Getting a kidney dialysis center in Franklin grew more likely last week after a state committee agreed Macon County had demonstrated a tangible need for such a facility.

With a county population older than that of many surrounding communities, an increasing number of residents here have been forced to travel over Cowee Mountain to Sylva for treatment.

Driving to Sylva is an inconvenience during the warm-weather months, but during snowfall, it is a true danger for those seeking the lifesaving medical procedure, dialysis family members and patients have said. Last winter’s harsh weather set the stage for Macon County’s dialysis-center push, highlighting the difficulties patients faced making their way to the nearest facility in Sylva.

Macon County has a loose agreement from DaVita, a publicly traded national company that operates the dialysis center in Sylva, to come into Franklin if the state gives the OK. The state limits health care competition to ensure hospitals and medical facilities are financially viable, issuing a “certificate of need” only if patient demand warrants it. In this case, the state said there wasn’t enough demand for a dialysis center in Macon County.

Macon County leaders objected to the state’s assessment, however. DaVita prepared a letter of support for the county to show state officials, signaling its intentions to consider opening a center in Franklin.

The state requires that new dialysis facilities be able to project a need for at least 10 dialysis stations, or 32 patients — at last official count, in the state’s semiannual Dialysis Report, Macon County had just 23 residents receiving dialysis.

But county officials dispute that number, saying that more than 30 dialysis patients currently drive U.S. 441 from Macon County to Sylva for treatment. Additionally, officials suspect there are some dialysis patients in the southern end of the county driving to neighboring Clayton, Ga., who aren’t included in that number. The state’s threshold for justifying a kidney dialysis center also doesn’t take into account the particularly arduous health challenges associated with end-stage renal disease — yet Macon County’s end-stage population is increasing by an average of 10 percent a year, according to county records.

The state uses a 30-mile radius to determine locations of dialysis centers.

Friday, the long-term and behavioral care committee, meeting in Raleigh, agreed unanimously with Macon County’s arguments, according to County Manager Jack Horton. The committee recommended Macon County be allowed to build a five-bed dialysis center; that bed number could change to accommodate increased need.

The proposal now hangs on a State Health Coordinating Council meeting set for Sept. 28, said Macon County Commissioner Ronnie Beale, who has led the dialysis-center push.

Beale was optimistic the 29-member council would approve the proposal. If that happens, in March the county would apply for a certificate of need, which Beale believed would be forthcoming.

“We couldn’t be more pleased,” Beale said.

Macon County officials, concerned by the growing numbers of residents here forced to travel over Cowee Mountain to Sylva for treatment, are pushing for a kidney dialysis center in Franklin.

Macon County is a Mecca of sorts for retirees and aging seasonal visitors — the 2010 U.S. Census showed the average age of all residents living here is older than 50. County officials, citing Macon’s aging population and growing numbers of residents requiring dialysis, has asked that the state adjust methods it uses to award the required certificate of need.

The state requires that new dialysis facilities be able to project a need for at least 10 dialysis stations, or 32 patients — at last official count, in the state’s semiannual Dialysis Report, Macon County had just 23 residents receiving dialysis.

But county officials dispute that number, saying that more than 30 dialysis patients currently drive U.S. 441 from Macon County to Sylva for treatment. Additionally, officials suspect there are some dialysis patients in the southern end of the county driving to neighboring Clayton, Ga., who aren’t included in that number. Nor, said Commissioner Ronnie Beale, has the state considered all of the part-time residents that flood into Macon County each summer, a boost that almost doubles Macon County’s official 33,922-resident population — some that, no doubt, require dialysis.

A resolution adopted in June by Macon County pointed out that the state’s rules for allowing a private company to consider building in a community doesn’t allow for developing a kidney dialysis center to serve end-stage renal disease — yet Macon County’s end-stage population is increasing by an average of 10 percent a year, according to county records.

End-stage renal disease is the complete, or almost complete, ability of the kidneys to function. There are only two ways for patients to stay alive once their kidneys stop functioning: dialysis, in which the blood is artificially filtered; or kidney transplant.

Additionally, the state uses a 30-mile radius for determining locations of dialysis centers — but, Beale said at a recent Macon County Board of Commission meeting, there’s simply no comparing driving 30 miles on Interstate 40 downstate to driving 30 miles on mountain roads.

“Because of the terrain of the mountains, the distance is much more time consuming and difficult,” he said.

That’s certainly what Juanita and Leonard Max Wiggins have discovered, too. The couple has owned a residence in Macon County for two decades, but only started spending half of each year here after both retired a few years ago. Leonard Max Wiggins, who is 75, experienced kidney failure, and in January 2009 started dialysis.

Initially, he was able to drive himself much of the time. But his wife has been driving lately.

“When he gets so weak, he just can’t make that trip by himself,” she said Monday.

Her husband goes to Sylva three times each week, with each treatment lasting four hours. It requires 40 minutes to drive there, Wiggins said, and during the time he is in treatment she usually spends sitting outside in the car working on crossword puzzles.

The situation isn’t so hard in Florida, with a dialysis center just four or five miles from their home. Then, Wiggins can either slip back home for the wait, or her husband can make the trip by himself since it is a shorter distance.

By leaving the area in November, the couple misses the added difficulties of driving over Cowee Mountain in the snow and ice.

Commissioners last week passed an official petition asking the state to adjust its need determination. There would have to be an adjustment made to the need determination contained in the 2012 N.C. Medical Facilities Plan.

