At least 15 rural hospitals have closed in the last year. Hundreds more are operating under sustained financial pressure from Medicaid cuts, reimbursement gaps and a workforce market that increasingly tilts toward larger systems. For the executives running small community hospitals, financial survival has become a daily discipline requiring thoughtful decision-making.

Justin Harris, became CEO of Daviess Community Hospital in Washington, Ind., in July 2025. The most consequential decision of his first year in the role was a partnership choice. The hospital had operated under a management agreement since 2017 and when Mr. Harris took the helm, Daviess Community entered a new arrangement with Evansville, Ind.-based Deaconess Health System — a regional operator whose model, is built explicitly around keeping care in the communities it serves rather than routing patients toward larger tertiary centers. Within roughly six months, the hospital shifted from losing millions of dollars each month to posting positive margins.

“That takes partnership, that takes commitment to the community, that takes involvement from the community,” Mr. Harris said. “And that is exactly what we’re doing at Daviess Community Hospital.”

The revenue cycle is ground no executive can afford to cede. Mr. Harris was direct about the personal role he believes leaders at every level must play.

“You are never too big to not be involved in the revenue cycle,” he said. “We need to be in our financials and revenue cycle, and we need to make decisions on a daily basis about how to lead the organization.”

He described recoupments, readmissions and pre-authorizations as executive responsibilities rather than back-office concerns.

“If we don’t make any money, it’s hard to provide good healthcare,” Mr. Harris said. “You don’t have the ability to bring services, you don’t have the ability to buy supplies, pay your staff.”

Eric Price, CFO of Schoolcraft Memorial Hospital in Manistique, Mich., arrived at the same conclusion. He watched successive waves of regulatory urgency — ICD-10, ACA implementation, the current rural transformation funding debates — generate intense pressure that generally resolves within months. For a 12-bed critical access hospital, chasing each one carries a cost in leadership bandwidth and organizational focus that small teams cannot easily absorb.

“The initial surge of information will usually resolve itself,” he said. “In six to eight months, things tend to settle down.”

That long view shapes how Schoolcraft evaluates any significant initiative. Mr. Price asks where a strategy will stand five or 10 years in the future and then collaborates with his team on the best path forward. The initiatives that can’t hold up under that question don’t command the organization’s attention.

“We’ve got to maintain that long-term strategy,” he said. “I’m hoping to come back here in five years and say, hey — we weathered that storm, and now we’re done with this new one.”

In practice, that also means staying anchored to patient care when financial pressures are pulling in multiple directions.

“The most decisive thing we’ve done is ensuring that among all the change we don’t lose sight of patient quality care,” said Mr. Price. “The fact that at the end of the day, especially in rural America, it’s our family members. It’s our mothers, our neighbors, people we grew up with and we’ll see them on the street and at the grocery store. We’ve got to stay focused on patient care and not lose sight of quality and access.”

He is equally clear that financial leadership demands physical presence in the building. A CFO who manages from a spreadsheet is ineffective.

“If you’re sitting at your desk, you’re not rounding on the med-surg unit, checking in on your OR team, having conversations with physicians, you may be a little behind the power curve already,” he said. “I need to know what’s going on so I can react effectively.”

JohnRich Levin, chief nursing officer at Reeves Regional Health in Pecos, Texas, relies on operational simplicity to weather storms. Reeves Regional is a critical access hospital in West Texas where the nearest major city is an hour and a half away. In that environment, complexity becomes a liability.

He described the limits of predictive analytics in a setting built on personal, direct knowledge of the patient population.

“You can’t be too complicated in a rural facility,” he said. “We have this AI technology, and we have all these things going on. And yet, we know that much of them don’t really apply until we actually desperately really need them. How do you apply predictive analytics when you know who your patients are and you actually know when they are not showing up and you wonder what’s going on with them? There’s nothing that could be replaced by human interaction.”

His emphasis is on workforce development, building the clinical versatility and leadership competency that a small team needs when backup is not nearby. The move from 20 years at a large Houston facility to rural West Texas reinforced a lesson Mr. Levin now applies at Reeves Regional: headcount and readiness are not the same thing.

“You’ve got to assess the kind of staff that you have and build them from there,” Mr. Levin said.

Across all three accounts, culture emerged as the variable that determines whether financial improvements hold. Operations and margins can shift relatively quickly under disciplined leadership. Whether those gains last is harder to influence.

“We can change our operations and financials, and sometimes pretty quickly,” Mr. Harris said. “But if your team is not on board, if your medical staff is not on board, then it’s hard to make that last and be sustainable.”

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