The New England Journal of Medicine—the most widely read and cited health care publication in the world—detailed the Immersion Day program in this report by Bock and Paulus, carried as the lead article in the March 31, 2016 issue.
United Airlines’ board was too isolated in recent years, allowing the carrier to fall behind rivals since its 2010 merger, said Chief Executive Oscar Munoz.
“As board members, we only meet infrequently and are not as engaged with the front line, necessarily … while directors don’t meet often, they carry “some of the blame” for not being more observant, said Munoz, who was named CEO in September.”
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“Since the creation of Immersion Day for Mission Health board members, the health system has created other immersion programs. One was a multiweek immersion program for a local journalist, and another is geared toward state and federal policymakers.” A significant disconnect between hospital boards and the real life happenings within the hospital poses a key barrier to effective governance and policymaking, according to Richard Bock, MD, a vascular surgeon at Mission Health, and Ronald Paulus, MD, the health system’s president and CEO.
“The judgment of independent directors must be informed by facts, knowledge, experience, and expertise. Gut instinct is not enough.”
— Richard Parsons, former Chairman of Citigroup and Chairman of Time Warner
“Directors who don’t know my business are often off base. We have to humor them and manage them, but in truth they don’t add much.”
—CEO of a global Fortune 50 company
“The more you educate the board, the less concerned you are,”
— former Honeywell chairman Larry Bossidy
The Citizen-Times observed Mission Health System — from the board room to the operating room — to report a series of stories that started March 29. On Sundays over four weeks, we opened a window into Western North Carolina’s largest company as regional health care undergoes the biggest change in its history.
Emergency departments take them as they come. Gunshot wounds. Car wrecks. The homeless who want to get out of the cold. The mentally ill who have nowhere else to go. People who can pay. People who can’t. Once, doctors at Mission Health spent $5.2 million in two months treating two separate men, both hemophiliacs who wrecked their motorcycles on the Blue Ridge Parkway. They lived. Mission lost millions.
On the floor above, 14 people with mental illnesses are in emergency beds normally reserved for chest pain patients. They don’t have life-threatening medical problems. Some might wait days in a department that measures turnaround in minutes. … And for all the good done at Mission’s ER, for all the lives saved, millions of dollars are lost.
The system showed 62 people in beds before noon with 17 waiting. An hour later, there were 91 patients — including those in waiting room. The number reached 106 and the evening commute hadn’t even begun.
Today, about a quarter of Emergency Department bed space at Mission Hospital is being used by people with mental health challenges who, in most cases, are waiting for longer-term care. Boarding days can stretch into weeks for the sickest patients due to a lack of space at Broughton Hospital, the state facility in Morganton, and other facilities.
The company loses millions of dollars a year caring for people with mental illnesses.
Donna Skigen scans a list of patients at one of five computers inside a work area at the St. Joseph’s Hospital campus. Armed with her charm, experience as a mental health clinician and a list of hospitals across North Carolina, she’ll sweet talk, cajole and demand bed space for as many patients as possible during her shift at the desk.
This is the dance. This is air traffic control.
It’s an old game in medicine, but the system is becoming unsustainable.
Asking people to pay their bills all day is not a job for everyone. Huff said her husband reminds her of all the charity care she’s been able to get to patients.
Huff does the work, in part, because without payment, the hospital wouldn’t be around. “You want to collect the money,” she says of her job. “Mission is a great hospital.”
Medicaid reimbursements don’t cover costs. Mission wrote off the cost of $17 million in (emergency room) care in 2013.
(Meanwhile), companies that own surgical centers posted double digit profit margins in 2014, Modern Health Care reported in March. The news service said one company, Surgical Care Affiliates based in Deerfield, Illinois, has a payer mix that is 62 percent private insurance.
That’s nearly the complete opposite of Mission, which has 75 percent of patients on Medicare and Medicaid. CEO Ron Paulus said the business model is unsustainable
“Like the old fee-for-service business model that is changing fast, the nation, too, must come to grips with what kind of care is appropriate, he says.” Bock has seen patients who’ve lost legs and suffer from terrible dementia taken by ambulance each week for kidney dialysis, just because family members want to keep them alive.
“Imagine,” he says, “a single mom working at a fast-food restaurant goes home today and finds a big, scary lump in her breast. She doesn’t have insurance. Should Mission treat her cancer even if she can’t pay? Most people would say yes.”
“The company will send her a bill every month, maybe for years, but the operation will be more than she can ever pay,” Bock says, so some of the cost will be covered by Mission’s charity funds.
