanced practitioners, such as PAs and nurse practitioners; and telehealth. These resources are faster and less expensive to provide than fully trained and licensed doctors, of which there is a shortage everywhere, but especially in far-flung areas like Tonopah. According to Nevada’s Office of Statewide Initiatives, 2 million of the state’s residents, including those in Nye County, live in federally qualified health professional shortage areas.
Eljena "Marie" Peterson at Tonopah Primary Care.
Besides Logan, there is one other advanced practitioner in Tonopah: Eljena “Marie” Peterson, owner of Tonopah Primary Care private practice. Although not a native, Peterson is also connected to the hospital. She became the director of nursing there after moving to the town in 2009, persuaded by her younger sister that it would be a better environment than Las Vegas for Peterson’s two young sons.
Tonopah Primary Care's small blood testing lab.
“Joining the hospital in 2009 really opened my eyes to what rural areas are missing in resources,” she says. “So when I had the opportunity to bring something more here, I jumped on it.”
After four years at the hospital, Peterson left to join a hospice provider. While helping to get those services established, she went back to school at UNLV, earning her Advanced Practitioner Registered Nurse degree in 2017. This credential, like the PA, allows her to do much of what a doctor can — see patients independently, diagnose them, order tests, make referrals, interpret data, perform in-office procedures, and write prescriptions. Having specialized in family medicine, Peterson is Tonopah’s version of the country doctor whom people go to for everything from a sore throat to a sprained ankle.
“When I came from the big city to this area, I found that people are people here,” she says. “People are not numbers, and I like that. When I was working in a 256-bed facility as a director of nursing, I still wanted my patients to be people, but it was an HMO and it just felt like running a mill. So when I got to this hospital and I could truly give the care that I wanted to give, I fell in love with that. Becoming a nurse practitioner was the next step up to providing more services.”
More importantly, though, Peterson sees herself as the hub for other resources in the community that people may not know are there. Rifling through one of the many stacks of paper on her assistant’s desk, she finds information, put out by the Nye Communities Coalition, with descriptions and contacts for Tonopah’s health nurse, mental health clinic, pharmacy, physical therapist, and transportation services. Most are within blocks of her small office just off Main Street, near the historic Mizpah Hotel. A couple of them have opened recently with the help of the hospital district’s community startup grant program.
Peterson took over the general medicine practice in early 2018 from the physician who’d been running it for decades. Her years as an administrative nurse, she says, helped her navigate the financial and insurance challenges. Today, she’s able to accept patients with Medicaid, Medicare, Blue Cross, and most of the major commercial insurers. And, she makes a lot of referrals to the Renown clinic, where telehealth connects patients to a wide range of specialists, such as cardiologists and pulmonologists, as well as Zsikla, who is based on Reno.
Like advanced practitioners, telehealth helps spread resources around by letting doctors see patients remotely. Equipped with a variety of instruments, the units in the Tonopah clinic are run by an on-site nurse or medical assistant. The patient sits on a chair in front of a unit, and Zsikla sits at her computer, so they’re looking at each other on screens. The doctor then examines the patient remotely, having him open his mouth, for instance, or asking the assistant to listen to his heart or look in his ears. All the information gathered is shared through an encrypted session to guard the patient’s privacy. And the doctor can instantly make diagnoses, order tests, write prescriptions, and recommend treatment, some of which can be completed at the clinic, which has a lab and basic radiology.
Some patients are resistant to the technology or the lack of hands-on care, but Thompson says that most people who’ve actually tried it like it.
“Dr. Zsikla is my primary-care doctor,” she says. “My family comes here, sees her over the cart. … Honestly, I don’t find it much different than having a physician in the room.”
Another barrier Thompson has had to overcome is Tonopah’s unreliable Internet service, which, for the clinic’s first couple years would periodically disrupt tele-appointments. In October 2018, Renown had a fiber-optic line installed, and connectivity has been smooth since, Thompson says.
That’s not to say she or Peterson can rest easy. Their experience with the hospital taught them first-hand the financial challenges of keeping any healthcare institution afloat, and there’s still so much the community needs that neither the clinic nor the family practice can do.
