By Mary Alice Murphy
At the regular monthly meeting of the Gila Regional Medical Center Board of Trustees on Friday, Jan. 27, 2017, board members first held a moment of silence for the loss of one of their caregivers.
"I would also like to thank our Chief Nursing Officer Peggy White for helping the grieving caregivers," Board Chairman Jeremiah Garcia said.
The members approved the Open Meetings Act, with no changes except for the year.
Garcia introduced the Interim Chief Executive Officer Alfredo Ontiveros. "Thank you for accepting this position."
"It's a pleasure to be here," Ontiveros said. "I've seen many that I remember from when I was here as the full regular CEO between 1995 and 1998. I've talked to many physicians about what we need. We are working on just moving forward."
Trustee Tony Trujillo, who is in charge of the selection process of choosing the interim and moving to picking a permanent CEO, said he was excited to have Ontiveros. "He hit the ground running."
Garcia also recognized District 4 Commissioner Billy Billings as being present at the meeting.
Three employees were recognized for their service to GRMC. Yvette Escudero has spent 25 years in financial services. Velia Fierro has spent 20 years in dietary. "I was hired when Ontiveros was CEO," Fierro said. "He came to us and met everyone personally as CEO." The third one, Donna Stewart, being recognized for her 20 years with EMS, was not present.
Frances Day, Auxiliary president, said she had refigured the number of hours auxilians have provided in service to GRMC since 1969, and they tallied more than 672,000 hours. "We have recently taken in 14 new ones over the past six to eight months. We work in five major areas. We have a volunteer at every entrance. We want to do more. Call on us and ask us to do things."
Ontiveros highlighted two items in his CEO report. He said GRMC continues on its journey to excellence. He noted the Leap Frog Group has awarded an A to Gila Regional for its patient safety. "I'm addressing the taskings the board has given me. We continue to improve."
Assistant Vice President of Administration Liana Ryan said she wanted to share the rural health clinic status. "We would be able to get a higher rate of reimbursement if the clinics were aligned with critical access."
She said she has been working in collaboration with Chief of Clinical Services Ray Goellner to increase the hours of some procedures. A problem is that the nuclear medicine camera is temporarily housed in a portable trailer.
Ryan said she is also working with all the senior directors on a lot of clinical initiatives that require collaboration.
Board member Dr. Tsering Sherpa asked for clarification on the health clinics. Ryan confirmed the reimbursement rate would be higher if they were critical access.
Board Member Dr. Victor Nwachuku asked if the status of critical access would be separate from the hospital status and Ryan said it would be.
Trujillo asked about medical marijuana and its availability locally.
Ryan said Ultra Health in the Albertson's plaza offers medical marijuana. "We want to make sure we provide education and bring them in to educate the community."
White highlighted that she asked Kelly Rodriguez to attach reports to her packet, including one from the Albuquerque Journal on the First Born program, which began in Grant County.
Garcia asked about the implementation of consolidating medical cases into one pod.
White said her department would be down to nine traveling nurses by the end of February as a result. "The team stepped up and has done well. We are still making adjustments."
"We started with 27 traveling nurses, got it down to about 11-14, where we got stuck," White said. "Now we're almost down to nine. It's taking longer to get them trained because our volume is up, which is good. When the implementation is complete and we have cut travelers, it will be a $1.5 million in savings to the hospital.
"We're adjusting and doing what was needed," Garcia said.
"We've had a lot of positive feedback," White said.
Chief Operations Officer Jed Rudd said the EKG equipment was one quality measure that the Centers for Medicare and Medicaid has identified needed to be improved. "Slowly over time, our efforts have brought us to within one item to being in the top 10 percent."
He said a recent article said many physicians were not aware of "what we've been doing since early summer, a merit-based incentive system. I think our physicians were aware of it."
Goellner said in the first six months, his department has received $1.025 million over budget, and has been $583,000 under budgeted expenses.
"I have asked my directors to let me know why we are over budget," Goellner said.
Sherpa asked about the difference in occupational therapy. Goellner said it was because of travelers. Sherpa said: "We get a lot of travelers. We need to keep an eye on the OT travelers."
Goellner said he hoped to get to zero. "We need to chat with the university on medical technician training.
Board Member Magdaleno Manzanares, who is also a Western New Mexico University vice president, said: "We will work on it."
Goellner said the rate of physical therapists who are travelers is even higher than the OTs.
Trustee Joel Schram asked if the positive variance was "real money," to which Goellner replied it was.
Chief Financial Officer Mike Metts noted that clinical services budgets are based on estimates, so it's not cash, but it is positive. It's a combination of inpatient services and other accounts.
Metts said: "Today, I will summarize the key points. We had a $52,000 operating margin for December, which was over a $1 million improvement over the prior month. A lot is attributed to a 22 percent increase in volume over our average starting in July, so seasonally our volume helps support the drive to better results."
He said the days of cash on hand at the end of December were 77. "The days of cash are based on accruals and payroll. Today's is 81, until we process the next payroll."
Manzanares said it looked like the clinics were not making sense financially.
Metts said, during a review in December, it was determined that three months earlier in the year the reports being generated by Athena, which manages the accounts receivable, provided information showing that incremental late charges were being put on top of other charges. "Year-to-date, the charge to contractual is a wash. We recognize the clinics are an initiative and we recognize they were running at a loss of $1.8 million in 2016. We are trying to right the ship."