If granted, “hopefully private companies (would then) come in and determine if it is profitable for them to establish a center,” Chairman Brian McClellan said.

What is dialysis?

Dialysis is a medical process in which blood is cleansed of toxins the kidneys normally would flush out. It’s used when a person’s kidneys no longer function properly. This can be a result of congenital kidney disease, long-term diabetes, high blood pressure or other conditions.

Dialysis may be either temporary or permanent, depending on the person. If a dialysis patient is waiting on a kidney transplant, the procedure may be temporary. However, if the patient is not a good transplant candidate, or a transplant would not alleviate the condition, dialysis may be a life-long routine.

A new $9.3 million surgery center in Haywood County is being financed with equity put up by 20 doctors in the community who invested capital in exchange for a real estate interest in the project.

The hospital will lease the space, outfit it with equipment and manage its operation, but won’t pay for any of the construction costs.

MedWest CEO Mike Poore said the hospital could have afforded to build the surgery center on its own if it had to, but prefers the business structure.

“We could have taken on the debt, but what’s more important is it has our physicians invested even more in the health care of our community,” Poore said.

Poore said the hospital-physician partnership makes the outpatient surgery center all the more unique.

The business arrangement marries the hospital and physician community. Now more than ever, their success is contingent on the other.

The doctors will profit from the lease paid by the hospital. The hospital profits from the patients the doctors will rake in.

Also involved in the project is Meadows and Ohly, a development company out of Charlotte that builds medical offices and outpatient centers. The firm will act as the general partner and orchestrate the construction.

The 20 physicians who bought shares in the project as limited partners fronted nearly one third of the building’s cost, accounting for all the equity.

At first blush, the number of doctors who bought in to the outpatient center is impressive — more than 20 percent of the doctors practicing in Haywood.

But it is a fairly fool-proof and risk-free venture. As long as the hospital keeps leasing the space, they’ll get a return on their investment.

Dr. Luis Munoz, a pathologist, said for some doctors who put up money, it may have seemed like an attractive real estate investment. But for most it was out of their conviction to support health care in the community they serve.

The project didn’t exactly hinge on the financial backing of physicians.

“I could always do it with my own equity,” said Jay Bowling, vice president of Meadows and Ohly.

And the firm could have kept all the profits for itself.

“Are we leaving money on the table? Probably,” Ohly said.

But, the project is much stronger thanks to doctors’ involvement, Bowling said. And certainly less risky.

Its success is nearly guaranteed since the doctors are doubly vested: not only in their own practices but also as a real estate investor. The more business they bring in, the better surgery center does, and the more they get back on their lease.

Storied history

An outpatient surgery center has been in the works for more than a decade, but at one time was a controversial undertaking, one that looked much different than the end result today.

Five years ago, the hospital was poised to break ground on a $16.5 million expansion, financed and funded solely by the hospital. In late 2007, hospital leadership held a reception to unveil the blueprints, and even showed off upholstery samples for new waiting room sofas.

But the entire project came crashing down a few months later when the hospital lost its Medicare and Medicaid status after failing federal inspections in early 2008. Savings squirreled away to pay for the $16.5 million surgery wing were spent instead to keep the hospital afloat until it rebounded from the crisis. The leadership in place at the time has been replaced.

More than $400,000 spent on architects and plans went down the drain.

The project today looks much different than the one pursued by the older hospital leadership — both in scope and cost.

While the old project was billed as a “surgery center,” in reality it was a new wing of the hospital. The old plans simply called for a makeover of existing surgery rooms, while the majority of the project was ancillary: a new lobby and main entrance, new administrative offices and two floors of “shell” space for future expansion, for example.

While that project was shelved, the idea for an outpatient center was not.

Starting over from scratch — and without a nest egg to work with — the hospital administration and more than a dozen doctors split the cost of a $40,000 feasibility study in 2009 to reassess the project.

The result is a far different project: a standalone building on the hospital’s campus with the entire footprint dedicated to outpatient services.

New era of physician involvement

Other than its physical differences, the most marked evolution in the project is the business arrangement, namely the partnership with the doctors.

Under the old leadership, that type of investment and partnership wasn’t welcomed or allowed, Poore said.

Doctors had previously sought a seat at the table, offering to partner with the hospital and help finance the surgery center.

But the former hospital CEO wanted “complete and total control” and shut the doctors out, said Dr. Luis Munoz, a pathologist and a partner in the project.

Munoz, one of the physician investors, is pleased with the new approach under today’s hospital leaders.

“I think this is a preferable scenario, when both parties are involved,” said Munoz. “This is another example of this administration being transparent.”

“This is a really good example of how collaboration should work,” agreed Dr. Al Mina, a general surgeon in Haywood.

Better for the bottom line

The new outpatient center should help Haywood capture more market share, namely those patients who now bypass Haywood and go to doctors in Asheville affiliated with Mission Hospital.

Currently, outpatient services accounts for two-thirds of the hospital’s revenue. Not all of those services and procedures will be relocated to the new center, but it provides a snapshot of just how important outpatient revenue is for a hospital’s bottom line.

The hospital hopes to attract more outpatient services — and thus bring in more revenue — to pay for the new building.