“I’m grateful for the primary care,” Thompson says. “But as my family ages … if something were to happen to one of them, having a heart attack or something, I know the outcome is probably not going to be good, living where we live, because there is no golden hour out here.”
The “golden hour” is the time frame within which a patient in crisis receives the care that has the greatest impact on the final result. Tonopah is more than 100 miles from the nearest emergency room, in Hawthorne, Nevada, and more than 200 miles from those with more advanced care in Las Vegas and Reno.
In case of emergency
This is where emergency medicine comes in. Tonopah has two forms of it: the county’s volunteer ambulance service, run by Emergency Medical Technicians, or EMTs, and REMSA’s community paramedicine program.
The Tonopah Volunteer Ambulance Service has two ambulances staffed round-the-clock by 16 volunteers. They have different levels of certification, from drivers, to those who can do CPR, to the hands-on EMTs.
“We handle sick people, so anywhere from diabetics, stubbed toe, to bleeding, cardiac events,” says Dawn Gudmunson, the program coordinator and an advanced EMT herself who notes she was trained by her own aunt. The volunteer service has been running continuously for decades — through the decline and loss of the hospital and arrival of replacement services. The months between the hospital closing and the Renown clinic opening were “scary,” she says. “But it improved our skills, because we had to practice medicine, and we saw the outcomes.” After a pause, she adds, “There’s been a lot of heartache that we’ve had to face as well.”
The arrival of REMSA helped diminish some of that hardship. Its paramedics provide a higher level of care than the EMTs.
“I’m classified as a frontier paramedic,” says REMSA’s Chris Perham. “Where that differentiates from a typical paramedic, at least in our company, is … we have an extra skill set, so we can do suturing, give extra drugs that they can’t administer in town, and we’re designed for this desert-like setting, where nothing’s close. There are no hospitals, and air assets like airplanes and helicopters are at least an hour away.”
Perham and two other two REMSA paramedics cover Tonopah and the surrounding area with emergency care 24/7 (there are an additional two backups). They meet the volunteer ambulance at 911 calls, go to the Renown clinic and Peterson’s practice for emergencies, and respond to referrals that come through REMSA’s help line, also staffed round-the-clock by nurses. They assess and treat patients and, when necessary, get them on the ambulance or plane to the nearest hospital that can treat their particular case.
Still, that transportation can take an hour to arrive, and then there’s the time it takes to reach that hospital. This life-or-death risk is lost on no one. Ask anyone what Tonopah needs most, and they’ll give the same answer: some kind of on-site emergency care.
“I’m very concerned about the people in this town, because the possibilities for emergency care are so slight in this area,” says local minister Tina Snyder. “The people we have here — both from Renown and Tonopah Primary Care — just bend over backwards to try and take care of us, but when we don’t have sufficient facilities, there’s no possibility of doing what really needs to be done for people in a timely manner. So, I’m hoping that our politicians will understand that, even though we’re a rural area and we don’t have a high census, we’re people. We need help.”
Zimmerman says the hospital district is working on it. Last year, the district received a $115,000 federal grant to assess what kind of facility would both fill the community’s needs and be financially sustainable. If the district follows the road map that the assessment lays out, then it will be poised to receive a loan to build the recommended facility. Zimmerman says the assessment should be done by year’s end; Tonopah could have some kind of emergency facility within three years.
Meantime, there are other hurdles to overcome. The closest hospital to Tonopah, in Hawthorne, is exactly 103 miles away. That means it’s just outside the limit for emergency facilities, which are required by federal law to be within 100 miles of a full-service hospital. And getting to the point where most residents’ insurance — particularly for the area’s four biggest employers — is accepted at the available providers has been a “big issue,” Zimmerman says.
Nevertheless, like everyone else in the community, he’s hopeful.
“I feel good, honestly,” he says. “I feel like we’re headed down the right path. Unfortunately, nothing happens quickly. And with healthcare, there’s no more important need. There’s no more urgent need.”
