[Editor's Note: This is part 2 of what will be a multi-part series of articles on about 8 hours of Grant County Commission meeting time, with almost five hours for the work session on April 16, 2019, and about three hours for the regular meeting on April 18, 2019. This article will cover the GRMC monthly report.]

By Mary Alice Murphy

After county reports at the Grant County Commission work session on April 16, 2019, which can be read at http://www.grantcountybeat.com/news/news-articles/50633-grant-county-commission-holds-lengthy-work-session-041619-part-1 , commissioners heard the monthly report from Gila Regional Medical Center.

GRMC Chief Executive Officer Taffy Arias said she is still heavily involved in physician recruitment. "Dr. Rosser did a second site interview. He came to talk about how he would like to expand the medical surgical services line. He also came to look for housing, which always seems to be a stumbling block. But he found a suitable one and is moving on with a contract with us. A pediatrician, Dr. Worrell is going through credentialing and will start June 1."

"We do what's called a risk assessment survey annually per department," Arias continued. "It is an in-depth evaluation of any risks. We put them into a risk management plan. Once it goes to the board for approval, I will share it with you. When we have unforeseen events, we do a root cause analysis in depth. We bring people together to determine whether it is a people, policy or procedural issue, so we can take corrective action."

Commissioner Alicia Edwards asked about the status of the Chief Nursing Officer search.

"We are interviewing our second applicant and hope to make an offer tomorrow," Arias replied.

Edwards asked who instigates the root cause analyses.

"It can be anyone," Arias said. "It goes through the compliance department to determine if it is a one-time event or they do a deeper dive if it could recur. It is generally a patient-involved situation."

She said she had a meeting with County Manager Charlene Webb and Silver City Assistant Town Manager James Marshall on the Dispatch issue. [Other entities in the county entered into an agreement on paying for Dispatch services, but Gila Regional did not join at that time.] "We had no different outcome," Arias said. "But I appreciated the level of communication. We could see what each faces. You could not give me Mrs. Webb's job. I have a deep new appreciation for what she faces and what you face. We look at operations through different eyes."

GRMC Chief Financial Officer Richard Stokes said, as usual, the report is a month late, because the commissioners meet before the monthly GRMC Board of Trustees meeting, which approves the financial report.

"We ended the month of February with a $29,000 profit," Stokes said. "That brings the year-to-date profit to $32,000. I want to note the renegotiation of commercial provider contracts. The Medicare ones are completed. Blue Cross Blue Shield is severely underpaying Gila Regional. They aren't paying us correctly. We are deploying a new software program that will take the bill we send and the payment we receive to bounce it through to determine whether it is underpaid or overpaid, which does happen occasionally."

For March, he said the income is projected to be about $1.5 million with $4.2 collected.

"I can relate to Mr. Moore's surprise from the state," Stokes said. "We have mentioned many times how government regulations affect hospitals. About three weeks or a month ago, I got a heads up that the Department of Health has changed the funding method for the Safety Net Care Pool. We received official notification this week that they have officially applied the new methodology. The impact will be to cut our reimbursement in half, which will cost us $5 million for uncompensated care for the 2017 calendar year and $4 million for calendar year 2019. That is quite a setback to the hospital. We are having discussions with DOH and the New Mexico Hospital Association. Our 2018 uncompensated care will be settled next year. I'm hearing there will be another change on how they calculate what is allowable to the hospital for uncompensated care. That is going to be partially related to the Medicare cost payment report form S-10, which didn't have an impact on hospital reimbursements until 2018. I will be going through our data to make sure we get as much of our uncompensated care into the S-10 form as possible."

Ponce said he's hearing $9 million the hospital won't be receiving. Edwards chimed in with, "not counting 2018." Ponce asked if Stokes had any way to project what they might receive in 2018.

Stokes said the Department of Health won't take anything back, but what the hospital will receive will be less than what would normally occur in the redistribution process. He said some of the smallest hospitals in the state are being paid above their Medicaid costs to provide care "We're receiving 23 percent of our cost to provide Medicaid care. The Safety Net Care Pool was designed to narrow the gap between what we spend and what we get reimbursed."

Edwards said she had a whole bunch of questions. "So, the state Safety Net Care Pool is funding encumbered to reimburse hospitals for their care of Medicaid and uninsured patients.

Stokes said the gap is in what Medicaid paid and the hospital costs. If it costs $1,000 to provide care, Medicaid will pay $100. The gap between the cost of care and what was reimbursed is the gap that was supposed to be paid by the Safety Net Care Pool. "We get 23 percent of that."

