Health insurance reform has garnered a seemingly incongruous ally: the already well-insured workers of the State Employees Association of North Carolina.

The association held a forum in Haywood County last week to educate state employees on exactly what the 1,017-page health care reform bill entails. The meeting at Haywood Community College was one of several held across the state. The organization did not publicize the meeting to the masses to avoid a big turnout by protestors, but as a result the audience was small, numbering fewer than two dozen.

Will Cubbison, health care campaign director for SEANC, said his organization supported health care reform even though its members have quality health care coverage.

“Many of the spouses and children of state employees are not covered,” Cubbison said.

Speakers rattled off a barrage of statistics to win over the audience, mentioning the million-dollar profits of BlueCross BlueShield, the thousands of people who die each year because they do not have insurance, and the immense amount of time and money insurance companies spend on administration. Meanwhile, they disputed claims raised by opponents that illegal immigrants and abortions would be covered under health insurance reform.

The SEANC representatives directly admonished Rep. Health Shuler, D-Waynes-ville, who does not support H.R. 3200.

Dr. Ed Morris from Macon County, who was a guest speaker at the forum, suggested health insurance for members of Congress should be suspended until a reform bill passed, prompting the audience to break out in applause.

Morris, a family physician, added that he has seen at least two dozen doctors move away from the Franklin area because so many of their patients were unable to pay for their care. Given the lower average income of residents in the mountains, doctors here write off up to 23 percent of their patients.

“So these doctors end up going to Charlotte or Atlanta or somewhere,” Morris said.

Chuck Stone, director of North Carolinians for Affordable Health Care, said while many in the past considered the institution of Medicare as a move toward socialism, Americans now don't think twice about the government-supported health care. Stone asked members of the audience to raise their hand if they opposed Medicare, but no hands went up.

According to Stone, the cost of doing nothing is far greater than reform.

“The current system is unsustainable,” Stone said.

Amy Street thought she could finally afford health insurance this year. But that was before Street’s employer slashed 25 hours from her 40-hour work week.

Street, a 62-year old Waynesville resident, recently applied for retirement and social security benefits, but said while that would help, it’s simply not enough.

When Street was recently told she might have kidney cancer, she fretted about more than her health. She worried she would lose her car and her home trying to scrape up enough money to pay for expensive treatment. Even worse for Street was the possibility of no one being around to care for her disabled daughter.

“I was in shock. Sometimes, I cried. Sometimes, I said wait and see,” said Street.

Luckily, Street learned she did not have cancer, but her continuing kidney problems have driven her to seek on-going care at the Good Samaritan Clinic of Haywood County, one of the few free clinics in Western North Carolina. While she waited for her appointment on a recent afternoon, a fellow patient who did not want to be named said she found out she had cancer just the day before.

Patients like Street represent almost 19 percent of Haywood County residents who are uninsured, a figure that includes 1,400 children.

While the number who can’t afford health insurance is on the rise, free clinics like the Good Samaritan are facing economic woes of their own due to funding cuts, forcing them to scale back services at a time they are needed most.

The Good Samaritan Clinic, which has offices in Waynesville and Canton, has reduced services by 40 percent and is no longer accepting new patients, who once came in droves of 40 each week.

The clinic had 4,500 patient visits last year, but can only afford to see 2,590 this year due to financial constraints.

Haywood County cut half of its funding to the clinic last year and ceased its funding completely this year, although it still allows the clinic to use one of its buildings for just $1 a year.

Donda Bennett, executive director of the clinic, said there’s little the clinic can do but step up fundraising efforts.

“Our budget is cut and dry, as bare as you can make it,” Bennett said. “There’s nowhere to cut it and still provide quality health care.”

No free ride

At a time of increasing need, free clinics across the area have had to turn away patients.

“We’re seeing a huge number of new patients coming to the clinic. People that have either lost their job or lost their insurance or both,” said Jerry Hermanson, executive director of the Community Care Clinic of Highlands-Cashier. Patients there are now waiting as long as three weeks for their appointment, and though the clinic does allow walk-ins, it has had to send away patients “more and more,” Hermanson said.

Haywood County’s Health Department, which sees 1,000 mostly uninsured, Medicare and Medicaid patients each month, no longer offers clinic hours on Tuesdays and Thursdays and has eliminated five positions. The department’s budget has decreased to almost $4.9 million, compared to about $5.7 million last year.

