GRMC Board of Trustees meeting of April 26, 2019 clarified safety-net-care-pool changes

GRMC Board of Trustees hears that the recent safety-net-care-pool changes do not create a loss from the hospital. The amounts were funding the hospital expected to receive, but will receive smaller amounts.

By Mary Alice Murphy

The safety moment usually begins the monthly meeting of the Gila Regional Medical Center Board of Trustees. On April 26, 2019, instead of a safety moment, Interim Chief Nursing Officer Kelly Rodriguez told a story to illustrate how the hospital cares for its patients. A little girl, 7 years old, was a patient in the hospital and was going to miss the Father-Daughter banquet she was looking forward to. The nurses and certified nursing assistants planned and attended a special dinner in her room with her father. "That's why we're here," Rodriguez said.

Chief Executive Officer Taffy Arias gave the safety moment. "We had the Rainbow People come through the hospital delivering ice cream to people. We had to make sure security was in place. They did not cause any havoc, but it was inappropriate."

Board Chairman Mike Morones announced that it was the last meeting for Controller Alfredo Pacheco. "We thank you for everything you've done for Gila Regional. He will be moving to Las Cruces."

Chief Financial Officer Richard Stokes said he would miss Pacheco, with whom he has worked closely in digging out old financial issues that have required fixing and would likely be calling him about financial issues "I have all his contact information."

In board input, Morones said Trustee Tony Trujillo would be late, as he had to welcome a legislator to Silver City. "I want to convey some information as people begin to hear about the safety-net-care-pool situation. People think the hospital has lost money. That is not correct. We just won't receive some funding that we expected to receive. We are still operating within our budget. It is not a loss."

Trustee Ed Wilmot asked if a statement would come from the board.

Morones said that after the financial report, the board might get some clarity on how to respond.

Wilmot said, in his board input, how much he appreciates the value of public input. "I want to thank Chris DeBolt for her talking about moral injury. I did some research on the issue. (Trustees) Jeannie (Miller) and (Dr. Victor) Nwachuku impressed me with what they’ve accomplished. I participated, but they did most of the work."

In reports and updates, Jennifer Yost, GRMC Auxiliary president, said auxilians had attended the District 4 meeting at Memorial Medical Center in Las Cruces. "Andra Losey of the Hospital Association said that fewer and fewer auxilians are belonging to the association. She's also getting less funding to spend on auxilians. In September, auxilians will be part of the association with everyone else, including CEOs, physicians, nurses and other staff. We're excited about being able to participate in any breakout sessions, not just those specifically for auxilians." She noted that because Memorial Medical Center is a for-profit organization, the auxiliary there cannot donate to the hospital.

"I had a meeting with our membership committee," Yost said. "We need some more volunteers. They go through the same hiring process as any hospital staff member. We have a new form. A lot of our volunteers are aging, and some are becoming associates, instead of full participants. Some are taking leaves of absence to take care of family members."

Arias said: "I want to thank you publicly for everything you do at Gila Regional. I always appreciate being greeted by smiling faces."

Allen Townsend presented the GRMC Foundation report. "We are looking for donors and donations for our golf tournament coming up in June. First American Bank is our title sponsor. We are trying to get an event going the Friday night before the tournament. We are looking for prizes. We have one for the lowest score and we want one for the highest score. Thank you, Joel (Trustee Schram of First American Bank). It's obvious Joel appreciates and supports the community. We are planning a meet and greet at the hospital to get more people fundraising for the foundation. We are trying to get us back out into the public, so people know who we are and what we do. Rep. Rebecca Dow is an honorary member of our Board of Directors. We are also looking at putting a banquet together for the sponsors of the golf tournament."

Arias gave her CEO report. "I want to highlight several departments that report to me, including EMS, Physical Therapy, and the Cancer Center. These are new to the packet. Rennie Mariscal is over the clinics. We wanted to keep you abreast of details."

Miller asked how the hospital is doing on finding housing for new physicians.

