Teton Valley Health Care - Economic Impact Study for 2017

FPO

Economic Impact Study December 2017

Table of Contents Economic Impact of TVHC (Executive Summary)

2

An Economic Anchor for Teton County

6

Delivering Patient-Centered Care Close to Home

7

Providing Well-Paying, Consistent Employment

9

Serving the Community

10

Building for the Future

11

A Good Neighbor

12

Caring for the Community

13

Conclusion

15

Appendix

16

1

Economic Impact of TVHC Teton Valley Health Care (TVHC) includes a team of professionals dedicated to providing high-quality care close to home for residents of and visitors to Teton County and the surrounding area.

Nestled at the base of the majestic Teton Range, Teton County, Idaho, offers uncluttered access to the beautiful landscape, a serene getaway for visitors, and a more affordable residence for many who work ‘over the pass’ in Jackson, WY. The three largest communities are Tetonia, Victor, and Driggs, which is the county seat and home to Teton Valley Health Care, a 13-bed acute care hospital and clinics system that has provided healthcare to the area since 1939.

Since opening as a 4-bed facility, TVHC has undergone two key transitions. Originally owned and operated by the Church of Jesus Christ of Latter-Day Saints, it became a county-run facility in 1965. Then, in 2012 TVHC became a private organization without tax-based funding that operates as a not-for-profit, charitable corporation, although the facility is still owned by the county.

With a rich history of community involvement and support, TVHC has grown to include Driggs Health Clinic, Victor Health Clinic, and Cache Clinic. The Victor location has broken ground on a new facility within the town and will include both a clinic and a drive-through pharmacy, which is a partnership with Corner Drug in Driggs. The Cache Clinic, located in downtown Driggs, is focused on convenient, cashonly care and operates after usual business hours from 4:00pm to 8:00pm, Monday through Friday. It provides services to the under- and uninsured of the community and helps deliver convenient access at low cost.

TVHC has grown over the years and remains one of the area’s largest and most community-focused employers. The hospital is the first Critical Access Hospital in Idaho to achieve three advanced-care certifications: Level IV Trauma Center, STEMI II (advanced cardiac care), and Stroke III designation. Additionally, TVHC has implemented a full electronic medical record system to keep patient records secure and accessible to providers across TVHC locations.

2

Committed to delivering quality care close to home, TVHC has partnered with nationally-recognized health systems to provide telemedicine services within TVHC facilities. Key relationships have been formed with University of Utah and Intermountain Healthcare for tele-stroke, tele-burn, and tele-oncology services. Tele-psychiatry and tele-crisis offerings are available through arrangements with Portneuf Medical Center and Behavioral Health Center (part of Eastern Idaho Medical Center), respectively.

Community members highlight the value of TVHC As part of the fact-finding for this report, interviews were conducted with community leaders and employers, local government officials, health system leadership, and other residents. These interviews provide a valuable perspective from those living in the vibrant Teton Valley community and express the importance of having an organization like TVHC in the area.

Key themes from the interviews: •

Residents feel that because they live in a rural area, they are lucky to have a hospital at all, much less one with the range of services available at TVHC; many are proud of their local hospital

So much better than the big city

•

They appreciate the clinics and are excited about the new Victor location and the Cache Clinic available for after-hours care

•

TVHC has come a long way from struggling to growing; the community invested in the hospital in 2008 and will do what it takes to see it flourish

•

There are more than 40 non-profits in the area, and TVHC plays a significant role in supporting and organizing events; it collaborates well with other organizations

•

TVHC brings in an educated workforce with well-paying jobs, and the area itself serves as an attraction to workers who are lured by the environment and outdoor activities (“work to live”)

•

Vacationers and retirees choose to buy homes in the area because they know they will have access to quality healthcare

•

The community is wide-spread, independent, and disparate, which makes it hard to reach through traditional marketing and communication methods

Always treated with kindness and care

• New businesses like distilleries, ‘rec-tec’ companies, and hotels are coming to the area; having a local hospital is a draw • Teton Valley forms the ‘bedroom community’ for Jackson, WY; residents of Teton County prefer not to be ‘like Jackson,’ and instead enjoy the slower pace and lower cost of living; they believe in “responsible growth and development” to see the community flourish without changing the way of life

“A mighty hospital providing amazing modalities”

3

Teton Valley Health Care is crucial to the economic viability of this community The health sector is an important engine of economic growth. It includes hospitals, clinics, and physician practices, as well as nursing homes, pharmacies, and other providers of medical services and products. Residents, especially in rural communities, rely on their local hospitals to: • • • •

Provide high quality, efficient healthcare Care for the aging Ensure safety during an emergency or disaster Educate people about good health and well-being

Less frequently recognized is a hospital’s valuable contribution to the local economy, such as the people it employs and the impact of its spending. Hospitals often serve as a pivotal institution for maintaining social and economic viability of communities, and can help attract other industries to a region, further increasing economic development. As one of the top employers and a major purchaser of goods and services, TVHC is critical to the economy while providing healthcare that allows people to be productive citizens. Based on data from 2012 to 2016, TVHC has more than $40 million in annual economic impact on Teton County.

Jobs Output Wages & Benefits Total Economic Impact

Direct

Indirect & Induced

Total

161

30

191

$16,862,038

$12,195,574

$29,057,612

$7,678,820

$3,334,930

$11,012,750

$24,540,858

$15,530,504

$40,071,362

Since 2012, the economic impact of TVHC has increased by 33%, resulting in nearly $10 million being added to the local economy.

