Presbyterian says hospital 'is not possible'
The president of one of the largest health care organizations in New Mexico came to Valencia County to tell commissioners about the needs and problems his company saw in the county.
And to talk about what is not possible — a hospital.
Jim Hinton, president and CEO of Presbyterian Healthcare Services, attended the commission meeting Wednesday morning, along with Lauren Cates, PHS' vice president of operations for Central New Mexico.
Hinton began his presentation by saying Presbyterian has been actively involved with individuals involved in organizing hospital efforts in the county since the mill levy passed in 2006.
"I've heard Presbyterian has not been actively engaged. We have been," Hinton said.
Hinton said he and Dr. Paul Roth, dean of the University of New Mexico School of Medicine, have visited the county together to assess the clinical needs of the community.
Presbyterian, a not-for-profit corporation, is the second largest employer in the state, behind Walmart, according to Hinton. In October, the company will celebrate its 104th birthday.
"I think most all of us know health care is going through some extremely challenging times," he said. "It is dramatically different than a few short years ago."
Hinton reported that for a hospital admission in New Mexico, the Medicare reimbursement is 70 percent of what it is in other states.
"That is the remnant of an old payment system that we have to take into account," he said.
Saying 25 percent of New Mexicans are on Medicaid, the fact that Presbyterian Health Care has seen a reimbursement reduction of nearly $160 million, coupled with 25 percent of the state being uninsured and a very challenged commercial insurance sector, and "you have a very difficult environment when it comes to things like replacing equipment and investing in automation. Any time you are investing in new care, that needs be taken into account," Hinton said.
The CEO said Presbyterian has been very consistent since 2006 in "surfacing our concerns on how the (mill levy) money would be spent."
He also reported that most health care delivery has transitioned to an outpatient setting. As an example, Hinton said Presbyterian started in 1983 with a 60-bed nursing unit dedicated to cataract surgery and its three to four day recovery period.
"Today, that's about a 15 minute outpatient procedure. That unit was converted to care for other types of patients," he said. "There are really only two reasons people go to a hospital anymore. You're either really, really, really sick, and need things like an ICU and ventilators, or you are really, really, really pregnant and about to deliver a baby. Most of the growth is in more of these outpatient type of areas."
Hinton said Presbyterian recently completed an assessment of Valencia County, taking a detailed, dispassionate look at the community.
Cates took over the presentation, saying Presbyterian began its study with the data the state and county had already gathered. Looking at information compiled by the local health council, top health needs in the county centered around issues such as teen and unplanned pregnancies, substance abuse and access to health care.
"We also looked at the number of primary care doctors compared to the number of patients," Cates said. "You have primary care doctors here but not numbers adequate to serve the needs."
Cates said the county scored poorly on health behaviors, such as smoking, drinking, adult immunizations and physical activities, and had high death rates for causes such as pneumonia, motor vehicles crashes, alcohol and suicide.
"You can connect those outcomes back to who could prevent them, to the right care," she said. "It really is unusual to have a high death rate of influenza and pneumonia. That gets back to managing behavior."
Of the people in the county with insurance, almost 40 percent, 24,150 residents, were covered by Presbyterian Health Plan, Cates said.
Of those nearly 25,000 people, 50 percent of them receive primary care in the county, but not necessarily at one of Presbyterian's two facilities, she said.
The remaining half receive primary care in Bernalillo County, Cates said, which matches the commuter trend of about half the population working outside the county.
Looking at any kind of care outside of primary, only 20 percent of Presbyterian's patients see a specialist in Valencia County while the rest travel to Albuquerque.
"There are not a lot of specialists in Valencia County. What we are going to see is the opportunity to bring some services to Valencia County. The first is radiology," Cates said. "It really surprised me that people were traveling to Albuquerque to get an Xray or MRI. That means we're not doing good job advertising what we have here at Presbyterian."
Because it is part of the New Mexico Hospital Association, Cates said Presbyterian has access to hospitalization data from across the state. Data on the patient's zip code, type of insurance and reason for admittance is collected monthly, she said.
"In the last three years, across the state, 6,700 Valencia County residents have been admitted," she said. "When you look at your population, that is about 8 percent admitted to a hospital."
About 950 of those admitted were for childbirth, Cates said.
"What really surprised me is, of the babies born, 43 percent had significant or major medical problems at birth and were admitted to the NICU," she said. "That very high rate of complications really led us to look at, are people accessing prenatal care? That connects back to the high teen pregnancy rates."
The second primary reason county residents were admitted to a hospital was for knee or hip replacement, which made sense given the county's aging population, Cates said, and the third reason was for ICU services.
Cates said after analyzing the data, Presbyterian found that a reasonable number of patients that could be treated in a small hospital, such as one in Valencia County, would be about 10 to 13 a day.
"We looked at financial stability. A hospital would not be sustainable on its own," she said. "It would need ongoing support from a mill levy or the county. This mirrors our experience in small hospitals."
Last year, there were 7,700 visits to Presbyterian's emergency room by Valencia County residents that could have been treated in an urgent or primary care setting, Cates said.
"We are only providing urgent care in Belen Monday through Friday. People are having to go to Albuquerque, to a more costly setting," she said. "As we step back, we can see significant opportunities to provide better care for Valencia County residents."
