Critical care redefined
Alexandria Bay’s River Hospital finds its niche in changing landscape
For River Hospital the last 10 years since Ben Moore III became CEO has been a transitional period as it experienced financial challenges, backlash from the Medicaid reimbursement changes, and then growth with the help of programs like the outpatient program for soldiers with PTSD coordinated with Fort Drum and TRICARE. Mr. Moore sat down with us this month to discuss how River Hospital overcame the challenges facing it and the future for the hospital and the north country’s health care industry as a whole.
NNYB: What brought you into the administration side of the health care business?
MOORE: I always had a fascination with medicine, but I didn’t like being around sick people, so being a physician I didn’t think was a good option. The administrative side I thought would be an option. I enjoyed administration when I was in the Navy. I thought that would be ideal. I’ve enjoyed it.
NNYB: Since 2006, you came on board during the midst of a lot of change. Tell me a little bit about the background of how things were when you came here 10 years ago and how you got to where you are right now.
MOORE: The challenges at the time were financial. We had some program issues that we needed to solve. We needed to recruit providers and we didn’t have a very strong financial accounting system. As a matter of fact, we didn’t even have a budget. Then through 2008 and 2009 we had a crisis with Medicaid reimbursement for our skilled nursing facility. We finally decided that we couldn’t hold on to our skilled nursing facility, so we had to close that. That was a very difficult period because it’s hard on everybody and it certainly was hard on the residents who were there. That was a pretty trying time. We’ve learned a lot of lessons from that experience. We started the closure in February. In that summer we had a board retreat to try to lay out our future, to map out what we needed to do. We’re still acting on some of those decisions from that time period. The other thing we did at that retreat was determine we needed to be more active in areas of care that there was a deficit of in the north country. We did a survey with the residents in the community, with providers in the community and one of the striking things to come out of that was lack of mental health services. So, we were looking for a way to be able to provide those services. We didn’t have any psychiatrists at the time or therapists. Fortunately this came up around 2012, Fort Drum and their insurance company TRICARE approached us to see if we’d be interested in setting up a post-traumatic stress program. I was very nervous about that to begin with, but they put me in touch with the Department of Defense hospital that treated PTSD for inpatients. I went down there, looked at it and I saw the possibilities, but again I was afraid to do on the job training with that kind of situation. I got them to agree to do a management contract with us. They would train our staff, help us set up the quality assurance programs, help us recruit and then monitor us to make sure we were doing things correctly. Once we got that contract I felt very positive about going ahead. That went from 10 soldiers a day all the way up to 40 soldiers a day in 2015. We had a really good program going. Then, in May of 2015 the Army was going to retrench the program back to the base. Unfortunately, that didn’t happen in its entirety. We still have the program. We have a more intense program than what they have on the base. So, that’s where we are, but like every other institution in the north country and probably in New York everyone is struggling.
NNYB: How has River Hospital been able to manage through lean economic times while growing its services and facilities into its present state?
MOORE: Two factors. Our employees, they will bend over backwards to help you. They’re committed. They see us as an economic engine for the community, so they want us to succeed and they’ll do what you ask them to do to help you do that and they help each other out. That part’s been very rewarding. They’ll come to you and give you ideas and tell you when things aren’t working well. You need to know both. The other thing is our board. We have a lot of really good talent on our board. We have people who are business people, people who are big accounting firm partners, so they really know finance, they really know business, and they’ve been very engaged. They don’t micromanage. They’ve been very engaged in helping us chart a future.
NNYB: Describe the relationship with the Army has matured and grown and how beneficial it is now.
MOORE: It started out very, very well. When we got that started everything worked out very well. Then, the problem was there was a facility-wide directive that said you have to have these programs on post. So the interpretation at the time that came out was you have to pull it all back. Col. McMurray said ‘the interpretation I would infer is that we can do things together.’ He did recognize that having the program off post could have benefits. He came out and visited. He had lunch with the soldiers. So he became an advocate for what we’re doing. He also engineered a better communications system for us with his own behavioral health folks to make sure we’re all on the same page. That works out very well now. I think they value us, we certainly value them. I think we’re back to a point where we view ourselves as a component of what they do and it’s a much more comfortable relationship than it was in May of 2015.
NNYB: In terms of Fort Drum, do you think that program and relationship will continue to grow as a partnership?
MOORE: I do. In addition to getting settled down on the immediate basis, I think what’s happened is Col. McMurray has really communicated very strongly with the Pentagon and his superiors about how this model works well and it ought to be maintained. We’ve had a number or people come out to visit and look at it, all the way up to the most senior uniform person in the medical command of the Pentagon.
NNYB: There are some interesting innovations within that program, the soldier art initiative, things that are out of the box, but they’re necessary right?
