By Joy Ufford

jufford@pinedaleroundup.com

PINEDALE – Eight candidates for the Sublette County Rural Health Care Board, including three incumbents, introduced themselves Monday, Oct. 29, with opening statements and took turns expressing their thoughts on health care in general and the critical access hospital in particular.

The three incumbents – John Godfrey (2-year), Laura Clark (4-year) and Scott Scherbel (4-year) – advised voters to select them to show support for the critical access hospital as currently envisioned.

Five challengers – Sam Bixler (4-year), Bill Johnson (2-year), Marti Seipp (4-year), Tonia Hoffman (4-year) and Mike Pompy (4-year) – presented a range of opinions. Most expressed a desire for a smaller CAH or to “wait and see.” All stated the current board has seriously damaged relationships with county commissioners and town officials.

The debate in the Pinedale High School’s Sheppard Auditorium was the second for Sublette County voters to hear from local candidates. Moderator Mindi Crabb presented questions with 90 seconds to respond. The debate is available on the Sublette County Chamber of Commerce’s Facebook page. The Oct. 22 debate for commissioner and Big Piney school district candidates is also posted there.

Opening statements

BIXLER: There needs to be a change. Instead of waiting for someone else to do it, he decided to do it himself. Change is needed to unify the community, resolve health-care challenges and rebuild relationships. He has written business plans and grants and worked with many groups on committees since his family moved to Sublette County.

GODFREY: He is a retired manager of the Western Railroad Association in Chicago. Born in Cheyenne, he attended the University of Utah. His career took him to Chicago, where he served in an elected office for a park district of 30,000 to build recreation. He retired to Pinedale in 1995, was active in passing the lodging tax and headed up the Visitor Center committee. On the board for one year, he supports a dedicated critical access hospital.

JOHNSON: He is a Sublette County native who attended Westminster College and the University of Wyoming. He served on the Pinedale Town Council in his 20s. He moved to Riverton with his dad’s trucking company. Next employed by BTI Trucking, he became a superintendent and then a vice president. His goal is to talk about current board members, why the existing clinic site is the best available and rebuild horrible relationships among the board and entities.

SEIPP: She has been in Sublette County about 30 years, with 25 years as a financial adviser and 12 as a full-time caregiver for their adult child with multiple sclerosis. She’s had a lot of interaction with health-care providers and has no complaints. She wants to help move forward and work with others within constraints of RHCD finances.

CLARK: A Wyoming native and Big Piney graduate, she received higher education to be a radiology tech. She returned to Sublette County to build the new clinics’ radiology departments. In 2010 she ran for the board and has been on it since, getting experiences with ups and downs. The board has laid good groundwork and the county needs the CAH.

HOFFMAN: She moved here at 14 and never left, serving as a nurse for 21 years. She thinks she has experiences that qualify her. She has learned a lot about seniors as part of Nurses for Community Health. Her work in Sublette County is with families to make sure they have health care. She would likes to be part of the solution.

POMPY: He has lived in Big Piney 40 years. He spent two years at UW, finished up at the South Dakota School of Mines and moved to Los Angeles for a job. He decided to buy in on a family ranch and moved back where he worked in the oil and gas industry and retired. He served on the RHCD board 20 years ago when Big Piney had 24-hour service. He supports the dedicated staff of medical professionals in the county.

SCHERBEL: He grew up in Big Piney except for several years in Jackson and is a surveyor. He is running again to carry the trust laid on him by people eight years ago. The RHCD staff is wonderful but the biggest need now is a critical access hospital. He’s absolutely committed to bringing a hospital into Sublette County. Votes for him, Clark and Godfrey will bring the CAH.

Can you explain your understanding of the designation and how it affects the ability to bill for services?

BIXLER: Yes, under the current designation we do not get cost-based reimbursement. The original version was $6 million at the existing clinic, not a $30-million project. Since then it expanded to a facility and site that are not appropriate.

GODFREY: The current designation of medical clinic means the district is reimbursed at a rate for a doctor’s office visit. RHCD billed Medicare $1.7 million and received $350,000 as opposed to a hospital. We are literally underpaid for the services we perform. Money is lost because not being reimbursed at our cost. With a CAH designation, Medicare will reimburse at 101 percent.

