[Editor's Note: This is part 1 of a multi-part series of articles on the Jan. 22, 2019 Grant County Commission work session. It will cover the GRMC monthly report. Other articles may include parts of the Jan. 24 regular meeting.]]

By Mary Alice Murphy

The first presentation of the meeting featured Gila Regional Medical Center's monthly update with Chief Executive Officer Taffy Arias and Chief Financial Officer Richard Stokes.

Arias said one of the items high on the CEO's list is recruitment. "We have recruited a new surgeon, Dr. James "Butch" Rosser. He is starting Feb. 10. We have two additional surgeon interviews this week, one today and one Thursday. We hired two nurse practitioners orienting right now at the GRMC Family Clinic. They are part of our strategic plan expansions. Dr. Iwaasa's podiatry patient volume is growing. One of our programs we are developing right now is really exploding. It's our occupational and physical therapy and rehab at the Wellness Center. We hired a new director in September. His name is Frank Graokmer. He has developed several new programs. One is women's health/pelvic floor. It's a new program. It started in September with revenue of $1,500 and in December it was $7,000 and more in January. We hired a new specialist for the program, and she has really started marketing women's health. The second program we are developing is lymphedema. It's not a brand-new program. We started it in January 2018, when revenue was $5,780 and in December it was $21,000, after our new director started."

"Last time I shared with you that we had started working with a company to bring in nurses from the Philippines," Arias continued. "Their hospitals mirror our hospitals. Their nursing programs mirror our nursing programs. We have eight starting in February. One of the crucial things for them is housing. The company that manages things for them will be looking for housing for them. We have nine nurses started in the grueling orientation and internship program, so they are better prepared when they start seeing patients. You've been seeing a lot in the newspapers about immigrants coming across the border and being processed in stations all along the border. I was scheduled to do a site visit with them on the day we were notified we would receive up to 65 at Gila Regional, so I had to reschedule. We did not get 65, but about 40 trickled in in groups of six-10. The Border Patrol agents have been nothing short of the most professional. The patients are most grateful. Primarily we are seeing families and are primarily treating children. We are seeing mainly respiratory and GI (gastro-intestinal) problems, as well as dehydration. We have a wonderful relationship with other hospitals, which are accepting the patients when the cases are of a higher acuity than we are prepared to treat. We hosted a meeting with other hospitals from New Mexico, Arizona and El Paso, Texas, to talk about how we were all addressing the concerns. Twenty-six representatives attended, with others by telephone. It was a most powerful meeting. We have other meetings set up with work groups to share our experiences and processes."

She said she also wanted to talk about "something that's very, very important to our organization" and that's about "how we are changing the culture at the hospital. We've been working on this for a about a year and a half. It's not good enough to say you treat every patient with compassion and dignity and respect. The only thing that is good enough is your behavior. We are making sure that every patient is processed in a compassionate and respectful manner. It includes from the time a person walks into the hospital or calls our hospital. We have been fortunate to hire someone in patient access, who is making sure his staff is doing just this. We are pleased with the process, because people must be held accountable for their behavior. In changing this behavior, some feathers have been ruffled, when we have said you cannot work at the hospital, because you do not possess these qualities in your heart or mindset. No matter their experience or qualifications, but if they do not have the attributes, they don't belong in health care. We can teach people how to do many technical things, but what we cannot teach is compassion. So, this is what we hire."

Commissioner Harry Browne said he was unclear about cases of children brought by Customs. "If they are unaccompanied, which I understand happens sometimes, somebody has to make medical decisions for them."

"They are brought in by Border Patrol," Arias said. "They are in the custody of Border Patrol. They are brought in for us to screen and treat. So, they do make decisions. I have not encountered anyone brought in by themselves. They are usually in a group—a father with a child, a mother with children, so that has not been an issue for us. The most important thing to remember is that all patients have rights. If the patient is in danger, they are under the supervision of the Border Patrol. Every time a patient is brought in, there has to be an agent within eyesight of the person. If the person is admitted to the hospital, a Border Patrol agent stays with them outside the room. The patients have rights as patients, but they also have rights under the protection of Border Patrol. A pediatric patient is treated no differently from an adult."

"So, the Border Patrol makes the decision?" Browne said.

"Really, we are the ones making the decisions," Arias said. "And we are letting Border Patrol know what needs to be done."