While government support is important to free clinics, contributions from individuals are just as vital. The Community Care Clinic of Highlands-Cashier has seen donations from individuals fall 20 percent below what was budgeted this year.

The Good Samaritan Clinic of Haywood County is reaching out to individuals and local churches but is still below target.

“A lot of people just think, we’ve been around since 1999, so surely we’ve figured it out and are able to support ourselves,” said Bennett. “Some people might not just realize it totally depends on individuals and organizations.”

While securing grants would certainly help, these types of clinics face tough competition.

“Most grantors want to fund something new and innovative and fun,” said Bennett. But when free clinics can’t even afford basic operational costs, it’s hard to pursue creative projects like the ones that attract potential grantors

Becky Olson, executive director of the Good Samaritan Clinic of Jackson County, also acknowledged that securing grants has been a bigger struggle this year with less money and more competition.

“At this moment, I’m working on four different grants to get a little piece for here, a little piece for there,” she said. The clinic is also trying to get more doctors to volunteer to expand the clinic and accommodate the increase in demand for services.

Meanwhile, the Community Foundation of Western Carolina has recognized the needs of clinics like Good Samaritan and the Community Care Clinic, and provided assistance through its Recession Response grants.

And the Good Samaritan Clinic of Haywood County is receiving help from churches that have stepped up and added the clinic to their budgets.

Dalton’s Christian Bookstore in Waynesville is teaming up with the clinic for nearly three months, to offer customers an opportunity to donate to the clinic, while the clinic will go in and do blood pressure checks on customers.

Good Samaritan continues to give presentations to a lot of churches to hopefully raise awareness about the clinic’s existence, as well as its troubles.

Turning to the big guys

Good Samaritan has been in talks with Haywood Regional Medical Center for two months now to see if the hospital can contribute financially to the clinic, as well as donate medical and office supplies.

HRMC already donates thousands of dollars annually in free laboratory and radiological services to the clinic each year.

“The hospital really realizes that we are struggling right now. By us cutting services, it puts them in a situation where they have to see more people who are uninsured,” said Bennett.

For every patient who does not pay up for an emergency room visit, it costs the hospital an average of $400, according to Good Samaritan’s research.

Carole Larivee, a retired nurse who works part-time at HRMC and volunteers at Good Samaritan, said helping the clinic would be beneficial for the whole community.

“The hospitals can’t turn people away who come to the ER. By the time they get to the ER, treatment is very, very expensive because they had to wait so long,” Larivee said. “Even before I was with Good Samaritan, I would see people admitted to the hospital because they couldn’t go to the doctor for preventative care. They had to get very, very sick.”

By the time the patient got to the ER, it would sometimes be too late, she said. “Whereas, if they had been seen regularly, what was wrong with them could have been treatable.”

Hermanson said about 10 to 12 percent of patients at Community Care Clinic would go to the emergency room if the clinic were not open. But most of the patients he sees at the clinic do not say they would have rushed to the nearest hospital.

“We ask every patient on every visit, ‘If we weren’t here, where would you have gone?’” Hermanson said. “The vast majority of patients say we wouldn’t have sought treatment.”

Catch-22 for the underserved

Carmine Rocco, health director at Haywood County Health Department, emphasized the need for the public to do their best to stay healthy, especially now.

“As more folks become uninsured, it’s even more crucial now that people do what they can personally to help reduce the risk factors that they have control over,” said Rocco.

The underlying issue, though, is that uninsured people who face a chronic condition have trouble managing what would be easy to handle — if they could afford care.

“Most people don’t worry about prevention if they feel well,” said Hermanson. “They may be diabetic and not treating it. Promoting wellness is a great thing, but getting it accomplished is another.”

Hermanson said one of the first patients at his clinic came in with a blood sugar level of more than 500, when 105 is the highest end of normal.

“It’s people like that who end up in the emergency room,” he said.

Street confirmed that it has been difficult for her to stay healthy without insurance.

“It’s really frustrating because you want to be ahead of the game to keep yourself healthy, but you can’t afford to do that,” she said. “It’s disheartening.

Even when patients get in through the door at swamped clinics, some have concerns about the quality of care.

Cynthia Teesateski, 49, said she worried that health care available to the uninsured might not stand alongside the care offered to patients backed by insurance companies.

