Confirms that paying staff is a priority
By Mary Alice Murphy
The Gila Regional Medical Center Board of Trustees meeting on Jan. 31, 2020, began with the first item of business— the safety moment.
Chief Quality Officer Tanya Carroccio said because of problems with an electrical plug, the hospital had some momentary issues with getting a ventilator to work. "I asked what the process was for checking the wall sockets, and I found out we did have a process. Now we're doing education on not jarring the socket by yanking plugs out. The outcomes were good in this situation, but we are warning people to be cautious with plugs."
Board Chairman Tony Trujillo said: "For my safety moment, if for any reason we have to exit this room, there is one door on this end of the room and another where you came in."
"We are what we are because of the people working here," Trujillo said of the recognitions of years of service for December, when the board did not meet, and for January. They include for December Angela Armijo for 20 years of service, now working in the intensive care unit; Elisha Sanchez for 15 years of service, now in the Emergency Room; Alvino Zubia for 15 years, now doing MRIs, who received his recognition when he arrived at the meeting. He said: "I love my work."
For January, the following were recognized for their years of service. Renee Carbajal for 40 years of service, now in sterile processing; Amedeo Ferruccio for 20 years of service, in physical therapy; Gwendolyn Burns for 10 years of service in the float pool, and Marisa Marshall for 10 years of service in the recovery room.
Chris DeBolt gave public input. "These people have put in a combined 125 years of service. 2020 is the Year of the Nurse, as established by the World Health Organization. I want to thank all of our nurses. They are the foundation of health care. I have been working with the Western New Mexico University school of nursing and the kinesiology department for grants. We want to integrate behavioral health courses in the curriculum. And use them for clinicals. These are HRSA (Health Resources and Services Administration) grants. These are monster grants." She showed the UNM 2019 study showing "where we need to go. Having worked for the hospital, I know the rumors go around: the BHU (behavioral health unit) is going to close; the BHU is not going to close. I'm wondering what the current thinking is. I would like to encourage you to take a good look at what will become reimbursable. Anything I can do to help, I'm willing."
Hugh Epping, representing the PFLAG (Parents, Families and Friends of Lesbians and Gays) and ACLU (American Civil Liberties Union), said one issue comes up often and that's health care for those who are transgender, transitioning and LGBT (lesbian, gay, bisexual and transgender). "As a community here, we are welcoming to them, so we are seeing an increase in numbers of them. I think it's crucial for the health care community to understand their issues, not only for their care, but the attitudes they face. We would like to see training so when someone comes to the hospital they are not intimidated. PFLAG and ACLU want to be part of the training. We are going to keep pushing to see proper training and attitudes toward them."
Board input gives the board members a chance to weigh in on issues.
Trustee Dr. Victor Nwachuku said: "After not having a meeting in December, we're back and have a lot of work to do."
Trustee Jeannie Miller said she had liked the ads the hospital is putting out, listing all of its departments and services. "I also liked (CEO) Taffy' Arias' letter about accomplishments. What are we doing about the coronavirus now that the WHO has described it is a global crisis?"
Chief Nursing Officer Rose Lopez reported that everyone with coronavirus presents with flu-like symptoms. If coronavirus is suspected, by where they may have traveled, for instance, "we draw labs and send them directly to the Centers of Disease Control and Protection. We are already isolating flu patients anyway. With normal flu, we treat, and they go home. We have seen no cases of coronavirus. Their symptoms will be prolonged. We will have to wait to hear from the CDC."
Carroccio noted that everyone with the symptoms receives the screening questions about travel and other potential ways they might have contracted the virus.
