The pending merger of Angel Medical Center with Mission Health System could be sidelined, at least temporarily, by a state bill aimed at limiting Mission’s influence in the region.

Sen. Jim Davis, R-Franklin, said he introduced the bill to offer a check on what he sees as a monopoly by Mission.

It would halt an affiliation between Mission and Angel that has been in the works for more than a year and is now close to a final deal.

“Right now it is in Angel’s court. We are certainly hoping within the next month,” said Janet Moore, director of communications at Mission.

Angel CEO Tim Hubbs said the decision of who Angel will affiliated with should rest with the people of Macon County, not Raleigh lawmakers.

“I have spoken to dozens of long term residents in our area that are outraged by the bill and are very upset with Senator Davis,” Hubbs said.

Hubbs said the bill was a shock.

“We were blindsided by it,” Hubbs said.

Davis met with Hubbs and key hospital leadership a couple of weeks ago to hear their concerns.

“He said the last thing he wanted to do was hurt Angel,” Hubbs said. But Davis has not withdrawn the bill or altered its language.

It is unclear just how much traction the bill has. Mission and Angel may complete their deal before the bill has a chance to move forward.

Davis suggests Mission could exploit its monopoly status to hoard health care services, limiting care patients can get locally and making them drive to Asheville.

But Davis’ bill would cause exactly that to happen, Hubbs said.

Mission will bring more health care service to Franklin, not less, Hubbs said. And without Mission, Angel may actually have to scale back what it provides, having the limiting effect Davis’ claims he doesn’t want.

“I think he has good intentions but the bill ironically would have the opposite effect,” said Trentham. “What he is trying to do ironically will limit free market choice.”

A partnership with Mission will make it easier to recruit doctors, bringing more specialties to Angel. Specialists from Asheville already hold occasional office days in Franklin if the services can’t already be found there.

“Mission and Angel have partnered for a very, very long time. We have been able to bring specialists and subspecialists to enhance what the community already has,” Moore said.

Angel most stands to gain financially. It will get better rates from insurance companies, can get more competitive prices on medical supplies and equipment due to bulk purchasing power, and tap Mission’s expertise on the complicated world of hospital administration and regulations.

“We aren’t to the point where we can’t survive without it, but we are definitely stronger with an affiliation,” Hubbs said.

Davis agreed Angel should be able to align with Mission if it wants to.

“I am not trying to stand I the way of that,” Davis said.

Davis said he understands why small hospitals need to be tied to a larger institution. Angel has 25 beds, and has 16 patients a day on average.

“The small ones just can’t survive by themselves,” Davis said.

But Davis’ bill would halt the merger for at least a year until the issue of Mission’s monopoly can be studied.

Hubbs last month announced he would retire in the next six months, altering solidifying the deal with Mission. That may be delayed now, too.

“I will stay here until we get some thing on the right footing,” said Hubbs.

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 Regional Medical Center, Harris Regional Hospital and Swain County Hospital have taken the next step in the affiliation that joined the three hospitals under the MedWest umbrella. The hospitals will now be known as MedWest-Haywood, MedWest-Harris and MedWest-Swain. MedWest is an affiliate of Carolinas HealthCare, the largest healthcare system in North and South Carolina.

“As we continue to work through our affiliation agreement, it became important to unite the medical staff and employees at each of our hospitals with a single name, while at the same time allowing each campus to retain its individual identity,” said Mike Poore, MedWest CEO.

MedWest is beginning to undergo signage changes to reflect the new name, although the process will take time. MedWest recently unveiled its new logo to employees and physicians, after undergoing an extensive market research study that involved a large-scale consumer perception survey and focus groups among staff and physicians.

Together, MedWest-Haywood (170 beds), MedWest-Harris (86 beds), MedWest-Swain (48 beds) and an outpatient clinic in Franklin employ 2,100. There are 230 physicians on the medical staff.

The hospitals in Haywood, Jackson and Swain Counties can boost their bottom line by $15 million a year under their new joint venture, according to a major analysis of hospital operations conducted over the past six months.

Saving money was one of the original goals when Haywood Regional Medical Center and WestCare joined forces at the beginning of the year to create a new entity called MedWest. Both were hovering dangerously close to the tipping point between losing money and barely breaking even each year — a common plight for small hospitals in the country today.

