Outpatient center to improve patient experience

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.

Mission in the crosshairs: Hospital turf war in WNC heats up

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.

Haywood jail hopes to trim inmate health care costs

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.”

Health care facilities to create new jobs

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.

At free clinics survival trumps politics

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.

Past illness leaves woman ‘uninsurable’

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.”

When insurance falls short, out-of-pocket costs become rapidly out-of-reach

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.”

When the health care crisis hits home: Three sisters share stories of insurance illusions

Nothing could have prepared Franklin sisters Suzanne Thomas and Karen Rice for the total financial ruin that followed their injuries.

Thomas, 63, and Rice, 70, are still coping with the impact of astronomical medical costs from nearly a decade ago, while another sister Shirley Ches, 74, is dealing with a health insurance bill that already scoops up about 33 percent of her household income and continues to climb significantly each year.

Thomas had to file for bankruptcy, while Rice had to move into a mobile home, giving up electricity and washing machines in the meantime. What astonished the sisters most about their plight was that they both had what they considered good health insurance when their injuries occurred.

Ches, Rice and Thomas have channeled the anger and frustration of their experience into an active fight for healthcare reform across the country, helping to organize vigils, sending petitions to Washington and sharing their story with crowds of strangers.

“We have all made a career out of writing letters to the editor,” said Ches.

Through their activism, the sisters have realized they are far from alone in their hardships.

“When you go to these things, you find people with phenomenal stories,” said Ches. “We’re shoulder to shoulder with so many people.”

Losing it all

Thomas had been perfectly happy with her health insurance before she suffered a major shoulder injury due to a fall in 2000.

“I had wonderful insurance. I didn’t worry about a thing,” said Thomas, who never hesitated to visit the doctor, the dentist or optometrist.

Two years later, Thomas had not only lost that health insurance, but also her job, her home and her good credit. Thomas had to file for bankruptcy and move from her two-bedroom apartment in rural Michigan to Ches’s home in Franklin about seven years ago.

It was all the result of a ruptured spleen that doctors didn’t even discover until two days after her accident. Thomas had complained about stomach pain, but her doctors wrote it off as a side effect of her pain medication and sent her home to await shoulder surgery.

Thomas began throwing up frequently and continued to suffer excruciating pain. Her friends decided to rush her back to the hospital as she floated in and out of consciousness.

After making the 32-mile ambulance trip to the hospital, Thomas summoned up enough strength to sign off for the splenectomy surgeons said she needed to stop her internal bleeding.

Along with the splenectomy, Thomas had five surgeries on her arm, and physical and occupational therapy over the next year and a half. Her hospital stay alone rang up $35,000.

When the time to pay the medical bills rolled around, the insurance company refused to pay for the splenectomy — Thomas had never gotten pre-approval for it.

Thomas was appalled that the insurance company expected her to give them a ring during the emergency ambulance transport.

“I was half-dead,” said Thomas.

Thomas couldn’t work her full-time job as she recovered, so she ended up losing her health insurance along with her job.

“You can only do Cobra for so long and afford it,” said Thomas.

Though Thomas tried to take on spot jobs, including a stint harvesting grapes with her non-dominant hand during Michigan’s chilly fall, she could not make enough to keep up with her monthly bills.

At one point, Thomas had to run outside as a tow truck began to pull away with her repossessed car to salvage all her belongings from the vehicle.

At a time when just getting dressed proved to be a struggle, Thomas had to deal with a steady stream of hospital bills and an unsuccessful legal battle to appeal the charges. Thomas had no recourse but to file for bankruptcy and move into Ches’s basement apartment.

According to Thomas, most people in the U.S. are not immune from suffering the same ordeal.

“I paid my bills. I had good credit,“ sad Thomas. “Yes, you have a job right now. Yes, you have health insurance right now, but ... maybe you’re going to end up having to pay.”

Thomas currently works as a cashier at Harrah’s Casino in Cherokee, mostly because the job provides health insurance.

“I never thought I would be working at this age,” Thomas said.

Extreme sacrifices

Because of her own shoulder injury, Rice now finds herself living in a single-wide mobile home in Franklin.

After several months of physical therapy and doctor’s visits, Rice had to pay between $25,000 and $30,000 in out-of-pocket expenses.

