Recovering from pneumonia is an unusual experience in the 10-bed intensive care unit at the Carolinas HealthCare System hospital in rural Lincolnton, North Carolina. The small hospital has its regular staff in Lincolnton, but Richard Gilbert, one of the ICU patients, has an extra nurse who is 45 miles away.

That registered nurse, Cassie Gregor, sits in front of six computer screens in an office building. She wears a headset, and her voice is piped into Gilbert’s room via computer speakers.

A doorbell sounds before the camera turns on, alerting Gilbert that the nurse is looking in. They chit-chat as Gregor monitors Gilbert’s vital signs. The nurse asks how he’s feeling and if there’s anything he needs.

Carolinas HealthCare System monitors ICUs in 10 of its hospitals from this command center near Charlotte. The command center is staffed 24-7 with a rotating crew of seven to nine nurses and doctors who specialize in critical care. Everyone on the team also does bedside shifts.

Carolinas HealthCare started this project about two years ago and says it’s good for staff and patients.

For one thing, medical staff at the command center can maintain a constant focus on patients. The command center is quiet — none of the alarms are going off that most ICUs need to alert nurses and doctors down the hall that they’re needed. Dr. Scott Lindblom says it’s a nice change of pace.

The peace, he says, “makes it a much more pleasant environment actually to work in than what we’re used to — the usual chaos of the ICU.”

Nurse Kimberly Purtill agrees.

“We might see a trend up with their white blood cells,” Purtill says, or “a trend up with their temperature, and their blood pressure going down.” All those symptoms might be warning signs of an infection.

“If you were off yesterday as a bedside nurse, and you’re on today, you don’t have the picture from yesterday,” she continues.

But the command center staff has easy access to medical histories and other data on the computer screen, she says, so it’s easy to give the bedside staff a heads up.

Lindblom oversees critical care for Carolinas HealthCare System and says there are clear signs the virtual ICU is working.

“We’re taking care of more patients than we were two years ago,” he says, “and across the system, our mortality rate is dropping … and our length of stay is dropping. It’s almost the perfect storm of good care.”

Among the 10 hospitals in the program, ICU mortality is down 5 percent and length of stay is down 6 percent. Lindblom says virtual care doesn’t get all the credit. He notes the hospitals have also rolled out a program to better manage sepsis, which is a leading cause of death. But Lindblom says that virtual care helps with that program and nearly everything else in the ICU.

Leah Binder is president of The Leapfrog Group, a national advocate for better hospital care. She said the gold standard is to have critical care doctors on-site, not on-camera.

“However, that’s not always possible for every hospital and particularly in rural areas,” Binder says, “so second to that is a virtual environment.”

As technology leads to better care, she says, it could also lead to lower costs.

In the Midwest, Avera Health estimates its virtual ICU has resulted in $70 million worth of savings over the past 10 years. Deanna Larson, who oversees the project for Avera, says that from one hub in South Dakota, Avera monitors patients as far away as Minnesota and Wyoming.

“I think we quit calculating miles a while back,” she says, and laughs. “It’s a very vast area of land.”

Before virtual care, Larson says, complicated cases were often transferred to major medical centers. Now some of those patients can stay closer to home, and that’s good for them, their families, and the town’s economy.

“Keeping 10 or 12 patients more … means another nursing job that stays local,” Larson says, “maybe another lab tech job. What the technology is really doing is keeping those economics closer to home and helping them maintain viability.”

In other words, it may help the hospital in a small community stay open.

In Lincolnton, a town of about 11,000, Dr. Jessica Fox said her ICU has been much busier.

“The unit went from basically having a couple patients, and closing all the time because we were having to transfer so many patients, “to now being almost full all the time because we’re able to keep patients here, ” Fox says.

From his ICU bed, lifelong farmer Richard Gilbert says the more people looking after him, the better.

“That’s sort of like me and farming,” Gilbert says. “If I’ve got a five-man job, and I go out there with two people, [I] might miss something.” But if you have your whole crew working, he says, “you don’t miss anything. You get it done.”