Annual Economic Impact of TVHC $50,000,000 $40,000,000 $30,000,000 $20,000,000

$10,000,000 $0 FY2012

FY2013

FY2014 Indirect Impact

Direct Impact

4

FY2015

FY2016

TVHC plays a vital role in the success of the Teton County community, a responsibility that its leadership, providers, and associates take very seriously. Community leaders and regional employers recognize the importance of having a strong local healthcare provider during a time when many communities are losing access due to industry consolidation and legislative changes. Continued collaboration between the health system and community can help drive growth and success for both.

This report, prepared with assistance from Quorum Health Resources, helps to quantify the role TVHC plays in the community. It identifies and measures the direct contribution of the health system to the local economy, and demonstrates the “ripple” effect (indirect & induced) of the dollars the healthcare sector brings to the region and the jobs it helps create. In addition, it illustrates the benefit the hospital provides in maintaining a safe, stable, and healthy community.

Mission Promote the health of our community by delivering quality, patient-centered medical services with compassion, integrity and respect. We operate in a sustainable manner to ensure continued economic viability.

Vision Teton Valley Health Care (TVHC) is the Teton Valley Community’s focal point and source for high-quality, professional medical services. TVHC is open and accessible every hour of every day, and provides compassionate, timely, and effective treatment. TVHC is differentiated by patient-centered service and treats everyone with honesty, dignity, fairness, and respect.

Through prudent management of its staff and facilities and relationships with other regional providers, TVHC provides the appropriate range of medical care while operating in a cost-effective manner that generates a positive net income. We adapt our scope of services to respond to healthcare needs and to promote public health care and awareness through community engagement, relationships with regional health care providers, and innovation in the use of technology. We focus on change to deliver improved patient care, safety, and cost-efficient health care.

TVHC continually improves the quality of patient care by providing ongoing development, training, and educational opportunities for its staff. TVHC staff takes individual and collective responsibility for its actions and works as a cooperative, integrated team that uses its skills for the benefit of the patient and organization. TVHC and the community work collaboratively to understand public health, develop awareness of individual responsibilities, and educate.

TVHC staff members treat each other, the patient, and the organization with dignity and respect. We staff based on the capabilities that our staff demonstrates and provide care to all in need. Everyone’s contributions to the quality of patient care and success of the organization are measured, recognized, appreciated, and celebrated.

Values Integrity | Dignity | Compassion | Quality | Community | Stewardship

5

An Economic Anchor of Teton County Hospitals are well-positioned to enhance the overall health and well-being of the community, and since opening in 1939, TVHC has endeavored to meet the health needs of the residents of the Teton Valley area and provide them with local access to the best possible care. In addition to its positive influence on health and wellbeing, TVHC greatly contributes to the economic activity of the area. Nationally, hospitals support nearly 1 in 9 jobs and more than $2 trillion in economic activity.i Based on this analysis, it is estimated that TVHC generates annual economic impact of more than $40 million and creates approximately 191 jobs through direct, indirect, and induced activities (for more detail on the below chart and methodology, see page 16).

Jobs Output Wages & Benefits Total Economic Impact

Direct

Indirect & Induced

Total

161

30

191

$16,862,038

$12,195,574

$29,057,612

$7,678,820

$3,334,930

$11,012,750

$24,540,858

$15,530,504

$40,071,362

When considering the benefit a hospital brings to an area, it makes sense to look at four key topics: delivering healthcare, providing employment, serving the community, and building and growth. Within each of these categories, ‘direct impact’ includes the actual dollars the hospital generates as a business. The ‘indirect impact’ goes a step further and extrapolates the impact that money has within the community.

For example, when TVHC renovates part of the facility, they spend a specific amount of money to complete the project (direct impact). The indirect & induced impact is when the local construction company hired to do the work pays its employees who then spend money within the community on regular goods and services. The categories described in the next several pages (Delivering patient-centered care close to home; Providing well-paying, consistent employment; Serving the community; and Building for the future) are a reorganization of the Direct, Indirect, and Induced impact values in the chart above. This reorganization helps to more practically display the impact of TVHC, with the ultimate dollar total remaining the same.

6

Delivering patient-centered care close to home

$24.1 million

$16.2 million in direct impact As the population ages nationwide, many healthcare organizations are experiencing high growth, boosting local and national economies. Across the U.S., hospitals spend $852 billion on goods and services annually, and generate more than $2.8 trillion in economic activity.ii In recent years, TVHC has adapted and aligned internally and with key partners to ensure it can meet the healthcare needs of Teton County now and into the future. TVHC has seen some organic growth of services, but most progress has been a result of thoughtful and deliberate investments to better meet the needs of Teton County residents.

Since 2012, TVHC has worked to build relationships with tertiary care providers in the region to allow residents to access care without traveling. Specialists from health systems including University of Utah Healthcare, Intermountain Healthcare, Eastern Idaho Regional Medical Center, and Portneuf Medical Center are available on site at TVHC (either in person or via videoconference), which reduces the need for patients to out-migrate for care.

From 2012 to 2016, TVHC’s contribution to the local economy has grown by nearly $10 million, or 33%. Plans for continued expansion of services are being pursued through independent investments and in collaboration with other providers.

It is well documented that patients have a more positive experience and improved outcomes when cared for with the support of family, friends, and neighbors.iii TVHC has made significant advancements in being able to provide needed healthcare services close to home, which is particularly important during the difficult winter months since Teton County is geographically isolated from larger cities.

City

Miles

Drive Time

Population

Jackson, WY

33

47 minutes

10,529

Rexburg, ID

48

52 minutes

28,222

Idaho Falls, ID

74

1 hour, 16 minutes

60,211

Pocatello, ID

124

1 hour, 56 minutes

54,746

Salt Lake City, UT

287

4 hours, 13 minutes

193,744

Boise, ID

359

5 hours, 8 minutes

223,154

7

Given the distance between TVHC and other locations for care, even during the non-winter months the ability for patients to receive care nearby and not have to travel for needed services is crucial, especially for time timesensitive emergencies like trauma, stroke, and heart attacks.

