Program with projects that support it. I have used this approach for longer than I care to admit in public,…
Brad Huerta is CEO of Lost Rivers Medical Center of Arco, ID.
Tell me about yourself and the hospital.
I am the chief executive officer of Lost Rivers Medical Center. We are a Critical Access Hospital in central Idaho. We are located in two really different communities in the middle of Idaho. One is Arco, Idaho, where we have our hospital and our rural health care clinic. The other is Mackay, Idaho, where we run a rural healthcare clinic.
The hospital itself is in fact a hospital district. We’re a taxing district. We operate in a geographical boundary that is larger than the state of Rhode Island. Despite that, we have fewer than 8,000 people in terms of population in that district. We are in an extraordinarily rural, mountainous area in the middle of Idaho. The census bureau doesn’t even consider us rural – we’re considered a frontier hospital because of the population density. We are in the middle of the wilderness.
As big health systems get bigger, are Critical Access Hospitals getting lost in the shuffle?
One of our biggest obstacles to overcome is the remoteness. You see that a lot with recruiting specialties in here, and sometimes on the technology side. There are a lot of additional considerations that we have to deal with that maybe larger hospitals, tertiary hospitals, and MSAs don’t have to focus on. The flip side of that coin is that one of the greatest benefits we have is the fact that we are remote. We have a very specific audience. We’ve cornered the market, if you will, in our area. That part is kind of helpful as well.
Are you using remote services or telemedicine to access expertise outside your geographic area?
Absolutely. In my own humble opinion, remote technology is the greatest force multiplier Critical Access Hospitals have at their disposal. We utilize a significant amount of telemedicine with a remote presence specialist that comes in from the University of Utah, Level One trauma centers, burn centers, telestroke, tele-STEMI, tele-ED, tele-behavioral health. These are things that, because of our location and our remoteness, we simply could not offer and certainly could never hope to recruit for in our area, short of any physician that just really loves to fly fish or go hunting. We use that quite a bit.
Our hospital was the very first hospital in the state of Idaho to utilize telepharmacy in conjunction with Idaho State University. We rely heavily on it. We are big adopters of it. We oftentimes are on the leading edge of technology for small hospitals. Certainly in Idaho, I think we are. It’s a huge part of our service lines and our mix of how we offer services.
We picked Athenahealth because of that. We talk about recruiting physicians, medical specialties, nurses, or whatever it is, but hospitals of my size in the middle of nowhere also have recruiting issues for IT people. One of the reasons we picked Athena was because at the time that we made this decision, about 18 months ago, they were the only strong platform for cloud-based EMR. We had come from another platform that wasn’t offering that.
Now it’s become the standard, but 18 months ago, one of the big things for me was that I can’t afford to have a server farm at my hospital. And even if I bought $100,000 worth of servers, I don’t have an IT person who can come out here and babysit those 24 hours a day. The remoteness piece, we see it on the clinical side in the applications that we use for patient care, but there is also these other externalities that often get overlooked, and part of that is the IT equation. Certainly anything we can throw in the cloud or do remotely — whether it’s patient care or patient records or EMR — that is something that we absolutely adopt.
Every patient room and clinic room utilizes an IBM thin client for uploading patient documentation or patient records, all done in real time. We do have servers and I do have kind of a part-time IT guy who lives here. He also does fire safety and telephones and everything else, but it’s mostly minimal. A lot of the on-site stuff for technical assistance we contract out with a company out of Idaho Falls, Idaho. They come up about once a month just to kind of kick the tires to make sure we have all of the right updates and all of that.
The Athenahealth platform was critical for us because it’s all cloud based. We utilize several components of their platform. Our entire outpatient or clinic population is managed by the Athenahealth platform. Our entire billing department is managed by Athenahealth. Our entire emergency room and acute care wing is managed by Athenahealth, and we are just doing that implementation right now as of last week. We are also doing all of our purchasing with the Athena Jump Stock program. We’ll have a unified platform across all of the hospital operations.
What are the most pressing hospital issues?
We came from a dated 1993 Healthland platform that we were getting no value out of. Small hospitals kick every rock over and hit every bush we can for revenue. One of the important things for us was making Meaningful Use attestation for Stage 1. That was huge. We hit the ground running. I got here about three years ago. We didn’t have a viable EMR. One of the things we had to do to make attestation to get reimbursement was to have an operational EMR right out of the gate. That is really what consumed us for the first 18 months.