Trustee Joel Schram referred to a letter from April 25, 2018, when the county was working with Juniper on a potential sale of Gila Regional. "It refers to Coldwater Regional Hospital in Coldwater, Michigan, where I lived for 15 years, and where I served as a hospital trustee. Juniper was steering the hospital to ProMedica as a potential purchaser of the hospital. ProMedica paid the county $17 million and absorbed their $9 million bond issue. Fast forward to today, and ProMedica is selling the hospital that is now profitable. I want to point out that we are not out of the woods yet on threats to sell our hospital. We need everyone's support and usage to keep us viable. We have to stop referring people out of the area. We don't want to repeat what ProMedica did. It's time we talk to our doctors and tell them, we don't want to drive to Las Cruces and that we trust the medical services here."
Trustee Ed Wilmot said he would have comments later.
Trustee James Marshall said he believes it is critical for the hospital to look at all its services and all line items "to make sure we are fulfilling the community's needs."
Trustee Cynthia Moreno had no input.
Trujillo said: "Last month, I had family members contributing to our hospital. The care from physicians, nurses and staff was incredible. I want to thank the folks here for their wonderful care."
He went on to say that he was in legislative mode because of the session going on in Santa Fe. "Gila Regional is impacted by things up there. The safety net care pool, for instance, when the federal folks changed the formula, we lost $9 million. The New Mexico Hospital Association asked for my assistance with challenges by the state to the Health and Human Services Department budget. We have the potential to lose $4 million. I will be working to make sure that doesn't happen. The NMHA is working hard, too. This 30-day session runs from Jan. 21-Feb. 20. It's a budget session. What's driving it is making cannabis legal, education, the red flag legislation, all things that are on the governor's agenda. Already 600 bills have been introduced, with Feb. 5 the last day to introduce a bill. I expect about 1,000 bills for the 30-day session. I'm working on health issues. The Patient Safety Act, which turns over staffing to a third party, but there's nothing included on how to pay for it. Good things are tax credits for pharmacists, nurse practitioners, therapists. Interestingly, there is a bill to turn Sierra County into a special hospital district. There is a process that they can go through, but they are going straight to statute to do it. They are doing it because the hospital is having a lot of issues right now. The state has $1 billion of new money, so there are a lot of appropriation bills out there."
In reports and updates, no one was present to give an Auxiliary report. Miller said she had had it called to her attention that the Auxiliary would hold a linen sale on Feb. 1 and Feb. 3, as a fundraiser.
The GRMC Foundation is working on the annual golf tournament.
Arias said her report was in the board members' packet. "The majority of my report is about activities of the hospital. A significant one was the Light Up a Live, which honors those who have passed away. People submit photos, which we post on a lattice fence. We had more than 300 photos submitted this year. It means a lot to the people. It's a very warm time, where speakers talk about things in their lives concerning their loved ones and what was meaningful to them. The dietary department provides cookies. Candles are lit. It's a moving event."
"A couple of things we are very concerned about," Arias reported. "One is that Dr. Teresa Arizaga, our BHU psychiatrist, has turned in her resignation for the first week in March. We are trying to find someone. We haven't found a psychiatrist yet, but we will have a temporary arrangement for telepsych. It is difficult to draw a psychiatrist to our community, and it costs $3,500 a day for a locums. We are already losing money on the unit, so it would be an additional financial burden. We are also looking for an anesthesiology group for a contract in the ER."
Wilmot asked if the county was aware of the issues.
"Yes, we are working with a community committee set up by Commissioner Alicia Edwards," Arias said. "She set up the committee to meet the needs of the community. I met some folks in Santa Fe that do the telepsych."
Miller asked if the hospital is seeking a full-time psychiatrist.
"The hours are part-time, but right now, we are looking at all options," Arias replied. "We have so many avenues for treatment among various age groups. We serve only adults right now, but there is a need for children and adolescent treatment."
Chief Financial Officer Richard Stokes said the unit, which has 10 beds, could expand.
Arias said one avenue is detox. "Where are they going now, and can we do it here? We have to be creative. We want the results of X, but we can do it with Y."