However, the most important economic role the health sector plays in local economic development is “keeping local healthcare dollars at home.” Sources of local healthcare dollars can include commercial and private insurance, Medicare, Medicaid, other transfer payments, and consumer out‐of‐pocket payments to healthcare providers and businesses. If these expenditures leave the community, they represent a loss of potential jobs and income to residents.

Furthermore, the goods and services needed to provide healthcare to the community are substantial. Hospitals and other health sector establishments are important purchasers of local goods and services, such as laundry and waste management. The health sector and other businesses that comprise the local economy mutually support one another through purchases and sales.

$7.9 million in indirect impact The ability to receive care locally has a positive impact on the economy as indirect expenditures in the community are more than $7.9 million annually. When people don’t have to out-migrate for care, there can be a ripple effect of growth for other more routine services provided by TVHC, and funds that might otherwise go toward travel expenses remain available for spending locally.

A strong healthcare system can also attract and maintain other businesses, spurring job growth. Research has documented the significant role of quality‐of‐life factors in business and industry location decisions,iv and a key quality‐of‐life factor is the availability and quality of healthcare services.

First, employees will be more amenable to moving to a community with high-quality and convenient health services.

Second, any business or industry making a location decision wants to ensure that the labor force will be productive, which is associated with good health. Further, the rising cost of healthcare services is a dilemma for employers, but the availability of local healthcare services can reduce direct and indirect healthcare costs for businesses and employees while providing value‐added services such as occupational health.

Finally, a high-quality, highly convenient healthcare system is important to retirees, a notable group of residents whose spending and purchasing is a significant source of income for the local economy. The Teton County environment (i.e., good climate and outdoor activities) attracts visitors and retirees, but the services available, especially healthcare, help retain them. The amount spent by retirees, including the purchasing power associated with Social Security, Medicare, and other transfer payments, is substantial. Additionally, middle‐ and upper‐income retirees often have relatively high net worth. Factors such as the availability of quality healthcare services, along with safety, housing, and recreation opportunities, are key predictors of retirement location choice.v

8

Providing well-paying, consistent employment

$14.5 million

$7.7 million in direct impact TVHC employs nearly 200 professionals, with a total payroll of well over $8 million in 2017. The number of people employed by TVHC and the overall payroll have increased since 2012, and TVHC employees realize high relative wages for the area. The mean annual wage is nearly $8,000 more per year compared to jobs in Idaho Falls, and almost $10,000 more than the state of Idaho.

MEAN HOURLY WAGE

MEAN ANNUAL WAGE

TETON VALLEY HEALTH CAREvi

$24.83

$51,645

IDAHO FALLS, ID

$21.22

$44,130

IDAHO

$20.15

$41,910

UNITED STATES

$23.86

$49,630

While the above chart does not include TVHC physicians, the number employed by TVHC has increased in recent years. The annual incomes of these physicians are among the highest of any residents in Teton County, and since many of these providers live in the community, the impact in stimulating the local economy is multiplied.

$6.8 million in indirect impact TVHC employees are an important segment of purchasers of goods and services supporting local business and industry. Most dollars earned by TVHC employees are spent in the Teton County community on items like groceries, clothing, and rent/mortgage payments. These expenditures generate nearly $6.8 million in economic activity and create additional jobs for the local economy.

TVHC indirectly brings more jobs and workers to the area in three ways. First, as people come to the area to work for TVHC, they usually bring family members who may work in other local businesses. Second, as local businesses are supported by the spending of TVHC employees, they have more capacity to hire workers and create new jobs.

Third, as businesses move into the area because of the positive presence of strong healthcare services, they also create more jobs.

9

Serving the community

$1.0 million

$492,000 in direct impact Many residents of Teton County are dedicated to philanthropy, as evidenced by the more than 40 non-profits in the area. As a not-for-profit hospital, TVHC is both a recipient and benefactor, doing what it can to improve the health of the community. In TVHC’s 2016 IRS Form 990, expenditures of $380,700 were invested toward community benefit— including financial assistance, community health improvement services, community benefit operations, subsidized health services, and other contributions.

TVHC offers financial assistance policies that include a sliding fee scale in the clinics, payment plans to ease the burden of healthcare costs, and a charity care offering. TVHC staff puts on a wide array of low- to no-cost health screenings, wellness events, and education sessions that take place throughout the year to help improve access to preventive care along with the overall wellness of the community. The organization even offers most telemedicine visits without charging provider fees to patients.

$559,000 in indirect impact The direct expenditures flow from the hospital and then ripple throughout the community’s economy. Sponsorships help encourage participation in local events and activities, which build positive economic growth. Investment in local programs helps retain other economic spending in Teton County. For example, TVHC underwrote most of the operations costs for the Community Resource Center of Teton Valley, which provides a centralized hub for services and information to assist the underserved and disadvantaged members of the community. This Center creates efficiencies, reduces burden on other entities, and helps more people be productive members of the local economy creating a positive cyclical effect.

Keith Gnagey, CEO wears high heels to support the annual Walk-A-Mile in Her Shoes fundraiser for domestic violence prevention

10

Building for the future $400,000

$200,000 in direct impact Since 2012, TVHC has spent over $2 million on capital improvements, which includes buildings and major equipment. Significant investments have been made to update diagnostic and surgical equipment, making new medical tools available to providers and patients, and keeping facilities up-to-date with current standards.