"We have found one for Dr. Rosser," Arias said. "We have a lead on one for our pediatrician. We have received leads from many people."

Wilmot said he likes data. "How's the performance?"

"That piece is coming," Arias said.

Miller noted that the Cancer Center is getting referrals. "And people are getting in to see the physician within a week and only two weeks to radiation. And referrals become our patients, correct?"

Arias said the referrals become the hospital's patients and the wait times are better than the standard.

Wilmot said he believes in transparency. "What can we share in open meeting and what in executive session?"

Arias said the process is still in refinement. "We always want to make sure when we get information to the public that it is correct."

Miller asked about the EMS transfers and transports. Rodriguez explained that transports are in town and transfers are out to other facilities.

Miller also noted that therapy seemed to be booming. "I also look forward to the brochure on Gila Regional service lines."

Marketing Director Doug Oakes said he was working on the brochures on the service lines, and it was taking time to get all the information.

Arias said Frank Grammer of the Wellness Center was reaching out to groups to inform them of the services at the center, which include pelvic floor services.

Rodriguez presented the Chief Nursing Officer report. "Beginning Years is rebranding itself with changes, using grant funding, to enhance the prevention and intervention parts of their mission. They have moved the age limit from 1 year to 3 years. Diana Perea is running the rebranding. The chaplain services have expanded. Chaplain Bill Holguin has seven volunteers helping him. We have an ongoing initiative and are in contact with the Department of Health for our Pod 1 optimization. Five of our traveling nurses are here. Two are starting in maternal and child, two in med surg and one in surgery. They did a four-day on boarding and are following their preceptors. I wanted to give a little debrief from our clinical educator." She read from the email from the educator, in which one of the travelers said she appreciated the mock code training because in her previous experience, only two people worked code. And usually, only one nurse was trying to revive a coded patient, because the work load was so heavy no one could step away to help. "They said they feel like 'they are pretty close to heaven here.' We have to appreciate what we have in our organization, even in our rural facility to have the equipment and skills we have here."

Rodriguez said the hospital had gone live with the sleep studies and had volunteers to be part of the studies, as part of the training. "We expect to be able to perform 35 to 40 sleep studies a month."

Wilmot asked about the status on the Trauma 4 designation.

Rodriguez said the hospital is collecting all the needed data. "Bernie Veseley is gathering it to report it to the state, and she is being supported by Trey Donovan."

Arias said Donovan could come to the next board meeting and give a report. Wilmot said he would appreciate that.

Stokes said, as the state moves to the new safety net care pool methodology, they are exploring how trauma designation can affect it. "Unbeknownst to us, it could have a positive financial impact on us if we receive the trauma designation."

Chief Quality Officer Tanya Carrasco presented her report. "I want to highlight that the module we are getting online with Meditech will replace the process we do now, which is primarily on paper. It's not the best way to track. We are setting up first the risk management module, which will go live in June. It is really important to the organization. We are working on a campaign for charting to go into the system. We will push it as part of our culture of safety. It will provide easy access to event reporting. We did an assessment with the environmental services department and laundry. They came back with great recommendations to reduce costs and wastage. We will have a decrease in costs and will have savings with efficiencies. The telemedicine contract has been signed. We are at the point where we are looking at credentialing by proxy, working with Las Palmas del Sol in El Paso and our attorneys to make sure our credentialing is the best."

"The other thing we're doing is working very closely with nursing in the ICU and ER," she continued. "We will be working with Dr. Sherpa and others who want to be at the table on our stroke and neurology protocols. Last summer, we had a campaign on what does it mean to be engaged in the patient experience. We called it Gila Healthy, Gila Proud. Staff members need to be proud of where they are. We will roll it out to the rest of our staff. What we've heard in our safety huddle has made us realize what we do is important in making our patients as healthy as possible and making our staff proud of what they do."

Nwachuku asked about the patients the Border Patrol is bringing in. "Can you talk about it and are we getting paid?"

