"Care at Gila Regional is still better than anything you can get in Las Cruces," Dr. Skee concluded.
By Mary Alice Murphy
Dr. James Skee said he has been practicing in Grant County, in Silver City, for 37 years. He is the Interim CEO of Silver Health Care clinic, where he worked alongside the founders Dr. John Bell and Dr. Dye. Prior to that he began one of the first five rural health clinics, with Johnson Foundation grant money, in Willsboro, New York on Lake Champlain.
In reference to the Gila Regional Medical Center, where he practices, he said since he has been in Silver City, he has seen all kinds of administrators come and go. "I was chief of staff and on the Medical Executive Committee and served on the Board of Trustees from 2005-2009, where I was vice chairman and chair of the Finance Committee. I was on all sorts of special committees, including peer review. Several administrations ago, Dr. Robinson and I chaired a committee to map out a plan for the future of the hospital. I founded and ran the original primary care Independent Physician Association until we formed the Gila Multi-Specialty IPA, and I'm currently on the board. I've been on state and national advisory boards, so I have a fairly broad perspective and I do a lot of reading."
He recommended everyone read "An American Sickness" by internist Elizabeth Rosenthal. She hits the points of why American medicine is so expensive and why it's so dysfunctional, he said.
"I have spent more time practicing at Gila Regional than anywhere else," Skee said. "Drs. Bell, Dye and I were hospitalists before it became a word. Each of us was on call every third night. If there was a problem, the hospital called us. When I first came here, the hospital was Hillcrest. Most surgery was going out of town. Dr. Bell and Dr. Dye, who had been here about seven years when I came, were keeping people here. Dr. Neely in the emergency room, Dr. McMullin in radiology, Dr. Sexton in ophthalmology, Dr. Deming in urology—those guys all came here for different reasons, but it was a magical combination. They turned things around with a steady hand and getting things done right."
He said it's the physicians and the nursing staff who determine what the quality of the hospital is. It's the caliber of care. "You cannot legislate good medical care anymore than you can legislate good education or anything else. It seems to be a lesson our government is incapable of learning."
"We work hard to make Gila Regional a good hospital," Skee said. "It's a concerted effort by dedicated individuals doing it for the public good."
He said he was not for or against privatization or other changes, because "it's really the quality of the individuals. After all, Silver Health Care is a private for-profit organization. I've seen a lot of not-for-profits doing less for the public than we do. I've done volunteer work with Indian Health Services and in South America. The practice of medicine is a calling."
Skee said he did his residency at Bellevue Hospital in the emergency room. " I was there when the electricity went out for three days. I was in the middle of discovering that a woman with continuing headaches had increased pressure on the brain—a very ominous thing. I was in that room when I was called because three emergencies had come in—a man not breathing, a man with uncontrollable heavy seizures and another with a heart attack. I was dealing with the three when the electricity went out in Manhattan. Bellevue had back-up power, but at the same time as the generator came on, Dispatch said we have some electricity, 'where do we send it?' Someone said Bellevue. It came in at the same time as the generator kicked in. It fused the circuit boards. Everything stopped. Everything went dark. Upstairs, 50 respirations stopped simultaneously. Nurses were bagging patients, so they could breathe. They brought in more generators outside, with cables running across the doorway. It was chaos. As soon as I got the other three stable, I went back to the first room, because she was as sick as the others. I opened the door and the room was empty. I asked where she was and finally a vice-administrator came by and said: 'I sent all the non-emergent ones home.' So, we had the police and fire officers out looking for her. We never found her, so I don't know what happened to her. So that formed my opinion of hospital administrators first of all. Well-intentioned, but not knowing what's going on clinically."
What happened in 2000 with the County Commission? "I spearheaded that effort not to sell the hospital. We were putting some heat on them. The chairman called me in and said; 'We aren't going to sell the hospital, but we want to get this bond passed.' I didn't back off. I felt I did the right thing."
"When I was on the Board of Trustees, Quorum was the management company and the CEO and CFO were employees of Quorum," Skee said. "It was about that time when Mountain View came into being and it became part of Quorum, which purchased it. They started advertising. Up to that point, we were capturing 80 percent to 90 percent of the local market. Things were going pretty well. I said I was a little uncomfortable having this company running us while competing with us, so we made the change from having the CEO and CFO be employees of Quorum, which I think was the right thing to do. After my time, the board decided to get rid of Quorum; I don't know why. When the company was there, I thought they were a good addition, because they kept the administration from doing stupid stuff. Medicine is complex. We have to do what's right today, but we have to look toward the future to stay viable."
Quorum had yearly training meetings, including for the board members. "It was a good program."
"Over the past 10 years I've seen decisions made that seemed right at the time, but it was totally predictable that it turn out badly," Skee said. "If Quorum or someone else had been here, it might have been less likely to happen, but nonetheless, they happened. Everyone is trying to keep the hospital viable. Everyone is sincere. Being a board member is a complex job and it takes a while to learn the job. They seem to depend on the administration for facts."
