Nurse practitioner Michelle Hall discusses a patient's health status. She and another nurse, Dallas Riley, opened a clinic in an effort to replace some of the health services lost when Berwick's hospital closed. (Sebastian Foltz/Post-Gazette)

Berwick Hospital owners unexpectedly shuttered four outpatient clinics in town. Then the 11-bed Berwick Hospital slid into bankruptcy. Two nurses stepped in.

The new medical clinic wasn’t scheduled to open for a few more days in this fading industrial town, but the answering machine was beeping that summer afternoon, blinking red with 59 calls, jammed.

Dallas Riley had returned to the clinic with Michelle Hall in July 2022 after signing the papers to create Hall & Riley Comprehensive Healthcare LLC. The two women were both advanced practice nurses who had worked treating patients, under a doctor’s direction, at a clinic owned by Berwick Hospital Center.

Nurse practitioners Michelle Hall, left, and Dallas Riley sit in an exam room in one of their healthcare offices. (Sebastian Foltz/Post-Gazette)

Earlier that month, Berwick Hospital owners had unexpectedly shuttered four outpatient clinics in town. Just like that, some 10,000 patients were left without primary health care.

Three months later, the 11-bed Berwick Hospital would slide into bankruptcy.

“I want to make an appointment,” voices spilled out of the answering machine. “I heard you’re opening up; can I still be a patient? How do I get my medical records? Hey, I need a refill.”

The women spent the afternoon making call backs.

That was the day that Ms. Riley decided to walk away from a job offer of $98,000 a year at a big hospital 25 miles away — to forfeit a regular paycheck, shoulder $75,000 in student debt and continue driving a Honda with 150,000 miles on it — so she could keep a promise to a small town where one out of five people live in poverty. Soon, Ms. Hall joined her, turning down an offer to work in a nearby urgent care center that is owned by a big health system.

A sign notifies visitors that the Berwick Hospital emergency room is closed. (Sebastian Foltz/Post-Gazette)

The plan had been for both of them to moonlight at second jobs until their new clinic got rolling. That wasn’t going to work.

“We saw a void,” said Ms. Riley, 40, who grew up in a nearby speck of a village where her mother and father run a gas station and car repair garage. “Taking care of the community was more important than me getting a paycheck. I’m not going to abandon them.”

Having now grown to a staff of seven employees, Hall & Riley Comprehensive Healthcare is trying to fill the need they see.

“I can’t leave these patients,” said Ms. Hall, 49, who had surgery at Berwick Hospital at age 3, the daughter of a truck driver father. “I cannot leave these people I told I wasn’t going to leave.”

Not sustainable

Berwick Hospital closed in 2022 and closed its outpatient clinics as well, leaving the town with no hospital. (Sebastian Foltz/Post-Gazette)

The closing of Berwick clinics and hospital has been part of a slow motion pileup around the country that’s leaving more small towns suddenly without medical care options. Some smaller hospitals are closing, while others are shrinking to survive — no longer serving as a one-stop health care provider. The numbers don’t work any more.

“Trying to support every kind of care at every place is not sustainable,” said Kate Musler, senior vice president, provider network and payment, at Pittsburgh-based Highmark Inc.

Bed counts have shrunk and services have been reduced at other small hospitals, including UPMC McKeesport and at Bradford Regional Medical Center in McKean County, redefining community medicine as big health systems absorb smaller ones with an eye for cutting costs.

Berwick is hardly alone; a new study found that more than 600 small, rural hospitals in the U.S. had serious money problems.

“People in rural areas are truly scared about access to health care,” state Rep. Marty Causer, a Republican from McKean County, said at a public hearing at the University of Pittsburgh at Bradford on Aug. 3. “We may go back to a situation where more beds are needed and there just aren’t any.”

Small town’s history

Berwick welcomes visitors with this sign. (Sebastian Foltz/Post-Gazette)

The 3-square-mile borough in rural Columbia County, four hours east of Pittsburgh, began to fade in 1961 when American Car and Foundry Corp., the region’s biggest employer for 100 years, announced its closing. The company made railroad dining cars, trollies and Good Humor ice cream trucks until World War II, when production shifted to battlefield tanks, artillery shells and other munitions.

Some 9,145 people worked at American Car’s sprawling plant during the peak war years; 2,800 jobs were lost when the company closed.

The steel car plant in Berwick circa 1906. (Wikimedia Commons)

A group of local workers and investors bought the plant and changed the company’s name, but the new operation was much smaller. Berwick’s glory days had passed.

Decades after the closing of American Car, Berwick Hospital employees rallied to save another community asset while exploring the idea of building a 10-bed replacement hospital. But cost estimates reached $30 million, far out of reach for a town of 10,300 people.

During the boom years, Berwick Hospital boasted more than 100 beds, a bustling 24-hour emergency room and intensive care unit; today it’s a 14-bed nursing home for psychiatric patients. General surgeon Mark C. Pyles said the hospital will not reopen.

