Commissioners hear presentations from Gila Regional Medical Center and Hidalgo Medical Services

[Editor's Note: This is part 1 of a multi-part series of articles on the County Commission work session of June 11, 2019.]

By Mary Alice Murphy

The work session of June 11, 2019 began with county reports.

Detention Center Mike Carillo called attention to a draft document on the jail's special management individuals. "The numbers change daily."

Road Superintendent Earl Moore said his department would complete the Local Government Road Fund projects by the next day. "We started on the Rosedale project yesterday."

Commissioner Harry Browne asked about the chipsealing and shoulder project on Mountain View.

Moore said the project is in Silver City. "I know they have projects planned for Ridge Road." The department sometimes helps municipalities with their chipsealing projects.

Browne said he would like to see the county portion of Ridge Road expanded to 24-feet wide, 12 feet per lane. Moore said his department is working on the project.

General Services Director Randy Villa said the recent Spring Fire burned about 3,000 acres. The prescribed burn, the Elk Fire, was ongoing. [Editor's Note: It has since been completed.] The Cameron Creek prescribed burn was also completed.

"Because of the arrival of hot shot teams and Forest Service aircraft to fight fires, we have upped our fuel sales, including to the bucket drop helicopter," Villa said. "Aircraft are also dropping fire retardant. We are also wrapping up our education on wildland fires, which we funded with a grant. It was part of the Community Wildfire Protection Plan."

He said his personnel were doing daily maintenance at Bataan Memorial Park to address weeds.

Commissioner Javier Salas asked if the Corre Caminos director was a county employee. Villa confirmed she is, and he oversees her.

Community Development and Planning Director Michael "Mischa" Larisch reported that Phase II on the old jail is underway, thanks to brownfields funding received by the New Mexico Environment Department and the Southwest New Mexico Council of Governments.

"I hope to have the infrastructure capital improvement plan (ICIP) draft out this week," Larisch said. "The Whiskey Creek metal building is almost erected and back on track. We also are moving along on part of a Colonias project on Rosedale. The Census Advisory Committee met on June 4, and the next meeting will take place July 30. Paul Dulin is no longer with the organization, and we will have a new person. A lady from Las Cruces came for the meeting. We also have new chairs, Curtis Clough, Sheila Hudman and me. Lori Bonomo will take minutes."

He has put out the bid packets for the ADA compliance project in Tyrone. "As has already been reported, we received $15,000 for the Community Wildfire Protection Plan. "

Villa said the report updates where Grant County stands as far as high-risk areas and where resources are. "It's a working document, to get feedback from the public. It does have all of the information of what to do and where to go in case of emergency. All the agencies involved play a role. We have to update every five years."

No one had public input.

The first presentation was the monthly Gila Regional Medical Center report. Chief Executive Officer Taffy Arias introduced the two latest physician recruits to the hospital.

Dr. Butch Rosser, general surgeon, said: "I've been high-profile my whole life and the global impact I've had, and people see that and wonder what I'm doing here. I was born in the Mississippi delta, and I wanted to be a small-town doctor. My life took me different places. Our five kids are grown and educated, and now I can do what I want. My wife and I love the high mountains. We want to make a difference in your beautiful community. You shouldn't have to leave home to get high-quality care. I thank Miss Taffy for helping me fulfill my boyhood dream."

Dr. Andre Worrell, pediatrician, said it is a pleasure and honor to be in Silver City. "This is my third stint in New Mexico. I worked in the northern part of the state with the Navajo. I worked with the Indian Health Services in North Dakota and in Oklahoma. I was a civilian contractor with the military in Alaska. My wife told me it was time to go back to New Mexico. She is the caregiver for my in-laws. I was born in a small community in Barbados. I, too, love serving small communities. We, who live in rural areas, have to make sacrifices, but there is no reason to have to leave to receive cutting-edge medical care. I pledge to you to give my very, very best. My wife has volunteered in the prisons, and she is a substance abuse counselor. We are looking forward to getting her plugged in here, too."

Arias said they asked permission to shake the hands of the commissioners, which they did.

She then introduced Rennie Mariscal, who is the physician practice administrator for the clinics.