Manzanares asked if everyone at the clinics is paid from the clinics' budgets or from somewhere else. "How do they collect? Where does it go? Are we looking at the clinics by themselves?"
Ryan said the expenses are complex. "We've been working with Mike and his team to make sure that what is being paid is coming out of the clinics and not the hospital. We've realized challenges in determining actual expenses. We are getting the numbers trued up. We are working to get discrepancies cleared up."
"The revenue streams are accurate," Ryan continued. "We hope to have an accurate report for by the next meeting, so you can see what we are capturing. The hospital-based system is different from the clinic-based system, which is more on a cash basis. We have more opportunities to enhance the revenues in our clinic settings."
Ontiveros said at the end of the month, "We try to take a snapshot and sometimes we have to go back and revamp."
"We are trying to be transparent by providing a supplemental report," Metts said.
Nwachuku said he sees it as looking at a clinic, for instance cardiology. "This is how many patients he sees in one month. How much do we pay him, and how much did he collect? It shouldn't be complex. Dr. Skee cannot survive if his practitioners are not making money. Everybody should be making money, because we have enough patients in town and not enough practitioners. A $1.6 million loss is a lot of money."
"Rest assured we're looking at it," Ontiveros said. "We will find out whether we're making money or not and will take appropriate actions. We have corrected quite a bit already."
Garcia said everyone needed to understand that the start-up operations had start-up expenses, and "now we have to dig in and complete the assessment. The service is needed and that's why we stepped in as the hospital."
Ryan asked for those who have more questions to meet with her.
Nwachuku said it has to change. "The clinics should at least break even."
Metts said it was necessary to differentiate between the initiatives that are hospital-based and those board-focused ones.
"One of the wins I would like to share with the board, which is of great importance, " Metts said, "is the restructuring from contractual to an employee model. The transition should be at the same time as the Meditech 6 live date. When implemented it will be about a $1.6 million reduction in costs. As of February, it will be a $640,000 reduction as part of the $1.6 million. We successfully have a candidate on site for our patient service director. We anticipate making an offer to that individual this week. We've had another candidate on site for the revenue integrity position and anticipate making an offer. We canceled the patient access and terminated that position as of February. We transitioned in house to a coordinator position. We have candidates for director of health information management to be on site. We are very proactively trying to decrease the amount of travel required."
Metts said the hospital last year anticipated making a $2.6 million payment to the safety net care pool. "We were able to postpone it with the understanding that we would pay $1.2 million this month. We are waiting to hear from the state on the safety net care pool and what the next steps will be. I hope we will have a higher allocation from the state than we anticipated because we provided more patient information and we will continue to make payments quarterly."
Schram asked about the safety net care pool and whether the reimbursements were being considered in the budget or had they already been factored into the profit/loss. Metts said it had been factored in, but might in the future become revenue again.
Garcia said the hospital tries to operate on the revenue it has, and the safety net care pool would be for extra things.
Nwachuku asked how many days of cash would be impacted by the payment and Metts said it would be a loss of about six days in cash. "We're trying to work to improve our days in cash."
Garcia said it was attainable without contractuals.
Metts said the $1.6 million includes the Jacobus consultants and the HIM (health information management) employees for the Meditech 6.
Garcia said as the hospital moves along, employees would replace such contractual positions.
Metts said what would help would come when employees can help as super users for Meditech 6.
"We can make improvements on the expense side," Ontiveros said.
On the topic of late charges, Metts said the hospital is attempting to capture the charges within 24 hours.
"We're not meeting the deadlines," Ontiveros said. "We have to get down to zero at soon as we can."
Sherpa noted that OT and PT were dominating the late charges. Metts said corrections had been made there.
Goellner said part of the problem came with having trouble with the software and most of those issues had been fixed, but the charges were of low impact.
"We have to focus on items that bring in the most revenue," Ontiveros said.
Metts said the software helps determine if a procedure is medically necessary. "If not and it is performed, the payment will get denied and the patient will be responsible for the payment."
Nwachuku asked if Metts was happy about when doctors drop the bills. "We do it within five days."
Metts said he was happier, but the bills are still not meeting the challenges.
Ontiveros noted the hospital is on track to go live June 1 with Meditech 6, but between now and then, "we have lots of opportunities to fix things."
Standing in for Chief of Staff Dr. Gregory Koury was Dr. Joyce Troxler.
Nwachuku said the Physicians Hospital Organization was looking for ways to work better with the Independent Physicians Association.
Troxler asked for approval of several items, including the medical staff bylaws changes. Several were listed and approved. The rules and regulations will be looked at further. "We ask for acceptance with the changes to be given to you later."
Sherpa said the majority of the Medical Executive Committee was happy with the changes to the bylaws.
Under board committee reports, Garcia said the Executive Committee met with Ontiveros and caught him up and created the agenda for this meeting. "Before we leave, we have to sign the affidavit of consent to serve and the conflict of interest disclosure."
Trujillo said the Quality Improvement Committee met in November, with him on the phone and Schram leading the meeting. "We provided some education and information on quality initiatives," Schram said.
On the organization quality assessment and performance improvement program, Rudd said the annual report was presented.
"The hospital and board have a fiduciary responsibility, as well as a quality responsibility," Ontiveros said.
Nwachuku said he would like to see a summary of what is happening with the quality assessment and improvement program and "what weG