Marshall asked how long credentialing would take. Arias said the hospital is already doing it with the telepsych service. "It goes through the medical staff office and then through credentialing. For a nurse practitioner, it takes 30 to 60 days. It depends with a physician, whether they have a clean application, a clean background and a New Mexico license."
Stokes said Brianna Romo of the medical staff office "keeps us up to date on insurance for the practitioners, including Medicare. Once we file the information, it takes 30 to 60 days to learn if they are accepted for the insurance. Medicaid is more challenging. It is very paper-driven, instead of electronic. We are doing much better with payer enrollment. Brianna has a data system she uses, and 90 percent of the credentialing is already in the system."
Trujillo pointed out that the BHU provides for community needs. "It has always been a money loser. We have to figure out how not to lose money on it. We have an opportunity during the transition to look at it and decide how to fix it. Do we have a lot of frequent flyers?"
"Yes, and we have a new generation of them," Arias said.
She said when she reported to the Prospectors (the community lobbying group), "we asked for $14 million for needed projects. We were kindly told to reduce our wants, but this is health care. There is nothing that costs $10 or even $100. When we go down our list in finance committee, labor is the most expensive. Ours seems to be higher than most hospitals."
Arias noted that in Santa Fe, "it's knowing how your request fits their needs. I don't know how Tony does it. He was described to me as the Godfather of Santa Fe. We have to get our interest out to spark their interest. If they don't give us any money, it's because they aren't giving a rat's(trans ass about Grant County. Get in touch with your representatives, your senator, the governor and say Grant County matters."
Moreno said she saw that the hospital is recruiting for a nurse practitioner in the ICU.
Arias said the ICU has six beds, of which usually four have patients on a daily basis. "Sometimes, it has less; sometimes, it's packed if we have a larger issue on some patients. We will be ready for our new surgeon, who will do more complicated cases."
Rennie Marsical, Clinical Services director, said he wanted to highlight in his report, a year's worth of data, "where you can see all of 2019. You will see the average of each value as a benchmark and we will add the national benchmarks for comparison. For Gila Cardiology, we have included the procedure, including transesophageal electrocardiograms. They are done in the radiology department, where it is safer for the patient, and we receive higher rates of reimbursement."
He said the number of CT-angiograms has continued to increase. In 2018, they had an average of 8.2 a month and now it's between 7-22 a month. "For Gila Surgery, we had 35 TNEs (transnasal esophagoscopy) in 2019, seven Bravos (esophageal pH test) since September and several scheduled. Dr. (James "Butch") Rosser will begin esophageal-manometry in March. In the Deming Clinic, it's all hands-on-deck with robust marketing. We are also engaging the community, working with non-profits, business people, officials, firefighters, the health council, senior services and with the Deming Schools. We can do things like physicals for sports day. We also have opportunities with businesses. The entire clinical staff is participating and going out to providers. We will schedule (pediatrician) Dr. (Andre) Worrell a day a month. When a woman from Deming has a baby at Gila Regional, she can do the follow up in Deming with Dr. Worrell. We are believing the numbers will grow."
Nwachuku asked how many patients would be needed in Deming to break even,"and for the clinics overall, can we have details about how much they are spending, losing and making?"
Miller asked what the Deming Clinics competition is. Mariscal replied that it includes Silver Health Care, the federally-qualified health clinic Ben Archer, and clinics from Mountain View and Presbyterian hospitals."
He said that he met with the fire chief and he said there was only one place in Deming for them to get DOT physicals. "He didn't realize we could also do physicals. They are also really clamoring for cardiology services. Once we have a new nurse practitioner in our cardiology practice, we can rotate there for cardiology services as well. The clinic in Deming is an opportunity for us to fill gaps in services. I talked to Western Skies and they have an automated enrollment process."
Wilmot questioned the Cancer Center statistics. "I have greater expectations."
Marsical said the Cancer Center has stabilized in its cases. "We need to stop people from going elsewhere when they can get their care here. We have medical oncology and radiation oncology here. We will do molecular mapping, which gives a more definitive diagnosis. We need to broaden our services."