This story is part of NPR’s reporting partnership with WFAE and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Requiring patients to get blood work and other tests before undergoing cataract surgery hasn’t been recommended for more than a dozen years. There’s good reason for that: The eye surgery generally takes less time than watching a rerun of “Marcus Welby, MD” — just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.

Yet more than half of Medicare patients received at least one pre-operative test in the month before undergoing surgery to remove cataracts in 2011, a recent study found.

Some doctors were much more likely than others to order a complete blood count, urinalysis, cardiac stress test and the like. Thirty-six percent of ophthalmologists ordered pre-operative tests for more than 75 percent of their patients, according to the study, which was published last month in the New England Journal of Medicine.

“Their patients were no sicker or older,” says Catherine Chen, an anesthesiologist at the University of California, San Francisco, and the lead author of the study. “It suggests that it’s habit or practice patterns.”

The study compared the prevalence and cost of pre-operative testing in the month before 440,857 Medicare beneficiaries had cataract surgery. Testing expenditures for Medicare patients during the 30 days prior to cataract surgery were 42 percent higher than the average monthly Medicare spending for testing on those patients during the previous 11 months, a difference of $4.8 million.

Cataract surgery used to take a few hours and require general anesthesia. In those days, preoperative testing made more sense, says Chen. Now people often receive only a topical anesthetic eye drop to numb the eye or sometimes a local anesthetic that may include a sedative for relaxation.

But research shows that today, pre-operative testing for cataract surgery doesn’t result in fewer adverse events or better surgical outcomes, regardless of a patient’s health, says Chen.

“It’s so low risk it’s almost like saying you’re going to get your nails done,” she says. “There’s always a chance you’ll get hit by a car or have a heart attack on the way,” but it’s unlikely to happen at the nail salon.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Congratulations to Eddie Johnson, the latest winner of the ongoing Nurse Photo Contest! Eddie writes: My name is Eddie Johnson. I’m 29 and an ER nurse in Ft. Lauderdale, Florida at Broward Health Medical Center. We have a very high paced, high acuity, short staffed, stressful job. It would be impossible to be successful or stay Continue Reading

In a leafy suburb of Cleveland, 108-year-old Lakewood Hospital is expected to close in the next two years. Mike Summers points to the fourth floor windows on the far left side of the historic brick building. He recalls spending three weeks in one of those rooms. It was Christmas 1965 and Summers had a broken hip.

“I remember hearing Christmas bells from the church across the street,” he says.

Summers was born at this hospital. His sister was born here. This hospital has a special place in his heart. But then he became mayor of Lakewood four years ago and realized the hospital was a financial liability for the small city, which has seen a sharp increase in poverty levels in the past two decades.

“I’ve grown to understand the situation we are in is not unique. There are considerable forces at play and we are in the middle of all of them and a lot of communities are just like us,” Summers says.

Lakewood Hospital is this community’s biggest employer, with 1,000 workers. It has been a rich source of municipal revenues even as manufacturing jobs left the region.

But the hospital, operated for the city by the large nonprofit Cleveland Clinic system, has lost money since 2005. Executives say they need to close it and replace it with a smaller outpatient health center and emergency room.

Residents who need to be admitted could go instead to another hospital that the Cleveland Clinic is building in nearby Avon, a more affluent suburb, says Dr. Toby Cosgrove, the chief executive officer of the Cleveland Clinic.

For generations, the hospital has been a source of pride for residents. Nearly everybody has a connection to it – they were born there, worked there, or spent time healing there when they were ill.

And hundreds turned out for a community meeting in January, heckling city leaders and hospital executives making a case for the closure.

“It is our intent to keep Lakewood Hospital fully functioning until Avon Hospital opens in September 2016,” Cosgrove said at the meeting.

Still, residents are pursuing legal action. The city has responded to the residents’ action, and Lakewood’s leaders say they’d like the community to focus on how to overcome the loss of the hospital, rather than a legal battle.

Lakewood is experiencing something that is increasingly common across the country.

The hospital, like others, has fewer patients and they aren’t staying as long – which can cut into revenues.

Who is using the hospital is also a factor, says Paul Ginsburg, chairman of medicine and public policy at the University of Southern California.