Typically, when two companies merge, workers performing duplicate roles lose their jobs when departments are consolidated.

So far, that hasn’t happened with MedWest, and CEO Mike Poore says it isn’t on the horizon.

“We don’t predict there will be any staff layoffs,” Poore said.

Instead, $15 million can be saved by implementing a long list of changes in operations — from overhauling how patients are billed to harder-nosed negotiating when buying supplies.

The recommendations are coming from Carolinas HealthCare System, a network of 32 hospitals based in Charlotte that now includes MedWest. MedWest entered a long-term management contract with Carolinas HealthCare System at the beginning of the year, coinciding with the joint venture.

Carolinas’ first step in its management role over MedWest has been to assess the hospitals from top to bottom.

“There were more than 60 of these people from Carolinas that came in and reviewed almost all aspects of our organization,” Poore said. “It is great to have this kind of depth and breadth of experience.”

For example, the analysis found MedWest charges less for some services compared to other hospitals, so those fees will be raised. The frustrating nature of medical billing — the dozens of insurance plans, the myriad charges racked up during a single hospital visit, the complicated codes that determine reimbursement — approaches an art form.

“It is very difficult as a standalone hospital to have all the expertise to do it correctly,” Poore said.

It’s one of the areas where MedWest benefits by being under the umbrella of Carolinas HealthCare System.

MedWest can also realize economies of scale when purchasing. It spends approximately $180 million a year on products and supplies, compared to $6.2 billion spent by Carolinas.

“That helps when you are negotiating for products,” Poore said. “You get the exact same products you were before but are buying from a larger pool.”

Poore said the full analysis and recommendations by Carolinas will not be made public, citing competitive interests.

“Pisgah doesn’t share its playbook with Tuscola,” he said, using a high school football analogy.

Poore held a one-hour phone press conference with reporters last week to explain the plan. Poore said he wanted to dispel any rumors that the plan amounts to a “slash and burn.”

“There is none of that in this plan,” Poore said. “It is bringing all the expertise of a very large system to our local hospitals, and we are going to be able to gain in every area.”

While Poore is the CEO of MedWest, he is technically an employee of Carolinas HealthCare System. He answers to both the corporate structure of the 32-hospital network and to the local MedWest board of directors.

The hospital’s fiscal year starts in October. Poore is ready to ready to roll out operational changes that will save $7 million for the coming fiscal year. When fully implemented two years from now, the savings will reach $15 million, he said.

The closest any of the recommendations come to layoffs involve consolidating management contracts for 12 departments where certain positions are already being outsourced. For example, the manager and assistant manager over housekeeping at Haywood Regional are contract employees that work for a management company, yet the rank-and-file housekeepers are in-house staff. In food services, the head chef and dietary manager are likewise contract employees that work for an outside company, yet all the kitchen staff are in-house.

These management positions will now be bundled into a single contract, saving $1.1 million a year, Poore said. Savings will largely come by cutting out the overhead of dealing with 12 different middlemen and instead dealing with just one.

The outright consolidation of departments between the hospitals and cutting redundant positions in the process, isn’t possible since most services have to be provided on the campus of each hospital, not necessarily from a central location, Poore said.

It isn’t even possible to consolidate billing since Haywood Regional and WestCare use two different computer systems.

“To consolidate those systems would cost us somewhere north of $8 million and move to electronic health records. Without that consolidation, there is very little you can do to streamline work processes,” Poore said. “That will be an evolution not a revolution.”

That said, the hospitals are always looking to increase productivity.

Changing patient habits

Not all the recommendations from Carolinas will be easy to implement.

One weak spot is the number of patients who go to Mission Hospital in Asheville for care they could just as easily get at home, Poore said.

The out-migration of patients is two-fold, Poore said. In a few cases, doctors in highly specialized fields don’t practice locally. But in most cases, the patients falsely think they can get better care in Asheville, according to Poore.

A strategic plan on how to capture this lost business surveyed patients about why they had gone to Asheville.

“There is a lot of misconception on the capabilities that our hospitals have,” Poore said. The same goes for the perception of doctors.

“The thinking is ‘If you live here in our small community, you can’t be that good.’ But they are that good,” Poore said. “They moved here for the same reason everybody else did. They just like living here. We have to do a much better job educating the public about the quality of our physicians.”