An important next step in the growth of TVHC is the building of the new Victor Clinic. Victor is positioned on the main highway that connects the rest of Teton County with Jackson, WY, where many Teton residents are employed.

This location provides necessary care and services to a growing area of Teton County, and is ideally located to provide convenient access for residents on their way to/from work (which also keeps healthcare dollars within the TVHC system). The new, expanded facility will double the number of exam rooms from four to eight, and offer an expanded lab in addition to a drive-through pharmacy that is a partnership with Corner Drug in Driggs.

Further investments have been made in the Driggs Clinic, which is connected to the hospital, as well as the specialty clinic area and Aesthetics clinic within the hospital building. Ongoing expansion and upgrades are planned to patient, common, and staff areas.

$200,000 in indirect impact Capital spending by TVHC generates approximately $214,341 in indirect dollars for the local economy each year. As TVHC undertakes construction projects, it will often hire local business and workers to complete these improvements. The wages made by those workers will likely be spent in the community, and any new jobs added will help the overall economy. The hospital will also purchase supplies and materials in conjunction with capital projects, and these purchases may be made from local businesses. Money spent on improvements drives a better patient experience, better quality healthcare, and supports other businesses and entities throughout the community.

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A Good Neighbor TVHC has had a positive impact on so many parts of the Teton Valley community. Many local organizations have been supported through the charitable activities of TVHC, with a focus on providing access to care, mental health and substance abuse treatment and education, physical activity guidance, nutrition and weight management classes, and more.

In 2016, TVHC performed a Community Health Needs Assessment (in addition to one in 2013) to determine the most important health needs facing residents of Teton County, and outlined a plan for how the hospital can help address those needs. The top health needs were:

1.

2.

3.

4.

5.

Affordability/Accessibility Mental Health/Suicide Prevention Prevention/Wellness Alcohol Abuse/Substance Abuse Accidents

Some of the TVHC programs, services, and resources available to meet these needs include: • • • • •

•

Financial Assistance policies Free mammography program Annual health fair with reduced-cost lab screenings and free preventive screenings Telemedicine offerings Senior Center health outreach

• •

12

Free concussion screenings for local athletic teams Educational seminars on subjects like cancer, drugs use, diabetes, and antibiotics Low-cost flu vaccines and sports physicals

Caring for the Community TVHC delivers vital healthcare services to the community. In 2016, the organization provided:

162

435

Hospitalizations

Inpatient & Outpatient Surgeries

1,880

7,825

Emergency Room Visits

Outpatient Clinic Visits

5,857 Imaging Procedures (X-ray, mammogram, CT scan, MRI, ultrasound)

In addition to providing care during or after a health event or emergency, TVHC works to deliver wellness and preventive services that help people stay healthier overall. Through education and screening programs aimed at disease prevention and chronic condition management, TVHC seeks to drive healthcare cost-savings and wellness for individuals and the community at large.

TVHC also makes available many services that community members might otherwise have to drive an hour or more to receive. Services include:vii • •

Emergency Services, 24/7 Tele-medicine ▪ ▪ ▪ ▪

• • • • • • • • • •

Tele-stroke and tele-burn in partnership with University of Utah Tele-psychiatry in partnership with Portneuf Medical Center Tele-oncology in partnership with Intermountain Healthcare Tele-crisis in partnership with EIRMC’s Behavioral Health Center Surgery (Orthopedic, laparoscopic, pain management, gynecological, colonoscopy) Cardiology (Diagnosis and management of cardiomyopathy, congestive heart failure, coronary disease, hypercholesterolemia, hypertension) Medical Imaging (CT, digital mammography, fluoroscopy, 3D ultrasound, high-definition MRI, X-ray)

Anesthesia Pain Management Neurology Psychiatry Pulmonology Oncology Respiratory Therapy 13

• •

•

•

•

•

Intensive Care Sports Medicine (injury prevention counseling; injury evaluation and management; nutrition counseling for athletes; general orthopedics; joint arthroscopy; hand, shoulder, and elbow surgery; adult hip and knee total joint replacement) Outpatient Infusion Therapy (peripheral and central line catheter care and management; hydration therapy; antibiotics; anti-emetics; injections; blood and blood product transfusions; medication infusions such as Remicade, Reclast, and others; wound care; therapeutic phlebotomy) Rehabilitative Services: Physical and Occupational Therapy (pediatric and adult speech/language; kinesiotaping; strength and conditioning; spinal, SI joint, and extremity orthopedics; vestibular rehabilitation; cardiopulmonary rehab; gait assessment; ergonomic evaluation; women’s health) Dermatology (cryosurgery; diagnosis and treatment of skin cancers, moles, and other tumors (benign or malignant) of the skin; dermatologic surgery; removal of tumors with simple, intermediate, and complex repair techniques as well as flaps or grafts; electrosurgery and electrodessication and curettage; general dermatology; intralesional and intramuscular injections of anesthetics, saline, or steroids; local anesthesia administration; management of cosmetic disorders of the skin such as hair loss and scars and the skin changes associated with aging; nail biopsy and/or removal; photomedicine, phototherapy, and topical/systemic pharmacotherapy; scalp surgery and/or biopsy; skin and hair biopsies; skin scrapings and preparations; wart, molluscum, etc., treatment) Aesthetics (Botox®, chemical peel)

14

Conclusion Hospitals are a key ingredient to quality of life and keeping communities healthy and vibrant. TVHC works hard to be a major contributor to the local economy and to keep families healthy and secure by providing necessary, high-quality healthcare services that are easily accessible and patient-centered.