Carrasco said the flow of patients coming to Gila Regional has significantly slowed, as the Border Patrol has brought in providers doing more screening at the border. "They are bringing the ones that need to be seen in a hospital."

"We are getting reimbursed," Stokes said. "We are making sure we have things documented well, so we do get paid. It is coming along nicely."

Miller asked about the telemedicine services. Carrasco said the hospital is working with Las Palmas del Sol in El Paso and St. David's in Round Rock, Texas. "They have training programs and how to get the video equipment we need. When we have it in place an emergency medicine physician can tap into a neurologist that can do the assessment and devise a plan of treatment for that patient, so we don't have to immediately ship them out. It's the same with behavioral health. It's specifically for emergent neurology stroke and emergent psych."

Stokes gave some background on St. David's Foundation, which has funding to reach out to rural areas. "I had worked with them on referrals when I was in Texas. I reached out to them when I came here and said I would have no possibility of referring anyone to them. They told me the directive from their board made an application from us for telemedicine much stronger, because we couldn't refer patients to them. They supply the equipment to us, and all we have to pay for is the monthly vendor fee."

Carrasco said the hospital brought in three vendors and chose the ones that would be best for Gila Regional.

Miller noted it would keep patients in town.

Wilmot asked about turnover in the hospital staff, especially in environmental services.

"I did notice that, and we are working on how to implement programs to alleviate the turnover," Carrasco said.

Arias said once the telemedicine is established in the ER, "we will be looking at expanding neurology throughout the hospital."

In the marketing report, Oakes said he wanted to point out that the does not include articles in the press in his report. "The Daily Press came to us and asked us if they could do features on some of our physicians. Dr. (Brian) Robinson (orthopedist and GRMC Chief of Staff) was the subject last month."

"We want to highlight service lines, not individuals," Arias said. "Robinson is representing the service line, which shows the quality of physicians we have here."

Oakes said the hospital does not pay for the article. Gila Regional does advertise in the Daily Press and other outlets, such as the Grant County Beat.

Robinson agreed and said the article is more about the patients and their experience, "not me."

Miller referred back to the CNO's report. "Is there a charge to participate in Beginning Years?"

Rodriguez said the service is free but is limited by the number of visitors available to provide the service, although they try to incorporate everyone who wants the services.

"As we further our branding and signage campaigns, Doug will be bringing to the board some possibilities," Arias said. "We have met with the Foundation and the Collaborative Council on ideas that we plan to present to the board at the May meeting."

Schram said the quality of the advertising is "superb compared to past efforts."

Stokes said people question why the hospital spends money on marketing. "But when I ask people what they know about the hospital and its service lines, I find a shocking lack of knowledge. They are nicely appointed messages."

Morones said marketing is one of the legs of a business. "We are answering: Does the public know what we are capable of doing? We need strong marketing."

"While we are digging ourselves out of a hole, we need to promote our excellent care," Robinson said.

Oakes said he appreciates Stokes' comments. "With the nature of health care, we are in competition. We need to keep as much business here as possible. Our marketing budget is less than 1 percent of our overall budget. We provide high quality at low cost."

Stokes presented his financial report. "This is for March, the ninth month of our fiscal year. We did a look back at our entire fiscal year and we have an excess revenue of $1,011,544 over expenses month to date. We reversed some accruals and added some accruals in March. Year-to-date, we have a profit of $25,019, which is slightly down from February, but still positive. As we make adjustments, we do not make them without talking to our external auditor, Tom Dingus. We work with a national CPA firm, BKD, and we gather our data and send to the firm and they forward it to CMS (Centers for Medicare and Medicaid) for consideration. We know that for 2015 and 2016, CMS has accepted our request for payment."

