Arkansas Hospitals, Fall 2022

Our Promise:

Unprecedented Child Health. Defined and Delivered.

Arkansas Children’s is the state’s only health system built just for kids. By working within the communities we serve, it’s our mission to make children better today and healthier tomorrow.

We are Champions for Children where they live, learn and play.

ARKANSAS

HOSPITALS

Arkansas Hospitals is published by The Arkansas Hospital Association

419 Natural Resources Drive | Little Rock, AR 72205

To advertise, please contact Brooke Wallace magazine@arkhospitals.org

Ashley Warren, Editor in Chief

Nancy Robertson, Senior Editor & Contributing Writer

Katie Hassell, Graphic Designer

Roland R. Gladden, Advertising Traffic Manager

BOARD OF DIRECTORS

Ron Peterson, Mountain Home / Chairman

Larry Shackelford, Fayetteville / Chairman-Elect

Peggy Abbott, Camden / Treasurer

Chris Barber, Jonesboro / Past-Chairman

Ryan Gehrig, Fort Smith / Director, At-Large Greg Crain, Little Rock

Barry Davis, Paragould Carol Evans, Harrison Phil Gilmore, Crossett James Magee, Piggott

Johnny McJunkins, Nashville Gary Paxson, Batesville Eric Pianalto, Rogers Brian Thomas, Pine Bluff Debra Wright, Nashville

EXECUTIVE TEAM

Robert “Bo” Ryall / President and CEO

Jodiane Tritt / Executive Vice President

Tina Creel / President of AHA Services, Inc.

Pam Brown / Vice President of Quality and Patient Safety

Lyndsey Dumas / Vice President of Education

Debbie Love / CFO

Melanie Thomasson / Vice President of Financial Policy and Data Analytics

PRESIDENT’S MESSAGE

Protect Our Hospitals,Protect Arkansas

Editor’s Note: This letter from AHA President and CEO Bo Ryall was printed as an op-ed in the Arkansas Democrat-Gazette. We include it here so that you can share the message.

Our state’s hospitals are facing a financial crisis. Hospital leaders have come to us this year, sharing concerns about their hospitals’ viability. To get a better grasp of how widespread the issues are, we collected data from members in all regions of the state to see what effect the COVID-19 pandemic has had on their margins up to this point. On average, the hospitals we surveyed saw a total margin decrease of 3.5 percentage points between early 2019 and 2022 –a downshift that left a full 52% of them now in the red. This should be a major cause for concern for everyone. If any of our hospitals were to collapse under this mounting pressure, it would put the health of our state – its economy and its people – at risk.

When Arkansans need health care, they know that hospitals are the only place where the doors are always open: It doesn’t matter who they are or what brings them there. To make good on that promise – to continue to provide such a high level of access to care for all patients – each hospital devotes a large percentage of its financial resources to maintaining a care infrastructure that’s effective, agile, and prepared to respond to the widest possible array of needs.

Even before COVID-19 spread to Arkansas, many of our hospitals were facing major financial challenges. More than half of all hospital care in the U.S. is paid for by Medicare and Medicaid, government agencies that administratively set rates that don’t cover the full cost of care; and the other major source of payments to hospitals is private insurers, with whom they have negotiated contracts. The result of this configuration of payers is that – unlike

other businesses – hospitals can’t simply raise their prices when costs go up.

And costs have gone up with the arrival of COVID. Since 2020, hospital expenses have outstripped revenues. Facilities have committed large sums of money to equip their buildings and employees with the technology they need to continue to provide a safe environment for their patients and employees during the pandemic. Per patient, drug costs have increased 36.9%, and medical supply expenses grew 20.6%. As COVID surged, the demand for health care workers spiked, and many were lured away by high-earning jobs in other states. As a result, hospitals of all sizes became reliant on expensive contract labor. Labor costs can account for more than half of a hospital’s total expenses, so any increase in these costs can have a huge impact on

a hospital’s total expenses and operating margins. In the spring, when COVID case numbers and hospitalizations started to decline, the financial pressures of inflation increased, making the situation even more serious for hospitals.

I hear stories every day that remind me of the strength and fortitude of hospital employees, from CEOs and critical care nurses to volunteer coordinators and engineers. Their heartfelt commitment to providing care to all Arkansans is essential to our recovery from this crisis. But hospitals won’t be able to do it alone. As a state, we must recognize the crucial role they play, as both the heart of the health care system and a major driver of the economy. Unless hospitals receive more help from state and federal government there will be no doubt: We will see more reductions in services and possibly even closures. Hospitals desperately needed the support and resources that the U.S. Congress, the Arkansas Legislature, and Governor Hutchinson’s administration have provided throughout the pandemic, and they are so grateful to have received it. But additional support is needed now.

Bo Ryall President and CEO Arkansas Hospital Association

For Further Reading: American Hospital Association, “Massive Growth in Expenses and Rising Inflation Fuel Continued Financial Challenges for America’s Hospitals and Health Systems,” April 2022; Kaufman Hall for the American Hospital Association, "The Current State of Hospital Finances, Fall 2022 Update," September 2022.

Critical for Care

As patients or visitors, when we enter the doors of a hospital we are very often in a vulnerable state – physically, mentally, emotionally, or some combination thereof. From check-in to discharge, the hospital workers we meet along the way guide and support us through some of the most profound challenges of our lives. We often find ourselves humbled by their expertise and compassion. We recognize that we need hospitals to be strong when we, ourselves, cannot be.

Today, Arkansas’s hospitals find themselves in an unbelievably precarious position as they face significant financial vulnerabilities in the wake of COVID-19. As a community of advocates for hospitals, this is an uncomfortable truth that we must face: Unless hospitals find some relief from rising costs and stagnant payments, there will be places in our state where health care access will be constricted, and there will be times when people will not be able to reach the care providers they need when they need them. Hospitals are speaking up, humbly, to say that they need help, and they are working to effect change by sharing their stories with lawmakers and with rulemaking bodies.

Though the financial peril affects hospitals large and small, it is in our smallest and most remote communities where hospital closures could mean a near-total loss of local health care. This, in turn, can reduce community viability: When a hospital closes its doors, a

community’s significant economic engine goes away.

The Arkansas Hospital Association and the American Hospital Association are among hospitals’ most effective advocates, both in Washington, D.C. and in the state Capitol in Little Rock.

In this issue’s cover story, John Supplitt, one of these longtime advocates for hospitals, looks back on the 25 years since the Critical Access Hospital designation was established. John is the American Hospital Association’s Senior Director of the Section for Small or Rural Hospitals. Since 1993, he has worked with and on behalf of the national association’s 2,000 small or rural hospital members to identify, develop, and advance their unique health care issues and needs. As he says in his article, “the CAH designation is designed to reduce the financial vulnerability of rural hospitals

and improve patient access to health care by keeping essential services located within rural communities.” Indeed, in CAHs – and in all of our hospitals – we must protect the financial health of the facilities so that the facilities can continue to provide quality health care to all Arkansans.

As we consider essential ways to bolster the strength and viability of our hospitals, recruiting and retaining staff is a key concern for every health care organization. To address this central concern, Dr. Tom Atchison, who will be facilitating the leadership workshop at this year’s annual meeting, shares his framework for creating sustainable and meaningful employee engagement. Immediately following his article, we meet Sammie Cribbs, CEO of North Arkansas Regional Medical Center – a hospital administrator who sees engagement with team members as an organizing principle of her leadership.

In this issue, you’ll also find examples of how our communities are creating new ways to offer health care to their citizens, and you’ll look, with Kay Kendall, at how rural hospitals can adopt principles in the Baldrige Excellence Framework to their advantage on their quality journey.

In all of these stories, we can see how vulnerability can become fertile ground for growth. We can also feel the humility from whence cries for help and new solutions arise. Arkansas’s hospitals need your help and support today. Will you join us in meeting their hour of vulnerability?

Ashley Warren Editor in Chief

HOSPITAL NEWSMAKERS

Ouachita County Medical Center’s Chemical Dependency Unit, a leader in substance-abuse treatment for more than 35 years, has been chosen to be featured on the awardwinning educational series “Viewpoint with Dennis Quaid.” The program highlights innovations and best new ideas across a variety of spectra, with this episode shining a light on addiction and the importance of professional treatment of substance abuse disorder. Filming took place in August, and the episode premieres in October of 2022.

members. Download the three-part guide and other AHA workforce resources at email.advocacy.aha.org.

Baxter Regional Medical Center now has a new name. The hospital, located in Mountain Home, is now Baxter Health.

The University of Arkansas for Medical Sciences is one of six medical entities nationwide to be named a Comprehensive Care Center by the Parkinson’s Foundation Global Care Network. The designation was granted due to UAMS, through its Movement Disorders Clinic, meeting exacting standards of excellence for treatment of Parkinson’s Disease in the areas of comprehensive clinical care, community education and resources, and community outreach. The Comprehensive Care Center designation was first granted in late November; a total of only 15 centers of excellence will be named over the next five years.

Teresa Roark, Program Director for Ouachita County Medical Center's Chemical Dependency Unit, is interviewed "by show producer Evan Shultz for the PBS program "Viewpoint with Dennis Quaid." OCMC's Chemical Dependency Program, a national standout for more than 35 years, is dedicated to helping people recover from chemical addiction in a safe and confidential environment.