MedWest will also recruit physicians in specialties that are prone to out-migration.

Convincing patients they don’t need to go to Asheville and recruiting more doctors are long-term goals the medical community can’t easily control, and therefore aren’t part of the $15 million in savings Poore says MedWest can realize by putting the action plan in place.

The first inpatient hospice west of Asheville had its groundbreaking in Clyde last week — complete with Jimmy Jack the mule and its own theme song.

The hospital is targeting September 2011 as the opening date for the Homestead hospice, to be located on the campus of Haywood Regional Medical Center. The new facility will house six beds for hospice patients, offering families with a dying loved one a choice in between hospitalization and in-home care.

Anyone who’s seen a loved one face a terminal illness can appreciate the hospice that’s to come, said N.C. Rep. Phil Haire, D-Sylva, who was at the ceremony.

“I can’t think of anything more stressful,” Haire said.

The second phase of the project will be the end-of-life outreach center, which will offer:

• private rooms for counseling services and bereavement therapy.

• a reference library for resources related to terminal diseases and end-of-life issues.

• a community education center with multimedia capacity.

A courtyard will connect the two buildings. Memorial gardens will serve as a site for butterfly and dove releases.

The Homestead is expected to create 15 new permanent jobs, with an annual payroll of more than $500,000, along with dozens of short-term construction jobs.

An inpatient hospice center is also in the planning stages in Franklin. But as of now, families seeking that kind of setting must go to Asheville.

Mike Poore, CEO of MedWest — Haywood Regional Medical Center’s parent company — emphasized the significance of building a hospice like this closer to home.

“Having family close around is very important for patients,” said Poore. “We think this is really a sort of a new era for Haywood County.”

Poore added that the hospice is a testament to MedWest’s philosophy of keeping care in the community.

With more family members living far away from each other, Haire said hospice workers could also provide caring support to those who live far from their family.

“This is another way,” said Haire. “A lot of retired people don’t have support of families that live close.”

The $1 million difference

After several years of planning and fundraising, Haywood Regional Medical Center has raised $2.66 million of the $4.9 million needed for the Homestead hospice.

The effort got a major bump with a recent $1 million donation left in the will of Bernice “Bee” Medford, a long-time Haywood County benefactor who split her time between Maggie Valley and Sarasota, Fla.

“She loved this community,” said Bill Medford, her stepson. “She gave more to Haywood County than anybody in Florida.”

Medford said Bee would’ve been pleased to see her donation invested in the hospice.

Poore called Bee Medford a great friend to the hospital. “Her generosity will touch people’s lives well beyond her time,” said Poore.

Other contributions toward the hospice include $150,000 from The Duke Endowment and a $132,000 grant from the N.C. Rural Center.

State legislators Joe Sam Queen, Ray Rapp and Haire, who helped secure the grant money, all attended the groundbreaking on Friday.

“North Carolina is very proud of this project and what this community is doing,” said Queen.

The fundraising effort is still underway, and HRMC is still actively seeking grants and donations to finish the outreach center.

Call 828.452.8471 for more info.

Measuring the overall health of a population at the local level is an elusive and cumbersome task. As a result, there have been few statistical studies historically that hint at how Western North Carolina stacks up.

But this year, an unprecedented study compiled health rankings for every county in each state across the country.

The results weren’t good news for Swain County, which ranked in the bottom 10 percent in several categories. However, Haywood, Jackson and Macon counties went against the stereotype of poor health in the Appalachian Mountains and ranked in the top third.

“The western part of the state is a good deal older. When you control for that, the east part of the state seems a good deal unhealthier,” said Dr. Tom Ricketts, past director of the North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill.

Compiled by the University of Wisconsin, the study divided heath rankings into two broad categories: health outcomes and the health factors that cause them.

Swain County ranked 91st out of 100 counties in the state — the lowest ranking of any county in WNC when it comes to health factors. Meanwhile, Jackson, Haywood and Macon Counties are ranked in the healthiest third at 31, 19 and 15 respectively.

Diet, smoking, drinking, exercise, access to quality health care, social and economic factors, and the physical environment all play into the ranking.

“Health and health behaviors and care are all tangled up in a multi-complex system,” said William Aldis, a World Health Organization representative to Thailand who lives in Sylva and has taught health classes at Western Carolina University and at a university in Thailand. “You can never completely separate these things.”