JOHNSON: We may not be reimbursed like we should but do we have to go magnificent with the CAH design? They say it will cost $25 million to build, not accounting for $2 million for a road and moving the ambulance barn. There will be cost overruns, between $30 million to $35 million. Now the board is chasing a 7-percent loan because it was turned down by the USDA at 4 percent. The CAH will cost $60 million to $70 million.

SEIPP: We need to use what we have – we spent $19 million on the clinics. If we don’t use the Pinedale clinic, someone else will lease it from the county and compete with the RHCD. She is not convinced the clinics can’t meet hospital standards.

CLARK: Reimbursement is well below what we could receive as a CAH. The current system was built without studies and is unsustainable. The CAH provides reimbursement and added revenue with services we don’t have. She doesn’t know if the location matters but hospital construction is very expensive. Studies show the CAH is needed for revenues and reimbursement.

HOFFMAN: She absolutely understands Medicare reimbursement and agrees new revenue sources are needed. She doesn’t believe the capture from a CAH will be enough. She agrees that every option should be explored with the county’s two state-of-the-art clinics before throwing more money into a new hospital.

POMPY: He understands the Medicare situation and the need to capture additional funding. He does not think the RHCD’s building a CAH by itself without help from commissioners or communities is the right way to do it. Everyone needs to work together; one board member tried to do this and was totally ignored.

SCHERBEL: We have looked at all other optional models and everyone came back with one answer and that is a CAH. We know the solution; the question is how do we get to that solution. We’ve gone to the county and involved everybody who wanted to be. We have been open and transparent. The current clinic site adds $5 million; we studied and looked at it extensively. To raise revenues, a new CAH is the only viable solution.

What have you done to advocate for health care in the county?

BIXLER: Almost four years ago he was one of the first people to ask Malenda Hoeslcher about the CAH business plan. He has followed studies and talked to the public often. He disputed previous costs cited for the BloomField site saying the $30 million includes $2 million to build road, water and sewer infrastructure required by Pinedale.

GODFREY: On the board one year, he meets with friends and speaks with people. He represents an age group that uses the facilities more than others and is beyond 4 percent of the market share. We are dedicated to see our Sublette County community not have to drive 80 miles over mountains. Our motto is “Quality service close to home.”

JOHNSON: He has gone to meetings for five months and started with an open mind but now has opinions, including the clinic. He advocates speaking to the county and if RHCD buys the $1-million property from Pinedale and builds a CAH next to it, Pinedale could move ball fields and build a sports complex. The Pinedale Cemetery would have what it needs, a win-win-win for everybody.

SEIPP: She has actively watched and participated in health care but felt public comment was not allowed at board meetings. She talked to Hoelscher as the CAH initiator, wrote letters to the editor and advocated on a personal basis. We do have good health care but some disruption on how to provide it. People deserve to receive good health-care services whether she is on the board or not.

CLARK: She was in the county a long time

before being an RHCD employee and board member. She is intimately involved in district workings and education to keep up with changes. It is absolutely not true that public comment is not allowed at meetings. Sometimes the board needs to discuss and make decisions and ask people to hold comments. All meetings have a time for public comment.

HOFFMAN: She works daily with families for whom she advocates to find them resources. She works closely with prevention and public health services. The Nurses for Community Health group she is in provides annual screenings for low-cost blood work and that money is invested for seniors and student scholarships for health-care management careers.

POMPY: Health care has changed so much and many physicians have left in the last five years. He wants to figure out how to keep people in positions and health care. He served on several RHCD committees and is trying to get health care back where we need it.

SCHERBEL: His advocacy is to bring a health-care model that is financially sustainable, which is the CAH. As for the $6-million CAH proposal for the clinic, commissioners said no, which is why nothing was done. He hears inflated numbers but $17 million is fixed for hard construction plus $8 million to $10 million in soft costs. The critical access hospital is his advocacy for this health-care district and the only way to provide the county’s needed and deserved health care.

Given recent denial by USDA of the loan application, what do you see as the next course of action for medical services in Sublette County?