"If it takes months to get an appointment, and someone goes somewhere else because of that, do you follow up with them?" Wilmot asked.
"Yes, we do follow with them and ask them why they have gone elsewhere," Mariscal replied.
Miller asked about the number of established patients. "One month it's 82 and the next month, it's 135. I presume that's visits. Does it mean we cured them?"
Mariscal said it can mean they completed their treatment, went into remission or, "unfortunately, some do pass away. We know when they go elsewhere, because they need their patient records sent."
Marshall said the Silver Health Care clinic in Deming has a three-month waiting list for some providers. "And we have 18 visits for the month? Can they do the cath lab at the Mountain View clinic?"
Mariscal said the Mountain View clinic refers patients to Las Cruces. It is a feeder to their hospital in Las Cruces
"When do you predict that Deming numbers will look better?" Marshall asked.
"We are taking action and hopefully our actions will take hold," Mariscal said. "The Deming chamber called me and told me they didn't want us to be discouraged. He said the way to get accepted is to participate in the community." In answer to another question, he said the Deming clinic is utilizing clerks from other clinics for pre-authorization.
Trujillo noted that a highlight in the report was that Dr. Rosser's volumes of patients are continuing to grow and they include out-of-area people.
CNO Lopez highlighted in her report that her department is partnering with the state on maternal mortality and how to prevent it. "A lot is due to hemorrhaging post-delivery. So, we have initiated guidelines for patients at high-risk of hemorrhaging post-partum. Midwife Gail Stamler is heading it up. On another issue, we are assessing patients who are being transferred for cardiac events. We are seeing an increase, likely because the median age of residents is increasing. We recognize the need to be certified in cardiology procedures. It's a long process, but we are working on it to ensure that from the time a person comes into the hospital to get the balloon treatment that it happens within the first 19 minutes, not the more than 45 minutes it's taking now. I think we can make a positive impact for our patients. All our doctors are excited."
She said that Gila Regional has established standing orders when a nurse receives a call from a physician. "The guidelines have changed, so we will review all standing orders to prepare for the Joint Commission survey."
Lopez said guidelines come from CMS. Arias said they are based on the Nurse Practice Act.
Carroccio gave the CQO report. "I can officially announce that Gila Regional is once again a 4-Star Quality hospital. It was posted on Jan. 29. The process looks at the overall quality of the hospital. We are focusing on readmissions and will dedicate 20 percent of our time to improving that number. We have a very dedicated staff and plans are in progress, with the case management staff."
She noted that Gila Regional compares quite favorably to other hospitals in the region. Mountain View has a 1-star rating; Memorial and Mimbres have 2-star ratings, Las Palmas and Sierra are 2-star and Providence at 3-star.
Trujillo said that Christus-St. Vincent in Santa Fe just achieved a 5-star rating.
Carroccio said she is on the New Mexico Hospital Association Quality Committee and "we go out to other high-rated hospitals to contact people and find out what their best practices are."
Marshall asked about PAMA (Protecting Access to Medicare Act) compliance and why the hospital is not compliant.
"The reason we're not compliant, but are working on it this year, is that we are required to be compliant in 2021," Carroccio said. "CMS said they have been putting the idea out as a good idea and they will put some money toward it. Now CMS made the statement that penalties will come with not being compliant. We will focus on it this year. It's another regulatory change. We have a compliance specialist focusing on it that will take us into compliance in 2021."
Stokes said it was not just the hospital, but all physician practices will also have to be compliant.
Carroccio said all will have to verify that they are compliant. "It's another way to save CMS money."
Stokes said the hospital will have to have the code number from the physician for Gila Regional to do the requested test and get paid. "It's giving us another unfunded mandate, and we are the only one at risk."
Chief of Staff Dr. Brian Robinson said it's a way for CMS to control costs. "My response is that we need to partner. It's a collaborative effort to get the physician to give the hospital the required number."