Aldis said he notices the difference in health as soon as he steps off the plane and into the airport terminal when he returns to the United States.

“It surprises me when I come back how sick people look here compared to other countries,” he said.

While the University of Wisconsin study took on an enormous task, the rankings are not universally accepted by public health officials.

Linda White, director of the Swain County Health Department, has not used the information in any strategic planning because she thinks the data may be skewed.

She often compares Swain to Graham County in her planning because the populations are similar. But she noticed the study reported Swain to have the highest percent of smokers in the state while failing to report a percentage of smokers in Graham.

“It causes me to question the validity of the data,” White said.

Macon County Health Director Jim Bruckner said some counties may need to look harder at some of the statistics to determine their quality because of the sampling methods. But Bruckner said the health department has a lot it can glean from the statistics.

Every three years, the health department uses a variety of statistics to create a “snapshot” of health outcomes and contributing factors in Macon County. Bruckner said the county health rankings will now be included in the project.

“We hope to use this report to shed light on what more we can do to help residents lead healthier lives and to mobilize community leaders to invest in programs and policy changes that will improve Macon County’s health,” Bruckner said.

 

Health behaviors

 

The University of Wisconsin study looked at key health behaviors — which will ultimately affect people’s health in the future — such as diet and exercise, tobacco use, unsafe sex and alcohol use.

The study uses obesity as the measure for a county’s commitment to diet and exercise. Although obesity is a problem across the state, Jackson, Macon, Haywood and Swain Counties are no worse than the state average, according to the County Health Rankings.

North Carolina is the 10th most obese state in the nation with an adult obesity rate of 29 percent, according to the Trust for America’s Health “F as in Fat” 2010 report.

And North Carolina has grown heavier. In 2009, North Carolina was the 12th most obese state, 16th in 2008 and 17th in 2007.

“Obesity is one of the most challenging issues and has had the more lasting impact on our society,” said Carmine Rocco, Haywood County Health Department director.

Reducing childhood obesity is a big focus for health departments in Western North Carolina.

“We’ve attempted to combat that for years,” White said. “It’s a lifestyle change. Kids will eat what’s offered to them.”

White has worked with schools in Swain County to get healthier food on the menu. Between five and six years ago, the health departments removed the deep fryers from the school cafeterias and purchased them ovens instead, White said.

But it’s other health behaviors that earned Swain County its low ranking. Swain has the highest percentage of smokers in the state and one of the highest teen birth rates, which is used to indicate unsafe sex tendencies.

Dr. Mark Engel, a family doctor in Swain County, said he thinks part of the problem with Swain’s health is that preventative care has not been emphasized until recently and that Swain has been more isolated than the counties to the east.

“Swain has been socially isolated long enough,” Engel said. “It will be an uphill climb for better health.”

He’s noticed higher social support for both smoking and teen pregnancy, he said, adding that it will take generations to change the population’s attitudes.

Forty percent of adults in Swain County smoke compared to 23 percent across the state.

“We’ve come leaps and bounds,” White said, who questioned the accuracy of the statistics. “We work on lessening those numbers regardless of what they are.”

Both Dr. John Stringfield and Dr. Michael Brown, who are family doctors in Waynesville, said that they’ve seen a decrease in the number of smokers in their offices even though the study reports that Haywood still has a higher percent of smokers compared to the state average.

“There’s been an increase in education and peer pressure against smoking,” Brown said.

Only Macon County with 19 percent of the population being smokers falls below the state average.

Ricketts said that there is a strong correlation between smokers and more rural environments. He suggested that smoking might be a form of entertainment where few other options exist.

“It’s hard to explain,” Ricketts said. “It just is.”

 

Clinical care

 

Another key component in assessing an area’s health is the availability of healthcare. Researchers at the University of Wisconsin examined several factors, including the percent of uninsured adults, the number of primary providers in the area and preventable hospital stays.

Jackson and Swain Counties have poor clinical care rankings at 86 and 93 respectively while Haywood and Macon Counties are both in the top 15, according to the study.

“In the early ‘70s, the main problem was that there’s been a misdistribution between urban and rural areas with primary care physicians,” said John Price, director of the N.C. Office of Rural Health and Community Care. “The issue over the years has changed a little. The issue is economic access to care.”