BIXLER: First repair relationships; no plan is successful until everyone is behind it. Retrofit the Pinedale Clinic or in Marbleton, which offered a very low interest loan to make it into a CAH. Create partnerships with St. John’s Medical Center and others. USDA didn’t deny the loan just because of its size; he listed seven reasons. Mediation is not the way to go. It’s time for Plan B.

GODFREY: Mediation is the way to go. We have issues with the USDA’s denial of the loan application. Staffing was never raised as an issue until we compared it to similar hospitals in Wyoming. USDA didn’t think we had enough people. We met with St. John’s, architects, facility advisors and all said it is designed on a best works basis to use personnel much better.

JOHNSON: He read several sentences from the USDA’s second refusal letter that says the CAH is not modest in size, design and cost – ongoing issues. It does not have community support; letters from government entities did not support the current plan. Other hospitals are having problems and still we march forth. This doesn’t need 100 employees.

SEIPP: We have to look at all our options; the USDA denial is not the end. Look first at what we have – she doesn’t believe it would take $28 million to retrofit the clinics and make them acceptable. People in Sublette County put up the money for their health care and you are supposed to provide services and there are more options. She suggested asking the USDA for a smaller loan to retrofit the current clinic.

CLARK: The USDA denial isn’t the end of everything; it means we exercise our right for mediation. She is convinced the board and advisors can change the USDA’s mind. If not, private companies are willing to lend money at a higher interest rate and studies show it can be paid back. They wouldn’t be interested in lending if it wasn’t viable. No matter the course, she will move forward with the CAH.

HOFFMAN: The best course now is to stand back and let the dust settle. She would like to mend relationships that were severed in these processes. After talking to people at the north and south ends of the county, she doesn’t think everyone’s wishes were heard. People give her very different ideas that haven’t been explored yet.

POMPY: It’s a tough situation. Johnson touched on not spending so much money with the Pinedale clinic. We could continue using it as it is without doing a thing to it and perhaps build a smaller CAH on land Pinedale is willing to sell for $1 million. The major thing USDA requested is community support. So far the board is unable to receive that.

SCHERBEL: As members of the board, we voted for mediation. We believe the denial is not based on a fair analysis. USDA recently approved a Thermopolis loan for the same size and dollars, designed by the same professionals. The only difference is public support. A vote for the three incumbents who absolutely support the CAH now would show the USDA clear support. The board moved away from the $6-million version because the gain from Medicaid is about $3.5 million. A full CAH as proposed would bring $10 million in the first five years and grow from there.

Can you define your philosophy on attracting and retaining quality staff?

BIXLER: I was always taught people don’t quit jobs; they quit managers. His philosophy for the quality staff is to make sure management continues a welcoming environment. The board has to give providers a sustainable business model to ensure they have their jobs.

GODFREY: How do you think the medical staff feels right now about their jobs, their future, with what has been happening? They’re heartsick, they’re fed up with the arguments, misstatements and innuendo. They know what is needed to provide health care for this county and they participated in the CAH’s design and implementation. It is based on the best advice from the best consultants we can find. Twelve consulting firms all concluded we need a CAH. Not a mini medical mart. Not a mini jug and loaf for prescriptions. They need a hospital, a real hospital.

JOHNSON: You are trying to put emotion over logic now. The staff should not feel threatened because we’re talking about the size of what to do. Employment and retaining staff is something he knows about. There has to be fairness, a decent schedule, be in community and be honest and honorable. There are more important things than money. Just a few days ago you gave them a 4-percent raise. It’s good for the staff but to make this practical, use logic.

SEIPP: I don’t see all of that doom and gloom. It must feel pretty nice to be an RHCD employee now because everyone is talking about it and interested. We have a wonderful place to live; the climate is not the best but people come here because they want to live in Sublette County, not whether there is or isn’t a hospital.

CLARK: That’s very complicated. People live here for different reasons. A problem in attracting physicians especially is the distance between us and a hospital. It is really hard to work in a clinic with one CT scanner and no support. They come from an environment of support. They need a competitive wage. They go to school for long time and have student debt to resolve. So we have incentives to keep them here but it’s a really big issue.

