SCRHCD Board approves proposed budget, changes to services ahead
Suspending Saturday hours, closing after-hours ER in Marbleton, salary reductions
by Sublette County Rural Health Care Board
May 22, 2016
Effective May 21, 2016, the Sublette County Rural Health Care District (RHCD) will begin initiatives to "right size" health care services provided in Sublette County. These initiatives come on the heels of an anticipated 46% reduction in tax revenue equating to an estimated $3.5 million for this coming budget year. Additional loss of tax revenue is anticipated for the 2017 budget year as well.
Over the past three years the RHCD has been successful in reducing a budgeted deficit of nearly $1.8 million to less than $300,000.00 for this past 2015-2016 fiscal year. The reductions in expenditures have consisted of adjustments to employee benefits including the employee share of contribution to the Wyoming Retirement System, a reduction of paid time off, position elimination per attrition, pay wage adjustments per attrition including significant wage adjustments to the health care administrator, lab director and EMS director salaries, changes in clinical and EMS schedules to prevent overtime and changes of purchasing group for supplies and equipment. At the same time, the RHCD has worked to increase revenue through additional services including a full array of lab tests, ultrasound services, and specialty providers renting clinic space.
"The employees of the District are to be commended not only for the excellent care they provide day in and day out, but for the work they have done in being fiscally responsible. Not only has the volume of patients using the clinics for routine and urgent care increased but we have done it without adding expenses. We were on track to balance our budget and then the bottom dropped out of the tax revenue that has supported the current system of care that includes two clinics and two after-hours Emergency Departments,"states Malenda Hoelscher, Health Care Administrator.
Over the past several months, the RHCD has solicited "best practice" for delivery of rural health care in our region from surrounding health care partners including Star Valley Medical Center- Afton WY, St John’s Medical Center-Jackson WY, Eastern Idaho Regional Medical Center- Idaho Falls ID, Teton Valley Health Care- Driggs ID as well as the Wyoming Hospital Association. This information coupled with an extensive review of the RHCD’s historical and current patient numbers, including where and when those patients visit the RHCD and the associated expenditure and revenue with the service provided, was the basis for the decision of upcoming changes. The goal of these changes is to assure the long term financial stability of the RHCD and ensure that the community has the highest quality of health care it can afford while providing a work environment that attracts and retains high caliber staff. In addition, a recent financial review of operations completed by Eide Bailly at the request of the County Commissioners affirms the direction of these changes. This report was released to the public earlier this week and is available on the County website.
One of the changes in service will be effective May 21, 2016. Saturday clinic hours in the Marbleton-Big Piney and Pinedale Clinics will be suspended. Both clinics will continue to operate their regular business hours of 8:00 AM – 5:00 PM, Monday through Friday.
Hoelscher indicates that "while the mission of the District is to provide accessible, progressive and patient-focused care… the current volume of urgent care patients seen on Saturday mornings and the cost related to provide that service simply don’t add up. The suspension of the Saturday Clinics is indefinite. The District will continue to provide the community with an after-hours answering service for the management of urgent care while all emergent care should continue to utilize 911."
Another significant change to the delivery of health care in Sublette County comes with a reduction of approximately $1.1 million in expenditures primarily related to personnel and equipment costs associated with two 24/7/365 emergency departments less than 35 miles apart.
Effective June 1st, the SCRHCD will have one Emergency Department (ED) in the county located at the Pinedale Clinic responding to after-hours emergencies. Both clinics will continue to provide emergency care during clinic hours. Both clinics will continue to have full teams of EMS responders 24/7/365. The decision to suspend the after-hours ER Department in Marbleton was based on historical and current utilization of that service. The Pinedale Clinic ED generally sees twice the volume of patients as the Marbleton Clinic ED. In addition, the Pinedale Clinic also houses the RHCD’s only CT scanner and fast scan ultrasound capability, both considered mainstays for diagnostics in rural settings. A paramedic-led rapid response system is in place in Marbleton to facilitate treatment and transport of critical and time sensitive cases of heart attack, stroke or trauma to the most appropriate facility as is the current protocol.
"The SCRHCD Board is keenly aware that health care in Sublette County cannot continue as it has and remain financially viable and sustainable. The decisions made have been difficult at best but have been done in a methodical manner taking into account numerous factors including patient volume, staffing models and best practices around us. It is the goal that the District continues to offer excellent patient care each and every day," states Laura Clark, Chairman of the Board.
With the strategic goal of reducing expenditures for the upcoming year, the RHCD will be making significant adjustments to the employee benefits of the Health Care Administrator as well as implementing an 11% salary reduction for the CFO. Additionally, the position of the IT Director will be reduced to a part time position. The RHCD will also be discontinuing retention bonuses and automatic annual salary adjustments for contracted employees. There will be a 10-12 position reduction in the work force between the two clinics and pay reductions reflective of the loss of call pay due to reduction of call hours. Other significant budgetary impacts include the RHCD electing to increase the rent fee of specialty providers and services that utilize clinic space as well as opting to not purchase a new CT scanner. These changes along with the previously stated changes to service will result in the RHCD moving from a more than $3 million deficit to just over a $1 million deficit for the coming year. The RHCD currently has approximately $9 million in reserves.
Hoelscher shares that "Unfortunately, as the RHCD continues to work at our bottom line, there are things that can’t be changed… these include RHCD reimbursement from Medicare, Medicaid and commercial insurances, cost of service contracts to maintain critical equipment, cost of critical equipment replacement, cost of recruitment of medical providers, salaries to retain critical positions and cost of maintenance of an electronic medical record system which is mandated by the federal government. Every day we are reminded that nothing in or associated with health care is cheap."
A proposed overall budget of approximately $8.7 million was approved at the RHCD Board meeting on May 18, 2016 with a 3-1 vote. Scott Scherbel was absent due to a meeting in Cody in which he and Hoelscher met with Pat Davis, Lead Engineer, and Laura Hudspeth, Director of Licensing and Survey for the WY Department of Health. Hoelscher and Scherbel received confirmation that the predesign of the CAH and the functional program that outlines the operation of hospital services in both the Pinedale and Marbleton clinics is ready for final approval. This final approval by the Dept. of Health will occur once authorization to move forward and funding have been solidified and the final architectural drawing by an engineer have been completed.
The RHCD has been aggressively committed to seeking Critical Access Hospital designation since August 2014. This change of designation would enhance revenue substantially through cost-based reimbursement for not only current services being provided, but the additional services a small general hospital offers including in-patient care, swing bed care and observation care. Currently, about 30% of the transfers out of the RHCD emergency departments would be eligible for this level of care. The RHCD is currently awaiting a "green light" from the County Commissioners to make the required physical changes to the clinic structures. At this time, the County owns the buildings in which the RHCD operates clinic services with the RHCD paying $100,000.00 annually for rent. Per the financial proforma completed by Eide Bailly earlier this year it is anticipated that without the CAH designation, the RHCD is losing about $1 million each quarter in potential revenue from federal monies, specifically Medicare. Sixteen other communities in Wyoming have benefited from these monies but more importantly, have brought critical services to their rural communities while enhancing the economics of their "main streets".
Hoelscher adds that "In the ever-changing world of health care, it would be irresponsible to promise that health care in Sublette County will not change or that we will revert back to previous levels of service down the road. But with that said, it remains our goal that the CAH and the additional revenue will allow us to reinstate the ER services in the Marbleton Clinic."
Additional budget information can be found on the Rural Health Care District website at: www.sublettehealthcare.com/financial.