MOORE: We learned that by signing on to be tutored by Holliswood Hospital. We had no clue about that before, but I saw that myself. I went down when I did the sight visit down there and I saw these paintings, one when the Marine first started and one when he was about to be discharged. The one from when he first started was just chaotic, not grotesque, but scary, and then upon leaving peaceful, pleasant. The person who was telling us about it said well, that’s our therapy. That was 10 weeks. Art therapy taught the Marine to first of all see the feelings that were going on by the art and then that made his therapy much more effective for him, and then you can see the progression. That really works here. All of the soldiers let us display that.
NNYB: Where do you think the hospital needs to focus its efforts in order to prosper well into the future?
MOORE: For us in our location, it needs to be primary care and emergency care. That’s what the community, in any survey you take, is looking forward to. Now, recently we added mental health and that has really come up as being a core competency as well. We just started a children’s psychiatry program in February of this year and the involvement in that has really skyrocketed and we haven’t even done any advertising. We’ve just let the schools know that we have this available. We went from one psychiatrist to two psychiatrists. Now, we’re doing this in a cooperative program with Upstate’s Department of Psychiatry. It’s telemedicine, but it works extremely well. What we feel we can contribute to the community, is needed by the community, and gives us the best shot for not only survival, but for working with other organizations, it’s those three things, primary care, emergency care and mental health.
NNYB: To what do attribute the growth in the need for mental health services?
MOORE: It’s always been an unmet need. There are stats that show that we have the fewest mental health providers for this region in all of New York apparently and one of our big DSRIP initiatives is to increase the amount of mental health providers that are available. It’s difficult to recruit and I think that’s one issue. Insurance coverage has not always been the greatest, so I think institutions have been reluctant to provide it. Now we were lucky in that regard because when we did the Army program funded by TRICARE, the staff was also willing to do community care. That’s a unique feature. The programs worked out as far as staffing meshed out very well and we were able to take on community at rates that other institutions might not want to do.
NNYB: With larger institutions and other hospitals in the region, is the north country a competitive environment?
MOORE: It’s supposed to be collaborative. That’s what the Department of Health is trying to get us to do through DSRIP, but it’s still competitive and I haven’t seen the transition yet from competitive to collaborative. Institutions are still trying to get services away from one institution to another because that’s the competitive model. At what point do you throw the switch? My concern is that we haven’t developed in this region yet the level of trust between the CEOs and other leaders in the health care system to just say this is what we need to do. It’s going to take us awhile to work through all of that. The more we work together the better that’s going to be. The DSRIP program is a huge complex program, but I think one of the benefits is its forcing us to get together and try to problem solve. I think everyone’s committed to make things work out for the community.
NNYB: What steps are necessary to tear down those walls of competition and be more collaborative?
MOORE: It starts with almost a new willingness to just put everything on the table, try to analyze it from the perspective of community and be willing to accommodate other institutions, realizing those institutions mean a lot to their communities. If you went full competitive model, some might argue some of these places should disappear. I don’t believe that. I think that we’re all going to have to change, but I think these communities, especially up here in the north country rely on these institutions for a lot of, not only access to care, but for the economic impact. If we can all be empathetic enough and wise enough, we can create a collaborative model that does that and lowers the cost of care, improves the quality of care and so forth. I think the physicians and the providers working through the clinical-integrated network are probably ahead of the hospital administrators in working on that. Maybe they can light the spark that gets the rest of us to embrace all of that.
NNYB: How has technology been a game changer for you? How has that enabled you to expand your services on a leaner operating budget?
MOORE: Child psych is a perfect example of that. There’s no way we could have hired a child psychiatrist, they’re very expensive, but once we reached that agreement with Upstate via telemedicine, the cost of running a program like that drops dramatically because of the technology. What I hear in the community is they really appreciate that we did that. The reaction to having the services has been almost overwhelming. The electronic health record has been a huge advance. That’s gone out view of the public as a big advance, but it has been. It makes for safer care because it has all of those software edits in it that check for bad drug to drug interactions that you forgot to do reminds them to do it and then you can do much better quality assurance by going back and looking at your care because you have much better data. And we’re able to transmit what happens to them back to their hometown doctor when they leave. It also helps because in many cases now we can have a radiologist from home see the actual x-ray on their home computer and be able to get a quick reading and no one has to wait around until the radiologist comes in. Getting to a diagnosis is much faster and easier with technology than it used to be.
NNYB: This has required a lot of leadership and I’m sure you’ve surrounded yourself with others like-minded and maybe some who challenge you. What lessons in leadership have you learned in 10 years?
MOORE: I’ve learned patience. I think when you first face a challenge and it’s difficult, it can be very easy to throw in the towel, but then you look around and you realize people are looking at you for an answer. You may not have one and then you start talking, you start listening. That’s the thing I learned a lot. There’s a lot of good information coming out of the employees, their observations, their feelings about things, what they think of work. We have a very good medical staff. They can tell you what they think will work or won’t work. The board can look at them really as consultants because they have some expertise.