CHI St. Vincent has been named to the 2022 Fortune / Merative 15 Top Health Systems list. This is the first time the system has been recognized as one of the topperforming health systems in the U.S. The annual list was published by Fortune . Merative, a data, analytics, and technology partner for the health industry, identified the top health systems from an evaluation of 349 health systems and 3,206 hospitals that are members of health systems. The annual list recognizes excellence in clinical outcomes, operational efficiency, and patient experience. Additionally, CHI St. Vincent Hot Springs is ranked #16 in the nation in Fortune /Merative’s Top 100 U.S. Hospitals list.

The American Hospital Association in early September released strategies for building your workforce team, the final section in its three-part guide to strengthening the health care workforce. This section focuses on recruitment and retention, diversity and inclusion, and creative staffing models. Sections one and two focus on supporting the team and using data and technology to support the workforce. The AHA Board of Trustees’ Task Force on Workforce provided guidance for the series, with input from AHA

Jeffrey Carrier, MiM , has been named President of the Baptist Health Western Region, including Baptist HealthFort Smith and Baptist Health-Van Buren. He formerly held leadership positions with Freeman Health and Centura Health. Carrier holds a master’s degree in management from Baker University; he earned his bachelor’s degree in nursing from MidAmerica Nazarene University.

Ryan Gehrig, MHA, has a new, expanded role as President of Mercy Hospitals Arkansas. Formerly the President of Mercy Fort Smith, he will now guide both the Fort Smith and Rogers locations. Eric Pianalto, MBA, formerly President of Mercy Northwest Arkansas in Rogers, assumes a new role of Chief Strategic Growth Officer for Mercy Arkansas

The Movement Disorders Clinic is located in the Jackson T. Stephens Spine & Neurosciences Institute at UAMS.

Mercy Arkansas will invest $500 million in the next phase of its health care expansion in Northwest Arkansas. Projects will include a state-ofthe-art cancer center, shown in the architect’s rendering above.

Mercy Arkansas recently announced a planned $500 million expansion of facilities and services in Northwest Arkansas. The projects will include a state-of-the-art cancer center, emergency department, isolation room expansion, additional clinic locations, more outpatient care facilities, and nearly doubling the current number of primary care physicians and specialists.

Tommy Hobbs has been named CEO of Johnson Regional Medical Center in Clarksville.

Shane Slade, MHA , has been named Administrator for the 19th Medical Group at Little Rock Air Force Base.

Dr. William Steinbach of Arkansas Children’s and Dr. Brian Fisher with Children’s Hospital of Philadelphia are teaming up for a seven-year project studying uncomplicated candidemia, an invasive fungal disease affecting children. Their project, funded by a $9.7 million grant from the National Institutes of Health, seeks an effective and shorter treatment period than the current 14-day medication course.

White River Health System , headquartered in Batesville, has changed its name to White River Health.

Washington Regional Medical Center’s blood bank, a part of the hospital’s laboratory department, recently earned reaccreditation from the Association for the Advancement of Blood & Biotherapies (AABB), which sets standards for blood banks and transfusion services to ensure quality and safety for both donors and patients. Washington Regional is one of only seven facilities in the state to earn AABB accreditation.

The Breast Cancer program at the University of Arkansas for Medical Sciences (UAMS) Winthrop P. Rockefeller Cancer Institute has earned reaccreditation from the National Accreditation Program for Breast Centers (NAPBC). The UAMS Breast Cancer program first received accreditation from NAPBC in 2011.

2022 Fall Calendar

Register for AHA Events Online!

Employees of AHA member hospitals can now log in to www.arkhospitals.org and register for events online.

REGISTER TODAY!

AHA Annual Meeting

November 9-10| Hot Springs Convention Center (More Information on page 11)

Scan this code for our event page

October 12

Cyber Workshop: Cyber Risk is Enterprise Risk Delta Hotels by Marriott Little Rock In-person event

October 14 Society for Arkansas Healthcare Purchasing and Materials Management (SAHPMM)

2022 Fall Conference Arkansas Hospital Association Classroom Little Rock In-person event

October 18 340B Forum

OCTOBER

October 5

ACHI: Naloxhome Program

Virtual event

October 6

Arkansas Healthcare Human Resources Association (AHHRA)

2022 Fall Conference

Winthrop Rockefeller Institute Petit Jean Mountain, Morrilton In-person event

Virtual event

October 20

October Quality Forum: Foundations of Healthcare Quality 102 Virtual event

October 27 AHA Workplace Violence Forum Virtual event

NOVEMBER

November 4

Arkansas Association for Healthcare Engineering, Inc. (AAHE)

2022 Scholarship Trust Trap Shooting Tournament Game & Fish Shooting Complex Jacksonville In-person event

November 9-10

Arkansas Hospital Association 2022 Annual Meeting

Hot Springs Convention Center Hot Springs In-person event

November 17

November Quality Forum: Foundations of Healthcare Quality 103 Virtual event

DECEMBER

December 1

Arkansas Hospital Association Workers’ Comp Self-Insured Trust

(AHAWCSIT) Quarterly Board Meeting

Virtual event

December 8

Workshop: CPT 2023 Procedure Coding Changes

Arkansas Hospital Association Classroom Little Rock In-person event

December 8

AHA Workplace Violence Forum Virtual event

BY OCTOBER 28

Our 2022 Presenters Include:

DR. TOM ATCHISON

Employee Engagement: A Guide to Rediscovering Purpose and Meaning in Healthcare Wednesday, November 9 | 9:30 a.m. – 3:30 p.m.

GINGER ZEE

A Little Closer to Home: How

Found the Calm After the

Thursday, November 10

7:30 – 9:30 a.m.

DR. KEVIN AHMAAD JENKINS

The Winning Race: Diversity, Equity & Inclusion (Coaching Clinic)

Thursday, November 10

9:45

11:30 a.m.

Critical Access Hospitals: Celebrating 25 Years

By John Supplitt

Happy anniversary, American Health Care! This year we celebrate 25 years, and a legacy of extraordinary success, since the establishment of Critical Access Hospitals (CAHs) in 1997.

Longtime members of the health care community might remember that the program was slow to evolve. But after some initial skepticism and a few legislative and regulatory tweaks, it has grown to 1,360 CAHs in 45 states. Why not all 50? Rhode Island, Connecticut, New Jersey, Delaware, and Maryland are ineligible for the program due to their dearth of rural areas.

Currently, the distribution of CAHs ranges from as few as three in Massachusetts to as many as 88 in Texas; 83 CAHs share 829 distinct part unit (DPU) inpatient psychiatric beds, and another four share 40 DPU inpatient rehabilitation beds.

This year we celebrate the improved access to rural health care these CAHs established and continue to provide. Here's to a quarter century!

WHAT ARE CRITICAL ACCESS HOSPITALS?

CAHs are limited to 25 beds and primarily operate in rural areas. Of the 1,360 CAHs in the U.S., 28 are located in Arkansas.

The Health Resources and Services Administration of the U.S. Department of Health and Human Services, under its Rural Health Information Hub, explains that “Critical Access Hospital” is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). Congress created the CAH designation through the Balanced Budget Act of 1997 (Public Law 105-33) in response to more than 400 rural hospital closures during the 1980s and early 1990s. Since its creation, Congress has amended the CAH designation and related program requirements several times through additional legislation.

The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve patient access to health care by keeping essential services located within rural communities.

Besides being limited to 25 or fewer acute care inpatient beds, to obtain CAH designation, eligible hospitals must generally meet the following conditions:

• Location is more than 35 miles from another hospital (there are limited exceptions).

• Maintain an annual average length of stay of 96 hours or less for acute care patients.

• Provide 24/7 emergency care services.

Congress also created the Medicare Rural Hospital Flexibility Program (Flex Program) in the Balanced Budget Act of 1997 to support new and existing CAHs. These hospitals receive certain benefits, such as cost-based reimbursement for Medicare services, as part of their reimbursement structure.

CAHs are limited to 25 beds and primarily operate in rural areas. Of the 1,360 CAHs in the U.S., 28 are located in Arkansas.

From top: Fulton County Hospital, CHI St. Vincent Morrilton, Mercy Hospital Booneville, and SMC Regional Medical Center.

Critical Access Hospitals in Arkansas

• Ashley County Medical Center

• Baptist Health Medical Center - Arkadelphia

• Baptist Health Medical Center - Heber Springs

Bradley County Medical Center

• CHI St. Vincent Morrilton

• Chicot Memorial Medical Center

• CrossRidge Community Hospital

• Dallas County Medical Center

• Dardanelle Regional Medical Center

• Delta Health System

• DeWitt Hospital & Nursing Home

Eureka Springs Hospital

• Fulton County Hospital

Howard Memorial Hospital

Izard County Medical Center

Lawrence Memorial Hospital

Little River Memorial Hospital

McGehee Hospital

Mercy Hospital Berryville

Mercy Hospital Booneville

Mercy Hospital Ozark

Mercy Hospital Paris

Mercy Hospital Waldron

Ozark Health Medical Center

Ozarks Community Hospital

Piggott Community Hospital

• SMC Regional Medical Center

Stone County Medical Center

From top: Baptist Health Medical CenterArkadelphia, Chicot Memorial Medical Center, and Ozark Health Medical Center.

