Back in May, Bay Area Hospital announced it would be closing its behavioral health unit due to rising costs. But after community outcry, the hospital found a way to stay open for another 12 months using funds provided by Advanced Health, which helps coordinate care for residents of Coos and Curry County on the Oregon Health Plan. Brian Moore is the President and CEO of the Bay Area Hospital. He joins us to share what led to the initial closure and how they will keep it open after the first year is up.
Note: The following transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB, I’m Dave Miller, coming to you this week from Coos Bay. We’re going to turn to health care now and the Bay Area Hospital, which serves a pretty big chunk of Oregon South Coast and surrounding areas. Like health care institutions all across the country, it’s had a rough 2.5 years dealing with surgeons and patients and shortages of staff. It’s also had to deal with the challenge that comes specifically from being the only hospital of its size in the region. Yesterday we sat down with Brian Moore, he is President and CEO of the hospital. He started his position in January of 2019, meaning he had about 15 months before the COVID pandemic hit this country. I asked if that was enough time to get used to his new job.
Brian Moore: I can’t imagine having less time. What it did allow me to do is kind of get my feet planted, begin to, you know, start building some relationships in the,...my new community, the city, the town, the county, establish some rapport with the board and how we would work together. So it was really important, you know, foundation building time in hindsight of what was going to happen in March of 2020.
Miller: Given that the floors were about from all of us at least you had a floor to start with…
Moore: Health care as we knew it, life as we knew it was about to go on pause and and really get reoriented in many ways.
Miller: I’m curious about your arrival here before that because if I understand correctly, you had previously worked in hospital administration in Orlando and in the metropolitan Denver area, two much bigger city areas where I imagine healthcare is different, where there’s more than one big hospital. What was it like to come to a place where this is the one hospital, not just for Coos Bay, but for the surrounding area?
Moore: We did have another phase where we started getting into smaller communities. We, my family and I spent about five years two hours south of Denver in Pueblo. And for us that was a small town. It didn’t get me many small town creds in the interview because, you know, the city was 100,000 and the county was 170,000.
Miller: But you come from a place with millions?
Moore: Right. Exactly. It was eye opening, there’s a value proposition of living in a smaller town. But you’re right, my healthcare experience had been in really competitive environments with multiple hospitals and large presence of physicians and services. And so with that background, I thought, ‘Oh, I’m going to have something to offer to this community,’ and I think I underappreciated how much this community would have me learn. And one of the things is Bay Area Hospital, we’re surrounded by smaller critical access hospitals. There’s three critical access hospitals within 30 or 45 minutes and another hour and a half away is another critical access hospital.
Miller: And what is a critical access hospital?
Morse: So a critical access hospital has less than 25 beds and is designed to provide really essential services in smaller communities. And it’s a structure which provides some cost-based reimbursement from the federal government. So it’s a special designation.
Miller: It’s more basic services as opposed to what you could have here. And then I imagine there’s another step up at a big academic hospital like OHSU?
Morse: Absolutely, there’s many steps – we run a level three trauma program here, a primary standing location for things that exceed our capabilities would be the level two trauma center in Eugene, Peace Health Riverbend. And there are things that we send to Portland to a level one trauma center just for example.
Miller: What does it mean? How does it change the business model of a hospital, when you are a kind of magnet?
Morse: Maybe I’ll talk a little bit about the care model before the business model. One of the things that in those competitive environments that I didn’t realize was you offer these specialty services and in today’s environment you have people coming and going – technologists with skills, nurses with specialized skills, physicians with specialized skills. And when you’re sharing a medical staff, and many times you are, to some degree, with your competing hospitals, when someone leaves with a talent, and there’s a gap you can borrow from your competitor…
Miller: Like a part time surgeon, or something?
Moore: Right. Or a Radiation Oncologist for our cancer center program. When we run a program here, two hours from the closest program providing the same service, that talent base is also two hours away. So when someone leaves you have an immediate hole. And of course the economics are still such, you know, a payer mix that’s high Medicaid, high government. You don’t have a lot of extra resources to keep people sort of idle in the wings. So you have just enough volume to keep your core people busy and the finances to work, and when they leave, you have an immediate service gap. That’s a challenge I underappreciated when I moved here.