Cates said the organization felt it could have the most impact by investing in more primary care, emergency care, speciality coverage and prenatal services.
"We think that's an opportunity Presbyterian has to really invest in the county," she said.
Cates tried to turn the presentation back over to Hinton, but County Commissioner Chairman Donald Holliday asked if they could take any questions the commissioners might have.
"We've been here for 35 minutes and this could go on all day," Holliday said.
Commissioner Georgia Otero-Kirkham noted the presentation had touched on ICUs and NICUs, asking if either would be something that could be supported "in our little hospital."
Hinton said because of what it takes to support an ICU, such as a pulmonologist on duty 24 hours a day, Presbyterian could not afford one at it's Kaseman or Rust facilities, instead keeping that at it's main, 500-bed hospital.
On the subject of a NICU, Hinton said due to malpractice issues, physicians would be very cautious to deliver a potentially high-risk baby at a hospital without one.
Stepping into the realm of the hypothetical, Otero-Kirkham asked Hinton what Presbyterian would do with the $20 to $22 million in mill levy funds, if they came without restrictions.
Hinton said the company would aggressively expand primary and urgent care, behavioral health services, and address the "horrible, horrible issue" of high teen pregnancy rates.
"A 40 percent NICU admittal rate is a huge problem in this day and age," he said. "These problems don't get solved by hospitals. They get solved by physicians helping young women have healthy babies."
Commissioner Ron Gentry pointed out that the mill levy did have restrictions — the operation and maintenance of a hospital in Valencia County.
The referendum passed by Valencia County voters in 2006 allows the mill levy to also be used for a 24-hour emergency room.
"I don't want it out there that we are negotiating to use it in some other way," Gentry said. "I've been here a long time. I remember when Presbyterian came on. And I remember when Presbyterian left, when the three mill levy didn't pass.
"You say we only have 8 percent who go to a hospital. Perhaps that's because we don't have a hospital."
Gentry said there have been three major feasibility studies done on a hospital, all of which said one was possible.
"From my understanding, Presbyterian has always said a hospital was not appropriate," he said.
Gentry said Hinton indicated the company had been actively involved with individuals moving the hospital forward, asking him for specific names.
Hinton said they had been actively engaged with Valencia Health Commons consultants Robin Hunn and Bill Johnson.
And Commissioner Otero-Kirkham said she met with Hinton and Roth.
Hinton said both UNM and Presbyterian studied the issue and came to the same conclusion.
"A hospital, in the traditional sense, is not possible," Hinton said.
Gentry said other health care organizations apparently agreed with Presbyterian's interpretation of the statistics and the need in the county, pointing out that Lovelace was putting in a primary care facility and First Choice was on the verge of completing it's brand new facility, both in Los Lunas.
"We have two who have made the commitment and stepped up to the plate," he said. "I guess it's in the eyes of the beholder whether something is possible.
"I think it would be great if Presbyterian steps up and builds (another) primary care, but we have to remember voters agreed to fund a hospital, not anything else."
Commissioner Mary Andersen said she had recently been asked to sit on a committee to look at possibly pooling state sole community provider and indigent fund monies.
"I'm not sure what they are intending to do, but if sole community provider goes away, what does that do to a small hospital like Socorro?" Andersen asked.
Hinton said their system of small hospitals would be "devastated," noting that Clovis is Presbyterian's only rural hospital without local support.
"The other four would not exist but for a mill levy and sole community funding," he said. "Anyone building a hospital in a community the size of Valencia County has to assume an ongoing mill levy."
Otero-Kirkham said Valencia County had about $8 million in uncompensated health care provided by Albuquerque hospitals. Andersen said that figure was for Presbyterian only, and didn't account for Lovelace or UNMH.
Otero-Kirkham asked what happened to the balance, did Presbyterian just "eat it."
In the cases of uninsured and lower reimbursed patients, Hinton said the cost is shifted onto employers.
"That's how it works. It's not a secret," he said.
"So my insurance goes up because I have insurance," Otero-Kirkham said.
Hinton replied that her premiums would be lower if "we had a better way to pay for the care people access."
Andersen said she has felt a hospital in Valencia County would be a chancy investment.
"It worries me. I see buildings, bonds, investments and five to eight years from now, we have a white elephant," she said. "My mind says it's not feasible, but my heart says we need it."
Given all the statistics showing a lot of need for additional services, Holliday asked, "Why haven't you done more for Valencia County? You have a captive audience. Why haven't you brought more doctors if so many people are going to Albuquerque? If you truly care, why haven't you done more?"
Hinton said Presbyterian built a new primary care facility in Los Lunas five years ago.
"We have built and invested in Valencia County and will continue to do so. This is a very, very challenging time if you look across the country. We have to be able to pay competitive wages," Hinton said. "We have worked to provide the broadest base of services we can."
During the public comment section of the meeting, Meadow Lake resident Bob Gostischa said it was "nice" of Presbyterian to present the information and "reiterate their opinion we don't need a hospital. The mill levy is for a hospital. But if we can't get that, there are funds that need to be returned."
Mary Wood, of Las Maravillas, said Presbyterian's presentation was simply an attempt to court the mill levy money, "nothing more, nothing less.
"In the past," she said, "they have done everything in their power to keep all the money in Valencia County going to Albuquerque. If we don't have anything down here, they can move it all up there."
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