[Editor's Note: This is part one of the combination work and regular sessions on Nov. 13, 2018. It covers the GRMC monthly report.]

By Mary Alice Murphy

The Grant County Commission combined work session and regular meeting on Nov. 13, 2018, began with the monthly report from Gila Regional Medical Center.

GRMC Board of Trustees Chairman Mike Morones said he appreciated the opportunity to speak to the commissioners.

"I am here to start off the conversations and make sure we add the Board of Trustees flavor and context to the report," Morones said. "Over the past few years, it was the culture to present the legal minimum to the public. We are now working on better communication. Even the Board of Trustees wasn't getting enough information.

"In order to do our business and for the community to know what's going on, we're trying to keep you informed," he continued. "We continue the philosophical conversation. We believe it is our responsibility to report what we can. We might be evolving this presentation. In the future, we will help present the audit report once it is approved by the state. One of our issues about a year ago was to decide who to send up here. Presenting what we know is always about 1 ½ months late, because the financial report, for instance, dates from the end of the month before the month just prior to this meeting in the middle of the month. There are times when the bulk of the information we can give is only from that report. With the forward-looking stuff, you, the public and the press, are getting information before the Board of Trustees gets it. That's why we want to have the Board members present here to hear the information, also."

Morones introduced the newest member of the Board of Trustees, Ed Wilmot, who was present.

"This past year has been challenging," Morones said. "We've worked toward meeting the needs of the public, but what we need is a financially stable organization. There has been pressure on the staff to meet the needs in a quick manner. The trustees have placed a huge burden on the staff to make the organization financially stable."

Chief Executive Officer Taffy Arias said she would report on the past month. "One of the happiest moments at the hospital occurred yesterday when we received a visit from Manitoba Premier Brian Pallister and his wife. Last year, he was a patient at the hospital. He had a misstep hiking in the Gila National Forest and fell quite a distance. A rescue involved many people in the community, including law enforcement, a surgeon and our staff. I talked with him about health care and he said the timeliness for the care he received here would not have happened in Canada."

She said recruitment has been active lately. "We have a new podiatrist, Dr. Iwaasa, who is already seeing patients. As his further credentialing is completed, he will begin surgery. I plan a mini-state-of-the-hospital talk for the Chamber in December. Then we will hold a larger state of the hospital in February, as we did last year. We will do a survey, a multi-faceted survey with everyone in the hospital. We will use the information to put together action plans to improve the satisfaction of the physicians and staff members."

Arias said she received a call from CMS (Centers for Medicare and Medicaid) about the hospital using its ambulances to transfer patients from the emergency room to nursing homes or to their homes. "We would bill for returning them to their place of residence. CMS questioned what is billable and said many transfers do not qualify. CMS has put us on alert to stop the unnecessary transfers. We are meeting with nursing homes and extended services. These patients must be discharged when their care is finished. But we don't feel comfortable putting them in the lobby or in the ER waiting room. Many have no way to get back home. This is causing problems that we wanted you to understand."

Commissioner Alicia Edwards asked how many are being affected. Arias replied that it runs into the hundreds a month. "Extended care facilities do not transfer people after hours or there are family members who do not respond to pick up the person."

Edwards said she would have more questions.

"As do we," Arias replied. "There are many criteria on whether it is billable or not, such as whether they are able to ambulate or not. It's a catch-22 and will cause a burden on us and the patients."

Edwards noted that many rural hospitals will have the same problems.

Arias agreed and said that the hospital gets all the transfers, as it has the only ambulances in the community. "Other communities, especially larger ones, have private ambulance services, such as AMR."

Edwards said: "But even if we had AMR, they couldn't bill."

Arias confirmed that was correct. "When we got the call, we had to scramble to take care of patients. The immediate burden is the transportation piece. But it puts a burden on the entire system."

"Have you come up with any wild ideas?" Edwards asked.

"As we are talking to the entities, we are discussing how we could bill the entity directly," Arias said. "It would be a cost to the entity. It's one plausible option. We are strategizing, because it is an immediate problem."

Edwards said she saw it as a huge issue, not only for the hospital but also for the community.

Arias said she would send the required criteria for billing CMS to the commissioners.

She also showed off the GRMC new logo, which better represents the area.

Commissioner Harry Browne complimented Marketing Director Doug Oakes for the art work. "I'm also thinking about the transportation issue. Could it be a role for Corre Caminos?"

"There is a liability that comes with these patients," Arias said.

Edwards said she could see an issue with the patients being able to even get into public transportation. She asked when most of the problems occur.

"Most are after hours," Arias said.

Edwards clarified by sounding out the problem. "If the ER visit doesn't require their being admitted to the hospital, there is a billing constraint required by CMS. Once, say, they are there for four hours, if they don't have a ride to get home, there is the problem. Any cost from the end of CMS billable time is incurred by the hospital without the capacity to bill any organization."