Three of the four counties — with Haywood being the exception — have more than 22 percent of adults without health insurance.

That portion is noticeably higher compared to about 15 percent of American and 17 percent North Carolinians who are uninsured.

The Good Samaritan Clinic in Jackson County is a free clinic that treats uninsured adults. A volunteer doctor at the clinic, Dr. David Trigg, said there are often misconceptions about who the uninsured are.

“They’re not unemployed. They’re just uninsured, and they certainly aren’t lazy,” he said,

But in the clinical care rankings, other factors have a role in bringing down Jackson and Swain counties’ rankings.

Swain County has a high rate of hospitalization for typical outpatient services, according to the study. This suggests that outpatient care in the area is less than ideal or that the people overuse the hospital as the primary source of care, the researchers wrote.

A strike against Jackson County’s ranking is a low percentage of diabetic Medicare patients getting annual blood sugar control tests. The tests are considered a standard of good healthcare — a standard at which Jackson is the lowest in the state.

“One reason that could be lower is the way it’s recorded,” said Paula Carden, the Jackson County Health Department director. “Whether all the numbers get reported or not is hard to say.”

Carden said doctors are responsible for reporting the screenings when their patients come to get them. The codes used by doctors in Jackson to report the data may be different from those in other counties.

In one aspect of clinical care, the number of primary care doctors per capita, the study found all four counties at or above average.

But some of the physicians are counted twice, inflating the number of doctors for Western North Carolina. Many doctors in Jackson, Macon and Swain counties practice across countylines — with their main office in one county but a satellite office in the other where they hold weekly office hours. These doctors appear to be counted in both counties.

“Even if there are enough providers to the population by the numbers and they appear at the right levels, they’re not,” Good Samaritan Clinic director Becky Olson said. “The problem is that Jackson County doctors don’t just serve Jackson County alone.”

The study also fails to take into account the influx of seasonal residents and tourists to the area. Doctors in Western North Carolina said they can tell when the part-time residents begin to arrive in the spring.

“It’s an elusive number, hard to quantify,” said the Haywood County Health Department director Carmine Rocco. “But it’s a reality we have to deal with when we plan health care. If something happens, we have to be able to respond.”

Flu and respiratory illnesses keep his schedule filled during the winter, and during the summer, he sees an influx of seasonal residents. Some older residents who come for four or five months in the spring and summer have chronic conditions that require a physician’s monitoring, said Dr. John Stringfield, a doctor at Waynesville Family Practice.

“What keeps me busy is different for each season of the year,” he said.

But Ricketts said he wouldn’t call seasonal homeowners or tourists a stress on the Western North Carolina healthcare system.

“For a rural place, it generally does pretty well on physician supply,” Ricketts said.

He gave the motorcycle rally in Sturgis, S.D., as an example of something that would cause stress on the system. In 2008, the rally brought more than 400,000 bikers and three rally related deaths to the small town.

“[Tourism in Western North Carolina] doesn’t necessarily provide stress but provides income,” Ricketts said.

 

Social & economic factors

 

Research has shown that social and economic factors also play a key role in determining health.

“To have an overall picture of health, it’s affected by economic factors,” health director Carden said. “If you don’t have enough money for the good health care, your overall health is affected. … Economics plays an important role in our overall health whether we like it or not.”

According to the University of Wisconsin study, Swain County has the lowest high school graduation rate, fewest college degrees, highest unemployment and most single-parent households compared to the other three counties.

“More educated people are in a much better position to analyze health choices,” Aldis said. “Education is a powerful tool in expanding people’s health choices.”

Aldis said that in his work in foreign countries where the populations are less literate than in the United States, women who can read are more likely to get their children vaccinated even if they haven’t had any medical training.

But even less educated patients are attentive and willing to learn how to make better health choices, Trigg said about his patients at the free clinic. But without the clinic, they don’t have the same knowhow about getting health information, he said.

“They don’t get on the Internet and look up health information the same way someone from the university would,” he said.

Hand-in-hand with education, poverty also limits a people’s health options in that they can’t afford the best or at times adequate care, said Stringfield, a Haywood doctor.

“Those in a lower social economic status may tend to have more medical problems,” Stringfield said. “Sometimes that has to do with access to care or access to medicine. Many simply can’t afford to fill a prescription.”