“And so where does that money come from?” Bock said. “Mission is a not-for-profit so it can’t come from shareholders. It’s got to come from either the privately insured or the government. So our system of cost shifting is teetering evermore as the percentage of people with insurance deteriorates.”
It has a children’s hospital, a cancer center, two helicopters, a neonatal intensive care unit that saves babies every day, and a nationally recognized heart program.
What the federal government, insurance or the patient won’t, or can’t, pay the hospital covers. This is medicine in America.
Mission CEO Ronald A. Paulus, MD, 52, is a medical doctor with an Ivy League business degree. He is positioning Mission to have more control over health care spending in Western North Carolina than ever before. “It is the biggest shift,” he says, in the company’s history. The goal is to be sustainable and continue to offer the big city medicine that this relatively rural place has come to expect.
His life story is one of a rise from a small town in Pennsylvania to recognition as one of the nation’s top health system CEOs…
Current board chairman Wyatt Stevens said he took the volunteer job to get a chance to work with Paulus, who has been recognized as one of the nation’s top health system CEOs. He’s been proud of the work the company has done. “Paulus,” he says, “has kept Mission’s top executive talent in place and recruited talented leaders from other places. Both are proud of safety improvements and Mission’s record of having lower costs compared to its peers.”
“We’ve gone from the minutiae of the details to setting the guard rails for the organization and saying OK here are the out-of-bounds stakes,” (previous board chair Bob) Roberts said. “The board had to make a call that rubbed those rails last summer. It agreed to the lowest margin in the company’s history.”
Stevens said the margin rate of 1.7 percent came through the finance committee, which includes a Harvard MBA as the chair and a former treasurer of Delta Air Lines. “We had a robust discussion about it. It was not easy,” he said.
But the board was confident in Paulus, and his executives, so it agreed. “Growth,” Stevens said, “is the plan today because it means the company will survive.”
Over the past several months, Citizen-Times writer Jon Ostendorff and I spent countless hours inside Mission Health’s massive network of facilities to document as much as we could of the changing landscape of health care and the people affected by it.
To witness the moving parts of a large medical facility and its crew of professionals will leave a lasting impression on anyone, regardless of knowledge of the health care industry.
The physically sick, the mentally ill, both young and old, continue to be treated each day at Mission while the rest of us live our normal lives. Can the system be made better? We’ll see. But to witness someone surrender their emotions to a stranger with the words “Thank you” filled my heart, and I could not help but be consumed with relief.
In running a business, a simple rule of thumb would be not to give away $55 million of your product every year. Yet that’s the challenge Mission Health System faces.
That’s one of the main takeaways from Citizen-Times reporter Jon Ostendorff and photographer William Woody’s months long, in-depth look at the area’s “500 pound health care gorilla.”
In doing the series, Mission CEO Ronald Paulus opened his organization’s doors — and many of its books — to allow unprecedented access to their operation without controlling who we talked to and what was said. Giving this kind of access to a journalist and hoping for the best is a risky proposition for any business, and we applaud their courage in letting us take such a detailed look at the inner workings of their operation, warts and all.
Under Paulus’ leadership, Mission has been proactive, taking steps to make itself sustainable by growing outpatient care, reducing mistakes and errors and controlling costs.
We all need health care. The path to how we get that care is being charted before our eyes. Yes, Mission is a business. But it has a heritage and an ethos that is local and honorable.
As I watch the heart-lung machine kick in, the surgeon explains how the patient, a woman in her 50s, got here. She she couldn’t afford her medication, Plavix (cash price at CVS of generic is $149.99/month), so instead she is getting emergency heart surgery that will cost more than $150,000, or the equivalent of 83 years’ worth of the medication. If she survives surgery, she will probably look forward to many years of medical bills that she can’t pay.
As day turns to night, we head to the emergency department where there’s a woman having difficulty breathing. She deteriorates quickly, no breathing, no pulse. Everyone is doing their jobs, airway established, CPR has begun, and the ER doctor is calmly and confidently giving instructions.
The team does not have the luxury of getting blood work done, X-rays, or a detailed medical history. They learn two things before she loses consciousness, she is on birth control and smokes: the perfect recipe for a pulmonary embolism.
Does she have insurance? Can she pay for her treatment? No one asks, no one cares, the goal is to save a life and they succeed. What did I learn and what do I want to share?
Western North Carolina is in good hands. Mission provides state-of-the-art care to people regardless of ability to pay, without passing judgment on the behaviors that brought them in the door, and in spite of the regulatory and compliance burdens placed on them by the state and federal government.