The data and information contained in this report provide compelling evidence that the economic benefit of TVHC to Teton County is substantial and necessary for the continued success of the Driggs, Tetonia, and Victor communities, Teton County, and the surrounding area. To continue attracting jobs, maintaining families, and delivering healthcare close to home in Teton County, it is critical that TVHC continue to deliver upon its Mission, strive to achieve its Vision, and ensure each staff member lives its Values daily.

TVHC urges Teton County community members, local business leaders, government officials, and community organizers to continue recognizing the value the system brings to the local economy, and to do everything possible to help further support TVHC as it works to deliver exceptional local healthcare.

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Appendix Methodology A blended model was employed to estimate the multiplier effects of TVHC on the overall economy of Teton County.

Inputs from the IMPLAN model (IMpact analysis for PLANning) and the Bureau of Economic Analysis were used to develop the proprietary set of multipliers in this analysis.viii Both IMPLAN and the Bureau of Economic Analysis are widely used economic input-output models that estimate how changes in final demand (i.e., output) ultimately translate into changes in employment (i.e., input) and associated compensation and benefits in a region.

The Idaho version of IMPLAN and Idaho-specific data from the Bureau of Economic Analysis were used to quantify impacts. Direct impacts are benchmarked to employment and compensation figures from the Idaho Department of Labor.

The blended multipliers are then used to calculate the indirect and induced impacts. These impacts are caused by supply chain purchases from hospitals and the spending of employees from both the hospital and supply chain providers.

Employee spending includes all day-to-day activities such as paying a mortgage, purchasing a vehicle, buying groceries, etc. Multipliers quantify the relationship between direct impacts and total impacts. For example, if 100 direct jobs support 50 indirect and induced jobs, then the multiplier is 1.5 [100 jobs * 1.5 = 150 jobs (direct and spin-off)]. The total impacts are simply the summation of the direct, indirect, and induced impacts. These multipliers are a respected and accurate method to determine how an industry or institution affects the economy around it.

Direct

Indirect

Hospital Jobs

Hospital Supplier Jobs

Output

Hospital Revenues

Hospital Supplier Revenue

Wages & Benefits

Hospital Employee Income & Benefits

Hospital Supplier Employee Income & Benefits

Jobs

16

Induced Local Retail & Service Jobs

Related to hospital & patient spending

Local Retail & Service Revenue

Related to hospital & patient spending

Local Retail & Service Income Related to employee spending

Interviews To augment the overall analysis and ensure accurate assessment of the full economic impact of TVHC’s operations, stakeholder interviews were conducted with key members of hospital leadership, the hospital foundation, community groups and organizations, and local government.

Twenty stakeholders were interviewed on November 8 and 9, 2017:

TVHC Leadership

TVHC Board

Keith Gnagey, Chief Executive Officer Angela Booker, Chief Nursing Officer Ann Loyola, Director Public Relations & Marketing

Aaron Hansen Robert Whipple, DVM, MD, MMM, FACS Michael Wine, DDS

Local Representatives

TVHC Foundation Board

Gloria Hoopes, Tetonia Mayor Hyrum Johnson, Driggs Mayor Brian McDermott, Teton Valley Business Development Center Executive Director Doug Self, Driggs Community Development Director Cindy Reigel, County Commissioner

Mark Anderson, Treasurer Carrie Snoey, Vice President Julie Whitlock, Secretary

Local Employers & Community Members Kim Beres, Grand Associates Realtor Jeannette Boner, Managing Editor of Teton Valley News Debbie Hunter, Sotheby's Realtor Nancy McCullough-McCoy, Publisher of Powder Mountain Press Joe Montesano, Principal/CEO of Wilkinson-Montesano Builders Traci Prenot, CFO of Grand Targhee Resort Dale Prows, CEO/GM of Huntsman Springs Anthony Snoey, President of Teton Springs Resort & Club

As gleaned from the interviews, in many ways, the people who choose to live in Teton County, Idaho, are unique. Their values and what they want in and out of life are quite different from people who live in cities. Living in the shadows of the Grand Teton, with everyday access to fly fishing or skiing, they are willing to trade convenience for community and access to ‘stuff’ for access to the outdoors.

The residents of Teton County understand they are lucky to have any hospital at all, much less one that offers the breadth and depth of services available at TVHC. They are also proud to see how it has improved over the past several years, from a facility in poor financial condition to a flourishing system looking to continually develop and consciously and sustainably grow. Interviewees noted key benefits include the ability to see providers quickly, without long wait times, and the kindness of the care provided by people who are friends and neighbors. TVHC’s orthopedics program is highly regarded, and its CEO is viewed as both a strong business leader and an active participant of the community.

To further its position as a valuable contributor to the community, TVHC is a critical driver of community activity, from philanthropy, to retail, to emergency preparedness. The system sponsors many local events including the annual fireworks display, the Mudzilla Fun Run, and the Tin Cup Challenge, a giving-campaign and fun-run to support the local 17

Community Foundation. While the See ‘n’ Save storefront is well-known, many residents do not realize that TVHC is responsible for the prominent thrift store in downtown Driggs that helps fund the Teton Valley Hospital Foundation.

Furthermore, in 2017, between 50,000 to 100,000 people were expected to descend on the area to view the solar eclipse. TVHC spearheaded many of the efforts for emergency planning, increased staff, and ran drills to ensure the safety of residents and visitors alike.

While many Teton Valley residents work in Jackson, WY, they prefer the lifestyle and benefits of their home community and want to avoid what comes with an expensive tourist destination. They enjoy being ‘the bedroom community’ for Jackson, with access to the jobs the area provides and the same natural wonders, but without the crowds and high cost of living. Many Teton County residents believe in ‘responsible growth and development’ that will strengthen the local economy without damaging the way of life that attracts visitors and residents to the area.

