I have only been a doctor for seven years, and I have only been in Southwest New Mexico for three. I quickly became confident in and invested in the quality and success of our healthcare delivery systems here. Over time, I realized providers here are leaving, more quickly than new ones arrive. I still hold some hope that we can turn things around, and so wanted to share my thoughts around Gila Regional Medical Center (GRMC) at this time.

To my Friends, Colleagues, and Neighbors:
First: who is responsible? And who is accountable?
I answer the first question with the cliché: we are all in part responsible. To the second question: it is no single person’s or entity’s fault.

Recommendation #1:
We all accept responsibility and accountability.
There is no good solution
Now, moving on to the more important aspects of this conversation: there is no optimal solution - this is a no-win situation, a losing enterprise.
Recommendation #2:
Accept there is no good, right, or correct solution to the current problem.

To the Provider and Healthcare Delivery Community:
The autocratic leadership, in-fighting, and the turf wars to protect personal interests, are what drive providers out of town, and lead to other community members’ mistrust in us and the healthcare delivery sector;
And it is cumulative: each let-down compounds their distrust in us;
Therefore, I recommend the following:
Recommendation #3:
Before we attempt to re-innovate again, let’s focus on stabilizing the system. I believe that is what the current administration is functionally working on.

To the Grant County Commission:
The actions taken regarding GRMC over the past 1-2 years seem reactionary and extreme, though they seem to have slowed in 2018 to a more urgent pace;
Please recognize this is not an acute problem - it is chronic;
The systemic failures have been happening for several decades, and serious signs of it have been happening here since well before I arrived three years ago;
Therefore, I recommend the following:
Recommendation #4:
I would encourage you to acknowledge the above, and that your current attention is belated, despite the lack of authority you have over the hospital, its governance, and its decision-making.
Regarding the latter, lack of formal oversight is the Commission’s lack of oversight;
Therefore, I recommend the following:
Recommendation #5:
Prior to selling the land the GRMC sits on, please consider approaching the hospital with a change in governance structure, or a good faith solicitation of a parent organization who is most likely to maintain our community's best interests in their governance.

The Problems
Many former colleagues I have spoken with have left our community for similar reasons, driven away by the autocratic medical leadership squabbling amongst themselves.
Certainly, there is no other Gila Regional Medical Center. But the argument that GRMC is so unique that there is nothing we can learn from the almost 2,000 other rural hospitals in the United States is shamefully short-sighted. I agree with the consensus that we lack the appropriate resources to do this on our own. Note: it is not possible to sufficiently meet all the systemic expectations. Therefore, a set of appropriate resources to succeed in our current system does not, and cannot, exist.

The Way Forward
One commonly attempted solution is to hire a large consulting group. We did this, two years ago, to help us trim unnecessary costs, improve the quality of our services, and meet the multitude of sometimes-overlapping stakeholder requirements, e.g. federal, insurance, etc. This effort was an attempt to mobilize the community healthcare provider stakeholders to collaborate to form a clinically integrated network (CIN). This effort was unfortunately not successful, never getting off the ground. Another common alternative is to sell the hospital. Nationally, as we know, the trend is that rural, independent hospitals are closing or getting bought out by larger, more remote parent hospital organizations. Not only do the rural hospitals experience an outflow of money, they frequently experience an outflow of jobs, a mandate to transfer patients to their larger centers, and too often the parent company eventually closes the hospitals’ doors. Regardless of the pathway, what happens if/when GRMC shuts down? I think we can all agree there will be economic, political, social, and educational repercussions.

What can we do?
As there is no good solution, I submit the following potential actions, and follow with a discussion of each:
A. Close our doors now;
B. Sell to a larger hospital institution or corporation;
C. Continue as an independent hospital;
D. Reframe ourselves as a regional hospital, and restructure accordingly; and/or
E. Become a critical access hospital.