Street said the urologist she was referred to did not fully inform her about her kidney troubles. It was only after she hunted down information on the Internet that she discovered more about her condition and decided to schedule another appointment at Good Samaritan.

Even if she wonders sometimes about the care she receives at clinics, Teesateski said she glad to have someplace to go to – for now. “As I get older, what’s going to happen? Will I have any place to go?” she asked.

Donna Brooks, a 46-year old patient at Good Samaritan in Canton, said she doesn’t worry about the care she receives at the clinic she refers to as her “lifesaver.” She has even become good friends with her doctor there.

Brooks is an avid supporter of the clinic and hopes it will make it through the recession.

“There should be no reason for these clinics not to stay open,” Brooks said. “If they don’t, not only me, but hundreds of people, are going to be in a world of hell.”

SMN: What did you learn from the teletown meeting? Anything new?

Heath Shuler: “The meeting reinforced my belief that most people don’t fully understand what is in the health-care reform bill and they have many valid questions about it. It also showed that we shouldn’t rush to pass this bill that will have a dramatic effect on most Americans’ lives.”

Why do a teletown meeting, rather than a regular regular town hall meeting?

“I decided to hold a tele-town hall meeting because I wanted to explain my position on health care reform and listen to constituents’ questions and comments without the grandstanding from political groups. It also allowed constituents in the western region to dial in from their own homes rather than having to drive hours to attend.”

How much have you been affected by the grassroots efforts on both sides?

“I listen to all my constituents, but at the end of the day, I still must vote for what I feel is right for the people of Western North Carolina. While I support health-care reform, I still oppose the H.R. 3200 legislation.”

There is a wellness, disease management, and prevention aspect in the bill. What specifically would you add to that? How much could focusing on this bring down costs?

“I’d like to see more tax benefits for individuals and companies to promote wellness and prevention. I’m looking at several proposals on this currently. The problem is that it’s hard for government agencies to quantify saving from wellness and prevention programs. But it makes sense that spending money on prevention will save costs down the road.”

Same with preventing waste, fraud and abuse – what specific measures would you add to the bill that aren’t already there?

“One item is streamlining medical codes for all procedures. Doctors often can get paid different prices for the same procedure depending on which medical procedure code they use to bill.”

H.R.3200 proposes that small businesses with under $500,000 in payroll be exempt from providing health care to their employees. What is your opinion on that proposal?

“I oppose any measure that mandates that business provide health care benefits and would saddle small businesses with higher costs at a time when many already are struggling in these economic times.”

Are you for or against having a public option for health care?

“So far, I have not seen a public-option proposal that I can support.”

What do you hope accomplish with the next tele-town hall meeting?

“I want to continue to listen to my constituents about their thoughts on health care and answer as many questions as possible.”

Against the backdrop of a nation embroiled in an emotional, high-stakes debate on health care reform, the voices of Western North Carolina citizens seemed remarkably calm and polite during a telephone town hall meeting with Congressman Heath Shuler, D-Waynesville, last week.

Shuler reiterated his opposition to H.R. 3200, the House health care reform bill, to the deeply concerned callers throughout the “meeting,” which lasted more than an hour.

Callers had to state their questions before being allowed to directly talk to Shuler during the teleconference. Citizens who dialed in to listen to the conversation were sometimes met with busy signals due to the teleconference reaching full capacity.

A cautious attitude toward the meeting was evident, as Shuler’s office at first held back the telephone number to prevent organized political groups from infiltrating the meeting.

Participating citizens on both sides of the issue voiced wide-ranging concerns. Some worried about paying for illegal immigrants’ health care, covering abortions with public money, losing Medicare coverage, and adding millions of new patients without also adding doctors and health care facilities. Others asked how much of Shuler’s campaign contributions came from the health care industry, recommended looking to countries like Switzerland that are reportedly happy with their health care system, and expressed anxiety about the political process stymieing the passage of reform.

Carole Larvee, a Waynesville resident who listened in to the meeting, said as a retired nurse and volunteer for the Good Samaritan Clinic, she has personally experienced the plight of uninsured patients and hopes to see a solution soon.

“I know Congressman Shuler wants to get the health care reform bill right, but again I see people suffering. I see a sense of urgency,” she said.