While the hospital won’t bear the upfront construction costs, it still has sizeable expenses to deal with: the annual lease on the space, the overhead, the nurses and other support staff to run it. The cost of the equipment, from waiting room chairs to operating tables, will fall to the hospital as well.

But some of the cost to run the new surgery center will be a wash. Nurses and technicians who currently work in the surgery wing, mammography services, and other departments of the main hospital will simply move to the new outpatient center.

Some services will be duplicated in both the hospital and outpatient center, such as MRIs or blood work, and will require doubling up of staff.

In other areas, the outpatient center will operate more efficiently thanks to a better layout. The hospital will no longer need such an extensive transport crew, a by-product of the cumbersome design of outpatient services inside the hospital.

“It will save on this whole group of people who spend all day transporting people up and down from the sixth floor to the basement,” Markoff said.

Patients using the new building also will be able to stay on the same stretcher during their pre-surgery prep, the actual surgery and the recovery. Again more efficient, and cost cutting since there’s not all the sheets to wash or staff to constantly strip stretchers.

In many urban areas, new outpatient centers aren’t being built alongside hospitals, but instead are free-standing medical office buildings across town, sometimes not even run by the hospital. But it is advantageous to have the surgery center on the same campus as the hospital, Poore said. If there’s an emergency, the full resources of the hospital right next door can be brought to bear.

“If you are a free-standing surgery center and something goes wrong, they call 911. Here, we are the 911,” Poore said.

The project should be completed by spring.

“This project has been in the planning stages for many, many years so it is a great thing to see it come to fruition,” said Mark Clasby, member of the hospital board and Haywood County economic development director.

Patients seeking simple, routine procedures from mammograms to cataracts will no longer have to ride the elevators and trek up the halls of the hospital in Haywood County.

Construction of a new $9.3 million outpatient center has been launched on the campus of MedWest Haywood, making health care more convenient and accessible.

“It is going to have such a positive impact for out patients and the region,” said Dr. Al Mina, a general surgeon in Haywood County and one of 20 doctors who invested in the surgery center.

The patient experience will be a better one psychologically as well. Some people have anxiety about entering the hospital, said Mike Poore, CEO of Med-West Health System. A routine colonoscopy has a far more solemn and serious air about it at the hospital, while the outpatient setting will make people more comfortable and at ease.

“It will be less institutional,” Poore said. “If you are having a simple, same-day surgery, you don’t have to go into the hospital.”

Dr. Luis Munoz, a pathologist, said patients needing simple blood work can easily get in and out without traipsing through the hospital to the lab like they do now.

“You avoid going through the halls where potentially people are ill,” said Munos, also a capital partner for the facility.

Patients who now bypass Haywood and travel to Asheville for outpatient surgery could stay closer to home thanks to the convenience of the new center.

“If I need a couple of items at the store, I don’t go to Super Wal-Mart where I have to walk a quarter mile,” said Dr. David Markoff with Mountain Eye Associates. Instead, he goes where he can park near the door and quickly skirt to the aisle he needs.

Markoff is pleased he will be able to pop down the hall to tell waiting family how a patient is doing, something he can’t do now given the disjointed layout of outpatient services in the hospital, where the family waiting room is several floors away from where the surgeries and procedures are performed.

The Haywood hospital currently has six surgery beds. Four will remain in the hospital. Major surgeries — those requiring a stay at the hospital for recovery like a hip replacement or spine surgery — will still be done in the hospital’s surgery rooms.

The new outpatient center will have two surgery rooms, two minor procedure rooms and one endoscopy room, along with other outpatient services like MRIs, CT scans, lab and blood work, wound care and physical therapy.

Separating major surgeries from minor, outpatient ones will make for a smoother workflow, Poore said.

When elective or routine procedures share the same suite of operating rooms as emergency surgeries, as is the case now, patients getting an eyelid lift, for example, get bumped from the schedule to make way for a woman in labor needing an emergency C-section.

Balancing the flow of rooms can be difficult, Poore said.

“If you were an air traffic controller, it’s like having the space shuttle landing at the same time as a prop plane,” Poore said.

Phyllis Prevost, a Waynesville philanthropist who has made several sizeable contributions to the hospital, said the hospital has been running out of room and a dedicated outpatient center is desperately needed.

“The citizens of Haywood County are growing older every year,” Prevost said.

Prevost is particularly excited about the Women’s Center.

The Women’s Center will have its own entrance and will serve as a central location for mammograms, breast imaging and breast MRIs. It will also house the nurse navigator program, which works with women when an abnormality is detected in their mammogram.

“They hold that patient’s hand through the process and coordinate that patient’s care,” said Teresa Reynolds, chief operating officer of MedWest-Haywood.

A state bill aimed at ensuring a balance of power between Mission Health System and smaller hospitals has placed lawmakers in the middle of a healthcare turf war.

As Mission steps up efforts to acquire smaller hospitals and doctors’ practices around the region, some fear the Asheville-based health system will siphon healthcare dollars away from local communities and limit the scope of medical care patients can get closer to home.

Meanwhile, patients don’t want business motives to drive the healthcare they receive. The medical community universally asserts that isn’t the case, even as hospitals jockey over market share and fiercely guard their territory from encroaching competition.

But Sen. Jim Davis, R-Franklin, who introduced the bill, isn’t so sure.

SEE ALSO: Angel close to merger with Mission if state bill stays at bay

“Health care is a business, it is a huge business, and for Mission it is close to a billion dollar a year business,” said Davis, an orthodontist in private practice who represents the six westernmost counties in the General Assembly. “Just like any other business we have to guard against monopolies.”