Miller: In terms of the payer mix. This is something that many of us learned for the first time in the pandemic. Some of the basics of the way a lot of hospitals work, which is that it’s some specialty services that end up paying for a lot of the other services, things more like preventive care or or other basic services that may get reimbursed at lower rates or that just may bring in less money for a hospital. What did that mean for Bay Area Hospital over the last 2.5 years?
Moore: Well the model got upended. Hospitals have kind of artfully arranged this kind of cross subsidy. The US healthcare system is interesting in how health care is reimbursed, and it isn’t always the most important service that is adequately reimbursed
Miller: ‘Interesting,’ is a very gentle way to put the economics of the American healthcare system
Moore: Absolutely. And so you find procedures, surgical procedures in the heart cath lab. Those types of procedures typically come reimbursed at a level that exceeds the hospital’s cost. There are other services – women’s services, childbirth and behavioral health services – that are typically reimbursed at a level that doesn’t cover the cost. And so hospitals across the nation, Bay Area Hospital, were able to figure out how to do things that are important and balance that portfolio.
Miller: As long as you’re getting all of those patients coming in and using all those services? But that didn’t happen in the pandemic, right?
Moore: During the pandemic We use this term of ‘elective surgeries,’ right? And we postponed those, we canceled those, we paused those across the state. Initially, as the pandemic first began to roll out and then hospitals, not by government decree but just by trying to manage responsibly said, ‘We don’t need government intervention. We can figure this out.’ We also had other time periods, extended time periods, where we curtailed those services. ‘Elective,’ is misleading, we’re not talking about a cosmetic procedure – elective for us is, a more accurate word would be a ‘scheduled procedure.’ But you know, I like to say ‘These are things that hurt, that shouldn’t hurt.’ These are bones that grind that shouldn’t grind. These are places in people’s bodies that leak, that shouldn’t leak, or places that are growing tumors that are growing that shouldn’t grow. Those are sometimes the things that fall into that ‘elective’ category
Miller: As opposed to a car accident where someone comes through the ER and then goes straight to the operating room and…
Moore: Right. That’s going to happen today.
Miller: The other things are still super important. But you might schedule two weeks from now.
Moore: That’s right.
Miller: You mentioned mental health care. This it’s a good chance to go to one of the more dramatic news stories and community issues that came out recently. In May you announced that, among other things, you were going to be closing your inpatient mental health care unit. What exactly was going on?
Moore: There were a lot of factors really behind that decision. Through the pandemic, we saw a pretty dramatic uptick in violence just across the campus. And one of the most difficult areas was our inpatient Behavioral Health Unit, to keep patients safe, to keep our staff safe.
Miller: When you say ‘violence,’ what do you mean?
Moore: I mean patients with mental conditions. I mean members of the public coming into the emergency department with physically violent assault of healthcare workers just to put it bluntly.
Miller: So that was in the background, going on affecting staff, probably other patients. But what led to the announcement that the unit was going to have to close?
Moore: Well, there are other factors. We look back at who is utilizing the services and you know, I’ve been here in Oregon for a little over 3.5 years and Behavioral Health Care Systems in each state are challenged. They each have their own unique flavor of challenge. In Oregon, I understand, there was a…
[Voices overlap]
Miller: Court ruling that really shifted how the state allocated availability of the state hospital and an ‘aid and assist’ population essentially got a permanent frontline position
Moore: What’s that?
