Reported by Donna Wilson, STATEWIDE Correspondent

It's a normal day at the Harlan County clinic and hospital. Dr. Richard Jay and his staff will see about 20 patients today. Dr. Jay is a general practitioner here. And do people come to you with what sort of ailments then?
[Dr. Richard Jay] "You name it. Everything. I mean from the simple infected hangnail to a life-threatening myocardial infarction. We see automobile accidents, burns, all sorts of farm injuries."
As a country doctor, Dr. Jay is forced to be a jack of all trades. If the doctor is that, then Allen Van Driel is the master of all budgets. Since the business of healthcare in a small town is patient-driven, dollars depend frankly on how sick people are and how much money their sickness generates. In a small town like Alma, there's going to be less specialized care, but they say the quality doesn't suffer.
[Allen Van Driel] "The biggest problem with offering a limited scope of services is in the perception of a community in that the danger that we face is in having them believe they have a second rate facility here. That's something we can't afford to do. The strength of what we do here is in the quality of the care and the personal touch that's associated with it."
Some people believe high tech is winning out over high touch care offered by rural hospitals. Some rural administrators believe low Medicare reimbursements by the federal government are what's making it difficult to keep doors open, especially when more than half of the patient load receives federal assistance. But the feds are not giving all that money back. Rural hospitals are put in a financial bind. It's been so bad for some, they've appealed to state government.
[Kim Engel, Legend Butte Hospital] "My goal today is to tell you the story of a small rural hospital who is struggling to survive in today's healthcare business. To cut costs, we outsource for meals from the local nursing home. We do not have a janitorial department as the nursing staff does all the necessary cleaning."
John Roberts was at that committee meeting. He wants to see more flexibility for rural healthcare, limited service access, and more federal reimbursement. He says about one fourth of Nebraskans' country hospital are in trouble.
[John Roberts, Nebraska Hospital Association] "Again, we have the 15 hospitals that are financially in very poor condition at this point in time. It will begin to be more difficult over the next four or five years particularly with the Medicare cuts that are proposed in congress."
State Legislative Bill 857 would allow some rural hospitals to be open on-call or for emergencies only. That scales back overhead significantly. In Alma, Harlan County Lake keeps the patient flow up. Lake accidents or minor ailments from campers contribute to their patient load. It's also no coincidence that the long term care facility is right up the road from the hospital. At some point the residents there have used the hospital and they still do frequently.
[Fred Birt] "Three meals a day and good bed to sleep in, you couldn't ask for anything better."
102-year-old Fred Birt is a long term care patient at the hospital. With the next town 30 miles away he needs the hospital in Alma so does the rest of the town.
[Van Driel] "My experience is that a town that doesn't have a source of healthcare at least isn't going to be able to maintain itself, you know, as a viable community. That certainly is one of the things we're concerned about here is the ability to provide health services to the residents."
And how much does it matter that the residents know the hospital will be there and run by people they know? It matters a lot.
[Janiece Imm, LPN] "We're pretty much family before they even come in here. We take care of people down the hall that I've known all my life because I'm from here. So that makes a big difference."
Kathy Hardesty moved to Alma from southern California two years ago.
[Kathy Hardesty] "You can see your doctor and he says you need a chest X-ray so you go get one and you take it back to him and hand it to him where in California, you would have to make an appointment and wait for two weeks to get the X-ray and then you would have to make an appointment to get back to your doctor. It was a real hassle."
Johnson County hospital's concerns are like Alma's.
[Donna Wilson] "Do you make house calls?"
[Dr. Keith Shuey] "Sure do. I still make house calls. Probably more during the winter than I do during the summer because it's tougher for some of my elderly people to get out during the winter so it's about as easy for me to go out and see them and take care of things during the winter."
Look closely, you probably don't see many like him and you probably won't see many more like him in the future. Dr. Keith Shuey has lived and worked in Johnson County, Nebraska for 31 years. You heard him right. He makes house calls. Today Dr. Shuey gives a cardiopulmonary in-service to Johnson County hospital nurses.
As a general practitioner most of Shuey's patients are over the age of 65. Like in Alma they're largely a Medicare population. They get only about 60% reimbursement here. The community is changing the way it treats its patients. Linda Branting is an administrator and a registered nurse.
[Linda Branting, Johnson County Health Dept.] "We have about 23% of our population 65 and over and most of the people that need home health visits are home bound, can't get out of their home for the visits so yes, most of our clientele is over 65."
Few country hospitals admit to being on slippery footing. In fact, some are so concerned about their ability to give medical care in the future, they didn't want to talk to us. Colleen Chapp knows first hand what these hospitals face. She's in direct contact with almost 30 of them. She says another issue is access to care. Country hospitals may not have as many resources as others do.
[Colleen Chapp, Heartland Healthcare Alliance] "Everyone has come together recognizing that in order for healthcare to survive and to provide access to very quality healthcare, people need to come together in a cooperative effort to make it happen. It can't just be one entity."
Chapp works with hospitals like Tecumseh where at in-services like this one, they concentrate on prevention rather than acute care on the back end. Dr. Shuey says a lot of the problems are costly but could be prevented, things like diabetes, heart disease, and some cancers. Shuey believes these are changing times and rural hospitals probably need to be more aware than anyone.
[Dr. Shuey] "I think that both my office and my practice and the hospital's general philosophy has been that to adapt to the changes and try to make them work. It's been painful sometimes for all of us to change, but there is nothing wrong with changing things if it's for the better. So I don't see any big problem there. I think in the future we're going to survive. But we will look different. We provide different services than we did 15, 20 years ago."
So what do they do?
[Roberts] "They're going to have to change and devise a new model of deliberative care, and I think that involves what we're seeing across the state is the networking of hospitals. I don't think any hospital is going to be able to stand alone in the future. They're going to have to have a network to be able to take care of the patients in their area, to be able to contract for managed care, to do other things."
Both Tecumseh and Alma are on the right track. They both participate with larger hospitals or unite with smaller hospitals to provide specialized care. For those 15 other hospitals who are in trouble, a limited service access bill has passed both the state and federal legislatures. They can now stay open as much as they need rather than the required 24 hour, 7-day a week schedule. They'll also get more money back from the federal government. About half a dozen Nebraska hospitals will participate in this program. Meanwhile, for the small hospitals doing pretty well but watching the dollar closely, they'll continue going with their guts and knowing who they treat.
[Dr. Jay] "If they come in and they're not well or they are severely ill, you can look at them and tell if there's something wrong."
At these small hospitals, high touch hasn't completely given way to high tech. Reporting for Statewide, I'm Donna Wilson.