If Mission’s dominance is allowed to expand unchecked, with more and more doctors and rural hospitals coming under its umbrella, Davis fears everything except routine medical procedures and basic care would be funneled to the flagship in Asheville.

“None of these hospitals in the western part of the state want to be an emergency care center and just shove everything to Asheville,” Davis said. “Local hospitals want to maintain care in the local communities.”

Mission leaders maintain they do not want to suck up business from smaller county hospitals — and if they tried, patients wouldn’t stand for it.

“The data has been very consistent that people prefer their local hospital for routine hospitalization,” said Janet Moore, communications director at Mission.

Mission plays a life or death role for patients across Western North Carolina as the only hospital in the state’s 17 westernmost counties where highly advanced medical care is provided.

It’s not in anybody’s interest to see that function undermined, Moore said. On that point, Davis agrees.

“It is essential that Mission hospital remain strong in the western part of the state,” Davis said.

Yet Moore said the freshman senator’s bill would hamstring Mission: it would bar Mission from affiliations or joint ventures with other hospitals and doctors’ practices until the end of the year, or until a study is completed.

“This bill says Mission has to compete with a different set of rules than everybody else,” said Moore. “We are a little perplexed by the bill. What problem is this legislation supposed to fix?”

Mission is already subject to anti-trust regulations, imposed when it merged with St. Joseph’s Hospital. The state dictates how much it can charge for procedures, sets a profit ceiling and limits how many doctors the hospital can employ.

“We basically operate under a microscope,” Moore said.

Davis questions whether the rules go far enough, however.

“I have heard of quite a few physicians that are concerned about the lack of competition in the medical field,” Davis said.

Davis’ bill would commission a study to determine if those concerns are warranted.

“I have no evidence Mission has done anything wrong,” Davis said. “The whole purpose of my bill is to start a conversation.”

Mission’s frontline

Doctors in the region are divided on whether Mission is predatory in its business practices.

“There always will be a lot of paranoia in healthcare that the big, 800-pound gorilla is going to come in and steal your patients,” said Dr. David Mulholland, a family doctor in Waynesville who is affiliated with Mission.

But, that’s not the case, he said.

“They have plenty of patients. They don’t need any more patients,” Mulholland said.

What Mission does need, however, is referrals for highly specialized care not available at local hospitals — such as neonatal intensive care, open-heart surgery or repairing aortic aneurysms. Mission needs enough volume to cover the cost of highly specialized doctors and equipment. It counts on smaller hospitals to send patients needing advanced medical care its way, Moore said.

But when the hospitals in Haywood, Jackson and Swain counties partnered up last year with Carolina’s Health System headquartered in Charlotte, Mission began fearing those patients could be sent out of the region to Charlotte.

“Hospitals have very small profit margins. If even a small percentage of that business was siphoned off to Atlanta or Charlotte, it would be a big thing. It would hurt access for everyone in Western North Carolina,” Mulholland said.

Mission had hoped the MedWest group of hospitals in Haywood, Jackson and Swain would partner with it. But when they chose Carolinas instead, Mission reacted.

Mission began actively recruiting doctors in Haywood to join its staff. It also set up an outpatient clinic practically next door to Haywood’s hospital staffed by rotating doctors from Asheville.

Critics fear such a toehold could allow Mission to steer patients to Asheville for services. But it could be Mission is merely protecting its interests.

“Would they have had an interest in Haywood County if it was still just Haywood Regional Medical Center? They probably would have said ‘No, it is a stable situation. We get the tertiary referrals and that’s what we need and that’s what we want,’” Mulholland said. But “hospital administrators know the history of what happens when other competing large health care systems come into your area.”

Perhaps the paranoia cuts both ways, however.

MedWest CEO Mike Poore said his hospitals are not sending patients to Charlotte rather than Mission.

“Our referral patterns have not changed at all,” Poore said. “Patients do not have to worry that if a physician is employed by whatever institution that healthcare decisions are made based on anything other than providing the best care.”

When Poore’s own son needed neurosurgery recently, he sent him to Mission, not Charlotte.

“The neurosurgeons at Mission are excellent,” Poore said. “There is no reason for anyone to go beyond there for tertiary care.”

Poore said there are a lot of fears, but they are nothing more than that.

“We are working very hard to work together,” Poore said.

Dr. Stephen Wall, a pediatrician in Haywood County, said Haywood is a great hospital with great doctors, as is Mission.

“I wish we could all work together regionally,” Wall said. “I wish we could do this without always feeling like we are cutting each other’s throats.”

While MedWest frets that Mission is trying to steals its local health care dollars, and Mission frets that MedWest will send patients to Charlotte instead of Asheville, competing hospitals are nothing new in major metropolitan areas.

“It is not uncommon to have surgery center, hospital, surgery center, hospital — all within a stretch of a quarter mile,” said Dr. Chuck Trentham, an anesthesiologist at Angel Medical Center in Franklin. “We just aren’t used to the big business of medicine.”

Trentham said both sides are off in their portrayal of Mission — as a predatory hospital on one hand, or a purely benevolent institution on the other.

“I don’t think they are as bad as they are portrayed, or as good as they portray themselves,” Trentham said.

Angel CEO Tim Hubbs said he does not resent doctors affiliated with Mission providing services in their territory.