"I think the common message you are hearing is service," Mariscal said. "We provide services to the community. My career started many moons ago here at Hillcrest Hospital. Now it's time for me to give back to my community. Our goal is to provide services to our community in Grant County, not those who already have a medical home, but we want the ones who are leaving for medical care in other locations in the state or even other states. We want to provide multi-specialists to everyone. It's all about service. Once I received my nursing degree in Arizona, I went on to become a nurse anesthetist. I served as a flight nurse. I later became an administrator of a large surgery center, and also worked at CMS as an auditor. I came back from Hawaii to take care of my parents and fell in love all over again with this awesome community. I didn't intend to stay, but I got hooked."

Arias asked at least one of the commissioners to attend the GRMC Board of Trustees meetings from time to time. "At the last meeting, we had five of our directors speak as my report. I can give the latest points, but they are the heart and soul of the hospital. They are totally committed to taking care of people in the hospital."

Commissioner Alicia Edwards said she appreciated the invitation. "Congratulations on the new physicians."

Arias said a family practice physician from Maine would be arriving in about three months.

GRMC Chief Financial Officer Richard Stokes presented the April report. "We had $60,000 in profits, bringing our year to date profits to $85,333. Our EBIDA (earnings before interest, depreciation and amortization) was less than last April, because we received a large safety net care pool payment that month."

He said the hospital is at 30 percent cash collections, with cash to net revenue at 124 percent.

"We have filed for 2015 and 2016 from CMS for declining volumes," Stokes said. "We expect $2.4 million in July. We have also submitted for 2017 and are finishing the application for 2018. We submitted our capital budget to the state. Jennifer Klotz is our new controller. She comes to us from West Virginia. She hit the ground running. We had 31 days in cash at the end of April, with net accounts receivable at 41.6 days and accounts payable at 20.5 days. Today we have 28 days of cash on hand. We are modifying how we manage accounts payable, and it's coming along nicely."

Commissioner Billy Billings said he appreciates the weekly report from the board chairman. "Can you tell us how days of cash got away from you?"

"Days of cash on hand depends on the day you look at it," Stokes said. "We had just been hit with the third payroll in a month and that knocked us down. Twice a year we have three payrolls in a month. Twenty days of cash was absurdly low, so we're managing accounts payable by taking a set amount of dollars and spending them on AP every Friday."

Billings asked how much a day of cash was worth. Stokes said: "It represents our daily expenses, which are about $190,000 a day. We were paying some vendors really quickly and others not so quickly. I would like to keep bills in AP about 30 to 40 days. Some we can stretch to 45 to 60 days."

Browne asked what percent of expenditures is AP as compared to payroll.

"Fifty-five percent of our expenses are payroll," Stokes said. "Thirty percent is accounts payable. The rest is employee benefits, insurance and supplies."

Commission Chairman Chris Ponce said he appreciates the financial reports. "I would also like to see a report on where you are on your strategic plan."

Stokes continued his report. "I think we are not going to get the $9 million that we did not get from the safety net care pool. So far, we've been unsuccessful in getting any relief. We might not have made some decisions, if we had known we would not be getting the $9 million we expected. We are dealing with it. We are not broke."

He said that the hospital has contracted with a group in Dallas to help GRMC convert its primary care clinics reach the Rural Health Clinic designation. "We submitted the data they needed within 48 hours of their request. The project is gaining steam. Community Hospital Corporation is giving us a roadmap for the primary care clinics. We want a good list of what we need to qualify for RHC.

"We are also gathering data for phase I of consideration of critical access," Stokes said. "We are doing analyses of the appropriateness for us to go that route, the pros and the cons. We had talked about the need for having $5 million in the bank before being able to go critical access. We were told we can still continue billing under our current Medicare number and provider number. If we decide to go critical access, once we've done it, we will have to rebill under critical access regulations. It's not unusual for hospitals to cancel bills and resubmit them, but it requires quite a bit of work. I want to remind everyone that critical access is a reimbursement methodology. It will have an impact on Medicare beneficiaries."

Browne said he missed something. "You would need $5 million to go critical access, but now you don't?"

Stokes said because there would be a gap in reimbursement during a conversion to critical access, the hospital would need about $2 million instead of the $5 million.

Edwards noted that she has seen some discussion in health care publications that funding for critical access is potentially shaky. "Gila Regional is now a 68-bed hospital. Once you go to critical access, it changes your licensure. If critical access funding goes away, will you have to reconsider licensing at a higher number of beds. The number of critical access beds, as I understand it, does not include OB and behavioral health."