HOFFMAN: It’s important to find people invested in our communities and like it here. This board has mishandled retention of staff. There are two nurses with families in the community and spouses working here and they want to be here, working to become midlevel nurse practitioners but are not offered any assistance to achieve that. They could have two homegrown practitioners coming back here. RHCD should support their efforts. Things like that need to be addressed.

POMPY: Why wouldn’t anyway want to come here? It’s a garden spot at least in June and July. Do the best we can to give them tools they need to do their job. Support from communities and the county and towns and supporting the people that are actually doing the job. The fantastic staff does a wonderful job.

SCHERBEL: We are blessed with the staff we have. We’ve been able to replace doctors when needed. The cost of living raise is a way to keep staff, recognize talents and provide raises and salaries that are appropriate. We’ve been “dissed” for paying them too much. You have to compare it with other hospitals in Wyoming.

How do you propose to control costs to customers and be competitive in the industry?

BIXLER: That’s a very tough but important question he hears often. People travel out of Sublette County to find cheaper gas, food and services. He doesn’t have an answer until he can open the books. But compensation for administration cost is 33 percent higher than the average for the state.

GODFREY: Costs are being controlled and the budget has $1 million less than the last fiscal year. A program to track supplies found they were not used in an economic way. The staff made changes that could save about $50,000 in the coming year. Do we charge too much for our services? I don’t think so. We’re not reimbursed what we should be to cover costs. Have you been satisfied with your service here? National health-care costs are out of sight, a bigger project than we deal with today. He doubts anyone would find overcharges in the books.

JOHNSON: Medical costs have to come down. Numbers from the clinic’s first quarter, July through September, show they expected $820,000 in revenue and $690,000 came in. Administration cost $462,000; clinic expenses $732,000. I can tell you it will lose $1.5 million this year. Two mil levies will bring in $438,000 for the quarter.

SEIPP: She isn’t sure about medical billing and if reimbursement is what Medicare or whomever pays to the clinic. If sent a bill, she pays it. Is the reimbursement for the actual cost or an arbitrary charge identified on a chart?

CLARK: Controlling costs to stay competitive can be done with a CAH but not the current situation. She set radiology prices when the clinic opened and rates didn’t change until 2017, I don’t think our prices are too high. People don’t understand that Medicare plays a huge role in prices by requiring certain equipment for reimbursements.

HOFFMAN: She meets families who won’t go to our clinics because of exorbitant costs. People on this board say their costs are in line with other places across the state. I disagree wholeheartedly. I’ve worked places with prices nowhere what our clinics’ are right now and I find that very wrong. When you focus on patient care instead of dollars, people will come back and increase revenues. We need to bring people back and give them faith.

POMPY: Several people say costs they are stuck with for care here is much higher than other places. These need to be reviewed. You can make a little bit by charging more but if you have fewer patients you don’t get the income that you need. The community is paying the health board to take care of them; you don’t need to stick it to them.

SCHERBEL: Remember these other clinics are supported by a hospital; that makes all the difference in the world. If we aren’t sustainable our charges will be further in a hole. Every month our stats show patient visits increase and 96 percent of health-care services go out of the community because a hospital is required for them. Costs will remain high until we have the CAH to level out and allow us to reduce health-care costs throughout the system.

Where do you see local health-care services in the next five, 10 and 15 years?

BIXLER: In the next five years, emergency services should be restored at the Marbleton Clinic and a CAH could be functional at the existing clinic. Technology is making strides and telemedicine could help expand services.

GODFREY: Telemedicine is being planned. In 1995 after moving back here, he found you couldn’t live here unless you had a grudge. Pure and simple. In five, 10, 15 years they will be arguing about the same issues unless the community unites behind the rural hospital. There are six inpatient beds and most have 25. We are headed in the right direction to have clinical services close by to use the staff and not double up with two staffs.

JOHNSON: The CAH is too big for Pinedale. A consultant said there is a 10,000 population in Sublette County; it’s more like 8,500. There are 32 rooms for two surgeries, 30 rooms that support them. We cannot afford that kind of thinking. If we want a surgery center we have to cut it down. No one has explained what kind of surgeries would be profitable for Pinedale and they bring in Jackson doctors and staff.