He also talked about the safety net care pool. "We made the calculations based on seven years of history. We came up with the numbers for 2017 and 2019. We vetted it with several outside entities. These were solid numbers. The bad news is the Department of Health and Human Services changed the methodology rules. The impact of the rule change is a decrease of $5 million in cash that the hospital would have received for 2017, but we are not going to receive. The impact for 2019 when we would have received $8 million is that we will receive $3.6 million. The bad news we will not receive the $9 million we anticipated receiving. But we have not been counting that funding in the month-to-month calculations. We are not receiving that money, but the hospital is profitable year-to-date."

Miller said maybe "we should say, we didn't spend it because we hadn't received it."

"We make decisions internally based on the expectation of receiving it, but we have not spent it," Stokes said. "We had seven years of history, and we may have not made some of the decisions we did if we had known this. So, our days of cash on hand are down."

Arias said: "We wanted and deserved this money. We wanted it as part of our growth strategy, for instance, to expand the ob area. That would have provided money for the project."

"This does not affect our operations," Arias emphasized. "Richard and I have worked for for-profit organizations and we are conservative. We don't spend on what we think we will get, but on what we know we have. If we don't have the money, we don't do what we may want to do. We're very conservative with our spending. We're very low risk."

Trujillo said the Department of Human Services has politics involved in this whole deal. "We are one of the four or five hospitals hardest hit."

Stokes noted that Gila Regional was the hospital hardest hit by the policy changes.

"What we're doing now is the right thing," Trujillo said. "We're not broke."

Morones said it's a matter of living "within our means. We may not be able to meet the wants of the public, this board or this staff, but we are committed to living within our means and serving the needs of the community."

Wilmot said he attended the Commission meeting where Stokes and Arias told the commissioners. "I believe we should keep saying it over and over. I think it will take more than one message to get the point across."

Arias said it hit the hospital with "such a blow, we didn't understand at first what they were saying and the impact it would have. We were on calls with the Hospital Association. Others that weren't going to get hit as hard as we did were already in an uproar."

Trujillo encouraged the administration not to stop with the Hospital Association. "You have to talk to the lieutenant governor and our senator face-to-face. It's a political situation. We need to get to the bottom of it. The Department of Health and Human Services has bosses."

Stokes said the Artesia General Hospital CFO has asked him to keep her in the loop. "They were the second hardest hit."

Arias thanked Wilmot for attending the Commission meeting. "It's good to have support of the trustees there, especially when we're delivering bad news."

Morones echoed that it was important, and he apologized at not being able to make the meetings during tax season.

"We need to keep Howie, Gabe and Rebecca informed and in the loop," Morones said. "I talked to all of them and they are aware of the situation and trying to learn more about it. They need to keep hearing from Richard and Taffy, who know the details and the numbers."

Wilmot asked about the urgency and whether there was time to change things.

Stokes said the rule change has already been submitted to CMS. "Now it is in the political realm. There may be action in discretionary funds, the little pockets of money that Health and Human Services has. During the conference call, I was surprised and shocked at UNM's position. They are netting $8 million new dollars through the Medicaid Rate Enhancement Program. Their position is that they see the most Medicaid patients, so they should get the most money. They basically said: 'you see some Medicaid patients, you should just deal with it. 'That's just a complete lack of understanding of what rural health care is all about. We will never have the flow through number of patients. You can't pay us the same as you pay a UNM. It just won't work. I was equally surprised at the reaction of the CFO, who took great exception to the fact that there are hospitals hurt by the Medicaid Rate Enhancement Project. We are one of the two hospitals that will actually lose money under this rate enhancement program to the tune of about $68,000. You look at the list of all the other hospitals in New Mexico, some will net half a million, a million, a million plus and UNM will get the lion's share of the rate enhancement. I don't begrudge them that, but they have to understand how important rural health care is."

"Before I conclude, this board has consistently encouraged us to work where we can with the County Commission," Stokes continued. "At the meeting Taffy and I attended, they received $200 thousand to replace their roof. We received $260,000 to replace our roof. I was talking to Charlene (Webb, Grant County manager) about another issue and I said: 'So you are replacing a roof. We're going to replace a roof. So why don't we talk to the same contractor, so they have to stage once, which will save both organizations money. It should be a win-win. Charlene was very receptive to that, so we will continue to push that."