Faces of the Rural Healthcare Crisis
Five medical flights have taught this Tonopah resident the value of nearby emergency care
Vitals: Tonopah resident, five-time REMSA Care Flight passenger
History: Moved to Tonopah in 2012, when his wife got a job at Crescent Dunes Solar Energy Project; has suffered a variety of acute gastrointestinal episodes, from appendicitis to a perforated colon
Notes: In 2014, difficulty breathing woke Jeff Martin up in the middle of the night. By the time his wife got him to the hospital, which was still open then, his blood pressure was around 65 over 42, as he recalls. “I was really to the point of crashing,” he says. “The nurse who was there, Theresa Campbell, she knew what to do. She just went right into action. She hooked me up to three different IVs, got me ready for flight, and they flew me out. I spent a couple of weeks in Reno. I was septic really bad.” Campbell, he believes, saved his life.
Compare that with Martin’s most recent ER experience, earlier this year. Unbeknownst to him, he’d been walking around with a ruptured appendix for several months. When the pain finally pushed him to action, he had his daughter drive him 90 minutes to the hospital in Bishop, California.
“They said, ‘Well, you need to fly to Reno,’ and I said, ‘I’m not flying anywhere. I’ve done it enough. I’m tired of it,’” he says. Over the hospital staff’s objections, he had his daughter drive him to Reno, where he underwent an emergency appendectomy.
Martin says he loves Tonopah’s new primary- and urgent-care clinic, but the town will always be limited. Even with an ER, there’s only so much the staff of a small rural hospital can do. For serious illness and injury, the critical question is how quickly a patient can be stabilized for transportation to a larger facility.
Vitals: Director, Renown Medical Group – Tonopah, registered nurse, fourth-generation Tonopah native
History: Worked 20-plus years in the ER at Nye Regional Medical Center; last out after the hospital closed in August 2015; first in at the new clinic when it opened in June 2016
Notes: In Thompson’s own words:
I had a family member — because we have a cattle ranch — who was thrown from a horse a year, two years ago, and was drug. And the horse stepped on the back of her head, knocked her out, and she had a large laceration. They weren’t even close to town when it happened. They had no cell signal, and they had to pick her up, tried to board her the best they could. They used the top of a cooler, put it behind her, and strapped her down to get her in a vehicle, and started heading toward Tonopah until they got (cell) signal and called an ambulance. Then they choppered her down to Las Vegas. And that turned out well for her. I don’t know how; somebody was watching over her that day, but she has really no deficits to this day. … I know it’s impacted a lot of other families here locally. You know, it’s knowing that something can happen. People can just say, ‘Well, you choose to live in rural Nevada.’ Well, you know, maybe it is a choice, but I don’t feel like we should suffer here more than anyone else. … We’ve always been limited here, but we’re severely limited now.
This public servant is making sure taxpayer dollars fund better healthcare for his community
Vitals: Secretary-Treasurer of the Northern Nye County Hospital District, property appraiser and collections clerk for the Nye County Assessor, Tonopah native
History: Works 10-hour shifts, Monday-Thursday, in the county assessor’s office; does hospital district work on days off.
Notes: Zimmerman was appointed to fill a vacancy on the Hospital District board in January 2017, after a member of the original five-person board resigned. He was working in the county comptroller’s office then, and says the assistant county manager contacted him to see if he’d be interested in the position. She and a county commissioner twisted his arm a bit, he says with a laugh, though he was interested.
“I wanted to be part of it,” he says. “I wanted to do what I could to make sure the money was put to the right use. And I think that’s what they were looking for too, someone who knew how public monies worked and had a feel for it.” The goal is to open a hospital in Tonopah as soon as it’s economically feasible.
Zimmerman definitely keeps close tabs on the funds generated through the Hospital District, rattling off tax collection figures and which tax produced which figure. He can similarly summon amounts spent on contracts and community incentives, earned through grants, and so on. It’s no surprise why he was elected to a four-year term last year.
And while he feels good about the district’s fiscal responsibility, his head for numbers is also a source of angst.
