They ratified CEO contract and discussed future options and challenges for Gila Regional

[Editor's Note: This is part 2 and the final article on the Gila Regional Medical Center Board of Trustees meeting held 012618. This article primarily addresses the regular monthly agenda items.]

By Mary Alice Murphy

After a short executive session prior to addressing the main topic of the day-ratification of the CEO contract-at least according to all those who filled the room, the Gila Regional Medical Center Board of Trustees asked for more public comments before making a decision.

Linda Nichols, Silver City resident and cancer survivor, said: "It's not so much the contract, but the manner in which it was done."

Board Chairman Jeremiah Garcia called for the vote on ratifying a five-year contract, retroactive to the date when Chief Executive Officer Taffy Arias came to work in June 2017.

Trustees Mike Morones, Jeannie Miller, Tony Trujillo, Joel Schram and Garcia voted to approve the contract. Trustee Dr. Victor Nwachuku opposed ratification. Dr. Tsering Sherpa was unable to attend.

"We are in support of you," Garcia said to Arias. "We think the public is, too. We welcome you for five years, and if you want to extend it to seven or 10, we will consider it. You haven't stopped doing what you're supposed to be doing. We didn't handle the previous ratification in November well."

Arias said she would "pass" on the seven to 10 years.

  "Physicians who do not want to go back to a for-profit hospital will leave." 

In reports and updates, Frances Day gave the Auxiliary report "I'm happy to hear the Foundation will be back and close by. As of our first half a year, we have given 11 scholarships for $21,000. We have provided $9,000 for hospital equipment. We have five new applicants to become members. We have a fundraiser coming up on Feb. 15. With the different departments wearing different color scrubs, we are incorporating the new colors into this scrub sale."

"We all care about this hospital," Day said. "The more open we are, the better."

Garcia said he appreciated how Arias and staff have worked to bridge the gap with the Foundation and bring it back to the hospital.

Arias gave her CEO report. "In surgical services, Dr. [David] Friedman is leaving and moving to Tennessee in February. He's getting married. Dr. Tariq Ibrahim will be taking his patients. We also have a young female surgeon who is interested in coming here. They are the future of our community. We will have an onsite interview with an ENT (ear, nose and throat specialist) from California, who is interested in coming here. We will work with him to get his New Mexico license and to get credentialed in the hospital."

She noted that the UNM Comprehensive Cancer Center, who provides the physicians to the Gila Regional Cancer Center, has sent Dr. Tawnower for six additional dates, in addition to her once weekly visits this month and next.

Kelly Rodriguez, Gila Regional Cancer Center director, said because Dr. Tawnower's specialty is breast cancer, they got all the breast cancer patients in with her.

Arias said specialists will be arriving at the hospital to calibrate the linear accelerator for radiation treatments. "The Gila Family Clinic has interviewed an additional physician. He got a tour of the mines. He does occupational medicine and will let us know in March, because he is dealing with family issues right now."

"We held an awards banquet for caregivers in December," Arias said. "Barbara Barela got an award for her 45 years of service here, as well as others for their extended years of service at Gila Regional. It was well attended and successful. I appreciate the staff that put it together. We also held our annual Light Up a Life, a beautiful and touching ceremony. The mayor [Ken Ladner] spoke and told the touching story about his family history. You never know the struggles people have been through."

She said in December, Dr. Sherpa had to leave for an extended time with family. "We had gaps in coverage for her as a hospitalist, but two physicians, Dr. [Colicia] Meyerowitz and Dr. [James] Skee stepped in and did a great job. What came out of it was a meeting with the hospitalist company to go over issues. They have the obligation to have a 30-day schedule out to us ahead of time. They have hired another physician."

Miller asked about Dr. Tariq Ibrahim working on Level 4 trauma.

"We will apply for Level 4 Trauma certification," Arias confirmed. "It helps in terms of revenue and with reimbursement. With the certification, we will not have to fly out as many patients. Not every patient can stay, of course, because we have no neurologists here."

Nwachuku noted that once an ICU (intensive care unit) is ready for Level 4 Trauma care, "we will need to get more than one physician. One can't be on call all the time."

Arias said: "Any time, we are bringing in a physician, there needs to be a consensus of need. Physicians need to take a part in this. We have to make sure we have enough patients to pay for the service. We need the certifications long before we get another physician in. We have to also have nurses trained in Level 4 Trauma. It's part of the emergency room. It's a level, where we have to say we have the right equipment, the right physicians and the right staff."

Trujillo commented about Arias and Chief Financial Officer JoBeth Vance attending Grant County Day on Jan. 24 at the legislative session going on in Santa Fe. "They were rookie Prospectors, but they did well."

"We will be better prepared next year," Arias promised. "I was extremely impressed with the quality of Grant County people who participated. I was proud of (Sen.) Howie (Morales). He received several commendations on childcare and on getting the Nursing Compact pushed through quickly. I was honored to be amongst everyone."