Miller: People who had been accused of crimes but were found to not be ready to aid and assist in their own defense, and so until they could get to that mental status or psychological status, they would get treatment. That is the theory and the hope on the street was happening theoretically at the Oregon State hospital
Moore: Thanks for that expanded definition. That’s exactly what I’m talking about. There’s another group of patients who find themselves civilly committed and compared, I think the thinking was compared to citizens who are sitting in jail, civilly committed are many times entering the health care system through an emergency department and they’re in a better setting. What we find is those patients’ needs and their acuity, programs like Bay Area Hospital, that’s designed for really a week-long kind of stabilization and then a movement to outpatient. Those civilly committed patients are In need of services for months. Our physical plant and we programmatically were not designed to meet their needs. So as we look back at in April, the preceding 12 months, we had a little over 2,000 patient-days of care that we provided. Half of that capacity, over 1,000 of those days went to 15 individuals, really in that civilly committed. The other 129 people that we were able to serve had an average length of stay of about six or seven days. So we had half of our program capacity consumed by people with needs that we weren’t designed [for]. Well that had multiple implications because with the high acuity, we had to shrink our census. So on a behavioral health unit, people aren’t locked in individual rooms – there’s a ‘Mill Room,’ they can move around the unit and interact with patients and staff, which is a positive therapeutic environment. But when you have someone who has violence or you know some other issues, how do you create more safety? Well, one way is to decrease the number of people on the unit and give more physical space. Well, that also has a financial implication because you’re not now able to care for those patients and subsequently bill for those services, and we’re not getting reimbursed for that longer length of stay for those patients who are there for months. So we were looking at a $2 million dollar annual loss on our program. And that was really the crux, combined with the other financial pressures where we’re trying to rebalance the hospital’s finances that led to that closure decision.
Miller: Can you give us a sense for the public outcry that followed your announcement that you were going to have to close the unit?
Moore: I think we knew, right? That this service was highly valued by the community members. In retrospect, ‘How could we have done a better job of communicating the process along the way,’ is a question that we’ve asked and, as we talk more about how we’re moving forward in the future. You can see the application of some of the lessons that we learned there, but there was a very dramatic and strong voice that said, ‘Hey, these are essential services for us,’ that still didn’t provide an answer for how we make the finances work. But as we reached out to community partners, we found one in Advanced Health, who offered $2 million over the next 12 months to help us sustain that program.
Miller: So that’s a kind of a one year stopgap. If I understand this correctly, different folks came together and said, ‘Well, we’ll make this work for a year.’ What’s the longer term plan? I mean, what’s, what is your vision for a sustainable Behavioral Health Unit, Mental Health Unit in this hospital, that, that both treats people, which is the heart of this, but also is financially sustainable.
Moore: If all we did was take 12 months of funding, ran the program exactly the same, that’s the likely outcome, right? We just delayed closure by 12 months. So what we have done is really serve as convener and invite all the players that we can come up with in the local region to the table, in a collaborative effort, to really look at improving and changing behavioral health here in the community and at Bay Area Hospital. So we just had our second meeting a couple weeks ago, we’ve had probably 30 to 40 people in the room representing, you know, 15, 16 different agencies. We have participation by local state representatives and senators. And we have really, three subgroups right now coming out of that work. One is focused on legislative changes at the state level, that would, we think, help the viability of our program, help improve access to behavioral health across the state and apply to communities just like us, wrestling with very similar issues. We have another focus group really looking at strengthening our community collaboration.
Miller: Let me just go back to, so what, exactly, do you want lawmakers to do? What’s a change in state law, coming from Salem that would change the way psychiatric beds work upstairs?
Moore: I think when the court ruling came down that prioritized that ‘aid and assist,’ there was an underlying assumption that didn’t connect with reality that, ‘Hey, the civilly committed people, the community programs are gonna have no problem adequately treating them.’ I would like to see changes at the state that align resources and create a model where civilly committed patients have access to the care and treatment that they need
Miller: At the state level. ‘Figure out a way,’ you’re saying, ‘lawmakers, make sure that those patients can be sent from Coos Bay or Bend or Portland or Enterprise and be sent to Salem’
Moore: ‘State hospital, state hospital, state hospital,’ has been the drum beat. I don’t know that that’s the answer in our go forward model and I’m not saying that I’m smart enough to have figured it out, but neither is, ‘Hey, the status quo, community programs can meet these needs.’ So maybe we do need to look at, as a state, some sort of distributed model where civilly committed patients, they don’t need to go all the way to the state hospital. But perhaps the assumption that every program, inpatient program in the state is resourced, is also inadequate. Maybe we need a regional approach. Maybe there needs to be an investment of funds and resources if we’re going to depend on the community programs, to help them spool up programs, knowing now there’s a new expectation and a new need at the local level to meet the needs of those civilly committed patients.