Stokes said if the critical access funding goes away, some bills will increase. "A good number of hospitals that have closed have been critical access. If you don't manage the critical access well, you will get crushed. If you rely on the government, it depends on the way the wind blows. We have to look ahead. If I personally felt it was risky, I would so advise. We looked at our bed numbers over the past two years, and we had only two days that we filled more than 25 beds. Behavioral health stands alone. We currently have 10 beds. At the state level, we are discussing how we might be impacted and how our decision will affect things. OB is part of the hospital and the bed numbers, but nurseries never count."

Edwards said the safety net care pool cut off is 30 beds. "Will the 10 behavioral health beds put you over?"

"That is the question," Stokes said. "Critical access is federal funding from CMS, but under the state the decisions are made by the Department of Health or Health and Human Services. It depends on whether we are provider-based or free-standing. No matter what, it is important to manage finances."

Salas asked where the Bayard Clinic stands.

Arias said the current facility is not viable, because it would take $350,000 to renovate. "It would have been a danger to the past renters, too. We have had a community member come to us with an alternate site. We are looking at it. The city of Bayard also approached us on a potential property. As we get the report from the architect, we will let you know."

Salas also asked if the hospital board was considering not being county-owned.

"We had one board member have that idea," Arias said. "It was a comment, not a discussion. We are not sure what it would take. We will investigate, but it would require community input."

She also announced the hospital has named a new Chief Nursing Officer, Rose Lopez, who will arrive June 20. "Her husband is also a nurse."

Arias said the hospital has also had an issue with payments for indigent claims. "We were late; we missed the deadline and our claims were denied. We will appeal, because the services were rendered. I know Richard will work with (County Manager) Charlene (Webb.)"

Ponce noted that one of the problems was getting bills for people who were not inmates at the jail when they received treatment.

"We understand that," Arias said. "It's for more than $70,000 in services, so we will look into it."

Ponce said he didn't believe it was the first time it had happened. "Our direction is to our county manager. We will take an appeal into consideration."

The next presentation was given by representatives of Hidalgo Medical Services. Chief Executive Officer Dan Otero said Chief Medical Officer and Family Residency Program Coordinator Dr. Darrick Nelson and Chief Mental Health Officer Neal Bowen, Ph.D., would also give updates.

"Just to clarify, Hidalgo Medical Services is a federally qualified health center and non-profit," Otero said. "HMS started in 1995 in Hidalgo County. We have almost 250 employees now at our facilities in Lordsburg and Silver City and in clinics throughout the region. We serve both communities. One of the requirements is that we need to do an assessment every other year to find gaps and to find out what the community really needs. That is why we have grown. Three years ago, we pursued the Malcolm Baldridge Award and, in order to fulfill the needs of our clientele, we are working on the four levels of excellence at the state. We have received the Adobe and Piñon levels. When we get the Zia award, we can apply to national. We have to report on 15 measures to the state. We have achieved or exceeded 10 of 14 at the state and 10 of 14 at the federal level. We are exceeding standards. For patient satisfaction, we meet the experience of care, with 93 percent satisfied. We have community support for services that happen in the background."

To meet requirements for the Health Resources and Services Administration, "we go above and beyond. We have a sliding fee for services, and we have 1,900 individuals included in the sliding fee schedule, and 2,500 in Medicaid. We enroll them. Many of our clientele have no access to food. We are filling the void. One hundred and ninety-three get utility support. We're trying to fill base needs. For the disabled, family support tries to meet the daily social determinants. We have provided for seniors, 24,860 congregate meals and 49,200 home-delivered meals for seniors, and 7,000 transportation trips. We have about 800 seniors taking advantage of the centers."

HMS received a Freeport-McMoRan Community Investment Fund grant to do a study at the senior centers. "New Mexico is moving from being 39th in the proportion of older adults in 2010 to 4th by 2030. We have a lot more to come."

"I promised to clarify the comment that HMS is run by federal funds as a federally qualified health center," Otero said. "That is true, but we are supplemented by federal funds to serve the uninsured and the underinsured. In 2016, we were a $19 million organization, with about $3 million in federal funds for the uninsured and underinsured, as well as our teaching branch. Today we are a $25 million organization. That growth is through our traditional payer sources and our expansion of services. The more patients that come to HMS changes our calculations. We work harder to provide care and services to them."

Nelson said he had several things to say. "In our residency program, we will graduate two new board-certified physicians. One we will retain at HMS, Dr. Armendariz. Rep. Xochitl Torres Small came to HMS to visit. She is supporting a bill to expand rural residency programs. It costs about $900,000 to train a resident. Her bill will expand the programs and funding. She took great pride in having the only rural residency program in the state in her district and not on the Rio Grande corridor."