Rice said she checked in with the insurance company each time she went to the doctor’s office to make sure she had enough coverage. It turned out her insurance company had not yet processed her bills, so they were not aware her coverage had already run out.

“I would have said ‘Look, I’m running out of money. I will settle for a certain level of disability, find an alternative source of treatment I can afford, or save up until I can afford to continue,’” said Rice.

Instead, Rice had to sell her 200,000-square-foot home and move to a single-wide trailer in Franklin to be closer to her two sisters and save up for the “next healthcare disaster,” Rice said.

Rice, who said she always paid her bills on time and never carried credit card balances, saw her credit ruined since she couldn’t keep up with medical payments.

But Rice decided to take a proactive approach after that financial catastrophe.

Rice slashed every expense that she could, using candles instead of electricity and washing all her clothes by hand. She stopped traveling to see her children and no longer sent them any gifts. Rice consolidated trips to the grocery store, going only every two or three weeks, to save on gas.

“If it wasn’t something I absolutely needed to survive, I didn’t spend the money,” said Rice, who didn’t meet her youngest grandson until he was three years old and came to the area to attend Rice’s husband’s funeral.

Now that Rice believes she’s saved up enough of a cushion, she has started using electricity again, though she continues to wash her clothes by hand.

Rice hopes the money she has saved will be sufficient to cover her future medical costs without relying on others.

“All seniors are afraid that we’re one disaster away from ruin,” said Rice. “I do not want to be a burden on my neighbors, friends, church and society.”

Rice said she had previously been ashamed about her financial turmoil, wondering what she could have possibly done wrong. But she decided to share her story because many others were experiencing similar predicaments.

“I’m not alone. I’m not unique,” said Rice. “That’s the sad part about it.”

Rice said she does not want health care reform for just her or her sisters.

“We want this for others, our children and grandchildren, for everyone,” said Rice.

A broken system

Ches said she and her husband are being punished unfairly for simply growing one year older. Her insurance costs have gone up by 15 percent this year.

“It has gone up for no reason,” said Ches. “We have not been sick. We haven’t even used the amount of money that we’ve paid into it.”

Ches wonders what will happen if she has a medical emergency like those her sisters experienced.

“We’ll join the mob in the emergency room,” said Ches. “Then, all the people currently have health insurance will be impacted negatively.”

After having such a terrible experience with the American health care system, the three sisters feel very strongly about passing health care reform.

“The people who have insurance don’t realize that they can lose it,” said Rice. “The people who have insurance are very happy with the status quo.”

The sisters say those who are sick should not be spending their time wondering about how they would pay for treatment.

“I think something is really broken here,” said Rice. “I have to be afraid to spend a penny because I’m afraid of a medical emergency.”

Ches said those who receive health insurance through their employer and believe they are safe from similar scenarios are living in a “fool’s paradise.”

“You have employer subsidized insurance until you are out of work,” said Ches.

According to Rice, the U.S. must ultimately come up with its own solution rather than following how other countries run their health care system.

Though all three sisters say they would like to see a single-payer system, Rice said she has had “wonderful conversations” and found common ground with those who oppose exactly what she supports.

“Fox, CNN, MSNBC – I watch all of them. I will listen to all sides, the truth is somewhere in between,” said Rice, who is disappointed that the health care debate has taken such an ugly turn.

“This should not have become a partisan issue, the people need to realize that,” Rice said.

While politics reign in Washington, real people struggle with health care costs

It was late September, and Travis George, a 27-year-old Waynesville resident, was almost done mowing his grandmother’s yard. With just five minutes left, his foot accidentally slipped right under the mower, chopping off three of his toes and part of his foot.

George was rushed to Mission Hospital in Asheville, where doctors performed surgery and cleaned up the gaping wound. A month later, George had to undergo skin graft surgery.

George was able to get Medicaid to pay much of the $30,000 bill, and he received about $1,000 from his grandmother’s homeowner’s insurance, but $7,000 must come out of his own pockets.

Unfortunately, George has not been able to find a new job after being laid off from his job as land surveyor last Christmas.

Now he’s caught in the middle. George no longer qualifies for unemployment, since he is no longer able to work. Yet he cannot receive disability benefits because he will be able to return to work in less than a year.