Now that we’ve attested successfully and gotten our reimbursement, we are onto different phases of attestation. One of the things that I have enjoyed f is having a unified platform across the clinic, the hospital, the billing, and the purchasing. Instead of having two or three different programs, all of these programs are knit together to give us a unified platform. Not that physicians can’t negotiate different platforms, but the easier we make it on our physicians, the happier they are going to be. If they only have to learn one system, that is a huge employee satisfaction deal for us.
What are you doing with managing populations?
Being a Critical Access Hospital, we want to be the provider of choice. One of the challenges we have in terms of managing our population would be getting the appropriate specialties to come up here. Like I said, our population is pretty small. The other part of it is that it’s an older population. We don’t deliver a lot of babies, but we do see a lot of trauma. Being rural, we will see a lot of shotgun and hunting incidents, ATV rollovers, horseback incidents, or cattle, these kinds of things.
Having services that cater to an older population from nuts to soup. It’s geriatric psych. Maybe it’s diabetes education or nephrology. We are looking at older population health issues for a crowd that is probably 45 and older, generally speaking. We do have young people, of course, but most of our biggest challenge is focusing on developing service lines that cater to an older population that we can serve by bringing in specialists from outside. That can be kind of a challenge. There’s just not a lot of physicians to be had anyway and there are even fewer that are willing to come out to a remote place like us. That is probably the biggest challenge.
How do you see the next five years?
We have stabilized hospital operations. We’re cash flowing nicely. We are capturing every bit of revenue that we possibly can.
Two main issues concern me. One is a political question, looking at the ongoing election and what is going to happen to healthcare depending on what party takes control. If it is in fact going to be one party, you hear talk of repealing, removing, or replacing the Affordable Care Act. That would cause absolute havoc for every hospital, not just small hospitals.
We’re just now continuing to try to implement the mandates of the ACA. Any type of change now would be catastrophic. That would hurt a lot of hospitals. It’s like steering the Titanic — you just can’t do something one day and turn around and go 180 degrees the next day. These things take time. As we’ve we’ve gone down the path of the Affordable Care Act, whether you like it or not, hospitals have adjusted their operations to start to accommodate that new environment. Any change to that would be extraordinarily difficult.
A component of the ACA is the mandate for accountable care organizations. Or in our case, any type of option that may allow itself to something different, like a CCO, or a community care organization. You are going to be moving towards a value- as opposed to volume-based reimbursement system. On one hand, that is probably a great harbinger for small hospitals because we do great quality care here. Our HCAHPS scores are some of the highest in our state. We are constantly fighting the battle with volume. We do great care, but we just don’t get a lot of patients.
Any payment system that replaces volume for value is a good thing, and I think my hospital in particular is uniquely positioned to do well in that environment. But at issue is some of the restrictions with regards to ACOs, where you are saying, "You have to have population health management.” You have to have a population to do that. If you are talking a population of 75,000 or 150,000 or a half a million people, that is one thing, but I live in a community with 8,000 people. How am I going to share risk and bring value if the reimbursement is tied to a certain percentage or a certain number of covered lives?
Small hospitals are going to have to look hard at who they want to partner with on these ACOs because you can’t do it by yourself. Rural hospitals with small populations are going to be asked to do population health and we’ve only got small pockets of populations. You are going to have to throw in with shared markets and bigger hospitals. That is not necessarily a bad thing, but certainly you want to be careful of who you partner with.
There is a lot of subtle distinctions between for-profit and not-for-profit and critical access and trauma centers and what kind of trauma centers there are. There is a lot of differences in hospitals. Some of the governing philosophies of what makes sense or doesn’t make sense are going to come into play. There is going to come a time when small hospitals are going to have to decide, are we going band together in an organization — perhaps a community care organization that has maybe a lot of small hospitals making a threshold for population — versus, are we just going to go with the biggest hospital next to us and hope for the best?
That to me is a real challenge that Critical Access Hospitals are going to have to face, probably in the next 18 to 24 months. It’s a mandate. We are going to have to go to value. I guess right now we are all in the dating phase to see who we want to take to the dance.