According to the House Committee on Energy and Commerce, about 23 percent of the population — or 154,000 individuals in the 11th Congressional District — are uninsured.

Shuler has said that he wants to spend time crafting a bill, even if it takes longer than the end of this year.

He is pressing for a bill that will stress wellness, disease management, and prevention to drive down costs; does not place mandates on small businesses; does more to cut waste, fraud, and abuse; and adds a clause to ensure abortions are not funded with government money.

“We’re only going to get one shot at this,” said Shuler. “Let’s do this right.”

Shuler expressed much hope about driving down health care costs by promoting healthier lifestyles and possibly providing tax incentives to curb excessive smoking or drinking.

A few callers from Waynesville, Maggie Valley and Franklin were able to get through and ask questions, though many of the callers came from Asheville.

Susan from Waynesville said Congress could not reform health care without also tackling tort reform. But Shuler said doing that has not lowered costs in states like Texas and Alabama.

“There’s still gross negligence on behalf of everybody,” said Shuler.

Kathy from Hendersonville expressed her concern about pre-existing conditions.

“I have a daughter with a congenital heart defect and I’m very concerned about people being penalized by pre-existing conditions and just the high cost of health care [and] insurance premiums in general,” she said. “I don’t want to see this issue die because the perfect plan doesn’t evolve.”

Shuler responded, “We need to get a health care reform done ... but we have to do it right ... Could you imagine, the bill was presented to us and then three weeks later to actually vote on the piece of legislation? That’s very, very difficult.”

Ron from Maggie Valley asked for Shuler’s position on the center of comparative effectiveness, which has been characterized by opponents of the bill as a “death panel” that makes health decisions for the elderly.

Shuler laughed, and said, “Obviously there is no panel. You don’t have to worry.”

He added that he understands why citizens do not want the government to make health decisions for them.

“You don’t want the federal government doing it, and you certainly don’t want the insurance companies telling you,” he said. “We need to put it in the hands of qualified people who understand health care, and that’s our physicians, our nurses, and the people that are in our hospitals.”

Shuler plans to gather more input from his constituents with another tele-town hall meeting scheduled for 7 p.m. on Sept. 1.

Although the board of Haywood Regional Medical Center could lose much of its control following its affiliation with WestCare, it will remain a public, county-owned entity nonetheless.

Haywood Regional and WestCare have announced their intention to unite under a newly created umbrella organization. The hospitals would be managed jointly, with just one CEO at the helm and one operating budget. That new organization will be run by a new board, comprised equally of members from both Haywood and WestCare.

“The joint operating company will sit atop the two entities. WestCare will remain its separate entity and Haywood will remain ours,” said Haywood County Commissioner Kirk Kirkpatrick. “To my knowledge there is nothing about the agreement that would change the public status of Haywood Regional.”

That public status means county commissioners appoint board members, the hospital’s books are open to the public and board meetings can be observed.

“We are under the impression that our hospital will still have a hospital authority with open board meetings,” agreed Pam Kearney, HRMC board member.

But it could be stripped of much of its power. Haywood’s current hospital board will likely no longer have hiring and firing authority over its CEO or autonomy over budget decisions, for example. Those would likely fall under the purview of the new board, which won’t be public. Members of the public and media would not be entitled to attend meetings of the joint entity where most decisions would likely be made.

Mike Poore, CEO of Haywood Regional, said the details of the arrangement are in the early stages to say the least. Exactly what power will remain with Haywood Regional’s existing hospital board and what will be delegated to the new entity will be refined over the lengthy affiliation process.

“There are a thousand things we still have to do,” said Roy Patton, an attorney and HRMC board member. “This whole thing is not a done deal. Whether it is done still depends on an awful lot of due diligence.”

This week, a team from Haywood Regional is at WestCare poring over all its financial ledgers and books.

“And vice versa they will be looking at everything within our organization,” Poore said, calling the two entities “deep into due diligence right now.”

“We are at the very beginning of this,” Kearney added.

Haywood Regional’s hospital board is appointed by county commissioners. How members are appointed to the board of the new joint entity are among the issues to be hammered out.

Poore said it is not unprecedented for a public hospital to come under the umbrella of an entity that’s not public, yet remain public itself.

“I think there are several examples of that within the state,” Poore said.