Stokes presented his CFO report. "In December, we had a $480,000 loss. In November, a $2.9 million loss. Year-to-date, we are at a $4.8 million loss, which is $221,000 difference from last year's $4.6 million at this point in the fiscal year. As happened last year, the first two weeks of November and December were strong, then the last two weeks of each month, the volume tanked. It's concerning for us."
He reported cash collections came in at 31 percent, "which means we get 31 cents for every dollar billed."
The hospital will hold a mock survey for the Rural Health Clinic status to prepare for scheduling the formal survey. "Once the formal survey is completed, we will go to the state around July or August to have our primary care clinics qualify for RHC status."
He noted the payer compliance system is up, which identified that Blue Cross, Blue Shield had underpaid the hospital by $77,000. "We will get about $22,000 of that. We will introduce new payers into the system. Twice a week, we look at the buckets and we will send claims back for reconsideration. In the labor productivity system, we learned that 62.7 percent of our expenses are personnel related. For profit hospitals have generally 36 percent of their expenses going to personnel. Non-profits usually stay in the 55 percent to 60 percent range. We are community-driven. If we could get down to 55 percent, we could avoid about $2 million in costs a year. We've talked about critical access and labor productivity. We will find departments that are over-staffed. We have already found some that are understaffed. Productivity suffers in those that are over-staffed, because everyone figures someone else will do it. We will work out how to better balance the under-staffed and over-staffed."
"When volumes drop, it does impact cash flow," Stokes said. "There are things we are looking at doing. Let me back up. In addition to our slump in volumes in December, Medicare has dark days, where it stops processing payments in order to update its systems, so when they brought it back up, in about half the U.S. the financial intermediaries' systems weren't working right. Even today, we are still feeling those impacts. Novitas, that manages our Medicare payments, was adversely impacted. They are working out the glitches. There's not anything we can do."
Wilmot asked if that was the reason the hospital has 19.5 days of cash on hand.
"Yes, that is part of the reason," Stokes said. "Medicare not paying for a time was a hit. We get small payments from Humana, but they stopped taking claims from those without their new Medicare beneficiary number. Yes, cash is tight, but we hope it will be resolved soon. What are we going to be doing moving forward?"
He noted the RHC designation for the clinics will add about $400,000 to the hospital's bottom line. "Internally, we're working to help us capture all our charges, and we started a revenue reconciliation process. The lab charges are supposed to go into the Meditech billing system. We spent a lot of time trying to understand the issue, because what was supposed to be in the module wasn't. It was supposed to be transferring to the billing module, but it wasn't. We have radiology pretty much squared away. The lab is pretty much squared away. Pharmacy is a whole other issue. There are lots of reasons why things won't move across modules. We're fixing them and making sure with daily reconciliation that things are moving across modules. We are building the 340B program where we partner with a local pharmacy to make sure prescriptions, written by a qualified physician, wrap into the system. When we activate it, we will make money. We want to make sure the prescriptions are treated properly in the community pharmacies. We're predicting about $400,000 cash flow by starting this program. We going to start with Walgreen's, then CVS and Walmart are next."
Stokes said Gila Regional is changing management of its billing office from HRG to AVEC. "I expect the difference to be noticeable. HRG moved our billing information into their proprietary system, where we couldn't see it. AVEC works within our Meditech system, so we know what's going on. We are working on a denial management system. When it comes back into the hospital it has the codes that show exactly why the claim was denied. Based on that, we are building rules to make sure it gets to the correct director. I can guarantee that payers know that Gila Regional doesn't have systems in place now that help us fight against them. They know who will fight and who won't fight. Getting this done will be a big step forward. There are other things we are working on to capture everything we can capture."
Marshall asked: "Are we in danger of not paying payroll?"
Stokes replied: "No."
Marshal asked: "Are we borrowing to meet payroll?"