“Ever since I got hurt, I have no income,” said George.

George said he almost didn’t qualify for Medicaid because of his wife’s income as a bank employee. While her health insurance covers their two children, George said adding him to the policy would result in outrageous costs.

“She would end up paying more for our family’s insurance than she would take home,” said George “It’s unreal.”

For George, the problem with the health care industry is tied to the greed of insurance companies. Despite taxpayers picking up the tab for part of his medical bill, George said the government should not be responsible for everyone’s health care.

George supports opening up competition among insurance companies across state lines to lower prices instead.

“I don’t think the government should make everybody pay,” said George. “I had a terrible accident, trying to get help as I can, but the rest of it I’m responsible for. That’s the way it should be.”

Two Waynesville companies recently decided to assist George by holding a chilly cook-off fundraiser to raise donations for his $7,000 payment.

“That’s helped out a little bit,” said George. “Other than that, I don’t know how I’m going to pay that balance.”

 

Bridget Nelson, 40, graduate student at Western North Carolina

Nelson was required to get health insurance after enrolling at WCU though she said not having insurance previously didn’t bother her.

“I view insurance companies as legalized organized crime.”

Nelson considers herself a healthy individual who would probably only use health insurance for medical emergencies.

While working for a nonprofit, she once faced the awkward situation of receiving good insurance coverage through her employer but being unable to extend that coverage to her two children. Nelson eventually acquired Medicaid benefits for her kids, which helped cover costs when her daughter broke her arm.

In Nelson’s view, health care reform should be a national priority. She said a single payer system would make more economic sense than the current wars in Iraq and Afghanistan.

“We’ve spent trillions on apparently useless wars, so if you’re willing to spend on that but not health care, there’s a priority problem.”

 

Amy Tucker, 24, server at Ryan’s Family Steak House in Sylva

Tucker is on her father’s company health insurance policy but has a $5,000 deductible, which means she usually pays for “pretty much everything.”

Tucker says she is against the health care bill. “I don’t think that it should be free for everyone,” said Tucker, “[But] everyone should have some kind of coverage.”

Tucker said she’s more in favor of an assistance program than universal health care.

 

Sunshine Cochran, 33, server at Ryan’s Family Steak House in Sylva

Cochran is considering buying health insurance through her job, but as of now, she has none. She said the health insurance rates through Ryan’s are pretty reasonable. “I just gotta make sure it fits my budget.”

Cochran has received Medicaid benefits when she was pregnant with her five kids, who are all on Medicaid now. But she is still paying off a $15,000 debt she incurred after breaking her arm in a car racing accident.

Cochran was able to pay the $900 upfront cost, but she hopes to avoid landing in the same situation in the future.

“I try to stay away from getting hurt.”

 

Kirk Childress, 22, manager of Black Rock Outdoor Company in Sylva

Childress will soon get a monthly allowance for health insurance after being promoted to manager at the store. Before that, however, Childress did not have health insurance of any kind. For Childress, the choice was between paying for health insurance or paying for a car. He chose the car.

“I’ve always been healthy. I’ve never had a problem.”

Childress says his approach to health care has been more reactive than pro-active. He once had a serious spider bite that needed to be treated. A friend’s father, who happened to be a doctor, was able to call in a prescription for antibiotics to take care of it.

Childress said those who cannot afford health care should be given the minimum for family doctor visits and emergencies, but he said most people should purchase health care for themselves.

 

Sheryl Rudd, 49, and Dieter Kuhn, 54, co-owners of Heinzelmannchen Brewery in Sylva

Rudd and Kuhn choose not to pay for health insurance, relying on natural medicine and wellness instead. They had been paying monthly premiums for a policy with a $5,000 deductible but decided to drop the insurance.

“Nothing was being covered,” said Rudd, adding that the insurance company would not help pay for her to see her preferred doctor.

Kuhn admits that not having health insurance places more responsibility on the individual to stay well and handle any resulting financial responsibilities.

When it comes to health care reform, Rudd said she is not in favor of placing more burdens on businesses through regulations.

“That’s not fair,” said Rudd. “That takes my choice away.”

Instead, Rudd would like to see everyone in the country get the same health insurance that Congress receives.

“But what they’re proposing, I’m against,” said Rudd.