“Unfortunately as a society we’ve created some powerful incentives,” Ginsburg says. “Hospitals are paid much better to treat privately insured patients than anyone else. After that comes Medicare, and the least payment is for Medicaid patients and, of course, the uninsured. That’s virtually no payments.”

Lakewood has become a poster child for the challenges of inner-ring suburbs.

A Brookings Institution report in 2012 on the nation’s growing suburban poverty includes Lakewood. It notes that free and reduced price lunches for high school students shot up from 9 to 46 percent between 1999 to 2010.

Mayor Summers says that there is no question Lakewood Hospital’s percentage of privately insured patients has dropped in recent years.

“In 2000, we were about maybe four or five percent of residents were at the poverty level. Today, we’re pushing 16 percent,” he says. “It’s been fairly dramatic.”

This story is part of a reporting partnership with NPR, WCPN and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Florida Gov. Rick Scott’s high-stakes visit to Washington D.C. Wednesday to persuade the Obama administration to keep the federal government’s $2.2 billion in annual funding for hospital care of the poor produced no breakthrough.

“We had a good conversation … but we don’t have a resolution,” the Republican governor told reporters after an hour-long meeting with U.S. Health and Human Services Secretary Sylvia Burwell.

Burwell said in a statement that Florida’s request for the $2.2 billion in federal funding “falls short of the key principles HHS will use in considering proposals regarding uncompensated care pool programs, and the size of the proposed LIP [Low Income Pool] appears larger than what matches the principles.”

Burwell added the decision on whether to extend funding for what’s known as the Low Income Pool beyond the program’s June 30 expiration does not depend on the state’s decision to expand Medicaid.

A letter HHS sent the state last month appeared to tie the two together and spurred Scott to file suit against HHS, alleging it was trying to coerce the state to expand Medicaid. The governors of Texas and Kansas, which receive similar funding to help their hospitals, have said they support Florida’s lawsuit.

But after meeting with Scott, Burwell insisted that “whether a state receives federal funding for an uncompensated care pool is not dependent on whether it expands Medicaid, and that the decision to expand Medicaid, or not, is a state decision.”

That seemed to leave open the question of whether some funding might still be available for the program, albeit at a lower level, if a state does not expand.

Scott said he needs an immediate answer from HHS on how much money, if any, the administration might provide so he and the state Legislature can complete their budget deliberations. “We need our answer right now,” he said.

Burwell indicated he might have to wait a while longer.

“HHS heard the Governor’s request for a timely response to help the state meet its budget timeline,” her statement said. “HHS believes completion of the public comment period, on-going discussions with the state, and the state’s submission of its proposal to CMS are the next steps in the process.”

The 30-day comment period has about two weeks remaining.

Florida is one of 21 states that chose not to expand Medicaid under the Affordable Care Act. That left about 800,000 Floridians without coverage.  Burwell has said HHS prefers the state expand coverage rather than continue full federal funding of the low-income pool.

The bitter dispute over Medicaid expansion between Republicans who control the state House and those who control the Senate led the Florida Legislature to adjourn last week without passing a state budget for the fiscal year that begins July 1. Lawmakers are expected to return to Tallahassee in June to resume budget deliberations.

The state House has adamantly opposed expanding Medicaid, with House Speaker Steve Crisafulli last week calling it a “broken system with poor health outcomes, high inflation, inseverable federal strings, and no incentive for personal responsibility for those who are able to provide for themselves.”

But on Wednesday, Scott had good things to say about how well Medicaid was working in Florida. In the past two years, the state has turned over most of the Medicaid program’s operations to private Medicaid health plans. “We now have a program that works,” Scott said.  “We know what it’s going to cost us. We have insurance companies responsible for taking care of Medicaid recipients and we have Medicaid recipients who know who is responsible for their care…and we now have a budget surplus.”

Nonetheless, Scott said he doesn’t trust the federal government’s promise to fund Medicaid expansion under the health law and the state will be on the hook to pick up too much of the cost. The federal government is paying all the costs through 2016 and then nothing less than 90 percent of the costs.

A year ago, federal officials warned Florida leaders the low-income program would end this year but Scott included the money in his proposed state budget anyway.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.