“It’s still difficult. You know?” he says. “It hasn’t been a complete turnaround, but I don’t know — the thing that we’ve struggled with most here is understanding the business end of it. It’s not as simple as just opening a hospital. What was here before wasn’t sustaining itself financially. So we’re funding it via this tax district. But the tax district couldn’t fund the setup that was here before. It’s complex. It’s not simple. You have to look at what your population can really sustain.”
For residents of Tonopah (and beyond), he’s like a mobile ER
Vitals: Frontier paramedic for Regional Emergency Medical Services Authority
History: After three years as a REMSA paramedic, got frontier training and was assigned to Tonopah and surrounding communities in 2017.
Notes: If you live in Northern Nye County and call 911 for a medical emergency, dispatch will send an ambulance staffed by EMTs with the county’s emergency medical service and, in addition, Chris Perham or one of REMSA’s other frontier paramedics, who can give more advanced care than EMTs and regular paramedics.
In an isolated area like Tonopah, Perham and his colleagues’ skills can be the difference between life and death. He recalls an incident when a man was thrown from the back of a truck, causing multiple severe injuries. “We did our best to package his head up, splinted some of the external trauma, controlled as much of the bleeding as we could. … A helicopter or a plane takes at least an hour to get here. So, we met them in the middle, got him on the helicopter, got him to a trauma center. … And to my knowledge, he had a good outcome. I feel like if we weren’t here, that could have gone quite badly.”
REMSA also runs a community paramedicine program, which sends Perham to homes of people with chronic illness for preventive care. Referred patients get regular visits to make sure they’re taking their medications, have their vitals checked, and are generally doing all they can to avoid needing that 100-plus mile trip to the nearest ER.
Perham says the ability to help people hands-on in a wide variety of cases and settings makes the job worth the 230-mile commute from his home in Reno. (He put 17,000 miles on his car the first year.)
“I love it,” he says. “Getting out here, having to rely on really just myself and maybe one volunteer (EMT), and then having to take care of somebody and think through it for possibly hours, depending on how long it takes, it’s been a real challenge.”
For this young mother, filling the healthcare gaps has meant a lot of driving
Vitals: Two-year Tonopah resident, sales manager at the Mizpah Hotel
History: Moved to Tonopah for husband’s job in 2017, four months pregnant and with three kids in tow; delivered baby in Las Vegas, still sees pediatricians and OB-Gyn in Pahrump
Notes: A brief oral history of pregnancy and pediatric care in Tonopah:
Before we moved up here, I was kind of in and out of the hospital, dehydrated, and morning sickness was not morning sickness; it was all-day sickness. I would gain weight and then lose it all and more. It took a toll on my body. So, my pregnancy was really hard on me in general, and then when we moved up here, thankfully, it kind of slowed down a little bit, but we still had to travel three-and-a-half hours to the doctor. That was really hard. … I actually had a cesarean with all of my kids, thankfully, because it was scheduled. Everything went fine. She is perfect — happy and healthy. …
In January, right after New Year’s, my now-4-year-old got sick. Like, really sick. I honestly thought she had the flu, but it was not the flu. So, I, of course, did the typical daily routine as a mother, and rotated her medication between Tylenol and Motrin, and water, and cool rags on her forehead, and you know, I did what I could. Then I took her to the local (Renown) clinic here, to see what they could do, if they could tell me what was going on. She had a fever of, like, 104.5. That’s borderline seizure. You know what I mean? It was scary. … When I went in there, we didn’t actually see a doctor. It was telemed. I don’t think I would have cared so much at the time if things had actually gone differently. And by that, I mean, the connection was terrible. It was in and out, you know, glitching. I couldn’t understand this lady that was on the other end, and here I am, my daughter’s flailing and screaming, and she’s just miserable, and they have an assistant who comes in and tries to do their best to check the temperature, check the blood pressure and all that. And, it’s just — it was chaotic. And we went through all that trouble for them to tell me to basically keep doing what I was doing, and I had to wait it out. … Aside from my pregnancy, that was the worst. You know, that’s my baby, and she’s in pain. I’m trying to do what I can, and when I try to get that extra peace of mind, it almost seemed worthless. … It did take another day or two, but she eventually kicked her fever and got better.