Affluent visitors are drawn to the community to purchase vacation homes in developments like Teton Springs and Huntsman Springs, and a key deciding factor is the availability of quality local healthcare. New companies have moved into the area including distilleries, restaurants, and hotels, and residents believe that a primary contributing factor to establishing business in Teton Valley is the presence of TVHC. As in any community, there are some challenges in the Teton Valley population. There are part-time residents for whom the area is a second (or third) home. These individuals bring considerable wealth to the area but are not always an active part of day-to-day life. Many of the workers who settle in the area are here for the scenery and way of life— “work to live not live to work” —which can lead to a workforce content with jobs that offer more flexibility for lower wages.

There are also several sub-segments of the population that access and utilize healthcare services differently, and TVHC must find ways to adapt to help provide equal opportunities to receive healthcare. The community is spread out and secluded, and so public awareness related to health, wellness, and available services is an issue. Even some of the interviewees were unaware of how many medical specialties are now accessible through tele-medicine offerings, and that TVHC is connected to physicians at the region’s leading healthcare systems.

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Community Characteristics Definition of Area Served by the Hospital TVHC defines its primary service area as Teton County in Eastern Idaho. From 2013 to 2015 the hospital received 79.9% of its patients from Teton County, Idaho, with an additional 3.1% from Alta, Wyoming (zip code 83414).ix

Community Demographicsx Teton County has a population of 10,776 and is expected to grow 5.8% over the next five years. This continues the trend of robust growth since 2006 (more than 35%).xi The area population is younger than the national population with a median age of 37.2 (U.S. median age is 38.8). Additionally, the age 65+ population is expected to grow over the next five years at a slower rate (10.0% for Teton County, 17.5% nationally). Females of child-bearing age represent 19.1% of the total population, but this group is expected to shrink by 0.3% over the next five years. Teton County has an educational level that is higher than the national average with a greater percentage of the population having completed some college or attained a bachelor’s degree or greater. The ethnic make-up of Teton County is primarily White (79.7%), with Hispanic representing just over 18% of the population.

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Teton County, Idaho - Demographic Characteristics Selected Area USA 10,161 308,745,538 10,776 325,139,271 11,399 337,393,057 5.8% 3.8% $70,665 $80,853

2010 Total Population 2017 Total Population 2022 Total Population % Change 2017 - 2022 Average Household Income

Total Male Population Total Female Population Females, Child Bearing Age (15-44)

POPULATION DISTRIBUTION

2017 2,477 449 836 1,219 3,439 1,274 1,082 10,776

2022 % Change 5,860 4.9% 5,539 6.7% 2,053 -0.3%

HOUSEHOLD INCOME DISTRIBUTION Age Distribution

Age Group 0-14 15-17 18-24 25-34 35-54 55-64 65+ Total

2017 5,584 5,192 2,060

% of Total 23.0% 4.2% 7.8% 11.3% 31.9% 11.8% 10.0% 100.0%

2022 2,482 527 1,044 1,085 3,432 1,372 1,457 11,399

% of Total 21.8% 4.6% 9.2% 9.5% 30.1% 12.0% 12.8% 100.0%

USA 2017 % of Total 18.8% 3.9% 9.8% 13.4% 25.7% 12.9% 15.5% 100.0%

EDUCATION LEVEL

Income Distribution

2017 Household Income <$15K $15-25K $25-50K $50-75K $75-100K Over $100K Total

USA HH Count % of Total % of Total 303 7.7% 11.8% 436 11.1% 10.1% 951 24.2% 22.9% 809 20.6% 17.4% 630 16.1% 12.1% 795 20.3% 25.7% 3,924

100.0%

100.0%

RACE/ETHNICITY

2017 Adult Education Level Less than High School Some High School High School Degree Some College/Assoc. Degree Bachelor's Degree or Greater Total

Education Level Distribution USA Pop Age 25+ % of Total % of Total 443 6.3% 5.8% 389 5.5% 7.7% 1,458 20.8% 27.8% 2,082 29.7% 29.1% 2,642 37.7% 29.6% 7,014 100.0% 100.0%

Race/Ethnicity White Non-Hispanic Black Non-Hispanic Hispanic Asian & Pacific Is. Non-Hispanic All Others Total

Race/Ethnicity Distribution USA 2017 Pop % of Total % of Total 8,584 79.7% 60.8% 23 0.2% 12.4% 1,964 18.2% 18.0% 74 0.7% 5.7% 131 1.2% 3.2% 10,776 100.0% 100.0%

Health Status An areaâ&#x20AC;&#x2122;s health status is determined by examining the population using the Claritas Prizm Premier consumer segmentation data. This system segments the population into 68 demographically and behaviorally distinct groups, each of which exhibits specific health behaviors and includes socioeconomic inputs like household income, educational attainment, and occupation. The makeup of the service area, based on the Prizm Premier segments and corresponding characteristics, is compared to the national population averages to determine probable lifestyle and medical conditions present in the population.

Teton County

Teton County is relatively healthy overall, with zip code 83422 falling below the average health status score for the United States but still ranking higher than the state of Idaho.

Zip Code

City

Score

Rank

83424

Felt

71

Very Good

83452

Tetonia

71

Very Good

83455

Victor

59

Good

83422

Driggs

54

Fair

59

Idaho USA Housing and Population Density 20

53

Fair

58

Good

The Geounit Quality Score suggests whether a geographic area is higher, lower, or equal to the United Statesâ&#x20AC;&#x2122; norm of social and economic achievement. The mean U.S. score is 100. An areaâ&#x20AC;&#x2122;s score is determined by the rating for each zip code in four weighted categories: household income, years of school completed by persons over age 25, occupation of employed civilian labor force, and home value. At 31.8%, Teton County has a relatively high rate of vacant housing units compared to Idaho (12.7%) and the United States (11.3%), but the county has a favorable Geounit Quality Score of 102.

