Rangely hospital chief looks for progress, strong future

Rangely Family Medicine nursing staff members answer calls and complete paperwork between patient appointments. Although factors like continued low patient volumes, electronic medical records mandates and rising insurance costs remain a cause for concern, Rangely District Hospital Chief Executive Officer Nick Goshe maintains that a $1.5 million annual Medicare payout starting next year and RDH’s status as a critical access facility has the hospital well-positioned for the future.

Rangely Family Medicine nursing staff members answer calls and complete paperwork between patient appointments. Although factors like continued low patient volumes, electronic medical records mandates and rising insurance costs remain a cause for concern, Rangely District Hospital Chief Executive Officer Nick Goshe maintains that a $1.5 million annual Medicare payout starting next year and RDH’s status as a critical access facility has the hospital well-positioned for the future.

RANGELY I Rangely District Hospital may face its share of challenges in the future, but for now, CEO Nick Goshe is happy to check a couple of current ones off the list.
Over the last year, the hospital has been dealt significant blows to its full-time care provider staff. Dr. Mercedes Cameron took leave last December to be treated for breast cancer, while Dr. Chris Adams began missing work periodically in February and resigned for medical reasons in June. Cameron had been on staff for eight years, Adams for almost five.
Losing two doctors in six months, despite Dr. Karyl Ting and Dr. Tim Hsu staying on rotation and locum tenens (fill-in) physicians helping bridge gaps, took its toll. Many appointments, some of them scheduled weeks or months in advance, simply had to be cancelled.
“Docs Who Care has been our main locum company,” Goshe said. “But they can’t help on short notice since their doctors are scheduled out three to six months in advance. We’ve had to use four or five different companies.
“This month alone, we’ve had five new physicians,” he said. “…We had several weeks this year where we only had one doc for the clinic and the ER. There were times when there was no continuity at all.”
By early summer, administrators and the board decided the hospital needed to actively recruit full-time care providers. Although it can be difficult to draw physicians to rural hospitals, Goshe hoped that RDH’s ability to offer every-other-week schedules, weekends off, competitive pay and a new facility would attract providers.
For the three providers who will join the RDH staff over the next few months, a combination of those factors and local connections has brought them here.
Dr. Katy Rieves, a friend of Dr. Cameron’s who worked with her at the St. Mary’s Women’s Clinic for two years before starting a private practice in Grand Junction, arrived in Rangely a couple of weeks ago. Shelby Lindsay, RN, who will take board exams early next year and see patients as a nurse practitioner in January or February, came to Rangely as a traveling nurse and signed a full-time contract with RDH in November. And Dr. Casey Aguirre, who will arrive in March, has roots in Salt Lake City and learned of Rangely indirectly through Rieves, who shared his recruiter.
Now, Goshe said, administrators can focus on decreasing the number of locum tenens physicians and re-establishing continuity in the organization.
The shift from four regular doctors to two occurred amidst financial struggles for the hospital, which cut hours and left positions unfilled after first-quarter numbers showed the continuation of a three-year decline in patient numbers in all but long-term care and assisted living departments.
Goshe said that while current volumes are still lower than expected, several indicators point to the hospital’s continued viability, from full long-term care and assisted living beds to the return of consistent staff and specialists filling needs in the community.
The hospital will also begin receiving a higher Medicare payout — approximately $1.5 million — based on the new hospital building’s depreciation schedule starting next year.
The hospital’s status as a critical-access facility also brings in substantially more revenue per patient than facilities in larger places. Goshe said that even with national challenges to which hospitals should qualify for that status, Rangely would still fall well within more stringent guidelines.
Assuming these factors hold steady, Goshe said the board has no plans to cut back on departments or staff despite rumors of services like home health going away.
“Home health on its own would not exist unless you had somebody donating money to keep it open,” Goshe said. “But I look at the services we provide — and home health is one of those that is essential — and I think that’s why the taxpayers kick in some money to ensure we have services here available.”
Still, challenges remain.
Until the government receives and processes RDH’s 2013 cost report, a process that takes the better part of a year, the hospital doesn’t have the allotted Medicare funds available. Instead, it is drawing from a low-interest, $1.5 million loan until Medicare pays what it owes.
“We’re using as little of that loan as possible because we don’t want to pay interest, obviously,” Goshe said. “The (bank giving the loan) sees it as a low risk because they see Medicare owes us the money and it’s coming.”
In addition, tiered requirements for an Electronic Medical Records (EMR) database under the Affordable Care Act mean a growing budget for information technology specialists to build and maintain it.
So far, Rangely has met Stage I of the plan’s Meaningful Use paradigm, but fulfilling the requirements of future stages could mean up to a 10 percent increase in IT staff annually according to some predictions, Goshe said.
Also on the horizon is the need for qualified medical and technical staff members who can interpret medical codes that will grow exponentially under the looming ICD-10 coding system.
“The number of medical codes right now is around 14,000 under ICD-9,” Goshe said. “ICD-10 is going to expand the number of medical codes from 14,000 to around 140,000 … It’s supposed to make diagnoses more precise, but it’s also going to make them more complicated.”
Goshe said that although he doesn’t know how the Affordable Care Act will play out over the long term, he believes the mandate will drive up co-pays and deductibles which, in turn, influence how often people use health care. Cost-shifting to consumers means that routine health care may become a luxury, not an automatic choice, and Goshe said that low numbers at RDH and across the country already reflect that.
Despite the unknowns moving forward, Goshe believes Rangely is well-positioned for the future.
“It’s a scary and exciting time in healthcare; it’s changing so rapidly,” Goshe said. “I think we’re positioned right now to do well. I don’t see us doing any kind of layoffs or downsizing.
“Hopefully you’ll see better consistency with docs and more specialists coming,” he said. “I feel good about where we are at now.”

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