Stokes replied: "No. Our priority is paying payroll. We are managing our vendors and maybe stretching out our payments if we need to from 30 days, for instance, to 45 days."
Trujillo said in comment to Marshall: "Someone is spreading false information. We are borrowing our own money to pay bills, but that is our money in the bank."
"That's why I'm asking," Marshall said. "I want the correct information to get out. Rumor has power behind it. Some employees are rethinking whether to stay, so I'm glad to hear that payroll is our priority."
Stokes said the rumor was going around on Wednesday that people weren't going to get paid. "Someone stopped me and asked me. I promised them that I knew my payment would be in my account that day and so would theirs."
Marshall asked if retirement payments were being made in a timely manner, to which Stokes said: "Yes, and we actually overpaid in November."
Schram said he wondered if something that happened at his bank had anything to do with the rumors. "Some employees get paper checks. An employee told me her check bounced. But it turns out she had already deposited it through the mobile app and then tried to deposit it again at the bank, but it was already in her account."
Stokes noted that the hospital is doing a lot of different things to stabilize it. "As Miss Taffy said, the difference is that last year we were trying to fix broken things. Now they are fixed and we're looking at thing to improve the revenue stream. We as an organization will have to make uncomfortable decisions, but they will be for the betterment of the community. Some things that happened in the past may not be the same now."
Trujillo said the hospital still has to do some things. "We will discuss critical access in executive session, but that won't fix everything."
Robinson in his Chief of Staff report presented the revised version of the medical staff bylaws.
Trujillo again requested that all action items be put in one place instead of scattered throughout the agenda.
Miller said she didn't understand the process for the medical staff bylaws. "I looked at the synopsis. Did the entire general medical staff approve them?"
Robinson said the process has been going on for two years, since 2018. "They were reviewed in 2018, then they came to the general medical staff, who had access to the entire document. Each piece got presented at the Medical Executive Staff meetings. They were sent to each person by email and each person could comment on them."
Miller noted that a lot had been deleted and a lot of new language included.
"Yes, it was written by a committee," Robinson said.
Nwachuku was a member of that committee and said a lot of work went into a lot of changes. "It is a living document and once approved goes back to the bylaws committee." About one item, he explained: "Every physician can come in even without board certification and can go through credentialing. If they are already here, they are grandfathered in."
The bylaws were approved.
The next item for board approval was the Community Based Delineation of Privileges.
Robinson said it included the addition of the New Mexico Board of Nursing, which involved a clinical issue. It was approved with an amendment.
The third item was Otolaryngology Delineation of Privileges, which was also approved, after Marshall's comment, which brought laughter, that he had waited almost two hours just to hear the word pronounced.
Trustee committee reports followed.
The first was the Executive Committee. Trujillo said the members created the agenda for the meeting. He also noted that each year in January, each trustee is required to fill out two forms—the affidavit of consent to serve and the conflict of interest disclosure form.
Trustees approved Resolution 2020-1, the Open Meetings Act resolution, after Marshall complained about why the meeting always takes place on a Friday afternoon and generally goes into the evening.
Miller gave the Quality Improvement Committee report and said they talked a lot about the PAMA (Protecting Access to Medicare Act). She noted the committee did not agree on the risk management plan, so it will be sent to the board in the next packet for discussion. "We also talked about changing the vision, mission and values"
Schram presented the Finance Committee. "Richard already touched base on most of the things we discussed. In executive session, we will talk about the hospitalist program and the clinics."
Wilmot said the Plant and Facility Committee didn't have a chance to dig into some issues with the board and would ask for a short meeting before the executive session to discuss some issues.
The Human Resources Committee, according to Marshall, did not meet.
Nwachuku said the board bylaws committee asks every board member to look at the bylaws and suggest changes.
The trustees took a short break before going into executive session.
Several items were discussed and approved after the executive session.
The issue about critical access can be read at https://www.grantcountybeat.com/news/news-articles/55766-grmc-to-take-first-step-toward-change-in-status