Poverty also influences people’s food choices. Fruits and vegetables are expensive compared to a value menu at the local fast food restaurant. Snack food is also cheaper but contains unhealthy ingredients such as excess salt and high fructose corn syrup, Aldis said.

“There’s not a sense of autonomy of choice,” he said. “We have a very interesting inversion going on. Obesity is a disease of the poor.”

To learn more, visit www.countyhealthrankings.org/north-carolina.

 

 

How WNC stacks up

The University of Wisconsin ranked all counties in all states by health outcomes and health factors. Within health factors, four subcategories determined the rankings: health behaviors (30 percent), clinical care (20 percent), social and economic factors (40 percent), and physical environment (10 percent).
There are 100 counties in North Carolina. A ranking of 1 would denote the healthiest county while 100 would signify the unhealthiest in that category.

Health Factor Rankings denotes overall health. The others show what went into determining the rankings.

Health Factors Rankings
Macon    15
Haywood    19
Jackson    31
Swain    91

Health Behaviors Rankings
Macon    12
Haywood    35
Jackson    39
Swain    97

Clinical Care Rankings
Haywood    11
Macon    14
Jackson    86
Swain    93

Social and Economic Factors Rankings
Haywood    16
Jackson    19
Macon    33
Swain    79

Physical Environment Rankings
Swain    14
Jackson    35
Macon    51
Haywood    72

Percentage of Smokers
Macon:    19%
Haywood    27%
Jackson    28%
Swain    40%
State Average    23%

Every hospital in the MedWest Health System — which covers Haywood, Jackson and Swain counties — will see new construction in the next few years.

A one-story urgent care center, also housing minor X-ray and laboratory services, will be built in Canton within the next two years.

There is already an urgent care center on the west end of the county in Waynesville. The second urgent care center in Clyde will be shut down once the new one in Canton opens.

Haywood will also see a groundbreaking on a six-bed hospice center, paid for with grants and donations, some time next month. Construction should be complete in about a year and a half.

Plans are also in the making for a $9 million outpatient surgery on property adjacent to Haywood Regional — a joint venture between the hospital and local doctors.

Large medical office buildings are being built next to the hospitals in Sylva and Bryson City.

With several practices housed in one office building, it serves as a one-stop shop that will cut down on patients having to run from office to office.

Sylva’s building is being built by a private firm and will also house an outpatient lab and imaging. Bryson City’s will include physician’s offices, a pharmacy and rehab services.

Moving to Canton

Haywood Regional Medical Center is relocating its urgent care center to Canton to better serve residents hailing from the eastern half of the county. Urgent care centers serve patients who don’t need an emergency room but can’t wait days for an appointment.

The new urgent care center in Canton will capture patients who may have otherwise driven to Mission Hospital in Asheville or postponed care, according to MedWest CEO Mike Poore.

“Access to care has always proven to increase the overall health of the community,” said Poore.

The planned location for the urgent care center is on Champion Drive, which hasn’t seen an upgrade of its sewer system since the 1970s.

Town officials consider Champion Drive in Canton a hotspot for future development, and a sewer line upgrade is a high priority.

“Without an upgrade, we would have to place a moratorium on future development,” said Town Manager Al Matthews.

The sewer project will cost about $1.2 million, and the town is actively pursuing both state and federal grants. Matthews says the town will likely have to take out a loan to match any grants it receives.

Haywood Regional Medical Center CEO Mike Poore has been named as the new chief executive officer of MedWest Health System following a unanimous vote of the MedWest System Board and the recommendation of Carolinas Heathcare System.

MedWest is the name of the affiliation of Haywood Regional, Harris Regional and Swain County hospitals.

“I’m excited about the challenges of bringing these two organizations together to better serve all of our communities,” Poore said. “With the resources of WestCare, Haywood and Carolinas HealthCare integrated, we’ll be able to enhance further the healthcare of our region,”

As soon as MedWest governing board members were appointed, they faced the tough decision of picking one of two leaders vying for the position of MedWest CEO: Poore, who served as CEO of Haywood Regional Medical Center, and Mark Leonard, CEO of WestCare Health System.

Poore will assume the MedWest CEO position Jan. 1, 2010.

Leonard congratulated Poore on his appointment upon learning the news.

“I would ask the WestCare staff to give Mike the same level of commitment and dedication they have provided me,” said Leonard.

