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Maternity care landscape evolves: Additional OB practices increases choices, competition

fr womenscareA shake-up in the medical world of maternity care and childbirth means more choices for pregnant women in Jackson, Swain and Macon counties, but also heightened competition for the profitable labor and delivery line.

Two new obstetrics practices were launched within weeks of each other this fall, both catering to women in Jackson, Macon, Swain and beyond. The number of existing practices in the region doubled nearly overnight. 

Meanwhile, the shifting OB medical landscape has set the stage for a tug-of-war between Harris Regional Hospital in Sylva and Angel Medical Center in Franklin. 

Harris has had the corner on the childbirth marketshare in the western mountain region for years. Harris delivers more than 600 babies a year, drawing women from a five-county area. 

But Angel Medical Center is no longer willing to take a backseat. Now owned and backed by Mission Health, Angel has been expanding its OB line since 2012. The latest move: a new OB practice run by Mission with offices in Sylva and Bryson City — aimed directly at pulling marketshare once considered squarely in Harris’ territory toward Angel.

Angel hopes its new providers — six since 2012 — will increase labor and deliveries by 25 percent over the coming year. Deliveries at Angel topped the 200 mark last year, but it’s still a third of the volume at neighboring Harris.

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Angel now has six OB providers doing deliveries there, and three offices in three counties. That’s compared to four providers who deliver at Harris, with offices only in Sylva.

Since the number of pregnant women is a finite pool, the hoped-for gains by Angel would likely be a hit for Harris, since it’s the only other hospital in the rural five-county region that delivers babies.

Delivering 600 babies a year has been big business for Harris. So much so, that Harris recently completed a major $1 million renovation of its labor and delivery suites, with a complete remodel of the mother-baby wing and a dedicated C-section suite in the planning stages.

The major investment in the OB service line is a testament to its importance for Harris. But now, it will have to fight a little harder given the forays by Mission working in concert with Angel.

“It was disappointing because we were building something special here in the community,” said Dr. Janine Keever, the owner of Sylva-based Smoky Mountain OB-GYN, who delivers at Harris. “But we aren’t going to sit back and cry about it.”

Mission officials have rejected the notion that one hospital, or one practice, has geographic entitlement in the western counties.

“Yeah, there is competition in health care. Sure. Is that a bad thing?” said Dr. Susan Mims, Vice President for Women’s Services at Mission Health. “I think it is important for women to have a choice and choose what is right for them.”

 

Shifting landscape

Sylva is ground zero in the shifting OB landscape. 

For much of the past decade, one megalithic private practice based in Sylva had a de facto monopoly on the reliable stream of maternity care and childbirth.

Harris has long been the go-to hospital for deliveries in the region. And that made Smoky Mountain OB/GYN the go-to provider. All 600 babies born at Harris were delivered by Smoky Mountain.

The founder and owner of the practice, Dr. Janine Keever, didn’t intend to corner the market when she opened her doors in 2006, with just herself and two employees. She grew organically but rapidly, as a smattering of solo OB practitioners serving the region consolidated under one roof — hers.

“I haven’t tried to recruit anyone over the past seven years. People would come and say ‘Can I work there too? Can I work there too?’ It grew into what it was as there was a need,” Keever said.

But with two new OB practices opening offices in Sylva recently, Smoky Mountain has shrunk considerably — from eight to just two providers.

The two new practices to join the game are both hospital-owned ventures.

One was started by Mission Health but is tied to Angel in Franklin rather than the Mission flagship in Asheville. The other was launched by Harris itself.

Both Harris and Mission were working on plans to start new OB practices, unbeknownst to each other.

One was not in response to the other, since both had been in the planning and start-up phase of new OB practices simultaneously. Coincidentally, they got to the finish line within weeks of each other — one opened in August, the other in September.

“We didn’t know about the Harris practice, and we had already gone down this road,” said Mims.

Despite the growth in OB practices, there hasn’t been much of a net increase in the number of doctors and midwives practicing in the region. The advent of new practices is more of a musical chairs of who was practicing where — namely providers moving from Keever’s practice to Mission’s or Harris’ new practices.

Mission decided to pursue a new OB practice based in Sylva after detecting hints of instability with Smoky Mountain, the main OB practice serving the region, said Mims.

“At the time there was some uncertainty. Things were a bit up in the air about who was going to be providing what,” Mims said.

Fearing OB care for the region — which rested almost entirely with one private practice — could be disrupted by an internal upheaval, Mission decided to take matters into its own hands and start a practice of its own.

“Having access to high-quality care close to home is a mission of Mission Health. We are constantly evaluating the needs,” Mims said.

Mims said it was risky to rely on one private practice as the sole OB provider for so many women from such a large geographic area, and thus was concerned after hearing rumors that Smoky Mountain was in flux.

Whether Mission played a role in creating that flux is unclear. Some believe Mission courted providers working for Keever to leave and start the new practice. Others say they were leaving anyway, and that they were the ones to approach Mission.