SEIPP: At a presentation on prospects for the CAH she asked how many hospitals have closed in the last year and they said 60. How many were built? None. A conventional loan for $28 million will cost $54 million and the $28 million as well. We are in way over our heads and need to find reasonable way to get it done.

CLARK: A CAH is the answer to our woes, according to different entities. Surgery is essential. Surgery in a CAH has a very high reimbursement rate. Bringing it up to hospital standards and staffing are very expensive, especially when we’re not reimbursed for the emergency room. Medicine is going to telemedicine. We can increase services with St. John’s, University of Utah and EIRMC are all committed to help us provide services and keep ones we have.

HOFFMAN: Maybe in the near future a hospital is the answer. At this time we have to look at more fiscally responsible options. The state of health care nationally makes her nervous about thinking about a hospital in Sublette County. Changes are rapid and not necessarily positive that could impact us greatly if we build this hospital now. Maybe a full-service hospital down the road where our kids can have babies, get chemo, dialysis, all the services? Not right now.

POMPY: First we have to get 24-hour seven days a week in the lower end of county. Yes we need more funds to do this. He doesn’t have problem with a CAH but feels it can be more efficient working with the county and the towns. It will take time for people to trust a hospital before they start using it. He doesn’t see income over and above Medicare reimbursement for the first five years. After that, doctors would come because there’s a hospital here to bring in specialists.

SCHERBEL: For the next five to 10 years health-care services have to be based on a CAH. The sooner we get started services will brought in. Many leave the county for services we could have at a hospital. Clinics have 10 to 20 patients a month who could have stayed in a local hospital if those services were available. Yes, we need 24-hour services back in Marbleton but it’s only affordable with revenue from the CAH. That was the critical answer to meet county needs. In the next five to 10 years we either get a CAH up and running or we continue to lose services in the county.

Closing statements

BIXLER: The incumbents had their opportunity and four years to work toward their solution That was denied by the USDA. He doesn’t know the best path forward until relationships are repaired.

GODFREY: There are three phases to building a hospital. Design, construction and accreditation. Rooms and closets are there for a purpose based on recommendations of the St. John’s surgical team. If you have family, children, parents living here, that drive is daunting. He coined the phrase mini medical mart; let’s not build one. Let’s build a hospital that can serve us all. Visit our website at www.hospitalfor23.

JOHNSON: There are about 150 rooms with doors; it’s too expensive, $30 to $70 million depending on interest and payout and too many employees. This is Pinedale; it’s not Jackson Hole. It’s sad the relationship the incumbents have with our county and towns. Is it healthy to have a board that goes it alone? I believe we need change. Please vote for a new board.

SEIPP: If we choose wisely, it can be somewhat affordable. $28 million for a bottom number is a little bit much for me, a little bit overdone. Sublette County shouldn’t be saddled with that kind of debt. We should be more conservative, work together and get it done.

CLARK: Health care will change, it’s a given. We can control that change. In 1905 a hospital was proposed. It’s time to come into this century and stop spending our money in other counties and states. Don’t cut your costs in health care. If your family is in dire straits, you don’t want a cut-rate place for help; you want the best. We can do it. Eighty to 100 employees to provide health-care services for 8,500 to 10,000 residents is not out of line.

HOFFMAN: The people of Sublette County deserve to have access to consistent and affordable primary and emergency care. They pay taxes to have those services. This is purely economics. She is willing to sit down and have those conversations to rebuild relationships in our county. That’s where it has to begin. I don’t want to see us lacking in any care but we have to be very smart in what changes we make.

POMPY: The issue isn’t who is for the CAH or who isn’t; everyone here has expressed an interest in some sort of health-care facility. It’s a question of how to do it and cooperating with the county, towns without taking away services. It’s not a choice of who is for the CAH and who isn’t. It’s a choice of who is willing to work together to get this thing done. Vote for me or other new candidates.

SCHERBEL: We can’t afford fighting over a hospital that brings much more economic value into the county. This is a $27.5-million project. There are some ancillary offsite costs in the future, not for this project. Revenue from the hospital and surgery will bring back services lost at Marbleton-Big Piney Clinic. If we build a $6-million hospital we don’t have financial resources to bring back lost services. A CAH is the solution. If you want a CAH, vote for the three candidates in support of it.