Browne said he was aware of at least one case of an unaccompanied child. "How does the person get made aware of their rights?"

Arias said all rights of a patient, whether under the Border Patrol rights or the hospital's are protected, while the patient is in the hospital.

Commissioner Alicia Edwards said she appreciates the hospital taking care of these patients but was uncertain how the hospital is being reimbursed.

"The Border Patrol brings in an identifier with each patient," Arias said. "We send that in for reimbursement."

Edwards asked where it was being sent and whether the hospital was being reimbursed.

"The Border Patrol has no funding for health care," Stokes replied. "It's under the ICE budget. And yes, we are being reimbursed at the Medicare rate. When we were first notified of immigrants coming in to the hospital, Taffy was asked to attend a meeting. I was there, too. It was a good meeting. We had to understand their rules and they had to understand ours."

Commissioner Javier Salas asked what specific tool the hospital is using to screen for qualities of compassion.

"For new hires, we have a screening process," Arias said. "We ask each one the same set of questions. How people respond gives us an inkling of how they will treat patients and how they will deal with difficult situations. For existing employees, we have rules and regulations for behaviors on how they deal with patients, with families, with those from different areas of the country or of different nationality or their sexual orientation, for instance. We have not done a good job in the past. Now that we are holding them accountable, we have a tighter avenue of functionality."

Salas asked if the policies are vertical.

"Absolutely," Arias said. "I'm probably held the most accountable."

Stokes gave the highlights of his financial report, after saying that it had not yet been approved by the Board of Trustees. "We ended the month of December with a loss of $160,387, bringing us to a loss year-to-date of $279,000 at the end of December, compared to a loss of $4.4 million at the end of December last year. So, we've made a little improvement."

The EBIDA (earnings before interest, depreciation and amortization) is a close approximation to cash flow within the organization, Stokes said. "For the month, we have positive EBIDA of $80,565. Year-to-date, we have a $1.316 million positive EBIDA number compared to last year's $2.3 million negative, so we are spinning off cash faster from the hospital."

The Meditech Fixed Asset Module moved to "live." It was an audit recommendation. "We trued it up to actual depreciation per month." He said the mid-year inventory count was completed, with inventory increasing $61,308. Stokes said the Western Sky Managed Care, which is the new Medicaid payer contract for New Mexico, has been going back and forth with Gila Regional on contract language. "We've not been able to come to agreement. We already have two managed care providers we work with—Blue Cross Blue Shield, which is a good and fast payer at 100 percent Medicaid scale, and Presbyterian. Rates are the easiest part of a contract. The devil's in the words. We have to get the words right. Western Sky has a set of criteria to do something to a patient in order to get reimbursed. Blue Cross has a set of criteria for us to get paid. Presbyterian has yet another set of criteria we have to comply with in order to get paid. Three sets of criteria for us to manage in order to get paid. I can't answer why Centennial 2.0 didn't standardize the criteria for getting paid. I'm trying to get Western Sky to get closer to what we're doing with Blue Cross and Presbyterian."

He gave an example that a bill has to go to Western Sky within 90 days, but they have the right to recoup costs up to three years. "Well, then I can't bill them again, because it's past the 90 days. Language is what's so difficult in contracts."

"So Western Sky is an MCO (managed care organization)," Edwards said. "How many who were with Molina and United, which are no longer here, transferred to Western Sky?"

Stokes said Molina transferred all its patients to Presbyterian. "If a patient is with Western Sky and comes in to the ER, Western Sky has to pay full Medicaid scale. If the patient comes in for outpatient or inpatient services, Western Sky is required to pay the out-of-network schedule, which is 95 percent of the Medicaid schedule. A lot of hospitals, in Texas, for example, will take the 95 percent, because they don't have to follow the criteria that have been set forth. It's not that patients cannot get care at Gila Regional, but we do not have a contract and we will take the 95 percent."

Edwards suggested it was almost a wash, if it was costing so much to get a contract.

"Experience has taught me that most of our denials come through managed care organizations, whether it's Medicaid or Medicare," Stokes said, "because all the organizations are different, so errors can come if criteria are not followed exactly. We have to take a step to mitigate that. This is where we are today."

Edwards had another question. "All of us were in Santa Fe last week for the New Mexico Counties conference. We heard a lot about Western Sky and these changes, and the Centennial 2.0 changes. Does the hospital have anyone on staff whose role is to talk to legislators about the changes not making sense? Part B of the question, is can we as commissioners help with that."