A 10-year-old Berwick boy begs President John F. Kennedy in a 1961 letter to prevent American Car & Foundry from shutting down that year. (Berwick Enterprise, Dec. 18, 1961, p. 1)

Dr. Pyles, a 66-year-old Berwick native and former hospital medical staff chief, said he was the “captain of the ship as the ship was going down.”

He’s pragmatic about the town he grew up in.

Dr. Mark Pyles talks about the pros and cons of having nurse practitioners versus having physicians offering care. (Sebastian Foltz/Post-Gazette)

“We don’t have a five-star rating,” he said. The squat, tired looking hospital building is surrounded by three-bedroom brick ranchers from the 1960s. “We don’t have beach front real estate. The hospital — I don’t think it’ll ever fly again.”

Today, a nuclear power plant and a snack factory that makes potato chips and cheese doodles are among the biggest employers left in the region.

Helpful push

Bette Grey, 63, whose own free clinic was closed, helped Ms. Hall and Ms. Riley open their practice. (Sebastian Foltz/Post-Gazette)

Months before the closure last year, things had begun to wobble at the hospital; staff was being let go, employee health insurance benefits were trimmed and HVAC problems left some hospital rooms hot and others freezing.

The two women began looking for other jobs while thinking about opening their own clinic.

For a while, they considered operating a mobile clinic, a kind of Winnebago medical office bringing basic health care services to Berwick and surrounding villages that dot the north shore of the Susquehanna River valley.

Central to those discussions was Bette Grey, a feisty 63-year-old Berwick native who was raised upstairs of a laundromat to become the first in her family to graduate from college.

Ms. Grey, a private health care advocate, had founded a free clinic in 2005 in Berwick after her own experience dealing with a medical emergency without health insurance. Ms. Hall and Ms. Grey met at a health fair for veterans Ms. Grey organized at her church about six years ago.

The Hall & Riley Comprehensive Healthcare office opened in Shickshinny in 2022 with nurse Bette Grey's encouragement. (Sebastian Foltz/Post-Gazette)

Ms. Grey, who served 17 years on the Berwick Borough Council, said she essentially ignored advice that she summed up as “Be a good little girl and sit in the corner.”

And she was happy to support the efforts of others trying to bring medical care to the community.

“Not one person should have to die in this country because they lack the means to access health care,” Ms. Grey wrote in her self-published book about her free clinic experience, published in 2012. “Not one.”

The free clinic has since closed.

As operations at Berwick Hospital began to fray early last year, rumors about a closure flew. About that time, Ms. Grey asked the two women about their plans to open a clinic.

Her confidence in them helped.

“She told us more than once that if anyone could do this and do it well, it would be you two,” Ms. Riley remembered.

‘We had nobody’

The Berwick Theater on Front Street in downtown Berwick thanks locals for their support. The loss of Berwick's hospital means residents have to travel up to 30 miles for emergency care. (Sebastian Foltz/Post-Gazette)

When the closing came, it came fast.

“It was sudden: there was no doctors left,” said Bill Brosious, 59, whose diabetes and heart problems forced him to retire early from running a pizza shop. “There’s just no doctors to go to. You couldn’t get anything.”

One local patient, Bill Brosious, describes the impact the hospital's closing has had on Berwick. (Sebastian Foltz/Post-Gazette)

After the four clinics closed, about 13 doctors and other medical providers employed by the for-profit hospital moved away or retired. A year later, former patients still scramble to track down their medical records as the company that owns the hospital slowly grinds its way through Chapter 11 bankruptcy proceedings two states away.

The hospital closing added 12 miles and 20 minutes to the drive to the nearest emergency room in an area where ambulances are already stretched thin, Ms. Riley said. Medical tests that took a day when Berwick Hospital was open now can take months to schedule.

Retired factory worker Sharon Stout, 71, said the clinic in tiny Shickshinny, several miles outside Berwick and the second office opened by the two women, has been a lifesaver.

“When the hospital closed, we had nobody,” Ms. Stout said.

The maternity ward was already closed when Berwick Hospital Center shut its doors for good. (Sebastian Foltz/Post-Gazette)

Ms. Hall entered the exam room where Mr. Brosious was seated — an amiable, round shouldered man, railroad engineer’s cap pushed back on his head.

“The garden’s doing good?” Ms. Hall asked. He said it was.

“Why are you wheezing,” she said, sliding her stethoscope around his chest.

“Because I always wheeze.”

“Not in your upper lobes,” Ms. Hall said, concerned. His medication may need to be increased to treat the wheezing.

The primary care that the two women provide is just that: regular, first line medical visits to spot problems early, tweak prescriptions and encourage exercise and dietary changes that have been shown to make life better. The women say they treat the “whole person.”

Along the way, they have become part of their patients’ families, with invitations to weddings and funerals.

Ms. Riley once helped a patient with disabilities get a special permit that allowed him to hunt deer from his truck. When the patient asked how he would get a deer back to his truck, Ms. Riley gave him her cell number.