NNYB: We all receive a lot of advice in our careers, what is the best advice that you have ever followed and tried to share with others?
MOORE: Listen. I’ve had that from several mentors. There can be a tendency when you’re leading an organization and you want to achieve deadlines and objectives, is to sort of march on with blinders almost. That can be a mistake and I’ve learned all the way that you listen. Sometimes silence tells you something’s wrong and then you try to get to it and find out what’s wrong. As well as listening, a secondary approach of that is being approachable. You find out so much when people are comfortable that you’re going to take them seriously, that you are going to respond to what they’re saying and be empathetic with what their concerns are.
NNYB: One of the tenets of the Affordable Care Act is a shift more toward prevention and not let’s let everyone get sick and be a major drain on the system. That’s a pretty tall order, but it also turns the hospital model on its head.
MOORE: It does. Now that part has been easier for us since we had a small inpatient operation to begin with and we’ve significantly grown the outpatient side, but that’s exactly right. On the preventative side, I think that’s where technology is helping. I don’t know what the actual outcome will be eventually, but this electronic medical record allows a provider to make sure they ask the patient the questions, it makes sure they have this test or that test, or they talk to them about nutrition and issues like that and then document that, so you can track what’s going on with the patient. The missing piece of that to me is the incentive for the patient and I don’t think the Affordable Care Act provides for that directly.
NNYB: What do you mean by incentives for the patient?
MOORE: Other than convincing the patient you want to be healthy, just with that exhortation are they going to do it? A lot don’t. So, how do you incentivize it? Do you have a higher premium for them if their behaviors are not so good? How do you do that? I don’t like that idea of taxing them if they’re not compliant. You cannot price discriminate based on someone’s health condition.
NNYB: What is the outlook and the way forward for care in the north country?
MOORE: We do have to solve the collaborative issue. I think that’s the most important thing. As I mentioned before, I don’t think we’re all in the same mindset yet to do that. I hope we get there because I do feel the next 24 months are going to be critical and you’re more successful the more thought and effort you put into it as opposed to an emergency consolidation of some sort, which I think could be disastrous.
NNYB: How do we regionally break through the silo mentality to deliver more cooperative and collaborative care?
MOORE: I think the communities have to, whether it’s the boards of directors of the institutions or the leadership of the community, say look, you guys, you’ve got to fix this in the interest of all of us. Just get to work and fix it. Hold our feet to the fire because if we don’t do this in the next 24 months, we’re going to leave the community with a mess in its hands. The community needs to come together and say we expect you to deliver and we want you accountable to us. Right now we’re sort of accountable to ourselves. I think it’s got to go beyond that. We have to be much more accountable than we are right now.
NNYB: Why the urgency of 24 months?
MOORE: The Department of Health is now conditioning some of their grants on our ability to collaborate and I understand why they’re doing it. They’re trying to move the agenda. If we aren’t successful in that, we won’t have some of the financial support we have now, which can be a spiral, especially for small institutions. So I feel a real sense of urgency to break through this collaborative type of issue.
NNYB: After 10 years, how would you grade the health care report card here?
MOORE: I’d give us a B. We need to do more work on our own financial sustainability just so we can assure the community that we’re going to be here for the long haul, to tell our employees we’ve got some of these issues solved and make them feel a little bit more secure. I think there’s nervousness, not just in our hospital, but across the region. The care I’d say is an A, but overall I think we’re a B because we haven’t moved the institution far enough into the future. That’s the challenge.
NNYB: If your wish list was limited to one or two things for your hospital that you could fix or improve at, what would they be?
MOORE: The first thing would be a system of collaboration where we can share physicians because when we have a vacancy we’re small and it impacts us, and it’s hard to recruit so it tends to be lengthy. I would love a collaborative relationship where we share, we plug things in, not only for the financial piece, but to make sure the community’s taken care of. That’s the number one thing I’d like to see. I think the second thing is a real secure financial strategic plan for the whole region. Again, no one’s really put that together.
The Ben Moore III file
Family: Cynthia McDonnell; twins, Matthew and Elizabeth
Job: CEO, River Hospital
Professional: Line officer, U.S. Navy, four years; Creighton University, Omaha, Neb.; University of North Carolina; SUNY Upstate Medical University, Syracuse
Hometown: Raised in Brawley, Calif.; splits time between Wellesley Island and Manlius.
Education: Bachelor’s in government, Harvard University, 1971; master’s in health administration, Duke University
Last book read: “No Ordinary Time: Franklin and Eleanor Roosevelt: The Home Front in World War II” by Doris Goodwin
—Interview by Ken Eysaman. Edited for length and clarity to fit this space.