Legislative Landmarks in the History of Critical Access Hospitals

• Balanced Budget Act (BBA) of 1997. Created the CAH program, outlining all details of the program including eligibility and operational regulations.

• Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999. Corrected unanticipated adverse payment and regulatory consequences of the BBA of 1997.

• Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. Provided further exemptions and reimbursement improvements to CAHs, strengthening the overall program.

• Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Enhanced CAH payments, expanded bed-size flexibility, provided continued funding for the Medicare Rural Hospital Flexibility (Flex) Program grants, and increased Medicare payments to 101% of reasonable costs. It also enacted a sunset of the necessary provider provision, effective January 1, 2006.

• Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. Further expanded Flex grants and allowed CAHs to receive 101% of reasonable costs for clinical lab services provided to Medicare beneficiaries even if the specimen was collected offsite or at another CAH-operated facility.

SERVICES AND REIMBURSEMENT

Under Medicare, the CAH represents a separate provider type with its own Medicare Conditions of Participation (CoP) and separate payment methods. Medicare pays CAHs based on each hospital’s reported allowable costs, known as cost-based reimbursement. Most CAH beds are "swing beds," where hospitals can choose to provide either acute or post-acute care.

In addition to 25 inpatient beds, CAHs can also provide other non-acute services. CAHs are allowed to have distinct-part skilled nursing facilities, 10-bed psychiatric units, 10-bed rehabilitation units, and home health agencies. However, these departments of the CAH are paid through Medicare’s prospective systems and are not eligible for cost-based reimbursement.

CAHs provide 24-hour emergency services, seven days a week, using on-site or on-call staff with specific on-site, on-call staff response times. CAHs also must stay under an annual average acute care inpatient length of stay of 96 hours or less (excluding swing bed services and DPU beds).

Under cost-based reimbursement, each CAH receives 101% of its reasonable costs for outpatient, inpatient, laboratory, and therapy services, as well as postacute care in the hospital’s swing beds. Payments are based on Medicare allowable costs. CAHs are subject to a federal budget sequester of 2%. Beneficiaries pay the standard hospital deductible for inpatient services and cost sharing equal to 20% of charges for outpatient services.

Under Medicare Part A inpatient services, CAHs are paid when a physician or other qualified practitioner orders admission, and the physician certifies that they

From top: Izard County Medical Center, Mercy Hospital Waldron, Ashley County Medical Center, and Dallas County Medical Center.

expect the individual to be discharged or transferred to another hospital within 96 hours of CAH admission. If a physician cannot certify at time of admission that they expect the individual to be discharged or transferred to another hospital within 96 hours, then the CAH will not receive inpatient service payment.

CAHs can be paid for professional services under several methods. Using the standard payment method, a physician or practitioner bills their outpatient professional services under the Medicare Physician Fee Schedule (PFS). However, CAHs may elect an optional payment method, Method II, for professional outpatient services. Under this method physicians and mid-level practitioners must assign their billing rights to the CAH; services are then paid at 115% of the allowable PFS amount. There also is a bonus for services provided in health professional shortage areas.

Looking at other services, Medicare pays CAHs for ambulance services and ambulance services provided by an entity the CAH owns and operates, based on 101% of reasonable costs if it is the only ambulance provider or supplier within a 35-mile drive of the CAH. Distinct part unit services for both inpatient rehabilitation and psychiatric services are paid under their

respective prospective payment systems. Additionally, Medicare has special payment guidelines for telehealth provided by a CAH. Finally, CAHs can choose to incur residency training costs directly or function as a Medicare Graduate Medical Education non-provider setting for payment purposes.

THE EVOLUTION OF CAH s

The program has undeniably improved not only access but also coverage and outcomes to rural communities and Medicare beneficiaries across America.

Baptist Health Medical Center - Heber Springs

Little River Memorial Hospital

But the story of CAHs took root several years prior to the BBA of 1997. Not until a series of demonstration projects showed how the new model of payment and delivery matured was it introduced to the balance of rural America.

Medical Assistance Facility Program in Montana iii

Concerned that hospitals closing in frontier Montana left residents without access to basic health care, the Montana State legislature authorized a Medical Assistance Facility program in 1987. The program was designed to provide continued access to health care by converting a full-service hospital into a low-intensity, short-stay health care service center. Montana law allowed these facilities to provide up to 96 hours of inpatient care. (Medical Assistance Facilities must be located more than 35 road miles from the nearest hospital or be located in a county with a population density of no more than six residents per square mile.)

Montana revised its licensure rules to reduce hospital staffing requirements and adapted other existing standards to the Medical Assistance Facility concept. The facilities are allowed to offer any health service for which it is adequately equipped and staffed to perform. The State authorized the Montana Hospital Research and Education Foundation – a non-profit organization affiliated with the Montana Hospital Association – to help implement the program, which was financed through a Health Care Financing Administration demonstration grant.

The Essential Access Community Hospital/Rural Primary Care Hospital Program iv

The Omnibus Budget Reconciliation Act of 1989 resulted in a new program designed to address the needs of small, rural community hospitals. One component provides for Medicare recognition of a new type of limited-service facility, a Rural Primary Care Hospital. Another required

Figure 1: Flex Monitoring Team Historical CAH Data (flexmonitoring.org)

As these [COVID-19] funding streams run out, rural hospitals must once again shoulder the brunt of the costs incurred by the pandemic, putting them in a financially precarious position moving forward.

Howard Memorial Hospital

that these primary care hospitals be formally linked, as a network, to a larger allied Essential Access Community Hospital with more than 75 beds. The program also allowed state designation in accordance with a state planning effort for rural areas.

CAH PROGRAM GROWTH

The program was launched with high expectations as a revolutionary model of payment and delivery that would stabilize care and improve outcomes for Medicare beneficiaries living in rural America. By August 1997, CMS certified 41 CAHs that included the Medical Assistance Facilities and Rural Primary Care Hospitals carried over from the earlier demonstrations. Yet, despite the success of the earlier demonstrations and promotion from the hospital and policy communities, the program gained little initial traction. In fact, after two years the program grew by only 35 more hospitals to a total of 78 CAHs in July 1999.

There are many reasons why rural hospitals did not convert to CAHs. Conversion does not necessarily result in financial improvement and is not, therefore, an economically viable option for every rural hospital. Limits on length of stay could not be met. Some hospitals had successful DPUs the program could not accommodate. Civic and citizen pride in their facilities was one element that influenced early decisions to maintain the size of current hospitals; and in some instances, the desire to attain CAH designation was stalled by mistrust of government involvement.

In 2000, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) mandated a study by the General Accounting Office (GAO) into the eligibility requirements of CAHs. In September 2003, GAO recommended to Congress that CAH-affiliated DPUs be paid under the same formulas as other inpatient psychiatric or rehabilitation providers and change the limit on acute care patient census from an absolute limit of 15 acute care patients to an annual average of 15 in order to give CAHs greater flexibility in the management of their patient census.

These GAO recommendations were among other changes included in Section 405 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Enhanced payment expanded bed-size flexibility, modified conditions of participation, and increased coverage – sparking new interest in the program.

The program began to grow incrementally because of these legislative fixes and education and technical assistance from state-based departments of rural health. Yet, as it grew so did criticism that the program had veered from its original

From top: CrossRidge Community Hospital, Piggott Community Hospital, Eureka Springs Hospital, and Delta Health System.

intent of supporting vulnerable frontier communities to one of absolving low performing hospitals in or adjacent to metro areas. The MMA also eliminated the state’s authority to designate a hospital as a “necessary provider,” effective Jan. 1, 2006. After that date, hospitals had to meet the federal distance requirements to qualify for CAH designation.

When they received notice that the necessary provider waiver of eligibility and the documented success of cost-based reimbursement had been eliminated, hospital executives, boards, and physicians began to reconsider their earlier positions. In December 2005, the last month before the waiver expired, 75 CAHs were certified. From August 1999 to December 2005 the program added 1,203 CAHs, bringing the total to 1,281 (including 11 Indian Health Service and tribal facilities). See Figure 1. The program now hovers around 1,360 certified CAHs.

THE FUTURE OF CRITICAL ACCESS HOSPITALS

Like many providers, CAHs have weathered the fits and starts of a new program as it is introduced and matures. Nevertheless, there have been challenging moments.

Perhaps the biggest threat to CAHs, if not the overall program, surfaced in August 2013 with a report from the HHS Office of Inspector General (OIG). The 34-page report advanced several recommendations to CMS that it posited would decrease spending for both Medicare and Medicare beneficiaries.

For example, the OIG recommended that CMS seek legislative authority to remove necessary provider CAHs’ permanent exemption from the distance requirement. This recommendation would impact approximately 75% of currently existing CAHs, which provide health care services to Medicare beneficiaries who would otherwise be unable to access hospital services.

While CMS chose not to adopt the OIG recommendations, the report nonetheless demonstrated an unfortunate lack of understanding of how health care is delivered in rural America. While the recommendations may have saved Medicare money, many facilities would have been forced to close and patients would have lost access to essential medical services. In addition, OIG failed to appreciate that CAHs are often the economic engines of rural communities, and that any loss could be disastrous to future economic development of these communities. Jobs are lost when CAHs close.