Nurse practitioner Dallas Riley talks about how having to drive farther during an emergency can mean the difference between life and death. (Sebastian Foltz/Post-Gazette)

Primary care providers refer those who need more complex care and sophisticated testing to a hospital, then follow up with the patients when the results are available — changing treatment plans as needed.

Without regular paychecks, the two women cashed in their 401(k)s to get them through the first year when each drew pay totaling only $4,000. Ms. Riley recently sold a rental property, which she said will help tide her through a while longer.

Just $6,000 remains from her IRA money, she said.

Riley & Hall contracts with some health insurers and has been working to accept other plans — in between everything else. The practice also recently bought a machine to treat skin problems as part of a strategy to get the clinic in the black.

No insurance will cover the dermatologic procedures, so treatments will only be on a cash basis. Nevertheless, Ms. Riley said they believe there will be a demand for the care, which will help subsidize care they provide to poor people, which is not fully covered by Medicaid reimbursement.

The clinic has about 3,100 patients — and growing, with a dozen new patients added during one week alone in August.

Community’s embrace

Berwick has a population of about 10,000. (Sebastian Foltz/Post-Gazette)

Berwick patients have other health care options besides Hall & Riley: Danville-based Geisinger Health System operates a primary care clinic and urgent care center in town; a couple of independent physician practices have formed in the past year.

But the women worry that medical care in the community would suffer if they weren’t there, given that the resources are already strained by the need.

“How do you put a dollar amount on a promise you made.” Ms. Hall said. “I’m going to choose taking care of those patients.”

Nurse practitioner Dallas Riley, left, discusses a patient with nurse Mary Marker. (Sebastian Foltz/Post-Gazette)

Nurse Mary Marker tests a patient's vitals at Hall & Riley Comprehensive Healthcare. (Sebastian Foltz/Post-Gazette)

The community’s response to Hall & Riley Comprehensive Healthcare told the women they’d made the right choice.

At an open house at their first office, which opened 12 days after the two women were locked out of the Berwick clinic, some 200 people lined up out of the building. The building owners waived rent for two months; a patient extended a no-interest loan for $12,000, which paid for vaccines for kids; people offered to answer phones; they brought notepads and pencils to the office.

Some patients drive an hour to the clinic. For others, the two women do home visits for patients ranging in age from 4 days to 99 years.

Nurse Michelle Hall says she couldn't leave her Berwick patients. (Sebastian Foltz/Post-Gazette)

Three months after opening, a private equity company offered to buy their fledgling medical practice; they turned it down. Ms. Hall worried her patients would be “treated like a number” if they sold to a for-profit outfit.

Corporate medicine had already failed Berwick.

“The community is suffering,” said Ms. Hall. “I want this community to be taken care of.”

Endangered hospitals

A sign advocating for saving Berwick hospital sits in a front yard in Berwick. (Sebastian Foltz/Post-Gazette)

Berwick Hospital had its own unique management issues, which likely fueled its downfall: In early May, for example, the state Department of Health cited the hospital after inspectors discovered that CEO Priyam Sharma had moved clothes, a refrigerator, food, dressers and other personal belongings into a one-time gift shop, where she stayed instead of a hotel room.

But a new study by Pittsburgh-based Center for Healthcare Quality & Payment Reform found that more than 600 rural hospitals in the U.S. are at risk of closing because of financial problems, including five in Pennsylvania that were at “immediate risk” of shutting down. The endangered hospitals were not named.

The big reason why closure looms for so many rural hospitals is simple: Health insurers pay them less than what it costs to deliver services to patients, according to the study, while labor and other costs escalate.

“Small rural hospitals are paid nothing for what residents of a rural community would likely view as one of the most important services of all — the availability of physicians, nurses and other staff to treat an injury or serious health problem quickly,” the study concluded.

The margin loss on providing patient care at UPMC Lock Haven Hospital in Clinton County, which closed all of its inpatient units in April to stem a tide of red ink, was 18.4% in 2022; the 23-bed Washington Health System Greene tallied a margin loss of 13.3%; and the loss at the 25-bed Titusville Area Hospital in Crawford County was 7.8%, according to the study.

Serving Shickshinny

Cars drive along Shickshinny's Main Street. (Sebastian Foltz/Post-Gazette)

Meanwhile, it’s Friday back at Riley & Hall’s clinic in Shickshinny, population 630, several miles outside of Berwick, where Ms. Riley got to work at 6 a.m., two hours before the office opened.

It’s slower than usual at the office this Friday, with Ms. Riley’s last patient of the day skipping an appointment — not unusual in an area without public transportation.

A nurse and receptionist begin emptying office waste baskets and straightening up. Ms. Riley mused about a community health fair the next day that she would staff with Ms. Hall. Outside, a sunny, late summer day beckoned.

“This whole thing has been bigger than me,” Ms. Riley said. “I’ve been given this gift. I want to use it. That’s just been who I am.”

Kris B. Mamula: kmamula@post-gazette.com