“If I didn’t have them coming a couple days a week I may not have an oncologist. For us it is not competition, it is providing a benefit to our community,” Hubbs said.

Wall said the outpatient clinic being run by Asheville doctors could be driven more by doctors’ interests than Mission’s.

“There are probably too many doctors in Asheville,” Wall said. “It is a great area and doctors want to live there, so there is competition for a shrinking healthcare dollar.”

In Franklin, doctors are used to competition from neighboring counties. Several Sylva-based practices have satellite offices in Franklin, holding office hours there one or two days a week, and sending business out of the county to Harris hospital run by MedWest in Sylva.

“The same way Mission is encroaching on MedWest, MedWest is encroaching on us,” Trentham said.

Who’s for it?

While battle lines are being drawn over the bill, exactly how it came to be isn’t completely clear. Davis wouldn’t name names when asked who approached him about the bill or who helped write it.

“I have talked to a lot of people about this bill,” Davis said. “There were hospitals and physicians groups and individuals that encouraged me to file this bill.”

It’s no secret that Park Ridge Hospital in Hendersonville supports the bill, and many believe it was the instigator. Park Ridge has reportedly brought two lobbyists on board to advocate for the bill in Raleigh.

For now, it remains the lone hospital that has gone public in support of the bill.

Park Ridge is part of the Adventist Health System, with 43 hospitals in 12 states. While Davis is a Seventh-Day Adventist, he said he did not introduce the bill to help Park Ridge because of that shared connection.

Davis said there are a “plethora” of theories about motives behind the bill. But he said his primary concern is that “health consumers’ interests are protected.”

Despite tension between Mission and Haywood, MedWest is not for the bill.

“We just don’t feel like we have any standing to support that bill,” said MedWest CEO Mike Poore. “We don’t see legislation as how you deal with competition. We believe in providing good quality health care, strong access and a great patient experience as how we compete, and that legislation is not needed.”

Some in the medical community have accused MedWest of advocating for the legislation, however.

“There has been a lot of goings on behind the scenes and behind closed doors,” Moore said.

Dr. Peter Goodfield, an Asheville cardiologist, claims the legislation was “promulgated by Park Ridge Hospital and MedWest.”

Park Ridge in Henderson and MedWest-Haywood are the region’s biggest and likely strongest hospitals after Mission. Yet their close proximity to Asheville makes it easy, too easy, for patients to defect — and thus have the most to lose should Mission launch an all-out affront.

While MedWest’s official position is against the bill, individual doctors in Haywood County are supporting it.

Three former chiefs of staff of MedWest-Haywood have gone on record supporting the legislation and accusing Mission of predatory practices. They wrote to the state as part of the public comment period on the COPA.

“Taking patients from the local hospital and medical community undermines the strong rural hospital system we are trying to build,” Dr. Shannon Hunter, an ear, nose and throat specialist in Haywood, wrote.

Dr. Al Mina, a general surgeon in Haywood County, believes Mission’s “aggressive expansion” into surrounding counties should be halted while the issue is studied.

“I have seen them duplicate services here in an attempt to weaken the local hospitals and siphon care that can very easily be performed here to Asheville,” Mina wrote.

Dr. Charles Thomas, an oncologist with 21st Century Oncology in Haywood County, has been at war with Mission hospital for more than 15 years.

Mission has attempted to block 21st Century Oncology from opening new cancer treatment centers in the region, from Franklin to Murphy to Marion. Mission challenged state permits for the competing cancer services and filed lawsuits to the same end.

“Throughout these many battles Mission’s ‘mission’ was to prevent competition,” Thomas wrote in his public comments to the state. “Mission will continue to do everything in its power to dictate healthcare delivery in Western North Carolina – even if it means cancer patients have to travel hours to receive necessary care.”

Recruiting doctors

In an effort to temper Mission’s dominance in the region, Davis’ bill aims to cap the number of doctors on Mission’s payroll.

Mission can’t employ more than 20 percent of the doctors in Buncombe County under its current anti-trust regulations. It is approaching that cap now.

Mission asked the state to increase the limit, which may have backfired by opening the door to the current debate. Davis’ bill would immediately stop Mission from employing more doctors during a study period, and would cap the number of doctors Mission can employ to 10 percent for the 18-county region. (The 20 percent cap now applies only to Buncombe.)

It’s not surprising that Mission wants to employ more doctors. It’s a national trend, driven by today’s generation of doctors who find the hassle of running their own office — the stress of being an entrepreneur on top of practicing medicine — isn’t worth the freedom.

It’s also financially attractive. Doctors are increasingly being squeezed by rising overhead and lower reimbursements from Medicare and Medicaid patients. As a result, doctors are gravitating toward a new model of being employed directly by hospitals. The hospitals keep the revenue generated from the patients, while providing a steady salary to the doctors.

But allowing Mission to employ more and more doctors will give them a lock on health care, Davis said.

“Where do you think the physicians are going to refer their patients if they are employed by Mission?” Davis said.

If Angel Medical in Franklin merges with Mission, Davis questioned whether doctors would start referring patients to Mission instead of the much closer hospital in Sylva.

But Mulholland in Waynesville said he does not steer them toward Asheville over Haywood.

“I let them decide where they want to go,” Mulholland said.

“I have no reason to stop using the local specialists. I still talk to and use our local physicians and trust them.”