Leonard has chosen to seek other professional opportunities and will be evaluating them in the upcoming weeks and months, according to WestCare spokesman Brian Thomas.

The transitional period will take approximately six months, according to Mark Clasby, chairman of the MedWest board.

“Mike Poore will be very busy over the next few months working with the new organization and with Carolinas HealthCare System as they develop the management action plan to be presented to the MedWest board,” said Clasby.

Before serving as HRMC’s CEO, Poore served as senior vice president and administrator for two hospitals and a nursing facility in Atlanta.

The MedWest Board of Directors is made up of 14 members and has equal representation from both Haywood Regional Hospital and Harris Regional and Swain County Hospitals. Two physicians each from Haywood and WestCare also serve on the board of directors.

Both WestCare and HRMC have experienced financial difficulties over the last two years. HRMC had its Medicaid and Medicare funding yanked after failing inspections. That controversy nearly led to the hospital’s closure and prompted the resignation of former CEO David Rice and the hiring of a new administrative staff. WestCare last year announced a job reduction of up to 90 employees as it struggled to remain financially viable.

The two hospitals announced earlier this year their intention to affiliate under the name MedWest and enter a management contract with Carolinas Healthcare System out of Charlotte. The two hospitals will remain separate and keep their own boards, but Poore will act as CEO of the joint MedWest system.

Despite their requests, Haywood County commissioners will not be guaranteed a spot on the new joint operating board of Haywood Regional Medical Center and WestCare.

Commissioner Mark Swanger initially called for the seat to ensure transparency and accountability to the public, which has a vested stake in the hospital.

Commissioner Bill Upton said as an elected leader, they are the first ones to be blamed “if things go south.”

“I think it would keep us closer to the situation,” Upton said. “It makes a difference. I think it would be positive for all of us.”

When HRMC failed federal inspections two years ago and had to all but shut down for five months, commissioners were criticized for not providing enough oversight of HRMC. Two commissioners up for election that year lost, with backlash over the hospital crisis blamed as one of the reasons for their ousting by voters.

Commissioner Skeeter Curtis said the public still thinks of HRMC as “their” hospital, since county taxpayers backed a loan used for its construction, even though the hospital in fact paid back the loans and the public did not have to pony up any money.

HRMC CEO Mike Poore said he disagreed that a commissioner’s presence would somehow provide more transparency. Poore said the county commissioner serving on the board would not be able to share what was discussed by the joint hospital board outside its private meetings anyway.

“The county commissioner has no more authority to speak outside that meeting than anyone else,” Poore said. “They are not a county commissioner at that meeting. They are a member of the joint operating committee.”

Mark Clasby, chairman of the HRMC board, said giving a county commissioner a permanent seat at the table would have been a deal killer in the joint venture. Clasby added that commissioners can serve, and indeed one is on the inaugural board, but they aren’t guaranteed a spot going forward.

Is it true that Haywood and WestCare have merged?

No. The boards of Haywood Regional Medical Center (HRMC) and WestCare Health System (WestCare) have formally agreed to form a unified healthcare system that will integrate the strategic, operational, and financial aspects of both organizations. This integration is not a “merger;” rather, it is a legal arrangement that will provide patients within the newly defined service area with enhanced access to a broader array of services.

WestCare Health System includes Harris Regional Hospital, Swain County Hospital and other healthcare facilities serving a four-county area in Western North Carolina. The goal of the new arrangement with Haywood Regional is to help reduce operating expenses, while improving quality and patient safety.

The recently approved Joint Operating Agreement (JOA) permits the continued existence of separate boards of directors, but vests much oversight responsibility with a newly formed Joint Operating Company (JOC) board of directors.

HRMC and WestCare will be the sole members of the Joint Operating Company (JOC) and will share equally in the financial operations of the new company. In the healthcare industry, hospitals may form a JOC to provide a stronger financial structure and to enhance service delivery.

 

By what process did the two organizations come together?

The boards of the respective hospital systems have been engaged in the process of selecting a partner and joining the two systems together for over 18 months. Members of both boards have spent hundreds of volunteer hours in meetings with consultants and legal advisors in order to garner and evaluate the technical advice needed to make the very best decision.

