By Mary Alice Murphy
Gila Regional Medical Center hosted a public meeting on March 7, 2018 at Southwest Bone and Joint Institute and heard from the many physicians and nurses in the meeting, as well as a few members of the public, who spoke about the position statement that the Board of Trustees had approved earlier that day.
The report on the earlier meeting approving the position statement can be read at http://www.grantcountybeat.com/news/news-articles/42791-gila-regional-medical-center-board-of-trustees-holds-special-meeting-030718
Although the original legal notice for the meeting had indicated an executive session to be held at the beginning of the meeting, the first action of the Board of Trustees was to delete that line item. Trustee Tony Trujillo made the motion and said the reason for calling the meeting was because: "You are the stakeholders and it is most important to hear from you."
Each board member introduced himself or herself. Chairman Jeremiah Garcia said the reason why the meeting was called was to hear from "you, the stakeholder."
"We, as the board, felt we needed to make a statement," Garcia said. "In our earlier special meeting and executive session, we discussed a lot of things about this statement, and when we came out into open session, we unanimously approved our position statement. We're all vested here. We want to envision where the hospital will be in six months, a year, five years and 10 years.
"It is so important to hear from you," he continued. "Some things in the past, we are still working on. You staff members are key. We can't be everything to everyone, but we're all concerned about our hospital."
He read the statement:
"GRMC TRUSTEES POSITION STATEMENT
"Gila Regional Medical Center (GRMC) is a county-owned regional hospital with a service area that includes Grant, Hidalgo, Luna, and Catron counties. It has always been and continues to be a county-owned hospital.
"The Grant County Commissioners are authorized to appoint the Board of Trustees for GRMC. The Board of Trustees is made up of Grant County residents who are committed to providing a community hospital under local control. This volunteer Board of Trustees has the full fiduciary authority to manage and operate the hospital.
"In June 2017, the Grant County Board of Commissioners hired a national firm, Juniper Advisory, to provide an in-depth analysis of ownership and management options for GRMC. The Commissioners state that no decision has been made regarding whether GRMC should remain locally-owned or whether an alternative relationship (partnership, merger or selling) would be better for the future of the hospital.
"The Commissioners, through the Juniper Advisory firm, have formed a task force to provide information on the analysis of the various options. The GRMC Board of Trustees does have representation on the County's task force.
"In May 2017, the Board of Trustees hired Taffy Arias as GRMC's permanent CEO. Following a nationwide search Ms. Arias was selected from 120 applicants after an intense, inclusive and transparent process that involved members of the community and caregivers from GRMC.
"In the short period since her arrival, Ms. Arias has recruited and retained a highly-qualified group of medical and administrative providers with extensive experience in and dedication to rural health care delivery. Under Ms. Arias' leadership, GRMC's finances are now in the black and all processes and procedures are under constant review to improve the hospital's finances. In April 2018, the GRMC Cancer Center will be fully operational and the nationwide search for a full-time oncologist is continuing. Cancer patient and family support groups are forming as a part of the Cancer Center patient services.
"In addition, the Hospital retained its Medicare Four Star Rating and was recognized by an independent organization that rates hospitals based on Medicare and Medicaid indicators as one of the Top 100 Rural Hospitals in the United States. GRMC is the only rural hospital in New Mexico to receive this recognition.
Ms. Arias is working on behalf of GRMC to increase partnerships with other health and safety organizations in Grant County, including Tu Casa, Hidalgo Medical Services, Grant County Emergency Response Services, and has begun the process to gain certification as a Level 4 Trauma Center.
"The GRMC Board of Trustees is committed to its full fiduciary responsibilities as recognized by New Mexico state statutes and is dedicated to supporting all the positive trends and enhancements that are occurring at the hospital. These include retaining providers and developing services that allow GRMC's patients to receive the highest quality of care close to their homes and families regardless of their ability to pay for services.
"Therefore, the full Board of Trustees is now recommending strongly that Gila Regional Medical Center continue to remain as an independent county-owned regional hospital in serving the healthcare needs of our communities.
"This position statement is in furtherance of our fiduciary duty owed to GRMC and the communities we serve.
"Signed this 7th day of March, 2018" by all board members."
Each then spoke.
