No-go on CAH

County votes down proposal ‘at this time’

Stephen Crane
Posted 4/14/17

Amid the boos and jeers of a hostile crowd, the Sublette County Board of Commissioners voted down the CAH “at this time” at a special meeting at the Pinedale Library on Wednesday night.

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No-go on CAH

County votes down proposal ‘at this time’

Posted

PINEDALE – Amid the boos and jeers of a hostile crowd, the Sublette County Board of Commissioners voted down the CAH “at this time” at a special meeting at the Pinedale Library on Wednesday night.

Board chairman Andy Nelson tried to set a constructive tone to start the meeting but that tone did not last.

“At times, we all can become very excited with our points of view,” he said in his opening remarks. “What I would ask is that we try to conduct this meeting devoid of emotion.”

He handed the microphone to Todd Hurd, of engineering firm Forsgren Associates, who gave an overview of the engineering assessment that was recently completed on the county’s two medical clinics as it relates to the critical access hospital designation.

“The existing buildings, nothing wrong with them structurally,” Hurd said. “But they just do not meet hospital-grade code.”

As a result, both clinics would need work, according to Hurd, with one getting the brunt of the construction as the primary location of the CAH. The other would still need work to come under the umbrella of the CAH reimbursement model.

The total cost is around $6 million, which includes just over $5 million for construction on both clinics and an additional $1 million for interior equipment and furnishings.

The Sublette County Rural Health Care District (RHCD) did a draft request for proposal (RFP) back in 2015, which came out with a similar total for the CAH, but it was a “different sized building,” Hurd said.

“9,100 (square feet) was 2015,” Nelson echoed. “And now it’s based on a 4,000-even square foot, so we’re getting half as much space at the same cost.”

Nelson then addressed RHCD board chair Laura Clark, wondering why the clinics’ equipment list the commissioners requested at their April 4 meeting was incomplete. It showed that the value of the current interior furnishings total about $250,000.

“What I did not see in (the list) was IT, phone systems, security, signage, medical equipment,” he told Clark. “Do you have a number?”

Clark said she did not.

“You didn’t give us a lot of time,” she said, adding that the remaining equipment was probably “another $250,000.”

Nelson further wondered if Clark was willing to provide insights into the “other options” she alluded to during her visit with the commissioners on April 4 – options that the district would be looking into if the commissioners turned down their request for a deed of the properties or permission to build.

“Are you at liberty at all to share any of those (options)?” Nelson asked her.

She said she was not.

Nelson then handed the mic to commissioner Dr. David Burnett, who delved into a PowerPoint presentation on a potential new option – a freestanding emergency center.

The Wyoming Legislature passed Senate File 257 last year, which took effect July 1, 2016. It would require the construction of an emergency center and also pave the way for an increase in reimbursement for visits to the emergency center.

The concept outlined in the state bill has yet to become a reality in Wyoming, and Burnett felt Sublette County could be the pioneers.

“I know that if we achieve a critical access hospital designation, we will be the last county in the state to have a hospital,” he said, contrasting that with the new concept of a freestanding emergency center. “I would rather take a chance on being first than take a chance on being last.”

Some in the crowd voiced their displeasure with the commissioners for introducing this option so late in the game – and at a meeting that was supposed to be about the CAH.

Pinedale resident Maike Tan felt like Burnett was “throwing a stick in at the last minute of this race.”

“If we’re looking at a freestanding ER, we’re looking at prolonging this again and again and gain,” Tan said. “To me, this feels very much like a mediocre option to compromise for everyone who was against the CAH.”

Others expressed skepticism that the freestanding emergency center would pan out, given the financial investment that would be ultimately be required by an outside entity.

“This is an option,” said Aaron Metcalf, who works for a Salt Lake City-based construction company that specializes in rural health care facilities. “But the issue is that it’s going to be a privately financed option. … You’re going to lose local control.”

Many wondered how the commissioners could discount the four financial assessments that have been done on the RHCD, as well as the community poll that found 60 percent supported the CAH.

“Four different audits, they’ve all said about the same thing. … The CAH is the only route to capture these (Medicare/Medicaid tax dollars) back,” said Dr. David Kappenman.

Dr. Tom Johnston was the sole voice of support in the crowd for the Burnett’s proposal, and he cited his own 40 years of “running an entrepreneurial clinic” in the county as the basis.

“I’ve never been in favor of the CAH from the very beginning,” he said, calling it an “unnecessary expenditure to milk more money out of the federal government.”

He thought the first place to start addressing the RHCD’s budget crisis was to look at operations.

“My choice would be to renovate the way the clinics are operated,” he said. “Rather than jack up the official calls and worry about not getting adequate insurance reimbursement, look at the coding, look at the procedures that are being done within the clinic – or not being done within the clinic.”

Commissioner Joel Bousman spoke up and also raised questions about the RHCD’s operations, as well as the “out migration” of patients to other medical facilities.

“Somehow, we have to convince patients that the quality of health care has improved so that they’ll make the decision to come here,” he said.

RHCD administrator Malenda Hoelscher responded by pointing to the work being done to establish “a level of trust” with the community, in addition to the “in migration” that’s also taking place.

“We have probably 1,300 new patients a year – people that have not used the clinic in over three years,” she said.

Commissioner Mack Rawhouser then made a motion “not to deed over the clinics and not to build a critical access hospital at this time,” which was immediately met by shouts from the crowd, many asking, “Why?”

“The failure of health care is now on your shoulders, Mack!” shouted one resident.

“Shame on you!” shouted others.

“Why are you in the way? If they don’t want money from you, why are you in the way?” shouted another.

After the first wave of dissent subsided, Burnett spoke up, pointing to the unwillingness by the RHCD board to disclose the options it’s contemplating, the constructions costs it wants the county to pay, and the incomplete list of equipment it turned over to the commissioners.

“It’s alarming that in 32 months, you can’t come up with a more complete list than what was turned in,” he said.

Nelson then called for a vote, which passed unanimously and was immediately met by loud boos from the crowd.