Trustee Schram asked about the Mosaic software package for the Cancer Center.

"UNM has been working with our IT folks," Arias said. "We will own the equipment and the software, so the patient records will remain with us."

Chief Nursing Officer Peggy White said most of last year's projects had been wrapped up in the nursing directors' meeting. "They will impact our HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. We are in a two-year process of policy writing and training. We are trying to get an agreement with a UNM physician to read pediatric echocardiograms, so we can keep child patients here."

"Many physicians are coming here because we are a not-for-profit hospital."

Miller asked what "labor productivity" does, and whether case management was for only inpatients.

"Labor productivity is how to handle scheduling with the API (application programming interface) upgrade," White said. "Case management also includes discharge planning. We help with contacts for those who need home health care or therapy for a safe discharge. We spent a whole year streamlining the department. We are moving into management outside the hospital to help people make the connections outside the hospital. We help with transition of care and community coordination of insurance. Case management makes sure patients get the medications they need after discharge. It's a growing field. You will be seeing transition of care reports in 2018. We're excited to have a Match director coming on Feb. 7. He comes from Tucson and is getting involved here. It was approved by physicians and staff."

Trujillo said the only issue on the nursing compact is that most legislators don't get anything done until the last week. "Now we have proven that we can get something done in the first week of the session. Senator Morales was our champion."

"We were grateful it passed," White said. "It opens a big door for travelers and new nurses to come here."

Trujillo also talked about the closing of the Taos hospital.

White said Gila Regional is marketing for nurses from hospitals closing in Taos, Phoenix, Ariz., and Dayton, Ohio.

Trujillo said Taos only had five days of cash left. Nwachuku said the hospital got Critical Care Access certification too late.

Vance gave the CFO report. She said admissions at 172 were a bit lower than last year's December report. Patients were 522 compared to 600 last year. "That is not surprising, as more patient care is moving to outpatient rather than inpatient." The year total of 3,708 isn't far off last year's number. "We had 1,324 ER visits, which is down from 1,394 last year. We have no explanation for that. There is nothing we can do to get ER visits. Total surgeries were 406 as compared to 296 last December. We had 176 cancer visits. How grateful we are for Dr. Tawnower. We had 31 births and the clinic numbers have increased. We received $16.4 million, which is higher than last year's $15.6 million. We had net $5.8 million as compared to $5.7 million last year. We paid $375,000 for contract labor, but two expensive ones left on Dec. 31. We added a Mosaic person. The sooner we get it running, the better off we are. Our expenses were $5.3 million as compared to $6.4 last year."

"And the really good news, is we were $138,000 to the positive as compared to last year's negative $832,000" Vance said. "We are at negative $4.4 million for the year, as compared to negative $5.9 last year. It's this team that has rallied together, cutting expenses. We had $4 million in cash collections, which is a bit lower. We're still working on Meditech and AR (accounts receivable). There are still processes we're cleaning up. We are focused on getting a clean bill out the door to get money in. We have dropped to 41 days of cash, but we will replenish it. We are catching things up. Days in net AR have increased. It builds up if revenue goes down. We see a patient today and get paid three months from now. Our daily expenses are $182,706 as compared to $202,000 last year. We have a daily average population of 16.1 with a 3.3 days average stay. The CMI (case mix index) is 1.38 with behavioral health cases and 1.34 for all without behavioral health cases."

Miller asked if the days in cash are just the hospital or include the clinics. Vance said they include everybody.

Morones said he was interested in seeing cash collections, and what piece is 30 days, 60 days and 90 days until payment. "I would love to see a graph of that. We talked about it on Wednesday [at the Finance Committee meeting]. We have dual programs on calculating. Will we start focusing on one of the software or calculators?"

"I agree," Vance said. "I would rather have no information that wrong information. We're trying to determine which is the right number and where do the numbers come from. We should not see FTE [full-time equivalents] numbers change that much. We're digging down to where it comes from. We will continue to report information, but we don't always have the right number and where it's coming from. Yes, we're looking at that."

Schram asked about EBITA (earnings before interest, taxes and amortization). "If this is a true trend, we are $1.95 million ahead of last year."

Vance agreed and said doing the EBITA comes from her for-profit background.

Schram noted bad debt was up.

"We are working on the 180-day debt to get focused," Vance said. "Then we can clean up the old accounts."

Arias said it was an unfortunate reality that people think they don't have to pay hospital bills. "They think because it is county-owned and a not-for-profit, they don't have to pay. Yes, you do owe us. We have discovered in many cases that they were written off before really trying to be collected. Including up-front payments."

Schram said the clinics are not making money and asked if the ancillary services help.

"Yes," Vance said, "but Blue Cross Blue Shield is paying less than Medicare rates. We will look at that. Physicians are working hard and we're working on an agreement."

Miller asked how "we decide when clinics are profitable?"