A. Close our doors now…
… as opposed to the significant risk of closing later, after suffering further financial losses.
B. Sell to a larger hospital institution or corporation…
This is the alternative to continuing as we are. While it would relieve a significant economic burden in the short-term, it seems unlikely to be in the best interests of our community in the long-term, in particular in the way of needs-based resource allocation, access, and community economic stability. Therefore,
Recommendation #6:
If we sell, I recommend we initiate a formal, clear effort with the appropriate parties of the one or two organizations whose priorities best align with ours, in particular with us as potential employees, and as patients.
C. Continue as an independent hospital…
This continues to be the alternative to selling. Considering our expenditures, and considering where our revenues come from, I can understand folks’ worries about GRMC’s financial sustainability as a county-owned hospital. That said, our current administration seems quite pragmatic and prudent in their management thus far, reportedly improving our current fiscal state substantially, which is promising. Additionally, we could also consider becoming a non-government-owned hospital, maintaining our independence in the form of a different organizational structure. Yet I can feel the apprehension, given experiences with the previous administrations’ fiscal reporting.
D. Reframe ourselves as a regional hospital, and restructure accordingly
Consider our patient population: what proportion of them reside (and pay taxes in) Grant County? what proportion of them reside in neighboring counties? Given that Grant County is the wealthiest of New Mexico’s four-county Southwest Area Health Education Center (AHEC) region, does the volume of patients from the other counties and the implication for likelihood of reimbursement change who we should be serving and how we should be serving them? Does EMTALA (Emergency Medical Treatment and Labor Act)?
E. Become a critical access hospital
I acknowledge it would prohibit the opportunity to maximize services and profit through innovation and investment. This does not mean we cannot grow or expand services. It does, however, mean that we’ll be reimbursed for our expenditures, leaving room for innovation-generated profit to be reinvested in replacing and maintaining necessary capital and other fixed costs as needed, and we can expand services with the remaining funds. At present, however, we do not have that luxury. Expansion is an unrealistic conversation right now. Please let us clarify our task at hand: coming up with a one- to three-year plan to avoid losing our only hospital. For this goal of rescue and stabilization, a critical access hospital designation would be wholly sufficient to achieve said goal. One to two years from now, we can begin to outline what investments are necessary for organizational maintenance. And perhaps around the three- to five-year mark we’ll be in a good position to turn our ideas forward toward expanding services with a go-live date between the five- and ten-year mark. In addition, a significant bulk of our reimbursement already comes from public state and federal funds, we already qualify as health professional shortage area, we have a relatively large population of Medicaid recipients, a relatively low average per capita income, and we essentially already operate much like a critical access hospital. Currently we eat the cost ourselves, when we could be getting reimbursed for it as a critical access hospital. Why are we leaving these dollars on the table? By hoping for the best, and preparing for the worst, we position ourselves in the best potential position to adapt to the possible outcomes outlined above and the ever-changing healthcare environment. Therefore,
Recommendation #7:
My strongest recommendation is to become formally recognized as a Critical Access Hospital.

In conclusion:
● We all have the same high-level goal: doing what is best to serve the healthcare needs of our community.
● We all bear a portion of the responsibility burden.
● This is no single person’s or entity’s fault.
● There is no good solution.
● No one of us (neither person nor entity) can solve this alone; we have to work together as a community, by a community, for the community, to maintain a system of the community.
● Let’s readjust our expectations: we cannot provide all the services we would like to with the resources we have now, nor with the resources we may have in the near future, i.e. anytime in the next 10-15 years.

Ms. Halaska, my favorite grade school teacher, used to begin every new service-learning conversation with the task: “define your community.” Likewise, whenever I facilitate conversations about building or rebuilding a new healthcare delivery entity, I always begin with a parallel task: “Step 1: Define your population.”

To all invested in our access to healthcare, and to the holistic health of our community, I invite you to regroup, and ask yourselves the above two questions:
“Who is my community?” and
“Who is my service population?”

Rachel Sonne, MD, MPH
American College of Preventive Medicine
American Academy of Family Medicine
Master of Public Health in Health Management & Policy

Live from Silver City

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