It is not surprising that the population density centile of Teton County is very low at 7. This number indicates where a geographic area falls out of one-hundredth of the population. The population is ranked by density, where centile 1 is the least densely populated, and centile 99 is the most densely populated.

HOUSING UNIT STATUS

OTHER HOUSING UNIT FACTORS

Owneroccupied

Renter-occupied

Vacant

Average length of residence

Geounit Quality Score

Population Density Centile

TETON COUNTY

48.4%

19.8%

31.8%

11.9

102

7

IDAHO

61.1%

26.2%

12.7%

12.0

97

37

USA

57.6%

31.1%

11.3%

13.3

100

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Community Economic Indicators Teton County offers many employment opportunities, particularly as they relate to seasonal offerings. Tourist and ski seasons drive an influx of business to the area, which provides for ongoing employment. These employment opportunities have translated into a relatively low unemployment rate of 3.2% in 2016, which compares favorably to Idaho and the United States.xii

Unemployment Rates 12.0 10.0 8.0 6.0 4.0 2.0 0.0

2006

2007

2008

2009 Teton County

2010

2011 Idaho

2012

2013

2014

2015

2016

United States

While home values are relatively high for the region (above national median and well above Idaho), household income and wealth are above Idaho but below the United States.

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Teton County

Idaho

USA

MEDIAN HOUSEHOLD INCOME

$57,141

$51,212

$61,078

MEDIAN HOUSEHOLD WEALTH

$70,332

$67,937

$78,383

MEDIAN HOME VALUE

$262,669

$190,069

$245,444

Part of the high relative home value is likely due to the draw of the pure natural beauty in the area, and subsequently, the presence of affluent individuals that choose Teton County for a second (or non-primary) residence. These mostly high net worth individuals do not factor into much of the available census-based demographic data chronicled in this report (not included in income and wealth, but the homes are included in home value calculations). It is challenging to capture accurately the number of these individuals and the impact they would have on demographic data such as household income and wealth.

But, these individuals are no less important. In fact, the key stakeholder interviews indicated that the part-time residents play an influential role in the community—and demand high quality medical care as a staple in their community of choice.

There are key employers in the community beyond TVHC. TVHC works well with these other employers by maintaining open lines of communication and seeking partnership opportunities to deliver care and value to the community.

Some of these employers include Broulim’s Supermarket, Teton County, and Teton County School District.

Another key factor in an individual’s propensity to seek healthcare at the appropriate time is whether that person has insurance coverage. Over half of Teton County residents have some form of commercial insurance—whether acquired through an employer-sponsored offering, through direct purchase, or via the healthcare exchange.

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Population Insurance Coverage by Payor Type - Teton County, Idaho 100%

80% 60%

9% 8%

12% 7%

6% 6%

7% 6%

53%

45%

54%

54%

11% 11%

13%

14%

14%

13% 7%

13% 6%

Driggs: Pop = 3,397 Zip 83422

Tetonia: Pop = 1,691 Zip 83452

Felt: Pop = 239 Zip 83424

40%

20% 0%

13% 8% 10% Victor: Pop = 5,449 Zip 83455

Medicaid Commercial - Employer Sponsored

Medicare Commercial - Exchange

Commercial - Direct Uninsured

TVHC has taken caring for its community to the next level with the Cache Clinicâ&#x20AC;&#x201D;a cash-only clinic available after usual business hours and in a convenient location in downtown Driggs. TVHC is clearly seeking to deliver on its vision of expanding care to meet community needs.

Outside of healthcare, other industries are important drivers in Teton County. The percentages of businesses related to construction and food services are above state and national averages. As TVHC grows and expands its offerings, many other industries in the following chart would be bolstered as well (i.e., as construction projects are undertaken, jobs follow).

18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

Industry Comparison

Teton County

State of Idaho

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USA

The presence of healthcare services in Teton County is attractive to many of the above industries, which serves to draw business and workers to the area. Moreover, due to the prohibitive costs of living in Jackson, Wyoming, many residents of Teton County, Idaho, live here while traveling over the pass to work in the popular tourist destination.

As the economy has recovered from the 2008 recession, traffic counts through Driggs and Victor have climbed back from their peak in 2007. It is important that TVHC continue to offer convenient and accessible services to meet the demands of the population that lives in its service area, yet may travel out daily for employment.

Average 24-Hour Traffic Count

8,000

6,000 4,000 2,000 0

Driggs

Victor

Healthcare Providers Idaho ranks very low in key physician supply statistics, including the second lowest in the United States for active physicians per 100,000 population and the fifth lowest for active primary care physicians per 100,000 population.xiii Still, TVHC has been successful in recruiting talented physicians, nurses, and other healthcare providers to serve the community. The system has formed strong relationships with regional and national provider organizations that enable it to deliver high-quality specialty care to the communityâ&#x20AC;&#x201D;atypical and impressive in a rural community with a hospital the size of TVHC.

Idaho

Idaho Rank in U.S.

U.S. Median

Active Physicians per 100,000 Population

192.6

49/50

257.9

Active Primary Care Physicians per 100,000 Population

73.1

46/50

90.8

The ability of the hospital to recruit healthcare talent to Teton County has a strong, positive impact. Jobs in healthcare provide employment to residents across many occupational segments. The healthcare sector also retains and attracts people to the area who have relatively high education levels and make a higher annual wage to spend on local goods and services.