Harris CEO Steve Heatherly countered the idea that there was a shortage of OB providers in Jackson and Swain that would prompt Mission to open its new OB practice.

“I do not believe access to care to women’s services have been an issue,” Heatherly said.

Three midwives left Keever’s practice en masse to join the new OB practice under Mission. Keever lost another doctor to Mission before she even started. A doctor slated to join Keever’s practice switched teams and joined Mission’s new practice instead. Another doctor in Keever’s practice left to join Harris’ newly formed OB practice.

Change has been a constant for Keever. This is the second time that a team of midwives have left to start their own practice. The last one didn’t make it.

The state of flux isn’t new to Keever.

“People move on, they have babies of their own, people get disgruntled, the grass is greener somewhere else, they go and then come back,” Keever said. “But over the years we have built a solid foundation. I think we are more stable in this community now than we have ever been.”

This year, Keever opened a giant, well-appointed, brand-new office in Sylva to accommodate the team of eight providers at the time. With only Keever and one other doctor remaining in the practice, the new building is over-sized. But Keever said she’s not over-extended on it financially.

“I didn’t go in further than what I can handle by myself. I have saved up a long time to have this building,” Keever said.

 

A united front at Harris

Keever has a mixed reaction toward the new competition.

One of the new practices has been launched by Mission, with the intent of snagging some of the labor and delivery market in Jackson and Swain — squarely in Harris’ territory — and siphoning it toward Angel, which Mission owns.

“It is always scary when there is change,” Keever said. 

But she’s a survivor.

For years, Keever had competed in Angel’s backyard. She had an office in Franklin, and pulled in a sizeable amount of business from Macon over the mountain to Harris.

Now, with the added competition in her own backyard and Angel upping its game, Keever has closed her office in Franklin.

But Keever is taking the other new practice launched by Harris — Mountain Regional OB/GYN — in stride. While it is technically in competition with Keever, they have pledged to cooperate and work together.

“We all got into this for the same reason, to take care of women and take care of babies. We all have the same goal to have healthy babies and healthy moms. That’s what unites us,” Keever said.

They have also been united by the shared threat of competition from Mission. Harris CEO Steve Heatherly said Harris did not set out to compete with Keever, nor is Harris trying to steal Keever’s business for itself. The only goal is to ensure a stable of high-quality doctors to serve the healthcare needs of the region.

When recruiting new OB doctors in the future, Heatherly said they would be welcome and encouraged to join whichever practice they feel is a better fit for them.

“We would continue to support the growth and development of Dr. Keever’s practice and our practice,” Heatherly said. “If we are in agreement that ‘Yes, we need to bring in another provider,’ we would begin bringing in candidates and introduce them to both practices. They could chose whichever model they are more comfortable with.”

But an increasing number of physicians want to work for hospital-owned practices rather than deal with the challenges of private practice. So Harris has to be prepared to offer that type of employment arrangement.

In a sense, the advent of a hospital-owned OB practice working side-by-side with a privately-owned OB practice reflects a national trend. 

“Many younger physicians are more risk- adverse as it relates to income and even entrepreneurialism,” Heatherly said.

Working for a hospital-owned practice means a steady paycheck, and not worrying about things like making payroll or the $50,000 annual malpractice insurance payments per provider.

“There are headaches that go with it,” Keever said of private practice.

And that’s why she doesn’t resent Harris for starting its own hospital-owned OB practice alongside hers.

The two practices now delivering at Harris — Smoky Mountain and Mountain Regional — also need each other.

With just two OB doctors under each practice, they have a cooperative arrangement to share on-call duty, delivering the babies of each other’s patients if they go into labor when it’s their shift to be on call.

“We all have to put in what we can to make this a great process,” Keever said. 

As a testament to their cooperation, Keever and Dr. Metcalf, a new doctor with Harris’s Mountain Regional OB practice, came together to do a joint interview for this article. Keever was coming off an on-call hospital shift, and Metcalf was coming on. It was during this changing of the guard that they took a break from swapping patient notes to talk about the new OB world.

They made a point to emphasize that they view themselves as being on the same team. The four doctors at the two practices delivering at Harris all have a similar philosophy.

“I am not really worried when I turn a patient over to Dr. Megan Metcalf. She is going to take care of this patient the way I would take care of this patient,” Keever said.

“Any doctor who is going to be taking care of you is going to be taking care of you really well,” Metcalf agreed.

Keever said they wouldn’t hesitate to “scrub together” if a patient needed two doctors on deck for an emergency surgery.

Harris recently completed a major $1 million renovation of its labor and delivery suites. Harris also has plans in the pipeline for a complete remodel of the mother-baby floor where women and their newborns stay over following childbirth, and a dedicated C-section suite, so women needing a C-section aren’t competing for general surgery beds.

That’s something that attracted Metcalf when she was recruited to Harris this year.