Mission employs 150 physicians out of 700 who have privileges to treat patients at the hospital. Other hospitals employ a greater percentage of their doctors than Mission does. Angel employs 15 of the 40 doctors on its active staff while MedWest employs 75 doctors out of 230 — both more than one-third.

The majority employed by Mission are specialists. If they had to operate as a private practice, they wouldn’t be here, Moore said.

“There isn’t the volume of work here, for them to maintain their own practice would be financially very difficult,” Moore said.

Specialists employed by the hospital include several children’s specialists, like pediatric cancer and surgery.

“Without those specialists here these families and their children would be driving anywhere from two to four to six hours to get care,” Moore said.

Rural hospitals that have affiliated with Mission in recent years were partly drawn by having a heavy-weight in their corner to help recruit doctors.

Once affiliated with Mission, Angel Medical may be able to attract doctors to Franklin that it couldn’t on its own.

“We have the resources to pay the competitive salaries,” Moore said.

Mission is better equipped to help set up their offices, to buy them the equipment and technology they need, and offer them a larger network of doctors to be a part of, Moore said.

However, Davis has heard that some physicians felt forced to give up their private practices and become employees Mission. State regulators who crafted Mission’s anti-trust regulations obviously thought a cap was necessary, but didn’t foresee 15 years ago that it would be necessary beyond Asheville’s borders.

“There is a reason that was there: to protect physicians’ practices and to protect patients,” Davis said.

But according to Dr. Peter Goodfield with Asheville Cardiology Associates, tightening the cap for Mission when the national trend is moving the opposite direction is ridiculous.

“There are going to be virtually no physicians remaining in private practice. None of us can survive,” Goodfield wrote in public comments submitted to the state.

Mission monopoly?

Mission has already folded three smaller hospitals into its umbrella — those in Marion, Spruce Pine and Brevard. The hospital in Franklin is headed that way.

Mission is also close to a deal to build a $45 million outpatient center in conjunction with Pardee Hospital in Henderson County, seen as a threat to Park Ridge, which is also based in Henderson County.

Mission is not taking advantage of its dominance when it comes to pricing, Moore said. Its is the third lowest hospital in the state for costs, even though Mission has the highest percentage of patients in the state on Medicare and Medicaid — nearly 70 percent — who pay less than other patients.

While Davis talks about Mission’s unfair advantage, Moore said the bill actually stacks the deck against Mission.

Mission’s neighbors include Park Ridge in Hendersonville, run by Adventist Health System, with hospitals in 12 states, and Carolinas Health System in Haywood County, which has 29 hospitals under its umbrella.

“And they are claiming that we are a monopoly?” Moore said. “We don’t mind competing on cost and quality. We just want there to be a level playing field.”

Angel is a stand alone hospital, an increasingly rare status for small hospitals. It can’t continue that way indefinitely and has brokered a deal to merge with Mission in coming months. The bill would delay or even derail it.

Angel might then have to turn to MedWest for a partnership, which already has hospitals in Haywood, Jackson and Swain.

“That’s a de facto monopoly right there,” said Dr. Chuck Trentham, an anesthesiologist at Angel.

But given its market share of only 60 percent in Haywood and 57 percent in Jackson, it doesn’t come close to the definition of a monopoly, MedWest CEO Mike Poore said.

“The contrast to that is Mission’s market share in Buncombe and Madison is north of 94 percent,” Poore said.

What is COPA?

While a bill circulates in Raleigh to limit the dominance of Mission Health System, a state regulatory process is already under way to examine just that issue, independent from the legislation.

Mission is governed by anti-trust regulations dating to its merger with St. Joseph’s 15 years ago. The regulations are up for review, prompting a flurry of debate in the medical community about whether Mission’s ambitions should be curbed or it should be given the freedom it needs to serve as the region’s healthcare leader.

The players

Mission Health System: Memorial Mission merged with St. Joseph’s hospital 15 years ago to form a single, large hospital serving the Asheville area. It has three smaller hospitals under its wing, with plans to add a fourth.

Park Ridge Hospital: Based in Hendersonville and perhaps Mission’s fiercest competitor, Park Ridge is part of Adventist Health System with 43 hospitals in 12 states.

MedWest-Haywood, MedWest-Harris, MedWest-Swain: The hospitals in Haywood, Jackson and Swain counties recently united forming the new entity MedWest and adopting new names in the process. They are 18 months in to a three-year management contract with Carolinas HealthCare System.

Carolinas HealthCare System: As the state’s largest hospital network, the Charlotte-based system has 33 hospitals under its umbrella.

Angel Medical Center: A small standalone hospital in Franklin, Macon County. Angel plan to affiliate with Mission.

The health care bills rolling into the Haywood County jail for inmate care might now be slashed by up to 25 percent after the sheriff’s office contracted with a company who will ferret out discounts on the county’s behalf.

Currently, the county pays full sticker price for all health care given to inmates, and since they’re legally obliged to foot the bill for any inmate treatment, it can get pricey.

Sherriff Bobby Suttles told county commissioners that $20,000 a year was on the low end of what they might expect to pay. In a year when an inmate needs major medical care, such as open-heart surgery, costs can skyrocket to more than $100,000.

What the company, Correctional Risk Services out of Brentwood, Tenn., would do is comb through the bills looking for mistakes, such as being billed for a higher priced procedure or more treatment than an inmate actually received.