Other concerns exist regarding the program’s viability. There is uncertainty among CAH executives in the permanence of the 340B drug discount pricing program in rural areas where access to

From top: Mercy Hospital Ozark, DeWitt Hospital & Nursing Home, Ozarks Community Hospital, and Mercy Hospital Paris.

medications and medication services has declined. According to the GAO, hospitals participating in the 340B program are typically smaller, critical access, or other rural hospitals. This is a major source of revenue to many CAHs and for some, offers their only margin.

CRITICAL ACCESS HOSPITALS AND CLOSURES

As successful as the CAH program has been at stabilizing the delivery of inpatient, outpatient, and post-acute care and providing a general medical presence in rural communities, it is not a remedy for all. Of the 182 rural hospital closures in the United States from 2005 to present, 64 have been CAHs. There are many possible reasons for a hospital closure, including lower patient volumes, lower reimbursement, staffing shortages, and the effects of the COVID-19 pandemic.

Many CAHs were in precarious financial positions even before the COVID-19 pandemic, and the pandemic exacerbated the challenges that many rural hospitals were already experiencing, including workforce shortages, limited access to critical supplies, and aging infrastructure. CAH executives identified uncompensated

care, affordability of health insurance, patient bypass, and prescription drug prices as high priority health system challenges. Funding programs developed by the federal government helped rural hospitals sustain services during the COVID-19 pandemic. Rural hospitals received COVID-19 relief funds from the Coronavirus Aid, Relief and Economic Security (CARES) Act and the American Rescue Plan Act. As these funding streams run out, however, rural hospitals must once again shoulder the brunt of the costs incurred by the pandemic, putting them in a financially precarious position moving forward.

Dardanelle Regional Medical Center

Bradley County Medical Center

Additionally, CMS utilized waiver authority tied to the National Public Health Emergency (NPHE) to enable the expansion of telehealth services during the COVID-19 pandemic. These flexibilities have had a huge and favorable impact on rural hospitals including CAHs, which used these telehealth waivers to increase access, avoid hospitalizations, and improve outcomes. Without congressional action, however, these waiver flexibilities will expire, jeopardizing the progress made over the last two years to increase patient access.

To mitigate rural hospital closures, hospitals continue to explore strategies that allow them to remain viable within their communities. Without the appropriate support and evaluation of existing policies by the state and federal government, rural hospitals and the communities they serve will remain at risk.

CAUSE FOR CELEBRATION

The CAH program has thrived for 25 years. It was built carefully and deliberately on the experience of prior demonstration programs.

While the BBA of 1997 established the CAH program, initial growth was slow. But the original founding legislation’s being tweaked multiple times continues to improve the CAH program, inspiring its growth. CAHs continually weather threats to the program’s existence, and we recognize that it doesn’t provide a remedy for all rural communities.

Special funding under the NPHE proved invaluable to CAHs, but is term limited. We believe policy makers need to safeguard the existing CAH program while providing new models of payment and delivery for those rural communities that cannot support an inpatient hospital.

John Supplitt, MBA, MPA, serves as Senior Director of the Section for Small or Rural Hospitals, a division of the American Hospital Association. Since 1993 he has worked with and on behalf of the AHA’s 2,000 small or rural hospital members to identify, develop, and advance their unique health care interests, issues, and perspectives.

References

i“Critical Access Hospitals Payment System,” Medicare Payment Advisory Committee, Washington, D.C., October 2020.

ii“Critical Access Hospitals,” U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services,iii Medicare Learning Network, MLN006400, Baltimore, Md., March 2022.Maureen Wilce, Cathaleen Ahern, Ron Kalil, Paula Bowker, and Ruth Reiser. “Medical Assistance Facilities: A Demonstration Program to Provide Access to Health Care in Frontier Communities,” U. S. Department of Health & Human Services Office of Inspector General, OEI-04-92-00731, Washington, D.C., July 1993.

iv Suzanne Felt and George Wright. “Developing Rural Health Networks under the EACH/RPCH Program,” Mathematica Policy Research, Inc. Washington, D.C., Sept. 30, 1993.

v Ann Maxwell. “Most Critical Access Hospitals Would Not Meet the Location Requirements if Required to Re-enroll in Medicare (OEI-05-12-00080),” U.S. Department of Health & Human Services, Office of Inspector General, Chicago, Ill., August 2013.

vi S. Thomas, K. Thompson, K. Knocke, and G. Pink. “Health System Challenges for Critical Access Hospitals: Findings from a National Survey of CAH Executives,” University of North Carolina, Charlotte, N.C. February 2021.

vii “Rural Hospital Closures Threaten Access: Solutions to Preserve Care in Local Communities,” American Hospital Association, Chicago, Ill., August 2022.

From top: Mercy Hospital Berryville, Stone County Medical Center, Lawrence Memorial Hospital, and McGehee Hospital.

Providing quality care for 100 years

For the last century, the Good Samaritan Society has been committed to providing an unprecedented level of quality service to ensure your patients are safe and cared for.

Our expansive footprint ensures we have the expertise to provide them with a smooth transition through various levels of care.

“We’ve been doing this for 100 years. We specialize in it,” says the Good Samaritan Society’s Chief Medical Officer, Gregory Johnson, MD. “We provide support that meets people where they are.”

And this support starts immediately after someone is discharged from the hospital.

“We work with our hospital and physician partners. That’s a special level of collaboration and integration,” Dr. Johnson says.

The impact of exceptional senior care

Delivering the best care in a resident-centered environment has always been our focus. We believe that relationships, collaboration and human connection are essential to what we do.

Using an integrated approach, we’re improving quality of life and well-being while continually developing better standards of care across our communities. Services vary by location but may include:

• Assisted living – Convenient, maintenance-free living with services, amenities and security features to help residents live vibrantly.

• Home-based services – Customized, in-home medical or non-medical care within the comfort of a person’s home with extra support for meals, medications and more.

• Long-term care – 24-hour care and services for those who need the assistance of licensed nursing or rehabilitative staff.

• Rehab therapy – Quality inpatient or outpatient services using physical, occupational and speech therapies to enhance recovery after a hospitalization, illness or injury.

When you choose the Good Samaritan Society, your patient will be cared for by dedicated experts there to promote their well-being. Partner with the right choice

Whether your patient needs 24-hour care, rehabilitation therapy or care at home, referrals to the Good Samaritan Society are easy and convenient:

• Call your local Good Samaritan Society location

• Call (855) 446-1862 to speak to a specialist about services

• Visit our Health Care Partners page at good-sam.com to use our simple online referral form

We partner with you to provide the best outcomes for your patient – supporting them physically, emotionally and spiritually through the health care journey.

Whatever level of care they need when leaving the hospital, the Society is ready to help restore their well-being.

If you have questions about referring patients or want to learn more about our services, please call (855) 446-1862 or visit our Health Care Partners page at good-sam.com.

This content is provided as a paid advertorial by the Good Samaritan Society.

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in

Stop the Bleeding

It's Time to Fix the Medicare Area Wage Index

By Bo Ryall, President & CEO Arkansas Hospital Association

The Medicare hospital inpatient prospective payment system (PPS) is designed to pay hospitals for services provided to Medicare beneficiaries based on a national average payment amount, adjusted for two factors that affect hospitals' costs: 1) the patient's condition and related treatment strategy and 2) market conditions in the hospital's location. One of the significant adjustments in the inpatient PPS is an adjustment for market conditions known as the area wage index (AWI). The AWI is intended to measure differences in hospital wage rates among labor markets; it compares the average hourly wage for hospital workers in each metropolitan statistical area (MSA) or statewide rural area to the nationwide average.

The area wage index (AWI) is a vital component of determining Medicare hospital payment rates. The AWI has become controversial in hospital and hospital association circles both because of the changes in the payments that have been influenced by Congress and because of the regulatory changes implemented by the Centers for Medicare and Medicaid Services (CMS).

WHAT IS AWI?

The basic premise of the AWI is that if, for example, it costs more to hire a nurse in one market than another, then payments should reflect that difference because area labor costs are beyond a health care provider’s control. Hospitals report wage data for their employees yearly, and those numbers are used to calculate the AWI. The same pool of funding is used for the AWI, so as payment is adjusted each year there are increases to some hospitals and decreases to others.

The AWI is broken down into metropolitan statistical areas (MSA), and the rest of a state is combined in one rural area. In Arkansas, our MSAs are in Little Rock, Fayetteville, Fort Smith, Texarkana, Pine Bluff, Memphis/West Memphis and Jonesboro.

WHAT’S WRONG WITH THE AWI?

Hospitals that moderate increases in hourly wages due to financial considerations, such as high government payer mix and low commercial pay rates, become low-cost providers unable to keep up with other regions’ pay increases. The result is that those regions have an increase in the AWI, and other states like Arkansas, Alabama and West Virginia continue to get pushed lower. This occurs incrementally over time, but with each passing year the gap widens.

To illustrate how this circularity happens, consider the following: In 2003, the lowest wage index was 0.759 and the highest was 1.5185 – a difference of 100%. However, this gap has since widened considerably; in 2019, the lowest wage index had dropped to 0.6704 and the highest rate had climbed to 1.9025 – a difference of 184%. In the AWI system, even small changes can cost hospitals millions of dollars, so this widening gap is quite alarming.