State statute

Haywood Regional’s status as a public hospital dates to its construction with publicly-backed bonds. The hospital building belongs to the county, and that ownership won’t change. While the daily operations of WestCare and Haywood will be co-mingled, each hospital will keep a separate balance sheet and its assets will remain segregated.

That is largely the reason Haywood Regional will still be considered a public hospital, even if it’s autonomy is siphoned off. State statute specifies a change in status occurs only if a public hospital is sold or leased.

“My understanding is that the ownership of the facility would rest with the county, and it wouldn’t be sold or leased,” said Jeff Horton, the director of N.C. Division of Health Service Regulation.

Another layer in affiliation is a management contract with Carolinas HealthCare System, a network of 23 hospitals based in Charlotte. The initial length of the contract could lock Haywood Regional and WestCare in for up to a decade, but a management contract does not qualify as a sale or lease, and therefore doesn’t trigger the state statutes regarding Haywood’s public status. If it did, the ultimate decision would rest with Haywood County commissioners. It appears commissioners will dodge such a vote, however.

“Right now with the anticipated structure it doesn’t appear there is any need for a change or for us to vote on it,” Kirkpatrick said.

If negotiations start heading in a different direction, however — one that would jeopardize the hospital’s public status and therefore land in the commissioners’ laps — Poore said he would let the commissioners know right away.

The commissioners, at least as a whole, haven’t drawn any lines in the sand about the ultimate structure the hospital takes on.

“I don’t know that it would matter to me as long as the services are better,” said Commissioner Kevin Ensley. “But I would want to listen to the medical community and hear what their consensus would be. I would also want to know what our hospital board thinks. We have appointed some really good people that understand the medical community.”

Patton said the hospital board hasn’t expressed a proclivity one way or the other, but it would be a major step to undo the hospital’s public status and wouldn’t be taken lightly, he said.

“Personally I would have to feel very comfortable if there would be a change like that,” said Patton, an attorney and member of the hospital board. “I would have to feel like that change is for the betterment of healthcare in this county and the area and that it would outweigh the benefits of being a public hospital.”

Haywood Regional Medical Center could miss out on as much as $750,000 in revenue over the course of a year after missing a federal billing deadline for its new mental health wing.

The missed deadline, which occurred last fall, was the result of a misunderstanding between the hospital and the federal Medicaid office.

The psychiatric unit is eligible for a higher rate of Medicare and Medicaid reimbursement than other hospital units. To qualify for the higher rate, the new wing had to be visited by state inspectors and get certified.

State surveyors told the hospital to apply for the survey by mid-August of 2008 in order to meet a cut-off date of Oct. 1. If the hospital missed the deadline, it would have to wait a full year for certification that qualifies it for the higher rate.

This is where state surveyors got picky. The surveyors received the hospital’s application for a survey on Aug. 19, “a date which apparently the state does not consider to be mid-August, although two of the four days in question were over a weekend,” explained hospital CFO Gene Winters, who didn’t work at the hospital at the time.

The state told the hospital that its request was four calendar days late — forcing HRMC to wait another year before it can qualify for a bigger return on the psychiatric unit.

The 16-bed unit has been mostly full since it opened in October of last year, thus serving as a steady source of revenue for the hospital, between $250,000 and $300,000 a month if the unit remains near capacity.

The amount of revenue the hospital is missing out on could be as high as $750,000 over a 12-month period until the window rolls around to get the unit certified, Winters said. According to Winters, the true budget impact from the missed deadline will likely be small, around $300,000. The hospital had budgeted for the psychiatric unit conservatively.

“We are in the process of sharing the pain of the reduced revenue with our psychiatric unit management company, so the impact to the hospital will be minimized,” Winters said.

— By Julia Merchant

It’s a cultural tradition in nearly every society, the firm belief that people and institutions become stronger once they’ve been tested. Whether that test comes about due to one’s own shortcomings or to circumstances outside one’s control is important, but in the end it’s the outcome that we remember.

So it is with Haywood Regional Medical Center. When its Medicaid and Medicare status was lost just over a year ago and the hospital went into a financial freefall, people were angry, upset and felt betrayed. They were also very worried that the place they considered their number one healthcare option was in real jeopardy of closing down and that many friends and neighbors would lose their jobs.