Calling All Doctors — to ‘Nevada’s Outback’
When Tonopah’s only hospital closed its doors, the sudden vacuum of healthcare providers in the region was a challenge to policymakers. In many ways, they’re still struggling with the fallout. “Tonopah wants their hospital back,” says Nye County Commissioner Lorinda Wichman.
But one of the main challenges they face is recruitment. Outside of Washoe and Clark counties, most Nevadans live in federally designated Health Professional Shortage Areas (HSPAs), where the number of primary care, mental health, and dental providers isn’t adequate to serve the population. Wichman says there aren’t many medical professionals willing to live in the rurals, which she calls “Nevada’s Outback.”
“In urban areas, people have become accustomed to everything being at their fingertips,” she says, pointing to the convenience of being able to compare everything from nearby schools to restaurants. “You don’t have those options within the center of the state.”
State Senator Joseph Hardy, who is also a doctor, hopes a new state law he introduced during this year’s legislative session will draw more healthcare providers to the rurals. Senate Bill 289 secures federal funding — matched with state money — to offer student loan assistance to providers who agree to work in the state’s HSPAs. “We need more doctors,” he explains. “And we need them to stay.”
To that end, the new funding provides up to $50,000 per year in loan repayment assistance for doctors, nurse practitioners, dentists, and other providers who participate for at least two years. The payments are tax-free, so the entire amount goes toward the substantial debt load medical students can accumulate. Providers can also elect to renew and continue receiving loan repayment assistance — a strong incentive that gives Senator Hardy high hopes for a long-term fix. “If you practice somewhere for six years,” he says, “you’ll probably stay.”
Neighboring states also participate in the program — including Oregon, Idaho, Utah, Arizona, and California — and early indications are that it’s working. Robert Duehmig, interim director of Oregon’s Office of Rural Health, launched the loan repayment program in his state as part of a larger project to attract doctors to rural areas. He notes that even if doctors leave after their tenure in the program, it’s still a net plus. “That’s still four or five years the community has a provider,” he says. -- Bert Johnson
‘They’re Looking for Me to Help’
A Westcare counselor faces a town’s mental health issues alone
Federal data shows that rural America has about the same rates of mental illness as urban areas; the difference is in access to treatment. “More than 60 percent of rural Americans live in mental health shortage areas,” says Dennis Mohatt, vice president for behavioral health at the Western Interstate Commission for Higher Education, summarizing a 2018 National Institute of Mental Health report. “More than 90 percent of all psychologists and psychiatrists and 80 percent of masters of social work, work exclusively in metropolitan areas.”
Tonopah, Nevada is one of these “shortage areas.” The state’s Division of Public and Behavioral Health has one mental health technician assigned to the town of 2,500; a few provider groups send counselors to the area once a week or month to meet with clients; and a smattering of others are available for phone consultations from Carson City, Elko, and Pahrump, according to the Tonopah Mental Health Resources Guide put out by the Nye Communities Coalition, a collaboration of agencies, businesses, and nonprofits.
And then there’s DaCota Terry. A certified drug and alcohol counselor intern at Westcare’s Tonopah Community Involvement Center, she’s the town’s sole full-time, on-site mental health care practitioner. Terry’s been at the clinic, which opened more than 20 years ago, since October of 2018, and has 30 clients. She conducts individual and group sessions — outpatient and intensive outpatient services — for drug and alcohol abuse disorder.
“Per capita, our drug problem is worse than Las Vegas’,” Terry says. “I have clients in their 60s who’ve been using their entire lives.”
She also does mental health evaluations for services beyond her purview, referring those who qualify to the appropriate off-site mental health provider, such as a marriage and family therapist or licensed psychologist or social worker, that clients meet with via the telehealth unit in a private room of her office.
Despite the heavy caseload and burden of unreliable Internet connectivity, Terry finds the work rewarding. “After seeing the mental health needs not being met yet here, it makes me want to go back to school and do (further training), so I don’t have to make as many referrals out,” she says. “It’s hard when they come back and say the person I referred them wouldn’t take their insurance or call them back. They’re looking to me for help, and it’s hard not to be able to give it to them.”