New generation of doctors prefer stability over autonomy

In an effort to boost recruitment of doctors to the region, hospitals across Western North Carolina are following in the footsteps of a national trend to employ physicians in-house.

Historically, doctors set up independent, private practices.

But doctors are increasingly being squeezed by rising overhead and lower reimbursements for 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.

“It allows them to do what they were trained for, the clinical work, and let someone else handle the administrative side,” said Tim Hubbs, CEO of Angel Medical Center in Franklin.

Whether it’s disciplining chronically late employees, shopping malpractice rates or billing insurance companies, “It is nice to say ‘Hey, can you all just handle that?’” Hubbs said.

Sylva-based WestCare is leading the hospitals west of Asheville in the number of physicians employed in-house. WestCare employs 19 physicians across six practices. Angel Medical Center employs 13, while Haywood Regional Medical Center employs five.

WestCare CEO Mark Leonard said the trend reflects a generational preference among younger doctors. He cited a recent survey of medical school grads at Duke University where 74 percent said they would rather be employed upon graduating than go into their own private practice.

“This really reflects a generational shift on the part of new physicians entering into medicine,” Leonard said. “It was incumbent on us to shift and embrace this new way of doing business.”

Leonard said he understands why the new model is attractive to today’s younger doctors, citing the long shifts doctors pull simply to care for their patients.

“When you put on top of that being a business owner and doing the taxes and the personnel issues, that causes the hours to stack up,” Leonard said. “These new physicians coming out say, ‘I just went to medical school and I want to emphasize the clinical side of medicine.”

Haywood CEO Mike Poore added that young doctors aren’t eager to follow the rigorous on-call schedule that had their older peers chained to beepers most of their lives. They want a steady salary and more free time.

Balancing autonomy

The only downfall of the model is a potential loss of autonomy. Doctors can suddenly find themselves answering to a hospital CEO, unlike a private practice model where they answer to no one but their patients.

All three hospital CEOs interviewed for this story said they recognize the concern.

“When I go to my personal physician, I don’t want to be thinking that there is a suit in another room influencing how he is going to care for me, my wife or my children,” Leonard said. “I want his decision to be based on what’s in my best interest as a patient.”

At WestCare, Leonard said he has laid the foundation of trust between physicians and administration and a collaborative decision-making model, which should in turn allay such fears.

“I am not a physician. I did not go to medical school. I am going to rely on and trust the physician’s judgment when it comes to clinical decision-making,” Leonard said.

Hubbs also pledged a hands-off management style when it comes to medical care.

“If a physician says I think we need a CAT scan on this, we are not going to second guess that,” Leonard said.

For Dr. Bruce Lobitz, an ER doctor who joined a team of hospital-employed doctors in the Angel emergency room this year, the possibility of hospital administration intruding on his care of patients was a top concern.

“That was one of my hesitations,” Lobitz said, who has found it not to be the case, however. “Here, there is very little of that.”

While it might give some physicians pause, the positves seem to outweigh the negatives.

“There is some trepidation in the loss of autonomy,” said Dr. Charles Trenthem. “But if you look at the trends nationally, this is what’s happening.”

While the nonprofit hospitals in the mountains have a community minded philosophy, larger for-profit hospitals could take advantage of the employment model.

“They do have a profit model, and they do push the providers at all levels to see that one extra patient, to generate that one extra charge,” said Dr. David Farley, an internist at Angel Medical. “I have not seen that be an issue here.”

Hubbs said there are external controls to ensure hospitals don’t prod physicians to order more costly tests than a patient really needs just to boost revenue. The insurance companies or Medicare who get stuck with the bill would notice an outlier ordering gobs of tests, Hubbs said.

There is one upside for patients: fewer bills. Anyone faced with a hospital stay braces for a litany of separate bills trickling in for lab tests, X-rays, various specialists and the hospital itself. Poore said bundled payments — where the bill for doctors is included with the bill from the hospital — is a model that shows promise.

Hospitals employing a critical mass of in-house doctors will often house them in a joint practice, even if they aren’t in the same specialty. It allows for integrated patient care, providing quick access to charts and reducing the chances of two doctors ordering the same test.