Board Vice President Dr. Victor Nwachuku said: "We've gone through difficult times, mostly financial. This board has tried to find ways out of our financial difficulties. There is still more work to be done, but we want to keep the hospital local. We have the responsibility, we have a good corps of physicians, but we need to be financially stable. There is much to be done, but I'm convinced we should keep working and that we should remain independent. I'm convinced we should keep the hospital the way it is."
Board Secretary-Treasurer Mike Morones said: "When we were looking at our statement, it outlines our duties, but we don't talk about how and why we are appointed to oversee your hospital. It is our fiduciary responsibility to operate a locally owned hospital as it was when we were appointed. We are going into strategic planning and retreats. In the strategic plan we will take ownership, but it's the community's plan, your plan. We need to take seriously where you see us headed. At a minimum, you must be satisfied."
Trustee Dr. Tsering Sherpa said she has been at the hospital 10 years. "At first, I commuted, but I fell in love with the hospital, the medical staff and the staff. How impressed I was with how sophisticated this little hospital is. I came from a hospital that was sold to a huge hospital. It was a huge change. This was a breath of fresh air here. I understand that small rural hospitals are going through changes. We went through a big dip, and we're coming back up, but we have to pull together to succeed. Since Taffy came, we have come back from red to black and soon to green."
Trustee Jeannie Miller said she comes from a systems background. "I look at the hospital from the point of view of systems and people working on systems. Hospitals are organic beings. I'm impressed with Taffy and who she has hired. They have a background in rural health and are interested in maintaining rural health care. We are participating in the county advisory process. It will not be our decision. We want to remain local and we are dedicated to coming up with plans to remain so. I've loved every second of being on the board."
Trustee Joel Schram said he wanted to recount two personal stories. "My wife fell and broke her wrist in Las Cruces. She was treated and released. Within 48 hours, she had an appointment at Southwest Bone and Joint Institute. That wouldn't happen in a big city in a big hospital." He also cited a family member going to see the local cardiologist with an "episode." Within a couple of days, the member had a heart catheter in Albuquerque and "everything is fine. I am passionate about remaining a county-owned hospital."
Garcia said: "We are listening to what you envision. Our plant is 34 years old, but we have a high-quality maintenance team that keeps things running well, so we can take care of our patients. We are a zero-debt hospital. Days in cash fluctuate, but we expect them to grow. We need physicians and members of the clinical network to be on our board. You are the key stakeholders for us to be a high-quality hospital. What are the attainable goals we can achieve? Who knows medicine and patient care better than you?"
Dr. Donald Stinar was the first to speak
'The way I look at the medical community is that it is a tale of two cities," Stinar said. "One group of people can complain and go elsewhere, but the other group can't go elsewhere. A lot of people who do medicine here could make more money elsewhere, but they remain. I started at Silver Health Care, now I'm at Hidalgo Medical Services. We're here for the group who can't go elsewhere. The difference from what we have now and what we will get with a commercial hospital is that the big hospital will be looking to make money, and we will lose the groups, like HMS and Skee's group that take care of those who can't go elsewhere. We will lose a lot of the love from all the people in this room. Here it's easy for our medical people to get along, not like other places where everyone is fighting. We might get more subspecialists, who go only where the money is. I have chosen to remain here where the money, whatever happens. is OK. The commercial group will not put emphasis on those who cannot go elsewhere. I think you have to look at what will happen with a commercial group running the hospital. One portion of the community will benefit and the other one won't."
Dr. Mark Donnell said he wanted to talk about the past. "I've been at the hospital for 22 years, and the problem has been the totally incompetent billing department." He said he is aware that Arias realizes the problem and is addressing it. "I strongly encourage you to keep the focus there. You have to get the money in to spend on other things."
Dr. Ronald Dalton, GRMC chief medical officer, said that Dr. Gregory Koury, who was unable to attend had asked him to speak. He clarified that critical access is a funding process and does not impact care. "A critical access hospital can't have more than 25 acute patients at a time, which does not include being in the behavioral health unit, births or observations. If you get to 25, you are obligated to transfer them to another facility. Ninety-six hours is the average length of stay in a critical access hospital. The average here is 3.1 days. Critical care does not reduce the services you can provide. Of the patients we service 60 percent to 70 percent are on Medicare, which pays 40 percent of the money billed. Third party payers pay for critical care 101 percent. Our new chief financial officer (Richard Stokes) has already figured that $6 million to $7 million could be added to the bottom line with critical access."
Trujillo noted that critical access is only in discussion at this time by the Trustees. "We have made no decisions."