“There is a lot of energy being put into the women’s health service line and labor and delivery. I liked the idea of being a part of that,” Metcalf said. “When I’m out in the community and tell someone what I do for a living, people have nothing but great things to say about how well they were taken care of here.”

 

Angel on the move

Angel, in concert with Mission, hopes to undo the historic reputation of Harris as the epicenter of labor and delivery.

Two things are paramount for the plan to succeed. Angel and Mission must also stop the outmigration of women from Macon bypassing their own hometown hospital to deliver at Sylva.

Angel delivered 219 babies last year — about a third of the volume at Harris. But it’s up from past years, likely due to two OB physicians recruited in 2012 to start Angel’s first full-time, dedicated OB practice.

But now, Angel must establish a presence beyond the borders of just Macon County, something the new Mission Women’s Care practice aims to do with offices in Sylva and Bryson City.

There was a desperate need for an OB office in Bryson City to serve women in Swain and Graham, who otherwise had to make the trek to Sylva for basic check-ups, Mims said.

“This is one of the bigger needs,” Mims said, and the providers saw that. “It was important to them to move further west so the patients wouldn’t have to drive so far for care. They said ‘We really want to go west,’ and we said ‘This really makes sense. There is a big need and we have providers who had a desire to do that.’”

It could take time to build up the patient base to support the new offices, however. Mission is subsidizing the salaries and overhead for the practice until the volume reaches that level. 

There were also start-up costs involved in buying and renovating office space, buying medical equipment, computers and furniture, and paying the salaries of staff for the first half a year or more.

“It is an investment but that’s what we do. We invest a lot to make sure we are meeting the needs of the people of Western North Carolina,” Mims said. “In the long haul we will be able to offer the kind of care women want close to home.”

Dr. Beth England, the physician leader of the new Mission Women’s practice, has an affinity for Bryson City. She and her husband both worked as river guides on the Nantahala in their younger days.

But it also fits her passion in medicine.

“I have always been interested in rural medicine and providing people with care that is close to where they live,” England said.

It’s wearying for patients to make the trek to Sylva for all their OB visits throughout pregnancy, particularly in the final weeks when appointments come fast and furious, once a week at best and sometimes more.

“In this part of the state particularly, I feel like people have to drive really long distances to have an OB take care of them,” England said. “I think it is really taxing on a lot of patients to get the care they need.”

As a counter to that theory, Keever said her practice had an office in Bryson City at one point, but found patients preferred to come to Sylva, since they usually had to hit the Wal-Mart anyway.

The Bryson office makes maternity care closer for women in Graham as well, however.

“The people who live way out in Graham County will be able to drive half as far for their routine appointments,” England said of the Bryson office.

But, there’s a catch. 

Women who choose England’s practice will be steered to deliver at Angel Medical Center in Franklin. That goes against the grain of what women in Swain are used to — namely, delivering at Harris. It will take some rebranding for Angel to be accepted as an equal player.

But ultimately, the practice and the doctors will drive patient choice, rather than the hospital where delivery happens, England said.

“In my experience, patients will feel comfortable with a provider or group, and then deliver at whatever hospital they are affiliated with,” England said. “Every patient will make that decision based on a lot of different factors for themselves and their family. They definitely have a choice.”

It could be a harder sell for women in Jackson, who would have to bypass the hospital in their own backyard to deliver at Angel.

But Mims believes women will gravitate toward the Mission Women’s practice for its philosophy and approach to maternity care — namely, as the only practice in the region that has midwife care.

England and three midwives with long histories in Jackson County make up the new Mission Women’s team.

“Midwives, I think, are trained slightly in a different way. They offer a real high touch experience,” Mims said. “Dr. England is a high-touch provider and so she fits very well with the midwives. But she has the ability to do any surgeries that are needed if complications arise.”

England explained why she chose to partner with Mission and start a new practice.

“Mission is known for their excellence in patient care and satisfaction. I felt like they were interested in really providing that quality patient-centric care that I want to provide,” England said.

England said patients who choose her practice will have the added benefit of her close affiliation with Mission, allowing her to consult with and tap the expertise of OB physicians. England is working from Mission in Asheville one day a week, something she sees as a way to stay up to date with the latest medical trends, and continue to be affiliated with high-risk patients that end up at Mission.

However, the OB providers who deliver at Harris also have a long-standing relationship with Mission, and readily consult on patients who need a higher level of care or with high-risk pregnancies.

Meanwhile, Harris is promoting the fact that the four providers who deliver there are all physicians.

That said, Metcalf said the physicians who deliver at Harris don’t push for unnecessary interventions. The C-section rate is only 17 percent, which is low compared to the national average. Harris last year was ranked second of all North Carolina hospitals for avoiding unnecessary C-section deliveries.

The doctors and midwives competing in the brave new world of OB care in the rural, western counties do have some things in common. They are all women, for starters. It’s the first time that the OB doctors serving the region have been entirely female.

They all also love Western North Carolina. It’s why they chose the region to practice.

“I just love this part of the world. I feel like this is where I belong, really,” said England.

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