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Glossary TERM

DEFINITION

STUDY YEAR

Fiscal Years 2012-2016

TOTAL ECONOMIC IMPACT

The direct and indirect impact generated in the economy because of the institution.

DIRECT ECONOMIC IMPACT

Revenue produced by the hospital through patient care and other activities.

INDIRECT ECONOMIC IMPACT

The re-spending of any money produced by the hospital in the local economy by employees, vendors supporting hospital operations, and the spending of households associated with both.

MULTIPLIER EFFECT

The additional economic impact created because of the institution’s direct economic impact. For instance, local companies that provide goods and services and increase employment or production to supply the hospital are part of the overall multiplier effect produced by the hospital.

DIRECT EMPLOYMENT

Total number of employees at an institution.

INDIRECT EMPLOYMENT

The additional jobs created as a result of the institution’s economic impact. Local companies that provide goods and services to an institution may increase employees as purchasing increases, thus creating an employment multiplier.

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Sources Data collected for the TVHC Economic Impact Study was compiled from multiple well-respected secondary sources to build a complete, accurate, and balanced picture of the community and how TVHC contributes positively to the economy of the region. In addition to the sources outlined below and those listed in this documentâ&#x20AC;&#x2122;s endnotes, facility data was provided by TVHC.

DATA SOURCE

DATA DESCRIPTION AND USE

BUREAU OF ECONOMIC ANALYSIS, U.S. DEPARTMENT OF COMMERCE

The Bureau of Economic Analysis multipliers are part of the Regional Input-Output Modeling System (RIMS II). Multipliers are developed at the state and county level for use in the analysis of various industry types.

2015

IMPLAN SYSTEM

IMPLAN (IMpact analysis for PLANning) is the input-output economic impact modeling system developed by the Minnesota Implan Group.

IMPLAN is used to create models of economies allowing for in-depth examinations of economic impacts. The IMPLAN system estimates output, employment, and labor income multipliers for each industry, at the state and national level, as well as total tax revenues (state and local) generated using a Social Accounting System. Data are taken from a number of sources including the Bureau of Labor Statistics (BLS), the Bureau of Economic Analyses (BEA) and the U.S. Census Bureau.

2016

TRUVEN HEALTH ANALYTICS

Assessment of characteristics of the hospitalâ&#x20AC;&#x2122;s primary service area, at a zip code level, based on classifying the population into various socioeconomic groups, determining the health and medical tendencies of each group, and creating an aggregate composition of the service area according to the proportion of each group in the entire area; and, accessing population size, trends, and socio-economic characteristics

2010 to 2017

RURAL HEALTH WORKS

Provides comparative data regarding other rural hospital operations and communities around the country. Rural Health Works regularly completes a literature review and comparison for rural healthcare organizations to aid in economic impact studies for rural hospitals.

2007 to 2016

DEFINITIVE HEALTHCARE

Used to assess hospital size, changes in operation, size and scope of competing hospitals, and to provide other benchmarking data for this study. Definitive covers all types of facilities and providers including highly detailed data on hospitals, physicians, ACOs, payors, Skilled Nursing Facilities, imaging centers, and more. Definitive uses a variety of sources from CMS Medicare Cost Reports, Medicare SAF, etc.

i

DATA DATE

2016

American Hospital Association (Jan 2013), Economic Contribution of Hospitals Often Overlooked.

American Hospital Association (Jan 2017). Hospitals are Economic Anchors in their Communities. iii Kuo, D.Z., Houtrow, A.J., Arango, P., Kuhlthau, K.A., Simmons, J.M., & Neff, J.M. (2012). Family-centered care: Current applications and future directions in pediatric health care. Maternal and Child Health Journal, 16(2): 297-305.

Wagner, E.H., Bennett, S.M., Austin, T.T., Greene, S.M., Schaefer, J.K., & Vonkorff, M. (2005). Finding common ground: Patientcenteredness and evidence-based chronic illness care. Journal of Alternate Complement Medicine, 11(1), S7-S15.

Bamm, E.L., & Rosenbaum, P. (2008). Family-centered theory: Origins, development, barriers, and supports to implementation in ii

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rehabilitation medicine. Archives of Physical Medicine and Rehabilitation, 89(8): 1618-1624.

Epstein, R.M., Fiscella, K., Lesser, C.S., & Stange, K.C. (2010). Why the nation needs a policy push on patient-centered health care.

Health Affairs, 29(8): 1489-1495. iv Deller, S.C., Tsai, T.-H., Marcouiller, D.W., & English, D.B.K. (2001). The role of amenities and quality of life in rural economic growth. Amer. J. Agr. Econ., 83(2): 352-365.

Johnson, J.D., & Rasker, R. (1995). The role of economic and quality of life values in rural business location. Journal of Rural Studies, 11(4): 405-416.

Salvesen, D., & Renski, H. (2003). The importance of quality of life in the location decisions of new economy firms. Center for Urban and Regional Studies, UNC at Chapel Hill. v Schiamberg, L.B., & McKinney, K.G. (2003). Factors influencing expectations to move or age in place at retirement among 40- to 65-year-olds. Journal of Applied Gerontology, 22(1): 19-41. vi Wages for TVHC only include employees who live within Teton County and do not include physicians. vii Teton Valley Health Care organization website, https://tvhcare.org/services/ viii American Hospital Association Annual Survey ix Inpatient Medicare market share x All demographic data from Claritas, accessed via Truven Health Analytics Market Expert tool; note that this includes census-based demographics and will not necessarily account for seasonal population or population where homeowners list an address outside of Teton County as a primary residence xi Idaho Department of Labor xii Idaho Department of Labor xiii 2017 State Physician Workforce Data Report, Association of American Medical Colleges

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