“Really it is kind of a data flow issue that is so clumsy in medicine right now,” Farley said. “If you’re housed in the same unit, you can walk down the hall and say ‘What did you think of Mrs. So-and-so this morning? Should I be concerned about this?’ You don’t have that when you are all scattered around in separate pods around town.”

Making the transition

While urban hospitals have launched a large-scale transition toward employing doctors, rural hospitals are using the model primarily to lure new recruits or to stabilize a faltering practice in a specialty the hospital can’t afford to lose within its medical community, said Dr. David Farley, an internist at Angel Medical.

“In this town, most of the employed physicians are the new recruits,” Farley said. “The existing doctors have remained solo, but I don’t think you can predict that will continue.”

Farley said the new model could be enticing to physicians at different points in their career, like a physician nearing retirement who wants to go part-time and no longer wants to deal with the hassle of managing a private practice.

As the new model develops, the result is a hybrid of traditional private practices and hospital-employed physicians within the community, Leonard said. Leonard largely follows the preferences of the doctor being recruited. If there is an existing private practice in the community the doctor wants to join, the hospital simply plays matchmaker.

When a doctor joins an existing practice, they are often expected to make an upfront investment.

“They buy in to do their fair share,” Poore said.

In Haywood County, both models exist within the same orthopedics office. Western Carolina Orthopedic Specialists has three doctors, two of whom own the private practice, while a third, Dr. Gerald King, is an employee of the hospital.

The hospital pays Western Carolina Orthopedic Specialists a management fee to covers King’s share of overhead, from office space to secretarial staff. The hospital also pays Kings salary.

In exchange, the hospital gets 100 percent of the revenue generated from King’s patients. It also benefits from having an orthopedist in the county who will bring business through the doors of the hospital. The hospital was suffering from a chronic orthopedist shortage that led patients unable to get appointments locally to take their business outside the county.

Haywood Regional Medical Center recently bought out Haywood Women’s Medical Center, the only Ob-Gyn practice in the county. The hospital now owns the practice and the doctors are employees of the hospital.

It was one of the first moves toward hospital-employed physicians in Haywood. The Ob-Gyn practice was a good starting place for several reasons, Poore said.

For one, doctors who deliver babies have some of the highest overhead.

“The malpractice is unbelievably high,” Poore said.

But the service is so crucial, no well-rounded hospital could afford to be without it.

“Our goals was to keep a viable Ob-Gyn practice in Haywood County,” Poore said.

Buying out an existing practice is more complicated than setting up the arrangement from the get-go with new hires. The process took six months and required outside consultants to help arrive at a fair purchase price.

Getting squeezed

The new model is particularly attractive to doctors in a climate of decreasing reimbursement rates for Medicare and Medicaid patients. Doctors take a bigger hit in rural areas, where a higher percentage of patients are likely to be on Medicare or Medicaid. It makes the offer of employment — and the steady salary that goes with it despite the poverty level of patients — an even more important recruiting tool in rural areas, according to Dr. Charles Trenthem, an anesthesiologist and chief of staff at Angel Medical Center.

“If we weren’t employing physicians and subsidizing their practices, the health care in Western North Carolina would suffer,” Trenthem said.

Angel Medical recently got a special “critical access” designation for its hospital that gets it a higher reimbursement rate from Medicare and Medicaid. Physicians employed by the hospital also enjoy the higher reimbursement rate, since billing is done by the hospital itself.

The issue is particularly acute in emergency room settings, where doctors are likely to see a higher number of patients without insurance who have no means to pay their bills.

While ER doctors theoretically treat patients without regard for whether they can pay, it can influence doctors on a subconscious level, said Dr. Bruce Lobitz, an ER doctor at Angel. But as a hospital-employed physician with a steady salary regardless, it makes it easier for doctors to ignore a patient’s ability to pay when providing care.

“I don’t care about the patient’s payer status. The hospital takes care of all that,” Lobitz said.

The hospital is left to absorb the hit, which can be a problem for rural hospitals already operating on a paper-thin margin, Trenthem said. The model also saddles hospitals with the upfront investment of setting up a new doctor and shouldering the risk if patient revenue falls short.

“Costs are being shifted to these smaller hospitals,” Trenthem said.

But given the trend, they had no choice but step up to the plate and adopt the model.

“The days of a physician going out and hanging a shingle are kind of over now,” Trenthem said.

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