The area wage index (AWI) is a vital com ponent of determining Medicare hospital payment rates. The AWI has become con troversial in hospital and hospital associ ation circles both because of the changes in the payments that have been influenced by Congress and because of the regulatory changes implemented by the Centers for Medicare and Medicaid Services (CMS).

What is AWI?

What’s Wrong with the AWI? CIRCULARITY

EXCEPTIONS

The basic wage index can result in large differences between adjoining geographic areas. Because of this, numerous exceptions to the basic calculation have been incorporated into the system that permit hospitals to have their payments adjusted by a higher wage index value. There are seven different reclassifications and exceptions that hospitals can obtain. More than 40% of hospitals take advantage of some type of exception. The most common is for hospitals around a state border to reclassify into a neighboring state’s nearby MSA. Any program that grants exceptions at more than 40% is not a fair and accurate formula to base payments on.

The basic premise of the AWI is that payments should be partially based upon the local cost of labor. If, for example, it costs more to hire a nurse in one market than another, then payments should reflect that difference because area labor costs are beyond a healthcare provider’s con trol. Hospitals report wage data for their employees yearly, and those numbers are used to calculate the AWI. The same pool of funding is used for the AWI, so as payment is adjusted each year, there are increases to some hospitals and decreases to others.

The AWI is broken down into metropoli tan statistical areas (MSA), and the rest of a state is combined in one rural area. In Arkansas, our MSAs are in Little Rock, Fay etteville, Fort Smith, Texarkana, Pine Bluff, Memphis/West Memphis, and Jonesboro.

The AWI gives financial benefit to hospi tals in regions that are already able to pro vide higher wages while decreasing funding to hospitals in other areas. Hospitals that moderate increases in hourly wages due to financial considerations, such as high gov ernment payer mix and low commercial pay rates, become low-cost providers, unable to keep up with other regions’ pay increases. The result is that regions with higher pay increases have an increase in the AWI, and other states like Arkansas, Alabama, and West Virginia continue to get pushed lower. This occurs incrementally over time, but with each passing year, the gap widens.

RURAL FLOOR

In 1999, CMS implemented the rural floor, as required by the Balanced Budget Amendment (BBA). In a particular state, an MSA cannot be paid lower than the rural AWI, hence the rural floor. To pay for the rural floor, a nationwide

To illustrate how this happens, consider the following: in 2003, the lowest wage index was 0.759, and the highest was 1.5185 — a difference of 100%. However, this gap has since widened considerably; in 2019, the lowest wage index had dropped to 0.6704, and the highest rate had climbed to 1.9025 — a difference of 184%. In the AWI system, even minor changes can cost hospitals mil lions of dollars, so this widening gap is quite alarming.

Median Area Wage Index by State, FFY 2022

budget neutrality adjustment is made each year. In essence, if a hospital receives more funding, then the pool is adjusted nationally, and others receive a decrease to offset the change.

In 2009, CMS proposed a rule to move to adoption of statewide, rather than nationwide, budget neutrality for the rural floor. Thus began a three-year period of transitioning to a statewide budget neutrality. As a result, states with hospitals receiving a rural floor wage index would have funded the higher payments for those hospitals entirely within the state.

Critical Access Hospitals were converting to IPPS status, apparently to raise the State’s rural wage index to a level whereby all urban hospitals in the State would receive the rural floor.”

RECENT DEVELOPMENTS

In 2010, the Affordable Care Act (ACA) included a provision to prohibit CMS from implementing the statewide budget neutrality adjustment. Instead, it required CMS to revert to a nationwide budget neutrality adjustment in 2011.

The legislative and regulatory changes as outlined above all added up to gaming the program and the best/worst case occurred in Massachusetts.

CMS cautioned about the potential for gaming this program by stating, “rural Critical Access Hospitals were converting to IPPS status, apparently to raise the

BAY STATE BOONDOGGLE

As the Affordable Care Act was wind ing its way through Congress, a backroom deal allowed every hospital in Massachu setts to benefit from the labor rates paid by tiny, 19-bed Nantucket Cottage Hospital. The sweetheart deal came at the expense of nearly every other hospital in the U.S. Known to many as the “Bay State Boon doggle,” the sleight of hand resulted in more than a billion dollars in additional payments to Massachusetts hospitals.

At the heart of the issue is Section 3141 of

the ACA. The provision allowed Massachu setts hospitals to gerrymander the arcane Medicare wage index system to their advan tage by using an extremely remote, lowvolume hospital located on an extremely high-cost-of-living island as the floor for all wages statewide. The increase benefited Massachusetts significantly and a few other states marginally. It disadvantaged the vast majority.

CMS quickly criticized the ACA policy as a “manipulation,” yet they are required by law to enforce it. Ultimately, tiny Nan tucket Cottage Hospital treats only about 150 inpatients a year, yet it influences pay ments nationally.

Any formula that allows for these types of gamesmanship should not be part of the formula for a hospital payment system. Karma did work in a strange way in 2017, when the hospital’s consultants misreported wages, which lowered the reimbursement to Massachusetts hospitals by $160 million.

CMS made a policy change in 2019 that was extremely helpful; under this change, hospitals with a wage index value below the lowest quartile would temporarily receive a wage index adjustment of 50% of the differ ence between the standard wage index value for the hospital and the 25th percentile wage index value. In short, those hospitals on the bottom got a raise, and those on the top got a reduction.

However, CMS also adjusted other hospi tals’ payments downward to make the policy budget neutral. The hospitals that lost sig nificant dollars filed a lawsuit arguing that CMS did not have the authority to make such a rule change. (Although, in 2005, CMS used rule-making authority to make the same type of adjustments.)

The court granted the hospitals’ motion for summary judgment on March 2, and CMS is currently contemplating whether to appeal the ruling. Should the ruling stand,

National Median Wage Index

Map created for the Arkansas Hospital Association by DataGen.

State’s rural wage index to a level whereby all urban hospitals in the State would receive the rural floor.”

The legislative and regulatory changes as outlined above all added up to gaming the program and the best/worst case occurred in Massachusetts.

BAY STATE BOONDOGGLE

As the Affordable Care Act was winding its way through Congress, a backroom deal allowed every hospital in Massachusetts to benefit from the labor rates paid by tiny, 19-bed Nantucket Cottage Hospital. The sweetheart deal came at the expense of nearly every other hospital in the U.S. Known to many as the “Bay State Boondoggle,” the sleight of hand resulted in more than a billion dollars in additional payments to Massachusetts hospitals.

At the heart of the issue is Section 3141 of the ACA. The provision allowed Massachusetts hospitals to gerrymander the arcane Medicare wage index system to their advantage by using an extremely remote, low-volume hospital located on an extremely high-cost-of-living island as the floor for all wages statewide. The increase benefited Massachusetts significantly and a few other states marginally. It disadvantaged the vast majority.

CMS quickly criticized the ACA policy as a “manipulation,” yet they are required by law to enforce it. Ultimately, tiny Nantucket Cottage Hospital treats only about 150 inpatients a year, yet it influences payments nationally.

Any calculation that allows for these types of gamesmanship should not be part of the formula

“The AWI gives financial benefit to hospitals in regions that are already able to provide higher wages while decreasing funding to hospitals in other areas. Hospitals that

moderate increases in hourly wages due to financial considerations, such as high government payer mix and low commercial pay rates, become low-cost providers, unable to keep up with other regions’ pay increases.”

for a hospital payment system. Karma did work in a strange way in 2017, when the hospital’s consultants misreported wages, which lowered the reimbursement to Massachusetts hospitals by $160 million.

RECENT DEVELOPMENTS

CMS made a policy change in 2019 that was very helpful; under this change, hospitals with a wage index value below the lowest quartile would receive a wage index adjustment of 50% of the difference between the standard wage index value for the hospital and the 25th percentile wage index value. In short, those hospitals on the bottom got a raise and those on the top got a reduction.

The hospitals that lost significant dollars filed a lawsuit arguing that CMS did not have the authority to make such a rule change. (Although, in 2005, CMS used rule making authority to make the same type of adjustments.)

The court granted the hospitals' motion for summary judgment on March 2, and CMS is currently contemplating whether to appeal the ruling.

CHANGES NEEDED

The pandemic has shown us that Arkansas hospitals are not only competing against other local facilites for workforce but we are also competing regionally

and nationally for the same pool of nurses, respiratory therapists, etc. The notion that an area wage index is needed because costs are lower in certain areas of the country is outdated.

The AWI in its current form is influenced by Congress, CMS, hospitals, and the courts. Because any change threatens that one hospital will receive more funding at the expense of another hospital, the present circumstance pits hospitals against each other, states against each other, and Congressional delegations against each other. Even the possibility of scrapping the entire system and starting over will lead to protectionism from those receiving the most money.

Unless more funding is appropriated to the pool to encourage reform, we are destined to continue battling over incremental changes that have sizeable consequences.

The circularity issue is most egregious. CMS’s last rule change raised those hospitals in the lowest quartile – a step in the right direction. CMS should maintain a funding floor to minimize the impact of ever greater differences between the highest and lowest wage indice.

This article, written by AHA President and CEO Bo Ryall, first appeared in the May/June 2022 edition of the Health Care Journal of Arkansas and is used with permission.