A company spokesman said that they save counties an average of 20 to 25 percent. They work solely on commission, keeping 30 percent of any savings that are found.

In addition to checking the bills for accuracy, the company will also be able to save the county from shelling out for full-price procedures by bringing them into a PPO — preferred provider organization — which would give the county the same kind of discounts private citizens can get by being under a medical insurance plan.

If the county sees savings from the contract, the majority would be from such markdowns.

Suttles characterized this as a win-win situation for the county. If no reductions are found, they lose nothing, and whatever savings they do glean will be a big help to the sheriff’s healthcare budget, which is, he said, notoriously hard to manage.

“Right now, we’re holding $8,000 worth of bills,” said Suttles. “It’s just hard to budget for the unknown.”

After successfully enlisting the help of local government, Haywood Regional Medical Center and Maggie Valley Health Investors are chasing state grants to fund two new medical facilities in Haywood County.

Haywood County commissioners agreed to apply on HRMC’s behalf to help pay for a new hospice center.

Meanwhile, the Town of Maggie Valley partnered with Maggie Valley Health Investors to apply for a grant to fund a nursing home planned in Maggie.

Both companies had to recruit government support since grants from the North Carolina Rural Center are only open to local governments and governmental agencies. The grants reward companies that are planning expansions or new construction with $12,000 for each new job created.

The Rural Center received just finished up a round of grant applications for its Rural Health Initiative this week. A total of 15 grant applicants will be competing for a pool of $2 million.

Plans for Maggie Valley nursing home

The Town of Maggie Valley agreed to sponsor Maggie Valley Health Investors’ application for a $480,000 grant to build a 114-bed single-story nursing home in town.

Though the skilled nursing facility will create approximately 80 new full-time jobs, the Rural Center grants reach a maximum of $480,000 for 40 new jobs.

Board members voted unanimously to lend their support to the 40,000-square-foot project, which is estimated to cost $12.5 million. The facility will bring rehabilitation services, Alzheimer’s management and respite care to the area.

While the Town of Maggie Valley will not directly funnel any money into the project, town staff will spend time administering the grant.

Maggie Valley Health Investors already operates the Canton Christian Convalescent Center. Its Virginia-based parent company, Smith/Packett Med Com, is building another assisted living facility in Jackson County.

Hospice in Haywood

HRMC hopes to score a $132,000 grant for the 11 new jobs it will initially create by building a six-bed in-patient hospice center, The Homestead of HRMC.

HRMC is also planning an End-of-Life Outreach Center.

It will also include space for counseling services and bereavement therapy, a reference library and a community education center.

So far, the hospital foundation has raised $2.4 million of its $5 million goal.

HRMC plans to complete construction by July 2011.

Haywood County will be required to provide about $4,000 in matching funds if the grant is approved. County commissioners unanimously agreed to sponsor the grant application.

Dr. David Trigg, medical director at the Good Samaritan Clinic of Jackson County, doesn’t know if he should do more or less to treat the uninsured. While he and the other volunteer doctors at free clinics are their patients’ only option for health care, he sometimes feels they’re the ones propping up a broken system.

“You feel like the boy with his finger in the dyke,” Trigg said. “Not only is it not the solution to the problem, but it paralyzes you. But don’t tell our patients that. They don’t have any alternative.”

Trigg has seen the failure of health care for the poor from a number of angles. As an emergency room doctor who currently works part-time intermittent shifts in Cherokee, he has seen the way uninsured chronic care patients clog the country’s critical care facilities.

“The ER is the safety net for people who don’t have insurance, and it’s not sustainable,” Trigg said. “If emergency rooms keep getting busier, not only will the poor suffer because they’ll continue to get boarded, but the rich will begin to suffer because they’ll be so inundated they won’t get to the critical cases,” said Trigg.

As a volunteer primary care provider at a free clinic, he has seen how people without insurance work to get better, to work some more to pay their bills, without ever having any real hope of getting insured.

“The patients will break your heart. Let’s talk about a man who works three jobs and his employers deliberately won’t give him 40 hours per week so they don’t have to provide insurance,” said Trigg.

As a teaching doctor at Western Carolina University’s health science program, he has seen how the insurance reimbursement system discourages doctors from going into primary care, creating shortages.

“Part of reform has to be — not debt forgiveness — but scholarships for doctors who go into primary care,” said Trigg. “I think a lot of young people would go a year for a year. You have to pay primary care providers more and specialists less.”

For Trigg, the fact that North Carolina has 77 free clinics — the most in the nation — is neither an indictment nor a credit. It’s a reality.

“Anytime someone gets into the free clinic, they realize — consciously or subconsciously — that the system is broken. They’re not necessarily politically motivated though because they’re in survival mode,” said Trigg.

Trigg thinks part of the reason the debate over health care is so contentious is because the people who know the system is broken are too disillusioned to join the discussion.

In many ways, the health care debate is as simple as the separation between rich and poor, and the poor don’t often tell their own story as well as others tell it for them.

Becky Olson, Good Samaritan Clinic of Jackson County’s executive director, said her impression of the clinic’s patients is they don’t believe their government listens to them, so they don’t bother speaking to it.

“What I do feel and see here is a real sense of disenfranchisement,” Olson said. “I’m not sure how many of our patients vote because there is a feeling it wouldn’t make a difference. The real voices in this discussion on both sides are coming from people who don’t have to worry in the same way about where their health care comes from.”