"I want to talk about medication-assisted treatment," Nelson continued. "It's a treatment we use to treat opioid addiction. Back in August of 2018, there was one physician in all of Grant County that had a special EA waiver to allow them to take care of opioid-challenged patients. Unfortunately, that physician left. HMS stepped up and we now have five with the EA waiver who can help these patients recover. We have two more in the pipeline. The story is that HMS is helping our community deal with the opioid epidemic. Our doors are open to anyone. We will do our best to help our community recover."

Bowen said he wanted to acknowledge that HMS has become the major behavioral health provider in the county, due to the debacle when the behavioral health providers were stopped throughout the state and providers from Arizona were brought in, who then left, and left a gaping hole in services for those with behavioral health needs.

"On June 13, KRWG will show a documentary on the behavioral health shakeup in the state," Bowen said. "I would like to emphasize how much we've done as a state to rebuild the behavioral health system into a better system. The behavioral health system has to work for everyone."

He noted that value-based purchasing is growing on the behavioral health site. "For Tu Casa, value-based purchasing requires physicians to use evidence-based therapies to show positive outcomes to manage costs. Many states have behavioral health associations who provide scorecards to show costs and outcomes. We are doing very well on the medical side. Medication-assisted therapy is part of what we are doing. For our prescribing practices, we are meeting with families to discuss the medications and we are diligent in monitoring them."

Bowen noted that Tu Casa had received its licensure to be a crisis triage center, the first in the state. Bernalillo County now also has the designation. "We are actively recruiting for the 21 staff members that we need to provide 24/7 care. We're well along the path to get there."

He thanked the county commission for being generous. "We asked if we could also provide services to Hidalgo County. You said, yes, of course, and why not Luna and Catron also. Luna County has approached us about their transporting people here for the medication-assisted therapy and other specialized services."

Edwards acknowledged "how fortunate the county is to have Dr. Bowen and his commitment to behavioral health in the community."

Browne asked about value-based purchasing. Bowen said there is a continuum of value-based purchasing choices. "It started in behavioral health. If we can demonstrate that we can meet the quality measures, we qualify. We have to make sure, for instance, that they are seen after discharge from a hospital. The standard is within seven days. Our goal is within three days, because the most dangerous time for a behavioral health patient is immediately after release from a hospital. Value-based purchasing is designed to reduce the overall health care cost, not per visit, but overall. We are working to get state approval for the assisted withdrawal process."

Browne asked Otero about the demographic shift from 39th to 4th in senior population. "Is it due to the influx of retirees?"

Otero said it is a combination of the influx of retirees and the aging baby boomers. "We will have more information on that in our report in August. It is creating a lot of challenges for caregivers."

"On another note, HMS is one of six who joined to create Care Partners to start a clinically integrated network specifically for the Medicaid population," Otero said. "We are taking the lead to improve the quality of care and reduce costs. It is mandated in Centennial Care by 2020. We're ahead of it. If we don't get the proper quality measures, we will be penalized. "

Edwards noted that it's not that far away for the demographic shift. "How much does it have to do with the loss of our young people? Last year, New Mexico lost 44,000 in population. Also, there are two distinct populations of seniors. The haves and those who don't have. There is a lack of awareness of how much stress there is for basic needs, such as enough to eat. How much is this population shift going to impact this situation. Will the number of low-income seniors rise?"

Otero said he didn't know the answer. "We have a large advisory committee talking about all the variables. We have two different surveys going out. We will know more after the study and what we will recommend. Think of it as a corollary with addiction. How long-term will the negative impacts be, if we don't address them adequately?"

Salas said it was amazing how many seniors are taken care of by their family, because there is nothing they can qualify for.

Otero said there are local resources, such as a nursing home and dialysis. He noted, however, that the Lordsburg nursing home was closing. "Yes, there are services, but not enough skilled care, for instance. We're trying to find and fill the gaps. Dr. Skee told me about four years ago that a lot of his patients were moving away to get better services."

Edwards said those who can't leave are left behind. "That leaves a disproportionate share of seniors with no one to take care of them. There is already a significant population of seniors who have no one to take care of them."

Ponce commended "you guys for looking at things and providing services. You are recognizing the gaps. I really appreciate what you're doing and glad you're looking into things."

Otero said he would return to report in August.

The next article will cover the presentations at the regular meeting. Then at least one article will cover the agenda items discussed in the work session and approved or not in the regular meeting.