A woman in the audience said she read on the internet that 50 percent of critical access hospitals failed.
"That is not true anymore," Dalton said. "There is no downside to critical access designation."
Schram noted that Gila Regional already qualifies as a critical access hospital. "Our average daily population is 16 with an average stay of 96 hours or less."
Garcia said it is an option. "We are looking at opportunities."
Dr. Neely, who said he has been in the community since 1980, spoke. "We have a board from the community. We have a locally-owned hospital which has been a big plus. It pushes for mental health. EMS was a money loser; now it's in the black. The hospital has been supportive of needed services, even when they are money losers. If we had a corporate owner, those services would go away. That's really important to remember. For the economics of our hospital it is so important that everyone paying for health insurance not go out of town. Keep the care local for our economics and the services."
A man who works in the anesthesiology department asked if the hospital could change to critical access.
Dalton replied: "Yes, it can change. But it's an accounting process, and paperwork to make the change. It doesn't happen immediately."
"We're nowhere near that," Trujillo said. "If we get close, we will have presentations and get before you."
Dr. John Stanley said: "There is no downside to starting the process, with CMS (Centers for Medicare and Medicaid). Several CEOs I talked to have told me it takes about a year."
Garcia said recent history "tells us that the numbers going through the hospital fit the model, but it's your hospital. On that part, we will call you back in."
Dalton recommended getting the process going, and if it doesn't look like it will work, it can be stopped.
Donnell said he was recently in northern Michigan where all the hospitals were critical access. "They were making money. It can succeed."
Nwachuku said the board would be going into a retreat and strategic planning session on March 16. "We're already operating like a critical access hospital, but we're not getting the money. We will present our plan to the County Commission."
Dr. Derrick Nelson, HMS chief medical officer, said: "We at HMS are wanting the hospital to remain here. The hospital could do better. For instance, we sent $240,000 worth of lab tests to Tri-Core because Gila Regional will not integrate with us electronically. The hospital has to do a better job creating partnerships with other health care providers."
Dr. Fox said Gila Regional is one of the primary reasons for the high quality of life in the area. "What's so different about us is that we're remote, but we address needs. I'm totally against selling the hospital or going to a commercial operation. It needs to stay local. We must have EMS, obstetrics, basic surgery, basic services, and diagnostic services for outpatients. In my observation, in the past, we have not had support from primary services. There seemed to be more support for big-ticket items that the hospital could bill for and make money on. Why not negotiate for better rates for diagnostic services with other local providers? Deming is critical access, so are Truth or Consequences and maybe Socorro. Regardless, it is important for the board and the county to look at what the community wants in the way of health care services, instead of just looking at the bottom line, but rather to look at what is the hospital's long-term stability financially as well as for the care services needed for the community."
Dr. Okay Odocha asked if it was the structure of the hospital or, over time, the governance or the management causing issues. "We, as providers, have commitments to the hospital. Over the years, have the issues been with medical staff or management or governance? The management for the hospital is different from the physicians that provide the care. Dr. Nwachuku said you are going to have a retreat. Don't retreat; you should advance. Management is so critical in terms of governance in terms of what comes out-care of patients. We saw what happened with the Cancer Center. We are seeing the hospital bleeding $3 million every month. Who will be held accountable? Look at yourself in terms of making sure who is accountable and fix it, so it doesn't happen again. The concerns we have as providers, it is difficult to tell you it's a pleasant experience. We can't function if the governance and management are not doing what is expected. Hold people accountable in terms of governance."
Marsha Lopez said: "The providers are important. They are the ones who keep the community hospital going. A director told me there are two people you have to please-the patients and the providers. You take care of those and everything else will run smoothly. I don't see it anymore, where doctors have more input. Their ideas have been pushed aside in the past. I have to commend Taffy for addressing things, but Dr. Odocha has something to say. It was much better run when the physicians had more input."
Nwachuku said when he came on the board, the hospital was getting $10 million to $17 million a year from the state. When that went away was when things changed. "We decided to make the decision to change the administration when we felt the CEO wasn't able to take care of the hospital. Now we have to collect every penny. We still have issues with collections. We could have done better with the Cancer Center, but UNM will be able to provide the same kind of service. We have to demand it. We need to look at working together better. If all the physicians join the Independent Physicians Associations, it would help. We still have a lot of work to do."
