Value-based pay­ment poses chal­lenge to ru­ral hos­pi­tals

Modern Healthcare - - Q & A -

Marty Fat­tig has been CEO of Nemaha County Hos­pi­tal,

a 20-bed, county-owned crit­i­calac­cess hos­pi­tal in Auburn, Neb., since 2002. His fa­cil­ity, which re­ported 2014 net op­er­at­ing in­come of $748,336 on to­tal op­er­at­ing rev­enue of $12.3 mil­lion, this year be­came the first Ne­braska hos­pi­tal and the sec­ond CAH in the coun­try to re­ceive ISO 9001 cer­ti­fi­ca­tion for its qual­ity man­age­ment sys­tem. Nemaha also was named to the 2015 list of Health­Care’s Most Wired fa­cil­i­ties com­piled by the Amer­i­can Hos­pi­tal As­so­ci­a­tion’s Health Fo­rum and the Col­lege of Health­care In­for­ma­tion Man­age­ment Ex­ec­u­tives. Fat­tig serves on the Crit­i­cal Ac­cess Hos­pi­tal Ad­vi­sory Board on Qual­ity and the fed­eral health in­for­ma­tion tech­nol­ogy co­or­di­na­tor’s Health IT Pol­icy Com­mit­tee’s Mean­ing­ful Use Work­group. Mod­ern Health­care re­porter Shan­non Much­more re­cently spoke with Fat­tig about ru­ral hos­pi­tals’ chal­lenges in re­cruit­ing staff, the prob­lems cre­ated by Ne­braska’s re­fusal so far to ex­pand Med­i­caid to low-in­come adults, and how he mo­ti­vates his employees. This is an edited tran­script.

Mod­ern Health­care: What are the big­gest chal­lenges fac­ing ru­ral hos­pi­tals right now?

Marty Fat­tig: The chal­lenges fac­ing ru­ral hos­pi­tals to­day are many. First of all, we have prob­lems re­cruit­ing and main­tain­ing staff of all kinds. It may seem strange, but we have a more dif­fi­cult time re­cruit­ing en­try-level staff than tech­ni­cal staff. The hard­est po­si­tions for us to fill are in en­vi­ron­men­tal ser­vices and di­etary. The un­em­ploy­ment rate in Ne­braska is among the low­est in the na­tion, so just about ev­ery­one who wants a job al­ready has one.

An­other prob­lem fac­ing ru­ral hos­pi­tals is the de­clin­ing pop­u­la­tion in most ru­ral com­mu­ni­ties. It is next to im­pos­si­ble to have any level of growth when we are serv­ing a smaller pop­u­la­tion ev­ery year. Many of the res­i­dents left in ru­ral com­mu­ni­ties are el­derly, which creates an­other set of prob­lems. And as the health­care in­dus­try changes to one driven by value rather than vol­ume, ru­ral hos­pi­tals and ru­ral providers are chal­lenged to de­ter­mine how they fit in with the new par­a­digm.

MH: How would the sit­u­a­tion be dif­fer­ent if Ne­braska ex­panded Med­i­caid?

Fat­tig: Ne­braska has a pop­u­la­tion of peo­ple that are in a unique po­si­tion. They have too much in­come to qual­ify for ex­ist­ing Med­i­caid and too lit­tle in­come to qual­ify for the pre­mium sub­si­dies on the in­sur­ance ex­change. Th­ese pa­tients fall into the group that are be­tween 100% and 138% of poverty. The ma­jor­ity of the peo­ple who would ben­e­fit from Med­i­caid ex­pan­sion in Ne­braska are the work­ing poor. Th­ese are the peo­ple that I would like to help. Med­i­caid ex­pan­sion would move many of the pa­tients we serve from hav­ing no way to pay for their health­care to hav­ing some sort of cov­er­age. They would ben­e­fit from this and so would our hos­pi­tal.

MH: Has the hos­pi­tal con­sid­ered join­ing a larger sys­tem?

Fat­tig: All small ru­ral hos­pi­tals have con­sid­ered or will con­sider join­ing a larger sys­tem. The ques­tion I al­ways ask when pre­sented with this op­tion is, what is the com­pelling rea­son for us to join? So far, as a hos­pi­tal that does not em­ploy any physi­cians, I have found no rea­son. We in­stalled our elec­tronic health-record sys­tem in 2004, so we have no needs there. We have strong fi­nan­cial re­serves and a stable med­i­cal staff, so we have no needs there. We do well with our qual­ity pro­grams and our score on the Hos­pi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems Sur­vey, so there is no prob­lem there. We are the first and only hos­pi­tal in Ne­braska to be ISO 9001cer­ti­fied for that qual­ity man­age­ment sys­tem. We are al­ways eval­u­at­ing our cur­rent state. But right now, we have no need to join a sys­tem.