AHA Connectivity Consortium

Delivers Federal Subsidies to Member Hospitals

The AHA Connectivity Consortium provides a vehicle for hospitals in both rural and urban settings to take advantage of the FCC's Rural Healthcare Program and to receive maximum funding offered through the program. Membership in the consortium enables urban hospitals the opportunity to participate in the program, something for which they would otherwise be ineligible. Consortia offer advantages by allowing higher caps and consortium-only eligible expenses. The details of the program, which provides for up to 65% subsidies on your vital telecom expenses, can be found at www.usac.org.

ALREADY PARTICIPATING? THINK AGAIN!

Our analysis of dozens of Arkansas hospitals revealed that while most hospitals were already participating in the program, almost none were taking full advantage of its benefits. Almost all hospitals are applying for a subset of eligible products and services depicted in the shaded boxes below. The lighter boxes represent millions of dollars collectively left on the table annually in Arkansas as the items are also eligible but not being applied for. Working with the Connectivity Consortium will ensure that you capture funding on these expenses every year moving forward beginning in July 2023.

FUND YEAR 2023 UPDATES

The 2023 fund year begins July 1, 2023 and applications are now underway. They will be completed by the fund year’s April 3 deadline. There are several procedural steps to apply, and each can take 30 days or more to complete. Takeaway: The best time to join the consortium for 2023 applications is right now.

INTERESTED HOSPITALS SHOULD ENGAGE IMMEDIATELY WHILE TIME IS STILL AMPLE

Take advantage of the benefits that your Hospital Association’s Connectivity Consortium provides for you!

Contacts: Tina Creel – tcreel@arkhospitals.org Consortium Administrators – info@fedfunding.net

HOW DO YOU COMPARE TO YOUR PEERS?

Contact info@fedfunding.net for a no-cost individualized analysis of your hospital

Employee Engagement: One of Today’s Most Crucial Leadership Challenges

by Tom Atchison

Many of the most significant challenges facing health care leaders today lie in the realm of “human capital.”

Recruitment and retention of talented, productive employees and professional staff has never been more difficult; we realize that many health care professionals continue to suffer the effects of the past three years, specifically fallout from the COVID-19 pandemic. Heightened work expectations, the stressors of not enough people or equipment to fight ongoing waves of sick patients, the physical challenges of exhaustion and burnout – these all take a continuing toll on health care’s greatest asset, its human capital.

Join Dr. Tom Atchison as he offers expertise and insight on engaging health care employees at this year's AHA Annual Meeting Leadership Workshop, November 9 at the Hot Springs Convention Center. Register online at www.arkhospitals.org. Each attendee will receive a copy of Dr. Atchison's newest book, Employee Engagement.

A May 2022 research study, Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce, paints a sobering picture. Major findings include:

• The COVID-19 pandemic has put extreme stress on the health care workforce in the United States, leading to workforce shortages as well as increased health care worker burnout, exhaustion, and trauma.

• Many health care workers who were not directly caring for COVID patients faced being furloughed or having their hours reduced, particularly early in the pandemic.

• Total employment in the health care industry declined during the early months of the pandemic.

• Many hospitals reported critical staffing shortages over the course of the pandemic, particularly when case numbers were high.

• Even post-pandemic, many of its effects on health care workers will likely persist. (ASPE: Office of Health Policy, May 3, 2022)

With demand exceeding supply, CEOs, CFOs, VPMAs, CNOs, and CHRs continue to pursue varied approaches in their quest to attract and retain quality staff.

It appears that the one most-utilized short-term tactic is offering greater sums of money in wages and benefits. Many hospitals are paying large signing bonuses, hiring “floaters” from private workforce companies for hundreds of dollars a day, and paying retention bonuses. These dollar-based efforts

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are short-term solutions that in many ways run counter to creating a high-performance culture anchored by completely engaged staff.

Melanie Holly Pasch’s research demonstrates that money is not a long-term motivator. She suggests that once money is used as the primary motivator, “It becomes part of employee expectations for the coming year. Expectations climb, and if a company fails to keep up, disappointment combined with the financial cost may not be the best strategy, at least in terms of employee engagement. Providing competitive salaries and bonuses is still a must, but don’t make the mistake of thinking high pay will keep employees at your company longer. Money may be a motivator in getting people to accept your offer and join your company, but money is not a long-term motivator in terms of performance.”

Particularly during COVID, ever-larger wages seemed to be the best, most effective tactic for attracting and retaining staff. However, as Pasch reminds us, money is not a very effective tool for those leaders endeavoring to create a strong corporate culture anchored by a highly engaged workforce. In fact, the long-term use of money as a motivator weakens, and in some cases, eliminates the possibility of employee engagement.

As I note in my 2021 book, Reigniting Employee Engagement: A Guide to Rediscovering Purpose and Meaning in Healthcare , money demotivates employees in two ways and motivates in only one way.

In order for money to motivate an employee, the amount of money must be perceived as fair. And, if you want to get on a very slippery slope – try to understand your employees’ perception of what amount will be perceived as fair, not too much and not too little!

If money only works to get the employee in the door, what are the keys to sustainable employee engagement? The answer lies in the organization’s corporate culture.

INTERCONNECTION OF EMPLOYEES AND CULTURE

Every corporate culture is defined by its Values, Vision, and Mission. The degree to which an employee is personally connected to these Values, Vision, and Mission equals the degree of that employee’s engagement.

The interconnectedness of an organization’s culture and sustainable employee engagement is shown in Figure 1.

Values alignment is the first, and most important, of three steps in building and maintaining sustainable employee engagement.

Figure 1: Employee engagement is achieved when he/she personally connects his/her work and values with the organization’s values, vision, and mission.

CONNECTING WITH VALUES AND VISION

Sustainable employee engagement begins with the alignment of each worker’s personal values with the organization’s core values. It is impossible to engage employees over time if there is a clash between their personal values and those of the organization (corporate values).

For example, if an individual who is motivated by providing the highest quality of care to any individual that needs help finds that the health care system in which they work has a dominant value of profit, regardless of the effects on patient care, then that employee will never be fully engaged. Their personal values and those of the organization are at odds with one another.

The highest performing health care organizations, those with the most highly engaged employees, place great emphasis on hiring to values. Values alignment is the first, and most important, of three steps in building and maintaining sustainable employee engagement.

The second cultural factor that can effectively engage employees is the organization’s vision. An organization’s vision statement is the context in which staff can find meaning in their work.

When an employee can identify their personal contribution to achievement of the organization’s vision, they will find every aspect of their job meaningful.

A great deal of research suggests that meaningful work is the strongest motivator for humans involved in any activity. The more meaningful the work, the greater the motivation for excellence and the more engaged an employee becomes.

In a McKinsey & Company article, Making Work Meaningful: A Leader’s Guide , Dan Cable and Freek Vermeulen note, “By now, it is well understood that people who believe their job has meaning and a broader purpose are likely to work harder, take on challenging or unpopular tasks, and collaborate effectively. Research repeatedly shows that people deliver their best effort when they feel part of something larger than the pursuit of a paycheck.

CONNECTING WITH MISSION

The third, and highest, level of employee engagement happens when employees find purpose through their connection to the organization’s Mission statement, or its overriding reason for being.

Again, McKinsey & Company research explains the importance of finding purpose in work. A 2020 study reports that, “Winning companies

are driven by purpose (Mission), reach higher for it, and achieve more because of it.” Mission statements explain the reason the company exists, which in the employee engagement process provides a transcendent purpose for performance.

SUCCESS IN ENGAGEMENT

The most successful health care delivery systems emphasize their

cultural elements of Values, Vision, and Mission, and an employee’s engagement can be readily identified through each.

1. Values: The beliefs that underpin leadership decisions. Values alignment connects the employee to the organization. Employees connected at the core values level might be heard to say, “I have a good Job.”

2. Vision: The statement that describes a desired future state of the organization – where we are headed. The employee who understands how their personal work promotes achievement of the corporate vision will find meaning in their work. Employees connected to the vision might be heard to say, “I have a fulfilling Career.”

3. Mission: This statement explains why the company exists. It states what the organization brings to the community. The mission provides a transcendent purpose for employees’ work. Employees who connect their work with the mission might be heard to say, “I have a Calling.”

Ask yourself—Do you have a Job? Do you have a Career? Or, do you have a Calling? Connect intensely with your organization’s Values, Vision, and Mission, and learn what true engagement really means.

Tom Atchison, EdD, is President and Founder of Atchison Consulting, LLC. Since 1984, he has consulted with health care organizations on managed change programs, team building, and leadership development. He has taught various courses for ACHE. His clients include senior executives, managers, trustees, and physician leaders. He has also worked with the military, health care vendors, and government agencies on the intangible aspects of health care. His book, Turning Healthcare Leadership Around, was published in October 1990. His newest book, Employee Engagement: A Guide to Rediscovering Purpose and Meaning in Healthcare, is now available.