Olson, a registered nurse who has spent the last 30 years working in a variety of settings from labor and delivery to long-term care, began volunteering at Good Samaritan when the free clinic opened in 2001 and became executive director in 2006. She is increasingly frustrated that health care has become a politicized discussion about costs, when the human cost of failing to provide affordable health care is decimating people’s lives and increasing the gap between rich and poor.

“The bottom line right now is it’s not working for a significant part of the population,” Olson said. “I haven’t heard anyone who can say with certainty how much it might cost or how much it might save to change the system.”

For Olson the issue is simple. The patients she sees everyday shouldn’t have to wait in lines at free clinics to get treated for everyday health issues like asthma, diabetes, hypertension, and back pain.

“This is not the way that health care ought to be gotten. If our clients had a better way into the system, we would with great pleasure close the doors,” Olson said.

For a long time, health care providers stayed out of the debate over health care policy. In general, doctors and nurses are practical people focused on their work, but Olson has grown increasingly exasperated by the argument that the government shouldn’t pay to provide care to the poor.

“That kind of argument ... if you don’t think the government should be running programs for poor folks, then maybe you shouldn’t take Medicare,” Olson said.

Though Sylva resident Marsha Crites had no risk factors, she suffered a major cerebellum stroke at the age of 49.

“Not only could I not walk, I couldn’t sit,” said Crites. “I would even fall out of bed for a while.”

Her health insurance covered much of the expenses but not everything.

“They covered all but $10,000, but still, that was a lot that I had to cover myself,” said Crites, who ended up fighting the insurance company for more coverage and lower costs. “They would cover occupational therapy, but not speech therapy.”

Crites said she had to argue logistics with the insurance company while she was “out of it.”

“I have always felt that you had to beg, plead and beat on the door to get the health insurance coverage that you needed,” said Crites.

Crites suspected finding another health insurance policy would be nearly impossible even though she fully recovered from the stroke. She was right.

After Crites lost her insurance policy due to a divorce, she became “uninsurable.”

Crites was turned down by insurance companies left and right. She finally settled for temporary insurance, which only works for six months at a time. She pays about $250 a month, but her deductible is $3,500.

“I get no preventative care, none,” said Crites. “If you get really sick in those six months, they won’t renew it.”

As a self-employed landscape designer, Crites said there’s no way she could afford individual insurance even if she had been approved for it.

“Personally, I think it’s embarrassing for me as an American that we don’t have universal health care,” said Crites. “It is so much cheaper to cover everybody to provide preventative care.”

Crites asked if the people who complain about government control would want to take away benefits for veterans, social security, Medicare, Medicaid, and health insurance for Congress.

“Why do some people get government help and others not?” asked Crites, adding she is willing to pay more taxes to get everybody covered. “There’s no way my taxes would equal what I’m paying for premiums.”

Crites said there’s an urgent need to pass health care reform in the U.S. now.

“I just see so much tragedy,” said Crites. “This is not just about it’s inconvenient or it’s expensive. People are dying because we as the supposedly most progressive country on Earth can’t take care of our people.”

As if dealing with the trauma of breast cancer wasn’t enough, Martha Yonce, 62, was also hit with a devastating $80,000 in out-of-pocket expenses for her surgery, chemotherapy and radiation.

Yonce, a Franklin resident, thought she had her bases covered with the equivalent of a state employee’s health insurance policy. She received the insurance through her husband, who was a science teacher at Macon Middle School at the time.

Yonce’s insurance company had agreed to pay 80 percent of the cost but left her to deal with the remaining 20 percent in whatever way she could.

Coming up with such a large sum of money proved to be a major struggle, as Yonce and her family neared the brink of bankruptcy and almost lost their home.

“We wiped out what savings we had,” Yonce said. “It just took everything we had. That was nine years ago, and we’ve never really recovered financially.”

To make matters even worse, Yonce and her husband were recently denied insurance coverage that would supplement Medicare due to pre-existing conditions, including her breast cancer, and his diabetes and heart problems.

Even though Yonce has been cancer-free for years, she said the worry about recurrence never goes away.

“Good days are days you don’t think about cancer,” said Yonce. “You know that if it recurs, you are going to have a tremendous financial burden. You’re going to do all you can to save your life and treatment costs money — even with insurance.”

Yonce said she recalled taking medication for nausea that cost $100 a pill, while other women went without because they simply could not afford it.

“The thought of somebody that’s kneeling at the toilet vomiting and there’s a medication out there that can help them and they can’t afford it, that’s sad, that really is,” said Yonce, who has actively been calling for health care reform in the past year.

Yonce has attended rallies and made frequent calls to representatives and fellow citizens in the past few months. She hopes that Congress will pass a health care bill that places a cap on out of pocket expenses.

Yonce said she was surprised by how many sad stories she came across while working at a phone bank. She once talked to a man who was asked to pay $900 cash for anti-rejection medication after receiving a kidney transplant and a woman who broke her hip but could not afford to go to the hospital.

Despite all the gloomy stories she’s heard, Yonce has managed to retain a sense of humor.

On a recent afternoon, Yonce prepared to go door-to-door to distribute flyers that featured a man named Vernon whose inadequate health insurance left him $28,000 in debt.

“This guy is not in as bad shape as me,” joked Yonce. “Vernon, you don’t know how good you’ve got it.”