Starting in the early months of 2008, HRMC and WestCare began informal discussions regarding how best to enhance the delivery of healthcare services to the people of their respective communities. In late 2008 both boards agreed that the best course of action was to secure a partner to assist in bringing the two organizations together.

Shortly thereafter, formal RFPs (requests for proposals) were sent to select organizations that had the resources needed to effect both a unification effort and also provide continuing management services to a combined operation.

Following a very intensive review process, the boards selected Carolinas HealthCare System as the manager. At that point, in April 2009, a Joint Study Committee was formed to negotiate the details of the future affiliation.

The JOA announcement on Oct. 21 represents the culmination of that effort.

 

What is the name of the new organization?

“MedWest Health System” is the name of the new Joint Operating Company; however each of the individual hospitals will continue to use their current names: Haywood Regional Medical Center, Harris Regional Hospital and Swain County Hospital.

 

When will the new company begin operations?

It is anticipated that MedWest Health System will begin integrating the operations of the two systems in January 2010. Some approvals are still pending, but those are expected to be received in a timely manner.

 

Who will be CEO of the new JOC?

That decision will be made by the newly constituted board of MedWest Health System and CHS in the next few months. A proficient management team at each hospital has helped to guide this integration effort, and they are to be commended for their conscientious and unselfish leadership throughout each step of the process.

 

Who will be on the governing board of the new JOC?

The board will be made up of 14 members, with seven from Haywood County and seven from the counties that comprise WestCare’s primary service area. The boards of HRMC and WestCare have appointed five members each and those 10 will select four at-large members to complete the board.

 

Will there be physicians on the new JOC board?

Each of the member systems, HRMC and WestCare, will have two active medical staff members on the board of MedWest Health System.

 

What will be Carolinas HealthCare System’s role with respect to MedWest?

The board of MedWest Health System will enter into a management services agreement with Carolinas HealthCare System. Under the terms of the agreement, Carolinas HealthCare will employ the executive team and provide MedWest Health System with a wide range of corporate-level management services.

Carolinas HealthCare will not have an ownership interest or a direct role in the governance of MedWest Health System.

Carolinas HealthCare will provide MedWest with the experience and resources of a comprehensive, multifaceted organization. Those resources will be brought to bear in a way that will help all of the MedWest hospitals improve patient access, lower patient costs and improve patient outcomes.

With the addition of the MedWest hospital group, CHS will operate 32 hospitals across the Carolinas. CHS provides a strong support structure for those hospitals and the hundreds of other care locations it manages. The management services agreement ensures that these support mechanisms are available to MedWest.

 

What will be the continuing responsibilities of the existing HRMC and WestCare governing boards?

Under the terms of the JOA the individual hospital boards will continue to credential medical staff at their respective facilities and will have certain other reserved powers. For example, the JOC could not accept new members without the approval of the individual boards.

 

What impact will the new arrangement have on employees?

Salaries, benefits and retirement plans have always been subject to annual review by HRMC and WestCare, and from time to time over the last few years changes have been made as necessary to those plans. That process will continue. The formation of the combined organization will not be a sole factor in deciding if there will be changes. In fact, one of the reasons for selecting the JOC organizational structure was so that the current retirement plans could remain in place.

 

Will any employees lose their jobs as a result of the JOC?

This question has not been addressed and likely will not be for at least several months. In some organizations that have formed a JOA, over the long term, the employment base has actually increased as the new organization developed new services and expanded existing services.

 

Will patients in this part of the state now have to travel to Charlotte for more complex medical services?

No. There is no plan to disrupt existing physician referral patterns. Patients, their families and their doctors will continue to make decisions about where patients will go for care.

As noted, it is anticipated that over time additional and more sophisticated services will be offered, thus allowing patients to stay closer to home for their care.

 

What impact will the JOC have on local doctors?

Physician representation has been important from the beginning of this process, and members of the medical staff at both HRMC and WestCare have participated in the work of the Joint Study Committee. The committee was diligent in seeking physician input and making sure that issues of particular interest to doctors were addressed during negotiations.

The JOC is expected to provide numerous benefits for the medical community, including the enhancement or expansion of existing services, and the development of new programs.

 

Will the three hospitals that form MedWest be jointly marketing their services?

Yes. MedWest will oversee the marketing of services for each of the individual hospitals. This is just one of many ways that savings can be realized, while highlighting the benefits that will be available through joint operations.