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| Jeffrey Thomas, Managing Director MitchellWilliamsLaw.com

LITTLE ROCK | ROGERS | JONESBORO | AUSTIN

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Engaging Through Encouragement Sammie Cribbs, North Arkansas Regional Medical Center

By Nancy Robertson

It may be hard to identify positive benefits arising from the COVID-19 pandemic, but Sammie Cribbs, President and CEO of North Arkansas Regional Medical Center (NARMC) in Harrison, is quick to acknowledge a standout. “COVID-19 taught us to identify previously unknown talents in our staff members,” she says. “Adapting and being flexible in changing our processes as the pandemic progressed was a must. We’ve learned that when forced to do more with less, to find answers where none seem possible – that’s when people step forward. They say, ‘I can do this; I can help with that.’ They have first-hand knowledge of what’s needed, and they offer both ideas and expertise. Working together as a cohesive unit – including all teams throughout the hospital – has improved the way we care for patients and the way we care for one another.”

Cribbs accepted the role of President and CEO in early April of this year, after serving as interim CEO upon Vince Leist’s retirement. Her NARMC story began 15 years ago when she moved to Harrison and signed on as a PRN nurse, working throughout the hospital in a variety of acute care settings.

Hers is truly a story of working hard, being recognized for achievement, and accepting ever more complex leadership roles.

“I try to encourage every person working at NARMC to advance their skills and education,” she says. “I love seeing our employees and medical staff achieve their goals and earn higher degrees. This not only improves patient care, but it also improves morale and engagement.”

Identifying young leaders and encouraging them to progress is one of her favorite activities as a leader. “It is gratifying to watch members of our hospital workforce grow and advance from their entry level positions to roles with more and more responsibility,” she says. “It is satisfying to watch people advance through the system. As they do, they provide higher and higher levels of care to our community. In the end, that’s what health care is all about.”

WHEN COVID STRUCK

NARMC is a 175-bed hospital employing more than 750 people. It serves a five-county region comprised of approximately 95,000 residents. NARMC delivers care to its constituency by way of the main hospital and 18 clinics located throughout the rural areas surrounding Harrison.

As did every local health care facility during the height of the COVID pandemic, NARMC served as northern Arkansas’s main hub of health care when citizens sought testing, vaccinations, care, and solace.

“We were as prepared as possible when our first COVID patient arrived,” she says. “A team of our physicians had put together a series of COVID processes and protocols before the virus came to northern Arkansas. They prepared the entirety of our staff for what was coming, and I believe that preparation helped our workforce maintain resilience throughout the

What’s on your music play list?

A little bit of everything: from Merle Haggard to Tom Petty, Kip Moore, Passenger, Amos Lee, Matchbox 20, Turnpike Troubadours, to Cher, Chris Stapleton, Guns and Roses, Cody Jinks, Tyler Childers, and Drake White, just to name a few! And of course, I have the Arkansas favorites (since I graduated from Highland) Ashley McBryde and Philip Sweet (Little Big Town), and Lazy Desperados.

What is the best advice you have received?

Be humble and stay true to yourself. The best things in life are the things we give away. Laughter is the best medicine! Give all you can!

What would you be doing if you were not in health care?

I would love to be working with the National Park Service to preserve our nation’s history.

What is something people don’t know about you?

Two things: I love to sky dive, and my favorite sound on earth is to hear an elk bugle or a turkey gobble in the woods.

What do you enjoy doing in your down time?

I enjoy time with my family and friends – lots of laughs and new adventures!

What are you reading (not necessarily work-related)?

Vance Trimble’s Sam Walton, Founder of Walmart: The Inside Story of America’s Richest Man ; James Elrod’s From Breadcrumbs to Cheesecake: A Struggling Inner City Sanitarium’s Journey to Become Louisiana’s Largest Medical Center; and Changing Altitude: How to Soar in Your New Leadership Role by Greg Hiebert and Dennis O’Neil, PhD. I am not sure you can classify these as completely non-work related, but they’re more exciting than reading the Federal Register or CMS regulations!

What is the most valuable lesson COVID has taught you?

Life is precious and constantly changing, and don’t ever forget what really matters – the people beside you on the journey! Together we can do anything!

pandemic. The entire NARMC team was in COVID response mode for more than two and a half years, and though we emerged tired and worn, we are stronger. We still have that resilience built into every team in our system.”

“It’s important to recognize that every person who put on their shoes and came to work during the pandemic is a hero,” she continues. “People are quick to recognize doctors, nurses, and respiratory therapists for their work during the pandemic. But every single member of our hospital workforce solved problems daily, held one another up, stepped forward to help wherever needed. The people who kept our hospital clean, engineered the negative pressure ward, the ones who served our meals, who kept our computer systems running – they were and are a part of the small city that makes health care possible, and they gave everything they had during COVID.”

A SERVANT LEADER

She sees her role not only as business leader and community liaison, but also as one who removes obstacles so others can progress to be their best selves. “A supportive culture is important, and I believe in making myself available to our team members. It’s important to make time and to recognize the little things, to say thanks to employees for their kindnesses. The person who helps a patient find the medical records department, the manager who comes in after hours to make certain her team is OK … noticing and saying thanks are both meaningful and essential.”

What is her motto? “Have strong interactions with the team. When having hard conversations, let it be known that it’s OK to disagree. Our job is to look for the right answers to our challenges, and to figure things out together.”

Cribbs says her lengthy time in hospital leadership prior to accepting the role as CEO prepared her for her work today. “Vince Leist was an excellent

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complete Continuum of Care

children and families

mentor, and I already had a working relationship with our board prior to taking on this new role. I see many opportunities for growth, and I’m dedicated to embracing every moment to help team members achieve their goals.”

What scares her, she says, is what she doesn’t know. “Hospitals everywhere are suffering financially post-COVID. We are all finding ways to do more with less. We all face severe workforce shortages, supply chain snags, and budgetary dilemmas due to inflation. How we’re all going to survive these challenges is the great unknown.”

In the end, the most important thing, she says, is to find ways to communicate effectively.

“During the pandemic, everyone experienced significant changes in their lives,” she explains. “Our teams experienced loss as well, and through that we grew stronger together. We shared our challenges and our successes, but our heartaches and our laughter kept us together.”

“We lost one of our nurses to COVID,” she says quietly. “It was devastating, but together we emerged more focused and committed than ever.”

She keeps a personal reminder in her desk drawer as a symbol of the need for caring words. “I ask myself, ‘Did we tell him thank you for the work he did every day? Did he know how much we cared? Did he know he was our family?’”

She emphasizes her mantra as we close our conversation.

“Find ways to communicate. Say thank you. Don’t be afraid to be wrong. Be innovative. Offer hope and compassion. Stay humble. Lead.”

Sammie Cribbs, MSN, AGCNS-BC, APRN Leadership Progression at NARMC

2007 – PRN, Charge Nurse

2010 – Clinical Documentation Coordinator

– Director of Nursing

– Vice President Clinical Services/Chief Nursing Officer

– Vice President Operations/Chief Nursing Officer

2018 – Chief Operating Officer/Chief Nursing Officer

– Interim President and CEO

– President and CEO

The most important thing is to find ways to communicate effectively.

Modern House Calls are Improving the Health of Two Rural Arkansas Communities

By: Rhelinda McFadden and Angie Hughes Walker

In De Queen, Arkansas, connecting marginalized populations with health care access and community resources is Job One for Dr. Randy Walker and his team of medical professionals. With the overall goal of improving both patients’ and the community’s social determinants of health, Walker and his team are upending the traditional model of care. They have created multiple ways to bring care and community resources directly to their patients.

The De Queen community, much like many of Arkansas’s rural communities, experiences elevated rates of chronic disease rooted in social determinants of health, those nonmedical factors that affect our overall health and wellbeing. They include the conditions in which we live, grow, learn, work, play, and worship, and they directly influence each person’s health outcomes.

De Queen has a population of 6,077 with a poverty rate of 25.8%. Its diverse population is 51.4% Hispanic or Latino, 40.6% White, 3.8% African American, 2.3% American

Indian and 1.3% Native Hawaiian or Other Pacific Islander (Marshallese).

Dr. Walker and his health care team know their regional communities and the needs that patients face. Their active patient base includes more than 11,000 patients. In the past three years, they have reinvented their care delivery model and are beginning to see improved health outcomes in their patients.

Angie Walker, office manager for the practice and Dr. Walker’s spouse, has been monitoring their patient population and its quality outcomes for more than a decade. Combining this data with the known needs of the community, The Walker Clinic built its foundation for care on the patientcentered medical home model. This model contains five key functions: access to and continuity of care, care management, patient and caregiver engagement, comprehensiveness, and coordination, planned care, and population health. This model has transformed how The Walker Clinic practices medicine.

The Walker Clinic’s fleet of care mobiles brings medical professionals right to their patients’ homes.

PLANTING SEEDS

In 2003, Randy Walker, MD selected De Queen, Arkansas as his home; it was there he chose to put down roots and open his medical practice. He had no crystal ball to predict the future of his community, and no way to guess that a future pandemic would completely change the way he practices medicine.

The COVID-19 pandemic exposed the stark realities of De Queen’s social determinants of health. With the nearest hospital more than 30 miles away, as COVID struck, members of the community struggled.

The onset of COVID gave the Walkers a clear view of their patients’ dire, immediate needs for better health care access. They set out to identify ways of delivering total population health care while addressing social determinants of health.

One of the immediate challenges identified was the need to greatly expand access to care for their patients. They opened additional clinic locations which operate seven days a week from 7 a.m. to 7 p.m. For afterhours needs, there’s a triage phone line where patients can speak directly with a health care provider.