Edwards said, because someone decided to do their math differently, "you're going to lose $9 million? Who makes these decisions?"

"Yes, ma'am," Stokes said. "The Department of Health decides. The Department of Health has to follow federal guidelines, but how they apply those guidelines is in the purview of the Department of Health. I believe, and the CFOs of many small hospitals, and even the Hospital Association will agree that the distribution is not equitable under this new methodology."

He said the state has the authority to formulate a response to the federal requirements. "CMS (Centers for Medicare and Medicaid) has to approve that response. However, we believe that the response they submitted is the wrong response."

Edwards asked if it was a holdover from the Martinez administration and Stokes said no, that it was recently decided. "The secretary will receive a letter from me."

"$9 million is worth more than a letter," Edwards said.

Stokes said the Department of Health has contracted with a firm, Myers and Stauffer to manage a lot of the Medicaid reimbursements. Myers and Stauffer formulated the response to the federal entities. And the DOH reviewed and signed off on it, "is the way I have understood it to happen."

"The way the reimbursement process works," Edwards said, "is that you have budgeted the amount based on a formula, but you did not receive that budgeted amount?"

Stokes said the hospital had budgeted to receive $1.5 million. Arias said they were expecting the full amount but felt uncomfortable budgeting the full amount.

"So, you are running a business based on a formula that has now changed," Edwards said.

"We are doing better," Stokes said. "This money we expected to be coming in would be icing on the cake to move forward projects that need to be done. We didn't base our budget on it."

He said the hospital has zero opportunity for response to the issue. Hospitals need more opportunities. "We are a tweener hospital. The smallest hospitals are doing great. We are taking it on the chin. The calculations that were done, I don't think are reasonable to even understand before they were submitted to CMS. There is no mechanism for appeal."

Stokes said the hospital has sent letters to several people at the state level, including Lt. Gov. Howie Morales, Sen. Gabriel Ramos, the Department of Health Secretary and Myers and Stauffer. "Our next step is having weekly calls with the hospital association. My opinion is that every day that goes by decreases the chances of change."

He explained that the changes were made as a result of a lawsuit. "The hospital association won, but with an adverse effect to smaller hospitals."

Arias said: "We wanted the public to be made aware of the potential impact to certain services. Several service lines, including OB, EMS and behavioral services, each lose more than $1 million a year. Other service lines balance out, but when the lack of funding affects services, we have to evaluate the service line. We don't want to have to."

"We rely on these services," Edwards said. "We're a low-income community. It seems like another broader amount of pressure on poor people."

Stokes said he didn't disagree. "In contrast to rural hospitals in Georgia, we're in good shape. No rural hospital in George has OB services. But then, here, we are fairly isolated. The other day we had a baby born. Without OB services at GRMC, that baby would have died."

He said people who work in rural hospitals …"I'm pretty used to getting hit in the back of the head with things like this funding issue. We have to have the constitution to weather storms. I have initiated action to allow Gila Regional to recapture 2015, '16 and '17 funding from CMS. We estimate it could result in a reimbursement of $3 million for 2015 and 2016. We have already submitted the request."

"Two years in, I'm still also chasing $250,000 to $500,000 by filing paperwork on how we discharge patients," Stokes continued. "There are other opportunities. What was going to be extra now just will replace what we won't get from the safety net care pool. If we don't apply for funding, we won't get it."

Edwards asked if it was basic funding money and they may take some away or an "I'm going to absorb this? Would some kind of letter or a resolution from us help? We all recognize how important this hospital is to the community. Do we all need to march up to Santa Fe and sit on the governor's head?"

Stokes said he thought letters to the governor were important.

[Editor's Note: Edwards encouraged everyone to write letters to Gov. Michelle Lujan Grisham protesting the cut in funding for Gila Regional Medical Center through changes in the formula for determining how much safety net care pool funding each hospital gets.]

Arias said she shared the notice with the physicians. "They see it as a state of emergency for us. If we let this go with uncompensated care, what's next?"

Commissioner Billy Billings said he supports a letter or resolution from the county. "Are you considering litigation?"

Stokes said it has been talked about, "but there is the beauty or the curse of litigation."

"I think it will require a political solution, not a legal solution," he said. The Department of Health needs to help all hospitals equally."

The next article will begin with a presentation by Col. Susan Beck, Ret. updating the Holloman proposed training flights over the Gila.