Arias confirmed it. "We keep peeling away the layers, we keep crying and peeling away the layers. We knew we were billing and not getting paid, but no one brought the reason why to us."

GRMC Chief Financial Officer Richard Stokes said he was late to the meeting because he was on the phone with CMS. "It's a national issue and has been on the radar of the OIG (Office of the Inspector General). CMS, unless we meet their arbitrary criteria, will not pay us. Urban or rural, the hospitals have to deal with the patient after discharge. We have to work through how to get them from the hospital to where they need to go. It could have been the OIG or the FBI calling us. We're glad it was the CMS, but it is a very serious issue."

Edwards said she, as the former director of The Volunteer Center, recalls that it was also a volunteer issue if volunteers offered to take someone somewhere.

"I'm not sure of the Good Samaritan laws in New Mexico," Stokes said.

Edwards asked, if the state has a Good Samaritan law, would it cover the issue.

"We should look into it," Stokes said.

He then launched into his financial report. "I told you last month that in the forecast for September, the financial situation was not looking good. We had a $540,000 loss, with year-to-date a $877,000 loss. That's bad, but if we compare it to last year at the same time, we had a $4 million loss. Improvements are being made, but I'm not satisfied. In September we burned through $130,000 in cash, but our EBIDA (earnings before interest, debt and amortization) is $327,000 positive year-to-date. Unbilled remains fairly steady. We have a known issue within Meditech that keeps unbilled high. We are at 29 percent cash collection and cash to net revenue is at 93 percent."

Stokes said Quadax, a clearinghouse software, has gone live. "Our drug charging went live on Nov. 5, with 1 percent unanticipated issues. I don't think any bill got out of house incorrectly. As we manage the finances, we have weekly calls with HRG (consultants). We had a pointed discussion on how we are interacting and managing the relationship. We are re-evaluating and making corrections. HRG has been receptive to how we need to work with them. We are working on the DRG (drug-related group managed care) transfer project for when the hospital discharges a patient to a skilled nursing facility or to home health. This project will look at whether they went where we discharged them to. We anticipate collecting a net $80,000 on this. With Cardinal Pharmacy, we are evaluating the relationship and whether what we intended is getting done."

The cash collection at the hospital was $4.2 million for September. He said the case mix was 1.37, with patients being a little less ill than the previous month.

In the look ahead, Stokes said he anticipates October would be better than September. He showed a graph of gross revenue by month. "I intend to continue this graph to help you understand the trends. The audit was presented to the board in executive session and submitted to the state in draft form. We will report when it is in final form. In draft form, we ended the fiscal year with $516,000 profit. Part of the audit includes the 1115 waiver. The waiver and our fiscal year are different, so we hired a guy to review it."

"We are confident that our numbers are good," Stokes said. "I'm a CPA, so I want to be conservative. These are accurate numbers, but they are not cash yet."

He said he was about to submit the 2019 projected numbers. "It's always an anticipated number. There are challenges for rural hospitals to have access to highly skilled talent. When we get ready to settle this year, we will re-evaluate our data and submit it to you."

Stokes said the hospital is doing a bed availability study. "We are trying to maximize what we have. We were in the small hospital category. We try to get into the smallest category to protect the safety net care pool funding."

Commission Chairman Billy Billings asked about whether the hospital is still pursuing critical access status.

"We are not moving ahead with that until we stabilize our financial status," Stokes said, "which will probably be next summer. We are requesting a Rural Health Care designation for our primary care. If we have under 50 beds, we can get the RHC designation, which for those subject to the Medicaid cap pays $78 per visit, but it can go up to $120 per visit. We will have to build indirect costs into RHC, so we can get the appropriate cost structure."

Edwards said: "Once you figure out the rural health care piece, do I remember your once saying, that when you get it into place, critical access may not make sense. And that finances may perform better by PPS (prospective payment system), rather than the cost-based system?"

"I don't know at this point," Stokes said. "If the hospital stayed the same, hands down, critical access made sense. Within the financial revenue cycle of the hospital, it has not remained the same. We could potentially do better on the PPS system rather than the cost-based system under critical access. It all hinges on … For the Medicare system, you make money on the DRG or the PPS, but under critical access, the most you can get is 101 percent of your costs. We don't know the correct answer yet until we get farther down the road with getting our revenue cycle stable."

Arias said: "We don't know what's going to happen with health care on the national level. We have to be prepared."

"I am as optimistic as I've ever been," Stokes said.

The next article will begin with public input, followed by a presentation on the value of agriculture economics in Grant County by the Grant Soil and Water Conservation District, a professor from New Mexico State University, and a USDA representative.