One of their clinics is Leopard Care, a facility based in the De Queen public schools. The newest location is in Dierks, a community in neighboring Howard County.

The medical team constantly searches for new ways to care for their communities. They have a fleet of lime green vehicles used to make house calls. This practice started when COVID arrived. The clinical team found they needed to monitor

high-risk COVID-positive patients to achieve the best possible outcomes. Today a health care provider internally refers patients for monitoring when identified as potentially "at risk" or with a homebound status.

“Quality team-based health care must be delivered to the right person, by the right person, at the right place, and at the right time every time,” Dr. Walker says. The care team consists of Randy D. Walker, MD, Phillip Glasgow, MD, eight advanced practice registered nurses (APRN) board certified in Family Practice, one psychiatric APRN, a dietician, three longitudinal care managers, and one episodic care manager, in addition to 33 other care team members spread across the practice’s three locations.

They utilize a care team approach in their house calls. A licensed health care professional completes the call, and it includes an interpreter when needed for Hispanic and Marshallese populations. The Walker Clinic can provide electrocardiogram and spirometry (pulmonary) testing during these visits. They can deploy remote patient monitoring technology for patients needing constant monitoring.

At any point during a house call, the health care professional can connect

directly with an MD using the clinic’s telehealth technology.

The team also connects patients or families needing additional services (i.e., home health, Meals on Wheels, childcare, etc.) at the point of care. The Walker Clinic created and maintains an easy-to-use community resource guide they share with patients and their families or caregivers. The guide helps patients connect to resources that help improve the patient’s, family’s, and caregivers' social determinants of health.

“Our communities are everything to us,” the Walkers say. Their reconfigured practice offers De Queen and its neighboring area a team of forward-thinking visionaries looking at tomorrow’s health care needs and identifying ways to meet those needs today.

Rhelinda McFadden, BSN, RN, CPHIMS, PCMH-CCE , serves as Manager of Practice Transformation and a Quality Consultant with the Arkansas Foundation for Medical Care. Angie Hughes Walker serves as office manager for The Walker Clinic, the family medicine practice of her husband, Dr. Randy Walker, in De Queen, Arkansas.

“Quality team-based health care must be delivered to the right person, by the right person, at the right place, and at the right time every time,”

York Institute of Technology College of Osteopathic Medicine (NYITCOM) at Arkansas State University is committed to training talented physicians who aspire to become servant leaders that positively impact their communities.

us to learn more about the two degree programs offered on our Jonesboro campus:

of Osteopathic Medicine (D.O.)

of Science, Biomedical Sciences

Pursuing Excellence in Rural Healthcare

by Kay Kendall

In preparation for writing my column for this issue, I was interested to learn, through American Hospital Association resources, that approximately 57 million rural Americans rely upon their local hospitals not only for health care, but also as economic and social drivers in the local community.

Hospitals of all sizes are experiencing challenges – fiscal and otherwise – in this period of COVID-19. We’re not yet out of the woods with the virus, but we’re learning how to cope with it and its fallout. Much of that fallout, where hospitals are concerned, is financial. And for rural hospitals, COVID’s effects can be devastating.

We know that many rural hospitals are struggling to keep their doors open. This was the case before the pandemic struck, and it is even more so the case today. Pre-COVID, rural hospitals faced significant financial challenges. Today, those challenges remain and are exacerbated by inflation, supply chain problems, and workforce shortages.

RURAL HEALTH CARE AND BALDRIGE EXCELLENCE

I wanted to seek some good news about rural hospitals, especially during these harsh times (or perhaps despite them). My familiarity with the Malcolm Baldrige National Quality Award led me to seek information on hospitals in the rural setting earning performance excellence accolades. I wasn’t a bit surprised that the same Baldrige Excellence Framework that applies to any sector, any size, any designation (for-profit and not-for-profit) organization also provides an effective leadership model that works in large metropolitan and small rural hospitals, alike.

RURAL HOSPITAL EXCELLENCE

It struck me that one of the common themes across many of the smaller health care award recipients was their culture of “Neighbors Caring for

strong sense of community also yields high levels of customer loyalty and employee engagement

Neighbors.” While this is the slogan coined by Wellstar Paulding Hospital (a 2020 Award recipient), the sentiment is seen in many other community hospitals that have won the Baldrige Award. This strong sense of community also yields high levels of customer loyalty and employee engagement that result in significantly lower levels of turnover, even during incredibly stressful times.

These same rural hospitals have earned other honors such as repeated Grade A designations from Leapfrog reflecting their focus on patient safety, CMS 5-star ratings for overall quality of inpatient care, designations as Great Places to Work utilizing the Fortune 100 “Best Companies to Work For” benchmarks, and top 10th percentile rankings for physician engagement.

AN INVITATION

If you’d like to learn more about these outstanding role models in rural health care, check out the recipients on the Baldrige website. You can search under the health care sector and scan the two-page recipient profile or even download their actual Baldrige applications. (https:// www.nist.gov/baldrige/award-recipients)

If you and your senior leaders would like to learn more about the Baldrige Excellence Framework and simple ways you can begin to use it to improve your organization’s performance, even in challenging times, please contact me for a free, no-obligation “virtual” overview of how to get started.

And if you send me your mailing address, I’ll also send you a copy of our book, Leading the Malcolm Baldrige Way: How World-Class Leaders Align Their Organizations to Deliver Exceptional Results, published by McGraw Hill.

The team at BaldrigeCoach would be glad to help guide your hospital’s quest for process improvement. As CEO and Principal of BaldrigeCoach, Kay Kendall coaches organizations on their paths to performance excellence using the Malcolm Baldrige National Quality Award Criteria as a framework. Her team, working with health care and other organizations, has mentored 24 National Quality Award recipients. In each edition of Arkansas Hospitals, Kay offers readers quality improvement tips from her coaching playbook. Contact Kay at 972.489.3611 or Kay@Baldrige-Coach.com.

LEADING THE

MALCOLM BALDRIGE WAY

How World-Class Leaders Align Their Organization to Deliver Exceptional Results

★KAY KENDALL AND GLENN BODINSON CO-PRINCIPALS, BALDRIGECOACH, INC.

Kay Kendall offers leaders of Arkansas hospitals a free, virtual overview of getting started with the Baldrige Excellence Framework. Those requesting a copy of her latest book will receive one free of charge as a benefit of association with the AHA.

OBSTETRICS | U.S. Rural Hospitals

Rural hospitals provide access to obstetrical care close to home for millions of Americans. But now, that crucial lifeline is being threatened.

1,796

There are 1,796 rural community hospitals in the U.S., slightly more than a third of all community hospitals.

Rural hospitals represented 35% of the nation’s 5,139 community hospi tals in 2020.

Rural community hospitals deliver nearly 1 in 10 babies in the U.S. The availability to local, timely access to care saves lives.

Rural hospitals accounted for 333,824 [9.5%] of the 3,505,115 total community hospital births in 2020.

Yet, nearly half of rural community hospitals did not offer obstetric services in 2020.

72% [1,292 of 1,796] of all U.S. rural community hospitals reported whether they offered obstetric services in 2020. Of these hospitals, 47% [601 of 1,292] indicated they did not provide obstetric services.

89Between 2015 and 2019, there were at least 89 obstetric unit closures in U.S. rural hospitals.

More than 2.2 million women of childbearing age live in maternity care deserts (1,095 counties) that have no hospital offering obstetric care, no birth center, and no obstetric provider.

Source: Nowhere to Go. March of Dimes, 2020.

For more information, visit: aha.org/advocacy/maternal-and-child-health

FEARLESS HEALTH.

Arkansas Blue Cross and Blue Shield is committed to the health of Arkansans. A whole person approach to health, including physical and behavioral well-being. And we recognize that total health is influenced by many factors, including medical history, genetics, lifestyle, environment, nutrition, safety and physical activity. We also realize it will take all healthcare providers working together to ensure future generations of Arkansans are their healthiest so they can fear less and live their best life. Fearless health.

WE BUILD

BUILD

PLACES TO HEAL

WE BUILD PLACES TO HEAL

PLACES TO HEAL

When Conway Regional Health System wanted to add a new 24-bed intensive care unit, they enlisted Nabholz’ help. The new ICU features 330-square-foot patient rooms and cutting-edge equipment, ensuring patients receive the highest quality care. The facility also showcases an impressive 4,600-square-foot atrium. This serene space provides visitors and family members with an additional waiting area when visiting patients in the unit.

When Conway Regional Health System wanted to add a new 24-bed intensive care unit, they enlisted Nabholz’ help. The new ICU features 330-square-foot patient rooms and cutting-edge equipment, ensuring patients receive the highest quality care. The facility also showcases an impressive 4,600-square-foot atrium. This serene space provides visitors and family members with an additional waiting area when visiting patients in the unit.

When Conway Regional Health System wanted to add a new 24-bed intensive care unit, they enlisted Nabholz’ help. The new ICU features 330-square-foot patient rooms and cutting-edge equipment, ensuring patients receive the highest quality care. The facility also showcases an impressive 4,600-square-foot atrium. This serene space provides visitors and family members with an additional waiting area when visiting patients in the unit.