In hindsight, that extreme emotional attachment to HRMC might have been its saving grace. County leaders, physicians, hospital staff, and a whole lot of concerned citizens stayed with HRMC when it might have been easier to let it sink. When the number of patients going to the hospital on a daily basis sank to single digits, inspectors still hadn’t given their final OK for re-certification, and the bank account was close to running dry, closing seemed imminent.

No one knows what corporate shape HRMC will finally take — affiliation with another hospital system and with WestCare seems certain, but the structure of that affiliation is still unknown — but now no one believes that Haywood County won’t have a hospital, which seemed a very real possibility in early March of 2008.

So what from this past year at HRMC should residents remember?

First and foremost is the responsibility that lies with the hospital’s board of trustees. These dedicated citizens who volunteer their time must be vigilant to strike a balance between the sometimes competing interests of hospital administrators and the medical staff. They must also be able to look beyond those personal and professional relationships to keep in mind the hospital’s value to the community. No person or group is more important than the institution. It’s a balancing act, but if trustees tip too far one way — as happened with the previous board’s almost blind allegiance to former CEO David Rice — bad things can happen.

Secondly, and probably just as important, is the wisdom and dedication of the long-time members of the medical community. When the medical staff asked some doctors to speak to the board of trustees at a December 2006 meeting, they pointed out very clearly that the relationship between the administration and the medical staff had become dysfunctional. The board, however, ignored those pleas.

Among those to speak at that meeting — where a well-liked ER group was about to be fired — were Dr. Henry Nathan, Dr. John Stringfield and Dr. Benny Sharpton, three of the county’s most respected physicians. HRMC’s medical community, by and large, are practicing medicine for the right reasons and need to be listened to.

Lastly, and like it or not, the CEO of a small hospital carries a lot of power. That can be either beneficial or detrimental, depending on the circumstances. If one went to Raleigh or Charlotte, the CEO of a large metro hospital might get lost among the thousands of employees, hundreds of doctors, and dozens of administrators. Not so at a hospital like HRMC. Former CEO David Rice was very powerful and became very polarizing, yet his strength of personality blinded those who should have seen his shortcomings.

HRMC’s new CEO Michael Poore will also wield a lot of influence. He has become the new face of HRMC, an affable, intelligent guy that has best been described as a “breath of fresh air.” Most believe he will serve the hospital well, and already he is restoring credibility both internally and in the community.

HRMC has survived and, perhaps, become stronger because of this crisis. It might not be so lucky if an event of this magnitude ever occurs again, a truth that should serve as a cautionary reminder to those who might too quickly forget the events of the past year.

One of three hospitals courting Haywood Regional Medical Center and WestCare for a partnership has dropped out of the running.

That leaves Mission Hospital of Asheville and Carolinas HealthCare System, a 23-hospital conglomerate based in Charlotte, still in contention. Both have submitted formal proposals, kicking off the next round in the lengthy affiliation process.

WestCare and Haywood Regional have each appointed blue-ribbon committees to steer the process. They will hold a joint meeting Monday (Feb. 16) to review the proposals and kick off discussions of which one is best. The formal proposals are a follow-up to talks held with the entities last summer.

While there’s only two left at the table, others would likely be interested in a partnership with Haywood Regional and WestCare. But invitations were only extended to the three. A fourth was ruled out following the discussions last summer, and others were ruled out earlier in the process.

It could be another six months before WestCare and Haywood Regional have made their decision. They have to weigh what each brings to the table, from medical expertise to a cash infusion, said Mike Poore, CEO of Haywood Regional.

An affiliation could follow a tier of options: an outright merger, a long-term lease, a year-to-year contract or some sort of loose partnership.

While playing Novant and Carolinas against each other would certainly give the home hospitals leverage in the negotiations, Haywood and WestCare still have plenty of bargaining power. If neither proposal meets the standard they want, they can simply choose none of the above, said Haywood County Commissioner Kirk Kirkpatrick, an integral player on the steering committee.

“If either is not beneficial to both Haywood and WestCare then we have to reconsider,” Kirkpatrick said. “It would be bad business not to.”

If neither of the large entities works out, Haywood and WestCare could still pursue a partnership of their own without hitching up to a larger entity.

“I feel like we have a qualified and competent CEO at Haywood and West Care. If they can put something together for the benefit of the entire community they will,” Kirkpatrick said.