A man asked what other models were being investigated.
Sherpa said: "Not that many."
Trujillo listed them-"critical access, remain as we are, create a hospital district or sell. Our focus is to look at critical access. It has given us more discussion to keep looking at it."
Dr. James Skee of Silver Health Care said 60 percent of rural hospitals are critical access. "It can be done either way. Whether you succeed or not will not depend on the designation, but rather getting operations running smoothly and accurately. When we talk about money, we have to talk about actual care for the people we are serving. I see patients all the time going without care because they can't afford elective surgery or their medications. We have to keep it affordable, not just for individual patients, but for the employers and government, for that matter. I have to do so much work and paperwork to care for my patients. Are the patients better off? I don't think so. It's why a lot of places are facing practitioners burning out and leaving. I have not heard why we are in the position we are in. How did we get to this point to considering critical access? Years, ago, the hospital was overfull. Are patients better cared for now than then. I don't think so. Were costs lower? No. If we don't look at how we got here, we will be less able to make decisions. Look back at how we got here and analyze it. Compare it to five or 10 years ago. In terms of a potential sale. I'm not prejudiced toward for-profit or not, although I worked at a for-profit, and it drove me crazy. I have heard the board is not in favor of selling the hospital. The county does not own the hospital. It drives me crazy every time I read that. The county only has authority to appoint the members of the Board of Trustees. The county has to be careful. It can't bail the hospital out when it goes in the red. In fact, the hospital used to and continues to provide and pay for services that the county needs to provide, such as ambulance service, and the behavioral health unit to keep people out of jail."
Skee went on to say that the Deming hospital is doing well, better than Silver City, which used to always do better. "A patient had a heart catheter and stent done there. It was done well. The heart hospital in Albuquerque was recently sold, and a treatment done there was not as good."
He noted that the county could call an election and the voters could invoke having a hospital district, with new rules, or it could replace the trustees one at a time.
Dr. Norman Ratliff III said he loves it in Silver City. "I have worked in a large health care facility. I believe it would be a drastic change for the worse if the hospital were sold to a for-profit, although it depends on which for-profit. Is that in the works?"
Trujillo said: "As far as we know, it isn't. If you have questions, you should go to the commissioners and ask them. They have a process for giving feedback and I encourage you to do that. I'm one who doesn't think it has happened. The commissioners assure us no decision has been made."
Dr. Michelle Diaz spoke next. "Here's the whole issue. I'm on the Juniper Advisory Committee with the county. I want to see our hospital be successful. Right now, there are issues in the environment of medicine. The reason why mergers or acquisitions are being considered is access to capital. Period. Which we don't have. I'm all for remaining independent. The reason for the evaluation was from past operations. We have to look at proposals. We cannot stand alone, if we are not in the black. The evaluation is also a means to clean up operations, which means collections and that is capital. We're already practicing as critical access; we're just not taking the money. We think of good ideas, but then we watch to see how it all plays out. We're a day late and a dollar short. We need to step forward and go ahead with the critical access application. If we don't like it, we can always say no, thank you. We should be going down different avenues simultaneously together. I'm competitive; I want to give better care than the outfit down the street. We gotta get our act together. Don't assume someone else will do it; we have to take responsibility to take care of each other. It is the responsibility of the providers, the administration, the hospital, the board of trustees, the county and the community. Our goal is to provide care. Whatever affiliation we may choose, we will lose control. I don't like to lose control. Just ask my husband. (to laughter). We have to be done with the blame game. We must move forward as a community, with dedication to our hospital as our No. 1 priority. If we collect, we will have capital. If we do critical access, we will have capital. Six months ago, I was against critical access, but I read up on it, and now I think why not get critical access capital. If we are going to be sustainable, we have to grow. With capital, we can keep our quality nurses. I don't want anyone telling me what services I can provide or to whom. I will not turn away a patient who can't pay."
She said there are proposals and people looking at the hospital. "It's not bad to have people to review our operations."
Dr. Brian Robinson said it was "hard to beat what Michelle said. What do we need in six months. If we go to critical access, we will get $6 million to $7 million. Why not go for it? It's the first time we've had this discussion. Deming is supporting its staff. We're part of the hospital as physicians, but we need the nurses and staff. If we sell out, the nurses will go where the money is. We don't get to make that decision. When will we start acting as a community? Why don't we act, take charge and create our own destiny?"