Stokes said the hospital does not have anyone specifically to interact with legislators. "We work with the New Mexico Hospital Association on issues like this. The language additions I attempted to get into the Western Sky contract were 100 percent recommended by the hospital association. As far as this body attempting to help us, I'm not sure."

"I think you answered the question," Edwards said. "The hospital association is representing you with the Legislature."

Stokes concurred and said he had talked to them about it. "They are well aware of it."

Salas said the bottom line of the hospital is looking good. "Is this an influx of one-time money or will it become the norm?"

Stokes replied that whether it becomes the norm or not is hard to predict, because things happen outside the control of the hospital, namely state and federal actions can occur if no contract is in place. "Over the past year, the bottom line shows that we are much better at getting charges captured, much better at getting bills out the door and much better collecting. Having said that, the hospital is no different from any community. There is a culture at the hospital. When we come in and say these are the things we need to do and why. It's up to the person to understand, one, it's not unreasonable, and two, it's what our patients expect of us. We have to make our staff realize they have to make people feel like they are welcomed, and we are appreciative that they have chosen GRMC for their care. If someone interacts with you without compassion, you don't want to come back. Modifying the culture is a seven-year project, and we have met with resistance. Normally, when we implement a change, 80 percent will accept it and 20 percent will work against you. It's no different at Gila Regional. It's where leadership comes in."

Salas said what he was really truly asking was whether the issue with Western Sky was one-time money.

Stokes replied that it was normal operations. "We do get some uncompensated care funds, but we've always gotten that and it should continue for at least the next 24 months. This all goes to how well we are running the revenue cycle."

To a question from Browne, Stokes said the hospital uses the American Hospital Association guidelines for depreciation. "We are audited against these standards."

Browne noted that the hospital still has a negative bottom line and is still losing money. "You haven't gotten to zero yet to build up reserves to replace equipment."

Arias said: "We like to celebrate where we can. We know we are far from finished. Every day we are strategizing. We are not where we want to be. These are excellent questions you have raised."

Edwards said she does appreciate the concentration on the culture of the organization. "In the two plus years, I've been involved in bringing the hospital around, I've never heard a single complaint against the people who work there."

"We know the staff is working with us," Arias said. "We appreciate that comment. What is there right now are some very caring people, some progressive people looking for better ways to do things. But there was a subculture about a year ago that was detrimental to our organization, but to the public it was not what they saw. When you're working there, you know the undercurrents. The public has always seen the quality and compassion of our staff. That's what we want the public to see. The public has never questioned our care."

Commissioner Chris Ponce asked about the culture change and what strategies are in place for leadership and staff.

"We have a culture of safety," Arias said. "We do extensive training on it and accountability for every member of our leadership team. We are working on leadership classes. We want to upgrade our training for all staff."

Salas said he understands the hospital wants people to use Gila Regional services and not go to Las Cruces or Santa Fe. "But when you hear that our services are higher in cost, why would people stay here?"

Stokes said that in comparing Gila Regional costs to Las Cruces, "in many cases we're lower. If it's a free-standing MRI service in Las Cruces, for example, my experience is that their equipment is of lower quality than ours. Plus, they have 9-5 hours and we have 24-hour services. Our patient support team works with people every day on these issues."

Salas said if someone needs blood services and they can get them for $100, the hospital gets nothing."That's what I'm struggling with. You still have the equipment and the staff, but you're getting nothing."

"I'm not arguing with you," Stokes said. "I understand. As an example, we looked at pharmacy costs. Today our pharmacy charges one-half what it did a few months ago. We lowered the pricing. We're looking at what we are reimbursed, and we have seen no change in reimbursement, but we're charging half."

Edwards went back to the 9-5 versus 24/7 issue. "It makes sense. There are entities in the community that are 9-5. I would like to see people stay in the community. Are you exploring opportunities to share and collaborate?"

"We are still working on getting the basics in line," Stokes said. "We do talk about who can we partner with, but we haven't had those conversations yet. We did talk to the chamber at a meeting and compared quality. The quality ratings of Gila Regional are much higher. If you are going to Las Cruces or Deming, you're going to lower quality. When a person goes to Las Cruces, they are making the Las Cruces economy stronger. We prefer to keep them here."

 

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