MH: How do you re­cruit qual­ity providers to prac­tice at your hos­pi­tal?

Fat­tig: We are in a good ge­o­graphic lo­ca­tion, be­ing 65 miles from both Lin­coln and Omaha and about two hours from Kansas City, which makes re­cruit­ing providers much eas­ier than when I lived in western Ne­braska and the near­est met­ro­pol­i­tan area was four hours away.

An­other thing we have done is, six years ago we en­tered an agree­ment with the fam­ily prac­tice clinic in our com­mu­nity to have a physi­cian as­sis­tant in our fa­cil­ity 24/7. They pro­vide

“Employees of a good ru­ral hos­pi­tal know they are making a dif­fer­ence in the lives of the pa­tients they serve.”

cov­er­age for the emer­gency depart­ment and also serve as a hos­pi­tal­ist. This means that the physi­cians are never on pri­mary call. A physi­cian is al­ways avail­able to back up the PA should they need some help. But about 80% of the time the PA can deal with the sit­u­a­tion. This has im­proved our physi­cian sat­is­fac­tion con­sid­er­ably. I also think it will help when it comes time to re­cruit new physi­cians.

Our out­stand­ing per­for­mance in the ar­eas of health IT and qual­ity also make this a great place to prac­tice, ac­cord­ing to the physi­cians who prac­tice here.

MH: Why have you stayed at a small ru­ral hos­pi­tal, and how do you mo­ti­vate and man­age employees there?

Fat­tig: I have stayed at a small ru­ral hos­pi­tal be­cause I am pas­sion­ate about ru­ral health­care. I grew up in a ru­ral com­mu­nity and I be­lieve that ru­ral res­i­dents have a right to have high­qual­ity health­care avail­able to them lo­cally. I also hap­pen to be­lieve that most of the time, as long as we keep pa­tients who are within our scope of prac­tice, we can pro­vide care that is as good if not bet­ter than they would re­ceive in a larger fa­cil­ity.

We mo­ti­vate employees by keep­ing them en­gaged. Employees of a good ru­ral hos­pi­tal know they are making a dif­fer­ence in the lives of the pa­tients they serve. We pro­vide our employees with good salaries and rich ben­e­fit plans, but we also pro­vide them with good equip­ment and en­gage them in the work we do. It was the en­gage­ment of the employees that al­lowed us to achieve our ISO 9001 cer­ti­fi­ca­tion. We are a site-- visit hos­pi­tal for our IT soft­ware ven­dor. So other hos­pi­tals are com­ing to us to find out how to use our com­puter sys­tem ei­ther be­fore they pur­chase the soft­ware or to find out how to use the soft­ware more ef­fi­ciently. Our staff are rec­og­nized as power users of the sys­tem, and they take a great deal of pride in this.

MH: Since 2000, the hos­pi­tal has been re­mod­eled to have pri­vate pa­tient rooms and fa­cil­i­ties for out­pa­tient pro­ce­dures. Has this been a pos­i­tive and nec­es­sary change?

Fat­tig: The re­model that we com­pleted in 2000 as well as the one that we com­pleted in 2012 were very nec­es­sary, and they have con­trib­uted to our suc­cess. We had pri­vate rooms in our old hos­pi­tal, which opened in 1963, but we had no bath­rooms in those rooms. We built new pa­tient rooms with bath­rooms and con­verted the old rooms to meet other needs.

In the re­model that we com­pleted in 2012, we started out want­ing to make our front en­trance friend­lier to peo­ple with mo­bil­ity is­sues. We wanted to have an en­trance with no steps or ramps and we wanted it to be cov­ered. By the time we fin­ished with the de­sign, we ended up ex­pand­ing the cafe­te­ria, build­ing a class­room for staff ed­u­ca­tion, and de­sign­ing space to help us be more ef­fi­cient in sev­eral other ar­eas. This last re­model ended up be­ing a $7 mil­lion project. I am proud to an­nounce that we com­pleted that project with­out in­cur­ring any debt.

You see, I stay at a ru­ral hos­pi­tal be­cause I am very proud of what we have been able to ac­com­plish and be­cause our fu­ture looks bright.

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