Miller: So that was just one of the prongs you were talking about, is essentially lobbying for changes of the state level through the Legislature. What else do you think is necessary, so that you’re not just delaying the closure of the unit?
Moore: So the other thing is, okay, Regionally, we’ve got a number of outpatient players. We have Bay Area Hospital and our inpatient program. We have the intersection of homelessness, law enforcement and the judicial system, and mental health, that also is a place where people sometimes get stuck right in the system. And so we have representatives from those groups at the table and we’re asking ourselves the question, ‘Okay, Salem, and the State, we need your help to fix things.’ But what can we do more in our local span of control? Can we identify more effectively than we have in our, you know, individual silos, some of the gaps where people fall as they’re kind of moving through the continuing of recovery. And can we build a bridge there. There’s a lot of state dollars that have been put into play over the last year. Can we more effectively pull those state dollars to maybe build resources and fill those gaps? Coordination isn’t perfect. So at the table, can we come up with more effective ways to coordinate our care and support the needs of our community members? So that’s what that kind of collaborative group is focused on.
Miller: I want to go back to something you mentioned earlier that unlike other larger cities where you’ve worked, where there might be a number of hospitals, all competing, but also in some ways sharing a talent pool, you don’t have that here. That has led your hospital and many others to have to, when there are staffing shortages to hire traveling nurses or other temporary healthcare staff, which as your hospital has noted, has led to serious budget problems because you end up spending a lot more money on these temporary positions. What’s the solution, I mean, what is the local solution for you to actually have more health care workers here?
Moore: There is no quick solution to that one. You know, looking back over the last, you know, several years, we have a community college here, Southwestern Oregon Community College. The hospital stepped up to the plate predating my arrival and made a multi-year, million dollar commitment. It took multiple years to get that million dollars in the hands of the college. But they were able to expand their physical plant over the years we’ve also provided…
Miller: Has that led to people going there and then transitioning into careers in this building?
Moore: So that’s allowed them to expand the size of their nursing class, which is fantastic. The other component is, do you have the teachers? Do you have the professors to expand that class and you know, what do you get paid for teaching nursing versus what do you get paid for nursing as a nurse taking care of patients? Well, that has made it very hard for schools, colleges to attract nursing faculty.
Miller: Every time, it seems like there’s a solution, there’s another issue that crops up.
Moore: Yeah, so we got to get scrappy, we gotta stay committed. And there have been support dollars paid to kind of level the gap if you will, between what the college can afford to pay and what it really takes to attract nursing faculty. And I think some of those kind of education / industry partnerships are probably key to how we move forward in the future.
Miller: We are at least two years past that one halcyon time when Americans would cheer for healthcare workers and ring bells, I think, was at seven pm, I forget what time, but this kind of time of solidarity when seeing healthcare workers as heroes, we are long past that and for a whole bunch of reasons. But it makes me wonder if in the last 2.5 years, if your understanding of what it takes to take care of the people who work here has changed permanently?
Moore: We have long talked about the shortage of healthcare workers, physicians, nurses, technologists, you know, my 20 year career, that’s something that just seems to come up. The pandemic has had some massive acceleration of that story of truth. And we feel that that shortage acutely now and that has been a big driver of burnout. And of course, that just starts building into the cycle of people looking for lower acuity, you know, positions in healthcare or perhaps leaving the healthcare industry altogether. And so we’ve done a lot of learning over the last year about the factors of burnout and certainly giving people tools on resiliency is a piece of it on the physical health side, you can take somebody with a depressed, you know, immune system and put them in a relatively pathogen free environment and they may still get sick, versus you can put somebody with a really robust immune system in a place that’s filled with pathogens and they may not get sick. So having a resiliency toolset, well, that’s good for all of us to have. But the underlying factors of the health care system, creating stress that imbalance that was accelerated by the COVID pandemic of a great increase in need and not being able to have a corresponding increase in the resource to meet that need. That’s a driver of burnout. We haven’t figured that out right now, and it’s still impacting our staff today.
Miller: Thank you very much for giving us some of your time. I appreciate it.
Moore: Thank you.
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