Conservative times

Novant will not say exactly why it pulled out, although the economy is a likely culprit. Novant operates Forsyth Medical Center in Winston-Salem and a host of smaller hospitals across the state.

A spokesperson for Novant said the hospital was honored to be a top contender, but could not over extend itself at the moment.

“After careful evaluation, we concluded that we needed to focus on our current commitments to capital projects,” said Freda Springs, media spokesperson for Novant.

Novant is building brand-new hospitals in Kernersville and Brunswick County, both in the ballpark of $100 million. Springs said the hospital would not comment further.

Neither Poore nor Mark Leonard, WestCare’s CEO, had additional insight as to why Novant dropped out.

“That is for them to explain if they choose to explain it,” Leonard said.

The letter from Novant announcing its withdrawal was only two paragraphs. Poore speculated, however, that is was likely the economy.

“They are like everybody else, trying to look at the economy and trying to decide what the future is going to be and none of us really know that,” Poore said.

If hospitals are reining in their resources, the deals on the table today might not be as good as they would have been two years ago, or two years from now. But Poore said there is no way of knowing that.

Poore’s bottom line: “This hospital is going to survive and thrive no matter what the affiliation is.”

Secret for now

For now, the public is largely in the dark about the nature of the proposals, or even what type of affiliation WestCare and Haywood are willing to entertain. WestCare and Haywood won’t release the letters sent to Mission, Carolinas and Novant inviting them to make a pitch — which would likely shed light on exactly what the home hospitals hope to get out of the deal.

They also won’t make public the proposals that came back from Mission and Carolinas. Carolinas and Mission don’t want their private business information shared, and might not have sent proposals if they thought they would be made public, Poore and Leonard said.

“Although we are bound by confidentiality agreements to not give out details of the proposals, we will continue to let the community know about the evaluation process and where we are in it,” Leonard said.

The process is fraught with complexity, with each entity forced to share inside details of their operations to accurately size each other up, but wishing they didn’t have to. While Haywood and WestCare shared information with Carolinas and Mission so they could craft their pitches, it’s not being swapped with each other. For now, the two are still technically competitors.

Another factor in play is anti-trust laws. If Haywood and WestCare joined, especially with Mission, they could be subject to anti-trust regulations.

“We are trying to deal with a pretty complicated situation. There are a lot of moving parts,” Poore said. “We have been very forthright — as much as we can — during the whole process.”

Many in the medical community have expressed concern over an affiliation with Mission, fearing it would steal local specialists and siphon the most profitable operations away to the flagship in Asheville. Mission has insisted it wouldn’t do that, and they are still considered in the running.

“It will be premature to say one organization has a lead over the other at this point,” Leonard said. Besides, the decision rests in the hands of WestCare’s and Haywood’s hospital boards, he said. They likely have a long way to go before reaching a final decision.

Depending on the arrangement, Haywood Regional Medical Center could face an added layer of scrutiny, and a significant one at that. If the arrangement takes the form of merger or long-term lease, final approval rests with county commissioners.

Haywood Regional is a public hospital, and state statute gives final authority to the county’s elected leaders rather than the appointed hospital board. The statute also requires all proposals for an affiliation — not just the one the hospital says it wants — to be made public so county residents can see for themselves the options on the table. It also requires two formal public hearings to provide for public input.

Poore said once the hospital gets further along with its own decision, it will begin following the state statute requiring public involvement.

Why affiliate?

Health care conglomerates, often organized under one flagship hospital, are increasingly common. On the other hand, rural hospitals flying solo are increasingly rare.

“The growing demands of providing healthcare have jeopardized the mission of small rural hospitals,” said WestCare CEO Mark Leonard.

Smaller hospitals are struggling to stay relevant in the rapidly changing world of health care. Doctors are more specialized, while equipment is more sophisticated and expensive. Theoretically, a larger patient base — achieved by pooling patients from more than one county — can justify the cost of providing the service. Those who don’t band together but opt to compete can end up unable to provide an advanced level of health care.

The economy has exacerbated the challenges, as more patients fail to pay their medical bills or turn to the emergency room for basic treatment, Leonard said.

The first stop for sick people in Haywood County should still be their local doctor.

Over-worked and underpaid. It’s a complaint most in America could wage against their boss. But at Haywood Regional Medical Center, it was just the tip of workplace complaints.