He noted that being a CEO is tough. He said when he was on the board, the CEOs seemed to be mad at him a lot of the time. "Right now, there is no historic longevity on the board. The previous county commissioners would appoint people they knew, as a favor, or something. I compliment this group for trying to figure it out. But something got us from 80 percent to 90 percent market coverage to the present 35 percent market coverage. "
He said in 1995, the Steel Workers Union decided to organize the hospital workers. "They went to the board, which said no thanks. So, they went to the County Commission and Manny Serna in a three-minute meeting approved the union. So, the hospital board took them to court. The National Labor Relations Board said the commissioners did not have the authority to do that. The only ones with the authority were the appointed trustees. There have been a lot of bad decisions, especially in the hospital relationship with the community. Now they have hospitalists, which is a group from outside. Few doctors actually go into the hospital now, so the hospital doesn't know them, and the doctors don't know the hospital. There are more ways to do wrong things than good things."
Skee said the hospital going with a regional firm of hospitalists was good, but "they are not familiar with the community. They don't do the stuff we used to take on ourselves. Now there are many more transports. Many that I would not have transported. The medical community is absent from the hospital now. That's been a detriment to the community."
He said when he first came to Silver City, there were no specific ER doctors. "I had Tuesday nights. It was just what we did, then the government came out with strict rules. The hospital couldn't donate over certain amounts. Now, doctors get paid for being on committees. I was on call every third day. I didn't get paid extra. I stopped counting after 10,000 hours."
"One big mistake the hospital made about three years ago was getting rid of home health and hospice," Skee said. "Everyone in this group through it was the best running part of the hospital. We had a special meeting and the doctors voted to oppose it. We told them then the problem was in the billing office and that they needed to train people, get them certified as billers and coders. They weren't given the tools. Now they have brought in outsiders."
He said for years, GRMC was the most subsidized hospital in the state. It was destroyed by being overfunded, he said. "When I first came, half my work was in the hospital. Now it's 1 percent to 2 percent. We would take a week out of the office to take care of patients in the hospital. The government now tries to give incentives to keep people out of the hospital. It's less efficient."
Skee said he went into mourning when he wasn't working in the hospital anymore. "It was what I did. It was hard for me to give it up. And I don't think it's as good for the patients. The patient wants to see someone familiar. Another bad decision was when they came out with DRGs – diagnostic related groupings (managed care by diagnosis and average length of stay). The hospital couldn't make money keeping the patients longer. Sometimes, nowadays, we don't even know that one of our patients is in the hospital or has been transferred out of the area."
He theorized that hospitals have developed other business lines for what they can't get with DRGs. He also said one of his theories is that board members who give the administrators a hard time don't get reappointed. "Don White would hold the administration responsible. When he didn't get reappointed, it made for a weaker board."
Skee said 70 percent to 75 percent of the hospital is now outpatient. "It means anyone can come to town and compete. A colonoscopy here costs about $6,000. In Las Cruces, it's about $1,200 to $1,500. With that price difference, people go to Las Cruces. It was short-sightedness to not create an outpatient endoscopy unit here."
The hospital should hire physicians that do tests at the hospital, so the hospital can capture the ancillary services.
He again cited "An American Sickness." "Insurance companies, of course, don't want to keep costs down. The incentive has to lie in growing the business." He noted in the Great Recession, all companies, except for insurance companies, were hurt.
In his opinion, Skee said critical access would help in the short term, but in the long term it would make no difference. "In the short term and the long term, it will hurt patients. Medicare patients will get hit more, because they will be brought in for observation, instead of treatment. It encourages the hospital to remain inefficient. More people will be transferred out. The theory for critical access in a rural area is to save a life. That's always been what a physician should do, but rules prevent it a lot of times. We don't have a blood bank. We could donate blood to save a life, but not anymore because of government rules."
"Doctors are having to work harder," Skee said. "It's tougher now that it used to be. I want to keep our good medical community here, but it takes making tough decisions. The prognosis is guarded. In my opinion, the Cancer Center was a bad decision. What's going on now isn't comparable. We had such a good group. My experience with UNM is that they are long on promises. I don't think there are enough patients to provide work for a full-time oncologist."
He recounted some of the history. Karen DeGenevieve said the community needed cancer care, so she got Dr. McAneny to bring her group here. With 340B, because cancer drugs are expensive, and because of Medicaid and people who cannot pay, the drug companies had to give drugs to the hospital at a cut rate.
"All industries go through shake-ups," Skee said. "There has been rationing; in medical care there is rationing and there will be rationing. It used to be committees that decided if a person could go on dialysis or not. If you didn't pass the committee, you died. Transplants are by committee."
He cited only four ways to pay for health care.
1) Bismarck in Germany came up with the idea of health insurance. Doctors are hounded by insurance companies. "We have that method in this country."
2) Britain has the National Health Service. Doctors are on salary and paid by the government.
3) In Canada, you can go where you want, but the government sets the rates. "Medicare and Medicaid are patterned off that."
4) And the oldest, he said, is if you can pay, you get care; if no money, you don't get care.
The U.S., along with France, Japan and Canada, has its systems breaking down because of the Baby Boomer generation retiring. "There are not enough people paying in to make the numbers."
"The care at Gila Regional is still better than anything you can get in Las Cruces," Skee concluded.