Neely said when he retired four years ago, the hospital had almost double the inpatient population. "One big change is we have hospitalists taking care of the medical inpatients. Every physician that sent patients to the hospital worked at the hospital. Since I've been retired, I don't know half the hospital staff. How can you integrate the community into the hospital? I don't see loyalty to our hospital."
An emergency room caretaker said he sees a lot of recidivism of those not getting care after they leave the hospital. "They are unable to contact their primary care doctor. We need to get the community doctors back into the hospital and have a better relationship with them."
Robinson said if he doesn't get a text, he doesn't know about the patient. "We avoid each other. If I don't have a cell phone number, I can't get hold of the doctor. If we don't help take care of our patients, someone else will."
The ER staff member said he can order something, "but I have to know what you want."
A man said he was for the hospital staying here and not being sold. "He said his father-in-law broke his hip. Then the Cancer Center brought me here. I'm lucky that I can take my father-in-law to Albuquerque, but many can't. We were told the Cancer Center would be a seamless transition, but we don't have a doctor here. I have two daughters who are doctors. Their in-laws want to stay here, not go to Albuquerque, but because of the decision of the board, we have to go to Albuquerque. The buck stops here with the board. I say to the physicians, you do good work. I say to the Board of Trustees, you do good work, but not enough."
Stanley said the commissioners tell me they have suitors interested in the hospital. "There's nothing wrong in listening. I want to stay independent. But up until Taffy, we were terrible. We were just junk bond status. We have a credibility problem. A lot of what has been said, we've said before. But we have to get the prices for lab work in line. How do we generate capital if the roof falls in or the air-conditioning goes out? We say it, but nothing happens. We have credibility issues. It takes money for people to get raises. Get the critical access paperwork going. Suitors will want to dump $20 million into the hospital, but we will lose autonomy. It's not wrong to get information. I would like to see the relationship between the board and the County Commission to be better. It's not just a PR campaign. We have to do it to improve the financial situation. How to generate capital? How to recruit specialists if we don't have capital?"
Donnell said he was also in favor of critical access. "I hear the federal government is talking about taking critical access away. We have to change contracts. We have to capture all imaging and labs."
Garcia asked if those in the room have other ideas to send them to the CEO's office. "We are all Grant County and we all care. I believe this is the time to have this type of dialogue. I challenge the physicians to keep having conversations. With the competitive practices and changes in health care, how do we make it better? This board has been working to turn the ship around. Now we're challenging ourselves. We want to hear more from you. I believe the commissioners have the same passion we have. We have to make sure we make decisions, We are not able to disclose why we've done certain things, but we depend on you to help us decide."
Skee said the board has made mistakes, but "it takes a learning of about three years to become a decent board member. The County Commission has done a revolving door on the trustees. Just leave them here for 10 years."
Fox said he agreed to getting the hospital on solid funding. "We have to look at long-term community health care. Physicians are aging across the country. We have more younger ones than most. Recruitment is important, as is the quality of life for the community and retention of staff. We have to address prevention and recognize social determinants. Look at the whole as a system."
Dr. Laura Davenport-Reed thanked the board. "It's time to have dialogue more often with the stakeholders. Sixteen years ago, we were debating selling the hospital, but we pulled together. This is a much more difficult circumstance. I task the Board of Trustees with continuing the dialogue. Several decisions of the board have met with a vote of no confidence. The way we found out about the Cancer Center was on Facebook. We still have issues with that process."
Trujillo thanked everyone. "We're all interested in the hospital. We hear you. Now it's up to us as trustees to do something about our position statement."
"When I joined the board, I heard the CFO take 20 minutes to explain a simple process," Schram said. "I knew we had a problem. We set in motion to turn things around. We're headed in the right direction. With your help, we can do it."
Morones said that with almost everything "you have talked about and considered, in my mind, I've been re-prioritizing things we need to move up in importance. The message I'm getting is to go forward with critical access. My question is what are the other options in lieu of critical access? We have other options in how we bill, how we expand, what services will be pursued, whether we're critical access or not. We need to operate more efficiently."
"My most important job is to represent the physicians," Nwachuku said. "I haven't done as well as I should have. I'm becoming more sensitive to that. I will be more responsive to you. It's most important to make the hospital financially stable. We have to revisit some issues. Come to me and say: 'This is my feeling.'"
The meeting lasted a little more than two hours.