Trujillo said, in addition to the Hospital Association, Stokes and Arias need to include Congresswoman Xochitl Torres-Small. "I think she serves on the House Health Committee."

Stokes continued the numbers part of the financial report. For gross revenues for March, the hospital projected $15 million, but received $13 million. Cash collections for March stood at $3.8 million.

Schram said he wanted to make a public statement regarding the safety net care pool. "The Department of Health pulled this same type of shenanigans five years ago on behavioral health providers, where they literally put 26 organizations out of business. They brought in an outfit from Arizona and they walked away from the agreement they had and pretty much left our community and our state without behavioral health services for a time. I see some of the same things occurring. We can't let this happen to our community. We must, we have to keep pressure on our elected officials."

Arias said: "I want us all to remember. It's about planning. Quality drives financials. We wouldn't be anywhere without our providers, with the people who take care of our patients, day in and day out. That's the whole reason we're fighting for these dollars, so we can put them back into our infrastructure."

Stokes, to add on to that, said the state is moving toward tying payment to quality outcomes. "I'm reminded that Kelly and her team are working toward the trauma designation, and Tanya was saying six months ago we need to do this quality surveillance system. Nobody at that time knew about what was coming up. What they are doing will seriously help this organization."

Wilmot said it all fits into a report that Chris DeBolt gave him.

Robinson highlighted items in his Chief of Staff report. He noted that Delicia Dimberg was active in getting the CME (continuing medical education) department up to snuff. He also said changes had been made to the bylaws.

"We were doing the CME before, but not correctly," Robinson said. "We are getting people re-accredited to provide the lectures here. Dr. Norman Ratliff (cardiologist) will be the first lecturer. The program fell by the wayside, but we are building it up again."

Nwachuku moved to approve the bylaws rules and regulations changes. The board approved them.

In board committee reports, Morones said the Executive Committee met and created the agendas. "We are looking forward to communicating with the county commissioners for recommendations on the board appointees. It can't really be a formal recommendation because we don't know who will apply. But we can come up with some guidance for knowledge or background for what the board needs. We need to do that relatively quickly. We will have some discussion in executive session."

"I want to make the comment that it is very difficult when we don't have consistency on the board," Arias said. "I hope the ones whose terms are ending will reapply. It takes a long time to orient a board member to decision making. It really enhances it for us to be able to make decisions more quickly. I'm hoping we can remain intact as much as possible."

Miller said the Quality Improvement Committee didn't meet because of lack of a quorum.

Schram said the Finance Committee had a long discussion on adjustments. "I would describe the financials were like being on an Easter egg hunt. One egg you'd open would have good news; the next would have not-so-good news. We heard some good news on the budgeting process. The software, once fully operational, will bring us some solid financial reporting going forward."

Three contracts were up for approval. The first was a new contract for an employed nurse practitioner contract with Michael Harris, CNP. The agreement is for initial 12 months with two annual renewals for a total of three years.

Two agreements, a renewal for an employed nurse practitioner agreement with Donna Kiehne, CNP, with the same 12 months and renewal periods, with no change from the prior contract in base pay and the new on-call agreement for orthopedic services with Robinson were tabled until after executive session.

Wilmot requested it be put into executive session, because of inconsistencies in the base salaries and uncertainty about the dates.

The Plant and Facilities Committee met. Miller said the committee decided to go to a quarterly schedule to keep a quorum, "but we can come back to meeting if needed. We will meet in May on the budget."

Stokes said he would present the capital budget at that time.

Morones presented the Human Resources Committee report. "With human resources, we are coming up with a better dashboard. Human Resources focuses on the calendar year."

Nwachuku said the trustees used to hear how much travelers cost. Morones pointed out that it is part of the contract labor line item.

The trustees went into executive session.