"There should be monthly meetings, so the providers can see what one is being paid for the procedure," Arias said. "Some physicians don't understand the coding. We must have the Family Practice to feed into referrals. The assumption is that the patient will get the X-ray at the hospital. We need to ask: 'What is it that we can help you with that has never been addressed before?'"

Vance said the practice has overhead and contractual. "This clinic shows your net. The physicians want to have this information. The contractual item is the difference between the bill and what the insurance pays."

Nwachuku said case collections are going on. "With a new person to collect, I hoped the number would go up."

"It's how our system is working," Vance said. "As the process gets better and Meditech is working, we will get the money in." To another question, she said Jacobus Consulting is gone and was replaced with a full-time person.

Trujillo said a state issue is getting payments from Molina. "Molina gets a clean bill and denies it," Vance said.

Trujillo said it's a challenge with private payers.

Chief of Staff Dr. Gregory Koury highlighted that the Medical Executive Committee members have taken upon themselves to get more involved. "The commissioners said they will approach the doctors one-by-one. One thing that is of importance is learning more about critical care access."

Koury said it requires a lot of paperwork. "I encourage getting going on the paperwork in case that becomes an option. We may not do it, but it is important to have the paperwork done and be prepared."

Garcia said: "We are Gila Regional are focused on options. We can't depend on the timeline of the commissioners. We're been talking about critical care access for our strategic plan."

"I caution us, when we talk about critical care access to remember what happened last time," Trujillo said. "We have to do the communication. We have to educate people on what it's about. Explain it to them and then maybe do it."

Koury said: "We are doing the paperwork to be prepared, in case."

Morones said materially, it makes sense to him, but "clinically I would have to defer to physicians. I appreciate what you are looking at. Get our ducks in a row, being clear that we're learning and soliciting clinical input-input that may educate us. We need to focus on cleaning up today but be prepared for the future. I'm in favor of researching it publicly. Physicians are educating themselves, why not us?"

"Physicians who do not want to go back to a for-profit hospital will leave," Koury said. "Many physicians are coming here because we are a not-for-profit hospital."

Nwachuku said, basically, Gila Regional is operating now as a critical access hospital, "but we aren't getting the money that comes with the critical access designation."

Koury said inpatients are the only ones that count in that number.

"We are working as critical access, but without the money or paperwork," Morones clarified.

Trujillo cautioned: "Make sure we have a discussion with the commissioners, so they know about this.

"Strategically, we have to have a plan in place," Garcia said.

Koury said he had a discussion with Commission Chairman Gerald W. "Billy" Billings. "Your UR (utilization committee) is dealing with it every day, looking at utilization."

"I ask that Nursing get involved," White said. "Nursing will be a part of it."

In board committee reports, Garcia said the Executive Committee approved the agenda. "Today, each of us also has to sign an affidavit of consent to serve and a conflict of interest disclosure form and we need to sign the Open Meetings Act resolution."

The Finance Committee got into a discussion at the separate meeting on Wednesday on drilling down to the details. "We 're talking about the inconsistent ones," Morones said.

Dr. Norman Ratliff has agreed to be staff secretary to replace Dr. Friedman, who is leaving. Dr. Tariq Ibrahim will serve on the Ongoing Professional Practice Evaluation Committee. Dr. Virginia Hernandez will serve on the Bylaws Committee. An amendment to the physician agreement for Dr. Brian Etheridge changes the payee name from Gila Regional to Hidalgo Medical Services.

"Our medical staff is second to none and so dedicated and involved," Arias said in reference to those contracts being reviewed and approved.

A resolution for state funding was approved. Vance said while she was in Santa Fe, she learned the New Mexico Finance Authority made it possible for the hospital to borrow money, "if we need to. Our requests will go before the Legislature. If we don't get legislative funding, we can get financing from NMFA."

Trujillo explained that it goes back to when Gila Regional first built its Cancer Center. "There are two hospitals, of which we are one, that can get funding. It was an opportunity to visit with the NMFA, but legislation needs to be introduced to get the funding. About $500,000 is just sitting there. The payback interest is minimal. This resolution is needed before the Legislature approves it."

Morones explained that when an entity is dealing with NMFA or any other state agency, a resolution "must be written showing our intent to make good on this action. But you still have to ask for it."

Trujillo said it comes from the Tobacco Permanent Fund.

Schram gave the Plant and Facility report. "We have had fewer stand-by hours in security. We had an update on private rooms and reviewed the active shooter report, which was based on the recent exercise."

"We have just gotten quotes on materials and labor for the private rooms," Arias said.

White said they are hoping for February or March at the latest to have some private rooms ready.

For the Human Resources Committee, Trujillo said they looked at overtime, which was up, and contracts, which were down.

Arias said the hospital had an influx of patients and many staff members were also ill with the flu, so it required overtime.

The trustees, after a short break, went into executive session.